Donor Financing of Global Mental Health, 1995-2015: An Assessment of Trends, Channels, and Alignment with the Disease Burden.

BACKGROUND: A recent report by the Institute for Health Metrics and Evaluation (IHME) highlights that mental health receives little attention despite being a major cause of disease burden. This paper extends previous assessments of development assistance for mental health (DAMH) in two significant ways; first by contrasting DAMH against that for other disease categories, and second by benchmarking allocated development assistance against the core disease burden metric (disability-adjusted life year) as estimated by the Global Burden of Disease Studies. METHODS: In order to track DAH, IHME collates information from audited financial records, project level data, and budget information from the primary global health channels. The diverse set of data were standardised and put into a single inflation adjusted currency (2015 US dollars) and each dollar disbursed was assigned up to one health focus areas from 1990 through 2015. We tied these health financing estimates to disease burden estimates (DALYs) produced by the Global Burden of Disease 2015 Study to calculated a standardised measure across health focus areas-development assistance for health (in US Dollars) per DALY. FINDINGS: DAMH increased from USD 18 million in 1995 to USD 132 million in 2015, which equates to 0.4% of total DAH in 2015. Over 1990 to 2015, private philanthropy was the most significant source (USD 435 million, 30% of DAMH), while the United States government provided USD 270 million of total DAMH. South and Southeast Asia received the largest proportion of funding for mental health in 2013 (34%). DAMH available per DALY in 2013 ranged from USD 0.27 in East Asia and the Pacific to USD 1.18 in the Middle East and North Africa. HIV/AIDS received the largest ratio of funds to burden-approximately USD150 per DALY in 2013. Mental and substance use disorders and its broader category of non-communicable disease received less than USD1 of DAH per DALY. INTERPRETATION: Combining estimates of disease burden and development assistance for health provides a valuable perspective on DAH resource allocation. The findings from this research point to several patterns of unproportioned distribution of DAH, none more apparent than the low levels of international investment in non-communicable diseases, and in particular, mental health. However, burden of disease estimates are only one input by which DAH should be determined.

Time-course of PTSD symptoms in the Australian Defence Force: a retrospective cohort study.

AIMS: Understanding the time-course of post-traumatic stress disorder (PTSD), and the underlying events, may help to identify those most at risk, and anticipate the number of individuals likely to be diagnosed after exposure to traumatic events. METHOD: Data from two health surveys were combined to create a cohort of 1119 Australian military personnel who deployed to the Middle East between 2000 and 2009. Changes in PTSD Checklist Civilian Version (PCL-C) scores and the reporting of stressful events between the two self-reported surveys were assessed. Logistic regression was used to examine the association between the number of stressful events reported and PTSD symptoms, and assess whether those who reported new stressful events between the two surveys, were also more likely to report older events. We also assessed, using linear regression, whether higher scores on the Kessler Psychological Distress Scale or the Alcohol Use Disorder Identification Test were associated with subsequent increases in the PCL-C in those who had experienced a stressful event, but who initially had few PTSD symptoms. RESULTS: Overall, the mean PCL-C scores in the two surveys were similar, and 78% of responders stayed in the same PCL-C category. Only a small percentage moved from having few symptoms of PTSD (PCL-C < 30) in Survey 1 to meeting the criteria for PTSD (PCL-C ≥ 50) at Survey 2 (1% of all responders, 16% of those with PCL-C ≥ 50 at Survey 2). Personnel who reported more stressful lifetime events were more likely to score higher on the PCL-C. Only 51% reported the same stressful event on both surveys. People who reported events occurring between the two surveys were more likely to record events from before the first survey which they had not previously mentioned (OR 1.48, 95% CI (1.17, 1.88), p < 0.001), than those who did not. In people who initially had few PTSD symptoms, a higher level of psychological distress, was significantly associated with higher PCL-C scores a few years later. CONCLUSIONS: The reporting of stressful events varied over time indicating that while the impact of some stressors endure, others may increase or decline in importance. When screening for PTSD, it is important to consider both traumatic experiences on deployment and other stressful life events, as well as other mental health problems among military personnel, even if individuals do not exhibit symptoms of PTSD on an initial assessment.

Post-traumatic stress disorder and major depression in conflict-affected populations: an epidemiological model and predictor analysis.

BACKGROUND: Despite significant research examining mental health in conflict-affected populations we do not yet have a comprehensive epidemiological model of how mental disorders are distributed, or which factors influence the epidemiology in these populations. We aim to derive prevalence estimates specific for region, age and sex of major depression, and PTSD in the general populations of areas exposed to conflict, whilst controlling for an extensive range of covariates. METHODS: A systematic review was conducted to identify epidemiological estimates of depression and PTSD in conflict-affected populations and potential predictors. We analyse data using Bayesian meta-regression techniques. RESULTS: We identified 83 studies and a list of 34 potential predictors. The age-standardised pooled prevalence of PTSD was 12.9% (95% UI 6.9-22.9), and major depression 7.6% (95% UI 5.1-10.9) - markedly lower than estimated in previous research but over two-times higher than the mean prevalence estimated by the Global Burden of Disease Study [3.7% (95% UI 3.0-4.5) and 3.5% (95% UI 2.9-4.2) for anxiety disorders and MDD, respectively]. The age-patterns reveal sharp prevalence inclines in the childhood years. A number of ecological variables demonstrated associations with prevalence of both disorders. Symptom scales were shown to significantly overestimate prevalence of both disorders. Finding suggests higher prevalence of both disorders in females. CONCLUSION: This study provides, for the first time, age-specific estimates of PTSD and depression prevalence adjusted for an extensive range of covariates and is a significant advancement on our current understanding of the epidemiology in conflict-affected populations.

Applications of the epidemiological modelling outputs for targeted mental health planning in conflict-affected populations: the Syria case-study.

BACKGROUND: Epidemiological models are frequently utilised to ascertain disease prevalence in a population; however, these estimates can have wider practical applications for informing targeted scale-up and optimisation of mental health services. We explore potential applications for a conflict-affected population, Syria. METHODS: We use prevalence estimates of major depression and post-traumatic stress disorder (PTSD) in conflict-affected populations as inputs for subsequent estimations. We use Global Burden of Disease (GBD) methodology to estimate years lived with a disability (YLDs) for depression and PTSD in Syrian populations. Human resource (HR) requirements to scale-up recommended packages of care for PTSD and depression in Syria over a 15-year period were modelled using the World Health Organisation mhGAP costing tool. Associated avertable burden was estimated using health benefit analyses. RESULTS: The total number of cases of PTSD in Syria was estimated at approximately 2.2 million, and approximately 1.1 million for depression. An age-standardised major depression rate of 13.4 (95% UI 9.8-17.5) YLDs per 1000 Syrian population is estimated compared with the GBD 2010 global age-standardised YLD rate of 9.2 (95% UI 7.0-11.8). HR requirements to support a linear scale-up of services in Syria using the mhGAP costing tool demonstrates a steady increase from 0.3 FTE in at baseline to 7.6 FTE per 100 000 population after scale-up. Linear scale-up over 15 years could see 7-9% of disease burden being averted. CONCLUSION: Epidemiological estimates of mental disorders are key inputs into determining disease burden and guiding optimal mental health service delivery and can be used in target populations such as conflict-affected populations.

Excess mortality from mental, neurological and substance use disorders in the Global Burden of Disease Study 2010.

AIMS: Mortality-associated burden of disease estimates from the Global Burden of Disease 2010 (GBD 2010) may erroneously lead to the interpretation that premature death in people with mental, neurological and substance use disorders (MNSDs) is inconsequential when evidence shows that people with MNSDs experience a significant reduction in life expectancy. We explore differences between cause-specific and excess mortality of MNSDs estimated by GBD 2010. METHODS: GBD 2010 cause-specific death estimates were produced using the International Classification of Diseases death-coding system. Excess mortality (all-cause) was estimated using natural history models. Additional mortality attributed to MNSDs as underlying causes but not captured through GBD 2010 methodology is quantified in the comparative risk assessments. RESULTS: In GBD 2010, MNSDs were estimated to be directly responsible for 840 000 deaths compared with more than 13 million excess deaths using natural history models. CONCLUSIONS: Numbers of excess deaths and attributable deaths clearly demonstrate the high degree of mortality associated with these disorders. There is substantial evidence pointing to potential causal pathways for this premature mortality with evidence-based interventions available to address this mortality. The life expectancy gap between persons with MNSDs and the general population is high and should be a focus for health systems reform.

The global burden of mental and substance use disorders: changes in estimating burden between GBD1990 and GBD2010.

Background. The main aim of this paper is to compare and contrast the methodological approaches of the new Global Burden of Disease 2010 Study (GBD 2010) with the original study conducted for 1990 (GBD 1990), in terms of calculating burden for mental and substance use disorders. Methods. We reviewed the conceptual and methodological changes to GBD burden calculations in the GBD 2010 study, compared with previous studies. We then discuss the possible implications of these changes with respect to burden estimates for mental and substance use disorders. Results. It is not possible to compare burden estimates arising from the GBD 1990 study with the most recent burden estimates. There have been important advances in the categorisation and definition of mental disorders, and the input and computation of epidemiological models for disease distribution. There have also been major changes to conceptual and social value choices aimed at addressing concerns that arose following publication of earlier GBD studies. Conclusion. Advancements to the GBD conceptual framework and method of calculating burden estimates has led to more accurate and equitable consideration of the burden for mental and substance use disorders. Proposed annual updates of GBD estimates by the Institute of Health Metrics and Evaluation provide an opportunity to continue to advance the evidence base that underpins the quantification of disease burden.