Elsevier

The Lancet

Volume 387, Issue 10028, 16–22 April 2016, Pages 1672-1685
The Lancet

Review
Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition

https://doi.org/10.1016/S0140-6736(15)00390-6Get rights and content

Summary

The burden of mental, neurological, and substance use (MNS) disorders increased by 41% between 1990 and 2010 and now accounts for one in every 10 lost years of health globally. This sobering statistic does not take into account the substantial excess mortality associated with these disorders or the social and economic consequences of MNS disorders on affected persons, their caregivers, and society. A wide variety of effective interventions, including drugs, psychological treatments, and social interventions, can prevent and treat MNS disorders. At the population-level platform of service delivery, best practices include legislative measures to restrict access to means of self-harm or suicide and to reduce the availability of and demand for alcohol. At the community-level platform, best practices include life-skills training in schools to build social and emotional competencies. At the health-care-level platform, we identify three delivery channels. Two of these delivery channels are especially relevant from a public health perspective: self-management (eg, web-based psychological therapy for depression and anxiety disorders) and primary care and community outreach (eg, non-specialist health worker delivering psychological and pharmacological management of selected disorders). The third delivery channel, hospital care, which includes specialist services for MNS disorders and first-level hospitals providing other types of services (such as general medicine, HIV, or paediatric care), play an important part for a smaller proportion of cases with severe, refractory, or emergency presentations and for the integration of mental health care in other health-care channels, respectively. The costs of providing a significantly scaled up package of specified cost-effective interventions for prioritised MNS disorders in low-income and lower-middle-income countries is estimated at US$3–4 per head of population per year. Since a substantial proportion of MNS disorders run a chronic and disabling course and adversely affect household welfare, intervention costs should largely be met by government through increased resource allocation and financial protection measures (rather than leaving households to pay out-of-pocket). Moreover, a policy of moving towards universal public finance can also be expected to lead to a far more equitable allocation of public health resources across income groups. Despite this evidence, less than 1% of development assistance for health and government spending on health in low-income and middle-income countries is allocated to the care of people with these disorders. Achieving the health gains associated with prioritised interventions will require not just financial resources, but committed and sustained efforts to address a range of other barriers (such as paucity of human resources, weak governance, and stigma). Ultimately, the goal is to massively increase opportunities for people with MNS disorders to access services without the prospect of discrimination or impoverishment and with the hope of attaining optimal health and social outcomes.

Introduction

The primary goal of Disease Control Priorities in Developing Countries, first published by the World Bank in 1993, is to synthesise evidence of the burden of specific health disorders and, more importantly, the relative effectiveness and cost-effectiveness of interventions so as to assist decision makers in allocating often tightly constrained budgets and ensuring that health system objectives are maximally achieved. The third edition of Disease Control Priorities (DCP-3) aims to provide up-to-date evidence and includes several novel features that build on previous editions, for example by addressing how interventions can be packaged together across a range of delivery platforms and channels (appendix p 1).1 Here we describe the key findings of the evidence related to mental, neurological, and substance use (MNS) disorders.

MNS disorders are a heterogeneous range of disorders that owe their origin to a complex array of genetic, biological, psychological, and social factors. Although many health systems deliver care for these disorders through separate channels, with an emphasis on specialist services in hospitals, the disorders have been grouped together here because they share several important characteristics, notably: all owe their symptoms and impairments to some degree of brain dysfunction; social determinants play an important part in the aetiology and symptom expression (panel 1);2, 3 they frequently co-occur in the same individual; their effect on families and wider society is profound; they are strongly associated with stigma and discrimination; they often take a chronic or relapsing course; and they all share a pitifully inadequate response from health-care systems in all countries, but particularly in low-income and middle-income countries. This grouping is also consistent with the DCP-3 goals of synthesising evidence and making recommendations across diverse health disorders and with WHO's Mental Health Gap Action Programme (mhGAP).4

In DCP-3, we have considered interventions for five groups of disorders (adult mental disorders, child mental and developmental disorders, neurological disorders, alcohol use disorder, and illicit drug use disorders) and for suicide and self-harm, a health outcome strongly associated with MNS disorders. Within each group, we have prioritised disorders that are associated with high burden and for which evidence exists in support of interventions that are cost effective and scalable. Inevitably, such an approach does not address a substantial number of disorders (eg, multiple sclerosis as a neurological disorder and anorexia nervosa as an adult mental disorder), but our recommendations could be extended to several other disorders that have not been expressly addressed, in particular with respect to the delivery of packages for care. Additionally, some important MNS disorders or concerns are covered in other volumes of the DCP-3 series, notably, nicotine dependence, early child development, neurological infections, and stroke.

In this report, we address five themes. First, we address the question of why MNS disorders deserve prioritisation by pointing to and reviewing the health and economic burden of disease attributable to MNS disorders. Second, we review the evidence of the effectiveness of specific interventions for the prevention and treatment of the selected MNS disorders. Third, we consider how and where these interventions can be appropriately implemented across a range of service delivery platforms. Fourth, we examine the cost of scaling up cost-effective interventions and the case for enhanced service coverage and financial protection for people with MNS disorders. Finally, we consider the barriers and strategies for successful scale-up.

Section snippets

Why MNS disorders matter for global health

The Global Burden of Disease Study 2010 (GBD 2010)5 identified MNS disorders as significant causes of the world's disease burden. We use GBD 2010 data to investigate trends in the burden due to MNS disorders. Between 1990 and 2010, absolute disability-adjusted life-years (DALYs) due to MNS disorders rose by 41%, from 182 million DALYs to 258 million DALYs (the proportion of global disease burden increased from 7·3% to 10·4%). With the exception of substance use disorders, which increased in

What works? Effective interventions for the prevention and treatment of MNS disorders

The evidence on interventions builds on the recommendations of the second edition of Disease Control Priorities (DCP-2)17, 18, 19 and is derived from several sources: the mhGAP guidelines developed by WHO for use in non-specialist health settings, which reviewed the literature published up to 2009 using the Grading of Recommendations Assessment, Development and Evaluation (GRADE);20 other recent reviews where appropriate (eg, Strang and colleagues [2012]21 for illicit drugs); interventions that

How to deliver effective interventions?

The implementation of evidence-based interventions for MNS disorders seldom occurs through the delivery of single vertical interventions. More frequently, these interventions are delivered via so-called platforms—the level of the health or welfare system at which interventions or packages can be most appropriately, effectively, and efficiently delivered. A specific delivery channel (such as a school or a primary health-care centre) can be viewed as the vehicle for delivery of a particular

How much will it cost? Universal health coverage for MNS disorders

For successful and sustainable scale-up of effective interventions and innovative service-delivery strategies (such as task-sharing and collaborative care), decision makers need not only evidence of an intervention's effect on health, but also their costs and cost-effectiveness. Even when this cost-effectiveness evidence is available, the question remains of whether or how an intervention might confer wider economic and social benefits to households or society, such as restored productivity,

How to scale up? Health system barriers and opportunities

Despite the evidence summarised in the preceding sections, most low-income and middle-income countries are taking relatively little action to address the health care and other needs of people with MNS disorders. Perhaps the most important reason for this failure to act is the overall poor political commitment to MNS disorders, as evident from the fact that less than 1% of the health budget in most low-income and middle-income countries is allocated to mental health.40 Similarly, despite the

Time to act, now

MNS disorders account for a substantial proportion of the global disease burden. This burden has increased dramatically since 1990 and is expected to rise in line with the epidemiological transition from infectious disease to non-communicable disease, with demographic transition in low-income and middle-income countries, and with the increase in the prevalence of several social determinants associated with these disorders. New analyses presented here suggest that the mortality-associated

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