Introduction & Global Burden of Mental Disease
Mental health: a state of well-being in which every individual realizes their own potential, can cope with the
normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community
- This state is disrupted in ⅓ individuals during their lifetime
- Despite the incidence, policy makers still fail to recognize the severity of the social,
economic, and human impact mental illness represents
- Consequently, people with mental illness are often neglected and faced with stigma as well as
discrimination
Mental disorders are a major drive of the growth of overall morbidity and disability globally. Five types of mental
illness are in the top 20 causes of global burden of disease:
- Major depression
- Anxiety disorders
- Schizophrenia
- Dysthymia
- Bipolar disorder
Importance of the global burden of disease (GBD):
- Projecting trends into the future
- Guides policy decisions and helps priority setting
- It goes beyond the standard measurements of health and quantifies what keeps us from living long, healthy
lives
DALYs (disability-adjusted life-years): years lost due to death and disability
- Allows direct comparison of burden across diseases
- ⅔ DALYs caused by depressive, anxiety and drug/alcohol use disorders
- Nonetheless, DALYs underestimate the true burden → 93% is non-fatal
- YLDs: years lived with disability
- Mental and Substance Use Disorders is a group of condition with the largest disability burden
(18.7% of global YLDs)
- True share of Global DALYs: 13%
- True share of Global YLDs: 32.4%
The global burden of mental illness is underestimated due to the following reasons:
1. Overlap between psychiatric and neurological disorders
- Neuroanatomical or neurophysiological basis → neurological disorder; otherwise → psychiatric
2. The grouping of suicide and self-harm as a seperate category outside the boundary of mental illness
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, - In 2013, mental illness accounted for 21.2% of years of healthy life lost due to disability (YLD).
However, using the composite measure disability-adjusted life-years (DALYs; years lost due to
death and disability), the burden of mental illness dropped to 7·1%
- This gap is explained by the fact that DALYs underestimate mental illness mortality due to
suicide. Suicide and all forms of self-harm, which are mainly imputable to mental disorders, are
coded under injuries and are excluded from calculations of the effect of mental illnesses
3. Conflation of all chronic pain syndromes with musculoskeletal disorders
- Musculoskeletal disorders include (1) anatomically based disorders and (2) syndromes and
symptoms characterized by pain with no specific anatomical correlations
- However, a substantial proportion of these disorders should be classified as either chronic pain
syndrome or somatoform disorder
- Moreover, the prevalence of these pain disorders in patients with a major affective, anxiety, or
stress-related disorder exceeds 30%, going up to 80% in certain samples when including PTSD
4. Exclusion of personality disorders from disease burden calculations
- Prevalence: 4 - 15%
- People with personality disorders have a shorter life expectancy and higher comorbidity with
other general and mental illnesses
- Due to the inconsistent quality of evidence, personality disorders were excluded from the GBD
2013 estimates within the mental illness category
- Another portion might be captured under the musculoskeletal aggregation since 30% of people
diagnosed with chronic pain also have personality disorders
5. Inadequate consideration of the contribution of severe mental illness to mortality from associated causes
- People with severe mental illness have up to 60% higher chances of dying prematurely from
non-communicable diseases that are neglected due to the underlying mental condition
- It has been estimated that around 8 million deaths each year are attributable to mental disorders
- However, the GBD estimates only show deaths directly attributable to mental disorders
(i.e., those recorded in death certificates)
- Increased mortality due to general conditions is challenging
- The GDB methodology is based on attributing mortality to a single disease rather than
investigating the partial impact of co-occurring disorders on years of life lost
Revising DALYs estimates for mental illness is required
1. Specific neurological symptoms should be aggregated within the overall mental illness category, resulting
in mental illness ranking from 5th to 3rd place in GBD
2. All DALYs related to self-harm should be reallocated from injuries to mental health
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, 3. A proportion of the burden due to chronic pain syndromes should be aggregated to mental rather than
musculoskeletal disorders
a. It has been estimated that one-third of the burden of these pain syndromes is potentially
attributable to mental disorders
Criteria of abnormality:
- Personal distress
- Deviance from cultural norms
- Statistical infrequency
- Impaired social functioning
Harmful dysfunction theory (Wakefield): disorders are seen as harmful dysfunctions hence taking into account
both scientific and social values in the contexts in which the behavior occurs
- Dysfunction: the failure of a mechanism to perform a natural function for which it was designed by
evolution
Mental disorder: clinically significant disturbance in “cognition, emotion regulation, or behavior” that indicates
dysfunction in mental functioning, that is, usually associated with significant distress or disability in work,
relationships, or other areas of functioning
- Important to note that the DSM has been outlined reflecting a medical model of psychopathology in
which each disorder is a categorically defined entity featuring a list of specific symptoms
Diagnostic labels are important in several ways:
- The presence or absence of a label for a particular condition/experience impacts the attention it receives
from clinical psychologists
- For clients, the presence of a label and diagnostic criteria may have beneficial consequences
- E.g., identify and demystify an otherwise nameless experience + get access to treatment
Nevertheless, it is essential to notice that the consequences of labeling could also be harmful by carrying a stigma,
leading to stereotyping or having effects on legal issues.
History of the DSM:
- 400 BCE: Hippocrates was the first to associate natural causes with psychopathology
- 19th century: The first mental institutions were established with the objective of treatment instead of
imprisonment and abuse. Also, the first terminology started to be developed to organize patients into
categories (e.g., melancholia, dementia, and mania)
- Around 1900: E. Kraepelin began using more specific labels such as “manic-depressive psychosis,”
contributing to being recognized as the founding father of the current diagnostic system
- A significant influence on the outline of the current DSM was given by the military categorization system
The characteristics of DSM-I (1952) and DSM-II (1968):
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, - They only contained three broad categories of disorders: psychoses, neuroses, character disorders
- The language reflected the predominance of the psychoanalytic approach of the time
- Descriptions of clinical conditions were vague
- The diagnostic categories had limited generalizability and offered little practical utility
DSM-III (1980) had a different approach to definition mental disorders
- More reliance on empirical data
- Use of specific diagnostic criteria to define disorders
- Dropped allegiance to any particular theory of therapy/psychopathology
- Introduction of the multiaxial assessment system, which allowed describing psychiatric problems on each
of five distinct axes:
- Axis 1: Episodic Disorders
- Axis 2: Stable and Long-Lasting Disorders
- Axis 3 & 4: Medical Conditions and Psychosocial/Environmental Problems
- Axis 5: Global Assessment Functioning, which provided an opportunity to place the client on a
100-point continuum describing the overall level of functioning.
DSM-5 (2013) shifted from using roman numbers to Arabic numbers as a way to allow for more frequent and
smaller changes (e.g., using denomination 5.2) which indicated that the manual is ever-changing
- This is also demonstrated by the addition of the “Emerging Measures and Models” section, which
prompts researchers and clinicians to consider conditions that have not yet been officially included but
may eventually be included in future editions
- Moreover, the multiaxial assessment system was officially dropped
- Finally, it introduced a number of new disorders:
- Premenstrual dysphoric disorder (PMDD)
- Disruptive mood dysregulation disorder (DMDD)
- Binge eating disorder (BED)
- Mild neurocognitive disorder (mild NCD)
- Somatic symptom disorder (SSD)
- Hoarding disorder
Revisiting disorders in DSM-5:
- Bereavement for the death of a loved one excluded from a major depressive episode
- Developmental disorders such as autistic disorder, Asperger’s, and related ones were combined into
autism spectrum disorder to enhance its continuum nature
- The number of symptoms required for adult diagnosis of ADHD was specified as 5 as opposed to 6 for
kids (7 - 12 y/o)
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