Largest Multi-National Mental Health Survey Shows Treatment Of Mentally Ill Woefully Inadequate

Harvard Medical School
Tuesday, 1 June 2004

The largest multi-national mental health survey of its kind ever undertaken has found that the challenge of treating those most severely affected by mental disorders is largely unmet. The study, developed by the WHO World Mental Health Consortium, appears in the June 2 Journal of the American Medical Association.

"The level of impairment we found to be associated with serious mental disorders was staggering," said Ronald Kessler, Harvard Medical School professor of health care policy and principal investigator of the consortium. The report found that between one and four percent of the population in most countries met the criteria for a serious mental disorder, and these patients typically reported being unable to carry out their normal daily activities because of these disorders for more than a month during the past year. "There are very few physical illnesses that have impairments as great as these," said Kessler.

The consortium surveyed over 60,000 adults from 14 countries across Europe, the Americas, Africa, Asia, and the Middle East. Interviewees were queried to assess if, during the previous 12 months, they had or were treated for a variety of mental disorders, including anxiety disorders (such as posttraumatic stress disorder and obsessive-compulsive disorders), mood disorders (such as bipolar disorders and depressions), impulse control disorders (such as bulimia) and substance abuse disorders.

The consortium also found that the proportion of mentally ill people who receive treatment is woefully inadequate throughout the world. This was even true of those with the most severe illnesses. Between 35 and 85 percent of these respondents received no treatment during the previous year, even though they were so debilitated that they lost the ability to function for between 30 to 80 days over the same time period. In the US, about 48 percent of those with serious mental illness received no treatment. In less developed countries percentages were higher.

The survey found that the substantial number of respondents with less serious emotional problems, although having a much lower probability of treatment than people with serious disorders, made up a large fraction of treated cases in all countries. "This means that reallocation of treatment resources could go a long way towards resolving the problem of unmet need for treatment of serious mental disorders," Kessler said.

But the consortium recognizes that shifting the balance of treatment to those who need it most may be easier said than done. "The practical complexities of reallocating resources are many and varied," commented Kessler. In the US, for example, with its decentralized health system, it is not readily apparent how one could divert resources from middle class patients with mild disorders to poorer patients with more serious illness. In other countries reallocation may be easier. A recent study by Kessler and colleagues showed that in Ontario, where the ability to pay is less of a constraint than in the US, a higher proportion of patients with serious mental illness are treated, while in the US a higher proportion of mild cases are treated.

But is reallocation alone the answer? "There is no guarantee that reallocating resources away from mild cases would solve the problem of unmet need for treatment among serious cases," said Kessler. This is true for a variety of reasons. Serious cases often require more intensive treatment, so resources for ten mild cases may be needed to help one patient with a serious disorder. In addition, treating mild cases can sometimes be more cost-effective, particularly if it prevents progression to a more severe disorder. "Wholesale reallocation of resources is not an answer," suggested Kessler. "Instead, we need more careful consideration of long-term cost-effectiveness of alternative treatment methods and treatment targets."

The World Mental Health survey is ongoing in a total of 28 countries and when completed will have questioned nearly a quarter of a million people.

The study was funded by several organizations: Eli Lilly and Company; European Commission; GlaxoSmithKline; Instituto de Salud Carlos III, Spain; Japan Ministry of Health, Labour, and Welfare; John D. and Catherine T. MacArthur Foundation; John W. Alden Trust; Lebanese Ministry of Health; Mexican Institute of Psychiatry; Ministry of Social Protection, Colombia; Pan American Health Organization; Pfizer Foundation; Robert Wood Johnson Foundation; U.S. National Institute of Mental Health; U.S. National Institute on Drug Abuse; World Health Organization.

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