Final Report On The Burden of Disease PIH Sites

Burden of Disease Attributable to
Mental Illness in
Partners In Health Sites
2017
Table of Contents
Background ................................................................................................................................................... 1
Haiti’s Burden of Mental Illness .................................................................................................................. 15
Rwanda’s Burden of Mental Illness ............................................................................................................ 20
Lesotho’s Burden of Mental Illness............................................................................................................. 25
Malawi’s Burden of Mental Illness.............................................................................................................. 30
Liberia’s Burden of Mental Illness............................................................................................................... 35
Sierra Leone’s Burden of Mental Illness ..................................................................................................... 40
Peru’s Burden of Mental Illness .................................................................................................................. 45
Chiapas’ Burden of Mental Illness .............................................................................................................. 50
Navajo Nation and Rosebud Burden of Mental Illness ............................................................................... 55
Russia’s Burden of Mental Illness ............................................................................................................... 58
Cross-site Trends of Burden of Mental Illness ............................................................................................ 63
References .................................................................................................................................................. 65
Background
Partners In Health
Partners In Health (PIH) is a global non-profit organization that works across ten countries (Lesotho,
Malawi, Sierra Leone, Liberia, Rwanda, Haiti, Mexico, Peru, Russia and Rosebud, South Dakota and
Navajo Nation, New Mexico in the United States) to provide preferential healthcare options for the
poor. PIH works in close partnership with in-country government officials and leading medical and
academic institutions to build local capacity and to strengthen health systems[1].
Since its foundation in
1987, PIH has worked
in Haiti where it is
known as Zanmi
Lasante (ZL) [2]. Over
the past three
decades, PIH has
grown to have a large
presence in Haiti and
across the globe,
working with local
governments to
provide a variety of
health care services
and support for health
care workers
PIH is currently involved with many programs and services worldwide. Below is a snapshot
of a few of them:
In Haiti, ZL provides comprehensive health In Rwanda, PIH/Inshuti Mu Buzima (IMB)

care services to a catchment area of 1.3 has launched a Cancer Center of Excellence
million people[2]. and the University of Global Health Equity
(UGHE)[3]
1
In Lesotho PIH/Bo-Mphato Litšebeletsong In Malawi, PIH/Abwenzi Pa Za Umoyo (APZU)
tsa Bophelo provides a program for multi- works in the rural district of Neno and has
drug-resistant tuberculosis (MDR-TB) worked with the public health system to
treatment, a maternal mortality reduction provide comprehensive health care and other
program, and comprehensive primary health services [6].
care coverage [4], [5].
Since PIH’s response to Ebola in Liberia, the In Sierra Leone, PIH supports health
program has become involved in system strengthening, provides services
strengthening health systems across three for Ebola survivors and more [8].
counties[7].
2
In Mexico, PIH/Companeros En Salud In Peru, PIH/Socios En Salud (SES) works
(CES) works in Chiapas to provide: to prevent and treat MDR-TB and HIV as
mentorship to pasantes (first year well as host of other health care services[10].
physicians), management for acompanantes
(community health workers) and support to
patients seeking complex care[9].
In Russia, PIH/Партнеры во имя здоровья

has worked to combat substance abuse and to
improve diagnostic testing and infection control Tim Sanders, of Timothy Sanders Design for Social Good. Map was
procedures for MDR-TB [12]. produced for the 2015 COPE annual report (created in 2016)
As Community Outreach and Patient

Empowerment (COPE), PIH works with the
Navajo Nation, New Mexico and the
Sicangu Lakota Nation/Rosebud Sioux
Tribe, South Dakota to support community
health workers and to improve access to
nutritious foods[11].
A map of the Sicangu Lakota Nation is unavailable at this
time.
.
PIH has many more activities globally, for more information please visit: http://www.pih.org/countries
3
Global Mental Health
The World Health Organization (WHO) defines mental health as a “state of well-being in which every
individual realizes his or her own potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to her or his community” [3]. One out of
three individuals will have an absence of this ideal state of mental health during their lifetime [4].
Predictions estimate that by 2030, depression alone will be the leading cause of disease
worldwide[5]. Mental disorders are often chronically disabling diseases, which make large
contribution to mortality and morbidity.
Moreover, mental health co-morbidity has substantially negative effect on other health outcomes. [6].
For example, among mothers, depressive symptoms are associated with preeclampsia, preterm
birth, intrauterine growth retardation and low birthweight in infants[7]. Psychiatric diagnoses are
more common in HIV patient groups and this comorbidity is associated with poor ART adherence
and mental illness is also associated with poor adherence to TB treatment[8], [9]. Additionally,
mothers with psychological distress exclusively breastfeed for a short duration although exclusive
breastfeeding is the safest and most effective intervention to reduce infant mortality and
morbidity[10].
Despite the large impact that mental health has on public health, the treatment gap for mental
disorders remains large[5]. In low and middle income countries, between 76% - 85% of people with
severe mental disorders do not receive treatment[5]. In efforts to address the treatment gap, PIH is
working in all its sites to develop, implement and scale–up mental health services integrated into
primary care and to encourage their governments to increase investment in mental health.
PIH’s Mental Health Program

PIH’s Mental Health Program supports mental health service integration across all ten of PIH’s sites
to help close the mental health treatment gap. The program focuses on the provision of safe,
effective, and culturally sound mental health care services and the strengthening of mental health
systems [11].
Before officially establishing the program, PIH provided mental health services in Haiti to patients
living with HIV/AIDS and tuberculosis and in Peru and Russia to MDR-TB patients. The mental
health program was launched in 2010 during the aftermath of Haiti’s devastating earthquake. PIH
has now begun to establish mental health programs across all other PIH sites and expanded their
mental health services. While there is a shared vision of service delivery in the PIH Cross-site
Mental Health Program, each site is uniquely situated and has its own goals and priority areas within
mental health.
4
Below is a snapshot of some of the mental health services provided in each site:
Mental Health in Haiti: After the 2010 earthquake, in response to Haiti’s Ministere de la Sante
Publique et de la Population (MSPP)’s
request, PIH/Zanmi Lasante (ZL)
established a mental health program
that would address the emergency
mental health needs in Haiti. With
funding from Grand Challenges Canada,
ZL established a community based
mental health model [12]. This model
was useful not only to provide
emergency mental health care to
individuals during the crises, but also to
develop a strengthened mental health
system for the long term. The program’s
strategy is to decentralize services by
integrating mental health services into Père Eddy (far right) speaks with Paul Mainardi (far left) in Mirebalais, Haiti,
on Jan. 14, 2014. Mainardi now lives a full life following treatment for his
primary care through a task-shifting mental illness.
model. This ensures that non-specialist (Photo by Rebecca E. Rollins / Partners In Health)
healthcare workers including
physicians, psychologist, social workers, nurses and community health workers are trained to deliver
mental health care services. ZL has developed training curricula and treatment packages for
prevalent disorders including depression, epilepsy, psychotic disorders and child/adolescent mental
health (CAMH). The program has now been implemented in 11 clinics and hospitals across Haiti.
Sustained supervision, continuous training, job aids and a data collection system among other
initiatives have contributed to the successes and sustainability of the program.
Mental Health in Rwanda: In 2009, PIH/Inshuti Mu Buzima worked closely with Rwanda’s Ministry
of Health’s (MOH) to establish the Mentoring and Enhanced Supervision at Health Centers for
Mental Health (MESH MH) program. The program involves decentralizing mental healthcare
services by upscaling the capacity of
frontline health workers to deliver
mental health care. MESH MH
adapts the WHO’s clinical mentoring
guidelines for task shifting of HIV
care for the provision of mental
health care. The program involves
primary care psychiatric nurses who
mentor general nurses and
community health workers who are
trained by nurses on case finding,
treatment adherence,
psychoeducation and stigma
reduction [13], [14]. The program
Hildegarde Mukasakindi (left) and Sifa Dorcas (right) of the mental health visit also focuses on continuous
with Olivier Kayitsinga and his mother, Zipola Kandirima, at home in Burera supervision in order to ensure
District, Rwanda on March 17, 2017.
(Photo by Cecille Joan Avila / Partners In Health) quality care. The MESH MH
5
program focuses on upscaling capacity for care for four major neuropsychiatric disorders:
schizophrenia, bipolar disorder, major depressive disorder and epilepsy. IMB has adopted WHO’s
Problem Management Plus (PM+), a psychological intervention used to treat depression, anxiety
and stress[15]. The MESH MH model has been implemented in all 19 IMB health centers[13].
Mental health in Lesotho: PIH Lesotho recently started an early childhood intervention program
which includes screening mothers for maternal depression. In addition, PIH Lesotho is beginning to
engage the clinical team to find cases of mental illness and are developing a work plan to pilot
community-based mental health program
in the district hospital at Mohale’s Hoek. In
response to a large population of children
who have been orphaned due to the high
prevalence of HIV/AIDs and TB in
Lesotho, PIH Lesotho plans to provide
child and adolescent mental health
(CAMH) services in conjunction with other
services for orphan and vulnerable
children. The program will also include
integration of mental health care into
primary care treatment for TB and HIV in
the future.
Mental Health in Malawi: In 2015, Lesotho
PIH/Abwenzi Pa Za Umoyo (APZU)
established a mental health program modeled after a three-pronged approach to build capacity
among staff for identifying and treating mental illness, to improve mental health care throughout
Neno’s health care system and to integrate mental health treatment into the broader scope of
treatment for chronic diseases. APZU’s strategy is to upscale a system whereby a core package of
treatment provided by non-specialists is integrated into primary health care. This strategy was
adapted from Rwanda’s MESH MH model.
Mental Health in Liberia: In 2015, PIH Liberia (PIHL) began its mental health program in the J.J
Dossen hospital and in community settings, and is now based out of Maryland County. PIHL
clinicians are trained using the WHO mhGAP (WHO Mental Health Gap Action Programme) in order
to accurately screen and diagnose patients for mental disorders. These clinicians work with
government clinicians to deliver mental health treatment for epilepsy, psychosis and depression. The
PIHL clinicians also provide refresher courses to government mental health clinicians in order to
strengthen provider skills and to support integration of mental health services into primary health
care. PIHL has publicized mental health issues via radio and has established a mental health referral
system. PIHL’s mental health team has also performed a needs assessment and provided care for
homeless people suffering from mental illness [16]. In addition, PIHL has also trained correctional
officers to manage their own mental health needs and to identify inmates who need mental health
care.
6
Mental Health in Sierra Leone: PIH
Sierra Leone is working to integrate
mental health care into Ebola survivor
care and other general health services
provided. The program plans to work with
social workers and community health
workers to integrate mental health care in
both community and hospital settings.
Mental Health in Peru: PIH/Socios En

Salud (SES) expanded its mental health
services from exclusively MDR-TB
patients to include people living with
chronic mental illness who needed Sierra Leone
shelter. Starting in 2015, Peru’s MOH

recruited SES to establish safe houses in efforts to decentralize mental health care services.
Thereby supplementing services already provided in primary care clinics, community clinics, and
outpatient community health centers [17]. SES has established a safe house for women in
Carabayllo and is embarking on establishing a safe house for men[17]. SES is working on a scale-up
plan to meet the demand for more houses, as well as support the Ministry in their roll out of the
program. Furthermore, SES will adapt the World Health Organization’s Thinking Healthy
intervention, which is a manual for psychological management of perinatal depression, as part of a
new Grand Challenges Canada “Casita” grant focusing on maternal and child health [18].
Mental Health in Mexico: To curb
unmet need for mental health care,
PIH/ Companeros En Salud (CES)
trains physicians and community
health workers to diagnose and treat
common mental illnesses [19]. The
program works to address issues such
as domestic violence and substance
use disorders and provides early
childhood interventions. Patients are
identified in the primary health care
setting through case finding and
screening using the Patient Health
Questionnaire (PHQ-9). A clinician at
CES is being trained in Community Health Workers Elma Clara Salas Roblero, Celmira López López
and Ernestina López Pérez attend a Mental Health training with Dr. Fátima
psychopharmacology and on Rodríguez in Chiapas, Mexico, on March 21, 2017.
diagnosing and treating mental (Photo by Mary Schaad / Partners In Health)
disorders.
Mental Health in Navajo Nation and Rosebud: The emerging COPE mental health program plans
to train local health care workers to find cases and to treat mental disorders. Given the rising rates of
suicide, depression, domestic violence, teenage pregnancy and drug abuse in the community,
COPE plans to take a life course approach to address these issues from both a mental health and
psychosocial perspective. COPE also hopes to integrate staff mental health care and traditional
healing into its practice.
7
Mental Health in Russia: PIH began
its work in mental health in Russia by
offering psychosocial support to TB
patients. Along with the high
prevalence of TB, rates of drug abuse
have risen rapidly. Many TB patients
having co-morbid alcohol and
substance use disorders and there is
an increased rate of HIV transmission
due to synthetic injected drug use.
Moving forward, the mental health
program will include a focus on harm
reduction, utilize adapted mental Russia
health materials from other sites and
implement a decentralized task-shifting model with care provided largely by non-specialists.
Assessment of the Burden of Mental Illness in PIH Partner Countries

In September 2016, the Partners in Health Cross-site Mental Health team hosted a three-day
meeting to bring together 120 attendants including representation from all 10 PIH sites and partner
institutions to foster the development and implementation of mental health services across the sites.
A core component of the meeting was presenting information on the burden of mental illness for all
PIH sites. This information is essential for discussion of priority conditions, appropriate platforms of
care and service models, and estimating necessary staffing, but is usually not well measured and is
often not available to implementers in the field.
The PIH Mental Health Program worked with Dr. Daniel Vigo from Harvard T. Chan School of Public
Health to use data from the Global Burden of Disease (GBD) Study to estimate the burden of mental
illness in Haiti, Rwanda, Lesotho, Malawi, Liberia, Sierra Leone, Peru, Mexico, Russia and the
United States. The GBD study was established in 1990 to measure the amount that each disease
contributes to the overall disease burden on a global or national scale [20]. For COPE sites (Navajo
Nation and Rosebud), the burden of mental illness was obtained from the Beals et al 2005 study
which used estimates of the Native American Southwest Tribes (including Navajo Nation) and
Northeastern Tribes (including Sicangu Lakota Nation). Results from the Beals et al study focus on
the mental illness burden unlike the GBD which includes the overall burden of disease.
Aims of Report
The objectives of this report include:
 To share burden of mental illness data in PIH sites with PIH colleagues and staff, the
ministries of health in PIH sites and other stakeholders involved in the implementation of
mental health services in these countries who were not at the September 2016 meetings
 To provide a comparison of the burden of disease attributable to mental illness across PIH
sites
 To provide useful information for assessing resource needs and for making data informed
decisions on actions to address mental health in these contexts
8
Data and Graphs in this Report
The data used in this report is from the 2015 GBD Study and will be updated in the future to reflect
any updates to available GBD data[21].
Traditionally, the burden of disease caused by self-harm including suicide, neuropsychiatric
syndromes and chronic pain syndrome are not included within the burden of disease attributable to
mental disorders in the GBD data set [4]. The data presented in this report include Vigo’s
adjustments, which include these diseases in an attempt to represent a thorough picture of the
mental health burden of disease in each country. For further description of the methods, please see
Vigo’s “Estimating the True Global Burden of Mental Illness” in Lancet Psychiatry [4].
Like in the GBD Study, the results of Vigo’s analyses are presented in measurements of disability
adjusted life years (DALYS) and years of life lived with disability (YLDs).
 Disability Adjusted Life Years (DALYs) are the number of years an individual loses due to
premature death from the disease added to the amount of years an individual lives with
disability due to the disease or mortality attributable to a disease [22]
 Years of Life Lived with Disability (YLDs) are the number of years an individual lives with
less than optimal health due to disease or morbidity attributable to a disease [22]
For more information on the GBD: http://www.healthdata.org/gbd
The results are presented in graphs, which offer visuals of the contribution disease categories make
to a country’s burden of disease.
The disease categories are:
 Non-Communicable diseases (NCDs) include cardiovascular disease, neoplasms, chronic

respiratory illness, mental illness, neurological diseases, diabetes and others [23]
 Communicable/infectious diseases, maternal, child, nutritional diseases which include
HIV/AIDS, tuberculosis, iron deficiency anemia and malaria [23]
 Injuries includes unintentional injuries, injuries due to transport, interpersonal violence,
forces of nature and war [23]
 Mental disorders include depressive disorders, anxiety disorders, drug use disorders,
migraine, chronic pain syndromes, self-harm, epilepsy, Alzheimer disease and other
dementias, schizophrenia, alcohol use disorders, bipolar disorder, conduct disorders, autistic
spectrum disorders, eating disorders, tension-type headache, idiopathic intellectual disability,
attention-deficit/hyperactivity disorder and other mental and substance use disorders [23]
9
Below is a description of graphs used throughout this report to visualize the burden of
disease in PIH’s sites (does not apply to COPE sites which are presented with different
methods):
Graph 1: Disease Burden Composition by DALYs including Mental Illness

Depicts each disease category’s
contribution to the nation’s DALY’s,
with mental illness disaggregated
from other non-communicable
diseases. It is useful to disaggregate
mental illness as a category in order
to assess the significance of its
contribution to NCD DALYs and total
DALYs. Additionally, self-harm is
disaggregated from the injuries
category and the proportion of
DALYs attributable to self-harm was incorporated into mental illness DALYs.
Graph 2: Disease Burden Composition by YLDs including Mental Illness

Depicts each disease category’s
contribution to the nation’s YLD’s.
Mental illness is disaggregated from
other non-communicable diseases.
Similar to the use of disaggregating
mental illness DALYS in Graph 3,
disaggregating mental illness YLDs
helps assess the burden that mental
illness causes in terms of its
contribution to morbidity. Additionally,
self-harm is disaggregated from the
injuries category and the proportion of YLDs attributable to self-harm was incorporated into mental
illness YLDs.
10
Graph 3: Nation’s Total DALYs with a Focus on NCDs
Depicts the contributions of disease categories to national DALYs with a focus on the contributions
of different NCDs including musculoskeletal disorders, cirrhosis, cardiovascular diseases. Special
emphasis is placed on mental and substance use disorders and the percentage contribution to
national NCDs are highlighted. The graph allows for analysis of trends by age group. This is
important because the impact of diseases may have vary across the life span.
11
Graph 4: Nation’s Total YLDs with a Focus on NCDs
Depicts the contributions of disease categories to national YLDs with a focus on the contributions of
different NCDs including musculoskeletal disorders, cirrhosis, cardiovascular diseases. Special
emphasis is placed on mental and substance use disorders and the percentage contribution to
national NCDs are highlighted. The graph allows for analysis of trends by age group. This is
important because the impact of diseases may have vary across the life span.
12
Graph 5: Nation’s Burden of Mental Disorders- DALYs
Illustrates contribution of specified mental disorders to national mental illness DALYs across
lifespan.
13
Graph 6: Ranking of Mental Disorder % MH DALYs Cumulative covera
disorders by their contributions to Depressive disorders 21.6 2
mental health DALYs. Anxiety disorders 13.7 3
Drug use disorders 8.5 4
Illustrates the percentage contribution Migraine 8.4 5
(from largest to least) that specified Chronic pain syndromes 6.9 5
mental disorders contribute to mental Self-harm 6.5 6
Epilepsy 5.5 7
health DALYs.
Alzheimer disease and other dementias 5.3 7
Schizophrenia 4.2 8
Alcohol use disorders 4.0 8
Bipolar disorder 3.7 8
Conduct disorder 3.5 9
Autistic spectrum disorders 3.1 9
Other mental and substance use disorders 2.8 9
Eating disorders 0.8 9
Tension-type headache 0.8 9
Idiopathic intellectual disability 0.5 9
Attention-deficit/hyperactivity disorder 0.3 10
Graph 7: Ranking of Mental

disorders by their contributions to
mental health YLDs.
Illustrates the percentage
contribution (from largest to least)
that specified mental disorders
contribute to mental health YLDs.
14
Haiti’s Burden of Mental Illness
Context in Brief: Haiti is an island in the Caribbean Sea with 10.7 million people [24]. Haiti is the
first black republic and has struggled with foreign exploitation, political conflict, environmental
degradation and natural disaster [25]. In 2010, the island was hit with a destructive earthquake which
killed about 220,000 and displaced 1.5 million people [25]. The aftermath of the earthquake was
compounded by a deadly Cholera outbreak. The majority of Haiti’s population (59%) lives below the
national poverty line, life expectancy is low at 63 years of age and the under 5-mortality ratio is
troublingly high at 73 deaths per 1,000 births [2].
Burden of Disease:
The point prevalence of mental illness in Haiti is 16.04%.
Graph 1: Disease Burden Composition: DALYs including Mental Illness DALYs
Graph 1 shows that
mental illness
accounts for 9% of
total DALYs and
injuries (excluding
self-harm) also
account for 9% of
DALYs. Infectious
diseases, maternal
and child and
nutritional diseases
are the leading
cause of disability in Haiti, comprising 48% of DALYs. With a similarly large burden, NCDs
(excluding mental illness) contribute to 33% of DALYs.
Graph 2: Disease Burden Composition: YLDs including Mental Illness YLDs
Graph 2 shows that

mental illness as a
single NCD
category contributes
a similar amount of
YLDs (31%) as the
total of other NCDs
(38%). Infectious
disease, maternal
and child and
nutritional diseases
contributes to 20%
of YLDs and injuries contributes to 10% of YLDs. Mental illness YLDs account for more YLDs than
injuries (10%) and infectious, maternal and child and nutritional diseases (20%) and both categories
combined.
Haiti 15
Graph 3: Haiti Total DALYs: Focus on NCDs
Graph 3 shows that excluding early infancy, mental and substance abuse disorders contribute to
DALYs throughout life course. The age groups most affected are late adolescence, young adulthood
and middle age. Mental and substance use disorders increasingly contribute to DALYs with age and
decrease in late adulthood. Communicable diseases, maternal, neonatal and nutritional diseases are
the biggest contributors to total DALYs and they affect young and middle aged groups the most.
Cardiovascular diseases contribute largely to DALYs in adulthood and injuries contribute to DALYs
throughout life course.
Haiti 16
Graph 4: Haiti Total YLDs: Focus on NCDs
Graph 4 shows that from childhood to middle age, mental and substance abuse disorders contribute
more to YLDs than any other category of disease. In teenage years and early adulthood, mental and
substance use disorders are the biggest contributors to YLDs, contributing as much as 46%. These
disorders contribute less YLDs with age, but do not contribute less than 18%. In childhood,
communicable diseases, maternal, neonatal and infectious diseases are the predominant cause of
YLDs among children. With increasing age, non-communicable disease become the largest
contributor to YLDs.
Haiti 17
Graph 5: Haiti’s Burden of Mental Disorders: Mental Health DALYs
During infancy, drug use disorders are the leading cause of mental health DALYs. This is due to
drug use of mothers during pregnancy as demonstrated by an increase in DALYs due to substance
use disorders in childbearing age. Among infants and young children, epilepsy, autistic spectrum
disorder and conduct disorders are substantial contributors to DALYs. Depressive disorders and
anxiety disorders are major contributors to mental health DALYs across all age groups except
infancy and depressive disorders are the leading contributors to DALYs throughout life course. In old
age, Alzheimer disease and other dementias take over from depressive disorders as the largest
single contributor to mental health DALYs. DALYs associated with self-harm, bipolar disorder and
schizophrenia are largest between adolescence and middle age. Chronic pain syndrome and alcohol
use disorder contribute increasingly to mental health DALYs with age and peaks at ages 50-69.
Migraine contributes to mental health DALY in every age group except children less than 4 years.
Haiti 18
Graph 6: Ranking Mental Disorders- DALYs Graph 7: Ranking Mental Disorders- YLDs
Disorder Disorder coverage
% MH DALYs Cumulative % MH YLDs Cumulative coverage
Depressive disorders 21.6 Depressive disorders
21.6 26.8 26.8
Anxiety disorders 13.7 Anxiety disorders35.3 17.1 43.9
Drug use disorders 8.5 Migraine 43.8 10.4 54.3
Migraine 8.4 Chronic pain syndromes
52.2 8.5 62.9
Chronic pain syndromes 6.9 Drug use disorders
59.1 5.5 68.3
Self-harm 6.5 Schizophrenia 65.6 5.1 73.4
Epilepsy 5.5 Bipolar disorder 71.1 4.6 78.0
Alzheimer disease and other dementias 5.3 Conduct disorder
76.4 4.4 82.4
Schizophrenia 4.2 Autistic spectrum80.5disorders 3.8 86.2
Alcohol use disorders 4.0 Other mental and 84.5substance use disorders 3.5 89.7
Bipolar disorder 3.7 Epilepsy 88.2 3.1 92.8
Conduct disorder 3.5 Alcohol use disorders
91.7 2.1 94.9
Autistic spectrum disorders 3.1 Alzheimer disease94.7and other dementias 2.0 96.9
Other mental and substance use disorders 2.8 Eating disorders 97.6 1.0 97.9
Eating disorders 0.8 Tension-type headache
98.4 1.0 98.9
Tension-type headache 0.8 Idiopathic intellectual
99.2 disability 0.6 99.6
Idiopathic intellectual disability 0.5 Attention-deficit/hyperactivity
99.7 disorder 0.3 99.9
Attention-deficit/hyperactivity disorder 0.3 Self-harm 100.0 0.1 100.0
Graph 6 shows that the top contributors to mental health DALYs are depressive disorders, anxiety
disorders, drug use disorders and migraine. The largest contributors to mental health YLDs are
depressive disorders, anxiety disorders and migraine.
Summary of Burden of Mental Illness in Haiti: NCDs including mental and substance abuse
disorders make up a large proportion of Haiti’s burden of disease, measured at 9% of total DALYs
and 31% of total YLDs. Depression and anxiety disorders contribute substantially to mental health
DALYs over the majority of life course. Adolescents, young adults and middle-aged adults are the
most affected by mental health disorders in this context.
Haiti 19
Rwanda’s Burden of Mental Illness
Context in Brief: Rwanda is a small landlocked Central African country [26]. The nation was
devastated by the 1994 genocide of Tutsis which killed about 1 million people and displaced millions
[27]. The genocide significantly worsened health status and quality of life, but Rwanda has made
significant progress since the genocide [28]. For example, in the aftermath of the genocide, life
expectancy plunged to below 40 years, now it is above 66 years [29]. Despite progress, Rwanda still
faces challenges to population health. The adult prevalence of HIV is high at 3.0% and 89 out of
100,000 people have tuberculosis [28].
Burden of Disease:
The point prevalence of mental illness in Rwanda is 15.8%.
Graph 1: Disease Burden Composition: DALYs including Mental Illness DALYs
As shown in Graph 1, Mental

illness contributes to 8% of total
DALYs. Infectious, maternal,
child and nutritional diseases are
the leading contributor to DALYs
(59%) and 22% of DALYs are
attributable to NCDs (excluding
mental illness) and 12% are due
to injuries (excluding self-harm).
Graph 2: Disease Burden Composition: YLDs

Graph 2 shows that mental illness
is the 2nd largest contributor to
YLDs (32%).NCDs (excluding
mental illness) account for the
majority of YLDs (33%). Mental
illness YLDs as a single category
of NCDs are almost the same
amount as the combination of
other NCD YLDs. Infectious,
maternal, child and nutritional
YLDs contribute 31% to total YLDs
and injuries contribute to 4%.
Rwanda 20
Graph 3: Rwanda’s Total DALYs - Focus on NCDs
Communicable, maternal, neonatal and nutritional diseases are the dominant cause of DALYs in
early childhood and remain major contributors to DALYs throughout life course. Injuries contribute to
DALYS across lifespan, but most especially in young adulthood and in middle age. Mental and
substance use disorders predominantly affect adolescents and young adults. In late adulthood,
cardiovascular diseases are the largest contributors to DALYs.
Rwanda 21
Graph 4: Rwanda’s Total YLDs: Focus on NCDs
Graph 4 shows a similar trend whereby communicable, maternal, neonatal and nutritional diseases
are the dominant cause of disability among young children. This is because prevalent diseases such
as acute respiratory infection and malnutrition are diseases that many children are vulnerable to and
they contribute largely to YLDs. In adolescence, mental and substance use disorders become the
largest contributor to YLDs, contributing to as much as 47% of YLDs among 20-24 year olds.
Though comparatively less, mental and substance use disorders contribute a substantial amount to
YLDs throughout the rest of life course. In middle age, the leading contributor to YLDs becomes
injuries.
Rwanda 22
Graph 5: Rwanda’s Burden of Mental Disorders: DALYs
In early infancy drug use disorders contribute as much as 90% of DALYs and this arises from
mother’s drug use during pregnancy. In early childhood a large proportion of DALYs are due to
epilepsy. Children have a substantial amount of DALYs due to autistic spectrum disorders, attention-
deficit/hyperactivity disorders, conduct disorders and idiopathic disabilities all of which make
decreased contributions to mental health DALYs with age. Drug and substance abuse disorders,
self-harm and anxiety disorders make substantial contributions to mental health DALYs in young
adulthood and middle age. Chronic pain syndromes contribute largely to mental health DALYs
amongst adults between 45-70 years of age. Depressive disorders are the largest contributors to
mental health DALYs across life course.
Rwanda 23
Graph 6: Ranking Mental Disorders-DALYs Graph 7: Ranking Mental Disorders-YLDs
Disorder % MH Disorder % MH
DALYs YLDs
Depressive disorders 32.4 Depressive disorders 39.4
Anxiety disorders 7.9 Anxiety disorders 9.6
Chronic pain syndrome 7.7 Chronic pain syndrome 9.2
Epilepsy 6.8 Migraine 6.6
Self-harm 6.6 Schizophrenia 4.6
Drug use disorders 5.9 Conduct disorder 4.5
Migraine 5.4 Drug use disorders 4.2
Alcohol use disorders 5.0 Autistic spectrum disorders 4.0
Schizophrenia 3.9 Bipolar disorder 3.9
Conduct disorder 3.7 Alcohol use disorders 3.1
Autistic spectrum disorders 3.3 Other mental disorders 3.1
Bipolar disorder 3.2 Idiopathic intellectual disability 2.8
Other mental disorders 2.5 Epilepsy 2.4
Idiopathic intellectual disability 2.3 Eating disorders 0.9
Alzheimer disease and other dementias 1.7 Tension-type headache 0.7
Eating disorders 0.8 Alzheimer disease and other dementias 0.6
Tension-type headache 0.5 Attention-deficit/hyperactivity disorder 0.3
Attention-deficit/hyperactivity disorder 0.3 Self-harm 0.1
Graph 6 shows that the top contributors to mental health DALYs are depressive disorders, anxiety
disorders, chronic pain syndromes and epilepsy. Graph 7 shows that the top contributors to mental
health YLDs are depressive disorders, anxiety disorders and chronic pain syndromes.
Summary of Burden of Mental Illness in Rwanda: Mental illness and substance use disorders
contribute largely to Rwanda’s burden of disease. They contributes to 8% of DALYs and 32% of
YLDs. Depressive disorders account for the majority of mental health DALYs and YLDs. The age
group with the largest burden due to mental illness are adolescents, young adults and middle age
adults.
Rwanda 24
Lesotho’s Burden of Mental Illness
Context in Brief: Lesotho is a small, landlocked kingdom in Southern Africa with 2 million people.
There is a 23% prevalence of HIV in Lesotho, compared to the average adult HIV prevalence in Sub-
Saharan Africa of 4.7%[30]. Although the number of AIDS-related deaths declined 16% from 2008
(12,000 deaths/years) to 2011 (8,500 deaths/year) and is stabilizing, deaths due to AIDS have
contributed to the high orphan rate[31]. Lesotho also has a high prevalence of tuberculosis (TB) at
671/100,000 [32], [33], compared to the average prevalence of 275/100,000 (including people with
HIV and TB) in Sub-Saharan Africa at large [23].
Overall disease burden distribution for Lesotho:
The point prevalence of mental illness is 20.8%.
Graph 1: Fraction of total disease burden attributable to mental illness for DALYs
Graph 1 shows that mental
illnesses account for 7% of
total DALYs, which is almost
half of the amount of DALYs
the rest of the NCDs (excluding
mental illness) contributes to
total DALYs (15%) [34].
Infectious, maternal, child, and
nutritional related diseases
account for the largest number
of DALYs – 68% and injuries
account for 10% [34].
Graph 2: Fraction of total disease burden attributable to mental illness for YLDs
Graph 2 shows mental illness
contributes to 32% of YLDs.
This is almost equivalent to
YLDs due to infectious,
diseases- 31% and those due
to NCDs (excluding mental
illness)-33% [34]. Injuries
(except self-harm) account for
4% of the burden of disease
[34].
Lesotho 25
Graph 3: Burden of Disease in DALYs by NCD group
Graph 3 shows that the burden of mental Illness and substance use disorders in Lesotho increases
as people age from childhood to adolescence, peaking between ages 15-19 to account for 21% of
the overall DALYs in that age group. As people age from adolescence to adulthood, the burden of
mental illness levels off but still accounts for between 5-16% of the overall burden of illness in
DALYS in adulthood. Communicable, maternal, neonatal and nutritional diseases are the largest
contributors to total DALYs throughout life course.
Lesotho 26
Graph 4: Burden of Disease in YLDs by NCD group
Graph 4 shows that the burden of mental Illness and substance use disorders increases as people
age from childhood to adolescence, peaking between ages 15-24 to account for 47% of the overall
disability (YLDs) in that age group. This is almost as great as the sum of YLDs attributable to all
other NCDs, infectious, maternal, child and nutritional diseases, and injuries. As people age from
early adulthood to old age, the burden of a mental illness in YLDs decreases with time. However,
YLDs attributable to mental illness in adulthood still range from 19% to 40%, still contributing to a
significant portion of YLDs compared to other conditions.
Lesotho 27
Graph 5: Lesotho’s Burden of Mental Disorders- DALYs
Graph 5 shows that during a person’s first year of life, drug use disorders (due to mother’s drug use
during pregnancy) contributes to almost 100% of the burden of mental illness. Almost 50% of the
burden of mental illness in adolescents is attributable to developmental conditions such as autistic
spectrum disorders, attention- deficit/hyperactivity disorder, conduct disorder and idiopathic
intellectual disability [35], [36]. Epilepsy contributes to DALYs throughout life course. Self-harm is a
prominent contributor to DALYs from late adolescence and throughout adulthood, contributing as
much as 40% to DALYS.
Lesotho 28
Graph 6: Ranking mental disorders- DALYs Graph 7: Ranking mental disorders- YLDs
Graph 6 shows that the top contributors to mental health DALYs include self-harm, depressive
disorders and epilepsy.The largest contributors to mental health YLDs include depressive disorders,
anxiety disorders and chronic pain syndrome.
Summary of Burden of Mental Illness in Lesotho: Mental illnesses contribute 7% to total

DALYs and to 32% of total YLDs. Therefore, mental illness and substance use disorders are
large contributors to Lesotho’s burden of disease. The populations most affected are
adolescents and adults. The largest contributors to the mental health disease burden are
depressive orders and self-harm.
Lesotho 29
Malawi’s Burden of Mental Illness
Malawi Background: Malawi is a small East-African country of about 16 million people. The nation
struggles with pervasive poverty and about 72% of its population lives below the national poverty
line. Malawi is one of the countries that was hardest-hit by the HIV/AIDS epidemic, which has
claimed many lives and left more than one million children orphaned. The HIV prevalence remains
high at 10% and the child mortality rate is 64 deaths per 1,000 live births [37].
Burden of Disease: The point prevalence of mental illness in Malawi is 15.03%.

Graph 1 shows that
6% mental illness accounts
17% NCD DALYs (except for 6% of total DALYs.
MI) Infectious, maternal,
5%
child and nutritional
Injuries DALYs (except diseases are the
self-harm) largest contributors to
DALYs (72%). NCD
Infectious, maternal, DALYs (excluding
child, nutritional mental illness) account
72%
DALYs for 17% of DALYs and
injuries account for 5%.

Graph 2 illustrates that mental illness contributes 29% to total YLDs, a substantial proportion. 36% of
YLDs are attributable to other NCDs. Infectious, maternal, child and nutritional diseases contribute
32% to YLDs and
injuries contribute 3%.
NCD-MI YLD
29%
36% Injuries YLDs (except
self-harm)
Infectious, maternal,
child, nutritional YLDs
3… Mental illness YLDs
32%
Malawi 30
Graph 3: Malawi’s Total DALYs with a Focus on NCDss
Mental and substance use disorders begin to contribute substantially to DALYs in childhood and
make large contributions during late adolescence and adulthood. The contribution of mental and
substance use disorders decline with age but remains substantial, contributing about 5-8% to total
DALYs in late adulthood and follow similar patterns to increase in other NCDs such as
cardiovascular disease. Communicable, maternal, neonatal and nutritional diseases contribute to the
majority of DALYs and the age groups most severely affected are children and middle-aged adults.
Malawi 31
Graph 4: Malawi’s Total YLDs with a Focus on NCDs.
Communicable, maternal, neonatal and nutritional diseases are leading contributors to YLDs during
early childhood (0- 9 years). Excluding these years, mental and substance use disorders contribute
large amounts to total YLDs throughout the rest of life course, with the largest effects in adolescence
and adulthood, where they contribute to as much as 45% of YLDs among 20-24 year olds. Although,
less prominently, mental and substance use disorders continue to contribute substantially to total
YLDs throughout life course and contribute to 18-27% of YLDs in late adulthood. Musculoskeletal
disorders and other NCDs contribute to YLDs throughout life course and caridiovascular diseases
contribute most substantially in late adulthood.
Malawi 32
Graphs 5: Malawi’s Burden of Mental Disorders- Mental Health DALYs
Drug use disorders are the largest contributors to mental health DALYs in the first days of life due to
maternal drug use disorders during pregnancy. After the first days of infancy, epilepsy takes over as
the leading contributor to mental health DALYs. Among 5-9 year olds, there is an increase in
contributions to DALYs from migraines, anxiety disorders, autistic spectrum disorders, attention-
deficit/hyperactivity disorders, conduct disorders and idiopathic intellectual disorders. Starting from
childhood, depressive disorders are the single largest contributor to mental health DALYs throughout
lifespan. DALY contributions from bipolar disorders, alcohol use disorders, drug use disorders and
eating disorders increase with age and peaks in adulthood. Chronic pain syndrome contributes
substantially to mental health DALYs in middle age and late adulthood. Self-harm contribute to ad
substantial amount of DALYs especially in younger years of adulthood (19-39 years old).
Malawi 33
Graph 6: Ranking Mental disorders-DALYs Graph 7: Ranking Mental disorders -YLDs
Graph 6 shows that the top contributors to mental health DALYs are depressive disorders, self-harm,
chronic pain syndrome and epilepsy. Graph 7 shows that the top three leading contributors to mental
health YLDs are depressive disorders, chronic pain syndromes and anxiety disorders.
Summary of Burden of Mental Illness in Malawi: Mental and substance use disorders are
prominent contributors to the burden of illness, accounting for 6% of total DALYs and 29% of
total YLDs. Depressive disorders, self-harm and chronic pain syndromes contribute largely to
the mental illness burden. The populations most affected are adolescents and young adults.
Malawi 34
Liberia’s Burden of Mental Illness
Background on Liberia: Liberia is a West African country with 4.5 million people. The nation has
struggled with two civil wars that claimed 250,000 lives and forced one third of the population to flee.
The conflicts devastated infrastructure, health status and quality of life. After the conflict, the nation
began efforts to rebuild, but in 2014, was struck with a deadly Ebola outbreak [38]. The epidemic
decimated the meager healthcare workforce and distressed the health system [38]. By 2015, the
epidemic came under control and the nation has since focused on recovering and rebuilding a
stronger health system. Life expectancy is 62 years of age and maternal mortality rate is 640 deaths
per 100,000 live births.
Liberia’s Burden of Disease:
The point prevalence of mental illness in Liberia is 14.07%.

illness contributes to 6% of
total DALYs. Infectious,
DALYs are the leading
contributors to DALYs, they
account for 66% of DALYs.
23% of DALYs are attributable
to NCDs (excluding mental
health) while 5% of DALYs are
due to injuries.
illness accounts for 24% of
YLDs, this is a large
proportion of total YLDs.
NCDs (excluding mental
illness) contributes 34% while
communicable, maternal, child
and nutritional account for
37% and injuries account for
5% of YLDs.
Liberia 35
Graph 3: Liberia’s Total DALYs with a Focus on NCDs
Mental and substance use disorders account for a substantial amount of total DALYs beginning in
childhood (5-9 years) and increasing to have a peak contribution to DALYs in adolescence and
adulthood where the category contributes as much as 19% of DALYs. In late adulthood, while
mental and substance use disorders contribute less to total DALYs, chronic respiratory diseases
contribute increasingly. Communicable, maternal, neonatal and nutritional diseases are the largest
contributors to Liberia’s total DALYs affecting children the most especially in their first year of life.
This category of disease are the predominant cause of DALYs throughout life course except in late
middle age and in late adulthood (45- 80 years).
Liberia 36
Graph 4: Liberia’s Total YLDs with a Focus on NCDs
Communicable, maternal, neonatal and nutritional diseases contribute predominantly to YLDs in the
first 5-9 years of life. As their contribution to YLDs reduces with age, the prevalence of mental and
substance use disorders increase. The greatest burden is between adolescence and middle age.
The contribution that these diseases contribute to total YLDs decreases in late adulthood.r 13% of
YLDs. Diabetes, urogenital, blood and endocrine disease and cardiovascular diseases contribute
substantially to YLDs throughout life course and injuries, musculoskeletal disorders and
cardiovascular diseases have a substantial contribution in adulthood.
Liberia 37
Graphs 5: Liberia’s Burden of Mental Disorders- DALYs
In the first few days of life, drug use disorders are the largest contributors to mental health DALYs.
Epilepsy is a substantial contributor to mental health DALYS in the first few days of life. Onset of
other mental health disorders occur in childhood. At age 10-14 year old, there is an onset of alcohol
use disorders, substance use disorders, bipolar disorders and schizophrenia. The highest
prevalence of these diseases are in middle age where they contribute the most to DALYs than in
other areas of life course. A large amount of DALYs are attributable to chronic pain syndromes, with
its highest contribution in middle age. Self-harm and anxiety disorders contribute a substantial
proportion to mental health DALYs in middle age. Starting from childhood, depression as a single
Liberia 38
disease contributes the most to mental health DALYs throughout lifespan. Alzheimer disease and
other dementias begin to contribute to mental health DALYs in the late adulthood.
Graph 6: Ranking Mental disorders - DALYs Graph 7: Ranking of Mental disorders-YLDs
Graph 6 shows that the largest contributors to mental health DALYs are depressive disorders,
chronic pain syndrome, drug use disorders, migraine and self-harm. Graph 7 shows that the largest
contributor to YLDs are depressive disorders, chronic pain syndrome and migraine.
Summary of Burden of Mental Illness in Liberia: Mental illness and substance use
disorders contribute to 6% of DALYs and 24% of YLDs. The largest contributors to mental
health DALYs are depressive disorders and chronic pain syndrome and the age group
most affected are adolescents and individuals in early adulthood and middle age.
Liberia 39
Sierra Leone’s Burden of Mental Illness
Background on Sierra Leone: Sierra Leone is a West African country with a rapidly growing
population of 5.8 million people. It struggled with a decade long civil war (1991-2002) where
thousands were killed and basic infrastructure was destroyed. Since 2002, the nation has focused
on rebuilding and rehabilitation. In 2007, Sierra Leone ranked as the least developed country in the
world. Life expectancy is low at 46 years of age, and while fertility rates are very high at 40 births per
1000 population, maternal mortality rates are the highest in the world (1,100 deaths per 100,000 live
births)[39].
Sierra Leone’s Burden of Disease:
The point prevalence of mental illness in Sierra Leone is 14.5%.
Graph 1 shows that mental illness

contribute 5% to total DALYs.
NCD DALYs (excluding mental
illness) accounts for 23% of
DALYs. Infectious, maternal, child
and nutritional DALYs make the
largest contribution (67%) to total
DALYs and injuries contribute
6%.

Graph 2 shows that 29% of total
YLDs are due to mental illness.
Therefore mental illness alone
makes a substantial portion of
total YLDs as compares to
disease categories such as other
NCDs which contribute 36% and
infectious, maternal, child,
nutritional diseases which
contribute 31%. Injuries
contribute 4% to total YLDs.
Sierra Leone 40
Graph 3: Sierra Leone’s Total DALYs with a Focus on NCDs
Mental and substance use disorders begin to contribute substantial amounts to total DALYs in
adolescence and peaks between the ages of 10 and 29 years where they contribute as much as 14-
18% of DALYs. From middle age to late adulthood, the contribution declines but does not fall below
4% and rises again amongst 80 years olds to 8%. Communicable, maternal, neonatal and nutritional
diseases make up a large proportion of the total DALYs. They are the dominant contributor to
DALYs among infants and young children (0-9 year old) and in middle adulthood. Chronic respiratory
diseases are also a large contributor to DALYs, with its largest contribution to total DALYs in late
adulthood.
Sierra Leone 41
Graph 4: Sierra Leone’s Total YLDs with a Focus on NCDs
Mental and substance use disorders begin to contribute largely to total YLDs in childhood and
continues to contribute substantailly throughout the life course. The age group most affected by this
disease category is between ages 5 to 34, contributing as much as 42% among 20-24 year olds.
Mental and substance use disorders as a contegory are the leading contributors to YLDs in
adolescence and adulthood, and gradually contribute less with age, but never contributing less than
15% to total YLDs. Communicable, maternal, neonatal and nutritional diseases contribute to total
YLDs primarily in infancy and early childhood, and contrinues to be a large contributor to total YLDs
into adulthood.
Sierra Leone 42
Graph 5: Sierra Leone’s Burden of Mental Disorders- DALYs
Drug use disorders contribute most significantly in the first days of life due to maternal substance
abuse in pregnancy. This is matched with an increase in DALYS due to substance use in
childbearing age, where alcohol use disorders, bipolar disorder and schizophrenia also become
substantial contributors to mental health DALYs. Self-harm and anxiety disorders contribute largely
in middle age. Chronic pain syndromes are also a large contributor in adulthood, but contribute the
most to mental health DALYs among 35-74 year olds. Depression is the largest contributor to mental
health DALYs and contributes this throughout childhood and adulthood. Epilepsy contributes largely
to mental health DALYs in infancy. Autistic spectrum disorders, attention-deficit/hyperactivity
disorder, conduct disorder and idiopathic intellectual disability contribute to mental health DALYs
mostly in adolescence between ages 4 -19 years. Migraines contributing to DALYS in adolescents
and remains throughout life course. Alzheimer disease and other dementias contribute to mental
health DALYs in late adulthood.
Sierra Leone 43
Graph 6: Ranking of Mental disorders – DALYs Graph 7: Ranking of Mental disorders –YLDs
Graph 6 shows that the leading contributors to mental health DALYs are depressive disorders,
chronic pain syndrome, drug use disorders and epilepsy. As shown in Graph 7, depressive
disorders, chronic pain syndromes and migraines are the leading contributors to mental health
YLDs.
Summary of Burden of Mental Illness in Sierra  Leone: Results show that mental illness
makes a large proportion of Sierra Leone’s burden
 of disease. Mental illness contributes to
5% of total DALYs and 29% of total YLDs. Depressive
 disorders and chronic pain syndromes
are the leading contributors to mental health DALYs
 and YLDs and the age group most
affected by mental disorders are adolescents, young
 adults and middle-aged groups.

Sierra Leone 44
Peru’s Burden of Mental Illness
Background on Peru: Peru is a South American country of approximately 30 million people[40]. It is
an upper middle-income country with one of the most successful economies in South America.
Although the nation seems to be performing relatively well, within Peru, there is vast economic
disparity and health inequity. As a result, Peru preforms poorly on many health indicators. 20% of
the population lives below the poverty line, life expectancy is 75 years, under-5 mortality is 17 deaths
per 1000 children and the prevalence of tuberculosis is 164 per 100,000.
Peru’s Burden of Disease:
The point prevalence of mental illness in Peru is 18.06%

illness contributes to 20%
of total DALYs. The largest
contributors to total DALY
are NCD (excluding mental
illness) DALYs (45%)
followed by infectious,
maternal, child and
nutritional DALYs (22%).
Injuries (excluding self-
harm) contribute 13% of
total DALYs.

illnesses account for a
large amount of YLDs
(36%). NCDs (excluding
mental illness) contributes
to the majority of total YLDs
(44%). Infectious, maternal,
child and nutritional YLDs
account for 11% of YLDs
and injuries (excluding self-
harm) contribute 10%.
Peru 45
Graph 3: Peru’s Total DALYs with a Focus on NCDs
Communicable, maternal, neonatal and nutritional diseases make the largest contributions to DALYs
in infancy and a substantially large amount in childhood. In adulthood, these diseases contribute less
to DALYs while mental and substance use disorders contribute more. Mental and substance use
disorders are the leading single contributor to DALYs from adolescence through middle age. These
diseases contribute to total DALYs less with age, but never contribute less than 8%. Injuries
contribute a substantial amount to DALYs throughout life course. Chronic respiratory diseases and
cardiovascular diseases also contribute substantially to total DALYs especially in late adulthood.
Peru 46
Graph 4: Peru’s Total YLDs with a Focus on NCDs
Mental and substance use disorders contribute to YLDs throughout life course, mostly in
adolescence and aduthood where they contribute as much as 55% of YLDs. Mental and substance
abuse disorders contribute less to YLDs with age, though reduced they contribute a substantial
amount through late adulthood where they contribute up to 15% of YLDs. Injuries are a significant
contributor in older age groups. Communicable, maternal, neonatal, and nutritional diseases
contribute the most YLDs to infants and children and their contribution decreases with increasing
age. Injuries, musculoskeletal disorders, chronic respiratory diseases and cardiovascular disease
contribute to DALYs especially in adulthood.
Peru 47
Graph 5: Peru’s Burden of Mental Disorders- DALYs
Autistic spectrum disorders, attention-deficit/hyperactivity disorder and conduct disorders contribute

predominantly in childhood and adolescence. Epilepsy largely contributes to DALYs in infancy and in
the early years of childhood. Most mental disorders arise in adolescence and remain large
contributors to mental health DALYs throughout adulthood. Depressive disorders account for a large
amount of mental health DALYs throughout adulthood (around 20%) and anxiety disorders and
chronic pain syndromes are also large contributors to mental health DALYs. Self-harm,
schizophrenia, bipolar disorder, alcohol use disorders and drug use disorders all begin to contribute
markedly in the teenage years of adolescence and continue to contribute to mental health DALYs
mostly in adulthood, decreasing as people age. Migraines contribute a substantial amount to mental
health DALYs starting from early childhood and persist throughout life course.
Peru 48
Graph 6: Ranking Mental disorders – DALYs Graph 7: Ranking Mental disorders -YLDs
DALYs YLDs
Chronic pain syndrome 17.7 Anxiety disorders 14.8
Anxiety disorders 11.6 Migraine 13.9
Migraine 11.0 Chronic pain syndrome 10.0
Alcohol use disorders 5.8 Epilepsy 4.9
Epilepsy 5.0 Schizophrenia 4.9
Self-harm 4.4 Bipolar disorder 4.2
Schizophrenia 3.8 Alcohol use disorders 4.2
Alzheimer disease and other dementias 3.8 Other mental disorders 3.3
Bipolar disorder 3.3 Autistic spectrum disorders 3.1
Other mental disorders 2.6 Drug use disorders 3.1
Conduct disorder 2.5 Idiopathic intellectual disability 2.0
Autistic spectrum disorders 2.5 Alzheimer disease and other dementias 1.8
Eating disorders 0.7 Tension-type headache 0.7
chronic pain syndrome, anxiety disorders and migraine. Graph 7 shows that the largest contributors
to mental health YLDs are depressive disorders, anxiety disorders and migraine.

Summary of Burden of Mental Illness in Peru: Mental and substance abuse disorders
make up a large portion of Peru’s burden of disease. They contribute to 20% of total

DALYs and 30% of total YLDs. Depressive disorders are the leading contributor to mental

health DALYs and the age-groups most affected by mental health and substance use
disorders are adolescents, young adults andmiddle aged groups.

Peru 49
Chiapas’ Burden of Mental Illness
Background on Chiapas, Mexico: Mexico is a South American country of 127 million people. It is
an upper middle-income country with the second largest economy in Latin America. Although the
country seems to be prospering, due to a large socioeconomic disparity, a large proportion of
Mexico’s population suffers from poverty and its consequences. These include harsh living
conditions in rural areas and drug related gang violence. Chiapas is a rural region in Mexico’s Sierra
Madre Mountains[19]. 74.7% of its population lives below the national poverty line. Of the 4.8 million
inhabitants, 11.7% have hypertension and 5.6% have diabetes[19].
Chiapas’ Burden of Disease:
The point prevalence of mental illness in Mexico is 16.9%.
illness DALYs contribute to
17% of total DALYs in
Chiapas. NCD (excluding
mental illness) DALYS are the
largest contributors to DALYs
(53%), followed by infectious,
maternal, child, nutritional
diseases which make up 19%
of total DALYs and 11% are
due to injuries (excluding self-
harm).

Graph 2 shows that 38% of
total YLDs are due to mental
illnesses alone. NCDs
(excluding mental illness)
contribute 49% to total YLDs.
Infectious, maternal, child and
nutritional diseases account
for 11% of YLDs and injuries
(excluding self-harm)
contribute 2%.
Chiapas 50
Graph 3: Chiapas’ Total DALYs with a Focus on NCDs
Graph 3 shows that mental and substance use disorders are major contributors to NCD DALYs.
These diseases begin to make a substantial amount to DALYs in childhood and their contribution
persists over life course. Mental and substance use disorders have their largest effect in
adolescence and young adulthood where they account for as much as 35% of NCD DALYs. They
contribute less with age but never less than 8% of total DALYs. Communicable, maternal, neonatal
and nutritional diseases contribute largely to total DALYs in childhood and injuries contribute a
substantial amount in adolescence and young adulthood. Diabetes, urogenital, blood and endocrine
diseases, as well as cardiovascular diseases contribute substantially in later years of adulthood.
Neoplasms contribute to total DALYs through life course.
Chiapas 51
Graph 4: Chiapas’ Total YLDs with a Focus on NCDs
Graph 4 shows that mental illness and substance use disorders account for a substantial amount of
total YLDs throughout life course. They become the leading contributor to total YLDS (52-55%)
between ages 15- 29 years and make their largest contribution to total YLDs in adolescence, young
adulthood and middle age. Mental illness and substance abuse account for a large amount of total
YLDs throughout late adulthood, never contributing less than 21%. Communicable, maternal,
neonatal, and nutritional diseases contribute largely to total YLDs in childhood. Musculoskeletal
disorders contribute to total YLDs in adulthood. Diabetes, urogenital, blood and endocrine diseases
contribute to YLDs throughout life course and chronic respiratory diseases contribute to YLDs in
adulthood.
Chiapas 52
Graph 5: Chiapas’ Burden of Mental Disorders- DALYs
Graph 5 shows that drug use disorders, epilepsy and autistic spectrum disorders contribute to
mental health DALYs in infancy. Attention-deficit/ hyperactivity disorders contribute largely in
adolescence. Most mental health disorders begin in adolescence and contribute to mental health
DALYs throughout the rest of life. Depressive disorders are one of the largest single contributors to
mental health DALYs, contributing about 25% from childhood to adulthood. Anxiety disorders and
self-harm affect adults and have the largest effect on young adults. Schizophrenia, bipolar disorder,
alcohol use disorders and drug use disorders make the largest contributions to mental health
disorders in adulthood and Alzheimer disease and other dementias take over as the largest
contributors to mental health DALYs in late adulthood.
Chiapas 53
Graph 7: Ranking Mental disorders -DALYs Graph 8: Ranking Mental disorders -YLDs
DALYs YLDs
Chronic pain syndrome 10.4 Chronic pain syndrome 12.2
Anxiety disorders 9.9 Anxiety disorders 11.8
Epilepsy 7.6 Migraine 7.9
Alcohol use disorders 7.4 Epilepsy 5.1
Migraine 6.6 Schizophrenia 5.0
Self-harm 4.9 Bipolar disorder 4.8
Alzheimer disease and other dementias 4.8 Alcohol use disorders 4.0
Schizophrenia 4.2 Drug use disorders 3.9
Bipolar disorder 4.0 Autistic spectrum disorders 3.4
Conduct disorder 3.2 Other mental disorders 3.3
Autistic spectrum disorders 2.8 Idiopathic intellectual disability 2.2
Other mental disorders 2.8 Alzheimer disease and other dementias 2.0
Eating disorders 0.8 Tension-type headache 0.9
chronic pain syndrome, anxiety disorders and epilepsy. The largest contributors to mental health
YLDs are depressive disorders, chronic pain syndrome and anxiety disorders.
Summary of Burden of Mental Illness in Chiapas, Mexico: Mental illnesses and substance

use disorders contribute a large proportion of Chiapas’ total and NCD DALYS and YLDs.
Mental illness and substance account for 17%of total DALYs and 38% of total YLDs.
Depressive disorders, chronic pain syndrome and anxiety disorders are the largest contributors
to mental health DALYs and YLDs. The age groups most affected by mental illness and
substance use disorders are adolescence, young  adulthood and middle adulthood.


Chiapas 54
Navajo Nation and Rosebud Burden of Mental Illness
Background: The Navajo Nation is a region in Utah, Arizona and New Mexico of North America
(PIH works with the population in New Mexico). Navajo Nation is constituted of 180,000 Navajo who
belong to the Southwest Tribes, as it will be referred to in the results below. Navajo Nation struggles
with poverty and unemployment and has the worst health indicators in North America [41]. The
unemployment rate is 42% and the population living below the national poverty line is 43%. There is
an increasingly high prevalence of diabetes of 22%, life expectancy is 74 years, over 4 years lower
that the overall life expectancy of the United States[41].
Sicangu Lakota Nation (also known as Rosebud) is in Rosebud, South Dakota. The region has a
population of 27,000. They belong to the Northern Plains Tribes and are referred to as such in the
analysis below[42]. Many of the hardships faced in Rosebud are similar to those of the Navajo
Nation including high prevalence of diabetes, cancer and alcohol and drug use[43].
COPE’s Burden of Mental Illness: The prevalence of mental illness in the Southwest tribes, which
includes Navajo Nation is 21% and may include depression, epilepsy, anxiety disorders, substance
abuse and other mental disorders 23].
The prevalence of mental illness in Northern plains tribes, which includes the Sicangu Lakota Nation/
Rosebud, is 24.3% [23].
Graph 1: United States: Mental Disorders by Contribution to Mental Health YLDs
The Southwest and Northern Plains Tribes have substantially different mental health prevalence and
statistics from the rest of the United States. Depressive disorders are the largest contributors to
mental disorders YLDs (23%) in the US, followed by chronic pain syndrome which contributes to
18% of mental health DALYs and anxiety disorders which contribute to 14% of mental health DALYs.
COPE 55
Alcohol use disorders account for 4% of mental health DALYs in the US. This means the national
burden is far lower than the 29% in Southwest tribes and 52% in Northern Plains tribes.
Graph 2: Southwest tribes: Mental Disorders by Contribution to Mental Health YLDs
Among the Southwest tribes, the majority of mental health YLDs (23%) are due to depressive
disorders, followed by alcohol use disorders (17%) and chronic pain syndrome (14%) and anxiety
disorders (13%).
COPE 56
Graph 5: Northern Plains tribes: Mental Disorders by Contribution to Mental Health YLDs
Among Northern plains tribes, alcohol use disorders are the largest contributors to mental health
YLDS (33%), followed by depressive disorders (13%), chronic pain syndrome (12%) and anxiety
disorders (11%).
Summary of Burden of Mental Illness in Navajo Nation and Rosebud: Both regions have a
large prevalence of mental disorders, and the burden far exceeds the national burden. Navajo
nation has 21.0% of mental illness and Rosebud has a 24.3% prevalence of mental illness. The
disorders that contribute the most to YLDs are alcohol use disorders, depressive disorders,
chronic pain syndrome and anxiety disorders. The national prevalence for alcohol use disorders
is 4% a much lower than in Navajo nation and Rosebud which have prevalence of 17% and 32%
respectively.
COPE 57
Russia’s Burden of Mental Illness
Background on Russia: Russia is the vastest nation on earth and has a population of 144 million
[44]. It is a resource rich nation with an upper-middle income economy and it is a key player in global
supply of oil and gas[44].Russia has a high incidence rate of tuberculosis at 89 tuberculosis cases
per 100,000 people, this is a high rate in comparison to nations in Russia’s income group. Russia
also struggles with an epidemic of multidrug-resistant tuberculosis and as of 2014, there were
39,000 cases in the country [45]
Russia’s Burden of Disease:
The point prevalence of mental illness in Russia is 15.26%

Graph 1 shows that NCDs
(excluding mental illness)
NCD DALYs (except accounts for the majority
17% (63%) of DALYs. Mental
mental illness)
illnesses account for 17% of
7% DALYs and are the second
Injuries DALYs largest contributors to DALYs.
(except self-harm) Injuries account for 13% of
13% DALYS and infectious,
63%
Infectious, maternal, child and nutritional
maternal, child, DALYs account for 7% of
nutritional DALYs DALYs.

Graph 2 shows that NCDs
NCD YLDs (except make up the majority of
mental illness) YLDs, contributing 56%.
Mental illness contributes
35% Injuries YLDs (except over 1/3 towards NCDs at
self-harm) 35% of YLDs. Infectious,
maternal, child and
Infectious, maternal, nutritional YLDs make up
56% child, nutritional YLDs 6% of YLDs and injuries
Mental illness YLDs make up 3% of YLDs.
6%
3%
Russia 58
Graph 3: Russia’s Total DALYs with a Focus on NCDs
Graph 3 shows that mental and substance use disorders contribute a large proportion to NCD
DALYs from childhood and throughout the rest of life course. Adolescents, young adults and middle
aged adults are the populations most affected by mental illness. Within these age groups mental and
substance use disorders contribute 24 -40% of total DALYs. Cardiovascular diseases make
increasing contributions to total DALYs with age and become the leading contributors to DALYs in
the later years of adulthood. Communicable, maternal, neonatal and nutritional diseases contribute
substantially to total DALYs in the early years of childhood.
Russia 59
Graph 4: Russia’s Total YLDs with a Focus on NCDs
Graph 6 shows that in the first years of childhood, communicable, maternal, neonatal and nutritional
diseases account for the large majority of total YLDs. Mental and substance use disorders contribute
largely to total YLDs throughout life course and contribute the most in adolescence and the earlier
years of adulthood. Musculoskeletal disorders account for about 10-15% of YLDs in adulthood
accompanying the decrease in of YLDs due to communicable, maternal, neonatal and nutritional
diseases.
Russia 60
Graphs 5: Russia’s Burden of Mental Disorders- DALYs
In the early years of childhood, drug use disorders, autistic spectrum disorders and epilepsy are the
largest contributors to mental health DALYs and decrease as people age. From childhood,
depression begins to make a substantial contribution to mental health DALYS and remains
substantially large throughout life course. Self-harm contributes largely to mental health DALYs
especially in adolescence, young adulthood and middle age, and while decreasing, continues to
contribute a substantial amount into late adulthood. Chronic pain syndrome contributes to mental
health DALYs throughout adulthood but contributes the most among people between 55-74 years
age. Schizophrenia, bipolar disorder, drug and alcohol use disorders start in early adulthood and
Russia 61
contribute substantially through adulthood. Russia has as much as 20% of its mental health DALYs
in adulthood due to drug use disorder, making drug use disorder a comparatively large contributor to
mental health DALYs. Alzheimer diseases and other dementias contribute majorly in the later years
of adulthood. Migraines start to contribute substantially from childhood and continue contributing
through life course.
Graph 6: Ranking Mental disorders- DALYs Graph 7: Ranking Mental disorders- YLDs
Disorder % MH Cumulative
Disorder % MH Cumulative
YLDs coverage DALYs coverage
Depressive disorders 25.8 25.8
Self-harm 19.7 19.7
Chronic pain syndrome 17.6 43.4 disorders
Depressive 15.9 35.7
Migraine 13.7 57.1
Alcohol use disorders 14.3 49.9
Alcohol use disorders 8.3 65.4
Chronic pain syndrome 10.9 60.9
Anxiety disorders 5.8 71.1
Alzheimer disease and other dementias 9.2 70.0
Schizophrenia 5.4 76.6
Migraine 8.4 78.5
Alzheimer disease and other dementias 4.6 Drug 81.2
use disorders 4.7 83.2
Bipolar disorder 3.8 84.9
Anxiety disorders 3.5 86.7
Other mental disorders 3.5 88.4
Schizophrenia 3.4 90.1
Drug use disorders 3.5 91.9
Bipolar disorder 2.3 92.4
Autistic spectrum disorders 2.5 Other94.4
mental disorders 2.1 94.6
Epilepsy 1.4 95.8
Autistic spectrum disorders 1.6 96.1
Idiopathic intellectual disability 1.3 97.1
Epilepsy 1.3 97.5
Conduct disorder 1.2 98.3 intellectual disability
Idiopathic 0.8 98.3
Tension-type headache 0.9 99.2disorder
Conduct 0.7 99.0
Eating disorders 0.5 99.7 headache
Tension-type 0.5 99.6
Self-harm 0.2 Eating99.9
disorders 0.3 99.9
Attention-deficit/hyperactivity disorder 0.1 100.0
Attention-deficit/hyperactivity disorder 0.1 100.0
Graph 6 shows that the leading contributors to mental health DALYs are depressive disorders,
chronic pain syndrome and migraine. The largest contributors to mental health YLDs are self-harm,
depressive disorders and alcohol use disorders
Conclusion on Russia’s Burden of Mental Illness: Mental and substance abuse

disorders contribute 17% to mental health DALYs and 35% to mental health YLDs. Self-
harm is the leading cause of mental health DALYs and depressive disorders contribute

substantially to both mental health DALYs and YLDs. The age range most affected by

mental health disorders are from adolescence to middle adulthood.

Russia 62
Cross-site Trends of Burden of Mental Illness
Across all 10 sites, mental illness contributes to a large burden of disease. It contributes as much as
20% of total DALYs in Peru and as much as 38% of total YLDs in Chiapas, Mexico.
Trends in Age Groups
The age groups most affected by mental illness are adolescents, young adults and middle aged
adults. Many of the diseases have their onset in adolescence and the disease burden is highest
among this age group, as shown by an increase in DALYs and YLDs in this period of life. For
example in Lesotho, 15-24 year olds have as much as 47% of their YLDs due to mental and
substance use disorders.
Across the sites, schizophrenia, bipolar disorder, alcohol use disorders, drug use disorders and
eating disorders follow a similar trend: onset is almost simultaneous at ages 10-14 years, and the
conditions contribute the most towards mental health DALYs in adulthood with dwindling amounts in
late adulthood.
Alzheimer disease and other dementias begin to contribute to the mental illness burden in the sites
among ages 70-80. These diseases are common to old age and have a similar trend across sites. In
late adulthood, although mental disorders continue to contribute substantially, they contribute less
than in early years of adulthood as other NCDs such as cardiovascular diseases begin to contribute
more to the total DALYs and YLDs in late adulthood. Cardiovascular diseases naturally have
increased prevalence in old age.
Prevalence of Disorders
The most prevalent disorders are depressive disorders, which contribute substantially to mental
health DALYs and YLDs across all age groups except infancy. For example, they contribute an
average of 32.4% of mental health DALYs and 39.4% of YLDs in Rwanda across the life course.
The sites largely follow a similar trend where epilepsy and substance use disorders are major
contributors to DALYs and YLDs in infancy. For example in Sierra Leone, both disorders contribute
as much as 92% of mental health DALYs within the first year of life. These high rates of substance
abuse are due to drug use of the mother during pregnancy and it corresponds with increases DALYs
and YLDs due to drug use in middle age.
In Russia and Peru, autistic spectrum disorders contribute a large amount of mental health DALYs
as compared with the other sites (as much as 52% in Russian and 25% in Peru) where the disorder
contributes mainly after infancy. This may be due to higher rates of early detection of autistic
spectrum disorders in both countries, but more research is needed to explain this trend.
Self-harm is a top contributor to mental health DALYs in a few sites, namely Malawi (11.2%) and
Liberia (7%) and self-harm has even larger contribution to mental health DALYs in Lesotho (27.3%)
and to mental health DALYs in Russia (19.7%). More research is needed to determine why these
countries have a large burden of self-harm.
Although alcohol use disorders are not among the top 3 leading contributors to mental illness burden
in many of the sites, in COPE sites, alcohol use disorders are the largest single contributor to mental
health YLDs (17% in Southeast Tribes and 33% in Northern Tribes).
63
Conclusion
Mental illnesses are a large contributor to the national burden of disease in all countries where PIH
works. This suggests that there is great need for mental health care in the communities and
countries where PIH works. Efforts to integrate mental health services into primary care in PIH
catchment areas are therefore strategic, both to address the unmet need of mental illness and
because of the impact untreated mental illness can have on other treatment outcomes, such as HIV
or TB outcomes. Efforts to advocate for national level awareness and funding for mental health care
should also be prioritized.
64
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67

Final Report On The Burden of Disease PIH Sites

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Final Report On The Burden of Disease PIH Sites

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Burden of Disease Attributable to

In Haiti, ZL provides comprehensive health In Rwanda, PIH/Inshuti Mu Buzima (IMB)

In Russia, PIH/Партнеры во имя здоровья

As Community Outreach and Patient

PIH’s Mental Health Program

Mental Health in Peru: PIH/Socios En

shelter. Starting in 2015, Peru’s MOH

Assessment of the Burden of Mental Illness in PIH Partner Countries

The objectives of this report include:

 Non-Communicable diseases (NCDs) include cardiovascular disease, neoplasms, chronic

Graph 1: Disease Burden Composition by DALYs including Mental Illness

Graph 2: Disease Burden Composition by YLDs including Mental Illness

Graph 7: Ranking of Mental

Graph 2 shows that

Graph 1: Disease Burden Composition: DALYs including Mental Illness DALYs

As shown in Graph 1, Mental

Graph 2: Disease Burden Composition: YLDs

Summary of Burden of Mental Illness in Lesotho: Mental illnesses contribute 7% to total

Graph 1: Disease Burden Composition by DALYs including Mental Illness

Graph 2: Disease Burden Composition by YLDs including Mental Illness

The point prevalence of mental illness in Liberia is 14.07%.

Graph 1: Disease Burden Composition by DALYs including Mental Illness

Graph 1: Disease Burden Composition by DALYs including Mental Illness

Graph 1 shows that mental illness

Graph 2: Disease Burden Composition by YLDs including Mental Illness

Graph 1: Disease Burden Composition by DALYs including Mental Illness

Graph 2: Disease Burden Composition by YLDs including Mental Illness

Autistic spectrum disorders, attention-deficit/hyperactivity disorder and conduct disorders contribute

Graph 2: Disease Burden Composition by YLDs including Mental Illness

Graph 1: United States: Mental Disorders by Contribution to Mental Health YLDs

Graph 2: Southwest tribes: Mental Disorders by Contribution to Mental Health YLDs

Graph 1: Disease Burden Composition by DALYs including Mental Illness

Graph 2: Disease Burden Composition by YLDs including Mental Illness

Conclusion on Russia’s Burden of Mental Illness: Mental and substance abuse

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