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    Epidemiologia de La SM

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    Manuel Cañas Lucendo

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    © All Rights Reserved
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    LOS | on OPEN Q ACCESS Freely available online Global Epidemiology of Mental Disorders: What Are We Missing? ‘Amanda J. Baxter’, George Patton®, Kate M. Scott®, Louisa Degenhardt®”, Harvey A. Whiteford’? 1 Schoo! of Popubtion Heath, Uniwesty of Qucensand, Heston, Asal, 2Oveerland Cente for Mental Heath Reseach, Wacol Ausaa, SDepament of Pacts, Univenty of Melbourne, Metioune, Asai, Murdoch Chidrens Research inte, Meboune, Asta, SDeparnent of Pci Meine, Univers of age, Dns, New Zand National Dug and Alea esarch Cente Unies of New South Was, Sey, Ausra, 7 ene for Heth Po, Programs and Economie, Soo f Population Heath Univenty of Melbourne, Melbourne, Aust Abstract Background: Population-based studies provide the understanding of health-need required for effective public health policy and service planning. Mental disorders are an important but, until recently, neglected agenda in global health. This paper reviews the coverage and limitations in global epidemiological data for mental disorders and suggests strategies to strengthen the data. ‘Methods: Systematic reviews were conducted for population-based epidemiological studies in mental disorders to inform new estimates forthe global burden of disease study. Estimates of population coverage were calculated, adjusted for study Parameters (age, gender and sampling frames) to quantify regional coverage. ‘Results: OF the 77,000 data sources identified, fewer than 19 could be used for deriving national estimates of prevalence, incidence, remission, and mortality in mental disorders. The two major limitations were (1) highly variable regional coverage, and (2) important methodological issues that prevented synthesis across studies, including the use of varying case ‘definitions, the selection of samples not allowing generalization, lack of standardized indicators, and incomplete reporting. North America and Australasia had the most complete prevalence data for mental disorders while coverage was highly variable across Europe, Latin America, and Asia Pacific, and poor in other regions of Asia and Africa. Nationally- representative data for incidence, remission, and mortality were sparse across most of the world Discussion: Recent calls to action for global mental heath were predicated on the high prevalence and disability of mental disorders. However, the global picture of disorders is inadequate for planning. Giobal data coverage is not commensurate with other important health problems, and for most ofthe world's population, mental disorders are invisible and remain a low priority ‘tation: tater A, Paton 6, Sot Kk Degen Whiteford KA 2013) lbs Eidemiology of Meal Does: What re We Mising? PLoS ONE Ae 65514 dO 1571jourrl pone 068514 tor Zar K Bh, Ag Khan Unie, akin Received Febuay 4, 2015: Accepted Api 2,203; Published June 26 2013 Copyright: © 2013 Batre a. This san open aces are dtibted under the tems ofthe Cathe Commons Atbuton Uicenee, which permits Sette ute, deiuton on rpradution many medium. provide the ang author an sure are re Funding Core funding or CHR s provides by the Qversand Deparment of Heath George Paton ad Loui Degenhardt at funds by NHMRC Saioe each Fellowships. The anders had no role i study esto date cllection and ans decor to push preparation ofthe manus Competing Interests The auhor have declted that ne competing interes ent + emai mands tadergembrgedioa Introduction "The Global Burden of Disease (GRD) sy published in 1996 showed that neuro-psychiatric disorders account for more than ‘quarter of all health loss duc to dsabilxy, more than eight times greater that that atributed to coronary heart disease and 20-old ‘greater chan cancer [I]. These findings highlighted for the fist time the central place of mental disorders in population health as well as need fora response from health service ystems. Sound cpidemiological information around mental disorders i an ‘essential starting point fort pie reponse The pansit of « comprehensive pictire of mental diorders laos, Global surveillance systems sch asthe WHO Ste Approach to Chronic Disease Factor Surveillance (STEPS) [2 the Maile Indicator Cluster Surveys (MICS) [3] and the MEASURE Demographic al Health Surveys (DHS) Projet [4] LOS ONE | wowplosoneorg now cover a number of major causes of disease burden in love income countries. These systems provide litle coverage of mental disorders and there is no comparable glabal data cllection system in place for mental divorders. Morcower there i as yet no global standard for collection of health measures or epository for eros hatinal data on meal order. Lack fanaa indicators for this large group of dsrders hinders at of a mpecensive bl ia agenda 3) O07 new, Global Buren of Disease Stuy (GHD 2010) commenced Funded by the Bill and Melinda Gates Foundation ie aim a to make comprehensive harden estimates for aver 200 dliease and injury categories by age and gender in 21 workd regions (ce Figure SI for GBD 2010 world region classifications) An important evolution of this latest GBD study i that new ‘estimates. for disease burden would be calculated within a Framework driven by the hest available epidemiological data [6] A series of systematic reviews wats therefore condhicted to identify June 2013 | Volume & | sue 6 | 265514 «epidemiological studies describing the prevalence, incidence and course ofillness for mental disorders that underpin the new burden ceximates. ‘This study provides an opportunity to consider the adequacy of current daca t guide a global mental health agenda Detailed report of the process used to conduct our systematic reviews have been published elewhere [78,9]. The aim of this paper is to report an overview of the strengths and limitations Found inthe curren epidemiologial research on mental disorders, ane from this appraisal arive at strategies for strengthening the ‘data needed to inform planning and public health poi. Overall, our review series encompassed seven clases of disorders: depresive disorders anxiety disorders; schizophrenia; bipolar disorder; eating disorders: childhood behavioural disorders (CBD) and autistic spectrum disorders (ASD). In considering adequacy of epidemiological measures for mental disorders, we found the challenges asaciated with collating data difered for cidhood lsorders compared to other mental disorders. ‘The ius of compiling epidemiological data om mental disorders for clildren deserves greater attention than is possible within this rmaper andl here we focus on eur findings in relation 4a the mont common disorders in adult populations Materials and Methods Defining disorders ‘Our review included depresive dors (major depression and ddysthymia}, anxiery disorders (any" anxiery disorder, bipolar lsorder, schizophrenia and eating disorders (anorexia nervosa and bulimia) defined as meeting clinical diagnostic threshold (se Table $2 for more deta). Data were sought for specific disorders (eg major depression and dysthymia, anorexia and bulimia nervosa) with the exception of anxiety diorders which, due to their high co-morbidity, were defined as meeting evteria foe “any ansiey disorder "To compare data availability, we grouped the mental disorders into broad ‘prevalence’ eategores asthe frequency ofa disrder in the population is relevant to the methelological approach taken to ‘desi cases and capture information on disease prevalence and incidence, Depresive disorders and anxiety divorders were considered high rowene dims for the purpose of this report ‘while bipolar, schizophrenia and eating disorders were classified as dno presence dsr. Systematic review Measures of prevalence, incidence, remision, and exces il cause mortality are required to derive prevalent and incident clsabilty for guiding health service delivery and intervention siritegies (Gee Appendix SI for descriptions of epidemiologic ‘measures We conducted a series of systematic reviews to identify these data based on an iterative strategy as recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group [10]. Electronic databases (Medline, Embase and PychoINFO) were interrogated using broad search strings developed with the assistance of rewearch librarians, Secondary searches of nowindexed journals and alemative academic dlaabsses were conducted for region-specific data, these methods are described in more detail in Appendix $2. Reference lists for review artis, editorials and resource books were manually serutinized and online searches conducted for data such as goverment surveys, international collaborative research projects, and research theses. Throughout this process the shortlisted tes ‘were critically reviewed through expere consultation. Details on the prevalence systemic reviews for bipolar disorder [7], major LOS ONE | wowplosoneorg ‘Global Epidemiology of Mental Disorders depressive disorder [8], anxiety disorders [9] and eating disorders [11] have heen accepted or published in peer-reviewed journals “There were minor differences in the review methodology for schizophrenia, which was completed prior o the GDB2010 study including use of broader incision criteria. MeGrath, § colleagues [12,1314] conducted reviews for the epidemiology of schizophrenia which formed the starting point for data collection in GDB2O10, Further detail on methods and data sources are reported in Appenli $2 and Table 82, Inclusion/exclusion criteria Since GBD estimstes were mace at national and regional level, data were required that described disease epidemiology in the broader population, Due to the scarcity of community-based studies for less common disorders (schizophrenia, bipolar and ag disorders) we included eemission and morality: suds Thawed on clinical samples with naturalistic follow-up, Studies were sought thats) defined mental disorders according to internation ally accepted diagnostic criteria, ie. the Diagnostic and Statistical Manwal of Mental Disorders (DSM) [15] o International Chasification of Mental and! Behavioural Disorders (ICD) [16], and b) were homogenously categorized. Only data reported by primary sources were inchaded, and sufficient detail on study ‘method and findings was requited to assess whether the above criteria were met, Studies published between 1980 and 2008 were included, with eatier repos added if provided through ‘expert consultation, No- limitation wi language of publication or sample size (ee Appendix S2 for more information ‘on suc nelson eriteri). Calculating population coverage To give a sense of how complete the available data were, in terms of GBD world regions, we calculated the proportion of regional populations for which prevalence data were reported and adjusted estimates forage, sex, and sampling frames ofthe tudes the provided data, Caleulasons were based on the popation ‘aged between 18 and 80 years wo allow comparison bewseen the disorder groups To illustrate, if one sty wis found for Eastern Sub-Saharan Airica, capturing men and women foam Exhiopia aged 0 t 0 years, the coverage was considered representative of the corresponling proportion of that country’s population aged {60-80 years, relative tothe population of the region, Where the study sampling frame was sub-national, for example one major ty, coverage was adjusted by the population ofthat communiyy relative to, frst the country, then the region. ‘These estimates are referred to a the population coverage of available data for specific liorders. Average coverage refers to the mean of cisorder-specti regional coverage, for example data coverage for high prevalence dlsorders i he simple mean ofthe coverage estimates for anxiety MDD and eythyinia, AMLestimsates were caleultedl with Microsolt Excel and bused on country population data from the United ‘Nations (UN) Population Division for 2005. These aleulations are described in_more detail in Appendix $3, including. speciti ‘examples svalablty of data by country economic sats, simple proportion of the high income (HI) lowe t9 middle-income (LMI) countries that provided any prevalenee data. Income categories ane based on the World Bank's clasiication for gross national income (GNI) per capita. (up://data. workdbankcorg/about/country-cassifcations/ ‘cowntey-andlending rps) June 2013 | Volume & | sue 6 | 265514 Results Our initial search identified almost 77,000 epidemiological studies related to higher and low prevalence mental darders (se lable 1). As expected, the majority ofthe inital stuies focused on prevalence of mental disorders ane relate nsies in HI countries, particularly in Western Europe and North America, While research into population mental orders is increasing in counties jn Asa and Latin America, studies remained searce for much of Africa and Central and Easter Europe. With daa on mental disorders aleeadytimited in many world regions, the vast number of dhe identified ste hat el not meet inclusion criteria further reduced the scape of useable data, Table | shou that lee than 1% of the studies idemtfed were siitable for tse in developing a global epidemiological pictare for mental slsorders Four main limitations led to exclusion of these stucies: 1) inability wo fall currently accepted standardized definitions for ‘mental disorders; 2) nonepresentative samples making the generiizaion of findings not possible; 8) use of measnesumable to provide comparable estimates between atudies and 4) incon plete reporting of study methods and results, "The remaining studies also varied in terms of methods and completenes of ‘reporting, and whilst these 1% of studies represent the best quality similar Limitations to some degree across even these higher quality stuis Global coverage of prevalence data ‘The population coverage of prevalence data, in terms of data completeness hy sex, age and national-reprewntativenes, are shown ia table 2. Regional and world estimates for popt ‘overage reflect the proportion of each population for whic the available data is considered representative. Coxerage is reported for specific disorders with the exception of anorexia nd bulimia for which the data were very sila, hence the data coverage for these disorders are aguresated under ‘eating disorder High prevalence disorders. The most complete data were from North America and Australasia with each of the dhrce common conditions having greater than 75% coverage in adults herween 18 and 80 years of age. ‘There was moderate to. goad ‘average of Western Europe andthe high income countries ofthe Asia Pacific for both major depression (MDD) and anxiety but not for dysthymia, In other regions coverage of common mental fsorders was poor to absent. For 61% of the world’s population, ‘Global Epidemiology of Mental Disorders aged between 18 and 80 years, there was no information om prevalence for common mental disorders (se table 2). Figure 1 shows the data coverige for high prevalence disorders, averaged ‘across MDD, dysthymia and ansiety disorders and adjusted for haGonal-representativeness of study samples Ge. age-group, sex and sampling frames Studies for MDD were available from 58 countries, comprising almost one ball of all HT countries and one sixth of all LML ‘countries, Dysthynia was reported in 27 countries, One quarter of all HI countries and one in 14 of all LMI countries provided at Teast some prevalence data. Forty-five countries provided data for ‘any’ ansiety disorders, including one quarter of all HI countries ‘and one sixth of all LAID cours [Low prevalence disorders. North America provided the ont complete data for low prevalence disorders with each of schizophrenia, bipolar and eating disorders. having about 90% coverage in adults aged 18 co 80 years. There was goad coverage For schizophrenia and bipolar disorder in Ausraasia but ot for cating disorders (ee table 2. Data for Tow prevalence disorders in other regions was scarce with data missing for almost 86% of the ‘lobal population. Figure 2 shows the average population coverage for low prevalence disorders based on the simple mean of coverage in adals for bipolar, schizophrenia and eating disorders. The regional population coverage for specific disorders is shown in table “The global data for schizoph across 27 counties) compared wit the global data for bipolar and cating disorders (24 and 22 countries, respectively) This can be attributed, at east in part, to the broader inchison rules that allowed schizophrenia studies based on einical samples. One {quarter of all HE countries and ome i fourteen EMI counties provided data for schizophrenia. One ith of HI countries provided data for bipolar disorders in comparison with one in filien of the LMI countries. For eating disorders, data were found for one in four ofall HI countries bt only one i 26 of all EME were more widely distributed Global coverage of incidence data High income countries in North America and Western Europe provided the majority ofthe incidence stuces for common mental orders. Incidence data for MDD and dysthymnia were almost ceirely limited to the United States and Canada, with the |Table 1. Results of systematic reviews conducted to identify community representative epidemiological data for higher and low prevalence mental disorders. = Sommeclatene Meni. sawed eng bude ite aaa dh Prva Oo ema ae ne» “ » : ‘ ay ce 2 * ™ : : : ee dc Po “ 2 2 ° : se en i a a 2 a rot re im ” 5 A a umber fata sources by sore Noe that some tes report data fr mre in rota 95399 esta sources were dented forthe review series le igh ad low pealence sotdes and ards wth onset choo J dt10137Vjoumaipoe 0433141001 LOS ONE | wowplosoneorg June 2013 | Volume & | sue 6 | 265514 ‘Global Epidemiology of Mental Disorders exception af one Eshiopian study for major depression in a rural sample [17]. cil any from only three countries, specifically the Netherlands, Norway and United Arab Emirates, ce for nxiesy disorder was available OF the low prevalence disorders more incidence stadies were found for schizophrenia compared with bipolar or eating disorders although the schizophrenia studies identified i a previous review [12] primarily relied on clinical samples whieh were less likely 10 te included for other disorders due to more stringent inclusion rules, Incidence rates for sehizophrenia were found for 13 countries (12 HIG and L LMIC). One country, the USA, reported incidence data for bipolar diorders. Six countries. provided incidence data for eating disorders, all of which were clasiied 4s HI and all, with the exception of one study from the USA [18 limited to females only Global coverage of remission data ‘The most compete remission data for high prevalence disorders remission was from HI countries in North America snd Western Europe. The single study outside these regions that reported remission as from a LMI county, examining ansiety in children and adolescents from India (19) Seventeen countries (L] HIC and 6 LMIQ) provided remission data for schizophrenia, of which one half were regional stdies LOS ONE | wowplosoneorg |Table 2. Estimated global coverage" of prevalence data for mental disorders by Global Burden of Disease 2010 Study world region, Regional population in| co world neglon”” 2005 (000) "High prevalence disorder Major ‘Anwony Eating (18-60 15) depression Dysthymin duorders orders ais Pac, High come woe? was «10% ry 2a asia cata ase ons oo 00% ow ai. ast a8 2K 8a 25% 798 asia South 387708 1% 00% 49% 0% asia, Southeast 38908 use ame 1558 as usu 7992 woe tons 1000 168% — 25908 2% 0% ao a0 Europe ental 91890 teow om om Re% Europe astern 4965 BS RHI 0% Europe Westen stoaas re 758 sm 126% 1908 5738 Ln Amer, Andean 23668 om 0% 00% 00% 0% 008 Latin Areca, Cental wiz ss M60 OTH Musk 710% xn Amen, Suthe san0 165s on 2% 00 16% 00% iste Arc, Te 125791 om ew cm 00m ma ho atic ast 2wpar0 40% THO 45% 00m Not Amerie High Income 20% Woe da fom ane Sub Saran Ate, Cent 33506 ons 0% 00% (Om 00% 00% subsahran Ata, est 15385 13% ore om 6a oom on Sub Saharan A, Southam 3908 om an nom <0 00% 0% Sur Soharan Af West u7si0 4s 456586 wo 00% wen re 2 ng 1826 coverage: of population representa by prevalence suds for mental dsordes, ads for ud ageranges, gender

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