https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61729-2.pdf

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010.

Summary Background Comparable data on the global and country-specific burden of neurological disorders and their trends are crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to neurological disorders in 2015 and its relationship with country development level. Methods We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification have been previously spread across multiple disease groupings. The more inclusive grouping of neurological disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer's disease and other dementias, Parkinson's disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility, to identify patterns associated with development and how countries fare against expected outcomes relative to their level of development. Findings Neurological disorders ranked as the leading cause group of DALYs in 2015 (250·7 [95% uncertainty interval (UI) 229·1 to 274·7] million, comprising 10·2% of global DALYs) and the second-leading cause group of deaths (9·4 [9·1 to 9·7] million], comprising 16·8% of global deaths). The most prevalent neurological disorders were tension-type headache (1505·9 [UI 1337·3 to 1681·6 million cases]), migraine (958·8 [872·1 to 1055·6] million), medication overuse headache (58·5 [50·8 to 67·4 million]), and Alzheimer's disease and other dementias (46·0 [40·2 to 52·7 million]). Between 1990 and 2015, the number of deaths from neurological disorders increased by 36·7%, and the number of DALYs by 7·4%. These increases occurred despite decreases in age-standardised rates of death and DALYs of 26·1% and 29·7%, respectively; stroke and communicable neurological disorders were responsible for most of these decreases. Communicable neurological disorders were the largest cause of DALYs in countries with low SDI. Stroke rates were highest at middle levels of SDI and lowest at the highest SDI. Most of the changes in DALY rates of neurological disorders with development were driven by changes in YLLs. Interpretation Neurological disorders are an important cause of disability and death worldwide. Globally, the burden of neurological disorders has increased substantially over the past 25 years because of expanding population numbers and ageing, despite substantial decreases in mortality rates from stroke and communicable neurological disorders. The number of patients who will need care by clinicians with expertise in neurological conditions will continue to grow in coming decades. Policy makers and health-care providers should be aware of these trends to provide adequate services. Funding Bill & Melinda Gates Foundation.

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Global, regional, and national burden of neurological disorders, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61238-0.pdf

No health without mental health.

Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.

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Suicide and Suicidal Behavior

The global burden of mental disorders is enormous. Approximately 450 million people suffer from some kind of mental or neurological disorder at any given moment. These conditions included unipolar depressive disorders, bipolar affective disorder, schizophrenia, epilepsy, alcohol and selected drug use disorders, Alzheimer’s and other dementias, post traumatic stress disorder, obsessive and compulsive disorder, panic disorder, and primary insomnia. Together, it is estimated that these disorders account for 13% of the disability-adjusted life years (DALYs) worldwide. Even in Africa, the WHO region for which mental disorders constitute the smallest percentage of the burden of disease, it is estimated that about 5% of all DALYs are due to mental disorders. Among the 15-44 age group, the most productive segment of the population, mental disorders account for 6 of the 20 leading causes of disability worldwide.1 In addition, there is very high comorbidity between mental and physical disorders, including both infectious and

A Framework for Mental Health Policy, Legislation and Service Development: Addressing Needs and Improving Services

Recent developments, including experience related to the development of WHO's World Health Report 2001, the WHO Atlas and the DCP Project related to Mental, Neurological, Developmental and Substance Abuse Disorders, indicate why advancing the interests of mental health is now so compelling. In order to deliver a high standard of mental health treatment and care WHO emphasizes the adoption of an integrated system of service delivery to address comprehensively the psychosocial needs of people with mental disorders. Even though the burden is large and increasing, the capacity to reach those in need is poor. This gap cannot be filled just by seeking more funding for mental health, more human resources, or more training. Of course, these aspects are key ingredients but what is often neglected is the need to conceive service delivery rationally. Mental health professionals' attention should be channeled towards mental health systems and service organization which obviously has consequences in their training which should include more public health knowledge. We need to know how to plan and organize services and improve the use of scarce financial and human resources in order to reach out to the mental health needs of the general population and to provide effective and humane services to those who need care.

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Mental health systems research is urgently needed.

Heavy drinking has been known for centuries to be a health hazard and cause of death. Eﬀorts to quantify the disease burden associated with diﬀerent risk fac-tors clearly demonstrate that hazardous and harmful alcohol drinking is one of the leading risk factors and is respon-sible for 4% of the global disease burden (1). This enormous health burden, with its numerous social problems associated with disorders attributable to alcohol use, is distributed unevenly: poor and underprivileged groups are often at higher risk and are deprived of health and social interventions that can help to alleviate individual and family distress. According to the results of the Com-parative Risk Assessment (CRA) within the Global Burden of Disease (GBD) study, alcohol is the main risk factor for ill-health in low mortality developing countries, where alcohol consumption is on the rise (2, 3).In countries with high levels of alcohol consumption and hazardous patterns of drinking, the impact of alcohol use on overall mortality and morbidity can be substantial. The article by Nicholson et al. in this issue (pp. 812–819) demonstrates a linear relationship between frequency of drink-ing and binge drinking and long-term all-cause mortality trends in men in the Russian Federation. Whereas cultural norms related to alcohol consumption and overall drinking patterns have probably not changed signiﬁcantly in the recent past, mortality ﬂuctuations in the Russian Federation — which are partly attributed to alcohol consump-tion — are dramatic. As discussed by Nicholson et al., other factors could be involved in these relationships, and a broad understanding of hazardous drinking patterns includes aspects other than just binge drinking. Social and economic factors are powerful determi-nants of alcohol and drug use (4, 5), and enormous social changes experienced by the Russian population (6) have aﬀected the broad context of drinking and risks

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Breaking the vicious circle of determinants and consequences of harmful alcohol use.

731 Psychiatric hospitals often represent the main and sometimes only treatment option available for people with mental disorders.1 This treatment model contradicts the balanced-care model, which suggests that a comprehensive mental health system needs to include and integrate outpatient community care, acute in-patient care in general hospitals and community-based residential care.2 In Italy, the transition from a hospital-based system of care to a model of community mental health care started in 1978 with a reform that led to the gradual closing of psychiatric hospitals. We now reflect on the public health lessons from this transition, which may be useful for countries aiming to implement a community mental health-care model. The first lesson is that psychiatric hospitals are not essential. In Italy, the number of people in psychiatric hospitals declined from 78 538 individuals in 1978 to 7704 in 1998. By 2000, all psychiatric hospitals were closed.3 Currently, no beds in psychiatric hospitals are available; however, there are 10 beds in psychiatric wards located in general hospitals per 100 000 population and 46 beds in community residential facilities per 100 000 population, with wide differences between geographical areas.4 Second, decreasing the number of psychiatric beds does not necessarily lead to increased suicide rates. According to the Organisation for Economic Co-operation and Development (OECD) database, suicide rates have remained stable in Italy: in 1978 there were 7.1 suicides per 100 000 population, while in 2012 there were 6.3 suicides per 100 000 population.5 Third, decreasing the total number of psychiatric beds does not lead to increased compulsory admissions. After the implementation of the Italian reform, the absolute number of compulsory admissions progressively declined, from more than 20 000 in 1978 to less than 9000 in 2015.6 Similarly, the proportion of compulsory psychiatric admissions progressively declined between 1978 and 2005 and remained stable thereafter, accounting in 2015 for less than 5% (8815) of all 187205 psychiatric admissions.6 Fourth, decreasing the total number of psychiatric beds does not lead to increased use of psychiatric forensic facilities. According to the few available data, in 1980 there were 1424 psychiatric patients placed in forensic psychiatric hospitals; in 1987 there were 977 and in 2012 there were 1264.7 In 2016, after the phasing out of forensic psychiatric hospitals, there were 541 individuals placed in new residential facilities providing intensive mental health care to socially dangerous individuals with mental disorders. Additionally, there were 201 individuals with mental disorders placed in psychiatric units in prison, yielding an overall number of 742 people for the year 2016.7 Fifth, the risk of custody, rather than rehabilitation, is not confined to psychiatric hospitals. Italy has invested in psychiatric beds placed in community residential facilities. However, the average length of stay in these facilities is almost two years, with high regional variability.8 This result may suggest that these facilities, rather than focusing on rehabilitation, only provide long-stay residential services. This explanation was also suggested by a survey that showed that almost half the patients in Italian residential facilities were totally inactive, not even assisting with their facility’s daily activities.9 Sixth, consolidation of this transition process may be an uncertain phase. As Italian psychiatry progressed from the stage of change to a consolidation and maintenance phase, the motivation and morale of mental health staff has progressively changed. In the early stages of a service reform, small groups may champion the main proposals and recruit support from other professionals and stakeholder groups.10 During this phase, enthusiasm and motivation is high. However, after a series of ground-breaking initiatives, the Italian mental health system now needs to systematize these changes so that they can be consolidated. However, maintenance activities are inevitably considered less attractive, professionals are less likely to be rewarded for their commitment to the service and are seldom involved in new initiatives for further improvement. Italy currently is in this consolidation phase, with fewer financial resources, and declining motivation and morale among mental health professionals. Countries aiming to implement a community mental health-care model may want to consider these public health lessons. Policy-makers and health-care providers should note that closing psychiatric hospitals was not the main objective of the Italian reform; rather, it was to ensure that citizens with mental disorders would be treated just as other patients. This principle has revolutionized the role and focus of psychiatry in Italy, from custody, coercion and segregation to treatment and care. All the changes to the Italian mental health system have been a consequence of this paradigm shift. ■ The Italian mental health-care reform: public health lessons Corrado Barbui, Davide Papola & Benedetto Saraceno

The Italian mental health-care reform: public health lessons.

This paper presents the results of an Italian multicentre study on the 6-month outcome of psychiatric patients discharged after short-term in-patient treatment from 21 general hospital psychiatric units. Two outcome measures were used: relapses (defined as readmissions for psychiatric treatment or suicide) and community tenure. The data showed, on average, a fairly high relapse rate (43% in 6 months) combined with a good community tenure. The findings are discussed in the light of the heterogeneity in patterns of care provision observed in Italian psychiatric services after the changes introduced by the 1978 Mental Health Act, reported in a previous paper.

Benedetto Saraceno

Papers

A Framework for Mental Health Policy, Legislation and Service Development: Addressing Needs and Improving Services

Mental health systems research is urgently needed.

Breaking the vicious circle of determinants and consequences of harmful alcohol use.

The Italian mental health-care reform: public health lessons.

Outcome of discharged psychiatric patients after short inpatient treatment: an Italian collaborative study