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By Catherine Robertson Souter
Thousands of interviewers in 28 countries are compiling information
on the prevalence, severity and treatment of mental health disorders
around the world. Researchers are calling it the most complex psychiatric
epidemiological study ever attempted.
The study's first section incorporates data from 60,463 face-to-face
household surveys with adults in 14 countries conducted from 2001
to 2003. The results, released in the June Journal of the American
Medical Association, were analyzed to identify trends in the occurrence
of mental illness around the world. The results list the U.S as
having the highest rates of mental illness (at 26.4% compared with
4.3% in Shanghai or 8.2% in Italy). It was, however, noted that
these numbers might be relatively high because of cultural opposition
to disclosing symptoms or recognizing their significance in other
countries.
"Some countries have a different tradition about public opinions.
In a number of these countries, the people have never been interviewed
before, didn't know there was such a thing as an interview. And
they don't know what 'confidential' means. They just assume we are
going to tell somebody about this. It's not terribly clear whether
we are getting the same results in every country," says Ronald Kessler,
Ph.D., a Harvard Medical School sociologist who co-authored the
study with World Health Organization (WHO) psychiatrist T. Bedirhan
Üstün, M.D., P.D.
The researchers are not as interested in which countries have higher
rates of illness, he explains, particularly because cultural variations
make comparisons difficult, Instead, they are focusing on comparing
mental health across a broader spectrum.
"For instance, does it look like depression is always higher in
women than in men in every country and what's the relationship between
poverty and treatment and what percent are getting treatment?" Kessler
says. "The interesting issue, one that's gotten a lot of interest,
is 'gee, is America more crazy than the rest of the world?' But,
that's one that's going to take us several years before we really
feel comfortable saying yes or no."
To date, a total of 28 countries have participated in the survey,
with more than 200,000 interviews conducted. Both Brazil and Bulgaria
have recently begun to conduct the study.
Because of the study's breadth and the commitment from various
funding sources including the World Health Organization, governments
of the various countries and foundations and industry supporters,
researchers have been able to direct the content of the study to
answer several questions.
"This study is close to a $100 million undertaking," Kessler says.
"As in most immense surveys, we have a number of goals. It's so
expensive, that if you just had one question to ask you could never
justify doing something this big. So there are several streams."
A very important piece, he says, is gaining support for the WHO's
Global Burden of Disease Initiative.
"The WHO is trying to convince governments around the world that
mental health problems should be taken seriously in a systematic
way, in ways that many governments don't and particularly in developing
countries where there is a lot more money spent on roads or on guns
than on health," Kessler says. "The argument is that the human capital
potential of a country requires you to have educated and healthy
citizens and you are just never going to become a developed country
unless you can do that. You have to make investments in your citizens."
"To many people's surprise when the Global Burden of Disease report
first came out in the late 1990s, it said that the number one most
burdensome illness in the world among people in the productive years
of life was not cancer or heart disease or diabetes. It was depression.
This just sort of knocked everybody's socks off. In fact four out
of the top 10 conditions in the world are mental disorders. It really
put mental illness on the map for a lot of governments," Kessler
adds.
The problem with the original study, Kessler says, was that results
were based on weak survey data about prevalence. The study did not
have the impact they had anticipated. Therefore, the current researchers
want to compile firm statistical data that will give a more accurate
estimate of the cost to society of mental illness in a way that
will persuade governments to fund mental health treatment.
"From a policy perspective, that's really the biggest reason for
doing the study," Kessler explains. "But once we decided it was
worthwhile doing it for that reason, a whole bunch of other things
that we've always wanted to know came up. We're interested in quality
of care and details of treatment, in barriers to treatment - are
they psychological or physical or monetary barriers? We're also
interested in some basic science questions like do gender differences
in depression look the same in every country or do the relative
rates of depression for men and women vary as a function of the
position of women in society?"
In addition, researchers hope to gain information on genetics'
role in mental illness and information that will help with the proposed
changes to the American Psychiatric Association's DSM-IV and the
International Classification of Diseases, both of which are scheduled
to undergo updates within the next several years.
The study, begun in 1998, is funded for an additional five years
of analysis. Additional research will include sending clinicians
familiar with each country on follow-up interviews to verify the
results. Several countries are planning to track the progress of
these same individuals and others have begun interviewing the children
of respondents.
"As it evolves, we're coming to realize that this is turning into
an ongoing international mental health network that probably will
have a life beyond this one study," Kessler says.
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