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INTEGRATING MENTAL HEALTH CARE & CHRONIC NONCOMMUNICABLE DISORDERS
Supported by World Health Organization
DRAFT- not for circulation “Integrating Mental Health Care & Chronic Noncommunicable Disorders” Joint Conference of the Gulbenkian Global Mental Health Foundation, Lisbon, Portugal, The World Health Organisation (WHO), Geneva and The National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India November 13- 15, 2015 NIMHANS Bangalore Patron
Dr. P. Satish Chandra
Convenor
Dr. Mathew Varghese
Organizing Secretary
Dr. Arun Kandasamy
Organizing Committee
Dr. Prabha Chandra Dr. Gururaj Gopalkrishna Dr. N.Girish
Editorial Board
Dr. Pratima Murthy Dr. Srikala Bharath Dr. Gitanjali Narayanan Dr. Soundarya Soundararajan
Scientific Committee
Dr. Vivek Benegal
Treasurers
Dr. C. Naveen Kumar Dr. P. T. Shiva Kumar
BACKGROUND DOCUMENT
EDITORS
Pratima Murthy Srikala Bharath Gitanjali Narayanan Soundarya Soundararajan
Conference on “Integrating Mental Health Care & Chronic Noncommunicable Disorders”
NIMHANS, Bangalore
2015
Table of Contents NONCOMMUNICABLE DISEASES ............................................................................................................. 1 Urgency for addressing NCDs ............................................................................................................. 2 Status of noncommunicable diseases in SAARC ................................................................................. 3 Mental health and NCDs ..................................................................................................................... 4 Indian context ..................................................................................................................................... 7 A LIFECOURSE PERSPECTIVE ................................................................................................................... 8 Children and adolescents .................................................................................................................... 8 Epidemiology of mental disorders in children and adolescents ..................................................... 8 Prenatal risk factors ...................................................................................................................... 11 Prematurity, low birth weight & mental health ........................................................................... 13 Childhood ...................................................................................................................................... 13 Adulthood, NCDs and mental health ................................................................................................ 18 Risk factors .................................................................................................................................... 19 NCDs and mental disorders in adults ............................................................................................ 23 Older adults....................................................................................................................................... 27 EFFECTIVE MENTAL HEALTH CARE - CHALLENGES & STRATEGIES IN SAARC........................................ 29 At policy level .................................................................................................................................... 30 Strategies ...................................................................................................................................... 30 At practice & research level .............................................................................................................. 31 Strategies ...................................................................................................................................... 31 At health care delivery level ............................................................................................................. 32 Strategies ...................................................................................................................................... 32 At individual level.............................................................................................................................. 35 Strategies ...................................................................................................................................... 35 Our goals ........................................................................................................................................... 39 Nationspeak - Speaking in the language of people........................................................................... 43 SUMMARY AND RECOMMENDATIONS ................................................................................................. 45 REFERENCES .......................................................................................................................................... 48
ABBREVIATIONS
ADHD
Attention Deficit Hyperactivity Disorder
ADL
Activity of Daily Living
COPD
Chronic Obstructive Pulmonary Diseases
CVAs
Cerebrovascular accidents
CVD
Cardiovascular diseases
DALYs
Disability adjusted life years
FASD
Fetal Alcohol Spectrum Disorder
HIV
Human immunodeficiency virus
LMICs
Low and middle income countries
NCDs
Noncommunicable diseases
NCMH
National Commission on Macroeconomics and Health
NDDTC
National Drug Dependence Treatment Centre
SAARC
South Asian Association for Regional Cooperation
SDG
Sustainable Development Goals
UNMDG
United Nations Millennium Development Goals
WAPPA
Workplace Alcohol Prevention Programme and Activity
NONCOMMUNICABLE DISEASES The rise in the prevalence and significance of Noncommunicable diseases (NCDs) is the result of complex interaction between health, economic growth and development. It is also strongly associated with universal trends such as ageing of the global population, rapid unplanned urbanization and unhealthy lifestyles. Common NCDs include cardiovascular diseases (diseases of the heart and blood vessels), stroke, cancer, diabetes, chronic respiratory diseases (asthma, chronic obstructive pulmonary disease due to indoor and outdoor pollution) and common mental health disorders (including anxiety and depression). Noncommunicable diseases (NCDs) impose a large burden on human health worldwide. FIGURE 1 NONCOMMUNICABLE DISEASES CONTRIBUTING TO GLOBAL BURDEN
Decrease productivity
NCDs
Economic, social, health burden
Prolong disability
Diminish resources
One of the UN Millennium Development Goals (UNMDG) 2015 and Sustainable Development Goals (SDG) 2030 is to eradicate extreme poverty1,2. NCDs threaten progress
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towards these agenda. Cumulative economic losses to low and middle-income countries (LMICs) from the four major diseases (cardiovascular, diabetes, respiratory and cancer) are estimated to surpass US$ 7 trillion over the period 2011-2025 (an average of nearly US$ 500 billion per year) globally3. In low-resource settings, health-care costs for cardiovascular diseases, cancers, diabetes or chronic lung diseases can quickly drain household resources, driving families into poverty. The rapid rise in NCDs is predicted to impede poverty reduction initiatives in low-income countries, particularly by increasing household costs associated with health care. Vulnerable and socially disadvantaged people get sicker and die sooner than people of higher Poverty is social positions, especially because they are at greater risk of being closely exposed to harmful products, such as tobacco or unhealthy food, and have limited access to health services. This is more so for indigenous linked populations including adivasis with poor access to health4. with In many countries, harmful alcohol use and unhealthy diet and NCDs lifestyles occur both in higher and lower income groups. However, highincome groups can access services in private sectors that protect them from the greatest risks while lower-income groups can often not afford such services. As in the West, majority do not have insurance to cover health care costs. The exorbitant costs of NCDs, including often lengthy and expensive treatment and loss of breadwinners, are forcing millions of people into poverty annually, stifling development. Urgency for addressing NCDs Adding urgency to the NCD debate is the likelihood that the number of people affected by NCDs will raise substantially in the coming decades. FIGURE 2: PROJECTION OF MORTALITY RATES (2012 TO 2030) 80 70 60 50 40
2012
30
2030
20 10 0 communicable diseases
non-communicable diseases
injuries 5, 6
2
Globally, NCDs accounted for 68.4% of all deaths in 2012 6and 80% of these deaths occurred in low- and middle-income countries6. This death toll due to NCDs has been projected to 14.2 million people die from NCDs prematurely between the ages of 30 and 70 years every year 5 increase to 73.9% in 20307. Most of these largely preventable deaths occur in developing countries, where this epidemic threatens to undermine social and economic development. Status of noncommunicable diseases in SAARC Although high-income countries currently bear the biggest economic burden of NCDs, the developing world, especially middle-income countries, are expected to assume an even larger share as their economies and populations grow. While we have been fighting with communicable diseases like tuberculosis and HIV, we find newer health problems in the form of Noncommunicable Diseases (NCDs). The countries are experiencing a rising burden of Noncommunicable Diseases (NCDs) emerging as a leading cause of death. FIGURE 3: MORTALITY RATES (IN MILLIONS) IN SAARC – 2012
Injuries
Communicable diseases
Non communicable diseases
Total deaths
0
2
4
6
8
10
12
14
5
(This graph depicts that, in SAARC 58.5% of deaths were due to Noncommunicable diseases in the year 2012) In 2013, 7.37 million died due to NCDs in SAARC countries5
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FIGURE 4: PROPORTIONAL MORTALITY (%) BY CAUSE IN 2012
Total Srilanka Pakistan
Injuries
Nepal Communicable diseases
Maldives India
Non - communicable diseases
Bhutan Bangladesh Afghanistan 0%
20%
40%
60%
80%
100%
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(Proportional mortality due to noncommunicable diseases is higher in SAARC countries especially in Sri Lanka and Maldives) Mental health and NCDs Poor mental health exacerbates a number of noncommunicable disease risk factors, including poor lifestyle choices leading to obesity, inactivity, and tobacco use; poor health literacy; poor access to health promotion activities; and symptoms such as lack of motivation and energy. Heavy alcohol use, besides being frequently associated with a range of mental disorders, is also a major risk factor for cancer, cardiovascular disease, stroke, and liver disease and can compromise immune and cognitive functions—which in turn could further complicate the delivery of and adherence to complex treatment regimens for comorbid conditions. Further, co-morbidity between mental disorders and NCDS affect help seeking behaviours due to which either can go unrecognized. The burden of mental disorders goes beyond what has been defined as Disability Adjusted Life Years (DALYs). A recent meta-analysis states that 14.3% of deaths worldwide, or approximately 8 million deaths each year, are attributable to mental disorders8. Thus mental disorders are one of the dominant contributors to the global economic burden caused by NCDs.
Poor mental health is associated with higher mortality in people with noncommunicable diseases compared to that of people without comorbid mental disorders8
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Recent data states that, globally, on average one in five adults (17.6%) experienced a common mental disorder within the past 12 months and 29.2% across their lifetime9.
GLOBAL PREVALENCE OF COMMON MENTAL DISORDERS AND LIFETIME ESTIMATES 9 COMMON MENTAL ILLNESSES Anxiety disorders
12 MONTH PREVALENCE RATES (%) 6.7
LIFETIME ESTIMATES (%)
Mood disorders
5.4
9.6
Substance Use Disorders
3.8
10.7
12.9
Also, there are robust gender effects across the clinical subdomains of mental disorder that is evident for both period and lifetime prevalence estimates. Females have higher prevalence rates of mood (7.3:4.0%) and anxiety disorders (8.7:4.3%) and relatively lower prevalence estimates of substance use disorders (2.0:7.5%)9. Not surprisingly, given the high prevalence of both noncommunicable diseases and mental disorders, comorbidity of these two groups of health conditions also occurs frequently10. Mental illnesses and noncommunicable diseases could potentially influence each other in terms of progression and hastening the consequences11. Unlike other diseases, much of the economic burden of mental illness is not only the cost of care, but the loss of income due to unemployment, expenses for social supports, and a range of indirect costs due to a chronic disability that begins early in life. Mental illness, in addition to itself being an NCD is also interrelated with other NCDs in many other ways.
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FIGURE 5 COMMONALITIES BETWEEN NCDS AND MENTAL DISORDERS – AT AN INDIVIDUAL LEVEL
COMMON RISK FACTORS stress, diet, substance use, physical inactivity, childhood adversities
CO-OCCURRENCE mental disorders might aggravate incidence of NCDs and vice versa
IMPACT absenteeism, early retirement, disability, poor productivity, poor quality of life, increased mortality
REDUCED ECONOMIC RESOURCES Greater spending on healthcare, debts, reduced savings
LOW ECONOMIC DEVELOPMENT Poverty and inequality
Shared risk factors and the high prevalence of co-morbidity between NCDs and common mental disorders provide clear support for the implementation of a shared framework for the prevention and treatment of NCDs and mental disorders12.
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Indian context
2.8 million 63 million
• living with cancer currently • living with diabetes currently
39 million
• living with respiratory illnesses currently
29 million
• living with cardiovascular diseases currently
52.82 million*
• adults living with mental illnesses currently
5,13
India stands to lose $4.58 trillion before 2030 due to NCDs and mental health conditions. Cardiovascular diseases, accounting for $2.17 trillion, and mental health conditions ($1.03 trillion), will be the main contributors to economic loss80
*(Calculated for the Indian adult population (2011 census)14 based on the 7.5% prevalence of any mental disorder in adult population of the district of Kolar, Karnataka, India)
The burden and impact of mental and behavioural disorders in India is high, though not Many recent reports suggest that the incidence of noncommunicable diseases and mental disorders are increasing 81,82,83.
measured. Distribution of mental disorders also varies with age, socioeconomic status, gender and rural and urban settings. The comorbidity between noncommunicable diseases and mental disorders is particularly associated with a strong social gradient and is more common in those living in deprived areas than in residents of areas with more resources. A high proportion of the Indian population resides in rural settings with significantly higher poverty rates than the urban setting. There is a strong association between age and mental illness in rural populations in India (R^2 = 0.81) meaning that 87% of the variance in the prevalence is explained by age15. Because poverty is an important social determinant of mental disorders, the differences in prevalence between rural and urban settings also need to be addressed for planning and development of services to the population.
The rural population has significantly higher rate of mental illness compared to the urban settings15.
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A LIFECOURSE PERSPECTIVE Children, adults and the elderly are all vulnerable to the risk factors that contribute to noncommunicable diseases, whether from unhealthy diets, physical inactivity, exposure to tobacco smoke or the effects of the harmful use of alcohol. There is an existing relationship between mental illnesses and noncommunicable diseases throughout the lifespan of an individual10. Children and adolescents NCDs impact the health of children (directly and indirectly) just as much as they influence the health of adults. Cancer, diabetes (both type 1 and type 2 diabetes), chronic respiratory diseases (such as asthma), congenital and acquired heart disease and many endemic NCDs all affect children. Children suffer from a wide range of NCDs: some are triggered in childhood by a complex interaction between the child's body, surrounding environment, living conditions, infectious agents, nutritional and/or other factors, with consequent scope for preventive action.
1.2 million children and youth under age 20 died of NCDs in 2002, globally6, 8
NCDs are a major cause of preventable mortality, morbidity and disability amongst children in Low- and Middle-Income Countries (LMICs). Many of these children die prematurely because of late diagnosis and/or lack of access to appropriate treatment; those fortunate to survive often experience significant hardship and disability as a result of living with a chronic health condition that is not optimally managed. The global profile of childhood NCDs in LMICs will continue to emerge as infectious conditions are increasingly brought under control. Epidemiology of mental disorders in children and adolescents
Psychiatric epidemiological studies from high-income countries indicate that more than a quarter of children and adolescents meet lifetime criteria for a mental disorder 16. Half of mental illnesses first manifest prior to 14 years of age17 and these tend to be enduring. The evidence base on the burden of child and adolescent mental disorders in LMIC is relatively small due to a number of factors: in particular, insufficient skilled human resources, low awareness and low priority, high service load and a greater concern for child mortality than morbidity. There was a recent meta-analysis reporting a prevalence of 6.4% in community samples and 23.33% in school samples in India16.
Neuropsychiatric conditions are the leading cause of disability in young people in all regions6, 9
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FIGURE 6: ADOLESCENT POPULATION AND PREVALENCE OF CHILD AND ADOLESCENT MENTAL DISORDERS
World population 7 billion
World adolescent population - 1.2 billion (17% of world population)
Prevalence of child and adolescent mental disorders
• •
Prevalence of child and adolescent mental disorders - 10-20%
India's adolescent population - 243 million (20% of world's adolescents)
community based studies – 6.46% school based studies – 23.33% 0-6 years 158.8 million 0-14 years - 30.9 million
16 ,18, 19, 20, 21
(This figure depicts the distribution of adolescent population in the world and Indian context. The prevalence of mental disorders among child and adolescent population from recent studies are quoted)
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FIGURE 7: SHARED RISK FACTORS OF MENTAL DISEASES AND NCDs FROM PRENATAL TO ADOLESCENT LIFE
BEFORE BIRTH
Prenatal exposure to tobacco and alcohol, maternal nutrition/stress Maternal stress
Low birth weight, prematurity, birth trauma
AT BIRTH
INFANCY AND CHILDHOOD
Substance use, Peer pressure, Stress, Physical inactivity, Obesity, Suicidal ideations, Internalizing (like depression/anxiety) & Externalizing disorders (like conduct disorders &ADHD)
ADOLESCENCE
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Malnutrition, Diabetes, Stress, Violence, Respiratory problems
Prenatal risk factors Recent evidence indicates that perinatal exposure to maternal obesity, metabolic disease, including diabetes and hypertension, and unhealthy maternal diet has a long-term impact on offspring behaviour and physiology. During the past three decades, the prevalence of both obesity and neuropsychiatric disorders has rapidly increased22. Epidemiologic studies provide evidence that maternal obesity and metabolic complications increase the risk of attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, anxiety, depression, schizophrenia, eating disorders (food addiction, anorexia nervosa, and bulimia nervosa), and impairments of cognition in the offspring22. Maternal drug exposure
Although the placenta was once thought to protect the fetus against exposure to toxins, it is now known that metabolites of drugs, including cocaine, opiates, amphetamines, marijuana, and tobacco, enter the fetal bloodstream. Active metabolites can penetrate the fetal bloodbrain barrier and interfere with early neuronal cell development or cause neuronal death 23. Researchers hypothesize that drug metabolites interact with an individual’s genetic makeup to influence cognitive development and behaviour. Excessive alcohol use in pregnancy can lead to a range of physical, behavioural and cognitive sequelae in the child, generally known as Fetal Alcohol Spectrum Disorder (FASD)24,25. Studies have shown that children exposed to low levels of alcohol in pregnancy displayed neuropsychological deficits, particularly in attention, learning and cognitive flexibility, when compared with those with no prenatal exposure to alcohol26. There is evidence for the deleterious long lasting effect of antenatal exposure of alcohol on cardiac autonomic regulation27.
Even low-to-moderate alcohol use in pregnancy can cause neuropsychological impairments without any evidence of physical abnormality86
Nicotine is just one component of tobacco smoke and smokeless tobacco products. However, there is increasing evidence for specific effects of prenatal nicotine exposure that leads to adverse health effects in new-borns, infants, children, adolescents and adults. Maternal smoking during pregnancy has been related to multiple adverse effects including pregnancy complications and risks of preterm delivery, lower birth weight, reduced lung function in infants and sudden infant death syndrome28. The majority of studies, and especially several recent epidemiological studies, observed a higher likelihood for attentiondeficit/hyperactivity disorder (ADHD) or ADHD symptoms in children who had prenatal tobacco exposure.
There is a higher risk for ADHD symptoms not only in children exposed to maternal smoking during pregnancy but also in those whose mother did not smoke but was
exposed to environmental tobacco smoke during gestation87
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Pregnant women using smokeless tobacco are not exposed to the combustion products in tobacco smoke (e.g. carbon monoxide and cyanide) that may contribute to fetal hypoxia and reduced birth weight, but as nicotine levels may be very high the fetal exposure to nicotine may be unaltered or even increased.
Consumption of smokeless tobacco during pregnancy decreases gestational age at birth and birth weight independent of gestational age88.
Maternal nutrition
Being born to a malnourished mother increases an infant’s risk of under-nutrition, low birth weight, and increased vulnerability to NCDs in adulthood.
The role of maternal dietary intake, specifically, has been highlighted after recent studies have shown maternal diet quality to predict mental health problems in offspring. During pregnancy, and particularly early pregnancy, exposure of the developing fetus to an unfavourable environment predisposes the unborn child to numerous chronic diseases 29. Even in the pre-conception period, maternal nutrition can have permanent and sustained phenotypic consequences for offspring. There is an established link between maternal diet and neurological, immunological, and central nervous system development of offspring, all of which can play a crucial role in the subsequent development of mental disorders. Higher intakes of unhealthy foods during pregnancy predicted externalizing problems among children, independently of other potential confounding factors and childhood diet 30. Maternal stress and mental health
Stress during pregnancy is one of the determinants of delay in motor and mental development in infants and may be a risk factor for later developmental problems33
In-utero exposure to elevated levels of the stress hormone cortisol negatively affects offspring cognition, health and educational attainment 31. Cortisol is considered a key agent in prenatal programming. Prenatal programming refers to “the action of a factor during a sensitive period or window of fetal development that exerts organizational effects that persist throughout life”32. Researchers have also linked stress and elevated cortisol in late pregnancy with poor mental and motor development of human offspring33.
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FIGURE 8: CONSEQUENCES OF MATERNAL DEPRESSION ON CHILD’S MENTAL HEALTH AND DEVELOPMENT
CHILDHOOD •lower cognitive performance •internalizing and externalizing disorders •lower rates of social interaction •low cognitive performance •delayed speech
SCHOOL AGE •impaired adaptive functioning •internalizing and externalizing disorders •affective disorders •anxiety disorders •conduct disorders •ADHD
ADOLESCENCE •depression •anxiety disorders •phobias •panic disorders •conduct disorders •substance use •ADHD •learning disorders
Prematurity, low birth weight & mental health
A very recent study suggests that children with ADHD born prematurely and/or whose mothers experienced moderate to extreme stress during pregnancy are at significantly higher risk of developing asthma than children born at term or those whose mothers were exposed to no or mild stress34. As reported by a recent study, very preterm (gestational age at birth
