From the Editor
Earlier this month, the Commonwealth Fund released a report that surveyed 11 countries for the performance of their health-care systems; it received much media attention. Their work helps provide perspective on our system’s strengths and weaknesses.
International comparisons are relevant in mental health, of course. As stigma fades and as evidence-based treatment options have expanded, we can ask: are people with common mental health problems getting better? And are there lessons to learn from our national experiences?
This week, we look at a study that has just been published in World Psychiatry, drawing data from four countries. In the paper, Jorm et al. find that – looking at the prevalence of mood and anxiety disorders and symptoms – people aren’t better off today. The authors consider several explanations.
This paper hasn’t gather much attention here in Canada. But as we look to increase funding for mental health services, it’s an important and relevant paper.
Care and Outcomes
“Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries”
Anthony F. Jorm, Scott B. Patten, Traolach S. Brugha, Ramin Mojtabai
World Psychiatry, February 2017
National surveys in a range of countries have found that mental disorders are common and are a major source of disability. However, many cases are untreated, even among people with the most serious disorders. In industrialized countries, 36-50% of serious cases are untreated in the previous year, whereas in developing countries the situation is even worse, with 76-86% untreated. It has been proposed that treatment services need to be expanded to reduce the prevalence and impact of mental disorders.
The ‘treatment gap’ is of such concern that the 2001 World Health Report made ten recommendations for addressing it, including making mental health treatment more accessible in primary care, making psychotropic drugs more available, and increasing the training of mental health professionals. Simulation data suggested that extending the provision of evidence-based treatment would reduce the population burden of mental disorders and provide an economic return on investment.
The aim of the present paper is to review evidence from four industrialized English-speaking countries – Australia, Canada, England (most of the UK population) and the US – on whether increases in treatment provision have been associated with a reduction in prevalence of common mental disorders.
So begins a new paper by Jorm et al.
Here’s what they did:
· Papers were identified based on a PubMed search with search terms like “depression” and “anxiety” and “trends.” Studies were included if they were published between 1990 and 2015.
· “Papers were considered relevant if they covered time trends in prevalence or treatment and were based on assessments at more than one time point.”
· References of retrieved articles were searched, as was “grey literature” based on the authors’ knowledge.
Here’s what they found:
Australia. The authors note a significant increase in mental health spending: “total government expenditure increasing by 178% in real terms between 1992-1993 and 2010-2011.” Availability of psychotherapy has increased; the use of antidepressants is up: “Antidepressant use showed a 352% increase (in terms of daily doses per 1,000 people per day) from 1990 to 2002, mainly associated with the introduction of selective serotonin reuptake inhibitors (SSRIs). This trend continued in the 2000s, with a 95% increase from 2000 to 2011…” Yet despite this, on several national surveys, no reduction in symptoms is noted; “Comparison of the Kessler Psychological Distress Scale (K10) data in the 1997 and 2007 national mental health surveys showed an increase in anxiety symptoms, but no change in depressive symptoms.”
Canada. The authors note an increase in the use of antidepressants. “By 2011, Canada ranked third among OECD countries (behind Australia and Iceland) in antidepressant consumption.” There is evidence that psychotherapy for the treatment of depression increased, too. But national surveys don’t show a reduction in prevalence of symptoms or disorders. For instance, looking at symptoms: “[The K6 scale] may provide broader coverage of common disorders in community populations. There was no evidence of change over time either in the prevalence of elevated distress or in mean distress ratings.”
England. “There was little change in primary care physician contact for a psychological problem over the period from 1993 to 2007. However, the receipt of antidepressants increased significantly, nearly trebling between 1993 and 2000, following which there was no further increase between 2000 and 2007.” The authors note some increase in hypnotics use, but no real change in therapy (up to the year 2007). Despite this: “Recent analyses of the NPMS [a national survey] found no clear secular trend in the prevalence of common mental disorders in general or in depressive episodes in particular between 1993 and 2007.”
United States. The authors look at several national surveys to consider treatment. For example: “Two studies based on 1987 data from NMES [a national
survey] and 1997, 1998 and 2007 data from MEPS [a successor survey] recorded a significant increase in treatment for depression over the 1987 to 2007 period. The increase was more marked in the 1987-1997 period (220% increase, from 0.73% to 2.33%) than the 1998-2007 period (22% increase, from 2.37% to 2.88%).” They note an increase in antidepressants: used for 37.3% of those with depression in 1987 compared to 74.5% in 1997; psychotherapy, though, declined over that period, from 71.1% to 60.2%. Yet “there is no evidence from available studies that the prevalence of these disorders has declined over the past two or three decades.” Indeed, in one national survey, depressive symptoms increased between 2005 and 2010.
All four countries have had increases in rates of treatment for these disorders since the 1990s. This has been consistently seen for use of antidepressants, with large increases in all countries. For psychological therapies, there has been more variability, with increases in Australia and possibly England, decreases in the US and no evidence available in Canada. Despite these changes, none of the four countries had any evidence for a reduction in prevalence of disorders or symptoms over the period. If anything, there were indications of changes in the opposite direction in Australia, England and the US.
The authors weigh different explanations for the lack of progress.
Has a reduction in prevalence been masked by risk factors? They find limited evidence for this. For example, in Canada: “There were no natural disasters affecting the national population. The global financial crisis has had a relatively limited impact in Canada.”
Is poor quality of care an explanation? There seems to be something there. Consider that in Australia: “It has been estimated that 39% of cases of mood or anxiety disorders sought professional help, 26% received an evidence-based intervention, and 16% received minimally adequate treatment…”
They go on to make a couple of suggestions, including a call for prevention:
There is evidence from randomized controlled trials that psychological interventions can have preventive effects in both young people and adults, and that these can be cost-effective. There is also considerable potential for prevention through risk factor modification, including parenting behaviours, school environments, workplace conditions, diet and lifestyle behaviours. Social determinants such as poverty and unemployment are also important for mental health. In all four countries, prevention is receiving piecemeal efforts, with no country having a coordinated national approach, despite calls to do so in several of them.
A few thoughts:
1. This is a good paper; it asks important questions, and provides an international perspective.
2. The results are disappointing, and seen for all four countries. Despite the fact that people are getting more treatment (at least in terms of medications), there has been no real reduction in the prevalence of mood and anxiety disorders and symptoms.
3. The paper does an excellent job of trying to sort out the reasons for the lack of success. It’s difficult not to agree with the conclusion that prevention needs to be more of a priority.
4. The paper doesn’t comment on national reforms, of course. But as Ottawa and the provinces consider mental health reforms – just last week, British Columbia formally agreed to a multi-year mental health investment – this paper holds important lessons. A quick summary in 16 words: more money isn’t enough; basic standards are needed; let’s not forget prevention; and let’s measure outcomes.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.