From the Editor

Tim Evans doesn’t mince his words: “The situation with mental health today is like HIV-AIDS two decades ago.”

Tim Evans is a senior director at the World Bank Group. He made these comments after the release of a major new study suggesting that depression and anxiety are undertreated – and costing the world’s economy hundreds of billions of dollars a year.

But this paper has good news: an investment in mental health services will offer a return (counting health benefits) in the range of 3.3 to 5.7.

This week’s Reading: this new paper from The Lancet Psychiatry, and the reaction to it. Note that coverage has included The Guardian and The New York Times (Evans comments are from The New York Times).

I also follow up on last week’s popular Reading on the Goldbloom-Bryden book.


Global Psychiatry

“Scaling-up treatment of depression and anxiety: a global return on investment analysis”

Dan Chisholm et al., The Lancet Psychiatry, April 12 2016, Online First


Worldwide, investments in mental health are very meagre. Data from WHO’s Mental Health Atlas 2014 survey suggest that most low-income and middle-income countries spend less than US$2 per year per person on the treatment and prevention of mental disorders compared with an average of more than $50 in high-income countries. As a result of this limited investment in public mental health, a substantial gap exists between the need for treatment and its availability. This large treatment gap affects not just the health and wellbeing of people with mental disorders and their families, but also has inevitable consequences for employers and governments as a result of diminished productivity at work, reduced rates of labour participation, foregone tax receipts, and increased health and other welfare expenditures. Findings of several national and international studies have shown the enormous economic challenge these disorders pose to communities and society at large as a result of foregone production and consumption opportunities as well as health and social care expenditures. In 2010, worldwide, an estimated US$2·5–8·5 trillion in lost output was attributed to mental, neurological and substance use disorders, depending on the method of assessment used. This sum is expected to nearly double by 2030 if a concerted response is not mounted. In view of this concern, the promotion of mental health and wellbeing have been explicitly included in the United Nations’ 2015–30 Sustainable Development Goals.

Dan Chisholm

So opens new paper written by Dan Chisholm et al. published in The Lancet Psychiatry. Drawing data from dozens of countries, Chisholm and his co-authors attempt to quantify the loss of economic value because of depression and anxiety – and the price and benefit of addressing these disorders.

Here’s what Chisholm et al. did:

· They focused on depression and anxiety disorders in 36 countries, representing 80% of the world’s population. In a nutshell: they estimated the population in need across these countries, then considered the health effects of scaling up intervention, and then the economic benefits.

· To make these calculations, the authors did systematic reviews of depression and anxiety disorders and economic outcomes (including labour force participation and productivity).

· They used the OneHealth tool which estimates the number of people with depression and anxiety living in these 36 countries by 2030. In terms of intervention: “In line with WHO’s Mental Health Gap Action Programme (mhGAP) intervention guide, modelled interventions included basic psychosocial treatment for mild cases, and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases.” Costs included the cost of medications, but follow up visits (14-18 for moderate to severe depression).

· To consider the effect on the labour force, they modeled assuming more participation, with a conservative estimate of 5% more participation because of reduced absenteeism and presenteeism.

· Drawing on the work of Stenberg and his colleagues, they considered the impact on health and economic elements.

Here’s what Chisholm et al. found:

· “Across the 36 largest countries in the world, in the absence of scaled-up treatment, it is projected that more than 12 billion days of lost productivity (equivalent to more than 50 million years of work) are attributable to depression and anxiety disorders every year, at an estimated cost of US$925 billion.”

· The cost of scaling up: “For all 36 countries, the total cost amounts to US$91 billion for depression and $56 billion for anxiety disorders. Treatment of mild cases accounts for less than 10% of total costs for depression and 20% for anxiety disorders.”

· The total then: $147 billion.

· In terms of health impact, scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period. An economic value on these healthy life-years? $310 billion. Bearing in mind economic gains by increased productivity, the gains are greater.

· Benefit ratios were strong:

The authors note:

However, the returns to this investment are also substantial, with benefit to cost ratios of 2·3–3·0 when economic benefits only are considered, and 3·3–5·7 when the value of health returns are also included. To put these findings into context, any benefit to cost ratio exceeding 1 provides a rationale for investment. Compared with some other potential investments in health, ratios of the order reported here can be deemed relatively modest. For example, a return on investment analysis for malaria, also for 2016–30, but using the full value of a statistical life-year, estimated benefit to cost ratios in the range of 28:1 to 40:1.


In an accompanying Comment, Tufts’ Paul Summergrad suggests that the “time for action is now.”

Dr. Paul Summergrad

You can find the piece here:

His commentary is short and readable and doesn’t require much of a summary here.

He reviews the Chisholm et al. paper, and notes that he is almost surely an under-estimate of the impact that global psychiatry could have.

Dr. Summergrad makes good points, including the need to address mood and anxiety disorders, but also to address stigma around mental health problems.

He closes:

We will neither achieve our health or development goals if we fail to move towards those who are suffering, and we will violate the core tenets of our common humanity if we fail to help those who are ill take their rightful place among the citizens of the world. The time for open hearted and generous action is now.

This paper has been widely reported. The New York Times describes both the paper and the interest of the WHO and World Bank in global psychiatry. The Guardian opens with the banner headline “50 million years of work could be lost to anxiety and depression.”

You can find these articles here:

And here:

A few thoughts:

1. This is an incredible study. It’s thoughtful and well constructed, and tangibly quantifies the burden of illness and the task ahead.

2. The coverage of this study is incredible, too. This paper isn’t buried in a journal; it landed in the front section of The New York Times.

3. The interest in this work in the international health community is real. This paper was released at a Washington conference of experts from the WHO and World Bank.

4. It’s difficult not to feel optimistic. For those of us who remember a time when mental illness wasn’t discussed and global psychiatry didn’t really exist (at least in the deliberations of international bodies), the interest raised by this work is compelling.

5. Of course, all economic modeling is crude. Still, as one expert commented to The New York Times, “the analysis used state-of-the-art methods and was persuasive, given how little is known about interventions in developing countries in particular.”

More on the Goldbloom-Bryden Book

Last week, the Reading was an excerpt from How Can I Help?, the new book by Drs. David Goldbloom and Pier Bryden.

In the second quotation, I made an error. “Daryl’s final words to me: It’s too hard.” It should have read: “Daryl’s final words to me: It’s hard.” It’s a significant error given that it misrepresents the comments of a patient who later suicides. I apologize.

I received much feedback about the Goldbloom-Bryden book. No wonder. It’s excellent, and a national bestseller.

Interested in reading more from the book? The Walrus runs a good excerpt in the current issue.

You can find it here:

Or you can pick up a copy. Caversham Booksellers has signed copies.

Here’s the link:

(And recall my disclosure. I’ll disclose that the Toronto community is small and that I’ve met Dr. Bryden on a handful of occasions. And I’ll disclose that, like many who have trained in psychiatry at the University of Toronto, I worked directly with Dr. Goldbloom in residency. I consider him a friend and a mentor. We have also co-written a paper together.)

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.