Itzhak Levav

The treatment gap in mental health care

Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.

Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations.

Shekhar Saxena and colleagues summarize the recent WHO Mental Health Gap Action Programme (mhGAP) intervention guide that provides evidence-based management recommendations for mental, neurological, and substance use (MNS) disorders.

Los trastornos mentales en América Latina y el Caribe: asunto prioritario para la salud pública

OBJETIVO: La creciente carga de trastornos mentales que afecta a las poblaciones de America Latina y el Caribe es demasiado grande para hacer caso omiso de ella. Por lo tanto, es una necesidad impostergable conocer la prevalencia de los trastornos mentales y la brecha de tratamiento, que esta dada por la diferencia entre las tasas de prevalencia verdadera y las de las personas que han sido tratadas, que en algunos casos es grande pese a la existencia de tratamientos eficaces. Si se dispone de mayor informacion, se hace mas factible 1) abogar mejor por los intereses de las personas que necesitan atencion, 2) adoptar politicas mas eficaces, 3) formular programas de intervencion innovadores y 4) adjudicar recursos en conformidad con las necesidades observadas. METODOS: Los datos se obtuvieron de estudios comunitarios publicados en America Latina y el Caribe entre 1980 y 2004. En esas investigaciones epidemiologicas se usaron instrumentos diagnosticos estructurados y se estimaron tasas de prevalencia. Las tasas brutas de diversos trastornos psiquiatricos en America Latina y el Caribe se estimaron a partir de las tasas media y mediana extraidas de los estudios, desglosadas por sexo. Tambien se extrajeron los datos correspondientes al uso de servicios de salud mental para poder calcular la brecha en el tratamiento segun trastornos especificos. RESULTADOS: Las psicosis no afectivas (entre ellas la esquizofrenia) tuvieron una prevalencia media estimada durante el ano precedente de 1,0%; la depresion mayor, de 4,9%; y el abuso o la dependencia del alcohol, de 5,7%. Mas de la tercera parte de las personas afectadas por psicosis no afectivas, mas de la mitad de las afectadas por trastornos de ansiedad, y cerca de tres cuartas partes de las que abusaban o dependian del alcohol no habian recibido tratamiento psiquiatrico alguno, sea en un servicio especializado o en uno de tipo general. CONCLUSIONES: La actual brecha en el tratamiento de los trastornos mentales en America Latina y el Caribe sigue siendo abrumadora. Ademas, las tasas actuales probablemente subestiman el numero de personas sin atencion. La transicion epidemiologica y los cambios en la composicion poblacional acentuaran aun mas la brecha en la atencion en America Latina y el Caribe, a no ser que se formulen nuevas politicas de salud mental o que se actualicen las existentes, procurando incluir en ellas la extension de los programas y servicios.

Self-reported Attenuated Psychotic Symptoms as Forerunners of Severe Mental Disorders Later in Life

CONTEXT It has been suggested that attenuated psychotic symptoms (APSs) reported by people who do not have psychotic disorders signal risk for later severe mental illness. OBJECTIVE To investigate this suggestion using follow-up assessments of hospitalization for clinical diagnoses of nonaffective psychotic and other psychiatric disorders. DESIGN Longitudinal cohort study of self-reported APSs with outcome assessment of severe mental illness obtained through linkage with a national hospitalization case registry. SETTING Israel. PARTICIPANTS A stratified full probability sample of 4914 persons aged 25 to 34 years who were screened for psychopathology in the 1980s. MAIN OUTCOME MEASURE Subsequent psychiatric hospitalization was ascertained using the psychiatric hospitalization registry, with a mean follow-up of 24 years. RESULTS After removing subjects with diagnosable psychotic disorders at baseline, 57.2% of the remaining sample reported at least 1 weak (infrequent) APS and 14.3% reported at least 1 strong (frequent) APS in the year preceding the assessment. Self-reported APSs predicted risk of later hospitalization for nonaffective psychotic disorders, mostly during the 5 years after baseline (adjusted odds ratio = 4.31; 95% CI, 2.21-8.41; positive predictive value = 1.27%; population attributable risk fraction = 33%). Also, APSs increased the risk of later hospitalization for other psychiatric disorders, albeit to a lesser extent (adjusted odds ratio = 2.21; 95% CI, 1.02-4.82). CONCLUSIONS Self-reported APSs signal risk for later nonaffective psychotic disorders but are not clinically useful as predictors. The difference between these population-based data and the high-risk literature in terms of the positive predictive value (1% vs 10%, respectively) and the time window of transition (5 years vs 12 months, respectively) can be attributed to the selective enrichment strategies that produce high-risk samples.

Cancer in schizophrenia: is the risk higher or lower?

Studies exploring the relationship between schizophrenia and cancer have shown conflicting results. Our study explores this association in three Jewish-Israeli population groups defined by their continent/place of birth (Israel, Europe-America, and Africa-Asia). The identification of the patients was made through the linkage of the nationwide psychiatric and cancer registries. The incidence of cancer in patients diagnosed with schizophrenia was compared with the incidence in the general population. The results showed that the cancer standardized incidence ratios (SIRs) for all sites were significantly lower among men and women with schizophrenia, 0.86 [95% confidence interval (CI) 0.80-0.93] and 0.91 (95% CI 0.85-0.97), respectively. This reduced overall risk was clearest for those born in Europe-America, both men (SIR 0.85, 95% CI 0.74-0.97) and women (SIR 0.86, 95% CI 0.77-0.94). Among women diagnosed with schizophrenia, the SIR was statistically higher for cancer in the breast among those born in Asia-Africa (1.37, 95% CI 1.12-1.63) and in the corpus uteri among the Israel-born (2.75, 95% CI 1.69-3.81) than among their counterparts in the general population. Lung cancer was significantly higher in men born in Asia-Africa diagnosed with schizophrenia than in the respective comparison population group (1.58, 95% CI 1.13-2.2). Our findings, and those of the literature, justify conducting a multinational study that includes identification of cancer-related risk factors among patients with schizophrenia and their families, and information on the use of psychotropic medications. This effort may clarify an epidemiological puzzle that remains outstanding.

Cancer incidence and survival following bereavement

OBJECTIVES This study investigated the effect of parental bereavement on cancer incidence and survival. METHODS A cohort of 6284 Jewish Israelis who lost an adult son in the Yom Kippur War or in an accident between 1970 and 1977 was followed for 20 years. We compared the incidence of cancer in this cohort with that among nonbereaved members of the population by logistic regression analysis. The survival of bereaved parents with cancer was compared with that of matched controls with cancer. RESULTS Increased incidence was found for lymphatic and hematopoietic malignancies among the parents of accident victims (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.30, 3.11) and among war-bereaved parents (OR = 1.47; 95% CI = 1.13, 1.92), as well as for melanomas (OR = 4.62 [95% CI = 1.93, 11.06] and 1.71 [95% CI = 1.06, 2.76], respectively). Accident-bereaved parents also had an increased risk of respiratory cancer (OR = 1.50; 95% CI = 1.07, 2.11). The survival study showed that the risk of death was increased by bereavement if the cancer had been diagnosed before the loss, but not after. CONCLUSIONS This study showed an effect of stress on the incidence of malignancies for selected sites and accelerated demise among parents bereaved following a diagnosis of cancer, but not among those bereaved before such a diagnosis.

Nongenetic Familial Transmission of Psychiatric Disorders? Evidence from Children of Holocaust Survivors*

There is considerable evidence that psychiatric disorders aggregate in families, a phenomenon for which both genetic and nongenetic explanations have been proposed. However, since genetic and social inheritance usually co-occur, it is difficult to separate out their effects. In this paper, we argue that examining the rates of disorder among children of Holocaust survivors provides a special situation where genetic and nongenetic factors in familial transmission can be separated, and where specific nongenetic mechanisms can be tested. We specify competing hypotheses, and test their viability using data from an epidemiological study of psychiatric disorders conducted in Israel. We find no evidence of higher symptom scale scores or higher rates of current psychiatric disorders for the children of Holocaust survivors. However, they did have higher rates of past disorders.

Trajectories of the course of schizophrenia: from progressive deterioration to amelioration over three decades.

BACKGROUND The extent of heterogeneity in the long-term course of schizophrenia is unclear. AIMS To examine the course of schizophrenia in a population-based cohort. METHODS This study included all Israeli individuals born in 1970-1988, of North African or European origin (N=2290), entered in the National Psychiatric Hospitalization Case Registry with a last discharge diagnosis of schizophrenia (1978-2004) and followed to 2009. Linked socio-demographic information was extracted from the Population Registry. Based on the number of hospitalized days at each age, trajectory groups were empirically derived, plotted and compared on psychiatric hospitalization measures of the course of illness, social factors and family stressors. RESULTS Trajectory analysis identified four course groups. Group I (57%) assumed a prototypical course, had an average first hospitalization age of 20, deteriorated until 23 and then ameliorated. Group II (15.5%) assumed an early-onset protracted course, had an average first hospitalization age of 17.1, and deteriorated until 21. Group III (15%) assumed a late-onset with longest deterioration period course, had an average first hospitalization age of 22.7, and deteriorated until 29. Group IV (12%) assumed an early-onset refractory illness course, had an average first hospitalization age of 18, and had the longest hospitalization period. Groups significantly differed on hospitalization (i.e., onset), social (i.e., socioeconomic and ethnic status) and familial factors (i.e., parental death). Despite group differences all deteriorated and then ameliorated on average by the age of 23. CONCLUSIONS The course of schizophrenia was heterogeneous, yet evolved from deterioration to assume a course consistent with amelioration.

Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas

Excess mortality in persons with severe mental disorders (SMD) is a major public health challenge that warrants action. The number and scope of truly tested interventions in this area remain limited, and strategies for implementation and scaling up of programmes with a strong evidence base are scarce. Furthermore, the majority of available interventions focus on a single or an otherwise limited number of risk factors. Here we present a multilevel model highlighting risk factors for excess mortality in persons with SMD at the individual, health system and socio‐environmental levels. Informed by that model, we describe a comprehensive framework that may be useful for designing, implementing and evaluating interventions and programmes to reduce excess mortality in persons with SMD. This framework includes individual‐focused, health system‐focused, and community level and policy‐focused interventions. Incorporating lessons learned from the multilevel model of risk and the comprehensive intervention framework, we identify priorities for clinical practice, policy and research agendas.

Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries

OBJECTIVE To outline mental health service accessibility, estimate the treatment gap and describe service utilization for people with schizophrenic disorders in 50 low- and middle-income countries. METHODS The World Health Organization Assessment Instrument for Mental Health Systems was used to assess the accessibility of mental health services for schizophrenic disorders and their utilization. The treatment gap measurement was based on the number of cases treated per 100,000 persons with schizophrenic disorders, and it was compared with subregional estimates based on the Global burden of disease 2004 update report. Multivariate analysis using backward step-wise regression was performed to assess predictors of accessibility, treatment gap and service utilization. FINDINGS The median annual rate of treatment for schizophrenic disorders in mental health services was 128 cases per 100,000 population. The median treatment gap was 69% and was higher in participating low-income countries (89%) than in lower-middle-income and upper-middle-income countries (69% and 63%, respectively). Of the people with schizophrenic disorders, 80% were treated in outpatient facilities. The availability of psychiatrists and nurses in mental health facilities was found to be a significant predictor of service accessibility and treatment gap. CONCLUSION The treatment gap for schizophrenic disorders in the 50 low- and middle-income countries in this study is disconcertingly large and outpatient facilities bear the major burden of care. The significant predictors found suggest an avenue for improving care in these countries.