Ritsuko Kakuma

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND Young peoples health has emerged as a neglected yet pressing issue in global development. Changing patterns of young peoples health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10-24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors. METHODS The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories. FINDINGS The leading causes of death in 2013 for young people aged 10-14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15-19 years (14·2%) and 20-24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20-24 years (17·1%) and the fourth highest for girls aged 15-19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15-19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20-24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20-24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20-24 years. Alcohol and drug use in those aged 10-24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs. INTERPRETATION Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young peoples health risk factors and their determinants in health information systems. FUNDING Bill & Melinda Gates Foundation.

Poverty and common mental disorders in low and middle income countries: a systematic review.

In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals.

Human resources for mental health care: current situation and strategies for action

A challenge faced by many countries is to provide adequate human resources for delivery of essential mental health interventions. The overwhelming worldwide shortage of human resources for mental health, particularly in low-income and middle-income countries, is well established. Here, we review the current state of human resources for mental health, needs, and strategies for action. At present, human resources for mental health in countries of low and middle income show a serious shortfall that is likely to grow unless effective steps are taken. Evidence suggests that mental health care can be delivered effectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, affected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden. We also discuss scale-up costs, human resources management, and leadership for mental health, particularly within the context of low-income and middle-income countries.

Should Meta-Analyses of Interventions Include Observational Studies in Addition to Randomized Controlled Trials? A Critical Examination of Underlying Principles

In their recent article, Shrier et al. (l) considered a 95% confidence interval as being one with a 95% probability that a population parameter is included in the interval and a 5% probability that it will lie outside the interval. We wish to clarify some aspects of confidence intervals’ interpretation. A simple example illustrates our points. Let us consider a group of 20 patients who receive a new treatment. Only 6 fail to respond to the treatment. Let p be the population proportion of possible patients who would not respond to the treatment. p is the parameter of interest; its true unknown value is the quantity to be estimated. Considering the Bernoulli process, the likelihood is p(1 p) for 0 < p < 1. We calculate an exact interval with 90% confidence (2) that happens to be nonsymmetric around 6/20: (0.175, 0.505). This may be the smallest (most precise) 90% confidence interval for the observation ‘‘6 out of 20.’’ The correct interpretation of the information that p is in this interval with 90% confidence is as follows: If we could repeat this procedure over a large number of samples of size 20, the true unknown value of p would be contained in 90% of the intervals; hence, we are confident that our particular interval, (0.175, 0.505), contains the true value of p. Note that we never use the term probability, since this interpretation is actually a frequentist one. The evaluation is based on samples that could have been observed but were not. Note also that since p is not a random quantity in the frequentist environment, p belongs (or not) to the interval without any probability attached to the statement. This is the reason to speak about confidence, not probability. Alternatively, to build Bayesian credible intervals (2, 3), consider a uniform prior in (0;1). This corresponds to normalizing the likelihood function, producing a beta posterior with, for example, a1⁄4 7 and b1⁄4 15. The 90% credible interval, the smallest interval with a posterior probability of 0.9, is (0.165, 0.483). This interval contains pwith a posterior probability of 0.9. In fact, this is the smallest interval that has 90%of the area under the likelihood function. This interval is a bit narrower than the confidence interval presented previously. We have shown that if one decides to use probabilities to replace confidences, the construction of the intervals is completely different than the usual method. In other words, Shrier et al.’s interpretation of the 95% confidence interval given on page 1204 of their article (1) and in their Appendix was technically incorrect. Rather than providing 95% confidence that the true value of the population parameter lies within the interval, the correct interpretation is that with the performance of equivalent studies, 95%of the observed confidence intervals would cover the true value of the parameter—a subtle but important difference, since population parameters are not random quantities and therefore probability statements should not be attached to them. Only in the Bayesian framework, which was not considered by Shrier et al., are parameters treated as random variables.

Delirium in older emergency department patients discharged home: effect on survival

OBJECTIVES: To determine whether prevalent delirium is an independent predictor of mortality in older patients seen in emergency departments (EDs) and discharged home without admission.

PRIME: A Programme to Reduce the Treatment Gap for Mental Disorders in Five Low- and Middle-Income Countries

Crick Lund and colleagues describe their plans for the PRogramme for Improving Mental health carE (PRIME), which aims to generate evidence on implementing and scaling up integrated packages of care for priority mental disorders in primary and maternal health care contexts in Ethiopia, India, Nepal, South Africa, and Uganda.

Public sector mental health systems in South Africa: inter-provincial comparisons and policy implications

BackgroundThere is growing recognition that mental health is an important public health issue in South Africa. Yet mental health services remain chronically under-resourced. The aim of this study was to document levels of current public sector mental health service provision in South Africa and compare services across provinces, in relation to current national policy and legislation.MethodsA survey was conducted of public sector mental health service resources and utilisation in South Africa during the 2005 calendar year, using the World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2.ResultsSouth African policy and legislation both advocate for community-based mental health service provision within a human rights framework. Structures are in place at national level and in all nine provinces to implement these provisions. However, there is wide variation between provinces in the level of mental health service resources and provision. Per 100,000 population, there are 2.8 beds (provincial range 0–7.0) in psychiatric inpatient units in general hospitals, 3.6 beds (0–6.4) in community residential facilities, 18 beds (7.1–39.1) in mental hospitals, and 3.5 beds (0–5.5) in forensic facilities. The total personnel working in mental health facilities are 11.95 per 100,000 population. Of these, 0.28 per 100,000 are psychiatrists, 0.45 other medical doctors (not specialised in psychiatry), 10.08 nurses, 0.32 psychologists, 0.40 social workers, 0.13 occupational therapists, and 0.28 other health or mental health workers.ConclusionsAlthough there have been important developments in South African mental health policy and legislation, there remains widespread inequality between provinces in the resources available for mental health care; a striking absence of reliable, routinely collected data that can be used to plan services and redress current inequalities; the continued dominance of mental hospitals as a mode of service provision; and evidence of substantial unmet need for mental health care. There is an urgent need to address weak policy implementation at provincial level in South Africa.

The treatment of attention-deficit hyperactivity disorder: an annotated bibliography and critical appraisal of published systematic reviews and metaanalyses.

Context: The Agency for Health Care Policy and Research charged the McMaster Evidence-based Practice Center with conducting a comprehensive systematic review of the literature on the treatment of attention-deficit hyperactivity disorder (ADHD), with input from various groups of stakeholders. One strategy used to avoid duplication of work included a critical appraisal of existing systematic reviews and metaanalyses. Objective: To identify and appraise published metaanalyses and systematic reviews on the treatment of ADHD and to produce an annotated bibliography. Data Sources: Medline, Cumulative Index in Nursing and Allied Health (CINAHL), Healthstar, Psycinfo, and Embase were searched to September 1998; the Cochrane Database (1998 issue 3), selected Internet sites, and the files of investigators were also reviewed. Study Selection: Review articles described as systematic reviews or metaanalyses or including a Methods section were identified independently by 3 reviewers. Data Extraction: Two reviewers extracted, by consensus, relevant information on the name, methodological quality, ADHD-related aspects (comorbid disorders, family characteristics) of those reviews; data on the population, study setting, interventions, and outcomes evaluated by the reviews were also retrieved. Results: Thirteen reviews, published from 1982 to 1998, were included. Eight included metaanalysis and 5 a qualitative review. Non-pharmacological treatments were mentioned in 6 reviews and combination therapies in 3. One review focused on the treatment of adults. Forty-seven drugs and 20 adverse effects were mentioned. Most reviews had major methodological flaws. Conclusions: Most published systematic reviews and metaanalyses on the treatment of ADHD have limited value for guiding clinical, policy, and research decisions. A rigorous, systematic review following established methodological criteria is warranted.

The Movement for Global Mental Health

The Movement for Global Mental Health is a coalition of individuals and institutions committed to collective actions that aim to close the treatment gap for people living with mental disorders worldwide, based on two fundamental principles: evidence on effective treatments and the human rights of people with mental disorders.

Spouse similarity for antisocial behaviour in the general population.

BACKGROUND In contrast with the large amount of research on the familial transmission of antisocial behaviour, few studies have investigated similarity between spouses for such behaviour. In addition, none of these studies have examined child conduct disorder (CCD) and adult antisocial behaviour (AAB) separately. METHOD We studied 519 pairs of spouses who completed the Diagnostic Interview Schedule. In each pair, one spouse belonged to a random subsample of persons who had participated in a large population survey and was re-interviewed. Association between spouses for lifetime symptoms and DSM-III criteria of CCD, AAB, antisocial personality disorder and co-morbid psychiatric diagnoses was examined with bivariate and multivariate logistic regression analyses. RESULTS We observed a moderate association between spouses for the presence of CCD (OR = 4.02, 95% CI = 2.03-7.96), and a strong association for the presence of AAB (OR = 20.1, 95 % CI = 5.97-67.5). This similarity for AAB was independent of the similarity for CCD and persisted after adjustment for spousal similarity for disorders co-morbid with AAB. An examination of the relationship between marital status and the presence of CCD and/or AAB in the general population sample (from which originated our sample of couples) suggested that the spousal similarity for AAB was more likely attributable to assortative mating rather than marital contamination. CONCLUSION Our finding of a strong similarity between spouses for AAB has significant implications for both clinicians and researchers. It also suggests that adult antisocial behaviour should be considered as a distinct diagnostic entity, an approach which diverges from DSM-IV diagnostic criteria.