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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 2 The Magnitude of the Problem Neurological, psychiatric, and developmental disorders exact a profound economic and personal toll in developing countries. Brain disorders affect the highest human faculties and, left untreated, can destroy a person's dignity, productivity, and autonomy. Yet despite their importance, these disorders have been largely ignored by public and private health systems in developing countries as compared with diseases that are better understood. Health policy on brain disorders has long been limited by the following misperceptions: The illnesses are a problem in the developed but not the developing world. They do not cause mortality. They are not amenable to treatment. They are too expensive to manage in developing countries. This report seeks to counter each of these notions, the first of which is addressed in this chapter. The impact of brain disorders in developing countries is reviewed from several perspectives: the impact on nations and communities in terms of the overall disease burden due to death and disability, the impact on individuals and families due to lost time, lost productivity, stigmatization and discrimination, the reinforcing roles of poverty and gender inequality, and the lack of capacity to address these problems.
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World EFFECTS ON COMMUNITIES AND NATIONS The Disease Burden Prompted by estimates of the disease burden first published in 1993, health leaders have begun to recognize the major role of brain disorders in the overall burden of disease.[1,2 and 3] Governments and public health policy makers are starting to investigate the impact of this burden on communities and nations (see, for example, Box 2-1 on the 1999 report of the U.S. Surgeon General). Previous comparisons of the contribution of various disorders to the overall burden of disease were based most commonly on the cause of death alone, or sometimes years of life lost (YLLs) by cause. These comparisons dramatically underestimated the importance of brain disorders because these conditions tend to be chronic (not an acute cause of death) and therefore are rarely listed as the immediate cause of death in official records.[ 2,4] Yet depression, epilepsy, and other brain disorders often cause many years of serious disability. Brain disorders are responsible for at least 27 percent of all years lived with disability (YLDs) in developing countries.1  With the exception of Sub-Saharan Africa, brain disorders are the leading contributors to YLDs in all regions of the world (see Table 2-1). In these calculations, the disability-adjusted life year, or DALY (a variant of the better known quality-adjusted life years, or QALY), assesses both disability and premature mortality in a single measure. In combining assessments of YLLs and YLDs, current DALY estimates highlight the significant contribution of brain disorders to the overall disease burden in developing countries (see Table 2-2). Absent data on most developmental disabilities and many adult neurological diseases,2 1998 estimates for brain disorders still show these conditions responsible for nearly 34 percent of all noncommunicable disease DALYs in developing countries (see Figure 2-1). Table 2-2 and Figure 2-2 show the contribution of brain disorders to all DALYs and mortality in developing countries. These conditions account for nearly 15 percent of DALYs and 12 percent of mortality among all disease categories. 3  Current DALY calculations for developing countries, however, reflect only a portion of the disease burden imposed by brain disorders. These sizable cal- 1 The percentage distribution of YLDs attributed to brain disorders is estimated using the 1990 data for neuropsychiatric conditions (25.5 percent), the cerebrovascular disease component of cardiovascular disease (approximately one percent), and the self-inflicted injury component of intentional injuries (approximately .5 percent). 2 Data on such developmental disorders as mental retardation, cerebral palsy, and autism along with adult neurological conditions such as peripheral nerve disease and severe migraine were not accounted for in the estimates of the 1996 Global Burden of Disease study. 3 Category I: Communicable disease, maternal and perinatal conditions and nutritional deficiencies; Category II: Non-communicable disease; and Category III: Injuries.
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World BOX 2-1 Mental Health: A Report of the U.S. Surgeon General In 1999, the U.S. Department of Health and Human Services issued its first Surgeon General's report on the topic of mental health. The report describes recent defining trends in research, treatments, care provision, and public opinion; reviews current knowledge on mental health care for children, adults, and the elderly; and charts a course for improving access to mental health services and effective treatment for mental disorders. About 10 percent of the U.S. adult population uses mental health services in the health sector in any given year, with another 5 percent seeking such services from social service agencies, schools, or religious or self-help groups. Yet despite the relative abundance of mental health care in the United States, as compared with most developing countries, critical gaps exist between those who need mental health care and those who receive service, as well as between optimally effective treatment and the care many people actually receive. Many of the findings in the Surgeon General's report concur with those in this volume. In the United States, as well as in much of the developing world, the stigma of having a mental illness represents a major barrier to treatment. A lack of awareness of the range of treatments for mental illness also hinders access to effective care. Financial barriers prevent many people from seeking mental health care, and capacity is limited by personnel shortages in several key fields. The two main findings of the Surgeon General's report are equally applicable in the developing world and in the United States: The efficacy of mental health treatments is well documented, and A range of treatments exists for most mental disorders. Accordingly, several recommended courses of action based on these findings are also relevant in a broader context: to fight stigmatization by dispelling myths about mental illness and by increasing public awareness of the effectiveness of existing treatments; to establish effective, evidence-based community mental health services; to facilitate access to mental health care by increasing potential points of entry and reducing financial barriers; and to provide “culturally competent ” treatment that recognizes individual differences. While focusing on a subset of the brain disorders discussed in this volume, the Surgeon General's report emphasizes the central importance of the brain. “We recognize that the brain is the integrator of thought, emotion, behavior, and health,” states Surgeon General David Satcher, M.D., Ph.D, in his preface to the report. “Indeed, one of the foremost contributions of contemporary mental health research is the extent to which it has mended the destructive split between ‘physical' and ‘mental' health.” Source: 
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World FIGURE 2-1 Non-communicable disease DALYs attributable to brain disorder, estimates for 1998. FIGURE 2-2 Burden of brain disorders as a percentage of total disease burden in low- and middle-income countries, estimates for 1998. Source:
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World culations are surely lower-bound estimates of the true impact of brain disorders because they do not fully incorporate many of the known neurological and psychiatric sequelae of infectious, nutritional, genetic, and perinatal disorders, as well as environmental exposures. 4 Current data estimating the prevalence of brain disorders is considered inadequate because many patients in developing countries, particularly children with developmental disorders, do not receive medical care. In the United States, 12 to 18 percent of children are estimated to be disabled in some way.[ 8] Comparable measures would be expected to be substantially higher in developing countries, where children are exposed more frequently to infectious diseases and nutritional deficiencies. While improvements in health care and sanitation are enabling more children to survive infancy in developing countries, concomitant efforts to reduce the occurrence of the number of disabled children is very likely to rise.[ 5] Brain disorders in general are expected to play an increasingly important role in the disease burden of developing countries during the next two decades. Data for 1990 on the burden of disease in developing countries have been projected to 2020, based on trends in cause-specific mortality rates, life expectancy, income per capita, human capital, smoking intensity, and HIV and tuberculosis infection rates. One projected calculation is that unipolar depression (the fourth leading cause of DALYs in 1990 for all age groups and the leading cause of DALYs among those aged 15 to 44) will become the leading cause among all age groups combined in 2020 (see Table 2-3, Table 2-4 through Table 2-5). This projected increase in DALYs attributable to depression reflects not only an aging population, but also recent increases in the rate of depression among younger people. Stroke, ranked as the tenth leading cause of DALYs in developing countries in 1990 (see Table 2-3), is projected to be the fifth leading cause in 2020 (see Table 2-5). Improvements in the reliability and validity of data and collection methods for brain disorders in developing countries may well reveal an even greater contribution to disease burden estimates. It should be noted that in calculating disease burden estimates (e.g., YLDs and DALYs), the years of productive life lost as a result of disability are weighted according to expert opinion regarding the severity of a given disability. For example, the disability caused by major depression is estimated by panels of experts as approximately equivalent to that caused by blindness or paraplegia, while the disability caused by schizophrenia lies between that caused by paraplegia and quadriplegia. The assumptions and judgments underlying DALY 4 Neurological and psychiatric sequelae not fully expressed in current DALY estimates include those caused by infectious disease (e.g.. cerebral malaria, HIV encephalopathy, and congenital rubella), nutritional deficiencies (e.g., iodine-deficiency syndrome and vitamin A blindness), perinatal conditions (e.g., birth trauma), genetic conditions (e.g., phenylketonuria and Duchenne's muscular dystrophy), and environmental exposures (e.g.. fetal alcohol syndrome and lead poisoning).
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World estimates are complex and have been controversial. Some of the problems involve the relative value of living assigned to each age group, the comparative severity of different disabilities at different ages, diagnoses of diseases and their classifications, the presumption of disability weights as universal, and the accuracy and completeness of data sets for each country (see Appendix B for additional information on measurement limitations). The estimates will continue to be refined as stronger data and more widely tested assumptions become available. Meanwhile, current estimates using this indicator have provided the public health community with a valuable way to rank the impact of various diseases on health and to recognize the major role of diseases that cause a high level of disability.
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-1 Percentage distribution of years lived with disability (YLDs) for specific causes, 1990 Region Condition Group EME FSE IND CHN OAI SSA LAC MEC Developed Developing World All Causes 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 I. Communicable, maternal, perinatal and nutritional conditions 5.5 7.8 33.6 18.9 28.5 39.3 19.0 24.6 6.3 27.8 24.4 A. Infectious and parasitic diseases 2.6 3.0 14.3 6.4 12.6 22.4 9.7 6.4 2.7 12.3 10.7 B. Respiratory infections 0.3 0.4 1.4 1.4 1.4 1.3 1.0 1.8 0.4 1.4 1.2 C. Maternal conditions 0.6 1.9 4.7 1.9 4.0 5.8 2.7 5.0 1.1 4.0 3.5 D. Conditions arising during the perinatal period 0.5 0.5 3.5 1.1 1.7 3.2 1.6 2.9 0.5 2.3 2.0 E. Nutritional deficiencies 1.5 2.0 9.8 8.2 8.7 6.6 4.1 8.6 1.7 7.9 6.9 II. Noncommunicable diseases 86.7 79.5 43.7 66.9 56.1 39.8 67.3 61.5 84.2 54.8 59.5 A. Malignant neoplasms 3.8 2.5 0.6 1.2 0.9 0.5 0.8 0.5 3.3 0.8 1.2 B. Other neoplasms 1.2 1.1 0.2 0.6 0.4 0.4 0.8 0.4 1.2 0.4 0.5 C. Diabetes mellitus 3.2 1.5 1.0 0.5 1.0 0.3 1.3 1.5 2.6 0.9 1.1 D. Endocrine disorders 1.7 0.7 0.1 0.4 0.4 0.9 2.1 1.2 1.4 0.7 0.8
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World E. Neuro-psychiatric conditions 47.2 37.6 20.9 30.7 28.5 16.3 34.6 25.4 43.9 25.5 28.5 F. Sense organ diseases 0.2 0.2 3.4 2.0 2.7 2.9 1.4 2.0 0.2 2.5 2.1 G. Cardiovascular diseases 6.2 7.1 3.6 3.5 2.9 1.6 2.4 3.8 6.5 3.0 3.6 H. Respiratory diseases 6.1 7.1 5.0 14.0 4.7 6.6 6.1 7.8 6.5 7.7 7.5 I. Digestive diseases 4.1 5.5 2.4 5.1 5.8 3.6 4.3 7.1 4.6 4.5 4.5 J. Genito-urinary diseases 1.1 2.0 0.5 0.8 0.8 0.9 1.3 3.4 1.4 1.1 1.2 K. Musculo-skeletal diseases 8.0 10.2 1.6 3.6 3.1 1.5 6.9 1.8 8.8 2.9 3.8 L. Congenital anomalies 2.0 14.8 3.2 3.0 2.6 3.1 2.8 3.6 1.9 3.0 2.9 M.Oral conditions 1.8 1.8 1.2 1.1 2.0 0.6 2.4 3.0 1.8 1.5 1.6 III. Injuries 7.9 12.7 22.8 14.2 15.4 20.9 13.6 13.9 9.5 17.4 16.1 A. Unintentional injuries 7.1 10.7 22.4 12.9 14.6 16.3 12.3 10.0 8.3 15.4 14.3 B. Intentional injuries 0.8 2.0 0.4 1.3 0.8 4.6 1.4 3.9 1.2 1.9 1.8 Note: EME = Established Market Economies; FSE = Formerly Socialist Economies of Europe; IND = India; CHN = China; OAI = Other Asia and Islands; SSA = Sub-Saharan Africa; LAC = Latin America and the Caribbean; MEC = Middle Eastern Crescent Source: 
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-2 Contribution of brain disorders to disability-adjusted life years (DALYs) and Mortality in low- and middle-income countries, estimates for 1998. Condition DALYs (1,000s) % of Total DALYs Deaths (1,000s) % of Total Deaths All Disease 1,274,259 45,897 Brain Disorders Unipolar major depression 51,217 4.02 0 0 Stroke 36,407 2.86 4,213 9.20 Self-inflicted injuries 19,095 1.50 818 1.80 Bipolar affective disorder 14,421 1.13 15 0.03 Alcohol dependence 13,553 1.06 42 0.09 Psychoses 11,984 0.94 40 0.08 Obsessive compulsive disorders 10,062 0.79 0 0 Alzheimer's disease and other dementias 5,527 0.43 111 0.24 Drug dependency 4,782 0.38 7 0.02 Panic disorders 4,710 0.37 0 0 Epilepsy 4,659 0.37 60 0.13 Post traumatic stress disorders 1,896 0.15 0 0 Multiple sclerosis 1308 0.10 20 0.04 Parkinson's disease 621 0.05 30 0.07 Other neuropsychiatric disorders 9,308 0.73 170 0.37 Total Brain Disorders 189,550 14.90 5,526 12.00 Source: 
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-3 Causes of DALYs (percentage total) in descending order, 1990 Developing Regions Rank Disease or Injury DALYs (1,000s) % of Total All causes 1,218,244 1 Lower respiratory infections 110,506 9.1 2 Diarrheal diseases 99,168 8.1 3 Conditions arising during the perinatal period 89,193 7.3 4 Unipolar major depression 41,031 3.4 5 Tuberculosis 37,930 3.1 6 Measles 36,498 3.0 7 Malaria 31,705 2.6 8 Ischemic heart disease 30,749 2.5 9 Congenital anomalies 29,441 2.4 10 Cerebrovascular 29,099 2.4 11 Road traffic accidents 27,253 2.2 12 Chronic obstructive pulmonary disease 25,771 2.1 13 Falls 24,232 2.0 14 Iron-deficiency anaemia 23,465 1.9 15 Protein-energy malnutrition 20,758 1.7 16 War 18,868 1.6 17 Tetanus 17,513 1.4 18 Violence 15,632 1.3 19 Self-inflicted injuries 15,199 1.3 20 Drownings 14,819 1.2 Source: 
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 2-4 Ten leading causes of DALYs at ages 15–44 years in developing regions, 1990 Both Sexes Males Females Rank Disease or Injury DALYs (1,000s) Cumulative % Disease or Injury DALYs (1,000s) Cumulative % Disease or Injury DALYs (1,000s) Cumulative % Developing Regions All causes 357,437 All causes 180,211 All causes 177,277 1 Unipolar major depression 35,398 9.9 Unipolar major depression 12,658 7.0 Unipolar major depression 22,740 12.8 2 Tuberculosis 19,451 15.3 Road traffic accidents 11,387 13.3 Tuberculosis 8,703 17.7 3 Road traffic accidents 14,321 19.4 Tuberculosis 10,747 19.3 Iron-deficiency anemia 7,135 21.8 4 War 12,382 22.8 Violence 9,844 19.3 Self-inflicted injuries 6,526 25.5 5 Iron-deficiency anemia 12,033 26.2 Alcohol use 8,420 24.8 Obstructed labor 6,033 28.9 6 Self-inflicted injuries 12,004 29.5 War 7,448 29.4 Chlamydia 5,364 31.9 7 Violence 11,448 32.7 Bipolar disorder 5,601 36.7 Bipolar disorder 5,347 34.9 8 Bipolar disorder 10,948 35.8 Self-inflicted injuries 5,478 39.7 Maternal sepsis 5,226 37.8 9 Schizophrenia 9,514 38.5 Schizophrenia 5,068 42.5 War 4,934 40.6 10 Alcohol use 9,371 41.1 Iron-deficiency anemia 4,898 45.3 Abortion 4,856 43.4 Source: 
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World CONCLUSION To compete in international markets and to build stronger national and local infrastructures, developing countries must produce well-educated workers, a process that begins with prenatal care and continues through the adult years of employment. Since many brain disorders interfere not only with health but also with education, they present an especially insidious limitation to developing economies. The consequences for a country's development of ignoring the burden imposed by these disorders are clearly large, and growing larger. These disorders create, special problems for developing countries not only because of the scarcity of resources available to address them but also because of their mutually reinforcing relationship with poverty. Poor women bear an even heavier burden than poor men as a result of several gender-specific risk factors, many of which are preventable. The implementation of cost-effective interventions can help to reduce the impact of these disorders and break this debilitating cycle. Thus, poverty and gender inequality, which contribute greatly to the burden of brain disorders in developing countries, should be viewed as a target of the recommendations made in this report. Despite the increasingly significant contribution of brain disorders to disease burden, these conditions are largely missing from the international health agenda. Stigma, discrimination, economic and gender inequalities, and lack of capacity for addressing these add to their burden in developing countries. Recognizing the importance of brain disorders is the first step toward reducing this burden. The process can be further advanced through increased understanding of the social and economic effects of brain disorders as well as through provision of cost-effective care. REFERENCES 1. R. Desjarlais, L. Eisenberg, B. Good, and A. Kleinman. World Mental Health. Oxford University Press: New York, 1995. 2. World Bank. World Development Report: Investing in Health Research Development World Bank: Geneva, 1993. 3. N. Sartorius, T. B. Ustun, J. A. Costa e Silva, D. Goldberg, Y. Lecrubier, J. Ormel, et al. An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on “Psychological Problems in General Health Care.” Archives of General Psychiatry Oct,50(10):819–824, 1993. 4. T. B. Ustun. The Global Burden of Mental Disorders. American Journal of Public Health Sept. 89(9), 1999. 5. C. Murray and A. Lopez, eds. The Global Burden of Disease. The Harvard Press: Boston, 1996.
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World SUMMARY OF FINDINGS: Integrating Care of Brain Disorders into Health Care Systems Although most developing countries have a system of primary health care, the services available vary widely among communities. They may involve private care (specialists, physicians, or traditional healers) or care provided by governmental or nongovernmental organizations (specialists, physicians, nurses, and other health care workers). Specialists are few and physicians limited; both are concentrated in the cities. Successful management of brain disorders through community-based primary care clinics requires guidance and training of health care workers. This must be followed by monitoring, continuing education, and periodic and continued support of clinics and their staffs by secondary and tertiary facilities, such as district hospitals and centers for training and research. Cost-effectiveness studies using established methods can best guide public investments in management of brain disorders. Optimal approaches to prevention and treatment of these disorders will vary with local needs and costs. Primary health care requires the support of robust national and local policies to adequately address the specific needs of different communities. International expertise and resources will be needed from development banks, international organizations, nongovernmental organizations, health professionals, research institutions, and others to establish comprehensive health care for brain disorders in developing countries.
Representative terms from entire chapter: