The WHO World Mental Health Survey: Global Perspectives on the Epidemiology of Mental Disorders

The effect of mental illness on a global level is profound, with an impact on communities worldwide from a social, cultural, and economic perspective. Although most psychiatry and psychology texts provide some statistical analyses of mental health disorders and their treatment, the epidemiology of mental illness is still poorly understood. This book reports results from the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative, the largest coordinated series of cross-national psychiatric epidemiological surveys ever undertaken. Results from discrete surveys of seventeen different countries on four continents are reported here for comparison and cross-referencing. Many of the countries included in the WMH surveys had never before collected data on the prevalence or correlates of mental disorders in their country, and others had information on mental disorders only from small regional studies prior to the WMH survey. These surveys provide valuable information for physicians and health policy planners and provide greater clarity on the global impact of mental illness and its undertreatment.

Dr. Ronald C. Kessler is a professor in the Department of Health Care Policy at Harvard Medical School.

Dr. T. Bedirhan Üstün works in the Classification, Assessment, Surveys, and Terminology Division of the Department of Health Financing and Stewardship at the World Health Organization, Geneva, Switzerland.

Ronald C. Kessler

Harvard Medical School

T. Bedirhan Üstün

World Health Organization

CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi

Cambridge University Press
32 Avenue of the Americas, New York, NY 10013-2473, USA

www.cambridge.org
Information on this title: www.cambridge.org/9780521884198

© World Health Organization 2008

This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

First published 2008
Printed in the United States of America

A catalog record for this publication is available from the British Library.

Library of Congress Cataloging in Publication Data

The WHO Mental Health Survey: global perspectives on the epidemiology of mental disorders /
edited by Ronald C. Kessler, T. Bedirhan Üstün.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-521-88419-8 (hardback)
1. World Mental Health Survey Initiative. 2. Mental health – Statistics. 3. Mental health
surveys. 4. Psychiatric epidemiology. I. Kessler, Ronald C. II. Üstün, T. B.
III. World Health Organization.
\DNLM: 1. Mental Disorders – epidemiology. 2. Health Surveys. WM 140 W927 2008]
RA790.5.W15 2008
362.2′0422–dc22 2008007732

ISBN 978-0-521-88419-8 hardback

Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this publication to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

Contents

Acknowledgments

The World Health Organization (WHO) World Mental Health (WMH) Survey Initiative had its beginnings in the late 1990s in the work of an earlier WHO research consortium (Kessler 1999). That earlier consortium was created to facilitate cross-national comparisons of the results obtained in community epidemiological surveys in which the WHO Composite International Diagnostic Interview (CIDI) (Robins et al. 1988) was used to estimate the prevalence and correlates of ICD-10 and DSM-III-R disorders. The members of that earlier consortium were frustrated by the lack of consistency in the measurement of the many nondiagnostic variables in early CIDI surveys that are of interest to researchers who carry out surveys of this type, such as measures of risk factors, social consequences, and treatment. As new researchers began contacting the consortium for advice in planning future CIDI surveys, we saw the opportunity to correct the problem of incomparability by bringing together these new researchers in order to coordinate the measurement of non-diagnostic variables in future CIDI surveys. Our hope at that time was that we might be able to coordinate such surveys from a half-dozen countries for purposes of rigorous cross-national comparison. We never anticipated that the new consortium would end up including the current complement of interviews with nearly 200,000 respondents in close to 30 countries, nor that our efforts to include nondiagnostic measures would result in the complete revision of the CIDI that has subsequently occurred (Kessler & Üstün, 2004).

This first volume in the series of volumes that will report key WMH results presents an overview of the Initiative and descriptive data on patterns and correlates of prevalence and treatment in the first 17 countries that completed their WMH surveys. Future volumes will investigate more targeted issues and will expand the number of countries included as the data from these countries come on line. The results in the current volume will be updated for new WMH countries as the data from these countries become available. Our web site (www.hcp.med.harvard.edu/wmh) will provide details on access to these new results. The web site also lists the many journal articles and reports prepared by WMH collaborators to present country-specific, regional, and worldwide WMH results in a wide variety of topic areas. These postings are updated on an ongoing basis to provide current information on all available WMH reports.

We want to thank many people for making the WMH Survey Initiative possible. To begin at the beginning, we thank Darrel Regier for his vision and Lee Robins for her implementation in creating the first fully structured research diagnostic interview capable of being used by trained lay interviewers to make accurate diagnoses of mental disorders in general population samples. The instrument they developed, the Diagnostic Interview Schedule (DIS) (Robins et al. 1981), was used in the landmark Epidemiologic Catchment Area (ECA) surveys in the United States. The widespread dissemination of ECA results (Robins & Regier 1991) led to a new generation of psychiatric epidemiological studies being carried out in many countries around the world (Cross-National Collaborative Group 1992; Weissman et al. 1993; Weissman et al. 1994) and these, in turn, led to the development of the CIDI.

The Institute for Social Research (ISR) at the University of Michigan helped us early in the development of WMH in supporting and hosting several collaborator meetings. Steve Heeringa and Beth-Ellen Pennell from ISR, in addition, have been key collaborators from the beginning of WMH as Co-Directors of the WMH Data Collection Coordinating Centre. Pennell spent a year in Geneva at WHO to help jump-start the training and quality control monitoring phases of the centralized data collection process. She and Heeringa and their staff have subsequently been the driving force behind the WMH data collection effort. We cannot thank them enough for their past and continued collaboration.

Norman Sartorius, the Director of the Department of Mental Health at WHO at the time the CIDI was developed, worked with Drs. Robins and Regier to expand the DIS to include ICD-10 criteria and in this way created the first version of the CIDI. Dr. Sartorius also worked to promote use of the CIDI once it became available, leading to the creation of the first WHO CIDI Consortium and indirectly to the WMH Survey Initiative. All WMH collaborators are very grateful to him, as we are to Drs. Robins and Regier, for their vision and their foundational work. Later Directors of the Department of Mental Health at WHO, including Jorge Alberto Costa e Silva and Benedetto Saraceno, along with WHO Executive Directors Tim Evans, Julio Frenk, Chris Murray, and Yasuhiro Suzuki, also supported our work in carrying out systematic cross-national comparative studies. Their help is gratefully acknowledged.

We would also like to thank the Pan American Health Organization (PAHO) for their assistance in helping us expand the WMH Survey Initiative into the countries of their region. We are especially grateful to José Miguel Caldas de Almeida, the past Chief of the Mental Health and Specialized Programs Unit at PAHO. His support was invaluable to us in promoting WMH and encouraging a number of countries in this part of the Americas to carry out WMH surveys. We are also grateful for the support of Itzhak Levav and Claudio Miranda during their tenures at PAHO, as well as for the support of Jorge Rodriguez, the present Unit Chief of the PAHO Mental Health, Substance Abuse and Rehabilitation Unit.

Bob Rose, during his tenure as Director of the Health Program at the John D. and Catherine T. MacArthur Foundation, supported the early developmental phases of WMH work. We are very grateful to Dr. Rose and the MacArthur Foundation for affording us the opportunity to hold international planning meetings and for supporting the work of the WMH Data Collection Coordinating Centre. We also want to thank the Pfizer Foundation, which provided additional core WMH support during the critical early phases of the Initiative. The Pfizer Foundation also funded the initial WMH surveys in China, as well as early Initiative planning meetings. They continue to support WMH in numerous ways that are essential to our success.

An important development in the early days of the WMH Survey Initiative was the simultaneous funding of surveys in six Western European countries in a public-private collaboration between the European Commission and SmithKlineBeecham, with subsequent continued support of this project by GlaxoSmithKline. We were fortunate to have very helpful and enthusiastic project officers, Marc Ratcliffe and Bruce Wang, who helped launch this project under the leadership of Jordi Alonso, providing us with a critical mass that sustained us during the early years of WMH. We thank them for this vital support.

The U.S. National Institute of Mental Health (NIMH) has also provided us with valuable support for a number of important WMH activities, including funding for surveys in three countries (South Africa, Ukraine, USA), for centralized data analysis, for our most recent annual WMH collaborator meetings, and for meetings to translate and adapt the CIDI into Spanish. We would like to thank our project officers, Karen Bourdon, Lisa Colpe, and Mercedes Rubio for all their help in these undertakings. We also thank Juan Ramos, who during his tenure at NIMH was instrumental in helping us expand our initiative into the PAHO countries, and the late Ken Lutterman, who during his tenure at NIMH was instrumental in helping us expand the WMH into South Africa.

Centralized WMH analyses have also been supported by a number of other funders whose assistance we would like to acknowledge here. In addition to NIMH (R01 MH070884, R13-MH066849, R01-MH069864), the John D. and Catherine T. MacArthur Foundation, and the Pfizer Foundation, these include AstraZeneca International, Bristol-Myers Squibb, Eli Lilly and Company Foundation, the Fogarty International Center (FIRCA R03-TW006481), GlaxoSmithKline, the U.S. National Institute of Drug Abuse (NIDA; R01 DA016558), Ortho-McNeil Pharmaceuticals, and the Pan American Health Organization.