The Burden Is Even Greater, The Solution Needs Rethinking

Vigo et al.’s paper in this issue of the Journal builds on their earlier work to calculate the burden of mental disorders, addressing limitations of the original Global Burden of Disease estimates, by reclassifying the burden associated with suicide, certain neurological disorders with significant behavioral implications (notably dementia), drug and alcohol use disorders and their somatic consequences, and syndromes associated with prominent pain which often have a psychogenic origin (such as headaches) to arrive at a composite estimate of “mental, neurological, substance use disorders and self-harm” (MNSS) disorders. This reclassification is justified to take into consideration a “clinically and epidemiologically rational framework for attributing disease burden to disorder groupings, rather than arbitrary methodological considerations” adopted by the Global Burden of Disease estimates; this is an argument I completely endorse and which we adopted in the Disease Control Priorities project. They show how this reclassification leads to a dramatic 3-fold increase in the proportionate burden of disease, estimated in Disability Adjusted Life Years, in the three countries of North America in 2017: in Canada, from 7.4% to 23.8%; in the United States, from 7.1% to 24.7%; and in Mexico, from 5.6% to 16.9%. Notably, while the relative burden is lowest in Mexico, partly due to the higher burden attributed to other health conditions (such as injuries and other noncommunicable diseases), it is also evident that Mexico has the lowest per capita burden of DALYs due to MNSS disorders. The highest burden is in the United States, which is 50% higher for men and 63% higher for women in Mexico, with Canada occupying a roughly midway position between these two countries. A substantial proportion of the excess burden in the United States can be attributed to opiate use disorders and self-harm. These observations are consistent with a recent study that reported the rising rates of suicide in the United States and the mounting evidence testifying to the devastating epidemic of opioid use disorders sweeping the country. The overriding implication of these findings is the need for greater investments to reduce the burden of suffering consequent to MNSS disorders. The allocation of resources, whether for research or service delivery, was already disproportionately lower than the original estimates of the burden of mental disorders in all three countries; if we used the recalculated burden estimates, this inequity reaches alarming proportions. But spending more money on mental health care alone cannot be the entire solution to the high burden for, if that were the case, surely we should have seen a higher burden per capita in Mexico which not only has the least resources allocated to mental health care but whose population also face a much higher prevalence of a range of social determinants of poor mental health, such as poverty and violence. Indeed, Mexico is a middle-income country, which ranks 64 places lower than Canada and 49 places lower than the United States in the Sustainable Development Index. Might this finding align with the provocative evidence emerging of a “vulnerability paradox,” that is despite the higher vulnerability for mental health problems in poorer individuals in a particular country, lower vulnerability at the country level, as reflected in the indices used to estimate sustainable development, is not necessarily associated with lower prevalence of mental health problems. Perhaps the most compelling example of this paradox is documented in a recent study that observed a negative association between suicide rates and country vulnerability in both genders. These findings indicate that despite a higher risk factor burden and lesser access to quality mental health care in poorer countries, there is a relatively lower prevalence of mental health problems in high vulnerability countries. These counterintuitive findings point to two key possibilities: first, that there are some, as yet not specified, risk factors driving higher burden in the United States and Canada or, conversely, protective factors helping reduce the burden in Mexico;