Post by Former NIMH Director Thomas Insel: Mental Health Awareness Month: By the Numbers
May is mental health awareness month. NIMH, as the federal agency for research on mental illnesses, has a number of activities this month to increase awareness (see website). While mental health is much more than absence of a mental illness, this is a useful moment to raise awareness of the toll of mental illness in America. I offer this tour of mental illness by the numbers.
Prevalence: 1 in 5; 1 in 25; 1 in 5
Our best estimate of the number of adults with any diagnosable mental disorder within the past year is nearly 1 in 5, or roughly 43 million Americans.1 Although most of these conditions are not disabling, nearly 10 million American adults (1 in 25) have serious functional impairment due to a mental illness, such as a psychotic or serious mood or anxiety disorder. Fully 20 percent—1 in 5—of children ages 13-18 currently have and/or previously had a seriously debilitating mental disorder.2 By comparison, 8.3 percent of children under age 18 have asthma3 and 0.2 percent have diabetes.4
Disability: 5; 13; 27
The Global Burden of Disease study assigned a single disability number—disability-adjusted life years or DALY score—to each of 291 conditions and injuries. The DALY score combines years of life lost to premature mortality and years lost to disability attributable to each condition. Of the 291 conditions and injuries assessed, major depressive disorder ranks #5 in terms of DALY burden in the U.S., with anxiety disorders #13, and schizophrenia #27.5 Across categories of illness and injury, brain disorders (mental, neurological, and substance abuse disorders) are the single largest source of DALYs in the U.S., representing nearly 20 percent of disability from all causes.6
Mortality: 41,149; 10; 350,000
According to the Centers for Disease Control and Prevention, 41,149 individuals committed suicide in the U.S. in 2013, the most recent year for which such data are available.7 That's approximately the same number of deaths as breast cancer in the U.S., and more than deaths from prostate cancer; it is six times the number of deaths from HIV; and it is nearly three times the number of homicides.8 Moreover, in contrast to all of these other causes of mortality, the rate of suicides has not decreased over the past two decades. The highest risk group? White males over 60: their suicide rate is well over twice that of the population as a whole. Further, suicide was the second highest cause of death in youth and young adults ages 15-34.
Earlier this year, authors of a paper on mortality associated with mental illness estimated that the median reduction in life expectancy among those with mental illness was 10.1 years (range from 1.4 to 32 years).9 Most of this early mortality was attributed to “natural causes” such as acute and chronic co-morbid conditions including heart, pulmonary, and infectious diseases. Based on the prevalence of mental illness globally, they concluded that fully 8 million deaths occur each year which could be averted if people with mental illness were to die at the same rate as the general population. For the U.S., this means roughly 350,000 deaths averted each year.
Psychosis: 100,000; 74; 39
There is no precise figure for the number of first episodes of psychosis each year in the U.S., but incidence data from other countries suggest that around 100,000 people per year have a first onset of psychosis in the U.S.10 Results from the NIMH RAISE (Recovery After an Initial Schizophrenia Episode) Early Treatment Program study, conducted in 34 sites across 21 states, provide some disturbing insights into the quality of care provided in the community. The duration of untreated psychosis for the 404 subjects in this study was 74 weeks.11 At the time of enrollment into the RAISE trial, 39 percent were not receiving medication consistent with guidelines in terms of agent or dose.12
Cost: $2.5T; $6.0T; $467B
The World Economic Forum, recognizing that chronic non-communicable diseases would be the largest cost drivers in health care in the 21st century, asked a group of health economists to estimate global costs and project costs to 2030.13 Their estimate based on 2010 data showed mental disorders as the largest cost driver at $2.5 trillion in global costs in 2010 and projected costs of $6.0 trillion by 2030. The costs for mental disorders were greater than the costs of diabetes, respiratory disorders, and cancer combined.
The Substance Abuse and Mental Health Administration estimated that the U.S. national expenditure for mental health care was $147 billion in 2009. Combining this figure with updated projections of lost earnings and public disability insurance payments associated with mental illness, an estimate for the financial cost of mental disorders was at least $467 billion in the U.S. in 2012.14
Making up part of these economic figures are Social Security disability benefits, including both Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), paid to individuals who are disabled as a result of mental disorders. The Social Security Administration reports that in 2012, 2.6 and 2.7 million people under age 65 with mental illness-related disability received SSI and SSDI payments, respectively, which represents 43 and 27 percent of the total number of people receiving such support, respectively.15,16
Treatment: 85; 75; 70
In contrast to many other brain disorders, including most neurodegenerative disorders, for mental disorders, even for the most severe mental disorders, we have treatments that work. Some 85 percent of severely depressed patients respond to electroconvulsive therapy or ECT.17 Among people with schizophrenia who receive treatment, approximately 25 percent experience good recovery and 50 percent show improvement over a 10-year period, meaning that, in contrast to neurodegenerative disorders, 75 percent are better in the long-term.18 For lithium responders, bipolar disorder is totally treatable.19,20 Several kinds of psychotherapy have been shown to be very effective treatments for depression and anxiety disorders, with response rates on the order of 70 percent following cognitive therapy for panic disorder and 50 percent for exposure-based therapy in obsessive-compulsive disorder.21,22 We must never forget, in the face of the stunning mortality numbers cited above, that even among those at highest risk for suicide, prevention and treatment save lives.
Beyond the Numbers
Mental illnesses are real disorders with real treatments, but too few people receive optimal care. Families of people with serious mental illness live with a patchwork of care and support services and they fear for their loved one’s safety and wellbeing. Many people with these disorders refuse the treatments available, either because they deny their illness or because part of their illness (paranoia, hopelessness, or phobias) precludes seeking care. And for too many, the treatments we have today are not good enough. While the numbers alone are compelling, the personal stories of families and individuals affected by mental illness complete the picture of why finding ways to prevent and treat mental illness is such an urgent need.
5 US Burden of Disease Collaborators. The state of US health, 1990-2010. Burden of diseases, injuries, and risk factors. JAMA. 2013 Aug 14;310(6):591-608.
8 All mortality data from the Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf
9 Walker ER, McGee RE, Druss BG. Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2015 Feb 11. doi: 10.1001/jamapsychiatry.2014.2502. [Epub ahead of print]
10 McGrath J et al. Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30:67-76. doi: 10.1093/epirev/mxn001. Epub 2008 May 14.
11 Addington J et al. Duration of untreated psychosis in community treatment settings in the United States. http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201400124
12 Robinson DG et al. Prescription practices in the treatment of first-episode schizophrenia spectrum disorders: data from the national RAISE-ETP study. http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.13101355
13 Bloom DE et al. (2011) The Global Economic Burden of Non-communicable Diseases. Geneva: World Economic Forum.
14 Estimates updated from: Insel TR Assessing the economic costs of serious mental illness Am J Psychiatry2008 Jun;165(6):663-5doi: 10.1176/appi.ajp.2008.08030366.
15 Calculated by NIMH based on: SSI Annual Statistical Report, 2012.
16 Calculated by NIMH based on: Annual Statistical Report on the Social Security Disability Insurance Program, 2012.
17 Kellner CH et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006 Dec;63(12):1337-44.
18 Leucht S et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet. 2012 Jun 2;379(9831):2063-71. doi: 10.1016/S0140-6736(12)60239-6. Epub 2012 May 3.
19 Bowden CL et al. Focus on bipolar disorder treatment. J Clin Psychiatry. 2005 Dec;66(12):1598-609.
20 Rybakowski JK. Factors associated with lithium efficacy in bipolar disorder. Harv Rev Psychiatry. 2014 Nov-Dec;22(6):353-7. doi: 10.1097/HRP.0000000000000006.
21 Clark DM et al. Brief cognitive therapy for panic disorder: a randomized controlled trial. J Consult Clin Pschol. 1999 Aug;67(4):583-9.
22 Hofmann SG et al. The efficacy of cognitive behavioral therapy : A review of meta-analyses. Cognit Ther Res. 2012 October 1;36(5):427-440. Epub 2012 Jul 31.