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Fragilities exposed

Worldwide survey shows that psychiatric disorders are frequent and get little treatment

eduardo cesarEven in the most isolated cities in the world, mental disorders begin early, still in childhood, and usually show the same stages of development,  regardless of the life styles or of the economic situation in which the populations live, according to the first results of the most wide-ranging study ever made in this area. Both in the rich countries and in the less fortunate ones, persistent emotional maladjustments may emerge from the age of 15 onwards, through intense fears – of open or closed spaces, of height, or of the dark -, anxiety without a concrete reason, or a slight depression, to which little importance is usually given. They advance slowly, and, around the age of  20 or so, can express themselves in the form of dependence  of alcohol, nicotine or drugs, or even as a serious depression, which debilitates to the point of  beating the will to eat or even to live.

By unveiling this sequence, this initial stage of the World Mental Health Survey, coordinated by the World Health Organization (WHO), is opening up prospects for detecting and containing the process of an ongoing loss of emotional control while still at the beginning, during life at school, and thus to prevent the emergence of more serious problems – Brazil is part of this study, but here, is still at the initial stage of collecting information. The delimitation of these stages is also promising news in the disheartening scenario of mental health in the world: portions of the population in the 14 countries now assessed varying from 4.3%  to 26%  show some kind of psychiatric disorder.

Besides the social impact, with the erosion of family and social relations,  psychiatric problems also have economic repercussions. Previous studies of the WHO showed that psychiatric disorders are among the main causes for lost workdays. According to this new study, in Italy, the country where these losses proved to be greatest, the sufferers from slight disorders lose on average four days a year, while those affected by serious forms spend 200 days every year without working. Mental disorders place life itself at risk: they are associated with about 870,000 suicides recorded every year in the world, an average of three deaths every two minutes.

The analysis of  the 60,463 interviews carried out in this first part of the study shows that mental disorders are still underdiagnosed, little treated, and neglected by the planners of public health policies, even though they can usually be controlled.  Subtle in the beginning, but corrosive in the course of time, they create prisoners of the uncontrolled imagination itself. This is the case – extreme and very rare – of Don Quixote, the knight created by Spanish writer Miguel de Cervantes four centuries ago. At the end of a peaceful life, Don Quixote began to suffer from delirium and hallucination, to the point of seeing comely maidens in poor peasant women, and palaces in humble inns.

All over the world, mental disorders are still associated with stigmas and economic and social exclusion. Such prejudices draw the 21st century close to the Middle Ages, when madness, then a term used to explain the behavior of any person who did not fit in with the socially accepted models, used to be seen as a manifestation of the devil. Madness today is a word of restricted use, applied only to the extremes of psychoses, the more serious states of loss of the capacity of judgment. Even so, an atavistic fear can persist in anyone of a permanent loss of reason and emotional control, perhaps because the limits between mental equilibrium and insanity are unknown.

Contrasts – The fact is that, as this study of the WHO has shown, tremendous contrasts still persist in the access to treatment. In countries like Belgium, the United States and France, at least half of those affected by serious problems are treated  – in Spain, which comes in first place, the proportion of those assisted is 65%.  The situation is more alarming in the less developed countries, where most people suffering from some serious form of mental illness do not have access to suitable medicines of treatment. In Colombia, in the Lebanon, in Mexico and in Ukraine, only one in four individuals with obsessive-compulsive disorders or advanced depression is medicated and followed up by the health services. The most disheartening scenario is in the Lebanon: only 14.6% of the people with serious cases of mental problems are given some kind of medical assistance and accompaniment.

“Mental disorders are a public health problem that can no longer be ignored”, comments Sérgio Aguilar-Gaxiola, a professor from the California State University and one of the coordinators of this work, presented at a seminar promoted in October by the National Institutes of Health (NIH) of the United States in Panama City. According to him, one of the strongest reasons for giving more attention to mental illnesses is their high prevalence, as the percentage of people affected is called.

According to this study, published in June last year in the Journal of American Medical Association, the country with the greatest prevalence of problems is the United States. Almost 80 million Americans – or 26.4% of the population – showed some kind of mental disturbance. 7.7% of this total are regarded as serious forms, such as the obsessive-compulsive disorder or intense depression. Ukraine has the second greatest prevalence, the second largest country in Europe, behind only the European portion of the Russian Federation.  Almost 9 million persons, the equivalent of 20% of the population, showed slight, moderate or severe mental disorders, and 3 million, or 6.45% of the total population, the highest rate in this initial sample of countries, suffer from chemical dependence.

Of the two Latin American countries now assessed, Colombia has the higher prevalence: 17.8% of the Colombians, or about 8 million persons, have some kind of mental disorder. Mexico comes in second with 12.2%, almost 12 million persons. “One of Latin America”s largest problems”, Aguilar-Gaxiola says, “is that people have no access to medicines, nor to treatment.” The lack of treatment is more dramatic than high prevalence, since anyone can pass through a psychiatric problem at some moment of life, in the same way that one runs the risk of catching a cold or breaking an arm. But what could be a simple solution continues to cause suffering.

Standing out at the opposite extreme is Shanghai, a city in China with 15 million inhabitants, of which only 4.3% have mental disorders. The second country in low prevalence is Nigeria (4.7%),  a former British colony in the west of Africa, with 100 million inhabitants making up about 250 ethnic groups. Italy comes third, with 8.2% of its 56 million inhabitants with mental disorders.

Stigmas – The data about Brazil is not yet ready, but one can already have an idea of what will be found. In February this year, under the coordination of  Laura Andrade, from the Psychiatry Institute of the University of São Paulo (USP) and of Maria Carmen Viana, from the School of Medicine of the Vitória Charity Hospital, Espírito Santo, interviews should begin with 5,500 inhabitants of the São Paulo Metropolitan Region, where 18 million persons live, almost 10% of the population of the country. Collecting and analyzing the data should take two years of work, but previous studies suggest that the prevalence of psychiatric problems in the country should come closer to the 26% of the United States than to the 8.8% of Japan.

Laura Andrade makes this estimate based on a survey that she herself coordinated in 1998. 1,464 inhabitants from two districts in São Paulo were interviewed – Vila Madalena, a sort of São Paulo Ipanema ( a neighborhood with a lively night life), with a little bar on each street corner, and Jardim América, a quiet neighborhood, with its large houses and gardens. Of the 100,000 or so inhabitants of these two regions, almost half (45.9%) showed some kind of psychiatric disorder, including dependence on nicotine – when even inside the cinema a person cannot manage to refrain from smoking, because he needs to keep the level of nicotine stable in the organism.

Excluding smoking, the percentage falls, but not much: one in three inhabitants of these two districts has shown some kind of mental trouble at some moment of his life. Taken in isolation, the most common problem was a depressive episode, characterized by sadness without a reason that extends for two weeks or more; its symptoms were reported by 17% of the interviewees. Depression, added to dysthymia, one of its milder, though chronic, forms, affects one in every four inhabitants from these two districts of the country”s largest city.

“We are beginning to aware of these problems in Brazil as well”, says Laura. The results she arrived at were also impressive because  she was dealing with districts with medium-high schooling and income, close to health services or prominent  public hospitals. Even so, their inhabitants turn little to doctors or health services. As the group from USP found in another study, less than half of those suffering from depression seek medical aid.

Prejudices also help one to understand this keeping away from doctors. There are stigmas about mental disorders themselves, since people fear being labeled as mentally handicapped – they do not even think that these problems may be as common as a cold.  Mistaken ideas also persist about treatment: the sufferers from these disorders are afraid of  becoming dependent on medication, something that does not always happen. Finally, an archaic view survives of the psychiatrists themselves, still seen as doctors of madmen, not as professionals generally fit for treating common and persistent emotional disturbances.

These stigmas were dimensioned in a study coordinated by Gregory Simon, from the Health Studies Center, of the Group Health Cooperative,  in Seattle, United States, with the participation of Marcelo Fleck, from the Federal University of  Rio Grande do Sul (UFRGS). They accompanied 968 sufferers of depression attended to at 34 health centers in six cities – from Brazil, Canada, Spain, United States, Israel and Russia. A little less than half (42%) of the inhabitants of the American city of Seattle, 37% of the residents of Melbourne, in Canada, and one in every three inhabitants of Porto Alegre said that they were afraid of the side effects of the medicines. In Seattle and in the capital of  Rio Grande do Sul, in the same proportion, one in every five interviewees is also afraid that looking for treatment may jeopardize new opportunities for employment.  At other times, it is their very friends who discourage them from starting the treatment.

But, according to this same study, published in September in the American Journal of Psychiatry, the greatest barrier to treatment is not the prospect of discrimination, but rather the cost of the medicines or of transport to the centers of medical assistance. In St. Petersburg, the second largest city in Russia, 75% of the interviewees complained of the expenses that they incur to take care of themselves. Porto Alegre appears in second place, with two of each five persons reporting the same problem.  Béatrice Alinka Lépine showed exactly how much is spent, in a study that she did at USP”s Faculty of Public Health: on average, R$ 4,300.00 a year in consultations, examinations and medicines in the case of common depressions, and R$ 6,100.00 with the resistant forms of depression, for which neither medicines nor the habitual psychotherapies are effective.

In Brazil, with a per capita income of almost R$ 7,000 and one third of the population in a state of poverty, it will certainly not be easy to face up to persistent mental disorders, in particular their most common form, depression. To make matters worse, roughly half of the cases of depression detected in the population at large is chronic, according to a study published in 2003 in the International Journal of  Methods in Psychiatric Research, comparing the data from ten countries, with a sample of  37,000 persons. In this work, the percentage of the Brazilian population with chronic depression, in relation to the total of depressed persons,  is close to the figure for Japan (42%), but lower than the figures for Turkey (72%) or Chile (62.6%).

This survey showed that depression is more common in women than in men in all the countries assessed – or is it, as the researchers themselves wonder, that men take longer to recognize this frailty and to seek help?  Up until now, depression has proved to be more frequent in the young than in the old, in the unmarried than in the married, in the lower income levels of the population that in the higher ones, and amongst those who live in countries with a cold climate than in those with a hot one.

But why are there so many people in the world with mental problems, depression in particular? According to Laura Andrade, the first reason is that there are today precise mechanisms for diagnosing this ailment, which half a century ago did not have an exact definition or medicines with which it could be treated. “High prevalence is also a consequence of the lack of emotional support for these people, which can lead to despair and to the lack of a will to live”, the doctor from USP comments. According to her, at least a part of the cases of depression can be understood using the Attachment Theory, created 50 years ago by English psychiatrist John Bowlby. “In people who suffer from a lack of support”, she says, “the neuron connections are different and the centers connected with pleasure and positive affectivity may not be activated entirely, as if the brain had few resources to prevent depressive states.”

Poverty – It was already known that mental disorders can be generated by genetic alterations, environmental pressures, biochemical disturbances, or usually by a combination of these factors. The WHO”s survey stresses the weight of poverty, expressed through unemployment, the low level of education and of privations of every order, which create an abyss between the citizens of some countries and the medicine that alleviate life”s anguishes.

“Any intense external stress can have an impact on the prevalence of mental illnesses”, says Aguilar-Gaxiola.  According to him, the civil wars that have been tormenting the Colombians for decades, caused above all by the interest of guerrilla groups in controlling the drug trade, are robbing the population of their peace and help to explain why this country has the fourth highest prevalence of mental problems. There are also more subtle reasons, connected with working conditions. “Tension, anguish, competitiveness or rejection, when excessive and long-lasting, favor the appearance of mental disturbances”, Aguilar-Gaxiola comments. It could be one way of understanding why one out of  every four Americans lives with an anxiety that seems as if it will never pass.

When it is concluded, in a few years, this work from the WHO is going to reveal the prevalence, the seriousness, the access to treatment, the social and economic impacts and the risk factors or the factors for protecting mental health in 28 countries.  Right away, though, some ways for mitigating this problem are emerging. As one now knows how mental disorders can progress, preventive actions could be carried out, particularly with the more vulnerable children and their families, to alleviate the impact of the sources of stress.  “You don”t necessarily have to treat the early manifestations of psychiatric disturbances with medicines, nor to regard them as a disease”, Laura suggests.

Campaigns – The first part of the WHO”s study stresses the importance of preparing better the general practitioners at the health centers to diagnose psychiatric disturbances, since they are the first to be sought out by someone who suspects that persistent sadness or anxiety may mean something more serious. But it is not enough to sharpen the observation of these doctors, Aguilar-Gaxiola warns: “The public at large has to be made aware, by means of campaigns, that mental disturbances are common and debilitating, to recognize the symptoms of the most frequent problems, and to know that there are treatments and services that they can rely on.”

He mentions as an example a campaign that the National Institute of Mental Health (NIMH), one of the units of the NIH, launched in 2003. Called  Real men, real depression, the campaign encouraged people to seek treatment, using medical information presented in a simple language and adverts like those reproduced on this page, with results regarded as positive. But integrated actions always have to be thought of. “It would be an irresponsible action just to look for victims of mental disturbances and not treat them properly”, Aguilar-Gaxiola says.

In the entire world, people are seeking the social reinsertion of victims of mental disorders. Brazil is following this line by progressively taking out of service homes for mental patients, the old asylums, and creating day hospitals or Psychosocial Attention Centers (CAPs in the Portuguese acronym), where sufferers from mental disturbances who live with their families are treated and medicated. More serious cases tend to be attended to in general hospitals.

So a revision of   history is happening. Until the end of the Middle Ages, mentally maladjusted individuals would walk freely through the towns – their hallucinations were even valued as sources of artistic inspiration. Only at the end of the 16th century, with the separation between body and mind, was the madman regarded as a being deprived of reason, and the first asylums arose. And also from those days was the ship of fools, as they called the boats that would circulate amongst the European ports, picking up madmen, prostitutes, hoboes and criminals, to be left adrift afterwards until they died or were thrown into the sea. What has now been discovered is that it is possible to reduce this persistent abandonment without such radical measures.

Carlos Fioravanti was in Panama City at the invitation of the National Institutes of Health (NIH) and of the International Center for Journalists (ICFJ).