ECNP/EBC Report 2011
The size and burden of mental disorders and other disorders of the brain in Europe 2010

https://doi.org/10.1016/j.euroneuro.2011.07.018Get rights and content

Abstract

Aims

To provide 12-month prevalence and disability burden estimates of a broad range of mental and neurological disorders in the European Union (EU) and to compare these findings to previous estimates. Referring to our previous 2005 review, improved up-to-date data for the enlarged EU on a broader range of disorders than previously covered are needed for basic, clinical and public health research and policy decisions and to inform about the estimated number of persons affected in the EU.

Method

Stepwise multi-method approach, consisting of systematic literature reviews, reanalyses of existing data sets, national surveys and expert consultations. Studies and data from all member states of the European Union (EU-27) plus Switzerland, Iceland and Norway were included. Supplementary information about neurological disorders is provided, although methodological constraints prohibited the derivation of overall prevalence estimates for mental and neurological disorders. Disease burden was measured by disability adjusted life years (DALY).

Results

Prevalence: It is estimated that each year 38.2% of the EU population suffers from a mental disorder. Adjusted for age and comorbidity, this corresponds to 164.8 million persons affected. Compared to 2005 (27.4%) this higher estimate is entirely due to the inclusion of 14 new disorders also covering childhood/adolescence as well as the elderly. The estimated higher number of persons affected (2011: 165 m vs. 2005: 82 m) is due to coverage of childhood and old age populations, new disorders and of new EU membership states. The most frequent disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%), somatoform (6.3%), alcohol and drug dependence (> 4%), ADHD (5%) in the young, and dementia (1–30%, depending on age). Except for substance use disorders and mental retardation, there were no substantial cultural or country variations. Although many sources, including national health insurance programs, reveal increases in sick leave, early retirement and treatment rates due to mental disorders, rates in the community have not increased with a few exceptions (i.e. dementia). There were also no consistent indications of improvements with regard to low treatment rates, delayed treatment provision and grossly inadequate treatment.

Disability: Disorders of the brain and mental disorders in particular, contribute 26.6% of the total all cause burden, thus a greater proportion as compared to other regions of the world. The rank order of the most disabling diseases differs markedly by gender and age group; overall, the four most disabling single conditions were: depression, dementias, alcohol use disorders and stroke.

Conclusion

In every year over a third of the total EU population suffers from mental disorders. The true size of “disorders of the brain” including neurological disorders is even considerably larger. Disorders of the brain are the largest contributor to the all cause morbidity burden as measured by DALY in the EU. No indications for increasing overall rates of mental disorders were found nor of improved care and treatment since 2005; less than one third of all cases receive any treatment, suggesting a considerable level of unmet needs. We conclude that the true size and burden of disorders of the brain in the EU was significantly underestimated in the past. Concerted priority action is needed at all levels, including substantially increased funding for basic, clinical and public health research in order to identify better strategies for improved prevention and treatment for disorders of the brain as the core health challenge of the 21st century.

Introduction

Depression, schizophrenia, panic disorder, drug dependence and insomnia are examples of “mental disorders”, while dementia, epilepsy and multiple sclerosis exemplify neurological disorders. Both groups together are also frequently referred to as neuropsychiatric disorders, as “Mental, Neurological and Substance use (MNS, Collins et al., 2011) disorders or more recently and more comprehensively as “disorders of the brain”. Until recently, the complexity of disorders with hundreds of specific diagnoses, codified in diagnostic classifications systems (International Classification of Diseases, ICD-10, WHO, 1993; Diagnostic and Statistal Manual of Mental Disorders, DSM-IV, American Psychiatric Association, 1994), was associated with disciplinary fragmentation in research and practice using different concepts and approaches which has significantly impeded a broader and comprehensive appreciation of the size and burden of disorders of the brain. Further, the marginalization and stigma attached to some disorders of the brain have been identified as barriers to a wider recognition of the core relevance of mental disorders (Saxena et al., 2007, Klin and Lemish, 2008, Corrigan, 2004). Both lay persons and professionals are typically unaware of the commonalities and the shared mechanisms of “brain disorders”. Further, there is little awareness of the full range of disorders of the brain and little knowledge about the size and burden associated with these diseases in the community and the society. The low levels of awareness and knowledge are major obstacles for improved research on the causes and the treatment of disorders, improved allocation of mental health treatment resources and improved provision of care.

During the past decade increasingly stronger evidence has become available documenting that disorders of the brain are not only much more frequent than previously thought but also contribute to a greater burden of disease than previously thought, and should, therefore, be considered as a top global health challenge of the 21st century (Collins et al., 2011, Murray and Lopez, 1996, Prince et al., 2007, World Health Organisation, 2001, World Health Organisation, 2008, Wittchen and Jacobi, 2005). Numerous epidemiological studies on mental disorders throughout the world have convergently shown with some variability by diagnoses that in each year about one third of the adult population suffers from a mental disorder (Kessler and Üstün, 2008). The Global Burden of Disease studies, that cover comprehensively all disease groups and injury categories (Murray and Lopez, 1996, World Health Organisation, 2002, World Health Organisation, 2008), have found that increasingly higher proportions of the global burden of disease can be attributed to disorders of the brain. For example, a recent analysis (Collins et al., 2011) estimated that about 13% of global disease is due to disorders of the brain, surpassing both cardiovascular diseases and cancer. However, such global estimates are of limited value for use in the European Union (EU). These estimates are heavily influenced by the most populous countries and regions of the world, with very diverse population, health, and mortality characteristics, as well as different socio-economic and health care systems.

The lack of EU-specific, comprehensive data on the size, burden and cost of mental and neurological disorders prompted the launch in 2003 of a major European wide interdisciplinary effort coordinated by the European Brain Council (EBC) and the European College of Neuropsychopharmacology (ECNP), involving multiple task forces and panels, and using sophisticated methodological approaches including reanalyses of data sets from epidemiological studies in the EU3 up to the year 2004, which resulted in a series of publications (Andlin-Sobocki et al., 2005, Wittchen et al., 2005). These publications documented the size and burden of neurological (Olesen and Leonardi, 2003, Berr et al., 2005, Campenhausen et al., 2005) and mental disorders (Wittchen and Jacobi, 2005) and provided comprehensive health, economic, and cost data for both groups of disorders. For mental disorders alone it was estimated conservatively that every year 27% of the total adult (18–65) EU population is affected by a mental disorder. This amounted to over 82.7 million affected persons of the applicable reference EU population 2004 aged 18–65 of 301.7 million people in the 2005 study. Most frequent disorders were anxiety, depressive, somatoform and substance use disorders.

Further, the 2005 report highlighted the tremendous size and range of associated psychosocial impairments and disabilities due to mental disorders and the generally low treatment rates; only 26% of all cases with mental disorders had any consultation with professional health care services. Among treated cases with mental disorders there was a long delay between onset and first treatment contact and only a small number of patients received minimally adequate interventions (see Kessler and Üstün, 2008, for an overview for the countries participating in the World Mental Health initiative). A substantial degree of the unmet treatment and intervention and poor service provision for mental disorders was due to the combined effects of underutilization, under-recognition, under-treatment and lack of resources.

Similarly detailed analyses for neurological disorders were not possible due to differing methods and standards of epidemiological studies which prohibit the derivation of overall prevalence estimates for having any mental or neurological disorder. Nevertheless, mental and neurological data were used to calculate and estimate the patterns and costs of treatment and the health economic implications in terms of total direct and indirect costs for EU nations (Andlin-Sobocki et al., 2005, Wittchen et al., 2005). This modeling revealed that mental disorders are extremely costly. Compared to many somatic diseases, the categories of costs were different with disproportionally high indirect costs and relatively low direct costs of health care. Together with additional epidemiological evidence for selected neurological conditions, the total EU cost burden of disorders of the brain in 2005 was estimated to be close to 386 billion Euros, of which 277 billion Euros were attributed to mental disorders alone.

The 2005 size, burden, and cost study suffered from several limitations particularly with regard to incomplete age ranges (18–65 for most diagnoses) and the diagnostic scope. As a result, mental disorders in childhood and adolescence, as well as frequent disorders of old age and neurological conditions were not included. Further, we were unable to provide consolidated DALY data for all EU member states, because available data were based on specific groupings of countries used by the World Health Organization that could not be applied to the EU. Along with the wish to describe changes that might have occurred since 2005, the limitations of the 2005 study prompted our efforts to improve the epidemiological estimations by incorporating new available study data. We were particularly interested in broadening the previously restricted scope of mental disorders and the age range covered, including as much as possible additional relevant mental and neurological conditions across the lifespan, and improving previously crude prevalence estimates for some disorders.

Section snippets

Goals

As part of the EBC's and the ECNP's initiative to conduct an updated and improved “Size, Burden and Cost of Disorders of the Brain in Europe” study, we launched a program in 2009 consisting of numerous work groups, organizations, and individuals with interrelated work packages. The major goals of this program were:

  • 1.

    To provide consolidated best estimates for the 12 month prevalence of mental and neurological disorders for the EU-27 total population in the year 2010.

  • 2.

    To cover as far as possible all

Overall strategy

Similar to our 2005 review, a stepwise multi-method study approach (described in greater detail in Wittchen and Jacobi, 2005) was adopted consisting of a) reiterative literature searches for epidemiological publications and subsequent data analyses of published material on mental disorders, b) reanalyses of existing accessible epidemiological data sets with uniform assessments, and c) supplementary surveys by country to gather input about existing epidemiological databases via national experts.

12 month prevalence of mental disorders (update of the 2005 report)

Table 2 presents information about the number of studies covered, the prevalence range of studies and median (Md) across studies, with the IQR and gender ratio (females:males) as derived from the findings of community studies. The resulting consolidated “expert-based best estimate” of the 12 month prevalence is highlighted, along with the estimated number of subjects in the EU affected within the applicable age ranges.

The updated and improved 2011 estimates for disorders listed in Table 2, based

Discussion

This report provides for the first time consolidated data on the current size and the burden of mental disorders and neurological disorders for the EU. Based on a complex interdisciplinary effort, structured literature reviews, reanalyses of existing data sets, and appraisals, we describe the 12 month prevalence and the associated disability burden. Extending our previous 2005 report, we cover the 27 EU countries plus Switzerland, Norway and Iceland, a much broader range of diagnoses and a

Conclusion

The results of this EU review are by and at large consistent with those of earlier international studies where a similar range of disorders is considered. However, we document that the true range of mental disorders is obviously considerably larger than the previously available “best-estimate” of 27% suggested in 2005 (Wittchen and Jacobi, 2005). The present survey has covered 27 diagnoses, adding 14 more core diagnoses of mental disorders arriving at a conservative estimate of 38.2%. Thus,

Role of the funding source

This paper was commissioned by the European College of Neuropsychopharmacology (ECNP) who provided grant support to the Technische Universitaet Dresden in the context of European Brain Council (EBC) Task Force project on “Size and Burden and Cost of Disorders of the Brain”. The overall Task Force project received unrestricted educational grant support by H. Lundbeck A/S as well as financial support by the European Federation of Neurological Societies. The funding agencies had no further role in

Contributors

See below under acknowledgements.

Conflict of interest

None of the authors have conflicts of interest associated with the work reported in this paper.

Acknowledgements

This paper was prepared in the framework of the European College of Neuropsychopharmacology (ECNP) and European Brain Council (EBC) Task Force project on “Size and Burden and Cost of Disorders of the Brain in Europe 2010”. The data summarized in this report provide the essential input for the 2011 EBC (www.europeanbraincouncil.org) initiative “Cost of Disorders of the Brain in Europe” (CDBE; steering committee: Jes Olesen, Bengt Jönsson, Hans-Ulrich Wittchen). The support and assistance of many

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