South African Psychiatry - February 2019

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FEATURE and deaf. Therefore, it is important to understand the context of the disability and the population among whom the disability weight is determined. THIS CONCEPT COULD ALSO SPEAK TO SEVERITY OF PSYCHOSOCIAL DISABILITY EXPERIENCED BY PEOPLE WITH MENTAL ILLNESS WHERE TREATMENT IS LESS ACCESSIBLE, OR IN HIGHLY VERSUS LESS STIGMATISING SOCIETIES. DISABILITY-ADJUSTED LIFE YEARS (DALYs) The DALY combines time lost through premature death (YLLs) and time lived in a state of less than optimal health (YLDs). The calculation has been simplified since the 1990 GBD study, so that in the 2010 and 2015 GBD studies, a DALY = YLLs + YLDs, and YLDs = prevalence x disability weight with calculations combined for comorbid conditions. HEALTHY LIFE EXPECTANCY (HALE) Like DALYs, HALE is a single summary measure of population health. It was introduced because of the aging population and the need to account for health loss before death, as measured against a lifespan in optimal health. A problem that occurred in this population was the high level of independent and dependent comorbidities, such that the sum of multiple YLDs resulted in more years lost to disability than possible in one lifetime. The HALE provides a measure of functional health loss at the level of the individual rather than at the level of the disease or injury. It weights the years lived with a measure of functional health loss before death and includes more comprehensive adjustments for comorbidity than YLDs. These include combining calculations for independently occurring comorbid conditions and for dependent comorbidities (e.g. a stroke secondary to hypertension). BURDEN OF DISEASE IN SUB-SAHARAN AFRICA AND SOUTH AFRICA As a single summary measure of population health which combines both YLLs and YLDs, DALYs are extremely useful for establishing disease priorities for health planning and funding. A comparison between high income countries and the different regions in sub-Saharan Africa (Table V) reveals the extremely high burden of poor obstetric and child health in Africa. The high number of YLLs outweigh YLDs due to chronic diseases. Notably, depression does not feature in sub-Saharan Africa when using DALYs. Using all three measures gives a more complete understanding of disease burden, and the top ten causes in YLLs, YLDs and DALYs for South Africa are shown in Table VI. Of note is that both depression and anxiety are amongst the top ten YLDs, but because of the impact of premature mortality by other prevalent conditions, they do not account for any of the top ten DALYs. Source: Robertson LJ, Szabo CP. Implementing Community Care in Large Cities and Informal Settlements: An African Perspective. 4 Data source: GBD 2015 DALYs and Hale Collaborators. 3 COPD=chronic obstructive pulmonary disease; LRTI=lower respiratory tract infections; PEM=protein energy malnutrition. a due to birth asphyxia/trauma Table V Top ten causes of disease burden in DALYs, globally, in high-income countries, and in sub-Saharan Africa (SSA) 1 2 3 4 5 6 7 8 9 10 YLLs HIV/AIDs Interpersonal Violence LRTIs Road Injuries Tuberculosis Ischaemic Heart Disease Diabetes Mellitus Stroke Diarrhoea Neonatal preterm delivery YLDs HIV/AIDs Back & neck pain Sensory deficits Depression Diabetes Mellitus Skin problems Iron deficiencies Migraine Asthma Anxiety DALYs HIV/AIDs Diabetes mellitus Interpersonal violence LRTIs Tuberculosis Road Injuries Ischaemic Heart Disease Back & neck pain Stroke Diarrhoea Source of data: GBD 2015 Mortality and causes of death collaborators. 5 GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. 6 GBD 2015 DALYs and Hale Collaborators. 3 LRTI=lower respiratory tract infections; DALYs=Disability-Adjusted Life Years; YLDs=Years Lived with Disability; YLLs=Years Lost to Life; Table VI Top ten causes of disease burden in South Africa, in YLDs, YLLs, and DALYs 10 * SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019
FEATURE FACTORS AFFECTING BURDEN OF DISEASE ESTIMATES FOR MENTAL HEALTH PRIMARY DATA The extent and quality of country-level data is the most important factor affecting the GBD estimates. 1 To be included in the GBD analyses, adherence to minimum standards around data transparency and methodology and data sharing is needed. While clinical data may be incorporated with sophisticated epidemiological modelling and statistical inference, it cannot fully make up for scarce primary population level data. CHANGES IN METHODOLOGY TO ACCOMMODATE POOR QUALITY DEATH CERTIFICATION AND OTHER DEFICITS IN DATA WERE MOST MARKED BETWEEN THE 1990 AND 2010 STUDIES. NEVERTHELESS AVAILABLE, HIGH QUALITY DATA LEAD TO CONSISTENT HEALTH ESTIMATES BETWEEN INSTITUTIONS, WHEREAS SCARCE, LOW QUALITY DATA LEAD TO DISCREPANCIES BETWEEN INSTITUTIONS. A lack of primary data is particularly prominent in LMICs and for serious mental illness. Baxter et al. (2013) 7 analysed epidemiological data used in the 2010 GBD study for high prevalence (depression and anxiety) and low prevalence (schizophrenia, bipolar disorder and eating disorders) mental illness. Globally, less than 1% of identified studies met inclusion criteria, and even those included had methodological limitations. Only North America had a 75-100% population coverage for both low and high prevalence disorders. Australasia had a 75- 100% for high prevalence and 50-74% population coverage for low prevalence disorders. South Africa’s population coverage was 25-49% for high prevalence disorders, possibly largely related to the South African Stress and Health Study, with no coverage for low prevalence disorders. Thus, these disorders may be perceived as not contributing to the burden of disease in the country. the behaviour is directly due to the mental illness is not so simple. Similarly, causal directionality is difficult to prove with medical causes of death. BOX 1. ILLUSTRATIVE EXAMPLE The following news report describes an incident in Kwa Zulu Natal in which a 20-year-old, on treatment for a psychotic disorder, killed his two-year-old niece and three year-old-nephew, injured his 57-year-old mother, and then was killed as he ran in front of a truck. https://www.sowetanlive.co.za/news/southafrica/2018-02-19-why-did-he-kill-his-mother-andthe-children-ask-family-of-mental-health-patient/ Estimated burden of disease Death YLLs Cause of death Niece, 2 years old Nephew, 3 years old Patient, 20 years old Disability 89.4 + 89.4 = 178.8 YLLs 69.7 YLLs (Total = 248.5 YLLs) YLDs Interpersonal violence Road injury or Suicide (injury due to self-harm) (Psychotic disorder) Cause of disability ATTRIBUTION OF CAUSE OF DEATH The cause of death attribution affects understanding of disease burden due to mental illness, as the immediate cause of death is documented, and underlying cause(s) may not be reported. Deaths attributed to mental illness are usually due to substance use or neurocognitive disorders. Suicide is not recorded as being due to a mental illness but rather to death by injury due to self-harm. Hence, the vulnerability of people with mental illness to premature death is not recognised in YLLs estimates. A note is made in the 2015 GBD study that mortality related to schizophrenia will be explored more closely in future studies. However, cause of death might not be unequivocally caused by mental illness. For example, it is easy to quantify the YLLs in violent behaviour of one individual, as illustrated in Box 1, but certainty that Mother, 57 years old (depression assumed) Patient, 20 years old DW=Disability Weight Prevalence of trauma x DW + Prevalence of depression x DW (note, HALE should count these as independent comorbidity) Prevalence of psychosis x DW (Total DALYs = Total YLLs + YLDs) Interpersonal violence Bereavement/ depression Psychotic disorder (Psychotic disorder) SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019 * 11
Page 1 and 2: ISSN 2409-5699 ABOUT the discipline
Page 3 and 4: Features THE GLOBAL BURDEN 7 OF DIS
Page 5 and 6: FROM THE EDITOR Dear Reader, Welcom
Page 7 and 8: FEATURE THE GLOBAL BURDEN OF DISEAS
Page 9: FEATURE YEARS LIVED WITH DISABILITY
Page 13 and 14: FEATURE Kristiansen CB, Munk-Jorgen
Page 15 and 16: Young Psychiatrist Leadership and P
Page 17 and 18: FEATURE DEADLY MEDICINE: PAYING THE
Page 19 and 20: FEATURE Neurosis, Freud argues, is
Page 21 and 22: FEATURE Nevertheless, failure to in
Page 23 and 24: FEATURE IT STRIKES ME THAT WHAT FRE
Page 25 and 26: FEATURE THE 2018 OXFORD DICTIONARY
Page 27 and 28: FEATURE PHARMACOGENOMIC T E S T I N
Page 29 and 30: FEATURE Table II provides an exampl
Page 31 and 32: Biological Psychiatry Congress 2019
Page 34 and 35: FEATURE THE CHALLENGES OF PERINATAL
Page 36 and 37: FEATURE that empowered mothers lay
Page 38 and 39: NEWS VISITING PROFESSOR - SEMINAR C
Page 40 and 41: NEWS ADDICTION PSYCHIATRY - NEW HEA
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Page 44 and 45: Specialised dementia care in luxuri
Page 46 and 47: UPDATE Corlia Schutte, occupational
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Page 50 and 51: REPORT FEEDBACK FROM THE ROYAL COLL
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PERSPECTIVE THE IMPACT OF CLINICAL
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PERSPECTIVE TWO VINYL CHAIRS, PRISO
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PERSPECTIVE reduce distress caused
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in Mental Health
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BOOK REVIEW POIGNANTLY, EMSLEY FORC
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CULINARY CORNER atrium of a large t
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CULINARY CORNER As expected, the EX
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WINE FORUM Rewind Raats; does it ma
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MOVIE REVIEW THE WIFE broadcast the
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SASOP HEADLINE FEBRUARY 2019 EDITOR
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SASOP HEADLINE Esidimeni tragedy; a
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SASOP HEADLINE errors, as well as a
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INSTRUCTIONS TO AUTHORS South Afric
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The fine art of mental health treat
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South African Psychiatry - February 2019

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