The Burden

of Mental Disorders
in the Region
of the Americas, 2018
 The Burden of Mental
Disorders in the
Region of the Americas, 2018

Washington, DC
2018
 Also published in Spanish
La carga de los trastornos mentales en la Región de las Américas, 2018
ISBN: 9789275320280

The Burden of Mental Disorders in the Region of the Americas, 2018

ISBN: 9789275120286

© Pan American Health Organization 2018

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Contents
Foreword vii
Acknowledgments viii
List of acronyms ix
Main findings x
Introduction 1
Disease burden distribution in the Americas 3
Regional disability and mortality: disability-adjusted life years (DALYs) 4
Regional disability: years lived with disability (YLDs) 4
Country-level analysis 5
Country-level disability and mortality (DALYs) 7
Country-level disability (YLDs) 7
Common mental disorders 11
Disability resulting from specific disorders 11
Depressive disorders 12
Anxiety disorders 13
Self-harm and suicide 14
Somatoform disorders/persistent somatoform pain disorder 15
Severe mental disorders 17
Schizophrenia 17
Bipolar disorders 17
Substance use and eating disorders 18
Disorders due to use of alcohol 18
Disorders due to substance use (not alcohol) 19
Eating disorders 20
Disorders with onset usually occurring in childhood and adolescence 21
Neurological disorders 22
Neurocognitive disorders 22
Epilepsy 22
Migraine and tension-type headaches 23
Health system response in the Americas: Government funding for mental health services 25
Mental health spending as a percentage of government health spending 26
Mental health spending allocation 27
Conclusion 31
References 33
Annex 1. Non-Latin Caribbean Subregion Countries and Population 35
List of Figures
Figure 1: Regional disability-adjusted life years (DALYs) distribution tree map (%) 4
Figure 2: Ranked mental, neurological, disorders due to substance use, and suicide DALYs 5
Figure 3: Regional years lived with disability (YLD) distribution (%) 6
Figure 4: Ranked mental, neurological, disorders due to substance use, and suicide years lived
with disability (YLDs) 6
Figure 5: Population distribution of the countries in the Americas 7
Figure 6: Disability-adjusted life years (DALYs) distribution by country (%) 8
Figure 7: Years lived with disability (YLDs) by country (% of total YLDs) 9
Figure 8: Mental, neurological, disorders due to substance use and suicide disability tree map
(YLDs by country as a percentage of total disability) 10
Figure 9: Depressive disorder disability tree map (YLDs by country as a percentage of total disability) 12
Figure 10: Depressive disorder: years lived with disability by age groups (total of YLDs) 13
Figure 11: Anxiety disorders disability tree map (YLDs by country as a percentage of total disability) 14
Figure 12: Suicide and self-harm burden tree map (DALYs by country as a percentage of total disability) 15
Figure 13: Total years of life lost by age group 16
Figure 14: Schizophrenia disability tree map (YLDs by country as a percentage of total disability) 18
Figure 15: Bipolar affective disorder disability tree map
(YLDs by country as a percentage of total disability) 19
Figure 16: Disorders due to use of alcohol disability tree map
(YLDs by country as a percentage of total disability) 20
Figure 17: Disorders due to substance use (not alcohol) disability tree map (YLDs by country
as a percentage of total disability) 21
Figure 18: Disorders with onset usually occurring in childhood and adolescence disability tree map 22
Figure 19: Dementia disability tree map 23
Figure 20: Epilepsy disability tree map 24
Figure 21: Mental health spending vs. per-capita GDP (PPP) 27
Figure 22: Ratio of % of total DALYs attributable to MNSS to % of health spending allocated
to mental health, ordered from smallest to largest 28
Figure 23: MNSS spending allocated to mental hospitals vs. GDP (PPP) 29
Figure 24: Imbalance in spending: ratio of MNSS burden to efficiently allocated spending 30
Foreword

This report aims to improve the assessment of mental health needs in the Americas by providing an updated and nuanced
picture of: (a) the disability resulting from mental, substance use, and specific neurological disorders, plus self-harm,
alone and in combination with premature mortality; (b) the imbalance between mental health spending and its related
disease burden; and (c) the inadequate allocation of the meager mental health spending by countries of the Region.

Consistent with global trends, the epidemiologic transition in the Americas has resulted in a shift from communicable
diseases, nutritional deficiencies, and maternal and child health conditions being the major causes of ill health and death,
to noncommunicable diseases, which are responsible for increasingly higher levels of disability and premature mortality.
A substantial proportion of the health problems in the Americas also arise from mental, neurological, and substance
use disorders. Data show that people with mental disorders have high levels of disability as well as high mortality rates.

The Global Burden of Disease (GBD) approach is a systematic, scientific process to quantify the comparative magnitude
of health lost due to diseases, injuries, and risk factors by age, sex and geography, for specific time periods. The GBD
has had a profound impact on health policy as it is able to reveal the hidden burden of mental illness around the world.

The Burden of Mental Disorders in the Region of Americas, 2018 documents the latest available estimates of the burden of
these conditions at the regional level. The data also reveal the consequences of these disorders in terms of lost health.
Furthermore, this report provides data that demonstrate the limited resources within countries to adequately meet
mental health needs, while underlining the often inequitable distribution and inefficient uses of such resources.

This report seeks to inform governments, civil society, and other stakeholders, and in so doing, raise the level of
awareness about mental disorders in the Region, so as to mobilize political will and the necessary resources to combat
mental, neurological, and substance use disorders and suicide in the Americas.

Dr. Anselm Hennis

Director
Department of Noncommunicable Diseases and Mental Health
Pan American Health Organization

The Burden of Mental Disorders in the Region of the Americas, 2018 vii
Acknowledgments

The Mental Health and Substance Use Unit of the Pan American Health Organization (PAHO/WHO) wishes to express
its sincere thanks to all who diligently collaborated during the development and implementation of this research. This
assessment of mental health needs in the Americas takes into account information from various sources concerning the
burden related to mental, neurological, substance use, and suicide as well as government spending. This report would
not have been possible without these contributions.

Dr. Daniel Vigo (Centre for Applied Research in Mental Health and Addictions, Simon Fraser University; Department of
Global Health and Social Medicine, Harvard Medical School) was responsible for collecting and analyzing data and was
the principal author of the text.
Mrs. Dévora Kestel (PAHO) coordinated the production of this report, supervised its content, and was responsible for
writing sections of the text.
Dr. Anselm Hennis (PAHO) contributed to the review process of the report.
Dr. Jorge Rodriguez (Consultant) and Dr. Wendel Abel (University of the West Indies) provided valuable peer review
comments.
Dr. Matías Irarrázaval (PAHO) participated in the review process of the report and was responsible for writing some
sections of the text along with Drs. Andrea Bruni (PAHO), Claudina Cayetano (PAHO), and Carmen Martinez (PAHO).
Drs. Arthur Kleinman, Graham Thornicroft, Rifat Atun, and Anne Becker provided invaluable input to the principal author
of this report.

viii The Burden of Mental Disorders in the Region of the Americas, 2018
List of Acronyms

DALYs Disability-adjusted life years

DSM Diagnostic and Statistical Manual of Mental Disorders

GBD Global Burden of Disease

GDP Gross domestic product

ICD International Classification of Diseases

LAMICS Low- and middle-income countries

mhGAP Mental Health Gap Action Programme

MNSS Mental, neurological, substance use, and suicide

NCDs Noncommunicable diseases

PAHO Pan American Health Organization

PPP Purchasing power parity

WHO World Health Organization

WHO-AIMS World Health Organization Assessment Instrument for Mental Health Systems

YLDs Years lived with disability

YLLs Years of life lost

The Burden of Mental Disorders in the Region of the Americas, 2018 ix

Main Findings

zzMental, substance use, and specific neurological disorders and suicide form a subgroup of diseases and conditions
that are a major cause of disability and mortality, and give rise to a third of total years lived with disability (YLDs) and
a fifth of total disability-adjusted life years (DALYs) in the Americas.

zzDepressive disorders are the largest cause of disability alone, and combined with mortality, account for 3.4% of total
DALYs and 7.8% of total YLDs.

zzThe second largest subset comprises anxiety disorders, with 2.1% and 4.9%, respectively, of total DALYs and YLDs.
Self-harm and somatoform disorders with prominent pain account, respectively, for 1.6% of DALYs and 4.7% of YLDs.

zzSouth America, in general, has higher proportions of disability due to common mental illness. Central America has
a larger proportion of disability due to bipolar and childhood onset disorders, as well as due to epilepsy, than other
subregions; and the USA and Canada suffer a high toll of disability from schizophrenia and dementia, as well as from
devastating rates of opioid-use disorder.

zzThe health system’s response to the challenge of mental illness shows a correlation with national income. Higher-
income countries spend a larger share of their health budgets on mental health services, and appear to allocate
their spending more efficiently, away from neuropsychiatric hospitals and based on integration of mental health into
primary care and community-based resources. Conversely, lower-income settings seem to compound their lack of
resources by allocating them to specialized neuropsychiatric hospitals instead of funding community-based mental
health services.

zzThe imbalance between the percentage of the total burden caused by mental disorders, and the percentage of total
health expenditures effectively allocated to mental health leads to the burden being three times the spending in the
high-income countries to 435 times the spending in lowest-income country, with a regional median of 34.

zzDespite the constraints affecting mental health budgets in the Americas, there is significant potential to make
meaningful improvements, while prioritizing the funding of community-based mental health services.

x The Burden of Mental Disorders in the Region of the Americas, 2018

Introduction
The global mental health field is rapidly evolving, particularly
since the early 2000s, thanks to the collaboration of
multilateral organizations, academic partners, patient
and user advocates, and mental health workers. This
joint effort yielded milestones such as the World Mental
Health Report, the mhGAP program, the Lancet Global
Mental Health series, the Mental Health Movement, and
other initiatives that led to a better understanding of the
disease burden of mental illness and of what the evidence-
based response to it should be (1–3). Mental illness is
increasingly acknowledged as a global health priority,
and given its economic burden it is also beginning to be
considered a global development priority (4–6). Ultimately,
this emergent prioritization led to its inclusion in the
Sustainable Development Goals and to a global consensus
that the drive for universal health coverage should be
inclusive of mental health and well-being (7,8).
The epidemiologic transition is transforming the world:
global health needs used to be determined by communicable
diseases and early mortality, whereas now they are largely
The Burden of Mental Disorders in the Region of the Americas, 2018
dominated by noncommunicable diseases (NCDs), multi-
morbidity, and survival with disability (9,10). Within this
landscape, mental illness is proving to be a particularly
complex challenge: despite its increasing visibility in the
global health and development community, pervasive
structural stigma, outdated frameworks and practices, and
organizational fragmentation affect the ability to adequately
assess, prioritize, invest in, and respond to mental illness in
proportion to burden, in parity with physical health, and in
keeping with effectiveness and cost-effectiveness evidence.
An adequate needs assessment is the cornerstone of
prioritization, sound investment, and appropriate response,
and traditional assessments of mental illness burden have
methodological constraints that result in an underestimation
of mental illness due mainly to five reasons: (i) the arbitrary
separation between psychiatric and neurological disorders;
(ii) the consideration of suicide and self-injurious behavior as
a separate category outside mental illness; (iii) the conflation
of painful somatoform disorders with musculoskeletal
disorders; (iv) the exclusion of personality disorders; and (v)
the inadequate consideration of the contribution of severe
mental illness to mortality from associated causes.
1

Panel 1.
Tree mapping.
Throughout this report, tree maps will be used to convey
multidimensional information in a single visualization.
Tree maps display data through nested rectangles, with
each rectangle having three dimensions: color, size, and
position.
The difference in colors within each tree map indicates
the four PAHO subregions (Latin America, the Non-Latin
Caribbean, South America, and Canada and the United
States). Figure 5 shows each subregion in a different
color, but the other tree maps in this report will use
different shades of the same color to identify the four
subregions, from lightest to darkest.
The difference in size reflects the quantitative difference
between each country. Figure 5 shows the difference in
the number of people, while the other tree maps reflect
the different magnitude of the disease burden for each
country.
The position depends on the size, with the largest
rectangles on the upper-left corner and the smallest in
the lower-right corner. It is useful to see all countries with
a similar size—hence a similar disease burden—clustered
together in the same region of the tree map.
So, at a glance we can see which countries have the
largest and the smallest disease burden, by the size of
the rectangles; whether countries belong to the same
subregion, hence of the same color; whether countries
share a similar burden or not, if they are clustered or
dispersed in the graph; and whether there are sub-
regional gradients, indicated by the existence of well-
defined color clusters.
Each tree map will have a color cue and a brief description
of its dimensions and what they represent.
2 The Burden of Mental Disorders in the Region of the Americas, 2018
An additional caveat is the fact that the disease burden varies
regionally and across time, so for burden estimations to be
valid they need to be updated. It is a well-established fact
that the disease burden profile differs between low-, middle-,
and high-income countries; urban and rural populations;
low- and high-income households; men and women; and
across different age groups. Though it is not scientifically
possible to address all these determinants simultaneously,
each assessment of need must explicitly define its scope,
and its validity limitations, both internal and external.
This report aims at improving the assessment of mental
health needs in the Americas by providing an updated and
nuanced picture of: (a) the disability resulting from mental,
substance use, and specific neurological disorders, plus self-
harm, alone and in combination with premature mortality;
(b) the imbalance between mental health spending and its
related disease burden; and (c) the inadequate allocation of
the meager mental health spending. The goal is to present:
1. A regional population-level view of mental disorders in the
context of an overall health perspective, understanding
how the disease burden varies between subregions and
from country to country, particularly in relation to the
other NCDs; to the communicable, maternal, nutritional,
and neonatal conditions; and to injuries.
2. A detailed analysis of the burden related to mental,
neurological, substance use, and suicide (MNSS) at
the continental level and by country, specifying the
percentage of the total disease burden that is due to
the different mental disorders in terms of disability and
combined with premature mortality.
3. A mapping of how the most relevant mental disorders
are distributed across the Americas, considering how
the different countries and subregions are affected.
4. An analysis of how government spending in mental
health varies across the Americas in relation to national
income, with a focus on mental health spending as a
fraction of total government health spending, and on
the percentage of mental health spending allocated to
psychiatric hospitals.
5. Finally, simple and intuitive metrics are proposed in
order to best assess the gap between disease burden
and effective government spending on mental health.
Disease burden distribution in the Americas
Since the publication in 1996 of the seminal work on the
Global Burden of Disease (GBD), and through the sustained
work by the World Health Organization and the Institute of
Health Metrics and Evaluation, the disease burden metrics
provide actionable, quantitative outcomes to measure
and compare the disability and mortality that different
illnesses impose upon individuals and communities (11–13).
Estimating the local, national, and regional disease burden
allows for rational disease prioritization, resource allocation,
and health system planning—in conjunction with other
criteria such as the broader social and economic burden,
ethical considerations, and local resources or preferences.
In gathering and analyzing the data, it is important to
understand the following three metrics:
Disability-adjusted life years (DALYs) provide a
composite measure of the mortality and disability
attributable to any given illness.
The Burden of Mental Disorders in the Region of the Americas, 2018
Years of life lost (YLLs) provide a measure of cause-
specific mortality weighted by life expectancy at time of
death.
Years lived with disability (YLDs) provide a measure of
a disease’s prevalence weighted by its disabling impact.
We extracted 2015 disaggregated data (country-age-
sex-specific absolute numbers, rates, and percentages)
from the Global Health Data Exchange for all disease causes
and countries in the Americas, and re-estimated the disease
burden for MNSS following the framework described by
Vigo et al., which includes: (a) self-harm-related disability
and mortality; (b) neurological conditions with prominent
mental and behavioral syndromes that present frequently
at the primary care level (dementia, epilepsy, migraine,
and tension-type headache); and (c) a fraction of pain
syndromes without anatomic correlation, corresponding to
an estimation for DSM-5 somatic symptom disorder with
3
prominent pain and ICD-10 somatization disorders, which
frequently constitute a presentation of mood, anxiety, and
personality disorders, particularly in contexts of high stigma
towards common mental illness (12,13,15,16).
Regional disability and
mortality: disability-adjusted
life years (DALYs)
Globally, NCDs accounted for 60% of total DALYs in 2015,
of which 12% corresponded to MNSS. Meanwhile in the
Americas, NCDs accounted for a much larger 78% of total
DALYs, with MNSS taking up a much larger fraction of DALYs
at 19%. The remaining 59% of NCD DALYs are distributed
among cardiovascular disease; cancer; musculoskeletal
disorders; diabetes; neurologic, respiratory, digestive,
urinary, gynecologic disorders, and others. Finally,
communicable, maternal, child, and nutritional disorders
are responsible for 12%, and injuries for 10% of total DALYs.
This distribution highlights the fact that MNSS comprise
nearly a fifth of total DALYs, constituting the largest
Figure 1: Regional disability-adjusted life years (DALYs) distribution tree map (%)
59%
Noncommunicable diseases
4 The Burden of Mental Disorders in the Region of the Americas, 2018
subgroup cause of disease burden in terms of disability
and mortality combined, even larger than two higher level
groupings: injuries and communicable, maternal, child,
and nutritional disorders.
Figure 1 shows the three groups of disorders (NCDs;
communicable, maternal, child, and nutritional disorders;
and injuries) with MNSS as a separate subgroup of NCDs.
The largest mental cause of DALYs is depressive disorders,
which account for 3.4% of total DALYs, followed by anxiety
disorders with 2.1%. A regional ranking of specific mental
disorder DALYs is available in Figure 2.
Regional disability: years lived
with disability (YLDs)
Mortality data do not adequately capture the deaths
caused by mental illness; therefore, it is useful to
compare disability separately, as measured by YLDs.
This metric is not affected by the exclusion of mental
illness deaths and provides a valid comparison across
19% 12%
Communicable,
mother, child
and nutritional
MNSS disorders
Injuries 10%
disease groupings. Our analysis shows that MNSS
account for more than a third of total disability in the
Americas: 34% of total YLDs.
All the other NCD sub-groups combined account for an
additional 54% of YLDs; communicable, maternal, child and
nutritional for 8% of disability; and injuries for 4%, making
MNSS by far the largest subgroup (Figure 3). Figure 4
shows a regional ranking of YLDs attributable to MNSS.
Country-level analysis
In order to complement the regional analysis, a by-country
study of the disease burden of mental disorders was
conducted. This detailed country-level grounding of the
data is important because of two main reasons:
(a) The Americas comprise a vast number of countries
and territories—36 of which have been included in this
report—of very dissimilar population numbers. Figure 5
shows a tree map of all countries grouped by subregions,
with the size of each square reflecting the population
size. It is clearly seen that three countries—the United
States, Brazil, and Mexico—comprise two-thirds of the
billion people living in the Americas, so the aggregated
regional disease burden will be highly determined by the
disease profile of these three countries. Furthermore,
an exclusively regional perspective would obscure the
disease burden of the Non-Latin Caribbean, given their
comparatively small populations (the green fraction of
Figure 5). Besides the country-specific percentages,
average country-level percentages will be provided when
meaningfully different from the regional aggregate.
(b) The goal of this report is to provide an actionable
needs assessment that can inform mental health
prioritization, system planning, and service delivery at
the country level, so it is with national-level decision-
makers in mind that this report has been conceived.

Figure 2: Ranking of mental, neurological, and substance use disorders, and suicide DALYs

Depression 3.35%
Anxiety disorders 2.10%
Pain disorders 2.04%
Neurocognitive disorders 1.95%
Migraine 1.86%
Self harm 1.62%
Substance use disorders 1.46%
Schizophrenia 0.86%
Alcohol use disorders 0.80%
Bipolar disorder 0.59%
Autism 0.52%
Other 0.51%
Epilepsy 0.49%
Conduct disorder 0.32%
Eating disorders 0.13%
Tension-type headache 0.12%
Intellectual disability 0.10%
Attention-deficit disorders 0.04%
0.000 0.005 0.010 0.015 0.020 0.025 0.030 0.035
% of total DALYs

The Burden of Mental Disorders in the Region of the Americas, 2018 5

Figure 3: Regional years lived with disability (YLD) distribution (%)

34%
54%
MNSS

Noncommunicable diseases
8% 4%
Communicable, maternal,
child and nutritional disorders Injuries

Figure 4: Ranking of mental, neurological, and substance use disorders, and suicide years lived with disability (YLDs)

Depression 7.84%
Anxiety disorders 4.92%
Pain disorders 4.71%
Migraine 4.36%
Schizophrenia 1.97%
Substance use disorders 1.84%
Bipolar disorder 1.37%
Autism 1.21%
Other 1.20%
Neurocognitive disorders 1.19%
Alcohol use disorders 0.94%
Epilepsy 0.75%
Conduct disorder 0.75%
Eating disorders 0.29%
Tension-type headache 0.27%
Intellectual disability 0.23%
Attention deficit disorders 0.08%
Self-harm 0.05%
0.00 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08
% of total YLDs

6 The Burden of Mental Disorders in the Region of the Americas, 2018

Figure 5: Population distribution of the countries in the Americas

Brazil Colombia Peru Venezuela Mexico

207,846,953 48,263,936 31,393,214 31,105,673 127,042,701

Argentina Chile Bolivia

Canada and US 43,413,241 17,948,052 10,766,601
Latin Central America
Paraguay
Non-Latin Caribbean Ecuador 6,652,900
South America 16,154,094 Uruguay
3,434,235

United States Canada

Guatemala Cuba Haiti
323,526,036 36,145,518
16,355,051 11,392,676 10,721,459

Dominican

El Salvador

Costa Rica
Nicaragua

4,808,814
6,088,617
6,137,389
Republic
10,529,766
Honduras
8,096,450 Panama Puerto Rico
3,928,551 3,683,846

Non-Latin Caribbean countries (those colored green) and their populations are listed in Annex 1.

Country-level disability and
mortality (DALYs)
There is significant heterogeneity in the distribution of the
main causes of disability combined with mortality in the
Americas. DALYs caused by NCDs, including mental illness,
are the largest fraction of total burden in every country in
the Region of the Americas, ranging from 50% in Haiti to
89% of total burden in Canada. The second regional cause-
group of DALYs, comprising communicable, maternal, child,
and nutritional disorders, ranges between 5.5% in Canada
and the United States and 39% in Haiti. The third regional
cause of DALYs is the group of injuries, which ranges from
6% in Canada, Cuba, Barbados and Bermuda, to 20% in El
Salvador. Figure 6 highlights that NCDs remain the largest
cause of disability and mortality combined across countries
despite large individual variations, whereas the group of
communicable, maternal, child, and nutritional disorders
and the group of injuries alternate in the second and third
rank-order, with a primacy of the former, especially in lower-
income countries. The subgroup of MNSS also shows large
between-country variation, ranging from 9% of total DALYs
in Haiti to 23% in Canada (see Figure 6).
Country-level disability (YLDs)
An analysis of years lived with disability (YLDs) provides
a picture that (a) complements the DALY burden analysis
and (b) is not biased by the differential exclusion of excess
mortality resulting from mental illness. The between-
country variation of YLDs as a percentage of total disability
is much lower than the DALY variation discussed in the

The Burden of Mental Disorders in the Region of the Americas, 2018 7

Figure 6: Disability-adjusted life years (DALYs) distribution by country (%)

Canada 23%
United States 22%
Chile 21%
Costa Rica 21%
Nicaragua 19%
Peru 19%
Bermuda 19%
Colombia 18%
Cuba 18%
Puerto Rico 18%
Brazil 17%
Antigua and Barbuda 17%
Uruguay 17%
El Salvador 17%
Paraguay 17%
Argentina 17%
Ecuador 17%
Panama 17%
Mexico 16%
Suriname 16%
Saint Lucia 16%
Dominican Republic 15%
Honduras 14%
Belize 14%
Bolivia 14%
Venezuela 14%
Trinidad and Tobago 14%
Guatemala 14%
Dominica 14%
Barbados 14%
Jamaica 14%
Saint Vincent and the Grenadines 14%
Grenada 14%
Virgin Islands, U.S. 14%
Guyana 13%
Haiti 9%
MNSS 0% 20% 40% 60% 80% 100%
Noncommunicable diseases
Injuries
Communicable, maternal, neonatal, and nutritional diseases

8 The Burden of Mental Disorders in the Region of the Americas, 2018

Figure 7: Years lived with disability (YLDs) by country (% of total YLDs)

Brazil 36%
Chile 36%
Paraguay 36%
Peru 35%
Colombia 35%
Nicaragua 35%
Costa Rica 34%
Argentina 34%
Honduras 34%
Mexico 33%
United States 33%
Ecuador 33%
Belize 33%
Antigua and Barbuda 33%
Bermuda 33%
Dominican Republic 33%
Uruguay 33%
Canada 33%
Suriname 32%
Panama 32%
Bolivia 32%
Saint Lucia 32%
Saint Vincent and the Grenadines 32%
Grenada 32%
Guatemala 32%
El Salvador 32%
Cuba 32%
Puerto Rico 31%
Dominica 31%
Jamaica 31%
Trinidad and Tobago 31%
Guyana 31%
Barbados 30%
Virgin Islands, U.S. 30%
Venezuela 29%
Haiti 28%
MNSS
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Noncommunicable diseases
Injuries
Communicable, maternal, neonatal, and nutritional diseases

The Burden of Mental Disorders in the Region of the Americas, 2018 9

previous section (except for disaster-related disability in
Haiti, which drives YLDs caused by injuries up to 10% of
total). The overall variation of NCD disability ranges from
70% of total YLDs in Haiti to 91% in Mexico. Focusing on
mental illness, the variation ranges between 28% in Haiti
to 36% in Brazil, Chile, and Paraguay. Communicable,
maternal, child, and nutritional disorders range from 5%
of YLDs in the United States and Chile to 20% of YLDs in
Venezuela and Haiti (see Figure 7).
Figure 7 shows that disability resulting from MNSS is
remarkably similar (and high) throughout the region.
MNSS constitute indisputably, and by a wide margin,
the largest subgroup cause of disability in every country,
regardless of income level or subregion. There appears
to be a subregional gradient in the disability resulting
from aggregated MNSS (see Figure 8), with South
American countries occupying the top five positions in
terms of YLDs, with most countries above the country-
average (33%) and regional aggregate (34%) disability.
As we will see in the disorder-specific sections, there
is a wide variation across countries in terms of which
specific mental disorders cause the largest burden. It is
important for decision-makers to consider the specific
disease profile that affects their country to adequately
prioritize conditions, allocate investments, and plan

Figure 8: Mental, neurological and substance use disorders and suicide disability tree map (YLDs by country as a percentage
of total disability)

Brazil Costa Rica Belize Suriname Panama Bolivia Saint Lucia

36.5% 34.1% 33.4% 32.5% 32.4% 32.3% 32.2%

Chile Argentina Antigua and Barbuda

36.2% 34.0% 34.0% Saint Grenada Guatemala El Salvador Cuba

Vincent

Paraguay Honduras Bermuda

and the
Grenadines
32.1% 32.0% 32.0% 31.6%
35.6% 33.5% 33.2% 32.2%
Peru Mexico Dominican Republic

35.5% 33.5% 33.5% Puerto Rico Guyana Venezuela

31.4% 30.6% 28.9%

Colombia United States Uruguay
Dominica Barbados
35.4% 33.4% 32.9% 31.4% 29.7% Haiti

Nicaragua Ecuador Canada

Jamaica Virgin Islands U.S.
28.2%
34.7% 33.4% 32.8% 30.8% 29.6%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

10 The Burden of Mental Disorders in the Region of the Americas, 2018

Disability resulting from specific disorders
service delivery.
Common mental disorders
Common mental disorders generally comprise depressive
and anxiety disorders. It is necessary to point out,
however, that a number of other very common mental
and behavioral syndromes are not considered in typical
burden of disease calculations and analyses, despite their
significant prevalence, disability, and mortality (15,19). Of
note, personality disorders and somatic symptom disorders
are excluded due to the lack of consistent cross-country
data, and self-harm and suicide are considered under the
heading of injuries, despite the well-established fact that
mental disorders and sub-threshold syndromes are largely
responsible for intentional self-harm (15,20). The result
is that somatoform disorders with predominant pain—a
psychiatric disorder formerly known as pain disorder, which
The Burden of Mental Disorders in the Region of the Americas, 2018
when properly studied emerges as the single most prevalent
mental disorder, affecting 8% of the general population
yearly (21)—is systematically and erroneously conflated
with musculoskeletal disorders, leading to inflation of that
category despite the absence of a causal link of these
syndromes to the musculoskeletal system (15,22). Similarly,
personality disorders—a group of behavioral and mental
syndromes frequently comprising problematic interpersonal
functioning, affective and cognitive symptoms, impulsivity,
self-harm, and somatic complaints—are not considered at
all in burden of disease calculations despite the fact that
they are highly prevalent (4 to 15% in community surveys)
(23). Following the method described in detail elsewhere
(15), this study includes self-harm and an estimation for
pain disorders, thus indirectly capturing a fraction of the
disability resulting from personality disorders and the
excess death from depression and other mental illnesses
due to suicide. Given the high prevalence of these mental
11
and behavioral syndromes, they are considered in this
section of common mental illness.
„„ Depressive disorders
For the purpose of the current analysis, depressive
disorders comprise depressive disorder and dysthymic
disorder. Depressive disorder can be a highly disabling
condition, as reflected by its disability weight in the
burden of disease framework. Severe depressive
episodes are considered, based on surveys of the
general population, to be the fifth-most disabling human
health state, after acute schizophrenia, untreated neck-
level spinal cord lesion, severe multiple sclerosis, and
severe heroin dependence (24). Even mild depressive
disorders and dysthymia are considered highly disabling,
at the same level of, for example, severe anemia or
uncontrolled asthma. The disability resulting from
depressive disorders, both at the individual and at the
population level can be considered as a continuum of
health states from moderately to severely disabling.

Figure 9: Depressive disorder disability tree map (YLDs by country as a percentage of total disability)

Paraguay Bermuda Suriname Nicaragua Saint Lucia Argentina Jamaica Bolivia

9.4% 8.1% 7.9% 7.8% 7.8% 7.8% 7.7% 7.7%

Brazil Antigua and
Barbuda
9.3% 8.1% Saint Vincent and Puerto Rico Trinidad & Dominica Panama

Chile
the Grenadines

7.7% 7.5% Tobago

7.5% 7.5% 7.4%

Peru

8.6% 8.1% Grenada

7.6%
Costa Rica United States El Virgin Guatemala
Ecuador
8.0% 7.4%
7.2% 7.0% 6.8%
Salvador Islands,
8.3% Honduras U.S.
7.6%
Belize Barbados
Colombia

8.2% 8.0% Uruguay

7.4%
7.6% Haiti Canada

Dominican Republic Cuba Mexico

Guyana
6.7% 5.9%
8.2% 7.9% 7.6% 7.3% Venezuela

6.7%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

12 The Burden of Mental Disorders in the Region of the Americas, 2018

At the regional level, this analysis places depression at
the top of disability causes, with 7.8% of total disability,
and a range from 5.9% in Canada to 9.4% in Paraguay. A
subregional pattern of increased disability in South America
is evident, as indicated by the following: (a) Paraguay, Brazil,
Peru, Ecuador, and Colombia constituting the top five in
the depression disability ranking; and (b) a clear majority
of South American countries at or above the country-
average (7.7%) and regional aggregate (7.8%) (see Figure
9). Another important aspect of depressive disorders
is that they affects mainly the young: nearly 10 million
of the 14.5 million depression YLDs in the Americas fall
within the 15- to 50-year-old age group (see Figure 10).
„„ Anxiety disorders
This group of disorders comprises many syndromes
characterized by prominent anxiety, such as generalized
anxiety disorder, panic disorder, social anxiety disorder,
and others. From a disability perspective, they can range
from severely disabling to mildly troublesome, and for

Figure 10: Depressive disorder: years lived with disability by age groups (total of YLDs)

15M

14M

13M

12M

11M

10M

9M
Total YLDs

8M

7M

6M

5M

4M

3M

2M

1M
0M
5-14 years 15-49 years 50-69 years 70+ years All Ages

The Burden of Mental Disorders in the Region of the Americas, 2018 13

our 2015 data analysis we consider them aggregated, disability (3.4%), followed by Mexico (3.6%) and the USA
including post-traumatic stress disorder and obsessive- (4.1%) also well below the regional average and aggregate.
compulsive disorders.

Anxiety disorder is the second-most disabling mental „„ Self-harm and suicide

disorder in most countries of the Americas. A subregional
pattern is even more discernible than for depressive
disorders, with Brazil at the top (7.5%); all but one South
American country showing above country-average (4.7%)
and regional aggregate (4.9%) disability; and 8 of the
top 10 countries in terms of disability corresponding to
this subregion (see Figure 11). North America falls at the
other end of the spectrum, with Canada showing the least
Given the well-established relationship of common mental
illnesses (such as depressive and personality disorders)
with suicide and self-harm, these illnesses are considered
in this section. The burden of disease framework does not
include personality disorders, a well-established cause of
non-lethal self-harm (23,27), and YLDs resulting from self-

Figure 11: Anxiety disorders disability tree map (YLDs by country as a percentage of total disability)

Brazil Peru Suriname Bolivia Saint Lucia Grenada Guyana Saint Vincent
and the
7.5% 5.3% 4.9% 4.9% 4.8% 4.8% 4.8% Grenadines

4.8%
Ecuador
Paraguay
5.2%
6.8% Jamaica Nicaragua Haiti Barbados Honduras

Dominican
Republic
4.7% 4.4% 4.4% 4.4% 4.3%
Chile
5.2% Dominica
5.5% 4.6%
Uruguay Virgin Islands U.S. Guatemala Panama El Salvador
Argentina
5.2% Cuba 4.1% 4.0% 4.0% 4.0%
5.4% 4.6%
Antigua Costa Rica
Colombia and Barbuda

5.3% 5.0%
Trinidad & Tobago
4.1%
4.6% Venezuela Canada

Belize Bermuda
Puerto Rico
United States
3.6% 3.4%
5.3% 4.9% 4.4% 4.1% Mexico

3.5%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

14 The Burden of Mental Disorders in the Region of the Americas, 2018

harm are not captured in the burden of disease framework.
Therefore, this section will focus on suicide DALYs, which
are largely due to years of life lost due to premature death.
Suicide is the fifth highest cause of DALYs in the Americas,
with an almost nine-fold range in terms of percentage of
total burden, from 0.4% in Antigua and Barbuda to 3.6%
in Suriname. There is a remarkable subregional pattern
affecting Suriname (3.6%), Guyana (3.5%), and, to a lesser
extent, nearby Trinidad and Tobago (2.1%); as well as Uruguay
(2.6%), Chile (2.5%), and Argentina (2%) in South America.
The United States (2.2%) plus Canada (2.1%) also comprise
subregional clusters affected by suicide well in excess of the
country-average (1.5%) and aggregate (1.6%) percentages
(see Figure 12). The toll that suicide takes in the Americas
is daunting, and it falls mainly on younger working-age
populations: 60% of the nearly 100,000 suicides occurred
between 15 and 50 years of age; 4,129,576 years of life
were lost, of which around 75% were lost by this same age
group (see Figure 13).
„„ Somatoform disorders/persistent
somatoform pain disorder
Somatoform disorders with predominant pain are poorly
understood syndromes and thereby frequently ignored
by clinicians, psychiatrists, and epidemiologists (22,28).

Figure 12: Suicide and self-harm burden tree map (DALYs by country as a percentage of total disability)

Suriname Canada Cuba El Salvador Costa Rica Venezuela Bolivia

3.6% 2.2% 1.9% 1.9% 1.9% 1.7% 1.7%

Trinidad & Tobago

Guyana 2.1% Ecuador Belize Grenada Saint Lucia Brazil

3.5% 1.5% 1.2% 1.1% 1.1% 1.1%

United States
Paraguay
2.1% Colombia
1.2% Dominican Bermuda Honduras Haiti
1.4% Republic

Uruguay Guatemala 1.2% 0.9% 0.9% 0.9%

2.6% Argentina
1.2%
2.0% Mexico

1.3% Saint Vincent and

the Grenadines Virgin Islands,U.S. Peru Jamaica
Chile Nicaragua 1.2% 0.8% 0.7% 0.6%
2.5% 2.0%
Panama

1.2% Puerto Rico

1.2%
Dominica Barbados Antigua and
Barbuda
0.8% 0.7% 0.4%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

The Burden of Mental Disorders in the Region of the Americas, 2018 15

When properly studied, however, they are highly prevalent,
especially in women: the 12-month prevalence of DSM-IV
pain disorder has been established by one study as 11%
for females and 4% for males, with an overall rate of 8%,
the largest for any mental disorder (21). Some 56% of pain
disorder patients meet the criteria for another psychiatric
disorder, most frequently depressive or anxiety disorders.
The prevalence of painful syndromes in patients diagnosed
with depressive or anxiety disorders has been found
to be greater than 30%, and up to 80% in specific post-
traumatic stress disorder populations (29). Routine burden
of disease assessments assign 0% of the burden of painful
syndromes to mental disorders, an assumption lacking
minimal face validity. Reattributing a fraction of this burden
to MNSS as described elsewhere yields an estimate of
4.7% of total YLDs due to somatic symptom disorder with
prominent pain (15). The estimated range is between 6.2%
in Canada and 3.2% in Haiti, and higher-income countries
seem to be more affected than lower-income countries.
These estimates should be considered indicative until

Figure 13: Total years of life lost by age group*

4200K

4000K

3800K

3600K

3400K

3200K

3000K

2800K
Total years of life lost

2600K

2400K

2200K

2000K

1800K

1600K

1400K 4,129,576
3,126,880
1200K

1000K

800K

600K

400K
804,402
200K 74,718 123,575
0K
5-14 years 15-49 years 50-69 years 70+ years All Ages

*Columns represent total YLLs in the Americas for four separate age groups, and a fifth column for all ages.

16 The Burden of Mental Disorders in the Region of the Americas, 2018

primary data on somatoform disorders disability become
available. Of note, the importance of this issue has led
to the recent creation of a specific section to screen for
somatic symptom disorders in the WHO World Mental
Health Composite International Diagnostic Interview, to
be administered in future World Mental Health Surveys,
filling this gap.
Severe mental disorders
Schizophrenia and bipolar disorders are usually referred to
as severe mental disorders. Indeed, they exact some of the
largest tolls conceivable on human beings: acute psychotic
episodes in the context of schizophrenia are considered
the most disabling health state in the burden of disease
framework (24); manic episodes are highly disabling
medical emergencies, frequently leading to socioeconomic
ruin, injury, or death if untreated; and depressive episodes
in the context of bipolar illness can be as severe as those
of depressive disorder, particularly in the context of bipolar
disorder type II. Severe mental illness is particularly lethal
in low-income settings, which tend to also be contexts of
high stigma. The increased lethality is due to the lack of
effective mental care and to inadequate general medical
care for people with severe mental disorders, which lead to
largely preventable excess mortality. The lack of effective,
accessible, or even available services, coupled with the
catastrophic economic and emotional burden on families,
frequently lead to systematic human rights abuses in
lieu of treatment, resulting in what has been memorably
labeled a “failure of humanity” (30). Indeed, as detailed in
the section devoted to the health system response, lower
country income is associated with decreased availability of
services, worse services when available, and earlier death
for severe mental illness.
„„ Schizophrenia
In the burden of disease framework, the schizophrenias
are considered the most disabling human disorders,
particularly during acute episodes.
The Burden of Mental Disorders in the Region of the Americas, 2018
The regional variation of schizophrenia disability as
a percentage of total disability ranges between 1.1%
in Haiti and 2.5% in the United States (see Figure 14).
Subregional patterns are less clear, but the USA, Canada,
and most South American countries are above the
country average (1.6%). Several factors could explain an
increasing share of the disability as income level grows,
most notably increased premature mortality and/or
decreased case-detection capacity in poor settings.
Research has shown that people with schizophrenia
die between 10 and 30 years younger than their peers,
with the worst outcomes seen in low-income countries
(17,31), which would explain the decreasing share of the
resulting survival with disability.
„„ Bipolar disorders
Bipolar disorders are the cause of significant disability and
mortality in the Americas. Clinical presentation is highly
variable both across and within cases: some episodes
constitute mild or moderate fluctuations in mood that are
compatible with a high functionality and quality of life, while
others evolve into severe depressive or manic episodes,
the former of which can lead to suicide, and the latter, as
mentioned before, to death, disability, or socioeconomic
ruin if untreated. So, unlike the uniformly high disability
resulting from schizophrenia, disability resulting from bipolar
disorders can range from mild dysfunction during residual
states to almost complete impairment during severe manic
and depressive episodes. For the purposes of our analysis,
bipolar disorders comprise types I and II, characterized
by manic and hypomanic episodes, respectively. The
latter constitutes a milder and shorter behavioral and
psychological activation syndrome than the former.
A subregional pattern seems to emerge for bipolar disorder
disability: every country in continental Central America is
above the country-average and regional aggregate of 1.4%
(see Figure 15), while both Canada and the United States
are below the aggregate (1.3% and 1.2%, respectively). The
range is between 1.1% of total YLDs in the Virgin Islands to
1.7% in Nicaragua.
17
Substance use and eating
disorders
Disorders stemming from the use of substances (alcohol,
drugs, or food) are frequently considered together due to their
similar clinical pattern, mostly related to their compulsive
nature and the direct behavioral dysfunction they entail. This
makes them different from smoking, which entails mostly
indirect disability through its physical consequences. The
current analysis focuses on alcohol use disorder, substance
use disorders, and eating disorders. These disorders include
varying severities that range from the low impairment of mild
cannabis use disorder to the almost total disability resulting
from severe heroin dependence, and including the moderate
disability resulting from anorexia and bulimia.
„„ Disorders due to use of alcohol
The disability resulting from alcohol use disorders
ranges from 0.5% in Paraguay to 1.9% in Guatemala
and El Salvador. It presents a subregional pattern with
the United States, Canada, and most South American

Figure 14: Schizophrenia disability tree map (YLDs by country as a percentage of total disability)

United States Mexico Peru Dominican Nicaragua Trinidad Barbados

Republic
2.5% 1.8% 1.7% 1.7% 1.7% & Tobago
1.6%
1.6%
Colombia
Chile

2.1% 1.8% Brazil Suriname Belize Honduras Venezuela

1.6% 1.5% 1.5% 1.5% 1.5%

Cuba
Argentina
1.7% Ecuador

1.9% 1.6%
Dominica El Salvador Jamaica
Panama
Saint Lucia
1.5% 1.4% 1.4%
Uruguay
1.7% 1.6%
1.9% Grenada

Bermuda
1.5% Bolivia Guyana Guatemala
Costa Rica
1.7% Puerto Rico 1.4% 1.3% 1.3%
1.9% 1.6% Virgin Islands U.S.

1.5%
Antigua & Saint Vincent and
Canada Barbuda Paraguay
the Grenadines
1.8% 1.7% 1.5% 1.5% Haiti
1.1%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

18 The Burden of Mental Disorders in the Region of the Americas, 2018

countries well below the country average of 1.2% (only
Chile exceeds it at 1.5%), and at or below the regional
aggregate (0.9%). Meanwhile, every country in Central
America and the Caribbean is above the regional
aggregate, and most are above the country average (see
Figure 16).
It should be noted that Figure 16 represents years lived
with disability (YLDs), but alcohol use disorders also
impose a significant burden in terms of years of life lost
(YLLs), both directly and through excess death due to
cardiomyopathy, liver cancer, and cirrhosis.
„„ Disorders due to substance use
(not alcohol)
We consider here together cannabis, cocaine,
amphetamine, and opioid use disorders. The variation
in disability burden resulting from drug use ranges from
0.5% in Barbados and 0.6% in Haiti and Cuba, to 3.1% in

Figure 15: Bipolar affective disorder disability tree map (YLDs by country as a percentage of total disability)

Nicaragua Guatemala Dominican Argentina Paraguay Venezuela Brazil Antigua

1.7% 1.5% 1.5% 1.5% 1.4% 1.4% 1.4% 1.5%

Republic and
Barbuda

Peru
Colombia

2.5% 1.5% Bermuda Saint Lucia Saint Vincent Jamaica Canada

1.4% 1.3% and the

Grenadines 1.3% 1.3%
El Salvador
1.3%
Honduras
1.5% Grenada

1.7% 1.4% Dominica Guyana Puerto Rico Haiti

Costa Rica
Chile
Bolivia
1.3% 1.3% 1.3% 1.3%
1.6% 1.5% 1.4%
Trinidad & Tobago

Mexico
Belice
Uruguay 1.3%
1.6% 1.5% 1.4% United States Virgin

1.2% Islands,
U.S.

Ecuador Suriname
Cuba 1.1%
Panama

1.6% 1.5% 1.4% 1.3% Barbados

1.2%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

The Burden of Mental Disorders in the Region of the Americas, 2018 19

the United States (see Figure 17). This six-fold variation
reflects the raging epidemic of opioid use disorders
affecting the United States and Canada (2.5%); in both
of which, the specific burden of opioid use disorders
constitutes around 70% of all drug use disability.
As is the case with alcohol, other substance use
disorders cause a significant number of years of life lost
across the region, but most notably in the United States
and Canada, where they produced 1.73% and 0.92% of
total years of life lost, respectively.
„„ Eating disorders
Anorexia and bulimia together account for a comparably
much smaller fraction of total burden; between 0.07%
in Haiti and 0.42% in the United States. Only the United
States and Canada are above the regional aggregate
percentage of 0.3%, indicating that the burden of eating
disorders falls mostly on well-off countries.

Figure 16: Disorders due to use of alcohol disability tree map (YLDs by country as a percentage of total disability)

Guatemala Nicaragua Belize Haiti Cuba Suriname Puerto Rico

1.9% 1.6% 1.5% 1.4% 1.4% 1.3% 1.3%

Grenada
El Salvador
1.6%
1.9% Costa Rica Mexico Honduras Colombia Panama

Dominica
1.3% 1.1% 1.1% 1.0% 1.0%
1.6%
Saint Vincent and the Trinidad & Tobago
Grenadines

1.9% Chile
1.2% Barbados Venezuela Canada

1.5% 1.0% 0.9% 0.9%

Dominican Republic

Virgin Islands, U.S. 1.2% Jamaica

1.7% Saint Lucia 1.0% Bolivia Peru

1.5% Argentina 0.9% 0.8%

1.2% United States

Antigua and Barbuda 0.9% Uruguay Paraguay

Guyana
1.7% 1.5%
Bermuda Ecuador 0.6% 0.5%
1.1% 0.9% Brazil

0.6%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

20 The Burden of Mental Disorders in the Region of the Americas, 2018

Disorders with onset usually
occurring in childhood and
adolescence
Collectively, disorders that affect mainly children and
adolescents account for 2.2% of total YLDs in America.
They include, in order of importance, autism (1.2%),
conduct disorders (0.7%), intellectual disability (0.2%),
and attention-deficit and hyperactivity disorder (0.1%).
They show a clear subregional pattern, with all continental
Central American countries and all South American
countries above the regional aggregate percentage.
Conversely, most of the English-speaking Caribbean
islands, the United States, and Canada (1.8% in both) show
the lowest burden (see Figure 18).

Figure 17: Disorders due to substance use (not alcohol) disability tree map (YLDs by country as a percentage of
total disability)

United States Peru Suriname Ecuador Uruguay Costa Rica Panama

3.1% 1.3% 1.0% 1.0% 1.0% 0.9% 0.9%

Guatemala

1.2% Honduras Saint Vincent Belize Colombia Antigua

0.9% and the

Grenadines 0.9% 0.9% 0.9% and Barbuda

Canada
0.9%
2.5% Bolivia

1.2%
Guyana Nicaragua Saint Trinidad Venezuela

Chile 0.9% 0.8% 0.8% 0.8% 0.8%

Lucia & Tobago

Puerto Rico 1.2%

1.6% Virgin Islands, U.S.

Mexico
0.9%
Jamaica Paraguay Cuba
Argentina 1.1% Dominica 0.8% 0.7% 0.6%
1.3% 0.8% Dominican Republic

Bermuda
Grenada
Brazil
0.7% Haiti Barbados

1.3% 1.1% 0.8%

El Salvador 0.6% 0.5%
0.7%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

The Burden of Mental Disorders in the Region of the Americas, 2018 21

Neurological disorders
This category includes the disability resulting from
neurocognitive disorders—such as Alzheimer’s disease,
epilepsy, migraine, and tension-type headache, all of
which have prominent mental and behavioral syndromes.
„„ Neurocognitive disorders
Alzheimer’s and other dementias account for 1.2% of total
disability, ranging from 0.4% in Haiti to 1.9% in Canada.
They reflect a highly significant trend, correlating higher
GDP with a higher percentage of total disability attributable
to the dementias. This is an expression of the demographic
change in age structure, where increased survival, and
disability resulting from the disorders of older adults,
accompanies economic development (see Figure 19).
„„ Epilepsy
Epilepsy is responsible for 0.8% of total disability in
the region, ranging between 0.2% in Canada and 1.6%
in Honduras. Subregionally, epilepsy produces a lower
percentage of disability in Canada and the United

Figure 18: Disorders with onset usually occurring in childhood and adolescence disability tree map

Honduras Ecuador Dominican Argentina Costa Rica Guyana Venezuela

3.3% 2.8%
Republic

2.6% 2.6% 2.5% 2.5% 2.5%

Guatemala Peru
3.2% 2.8% Haiti Grenada Bermuda Antigua Saint

2.4% 2.3% 2.3% and

Barbuda
Vincent
and the

Nicaragua Paraguay 2.3% 2.3% Grenadines

3.2% 2.8% Chile

2.4%
Jamaica United Canada Cuba
Mexico El Salvador
2.2% 1.8% 1.8% 1.8%
States

3.1% 2.7% Suriname

2.3% Saint Lucia

Bolivia Panama
Uruguay
2.1%
2.9% 2.7% 2.3% Dominica Puerto Rico Virgin
Islands.
2.1% 1.8% U.S.

Belize Colombia Brazil 1.7%

2.8% 2.7% 2.3% Trinidad & Tobago Barbados

1.9% 1.8%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burdens are clustered together in the same region of the tree map.

22 The Burden of Mental Disorders in the Region of the Americas, 2018

Figure 19: Dementia disability tree map

Canada Barbados Brazil Dominican Bermuda Saint Lucia Colombia

1.9% 1.3% 1.0% Republic

0.9% 0.9% 0.9%
0.9%

Costa Rica

United States 1.2% Dominica Paraguay Jamaica Bolivia Grenada

1.6% 0.9% 0.8% 0.8% 0.8% 0.8%

Uruguay

1.1% Nicaragua

Puerto Rico 0.8% Chile Venezuela Saint

1.4% El Salvador 0.8% 0.7% Vincent
and the
Peru
1.1% 0.8%
Grenadines
Trinidad & Tobago 0.7%
Cuba 0.8% Suriname Guatemala
1.3% Panama Argentina
0.7% 0.7%
1.1% 0.8% Antigua and Barbuda

0.7%
Virgin Islands, U.S. Guyana
Mexico Ecuador Belize
1.3% 1.0% 0.8%
Honduras 0.4% 0.4%
0.7% Haiti
0.4%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burden are clustered together in the same region of the tree map.

States, and a larger proportion in Honduras, Guatemala,
and Mexico. In fact, most countries in Central America,
South America, and the Caribbean are above the regional
aggregate percentage (see Figure 20).
„„ Migraine and tension-type headaches
does not appear to be a subregional pattern for either
condition. However, the significant burden of headache-
related disability and its potential implications for health
systems–namely, the need for widespread training of
primary care workers in their detection and management—
have only recently come to the fore.

Migraines account for 4.4% of the regional disability

burden, ranging from 3.6% in the United States (3.6%)
to 5.4% in Peru. Tension-type headaches produce a
comparatively lower regional burden (0.3%), and there

The Burden of Mental Disorders in the Region of the Americas, 2018 23

Figure 20: Epilepsy disability tree map

Honduras Haiti Venezuela Suriname El Salvador Saint Bolivia

1.6% 1.2% 1.1% 1.1% 1.1% Vincent

and the
Grenadines
1.0%
1.0%
Dominica
Guatemala

1.6% 1.2%
Saint Lucia Trinidad & Jamaica Paraguay

1.0% Tobago
0.9% 0.9%
Panama 0.9%
Mexico 1.2%
1.4% Antigua and Barbuda

1.0% Uruguay Dominican Barbados Brazil

Ecuador
0.8% Republic
1.6% 0.7%
Chile
1.2% 0.7%
1.3% Belize

1.0%
Peru
Nicaragua

1.3% 1.2% Grenada Bermuda Puerto Rico United

States
1.0% 1.6% 0.6% 0.5%
Cuba
Colombia Costa Rica
Guyana Virgin Islands, 0.6%
1.3% 1.2% 0.9% U.S. Argentina Canada
0.6% 0.5% 0.2%
Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar
burden are clustered together in the same region of the tree map.

24 The Burden of Mental Disorders in the Region of the Americas, 2018

Health system response in the Americas:
Government funding for mental health
services
This section will focus on how our societies respond
to the challenge presented by the MNSS. In so doing,
this study will analyze how investment in mental health
services and allocation of spending vary as a function of
national income. As a result, simple intuitive metrics are
presented that allow for comparison of the gap between
burden and spending across countries.
The present analysis is based on a set of estimates of
health spending and allocation obtained by collating the
latest available data reported to PAHO by governments
of the Americas and published in the WHO Assessment
Instrument for Mental Health Systems (WHO-AIMS). This
The Burden of Mental Disorders in the Region of the Americas, 2018
was supplemented with additional published data when
missing, or when more recent WHO-AIMS country-level
data were available (range: 2009-2015). For countries
or territories with unavailable data for mental health
spending or for fraction spent on mental hospitals, we
imputed the median regional value. We excluded countries
missing both data points, as well as territories without
burden of disease data. We also obtained 2015 real
per-capita GDP from the International Monetary Fund’s
World Economic Outlook Database. For the British Virgin
Islands we imputed the subregional median for the Non-
Latin Caribbean territories. A limitation to the following
analysis emerges from the fact that these data are self-
25
reported by ministries of health to WHO, and its quality
is variable due to lack of unified reporting criteria about
which types of expenditures are included or excluded.
For example, potentially significant resources allocated
to dementia care or suicide prevention, or services
delivered through the non-health sectors are probably not
captured in these estimates. However, even considering
these limitations, it is unlikely that inconsistencies in the
inclusion of dementia, suicide prevention, or non-health
sector expenditures would decrease the imbalance found
in low-income countries. In fact, it is actually more likely
that these expenditures would be much higher in high-
income countries, thus increasing the strength of the
inverse correlation shown here. Therefore, the following
findings about the imbalance between the burden and the
spending on mental health services can be considered
conservative.
Mental health spending as a
percentage of government
health spending
Median spending in mental health services stands
globally at 2.8% of total government health spending,
despite the fact that mental disorders account for 12% of
total DALYs and 35% of total YLDs. Low-income countries
spend around 0.5% of their health budget in mental
health services, and high-income countries, 5.1% (15).
In the Americas, spending ranges from 0.2% in Bolivia
to 8.6% reported by Suriname. There is a significant
direct linear correlation between national income and
Government spending in mental health as a proportion
of the total health budget (see Figure 21).
WHO recommends that health spending allocation should
be in proportion to the health burden, and that there
should be parity between physical and mental aspects of
26 The Burden of Mental Disorders in the Region of the Americas, 2018
health care (32,33). In practical terms, this means that
physical and mental health services should be provided
in an integrated manner, and that the percentage of
spending allocated to mental health services should
be proportionate to the percentage of its attributable
burden. There are several challenges to operationalizing
these concepts: (a) as noted earlier, the DALY burden for
mental disorders is usually underestimated due to lack of
registration of deaths due to most mental illnesses. YLDs
would provide a less biased comparator for disability
across diseases, because disability is adequately
registered for all disorders through prevalence estimates.
However, since YLDs do not include mortality, they
would not be appropriate as the only measure of overall
burden. Also, (b) reporting mental health expenditures
as a specific percentage of total government health
spending is inconsistent across countries due to the
lack of a unified reporting strategy (e.g. which types
of services are included or excluded, how to estimate
services delivered through other sectors, etc.). Moreover,
it does not account for private spending, which in many
countries is the main source of mental health funding.
Despite these caveats, a simple measure is provided of
mental health spending gap resulting from dividing the
percentage of total DALYs attributable to MNSS by the
percentage of the government health budget allocated to
mental health services. A ratio of 1 would entail equality
between the proportions of disease burden and spending,
implying the assumption of equivalent cost-effectiveness
of interventions across health sectors, which would not
be based on current evidence.
Figure 22 shows all countries ordered by the ratio of mental
illness burden to expenditure on mental health. A wide
regional variation is evident, ranging from a burden that is 1.8
to 72 times the reported spending. The median for countries
of the Americas is 6.1, indicating that the proportion of
burden attributable to mental disorders is 6 times the
proportion of health funds allocated to mental health.
Mental health spending to neuropsychiatric hospitals can be considered a proxy
allocation for how well allocated mental health spending is, since
asylums lack any evidence of effectiveness, are notoriously
The previous analysis, however, does not take into account inefficient, and can in fact lead to iatrogenic practices.
allocation of spending within the mental health subsystem. Despite some outliers, a linear trend model correlating the
International guidelines and evidence indicate that services natural logarithm of the percentage of the mental health
for mental disorders should aim at caring for people in the budget allocated to neuropsychiatric hospitals and 2015
community, providing integrated services for mental illness in GDP is highly significant (see Figure 23).
primary care or general hospitals, and community treatment
plus social support for severely affected individuals (33). The figure suggests that higher income countries not
The fraction of mental health spending that is not allocated only spend a larger proportion of their health budget on

Figure 21: Mental health spending vs. per-capita GDP (PPP)*

2.2 Canada and US Suriname

In (% of government health spending allocated to mental health services)

2.0 Latin Central America United States

Non-Latin Caribbean Barbados Canada
1.8 Uruguay
South America Jamaica
1.6 Saint Vincent and the Grenadines
1.4 Saint Lucia Antigua and Barbuda
1.2 Dominica British Virgin Islands Trinidad & Tobago
Argentina
1.0 Peru
Panama
0.8 Turks and Caicos Brazil
Chile
0.6 Haiti Costa Rica Mexico
Belize
0.4 Honduras
Montserrat
0.2 Guyana
Ecuador
-0.0 El Salvador Saint Kitts and Nevis
Paraguay
-0.2
Nicaragua
-0.4
-0.6 % allocated to
Guatemala mental health
-0.8 0.200
-1.0 Dominican Republic 2.000
4.000
-1.2 6.000
-1.4 8.600
-1.6 Bolivia
-1.8
7.4 7.6 7.8 8.0 8.2 8.4 8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0
In (GDP 2015)

*Linear model: ln (% of health expenditures spent on MNSS) = 0.68*ln (GDP) + -5.6. R2:0.26. p=0.0036. Confidence bands show upper and lower
95% confidence lines.
MNSS: Mental, neurological, substance use disorders and self-harm
GDP (PPP): gross domestic product, purchasing-power parity adjusted

The Burden of Mental Disorders in the Region of the Americas, 2018 27

mental health services, but also potentially allocate that be managed in the community over the spending not
increasing proportion better, to mental health services that absorbed by neuropsychiatric hospitals, a very different
are evidence-based and follow international guidelines, ordering can be obtained (compare Figures 22 and
providing integrated treatment in general health services 24).1 It is clear that in terms of percentage of burden
and community support. This community-based approach over percentage of spending efficiently allocated, the
is respectful of the social and human rights of patients, as imbalance varies by two orders of magnitude: from the
opposed to asylum-based segregationist approaches that burden being three times the spending in the USA and
foster isolation and potentially human rights violations. Canada to 435 times the spending in Haiti. The regional
median indicates an imbalance between mental health
In order to visualize the magnitude of the imbalance in burden and spending of 31.5 to 1. What this metric
spending, and considering the mental burden that should indicates is that there is a gap in spending associated

Figure 22: Ratio of % of total DALYs attributable to MNSS to % of health spending allocated to mental health, ordered
from smallest to largest

72.1
Ratio of mental health burden to expenditures

37.1

28.5
24.1

16.9
15.4
m=6.1 13.9
9.6 10.2 10.3
7.2 8.0 8.2 9.1
5.6 5.7 6.4
3.8 3.9 4.2 4.3 4.4 4.4
1.8 1.9 2.3 2.4 2.5 2.7 3.2
ited e...

zil

r
r
ay
gua

ala
blic
ivia
Bar me
Jam os
a
and ay

Can s
Trin Sain ada
To a
Ant Virgi bago
nd ands
Do uda
ica

ent i
ina
a
u

ize
Ho ico
ras
ile
a
a
it

ado
ado
te
aic

Bri idad & Luci

am

yan
Ric
Per
Ha

Bra

agu
u

Ch
bad

Bel
min

tem
x
Sta

ndu
th
ina

Bol
ent Urug

epu
ara
b

Me
Pan

al v
Ecu
Gu
l

st a
Bar
n Is

Par
t
Sur

Arg

a
Nic

nR
El S

Gu
Co

ica
Un

aa
inc

min
tish
igu
nt V

Do
Sai

MNSS: Mental, neurological, substance use disorders and self-harm

m indicates the regional median value

1 This study subtracted from the numerator the percentage of burden attributable to the most severe health state associated with schizophrenia
(69%), assuming that neuropsychiatric hospitals would be adequately suited to treat this fraction of the most severely affected. From the
denominator, this study subtracted the fraction of spending allocated to neuropsychiatric hospitals.

28 The Burden of Mental Disorders in the Region of the Americas, 2018

with country-level income, disproportionately affecting undertreatment, which a recent study estimated to be
lower-income countries. 5 to 1 for depressive disorder in high-income countries.
As such, only 22.4% received minimally adequate
This gap likely results in (a) an increasing treatment treatment in high-income countries, and specifically
gap for poorer countries and (b) increased private 26% in the United States (34). In low- or lower-middle
spending in mental health services, particularly out-of- income countries, the ratio was estimated at 27 to 1,
pocket expenses. For example, the 3 to 1 imbalance with only 4.7% of people in need receiving minimally
documented in Canada and the United States results in adequate services. Specifically, it was found that in Peru,

Figure 23: MNSS spending allocated to mental hospitals vs. GDP (PPP)1

Canada and US
In (% of mental health spending allocated to mental health services)*

5.8 Latin Central America

Non-Latin Caribbean
5.6 South America
5.4
5.2
5.0
4.8 Saint Vincent and the Grenadines
4.6 Nicaragua El Salvador Saint Lucia Trinidad & Tobago
Guatemala Paraguay Peru Barbados
Haiti Saint Kitts and Nevis
4.4 Honduras Suriname
Jamaica Dominica Mexico Antigua and Barbuda
Bolivia
4.2 British Virgin Islands Uruguay
Costa Rica Argentina
4.0 Guyana Ecuador Dominican Republic
3.8 Brazil
Panama
3.6
3.4 % spent on
mental hospitals
3.2 10.00
Belize
3.0 20.00
40.00
2.8 60.00
80.00 Chile
2.6 100.00 United States
2.4
Canada
2.2
7.3 7.5 7.7 7.9 8.1 8.3 8.5 8.7 8.9 9.1 9.3 9.5 9.7 9.9 10.1 10.3 10.5 10.7 10.9 11.1
In (GDP 2015)

*Linear model: Ln (% MNSS expenditures spent on mental hospitals) = -050*ln(GDP) + 8.9. R2=0.32. p=0.0012. Confidence bands show upper and
lower 95% confidence lines.
MNSS: Mental, neurological, substance use disorders and self-harm
GDP (PPP): gross domestic product, purchasing-power parity adjusted
1
Figures 21 and 23 raise the possibility that Haiti, Canada, and the United States may be outliers and influence our results. Hence, we re-ran the
analyses excluding Haiti, Canada, and the US for both models. The results and their significance hold for the model correlating the fraction of overall
health expenditures spent on mental health with GDP (with a p value <0.05) but lose significance for the model correlating the fraction spent on
mental hospitals with GDP.

The Burden of Mental Disorders in the Region of the Americas, 2018 29

one person received minimally adequate treatment for further study, for example, about whether the imbalance
every 100 persons with a valid diagnosis of depressive found is partly closed by private spending, leading to
disorder. These numbers are consistent with the findings the 100 to 0.9 undertreatment found by Thornicroft et
presented herein: (a) the United States and Canada show al., which in low-income countries would mean mostly
the lowest imbalance and (b) Peru has one of the largest out-of-pocket spending, piling potentially catastrophic
gaps in the continent, with a 313-fold imbalance in burden economic burden upon the disease burden (34).
relative to government spending. These findings merit

Figure 24: Imbalance in spending: ratio of MNSS burden to efficiently allocated spending *
Ratio of MNSS burden to efficiency allocated expenditures

435

352
312
279
261
244

185 188

123
103
m=31.5
73
63 72
33 39
14 16 20 21 22 26 30
3 3 8 10 11 11 11 11
Can s
ada

Pan y
a
Sur ize
me

Jam e
a
il
a
nds

Do da

Gu a
st a a
Ecu a
r
co
n R ago
Ho blic
Par ras
Sai guay
Bar cia
inc l Salv os
and dor
...

ate a
la
u
ivia
iti
ado
gua
e

z
am

aic

Ant h Virg entin

u
ic
yan
Ric
il

Per
ma

Ha
the
Br a
tat

Ch

ad
ida Mexi

g
bu
Bel

min

u
ndu
ina

Bol
epu
a a n Isla

ara
Tob

nt L
Uru

b
Bar
dS

rg

Nic
d&

Gu
Co
A
ite

i
nd

E
ent
ica
Un

min
Trin
igu
tis

nt V
Do
Bri

Sai

MNSS: Mental, neurological, substance use disorders and self-harm

m indicates the regional median value 

* This ratio excludes from the nominator the percent of burden attributable to the most severe form of schizophrenia, and from the denominator
the percent allocated to neuropsychiatric hospitals: (mental disorders as % of total DALYs–63% of schizophrenia DALYs)/(% health budget–% spent
on neuropsychiatric hospitals). The GBD model estimates that 63% of prevalent cases correspond to acute schizophrenia, which carries a disability
weight of 0.778. Meanwhile, 37% of prevalent cases correspond to residual schizophrenia, carrying a disability weight of 0.588 (disability weights
range from 0, perfect health, to 1, equivalent to death). As YLLs for schizophrenia are negligible and YLDs result from multiplying prevalent cases
by disability weight, it was estimated that 69% of the disease burden of schizophrenia is attributable to the acute state.

30 The Burden of Mental Disorders in the Region of the Americas, 2018

Conclusion
MNSS is a group of diseases and conditions that constitute
a major cause of disability and mortality, and give rise
to a third of total YLDs and a fifth of total DALYs in the
Americas. Of the mental disorders, depressive disorders
are the largest cause of disability alone, and combined
with mortality, accounting for 3.4% of total DALYs and
7.8% of total YLDs. The second largest subset comprises
anxiety disorders, with 2.1% and 4.9%, respectively, of total
DALYs and YLDs. Self-harm and somatoform disorders
with prominent pain should also be considered common
mental disorders, accountable respectively for 1.6% of
DALYs and 4.7% of YLDs. Severe mental illness leads to
increased mortality, particularly in low-income settings,
with high-income countries thus coping with an increased
share of the disability burden due to schizophrenia. Several
subregional patterns emerge in the distribution of specific
mental disorders, and this report provides decision-
The Burden of Mental Disorders in the Region of the Americas, 2018
makers with a nuanced picture of mental disorders in most
countries or territories of the Region. South America has
in general higher proportions of disability due to common
mental illness; suicide imposes a disproportionately high
burden on three subregional clusters: Suriname, Guyana,
and Trinidad and Tobago; Uruguay, Chile, and Argentina;
and Canada and the USA. Depressive disorders take their
largest toll on young working-age populations. Continental
Central America has a larger proportion of disability
due to bipolar and childhood onset disorders than other
subregions, as well as due to epilepsy; and the USA and
Canada suffer a high disability toll from schizophrenia
and dementia, as well as devastating rates of opioid-use
disorder disability and premature death.
The health system’s response to the challenge of mental
illness also shows regional variations, notably a correlation
31
with national income. Higher-income countries spend
a larger share of their health budgets on mental health
services, and appear to allocate their spending more
efficiently, away from neuropsychiatric hospitals, towards
integration of mental health into primary care and
community resources. Conversely, lower-income settings
seem to compound their lack of resources by allocating
them to specialized neuropsychiatric hospitals instead of
funding community and primary mental health services, a
strategy that would target not only the increasing disability
resulting from depression and common mental illness,
but also the amenable mortality resulting from severe
mental illness, largely due to treatable causes that remain
uncared for due to stigma, lack of community support, and
insufficiently integrated health services. The imbalance
between the burden and the effectively allocated mental
health services is appalling, ranging from 3 times in the
United States and Canada to 435 times in Haiti, with a
regional median of 32. This government spending gap,
which disproportionally affects lower-income countries,
can be expected to result in (a) undertreatment and
increased amenable disability and mortality; and (b)
increased out-of-pocket spending resulting in potentially
catastrophic health spending, and decreased productivity
both at the individual and national level.
In summary, MNSS is a group of diseases and conditions
that are a major cause of disability and mortality, and
give rise to a third of total YLDs and a fifth of total
32 The Burden of Mental Disorders in the Region of the Americas, 2018
DALYs in the Americas; furthermore, mental health
is increasingly acknowledged as a global health and
economic development priority. Indeed, the United
Nation’s Sustainable Development Goals explicitly refer
to universal health coverage inclusive of mental health
and well-being as a global commitment. It is imperative
that Governments—especially of low- and middle-
income countries (LAMICS)—reconsider how their health
budgets are allocated. Instead of yielding to the inertia of
minimal—usually reactive—adjustments to last year’s line-
item budgets, they can take bold steps to purposefully
allocate funds following a rational assessment of needs,
priorities, available resources, and existing evidence.
Despite the obvious constraints that health and mental
health budgets have in LAMICS, there is significant room
to make meaningful improvements. In fact, it is precisely
because of these constraints that effective and cost-
effective use of resources is of paramount importance.
Rather than allocating the lion’s share to specialized
hospitals, countries should prioritize funding community
and primary mental health services, following a balanced
care strategy that would target the multiple sources of
disease burden resulting from mental disorders: mood
disorders and suicide; substance use disorders and death
by overdose or alcohol-related accidents and illnesses;
and, finally, the increased mortality resulting from
severe mental illness due to treatable causes that are
ineffectively cared for due to stigma, lack of community
support, and poorly integrated health services.
References
1. World Health Organization. Mental health gap action programme. Scaling up care for mental, neurological, and
substance use disorders. Geneva: WHO; 2008.
2. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370(9590):859-877. doi:10.1016/
S0140-6736(07)61238-0.
3. World Health Organization. The world health report 2001. Mental health: new understanding, new hope. Geneva:
WHO; 2001.
4. Mnookin S, Kleinman A, Evans T, et al. Out of the shadows: Making mental health a global development priority.
Washington, DC: World Bank; 2016.
5. Bloom DE, Cafiero ET, Jané-Llopis E, et al. The global economic burden of noncommunicable diseases. Geneva:
WHO; 2011.
6. Patel V, Chisholm D, Parikh R, et al. Addressing the burden of mental, neurological, and substance use disorders:
key messages from Disease Control Priorities, 3rd edition. Lancet. 2016;387(10028):1672-1685.
7. Votruba N, Eaton J, Prince M, Thornicroft G. The importance of global mental health for the Sustainable Development
Goals. J Mental Health. 2014;23(6):283-286. doi:10.3109/09638237.2014.976857.
8. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015.
9. Atun R. Transitioning health systems for multimorbidity. Lancet. 2015;6736(14):8-9. doi:10.1016/S0140-
6736(14)62254-6.
10. Murray CJL, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs)
for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the
epidemiological transition. Lancet. 2015:386(10009):2145-2191. doi:10.1016/S0140-6736(15)61340-X.
11. Murray C, Lopez A, editors. The global burden of disease: a comprehensive assessment of mortality and disability
from diseases, injuries, and risk factors in 1990 and projected to 2020. Geneva: WHO; 1996.
12. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence,
prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the
Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1545-1602. doi:10.1016/S0140-6736(16)31678-6.
13. GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life- years (DALYs) for
315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global
Burden of Disease Study 2015. Lancet. 2016;388(10053):1603-1658. doi:10.1016/S0140-6736(16)31460-X.

The Burden of Mental Disorders in the Region of the Americas, 2018 33

14. Charlson FJ, Baxter AJ, Dua T, Degenhardt L, Whiteford HA, Vos T. Excess mortality from mental, neurological and
substance use disorders in the Global Burden of Disease Study 2010. Epidemiol Psychiatr Sci. 2014;24:121-140.
doi:10.1017/S2045796014000687.
15. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016;3:171-178.
16. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Study 2015 (GBD 2015) results.
Seattle. http://ghdx.healthdata.org/gbd-results-tool.
17. Fekadu A, Medhin G, Kebede D, et al. Excess mortality in severe mental illness: 10-year population-based cohort
study in rural Ethiopia. Br J Psychiatry. 2015;206(4):289-296. doi:10.1192/bjp.bp.114.149112.
18. Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychiatric
patients in Western Australia: retrospective analysis of population based registers. BMJ. 2013;346:f2539.
19. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use
disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575-1586.
20. Atun R, Vigo D, Thornicroft G. Challenges to estimating the true global burden of mental disorders - authors’ reply.
Lancet Psychiatry. 2016;3(5):403-404. doi:10.1016/S2215-0366(16)30045-1.
21. Fröhlich C, Jacobi F, Wittchen H-U. DSM-IV pain disorder in the general population. An exploration of the structure
and threshold of medically unexplained pain symptoms. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):187-196.
doi:10.1007/s00406-005-0625-3.
22. Vigo DV, Selle V, Baldessarini R. [Enduring pain I. Nosology and epidemiology]. Argentine Journal of Psychiatry,
Vertex. 2013;24(111):345-350.
23. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet.
2015;385(9969):717-726. doi:10.1016/S0140-6736(14)61995-4.
24. Salomon JA, Haagsma JA, Davis A, et al. Disability weights for the Global Burden of Disease 2013 study. Lancet
Glob Health. 2015;3(11):e712-e723. doi:10.1016/S2214-109X(15)00069-8.
25. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-1104. doi:10.1016/S0140-
6736(05)71146-6.
26. Lund C, Breen A, Flisher AJ, et al. Poverty and common mental disorders in low and middle income countries: a
systematic review. Soc Sci Med. 2010;71(3):517-528. doi:10.1016/j.socscimed.2010.04.027.
27. Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: Prevalence, risk factors,
prediction, and prevention. J Pers Disord. 2004;18(3):226-239. doi:10.1521/pedi.18.3.226.35445.
28. Baldessarini R, Selle V, Vigo DV. [Enduring pain II. Treatment]. Vertex. 2013;24(111):351-358.
29. Asmundson GJG, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art.
Depress. Anxiety. 2009;26(10):888-901. doi:10.1002/da.20600.
30. Kleinman A. Global mental health: a failure of humanity. Lancet. 2009;374(9690):603-604.
31. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic
review and meta-analysis. JAMA Psychiatry. 2015;72(4):334-341. doi:10.1001/jamapsychiatry.2014.2502.
32. World Health Organization. The mental health context–mental health policy and service guidance package.
Geneva: WHO; 2003.
33. World Health Organization. Mental health action plan 2013-2020. Geneva: WHO; 2013.
34. Thornicroft G, Chatterji S, Evans-Lacko S, et al. Undertreatment of people with major depressive disorder in 21
countries. Br J Psychiatry. 2016. doi:10.1192/bjp.bp.116.188078.
35. Pan American Health Organization. WHO-AIMS: informe regional sobre los sistemas de salud mental en América
Latina y el Caribe. Washington, DC: PAHO; 2013.
36. Institute of Health Economics. The cost of mental health services in Canada. Edmonton, Canada: IHE; 2010.
37. WHO-AIMS. Sistema de salud mental de Chile. Santiago de Chile: WHO; 2014.

34 The Burden of Mental Disorders in the Region of the Americas, 2018

Annex 1
Non-Latin Caribbean Subregion Countries and Population

Country
Antigua and Barbuda 91,861
Barbados 283,841
Belize 358,715
Bermuda 66,868
Dominica 71,672
Grenada 106,968
Guyana 770,068
Jamaica 2,823,613
Saint Lucia 185,108
Saint Vincent and the Grenadines 109,755
Suriname 542,588
Virgin Islands, U.S. 106,626

The Burden of Mental Disorders in the Region of the Americas, 2018 35