How to understand and reduce the high prevalence of psychiatric disorders

Abstract

Since the first waves of representative community surveys of mental disorders, prevalence estimates of psychiatric disorders have been so high as to generate criticism of their believability. Those who have found these estimates shocking conceive mental health as a statistical deviation from normal where only a few should experience diagnosable pathology and thus psychiatric disorder is viewed as a rare, severe phenomenon that clearly separates the ill from the normal. The second generation of epidemiological surveys included measurements of impairment in order to address the criticisms of the first generation and despite this, the prevalence estimates of significantly impairing psychiatric disorders remained high.1 A meta-analysis of epidemiologic surveys conducted between 1980 and 2013 documents a pooled estimate of 1 in 5 adults (from 155 surveys in 59 countries) meeting criteria for a common psychiatric disorder in the prior 12-months and almost 30% meeting criteria in their lifetime (in 85 surveys from different regions of the world).2 The World Mental Health Surveys in 17 countries report a projected lifetime prevalence risk between 18-55%.3 Estimates in children and adolescents are even higher with an 8-year incidence of 39% in Mexican adolescents and a cumulative prevalence of 83% by age 21 in U.S. youth. 4,5 Furthermore, longitudinal studies show even higher cumulative prevalence rates than cross-sectional studies and the greater the number of measurement points the greater the cumulative prevalence. 5,6 Those who continue to be skeptical of these estimates should consider this. Nearly the entire population can be expected to be physically ill at some point in their life. If a representative epidemiologic survey was done to estimate the lifetime prevalence of experiencing any physical illness in the population, no one would be alarmed to find rates close to 100%. In fact, it would be considered silly to even carry out such a survey. Longitudinal studies would find higher rates than cross-sectional studies because many people forget about common illnesses in their past, especially early-life illnesses. The combined lifetime risk of major chronic physical conditions such as cardiovascular disease or cancer is over 80% in industrialized countries.7 So why should we be surprised that a large proportion of the population will at some point suffer one or more of numerous psychiatric disorders?One important qualification that should be noted is that epidemiological surveys have found lifetime prevalence to be higher in Westernized, English-speaking and/or high income countries than in low income countries and non-Western setttings. This pattern is evident in the meta-analysis cited above and in more recent publications from the World Mental Health Surveys.2,8 Nonetheless, given the amount of evidence from cross-sectional and longitudinal surveys over several decades in various regions of the world, it is undeniable that large proportions of many populations worldwide will experience psychiatric symptomatology ...

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