Economic Grand Rounds
Psychopharmacosocioeconomics
and the Global Burden of Disease
Martin Fleishman, M.D.
T he Global Burden of Disease
Study was a five-year study con-
ducted by the Harvard School of Pub-
lic Health on behalf of the World
Health Organization and the World
Bank. The study began in 1992, and
its goal was to quantify and compare
the burden of premature mortality,
disease, and injury across the various
cultures and countries of the world
community.
Until recently, the most common
measure of a society’s health status
was the rate of death per population,
or the rate of death by age per popu-
lation. The exclusive dependence on
death rates to evaluate health status
has long been criticized. However,
finding a way to compare diseases,
disabilities, and injuries across inter-
national populations has been ex-
traordinarily difficult. As part of the
Global Burden of Disease Study, re-
searchers created a measure of health
status that accounted for disability
along with the number of deaths and
the impact of premature death.
The first volume of the final prod-
uct of the study is a 990-page publica-
tion entitled The Global Burden of
Disease: A Comprehensive Assess-
ment of Mortality and Disability
From Diseases, Injuries, and Risk
Factors in 1990 and Projected to 2020
(1). Volume 1 provides worldwide
epidemiological information on 240
conditions. The statistical techniques
used to derive the formula for estab-
lishing premature death and the dis-
ability measures developed for the
Dr. Fleishman is staff psychiatrist at St.
Francis Memorial Hospital, 909 Hyde
Street, Suite 115, San Francisco, Califor-
nia 94109 (e-mail, martin120@aol.com).
Steven S. Sharfstein, M.D., is editor of this
column.
142
study represent a new approach to
evaluating a society’s health. A new
index called the disability adjusted
life year—the DALY—has now be-
come the international standard for
evaluating and comparing a society’s
burden of disease (2).
The calculation of the DALY is
complex and depends on the sum of
numbers representing the years of
life lost (YLL) and years lived with
disability (YLD). Each of these values
is in turn derived from complicated
mathematical formulas, but even the
mathematically challenged can easily
understand the concept of YLD,
which is defined as time lived in
health states that are less than per-
fect. This concept is especially easy
for psychiatrists to understand: they
rarely save lives, but they generally
focus on states of health that can be
euphemistically described as less than
perfect.
The concept of the DALY is useful
because the traditional use of death
rates to evaluate a society’s health sta-
tus may not reflect the economic and
social burdens that illnesses impose
on a society. From the viewpoint of
individuals who are thrust into the
caretaking role, illnesses with a pro-
longed course can impose a greater
emotional and economic burden than
illnesses that end in a relatively quick
death
The findings of the Global Burden
of Disease Study demonstrate clearly
that disability plays a central role in
determining the overall health status
of a population. Yet that role has been
almost invisible to public health au-
thorities. The study shows that the
leading causes of disability are sub-
stantially different from the leading
causes of death, thus casting serious
doubt on the practice of judging a
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ February 2003 Vol. 54 No. 2
population’s health from its mortality
statistics alone.
The findings may be surprising to
some but not necessarily to psychia-
trists. The study shows that the bur-
den of psychiatric conditions, such as
depression, alcohol dependence, and
schizophrenia, has been heavily un-
derestimated. Although psychiatric
conditions are responsible for little
more than 1 percent of deaths, they
account for almost 11 percent of dis-
ease burden worldwide. Of the ten
leading causes of disability worldwide
in 1990, measured in YLD, five were
psychiatric conditions: unipolar de-
pression, alcohol abuse and depend-
ence, bipolar affective disorder, schiz-
ophrenia, and obsessive-compulsive
disorder (see box).
The study made projections about
disease burden in the year 2020 on
the basis of DALYs but not YLDs,
perhaps because years lived with dis-
ability are more difficult to predict
(see box with list of predictions). This
is particularly true for psychiatric
conditions, because many drug treat-
ments are only partially effective. It is
entirely possible that in 2020 unipolar
depression will fall to third place as a
cause of disability, as predicted by the
study, because improved treatments
will lead to recovery.
The rank order of schizophrenia in
2020 is more difficult to predict, be-
cause the treatment results are less
clear. Current treatment of schizo-
phrenia is somewhat less than cura-
tive but somewhat more than pallia-
tive. Drug therapy for schizophrenia
has complex effects on the global bur-
den of disease. Currently, the savings
attributable to drug therapy result
from the reduction in direct hospital-
ization costs. However, people who
have schizophrenia are now living
longer because of decreased suicide
rates and better psychiatric care, and
many will continue to live in econom-
ic dependency. As a result they will
incur the increased costs of medical
illnesses associated with advancing
age, such as heart disease, diabetes,
chronic obstructive pulmonary dis-
ease, osteoporosis, and arthritis. Per-
haps an ecosystem-like balancing
principle is at play, wherein the atten-
uation of one illness is followed by a
proliferation of other illnesses to oc-
cupy the empty space.
Given the relatively high cost of
atypical antipsychotic medications, it
appears to be safe to say that even if
some people who have chronic schizo-
phrenia improve sufficiently to be less
than totally disabled, many will contin-
ue to be dependent on public subsi-
dies because they cannot afford the
medication that produced the im-
provement (3). Given the increased
cost and effectiveness of these medica-
tions, the resulting decrease in suicide
rates, and the greater longevity and
higher medical costs of people who
have schizophrenia, schizophrenia
may move closer to the top of the list
in 2020 as measured by DALYs, even
though the study’s projections do not
place it in the list of the top ten.
Nothing better illustrates the haz-
ards of predicting the future socioe-
conomic impact of psychiatric treat-
ments than the story of chlorpro-
mazine. Chlorpromazine, which was
first used in the United States in
1953, and the antipsychotics and oth-
er psychiatric medications that were
later developed have changed the
world in ways that no one could have
predicted. The prediction of global
burdens in the 21st century is even
more difficult.
As noted, one of the socioeconomic
effects of antipsychotic medications is
the increased medical costs attributa-
ble to patients’ greater longevity.
Many other socioeconomic changes
were brought about directly or indi-
rectly by antipsychotic drugs:
♦ the migration of most chronical-
ly mentally ill patients out of state
hospitals
♦ the transformation of many state
hospitals to exclusive repositories for
the criminally insane
♦ the return of many chronically
PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ February 2003 Vol. 54 No. 2
The ten leading causes of years lived with disability in
1990 according to the Global Burden of Disease Study
1. Unipolar major depression
2. Iron deficiency anemia
3. Falls
4. Alcohol use
5. Chronic obstructive pulmonary disease
6. Bipolar disorder
7. Congenital anomalies
8. Osteoarthritis
9. Schizophrenia
10. Obsessive-compulsive disorder
mentally ill patients to their families mental health centers, rehabilitation
♦ the ability of some chronically programs, substance abuse clinics,
mentally ill patients to resume their psychosocial rehabilitation clubhous-
careers or education es, shelters for the homeless, and
♦ the transfer of many other chron- elsewhere
ically mentally ill patients to special ♦ the creation of a minivan trans-
residential facilities in the community portation system to transport people
♦ the creation of domiciliary facili- with mental illness to physicians’ of-
ties as alternatives to hospitalization in fices, clinics, activity centers, partial
which on-site treatment is provided hospitalization programs, and other
♦ the transfer of some mentally ill programs
patients to jails and prisons ♦ the passage of rights-driven legis-
♦ the transfer of some elderly pa- lation based on the least-restrictive al-
tients with mental illness to nursing ternative
homes ♦ the passage of other laws, such as
♦ the transformation of some nurs- the Community Mental Health Cen-
ing homes into geriatric mini–mental ters Act, designed to facilitate the
hospitals treatment of persons with mental ill-
♦ the proliferation of acute psychi- ness in the community
atric treatment facilities in communi- ♦ the creation of special industries,
ty hospitals large and small, dedicated to the
♦ the creation of special nonhospi- treatment and rehabilitation of the
tal treatment facilities in community mentally ill
The ten leading causes of disability in developed regions
in 2020 as measured by disability adjusted years
1. Ischemic heart disease
2. Cardiovascular disease
3. Unipolar major depression
4. Trachea, bronchus, and lung cancer
5. Road traffic accidents
6. Alcohol abuse
7. Osteoarthritis
8. Dementia and other degenerative and hereditary central nervous
system disorders
9. Chronic obstructive pulmonary disease
10. Self-inflicted injuries
143
 ♦ the emergence of a homeless
mentally ill constituency that is either
unwilling or unable to live in special-
ized community facilities
♦ the growth of special neighbor-
hoods characterized by urban decay
and poverty in which people with
mental illness reside
♦ the rise of the NIMBY—not in
my back yard—movement among
homeowners wishing to prevent peo-
ple with mental illness from living in
their neighborhoods
♦ the rise of consumer advocacy
groups, such as the National Associa-
tion for Rights Protection and Advo-
cacy, the purpose of which is to fight
the use of medications and question
the biological basis of mental illness
♦ the rise of groups, such as the
National Alliance for the Mentally Ill,
created by families of people with
mental illness in order to defend the
rights of the mentally ill and lobby for
increased funding for treatment and
research
♦ the decline in psychoanalytically
dominated faculties in medical
schools
♦ the demise of purely psychogenic
etiologic theories of schizophrenia in-
volving “schizophrenogenic moth-
ers,” “double-binds,” and “family
skews and schisms,” and other assort-
ed forms of parent-bashing
♦ the rise of legislative militancy as
a legitimate means of expanding pre-
scription-writing privileges to non-
medical professionals
♦ the increased pressure by man-
aged care companies to reduce psy-
chotherapy services
♦ the increased incentive to discov-
er medications for psychiatric condi-
tions formerly thought to be treatable
only by psychotherapy
♦ the creation of a vast potential
market for antipsychotic drugs for
formerly hospitalized patients and the
realization by pharmaceutical drug
houses that the funding for this mar-
ket could be extracted from public
budgets.
These changes transcend the con-
cept of disease burden and are best
understood within the context of psy-
chopharmacosocioeconomics—a per-
sonally constructed but useful neolo-
gism for the study of the ways in
which psychiatric drugs have had a
144 PSYCHIATRIC SERVICES
worldwide impact on social and eco- hospitals leading to community place-
nomic systems (3). However, it is use- ments (with various states of supervi-
ful to consider these changes when sion or neglect) leading to the world-
attempting to predict the global bur- wide endorsement of the least-re-
den of disease, because many of them strictive alternative as a morally justi-
effect the YLD measure—years lived fiable principle for the treatment of
with disability. Some will shorten the mentally ill and, in many in-
years lived with disability—for exam- stances, leading to a sink-or-swim
ple, by making it possible for some mental health policy.
people with mental illness to resume As a result, we practice the adaptive
careers or education. Others will pro- mechanism of numbing down—a re-
long years lived with disability, such action that one psychiatrist has de-
as when people with mental illness scribed as “a universal and necessary
are housed in jails and prisons. The complement to awareness” (4)—an
variety and extent of the changes list- adaptation that permits us to disre-
ed above should make it clear that gard unpleasantness and attend to the
predictions about the disease burden compelling realities of our existence
of schizophrenia in the year 2020—or without the distractions created by
in any other year—are fraught with the problems of others pushing shop-
uncertainties. ping carts while exercising the free-
Psychiatric drugs have had a pro- doms afforded to them by virtue of
found influence on society. Their in- the “least-restrictive alternative.” ♦
fluence is unappreciated because we
have become used to the sight of peo- References
ple with chronic psychosis, unwashed 1. Murray CJL, Lopez AD (eds): The Global
and deranged, wandering the streets Burden of Disease: A Comprehensive As-
sessment of Mortality and Disability from
in states of obvious neglect. There Diseases, Injuries, and Risk Factors in 1990
was a time when such deplorable and Projected to 2020. Cambridge, Mass,
tableaus did not exist, although this Harvard University Press, 1996
may not be conceivable to younger 2. Murray CJL: Quantifying the burden of
people. We have become inured to disease: the technical basis for DALY’s.
Bulletin of the World Health Organization
the effects of psychopharmacosocioe- 72:429–445, 1994
conomic negligence, because we are
3. Fleishman M: Issues in Psychopharma-
confronted daily with its results and cosocioeconomics. Psychiatric Services 53:
we do not connect the dots. The dots 1532–1534, 2002
are the invention of antipsychotic 4. Geneva P: Numbing out. Psychiatric
drugs leading to the closure of state Times, Nov 2002, p 71–73
Submissions for Datapoints Invited
Submissions to the journal’s Datapoints column are invit-
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terns, treatment modalities, treatment sites, patient char-
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include a short description of the research question, the
database and methods, and any limitations of the study.
Inquiries or submissions should be directed to Harold
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of the column. Contact Ms. Tanielian at Rand, 1200
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