Mental health: A Truly Global Issue

Mental health or psychological well-being is the cornerstone for social functioning of any individual. Mental illness may arise from naturalistic factors such as the genetic and psychological makeup of an individual and also from the socio-environmental conditions (Patel, Chisholm, Dua, Laxminarayan, & Medina-Mora, 2015; World Health Organization, 2014). Mental health issues limit the capacity of individuals to engage in everyday social life and may lead to impaired functioning in extreme cases. In addition to the personal and social costs associated with mental disorders, the economic costs of this important public health issue transcend 4% of GDP in a number of countries (OECD, 2014). In the UK alone, mental disorders cost about £105 billion (Centre for Mental Health, 2010; Thomas et al., 2016), around 100 times more than the total health budget of a developing country such as Pakistan.

There are stark differences in spending on mental health issues when viewed from the perspective of inequality of wealth among countries. Developing countries tend to spend lesser on mental health issues than developed countries even when accounted for their comparative spending on physical health issues (Gadit, 2007; Saraceno et al., 2007). It is understandable to a certain extent since under budgetary constraints, governments are likely to prioritize those issues which are deemed to be emergent (Hate & Gannon, 2010; World Health Organization, 2005). In other words, the health priorities of most developing countries are heavily skewed towards the provision of curative rather than promotive or prevention services. However, a number of developing countries are partially dependent on the financial assistance and patronage of supranational institutions such as World Health Organization (WHO). Under the auspices of these global bodies, there has been some improvements in terms of service provisions regarding mental illnesses in developing world (World Health

29 Organization, 2013). Nonetheless, there remains an acute shortage of resources as compared with the magnitude of impact which mental illnesses pose on health levels of populations.

Mental health issues share a significant burden of disease across the world (Murray et al., 2012; Patel et al., 2015; World Health Organization, 2013). In 2010, mental health, neurological and substance use disorders accounted for 258 million Disability Adjusted-Life Years (DALYs), constituting 10.4% of global DALYs. Amongst these, mental disorders accounted for 56.7% of DALYs, followed by neurological (28.6%) and substance use (14.7%) disorders. Within mental and substance use disorders, depressive disorders accounted for the largest number of DALYs (40.5%) whereas anxiety disorders (14.6%), drug use disorders (10.9%) and alcohol use disorders (9.6%) follow them respectively.

Graphical illustration is presented in Figure: 2.6.

The women were slightly more affected by mental, neurological and substance use disorders with 134 million DALYs as compared to the men who had 124 million DALYs. In terms of age, people aged 20 to 30 years were substantially more affected by mental and substance use disorders as compared to other age groups. Mental, neurological and substance use disorders were the leading cause, accounting for 28.5% of global YLDs as illustrated in Figure 2.7 (Erskine et al., 2015; Vos et al., 2012; Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015;

World Health Organization, 2013). While these figures explain the significance of mental disorders within realm of the global burden of disease, it seems plausible to assert that the actual prevalence and distribution of these disorders could be even higher. One of the reasons for this speculation is paucity of the research measuring prevalence and distribution of mental illnesses in developing countries. Furthermore, mental illnesses are known to exacerbate other chronic diseases such as diabetes and cardiovascular disease (Prince et al.,

Figure 2.6: Percentages of DALYs constituting mental health, neurological & substance use disorders

30 2007) and it is difficult to measure this indirect impact in terms of DALYs, YLDs, morbidity and premature mortality.

Unlike most of other health problems, mental health issues are more evenly distributed across different geographical and economic regions of the world. It is estimated that the prevalence of mental disorder is 26.4% among the adults in the United States of America (USA) (World Health Organization, 2008) whereas 17.6% of adults in England have one of the more common mental disorders (McManus, Meltzer, Brugha, Bebbington, & Jenkins, 2009).

Mental illnesses are more prevalent in the United Kingdom (UK) (22.8%) than any other disease such as cardiovascular disease (16.2%) and cancer (15.9%) while also leading in terms of intensity and impact (Royal College of Psychiatrists, 2010). The persistence of mental health issues in countries with arguably one of the most advanced health care systems points towards the peculiarities of dealing with this subject and the need for research which could inform policy decisions (Ramon, Healy, & Renouf, 2007).

A meta-analysis based on a review of 174 surveys conducted across the world, including both high and low income countries, revealed that 29.2% of adults suffer from a common mental disorder in their lifetime (Steel et al., 2014). However, this study also reported substantial variation among the surveys in terms of prevalence of mental disorders. Arguably, this could be because of the different measuring tools employed in these surveys. Given the general scarcity of research on mental health issues, this inconsistency further complicates attempts to compare findings from different studies and to generalize them.

Figure 2.7: Proportion of global YLDs attributable to mental, neurological, and substance use disorders, 2010

Source: (Whiteford et al. 2015)

31 2.2.1.1 Mental health issues among the university students

The global data on the Burden of Disease (2010) suggest that youth are the most vulnerable segment of population in terms of mental and substance use disorders (Vos et al., 2012;

Whiteford et al., 2013; Whiteford et al., 2015). According to WHO estimates, around one in four young people aged 12-24 experience a mental disorder in any one year (World Health Organization, 2014) whereas Fisher et al. (2011) estimates that one in five adolescents suffer from a mental health issue each year. A number of other studies have contended that most mental health issues occur at a young age and persist through later stages of life (Erskine et al., 2015; Kessler et al., 2005; Patel, Flisher, Hetrick, & McGorry, 2007). However, young people generally receive less attention as a vulnerable group in terms of health and well-being.

Figure 2.8: Absolute DALYs attributable to mental, neurological, and substance use disorders, by Age, 2010

Adopted from (Whiteford et al., 2015)

Within the youth segment, university students have been found to be typically affected by mental illnesses (Chew-Graham, Rogers, & Yassin, 2003; Eisenberg, Hunt, & Speer, 2013;

Roberts, Golding, Towell, & Weinreb, 1999; Saleem, Mahmood, & Naz, 2013). In terms of mental health issues, the university students are in a doubly disadvantageous state due to their age group and their role as students. In addition to the developmental and emotional issues faced by them, university students have added pressures of academic success, financial dependency, and career aspirations (Bayram & Bilgel, 2008; Bojuwoye, 2010; Dyrbye, Thomas, & Shanafelt, 2006; Eisenberg, Golberstein, & Hunt, 2009; El Ansari, Khalil, &

Stock, 2014; Mikolajczyk, Maxwell, Naydenova, Meier, & El Ansari, 2008). The overall situation is exacerbated by the fact that these influences operate in an increasingly competitive environment in terms of economic opportunities as well as life chances.

32 In view of the above, it is important to produce empirical data identifying the burden of mental health illnesses among university students. Such data and the patterns emerging from it may be useful in interventions which could result in better management of mental health issues. A review of literature indicates that the studies concerning prevalence of mental health issues have generally focused on different subgroups of students. These include first year students (Al-Daghri et al., 2014; Bojuwoye, 2010; Brown & Ralph, 1999; Christensson, Vaez, Dickman, & Runeson, 2011), undergraduate students (Dachew, Bisetegn, &

Gebremariam, 2015; Iqbal, Gupta, & Venkatarao, 2015a; Shah, Hasan, Malik, &

Sreeramareddy, 2010), university health service patients (Amir, Gilany, & Hady, 2010;

Hyun, Quinn, Madon, & Lustig, 2007; Stallman, 2010; Tosevski, Milovancevic, & Gajic, 2010), international students (Andrade, 2006; Kramer, Profer-Kramer, Stock, & Tshiananga, 2004; Mori, 2000; Zhou, Jindal-Snape, Topping, & Todman, 2008), and medical students (Alvi, Assad, Ramzan, & Khan, 2010; Rahimi, Baetz, Bowen, & Balbuena, 2014;

Venkatarao, Iqbal, & Gupta, 2015).

2.2.1.2 General limitations of studies examining students’ mental health

There is a dearth of studies covering the general student body with large samples which could allow for measurement of general prevalence among university students, comparative analyses between subgroups and identification of high risk student groups. While it is speculated that student population is more vulnerable to mental illnesses than the general population, benchmarking in this regard is required. A handful of studies attempting to make such a comparison mostly did not use elaborate tools to measure prevalence which limited validity of their claims. For instance, some studies have relied on the perceived depression and symptoms checklist to ascertain the mental health of students (Chen, Wang, Qiu, Yang, Qiao, Yang, Liang et al., 2013; Sidana et al., 2012). Only a few studies have used elaborate screening tests to identify mental issues (Eisenberg, Gollust, Golberstein, & Hefner, 2007;

Monroe & Harkness, 2005) but even in these studies, comparable data from the general population was missing. However, those studies which compared students‟ mental health issues with general population found higher level of stress among students (Kessler et al., 2003; Stallman, 2010). The point here is that even if comparisons with general population are not made in a study, the tools used to measure prevalence should be such that a comparison could be made at a later stage.

33 Most research on mental health issues have focused on common mental health problems whereas some studies have also examined self-harm, obsessive compulsive disorder and suicidal ideation (Eisenberg, Gollust, Golberstein, & Hefner, 2007; Tran, 2015). Depression is by far the leading cause of mental problems among university students (Andrews &

Wilding, 2004; Christensson et al., 2011; Khan, Haider, & Khokhar, 2015). A systematic review conducted in 2013 puts the weighted mean prevalence of depression among university students at 30.6% with a range of 10%-85% (Ibrahim, Kelly, Adams, & Glazebrook, 2013).

While there are a handful of studies concerning mental issues among university students, very few studies have taken account of factors such as utilization of health services over time, development of disease across different stages of academic career and the effectiveness of coping strategies. While these important questions may appear to be more relevant to a longitudinal research design, cross sectional studies could also draw an elaborate snapshot covering important aspects of these questions.

Several studies have taken depression and perceived stress to be the most frequent of mental health issues prevalent among university students (Andrews & Wilding, 2004; Bayram

& Bilgel, 2008; Venkatarao et al., 2015). Although it may appear counter intuitive, university students from both developed and developing countries experience high levels of distress (Dachew et al., 2015). In almost all the cases, the prevalence of distress among university students was higher than that of general population (Kessler et al., 2003; Stallman, 2010).

Considering depression as a common issue among university student, it is important to distinguish depression from the occasional sad feelings that are situational which could be overcome them in short period of time. On the other hand, the severity of depression need also be differentiated as it could lead to impaired functioning as reported by 17.3 % of college students in a national survey conducted in USA (Eisenberg et al., 2007). Thus, depression is a sort of transitory state which needs careful examination to avoid misdiagnosis.

2.2.1.3 Differential risk in terms of sex and demography

There are also significant gender variations in terms of mental disorders. While males are more vulnerable to commit suicide, females have been found be more prone to depressive disorders (Eisenberg et al., 2007). A study conducted at a public university found that undergraduates had a slightly higher prevalence of depressive disorder as compared to graduates (Iqbal et al., 2015). Female students have been found to experience more distress than their male counterparts (Shah, Hasan, Malik, & Sreeramareddy, 2010; Stallman &

34 Shochet, 2009). However, male students utilize mental health services more often than females for reasons yet to be elaborated by the current literature. As with the general population, distress is more common with the students aged 18-34 years (Australian Bureau of Statistics, 2008; Stallman, 2010). The first and second year students have been found to experience most distress and the third year students came at second rank (Abdulghani, AlKanhal, Mahmoud, Ponnamperuma, & Alfaris, 2011; Bayram & Bilgel, 2008; Chen, Wang, Qiu, Yang, Qiao, Yang, Liang et al., 2013). These findings were also supported by other studies where stress among first year students was thought to continue till the end of their undergraduate degree (Borjalilu, Mohammadi, & Mojtahedzadeh, 2015; Cooke, Bewick, Barkham, Bradley, & Audin, 2006). The distress level has been, however, lower in postgraduate students (Borjalilu et al., 2015; Eisenberg, Golberstein, & Hunt, 2009; Stallman, 2010) which could be due to their improved skills to manage stressful conditions.

Students who live with their families reported lower level of distress than those living away from family, including those living in shared accommodations (Shaikh & Deschamps, 2006;

Sreeramareddy et al., 2007; Stallman, 2010). The level of dissatisfaction with shared accommodation indicated that it was not the lack of social support that accounted for distress since shared accommodation offered a degree of such support (Abolfotouh, Bassiouni, Mounir, & Fayyad, 2007; Sreeramareddy et al., 2007). Perhaps it could be nostalgia or home sickness which may have contributed to distress faced by students living away from home.

It is evident from the foregoing discussion that measuring the prevalence of mental health issues is a problematic endeavor which lack much required uniformity in terms of methodological tools applied. Furthermore, mental health issues are substantially influenced by the demographic and contextual factors and an assessment of these factors need a careful appraisal of cultural reality of studied population. Given the rank of mental health issues in the global burden of disease, it becomes important to conduct studies which are sensitive to these issues in current research. As such, the present study has considered the demographic and contextual issues as intervening variables in terms of prevalence of mental health.