Psychiatry: Deciphering the Adolescent Brain Medicine: Strategy Is Developed to Fortify DNA Vaccine Against AIDS Virus Social Medicine: Conference Takes Global Measure of Mental Illness Research Administration: New Office Protects All Research Subjects Diversity: Program Probes Barriers to Benefits for Gays, Lesbians, Presents 2nd Annual Diversity Awards No Home Run, But Batter on Base Against Lou Gehrig's Disease Study Makes Sweet Discovery of Bitter Taste Receptors Mutation Bias Maintains Length of Genetic Repeats MRI May Predict Alzheimer's Disease HMS Faculty Council: Faculty Growth, Library Discussed In Memoriam: Sharon Clayborne New Appointments to Full Professor A View from the Inner City: Tolerance Is Not Enough Front Page

SOCIAL MEDICINE Conference Takes Global Measure Of Mental Illness Last month the World Health Organization launched a 25-country survey of mental disorders, which often go undiagnosed and untreated. The WHO estimates that in 20 years, depression will be second only to heart disease in causing disability worldwide. But to identify the scope of mental disability, measure its impact, and mobilize nations against it remains a daunting challenge. What the World Needs Now A conference at the Medical School on April 10 and 11, "Placing Mental Health on the International Health Agenda," explored the problem from a research perspective. Presentations invited further discussion and encouraged the creation of more accurate tools to quantify the scope and costs of these illnesses. More effective interventions are, in some cases, possible with available resources, but greater government support is necessary for broad improvements. Amartya Sen, the 1998 Nobel laureate in economics, was the featured speaker, giving the second annual W.H.R. Rivers Lecture, "Health in the Perspective of Freedom." Sen bases his framework for understanding the benefits of health and the costs of disease on freedom, the capability to do anything we have reason to value. "Freedom and capability are at the center of the stage in discussing health," he said. And "health is capability-enhancing." Amartya Sen encouraged researchers to examine the connection between mental conditions and individual freedom. Photo by Steve Gilbert A master at Trinity College, Cambridge, England, and Lamont University Professor emeritus and adjunct professor at Harvard University, Sen distinguished freedom as a value from pleasure, a primary value in the utilitarian school of thought, to refine his conceptual framework. Bringing the distinction down to earth, he said, "Poor mental health makes us less free." But if a decline in mental health were to be measured by loss of pleasure, the measure would not necessarily reflect any decline. "A person [with poor mental health] could be quite high, in good spirits, but limited in capability," he said. Sen drew on the concept of disease burden as did speakers in the workshop portion of the conference on the second day. It derives from the Global Burden of Disease study initiated by Christopher Murray, professor of international health economics at HSPH, who is now serving at the WHO. This study developed the health indicator known as DALY, disability-adjusted life year, which accounts for time lost due to premature death and time lived with a disability. Sen called for a broader burden of disability measure that would include loss of capability. "The connection between mental conditions and freedom remains to be fully explored," Sen said. "This is my central point." Global Perspectives Introduced by Arthur Kleinman, HMS professor and chair of social medicine, the workshop portion of the program included speakers representing the WHO, World Bank, and Brazil, India, Mexico, sub-Saharan Africa, China, and Pakistan in addition to those from HMS. "Mental health makes up 11.5 percent of the global burden of disease, but ministries of health in low-income countries allocate less than one percent of their budgets to this area of health," Kleinman said. Evaluation of cost-effectiveness of interventions may be the most important research issue, he asserted, while funding is the key practical challenge. Speaking globally, Benedetto Saraceno, director of the Department of Mental Health at the WHO, underscored the need to revamp the approach to mental disorders. "The mental component of health has not improved over the course of the last century," he said, adding that the burden of mental illness is expected to become worse. One of the two respondents at the end of the workshop, Ronald Kessler, professor of health care policy and architect of the international mental health survey being conducted by the WHO, made a point that every marketer knows. "We need to understand other kinds of rationalities that people deal with," he said. What is important to whom? Determining not only the costs of mental disease but who bears them might help in allocating resources and attracting support for interventions. Companies, for example, have to be concerned with their bottom line, so ways of reducing costs over time are attractive. "Treating people with depression is literally an investment opportunity for employers," Kessler said, suggesting that research findings on depression might spur a shift in policy, if presented to the right people. "Each person you treat saves you $1,800." —Robert Neal