Prevalence of mental health problems in medical professionals caused by exposure to death?

Prevalence of mental health problems in medical professionals caused by exposure to death?

Some medical professionals work in areas where they are exposed to death often (say, E.R, O.R, Cancer Treatment, etc.), specifically in an area where they bond with the patient and the patients' families over a long period of time, such as cancer treatment.

  • Does such exposure sometimes cause psycopathic/sociopathic behavior, shizophrenia, apathy, and other mental and emotional scarring?
  • Does such exposure cause changes to thoughts on death significantly?
  • In an attempt to numb this pain, would the subjects be more likely to believe excessively and obsessively in religion and the afterlife? (Please don't take offense if you are religious.)

Of course I'm not saying that all subjects in this situation would display these symptoms, but depending on pre-existing conditions I wonder whether some are more susceptible to emotional trauma than others.

I believe, and I do not know if good quality epidemiological evidence exists, that such situations may trigger abnormal illness representations among medical professionals. Factitious disorders, for instance, I believe could be some way to deflect depression in some individuals. Along with abnormal illness representations could also come abnormal moral representations of illness, which, if not outright religious, links in somewhat with the notion of salvation.

Studies concerning abnormal illness representations are usually concerned with patient's illness representations. I see no epidemiological studies or data concerning the illness representations of medical staff, would be medical staff, or former medical staff (for instance, those who quit after traumatic experiences with patients) when they present as patients. Indeed, calling into question the illness representations of medical staff is not exactly politically correct. It's even a rather effective way to get you labelled as psychotic in some flavour or another.

However, from a clinical perspective, (i.e. with a clinical bias) a risk factor for factitious disorder is when someone has or has had a professional wish of working in the health care field. Such as a medical doctor who went into depression after a patient died and who did not fully get over it…

I'd love to know what data there really is out there to back up this clinical claim. Best I could find is Lois Krahn's work at Mayo Clinic:

To me, this is an extreme manifestation of more common mental issues affecting medical professionals.

I can offer a case study - Elisabeth Kubler-Ross, creator of the infamous "Kubler-Ross Model" or "five stages of grief" (Denial, Anger, Bargaining, Depression, Acceptance). Her entire career as a psychiatrist was spent working with terminally ill patients and their grieving families. She strongly believed in a life after death and outer-body experiences, and worked with a man at her Healing Centre who claimed to be able to contact people after they had passed over. This was of course a sham, you can read more about it here.

Physical and Mental Health

Respiratory hospital admissions increased significantly among lower Manhattan residents the first week after 9/11 compared with a similar demographic in Queens. Cardiovascular and cerebrovascular disease admissions also increased two to three weeks after 9/11, especially among women and those over 65 years of age. 12

Two literature reviews focusing on birth outcomes among WTC-exposed pregnant women suggest that environmental exposure or attack-related stress reduced fetal growth in some women, a finding similar to that in studies of birth outcomes after other terrorist attacks, environmental/chemical disasters and natural disasters. Disaster literature not specific to 9/11 indicates that child development may be more influenced by maternal mental health than by direct effects of disaster-related pre-natal stress. 2,21 A newer study not included in these reviews compared two groups of women who were pregnant between September 11 and December 1, 2001: 500 women who were enrolled in the WTC Health Registry, and 50,000 women who lived at least 5 miles from the WTC site. Although researchers found similar birth weight and gestational age at delivery in the groups, Registry enrollees with probable PTSD were more likely than women without PTSD to deliver premature or underweight babies. 22

A study compared the estimated smoke plume path 5 days after 9/11 with health survey findings of about 3,000 New Yorkers 6 months after 9/11. Of respondents outside lower Manhattan, the study showed no connection between the estimated smoke plume intensity and new or worsening respiratory symptoms among those with asthma. However, the smoke plume was different from the WTC dust cloud. 3

Among a small group of lower Manhattan residents, lower respiratory symptoms, such as a cough and wheezing, decreased almost 8% four years after 9/11. Yet the prevalence remained elevated compared with those not exposed to 9/11. Residents who also worked in lower Manhattan on 9/11 were at highest risk for persistent symptoms. 13

Eight percent (8%) of residents enrolled in the WTC Health Registry reported newly diagnosed asthma 5 to 6 years after 9/11. Intense dust cloud exposure on 9/11, experiencing a heavy coating of dust in the home and not evacuating homes were major contributors to new asthma diagnoses. 4

A study of nearly 2,000 people exposed to WTC dust who sought care at the WTC Environmental Health Center 5 to 7 years after 9/11 showed high rates of respiratory symptoms, including persistent shortness of breath, cough and sinus or nasal problems. While pulmonary function was normal for the total group, about one-third (31%) had below-normal pulmonary function similar to the level found in WTC rescue, recovery and clean up workers. 5

The WTC Health Registry, in collaboration with the WTC Environmental Health Center, found abnormal lung function in Lower Manhattan residents and area workers who reported persistent respiratory symptoms 7 to 8 years after exposure to the WTC disaster. In a case control study using spirometry and oscillometry, a test to measure how well the lungs&rsquo small airways are working, researchers found that 180 enrollees with persistent respiratory symptoms (cases) were more likely to have abnormal lung function than nearly 500 enrollees who had not reported any new respiratory symptoms since 9/11 (controls). Oscillometric abnormalities were found even among cases with normal spirometry. 23

WTC Health Registry researchers identified 790 deaths from 2003 through 2009 among 41,930 adults who resided in New York City at the time of their enrollment in the Registry. The all-cause death rate among Registry enrollees was 43% lower than among NYC residents as a whole. Researchers detected exposure-related differences in mortality rates among those in the Registry: lower Manhattan residents, area workers and passersby with intermediate or high levels of exposure, including those with 2 or more injuries on 9/11, had elevated all-cause and heart disease mortality risks in comparison to those with intermediate or lower levels of exposure. The study did not detect exposure-related mortality differences among rescue and recovery workers even when internal comparisons were conducted. 24

Researchers found an association between chronic WTC exposures and lower respiratory symptoms in a case control study of nearly 800 Lower Manhattan residents and area workers in the WTC Health Registry up to 6 years after 9/11. Residents reporting lower respiratory symptoms were 2 to 3 times more likely than residents who never had symptoms to recall that the surfaces in their homes were covered in dust following the WTC collapse residents who recalled a thicker layer of dust were at greater risk, suggesting a dose/response relationship. 27

Among residents, office workers and passers-by enrolled in the WTC Health Registry who reported either lower respiratory symptoms or probable posttraumatic stress disorder, more than 25% said they had both conditions 5-6 years after 9/11. Also, enrollees who had both conditions were much more likely to report 14 days of activity lost in the 30 days before being surveyed compared to enrollees with only 1 condition. 28

In a longitudinal study of nearly 1,000 office workers, residents and clean-up workers who sought care for respiratory illness at the World Trade Center Environmental Health Center between 2005 and 2011, and who were symptom-free prior to 9/11, researchers found improvements in lung function overall among treated patients who were not heavy smokers. However, lung function among office workers, who had the highest likelihood of dust cloud exposure, improved the least. 29

A WTC Health Registry analysis of verified cancer diagnoses among 33,928 adult enrollees NOT involved in rescue and recovery work, including Lower Manhattan residents, found no increase in cancer rates compared to non-exposed New York State residents during the period studied (2003-2008). 30

Mental Health

Those directly affected by 9/11 were more likely to report post-traumatic stress disorder (PTSD) symptoms 6 months after 9/11. However, a substantial number not directly affected also met the criteria for probable PTSD. 6

In a study that examined the prevalence of resilience among New Yorkers during the 6 months after 9/11, 65% of participants showed resilience (ability to recover). This suggests that more New Yorkers demonstrated resilience during the 6 months after 9/11 than previously believed. Even among those with the highest levels of exposure and highest probable PTSD, the proportion that were resilient never dropped below 33%. 7

A study of low-income patients seven to 16 months after 9/11 found that:

  • Those suffering a 9/11-related loss were twice as likely to be diagnosed with a mental health condition, such as depression, anxiety or PTSD. 14
  • This group was also more likely to suffer functional impairment and work loss. 14
  • Patients with loved ones in danger on 9/11 or who knew someone involved in the rescue and recovery effort were twice as likely to suffer from an anxiety disorder. 15

A small study of New Yorkers 18 to 21 years of age with and without generalized anxiety disorder compared their mental health before and after 9/11. Among those with generalized anxiety disorder, findings showed high rates of functional impairment but no increase in post-traumatic stress symptoms. 8

A study of 2,300 New Yorkers interviewed 1, 2 and 3 years after 9/11 showed that:

  • People who received early, brief interventions at their worksites reported better mental health than those who received more extensive interventions, such as psychotherapy of 30 minutes or longer. Although the study adjusted for 9/11 exposure, it did not adjust for illness severity. Support from friends, neighbors and spiritual communities was also beneficial. 9
  • Problem drinking and alcohol use were connected with psychological trauma up to 4 years after 9/11, as well as other mental health problems. 10

Analyses of NYC death records that compared suicide rates before and after 9/11 found that suicide rates did not increase four years after the terrorist attacks. 16,17

Among a sample of 455, mostly female patients who were screened for mental health conditions when they sought primary care at a general medicine clinic in New York City, the PTSD rate decreased significantly from 9.6% 1 year after 9/11 to 4.1% 3 years later. Patients who reported pre-9/11 depression, the only significant predictor of PTSD trajectory, were 10 times more likely to have PTSD 4 years after the WTC attacks than those who didn&rsquot. 25

A study of national mortality data showed that suicide rates among New Yorkers declined significantly six months after 9/11. 18

Lower-income New Yorkers exposed to ongoing stress and trauma were more likely to suffer from persistent depression. 19

While low-income adolescents and mothers exposed to the WTC disaster were more likely to suffer from depression and PTSD 15 months after 9/11, respectively, there were few long-term associations between 9/11 exposure and mental health among this group. 20

More than 21% of residents enrolled in the WTC Health Registry reported new PTSD symptoms 5 to 6 years after 9/11. Probable PTSD among residents increased from more than 13% 2-3 years after the attacks to more than 16% 5-6 years later. Risk factors included:

  • Intense dust cloud exposure
  • Witnessing horror
  • Returning to a home with a heavy layer of dust
  • Job loss
  • Lack of social support 11

To search for 2003/2004 baseline survey data, visit the Health Department's interactive data tool.

A small, cross-sectional study assessed more than 300 low-income, trauma-exposed patients in a large urban primary care clinic, including some who had been exposed to the WTC disaster, for mental health disorders and functioning at 2 time points after 9/11. Although patients with a past PTSD diagnosis functioned better than patients with a current PTSD diagnosis, they continued to experience more difficulties with their social and family lives than patients who had never been diagnosed with PTSD. 26


Primary paper

Arango C, Díaz-Caneja CM, McGorry PD, Rapoport J, Sommer IE, Vorstman JA, McDaid D, Marín O, Serrano-Drozdowskyj E, Freedman R, Carpenter W. (2018) Preventive strategies for mental health. The Lancet Psychiatry Published Online May 14, 2018

Other references

Mental Health Foundation (2015) Prevention review: landscape paper. Mental Health Foundation, Nov 2015.

Photo credits

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Causes of Exhibitionism

Just like any other mental disorder it is hard to determine the cause of Exhibitionism and it can vary in every individual. Although none have been conclusive, several theories regarding the cause of this disorder have been proposed. One theory is that a person who suffers emotional abuse as a child or has a dysfunctional family can grow up to develop this disorder. Or, there is the biological theory that states that people with high levels of testosterone are predisposed to develop sexually deviant behavior, which can ultimately lead to the act of Exhibitionism.

According to police records, Exhibitionism is one of the three most common sexual offenses, along with Voyeurism and pedophilia. It’s hard to determine how many people actually have this disorder though, because those that do have it rarely seek help. Although the stereotype of an exhibitionist is a dirty old man in a raincoat, those who are usually arrested for it are males in their late teens or twenties. In the U.S., most exhibitionists are Caucasian males and about half are married.

Mental Illness and Addiction: Facts and Statistics

The terms "mental illness" and "addiction" refer to a wide range of disorders that affect mood, thinking and behaviour. Examples include depression, anxiety disorders and schizophrenia, as well as substance use disorders and problem gambling. Mental illness and addiction can be associated with distress and/or impairment of functioning. Symptoms vary from mild to severe.

With appropriate treatment and support, most people will recover.


  • In any given year, 1 in 5 Canadians experiences a mental illness or addiction problem. 1
  • By the time Canadians reach 40 years of age, 1 in 2 have&mdashor have had&mdasha mental illness. 1

Who is affected?

  • 70% of mental health problems have their onset during childhood or adolescence. 2
  • Young people aged 15 to 24 are more likely to experience mental illness and/or substance use disorders than any other age group. 3
  • 34% of Ontario high-school students indicate a moderate-to-serious level of psychological distress (symptoms of anxiety and depression). 14% indicate a serious level of psychological distress. 35
  • Men have higher rates of addiction than women, while women have higher rates of mood and anxiety disorders. 3
  • Mental and physical health are linked. People with a long-term medical condition such as chronic pain are much more likely to also experience mood disorders. Conversely, people with a mood disorder are at much higher risk of developing a long-term medical condition. 36
  • People with a mental illness are twice as likely to have a substance use problem compared to the general population. At least 20% of people with a mental illness have a co-occurring substance use problem. 4 For people with schizophrenia, the number may be as high as 50%. 5
  • Similarly, people with substance use problems are up to 3 times more likely to have a mental illness. More than 15% of people with a substance use problem have a co-occurring mental illness. 4
  • Canadians in the lowest income group are 3 to 4 times more likely than those in the highest income group to report poor to fair mental health. 6
  • Studies in various Canadian cities indicate that between 23% and 67% of homeless people report having a mental illness. 7

Morbidity and mortality

  • Mental illness is a leading cause of disability in Canada. 8,9,10
  • People with mental illness and addictions are more likely to die prematurely than the general population. Mental illness can cut 10 to 20 years from a person&rsquos life expectancy. 11
  • The disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together and more than 7 times that of all infectious diseases. This includes years lived with less than full function and years lost to early death. 12
  • Tobacco, the most widely used addictive substance, is the leading cause of premature mortality in Canada. Smoking is responsible for nearly 17% of all deaths. 13
  • Among Ontarians aged 25 to 34, 1 of every 8 deaths is related to opioid use. 14


  • About 4,000 Canadians per year die by suicide&mdashan average of almost 11 suicides a day. 15 It affects people of all ages and backgrounds.
  • On a per-capita basis, suicide rates in Canada are on a downward trend. They peaked in 1983 at 15.1 deaths per 100,000 people (compared to 11.0 per 100,000 in 2016&mdashthe latest year for which these data are available). 15, 16
  • In Ontario about 2% of adults and 14% of high-school students report having seriously contemplated suicide in the past year. 4% of high-school students report having attempted suicide. 17,35
  • More than 75% of suicides involve men, but women attempt suicide 3 to 4 times more often. 15,17
  • More than half of suicides involve people aged 45 or older. 19
  • In 2016, suicide accounted for 19% of deaths among youth aged 10 to 14, 29% among youth aged 15 to 19, and 23% among young adults aged 20-24. 19
  • After accidents, it is the second leading cause of death for people aged 15-24. 15
  • First Nations youth die by suicide about 5 to 6 times more often than non-Aboriginal youth. Suicide rates for Inuit youth are among the highest in the world, at 11 times the national average. 20


According to a 2008 survey: 21

  • Just 50% of Canadians would tell friends or co-workers that they have a family member with a mental illness, compared to 72% who would discuss a diagnosis of cancer and 68% who would talk about a family member having diabetes.
  • 42% of Canadians were unsure whether they would socialize with a friend who has a mental illness.
  • 55% of Canadians said they would be unlikely to enter a spousal relationship with someone who has a mental illness.
  • 46% of Canadians thought people use the term mental illness as an excuse for bad behaviour, and 27% said they would be fearful of being around someone who suffers from serious mental illness.
  • 57% of Canadians believe that the stigma associated with mental illness has been reduced compared to five years ago.
  • 81% are more aware of mental health issues compared to five years ago.
  • 70% believe attitudes about mental health issues have changed for the better compared to five years ago.

But stigma remains a barrier:

  • 64% of Ontario workers would be concerned about how work would be affected if a colleague had a mental illness. 21
  • 39% of Ontario workers indicate that they would not tell their managers if they were experiencing a mental health problem. 21
  • 40% of respondents to a 2016 survey agreed they have experienced feelings of anxiety or depression but never sought medical help for it. 35

Access to services

  • While mental illness accounts for about 10% of the burden of disease in Ontario, it receives just 7% of health care dollars. Relative to this burden, mental health care in Ontario is underfunded by about $1.5 billion. 8,24
  • The Mental Health Strategy for Canada recommends raising the proportion of health spending that is devoted to mental health to 9% by 2022. 25
  • Only about half of Canadians experiencing a major depressive episode receive &lsquo&lsquopotentially adequate care.&rsquo&rsquo 38
  • Of Canadians aged 15 or older who report having a mental health care need in the past year, one third state that their needs were not fully met. 41
  • An estimated 75% of children with mental disorders do not access specialized treatment services. 26
  • In 2013-2014, 5% of ED visits and 18% of inpatient hospitalizations for children and youth age 5 to 24 in Canada were for a mental disorder. 27
  • Wait times for counselling and therapy can be long, especially for children and youth. In Ontario, wait times of six months to one year are common. 39,40

Costs to society

  • The economic burden of mental illness in Canada is estimated at $51 billion per year. This includes health care costs, lost productivity, and reductions in health-related quality of life. 1,10
  • Individuals with a mental illness are much less likely to be employed. 26 Unemployment rates are as high as 70% to 90% for people with the most severe mental illnesses. 29
  • In any given week, at least 500,000 employed Canadians are unable to work due to mental health problems. This includes:
    • approximately 355,000 disability cases due to mental and/or behavioural disorders 30
    • approximately 175,000 full-time workers absent from work due to mental illness. 31
    • The cost of a disability leave for a mental illness is about double the cost of a leave due to a physical illness. 30
    • A small proportion of all health care patients account for a disproportionately large share of health care costs. Patients with high mental health costs incur over 30% more costs than other high-cost patients. 32
    • In Ontario the annual cost of alcohol-related health care, law enforcement, corrections, lost productivity, and other problems is estimated to be at least $5 billion. 33
    • A growing body of international evidence demonstrates that promotion, prevention, and early intervention initiatives show positive returns on investment. 9,34
    • A growing body of international evidence demonstrates that promotion, prevention, and early intervention initiatives show positive returns on investment. 42
    • The economic cost of substance use in Canada in 2014 was $38.4 billion. This includes costs related to healthcare, criminal justice and lost productivity. 42
    • More than 2/3 of substance use costs are associated with alcohol and tobacco. 42
    • The substances associated with the largest costs to Canadians are alcohol ($14.6 billion), tobacco ($12 billion), opioids ($3.5 billion) and cannabis ($2.8 billion) 42


    1 Smetanin et al. (2011). The life and economic impact of major mental illnesses in Canada: 2011-2041. Prepared for the Mental Health Commission of Canada. Toronto: RiskAnalytica.

    2 Government of Canada (2006). The human face of mental health and mental illness in Canada. Ottawa: Minister of Public Works and Government Services Canada.

    3 Pearson, Janz and Ali (2013). Health at a glance: Mental and substance use disorders in Canada. Statistics Canada Catalogue no. 82-624-X.

    4 Rush et al. (2008). Prevalence of co-occurring substance use and other mental disorders in the Canadian population. Canadian Journal of Psychiatry, 53: 800-9.

    5 Buckley et al. (2009). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35: 383-402.

    6 Mawani and Gilmour (2010). Validation of self-rated mental health. Statistics Canada Catalogue no. 82-003-X.

    7 Canadian Institute for Health Information (2007). Improving the health of Canadians: Mental health and homelessness. Ottawa: CIHI.

    8 Institute for Health Metrics and Evaluation (2015). Global Burden of Diseases, Injuries, and Risk Factors Study, 2013. Data retrieved from

    9 Mental Health Commission of Canada (2014). Why investing in mental health will contribute to Canada&rsquos economic prosperity and to the sustainability of our health care system. Retrieved from

    10 Lim et al. (2008). A new population-based measure of the burden of mental illness in Canada. Chronic Diseases in Canada, 28: 92-8.

    11 Chesney, Goodwin and Fazel (2014). Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry, 13: 153-60.

    12 Ratnasingham et al. (2012). Opening eyes, opening minds: The Ontario burden of mental illness and addictions. An Institute for Clinical Evaluative Sciences / Public Health Ontario report. Toronto: ICES.

    13 Whiteford et al. (2013). Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet, 382: 1575-86.

    14 Gomes et al. (2014). The burden of premature opioid-related mortality. Addiction, 109: 1482-8.

    15 Statistics Canada (2018). Deaths and age-specific mortality rates, by selected grouped causes, Canada, 2016. Table: 13-10-0392-01

    16 Statistics Canada (2017). Deaths and mortality rate, by selected grouped causes, age group and sex, Canada, 2014. CANSIM 102-0551.

    17 Ialomiteanu et al (2016). CAMH Monitor eReport: Substance use, mental health and well-being among Ontario adults, 1977-2015. CAMH Research Document Series no. 45. Toronto: Centre for Addiction and Mental Health.

    18 Navaneelan (2012). Suicide rates, an overview, 1950 to 2009. Statistics Canada Catalogue no. 82-624-X.

    19 Statistics Canada (2018). Leading causes of death, total population, by age group. Canada, 2016. Table 13-10-0394-01

    20 Health Canada (2015). First Nations & Inuit health &ndash mental health and wellness. Retrieved from

    21 Canadian Medical Association (2008). 8th annual National Report Card on Health Care. Retrieved from

    22 Bell Canada (2015). Bell Let&rsquos Talk: The first 5 years (2010-2015). Retrieved from

    23 Dewa (2014). Worker attitudes towards mental health problems and disclosure. International Journal of Occupational and Environmental Medicine, 5: 175-86.

    24 Brien et al. (2015). Taking Stock: A report on the quality of mental health and addictions services in Ontario. An HQO/ICES Report. Toronto: Health Quality Ontario and the Institute for Clinical Evaluative Sciences.

    25 Mental Health Commission of Canada (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary: MHCC.

    26 Waddell et al. (2005). A public health strategy to improve the mental health of Canadian children. Canadian Journal of Psychiatry, 50: 226-33.

    27 Canadian Institute for Health Information (2015). Care for children and youth with mental disorders. Ottawa: CIHI.

    28 Dewa and McDaid (2010). Investing in the mental health of the labor force: Epidemiological and economic impact of mental health disabilities in the workplace. In Work Accommodation and Retention in Mental Health (Schultz and Rogers, eds.). New York: Springer.

    29 Marwaha and Johnson (2004). Schizophrenia and employment: A review. Social Psychiatry and Psychiatric Epidemiology, 39: 337-49.

    30 Dewa, Chau, and Dermer (2010). Examining the comparative incidence and costs of physical and mental health-related disabilities in an employed population. Journal of Occupational and Environmental Medicine, 52: 758-62. Number of disability cases calculated using Statistics Canada employment data, retrieved from

    31 Institute of Health Economics (2007). Mental health economics statistics in your pocket. Edmonton: IHE. Number of absent workers calculated using Statistics Canada work absence rates, retrieved from

    32 De Oliveira et al. (2016). Patients with high mental health costs incur over 30% more costs than other high-cost patients. Health Affairs, 35: 36-43.

    33 Rehm et al. (2006). The costs of substance use in Canada, 2002. Ottawa: Canadian Centre on Substance Abuse.

    34 Roberts and Grimes (2011). Return on investment: Mental health promotion and mental illness prevention. A Canadian Policy Network / Canadian Institute for Health Information report. Ottawa: CIHI.

    35 Boak et al. (2016). The mental health and well-being of Ontario students, 1991-2015: Detailed OSDUHS findings. CAMH Research Document Series no. 43. Toronto: Centre for Addiction and Mental Health.

    36 Patten et al. (2005). Long-term medical conditions and major depression: strength of association for specific conditions in the general population. Canadian Journal of Psychiatry, 50: 195-202.

    37 Shoppers LOVE. YOU. Run for Women Poll (2016). Online survey conducted by Environics Research.

    38 Patten et al. (2016). Major depression in Canada: what has changed over the past 10 years? Canadian Journal of Psychiatry, 61: 80-85. &ldquoPotentially adequate treatment&rdquo defined as &ldquotaking an antidepressant or 6 or more visits to a health professional for mental health reasons.&rdquo

    39 Children&rsquos Mental Health Ontario (2016). Ontario&rsquos children waiting up to 1.5 years for urgently needed mental healthcare. Retrieved from

    40 Office of the Auditor General of Ontario (2016). Annual report 2016, volume 1. Toronto: Queen&rsquos Printer for Ontario.

    41 Sunderland & Findlay (2013). Perceived need for mental health care in Canada: Results from the 2012 Canadian Community Health Survey &ndash Mental Health. Statistics Canada Catalogue no.82-003-X.

    Mental health is one of the biggest pandemic issues we'll face in 2021

    (CNN) — With progress in efforts for Covid-19 vaccines and predictions for when the population will receive them, there seems to be a light at the end of the long, harrowing pandemic tunnel.

    As the physical risks are better managed with vaccines, however, what will likely still remain is the indelible impact of the pandemic weighing on the collective psyche.

    "The physical aspects of the pandemic are really visible," said Lisa Carlson, the immediate past president of the American Public Health Association and an executive administrator at the Emory University School of Medicine in Atlanta. "We have supply shortages and economic stress, fear of illness, all of our disrupted routines, but there's a real grief in all of that."

    "We don't have a vaccine for our mental health like we do for our physical health," Carlson added. "So, it will take longer to come out of those challenges."

    Based on the mental struggles endured by so many this year, these are the issues mental health professionals anticipate coming to the fore in 2021.

    Spanking Children Can Cause Mental Illness

    American Academy of Pediatrics, which is already opposed to using physical punishments on children, has released a new study today, backing their stance and reinforcing the belief that spanking children belongs firmly in the past.

    The study, named &ldquoPhysical Punishment and Mental Disorders: Results From a Nationally Representative U.S. Sample,&rdquo is released in the August edition of Pediatrics, which is online July 2nd.

    It states clearly that children who are spanked, hit or pushed have an increased risk of mental problems when they grow older . The research seems to show that the effect can range from mood and anxiety disorders to drug and alcohol abuse.

    Afifi, an assistant professor of epidemiology in the Department of Community Health Sciences at the University of Manitoba, Canada, clarified to USA Today:

    &ldquoThere is a significant link between the two &hellip Individuals who are physically punished have an increased likelihood of having mental health disorders&hellip.[the studies findings confirm that] physical punishment should not be used on any child, at any age,&rdquo

    She goes on to state that between 2% and 7% of mental disorders found in the study were linked to physical punishment.

    The study involved a large number of subjects with data collected from some 35,000 non-institutionalized adults in the USA. Around 1,300 of the subjects confirmed that they had, at sometime, or regularly been &ldquopushed, grabbed, shoved, slapped or hit by your parents or any adult living in your house.&rdquo

    The aim was not to look at more aggressive physical or sexual abuse, emotional abuse, neglect, but rather to identify the link between light deliberate punishment and Axis I and II mental disorders.

    Axis I is defined as clinical disorders, including major mental disorders, learning disorders and substance use disorders, while Axis II relates to: personality disorders and intellectual disabilities (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I).

    The study has been criticized, however, with Robert Larzelere, of Oklahoma State University, Stillwater stating to USA Today that:

    &ldquoCertainly, overly severe physical punishment is going to have adverse effects on children &hellip But for younger kids, if spanking is used in the most appropriate way and the child perceives it as being motivated by concern for their behavior and welfare, then I don&rsquot think it has a detrimental effect.&rdquo

    His own 2005 research showed that when light spanking is used appropriately, rather than wantonly and where it only servers to back up non physical discipline, such as talking sternly to the child or enacting some kind of punishment or removal of privileges, it does, in fact, prove very effective at removing non-compliant behavior.

    He goes on to state that the current study &ldquodoes nothing to move beyond correlations to figure out what is actually causing the mental health problems &hellip The motivation that the child perceives and when and how and why the parent uses (spanking) makes a big difference. All of that is more important than whether it was used or not.&rdquo

    This would probably concur with the ideals of many mentally balanced and well educated parents, who would do anything to avoid having to get physical with their children, but ultimately, in the appropriate moment, with the correct words and mood, find that spanking can be useful and not cause long term detriment.

    Afifi&rsquos report concludes that the findings inform the ongoing debate around the use of physical punishment and provide evidence that harsh physical punishment, independent of child maltreatment, is related to mental disorders.


    Exposure to disasters has been associated with a variety of mental health consequences (50). Although the majority of individuals cope well in the face of a disaster (53), a substantial proportion experience some psychological impairment (50), and a smaller proportion will go on to develop mental disorders. Studies have documented the prevalence of various types of psychopathology following different types of disasters, from natural disasters such as Hurricane Katrina (31) to the September 11, 2001, WTC attacks (19). In this section, we describe the manifestations and burden of mental illness that have been observed after disasters.


    Studies of traumatic event experience have shown that most people who experience an event do not develop psychopathology (9, 53). Having the capacity to continue functioning after a traumatic event is common and characteristic of normal coping and adaptation (5, 6). This phenomenon has become known as “resilience” and is an emerging concept in the disaster mental health literature (6, 53). Research on resilience advanced in the 1970s, as researchers noted a preponderance of healthy development among children exposed to substantial hardship (6, 41). There is a growing consensus, however, that resilience does not indicate the complete absence of any psychological symptoms after traumatic event exposure rather, it describes the ability to “bounce back” (35, 53). Resilience has been documented in populations exposed to disasters (6, 53, 60). Resilient individuals generally experience distress for a short period and quickly return to pre-disaster levels of functioning (50), distinguishing them from those who experience a longer period of dysfunction and a more gradual return to baseline functioning (“recovery”) (4).

    Although most work in this area has relied on cross-sectional assessments, more recent work has capitalized on longitudinal samples that allow investigators to document the course of symptomatology over time (53). In one such study, Pietrzak and colleagues examined the course of PTSD and other mental disorders in Galveston, Texas, following Hurricane Ike at three post-hurricane time points. They found that ∼7% of participants had symptoms of PTSD at baseline. This prevalence declined over time, with most symptoms resolving by the follow-up interviews, demonstrating resilience as a common post-disaster outcome (60).

    Posttraumatic Stress Disorder

    PTSD is a mental illness that can follow exposure to a traumatic event and is characterized by reexperiencing of the event through nightmares and/or flashbacks avoidance of stimuli reminiscent of the event and numbing of emotional responses and symptoms of hyperarousal (e.g., being particularly watchful or on guard) (2). PTSD is the only disorder whose diagnosis is predicated on the experience of a traumatic event and is, therefore, one of the most commonly occurring (and studied) post-disaster psychopathologies (23, 48, 50). Post-disaster burden can be substantial one review of the literature estimates the prevalence of PTSD at 30–40% among direct victims, 10–20% among rescue workers, and 5–10% in the general population (23, 48, 50). The prevalence of PTSD is also particularly high among children directly exposed to a disaster (48). Prevalence estimates vary greatly between studies owing to differences in factors such as disaster type, degree of exposure, and methods of measurement studies of children exposed to sudden, unexpected acts of mass violence report PTSD prevalence in up to 100% of those studied (27).

    Major Depressive Disorder

    Major depressive disorder (MDD) is one of the most common mental illnesses in the general population (29), characterized by sadness and loss of pleasure or interest in things once enjoyed, as well as a combination of other symptoms such as changes in sleep and weight, difficulty concentrating, and irritability (2). In disaster research, depression is, after PTSD, the second most commonly studied post-disaster mental health condition (50) however, owing to its large burden in the general population, it may be the most prevalent post-disaster disorder. Studies report a range of MDD prevalence estimates after disasters because prevalence estimates depend on factors such as MDD prevalence in the study population prior to the disaster, symptom measurement, sampling design, degree of disaster exposure, and post-disaster social support (40). For example, 5% of the Texas population affected by Hurricane Ike met criteria for MDD in the month following the storm (65), whereas almost one in ten adult New Yorkers showed symptoms of MDD in the month following the WTC attacks (20).

    Substance Use Disorder

    Substance use disorders are characterized by problematic alcohol or drug use that results in difficulty fulfilling obligations in work, home life, or school legal issues difficulties in social relationships involvement in dangerous situations increased tolerance symptoms of withdrawal and unsuccessful efforts to quit (2). These conditions have been less frequently studied after disasters than has PTSD or MDD. Some studies have observed increases in the use of alcohol, drugs, and cigarettes after a disaster, and some evidence shows that disaster victims use substances, particularly alcohol, as a coping strategy (69). For example, ∼15% of Oklahoma City bombing survivors reported using alcohol to cope with their experience (55). Studies have also demonstrated increased use of alcohol, cigarettes, and marijuana in the period following the WTC attacks, with almost 10% of New Yorkers reporting increased cigarette use, almost 25% reporting increased alcohol use, and 3% reporting increased marijuana use (71). Despite some evidence of substance use problems after disasters, however, a recent review of the literature argues that the prevalence of substance use disorders does not increase substantially after a disaster and that problematic use is found primarily among those with prior substance use problems or those who developed other psychopathology in response to the disaster (50, 69).

    Other Psychological Symptoms

    In addition to these disorders, other psychological sequelae of disasters have been described. Studies have reported elevated prevalence of generalized anxiety disorder (GAD) among those affected by a disaster, although it is less commonly studied than PTSD and depression (42). Death anxiety, panic disorder, and phobias have also been reported among disaster victims, although few epidemiologic studies have focused on these conditions (50). Given the potential for sudden loss of a loved one in a disaster situation, studies have also evaluated the burden of prolonged grief disorder (PGD) in disaster-affected populations (40). Additional post-disaster symptoms documented include nonspecific psychological distress, perceived stress, ataques de nervios (in a study in Puerto Rico), suicidality, and remorse (21, 50).

    Somatic symptoms also manifest in the aftermath of disasters these may be associated with psychological distress. For example, exposed persons frequently report sleep disruption, due to feelings of grief over loss and anxiety about disaster reoccurrence and ongoing threats or due to symptoms of depression or PTSD (45, 68). Disasters have been found to precipitate other physical symptoms such as headache, fatigue, abdominal pain, and shortness of breath. The prevalence of these symptoms varies by study, from 3% to 78% in one review. Although physical symptoms generally subside over time, some persist for years following the disaster (74). For example, women who survived the Chernobyl disaster continued to report significantly greater physical symptoms more than a decade after the accident compared with controls (11).


    The disorders discussed here rarely present in isolation, in the general population (30) and in the post-disaster environment. Disaster-related PTSD is often accompanied by symptoms of other anxiety disorders, MDD, and substance use disorders (42). For example, more than half of all survivors of both the Oklahoma City bombing and the WTC attacks who met criteria for PTSD were also identified as having major depression (20, 55). Chiu and colleagues (15) describe three potential explanations for the high prevalence of PTSD and depression comorbidity following a traumatic event such as a disaster: Both disorders are psychological consequences of traumatic exposure, suffering with PTSD brings on secondary depression, and symptoms that characterize the two conditions overlap (15). Those with comorbid psychological disorders are generally more impaired than those with only one condition and are at greater risk for chronic disorder (42, 69).


    At this point, the burden of mental disorders after disasters has been well documented, and interest in the course or trajectory of psychological symptoms following disasters is growing. Evidence from longitudinal studies suggests that post-disaster symptoms of mental health problems reach their peak in the year following the disaster and then improve, but in many studies symptoms persisted for months and years for some participants (49). Norris et al. (53) have suggested four distinct symptom trajectories: resistance, resilience, recovery, and chronic dysfunction. Resistance is defined as experiencing no symptoms of mental illness or only mild symptoms after the disaster. Resilience, described in detail above, is characterized by symptoms of mental disorder in the period immediately following the disaster that rapidly decline after a short while. Recovery differs from resilience such that symptoms that present after the disaster decrease gradually after a longer period of suffering. Finally, chronic dysfunction describes moderate or severe symptoms whose levels remain stable over time, and it is found only in a relatively small proportion of persons exposed to a traumatic event (6). Although rare (49), there is some evidence of delayed dysfunction, in which symptoms develop not immediately following the disaster but after some time (53). Persons with delayed reactions tend to have high levels of symptoms right after the disaster that may not be severe enough to meet full criteria for a disorder but may worsen over time and develop into full-blown disorder (6).

    Empirical View

    Prevalence of mental health and substance use disorders

    The predominant focus of this entry is the prevalence and impacts of mental health disorders (with Substance Use and Alcohol Use disorders covered in individual entries). However, it is useful as introduction to understand the total prevalence and disease burden which results from the broad IHME and WHO category of ‘mental health and substance use disorders’. This category comprises a range of disorders including depression, anxiety, bipolar, eating disorders, schizophrenia, intellectual developmental disability, and alcohol and drug use disorders.

    Mental and substance use disorders are common globally

    In the map we see that globally, mental and substance use disorders are very common: around 1-in-7 people (15%) have one or more mental or substance use disorders.

    Click to open interactive version

    Prevalence of mental health disorders by disorder type

    It’s estimated that 970 million people worldwide had a mental or substance use disorder in 2017. The largest number of people had an anxiety disorder, estimated at around 4 percent of the population.

    Click to open interactive version

    Prevalence of mental health disorders by genders

    The scatterplot compares the prevalence of these disorders between males and females. Taken together we see that in most countries this group of disorders is more common for women than for men. However, as is shown later in this entry and in our entries on Substance Use and Alcohol, this varies significantly by disorder type: on average, depression, anxiety, eating disorders, and bipolar disorder is more prevalent in women. Gender differences in schizophrenia prevalence are mixed across countries, but it is typically more common in men. Alcohol and drug use disorders are more common in men.

    Click to open interactive version

    Deaths from mental health and substance use disorders

    The direct death toll from mental health and substance use disorders is typically low. In this entry, the only direct death estimates result from eating disorders, which occur through malnutrition and related health complications. Direct deaths can also result from alcohol and substance use disorders these are covered in our entry on Substance Use.

    However, mental health disorders are also attributed to significant number of indirect deaths through suicide and self-harm. Suicide deaths are strongly linked — although not always attributed to — mental health disorders. We discuss the evidence of this link between mental health and suicide in detail later in this entry.

    In high-income countries, meta-analyses suggest that up to 90 percent of suicide deaths result from underlying mental and substance use disorders. However, in middle to lower-income countries there is evidence that this figure is notably lower.ਊ study by Ferrari et al. (2015) attempted to determine the share disease burden from suicide which could be attributed to mental health or substance use disorders. 1

    Based on review across a number of meta-analysis studies the authors estimated that only 68 percent of suicides across China, Taiwan and India were attributed to mental health and substance use disorders. Here, studies suggest a large number of suicides result from the 𠆍ysphoric affect’ and ‘impulsivity’ (which are not defined as a mental and substance use disorder). It is important to understand the differing nature of self-harm methods between countries in these countries a high percentage of self-harming behaviours are carried out through more lethal methods such as poisoning (often through pesticides) and self-immolation. This means many self-harming behaviours can prove fatal, even if there was no clear intent to die.

    As a result, direct attribution of suicide deaths to mental health disorders is difficult. Nonetheless, it’s estimated that a large share of suicide deaths link back to mental health. Studies suggest that for an individual with depression the risk of suicide is around 20 times higher than an individual without.

    Disease burden of mental health and substance use disorders

    Health impacts are often measured in terms of total numbers of deaths, but a focus on mortality means that the burden of mental health disorders can be underestimated. 2 Measuring the health impact by mortality alone fails to capture the impact that mental health disorders have on an individual’s wellbeing. The 𠆍isease burden‘ – measured in Disability-Adjusted Life Years (DALYs) – considers not only the mortality associated with a disorder, but also years lived with disability or health burden. The map shows DALYs as a share of total disease burden mental and substance use disorders account for around 5 percent of global disease burden in 2017, but this reaches up to 10 percent in several countries. These disorders have the highest contribution to overall health burden in Australia, Saudi Arabia and Iran.

    Click to open interactive version


    Definition of depression

    Depressive disorders occur with varying severity. The WHO’s International Classification of Diseases (ICD-10) define this set of disorders ranging from mild to moderate to severe. The IHME adopt such definitions by disaggregating to mild, persistent depression (dysthymia) and major depressive disorder (severe).

    All forms of depressive disorder experience some of the following symptoms:

    • (a) reduced concentration and attention
    • (b) reduced self-esteem and self-confidence
    • (c) ideas of guilt and unworthiness (even in a mild type of episode)
    • (d) bleak and pessimistic views of the future
    • (e) ideas or acts of self-harm or suicide
    • (f) disturbed sleep
    • (g) diminished appetite.

    Mild persistent depression (dysthymia) tends to have the following diagnostic guidelines:

    �pressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described on page 119 (for F32.-) should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks. An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.”

    Severe depressive disorder tends to have the following diagnostic guidelines:

    “In a severe depressive episode, the sufferer usually shows considerable distress or agitation, unless retardation is a marked feature. Loss of self-esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in particularly severe cases. It is presumed here that the somatic syndrome will almost always be present in a severe depressive episode. During a severe depressive episode it is very unlikely that the sufferer will be able to continue with social, work, or domestic activities, except to a very limited extent.”

    The series of charts below present the latest global estimates of the prevalence and disease burden of depressive disorders. Depressive disorders, as defined by the underlying source, cover a spectrum of severity ranging from mild persistent depression (dysthymia) to major (severe) depressive disorder. The data presented below includes all forms of depression across this spectrum.

    Prevalence of depressive disorders

    The share of population with depression ranges mostly between 2% and 6% around the world today. Globally, older individuals (in the 70 years and older age bracket) have a higher risk of depression relative to other age groups.

    Click to open interactive version

    Click to open interactive version

    In 2017, an estimated 264 million people in the world experienced depression. A breakdown of the number of people with depression by world region can be seen here and a country by country view on a world map is here.

    In all countries the median estimate for the prevalence of depression is higher for women than for men.

    DALYs from depression

    The chart found here shows the health burden of depression as measured in Disability Adjusted Life Years (DALYs) per 100,000. A time-series perspective on DALYs by age is here.

    Anxiety disorders

    Definition of anxiety disorders

    Anxiety disorders arise in a number of forms including phobic, social, obsessive compulsive (OCD), post-traumatic disorder (PTSD), or generalized anxiety disorders.
    The symptoms and diagnostic criteria for each subset of anxiety disorders are unique. However, collectively the WHO’s International Classification of Diseases (ICD-10) note frequent symptoms of:

    “(a) apprehension (worries about future misfortunes, feeling “on edge”, difficulty in concentrating, etc.)

    (b) motor tension (restless fidgeting, tension headaches, trembling, inability to relax)

    (c) autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.).”

    The series of charts here present global data on the prevalence and disease burden which results from this range of anxiety disorders.

    Prevalence of anxiety disorders

    The prevalence of anxiety disorders across the world varies from 2.5 to 7 percent by country. Globally an estimated 284 million people experienced an anxiety disorder in 2017, making it the most prevalent mental health or neurodevelopmental disorder. Around 63 percent (179 million) were female, relative to 105 million males.

    Click to open interactive version

    Click to open interactive version

    In all countries women are more likely to experience anxiety disorders than men. Prevalence trends by age can be found here.

    DALYs from anxiety disorders

    The chart found here shows the health burden of depression as measured in Disability Adjusted Life Years (DALYs) per 100,000. A time-series perspective on DALYs by age is here.

    Bipolar disorder

    Definition of Bipolar disorder

    Bipolar disorder (also termed bipolar affective disorder) is defined by the WHO’s International Classification of Diseases (ICD-10) as follows:

    “This disorder is characterized by repeated (i.e. at least two) episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression). Characteristically, recovery is usually complete between episodes, and the incidence in the two sexes is more nearly equal than in other mood disorders. As patients who suffer only from repeated episodes of mania are comparatively rare, and resemble (in their family history, premorbid personality, age of onset, and long-term prognosis) those who also have at least occasional episodes of depression, such patients are classified as bipolar.”

    The charts here present global data on the prevalence and disease burden of bipolar disorder.

    Prevalence of bipolar disorder

    The prevalence of bipolar disorder across the world varies from 0.3 to 1.2 percent by country. Globally, an estimated 46 million people in the world had bipolar disorder in 2017, with 52 and 48 percentꂾing female and male, respectively.

    In almost all countries women are more likely to experience bipolar disorder than men. Prevalence of bipolar disorder by age can be found here.

    Click to open interactive version

    Click to open interactive version

    DALYs from bipolar disorder

    The chart found here shows the health burden of depression as measured in Disability Adjusted Life Years (DALYs) per 100,000. A time-series perspective on DALYs by age is here.

    Eating disorders

    Eating disorders are defined as psychiatric conditions defined by patterns of disordered eating. This therefore incorporates a spectrum of disordered eating behaviours. The underlying sources presented here present data only for the disorders of anorexia and bulimia nervosa (as defined below). It is however recognised that a large share of eating disorders fall outwith the definition of either anorexia or bulimia nervosa (these are often termed �ting disorders not otherwise specified’ EDNOS) — some estimates report at least 60 percent of eating disorders do not meet the standard criteria. 3

    It is therefore expected that the data presented below significantly underestimates the true prevalence of eating disorders, since it concerns only clinically-diagnosed anorexia and bulimia nervosa.

    Anorexia nervosa

    𠇊norexia nervosa is a disorder exemplified by deliberate weight loss, and associated with undernutrition of varying severity.

    For a definite diagnosis, the ICD note that all the following are required:

    (a) Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet’s body-mass index4 is 17.5 or less. 4 Quetelet’s body-mass index = weight (kg) to be used for age 16 or more – 139 – Prepubertal patients may show failure to make the expected weight gain during the period of growth

    (b) The weight loss is self-induced by avoidance of �ttening foods”. One or more of the following may also be present: self-induced vomiting self-induced purging excessive exercise use of appetite suppressants and/or diuretics

    (c) There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself

    (d) A widespread endocrine disorder involving the hypothalamic – pituitary – gonadal axis is manifest in women as amenorrhoea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy, most commonly taken as a contraceptive pill.) There may also be elevated levels of growth hormone, raised levels of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion

    (e) If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases in girls the breasts do not develop and there is a primary amenorrhoea in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late.”

    Bulimia nervosa

    𠇋ulimia nervosa is an illness defined by repeated behaviours of overeating, preoccupation with control of body weight, and the adoption of extreme measures to mitigate the impacts of overeating.

    For a definite diagnosis, the ICD note that all the following are required:

    (a) There is a persistent preoccupation with eating, and an irresistible craving for food the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time.

    (b) The patient attempts to counteract the �ttening” effects of food by one or more of the following: self-induced vomiting purgative abuse, alternating periods of starvation use of drugs such as appetite suppressants, thyroid preparations or diuretics. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment.

    (c) The psychopathology consists of a morbid dread of fatness and the patient sets herself or himself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval between the two disorders ranging from a few months to several years. This earlier episode may have been fully expressed, or may have assumed a minor cryptic form with a moderate loss of weight and/or a transient phase of amenorrhoea.”

    Prevalence of eating disorders

    The prevalence of eating disorders (anorexia and bulimia nervosa) ranges from 0.1 to 1 percent by country. Globally an estimated 16 million had clinical anorexia and bulimia nervosa in 2017. Bulimia was more common: around 79 percent had bulimia nervosa.

    Click to open interactive version

    Click to open interactive version

    In every country women are more likely to experience an eating disorder than men. Eating disorders tend to be more common in young adults aged between 15 and 34 years old. Trends in prevalence by age can be found here.

    Deaths from eating disorders

    Direct deaths can result from eating disorders through malnutrition and related health complications. The chart shows the estimated number of direct deaths from anorexia and bulimia nervosa. Evidence suggests that having an eating disorder can increase the relative risk of suicide suicide deaths in this case are not included here.

    Trends in death rates from eating disorders can be found here.

    Click to open interactive version

    DALYs from eating disorders

    The chart found here shows the health burden of eating disorders as measured in Disability Adjusted Life Years (DALYs) per 100,000. A time-series perspective on DALYs by age is here.


    Schizophrenia is defined by the IHME based on the definition within the WHO’s International Classification of Diseases (ICD-10) as:

    “The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) below, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more:

    • (a) thought echo, thought insertion or withdrawal, and thought broadcasting
    • (b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations delusional perception
    • (c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body
    • (d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and – 79 – abilities (e.g. being able to control the weather, or being in communication with aliens from another world)
    • (e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end
    • (f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms
    • (g) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor
    • (h) “negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance it must be clear that these are not due to depression or to neuroleptic medication
    • (i) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.”

    The following charts present global-level data on the prevalence of schizophrenia.

    Prevalence of schizophrenia

    The prevalence of schizophrenia typically ranges from 0.2 to 0.4 percent across countries. It’s estimated that 20 million people in world had schizophrenia in 2017 the number of men and women with schizophrenia was approximately the same (around 10 million each).

    Click to open interactive version

    Click to open interactive version

    Overall the prevalence of schizophrenia is slightly higher in men than women. Prevalence by age can be found here.

    DALYs from schizophrenia

    The chart found here shows the health burden of schizophrenia as measured in Disability Adjusted Life Years (DALYs) per 100,000. A time-series perspective on DALYs by age is here.


    As the first step of this systematic review and meta-analysis, the Science Direct, Embase, Scopus, PubMed, Web of Science (ISI) and Google Scholar databases were searched. To identify the articles, the search terms of Coronavirus, COVID-19, 2019-ncov, SARS-cov-2, Mental illness, Mental health problem, Distress, Anxiety, Depression, and all the possible combinations of these keywords were used.

    (((((((((((((Coronavirus [Title/Abstract]) OR (COVID-19[Title/Abstract])) OR (2019-ncov [Title/Abstract])) AND (SARS-cov-2[Title/Abstract])) AND (Mental illness [Title/Abstract])) OR (Mental health problem [Title/Abstract])) AND (Anxiety [Title/Abstract])) AND (Social Anxiety [Title/Abstract])) OR (Anxiety Disorders [Title/Abstract])) AND (Depression [Title/Abstract])) OR (Emotional Depression [Title/Abstract])) OR (Depressive Symptoms [Title/Abstract]))))))))))))

    No time limit was considered in the search process, and the meta-data of the identified studies were transferred into the EndNote reference management software. In order to maximize the comprehensiveness of the search, the lists of references used within all the collected articles were manually reviewed.

    Inclusion and exclusion criteria

    The criteria for entering the systematic review included: 1- Studies that examined the prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic. 2- Studies that were observational (i.e. non-interventional studies) 3- Studies that their full text was available. The criteria for excluding a study were: 1- Unrelated research works, 2- Studies without sufficient data, 3- Duplicate sources, 4-Pieces of research with unclear methods 5- Interventional studies 6- Case reports, and 7- Articles that their full text was not available.

    Study selection

    Initially, duplicate articles that were repeatedly found in various databases were removed. Then, a title list of all the remaining articles was prepared, so that the articles could be filtered out during the evaluation phase in a structured way. As part of the first stage of the systematic review process, i.e. screening, the title and abstract of the remaining articles were carefully examined, and a number of articles were removed considering the inclusion and exclusion criteria. In the second stage, i.e. eligibility evaluation, the full text of the studies, remaining from the screening stage, were thoroughly examined according to the criteria, and similarly, a number of other unrelated studies were excluded. To prevent subjectivity, article review and data extraction activities were performed by two reviewers, independently. If an article was not included, the reason for excluding it was mentioned. In cases where there was a disagreement between the two reviewers, a third person reviewed the article. Seventeen studies entered the third stage, i.e. quality evaluation.

    Quality evaluation

    In order to examine the quality of the remaining articles (i.e. methodological validity and results), a checklist appropriate to the type of study was adopted. STROBE checklists are commonly used to critique and evaluate the quality of observational studies. The checklist consists of six scales/general sections that are: title, abstract, introduction, methods, results, and discussion. Some of these scales have subscales, resulting in a total of 32 fields (subscales). In fact, these 32 fields represent different methodological aspects of a piece of research. Examples of subscales include title, problem statement, study objectives, study type, statistical population, sampling method, sample size, the definition of variables and procedures, data collection method(s), statistical analysis techniques, and findings. Accordingly, the maximum score that can be obtained during the quality evaluation phase and using the STROBE checklist is 32. By considering the score of 16 as the cut-off point, any article with a score of 16 or above is considered as a medium or a high-quality article [20]. Sixteen papers obtained a score below 16, denoting a low methodological quality, and were therefore excluded from the study. In the present study, following the quality evaluation by means of the STROBE checklist, 17 papers, with a medium or high quality, entered the systematic review and meta-analysis phases.

    Data extraction

    Data of from all the final studies were extracted using a different pre-prepared checklist. The items on the checklist included: article title, first author’s name, year of publication, place of study, sample size, assessment method, gender, type of study, the prevalence of depression, anxiety, and stress.

    Statistical analysis

    The I 2 (%) test was used to assess the heterogeneity of the selected research works. In order to assess publication bias, due to the high volume of samples that entered the study, the Egger’s test was conducted with the significance level of 0.05, and the corresponding Forest plots were drawn. Data analysis was performed using the Comprehensive Meta-Analysis (CMA version 2.0) software.

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