Care for Mental Health Conditions in

Jamaica
The Case for Investment
Evaluating the Return on Investment of Scaling Up Treatment
for Depression, Anxiety, and Psychosis
Care for Mental Health Conditions in
Jamaica

The Case for Investment

Evaluating the Return on Investment of Scaling Up Treatment for
Depression, Anxiety, and Psychosis

Prepared for the Ministry of Health and Wellness of Jamaica

by
Pan American Health Organization
United Nations Development Programme
Care for Mental Health Conditions in Jamaica: The Case for Investment. Evaluating the Return on Investment of Scaling
Up Treatment for Depression, Anxiety, and Psychosis
ISBN: 978-92-75-12118-4

© 2019 UNIATF, UNDP and PAHO

All rights reserved. Publication is available on the PAHO website (www.paho.org) and on the UNIATF website
(http://www.who.int/ncds/un-task-force/en/). Requests for permission to reproduce or translate this publication should be
addressed to PAHO Publications via the PAHO website (www.paho.org/permissions).

Suggested citation. Care for Mental Health Conditions in Jamaica: The Case for Investment. Evaluating the Return on
Investment of Scaling Up Treatment for Depression, Anxiety, and Psychosis. Washington, D.C.: UNIATF, UNDP and
PAHO; 2019.

Cataloguing-in-Publication (CIP) data. CIP data are available at http://iris.paho.org.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion
whatsoever on the part of UNIATF, UNDP and/or PAHO concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border
lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or
recommended by UNIATF, UNDP, and/or PAHO in preference to others of a similar nature that are not mentioned. Errors and
omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by UNIATF, UNDP and PAHO to verify the information contained on this
publication. However, the published material is being distributed without warranty of any kind, either expressed or implied.
The responsibility for the interpretation and use of the material lies with the reader. In no event shall UNIATF, UNDP
and/or PAHO be liable for damages arising from its use.

I
CONTENTS

EXECUTIVE SUMMARY 1
I. INTRODUCTION 2
WHO MENTAL HEALTH GAP ACTION PROGRAMME 2
INVESTMENT CASE OVERVIEW 3
II. SITUATION ANALYSIS ON MENTAL HEALTH IN JAMAICA 4
DEPRESSION AND ANXIETY 4
PSYCHOSIS 4
INSTITUTIONAL AND CONTEXT ANALYSIS 5
III. ECONOMIC ANALYSIS 6
OVERVIEW OF METHODOLOGY 6
INTERVENTIONS MODELED 9
Depression and Anxiety 9
Psychosis 11
RESULTS 12
Health Benefits 12
Economic and Social Value of Health Gains 12
Return on Investment 14
IV. DISCUSSION 16
REFERENCES 18

II
Acknowledgments
The authors would like to express their sincere gratitude to the Ministry of Health and Wellness of Jamaica
and the national team who supported the data collection and analysis, and those stakeholders who took
the time to be interviewed and share their views, particularly, from the Ministry of Health and Wellness:
Dr. Maureen Irons-Morgan, former Director of Mental Health and Substance Abuse; Dr. Tamu Davidson,
Director of Noncommunicable Diseases and Injuries Prevention; and Mr. Jasper Barnett, Acting Director
of Health Systems Improvement.

The development of this investment case (assessment country visits and elaboration of the report), jointly
with the noncommunicable disease investment case for Jamaica, was conducted under the supervision of
Rosa Sandoval, Regional Advisor on Tobacco Control and Economics of Noncommunicable Diseases at
PAHO. The economics analysis was commissioned to Rachel Nugent, Kofi Acquah, Brian Hutchinson, and
Grant King from RTI International. The institutional context analysis was undertaken by Roy Small and
Karin Santi from UNDP. This report was largely written by members of the RTI team, Itziar
Belausteguigoitia (former PAHO) and Maxime Roche (PAHO).

Comments received from Dr. Kevin Goulbourne, Director of Mental Health and Substance Abuse at the
Ministry of Health and Wellness of Jamaica, and from peer reviewers Devora Kestel, Director Mental
Health and Substance Abuse at WHO; Claudina Cayetano, Regional Advisor on Mental Health at PAHO;
Daniel Chisholm, Programme Manager Mental Health and Mental Disorders at WHO Regional Office for
Europe; Amy Tausch, Consultant in Mental Health at PAHO; and Michelle Harris, Advisor on
Noncommunicable Diseases and Mental Health at PAHO/WHO Office in Jamaica, are much appreciated.

The assessment country visits team was comprised of Rosa Sandoval (PAHO), Alexey Kulikov
(WHO/UNIATF), Karin Santi (UNDP), Roy Small (UNDP), Itziar Belausteguigoitia (former PAHO), Elisa Prieto
(PAHO), Rachel Nugent (RTI), Kofi Acquah (RTI), and Brian Hutchinson (RTI). The contributions of the
PAHO/WHO Country Office in Jamaica to organize the assessment country visits and provide national
materials to inform this report are gratefully acknowledged.

The report was financed by the United Nations Interagency Task Force on the Prevention and Control of
Noncommunicable Diseases, PAHO, and through the voluntary contribution from the Centers for Disease
Control and Prevention (CDC).

III
Executive Summary
Mental health is critical to personal well-being, interpersonal relationships, and successful contributions
to society. Mental health conditions consequently impose a high burden not only on individuals, families
and society, but also on economies, as those who suffer from mental disorders are more likely to
experience premature death, exit the labor force, miss days of work (absenteeism), or work at a reduced
capacity (presenteeism). Mental illness is thus increasingly acknowledged as a global health and
development priority, including in the 2030 Agenda for Sustainable Development and considering the
2030 Agenda pledge to leave no one behind. Encouragingly, with timely and effective treatment,
individuals suffering from mental illness can regain full health and wellness.

To help strengthen Member States’ capacity to generate and use economic evidence on mental health,
the Pan American Health Organization (PAHO) partnered with the Ministry of Health and Wellness of
Jamaica, the World Health Organization (WHO), the United Nations Development Programme (UNDP),
and RTI International, under the framework of the United Nations Interagency Task Force on the
Prevention and Control of Noncommunicable Diseases, to develop this Investment Case for mental health
in Jamaica.

This project aims to develop evidence and guidance to support the development, financing, and
implementation of mental health interventions in Jamaica. Specifically, it estimates the return on
investment (ROI) from scaling up interventions targeting anxiety, depression, and psychosis.

Overall, the results indicate that investing in mental health would support the Government of Jamaica to
avoid significant economic losses and social costs. Over the period 2019 to 2033, scaling up the selected
package of interventions would:

 Improve health. Scaled-up treatment for depression, anxiety, and psychosis would restore 75,883
healthy life years to the Jamaican population. For depression and anxiety, scaled-up treatment would
increase healthy life years by 51,328 and 22,671, respectively, by reducing disability states and
increasing remission rates. For psychosis, an extra 1,884 healthy life years would be gained from
reduced disability states alone.

 Provide total benefits (60 billion Jamaican dollars [J$]) that significantly outweigh the costs
(J$ 14.2 billion). Health gains from scaled-up treatment for depression, anxiety, and psychosis would
lead to large economic productivity gains (J$ 39 billion) and social benefits (J$ 21 billion). These
benefits significantly outweigh the medical (J$ 12.5 billion) and intervention package implementation
costs (J$ 1.7 billion) associated with scaling up treatment.

 Have a high return on investment. Comparing the economic and social benefit from scaling up
treatment for depression, anxiety, and psychosis to the cost, anxiety interventions have the highest
return on investment: for every Jamaican dollar invested in clinical treatments for anxiety, Jamaica
can expect 5.5 Jamaican dollars in return. The depression treatment package has the next highest
return on investment (5.2), followed by the psychosis treatment package (1.1).

1
Though inadequate responses to mental illness pose a significant health and economic burden, the results
from this analysis show that Jamaica can significantly reduce the burden of mental illness by investing in
interventions designed to improve mental health.

I. Introduction
Insufficient prevention, treatment, care, and management of mental health conditions is causing
significant human suffering worldwide. It is also imposing high economic burdens on countries, since
individuals who suffer from mental illness are more likely to exit the labor force, miss days of work
(absenteeism), or work at a reduced capacity (presenteeism) (1, 2). In Jamaica, the burden of mental
illness is considerable and is predicted to cause US$ 2.76 billion in lost economic output from 2015-2030,
a higher economic burden than from any single category of noncommunicable disease conditions except
cardiovascular disease (3). Additionally, many mental health problems and illnesses begin in childhood or
adolescence, making investments in addressing mental health important to improve quality of life from
childhood through older age.

Over time, in Jamaica, there has been a rise in the number of individuals seeking treatment for mental
illness. In 2013 and 2014, there were approximately 90,000 visits to public health facilities for mental
health treatment annually (4). Visits increased by about 20% per year in the following two years, with
nearly 108,000 visits in 2015 and 132,000 in 2016 (4, 5). These numbers may represent as little as half of
the actual need for treatment, as the treatment gap for mental disorders in the Caribbean region ranges
from 37.4% (non-affective psychoses) to 64.0% (bipolar disorder) (6).

In recognition of the unmet need and the imperative to improve mental health treatment, a 24-member
Jamaican task force on mental health and homelessness was formed in 2016 to address resource
challenges. Separately, in coordination with the Ministry of Health and Wellness of Jamaica, the Pan
American Health Organization (PAHO), the World Health Organization (WHO), and the United Nations
Development Programme (UNDP) began developing a mental health investment case in Jamaica in 2017.
The investment case analyzes the costs and benefits of scaling up coverage of selected clinical
interventions related to anxiety, depression, and psychosis that are part of the WHO Mental Health Gap
Action Programme (mhGAP). The investment case in Jamaica is part of a series of investment cases
designed to strengthen Member States' capacity to generate and use economic evidence to scale up cost-
effective policy and clinical interventions for noncommunicable diseases and mental illnesses.

WHO Mental Health Gap Action Programme

Recognizing the urgent need for action to reduce the burden of mental health conditions, the WHO
developed the mhGAP. This action plan is an initiative to reduce the global treatment gap by scaling up
treatment of mental, neurological, and substance use disorders (7). The mhGAP provides a framework—
based on evidence about the effectiveness and feasibility of scaling up—for increasing coverage of care
for mental, neurological, and substance use disorders.

2
To further assist Member States in the implementation of the mhGAP, the WHO developed the mhGAP
Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health
Settings (mhGAP-IG). The mhGAP-IG provides a full range of recommendations to facilitate high-quality
care for mental, neurological, and substance abuse disorders by non-specialized health care providers (8).

Investment Case Overview

Mental health investment cases seek to help policymakers understand the expected benefits and costs
from investing in mental health interventions in their respective countries. Generally, a country
investment case consists of a combined economic analysis and institutional and context analysis (ICA).

The economic analysis evaluates the country-specific costs and benefits of scaling up a selected package
of priority interventions identified in the WHO mhGAP-IG. Concretely, it examines the costs and benefits
of scaling up treatment for 1) depression, 2) anxiety, and 3) psychosis, which together accounted for 93%
of all mental health related visits to public health centers in Jamaica in 2016 (5). By providing policymakers
with return on investment (ROI) estimates for interventions, the economic analysis also aims to inform
the establishment of priorities for resource allocation within the framework of the country’s mental health
strategy. The economic analysis makes use of the OneHealth Tool (9, 10), along with the mhGAP costing
tool (11), both developed by United Nations partners, to estimate the cost of clinical interventions and to
project the expected health and economic benefits from their implementation.

The economic analysis is complemented by an ICA, developed to understand the diverse range of
institutions, actors, and stakeholders relevant to mental health in a given context, including how ROI
estimates on mental health would affect them. The ICA recognizes that policy and investment decisions
usually consider more than social and economic data. Combining a desk review and interviews with key
stakeholders, the ICA uncovers areas of consensus and opportunity as well as challenges and barriers. It
supports institutions to examine the political space for adopting and implementing the investment case
interventions and recommends context-specific strategies and approaches to increase that space.

3
II. Situation Analysis on Mental Health in Jamaica
This section provides a brief overview of the mental health situation in Jamaica. It includes summaries on
the epidemiological situation related to depression, anxiety, and psychosis as well as an overview of the
institutional and societal contexts under which interventions for mental health conditions take place.

Depression and Anxiety

Depression and anxiety are serious and debilitating mental Depression
health concerns. Depression, a persistent mood disorder
that results in feelings of dejection, can pervade daily life,  Around 3% of Jamaicans suffer from
depression.
affecting basic activities such as eating and sleep, and
provoke suicidal thoughts (12). Anxiety disorders, which  Women have higher rates of depression
and anxiety than men.
involve a persistent state of worry or fear, similarly manifest
in everyday activities, causing fatigue and sometimes hurting academic or professional performance (13).

The 2017 Global Burden of Disease database shows that depression and anxiety disorders are among the
most common mental health concerns facing the population of Jamaica. Around 3% of Jamaicans have a
depressive disorder and 4.1% have an anxiety disorder. Women are at a disproportionate risk for both
disorders, as 3.7% have depression and 4.3% have anxiety, compared to just 2.3% of men for each disorder
(14).

Local studies have also indicated that depression is a Anxiety

significant problem in Jamaica. The Jamaica Health and  Approximately 4% of Jamaicans suffer
Lifestyle Survey 2007-2008 found that 20% of respondents from anxiety.
aged 15-74 reported symptoms of depression within the  Most new cases of anxiety disorders
past month (15). Depression and anxiety manifest in appear in Jamaicans in the 20-34 and
markedly different age groups. Jamaicans aged 60 and 35-59 age groups.
above are more likely to have depressive disorders than  Anxiety is common among working-age
younger Jamaicans (5.2% among Jamaicans aged 60-74 and Jamaicans; 5.5% within the 35-39 age
5% among those aged 75+). In contrast, anxiety is most group suffer from anxiety.
common in those aged 35-59 (5.5%), who suffer from
anxiety disorders at higher rates than other age groups (14).

Psychosis
Psychosis is a mental health condition that manifests as Psychosis
hallucinations, erratic social behavior, and delusions, all of
 In Jamaica, psychosis was responsible
which may occur during ‘psychotic episodes’ when an
for 106,674 visits to public health clinics
individual’s perception of reality is disrupted. Disorders for mental illness in 2016, accounting
such as schizophrenia, bipolar disorder, and severe for more than 80% of mental illness
depression or anxiety can cause psychosis. Substance abuse related public clinic visits nationwide.
or general medical conditions such as Alzheimer’s disease
can also trigger psychotic episodes (16). The incidence of psychosis in Jamaica has been estimated at 2.09

4
per 10,000 people (17), and psychosis and schizophrenia together account for 80% of mental illness
related public clinic visits nationwide (5).

Psychotic disorders place a major burden on the social and physiological aspects of individuals’ lives. In a
comparison of bipolar and schizophrenic patients, schizophrenic patients were less likely to have
marketable job skills than bipolar patients and schizophrenia was associated with lower educational
attainment (18). Research suggests that psychotic disorders such as schizophrenia are stigmatized (19), a
problem worsened by the fact that many Jamaicans with psychotic disorders also have substance abuse
problems (20). Psychotic disorders can also lead to increased risk for other health problems: those with
schizophrenia and other severe mental disorders have been found to die 10 to 20 years earlier than the
general population, mostly due to cardiovascular disease and other preventable physical illnesses (21).
Moreover, the costs of psychosis do not fall exclusively on the mentally ill. Caregivers for schizophrenic
patients, for example, have a considerable burden, especially when patients cannot care for themselves
(22). Long-term psychosocial intervention and case management services are effective measures that can
be considered when managing psychosis, resulting in less people transitioning to long-term disability.

Institutional and Context Analysis

Historically, mental health has not been a priority in Jamaica, but it is now of growing public and political
concern. Considering the current government’s simultaneous emphasis on general well-being and gross
domestic product (GDP) growth, and the importance of addressing mental health for both, Jamaica is ripe
for a significant push (23). It also has institutional and individual arrangements in place to scale up its
mental health response. The multisectoral Jamaica National NCD Committee includes as sub-committees
the Mental Health and Homelessness Task Force and the National Council on Drug Abuse, Tobacco,
Alcohol and Cannabis, both of which are strongly engaged. At the time of the analysis, a National Mental
Health Policy and National Strategic Plan are being prepared for Cabinet approval. The current Health
Minister has been vocal about the need to address mental illness in Jamaica, including through public
education to destigmatize affected persons (24,25).

Central to Jamaica’s efforts to strengthen the national response to mental illness is its desire to transition
from a hospital-focused mental health approach to a community-based one. This would support those
with persistent issues to avoid mental hospitals and homelessness while increasing productivity.

To support this objective, in 2017, the Jamaica Task Force on Mental Health and Homelessness issued
recommendations including integrating mental health services into primary care by expanding mental
health training of health professionals (e.g., psychiatric nurse aides, and community and social workers)
(26). A recent survey found that two-thirds of public sector doctors in the Kingston and St. Andrews
parishes “felt that they were not adequately trained to deal with depression and less than 20% routinely
screened patients with chronic illnesses for depression” (27, p. 1). Many individuals with depression and
anxiety are never diagnosed or treated, and psychosocial support is generally only available in public
sector facilities.1

1
Source: Ministry of Health, Mental Health and Substance Abuse Unit, personal communication, 2017.

5
The Task Force also recommended a concerted health promotion campaign aimed at stigma reduction.
Stigma around mental illness can prevent individuals from accessing services or seeking assistance from
family or friends to help cope with and treat psychological problems (28). In Jamaica, data from a 2006
national survey on mental health indicate stigma around mental health. Of 1,306 people surveyed, 64.9%
said they seek to avoid mentally ill persons, and only 26.7% said that they felt comfortable with mentally
ill persons (29).

Arthur et al. (2010) wrote that Jamaicans tend to organize mental illness into three distinct categories that
correspond closely to medical terminology for mental disorders: considering some people healthy, others
“mentally ill” (e.g., those who suffer from phobias, anxiety, or mild to moderate depression), and others
as “mad” (e.g., schizophrenics, bipolar, major depressive disorder) (30). Similarly, there is a perception
that being treated at a health center constitutes help and the possibility of recovery, whereas treatment
at a formal mental health institution signals that a person is severely, and perhaps permanently, ill (31).

Besides recommending increasing integration of mental health into primary care and reducing stigma, the
Task Force recommended more direct outreach to underserved and nonadherent populations through
expansion of the number of “assertive outreach teams”. These teams provide emergency psychiatric
response, home visits, and direct transportation to health facilities for those with moderate and severe
forms of mental illness, helping to reach those most in need and ensuring they receive treatment.

Funding for mental health services is a significant challenge in Jamaica. Due to resource deficiencies, there
is no organizational structure for community health posts, nor are there posts for social workers or
psychiatrists. Instead, there is overreliance on contract jobs provided through regional authorities, which
results in the defection of highly skilled, qualified personnel to more secure opportunities. Resource
constraints also limit vehicle and bus provision for mental health services.

III. Economic Analysis

The economic analysis evaluates the cost and benefits of selected mhGAP interventions. This section
provides an overview of the methodology used to conduct the economic analysis, a description of the
interventions modeled, and the results.

Overview of Methodology
Step 1. Estimating medical costs. An ingredients-based approach, whereby each resource required for
the intervention is identified and valued, was used to cost the interventions. The total cost of providing
treatment is a function of the resources used to treat patients (e.g., pharmaceutical drugs and
diagnostics), as well as the cost of outpatient visits2 or inpatient stays required as part of the regimen.
Specifically, the quantity of resources used is multiplied by the unit cost of the resource, then by the

2
Outpatient visits may include visits to primary care providers for medication monitoring or psychosocial support (e.g., group or individual
counseling).

6
additional number of patients who receive treatment, to arrive at the total cost of scaling up coverage
rates in the population.

The costs of pharmaceutical drugs were sourced from the Jamaica National Health Fund (32). Based on
the WHO CHOICE methodology, an additional cost, equivalent to 13% of the medicine’s value, is added to
account for the supply chain costs to import and distribute the medications throughout Jamaica (33). The
average costs of an outpatient visit or inpatient stay are derived from the 2010 WHO CHOICE study (34).
Outpatient and inpatient costs are modified—according to mhGAP Costing Tool assumptions—to
estimate the cost of providing specialized mental health services, such as individual or group therapy.

Step 2. Estimating package implementation costs. In addition to the medical costs associated with
treatment, the analysis accounts for program and health system costs that support the delivery of
interventions and their uptake by individuals with mental illness. Within this category the analysis includes
the costs of: 1) training a mental health workforce; 2) operating five “assertive outreach teams” 3 that
provide emergency response, home visits, and transportation to health facilities for mental health
patients; 3) promoting awareness and knowledge of mental health conditions through public education
and a social media campaign, and 4) program management and administration costs for the Ministry of
Health and Wellness’ Mental Health and Substance Abuse Unit (including human resources, supplies and
equipment, and surveys).

The costs of items 1-3 listed above, were adapted from cost and resource-intensity estimates within the
Proposal for Implementation of Recommendations from the Task Force on Mental Health and
Homelessness, and from correspondence with the Ministry of Health and Wellness’ Mental Health and
Substance Abuse Unit. The costs of program management and administration were extrapolated from
assumptions within the WHO mhGAP Costing Tool.

To evaluate the total cost of scaling up interventions, the OneHealth Tool was used. The OneHealth Tool
is a freely available software program produced by the WHO and other United Nations agencies, which
has been used by United Nations agency actors and others to publish analyses of the benefits and financial
return from implementing health interventions (35,36). The OneHealth Tool is customizable, meaning
users can input data that reflect a country’s health services and local costs. The tool also allows users to
define intervention parameters (e.g., drugs prescribed, the number of outpatient and inpatient visits),
their unit cost, the current coverage levels of interventions and the prevalence and incidence rates of
diseases and risk factors.

Step 3. Estimating health gains. The OneHealth Tool was used to calculate the expected health gains from
scaling up treatment for depression, anxiety, and psychosis. To estimate health gains, the OneHealth Tool
calculates the depression, anxiety, and psychosis episodes that would occur in the population without
scaling up any of the clinical interventions identified in the mhGAP-IG (the no scale-up scenario). It then
calculates episodes of depression, anxiety, and psychosis that will occur with a scale-up (the scale-up
scenario). The health gains from the investment case analysis are calculated as the reduction in the

3
The Task Force on Mental Health and Homelessness proposed the establishment of five “assertive outreach teams”.

7
prevalence of mental illness, healthy life years gained,4 and lives saved from scaling up clinical
interventions identified in the mhGAP-IG.

Step 4. Monetization of economic and social value of health gains. In this study, the economic and social
value of health gains from scaling up treatment for depression, anxiety, and psychosis is monetized. The
economic value of health benefits captures improvement in labor force outcomes, while the social value
of health gains captures the monetary value of being alive and healthy to form and maintain relationships,
pursue leisure interests, and make decisions in everyday life. To monetize the social value of health gains
for the depression, anxiety, and psychosis treatment packages, the formula developed by Stenberg and
colleagues is used: healthy life years gained from scaling up treatment interventions × 0.5 × per person
income (36). The approach to calculate the economic value of health gains from scaling up depression and
anxiety interventions was different than the approach used to calculate the economic value of health
gains from scaling up psychosis interventions.

Depression and anxiety. To estimate the economic value of health gains derived from scaling up
treatment for depression and anxiety, the report estimates the discounted value of future
earnings from improved labor outcomes that result from saving lives, missing fewer days at work
(absenteeism), reducing impaired activity while at work (presenteeism), and increased labor
participation (35,37-39).5

Psychosis. Since there is currently no consensus on the impact of psychosis on mortality,

presenteeism, absenteeism, and employment, we estimate the economic value of health gains
solely from healthy life years gained. Approximately 1.1 x GDP per capita can be attributed to the
economic value of an extra healthy life year (40).

The economic benefits and social value of health gains as well as the medical and package implementation
costs are reported as present values in constant Jamaican dollars 2017 and discounted annually at a rate
of 3%.

Step 5. Return on investment. Return on investment (ROI) analysis measures the financial gain from an
investment relative to its costs. An investment is efficient in economic terms if the financial gain from the
investment exceeds the cost of making the investment (ROI>1). This mental health investment case
calculates the ratio of the total benefits (economic and social value of health gains) from scaling up
treatment for depression, anxiety, and psychosis to the costs (medical and package implementation). An
ROI greater than one indicates that the financial gains from scaling up treatment for depression, anxiety,
and psychosis exceed its costs.

4
Reduction in the prevalence of mental illness is derived from remission of mental illness. Healthy life years gained, on the other hand, are
derived from both remission and improved functioning as a result of treatment.
5
Increases in hours worked were obtained from the literature.

8
Interventions Modeled

The analysis modeled three categories or packages of mental health interventions: 1) depression, 2)
anxiety, and 3) psychosis. This subsection overviews the interventions modeled under each package along
with their respective targets and baselines. Where relevant, the increases in coverage levels
recommended by the Jamaica Task Force on Mental Health and Homelessness were taken into account
(27).

Depression and Anxiety

According to the mhGAP-IG, psychosocial interventions are the first-line treatments for depression and
other significant mental health complaints such as anxiety disorders. These treatments can be categorized
as either basic or intensive. Basic psychosocial interventions can be carried out by nonspecialized health
care providers with little extra training, while intensive psychosocial interventions require extensive
training and take time to implement, usually over weeks or months.

Basic psychosocial interventions for depression and anxiety include teaching patients and caregivers
about mental illness, addressing psychosocial stressors, reactivating social networks, designing structured
physical activity programs, and offering regular follow-up. Recommended intensive psychosocial
interventions for anxiety and depression include behavioral activation, relaxation training, problem-
solving treatment, interpersonal therapy, and cognitive behavioral therapy.

For individuals with moderate to severe depression, or anxiety accompanied by depression, initiation of
antidepressant medication may be necessary. The mhGAP-IG recommends selecting an antidepressant
from the national or WHO formulary, such as fluoxetine, a selective serotonin reuptake inhibitor (SSRI),
or amitriptyline, a tricyclic antidepressant (TCA). Patients on antidepressant medication should be
monitored regularly for side effects, adherence, and response. The mhGAP-IG does not recommend
pharmacological treatment for patients with mild depression or patients with anxiety disorders that have
no depressive or other priority symptoms.

For patients with recurrent depressive episodes, therapy continues either on an episodic or a maintenance
basis. Episodic therapy treats acute symptoms as they appear, while maintenance therapy is continued
after the treatment of acute symptoms to reduce the risk of relapse (41).

The mental health investment case models the scaling up of interventions such that coverage is expanded
to reach more patients in need. Table 1 presents current coverages (2018) and target coverages (2033)
for the depression interventions in Jamaica. The estimates on current coverage were provided by Jamaica
Ministry of Health and Wellness officials and represent the percentage of individuals with depression who
are currently receiving each type of treatment. The target coverage goals—for scaling up treatment—over
the next 15 years were also provided by Ministry of Health and Wellness officials.

9
Table 1. Current coverage rates and targets of selected interventions related to depression

Current Coverage Target Coverage

Depression Package
(2018) (2033)
Depression Interventions
Basic psychosocial treatment 15% 50%
Basic psychosocial treatment and antidepressant medication
30% 65%
for first episode moderate-severe cases
Intensive psychosocial treatment and antidepressant
50% 80%
medication for first episode moderate-severe cases
Intensive psychosocial treatment and antidepressant
medication for recurrent moderate-severe cases on an episodic 53% 80%
basis
Intensive psychosocial treatment and antidepressant
medication for recurrent moderate-severe cases on a 55% 80%
maintenance basis

For patients with depression, the mhGAP-IG advocates for differential treatment based on severity of
symptoms. Because multifaceted treatment is recommended for patients with moderate-severe
depression, the study analyzes the five treatment combinations listed in Table 1 for patients with mild
depression, first episode moderate-severe depression, and recurrent moderate-severe depression.

Table 2 presents current coverages (2018) and target coverages (2033) for the anxiety interventions in
Jamaica. The estimates on current coverage were provided by Jamaica Ministry of Health and Wellness
officials and represent the percentage of individuals with anxiety who are currently receiving each type of
treatment. The target coverage goals were also provided by Ministry of Health and Wellness officials.

Table 2. Current coverage rates and targets of selected interventions related to anxiety

Current Coverage Target Coverage

Anxiety Package
(2018) (2033)
Anxiety Interventions
Basic psychosocial treatment for anxiety disorders 11% 50%
Basic psychosocial treatment and antidepressant medication
26% 65%
for anxiety disorders
Intensive psychosocial treatment and antidepressant
46% 80%
medication for anxiety disorders

Because multifaceted treatment is recommended for patients with anxiety usually accompanied by
depression, the study analyzes three treatment combinations for anxiety. These treatments combine
either basic/intensive psychosocial interventions with antidepressant medication for cases accompanied
by depression and use basic psychosocial interventions only for mild cases.

10
Psychosis
The mhGAP-IG recommends both psychosocial interventions and antipsychotic medication for all patients
with psychosis, though pharmacological treatment can eventually be discontinued if symptoms are
controlled or the patient is in remission. Similar to depressive and anxiety disorders, basic psychosocial
interventions for psychosis can be carried out by nonspecialized health care personnel with little extra
training, while intensive psychosocial interventions require advanced training and take time to
implement.

Basic psychosocial interventions for psychosis in the mhGAP-IG are focused on educating patients and
their caregivers about psychosis and its treatment, facilitating rehabilitation into the community, and
requiring regular follow-up. Intensive psychosocial interventions, on the other hand, include all basic
psychosocial interventions plus family therapy and social skills therapy.

Recommended antipsychotic medications include haloperidol, chlorpromazine, and fluphenazine, among

others. It is important to ensure regular follow-up with psychotic patients to assess symptoms, side
effects, adherence to medication, and in some cases for routine laboratory monitoring.

Table 3 presents the current coverages (2018) and target coverages (2033) for the psychosis interventions
in Jamaica. The estimates on current coverage were provided by Jamaica Ministry of Health and Wellness
officials and represent the percentage of individuals with psychosis who are currently receiving treatment.
The target coverage goals were also provided by Ministry of Health and Wellness officials.

Table 3. Current coverage rates and targets of selected interventions related to psychosis

Psychosis Package Current Coverage Target Coverage

(2018) (2033)
Psychosis Interventions
Basic psychosocial treatment and antipsychotic medication; &
70% 90%
Intensive psychosocial treatment and antipsychotic medication

As evidenced by Tables 1-3, coverage rates for individuals with mental disorders are low. Under-resourced
community mental health services, low levels of training among general health practitioners, and stigma
around mental illness may all play a role in low screening, diagnosis, and treatment rates (5).

11
Results
The analysis finds that implementing the intervention packages would result in significant health and
economic benefits which exceed the needed financial investment. This subsection presents the health
benefits, economic benefits, and ROI estimates of scaling up the selected packages of interventions
outlined in the previous section. Overall, the analysis finds that all three packages of interventions
(depression, anxiety, and psychosis) are cost-efficient, since the gains from these investments exceed
their costs over the 15-year period (2019-2033).

Health Benefits
Over 15 years, scaling up treatment for mental illness is expected to improve functioning (or reduce
disability) for depression, anxiety, and psychosis patients and to increase remission rates for patients with
depression and anxiety. For depression and anxiety patients, improvements in functioning and remission
are expected to increase healthy life years by 51,328 and 22,671, respectively; reducing the prevalence of
depression and anxiety cases by 120,259 and 108,968 cases, respectively, by 2033 (15-year period). For
psychosis patients, the cumulative number of healthy life years gained over the 15-year period from
improved functioning alone is 1,884. Table 4 shows results for two key health outcomes: healthy life years
gained and cases averted (reduced prevalence).

Table 4. Estimated health benefits over a 15-year time horizon

Intervention Healthy Life

Cases Averted
Package Years Gained
Depression 51,328 120,259
Anxiety 22,671 108,968
Psychosis 1,884 -

Economic and Social Value of Health Gains

Monetizing the value of the health benefits, to account for both economic and social gains, yields a
present value of J$ 60 billion: J$ 35.8 billion from the depression package, J$ 22.6 billion from the anxiety
package, and J$ 1.6 billion from the psychosis package. The J$ 60 billion in gains can be disaggregated into
economic gains and social gains. The economic gains account for J$ 39 billion: J$ 21.5 billion from the
depression package, J$ 16.4 billion from the anxiety package, and J$ 1.1 billion from the psychosis
package. The social gains account for J$ 21 billion: J$ 14.3 billion from the depression package, J$ 6.2
billion from the anxiety package, and J$ 0.5 billion from the psychosis package. The present value of the
economic and social gains from improved health are shown in Figure 1.

12
 Figure 1. Economic and social value of health gains

40.0 35.8

30.0
22.6
Billion (J$)

21.5
20.0 16.4

10.0
1.1 1.6
0.0
Depression Anxiety Psychosis

Economic gains Economic + social value of health gains

For depression and anxiety, the methodology allows for further disaggregation of the gains from mortality
averted, reduced absenteeism, reduced presenteeism, and restored employment. Of the J$ 58.4 billion
expected from scaling up treatment for depression and anxiety, mortality averted accounts for
J$ 3.1 billion, reduced presenteeism for J$ 15.2 billion, reduced absenteeism for J$ 7.6 billion, restored
employment for J$ 11.9 billion, and the social value of health gains for J$ 20.6 billion. Figure 2 provides a
breakdown of the present value of the total gains from scaled-up treatment of depression and anxiety
interventions. As explained in the methodology section, for psychosis treatment, the economic gains
could not be disaggregated as there is currently no consensus on the impact of psychosis on mortality,
presenteeism, absenteeism, and employment.

Figure 2. Breakdown of total gains from scaled-up depression and anxiety treatment

70.0
20.6 58.4
60.0
50.0
Billion (J$)

40.0 11.9
30.0 7.6
15.2
20.0
10.0
3.1
0.0
Mortality Reduced Reduced Restored Social value of Total*
Averted Presenteeism Absenteeism Employment health gains

* Total is the sum of economic productivity gains and the social value of health gains from scaled-up depression and anxiety treatment. The
results from psychosis (J$ 1.1 billion economic gains & J$ 0.5 billion in social value) are not added to the graph. The total would then be J$ 60
billion.

13
Return on Investment
Comparing the costs and benefits of each intervention package, the analysis finds that scaling up
treatment for all three intervention packages—1) depression, 2) anxiety, and 3) psychosis—delivers an
ROI higher than one, not just over the 15-year analytic period (2019-2033), but also in the very first year
of implementation (2019), with the ROI continuing to increase steadily every year thereafter. Figure 3
illustrates the cumulative ROI over the 15-year period; at the 5-year mark, the ROI of the combined three
packages is 2.4, and it grows to 4.2 by the 15-year mark, meaning that for every J$ 1 invested in the mental
health intervention packages analyzed, Jamaica can expect to see J$ 4.2 in economic and social returns.

Figure 3. ROI in mental illness intervention packages by year over 15 years

ROI
5.0 4.2
3.9 4.1
3.6 3.8
4.0 3.3 3.4
2.9 3.1
3.0 2.4 2.7
1.9 2.2
2.0 1.6
1.1
1.0
0.0
2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Figure 4 illustrates the cumulative value over the 15-year period of the two components that make up the
ROI calculation: 1) the benefits of implementing the mental health intervention packages described above
(blue line), and 2) the medical and implementation costs of the same packages (orange line). In 2033, total
benefits from the combined three intervention packages are J$ 60 billion while the investment costs are
J$ 14.2 billion. The figure shows that the combined policy packages are productive investments in the
short-run but deliver even higher returns in the long-run as the gap between total benefits (economic and
social) and costs (medical and implementation) increases over time.

Figure 4. Cumulative benefits and cost of all mental illness intervention packages over 15 years

70.0
60.0
60.0
50.0
40.0
Billion (J$)

30.0
20.0 14.2
10.0
0.0
2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
Years
Cumulative Benefits Cumulative costs

14
Comparing the costs and benefits of the three intervention packages, the analysis finds that in the first
five years, the depression treatment package has the highest social and economic benefits (J$ 3.90 billion;
ROI of 3.97), followed by anxiety (J$ 1.49 billion; ROI of 3.35) and psychosis (J$ 0.22 billion; ROI of 0.90).

Over the 15-year period, the depression treatment package continues to have the highest social and
economic benefits (J$ 35.8 billion), followed by anxiety (J$ 22.6 billion), and psychosis (J$ 1.6 billion).
Comparing total benefits (economic and social) to the costs (medical and implementation) at year 15,
anxiety interventions deliver the highest ROI: for every J$ 1 invested in clinical treatment for anxiety,
Jamaica can expect to see J$ 5.5 in return. The depression treatment package has the next highest 15-
year ROI (5.2), followed by the psychosis treatment package (1.1). Table 5 summarizes the benefits, costs
and ROI of the three packages.

Table 5. Benefits, costs, and ROI of the mental illness intervention packages

5 Years of Implementation 15 Years of Implementation

Total Social Total Social
and and
Packages Total Costs Total Costs
Economic 5-year ROI Economic 15-year ROI
(J$ billion) (J$ billion)
Benefits Benefits
(J$ billion) (J$ billion)
Depression 3.90 0.98 3.97 35.8 6.9 5.2
Anxiety 1.49 0.45 3.35 22.6 4.1 5.5
Psychosis 0.22 0.24 0.90 1.6 1.5 1.1
All packages 5.60 2.29* 2.4 60.0 14.2* 4.2

* The cost of “all packages” is not the sum of the costs of the depression, anxiety, and psychosis packages. In addition to medical costs, the
package accounts for the cost to 1) train mental health professionals; 2) operate five mobile “outreach teams” that provide emergency response
and transportation to health facilities, and conduct home visits; 3) promote awareness and knowledge of mental health conditions through public
education and a social media campaign, and; 4) provide for program management and administration costs of the Ministry of Health and Wellness’
Mental Health and Substance Abuse Unit (including human resources, supplies and equipment, and surveys)—additional costs 5 years: J$ 0.62
billion; 15 years: J$ 1.7 billion. These additional program and health system costs support the delivery of the interventions and their uptake by
individuals with mental illness. However, the additional social and economic benefits derived from these 4 supplemental non-medical costs were
not assessed. Therefore, the ROI estimates for “all packages” at 5 years and 15 years are conservative.

15
IV. Discussion
In Jamaica, mental health conditions are highly prevalent and major contributors to morbidity, disability,
and premature mortality. Currently, access to mental health services in Jamaica is low, with insufficient
resources allocated to scale up treatment. Without an enhanced national response, the health and
economic burden of mental health conditions in Jamaica will become more severe and costlier for society.

Fortunately, proven interventions exist to reduce the burden of mental health conditions. The results from
this analysis estimate an ROI greater than one from implementing selected psychosocial and
pharmacological interventions related to depression, anxiety, and psychosis. These results show that
Jamaica can significantly reduce the burden of mental illness and improve the quality of life of its citizens
by investing in interventions designed to improve mental health. Encouragingly, Jamaica is favorable to
strengthening the response to mental health conditions and mental health is gaining ground on the public
agenda. In addition to implementing the interventions modeled in this report, opportunities to further
strengthen national mental health in Jamaica include:

1. Accelerating momentum to transition from a hospital focus to a community-based response.

Community-based mental health services should be comprehensive and include psychosocial
rehabilitation, allowing for early detection and social reintegration of persons with mental
disorders. The integration of a mental health component into primary health care and the shift to
a community-based response is a crucial strategy for alleviating the existing mental disorder
treatment gap. Besides building capacity among health professionals, the shift also involves
ensuring the availability of essential psychotropic drugs in community outpatient services and in
primary health care.

2. Identifying and addressing common barriers to the improvement of mental health services.
Barriers include social stigma towards persons affected by mental health, misperceptions that
care is not cost-effective and that only persons with psychosis should be seen by mental health
providers, low numbers and limited categories of health workers trained and supervised in mental
health care, and poor investment. The investment case counters misperceptions around the cost-
effectiveness of mental health interventions, delivering a strong ROI even while including
additional costs to train mental health professionals, operate mobile outreach teams, and
promote mental health awareness and knowledge.

3. Encouraging a multisectoral response to mental health. An approach that supports individuals at

different stages of the life course is required. Integration of a mental health component should
be available in settings other than hospitals and primary care, such as school health clinics,
workplaces and within the criminal justice system. Mainstreaming the discourse and response
among sectors beyond health, such as education, labor, justice, transport, environment, housing
and social welfare, can deliver win-wins for health and sustainable development while reducing
the social stigma associated with mental health conditions and with seeking mental health
services.

16
4. Reorienting mental health services. This includes rethinking the focus of primary care with
emphasis on management of common mental disorders and improvement of referral and back
referral mechanisms. It requires defining a unique model of collaboration between mental health
and primary care: a collaborative model (secondary care assisting primary care) or an integrated
model (mental health specialist integrating primary care); promoting supervision of primary care.

5. Improving the management of mental disorders with the aim of decreasing morbidity and
premature mortality. This also requires proper coordination of mental health services and the
need for transitional funding to shift to community-based services.

6. Leveraging investment case findings to show that action to improve mental health supports
Jamaica’s “5 in 4” economic growth plan. The results of the study show that interventions
targeting depression, anxiety, and psychosis have positive returns and support the economic
growth plan by alleviating the financial and human toll. With an ROI greater than 1 reached in the
very first year of implementation (2019) and steadily increasing ROI over the ensuing years, the
mental health interventions deliver immediate economic gains to Jamaica which only escalate
over time. Addressing mental health would not only support GDP growth but also improve general
well-being and related endeavors, including moving towards universal health coverage and
ensuring the right to health.

17
References
1. Haro JM, Novick D, Bertsch J, Karagianis J, Dossenbach M, Jones PB. Cross-national clinical and functional
remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. British Journal
of Psychiatry 2011 Sep;199(3):194-201.
2. Woo JM, Kim W, Hwang TY, Frick KD, Choi BH, Seo YJ, et al. Impact of depression on work productivity and
its improvement after outpatient treatment with antidepressants. Value in Health 2011 Jun 1;14(4):475-
482.
3. Bloom DE, Chen S, McGovern ME. The economic burden of noncommunicable diseases and mental health
conditions: results for Costa Rica, Jamaica, and Peru. Revista Panamericana de Salud Pública 2018;42:e18.
4. Jones R. Mental emergency! - more than 107,000 Jamaicans treated for psychological issues last year
[website]. The Gleaner 2016 May 22; http://jamaica-gleaner.com/article/lead-stories/20160522/mental-
emergency-more-107000-jamaicans-treated-psychological-issues.
5. Task Force on Mental Health and Homelessness. Report; Mental Health and Homeless Task Force.
Kingston: Ministry of Health; 2017. (Unpublished document).
6. Pan American Health Organization. WHO-AIMS: Report on mental health systems in Latin America and the
Caribbean. Washington, DC: PAHO; 2013.
7. World Health Organization. mhGAP: Mental Health Gap Action Programme: Scaling up care for mental,
neurological, and substance use disorders. Geneva: WHO; 2008.
8. World Health Organization. mhGAP intervention guide for mental, neurological, and substance use
disorders in non-specialized health settings: Mental Health Gap Action Programme (mhGAP). Geneva:
WHO; 2010.
9. World Health Organization. OneHealth Tool [computer program]. Available from
http://www.who.int/choice/onehealthtool.
10. Stenberg K, Chisholm D. Resource needs for addressing noncommunicable disease in low- and middle-
income countries: current and future developments. Global Heart 2012 Mar 1;7(1):53-60.
11. Chisholm D, Burman-Roy S, Fekadu A, Kathree T, Kizza D, Luitel NP, et al. Estimating the cost of
implementing district mental healthcare plans in five low- and middle-income countries: the PRIME study.
British Journal of Psychiatry 2016 Jan;208(s56):s71-78.
12. National Institute of Mental Health. Depression [website] 2016.
https://www.nimh.nih.gov/health/topics/depression/index.shtml.
13. National Institute of Mental Health. Anxiety Disorders [website] 2016.
https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
14. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national
incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries,
1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet
2017;390(10100):1211-1259.
15. Wilks R, Younger N, Tulloch-Reid M, McFarlane S, Francis D. Jamaica health and lifestyle survey 2007-8
[technical report]. Kingston: Tropical Medicine Research Institute, University of the West Indies; 2008 Dec.
16. United Kingdom National Health System. Causes of psychosis [website] 2016.
https://www.nhs.uk/conditions/psychosis/causes/.
17. Hickling FW, Rodgers-Johnson P. The incidence of first contact schizophrenia in Jamaica. British Journal of
Psychiatry 1995 Aug;167(2):193-196.

18
18. Burgess B, Curtis-Downes D, Gibson RC. Education and employment levels among Jamaican patients
newly diagnosed with schizophrenia and bipolar disorder. International Journal of Social Psychiatry 2013
May;59(3):247-253.
19. Youssef FF, Bachew R, Bodie D, Leach R, Morris K, Sherma G. Knowledge and attitudes towards mental
illness among college students: insights into the wider English-speaking Caribbean population.
International Journal of Social Psychiatry 2014 Feb;60(1):47-54.
20. Iballaboh H, De La Haye W. 1675 – Co-occurring substance misuse in clients presenting to a psychiatric
unit in a general hospital in Jamaica. European Psychiatry 2013 Jan 1;28:1. (Conference abstract).
21. Liu NH, Daumit GL, Dua T, Aquila R, Charlson F, Cuijpers P, et al. Excess mortality in persons with severe
mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and
research agendas. World Psychiatry 2017 Feb;16(1):30-40.
22. Alexander G, Bebee CE, Chen KM, Des Vignes RM, Dixon B, Escoffery R, et al. Burden of caregivers of adult
patients with schizophrenia in a predominantly African ancestry population. Quality of Life Research 2016
Feb 1;25(2):393-400.
23. The Jamaica Labour Party. Manifesto 2016: Partnership for Prosperity [website]. 2016.
http://jamaica-elections.com/general/2016/JLP-Manifesto/
24. Bryan C. Some Recommendations of Mental Health Task Force to Be Implemented This Year [website].
Jamaica Information Service 2018 April 4, https://jis.gov.jm/some-recommendations-of-mental-health-
task-force-to-be-implemented-this-year/
25. Clarke P. Destigmatise mental health in Jamaica - Tufton [website]. The Gleaner 2018 October 11,
http://jamaica-gleaner.com/article/lead-stories/20181011/destigmatise-mental-health-jamaica-tufton
26. Task Force on Mental Health and Homelessness. Proposal for implementation of recommendations from
the Task Force on Mental Health and Homelessness. Kingston: Ministry of Health; 2017. (Unpublished
document).
27. Gibson RC, Walcott G. Are primary care physicians equipped to help persons with depression? An
exploration of knowledge, attitudes and practices in Kingston, Jamaica. West Indian Medical Journal 2016
Jun 30; doi: 10.7727/wimj.2016.189.
28. Conner KO, Copeland VC, Grote NK, Koeske G, Rosen D, Reynolds III CF, et al. Mental health treatment
seeking among older adults with depression: the impact of stigma and race. American Journal of Geriatric
Psychiatry 2010 Jun 1;18(6):531-543.
29. Gibson RC, Abel WD, White S, Hickling FW. Internalizing stigma associated with mental illness: findings
from a general population survey in Jamaica. Revista Panamericana de Salud Pública 2008;23:26-33.
30. Arthur CM, Hickling FW, Robertson-Hickling H, Haynes-Robinson T, Abel W, Whitley R. “Mad, sick, head
nuh good”: mental illness stigma in Jamaican communities. Transcultural Psychiatry 2010 Apr;47(2):252-
275.
31. Hickling FW, Robertson-Hickling H, Paisley V. Deinstitutionalization and attitudes toward mental illness in
Jamaica: a qualitative study. Revista Panamericana de Salud Pública 2011;29(3):169-176.
32. Jamaica National Health Fund Pharmaceutical Division. Price list [Excel spreadsheet] November 2017;
http://www.nhf.org.jm/.
33. Bertram MY, Stenberg K, Brindley C, Li J, Serje J, Watts R, et al. Disease control programme support costs:
an update of WHO-CHOICE methodology, price databases and quantity assumptions. Cost Effectiveness
and Resource Allocation 2017 Dec;15(1):21.
34. World Health Organization. WHO-CHOICE unit cost estimates for service delivery - Estimation file [Excel
spreadsheet] 2010. Available from: http://www.who.int/choice/country/country_specific/en/.

19
35. Chisholm D, Sweeny K, Sheehan P, Rasmussen B, Smit F, Cuijpers P, et al. Scaling-up treatment of
depression and anxiety: a global return on investment analysis. The Lancet Psychiatry 2016 May
1;3(5):415-424.
36. Stenberg K, Sweeny K, Axelson H, Temmerman M, Sheehan P. Returns on Investment in the Continuum of
Care for Reproductive, Maternal, Newborn, and Child Health. In: Black RE, Laxminarayan R, Temmerman
M, Walker N. Disease Control Priorities, Third Edition (Volume 2): Reproductive, Maternal, Newborn, and
Child Health. Washington, DC: The World Bank; 2016:299-317.
37. Holden L, Scuffham PA, Hilton MF, Ware RS, Vecchio N, Whiteford HA. Which health conditions impact on
productivity in working Australians? Journal of Occupational and Environmental Medicine 2011 Mar
1;53(3):253-257.
38. Wang PS, Beck A, Berglund P, Leutzinger JA, Pronk N, Richling D, et al. Chronic medical conditions and
work performance in the health and work performance questionnaire calibration surveys. Journal of
Occupational and Environmental Medicine 2003 Dec 1;45(12):1303-1311.
39. Anesetti-Rothermel A, Sambamoorthi U. Physical and mental illness burden: disability days among
working adults. Population Health Management 2011 Oct 1;14(5):223-230.
40. Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, et al. Advancing social
and economic development by investing in women's and children's health: a new Global Investment
Framework. Lancet 2014 Apr 12;383(9925):1333-1354.
41. Gelenberg AJ, Kocsis JH, McCullough Jr JP, Ninan PT, Thase ME. The state of knowledge of chronic
depression. Primary Care Companion to the Journal of Clinical Psychiatry 2006;8(2):60-65.

20
21