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42 The APA Publishing Textbook of Mood Disorders, Second Edition
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individuals suffered from mood disorders, costing €113 billion in purchasing power
parity—a measure designed to allow for price comparisons across countries (Gustavs
son et al. 2011). In this study, mood disorders were estimated to be the costliest of
brain disorders, due mainly to indirect costs from individuals being unable to work.
The true economic costs of mood disorders to society are almost certainly larger
than those suggested in the paragraph above, because these estimates do not capture
the potentially devastating long-term consequences of mood disorders on educa
tional and occupational attainments (Breslau et al. 2013; Kessler et al. 1995). Current
cost-of-illness studies are also predicated on assigning a value to life that is limited to
the person’s productive contribution to society (i.e., a human capital model). In addi
tion to not accounting for non-monetary costs, such as pain, suffering, and decrements
in quality of life, such models place no value on the contributions of individuals not
employed in the labor market, such as children, those engaged primarily in non-wage
household work, and elderly retirees.
Taken together, these results point to three broad factors accounting for the high
estimated costs of mood disorders from a societal perspective. The first is that mood
disorders are among the most commonly occurring chronic diseases in the population, with a much earlier age at onset than the chronic physical disorders that have
relatively comparable prevalence and individual-level effects (Kessler et al. 2007c).
The second set of factors accounting for the high estimated costs of mood disorders
from a societal perspective is that these disorders have powerful negative impacts on
work performance (Alonso et al. 2011; Kessler et al. 2006a, 2006b). As mentioned in
the preceding section on comparative impairments, both MDD and bipolar disorder
are associated with substantial numbers of days out of role each year (Alonso et al.
2011). MDD in particular was associated in the WMH surveys with by far the highest
population attributable risk proportion of days out of role among all mental and sub
stance use disorders (Kessler et al. 2006a). In addition, MDD and bipolar disorder
were associated in these surveys, as well as in other studies, with the highest numbers
of days across conditions in which the respondent was at work but performing poorly
(Stewart et al. 2003). Other research additionally has shown that unemployment and
disability are predicted by prior mood disorders (Birnbaum et al. 2010).
The third set of factors accounting for the high estimated costs of mood disorders
from a societal perspective is related to the fact that few people with mood disorders
receive adequate treatment despite the availability of effective treatments that could
otherwise lead to improved clinical and work outcomes. A WMH survey with more
than 50,000 participants across 21 countries found that only a minority of individuals
with MDD receive adequate treatment (Thornicroft et al. 2017). The majority (71%) of
individuals who reported that they felt they needed treatment made at least one visit
to some type of service provider. However, only 41% of these individuals received
treatment consistent with established treatment guidelines. The reasons that such a
large proportion of individuals with mental disorders receive inadequate care may be
related to high dropout from mental health care treatment (Fernández et al. 2020).
There is also evidence that bipolar disorder is often unrecognized and inadequately treated (Keck et al. 2008). Individuals with bipolar disorder are more likely to
present to treatment for depressive symptoms than for mania/hypomania, and therefore they are often inaccurately diagnosed with and treated for unipolar depression
(Keck et al. 2008). The WMH surveys found that a substantial proportion of people
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43 Epidemiology and Burden of Mood Disorders
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with bipolar spectrum disorders do not receive treatment for these disorders (Merikangas et al. 2011). The proportion of respondents who reported treatment was higher
in high-income countries (50% for lifetime and 28% for 12-month prevalence) than in
middle-income countries (33% for lifetime and 15% for 12-month prevalence) and lowincome countries (25% for lifetime and 13% for 12-month prevalence). Most individuals who received treatment used mental health specialty sectors. Individuals with bipolar I disorder and bipolar II disorder had greater odds of reporting treatment
compared with individuals with subthreshold bipolar disorders.
Addressing the Burdens
Preventive interventions and best-practice treatments could reduce the burdens of
mood disorders. Prevention is an underdeveloped area that requires improved meth
ods of early detection and interventions (Malhi et al. 2018). Increased use of best-practice treatments, in comparison, is possible but would require new investments and, to
be cost-effective, changes in the organization of treatment to implement an evidencebased stepped-care approach (Murray 2019; Parikh 2014; van Straten et al. 2015). The
decision to implement such an approach will require an increased understanding of
the costs to society as well as to institutional payers (most notably, employers) of un
treated and undertreated mood disorders (Chisholm et al. 2016), an understanding
that will be necessary to motivate payers to carry out rigorous large-scale demonstra
tion projects that evaluate the return on investment of best-practice treatment systems
(Levin and Chisholm 2016). Initial efforts along these lines are promising (Clark 2018)
but require expansion and refinement.
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