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Table of Contents
Year : 2023  |  Volume : 5  |  Issue : 1  |  Page : 15-20

The Onslaught of Civilization and Emerging Mental Health Issues

Hon Fellow Amer College of Psychiatrists; Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission09-Mar-2023
Date of Acceptance09-Mar-2023
Date of Web Publication26-Apr-2023

Correspondence Address:
Prof. Savita Malhotra
# 425, Sector 37 A, Chandigarh - 160 036
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_8_23

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Civilization evolved through 1000 of years as epicenters in several parts of the world and has now become a global civilization. The main pursuits have been for better survival, increased longevity, societal development, peaceful living, and individual development among others. It is also known that the evolution of civilization goes parallel with evolution of brain through continuous processes of adaptation and reorganization of brain functions by gene–environment interactions and epigenetic processes. Thus, civilization has a major impact on brain development and mental health. Current civilization in many ways has come in conflict with the biological objective of survival of the human species. There is value on economic growth and productivity, control and conquering of nature with devastating consequences. Socioeconomic disparities, poverty, inequity in resource distribution and social power, fragmentation of family and communities, individualistic materialistic outlook, lack of psychological anchoring, mindless globalization, climate crisis, and so on are some of the facets that have unleashed a spate of new mental health challenges across the globe. Researches on social determinants of mental illness have shown significant risk factors emanating from one common factor that is civilization. Mental illness is not individually produced and therefore cannot be tackled in silos. It will require whole society's response and systemic approaches beyond the domain of health alone. There is a need to pursue pro-mental health policies at the global societal level to rein in the ever-expanding pool of mentally unwell population.

Keywords: Civilization, emerging, issues, mental health

How to cite this article:
Malhotra S. The Onslaught of Civilization and Emerging Mental Health Issues. World Soc Psychiatry 2023;5:15-20

How to cite this URL:
Malhotra S. The Onslaught of Civilization and Emerging Mental Health Issues. World Soc Psychiatry [serial online] 2023 [cited 2023 Jun 10];5:15-20. Available from: https://www.worldsocpsychiatry.org/text.asp?2023/5/1/15/374626

  Introduction Top

I am deeply honored and humbled at being chosen for the Yves Pelicier Prize 2022, more so because of the stature of some of the earlier recipients of this award who were none other than Prof Norman Sartorius and Prof Julian Leff, whose research and works I have grown up reading since my early years in psychiatry. It makes me nervous but also proud that Indian psychiatry has come of age.

I believe this award is not merely a recognition of my individual accomplishments alone, it is for Indian psychiatry as much. India is an enigma, a third-world country with all the related problems and difficulties existing aplenty on the one hand, and a country of great hopes and potential for progress and development in the most advanced fields of science and technology on the other. Living and working in India is a huge challenge and to bring out research achieving international recognition requires several folds greater effort and grit than would be required in any developed/resource-rich country in the world. However, it provides an opportunity to tackle unique problems, survive odds, face challenges, and counter-balance what can be considered Indianism versus globalism.

Professor Yves Pélicier was a renowned French psychiatrist who lived in 1926–1996. He had a distinguished university career, at the de l'Université René Descartes, Paris. He was the founder of the fields of medical psychology and medical ethics at the university in Paris. He was extremely respectful to his patients, a humanist with regard for the personhood in every patient.

The subject I have chosen is “The Onslaught of Civilization and Emerging Mental Health Issues.” Every discussion on public mental health brings to fore this uncomfortable question, a gnawing disquiet about the state of our being and pursuits. Are we headed on the right path as far as the civilizational momentum is concerned?

I wish to build on the thesis that brain and mind incorporate culture and civilization through several neurobiological mechanisms, thus influencing mental health in a significant way, so much so, that mental health and illness gets nested in civilization itself.

I'd like to start with a quote from Charles E Rosenberg, a medical historian, who delivered the Robert and Maurine Rothschild Distinguished Lecture in the History of Science at Harvard University, April 23, 1998, and spoke on “Pathologies of Progress: The Idea of Civilization as Risk” (Bull. Hist. Med., 1998, 72: 714-730). It was amply demonstrated that civilization has majorly contributed to mental ill health in the humanity. According to Scull,[1] “it (mental illness) remains a fundamental puzzle, a reproach to reason, inescapably part and parcel of civilization itself.”

  Civilization Top

Civilization is commonly defined as nations and peoples that have reached advanced stages in cultural and technological development (Merriam-Webster dictionary). Civilizatioń includes all societies that live according to certain shared cultural norms (e.g., nation states, private property, law enforcement, and monetary medium of exchange) and technological methods (e.g., agriculture, husbandry, industry, and irrigation). The earliest development of civilization as characterized by domestication, agriculture, permanent settlements, and conquest is estimated to begin from 14,000 to 2000 BCE. There were several epicenters in different parts of the world gaining ground that merged and intermixed as the means of transport became available. By about the 16th–20th century, it turned into a global civilization.

At the macro level of society, civilization denotes societal development, advanced technology, division of labor, hierarchical organization, and globalization. At the social level, it includes matters such as taboo on cannibalism or incest, respect for human rights, peacefulness, and flourishing of arts and science. At micro level of individual, civilization denotes decency, control of emotions, observance of code of conduct, intellectual development, and refined taste.

  Culture and Psyche Top

Culture is part of civilization and culture has close links with psyche. Culture gets incorporated in the brain and mind through the processes of acculturation and assimilation. It gets hard wired in the brain and the person is indentured for life. Culture incorporates social mores, ethics, values, social norms, and practices. Neki[2] has said that psychodynamics are nothing but ethno-dynamics lived at the individual level. Parenting practices are an important component of culture. Parenting transmits culture through generations.

  Pre Civilization Top

For hundreds of thousands of years, humans, like other animals, lived simple life, in accordance with the rhythms of the planet. Then, the man tried to conquer nature as there were many great challenges in living so directly with nature. Over a period of time, the environment in which the man lived, began to change and his adaptive capacities were challenged. As we evolved, our internal systems (brain and nervous system) adapted to enhance our chances for survival. The human organism is constantly adapting itself to its environment, and new systems grow and develop while others are replaced and modified. It greatly impacted the health of human beings. In ancient hunter-gatherer society, humans lived short but fairly healthy. In agrarian revolution, longevity increased, but health went down. In industrial phase of development, longevity has continued to go high along with increase in per capita income/consumption, higher levels of education, industrialization, urbanization, and globalization. It has increased longevity, but there are variable gains in the health status and quality of life.

The evolution of mind and civilization has proceeded hand in hand for millennia. Evolution of the mind and brain is to be understood through the study of phylogeny and ontogeny.

Environment for human beings has changed over time. There is a constant interplay of biological and environmental factors leading to series of adaptations which serve the needs for survival, contributing to evolutionary changes in the structure and functions of the brain and gaining of new functions and capacities.

  Brain Development Top

Development of brain is driven by two interacting processes:

  1. Evolutionary past through organizations and functioning of nervous system with its own developmental timetable
  2. Shaping of neural architecture within the context of environment.

Brain incorporates not only the lived experience but also evolution. Brain is trying to adapt to the physical and the sociocultural environment through ages. From being the hunter-gatherer, man started to live in a civilized society, needing very different kinds of survival skills that impact the structure as well as functions of the brain. Learning of language, reading and writing and cognitive skills requires specific neural structures and connections in a stimulatory environment in early childhood. Experience wires the brain through learning, a process that influences gene expression and strength of synaptic connections, through the process of epigenesis. Thus, experience translates into neurobiology and nature and nurture become one. Over a period of time, this leads to biological evolution and cultural evolution. Cultural evolution is stronger and faster. Biological evolution and human civilization are concomitant developmental processes, and have both similar functions of adaptation and survival.

There is a reciprocal relationship between the mental functions and civilization. Civilization leads to the development of newer capacities of mind, and the development of new capacities of mind makes possible the development of new tools, language, agriculture, towns, cities, religion, trade, transportation, communication, government, law, money, literature and the arts, education, nation states, and scientific and technological research.

In current times, biological evolution and cultural evolution have come in conflict with each other. Humanity is caught in a conflict. There is a poor fit between modern life and evolutionary objective of self-preservation.

  Civilization is a Boon Top

Civilization symbolizes progress and development. It has improved life, health, and longevity; made life more comfortable and efficient; has empowered humanity; and has accorded mastery/control over natural forces, environment and biology, and created systems, products, and amenities. Advancements in science and technology have a huge impact on all aspects of human life. There is an effort to develop a truly global civilization on the foundations of science and technology.

  Civilization: The Bane Top

Civilization is also a bane. Current civilization is focused more on: (a) economic growth and productivity and (b) control of and conquering nature, with devastating consequences. This has led to rising economic insecurity, political turmoil, social unrest, and environmental instability. In spite of ever-increasing knowledge, our sense of insecurity and uncertainty is increasing. Our economic system leaves billions in poverty and widening inequalities. Our mechanical inventions displace, alienate, and dehumanize us. Future course of our evolution is far more uncertain than it was ever before.

At the individual level, man has become materialistic and individualistic in outlook; faith in spiritualism and religion is eroded leading to lack of anchoring in times of distress; family ties and relationships have become fragile; and sense of boredom and inner restlessness, dissatisfaction has become rampant.

Modern economic theory has become an impediment to well-being. Globally dominant policies are driven by market forces at the expense of social environmental and personal well-being. Consumerism and materialism is increasing at the expense of social relations and leisure time. There is a widening gap between the rich and the poor (United Nations Development Program 2005). Most systems that are socially rewarding are built on exploitation, domination, and atrocity. Modern economic theory is an obstacle for health promotion.

Humanity has a tremendous amount of social power in various fields such as power to interact, communicate, educate, exchange, produce, discover, invent, prolong life, entertain, and enjoy. There is inequity in social power. Distribution is uneven, inequitable. Even though there is a sufficient amount of food, clothing, and health care, billions are still struggling for survival. Existing social institutions and policies breed inequity.

There is a culture of capitalism. Everyone clamors for pleasure and possessions leading to a struggle for social status and recognition. Those who remain at the lower rung of the society experience shame and humiliation.

There is a flaw in thinking. Human beings are thought of or treated on the parameters of mathematical and statistical modeling, which is inappropriate for making sense of the complexities involved in dealing with human beings.

Norman Sartorius in his award paper on “Fighting Stigma 2020: Synopsis of the presentation of the Yves Pelicier Prize Lecture at the World Congress of Social Psychiatry, Bucharest, October 2019[3] wrote about “social changes which are characterizing modern times and will probably also continue to shape future of humankind. Among them is the disappearance of the classical family with its obligation of mutual help among members; the waning of the communities (protecting and supporting its members) in the process of rapid urbanization; the replacement of previously important pathways to recognition and fame – such as those of scholarly authority, noble descent, and personal courage – by the single criterion of wealth and capacity to augment it; and what has been called “decivilization” the tendency of governments to cease their support of the societies' feeble and vulnerable members such as the elderly, the disabled, and others whom a civilized society keeps alive and in good hands.

  The Onslaught of Civilization Top

In order to fit into this civilized society, the individual becomes subservient to the social system. Individuals are conditioned from birth not to reveal their underlying distress, and instead find ways to adapt to the familial and cultural norms. People are required to learn to master the art of meeting external demands, thereby forming the socially adjusted roles they are commanded to assume. They may look apparently calm, yet underneath this calmness, there is brewing, simmering, seething, distress, anger, and aggression that is dangerous to the society. This process of development can proceed in an optimal fashion when the environment we are raised in is safe, nurturing, predictable, repetitive, gradual, and attuned to the infant or child's developmental state. When the environment is chaotic, extreme, or mismatched to developmental stage, development is disrupted.[4] Accordingly, the potential for our evolution is greatly compromised when our basic needs are unmet, and instead, we are faced with overwhelming, abusive, or misattuned environments.

There is ample evidence to show that our environment, the world over, has become unsafe, chaotic, stressful, and violent, especially for children. Children are unsafe even in their homes. Although there is debate whether the treatment of children has evolved or devolved since precivilized times, there is little doubt that civilization's treatment of its children has a horrific record.[5],[6]

Globalization, urbanization, and technological advancements retreated man further from the “great outdoors” to the gadget-oriented world of televisions, computers, and gaming, and accelerated the pace of ecological disequilibrium on an unprecedented scale[7],[8] Man is an integral and inseparable part of nature and has been emphasized in Indian philosophy from time immemorial. Nature is worshipped and considered sacred in India. Nature is not considered commodity for man's consumption and fulfillment.

Modern civilization is characterized by:

  • Globalization
  • Commercialization
  • Commodification of services, people, and ideas
  • Consumerism
  • Erosion of values
  • Competitiveness
  • Sexual liberalization
  • Human rights movement from protection to perversion
  • Challenging and pushing nature (biology and planet) to extreme
  • Rebellion against social norms and social institutions
  • Kindling of unsustainable aspirations in an environment of insufficient resources.

With advancements in biotechnology, information technology, and nanotechnology, humanity is at the cusp of an enhancement revolution. These interventions help improve on the human capabilities, health status and conquer disabilities. These may take control of the bodies and minds in future, thus fundamentally taking control of our species development leading to what has been called as transhumans. Radically changing human physiology is risky. There is philosophical, ethical, and religious opposition to transhumanism. With these possibilities, future is uncertain.

  Determinants of Mental Health Top

The WHO Report 2022[9] has highlighted what has been considered global threats to mental health today. These include:

  • Economic and social inequalities
  • Public health emergencies (such as COVID-19)
  • Humanitarian emergencies (including conflict and forced displacement)
  • Climate crisis.

Countries with greater income inequalities and social polarization have been found to have a higher prevalence of schizophrenia, depression, anxiety, and substance use.

Poverty, financial problems, social deprivation, and socioeconomic inequality are risk factors for mental health problems and mental disorders, and have been described as the determinants of mental health. Relatively high frequency of common mental disorders is associated with poor education, material disadvantage, and unemployment. Socioeconomic factors in mental health were a subject of research in the early 20th century. Then, there was ascendency of biological research which has also not provided a direction for public mental health. Now again, there is resurgence of interest in socioeconomic determinants of mental health. The poor are hit hardest in any economic crisis. Determinants of mental health are often outside the remit of health systems, and all government sectors have to be involved in promoting mental health.

Environmental contributors to poor mental health include:

  • Poor diet (is the leading cause of illnesses responsible for 26% of preventable deaths).
  • Poor sleeping habits
  • Lack of exercise
  • Excessive use of alcohol, tobacco, and substances
  • Excessive use of the Internet and social media
  • Excessive insecurities, disappointments, failures, stresses, and loss
  • Excessive socioeconomic disparity
  • Overcrowding and poor housing
  • Breakdown of family system.

Most of these stems from one primary cause: Civilization.

Also, although the risks and contradictions of life go on being as socially produced as ever, the duty and necessity of coping with them has been delegated to our individual selves.[10] “The poor will always be with us, but what it means to be poor depends on the kind of 'us' they are 'with'.”[10]

  Civilization at the Root of Psychopathology Top

Toffler and Farrell[11] argued that society is undergoing an enormous structural change, a revolution from an industrial society to a “super-industrial society.” This change overwhelms people. He believed the accelerated rate of technological and social change left people disconnected and suffering from “shattering stress and disorientation” – future shocked. Toffler stated that the majority of social problems are symptoms of future shock. In his discussion of the components of such shock, he popularized the term “information overload.” His analysis of the phenomenon of information overload is continued in his later publications, especially The Third Wave and Powershift.

Society experiences an increasing number of changes with an increasing rapidity, while people are losing the familiarity that old institutions (religion, family, national identity, and profession) once provided.

Freud[12] defines civilization as the whole sum of human achievements and regulations intended to protect men against nature and “adjust their mutual relations.” A “decisive step” toward civilization lies in the replacement of the individual's power by that of the community. This substitution henceforth restricts the possibilities of individual satisfaction in the collective interests of law and order. According to Freud, the first man who hurled an insult or a verbal abuse instead of a stone was the starting point of civilization. Every mind has a war within and without. Superego is a social construction. Intrapsychic struggle of man against expected social behavior to suppress the expression of emotions freely, to comply with social norms or rules, and to accept constraints of reality, is at the root of most psychopathology.

Jung[13] said that modern man has feelings of inadequacy, insignificance, and hopelessness. In remodeling of society on scientific and rational principles, uniqueness of the individual is negated in favor of statistical averages. Redesign of the society is enacted by a group of the elites and technocrats, who view humans as nothing but an abstraction, homogenous social units to be managed and manipulated. “The individual's feeling of weakness, indeed of nonexistence, is compensated by the eruption of hitherto unknown desires for power. It is the revolt of the powerless, the insatiable greed of the have-nots.”

”The goal and meaning of individual life no longer lie in individual development but in the policy of the State, which is thrust upon the individual from outside. The individual is increasingly deprived of the moral decision as to how he should live his own life, and instead is ruled, clothed, fed, educated as a social unit.”

  Emerging Mental Health Challenges Top

Definition of “normalcy” is shrinking and list of mental disorders is expanding. DSM1 (1952) included 128 disorders and DSM 5 (2015) has 541 disorders. Several new disorders such as behavioral addictions are described. There is also a tendency for over-medicalization of everything.

Rates of mental disorders have steadily increased. Overall rates of mental disorders have modestly increased between 1978 and 2015 (odds ratio: 1.179).[14]

There is evidence of an increase in the worldwide prevalence of mental disorders concurrent with urbanization.[15] Burden of mental and substance use disorders increased by 37.6% between 1990 and 2010.[16] Depression, anxiety, substance use disorders, suicide, attention deficit hyperactivity disorder (ADHD), bipolar disorders, and posttraumatic stress disorder have increased. Rates of neurodevelopmental disorders such as specific learning disability (SLD) and persistent depressive disorder have increased.

Prevalence rates are higher in America (15.6%) than Africa (10.9%). Countries with greater income inequalities and social polarization have been found to have a higher prevalence of schizophrenia, depression, anxiety, and substance use.[9],[17]

Looking at the state of mental illness worldwide, it is seen that:

  • Nearly I billion people live with mental illness worldwide
  • 1 in 8 suffer from mental disorder
  • 75% of those with disorders do not receive treatment in low-income countries
  • Nearly 3 million die every year due to substance abuse
  • Every 40 s a person dies by suicide
  • 50% of mental health disorders start before the age of 14.
  • Mental health is the most neglected area of health globally.

There are newer mental health challenges such as:

  • Cyberbullying
  • Sexting
  • Violent video games
  • Self-harm
  • Criminality
  • Abuse, rape, and exploitation
  • Behavioral addictions (the Internet, gaming, sex, gambling, and eating)
  • Torture (domestic violence, prostitution, child labor, slavery, and child pornography).

  Possible Solutions Top

Concerted efforts are being made at the national and global levels to address these political, economic, social, and ecological threats to humanity in the 21st century. Yet these are ineffective and counterproductive. There is rapid globalization without the effective institutions for global governance.

We do not fully understand how the human society grows, develops, and evolves. There is a need for new thinking in human-centeredness in economic theory founded on the values of human welfare and well-being.

Mental health cannot be tackled in a silo. It is embedded in the sociocultural ethos of the society. No one can be healthy in a sick society. Mental health percolates in every sector of the country's economy. It is strongly linked to socioeconomic agenda. According to the WHO, every 1 dollar invested in mental health yields 4 dollars return on investment. Investing in mental health requires a multisectoral and integrated approach, a whole society approach.

The WHO has advanced the agenda that mental health should be at the center of all nonhealth policy areas such as protective employment policies, concern for welfare, labor market regulation, social protection, health and food safety, housing, and access to health care and education.

Mental health is a collective responsibility. Ultimately, mental health, like freedom, culture, and everything else, is not produced individually but by entire civilization. Discussion of mental health should not be limited to those who identify as mentally ill: It concerns all of us.

Although no one knows how to ensure the best or the optimal development of human beings, based on the available knowledge, some of the pro-mental health measures could include:

  • Protection, support, and nurturing of the natural family system
  • Focus on parenting and childcare
  • Value and support for uniqueness of individuals
  • Embark on human-centric policies and plans based on principles of social justice, equity, and protection
  • Redefine parameters of success
  • Restrain mindless globalization.

  Conclusions Top

Despite all the gains of civilization reflected in better survival, more material comforts, conquest of nature, economic progress, scientific and technological advancement; burden of mental illness has not lessened. On the contrary, there is worsening in all indices of mental health with newer challenges confronting the humanity. There are ingredients in civilization that are not conducive to mental health or rather are contributory factors to mental ill health. Mental disorders are a product of civilization. Functioning of brain and mind is inextricably interwoven with experience including the historical past, present, and future. It is essential to underscore such influences and take corrective steps before it is too late and becomes self-destructive. Human beings have the capacity to evolve into higher levels of cognition, awareness, and consciousness, a potential that needs to be protected and harnessed.

Thus, mental health problems as understood today are an inevitable outcome of civilization and hence probably not amenable to our current “band-aid-like” approaches or solutions. There is a dilemma: Do we continue to invest our vital energy into upholding this civilization despite the collateral damage along the way; or, do we face up to the damage we have caused to ourselves and to our planet in such a short period of time, and look for alternative ways to survive and prosper?

It is not an easy dilemma, for everything in our modern lives is geared toward the preservation of civilization, with little regard to the consequences. The push of civilization is very strong and overpowering.

The question is that: Are we trying to cool the boiling pot without dousing the fire underneath; or/rather; are we fueling the fire underneath and simultaneously trying to cool the pot from the top?

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Conflicts of interest

There are no conflicts of interest.

  References Top

Scull A. Madness in civilization: A cultural history of insanity, from the Bible to Freud, from the madhouse to modern medicine. Princeton University Press. NJ, USA. 2015.  Back to cited text no. 1
Neki JS. Psychotherapy in India. In: Kapur M, editor. Psychotherapeutic Processes: Proceedings of a Seminar held at National Institute of Mental Health and Neurosciences in 1978. Bangalore India: A Nimhans Publication; 1979.  Back to cited text no. 2
Sartorius N. Award paper fighting stigma: Synopsis of the presentation of the Yves Pelicier prize lecture at the World Congress of Social Psychiatry, Bucharest, October 2019. World Soc Psychiatry 2020;2:181-3.  Back to cited text no. 3
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Perry BD, Pollard R. Homeostasis, stress, trauma, and adaptation. A neurodevelopmental view of childhood trauma. Child Adolesc Psychiatr Clin N Am 1998;7:33-51, viii.  Back to cited text no. 4
DeMeo J. Saharasia: The 4000 BCE Origins of Child Abuse, Sex-Repression, Warfare and Social Violence in the Deserts of the Old World: The Revolutionary Discovery of a Geographic Basis to Human Behavior. Jung CG: Trench, Germany; Natural Energy Works; 1998.  Back to cited text no. 5
Karr-Morse R, Wiley MS. Ghosts from the Nursery: Tracing the Roots of Violence. New York: The Atlantic Monthly Press; 1998.  Back to cited text no. 6
Chawla L. Benefits of nature contact with children. J Plan Lit 2015;30:433-52.  Back to cited text no. 7
Hartig T, Mitchell R, de Vries S, Frumkin H. Nature and health. Annu Rev Public Health 2014;35:207-28.  Back to cited text no. 8
World Mental Health Report: Transforming Mental Health for All. World Health Organization; 2022.  Back to cited text no. 9
Bauman Z. Liquid Times: Living in an Age of Uncertainty. Polity Press Cambridge UK; 2007. p. 14.  Back to cited text no. 10
Toffler A, Farrell A. Future Shock. Freud S: Austria: Publishing Random House; 1970.  Back to cited text no. 11
Freud S. Civilization and its Discontent. Alvin Toffler: New York, USA: Publishing Internationaler Psychoanalytischer Verlag; 1930.  Back to cited text no. 12
Jung CG. Modern Man in Search of a Soul. DeMeo J, Saharasia : Oregon USA: Publishing Kegan Paul; 1933.  Back to cited text no. 13
Richter D, Wall A, Bruen A, Whittington R. Is the global prevalence rate of adult mental illness increasing? Systematic review and meta-analysis. Acta Psychiatr Scand 2019;140:393-407.  Back to cited text no. 14
Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: A global public-health challenge. Lancet 2007;369:1302-13.  Back to cited text no. 15
Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86.  Back to cited text no. 16
Ferrari AJ, Santomauro DF, Herrera AM, Shadid J. Global, regional and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: A systematic analysis for the global burden of disease study 2019. The Lancet Psychiatry 2022. p. 1-14. DOI:10.1016/S2215-0366(21)00395-3.  Back to cited text no. 17


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