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www.thelancet.com/psychiatry Published online November 1, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30337-7
1
Articles
Lancet Psychiatry 2018
Published Online
November 1, 2018
http://dx.doi.org/10.1016/
S2215-0366(18)30337-7
See Online/Comment
http://dx.doi.org/10.1016/
S2215-0366(18)30390-0
*Collaborators listed at the end
of the Article
Correspondence to:
Prof Louisa Degenhardt,
National Drug and Alcohol
Research Centre, University of
New South Wales, Sydney,
NSW 2052, Australia
l.degenhardt@unsw.edu.au
The global burden of disease attributable to alcohol and drug
use in 195 countries and territories, 1990–2016: a systematic
analysis for the Global Burden of Disease Study 2016
GBD 2016 Alcohol and Drug Use Collaborators*
Summary
Background Alcohol and drug use can have negative consequences on the health, economy, productivity, and social
aspects of communities. We aimed to use data from the Global Burden of Diseases, Injuries, and Risk Factors Study
(GBD) 2016 to calculate global and regional estimates of the prevalence of alcohol, amphetamine, cannabis, cocaine,
and opioid dependence, and to estimate global disease burden attributable to alcohol and drug use between 1990 and
2016, and for 195 countries and territories within 21 regions, and within seven super-regions. We also aimed to
examine the association between disease burden and Socio-demographic Index (SDI) quintiles.
Methods We searched PubMed, EMBASE, and PsycINFO databases for original epidemiological studies on alcohol
and drug use published between Jan 1, 1980, and Sept 7, 2016, without language restrictions, and used DisMod-MR
2.1, a Bayesian meta-regression tool, to estimate population-level prevalence of substance use disorders. We combined
these estimates with disability weights to calculate years of life lived with disability (YLDs), years of life lost (YLLs),
and disability-adjusted life-years (DALYs) for 1990–2016. We also used a comparative assessment approach to estimate
burden attributable to alcohol and drug use as risk factors for other health outcomes.
Findings Globally, alcohol use disorders were the most prevalent of all substance use disorders, with 100·4 million
estimated cases in 2016 (age-standardised prevalence 1320·8 cases per 100 000 people, 95% uncertainty interval [95% UI]
1181·2–1468·0). The most common drug use disorders were cannabis dependence (22·1 million cases; age-standardised
prevalence 289·7 cases per 100 000 people, 95% UI 248·9–339·1) and opioid dependence (26·8 million cases; age-
standardised prevalence 353·0 cases per 100 000 people, 309·9–405·9). Globally, in 2016, 99·2 million DALYs (95% UI
88·3–111·2) and 4·2% of all DALYs (3·7–4·6) were attributable to alcohol use, and 31·8 million DALYs (27·4–36·6) and
1·3% of all DALYs (1·2–1·5) were attributable to drug use as a risk factor. The burden of disease attributable to alcohol
and drug use varied substantially across geographical locations, and much of this burden was due to the eect of
substance use on other health outcomes. Contrasting patterns were observed for the association between total alcohol
and drug-attributable burden and SDI: alcohol-attributable burden was highest in countries with a low SDI and middle-
high middle SDI, whereas the burden due to drugs increased with higher SDI level.
Interpretation Alcohol and drug use are important contributors to global disease burden. Eective interventions
should be scaled up to prevent and reduce substance use disease burden.
Funding Bill & Melinda Gates Foundation and Australian National Health and Medical Research Council.
Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND
4.0 license.
Introduction
Alcohol and other drugs have long been consumed for
recreational purposes.1 So-called illicit drugs are
substances for which extramedical use has been prohibited
under international control systems.2 Illicit drugs include,
but are not limited to, opioids including heroin, morphine,
opium, and other pharmaceutical opioids; cannabis;
amphetamines; and cocaine. Harms can also occur due to
extramedical use of prescription drugs. In this Article, we
will refer to all use of drugs as drug use.
Dependence on illicit and prescription drugs can
develop among people who use them regularly over a
sustained period, and is characterised by a loss of control
over use and increased prominence of use of the
substance in a person’s life. The ICD 10th edition
definition,3 which was broadly similar to the American
Psychiatric Association’s DSM-IV definition,4 requires
that at least three of the following criteria are met: a
strong desire to take the substance; impaired control over
use; a withdrawal syndrome on ceasing or reducing use;
tolerance to the eects of the drug; a disproportionate
amount of time spent by the user obtaining, using, and
recovering from drug use; and continuing to take drugs
despite the problems that occur.
Substance use also carries risks of other adverse health
outcomes. For example, injection of drugs carries risks if
non-sterile injecting equipment is used, because of
potential exposure to HIV and viral hepatitis, other
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infections, and other injection-related injuries and
diseases such as sepsis, thrombosis, and endocarditis.5
Alcohol use increases the risk of unintentional and
intentional injury, and both non-communicable
(eg, cancer, gastrointestinal, and cardiovascular) and
infectious (eg, tuberculosis and pneumonia) diseases.1,6
Use of both alcohol and drugs can cause harm to others.7
Since 1993, estimates of the causes of global disease
burden have used disability-adjusted life-years (DALYs),8
which combines measures of disease burden caused by
premature mortality (years of life lost [YLLs]) and burden
due to disability (years of life lived with disability [YLDs]).
The comparative risk assessment approach developed for
GBD provides a conceptual framework for population risk
assessment of exposures to risk factors and their
attributable health burden;9 alcohol and drugs are included
as risk factors in this approach. Each iteration of GBD has
updated estimates of modelled prevalence of alcohol and
drug use disorders, burden due to those disorders, and
burden attributable to alcohol and drug use. Improved
methods are used in each iteration of GBD, with increased
data coverage, and better strategies to inform the
modelling that occurs in GBD. In this Article, we use data
from the Global Burden of Diseases, Injuries, and Risk
Factors Study (GBD) 2016, to estimate the prevalence of
alcohol and drug use disorders, and to calculate the
burden attributable to alcohol and drug use globally and
for 195 countries and territories within 21 regions and
seven super-regions between 1990 and 2016. We present
global and regional estimates of alcohol, amphetamine,
cannabis, cocaine, and opioid use disorders; report disease
burden attributable to each of these disorders in terms of
YLDs, YLLs, and DALYs; summarise burden due to
alcohol and drug use as risk factors for other health
outcomes; and analyse the association between alcohol-
attributable and drug-attributable burden and Socio-
demographic Index (SDI) quintiles.
Methods
Overview
All GBD 2016 analyses adhered to the Guidelines for
Accurate and Transparent Health Estimates Reporting
Research in context
Evidence before this study
We did a systematic review of PubMed, EMBASE, and PsycINFO
for epidemiological studies of prevalence, incidence, remission,
duration, and excess mortality associated with substance use
and substance dependence published between Jan 1, 1980, and
Sept 7, 2016, without language restrictions. Full search terms
are listed in the appendix. We also searched grey literature, and
supplemented our search through consultation with experts.
Previous Global Burden of Disease (GBD) studies have provided
evidence on overall burden attributable to alcohol and drug use
and more detailed assessment of alcohol and drug use burden,
but with each iteration of GBD, new data and improvements to
methods provides better estimates of this burden. Other
organisations, including WHO and the UN Office on Drugs and
Crime, periodically produce estimates of health consequences
of alcohol and drug use. This GBD study provides the first
detailed peer-reviewed estimates of attributable burden due to
both alcohol and drug use available for all locations between
1990 and 2016, directly contrasting the prevalence and burden
due to these different substances.
Added value of this study
We provide clear comparative analysis of alcohol and drug
epidemiology and attributable burden. The results of this study
show that considerable geographical variation exists with
regard to the magnitude and relative contribution of alcohol
and drug use to disease burden. To the best of our knowledge,
this study is the first to provide estimates of the association
between alcohol and drug attributable burden and
sociodemographic development. Our results show that burden
attributable to alcohol and drug use is strongly associated with
socioeconomic development, and its composition varied across
Socio-demographic Index (SDI) quintiles. Other consequences
of alcohol use were much larger causes of disease burden than
alcohol use disorders, and many of these were much more
common in countries with a lower SDI than those with higher
SDIs. Drug-attributable burden was higher in countries with
higher SDI than those with a lower SDI, and most of this burden
was attributable to drug use disorder, rather than other
consequences of drug use such as HIV/AIDS, acute hepatitis,
liver cancer, cirrhosis and other liver disease due to hepatitis,
or self-harm.
Implications of all the available evidence
Alcohol and drug use cause substantial disease burden globally,
and the composition and extent of this burden varies between
countries and is strongly associated with sociodemographic
development. Since 1990, there has been a considerable increase
in the number of people with alcohol and drug use disorders
globally, driven by population growth and population ageing.
Age-standardised prevalence also increased for opioid, cocaine,
and amphetamine use disorders. The prevalence of substance use
disorders varied substantially by substance and across countries,
with clear differences between different geographical regions.
Alcohol and drug use contribute substantially to the global
burden of disease, not only through substance use disorders but
also from other disease consequences resulting from use. For
example, a high proportion of disease burden attributable to
alcohol was due to other outcomes, including unintentional
injuries and suicide, cancers, and cirrhosis, and the
consequences of chronic hepatitis C infection (ie, cirrhosis,
cancer) make a substantial contribution to the burden
attributable to drug use. Interventions that reduce the
prevalence of these other health outcomes are available and
need to be scaled up, but this scaling remains a challenge even
in high-resource settings.
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3
(GATHER).10 A suite of visualisation tools is available to
explore GBD data inputs and outputs. Full details of the
overall methods used to assess disorder prevalence,11
burden of disorders (YLDs),11 mortality (YLLs),12 overall
substance use disorder burden (DALYs), calculated by the
equation DALYs = YLLs + YLDs,13 and burden attributable
to risk factors, including alcohol and drug use (comparative
risk assessment)14 have been described previously.
Disease burden was quantified by geography, for 23 age
groups (0–6 days to >95 years), both sexes, and six
timepoints between 1990 and 2016. The GBD 2016
geographical hierarchy included 775 total geographies
within 195 countries and territories, within 21 regions
and seven super-regions. Comprehensive methods used
in GBD 2016 for estimating YLDs, YLLs, and DALYs have
been described previously, and the process used to
estimate prevalence-based YLDs, YLLS, and DALYs is
described in the appendix (p 2).
Case definition of substance use disorders
Substance use disorders were defined according to
DSM-IV4 and ICD-10.3 Six substance use disorders were
included: opioid dependence, cocaine dependence,
amphetamine dependence, cannabis depen dence, alcohol
dependence, and fetal alcohol syndrome (a disorder that
aects ospring due to maternal alcohol use during
pregnancy).15 A residual category of other drug use
disorders was also included.
YLLs
Input data on causes of death were obtained from vital
registration, verbal autopsy, and surveillance databases
from 1980 to 2016.16 Normative life tables were generated
using data on the lowest death rates for each age group
within geographies with total populations of more than
5 million. YLLs were then estimated by multiplying
cause-specific deaths at a specific age by the standard life
expectancy at that age obtained from normative life
tables. Full details of all the modelling processes have
been published previously.16
The Cause of Death Ensemble model (CODEm)
strategy was used to model cause of death data by location,
age, sex, and year for each substance use disorder.12 The
CODEm outputs for all GBD causes were then rescaled to
establish estimates consistent with all-cause mortality
levels for each age, sex, year, and location. Deaths coded
as alcohol and drug poisonings were attributed to the
relevant alcohol and drug use disorders.
YLDs
We did systematic reviews of the literature to compile
data on the prevalence, incidence, remission, and excess
mortality associated with each disorder. We searched
PubMed, EMBASE, and PsycINFO databases and grey
literature sources in accordance with the Preferred
Reporting Items for Systematic Reviews (PRISMA)
guidelines.17 For each epidemiological parameter, eligible
estimates were derived from studies published since
1980. Datapoints are summarised for each disorder in
the appendix (p 5) and the data input tools are available
elsewhere.
The epidemiological data obtained from our systematic
literature reviews were modelled in DisMod-MR 2.1,18 a
Bayesian meta-regression tool that pools datapoints from
dierent sources and adjusts for known sources of
variability (eg, dierences in case definitions and sampling
method) to produce internally consistent estimates of
incidence, prevalence, remission, and excess mortality
(appendix pp 6–31). Estimates are generated for locations
where raw data are unavailable using the modelled output
from surrounding regions. According to the GBD
protocol, an uncertain estimate is preferable to no
estimate, even when data are sparse or not available,
because no estimate would result in no health loss
from that condition in the location being estimated.
DisMod-MR 2.1 also uses both study-level and location-level
covariates to better inform the epidemio logical models.
Study-level covariates adjust suboptimal data toward those
considered to be the gold standard (eg, adjusting data
from population surveys of opioid dependence toward
estimates from so-called indirect estimates of opioid
dependence, which were preferred), whereas location-
level covariates help DisMod-MR 2.1 better predict
disorder distribution. DisMod-MR 2.1 analyses ran in a
sequence of estimations at each level of the GBD
geographic hierarchy (global, super-region, region,
country, and if applicable, subnational locations) with
consistency imposed between estimates at each level.
Although our inclusion criteria ensured minimum
study quality, considerable variability was identified
between studies that reflected the use of dierent
methods and analyses.19 Data availability varied across
disorders and regions (appendix p 5). Uncertainty in
both the epidemiological data and in modelling was
propagated to the final prevalence output used to
calculate YLDs in addition to the uncertainty from fixed
eects and random eects for country and regions.18
Disability weights
We used disability weights to quantify the severity of the
health loss associated with a particular disease or injury,
and disability weights for each injury or disease were
applied to the prevalence of that condition.
In this study, we used disability weights generated by
the general public, on the basis of the argument that
their views are relevant in comparative assessments that
inform public policy.20,21
In GBD 2016, disability weights were obtained from
population surveys in various dierent countries
(Bangladesh, Indonesia, Peru, Tanzania, USA, Hungary,
Italy, Sweden, and the Netherlands) and from an
open-access survey available in multiple languages in
which lay participants were presented with pairs of
short non-clinical descriptions of the health states of
For more on visualisation tools
see http://www.healthdata.org/
gbd
For more on data input tools
see http://ghdx.healthdata.org/
gbd-2016/data-input-sources
and https://vizhub.healthdata.
org/epi/
See Online for appendix
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two hypothetical individuals and asked to rate which they
considered healthier.20,22 Participant responses were
scored on a scale ranging from 0 to 1 (0=no loss of health;
1=loss equivalent to death) using a series of questions
comparing the benefits of lifesaving and disease-
prevention programmes for a number of health states.
The pair-wise comparisons showed the relative position
of health states to each other, and this additional step in
the analysis was necessary to anchor those relative
positions as values on a 0 to 1 scale. Disability weights
were generated for all sequelae of diseases and injuries
included in GBD. Further details regarding the
calculation of disability weights have been published
previously.20,22 Each country-specific, age-specific, sex-
specific, and year-specific prevalence derived by
DisMod-MR 2.1 was multiplied by a disorder-specific
disability weight to estimate YLDs.
For each substance use disorder, we estimated the
proportion of cases that were asymptomatic using data
from the US National Epidemiological Survey on Alcohol
and Related Conditions (NESARC) for the time periods
2000–01 and 2004–05,23 and the Australian Comorbidity
and Trauma Study (CATS) for opioid dependence
(2005–08).24,25 These proportions were used to calculate a
mean disability weight for each disorder across the
dierent levels of severity in which asymptomatic cases
were assigned a disability weight of 0. For all substance
use disorders in GBD 2016, we removed the proportion
of diagnosed individuals who reported no additional
disability at the time of the survey. The remaining pro-
portion of individuals represented so-called asymptomatic
cases (ie, people with substance use disorders who
experienced no disability due to their disorder).11
Comorbidity
The burden due to each cause in the GBD study was
estimated separately. Since individuals might have more
than one disease or injury at a specific timepoint, a
simulation method was used to adjust for presence of
comorbidity. The co-occurrence of dierent diseases and
injuries was estimated by simulating populations of
40 000 individuals in each GBD location stratified by
age, sex, and year. Hypothetical individuals within each
population were exposed to the independent probability of
having any combination of sequelae included in GBD 2016.
The probability of being exposed to a sequela corresponded
to its prevalence in the population. A combined disability
weight to account for individuals with more than one
condition was calculated by combining the disability
weights, with the health loss associated with two disability
weights multiplied together and then a weighted average
of each constituent disability weight was calculated. The
so-called GBD comorbidity correction was the dierence
between the average disability weight estimated for
individuals with one sequela and the combined disability
weight estimated for those with multiple sequelae. The
average comorbidity correction estimated for each sequela
was applied to the respective location-specific, age-specific,
sex-specific, and year-specific YLDs. Although the prob-
ability of two sequelae co-occurring might be dependent,
insucient data were available to confidently estimate all
dependent probabilities by age and sex in the GBD study.
Thus, all probabilities of comorbidity were modelled as
independent.
DALYs
We estimated burden by aggregating substance-use-
disorder-specific epidemiological data and disability
weights to calculate prevalent YLDs; multiplying
substance-use-disorder-specific estimates of mortality by
standard life expectancy at the age of death to calculate
YLLs; summing YLDs and YLLs to generate substance use
disorder-specific DALYs; and estimating YLDs, YLLs, and
DALYs attributable to alcohol and drug use as a risk factor
for other health outcomes (comparative risk assessment).
DALYs were derived as the sum of YLD and YLLs for
each disorder, location, age group, sex, and year. Age-
standardised prevalence, deaths, YLLs, YLDs, and DALYs
were estimated using the GBD world population age
standard. Uncertainty was derived for all estimates by
simulating 1000 draws from each estimate’s posterior
distribution, to calculate uncertainty arising from primary
inputs, sample sizes in the data collected, adjustments
made to the data during modelling, and model estimation.
For YLLs, uncertainty estimates reflected uncertainty due
to study sample sizes, adjustments made to the all-cause
mortality data, and model estimation.
Comparative risk assessment
GBD 2016 also quantified burden attributable to alcohol
and drug use as risk factors for other health outcomes
in the comparative risk assessment.26 The comparative
risk assessment method estimated the burden from a
risk factor attributable to an exposure compared with an
alternative (counterfactual) exposure distribution.9 For
drugs, the counterfactual exposure distribution was no
use of the substance in the population; for alcohol it was
between 0–0·8 standard daily drinks. Literature reviews
were done to estimate relative risks (RR) for dimensions
of substance use as a risk factor for other health
outcomes to which alcohol and drug use was considered
causally linked for dimensions of alcohol and drug use
as a risk factor for other health outcomes. Disease
burden associated with the characteristics of alcohol
consumption patterns has been explored in detailed
elsewhere.27 Causality was established by standard
epidemiological criteria with an attempt to be com-
paratively similar across all risk factors included in the
GBD comparative risk assessment. On the basis of
exposure and relative risk (RR), population attri butable
fractions (PAFs) were calculated, which denote the
burden of disease that could have been avoided
if individuals were not exposed to substances.28
The substance-attributable burden was calculated by
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5
multi plying the attributable fractions with the respective
burden estimates.
The alcohol and drug use risk factor outcome
pairings included in GBD 2016 are summarised in the
appendix (p 32). RR estimates were used together with a
mixed eect meta-regression with age-integration from
DisMod ordinary dierential equations to calculate PAFs.
PAFs were multiplied by relevant cause-specific DALYs to
calculate attributable burden. Details of the comparative
risk assessment modelling process have been published
in full elsewhere.26
Comparative risk assessment requires exposure and
relative risk for pairings that have been defined as causally
linked. Alcohol exposure was modelled as a continuous
1990 2016 Percentage
change in
prevalence from
1990 to 2016 (%)
Percentage change in
age-standardised
prevalence from 1990
to 2016 (%)
Prevalence, in
thousands (95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence, in
thousands (95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Alcohol use disorders
Total 69 618·9
(61 748·5–77 915·2)
1407·7
(1260·8–1558·1)
100 389·4
(89 591·7–111 658·6)
1320·8
(1181·2–1468·0)
44·2% –6·2%
Women 21 145·8
(18 554·1–24 049·8)
858·8
(757·6–968·9)
29 516·0
(25 833·0–33 485·2)
783·1
(685·4–888·2)
39·6% –8·8%
Men 48 473·1
(43 065·2–54 175·1)
1954·9
(1763·8–2156·0)
70 873·4
(63 453·2–78 522·9)
1853·3
(1666·2–2052·8)
46·2% –5·2%
Amphetamine use disorders
Total 4044·7
(2924·8–5395·7)
70·4
(51·8–92·7)
4955·2
(3693·4–6490·5)
64·7
(48·3–84·8)
22·5% –8·0%
Women 1439·0
(1037·8–1901·6)
51·0
(37·5–66·8)
1701·1
(1273·6–2223·4)
45·4
(33·9–59·5)
18·2% –10·9%
Men 2605·7
(1874·4–3493·9)
89·2
(65·3–117·9)
3254·0
(2438·5–4279·8)
83·2
(62·4–109·3)
24·9% –6·7%
Cannabis use disorders
Total 17 584·8
(14 846·9–20 983·9)
311·7
(267·2–367·3)
22 094·5
(18 964·7–25 855·5)
289·7
(248·9–339·1)
25·6% –7·1%
Women 5714·2
(4798·1–6778·1)
207·0
(175·7–243·3)
7026·2
(6011·5–8188·0)
187·8
(160·6–219·0)
23·0% –9·3%
Men 11 870·6
(9971·3–14 194·7)
413·6
(353·5–486·0)
15 068·4
(12 887·9–17 649·6)
387·5
(331·9–455·4)
26·9% –6·3%
Cocaine use disorders
Total 4180·7
(3781·7–4653·3)
82·6
(75·2–91·0)
5840·3
(5321·7–6473·4)
77·6
(70·7–85·9)
39·7% –6·0%
Women 1337·7
(1205·7–1495·3)
53·2
(48·3–58·9)
1845·3
(1667·5–2051·6)
49·4
(44·7–54·9)
37·9% –7·2%
Men 2843·0
(2575·2–3151·4)
112·1
(102·2–123·1)
3995·0
(3638·0–4414·3)
105·5
(96·3–116·3)
40·5% –5·8%
Opioid use disorders
Total 18 218·7
(16 148·9–20 800·5)
360·8
(322·5–406·9)
26 834·5
(23 563·1–30 952·0)
353·0
(309·9–405·9)
47·3% –2·2%
Women 7330·2
(6439·8–8505·1)
290·8
(256·6–333·4)
10 408·6
(9023·7–12 193·6)
275·8
(239·1–322·8)
42·0% –5·2%
Men 10 888·6
(9684·8–12 291·6)
431·3
(387·6–481·3)
16 425·9
(14 490·4–18 696·7)
429·6
(380·2–487·5)
50·9% –0·4%
Other drug use disorders
Total 2514·2
(2258·7–2781·2)
51·9
(46·7–57·1)
3944·0
(3536·6–4361·6)
52·1
(46·9–57·6)
56·9% 0·6%
Women 1356·9
(1216·9–1501·5)
56·3
(50·5–62·1)
2146·3
(1923·4–2375·0)
56·9
(51·0–62·9)
58·2% 1·0%
Men 1157·3
(1040·2–1278·3)
47·2
(42·6–51·9)
1797·7
(1621·0–1981·4)
47·3
(42·7–52·0)
55·3% 0·2%
95% UI=95% uncertainty interval.
Table 1: Global prevalence and age-standardised prevalence of substance use disorders in 1990 and 2016
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Alcohol Amphetamines Cannabis Cocaine Opioids Other drugs
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95%UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 per people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-
standardised
prevalence per
100 000 people
(95% UI)
Global 100 389·4
(89 591·7–
111 658·6)
1320·8
(1181·2− 1468·0)
4955·2
(3693·4−
6490·5)
64·7
(48·3−84·8)
22 094·5
(18 964·7−
25 855·5)
289·7
(248·9−339·1)
5840·3
(5321·7−
6473·4)
77·6
(70·7−85·9)
26 834·5
(23 563·1−
30 952·0)
353·0
(309·9−405·9)
3944·0
(3536·6−
4361·6)
52·1
(46·9−57·6)
East Asia 17 126·8
(15 327·6–
19 115·7)
1023·8
(915·5−1143·6)
1195·7
(820·8−
1658·7)
85·4
(57·9−120·0)
5309·9
(4469·0−
6321·7)
375·9
(310·7−453·2)
418·3
(364·4−
483·1)
25·6
(22·3−29·8)
4654·3
(4131·1−
5292·9)
285·8
(252·9−326·8)
901·5
(808·8−
1000·8)
54·7
(49·1−60·5)
Southeast Asia 5464·9
(4789·9–
6183·0)
806·1
(710·7−907·4)
890·7
(593·9−
1254·1)
126·4
(84·3−177·9)
2535·6
(2091·0−
3071·1)
362·5
(299·3−438·8)
99·5
(84·6−
117·6)
14·8
(12·6−17·3)
1345·3
(1138·6−
1603·4)
200·7
(171·3−237·1)
263·8
(233·8−
295·7)
39·1
(34·7−43·5)
Oceania 88·7
(76·2–
101·9)
860·0
(751·2−976·7)
7·7
(4·9−11·1)
61·6
(40·3−88·0)
50·0
(40·3−61·3)
408·2
(334·8−495·8)
1·6
(1·4−1·9)
15·8
(13·5−18·5)
18·2
(14·6−22·5)
178·2
(146·0−216·9)
3·7
(3·3−4·2)
37·6
(33·4−41·9)
Central Asia 1852·8
(1644·8−
2070·0)
2023·9
(1810·1−2251·4)
68·5
(47·5−95·6)
70·4
(48·7−98·1)
223·4
(183·5−
268·7)
236·4
(194·9−286·1)
65·0
(56·9−74·8)
71·7
(62·8−82·1)
241·6
(207·5−
285·0)
262·5
(227·4−305·4)
53·4
(47·8−59·0)
59·7
(53·5−65·8)
Central Europe 2225·5
(2017·8−
2450·5)
1730·3
(1553·1−1919·4)
121·6
(96·2−
152·8)
121·4
(94·2−154·0)
315·9
(272·3−
367·1)
307·7
(259·3−363·7)
75·3
(66·0−
85·8)
63·6
(54·9−73·4)
191·9
(166·1−
223·2)
151·3
(130·0−180·0)
76·9
(69·0−84·9)
58·6
(52·2−65·0)
Eastern Europe 10 217·7
(9199·5−
11 293·4)
4245·6
(3799·9− 4739·6)
237·5
(178·1−
312·5)
122·4
(88·6−163·0)
509·6
(433·7−
595·4)
270·1
(223·6−323·8)
238·1
(211·7−
267·9)
110·5
(97·2−125·7)
1188·5
(1058·0−
1336·0)
497·8
(438·6−562·6)
231·3
(211·9−
252·6)
96·0
(87·7−105·2)
High-income
Asia Pacific
1689·2
(1485·7−
1906·6)
967·7
(834·6−1105·1)
147·1
(106·1−
198·5)
100·6
(69·9−140·3)
546·0
(462·6−
639·5)
367·5
(303·0−437·2)
265·9
(235·7−
298·7)
148·7
(129·8−169·7)
462·5
(392·8−
540·7)
250·5
(207·8−302·0)
124·4
(110·2−
139·4)
62·8
(55·0−70·9)
Australasia 384·4
(332·8−
439·0)
1305·4
(1120·5− 1498·4)
154·9
(131·1−
178·5)
574·2
(483·7−664·7)
204·4
(173·8−
239·0)
747·9
(628·5−882·3)
68·2
(59·5−77·1)
234·9
(204·1−267·6)
123·5
(107·4−
141·5)
414·7
(358·6−479·4)
46·9
(42·9−51·2)
154·6
(141·0−169·8)
Western Europe 5177·2
(4632·9−
5727·3)
1203·1
(1053·8−1353·5)
387·3
(302·6−
500·6)
110·2
(84·3−146·6)
1586·2
(1405·3−
1771·5)
450·8
(391·5−509·2)
673·5
(609·7−
744·2)
162·8
(146·1−181·2)
1149·3
(1048·0−
1264·7)
267·1
(242·5−297·9)
402·8
(365·4−
441·2)
89·5
(80·9−98·6)
Southern
Latin America
1187·3
(1021·4−
1366·3)
1775·6
(1526·8−2044·2)
117·4
(82·6−
164·5)
179·3
(126·3−252·0)
262·6
(216·1−
316·2)
402·0
(330·0−485·7)
172·6
(151·8−
196·6)
259·6
(227·7−295·8)
177·8
(147·5−
214·9)
262·3
(217·1−317·9)
43·4
(38·5−48·3)
63·5
(56·2−70·8)
High-income
North America
6947·1
(6438·5−
7526·1)
1880·4
(1734·7−2046·8)
816·0
(695·3−
967·8)
240·5
(202·5−287·2)
2958·3
(2608·0−
3360·2)
884·3
(772·7−1013·2)
1905·2
(1767·8−
2057·5)
524·1
(484·6−567·0)
4199·6
(3812·1−
4584·3)
1168·3
(1051·4−1282·5)
486·7
(448·7−
527·1)
129·2
(118·9− 140·3)
Caribbean 744·4
(657·7−
834·7)
1602·7
(1416·2−1794·8)
4·5
(3·3−5·9)
9·7
(7·0−12·6)
125·3
(105·0−
150·5)
267·6
(224·8−321·1)
59·4
(51·6−
68·4)
127·8
(111·2−147·2)
117·9
(99·1−
141·9)
256·5
(215·8−308·4)
20·1
(17·9−22·3)
43·5
(38·8−48·2)
Andean
Latin America
844·3
(731·3−
960·4)
1421·3
(1246·6−1607·3)
59·4
(39·6−
84·5)
91·3
(61·4−129·2)
96·0
(80·1−
113·7)
153·0
(128·5−180·0)
78·7
(68·3−
90·4)
130·3
(113·6−149·4)
152·7
(127·4−
185·5)
263·8
(223·0−316·5)
24·0
(21·3−27·0)
41·7
(37·1−46·5)
Central
Latin America
4202·1
(3764·3−
4674·1)
1602·5
(1442·5−1769·7)
228·8
(167·4−
308·6)
81·8
(60·0−109·6)
292·0
(253·9−
337·5)
107·5
(93·9−123·4)
249·7
(217·2−
286·8)
95·4
(83·3−109·3)
601·6
(506·7−
721·4)
229·5
(194·6−273·0)
106·6
(94·5−
119·3)
41·8
(37·2−46·6)
(Table 2 continues on next page)
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7
risk factor for the dimension of level of consumption, and
for injury and coronary heart disease outcomes, patterns
of drinking (binge drinking) were added as an additional
dimension. Exposure to alcohol was based on a
triangulation of survey and sales data,29 as described
previously.14,27,30 For opioid, amphetamine, and cocaine as
risk factors for suicide, dependent use of these substances
(as modelled in GBD 2016) was the defined exposure.14 For
injecting drug use as a risk factor for HIV, we extracted
data on the proportion of notified HIV cases by trans-
mission route from global HIV surveillance agencies.14,31
For injecting drug use as a risk factor for hepatitis C and
hepatitis B viruses, we used a cohort method, estimating
the accumulated risk of individuals having incident
hepatitis B and C due to injecting drug use. We pooled
data on injecting drug use in DisMod-MR 2.1, did a meta-
analysis of hepatitis B and hepatitis C incidence among
people who inject drugs, and estimated the population-
level incidence of hepatitis B and C since 1960.14,31
Estimating association between burden and SDI
The SDI is the geometric mean of total fertility rate,
income per capita, and mean years of education among
individuals aged 15 years and older, which was included
as a composite measure of developmental status in GBD
2016. The index is similar to the human development
index. SDI scores range from 0 to 1 (0=highest fertility,
lowest income, and lowest education; 1=highest income,
highest education, and lowest fertility). To calculate the
SDI, these three attributes were rescaled whereby 0 was
the lowest value observed between 1980 and 2016, and
1 was the highest observed value. Each GBD location
was allocated an SDI score for each year. In this study,
we investigate the association between SDI and DALYs
attributable to alcohol and drug use.
Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or the
writing of the report. All authors had full access to the
data in the study and final responsibility for the decision
to submit for publication.
Results
Prevalence of substance use disorders
Globally, alcohol dependence was the most prevalent of the
substance use disorders (table 1), with 100·4 million
estimated cases in 2016 (age-standardised prevalence
1320·8 cases per 100 000 people, 95% uncertainty interval
[UI] 1181·2–1468·0). The most common drug use disorders
in 2016 were cannabis dependence (22·1 million cases;
age-standardised prevalence 289·7 cases per 100 000 people,
95% UI 248·9–339·1) and opioid dependence (26·8 million
cases; age-standardised prevalence 353·0 cases per
100 000 people, 309·9–405·9). Amphetamine and cocaine
dependence were less common, with cocaine dependence
the least common. Across all substance use disorders,
Alcohol Amphetamines Cannabis Cocaine Opioids Other drugs
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 people
(95%UI)
Prevalence,
in thousands
(95% UI)
Age-standardised
prevalence per
100 000 per people
(95% UI)
Prevalence,
in thousands
(95% UI)
Age-
standardised
prevalence per
100 000 people
(95% UI)
(Continued from previous page)
Tropical
Latin America
6210·4
(5502·5−
6914·4)
2656·5
(2357·7− 2956·5)
272·7
(190·9−
372·9)
118·4
(82·5−161·9)
622·0
(523·5−
731·8)
268·8
(226·4−316·9)
678·3
(601·5−
767·2)
294·6
(261·5−333·4)
517·8
(445·2−
606·1)
223·4
(192·9−260·5)
86·2
(76·3−96·5)
37·4
(33·3−41·8)
North Africa and
Middle East
3484·0
(2948·1−
4048·9)
593·0
(507·9− 683·0)
81·5
(60·8−
105·3)
13·1
(9·9−16·7)
937·9
(779·0−
1128·2)
151·4
(126·4−180·5)
266·6
(228·4−
312·9)
45·9
(39·6−53·3)
4164·7
(3507·7−
4977·3)
705·4
(603·3−832·9)
235·4
(208·7−
264·3)
41·7
(37·1−46·5)
South Asia 21 024·0
(18 583·8−
23 815·0)
1252·3
(1116·0− 1407·6)
82·7
(59·4−
111·4)
4·6
(3·4−6·1)
3813·4
(3162·1−
4567·3)
204·1
(171·1−242·8)
405·9
(350·9−
474·7)
23·9
(20·8−27·8)
5435·1
(4610·0−
6346·6)
308·7
(265·2−357·8)
567·4
(499·5−
637·1)
34·0
(30·2−37·9)
Central
sub-Saharan
Africa
1320·0
(1122·8−
1533·0)
1413·3
(1225·6− 1618·6)
7·7
(5·2−10·4)
6·7
(4·6−9·2)
201·4
(166·9−
244·6)
179·1
(151·1−212·9)
13·6
(11·4−16·4)
14·6
(12·4−17·2)
222·0
(181·6−
273·1)
240·1
(201·5−288·9)
28·9
(25·3−32·9)
33·6
(29·7−37·8)
Eastern
sub-Saharan
Africa
5176·7
(4389·9−
5926·1)
1611·0
(1410·9− 1810·8)
24·5
(16·5−33·8)
6·2
(4·3−8·4)
810·8
(651·8−
1002·1)
206·8
(170·3−249·6)
44·4
(36·7−53·8)
13·8
(11·7−16·4)
664·9
(538·5−
839·1)
212·1
(176·1−258·2)
100·8
(88·1−
114·2)
34·0
(30·0−38·0)
Southern
sub-Saharan
Africa
1178·3
(1010·2−
1364·0)
1515·0
(1324·1−1719·2)
25·0
(17·8−33·4)
27·3
(19·8−35·9)
180·9
(151·0−
217·3)
204·0
(172·4−241·9)
14·7
(12·6−17·4)
20·0
(17·3−23·1)
305·7
(261·5−
359·6)
376·8
(325·6−436·1)
29·3
(26·0−32·8)
40·2
(36·0−44·4)
Western
sub-Saharan
Africa
3843·4
(3247·2−
4471·2)
1168·1
(1012·8−1335·2)
24·0
(16·2−32·5)
6·1
(4·2−8·2)
513·0
(429·0−
610·7)
133·4
(113·5−155·9)
45·9
(38·3−55·4)
14·4
(12·3−16·9)
899·5
(753·2−
1088·7)
276·4
(235·8−327·9)
110·4
(96·5−
125·6)
36·2
(31·9−40·5)
95% UI=95% uncertainty interval. GBD=Global Burden of Disease.
Table 2: Modelled estimates of prevalence and age-standardised prevalence per 100 000 people of substance use disorders by GBD region, 2016
Articles
8
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DALYs, in
thousands
Age-standardised
DALYs per
100 000 people
Deaths, in
thousands
Age-standardised
DALYs per
100 000 people
YLLs, in
thousands
Age-standardised
DALYs per
100 000 people
YLDs, in
thousands
Age-standardised
YLDs per
100 000 people
All causes 99 204·9 1352·0 2814·6 40·4 81 959·3 1120·1 17 245·6 231·9
Communicable, maternal, neonatal, and
nutritional diseases
12 868·9 174·6 394·1 5·6 12 156·2 164·9 712·7 9·7
HIV/AIDS and tuberculosis 10 169·5 136·8 280·5 3·9 9479·7 127·4 689·8 9·4
Tuberculosis 10 169·5 136·8 280·5 3·9 9479·7 127·4 689·8 9·4
HIV/AIDS ·· ·· ·· ·· ·· ·· ·· ··
HIV/AIDS resulting in other diseases ·· ·· ·· ·· ·· ·· ·· ··
Diarrhoea, lower respiratory, and other
common infectious diseases
2699·4 37·8 113·6 1·7 2676·5 37·5 22·9 0·3
Lower respiratory infections 2699·4 37·8 113·6 1·7 2676·5 37·5 22·9 0·3
Other communicable, maternal, neonatal,
and nutritional diseases
·· ·· ·· ·· ·· ·· ·· ··
Hepatitis ·· ·· ·· ·· ·· ·· ·· ··
Hepatitis B ·· ·· ·· ·· ·· ·· ·· ··
Hepatitis C ·· ·· ·· ·· ·· ·· ·· ··
Non-communicable diseases 65 381·3 900·4 1982·3 28·9 51 421·6 713·3 13 959·8 187·1
Neoplasms 14 750·5 207·8 606·5 9·0 14 374·6 202·3 375·9 5·4
Lip and oral cavity cancer 1769·4 24·5 66·2 1·0 1715·9 23·7 53·5 0·8
Nasopharynx cancer 843·7 11·5 28·4 0·4 826·1 11·2 17·5 0·2
Other pharynx cancer 1285·1 17·7 46·3 0·7 1259·3 17·3 25·8 0·4
Oesophageal cancer 3052·6 43·3 130·6 1·9 3017·9 42·8 34·7 0·5
Colon and rectum cancer 2544·9 36·6 116·8 1·8 2452·2 35·2 92·7 1·4
Liver cancer 2924·5 41·8 129·2 1·9 2890·9 41·3 33·6 0·5
Liver cancer due to hepatitis B ·· ·· ·· ·· ·· ·· ·· ··
Liver cancer due to hepatitis C ·· ·· ·· ·· ·· ·· ·· ··
Liver cancer due to alcohol use 2924·5 41·8 129·2 1·9 2890·9 41·3 33·6 0·5
Larynx cancer 764·4 10·7 29·8 0·4 741·5 10·4 22·8 0·3
Breast cancer 1565·9 21·8 59·2 0·9 1470·7 20·4 95·2 1·4
Cardiovascular diseases 20 833·0 293·9 797·9 11·8 18 975·8 266·8 1857·3 27·1
Ischaemic heart disease 1084·0 12·2 –24·2 –0·7 1076·6 12·2 7·4 0
Cerebrovascular disease 13 888·4 198·0 581·9 8·8 12 807·2 182·4 1081·3 15·7
Ischaemic stroke 2931·0 43·1 124·2 1·9 2297·7 33·9 633·2 9·2
Haemorrhagic stroke 10 957·5 155·0 457·7 6·8 10 509·4 148·5 448·1 6·5
Hypertensive heart disease 2547·3 37·4 131·9 2·1 2337·8 34·3 209·5 3·1
Cardiomyopathy and myocarditis 2590·3 35·2 83·3 1·2 2493·5 33·8 96·8 1·4
Atrial fibrillation and flutter 722·9 11·2 25·0 0·4 260·6 4·2 462·2 7·0
Cirrhosis and other chronic liver diseases 9748·7 133·4 334·7 4·8 9435·2 129·1 313·5 4·4
Cirrhosis and other chronic liver diseases due
to hepatitis B
·· ·· ·· ·· ·· ·· ·· ··
Cirrhosis and other chronic liver diseases due
to hepatitis C
·· ·· ·· ·· ·· ·· ·· ··
Cirrhosis and other chronic liver diseases due
to alcohol use
9748·7 133·4 334·7 4·8 9435·2 129·1 313·5 4·4
Digestive diseases 1196·6 16·2 37·3 0·5 1174·8 15·9 21·8 0·3
Pancreatitis 1196·6 16·2 37·3 0·5 1174·8 15·9 21·8 0·3
Neurological disorders 1903·2 25·5 22·0 0·3 876·7 11·6 1026·5 13·8
Epilepsy 1903·2 25·5 22·0 0·3 876·7 11·6 1026·5 13·8
Mental and substance use disorders 16 237·2 214·3 173·8 2·4 6211·8 82·6 10 025·4 131·8
Alcohol use disorders 16 237·2 214·3 173·8 2·4 6211·8 82·6 10 025·4 131·8
Drug use disorders ·· ·· ·· ·· ·· ·· ·· ··
Opioid use disorders ·· ·· ·· ·· ·· ·· ·· ··
Cocaine use disorders ·· ·· ·· ·· ·· ·· ·· ··
(Table 3 continues on next page)
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9
age-standardised prevalence was significantly higher for
men than women, with the exception of other drug use
disorders.
Between 1990 and 2016, the global prevalence of all
substance use disorders increased for both men and
women (table 1). Conversely, age-standardised prevalence
decreased for all substance use disorders, with the
exception of the other drug use disorders group. The
estimated decrease in age-standardised prevalence was
greater among women than men for all substance use
disorders. For all ages, the increase in prevalence of
disorders was greater among men than women, with the
exception of other drug use disorders, whereby the
increase in prevalence was greater for women than men
(table 1).
Substantial regional variations were observed in the
estimated prevalence of substance use disorders
(table 2). Australasia was among the regions with the
highest age-standardised prevalence across all drug
use disorders, and age-standardised prevalence of
amphetamine depend ence was highest in this region.
High-income North America had the highest prevalence
of cannabis, cocaine, and opioid dependence. The
prevalence of alcohol use disorders was highest in
Eastern Europe.
The disease burden of substance use disorders
varied substantially by region (appendix pp 34, 35)
and country (appendix pp 36–46), reflecting variations
in prevalence.
Burden due to substance use as risk factors for injuries
and diseases
Global DALYs attributable to alcohol use were highest for
injuries (21·0 million DALYs, 95% UI 15·9–26·3),
cardiovascular diseases (20·8 million DALYs, 14·9–27·1),
and cancers (14·8 million DALYs, 13·5–16·1; table 3;
appendix p 47). Drug-attributable DALYs were highest for
drug use disorders (20·4 million DALYs, 95% UI
16·2–24·7), cancers (1·6 million DALYs, 1·4–1·9) and
cirrhosis (4·8 million DALYs, 4·2–5·5) driven by chronic
hepatitis C infection due to injecting drug use, and HIV
(3·2 million DALYs, 2·6–3·9; table 4; appendix p 49).
There were similar patterns for deaths, YLLs, and
YLDs (table 3, table 4). Overall, 2·8 million deaths (95% UI
2·4–3·3) were attributed to alcohol use, and 452 000 deaths
(420 000–487 000) were attributed to drug use.
DALYs, in
thousands
Age-standardised
DALYs per
100 000 people
Deaths, in
thousands
Age-standardised
DALYs per
100 000 people
YLLs, in
thousands
Age-standardised
DALYs per
100 000 people
YLDs, in
thousands
Age-standardised
YLDs per
100 000 people
(Continued from previous page)
Amphetamine use disorders ·· ·· ·· ·· ·· ·· ·· ··
Cannabis use disorders ·· ·· ·· ·· ·· ·· ·· ··
Other drug use disorders ·· ·· ·· ·· ·· ·· ·· ··
Diabetes, urogenital, blood,
and endocrine diseases
712·2 9·3 10·1 0·1 372·8 5·0 339·4 4·3
Diabetes mellitus 712·2 9·3 10·1 0·1 372·8 5·0 339·4 4·3
Injuries 20 954·6 277·1 438·3 5·9 18 381·5 241·9 2573·1 35·1
Transport injuries 9294·3 123·3 182·2 2·5 7611·9 100·2 1682·4 23·0
Road injuries 8577·2 113·7 170·3 2·3 7118·2 93·7 1459·0 20·0
Pedestrian road injuries 2791·7 37·2 66·2 0·9 2485·5 33·0 306·3 4·2
Cyclist road injuries 647·1 8·7 10·1 0·1 371·2 4·9 275·9 3·8
Motorcyclist road injuries 1857·7 24·4 32·4 0·4 1522·0 19·8 335·7 4·6
Motor vehicle road injuries 3120·5 41·2 60·0 0·8 2675·4 35·1 445·1 6·1
Other road injuries 160·2 2·2 1·6 0 64·1 0·8 96·0 1·3
Other transport injuries 717·1 9·5 11·9 0·2 493·8 6·5 223·3 3·0
Unintentional injuries 1824·2 24·4 33·9 0·5 1339·3 17·7 485·0 6·6
Drowning 632·3 8·4 15·2 0·2 618·3 8·2 14·0 0·2
Fire, heat, and hot substances 386·4 5·2 7·0 0·1 226·6 3·1 159·8 2·2
Poisonings 150·1 2·0 3·4 0 129·3 1·7 20·7 0·3
Exposure to mechanical forces 87·0 1·1 1·6 0 70·0 0·9 16·9 0·2
Unintentional firearm injuries 87·0 1·1 1·6 0 70·0 0·9 16·9 0·2
Other unintentional injuries 568·5 7·6 6·8 0·1 295·0 3·9 273·5 3·8
Self-harm and interpersonal violence 9836·1 129·5 222·1 3·0 9430·3 124·0 405·8 5·5
Self-harm 6499·1 85·8 160·7 2·2 6406·5 84·6 92·6 1·3
Interpersonal violence 3337·0 43·6 61·5 0·8 3023·8 39·4 313·2 4·2
95% uncertainty intervals are reported in the appendix (pp 47, 48). DALYs=disability-adjusted life-years. YLLs= years of life lost. YLDs=years of life lived with disability.
Table 3: DALYs, deaths, YLLs, and YLDs attributed to alcohol use, globally, in 2016
For more on the human
development index see
http://hdr.undp.org/en/content/
human-development-index-hdi
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DALYs, in
thousands
Age-standardised
DALYs per
100 000 people
Deaths, in
thousands
Age-standardised
DALYs per
100 000 people
YLLs, in
thousands
Age-standardised
DALYs per
100 000 people
YLDs, in
thousands
Age-standardised
YLDs per
100 000 people
All causes 31 836·3 421·0 451·8 6·2 16 782·3 223·1 15 053·9 197·9
Communicable, maternal, neonatal, and
nutritional diseases
3223·6 42·1 64·6 0·8 2973·2 38·8 250·4 3·3
HIV/AIDS and tuberculosis 3193·8 41·7 63·8 0·8 2944·6 38·5 249·2 3·3
Tuberculosis ·· ·· ·· ·· ·· ·· ·· ··
HIV/AIDS 3193·8 41·7 63·8 0·8 2944·6 38·5 249·2 3·3
HIV/AIDS resulting in other diseases 2670·8 34·9 53·2 0·7 2460·8 32·1 210·0 2·8
Diarrhoea, lower respiratory, and other
common infectious diseases
·· ·· ·· ·· ·· ·· ·· ··
Lower respiratory infections ·· ·· ·· ·· ·· ·· ·· ··
Other communicable, maternal,
neonatal, and nutritional diseases
29·8 0·4 0·8 0 28·6 0·4 1·2 0
Hepatitis 29·8 0·4 0·8 0 28·6 0·4 1·2 0
Hepatitis B 11·5 0·2 0·3 0 11·1 0·1 0·4 0
Hepatitis C 18·2 0·2 0·5 0 17·5 0·2 0·7 0
Non-communicable diseases 26 806·4 355·3 349·9 4·9 12 025·7 161·0 14 780·7 194·3
Neoplasms 1636·6 22·8 65·0 0·9 1617·5 22·6 19·1 0·3
Lip and oral cavity cancer ·· ·· ·· ·· ·· ·· ·· ··
Nasopharynx cancer ·· ·· ·· ·· ·· ·· ·· ··
Other pharynx cancer ·· ·· ·· ·· ·· ·· ·· ··
Oesophageal cancer ·· ·· ·· ·· ·· ·· ·· ··
Colon and rectum cancer ·· ·· ·· ·· ·· ·· ·· ··
Liver cancer 1636·6 22·8 65·0 0·9 1617·5 22·6 19·1 0·3
Liver cancer due to hepatitis B 78·1 1·1 2·6 0 77·2 1·0 0·8 0
Liver cancer due to hepatitis C 1558·5 21·8 62·5 0·9 1540·3 21·5 18·3 0·3
Liver cancer due to alcohol use ·· ·· ·· ·· ·· ·· ·· ··
Larynx cancer ·· ·· ·· ·· ·· ·· ·· ··
Breast cancer ·· ·· ·· ·· ·· ·· ·· ··
Cardiovascular diseases ·· ·· ·· ·· ·· ·· ·· ··
Ischaemic heart disease ·· ·· ·· ·· ·· ·· ·· ··
Cerebrovascular disease ·· ·· ·· ·· ·· ·· ·· ··
Ischaemic stroke ·· ·· ·· ·· ·· ·· ·· ··
Haemorrhagic stroke ·· ·· ·· ·· ·· ·· ·· ··
Hypertensive heart disease ·· ·· ·· ·· ·· ·· ·· ··
Cardiomyopathy and myocarditis ·· ·· ·· ·· ·· ·· ·· ··
Atrial fibrillation and flutter ·· ·· ·· ·· ·· ·· ·· ··
Cirrhosis and other chronic liver diseases 4784·9 64·2 141·2 1·9 4622·0 62·0 162·9 2·2
Cirrhosis and other chronic liver diseases
due to hepatitis B
82·8 1·1 2·4 0 80·1 1·1 2·7 0
Cirrhosis and other chronic liver diseases
due to hepatitis C
4702·2 63·1 138·7 1·9 4542·0 60·9 160·2 2·2
Cirrhosis and other chronic liver diseases
due to alcohol use
·· ·· ·· ·· ·· ·· ·· ··
Digestive diseases ·· ·· ·· ·· ·· ·· ·· ··
Pancreatitis ·· ·· ·· ·· ·· ·· ·· ··
Neurological disorders ·· ·· ·· ·· ·· ·· ·· ··
Epilepsy ·· ·· ·· ·· ·· ·· ·· ··
Mental and substance use disorders 20 384·8 268·3 143·7 2·0 5786·1 76·5 14 598·7 191·8
Alcohol use disorders ·· ·· ·· ·· ·· ·· ·· ··
Drug use disorders 20 384·8 268·3 143·7 2·0 5786·1 76·5 14 598·7 191·8
Opioid use disorders 14 782·0 194·2 86·2 1·2 3656·1 48·1 11 125·8 146·1
Cocaine use disorders 1153·6 15·3 8·8 0·1 356·9 4·7 796·7 10·6
(Table 4 continues on next page)
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11
The estimated number of deaths, YLLs, YLDs, and
DALYs attributed to alcohol and drug use varied
considerably between regions (table 5; appendix
pp 50, 51). The highest alcohol-attributable burdens were
in Eastern Europe (4730·9 age-standardised DALYs per
100 000 people [95% UI 3591·3−6104·9]) and Southern
sub-Saharan Africa (3178·8 age-standardised DALYs per
100 000 people [2599·8−3759·5]). The highest drug-
attributable burdens were in Eastern Europe (1252·3 age-
standardised DALYs per 100 000 people [95% UI
1029·6−1498·4]) and high-income North America
(1380·3 age-standardised DALYs per 100 000 people
[1173·9−1579·0]). In terms of absolute burden, the largest
number of alcohol-attributable DALYs were in East Asia,
South Asia, Eastern Europe, and Tropical Latin America,
and the largest number of drug-attributable DALYs were
in East Asia, high-income North America, South Asia,
and Eastern Europe.
Globally, in 2016, 99·2 million DALYs (95% UI
88·3–111·2) and 4·2% of all DALYs (3·7–4·6) were
attributable to alcohol use, and 31·8 million DALYs
(27·4–36·6) and 1·3% of all DALYs (1·2–1·5) were
attributable to drug use (table 5). Globally, alcohol
accounted for around three-quarters (76%) of all
substance-use-attributable DALYs. Drugs accounted for a
higher percentage of substance-use-attributable DALYs
than alcohol in two regions: high-income North America
(53% of total alcohol and drug attributable DALYs) and
North Africa and the Middle East (69% of total alcohol
and drug attributable DALYs).
The proportion of DALYs attributable to alcohol and
drug use, and the contribution of each to overall DALYs,
varied substantially, both in the absolute and relative
data, at the regional level. Alcohol attributable burden
was largest for Eastern Europe (12·3 million DALYs,
95% UI 9·3–16·1; 13·8% of all DALYs, 95% UI 11·3–16·7)
and Central Europe (3·6 million DALYs, 2·7–4·5; 9·4% of
all DALYs, 7·0–11·8), whereas alcohol attributable burden
was smallest for North Africa and the Middle East
(1·3 million DALYs, 1·1–1·6; 0·8% of all DALYs, 0·7–1·0)
and Western sub-Saharan Africa (7·1 million DALYs,
5·9–8·3; 1·7% of all DALYs, 1·4–2·1).
The regions where drug use accounted for the highest
proportion of DALYs were high-income North America
(5·2 million DALYs, 95% UI 4·4–5·9; 5·1% of all DALYs,
4·5–5·6), Eastern Europe (3·0 million DALYs, 2·5–3·6;
DALYs, in
thousands
Age-standardised
DALYs per
100 000 people
Deaths, in
thousands
Age-standardised
DALYs per
100 000 people
YLLs, in
thousands
Age-standardised
DALYs per
100 000 people
YLDs, in
thousands
Age-standardised
YLDs per
100 000 people
(Continued from previous page)
Amphetamine use disorders 881·4 11·5 5·2 0·1 224·2 2·9 657·2 8·6
Cannabis use disorders 646·5 8·5 ·· ·· ·· ·· 646·5 8·5
Other drug use disorders 2921·4 38·8 43·5 0·6 1548·9 20·7 1372·5 18·1
Diabetes, urogenital, blood,
and endocrine diseases
·· ·· ·· ·· ·· ·· ·· ··
Diabetes mellitus ·· ·· ·· ·· ·· ·· ·· ··
Injuries 1806·2 23·6 37·3 0·5 1783·4 23·3 22·8 0·3
Transport injuries ·· ·· ·· ·· ·· ·· ·· ··
Road injuries ·· ·· ·· ·· ·· ·· ·· ··
Pedestrian road injuries ·· ·· ·· ·· ·· ·· ·· ··
Cyclist road injuries ·· ·· ·· ·· ·· ·· ·· ··
Motorcyclist road injuries ·· ·· ·· ·· ·· ·· ·· ··
Motor vehicle road injuries ·· ·· ·· ·· ·· ·· ·· ··
Other road injuries ·· ·· ·· ·· ·· ·· ·· ··
Other transport injuries ·· ·· ·· ·· ·· ·· ·· ··
Unintentional injuries ·· ·· ·· ·· ·· ·· ·· ··
Drowning ·· ·· ·· ·· ·· ·· ·· ··
Fire, heat, and hot substances ·· ·· ·· ·· ·· ·· ·· ··
Poisonings ·· ·· ·· ·· ·· ·· ·· ··
Exposure to mechanical forces ·· ·· ·· ·· ·· ·· ·· ··
Unintentional firearm injuries ·· ·· ·· ·· ·· ·· ·· ··
Other unintentional injuries ·· ·· ·· ·· ·· ·· ·· ··
Self-harm and interpersonal violence 1806·2 23·6 37·3 0·5 1783·4 23·3 22·8 0·3
Self-harm 1806·2 23·6 37·3 0·5 1783·4 23·3 22·8 0·3
Interpersonal violence ·· ·· ·· ·· ·· ·· ·· ··
95% uncertainty intervals are reported in the appendix (p 49). DALYs=disability-adjusted life-years. YLLs=years of life lost. YLDs=years of life lived with disability.
Table 4: DALYs, deaths, YLLs, and YLDs attributed to drug use, globally, in 2016
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3·4% of all DALYs, 3·0–3·7), and Australasia
(203 000 DALYs (169 000–238 000; 3·1% of all DALYs,
2·7–3·6). Drugs accounted for the smallest percentage of
total DALYs in several regions in sub-Saharan Africa
(table 5).
The overall disease burden attributable to alcohol
and drugs (age-standardised DALY rates per
100 000 population) varied substantially between countries
(figure 1, figure 2). The countries with the highest alcohol-
attributable age-standardised DALYs per 100 000 people
were in Eastern Europe (Russia [4942·7 DALYs, 95% UI
3368·7 to 6832·1], Ukraine [4487·7 DALYs, 3241·2 to
6034·9], and Belarus [3897·1 DALYs, 2864·9 to 4981·4),
and sub-Saharan Africa (Lesotho [9387·2 DALYs, 6374·2
to 12 638·7], Central African Republic [7091·6 DALYs,
3752·8 to 10 694·0], and Burundi [6396·3 DALYs, 4976·1
to 8121·1). Countries with the highest age-standardised
DALYs per 100 000 people attributable to drug use
were the USA (1460·3 DALYs, 1242·1 to 1666·3), Russia
(1380·2 DALYs, 1089·6 to 1719·1), and Mongolia
(1057·4 DALYs, 872·5 to 1259·5).
The distribution of diseases or injuries that contributed
to alcohol and drug-attributable burden varied by GBD
region (figure 3). HIV accounted for a large proportion of
disease burden attributable to drug use in African regions.
Drug use disorders were the largest contributor to drug-
attributable burden in almost all regions, particularly
Australasia, high-income North America, and
North Africa and the Middle East. Alcohol burden was
attributed to a wider variety of diseases and injuries than
drug burden (figure 3).
Disease burden attributable to alcohol and drug use was
strongly associated with socioeconomic development,
and burden composition varied across SDI quintiles
Burden attributable to alcohol Burden attributable to drugs
DALYs, in thousands (95% UI) Age-standardised DALYs per
100 000 people (95% UI)
Percentage of
DALYs (95% UI)
DALYs, in thousands
(95% UI)
Age-standardised DALYs per
100 000 people (95% UI)
Percentage of
DALYs (95% UI)
Andean Latin America 595·4 (482·9−727·2) 1115·9 (897·5−1372·3) 4·4% (3·6–5·3) 167·5 (135·1−203·2) 293·4 (238·0−352·0) 1·2% (1·0–1·4)
Australasia 346·3 (265·5−435·2) 1017·0 (799·8−1253·6) 5·4% (4·1–6·7) 202·9 (169·2−238·1) 686·4 (567·8−814·4) 3·1% (2·7–3·5)
Caribbean 620·4 (509·4−744·9) 1348·0 (1105·6−1617·3) 4·4% (3·6–5·2) 156·2 (132·6−179·9) 339·4 (288·4−391·3) 1·1% (1·0–1·3)
Central Asia 1780·3 (1402·8−2195·7) 2151·6 (1632·1−2745·4) 6·6% (5·3–8·2) 516·1 (455·4−573·3) 596·6 (529·7−660·1) 1·9% (1·7–2·1)
Central Europe 3576·7 (2697·8−4466·8) 2229·6 (1713·1−2745·0) 9·4% (7·0–11·8) 470·8 (402·2−547·9) 339·6 (291·0−394·4) 1·2% (1·1–1·4)
Central Latin America 3789·5 (3293·4−4370·2) 1596·0 (1372·6−1843·3) 6·4% (5·5–7·4) 1050·8 (917·0−1199·0) 423·1 (368·9−480·4) 1·8% (1·6–2·0)
Central
sub-Saharan Africa
1849·9 (1246·9−2585·7) 2733·4 (1738·6−3961·7) 2·9% (1·9–4·2) 180·5 (144·3−220·3) 199·3 (161·2−240·5) 0·3% (0·2–0·4)
East Asia 22 213·1 (19 192·0−25 298·4) 1295·8 (1115·8−1485·4) 6·1% (5·2–7·0) 5315·2 (4530·8−6123·9) 321·8 (272·4−373·3) 1·5% (1·3–1·7)
Eastern Europe 12 349·8 (9271·6−16 063·8) 4730·9 (3591·3−6104·9) 13·8% (11·3–16·7) 3005·5 (2477·8−3590·1) 1252·3 (1029·6−1498·4) 3·4% (3·0–3·7)
Eastern
sub-Saharan Africa
4687·4 (3827·3−5571·1) 2010·6 (1582·4−2467·0) 2·7% (2·2–3·2) 726·3 (564·8−913·4) 251·4 (194·3−320·2) 0·4% (0·3–0·5)
High-income Asia Pacific 1144·8 (708·4−1599·0) 534·4 (364·5−713·8) 2·5% (1·5–3·4) 592·7 (492·9−703·0) 305·2 (247·6−371·4) 1·3% (1·1–1·5)
High-income
North America
4588·4 (3472·1−5788·8) 1139·3 (874·3−1414·8) 4·5% (3·4–5·8) 5146·5 (4410·5−5852·5) 1380·3 (1173·9−1579·0) 5·1% (4·5–5·6)
North Africa and
Middle East
1311·8 (1055·6−1625·3) 264·6 (204·8−342·2) 0·8% (0·7–1·0) 2881·6 (2299·6−3522·1) 512·3 (414·7−619·2) 1·7% (1·4–2·1)
Oceania 159·0 (95·3−229·6) 1706·4 (941·4−2599·4) 3·3% (2·0–4·7) 20·5 (16·3−25·4) 190·5 (150·4−233·3) 0·4% (0·3–0·5)
South Asia 14 501·1 (12 413·8−16 876·2) 967·0 (810·3−1135·3) 2·5% (2·1–2·8) 4408·8 (3568·7−5339·6) 253·3 (206·2−305·4) 0·7% (0·6–0·9)
Southeast Asia 7575·6 (6499·4−8644·9) 1255·7 (1072·4−1439·0) 4·1% (3·6–4·7) 2235·1 (1918·1−2601·2) 329·9 (284·0−382·0) 1·2% (1·1–1·4)
Southern Latin America 792·2 (549·1−1059·1) 1159·8 (819·5−1540·8) 4·8% (3·4–6·4) 327·2 (275·8−384·4) 482·3 (405·9−567·6) 2·0% (1·7–2·2)
Southern
sub-Saharan Africa
2054·4 (1710·3−2409·4) 3178·8 (2599·8−3759·5) 5·1% (4·3–6·0) 434·6 (359·9−522·3) 584·0 (490·1−692·2) 1·1% (0·9–1·3)
Tropical Latin America 12 433·3 (10 547·1−14 476·7) 2075·5 (1701·3−2495·9) 7·4% (6·1–8·7) 724·6 (582·9−875·5) 312·4 (251·5−378·2) 1·2% (1·0–1·4)
Western Europe 4347·6 (3601·0−5101·9) 1921·8 (1578·9−2267·7) 6·3% (5·3–7·5) 1994·5 (1745·2−2248·7) 425·2 (366·5−486·3) 1·8% (1·6–2·0)
Western
sub-Saharan Africa
7079·6 (5951·2−8252·9) 1166·0 (997·1−1346·1) 1·7% (1·4–2·1) 1278·5 (1045·3−1568·9) 410·5 (341·3−492·1) 0·6% (0·5–0·7)
Global 99 204·9
(88 310·4−111 168·3)
1352·0 (1198·4−1521·4) 4·2% (3·7–4·6) 31 836·3
(27445·9−36580·0)
421·0 (363·7−483·1) 1·3% (1·2–1·5)
DALYs=disability-adjusted life-years. 95% CI UI=95% uncertainty interval.
Table 5: Regional data on number, age-standardised rate and percentage of all DALYs attributed to alcohol and drug use, 2016
Figure 1: Age-standardised DALYs per 100 000 people attributable to alcohol
and drug use for both sexes by country in 2016, in 195 locations
(A) DALYs attributed to alcohol use. (B) DALYs attributable to drug use.
DALYs=disability-adjusted life-years. ATG=Antigua and Barbuda. FSM=Federated
States of Micronesia. Isl=Islands. LCA=Saint Lucia. TLS=Timor-Leste.
TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines.
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13
P
A
B
Age-standardised DALYs attributable to alcohol use
Age-standardised DALYs attributable to drug use
Persian Gulf
Caribbean LCA
Dominica
ATG
TTO
Grenada
VCT
TLS
Maldives
Barbados
Seychelles
Mauritius
Comoros
West Africa Eastern
Mediterranean
Malta
Singapore Balkan Peninsula Tonga
Samoa
FSM
Fiji
Solomon Isl
Marshall Isl
Vanuatu
Kiribati
Persian Gulf
Caribbean LCA
Dominica
ATG
TTO
Grenada
VCT
TLS
Maldives
Barbados
Seychelles
Mauritius
Comoros
West Africa Eastern
Mediterranean
Malta
Singapore Balkan Peninsula Tonga
Samoa
FSM
Fiji
Solomon Isl
Marshall Isl
Vanuatu
Kiribati
10·5 to <288·29
288·29 to <414·59
414·59 to <882·68
882·68 to <1068·89
1068·89 to <1296·24
1296·24 to <1580·67
1580·67 to <1822·74
1822·74 to <2356·24
2356·24 to <3015·55
3015·55 to 9387·2
Age-standardised DALYs
per 100
000 people
147·8 to <198·36
198·36 to <238·17
238·17 to <277·59
277·59 to <318·05
318·05 to <350·34
350·34 to <386·53
386·53 to <438·57
438·57 to <504·4
504·4 to <681·82
681·82 to 1460·3
Age-standardised DALYs
per 100
000 people
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Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to drug use
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to alcohol use
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
685·9
(529·1 to 863·4)
237·7
(197·7 to 283·2)
382·3
(294·7 to 481·9)
221·2
(181·2 to 270·1)
395·6
(316·6 to 492·2)
196·7
(150·6 to 248·2)
323·6
(270·6 to 378·6)
499·5
(414·2 to 594·6)
380·4
(323·9 to 437·9)
732·5
(606·9 to 865·4)
507·7
(434·4 to 584·1)
480·1
(400·0 to 572·0)
423·3
(325·7 to 533·2)
184·2
(135·9 to 239·9)
254·7
(213·3 to 301·4)
718·9
(594·0 to 850·4)
329·3
(275·6 to 388·3)
416·1
(348·6 to 491·7)
220·7
(172·3 to 274·4)
323·6
(262·7 to 389·8)
208·4
(157·1 to 265·5)
355·4
(276·2 to 441·3)
231·9
(185·6 to 280·5)
622·5
(467·8 to 770·6)
315·6
(254·3 to 381·9)
238·3
(181·0 to 305·7)
316·2
(251·4 to 385·9)
150·5
(113·6 to 191·8)
168·5
(125·8 to 216·1)
248·9
(192·3 to 306·8)
295·1
(235·5 to 354·8)
402·1
(277·5 to 540·7)
112·8
(81·3 to 148·3)
274·8
(190·0 to 364·2)
114·9
(81·2 to 155·8)
183·2
(131·5 to 238·6)
116·7
(81·0 to 156·2)
147·8
(105·5 to 194·7)
252·6
(177·8 to 335·8)
152·1
(109·3 to 196·9)
412·9
(294·1 to 547·2)
224·4
(162·3 to 284·2)
165·1
(118·5 to 215·0)
297·2
(208·0 to 396·7)
140·1
(95·4 to 194·0)
125·2
(87·0 to 166·1)
227·2
(162·9 to 295·4)
155·6
(110·5 to 203·6)
140·6
(99·2 to 186·8)
128·1
(88·6 to 171·6)
188·1
(134·2 to 245·9)
150·6
(103·2 to 206·1)
214·3
(150·1 to 289·4)
110·8
(79·1 to 144·8)
226·5
(161·2 to 298·1)
201·1
(142·6 to 264·8)
187·7
(133·2 to 250·9)
124·4
(87·9 to 165·2)
104·5
(72·4 to 140·9)
103·2
(71·8 to 138·4)
133·0
(94·3 to 176·3)
144·3
(100·5 to 192·5)
283·7
(189·6 to 386·2)
125·0
(100·0 to 153·8)
107·5
(84·4 to 136·7)
106·3
(84·0 to 131·7)
212·4
(149·4 to 284·2)
80·0
(56·9 to 112·2)
175·9
(148·5 to 205·1)
246·9
(213·2 to 287·4)
228·3
(196·1 to 262·2)
319·6
(282·0 to 359·8)
283·3
(240·4 to 327·9)
315·0
(249·1 to 392·6)
126·0
(97·0 to 164·8)
44·0
(33·1 to 57·5)
129·5
(111·6 to 149·1)
491·7
(396·1 to 604·4)
173·7
(145·6 to 203·6)
275·5
(225·4 to 331·1)
92·6
(65·1 to 123·9)
135·5
(112·3 to 164·8)
57·7
(42·4 to 77·6)
141·1
(103·1 to 185·1)
121·1
(82·4 to 157·4)
396·0
(263·9 to 517·4)
114·4
(94·7 to 139·8)
50·5
(35·1 to 72·0)
191·8
(146·3 to 245·6)
46·0
(32·1 to 65·1)
65·2
(42·1 to 98·1)
115·9
(78·2 to 163·2)
150·8
(112·8 to 188·7)
8·5
(5·6 to 11·7)
4·5
(3·5 to 5·5)
3·3
(2·5 to 4·4)
3·2
(2·6 to 3·9)
5·6
(4·1 to 7·4)
1·9
(1·4 to 2·6)
6·3
(5·4 to 7·4)
8·1
(7·2 to 9·3)
8·5
(7·3 to 9·8)
7·9
(7·1 to 8·7)
8·3
(7·0 to 9·6)
10·6
(8·4 to 13·2)
3·6
(2·7 to 4·6)
1·1
(0·8 to 1·4)
4·6
(4·0 to 5·3)
12·3
(10·0 to 15·0)
5·1
(4·2 to 5·9)
9·9
(8·2 to 11·6)
2·3
(1·6 to 3·1)
5·5
(4·7 to 6·6)
1·5
(1·1 to 1·9)
4·3
(3·2 to 5·6)
4·2
(3·0 to 5·3)
9·8
(6·6 to 12·9)
2·8
(2·3 to 3·3)
1·3
(0·9 to 1·8)
5·8
(4·4 to 7·5)
1·1
(0·8 to 1·6)
1·7
(1·1 to 2·5)
2·7
(1·8 to 3·8)
3·8
(2·8 to 4·6)
54·5
(–154·7 to 256·0)
1188·1
(772·5 to 1662·7)
173·2
(68·6 to 344·2)
455·5
(128·8 to 986·2)
1141·0
(780·0 to 1581·6)
2615·9
(1397·3 to 4106·6)
767·2
(511·0 to 1108·5)
1137·3
(714·4 to 1690·9)
948·4
(618·8 to 1332·2)
1018·3
(769·7 to 1278·8)
1356·7
(1011·0 to 1720·8)
1826·3
(1006·0 to 2782·5)
309·7
(85·8 to 618·5)
371·0
(302·2 to 445·6)
1229·2
(932·1 to 1578·7)
3897·1
(2864·9 to 4981·4)
1291·0
(980·0 to 1663·3)
2270·4
(1664·8 to 2920·1)
973·9
(469·8 to 1726·7)
1334·5
(1059·5 to 1652·7)
882·6
(492·4 to 1334·4)
1013·3
(661·9 to 1451·7)
1724·8
(1380·6 to 2107·2)
3507·1
(1645·0 to 5463·9)
1924·6
(1572·4 to 2279·4)
186·8
(120·6 to 244·0)
1906·4
(1317·9 to 2522·7)
2580·0
(1289·8 to 3965·9)
6396·3
(4976·1 to 8121·1)
2789·6
(2283·2 to 3299·0)
2692·8
(1933·8 to 3493·3)
43·1
(22·1 to 66·4)
290·0
(194·3 to 398·9)
65·5
(37·1 to 107·5)
108·0
(41·1 to 207·7)
289·1
(194·0 to 410·7)
255·0
(160·5 to 380·2)
219·7
(139·2 to 306·8)
247·1
(153·3 to 370·3)
265·6
(178·4 to 370·9)
254·9
(170·0 to 350·4)
343·2
(234·4 to 474·1)
358·4
(237·2 to 501·5)
103·1
(45·8 to 185·9)
153·8
(104·8 to 213·4)
253·2
(166·2 to 359·9)
647·1
(454·2 to 868·7)
272·5
(178·8 to 389·1)
311·6
(206·3 to 438·4)
149·6
(91·7 to 232·4)
312·6
(208·5 to 445·1)
295·3
(198·8 to 414·8)
183·2
(117·1 to 265·2)
453·1
(318·2 to 619·3)
379·4
(243·4 to 548·3)
372·9
(260·6 to 502·9)
75·1
(45·4 to 108·3)
333·9
(221·2 to 462·3)
225·0
(128·3 to 340·2)
379·6
(254·6 to 527·9)
263·6
(182·0 to 366·4)
246·7
(166·4 to 348·0)
11·4
(–184·4 to 210·6)
898·1
(552·8 to 1324·8)
107·7
(23·5 to 241·7)
347·5
(78·0 to 785·6)
851·8
(551·3 to 1241·3)
2360·9
(1200·6 to 3791·3)
547·5
(338·4 to 823·1)
890·3
(530·3 to 1336·9)
682·8
(401·3 to 1022·9)
763·4
(568·8 to 961·7)
1013·5
(736·0 to 1295·4)
1467·9
(726·9 to 2346·8)
206·6
(37·5 to 465·9)
217·2
(175·3 to 265·7)
976·0
(730·2 to 1254·7)
3250·0
(2297·3 to 4268·5)
1018·4
(757·6 to 1314·5)
1958·9
(1400·7 to 2534·7)
824·3
(350·6 to 1534·8)
1022·0
(791·4 to 1290·8)
587·2
(258·4 to 1007·3)
830·1
(511·5 to 1234·4)
1271·6
(974·4 to 1624·6)
3127·7
(1270·9 to 5058·5)
1551·7
(1247·4 to 1852·8)
111·8
(66·3 to 158·1)
1572·5
(1029·6 to 2161·6)
2355·0
(1131·4 to 3685·9)
6016·7
(4597·2 to 7752·1)
2526·0
(2059·4 to 3002·1)
2446·0
(1718·3 to 3216·0)
–3·6
(–13·3 to 4·0)
43·6
(23·1 to 70·1)
2·5
(–1·8 to 9·4)
8·5
(–1·9 to 26·5)
38·0
(20·5 to 58·2)
83·5
(37·1 to 141·4)
17·4
(9·2 to 30·1)
27·4
(9·7 to 50·6)
28·5
(13·6 to 47·0)
26·0
(15·9 to 36·6)
42·0
(24·9 to 61·1)
47·9
(12·0 to 91·7)
7·2
(–1·9 to 23·0)
9·2
(7·4 to 11·1)
35·5
(23·4 to 49·2)
108·8
(64·4 to 159·5)
39·2
(26·1 to 54·5)
71·6
(48·4 to 96·7)
26·2
(4·4 to 60·3)
46·5
(34·8 to 59·7)
23·9
(7·3 to 47·2)
27·0
(15·1 to 43·1)
56·1
(41·7 to 71·9)
110·0
(44·2 to 184·6)
47·3
(35·4 to 59·5)
3·9
(1·0 to 5·7)
59·1
(29·5 to 89·1)
88·2
(34·4 to 157·6)
234·1
(173·4 to 304·5)
104·1
(81·3 to 128·6)
101·5
(64·8 to 140·6)
(Figure 2 continues on next page)
Articles
www.thelancet.com/psychiatry Published online November 1, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30337-7
15
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to drug use
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to alcohol use
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Federated States of Micronesia
Fiji
Finland
France
693·2
(569·7 to 818·6)
469·9
(363·6 to 574·8)
284·9
(224·4 to 354·5)
312·0
(228·4 to 424·3)
461·0
(371·4 to 563·5)
318·4
(269·1 to 370·6)
256·5
(201·7 to 320·7)
150·3
(114·0 to 195·0)
254·3
(203·6 to 307·5)
326·8
(272·8 to 389·5)
372·0
(281·4 to 493·7)
356·7
(293·3 to 429·7)
291·6
(239·9 to 344·5)
266·6
(222·4 to 321·2)
334·9
(278·9 to 396·4)
187·6
(150·5 to 228·9)
467·7
(396·5 to 542·6)
171·6
(128·9 to 217·9)
338·8
(281·9 to 398·8)
296·2
(237·2 to 371·8)
298·6
(244·9 to 359·3)
680·9
(509·7 to 887·2)
451·6
(383·0 to 539·3)
303·3
(235·9 to 381·0)
162·0
(124·0 to 208·4)
864·1
(731·6 to 995·3)
192·1
(150·3 to 239·6)
242·1
(186·7 to 308·2)
170·5
(133·1 to 214·1)
625·2
(534·4 to 723·6)
390·4
(333·7 to 451·1)
403·7
(286·8 to 524·2)
230·1
(161·2 to 302·5)
114·6
(79·7 to 153·4)
129·2
(89·9 to 171·6)
190·2
(133·2 to 252·3)
164·3
(119·0 to 212·9)
160·6
(113·6 to 219·1)
102·0
(72·2 to 138·7)
123·9
(85·4 to 165·9)
147·3
(102·4 to 197·9)
146·7
(103·2 to 194·1)
142·4
(101·3 to 187·1)
147·2
(104·8 to 199·8)
125·8
(90·2 to 165·7)
159·5
(112·6 to 213·3)
112·3
(78·9 to 150·1)
188·4
(136·4 to 246·7)
104·3
(72·9 to 141·7)
148·7
(105·2 to 197·1)
141·2
(98·5 to 187·6)
173·5
(121·7 to 230·9)
269·4
(182·1 to 370·8)
125·7
(87·7 to 171·9)
132·6
(93·5 to 174·3)
102·6
(70·2 to 138·7)
295·8
(211·1 to 385·9)
108·9
(75·5 to 147·2)
111·6
(78·5 to 149·7)
108·5
(76·2 to 145·2)
230·7
(167·5 to 295·1)
176·0
(126·1 to 231·8)
289·6
(248·7 to 336·9)
239·8
(176·8 to 325·3)
170·3
(125·3 to 228·8)
182·8
(115·8 to 287·6)
270·8
(203·7 to 361·7)
154·0
(140·9 to 185·2)
95·9
(75·8 to 117·7)
48·3
(30·0 to 74·1)
130·5
(99·0 to 167·9)
179·5
(149·5 to 212·5)
225·3
(151·0 to 338·3)
214·3
(168·2 to 274·4)
144·4
(126·8 to 165·5)
140·7
(117·6 to 187·8)
175·4
(150·1 to 205·5)
75·3
(57·7 to 94·0)
279·4
(231·4 to 331·1)
67·3
(45·2 to 98·8)
190·1
(159·2 to 227·4)
155·0
(119·5 to 222·4)
125·1
(105·1 to 148·0)
411·4
(275·6 to 586·0)
325·9
(272·3 to 401·0)
170·7
(121·2 to 234·4)
59·4
(41·7 to 84·8)
568·3
(475·0 to 678·7)
83·2
(60·2 to 112·1)
130·5
(90·5 to 193·5)
62·1
(41·5 to 88·5)
394·5
(328·9 to 461·6)
214·5
(186·8 to 246·7)
7·3
(6·3 to 8·3)
6·0
(4·6 to 7·9)
4·0
(3·0 to 5·2)
4·4
(2·8 to 6·7)
9·4
(7·2 to 12·3)
4·8
(4·4 to 5·5)
3·2
(2·5 to 4·0)
1·2
(0·8 to 1·8)
3·1
(2·4 to 3·9)
5·7
(4·5 to 7·0)
5·5
(3·8 to 8·0)
6·4
(5·0 to 8·2)
5·5
(4·8 to 6·3)
3·6
(3·0 to 4·6)
5·5
(4·7 to 6·3)
1·9
(1·4 to 2·3)
7·8
(6·5 to 9·2)
1·7
(1·2 to 2·4)
6·8
(5·8 to 8·0)
5·7
(4·3 to 7·7)
4·1
(3·4 to 4·8)
12·6
(8·2 to 18·7)
11·0
(9·3 to 13·4)
4·0
(2·9 to 5·5)
1·5
(1·1 to 2·1)
12·5
(10·5 to 14·8)
2·2
(1·6 to 2·9)
3·1
(2·1 to 4·5)
1·5
(1·0 to 2·1)
10·4
(8·9 to 12·2)
7·4
(6·4 to 8·5)
806·9
(606·1 to 1018·1)
1609·5
(1195·5 to 2082·6)
7091·6
(3752·8 to 10694·0)
1599·9
(1089·6 to 2263·8)
1219·3
(861·5 to 1655·6)
1301·5
(1117·3 to 1493·1)
1227·4
(900·1 to 1584·8)
330·0
(187·9 to 478·3)
2556·8
(1488·8 to 3845·5)
1017·1
(773·4 to 1295·8)
2265·6
(1099·9 to 3687·6)
2135·3
(1700·1 to 2592·0)
1091·7
(826·8 to 1414·2)
767·0
(460·2 to 1117·9)
1633·4
(1286·4 to 2016·7)
2472·0
(1182·9 to 4112·7)
1530·8
(1160·9 to 1925·2)
439·9
(92·9 to 817·6)
1741·1
(1274·2 to 2275·3)
1061·1
(734·1 to 1446·8)
1461·7
(1227·7 to 1746·0)
392·1
(317·7 to 474·8)
2331·6
(1787·8 to 2944·7)
2300·9
(1278·9 to 3699·8)
1432·8
(621·4 to 2572·0)
2982·7
(2391·5 to 3616·4)
1576·6
(927·4 to 2365·7)
389·8
(126·8 to 761·2)
1017·8
(452·9 to 1770·4)
1567·1
(1257·7 to 1925·6)
1528·2
(1184·9 to 1891·7)
232·7
(154·7 to 324·0)
234·0
(156·3 to 329·6)
247·0
(155·4 to 363·3)
175·3
(116·3 to 245·4)
321·5
(213·8 to 456·0)
225·4
(158·8 to 302·2)
270·4
(183·1 to 379·9)
140·7
(96·0 to 197·0)
261·9
(171·7 to 379·8)
233·4
(156·1 to 335·8)
209·7
(130·0 to 318·9)
390·7
(269·9 to 532·4)
240·9
(161·7 to 330·3)
197·5
(121·5 to 287·5)
379·4
(257·9 to 525·9)
204·5
(127·5 to 307·2)
330·5
(221·6 to 466·7)
144·0
(93·3 to 209·8)
307·5
(202·6 to 446·6)
231·1
(149·2 to 325·8)
269·1
(183·0 to 374·5)
73·3
(49·9 to 103·0)
360·3
(238·2 to 511·5)
332·4
(215·6 to 493·0)
184·4
(121·2 to 269·1)
600·9
(413·2 to 818·2)
250·6
(163·8 to 345·8)
82·6
(44·6 to 128·2)
172·5
(102·7 to 274·1)
409·7
(279·1 to 569·1)
317·2
(208·1 to 445·6)
574·1
(419·8 to 727·2)
1375·5
(1002·2 to 1802·8)
6844·6
(3572·4 to 10424·1)
1424·6
(948·6 to 2052·0)
897·8
(581·9 to 1277·8)
1076·1
(918·2 to 1233·9)
957·1
(667·7 to 1264·8)
189·4
(70·1 to 325·9)
2294·9
(1251·2 to 3527·8)
783·7
(579·0 to 997·8)
2056·0
(957·1 to 3430·5)
1744·6
(1367·9 to 2138·7)
850·8
(624·3 to 1125·5)
569·4
(316·3 to 854·7)
1254·0
(972·8 to 1556·6)
2267·6
(1026·8 to 3844·6)
1200·3
(896·2 to 1542·8)
295·9
(–32·3 to 650·3)
1433·6
(1027·5 to 1921·5)
830·0
(539·7 to 1181·1)
1192·5
(987·7 to 1431·5)
318·7
(249·5 to 393·1)
1971·3
(1486·9 to 2504·2)
1968·5
(1000·8 to 3350·5)
1248·5
(461·7 to 2376·4)
2381·8
(1866·6 to 2923·7)
1326·1
(710·4 to 2105·6)
307·1
(57·6 to 658·0)
845·2
(332·2 to 1505·7)
1157·3
(921·9 to 1422·0)
1211·0
(937·8 to 1494·0)
16·6
(9·6 to 24·4)
57·1
(35·1 to 79·9)
228·4
(107·8 to 368·7)
46·6
(28·5 to 71·7)
31·8
(18·4 to 48·6)
46·3
(37·9 to 55·1)
28·4
(17·2 to 42·7)
6·1
(0·8 to 11·7)
81·8
(41·0 to 131·4)
28·2
(19·3 to 38·3)
69·6
(26·7 to 129·9)
74·5
(54·5 to 95·1)
30·6
(20·4 to 44·2)
19·7
(6·0 to 35·8)
49·2
(31·2 to 69·7)
76·5
(29·3 to 142·4)
51·8
(34·5 to 72·5)
7·5
(–4·6 to 19·9)
53·0
(33·6 to 77·3)
29·6
(17·2 to 44·7)
43·1
(36·0 to 51·1)
15·8
(12·5 to 19·5)
60·0
(42·5 to 79·7)
78·7
(37·0 to 134·7)
41·4
(13·2 to 87·1)
81·5
(56·6 to 108·5)
42·9
(19·9 to 72·9)
4·2
(–3·8 to 14·5)
24·3
(5·6 to 49·6)
37·4
(24·8 to 53·4)
47·5
(34·1 to 62·4)
(Figure 2 continues on next page)
Articles
16
www.thelancet.com/psychiatry Published online November 1, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30337-7
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to drug use
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to alcohol use
Gabon
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
246·8
(197·5 to 304·2)
410·5
(342·1 to 490·2)
366·2
(307·5 to 428·7)
289·3
(232·9 to 351·0)
330·2
(272·2 to 388·5)
1006·8
(775·8 to 1302·1)
416·8
(350·1 to 485·7)
235·1
(190·6 to 285·7)
708·7
(542·2 to 883·5)
257·6
(195·8 to 332·3)
375·3
(272·5 to 510·3)
656·3
(546·8 to 768·7)
372·6
(294·7 to 461·2)
442·6
(329·2 to 593·9)
401·1
(334·9 to 471·6)
386·0
(324·7 to 450·2)
242·7
(195·2 to 291·9)
226·8
(188·1 to 270·4)
654·7
(526·2 to 792·9)
845·2
(654·0 to 1045·9)
494·9
(415·5 to 581·3)
253·9
(201·7 to 310·9)
481·4
(404·6 to 554·0)
288·4
(228·2 to 356·0)
305·6
(248·0 to 365·8)
475·5
(366·1 to 596·6)
782·8
(658·2 to 929·5)
416·3
(345·4 to 499·0)
368·1
(268·5 to 472·8)
384·1
(286·8 to 497·2)
738·6
(658·1 to 829·2)
129·8
(89·0 to 174·0)
140·8
(99·6 to 187·5)
156·9
(112·8 to 206·2)
141·2
(97·6 to 187·1)
163·2
(116·1 to 210·5)
372·1
(268·6 to 486·0)
151·8
(107·4 to 201·1)
117·7
(84·2 to 158·2)
176·6
(124·5 to 230·7)
126·3
(86·5 to 167·0)
139·9
(98·4 to 186·3)
177·7
(125·8 to 231·1)
137·9
(96·6 to 182·9)
139·4
(96·7 to 185·6)
130·9
(91·2 to 178·4)
188·3
(136·0 to 243·6)
135·5
(95·8 to 177·8)
122·0
(88·3 to 161·7)
418·6
(303·5 to 541·9)
542·9
(383·3 to 716·0)
216·0
(154·7 to 278·8)
147·5
(103·6 to 194·8)
245·6
(176·1 to 313·2)
177·9
(124·8 to 237·0)
177·8
(128·4 to 232·4)
333·1
(230·6 to 441·4)
196·9
(140·9 to 257·7)
121·8
(88·2 to 159·6)
164·6
(118·5 to 218·2)
274·0
(186·8 to 373·3)
181·5
(128·9 to 236·0)
117·0
(88·3 to 153·9)
269·7
(211·5 to 343·0)
209·2
(175·6 to 248·9)
148·0
(109·7 to 189·6)
167·0
(136·4 to 201·3)
634·7
(450·8 to 904·6)
265·1
(219·5 to 322·5)
117·4
(90·6 to 150·3)
532·1
(371·3 to 708·4)
131·3
(88·5 to 192·7)
235·4
(146·7 to 357·5)
478·6
(393·6 to 577·1)
234·7
(171·1 to 312·2)
303·2
(202·9 to 441·7)
270·2
(218·4 to 328·3)
197·7
(173·3 to 226·1)
107·2
(91·2 to 126·1)
104·8
(90·8 to 119·6)
236·0
(176·7 to 296·9)
302·3
(206·3 to 412·8)
278·9
(227·7 to 337·3)
106·4
(80·7 to 137·2)
235·8
(208·9 to 264·3)
110·5
(85·8 to 148·2)
127·9
(111·1 to 148·4)
142·4
(101·9 to 195·2)
585·8
(478·3 to 710·5)
294·6
(236·8 to 369·5)
203·6
(116·4 to 280·2)
110·0
(74·9 to 155·3)
557·0
(493·3 to 627·8)
2·8
(2·2 to 3·7)
8·7
(7·0 to 10·8)
6·1
(5·1 to 7·4)
3·7
(2·7 to 4·6)
3·6
(3·0 to 4·4)
14·0
(10·4 to 19·2)
8·7
(7·3 to 10·4)
3·0
(2·3 to 3·7)
16·2
(11·3 to 21·6)
3·2
(2·2 to 4·6)
5·6
(3·6 to 8·2)
14·1
(11·6 to 17·0)
7·2
(5·2 to 9·7)
11·4
(7·9 to 16·5)
8·6
(6·9 to 10·5)
5·3
(4·6 to 5·9)
2·6
(2·2 to 3·0)
3·1
(2·7 to 3·5)
6·1
(4·9 to 7·7)
7·3
(5·2 to 9·7)
6·7
(5·6 to 8·1)
3·5
(2·6 to 4·5)
9·0
(7·9 to 10·2)
4·2
(3·3 to 5·5)
3·5
(3·1 to 4·0)
4·5
(3·3 to 6·2)
17·3
(14·3 to 20·8)
7·0
(5·8 to 8·5)
4·6
(2·6 to 6·2)
3·8
(2·5 to 5·3)
16·2
(14·3 to 18·4)
2495·5
(1591·3 to 3635·4)
1755·0
(1110·7 to 2512·7)
1362·1
(1006·1 to 1770·3)
3022·5
(1956·0 to 4014·4)
1004·0
(586·4 to 1410·2)
2558·3
(1496·1 to 3925·8)
1876·2
(1356·3 to 2463·1)
414·2
(124·4 to 1014·4)
2385·9
(1850·6 to 3038·6)
415·2
(192·1 to 625·2)
2690·9
(1262·4 to 4519·2)
2779·3
(2109·0 to 3446·1)
2092·9
(1388·7 to 2895·9)
1550·8
(1150·9 to 2128·8)
2796·8
(1543·9 to 4023·8)
627·0
(405·5 to 887·9)
1117·8
(926·2 to 1316·4)
411·2
(341·1 to 491·2)
77·1
(60·1 to 96·7)
186·4
(–53·8 to 572·3)
1439·7
(1065·8 to 1884·6)
289·4
(188·7 to 410·6)
823·0
(522·6 to 1132·1)
1181·4
(800·6 to 1599·5)
395·7
(242·2 to 550·5)
88·4
(14·6 to 212·1)
3452·9
(2306·2 to 4748·7)
1318·2
(993·3 to 1632·7)
968·4
(484·8 to 1569·5)
84·0
(58·4 to 109·7)
2413·2
(1758·1 to 3109·3)
300·6
(195·6 to 429·4)
273·8
(183·4 to 376·3)
335·8
(223·3 to 473·2)
297·6
(189·0 to 423·7)
251·9
(158·5 to 362·2)
355·3
(234·4 to 510·9)
289·9
(191·4 to 409·6)
89·5
(41·6 to 166·0)
353·6
(244·2 to 491·1)
112·5
(75·1 to 155·3)
187·1
(111·0 to 295·8)
283·0
(192·4 to 390·2)
252·5
(169·1 to 359·3)
247·8
(167·8 to 345·5)
416·9
(208·7 to 649·3)
193·0
(122·6 to 288·2)
181·8
(126·2 to 242·9)
75·8
(52·8 to 104·6)
46·4
(31·7 to 64·2)
58·9
(24·3 to 112·1)
383·8
(261·0 to 542·6)
73·8
(42·0 to 114·1)
185·1
(106·4 to 279·3)
245·8
(155·9 to 360·8)
70·9
(30·1 to 117·2)
47·9
(24·9 to 81·0)
469·2
(319·7 to 653·5)
187·2
(131·4 to 255·1)
110·2
(60·0 to 172·2)
58·5
(39·1 to 82·4)
360·1
(244·5 to 491·0)
2194·9
(1350·1 to 3263·4)
1481·2
(867·3 to 2216·3)
1026·3
(750·4 to 1325·5)
2724·9
(1737·3 to 3666·4)
752·1
(409·8 to 1104·7)
2203·0
(1203·7 to 3530·3)
1586·3
(1105·4 to 2119·3)
324·7
(63·3 to 854·7)
2032·3
(1480·6 to 2663·5)
302·7
(89·0 to 511·3)
2503·8
(1138·7 to 4282·7)
2496·3
(1860·4 to 3146·3)
1840·5
(1180·1 to 2615·2)
1303·0
(915·9 to 1869·7)
2379·9
(1315·7 to 3414·0)
434·0
(255·3 to 630·9)
936·0
(758·5 to 1115·3)
335·4
(275·8 to 401·9)
30·8
(24·6 to 39·0)
127·5
(–84·6 to 489·8)
1055·9
(726·0 to 1400·2)
215·6
(132·8 to 312·3)
637·8
(398·3 to 881·6)
935·6
(596·4 to 1315·4)
324·8
(188·1 to 450·6)
40·4
(–19·4 to 139·4)
2983·7
(1927·5 to 4150·9)
1131·0
(835·3 to 1442·1)
858·2
(408·6 to 1417·3)
25·5
(12·8 to 38·4)
2053·1
(1435·2 to 2699·2)
83·0
(45·9 to 134·5)
45·6
(19·2 to 76·5)
41·3
(24·9 to 60·9)
115·1
(63·3 to 166·2)
31·8
(11·5 to 52·7)
60·6
(29·0 to 108·6)
55·6
(34·9 to 79·6)
4·1
(–4·1 to 20·6)
68·1
(51·3 to 87·4)
8·2
(–1·2 to 16·3)
86·0
(29·7 to 169·4)
76·4
(53·3 to 99·6)
60·7
(33·6 to 92·8)
49·5
(35·4 to 69·0)
95·6
(43·1 to 149·6)
15·2
(3·9 to 30·6)
31·6
(23·9 to 39·6)
14·6
(11·6 to 18·4)
1·4
(1·1 to 1·7)
0·0
(–10·0 to 16·4)
46·8
(27·9 to 66·9)
7·1
(3·3 to 11·7)
31·4
(16·9 to 46·6)
34·4
(18·4 to 51·1)
9·1
(4·3 to 14·0)
0·1
(–3·5 to 5·0)
103·4
(56·2 to 162·7)
43·2
(29·9 to 56·9)
22·5
(8·4 to 40·8)
1·1
(0·3 to 1·7)
53·9
(26·1 to 86·2)
(Figure 2 continues on next page)
Articles
www.thelancet.com/psychiatry Published online November 1, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30337-7
17
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to drug use
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to alcohol use
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Moldova
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nepal
Netherlands
New Zealand
Nicaragua
Niger
255·2
(202·5 to 317·8)
627·7
(543·4 to 717·3)
384·3
(289·3 to 487·8)
846·5
(680·0 to 1043·8)
263·0
(203·4 to 332·1)
467·8
(364·6 to 579·5)
759·5
(668·7 to 855·6)
415·6
(349·3 to 486·7)
232·8
(190·9 to 280·3)
172·0
(126·8 to 222·5)
330·9
(207·7 to 540·1)
368·1
(282·2 to 476·8)
210·0
(166·1 to 262·1)
221·0
(168·8 to 281·7)
345·3
(279·8 to 410·4)
206·1
(158·0 to 256·6)
200·8
(143·4 to 268·6)
359·2
(301·2 to 424·1)
497·8
(438·0 to 559·4)
904·3
(796·6 to 1021·2)
1057·4
(872·5 to 1259·5)
335·5
(281·0 to 395·8)
364·2
(278·3 to 459·6)
347·0
(218·0 to 572·2)
573·6
(477·9 to 691·0)
540·1
(438·1 to 656·8)
238·1
(182·3 to 306·3)
260·8
(211·6 to 315·8)
427·0
(342·6 to 534·4)
456·2
(363·9 to 557·9)
190·8
(144·8 to 236·9)
136·1
(96·9 to 183·3)
241·7
(172·9 to 311·6)
283·2
(196·4 to 380·7)
210·9
(150·1 to 277·8)
126·0
(88·5 to 167·2)
303·4
(211·2 to 401·3)
197·2
(139·4 to 256·5)
180·6
(128·2 to 238·7)
106·1
(76·0 to 141·7)
101·7
(69·8 to 137·6)
119·8
(83·4 to 162·7)
170·1
(122·5 to 225·2)
128·4
(91·8 to 174·5)
118·4
(80·6 to 159·4)
196·8
(139·3 to 256·0)
108·6
(77·2 to 144·0)
127·2
(86·9 to 170·2)
134·1
(93·8 to 180·9)
146·5
(104·1 to 190·3)
200·2
(144·6 to 261·8)
148·1
(106·9 to 192·8)
149·9
(106·8 to 197·3)
262·4
(182·7 to 350·8)
114·7
(78·9 to 156·9)
129·2
(93·0 to 173·6)
203·3
(143·8 to 266·3)
141·0
(96·2 to 190·2)
159·1
(112·4 to 211·4)
268·0
(191·8 to 361·1)
127·5
(88·2 to 172·4)
116·3
(81·5 to 155·9)
119·1
(85·9 to 160·0)
386·0
(337·1 to 437·3)
101·2
(72·8 to 137·7)
635·5
(497·2 to 816·5)
137·0
(94·2 to 197·5)
164·4
(119·8 to 211·5)
562·3
(496·2 to 630·2)
235·0
(193·7 to 279·7)
126·6
(99·6 to 151·9)
70·3
(42·4 to 108·6)
211·1
(102·1 to 388·6)
198·1
(134·2 to 293·7)
81·7
(61·2 to 110·5)
102·7
(69·0 to 152·5)
148·5
(116·2 to 186·4)
97·4
(68·0 to 135·5)
73·6
(36·1 to 131·4)
225·1
(186·9 to 269·2)
351·2
(308·3 to 392·4)
704·2
(613·1 to 804·3)
909·3
(730·4 to 1104·8)
185·6
(156·8 to 228·2)
101·8
(79·1 to 135·0)
232·3
(116·3 to 432·2)
444·4
(363·5 to 556·6)
336·8
(258·9 to 431·9)
97·2
(71·3 to 153·0)
101·7
(86·9 to 118·7)
158·9
(128·2 to 202·8)
328·7
(247·8 to 422·8)
74·5
(50·1 to 103·9)
2·8
(2·0 to 3·8)
9·5
(8·3 to 10·7)
3·3
(2·4 to 4·4)
14·8
(11·7 to 18·6)
3·5
(2·4 to 4·8)
5·1
(3·7 to 6·6)
13·8
(12·3 to 15·4)
7·0
(5·8 to 8·2)
4·5
(3·5 to 5·4)
1·8
(1·1 to 2·7)
5·1
(2·7 to 9·3)
5·2
(3·7 to 7·3)
2·8
(2·1 to 3·7)
2·6
(1·8 to 3·8)
4·2
(3·3 to 5·2)
2·2
(1·6 to 3·1)
1·9
(1·0 to 3·4)
6·7
(5·6 to 7·9)
10·3
(8·9 to 11·6)
22·8
(19·9 to 25·9)
36·6
(28·6 to 46·0)
5·2
(4·4 to 6·1)
2·9
(2·2 to 3·9)
5·7
(3·1 to 10·3)
11·5
(9·3 to 14·3)
8·2
(6·3 to 10·2)
2·4
(1·8 to 3·7)
3·3
(2·8 to 3·8)
3·9
(3·3 to 4·8)
10·2
(7·6 to 13·3)
2·0
(1·3 to 2·7)
1567·0
(902·7 to 2411·7)
3127·6
(2403·2 to 3879·3)
266·7
(140·2 to 429·9)
9387·2
(6374·2 to 12638·7)
2101·0
(1255·2 to 3040·7)
91·9
(59·2 to 122·9)
3754·2
(3222·7 to 4410·1)
1614·1
(1296·4 to 1957·1)
698·0
(418·1 to 1053·3)
1114·1
(567·1 to 1938·2)
1691·4
(926·2 to 2739·1)
783·8
(619·4 to 956·7)
142·4
(28·0 to 323·0)
787·2
(528·4 to 1077·8)
413·4
(202·4 to 676·2)
339·8
(–225·7 to 1326·9)
328·9
(247·3 to 418·4)
990·9
(530·9 to 1512·4)
1596·9
(1343·8 to 1903·6)
3427·0
(2380·0 to 4542·0)
4033·7
(2848·8 to 5353·3)
2423·5
(1778·3 to 3007·1)
304·4
(234·5 to 395·5)
1463·4
(597·5 to 2594·0)
1222·6
(851·4 to 1637·4)
3332·8
(1835·9 to 4982·6)
777·9
(509·4 to 1136·2)
786·5
(559·4 to 1058·2)
1011·7
(738·4 to 1327·2)
1427·6
(1141·5 to 1741·4)
326·1
(128·8 to 541·5)
177·1
(104·0 to 263·6)
511·9
(349·4 to 688·6)
105·4
(68·6 to 153·6)
385·2
(244·4 to 566·7)
211·3
(132·4 to 313·6)
54·0
(34·8 to 76·9)
591·6
(413·1 to 795·7)
377·7
(250·1 to 521·7)
200·9
(129·8 to 289·6)
186·0
(120·7 to 264·6)
201·0
(131·2 to 287·2)
129·5
(87·9 to 181·4)
80·3
(47·6 to 125·4)
143·3
(97·3 to 196·5)
153·3
(94·0 to 228·3)
74·2
(1·6 to 195·2)
118·1
(80·2 to 164·5)
183·1
(108·5 to 270·6)
262·9
(169·7 to 380·1)
495·2
(328·8 to 695·5)
472·0
(318·0 to 644·5)
415·0
(276·2 to 574·5)
66·5
(45·8 to 92·6)
180·3
(115·4 to 267·1)
142·7
(95·5 to 198·9)
342·5
(208·8 to 524·2)
192·5
(131·2 to 259·0)
181·0
(112·1 to 274·0)
276·6
(185·3 to 384·2)
275·4
(189·6 to 378·4)
112·5
(77·2 to 156·8)
1389·9
(774·8 to 2178·4)
2615·7
(1931·1 to 3296·9)
161·3
(55·4 to 290·5)
9002·0
(5979·9 to 12234·3)
1889·7
(1095·5 to 2796·6)
37·9
(16·0 to 57·4)
3162·6
(2672·4 to 3741·8)
1236·4
(1000·1 to 1495·5)
497·1
(243·7 to 822·6)
928·0
(409·3 to 1709·9)
1490·4
(763·1 to 2491·8)
654·3
(505·3 to 803·0)
62·1
(–30·0 to 214·7)
643·9
(404·5 to 916·8)
260·1
(84·9 to 480·8)
265·6
(–238·0 to 1134·9)
210·8
(141·9 to 286·4)
807·8
(407·8 to 1286·2)
1334·0
(1127·0 to 1565·7)
2931·8
(1953·7 to 3958·0)
3561·7
(2440·7 to 4811·1)
2008·5
(1437·2 to 2541·5)
238·0
(174·6 to 317·8)
1283·1
(462·8 to 2384·8)
1079·8
(741·6 to 1466·0)
2990·4
(1573·2 to 4548·6)
585·4
(345·7 to 910·4)
605·5
(427·5 to 822·3)
735·1
(503·5 to 983·4)
1152·2
(908·6 to 1457·8)
213·6
(28·2 to 422·9)
51·0
(23·8 to 86·4)
77·3
(49·7 to 107·7)
4·5
(–0·4 to 10·9)
292·8
(181·2 to 410·4)
72·0
(36·4 to 115·6)
1·4
(0·0 to 2·4)
97·6
(75·1 to 122·6)
58·6
(44·6 to 75·5)
23·1
(9·1 to 43·0)
31·0
(10·7 to 64·5)
49·7
(24·2 to 86·8)
28·6
(21·3 to 36·5)
1·0
(–3·9 to 8·1)
26·8
(14·9 to 41·1)
6·8
(–3·1 to 19·4)
–2·2
(–20·7 to 31·6)
8·2
(5·8 to 11·0)
23·8
(7·3 to 44·3)
46·6
(38·1 to 56·8)
93·7
(51·1 to 141·2)
126·7
(78·3 to 182·4)
100·2
(64·5 to 136·0)
9·6
(6·6 to 13·6)
40·8
(11·7 to 82·7)
38·4
(24·7 to 53·6)
93·1
(41·4 to 157·6)
19·1
(10·1 to 32·5)
25·6
(15·7 to 37·0)
22·1
(10·7 to 35·8)
40·5
(31·0 to 51·6)
5·2
(–3·0 to 12·7)
(Figure 2 continues on next page)
Articles
18
www.thelancet.com/psychiatry Published online November 1, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30337-7
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to drug use
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to alcohol use
Nigeria
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Lucia
Saint Vincent and the Grenadines
Samoa
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
577·9
(467·8 to 725·8)
388·7
(309·7 to 504·3)
175·9
(139·9 to 219·5)
591·3
(504·0 to 679·9)
360·4
(266·5 to 469·4)
397·2
(287·9 to 516·7)
601·3
(485·3 to 724·5)
276·2
(226·6 to 334·3)
206·1
(159·3 to 259·8)
221·2
(172·0 to 271·1)
269·8
(215·7 to 331·1)
199·1
(155·9 to 245·4)
316·8
(262·9 to 374·4)
313·6
(262·5 to 370·1)
645·4
(537·9 to 763·8)
432·4
(313·7 to 563·8)
448·3
(374·4 to 531·5)
1380·2
(1089·6 to 1719·1)
166·2
(124·7 to 215·0)
335·7
(285·1 to 388·5)
378·2
(324·4 to 436·0)
204·6
(163·0 to 251·2)
157·8
(116·2 to 218·6)
461·7
(375·1 to 549·1)
211·5
(165·0 to 260·0)
258·9
(218·5 to 302·6)
458·4
(391·5 to 537·4)
225·2
(177·4 to 276·8)
241·3
(182·3 to 310·1)
321·7
(260·7 to 396·1)
350·2
(290·0 to 414·7)
151·0
(105·8 to 198·0)
163·7
(118·5 to 215·0)
109·0
(76·6 to 146·4)
240·5
(173·6 to 311·2)
275·1
(184·5 to 377·1)
235·3
(155·5 to 318·4)
355·2
(247·2 to 469·5)
133·8
(95·3 to 178·6)
105·5
(75·6 to 141·5)
121·2
(84·7 to 163·6)
152·5
(107·2 to 202·6)
132·5
(94·5 to 177·4)
131·0
(92·6 to 175·4)
151·2
(109·1 to 199·1)
239·0
(168·2 to 313·8)
303·9
(209·4 to 409·7)
103·4
(74·4 to 135·2)
325·7
(234·8 to 423·6)
108·0
(76·2 to 145·2)
142·2
(101·3 to 190·8)
147·2
(105·7 to 195·3)
112·1
(78·9 to 149·0)
110·5
(76·6 to 147·0)
275·8
(194·6 to 360·8)
126·9
(88·3 to 168·1)
94·2
(66·5 to 124·1)
160·3
(116·1 to 212·1)
124·4
(86·2 to 166·5)
186·9
(131·3 to 253·2)
115·2
(82·4 to 154·8)
135·2
(96·1 to 177·0)
426·9
(329·9 to 563·2)
225·1
(160·4 to 339·6)
66·9
(49·0 to 90·3)
350·9
(296·8 to 405·0)
85·3
(62·9 to 111·9)
161·9
(106·0 to 258·1)
246·1
(209·1 to 296·9)
142·4
(113·7 to 177·8)
100·6
(69·6 to 143·1)
100·0
(72·0 to 129·7)
117·3
(89·7 to 151·8)
66·6
(52·7 to 83·4)
185·8
(150·5 to 227·3)
162·4
(137·6 to 192·8)
406·4
(330·9 to 499·8)
128·5
(81·7 to 194·1)
345·0
(276·7 to 425·4)
1054·4
(790·8 to 1367·2)
58·3
(39·3 to 90·0)
193·5
(167·3 to 219·8)
231·0
(203·3 to 262·2)
92·5
(72·9 to 116·5)
47·3
(24·6 to 97·1)
185·9
(158·6 to 212·7)
84·7
(60·0 to 110·3)
164·7
(135·6 to 192·4)
298·1
(250·6 to 366·4)
100·8
(73·0 to 129·2)
54·3
(40·0 to 71·6)
206·4
(151·2 to 269·4)
215·0
(169·1 to 262·4)
9·7
(7·6 to 12·3)
6·5
(4·7 to 9·3)
1·8
(1·3 to 2·3)
8·3
(7·1 to 9·5)
2·5
(1·8 to 3·5)
3·9
(2·6 to 6·1)
11·0
(9·2 to 13·3)
5·0
(3·8 to 6·2)
2·2
(1·5 to 3·2)
2·8
(2·0 to 3·7)
3·8
(2·9 to 5·0)
1·6
(1·3 to 2·0)
5·3
(4·3 to 6·5)
4·9
(4·1 to 5·8)
11·7
(9·8 to 13·9)
4·7
(2·9 to 7·2)
11·9
(9·5 to 14·6)
24·5
(18·6 to 31·7)
1·5
(1·1 to 2·4)
6·5
(5·7 to 7·3)
8·0
(7·1 to 9·0)
2·3
(1·8 to 2·9)
1·2
(0·6 to 2·3)
7·4
(6·3 to 8·6)
2·2
(1·5 to 2·9)
5·4
(4·6 to 6·4)
8·2
(6·9 to 9·9)
2·6
(1·8 to 3·2)
1·5
(1·1 to 2·1)
6·1
(4·5 to 8·1)
6·9
(5·4 to 8·5)
1527·0
(922·6 to 2257·0)
1070·8
(681·7 to 1534·2)
574·1
(277·5 to 1083·5)
698·0
(473·0 to 958·5)
181·0
(69·8 to 374·8)
282·6
(217·4 to 359·5)
10·5
(–80·1 to 81·9)
1313·5
(1042·3 to 1627·4)
2372·6
(1198·6 to 3788·6)
1866·7
(1308·3 to 2415·6)
975·7
(664·9 to 1343·1)
1612·0
(1006·1 to 2333·0)
2065·4
(1619·6 to 2528·5)
1790·9
(1464·4 to 2122·2)
1542·6
(1043·5 to 2063·8)
393·3
(210·9 to 652·2)
3244·3
(1584·7 to 4865·0)
4942·7
(3368·7 to 6832·1)
2766·5
(1572·7 to 4087·2)
1634·8
(1249·3 to 2068·8)
1726·1
(1217·0 to 2289·3)
751·4
(370·9 to 1320·9)
1969·6
(1503·3 to 2461·2)
87·1
(50·6 to 121·4)
614·5
(420·6 to 839·6)
2156·2
(951·8 to 3550·3)
1713·5
(1173·0 to 2262·1)
3171·9
(1920·2 to 4289·6)
61·3
(–16·3 to 145·7)
1991·0
(1522·8 to 2509·7)
1635·8
(1308·7 to 2020·9)
213·6
(132·9 to 315·0)
163·0
(108·1 to 234·2)
130·6
(70·0 to 225·0)
230·1
(139·4 to 335·5)
73·0
(42·2 to 115·9)
154·2
(105·3 to 214·8)
45·0
(26·0 to 67·7)
273·1
(181·9 to 381·5)
213·5
(116·2 to 329·3)
349·4
(233·3 to 479·0)
220·3
(139·2 to 316·7)
202·2
(127·3 to 296·0)
362·9
(246·6 to 487·8)
307·2
(206·6 to 423·2)
291·9
(180·8 to 425·3)
129·9
(73·7 to 206·8)
428·5
(198·0 to 691·7)
638·1
(449·2 to 865·1)
347·5
(215·1 to 507·5)
285·2
(188·5 to 407·2)
296·7
(194·8 to 416·8)
135·3
(75·9 to 215·2)
241·6
(169·6 to 337·9)
51·3
(32·9 to 73·3)
132·3
(90·7 to 183·9)
406·5
(190·3 to 646·9)
212·0
(138·3 to 301·0)
250·1
(156·1 to 359·5)
33·0
(11·1 to 61·0)
392·1
(268·3 to 529·8)
387·4
(272·7 to 527·5)
1313·3
(765·6 to 2002·8)
907·8
(529·9 to 1334·8)
443·6
(189·0 to 855·6)
467·9
(294·9 to 681·9)
108·0
(17·4 to 272·1)
128·4
(88·4 to 174·8)
–34·5
(–115·4 to 24·2)
1040·4
(800·5 to 1315·7)
2159·2
(1049·5 to 3502·3)
1517·3
(1011·8 to 2014·3)
755·4
(482·1 to 1081·2)
1409·7
(856·0 to 2063·0)
1702·5
(1298·3 to 2097·4)
1483·7
(1211·5 to 1750·3)
1250·7
(814·2 to 1710·0)
263·4
(123·4 to 469·4)
2815·8
(1376·9 to 4191·7)
4304·6
(2769·0 to 6144·6)
2419·0
(1274·2 to 3693·8)
1349·7
(1035·6 to 1714·2)
1429·4
(987·0 to 1943·8)
616·1
(275·3 to 1114·4)
1728·1
(1277·9 to 2181·5)
35·8
(11·0 to 61·5)
482·2
(302·4 to 698·7)
1749·6
(736·6 to 2961·5)
1501·4
(1010·7 to 2007·4)
2921·7
(1722·6 to 4011·1)
28·3
(–38·0 to 101·1)
1598·8
(1184·6 to 2053·0)
1248·5
(986·9 to 1568·8)
46·7
(23·0 to 79·8)
30·7
(14·2 to 50·4)
13·3
(4·1 to 30·9)
16·0
(5·8 to 29·3)
2·2
(–2·2 to 10·5)
4·2
(2·8 to 5·7)
–3·4
(–9·8 to 0·7)
40·0
(29·0 to 52·7)
69·1
(25·2 to 127·3)
48·0
(28·3 to 68·0)
26·9
(15·0 to 42·4)
48·7
(25·4 to 76·9)
57·8
(38·5 to 78·4)
68·1
(52·2 to 83·8)
40·3
(24·8 to 56·9)
10·0
(3·1 to 21·6)
124·1
(50·3 to 197·2)
119·3
(72·6 to 176·0)
90·0
(41·2 to 152·5)
45·4
(31·9 to 61·4)
47·8
(28·6 to 72·9)
17·6
(4·0 to 38·5)
74·9
(51·8 to 100·2)
1·0
(–0·6 to 2·6)
18·7
(11·3 to 28·4)
77·2
(25·8 to 140·4)
61·1
(38·3 to 85·0)
117·7
(54·5 to 177·4)
–0·6
(–3·7 to 2·3)
55·5
(32·2 to 81·8)
54·6
(40·7 to 70·5)
(Figure 2 continues on next page)
Articles
www.thelancet.com/psychiatry Published online November 1, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30337-7
19
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to drug use
Age-standardised
DALYs per 100
000
people (95% UI)
Age-standardised
YLDs per 100
000
people (95% UI)
Age-standardised
YLLs per 100
000
people (95% UI)
Age-standardised
deaths per 100
000
people (95% UI)
Attributable to alcohol use
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan (province of China)
Tajikistan
Tanzania
Thailand
The Bahamas
The Gambia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Uganda
Ukraine
United Arab Emirates
UK
USA
191·8
(150·2 to 240·1)
156·6