AKU National Health Sciences Research Symposium on Mental Health

Mental Ill Health: A Growing Burden

There is a rapid rise of mental health disorders. They represent a major challenge to global development. The rise in this burden will be relatively higher in developing countries which have the least resource to respond. Mental, neurological and behavioural disorders take a huge toll. Worldwide, 450 million people are affected at any given time. Put in another way, one in four families has at least one member with a mental disorder. No group is immune to mental disorders but the risk is higher among the poor, children and adolescent, abused women, the unemployed, persons with low education, the neglected elderly, victims of violence, migrants and refugees and indigenous populations.

Neuropsychiatric disorders are non-fatal (in general) but highly disabling (if we take disability alone, neuropsychiatric disorders account for 31% of all disability worldwide) and highly prevalent (12-month prevalence rate of psychiatric disorders is in the order of 20-25%). 12.3% of all DALYS lost in the world are attributable to neurological, psychiatric and substance abuse disorders, in 2020 these disorders will account for 15% of all DALYS.

However, neuropsychiatric disorders should also be considered as linked with death and not only with morbidity and disability: depression severity is correlated with a greater relative risk of death in the elderly.

Talking about mental disorders means talking about poverty - they are linked in a vicious cycle.

Mental disorders can result in substantial and sustained disability leading to social and occupational disadvantage, both in developed and developing countries. Mental disorders impair psychological and social functioning and individuals with mental disorders and disability end up in more socially disadvantaged circumstances. We can say that mental ill health is a significant contributor to poverty.

The poor have been shown to be more likely to have a mental disorder than those with higher incomes. People in socially disadvantaged situations are exposed to more psychosocial stressors (adverse life events) than those in more advantaged environments. We can say that poverty is a significant contributor to mental ill health.

Poor provision of mental health care results in poor outcomes, avoidable relapses and insufficient rehabilitation. We can say that poor mental health service provision is a significant contributor to perpetuation of mental ill health and poverty.

Not only are mental disorders framed in poverty but they also represent a cost for all communities.

Mental disorders represent an importance cost for all communities:

1. For health service utilisation the most important contributor to direct costs of depression is hospitalisation, accounting for around half the total in the UK and three-quarters in the US.
2. For social welfare utilisation.
3. For days out of role (US data suggests that for mental disorders, the number of work cutback days is five times the number lost through absenteeism).
4. For days out of role and lost employment of caregivers.

Most mental, brain and substance use disorders can be managed effectively with medication and/or psychosocial interventions.

Effective (in some cases cost-effective) interventions are available for almost all mental disorders. Often interventions do not cure disorders but substantially improve symptoms are decrease relapses, or lead to social recovery (not clinically) or improve quality of life.

Mental health promotion and mental ill health prevention can reduce the overall vulnerability to disorders ad improve the general mental health of the population through improved individual skills and resources, the empowerment of the communities and improvements in the socio-economic environment.

However, the cost-effectiveness criterion is just one among several in the decision process of funding prevention/treatment of mental disorders.

Other arguments should be considered:

1. People with mental disorders are more at risk of human right violations and are more likely to be discriminated against in accessing treatment and care (moral argument).
2. Catastrophic costs inflicted by treatment upon care seekers (argument of population protection).
3. Employer benefit from reduced absenteeism and higher productivity.
Caregivers benefit from lower burden of care and loss of productivity (workplace costs are nearly as large as the direct costs of successful depression treatment).
4. Governments benefit from fewer Transfer Payments (welfare and social security)
5. Achievement of physical health targets.
   • Infant and child mortality will be reduced through improved treatment of post natal depression (e.g. attendance to vaccinations, nutrition and hygiene regimes)
   • HIV infection rates for 17-24 year old age group are reduced because improved mental health reduces unsafe sex and drug usage.
   • Adherence (TB, HIV/AIDS, hypertension, diabetes and cancer treatments)

Nevertheless, cost effective interventions are not implemented and there is a huge gap between treated and untreated.

Urgent action is needed to close the treatment gap and to overcome barriers which will prevent people from receiving appropriate care.

Barriers:

Stigma
Around the world, many people with mental disorders are victimised for their illness and become targets of unfair discriminations. Access to housing, employment, and other normal societal roles is often compromised.

Discrimination in coverage for mental disorders
In many countries, mental disorders are not covered by health insurance schemes, so many people cannot afford the treatment. One-quarter of all countries do not provide disability benefits to patients with mental disorders. One-third of the world's population - 2 billion people - live in countries that spend less than 1% of their health budget on mental health.

Lack of drugs
Though 85% of countries have an essential drug list that countries use as a basis for procuring therapeutic drugs, almost 20% of countries do not have at least one common anti-depressant, one anti-psychotic, and one anti-epileptic in primary care. 

Wrong priorities
Too many countries (mostly developed countries) still spend most of their resources on a few mental asylums, which not only focus on a small fraction of those who need treatment but provide poor quality and often inhumane care.

Lack skills at the primary health care level
Too few doctors and nurses know how to recognise and properly treat mental disorders. 41% of countries do not have any mental health training programme for primay health care professionals.

Lack of rational and comprehensive mental health policies and legislation

Worldwide, 40% countries do not have any mental health training policy.

Worldwide, 25% of countries do not have mental health legislation.

Worldwide, 30% of countries do not have a national mental health programme.

Closing this gap is a clear obligation; otherwise no discourse around new classifications, concerns about more sophisticated diagnosis, the development of innovation psychopharmacological research can be credible, at least not from the WHO global and moral perspective.

WHO Global Action Programme

Mental health 2001
2001 was the "year of mental health" at WHO. World Health Day 2001 was a resounding success. Over 150 countries organised significant activities, including the delivery of major addresses by political leaders and the adoption of new mental health legislation.

At last year's World Health Assembly, over 130 Ministers responded positively with a clear and unequivocal message: mental health neglected too long is crucial to the overall well-being of individuals, societies and countries and must be universally regarded in a new light.

The theme of the World Health Report 2001 was mental health and its 10 Recommendations have been positively received by all Member States.

As a result of 2001 activities the Mental Health Global Action Programme (mhGAP) has been created. GAP is our major new effort to put strategic directions in place for addressing the findings in the World Health Report. GAP logic is based on four strategies.

1. Increasing and improving information for decision making and technology transfer. We should know more about the magnitude and the burden of mental disorders around the world, and know more about the resources (human, financial, socio-cultural) that are available in countries to respond to the burden generated by mental disorders. We should increase and improve the transfer of mental health related technologies.
2. Raising awareness about mental disorders through education and advocacy for more respect of human rights and less stigma; we should address not only the general public but policy makers, politicians and other sectors
3. Assisting countries in designing policies and developing comprehensive and effective mental health services. The scarcity of resource forces a rational use of them
4. Finally, we should build a local capacity for public mental health research in poor countries.

These key words: information/advocacy/policy/research are the key words of WHO's new global mental health programme aiming at closing the gap between those who receive care and those who do not.

At the Executive Board meeting in January 2002 a resolution on mental health encouraging continued activity in this area was adopted. The language of the resolution strongly supports the direction of mhGAP and urges action by Member States. The resolution was endorsed unanimously by the World Health Assembly in May 2002.