Thank you for raising such an important issue and for the excellent article. I agree with almost everything you have written. Some additional thoughts, with inspiration from the excellent speakers at yesterday’s Global Burden of Depression event at UCL (https://www.eventbrite.co.uk/e/global-mental-health-addressing-the-global-burden-of-depression-tickets-10893337265):
- There is good reason to believe that the Global Burden of Disease estimates, based on DALYs, may *underestimate* the burden of mental health problems. Mental distress, as distinct from disability (which implies some functional or occupational impairment), is to my knowledge not well captured in the DALY (or QALY for that matter, although extensions to EQ-5D may be an improvement). In many LMICs where welfare support may be minimal or non-existent, people with mental health problems may have no choice but to keep working to earn wages, even if they feel subjectively terrible; and especially if this is compounded by a stigma against mental illness. Further, as has been emphasised by Richard Layard and others, we know that individuals on the whole can and do adapt to disability over time, but not to mental illness. So I would argue that in terms of disease burden, mental ill health is probably an even bigger problem than the current numbers suggest.
- You mention the role of UHC and ensuring medicines within an essential package. Evidence-based psychosocial interventions are equally important, and can be as clinically and cost-effective as drugs (and sometimes more so) for a range of mental health conditions, as established in UK's NICE guidelines (http://www.nccmh.org.uk/guidelines.html). With respect to their application in LMICs, there are however at least two challenges:
1) Defining the package of essential interventions
This is essentially an issue of priority-setting, i.e. within a given health budget, what mix of interventions can deliver the greatest health gains? Evidence-based clinical guidelines based on cost-effectiveness considerations would be very helpful here. Given that developing clinical guidelines de novo is time consuming and resource intensive, adapting existing guidelines could be a solution. For example, some success stories have been reported in sub-Saharan Africa: WHO mental health guidelines were adapted in Nigeria, contextualised to local cultural and health system context, and through a locally acceptable inclusive process (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001501). We still yet to see any guideline adaptation processes that explicitly consider cost-effectiveness; this is a methodology we are currently developing as part of the International Decision Support Initiative (www.idsihealth.org, led by NICE International with Gates Foundation and UK DFID funding support).
2) Downstream implementation issues
What could be realistically delivered in LMIC settings, where there are not enough specialist psychiatrists and psychologists? Then this might mean adapting evidence-based, manualised interventions for delivery in community and primary care settings, by non-specialists (e.g. nurses, graduates, even 'lay counsellors') with minimal training and ongoing supervision, and using group-based interventions. In the UK NHS, most psychological therapy delivered through a stepped-care model, with mild mental health problems treated by trained graduate mental health workers (http://www.iapt.nhs.uk/workforce/low-intensity/) My personal experience was as a PhD student delivering effective CBT for dementia carers, following 2 weeks training alongside other graduate psychologists, and this proved to be extremely cost-effective intervention (http://www.bmj.com/content/347/bmj.f6276). There are also many good and innovative examples in LMICs, for example Vikram Patel's work with lay counsellors in India.
- Finally, mental health is a particularly thorny issue for the clinician or policymaker, irrespective of any quantitative differences in burden, for various reasons:
1) Stigma across the broad spectrum of mental health problems has arguably been universal across different cultures in the world through time, in a way that has not dominated physical health problems as a whole (perhaps with the exception of some infectious diseases). Societal attitudes are improving in Western societies, but this has not happened overnight nor without changes in policy and legislation.
2) We simply know much less about the aetiology of mental health problems on the whole as compared with physical health problems; and we do know that they tend to be much more complex. Science tells us quite a lot about the multitude of biopsychosocial risk factors for depression, but no-one can say what “causes” depression. Primary prevention is relatively easy when statins can be prescribed to lower the population average cholesterol levels, but how do we do primary prevention for depression if we don’t even know the cause? Better identification through risk algorithms, as proposed by Michael King and colleagues, with targeted prevention/intervention might be one way forward.
In all, this is a timely article with timely action from the World Bank. Clearly the problem of mental illness is complex and needs to be tackled from multiple directions. If UHC is our goal, then mental health and physical health are inseparable. At NICE International and the International Decision Support Initiative, we believe that an evidence-based and inclusive approach should be an overarching principle to priority-setting, and is a necessary condition for achieving sustainable UHC (http://www.nice.org.uk/media/0A7/35/LancentBellagioHTAUHC.pdf).