It is essential that mental health issues and needs gain more traction in the discussion on health priorities – and Patricio provides a well-informed overview of historical shifts in perceptions as well as key issues and globally-needed responses.
It is true that mental health is a far-reaching issue with strong linkages to poverty, violence, substance abuse and other high-risk behaviors. Available evidence also shows that it is bi-directional—poverty places people at risk for poor mental health and poor mental health places individuals at risk of falling into poverty. It is also a common consequence of conflict as decades of research initially from veteran populations and more recently civilian populations throughout the world has shown. As an institution, if we want to reach the poorest of the poor and help the most vulnerable, mental health needs to take its place higher on the development agenda.
I have spent some time (at the Harvard Program in Refugee Trauma, UNHCR and even within the Bank) trying to better understand the problems and the solutions. From my own research and from the dialogue surrounding mental health, I have come to think the pervasiveness of mental health issues (in terms of both cause and effect) and the innumerable points of intervention can sometimes frustrate or even paralyze our efforts to take action – or leave us in a situation where we don’t even know where to begin. Moreover, in providing assistance, it is critical to ensure culturally-sensitive responses are supported. Taken together, its complexity and far-reaching linkages to other social and economic issues, seem to relegate mental health issues as only a consequence of or something trumped by other development priorities, rather than its own problem deserving direct assistance.
Furthermore, a large body of literature provides ample evidence, contrary to the common view point that mental health issues are something experienced by a small portion of the population, that such problems just “go away”, and there is nothing that can be done. Mental health is an issue affecting a large portion of the population (this is true in terms of overall prevalence and among conflict-affected populations – with large epidemiologic surveys finding that depression and PTSD can be up to seven to ten times the baseline level found in non-traumatized populations). And, there are culturally sensitive instruments to measure these disorders and culturally sensitive ways to respond. Poor mental health also has a high economic burden (with most of the research based on depression). The economic burden cannot be measured solely in terms of the cost of care, but also needs to consider the loss of income due to unemployment and expenses for social support. Furthermore, this does not even touch on the high personal costs in terms of lost potential. Mental disorders can also have an inter-generational impact on health and growth -- for example, research shows that a depressed mother may not be able to provide her child with adequate attention and/or nutrition which in turn can lead to developmental delays in an infant.
As an evidence-based institution we should respond to the evidence. Some important statistics, in addition to those provided by the author (the following points are directly taken from a blog by Tom Insel, Director of NIMH):
• The global cost of mental illness was nearly $2.5T (two-thirds in indirect costs) in 2010, with a projected increase to over $6T by 2030 (global health spending in 2009 was $5.1T; the entire overseas development aid over the past 20 years is less than $2T). (Global Economic Burden of Non-Communicable Diseases, WEF and Harvard School of Public Health, 2011).
• This WEF/HSPH report (2011) provides comparisons across non-communicable diseases (NCDs) to give some sense of the drivers of global economic burden. The study finds that mental health costs are the largest single source; larger than cardiovascular disease, chronic respiratory disease, cancer, or diabetes. Mental illness alone will account for more than half of the projected total economic burden from NCDs over the next two decades and 35% of the global lost output. Considering that those with mental illness are at high risk for developing cardiovascular disease, respiratory disease, and diabetes, the true costs of mental illness must be even higher.
This report concludes that: "Economic policy-makers are naturally concerned about economic growth. The evidence presented in this report indicates that it would be illogical and irresponsible to care about economic growth and simultaneously ignore NCDs. Interventions in this area will undeniably be costly. But inaction is likely to be far more costly.”
Similar to any other health condition, we can treat the outcome of a problem but if we don’t address the cause we will never arrive at long-term solutions that the populations we aim to assist desperately need. We can address poverty by providing money to people (e.g., cash transfers) which is important and useful but unless we also address the underlying causes of poverty (limited access to schooling, health care, stigma, etc.) we will never see its full eradication. The same is true with mental health and its consequences. As a practitioners workshop in early May will ask – what if traumatic experiences (e.g., in the context of conflict) could be preventing a portion of the population from even participating in Bank-supported activities (skills development, job market insertion efforts, health prevention, etc.)?
The World Bank as a global leader in health and social assistance is well-placed to address this area of health just as any other health issue given its reach, leverage, ability to shape policy, etc. Consistent support from the Bank could affect real change in the lives of populations that we aim to assist as an institution. Similar to Jefferson’s quote – we also understand the various dimensions of well-being where health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (WHO) This understanding where mental health also figures prominently – should guide our actions.