Published on Investing in Health

Shining a light on mental illness: An “invisible disability”

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This year’s International Day of Persons with Disabilities, observed December 3, takes as its theme: “Inclusion matters: Access and Empowerment for People of all Abilities.”  Under this umbrella, the U.N. and other international agencies urge inclusion of persons with “invisible disabilities” in society and in development efforts.

This call is long overdue; persons with mental and psychosocial disabilities represent a significant proportion of the world’s population with special needs.  The World Health Organization (WHO) estimates that millions of people have mental disorders, and that one in four people globally will experience a mental disorder in their lifetime. Moreover, almost one million people die each year due to suicide, which is the third leading cause of death among young people. According to several recent reports, suicide has surpassed maternal mortality as the leading cause of death among girls aged 15-19 years globally.  

Aside from facing entrenched stigma and discrimination – and physical and sexual abuse in homes, hospitals, prisons, or as homeless people --  persons affected by mental disorders are excluded from social, economic and political activities.

When I was a student in the early 1980s working at St. Elizabeths Hospital in Washington, D.C., I had the opportunity to witness first-hand the plight of those “excluded and marginalized” from society due to mental disorders.  At that time, one of the programs run by the hospital, which opened in 1855 as the first psychiatric hospital in the United States, provided care  for mentally handicapped refugees and immigrants—both those admitted due to acute need for psychiatric care and those adjudicated to be criminally insane. Here, I helped deal with the “extreme of behaviors” experienced by “catatonic” patients who were confined to locked wards  and monitored around-the-clock by security guards. 

These patients included those who were not able to speak, move or respond, or appeared to be in a daze; and those that were overexcited or hyperactive, mimicking sounds or movements around them.  I also experienced the joy of seeing some of these patients recuperate as a result of drug therapy and psychosocial support that helped manage their symptoms and start a process of supervised re-integration into the community. This often meant being discharged to a “halfway” house--a residence for persons after release from institutionalization for mental disorders.

We need to be clear, however, and accept the reality that ill mental health is not only limited to persons with severe mental disorders confined to psychiatric hospitals. Ill mental health is a widespread but often “invisible” phenomenon. Many of us or our parents, partners, sons and daughters, have felt a sense of loss or detachment from families, friends and regular routines. We also have experienced nervousness and anxiety about changes in our personal and professional lives, as well as real or imagined fears and worries that have distracted, confused and agitated us. 

While these episodes tend to be transitory for most of us, some of these conditions force us to take frequent breaks from our work, or we need time off or a leave of absence because we are stressed and depressed, or because the medication that we are taking to alleviate a disorder makes it difficult to get up early in the morning or concentrate at work.  And on occasion, because of these disorders, some fall into alcoholism and drug use, further aggravating “fear attacks” or sense of alienation from loved ones and daily routines.  

And, apart from personal consequences, the social and economic costs of ill mental health are staggeringly high, measured in terms of potential labor supply losses, high rates of unemployment, disability costs, high rates of absenteeism and reduced productivity at work. 

This year’s observance of the International Day of Persons with Disabilities offers a good opportunity to shine a light on some of the myths surrounding mental illness, particularly at the workplace where we tend to spend most of our waking hours. Indeed, a recent OECD report provides evidence that most people with mental disorders are in work and many more want to work. 
It is estimated that the employment rate of people with a mental disorder is around 55-70%, or 10-15 percentage points lower than for people without a mental disorder, on average across the OECD-member countries.  Many more people with a mental disorder want to work but cannot find a job; as a result, they are typically twice as likely to be unemployed as people with no such disorder.
In moving forward the disability-inclusive development agenda, including the gradual realization of universal health coverage, we need to start paying particular attention to common mental disorders of workers,  the unemployed, and their families, and not only on the provision of services for people with a severe mental disorder.  This would require, as suggested by the OECD report, dedicated effort to integrate health, employment and social services, moving away from silo-thinking and developing strong coordination and integration of policies and services. 
Action is also needed to inform, train and empower actors outside the traditional mental health sphere, such as school authorities, managers, general practitioners, and in particular public employment services caseworkers, to facilitate labor market re-integration of people with mental health disorders, given the frequent unawareness and non-disclosure of mental disorders. Strengthened data collection and monitoring systems are critical to guide policy decisions and programmatic action on the basis of evidence and better understanding of the different characteristics and outcomes of ill mental health. 
It is time to open our eyes to make this “invisible disability” visible! We at the World Bank Group, in partnership with other organizations, can contribute to advancing the mental health agenda globally on the basis of cross-cutting and multidisciplinary approaches that build social resilience. 
In doing so, paraphrasing Judith Rodin, President of The Rockefeller Foundation, individuals, communities, organizations and systems will have the capacity to assist affected and vulnerable populations to bounce back from the shock and disruption of ill mental health and offer them opportunities to reintegrate, participate and contribute to community life.  

Follow the World Bank health team on Twitter: @WBG_Health

Mental Health and Development
Global Burden of Disease: Generating Evidence, Guiding Policy
WHO Mental Health Action Plan 2013-2020
Sick on the Job?: Myths and Realities about Mental Health and Work
Judith Rodin. 2014.  The Resilience Dividend. 
Mental Health, Well-being and Disability: A New Global Priority. Key United Nations Resolutions and Documents

OUT OF THE SHADOWS: Making Mental Health a Global Development Priority (April 2016)

Bringing Mental Health Services to Those Who Need Them Most
Blog: The zero hour” for mental health
Blog: Mental Health: Time for a Broader Agenda
Blog:  Is Violence a Public Health Problem?
Blog:  Is Unemployment Bad for Your Health?
Blog: Healthier Workplaces = Healthy Profits



Patricio V. Marquez

Former World Bank Group (WBG) Lead Public Health Specialist

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