Mental Health: Time for a Broader Agenda

Thank you for this blog post. It’s heartening to read what the World Bank is doing to support mental health care as part of a holistic approach to health and societal well-being. Indeed, job creation and training is an important factor in implementing the WHO Mental Health action plan 2013-2020. One of the challenges in providing universal mental health care is building a cadre of skilled mental health... and psychosocial practitioners, since many low-income countries have few, if any, mental health professionals. In our direct care programs in Africa and the Middle East, the Center for Victims of Torture trains national and, when possible, refugees from affected populations to be skilled psychosocial counselors. Supporting efforts such as these, and increasing the level of support for training, supervision and curriculum development for mental health workers, combined with integrating them into recognized existing, sustainable, structures will further help close the treatment gap in mental health. http://blog.cvt.org/

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This is such an imporant conversation to be having, espcially in the context of the Bank reform process and our deepening engagement in FCS. Responding to the mental health challenges is key if our projects are to be truly inclusive and effective. Readers might be interested in an event that our team is organizing at headquarters on May 6, titled "Invisible Wounds: A Practitioners' Dialogue on Improving... Development Outcomes through Psychosocial Support," convening a group of experts from disciplines ranging from neuroscience to education and youth employment. For more info see http://www.worldbank.org/en/events/2014/04/07/invisible-wounds-a-practitioners-dialogue-on-improving-development-outcomes-through-psychosocial-support

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Thank you for this article. It is encouraging to see WB interest and commitment to join forces with other organizations trying to move mental health up in their policy agenda. Integrating mental health in general health is a key component to ensure that those suffering from mental disorders receive the due attention and care. There are many good examples and initiatives going on in low- and middle-income... countries, where situations of abandonment can be reverted with governments’ commitment and support. The Pan American Health Organization (PAHO/WHO) is actually collaborating with countries to answer appropriately to the mental health needs of their populations.

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I fully agree with the previous comments. The WB is finally putting mental health on its development agenda. Allow me to cite two additional reference documents: (a)the WHO Mental Health Atlas 2011; and (b) World Health Organization Assessment Instrument for Mental health Systems (WHO-AIMS). The main messages of the Atlas are: 1. RESOURCES TO TREAT AND PREVENT MENTAL DISORDERS REMAIN INSUFFICIENT:... Globally, spending on mental health is less than two US dollars per person, per year and less than 25 cents in low income countries. Almost half of the world's population lives in a country where, on average, there is one psychiatrist or less to serve 200,000 people. 2. RESOURCES FOR MENTAL HEALTH ARE INEQUITABLY DISTRIBUTED: Only 36% of people living in low income countries are covered by mental health legislation. In contrast, the corresponding rate for high income countries is 92%. Dedicated mental health legislation can help to legally reinforce the goals of policies and plans in line with international human rights and practice standards. Outpatient mental health facilities are 58 times more prevalent in high income compared with low income countries. User / consumer organizations are present in 83% of high income countries in comparison to 49% of low income countries. 3. RESOURCES FOR MENTAL HEALTH ARE INEFFICIENTLY UTILIZED: Globally, 63% of psychiatric beds are located in mental hospitals, and 67% of mental health spending is directed towards these institutions. 4. INSTITUTIONAL CARE FOR MENTAL DISORDERS MAY BE SLOWLY DECREASING WORLDWIDE: Though resources remain concentrated in mental hospitals, a modest decrease in mental hospital beds was found from 2005 to 2011 at the global level and in almost every income and regional group.

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Useful data from ATLAS 2011 (by the way, WHO is starting the process of collecting data for the ATLAS 2014, that will serve as baseline for the implementation of the plan mentioned in the blog). Another important element to consider, the treatment gap: 35.5 to 50.3% of people with severe mental disorders did not receive any treatment within the prior year in developed countries, but the proportion... of cases not receiving any treatment in developing countries was much higher - 76 to 85%. How many people with a broken leg, i.e., do not receive treatment in those countries? And how many people with diabetes ended up hospitalized in an institution for the rest of his/her life, with their human rights almost systematically violated? Or how many will end up in a jail due to their heart condition? Whenever key stakeholders will accept or understand that mental disorders are just another health related issue, governments will do their best to strengthen their mental health systems in order to offer appropriate services and treatment options. Investing in mental health will have repercussions in individuals and populations well-being, in the human rights protection of vulnerable groups, but also in reducing the public health and economic burden of un-treated, marginalized persons with mental health problems. There are cost-effective options available to deal with these situations. It will be hard to talk about reaching Universal Health Coverage unless we include also mental health in it.

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Thanks for sharing. Shocking stats, especially considering the mostly affected (young) group age! Will spread the word in other social media; we need to somehow support the WHO's plan at the local community level too, until we wait for higher level interventions.

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Thanks Patricio for drawing attention to this important topic. A close relationship exists between the four main noncommunicable diseases (NCDs) and mental health which I recall was particularly highlighted when we were researching the Sub-Saharan African NCD Report. For example, in the WHO African Region Ministerial Consultation on Noncommunicable Diseases, the contribution of mental health conditions... to the NCD burden (and vice versa) was recognised as a major challenge to public health in the region (http://www.who.int/nmh/events/2011/africa_ncds_background_paper.pdf) and some even suggested that Africa needed a '5-by-5' strategy that addressed neuropsychiatric disorders as a fifth NCD and transmissible agents as a fifth risk factor given the substantial preventable death and disability caused by each (see Mensah & Mayosi 2012: http://www.ncbi.nlm.nih.gov/pubmed/23374298).

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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).

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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.

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Bravo Patricio! Thanks for reminding us about this very neglected but important issue of mental health. You have helpfully reminded us of the journey which has brought us here today--the context of our past, our cultural and societal understandings, and the burden of disability and stigma. You draw out two very important aspects that I wanted to add my thoughts on: 1. WHO's Mental Health Action Plan... and 2. What this means for us here at the country level in Ghana. The WHO Action Plan provides the foundation for us take actions forward at a country and local level. Many countries are now struggling for mental health to receive the attention, services and resources it needs to take this forward. Ghana is one of them. There is no doubt that Ghana has a long way to go to improve mental health services. There are no population-based figures to show the extent of mental illness, estimates range from 650,000 with severe mental disorders to a general figure of 2.4 million Ghanaians living with various mental disorders. It is estimated that only 2% of the population have access to some form of care. Ghana has had a long and diffuclt history of mental illness treatment and care. However, I think the recent and current efforts give us all cause for hope. In 2012, Ghana passed the The Mental Health Act of 846. Since then, there has been additional mental health officers trained, community and primary care referral structures put in place and excellent cross working with communities and faith organisations to reduce stigma. The Mental Health Board has been established and just two weeks ago the strong foundations were placed through the Legislative Instrument. The process as well as the outcomes were so encouraging to see--faith communities, self help groups, traditional leaders, clinicians, pharmacists, and other health professionals, all working together to detail and agree on the organisation and structures of the new Mental Health Authority. There is still a very long way to go: health workers are few, services are far, drugs are scarce. Faith and community services play a key role in picking up and providing for many of the poor who do not have the money or the information to receive diagnosis and treatment. But alongside this, I also see strong health leadership, passionate advocates, talented healthworkers, and dedicated NGOs, CSOs and faith communities all working collectively to remind us that good mental health is not just for the few who are suffering with addictions,pyschosis, or other conditions, it is for the good of all of us.

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