A neglected public health issue

Dorota Sienkiewicz

 

Introduction

Thinking of neglected diseases, what comes to mind are mostly tropical conditions: dengue, leishmaniasis, rabies, schistosomiasis, leprosy and so on. What escapes the attention of most is mental health. One might wonder why: is it not tropical or new enough? Does it really deserve to be given a lower priority than other, high mortality diseases?

The WHO’s definition of health clearly states that mental health is an inseparable constituent of health as a whole. However, mental health problems remain marginalized and deeply stigmatized across both western and eastern societies, the same societies that have always paid a lot of attention to the human mind and consciousness in philosophy and the arts.

No health without mental health

According to the WHO European Ministerial Conference report on Mental Health (2005), there is a steadily growing body of evidence supporting that no complete health can be reached when no attention is given to mental health. Mental disorders (especially depression, alcohol and other substance abuse, psychoses) chronically disable, both physically and socially, millions of people worldwide. The 2005 Global Burden of Disease report has unveiled that mental disorders substantially contribute to global disability and mortality rate – 31.7% of all years lived-with-disability are attributed to neuropsychiatric conditions. In fact, mental illnesses are as disabling as cardiovascular diseases and cancer in terms of productivity loss and premature death and up to 30% of the global population suffers from some form of mental disorder every year. At least two-thirds of those people receive no treatment. In developing countries, the prevalence of mental disorders is still relatively low, but is expected to grow substantially in the next 20 years. Mental conditions are known to negatively affect other both non- and communicable diseases (i.e. cardiovascular disease, diabetes, HIV/AIDS, TB, malaria), reproductive and sexual health, maternal and child health, and injuries.

Stigma of mental illness

Stigma is a mark put on an individual as being different and as such it evokes a social sanction. In many cultures the concept of mental illness is strongly associated with feelings of fear, beliefs of threat, self-blame and none or poor treatment. It is often the stigma that is associated with mental illness that forms the main obstruction when it comes to the provision of mental healthcare. Thornicroft et al. recently conducted a study in 27 countries revealing the global pattern of discrimination against people with schizophrenia. Over 95% of patients report experiencing negative discrimination. The consequences of this stigma are not confined to the patient, the patient’s family is also often involved, as are the institutions and professionals that provide care and treatment. Surprisingly however, health care professionals can also enforce stigma. Research by Nordt et al. even suggests that many health professionals stigmatize their patients to a greater extent than the lay population, e.g. by the use of stigmatizing words or refusal to treat other, physical conditions. The problem of stigma associated with mental health has been identified all over the world – from west to east and from south to north.

The treatment gap for mental disorders  

According to the study on costs of affective disorders in Europe (Wittchen & Sobocki-Andlin, 2005) and prevalence of mental disorders in the US (Kessler et al., 2005), 27% of the European and 31% of the US population are affected by a mental illness each year. The so-called treatment gap – the difference between the number of people suffering from a certain condition and the number of people actually being treated for it – is already known to be high and growing worldwide. Due to multiple causes such as scarce human resources in psychiatry, poor mental health financing and stigma and discrimination attached to mental illness, many people never receive the treatment they need. The treatment gap for mental conditions in the developed part of the world is confirmed to be big (35-50%). Such data are unknown for the majority of low- and middle-income countries because priority is given to other, mostly communicable diseases. However, the treatment gap there is believed to reach 85%. Only one study by Kohn et al. (2004) sheds light on this issue in the African region, and only for one mental condition: major depression. They estimated the treatment gap to be 67%. In comparison, the MD treatment gap in the Netherlands has been estimated to be 36% - almost two times lower than for Africa (Bijl & Ravelli, 2000). Taking into account the significant underreporting of many health conditions in underdeveloped parts of the world, it is likely that there are actually a lot more people suffering from mental conditions and even more for whom treatment is unavailable, inaccessible and/or inadequate, than this study implies.

Mental health economics – how expensive is it to provide the treatment needed?

Health is widely considered as an important part of every country’s internal policy. Every country strives to provide a certain standard of health care to its inhabitants. However, only 2% (for low- and middle-income countries) to 14% (for high-income countries) of total GDP is spent on health. 31% of all countries do not even have a specified public budget for mental health and if so, it is usually only 0.5 to 10% of the total health budget (Saxena et al., 2007). Furthermore, mental health budgets are often inadequately allocated, with money being channeled mostly to in-patient, hospital-based facilities (up to 80%). This overlooks evidence-based effectiveness of outpatient and community-based mental health care. For example, adding two to three dollar per capita per year to mental health spendings and shifting treatment from hospital- to community-based facilities would greatly improve global mental health, especially in places where mental health care currently is not optimal. According to the WHO report on global mental health economics, the use of low-cost and relatively easily available, highly effective drug and/or psychotherapy would limit the burden of disease that is caused by mental conditions (Chisholm et al., 2006). Although this knowledge is widely spread nowadays, mental health still suffers from significantly lower priority on the public health policy agenda. To give an example, in a low-income country like Eritrea (4.2 million inhabitants) there is only one psychiatrist, while there are between 25-600 mental health workers per 100 000 inhabitants in high-income countries like the Netherlands.

Conclusion

In this article, mental health has been identified as a neglected public health issue. As we have seen, there cannot be a state of complete health without mental well-being as they are closely interrelated. Mental conditions are at least as socially and physically burdensome as other health problems (if not more in some parts of the world). The stigma and discrimination that are often associated with mental illnesses add greatly to the already existing treatment gap for mental diseases. This gap could be bridged partly by shifting health fund allocation to more effective and sustainable (community based) treatment options. Slowly but steadily, the voices of patients and professionals are reaching the ears of policy makers, donors and the academic world. The WHO has already recognized the need for action in the prevention and management of mental problems worldwide. Evidence-based treatment is to be scaled-up, human rights of people with mental disorders are to be protected and research to support these developments is to be invested in. Now that a commitment to mental health has been made, action will have to follow.  

About the author

Dorota Sienkiewicz has a Master's degree in Social Psychology and in International Public Health. She has worked on international mental health, promotion of sexual and reproductive health and rights of refugees, asylum seekers and undocumented migrants.  

Further reading

• www.globalmentalhealth.org 
• The Lancet Series on Global Mental Health. 2007

References

 

Photo © by Amfion Fotoshoots (Antonette de Groot-Klootwijk), photos for Global Medicine only, all rights reserved.