The mental health burden: Where are we?

Tuesday, 2 May 2017

By Elnaz Naseri, Health Policy Officer at IAPO. 

 

Depression is the leading cause of ill health and disability worldwide.[1] Alcohol-use disorder, Schizophrenia, and other mental, neurological and sub­stance-use (MNS) disorders constitute 13% of the global burden of disease surpassing both cardiovascular disease and cancer. [2]

 

By 2020, an estimated 1.5 million people will die each year by suicide, and between 15 and 30 million will make the attempt [3]. In September 2015, the World Health Organization (WHO) recognised the promotion of mental health, as one of the health priorities and goal three of the seventeen Sustainable Development Goals (SDGs).[4]

Further, mental disorders increase risk for communicable and non-communicable diseases, causing unintentional and intentional injury. [5] [6] Mental illness, also, decreases life expectancy more than well-recognised adverse exposures such as smoking, diabetes and obesity. [7]

 

Treatment approaches

Currently mental health treatmens approaches can be categorised into medicalised and contextual approaches.

Medicalised interventions include biomedical medicine, short-term psychotherapy, family-level interventions and peer-and community-based interventions technique. Both techniques use evidence-based tools following Cognitive Behavioural Therapy (CBT) that is commonly used in high income countries.

Although medicalised approach is widely used in treating different mental health conditions, it has been criticised for its ‘short-sightedness’, especially in Low Middle Income countries (LMIC) where scarcity of specialsed professionals and stigma associated with mental-health problems are challenging. [8] [9] In contextual approach; however, the major focus is building community resource capacities using collective interventions including community involvement. Collective intervention utilises local forum of teachers, social workers, and health professionals for development of screening procedures and follow up partnership with community for mental illness such as depression. [10] [11] In this approach, recent development, training, supervision, and management of peer support/workers are required. [11]

 

Barriers to help seeking

Among the most important barriers to help-seeking for mental ill health are stigma, problems recognising symptoms (poor mental health literacy), and a preference for self-reliance. Data shows stigma leads to discrimination in the provision of services to those who are mentally ill in rural population more than urban population; and it has higher impacts on those with ethnic minorities, youth, men and those in military and health professions. [12] [13]

Other barriers in treating mental ill health include under-researched facilities, scarcity of professional healthcare, concern about characteristics of provider (e.g. race, and their credibility), and unavailability of innovative drugs especially in LMIC.

Vohra et al. (2014) highlight further barriers, such as lack of accessibility (i.e. transport cost); existing clinical data, linked electronic health information; source of care, shared decision making, care coordination and inadequate insurance coverage. [14]

 

Barriers to Treatment

Treatment provisions are in different forms from no treatment, under-treatment, expansion of private and governmental treatment resource as well as private means of financing. [15]  At least two-thirds of people who are mentally ill receive no treatment.[16]

Another barrier to mental health treatment is cultural superstition. In some cultures, mental disorders are considered as a way of punishment to those affected. The Commission on Social Determinants of Health refers to non-equitable provision of health services (including mental health) and emphasizes on the importance of early child development, social and emotional development alongside physical and cognitive or linguistic development (Marmot et al., 2008). Furthermore, Marmot et al (2008) name fair employment, social protection throughout life, and universal health care as means to equitable provision of services.[17]

 

Recommendations for advocates

In order to tackle inequity of resources, mental health equity must be implemented in all policies, systems, and programmes. For that, WHO recommends mental illness (i.e. anxiety and depression) should be treated in primary care, and that specialist psychiatric services should be prioritized to patients who are more severely ill.[18]  

Advocates for people with mental disorders will need to clarify and collaborate on a health system context. In addition, mobilisation and recognition of non-formal resources in the community must be encouraged. For example, community and family members without formal professional training need to participate in advocacy and service delivery.

Another way in raising awareness and enforcing mental health treatment is political will to take action and to make or block change. Political will could be affected by professionals, advocacy groups and expressions of public opinion and their priorities. Other factors to enforce political will are appointments of public-health experts in leadership positions; collaboration with ministries of social welfare; engagement of all stakeholders to ensure community-based movement, and implementation of powerful legislation and policies that protect people with mental disorders from human-rights violations. Finally, people responsible for service development need to be much more effective in community and specialist staff should be used mainly as supervisors, rather than as clinicians.[19]

 

Mental health outlook for the coming years

The subject of mental health is gaining more attention globally. This year, WHO has celebrated World Health Day on 7 April to mobilize action around depression.1 In the UK, the campaign called Heads Together with the aim to end stigma around mental health in encouraging and supporting people with mental health disorder to seek professional help without fear of stigma. This and similar projects highlight the importance of mental health in a more collective intervention. [20] Also, evidence shows that there is a direct correspondence between countries’ percentages of gross domestic product (GDP) spent on health care and receiving mental health services. [21]

Finally, in treating mental health, a combined evidence based approach considering both medicalised and contextual approaches is more powerful. To achieve a more effective treatment, interdisciplinary long-term collaboration between clinicians, governments and local community are recommended to overcome barriers and provide quality access to patients. Therefore, it is important to remember that ‘Health is not a tradeable commodity. It is a matter of rights and a public-sector duty. As such, resources for health must be equitable and universal.” [17]

 

[1] WHO (2017). "Depression: let’s talk" says WHO, as depression tops list of causes of ill health. [online] World Health Organization. Available at: http://www.who.int/mediacentre/news/releases/2017/world-health-day/en/ [Accessed 19 Apr. 2017].

[2] WHO (2004). Promoting Mental Health. [online] WHO. Available at: http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf [Accessed 15 Apr. 2017].

[3] Bertolote, /. and Fleischmann, A. (2015). A global perspective in the epidemiology of suicide. Suicidologi, 7(2).

[4] WHO (2010). [online] Atlas on Substance Use. Available at: http://WHO Atlas on Substance Use [Accessed 19 Apr. 2017].

[5] Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. and Rahman, A. (2007). No health without mental health.

[6] Ivbijaro, G. (2011). Mental health as an NCD (non-communicable disease): the need to act. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314268/ [Accessed 19 Apr. 2017].

[7] Chang, C., Hayes, R., Perera, G., Broadbent, M., Fernandes, A., Lee, W., Hotopf, M. and Stewart, R. (2011). Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London.

[8] Betancourt, T. and Khan, K. (2008). The mental health of children affected by armed conflict: Protective processes and pathways to resilience.

[9] Behrouzan, O. (2015). MAT. [online] Medanthrotheory.org. Available at: http://www.medanthrotheory.org/read/5774/medicalization-way-of-life [Accessed 19 Apr. 2017].

[10] Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., Rohde, L., Srinath, S., Ulkuer, N. and Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action.

[11] Repper, J. and Carter, T. (2011). A review of the literature on peer support in mental health services: Journal of Mental Health: Vol 20, No 4. [online] Available at: http://www.tandfonline.com/doi/abs/10.3109/09638237.2011.583947?instName=UCL+%28University+College+London%29 [Accessed 16 Apr. 2017].

[12] Sartorius, N. (2007). Stigma and mental health. [online] The Lancet. Available at: http://www.sciencedirect.com/science/article/pii/S0140673607612458 [Accessed 18 Apr. 2017].

[13] Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., Morgan, C., Rüsch, N., Brown, J. and Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(01), pp.11-27.

[14] Vohra, R., Madhavan, S., Sambamoorthi, U. and St Peter, C. (2014). Access to services, quality of care, and family impact for children with autism, other developmental disabilities, and other mental health conditions. Autism, 18(7), pp.815-826.

[15] Wahlbeck, K., Westman, J., Nordentoft, M., Gissler, M. and Laursen, T. (2011). Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. The British Journal of Psychiatry, 199(6), pp.453-458.

[16] Thornicroft, G. (2007). Most people with mental illness are not treated. [online] Sciencedirect.com. Available at: http://www.sciencedirect.com/science/article/pii/S0140673607613920 [Accessed 16 Apr. 2017].

[17] Marmot, M., Friel, S., Bell, R., Houweling, T. and Taylor, S. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372(9650), pp.1661-1669.

[18] WHO (2015). Comprehensive mental health action plan 2013–2020. [online] Available at: http://www.who.int/mental_health/action_plan_2013/en/ [Accessed 6 Jul. 2016].

[19] Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J., Sridhar, D. and Underhill, C. (2007). Barriers to improvement of mental health services in low-income and middle-income countries. [online] Available at: http://www.sciencedirect.com/science/article/pii/S014067360761263X [Accessed 16 Apr. 2017].

[20] Hannah Furness (2017). Prince Harry: I sought counselling after 20 years of not thinking about the death of my mother, Diana, and two years of total chaos in my life. [online] The Telegraph. Available at: http://www.telegraph.co.uk/news/2017/04/16/prince-harry-sought-counselling-death-mother-led-two-years-total/ [Accessed 18 Apr. 2017].

[21] Wang, P., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M., Borges, G., Bromet, E., Bruffaerts, R., de Girolamo, G., de Graaf, R., Gureje, O., Haro, J., Karam, E., Kessler, R., Kovess, V., Lane, M., Lee, S., Levinson, D., Ono, Y., Petukhova, M., Posada-Villa, J., Seedat, S. and Wells, J. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.