No health without mental health

The enormous gap between mental health needs and available services in developing countries has been well documented, culminating in the 2001 World Health Report. Of the 450 million people worldwide with mental health problems most live in developing countries. Mental and behavioural disorders affect one out of four people during their lives. Although treatment is not expensive, most people do not receive the treatments they need and governments on average allocate less than one percent of their health expenditure to mental health.

Five of the ten leading causes ofdisability and premature death worldwide are psychiatric conditions. Depression,anxiety, and alcohol and drug abuse are the most common mental disorders.Psychotic disorders such as schizophrenia and bipolar disorder, althoughrelatively less common, are profoundly disabling. It is no surprise, then, thatmental disorders feature prominently in the list of leading causes of disabilityworldwide. Although children make up a large proportion of the populations ofmany developing countries, the number of people over 60 is growing. Mental disordersspecific to childhood and, as Princeargues in this issue of insights health, ageing are perhaps the leastacknowledged.

The right treatment

Many people with mental disorders do not seek help and families bear the brunt of the untreatedcondition and resulting disability. Swartzdescribes the significant impact of globalisation and social change on the riskof mental health. These changes are influencing how families are able to cope andas Prince points out, care inthe home cannot be assured. For those few who do seek formal care, most willturn to primary or traditional medical care. In primarycare, mental disorders can go undetected and patients may receive a cocktail oftreatments, for example, sleeping pills for sleep problems and vitamins fortiredness. Treatment dealing with psychological and social aspects is rarely provided.

Typically, only people with psychotic disorders or very disturbed behaviour aretaken to specialist mental health services (if available). Here, care is heavilybiased towards drug therapies and many out-of-date colonial-style mentalhospitals remain the mainstay of specialist care services. Thara and Thornicroftbring to our attention the stigma, human rights violations and institutionalisationwhich characterise services for severe mental disorders.

This evidence has played a role inincreasing the profile of international mental health. More countries aredesigning and implementing mental health policies. More donors are supporting mental health related work. Morepublic health professionals and policy-makers are taking an interest in mental health issues. But the pace of reform is slow,and with every new challenge facing the public health sector, mental health is once again being relegated to the bottom of the agenda.

A globalpublic health priority

Freemanshows how mental health is inseparable from HIV/AIDS, arguably the singlemost important global public health priority. People with HIV are prone todepression, cognitive impairment and dementia. Rahman describes how poor mental health, particularlydepression, can be devastating for mothers and children. In South Asia, depression duringpregnancy and after childbirth is strongly associated with low birth weight,poor growth and development and a higher risk of physical health problems inbabies. Failure to thrive is a key public health challenge in the region,affecting more than one in three babies.

Evidence exists to link mental health withother public health priorities: stress and depression can predispose people toheart attacks or strokes for example, and up to half of these people will then sufferfrom depression and dementia. As highlighted in the 2004 World Health Report, substance abusecontributes enormously to the risk of road accidents, and depression can be anafter effect. Violence is a global health priority; alcohol abuse and personality disorder frequently precede violence and,as Silove points out,depression, self-harm and post-traumatic stress disorders often follow.

Marginalisation and mental disorders are closely linked. Arguably,no other health issue has aroused such misunderstanding and fear, acrosshistory and cultures. As Thara andThornicroft show, stigma lies at the heart of systematic discriminationagainst the mentally ill, from their exclusion from daily community activitiesto incarceration in institutions where basic human rights are ignored. Amongstthe myths surrounding mental illnesses is the idea that they are linked to affluence and less relevant in developing countries.Nothing could be further from reality. Virtually every study from around theworld shows that those living in poverty are more likely to suffer from depression.

Globalisation has benefited millions, but as Swartz argues,not everyone has benefited equally. Economic and social change is accompaniedby massive migration that disrupts social networks, increasing unemployment ofsmall scale entrepreneurs and farmers, and reductions in spending on socialwelfare. The rising tide of suicides and premature mortality in somecountries, as vividly demonstrated by alcohol-fuelled deaths of men in EasternEurope, the suicides of farmers in India, and of young women in rural China andSouth Asia can, at least in part, be linked to rapid economic and socialchange. Silove draws ourattention to the burden of conflict and displacement worldwide: it is the civiliansand poor people who suffer the most and whose mental health is consequentlyaffected.

For many years, there was little evidence that anything could be done. However,a number of clinical trials from across the developing worlddemonstrate the efficacy and cost-effectiveness of local treatments fordepression, schizophrenia and substance abuse. Studies now show that community care for schizophrenia is feasible andeffective. Antidepressant and psychosocial treatments for depression are successful. Silove points out that faced with conflict,local communities often have their own mechanisms to increase resilience andpromote healing. He argues for the strengthening of social policies which focuson culturally appropriate healing strategies. Verdeli shows, on the other hand, that treatmentsoriginating in developed countries can be adapted and implemented successfully indeveloping countries. In rural Uganda, inter-personal group therapy, a low costtreatment delivered by people with no previous mental health training, washighly effective against depression.

The moral case

Themoral case, put simply, is that it is unethical to deny effective, feasible and affordabletreatment to millions of people suffering from treatable disorders. There is nohealth without mental health. We should prioritise depression, not because itco-exists with HIV/AIDS, but because planningan HIV/AIDS initiative without amental health component discriminates against a highly vulnerable group. Mentaldisorders must be included in programmes directed at promoting poor people'shealth and improving economic conditions in developing countries. Community andprimary treatment programmes are not costly to implement and must be supportedby donor agencies. The challenge for the mental health community is to cross its professionalboundaries and step closer to its colleagues in public health and seek supportfor international mental health in collaboration with other health disciplines.