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 of disability 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, although less common, are profoundly disabling. It is no surprise, then, that mental disorders feature prominently in the list of leading causes of disability worldwide. Although children make up a large proportion of the populations of many developing countries, the number of people over 60 is growing. Mental disorders specific to childhood and, as Prince argues in this issue of insights health, ageing are perhaps the least acknowledged.

The right treatment

Many people with mental disorders do not seek help and families bear the brunt of the untreated condition and resulting disability. Swartz describes the significant impact of globalisation and social change on the risk of mental health. These changes are influencing how families are able to cope and as Prince points out, care in the home cannot be assured. For those few who do seek formal care, most will turn to primary or traditional medical care. In primary care, mental disorders can go undetected and patients may receive a cocktail of treatments, for example, sleeping pills for sleep problems and vitamins for tiredness. Treatment dealing with psychological and social aspects is rarely provided. Typically, only people with psychotic disorders or very disturbed behaviour are taken to specialist mental health services (if available). Here, care is heavily biased towards drug therapies and many out-of-date colonial-style mental hospitals remain the mainstay of specialist care services. Thara and Thornicroft bring to our attention the stigma, human rights violations and institutionalisation which characterise services for severe mental disorders.

This evidence has played a role in increasing the profile of international mental health. More countries are designing and implementing mental health policies. More donors are supporting mental health related work. More public 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 global public health priority

Freeman shows how mental health is inseparable from HIV/AIDS, arguably the single most important global public health priority. People with HIV are prone to depression, cognitive impairment and dementia. Rahman describes how poor mental health, particularly depression, can be devastating for mothers and children. In South Asia, depression during pregnancy and after childbirth is strongly associated with low birth weight, poor growth and development and a higher risk of physical health problems in babies. 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 with other public health priorities: stress and depression can predispose people to heart attacks or strokes for example, and up to half of these people will then suffer from depression and dementia. As highlighted in the 2004 World Health Report, substance abuse contributes enormously to the risk of road accidents, and depression can be an after 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, across history and cultures. As Thara and Thornicroft show, stigma lies at the heart of systematic discrimination against the mentally ill, from their exclusion from daily community activities to incarceration in institutions where basic human rights are ignored. Amongst the 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 the world 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 accompanied by massive migration that disrupts social networks, increasing unemployment of small scale entrepreneurs and farmers, and reductions in spending on social welfare. The rising tide of suicides and premature mortality in some countries, as vividly demonstrated by alcohol-fuelled deaths of men in Eastern Europe, the suicides of farmers in India, and of young women in rural China and South Asia can, at least in part, be linked to rapid economic and social change. Silove draws our attention to the burden of conflict and displacement worldwide: it is the civilians and poor people who suffer the most and whose mental health is consequently affected.

For many years, there was little evidence that anything could be done. However, a number of clinical trials from across the developing world demonstrate the efficacy and cost-effectiveness of local treatments for depression, schizophrenia and substance abuse. Studies now show that community care for schizophrenia is feasible and effective. 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 and promote healing. He argues for the strengthening of social policies which focus on culturally appropriate healing strategies. Verdeli shows, on the other hand, that treatments originating in developed countries can be adapted and implemented successfully in developing countries. In rural Uganda, inter-personal group therapy, a low cost treatment delivered by people with no previous mental health training, was highly effective against depression.

The moral case

The moral case, put simply, is that it is unethical to deny effective, feasible and affordable treatment to millions of people suffering from treatable disorders. There is no health without mental health. We should prioritise depression, not because it co-exists with HIV/AIDS, but because planning an HIV/AIDS initiative without a mental health component discriminates against a highly vulnerable group. Mental disorders must be included in programmes directed at promoting poor people's health and improving economic conditions in developing countries. Community and primary treatment programmes are not costly to implement and must be supported by donor agencies. The challenge for the mental health community is to cross its professional boundaries and step closer to its colleagues in public health and seek support for international mental health in collaboration with other health disciplines.

Vikram Patel
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK
T +44 (0) 20 7958 8123
vikram.patel@lshtm.ac.uk

See also

'Poverty and common mental disorders in developing countries', Bulletin of the World Health Organisation 81: 609-615 by V. Patel and A. Kleinman, 2003

'Treating depression in developing countries', Tropical Medicine and International Health 9: 539-541 by V. Patel, R. Araya and P. Bolton, 2004

'Meeting mental health needs in developing countries: NGO innovations in India', New Delhi: Sage (India) by V. Patel and R. Thara, 2003

'Mental health: new understanding; new hope', World Health Report, World Health Organisation, 2001
www.who.int/whr/2001/en

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