Jumping on the Global Mental Health Bandwagon? Injustices Preventing the Reduction of the Mental Health Treatment Gap

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Introduction

Global Mental Health is defined as a field which “aims to improve treatments, increase access to services, and reduce human rights abuses of people experiencing mental disorders”¹. Many countries have become increasingly interested in Global Mental Health issues and have consequently attempted to place mental health at the forefront of practice and politics. Advocacy measures include the marking of World Suicide Prevention Day (September 10th) and World Mental Health Day (October 10th), as well as the implementation of the Mental Health Gap Action Programme, which was developed by the World Health Organization (WHO) to scale up mental health resources and reduce mental health treatment gaps². In addition, there has been an increased effort to include people with lived experience and their families in the development of mental health policies, services, and clinical tools. For example, the WHO is inviting service users and their families to help in the revision of the International Classification of Diseases (ICD), a diagnostic tool widely used around the world³.

Such initiatives, supported by organizations such as the WHO, have without a doubt increased the world’s interest in the field, generating a flux of advocacy regarding the improvement in care offered to those affected by mental illness. However, there are still grave injustices faced by many living with mental health problems, prompting authors to suggest that they are “the most vulnerable throughout the world”⁴.

Access to mental health care

Access to healthcare is one important prerequisite for overall health. However, statistics show that 35-50% of people living with mental health problems in high-income countries do not have access to the care they need5. In low- and middle-income countries, that statistic is estimated to be between 76-85%5. This gap is caused by many factors. First, there is a shortage of professionals trained in mental health care, forcing them to migrate to more densely populated city centers. Besides causing an unequal distribution of these professionals within countries, this results in an over-reliance on non-specialized mental health professionals outside of cities, resulting in barriers to accessible and effective care^{6, 7}. Financial resources are also unevenly distributed. Resources are mainly focused on urban and affluent areas¹, where they are used to sustain large psychiatric hospitals at the detriment of further developing community mental health care⁸. Second, stigma against mental illness is common. Shame, worry, and a fear of ridicule or exclusion are stressors that prevent people from seeking care⁹, resulting in a decrease in overall quality of life¹⁰. Also, stigma against mental illness has wrongly led people to believe that mental health care is solely effective within psychiatric institutions. This myth prevents the development of responsive services that meet needs within communities^{5, 11, 12}.

Premature deaths

It is estimated that the life expectancy of people living with mental health problems is 10-25 years less than the general population^{13, 14}, and this gap is increasing. Worthy of note is that people do not die of mental illness per se, but of associated, avoidable and untreated health conditions. Such conditions include cardiovascular, respiratory, metabolic (i.e., diabetes, hypertension and high weight gain)⁵. Many of these conditions are developed due to behaviors such as an increase in tobacco use and lack of exercise15, or the high prevalence of risky behaviors observed within some people experiencing mental illness⁵. Although mental health patients are more likely to suffer from these conditions, they often do not receive appropriate care to prevent or treat them¹⁵.

Furthermore, people with mental disorders are at a higher risk of suicide^{5, 16}. Suicide is a leading cause of death among people living with mental health problems aged 15 to 44, despite awareness of how to predict and prevent it by responding to certain key indicators. Indicators include social determinants of health (i.e., financial difficulties, employment insecurities, poor living conditions), and not taking medication as prescribed¹⁶. These health injustices underscore the need to provide access to effective and timely mental health care.

What now?

The WHO Mental Health Action Plan advocates for more “comprehensive, integrated and responsive mental health and social services in community-based settings”⁵. Community-based settings have been proven to be effective, especially in areas with a scarcity of mental health resources^{2, 17, 18}. They are more cost-efficient than psychiatric institutions, and have been described as more beneficial due to their ability to increase access to services for a wider population^{19, 20}. Increased access would allow early intervention. Early intervention has been found to improve life-long mental health prognoses and to be key to reducing the global burden associated with mental disorders worldwide²¹. However, the comparative slowness with which such solutions are being implemented reflects systemic injustice, reinforcing issues of stigma against people with mental health problems.

A first step to target injustices against people living with mental health problems has been recently addressed at an international level: mental health has been included in the new United Nations’ Sustainable Development Goals (SDGs). These new goals will frame policy development for the next 15 years and will allow for crucial and long overdue investments in the field of mental health²². Investment in the mental health field is crucial given that neglecting the reduction of the mental health treatment gap impedes the success of the other goals, such as poverty and child mortality reduction. For example, people living with mental health problems are at an increased risk of living in poverty²³, making the realization of poverty reduction without increasing access to effective mental health care difficult. In addition, including mental health as a global effort is likely to reduce worldwide stigma against mental illness, consequently encouraging the successful development of community mental health initiatives⁵.

However, questions now remain on what targets are being developed in order to adequately target mental health issues, such as reducing the treatment gap and addressing injustices that still persist. Clear indicators are important to monitor progress and to hold countries accountable to the goal.

To conclude, by focusing on mental health and the reduction of the mental health treatment gap, the Global Health community has the opportunity to empower a neglected population, and prevent further injustices. However, without clear indicators to measure progress in this field, countries will merely be jumping on the Global Mental Health bandwagon, and lose an opportunity to truly make a difference in the mental health field worldwide.

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The author wishes to thank Matthew Bergamin for editing the first draft of this piece.

References

1. Cohen, Al., Patel, V., & Minas, H. (2014). A Brief History of Global Mental Health. In V. Patel et al. (Eds.), Global Mental Health: Principles and Practice. New York, NY: Oxford University Press.

2. World Health Organization [WHO]. (2008). mhGAP: Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders. Geneva, Switzerland. WHO Press.

3. World Health Organization [WHO]. (2015). International Classification of Diseases (ICD). Retrieved from http://www.who.int/classifications/icd/en/

4. Patel, V., Minas, H., Cohen, A., & Prince, M.J. (2014). Preface. In V. Patel et al. (Eds), Global Mental Health: Principles and Practice. New York, NY: Oxford University Press.

5. World Health Organization [WHO]. (2013). Mental Health Action Plan 2013-2020. Geneva: Switzerland. WHO Press.

6. World Health Organization [WHO]. (2005). Mental Health Atlas. Geneva, Switzerland: WHO Press.

7. Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370, 878-89.

8. Patel, V. (2007). Mental health in low- and middle-income countries. British Medical Bulletin, 81 and 82, 81-96.

9. Hickling, F.H., Robertson-Hickling, H., Haynes-Robinson, T., Abel, W., & Whitley, R. (2010). “Mad, Sick, Head Nuh Good”: Mental Illness Stigma in Jamaican Communities. Transcultural Psychiatry, 47(2), 252-275.

10. Lauber, C., & Rossler, W. (2007) Stigma Towards People with Mental Illness in Developing Countries in Asia. International Review of Psychiatry, 19(2), 157-178.

11. Westhues, A. (Ed.). 2006. Canadian social policy: Issues and perspectives. Waterloo: Wilfrid Laurier University Press.