Positive mental health for all serving the under-served

ABSTRACT

Mental disorders are major contributors to global burden of disease measured in Disability Adjusted Life Years (7% of all disease burden in 2017). Large treatment gaps for these disorders exist in all parts of the world. In India, overall treatment gap for mental disorders was found to be 83%. Women, children and adolescents, ethnic minorities, LGBTQ+ community, elderly and those living in remote and inaccessible areas have disproportionately higher rates of mental illness. They face unique and characteristic barriers to access to mental healthcare which increases treatment gap. These gaps have persisted despite global efforts and interventions to mitigate these barriers. Hence, there is a need to find alternatives to reduce mental health gap in these groups. Positive Mental Health interventions focuson well-being and health promoting activities, rather than on illness. The potential role of these interventions in promoting mental health and reducing treatment gap has been explored in this article.

WHO has defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It has further endorsed that there is no health without mental health.[1] These propositions underlie the importance of mental health in the overall well-being of an individual. Persons with sound mental health are able to realize their abilities, cope with stresses of life and contribute to society.[2] However, Mental Health remains a low priority globally.[3] Mental disorders remain significant contributors to the global disease burden. In 2016, they were responsible for 7% of all disease burden as measured in Disability Adjusted Life Years (DALYs).[4] Moreover, Mental Health treatment gap to the tune of 76% to 85% exists in developing countries.[5]

Certain population groups are more vulnerable to development of mental disorders and have unmet mental health needs. Women, children and adolescents, ethnic minorities, LGBTQ + community, elderly, the impoverished and those living in remote and inaccessible areasconstitute these groups. These groups face various unique barriers to access to mental healthcare and mitigating them would reduce overall mental health burden.[6]

Mental health promotion activities, which includes building Positive Mental Health (PMH) have been shown to reduce the risk of future development of mental disorders and to improve mental well-being.[7] Hence, there is a need for further impetus on mental health promotion activities to reduce the burden of mental disorders and to overcome the large existing gaps in their treatment. In this article, we outline the global burden of mental disorders, existing treatment gaps and contributing factors. We look at the factors contributing to high unmet mental health needs among under-served populations and ways to overcome them. In the end, the possible role of PMH as a means to improve mental well-being and to reduce burden of mental disorders is highlighted.

Burden of mental disorders and treatment gap

More than one billionpeople worldwide were affected by mental or addictive disorders in 2016. This constitutes roughly 16% of the world population. In the same year 162.5 million DALYs were attributed to these disorders contributing 6.8% of the total DALYs. Further, they contributed to 19% of all Years Lived with Disability (YLD). 66% of the DALYs were related to three disorders, namely Depressive disorders (27.20%), Anxiety disorders (16.24%) and Drug and Alcohol use disorders (22.56%).[4]

In India, 197·3 million people suffered mental disorders in 2017. Depressive and anxiety disorders were the most frequent with 45·7 and 44·9 million suffering from them respectively. Further, contribution of mental disorders to total DALYs showed an increase from 2.5% in 1990 to 4.7% in 2017. Almost all (>99·9%) the DALYs were contributed by YLDs.[8] According to the National Mental Health Survey (NMHS) of 2015–2016, the lifetime prevalence of any mental morbidity was 13.67%. Current prevalence of mental disorders was estimated to be 10.56%.[9]

Despite the high burden of mental disorders and their significant impact, a large proportion of people suffering from these disorders do not have access to timely and appropriate treatment.[10] This is a global phenomenon with reports suggesting that only 23% people in high income countries get minimally adequate treatment for depression.[11] In low- and middle-income countries, 75% to 95% of those with mental disorders are unable to access mental healthcare.[12] Many countries still do not have any legislation on mental health or no healthcare policies related to mental health.[13] NMHS 2015 – 2016, reported that the overall treatment gap in India was 83%. Alcohol and Tobacco Use Disorders had maximum treatment gap with Bipolar Disorder and Severe Mental Disorders having comparatively low yet significant treatment gap of 70.4% and 73.6% [Table 1].[9] India has 0.75 psychiatrists per hundred thousand population, against the recommended 3 per hundred thousand.[14]

Table 1.

Mental Health Gap in India (NMHS 2015 - 16)[9]

Treatment Gap	Magnitude
Overall	83%
Bipolar Affective Disorder	70.4%
Severe Mental Disorder	73.6%
Psychoses	75.5%
Common Mental Disorders	85%
Alcohol Use Disorder	86.3%
Tobacco Use Disorder	91.8%

Factors and barriers contributing to high mental health gap

Various barriers to access to mental health healthcare and contributors to high mental health gap can be broadly grouped as structural barriers, factors related to health culture, cost factors, rehabilitation management related factors and factors related to bio-medical illness model of psychiatric disorders.

Structural barriers include factors related to policy and legislation that maintain health inequity. Weak public health policies and low priority to mental health in these policies contribute to these barriers.[15,16]

Stigma at various levels (self-stigma, interpersonal stigma and structural stigma) has been identified as a major barrier in access to mental healthcare).[17] There are reports suggesting that people with mental illness may underutilize available healthcare facilities.[18] Further, the use of ritualized and alternative medicine hampers early appropriate treatment of mental disorders.[19]

Lack of affordable care also deters many patients with mental disorders from receiving care. Governmental expenditure on mental health is low compared to the existing mental health burden. Further, a majority of funds allocated to mental healthcare goes to psychiatric hospitals which are themselves accessible to only a few.[20] Hospitalisation for major mental illness may be a necessity, but in-patient expenditures are high and may prohibit many from seeking care.[21] Currently, trained mental health resources specifically catering to LGBTQIA + community are unavailable.

A shortage of mental health professionals trained in rehabilitation, lack of resources and trained manpower in the community and inadequate follow-up are other factors contributing to unmet mental health needs.[22,23] A purely bio-medical approach to mental illness often neglects the contributing socio-cultural factors.[24] Lack of integration of mental health serviceswith primary care denies many appropriate interventions, when needed.[23]

Mental health gap in the underserved population groups

As discussed earlier, the existing mental health treatment gap is high. However, there are certain vulnerable population groups that experience disproportionately high rates of mental disorders.[25] They seldom receive adequate treatment, which leads to higher rates of unmet mental health needs.[6] Women, children and adolescents, ethnic minorities, LGBTQ+ community, elderly, the impoverished and those living in remote and inaccessible areashave been identified in various studies to have high unmet mental health needs.[26-30]

Apart from the various barriers to access to mental healthcare discussed earlier these groups encounter certain unique and characteristic barriers [Table 2]. Understanding them helps in formulating appropriate policy and healthcare treatment decisions to help these groups better.

Table 2.

Barriers to mental healthcare faced by vulnerable population groups

Population Group	Barrier to Access to Mental Healthcare
Women[31,32]	Stigma associated with mental illness
	Lack of awareness about mental health issues, treatment options, and available services
	Relative lack of insurance cover in informal sector Lack of time and related support (time off work, child care, transportation)
	Intimate partner violence
Children and Adolescents[33]	Individual factors -
	Limited mental health knowledge
	Perceptions regarding help-seeking
	Social factors -
	Social stigma and embarrassment
	Perceptions of therapeutic relationship with professionals -
	Confidentiality and ability to trust an unknown person
	Systemic and structural barriers -
	Costs, logistical barriers and availability of professional help
Ethnic Minority[34,35]	Language barrier
	Social stigma
	Long waiting times for initial assessment
	Poor social communication between service users and providers
	Imbalance of power and authority between service users and providers
	Cultural naivety, insensitivity and discrimination
	Lack of awareness of different services among service users and providers
LGBTQIA+Community[36,37]	Stigma of being labelled/discriminated
	Cost of private mental health services
	Belief that services could not help them
	Belief that services are not LGBT+friendly
	Informationof someone/oneself having a previous bad experience of mental health services
Elderly[38]	Stigma
	Lack of knowledge about availability of mental health services
	Lack of perceived need for care
	Limited availability of affordable services
	Difficulty arranging transportation
	Challenges finding care consistent with linguistic, cultural and personal preferences and values
People living in remote/Geographically inaccessible areas[30,39]	Reduced access to providers
	Limited availability of specialty mental health care
	Lack of trained mental health providers and care coordination in rural medical care
	Underutilization of available services
	Long travel distance for appropriate care
	Affordability of care

Reducing mental health gap in underserved communities

Clinicians and researchers have attempted to reduce the unmet need of mental illness in the under-served communities. Interventions that have been found effective include interventions to reduce stigma, interventions that are culturally sensitive, insurance programs sponsored by government and legislation that is inclusive of all communities (e.g. for LGBTQIA+). Effective community based interventions include housing first, mobile outreach teams, peer navigator programs etc. Certain cost-effective interventions are group therapy and service delivered by non-specialist health workers. Tele-psychiatry has been found as an effective means of reducing mental health gap.[40]

Other interventions targeting specific population groups are outlined in Table 3.

Table 3.

Interventions among specific vulnerable population groups to reduce mental health gap

Population Group	Interventions to reduce mental health gap
Women[41,42]	Recognize and address prevalence of trauma, violence and abuse
	Address the cultural and social disparities
	Balance in gender roles and obligations, pay equity, poverty reduction
	Gender sensitive services and equitable access
	Improve interface of primary care and mental health services
	Multi-level, intersectoral approach, gendered mental health policy
	Build resilience and protective factors to promote the mental health
	Understand sources of resilience & capacity for good mental health
Children and Adolescents[43,44]	Sustainable Child and Adolescent Mental Health (CAMH) policies –
	Specific mental health care for children and adolescents
	Integration of CAMH services in primary health care
	Availability and accessibility of necessary services for equitable distribution of care
	Promotion of protective factors
	Friendly environment for the optimum development of the children and adolescents
	Integrating mental health in primary paediatric care
Ethnic Minority communities[45,46]	Interventions addressing –
	Social Isolation and Loneliness
	Promoting access and use of services
	Service delivery by lay health worker
	Cultural and Linguistic Competence of care providers Integrated care
LGBTQIA+population[37 ,47,48]	Competency training for practitioners
	Expanding culturally affirming telehealth programs
	Integrated and intersectional community intervention programs aimed at social inclusion
	Community support
	School-based interventions with a ‘whole-school’ approach that addresses the dominant cis-heteronormative school environment
	Support groups
Elderly[49,50]	Self-care
	Informal care and home-based mental health care
	Integrating mental healthcare with primary care
	Care through “health and wellness centres”
	Training and availability of primary care workers in Geriatric Mental Health
	Mental health promotion and preventive interventions
	Support to caregivers
	Digital Mental Health Interventions
Poor and those living in remote/geographically inaccessible areas[6, 39,51,52]	Digital Mental Health Interventions
	Integration of mental health care with primary care
	Task shifting and training primary care health workers in the villages to manage Common Mental Disorders
	Increasing knowledge about mental health and reducing stigma related to mental illness
	Interventions through community volunteers

Positive Mental Health to reduce mental health gap

The goal of achieving affordable, accessible and appropriate mental healthcare for all had been difficult to achieve despite efforts at various levels. Treatment interventions alone have not been effective in reducing the burden of mental illness. There is a need to look beyond the illness model and focus on the wellness model as a means to achieve the till now elusive goal of mental health for all. PMH targets those with optimal and less than optimal levels of mental health, and focuses on positive health rather than illness. It aims at gains in mental health to decrease risk of future mental illness.[7] PMH has been conceptualized as well-being in the domains of physical, emotional, psychological, social and spiritual.[53]

Cross-cultural evidence indicates that various psychological, social and behavioural factors can help support PMH. Such protection facilitates resistance to illness, minimizes and delays the emergence of disabilities, and promotes more rapid recovery from illness.[54] Benefits of interventions aimed at building PMH include positive effects on mental health, improvement in mental well-being, association with longevity and reduced likelihood of certain physical ailments.[7,55,56]

Interventions to build PMH can be broadly divided as at individual level, community level and structural level interventions. Some of these are highlighted in Table 4.

Table 4.

Interventions to build Positive Mental Health[53]

Intervention Type	Examples
Individual Level	Generic Life Skills Programs
	Social competencies (effective communication, cognitive style, problem-solving, coping skills, and resilience)
	Early attachment, warm and affectionate parenting, a secure and safe home and awareness of informal sources of community support
	Home visiting programmes
	High quality pre-school education
Community Level	Social participation
	Social inclusion
	Improving sense of social belonging
	Strengthening community networks
	Building social capital
	Improving neighbourhood environments
	Promoting self-help networks and community services which support mental health
	Group parenting classes
Structural Level	Reducing poverty, discrimination and inequalities
	Promoting access to education, employment and housing
	Support for the most vulnerable Improving physical health

CONCLUSION

Mental disorders are major contributors to the Global Burden of Disease. Despite this, treatment gap for these disorders continues to be high in all countries. Various barriers contribute to this persistently high mental health gap. Women, children and adolescents, ethnic minorities, LGBTQ + community, elderly and those living in remote and inaccessible areas are more vulnerable to mental illness. These groups have disproportionately high mental health gap. Understanding barriers to treatment in these groups and mitigating them is of paramount importance in the overall effort to reduce the mental health gap.

Perceptibly, efforts thus far to reduce the mental health gap have not been able to achieve the desired goal. Therefore, there is a need to look beyond the illness model. Positive Mental Health interventions which aim at promoting mental health and well-being have been found to be effective at reducing the risk of mental illness and in promoting general wellness. Future efforts need to include these interventions at all levels and particularly for the vulnerable populations. These efforts can possibly help in achieving the so far elusive goal of mental health for all.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.