Should development agencies care about mental health?

Introduction

This issue of Mental Health in Family Medicine contains a series of four articles, together with accompanying editorials, which explore how international donors can invest effectively to address mental health needs in low income countries in order to build mental capital at both individual and population level, reduce the burden of mental disorders within current health system constraints and prepare health systems for the projected increase in mental disorders resulting from demographic, epidemiologic and socio-economic change.

Given the substantial contribution of mental disorders to the global burden of disease,¹ the critical importance of mental health in development of human, social and economic capital² and the availability of highly cost-effective interventions,^3,4 it is paradoxical that mental health is not considered a priority across the world, including in low- and middle-income countries.^5–7

Despite well-established links between poor mental health, poverty, education, communicable and other non-communicable diseases, attempts at prioritisation of mental health have yielded little change in international or domestic financing flows to address mental disorders.⁸ Mental health remains highly stigmatised both by the general public and by policy makers,^6,7 and even when considerable emphasis is rightly being placed on chronic conditions such as diabetes, cardiovascular disease and respiratory illness, mental disorders, which account for a greater global disease burden, remain woefully unaddressed.

One key barrier to progress in investment in mental health relates to limited understanding by key decision makers at policy, professional and intersectoral levels of the core concepts of mental health and mental illness, and limited knowledge of the risk factors and contextual factors associated with these, the human and socio-economic consequences of not addressing the mental disease burden and the outcomes that could be achieved through promotion, prevention, treatment and rehabilitation actions, including contributions to help achieve the Millennium Development Goals (MDGs).

The first article in the series⁹ therefore aims to address this knowledge gap, setting out some of the core concepts in modern mental health and summarising the current state of knowledge on key mental health issues. It explores the links between mental disorders and physical illness – including morbidity, disability and mortality – and considers how the adverse impacts of these can be effectively avoided. It examines the root causes of mental disorders, demographic trends influencing mental disorders and gender issues. It also looks at the adverse impacts of mental disorders, including the adverse effects on progress towards achievement of the MDGs, and the consequences of not addressing them. Finally, the paper points to the missed opportunities for forming effective partnerships between specialists and policy makers working in non-communicable diseases and those working in the field of mental health.

The paper puts forward arguments to enable policy makers and international donors to better understand the significant benefits of both promoting good mental health and of policies that aim to prevent the development of mental disorders. Better mental health and well being can also contribute to healthy personal development, achievement of educational, social and economic goals and the avoidance of both communicable and non-communicable health problems, with the consequent risk of premature mortality. Social and economic gains from public policies that recognise and address the burden of mental disorders are substantial.² Yet conversely in many countries mental disorders, which will continue to increase, remain unaddressed. Population growth and ageing, persisting HIV, tuberculosis and malaria epidemics, an increasing number of orphans and child-headed households, migration from rural to urban areas and the breakdown of family ties, marital breakdowns, economic transition including risk of increased debt and income disparities and worsening alcohol and substance abuse are some of the major drivers of the projected global increase in mental disorders.¹⁰ The socio-economic consequences of not investing in cost-effective interventions to improve mental wellbeing will be substantial, especially as the poor disproportionately bear these consequences.

In addressing the burgeoning rates of mental illness and the determinants of mental ill health, policy makers face many challenges. For example, intersectoral responses are needed to effectively address mental illness driven by poverty and socioeconomic exclusion. As populations age, healthcare systems will need to be able to adapt in order to address more effectively mental disorders and comorbid physical health problems. Policy makers will need to pay particular attention to ‘at-risk groups’ such as children, for whom the social and educational impacts of poor mental health can be substantial, persisting into adulthood.

A number of key messages emerge from the first article in this series ‘Mental health and the global agenda: core conceptual issues’:⁹

• Mental disorders represent a large and growing proportion of the global disease burden. This growing burden is poorly addressed in low-and middle-income countries, resulting in widespread poverty, as well as worsening health and economic losses for the affected individuals, their families and communities.

• Mental illnesses are closely interlinked with AIDS, tuberculosis and malaria, with those affected by these diseases also disproportionately suffering from mental illness. The increased numbers of orphans and vulnerable children as a result of HIV and AIDS are particularly vulnerable to low human, mental and social capital due to the loss of their caregivers, as well as alcohol and drug abuse and gender-based violence. Early sexual activity also places them at risk of infection by the HIV virus and in the case of young girls at risk of teenage pregnancy.

• The increased risk of co-morbidity and mortality linked to mental illness is not restricted to communicable diseases alone, it is also associated with a substantially increased risk of non-communicable diseases, including cardiovascular disorders and diabetes. The magnitude of mental health-related morbidity and mortality from communicable and non-communicable physical diseases in people with mental illness is not appreciated. Too often, understanding of the mortality associated with mental illness is restricted to suicide alone.

• The mortality caused by suicide is very great, but there is an additional mortality, probably at least equivalent in size to that of suicide, due to premature mortality from co-morbidity with physical diseases such as malaria,¹¹ HIV/AIDS,^12,13 tuberculosis,¹⁴ cardiovascular disease^15,16 and diabetes,^17,18 among others.

• Success in addressing mental disorders will require comprehensive multisectoral approaches that include population-based interventions to identify and control risk factors and integrated clinical services that provide accessible assessment, treatment and care.

• Ineffectively addressing mental disorders will hinder progress towards the MDGs. Conversely, interventions that help improve ‘mental capital’ and wellbeing could help in the socio-economic development of countries and contribute to both the alleviation of poverty and a reduction in the burden of disease.

Later articles in this series will address in detail the contextual social, economic and political challenges to the effective action needed for addressing the growing burden of mental illness;¹⁹ the international and national policy challenges and solutions to these challenges;²⁰ and health system challenges and ways in which these can be effectively addressed;²¹ while the accompanying editorials will highlight key issues from a public policy perspective.