The Burden Is Even Greater, The Solution Needs Rethinking

Vigo et al.’s paper in this issue of the Journal¹ builds on their earlier work to calculate the burden of mental disorders, addressing limitations of the original Global Burden of Disease estimates, by reclassifying the burden associated with suicide, certain neurological disorders with significant behavioral implications (notably dementia), drug and alcohol use disorders and their somatic consequences, and syndromes associated with prominent pain which often have a psychogenic origin (such as headaches) to arrive at a composite estimate of “mental, neurological, substance use disorders and self-harm” (MNSS) disorders.² This reclassification is justified to take into consideration a “clinically and epidemiologically rational framework for attributing disease burden to disorder groupings, rather than arbitrary methodological considerations” adopted by the Global Burden of Disease estimates; this is an argument I completely endorse and which we adopted in the Disease Control Priorities project.³

They show how this reclassification leads to a dramatic 3-fold increase in the proportionate burden of disease, estimated in Disability Adjusted Life Years, in the three countries of North America in 2017: in Canada, from 7.4% to 23.8%; in the United States, from 7.1% to 24.7%; and in Mexico, from 5.6% to 16.9%. Notably, while the relative burden is lowest in Mexico, partly due to the higher burden attributed to other health conditions (such as injuries and other noncommunicable diseases), it is also evident that Mexico has the lowest per capita burden of DALYs due to MNSS disorders. The highest burden is in the United States, which is 50% higher for men and 63% higher for women in Mexico, with Canada occupying a roughly midway position between these two countries. A substantial proportion of the excess burden in the United States can be attributed to opiate use disorders and self-harm. These observations are consistent with a recent study that reported the rising rates of suicide in the United States⁴ and the mounting evidence testifying to the devastating epidemic of opioid use disorders sweeping the country.⁵

The overriding implication of these findings is the need for greater investments to reduce the burden of suffering consequent to MNSS disorders. The allocation of resources, whether for research or service delivery, was already disproportionately lower than the original estimates of the burden of mental disorders in all three countries⁶; if we used the recalculated burden estimates, this inequity reaches alarming proportions. But spending more money on mental health care alone cannot be the entire solution to the high burden for, if that were the case, surely we should have seen a higher burden per capita in Mexico which not only has the least resources allocated to mental health care but whose population also face a much higher prevalence of a range of social determinants of poor mental health, such as poverty and violence. Indeed, Mexico is a middle-income country, which ranks 64 places lower than Canada and 49 places lower than the United States in the Sustainable Development Index.⁷

Might this finding align with the provocative evidence emerging of a “vulnerability paradox,” that is despite the higher vulnerability for mental health problems in poorer individuals in a particular country, lower vulnerability at the country level, as reflected in the indices used to estimate sustainable development, is not necessarily associated with lower prevalence of mental health problems. Perhaps the most compelling example of this paradox is documented in a recent study⁸ that observed a negative association between suicide rates and country vulnerability in both genders. These findings indicate that despite a higher risk factor burden and lesser access to quality mental health care in poorer countries, there is a relatively lower prevalence of mental health problems in high vulnerability countries. These counterintuitive findings point to two key possibilities: first, that there are some, as yet not specified, risk factors driving higher burden in the United States and Canada or, conversely, protective factors helping reduce the burden in Mexico; and second, that there is, at best, only a weak association between spending on mental health care or access to mental health care (the authors cite other studies that report that over 90% of people with depression and substance use disorders receive “minimally effective” care in Mexico, a proportion much higher than either of the other two countries) and the population burden of MNSS disorders.

Thus, while it is important that all three countries invest more in mental health care to reduce the so-called treatment gap, it is also clear that the way resources are allocated will need to be carefully rethought if these investments are to have the desired impact on reducing the population burden of MNSS disorders. Most importantly, far greater emphasis is needed on scaling up effective strategies to reduce the “prevention gap” by addressing the known risk and protective factors for poor mental health, notably investing in enabling nurturing environments in the earliest years of life, provision of quality education and secure employment opportunities for young people, strategies to reduce violence in the home, schools and neighborhood, and building social capital and gun control (both key county-level determinants of suicide in the United States⁴). Most of the actions will take place outside the health sector, for example, support services for parents of young children, enabling schools to be health promoting, and appropriate regulatory policies.

A second inference is reimagining the architecture of the mental health care system by building a robust community-facing foundation that aims to scale up informal and formal mental health care provision by front-line nonspecialist providers. There is now a rich evidence base, particularly from the global south, offering compelling evidence demonstrating that such providers can effectively deliver psychosocial interventions to manage mood and anxiety disorders and substance use disorders and improve social and occupational functioning for people with psychoses.^9,10 These delivery strategies help address one of the most significant gaps in mental health care, that is, access to evidence-based psychological and social interventions and, in doing so, can greatly reduce the “quality gap” in mental health care. Such a foundation offers the opportunity to pragmatically realize a staged or stepped care approach to the heterogeneous and dimensional nature of mental health problems and makes care contingent on needs rather than diagnoses. The potential for such approaches is increasingly being advocated for the richer countries of North America¹¹ and is now a widely accepted approach for mental health care globally.¹²

An obvious observation from these two inferences is that much of the additional spending will need to be outside the specialist mental health sector. Nevertheless, it is important for the mental health professional communities to strongly advocate for such approaches, as our overall goal must be to reduce the burden of MNSS disorders. Additionally, in advocating for strategies to enhance prevention and build the community-facing workforce, we can also reallocate our overstretched specialist resources to the care of persons with the most severe forms of mental health problems. While one can hope that such investments will be much more effective than simply focusing on access to mental health care, it is also likely that such impacts may take a long time to become apparent. In the interim, policy makers need reliable metrics to evaluate the short-term impacts and track these regularly to ensure accountability of these investments. Such an initiative, Countdown Global Mental Health 2030,¹³ has recently been launched with the goal of building on the Lancet Commission on global mental health and sustainable development effort to define a range of indicators covering the determinants of mental health, mental health services, and mental health outcomes.¹⁴ It is hoped that this initiative will derive a “mental health system index” that can be applied across all countries (or other administrative units) which will both help shed light on what works to reduce the burden of MNSS disorders and to evaluate the impact of investments in specific interventions.

Finally, I return to the intriguing question of the vulnerability paradox; if it is truly the case that this is accounted for by protective factors operating in countries with higher levels of vulnerability, then identifying these is a matter of the highest public policy importance not only to ensure they are preserved and strengthened in those countries but that other countries can also attempt to integrate them into the architecture of their societies. If, as has been argued, mental health must be viewed as a global public good, integral to the economic notions of human capabilities and capital,¹⁴ then we must cast a wide net on how to protect, promote, and preserve mental health in all people equitably. Focusing on the treatment gap alone will not suffice; we need renewed emphasis on reducing the prevention and quality gaps and on enhancing the factors operating at the societal level which promote population mental health.