Public mental health: An opportunity to address implementation failure

INTRODUCTION

Public mental health (PMH) involves a population approach to mental health in order to improve coverage, outcomes, and coordination of interventions to treat mental disorder, prevent associated impacts, prevent mental disorder from arising, and promote mental well-being and resilience (Campion et al., 2022).[1] This supports efficient, equitable, and sustainable reduction of the burden of mental disorders and promotion of mental well-being of populations.

IMPACTS OF MENTAL DISORDER AND WELLBEING

Prior to the COVID-19 pandemic, mental disorder contributed to at least 18% of global disease burden (measured by years lived with disability) (GBDCN, 2021)[2] although even this underestimates true burden by a third (Vigo et al., 2016).[3] Furthermore, the proportion of disease burden in India due to mental disorder almost doubled between 1990 and 2017 (ISDBIMDC, 2020).[4] The annual global economic cost of mental disorder is projected to exceed $US 6 trillion by 2030 (Bloom et al., 2011).[5]

Three factors account for such a large proportion of disease burden: the first is the high prevalence with 14.3% of the population in India affected by mental disorder in 2017 (excluding substance use disorder and dementia) (ISDBIMDC, 2020),[4] more than 5% with substance use disorders (Ambekar et al., 2019),[6] and up to 10% of older people with dementia (Ravindranath and Sundarakumar, 2021).[7] The second reason is that the majority of lifetime mental disorder arises before adulthood and then often reoccurs across the life course (Jones, 2013).[8] The third is the broad consequences of mental disorder (Campion, 2019):[9] health impacts include increased health risk behaviors (such as self-harm, physical inactivity, and use of alcohol, drugs, and tobacco), physical illness, and mortality (Campion, 2019)[9] with most of the excess mortality associated with mental disorder due to physical illness (Walker et al., 2015).[10] Mental disorders are also responsible for 62% of global disability-adjusted life years allocated to suicide (Ferrari et al., 2014)[11] with higher than expected suicide death rate in India (ISDBISC, 2018; Vijayakumar et al., 2021).[12,13] Broader impacts of mental disorder occur across education, employment, social interaction, and violence (victimization and perpetration) (Campion, 2019).[9]

In contrast, mental wellbeing results in a broad range of health and wider impacts across different sectors.[9]

PUBLIC MENTAL HEALTH INTERVENTIONS

Effective PMH interventions exist to treat mental disorder, prevent associated impacts, prevent mental disorder, and promote mental well-being and resilience (Patel et al. 2018, Campion, 2019; Campion et al., 2022).[1,9,14] However, treatment alleviates a relatively small proportion of disease burden of mental disorders (Andrews et al., 2004)[15] which highlights the importance of prevention. Many PMH interventions also have economic evaluation demonstrating an economic return on investment even in the short term including in India (Chisholm et al. 2016; Chisholm et al. 2017; Campion and Knapp, 2018; Math et al., 2019; Campion, 2019).[9,16,17,18,19] All PMH interventions require more targeted approaches for groups at higher risk of mental disorder and poor mental well-being in order to prevent widening of inequalities.

India has an ambitious and progressive national mental health policy (Government of India, 2014)[20] and a pathbreaking mental health-care law enacted in 2017 (Government of India, 2017).[21] India is also a signatory to the World Health Organization’s Comprehensive Mental Health Action Plan 2013–2030 to support implementation of PMH interventions (WHO, 2013).[22] Mental health has been included as an integral component of the United Nations Sustainable Development Goals (UN, 2016)[23] and has a broad range of impacts across both health and other sectors (Patel et al., 2018).[14] This is particularly relevant for India, being one of the largest developing countries in the world.

PUBLIC MENTAL HEALTH IMPLEMENTATION FAILURE

Despite the existence of effective PMH interventions and policy, globally only a minority with mental disorder receive any treatment with far less treatment coverage in low- and middle-income countries (WHO, 2021a).[24] For instance, proportion not receiving treatment in India ranged from 70% to 92% depending on type of mental disorder (Gururaj et al., 2016).[25] Even less coverage occurs for interventions to prevent associated impacts of mental disorder with negligible coverage of interventions to prevent mental disorder or promote mental well-being and resilience. The implementation gap contravenes the right to health and results in population-level suffering, broad associated impacts, and economic costs. Furthermore, the implementation gap has widened during the COVID-19 pandemic (WHO, 2020; WHO, 2021a).[24,26]

Several reasons account for this gap (Campion et al., 2022):[1]

• Insufficient resource (WHO, 2021a)[24] with <1% of the health budget in India allocated to mental health (Central Bureau of Health Intelligence [CBHI],[27] 2021) and high reliance on out-of-pocket expenditure on health which disproportionately affects poorer sections of society (Chisholm et al., 2019; CBHI, 2021).[27,28] Furthermore, there is a large underspend of allocated resource (Patel et al., 2016; Chisholm et al., 2019)[28,29]

• Low coverage of insurance for mental disorder (Singh, 2019; Chisholm et al., 2019)[28,30]

• Inadequate and uneven implementation of mental health policy and commitments across the different states of India (Gururaj et al., 2016; Gupta and Sagar, 2018; Chisholm et al., 2019)[25,28,31]

• Low prioritization of mental health at state level (Chisholm et al., 2019)[28] associated with insufficient political will, stigma toward mental health, and the political nature of some PMH interventions (Campion, 2019; Campion et al., 2022)[1,9]

• Challenge of required multilevel action across various sectors particularly for prevention and promotion activities (Vijayakumar et al., 2021)[13] while cultural partnerships through pluralistic health systems are required for sensitive service provision and uptake (Gopalkrishnan, 2018)[32]

• Insufficient PMH knowledge among both professionals and the wider population

• Specific causes for the treatment gap include insufficient staff (Math et al., 2019)[19] and skills, insufficient perceived need and population mental health literacy, stigma and discrimination which reduces helping seeking, poor quality treatment, poor adherence and negative attitudes toward treatment, and insufficient involvement of service users and carers.

ACTIONS TO ADDRESS THE PUBLIC MENTAL HEALTH IMPLEMENTATION GAP

The COVID-19 pandemic has further widened the global PMH implementation gap[24,26] and brought unprecedented challenges. This highlights how a PMH approach is even more important to address the PMH implementation gap. Actions to address the PMH implementation gap include PMH practice, PMH advocacy, improving understanding about PMH among relevant professionals and the wider population, settings-based and integrated approaches, digital technology, maximizing existing resources, a focus on high-return interventions, a human rights approach, an approach based on cultural partnerships, and implementation research (Campion et al., 2020; Campion et al., 2022).[1,33]

PMH practice involves several steps (Campion et al., 2022):[1]

1. Assessment of PMH need at national and more local levels which takes account of issues such as COVID-19. This is important due to the substantial national and regional variation in prevalence of mental disorder, associated risk factors and social determinants as well as provision of PMH interventions. Such assessments are supported by the strengthening of appropriate information systems

2. Use of the PMH needs assessment to identify opportunities to improve implementation of different PMH interventions by different sectors

3. Estimation of impact of improved coverage including on existing policy objectives as well as associated economic benefits (Chisholm et al., 2016; Campion and Knapp, 2018)[16,17] to inform:

   • Policy and strategy development in different sectors
   • Transparent agreement about acceptable levels of coverage of different PMH interventions which should involve a broad range of stakeholders including patients and carers, take account of the impact and cost of implementation failure, the right to health, and the UN Sustainable Development Goal (SDG) target of universal coverage by 2030[23]
   • Required resource for agreed level of implementation: Global mental health targets for 2030 can only be reached through collective commitment to make massive investment at the country level (Stenberg et al., 2017; WHO, 2021a).[24,34] Governments have the lead responsibility for their population’s health although can work with other organizations including the United Nations (WHO, 2021b)[35]
   • Coordination between providers of different PMH interventions.

4. Operationalization of agreed PMH implementation decisions

5. Evaluation of coverage, outcomes, and economic benefits of PMH interventions including for higher risk groups.

The PMH case can be made through assessment of PMH need (see above), collaborative advocacy, and leadership between sectors. This can be supported by briefings for different sectors which summarize the impact of mental disorder and well-being, existence of effective PMH interventions, impact and associated cost of implementation failure, and how this breaches the right to health. Leadership is important at both national and international levels. For instance, the World Psychiatric Association has made PMH a central part of its 2020–2023 Action Plan (WPA, 2020).[36] Actions to strengthen mental health systems to both address and prevent mental impacts of COVID-19 are required and can be applied in India (Campion et al., 2020; Maulik et al., 2020).[33,37]

Understanding about PMH can be improved through training for professionals and trainees in mental health, primary care, public health, education, employment, criminal justice, and policy which can be delivered online (Campion, 2020)[38] although such training should start at undergraduate level. Among the wider population, improved PMH understanding can support early recognition and intervention for mental disorder as well as actions to stay mentally well and resilient.

Further actions to improve coverage of PMH interventions include (Campion, 2019; Campion et al., 2022):[1,9]

• Resource: Utilization of existing budgets can be improved through planning, capacity building, and public–private partnerships (Chisholm et al., 2019)[28]

• Insurance: Inclusion of mental disorder in national health insurance or reimbursement schemes (WHO, 2021)[24] has been mandated by the Mental Health Care Act (Government of India, 2017).[21] India has recently introduced national health insurance reforms to secure greater financial protection for individuals and households affected by mental disorders and psychosocial disabilities although opportunities exist to address inconsistencies (Singh, 2021)[39]

• Integrated approaches: This includes integration both within and between sectors. For instance, integration between primary care and secondary mental health care can be supported by collaborative care and task sharing (van Ginneken et al., 2021).[40] India is trying to integrate mental health care into community and primary health-care settings as part of an integrated chronic disease management approach (Ved et al., 2019).[41] An integrated, multilevel approach across sectors is required to prevent suicide (Vijayakumar et al., 2021).[13] Integration of mental health with public health can also support achievement of range of public health policy objectives

• Settings-based approaches: Particular settings attended by large sections of the population include preschools, schools, workplace, and prisons and can support the scale implementation of more than one PMH intervention

• Digital technology can deliver a range of PMH interventions (Math et al., 2020)[42]

• Maximizing existing resources including through self-help, integrated approaches, improved concordance with and quality of treatment, adopting a recovery approach, service user involvement in mental health planning and policy development, shifting resources to community services, engagement with traditional healers and practitioners of complementary medicine, and mental health providers effectively working across cultures (Gopalkrishnan, 2018)[32]

• Focus on high-return interventions: These include PMH interventions during childhood and adolescence given the majority of lifetime mental disorder arises before adulthood. A large proportion of childhood mental disorder could be prevented by addressing parental mental disorder, socioeconomic inequalities, and poverty.

Legislation and a rights approach to mental health can support improved PMH implementation. A focus on implementation research is also important given the current implementation failure of effective PMH interventions.

SUMMARY

Mental disorder and poor mental well-being have large impacts across sectors. Effective PMH interventions exist to treat mental disorder, prevent associated impacts, prevent mental disorder from arising, and promote mental well-being and resilience. However, the implementation failure of PMH interventions represents a breach of the right to health and results in preventable suffering, broad impacts, and associated economic costs which have been further amplified by COVID-19. Implementation of PMH interventions can be improved in several ways outlined in this article. Improved implementation results in broad impacts across sectors and the achievement of a range of policy objectives and supports the SDG goal of universal coverage by 2030. Associated economic benefits make PMH an important part of sustainable economic development and recovery.