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Global Mental Health A New Global Health Field Comes of Age

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Vikram Patel
Vikram Patel
Vikram Patel
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Martin Prince at King's College London
Martin Prince
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Abstract

Global health is “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”1 Global mental health is the application of these principles to the domain of mental ill health. The most striking inequity concerns the disparities in provision of care and respect for human rights of persons living with mental disorders between rich and poor countries. Low- and middle-income countries are home to more than 80% of the global population but command less than 20% of the share of the mental health resources.2 The consequent “treatment gap” is a contravention of basic human rights—more than 75% of those identified with serious anxiety, mood, impulse control, or substance use disorders in the World Mental Health surveys in low- and middle-income countries received no care at all, despite substantial role disability.3 In sub-Saharan Africa, the treatment gap for schizophrenia and other psychoses can exceed 90%.4 Even where treatment is provided, it often is far below minimum acceptable standards. Failure to provide basic necessities such as adequate nourishment, clothing, shelter, comfort, and privacy; unauthorized and unmonitored detention; and shackling and chaining are all well-documented abuses, described recently as a “failure of humanity.”5
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Global Mental Health: A New Global Health Field Comes of
Age*
Vikram Patel
Abstract
Global Health is ―an area for study, research and practice that places a priority
on improving health and achieving equity in health for all people worldwide.‖1
Global mental health is the application of these principles to the domain of
mental ill health.
The most striking inequity concerns the disparities in provision of care and
respect for human rights of persons living with mental disorders between rich
and poor countries.
Low- and middle-income countries are home to more than 80% of the global
population but command less than 20% of the share of the mental health
resources.2 The consequent ―treatment gap‖ is a contravention of basic human
rights—more than 75% of those identified with serious anxiety, mood, impulse
control, or substance use disorders in the World Mental Health surveys in low-
and middle income countries received no care at all, despite substantial role
disability.3 In sub-Saharan Africa, the treatment gap for schizophrenia and other
psychoses can exceed 90%.4 Even where treatment is provided, it often is far
below minimum acceptable standards. Failure to provide basic necessities such
as adequate nourishment, clothing, shelter, comfort, and privacy; unauthorized
and unmonitored detention; and shackling and chaining are all well-
documented abuses, described recently as a ―failure of humanity.‖5
Three critical foundations of evidence account for the emergence of the new
field of global mental health. First, a large body of cross-cultural research and,
equally important, the narratives of health care workers and persons living with
mental disorders have put to rest any notion that mental disorders were a
figment of a ―Western‖ imagination and that the imposition of such concepts on
traditional and holistic models of understanding amounted to little more than an
exercise in neocolonialism. Second, an increasing amount of epidemiological
research has attested to the considerable burden of mental disorders in all
world regions. The Global Burden of Disease6 indicated that 5 of the top 10
contributors to years lived with disability globally were mental disorders. The
vicious circle of disadvantage, social exclusion, and mental disorder was a key
message of the World Health Report 2001.7 Third, evidence has shown that
efficacious drug and psychological treatments are available for a range of
mental disorders and that nonspecialist health care workers can deliver
psychological treatments or multicomponent stepped care interventions for
mental disorders, with large treatment effect sizes that are sustained for
extended periods.8 With severe and persistent shortages of personnel and the
spiraling costs of specialist mental health care, such evidence counters the
nihilistic view that nothing can be done.9
The recent rapid increase in the visibility of the field can be seen in several
articles on global mental health that suggested scaling up services for persons
with mental disorders on the twin principles of scientific evidence and human
rights.9 This has now been adopted as a focus of action in global mental health,
such as with the World Health Organization’s (WHO’s) mhGAP (Mental Health
Global Action Program) and the Movement for Global Mental Health.10 WHO has
declared mhGAP as its flagship program in mental health and will publish
evidence-based guidelines for non-specialist health care workers to provide
treatments for 8 mental, neurological, and substance use disorders in routine
health care settings. The Movement for Global Mental Health is a coalition of
individuals and institutions committed to actions to close the treatment gap. It
derives its inspiration from the success of the Treatment Action Campaign in
transforming the lives of persons living with human immunodeficiency virus
(HIV) infection worldwide by campaigning to ensure access to antiretroviral
medicines.
Scaling up services can take 2 distinct paths. Integrating mental health care
into programs already in place for other health conditions is a pragmatic and
efficient approach that may require only marginally additional resources; HIV/
AIDS, chronic diseases, and maternal and child health are some examples.
However, the most vulnerable individuals with mental disorders are those living
with serious, enduring, and disabling conditions: intellectual disabilities,
schizophrenia, and dementia are hallmark examples of such conditions across
the life course. For these individuals, there is an urgent need for
deinstitutionalization and provision of acute and continuing care services closer
to the communities where those affected live.
There is a critical need for more research. While the essential ingredients of
packages of care have already been identified, 8 there is uncertainty as to
precisely how these should be delivered. Hence, much attention needs to be
directed to the implementation science. This needs to focus particularly on the
most effective interaction between specialist and nonspecialist care providers,
such as the extent to which tasks can be shifted and the duration, type, and
frequency of training and supervision that are required. So far, the field of
global mental health has been largely focused on the large treatment gaps in
low- and middle-income countries, a clear moral and ethical priority. However,
the field will reach maturity only when it recognizes its potential to bring about
improved care and outcomes and reduced inequities in all world regions. There
are many underserved subpopulations in highincome countries too, and the
provision and quality of mental health care has been shown to vary widely. In a
globalizing world, the field will increasingly need to address transnational
influences on mental health; migration, conflict, disasters, and the effects of
global trade policies are notable examples.
Knowledge can and must flow in both directions between high-income countries
and low- and middle-income countries. Researching mental disorders and
treatments in diverse populations and translating advances in neuroscience to
the benefits of patient care in the global mental health context are major
challenges for the field. Ultimately, the search for a better understanding of the
causes of mental disorders and affordable and effective treatments is of
importance to improving the lives of individuals living with these disorders in all
countries. This is the ultimate goal of global mental health.
REFERENCES
1. Koplan JP, Bond TC, Merson MH, et al; Consortium of Universities for Global Health Executive Board.
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2. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and
inefficiency. Lancet. 2007;370(9590):878-889.
3. Demyttenaere K, Bruffaerts R, Posada-Villa J, et al;WHOWorld Mental Health Survey Consortium.
Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization
World Mental Health Surveys. JAMA. 2004;291(21):2581-2590.
4. Kebede D, Alem A, Shibre T, et al. Onset and clinical course of schizophrenia in Butajira-Ethiopia—a
community-based study. Soc Psychiatry Psychiatr Epidemiol. 2003;38(11):625-631.
5. Kleinman A. Global mental health: a failure of humanity. Lancet. 2009; 374(9690):603-604.
6. Murray C, Lopez A. The Global Burden of Disease. Boston, MA: Harvard School of Public Health, World
Health Organization, and World Bank; 1996.
7. World Health Organization. The World Health Report 2001: Mental Health: New Understanding, New
Hope. Geneva, Switzerland: World Health Organization; 2001.
8. Patel V, Thornicroft G. Packages of care for mental, neurological, and substance use disorders in low-
and middle-income countries: PLoS Medicine series. PLoS Med. 2009;6(10):e1000160.
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10. Movement for Global Mental Health. http://www.globalmentalhealth.org. Accessed April 7, 2010.
*
Vikram Patel, MD, PhD & Martin Prince, MD, PhD in
JAMA
, May 19, 2010 – Vol.303, No.19
(Reprinted)
... Project TITAN was designed as a partnership between U.S. and Cambodian teams to reduce the mental health treatment gap that is endemic to Cambodia and other resource-limited countries. Mental health disorders have increased worldwide [1], and low-and middle-income countries (LMIC), like Cambodia, are significantly and disproportionately burdened [2]. Cambodia has suffered unique traumas rendered during the Khmer Rouge Regime of the late 1970s [3,4]. ...
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... Several randomized controlled trials (RCTs) have shown that particularly the outreach model and the task-shifting models hold the potential to increase mental health awareness and decrease the symptom burden of people with mental health complaints in LMICs [8,[10][11][12]. However, utilizing non-specialists to bridge the MHC gap still requires appropriate training and ongoing support to ensure the safety of patients and non-specialists [13,14]. ...
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Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys The WHO World Mental Health Survey Consortium JAMA 2004 291 2581 2590 10.1001/jama.291.21.2581 15173149
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Little is known about the extent or severity of untreated mental disorders, especially in less-developed countries. To estimate prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders in 14 countries (6 less developed, 8 developed) in the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative. Face-to-face household surveys of 60 463 community adults conducted from 2001-2003 in 14 countries in the Americas, Europe, the Middle East, Africa, and Asia. The DSM-IV disorders, severity, and treatment were assessed with the WMH version of the WHO Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay-administered psychiatric diagnostic interview. The prevalence of having any WMH-CIDI/DSM-IV disorder in the prior year varied widely, from 4.3% in Shanghai to 26.4% in the United States, with an interquartile range (IQR) of 9.1%-16.9%. Between 33.1% (Colombia) and 80.9% (Nigeria) of 12-month cases were mild (IQR, 40.2%-53.3%). Serious disorders were associated with substantial role disability. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5% to 50.3% of serious cases in developed countries and 76.3% to 85.4% in less-developed countries received no treatment in the 12 months before the interview. Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country. Reallocation of treatment resources could substantially decrease the problem of unmet need for treatment of mental disorders among serious cases. Structural barriers exist to this reallocation. Careful consideration needs to be given to the value of treating some mild cases, especially those at risk for progressing to more serious disorders.
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Onset and clinical course of schizophrenia in Butajira-Ethiopia - A community-based study
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Full-text available
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There are reports on favourable course and outcome of schizophrenia in lowincome countries. The aim of the present study was to examine onset and clinical course of the illness in a community-based sample in rural Ethiopia based on crosssectional information. A two-stage survey was carried out in Butajira-Ethiopia, a predominantly rural district. Altogether 68,378 individuals aged 15-49 years were CIDI-interviewed, of whom 2,159 were identified as cases according to the CIDI interview with regard to psychotic or affective disorders. Key informants identified another group of 719 individuals as being probable cases and a total of 2,285 individuals were SCAN-interviewed. The present paper reports on cases with schizophrenia. There were 321 cases of schizophrenia giving an estimated lifetime prevalence of 4.7/1,000). Of the cases,83.2% (N = 267) were males. Mean age of first onset of psychotic symptoms for males was 23.8 (sd 8.6) compared to 21.0 (sd 7.8) for females (P = 0.037; 95 %CI 0.16-5.47). Over 80% had negative symptoms and over 67% reported continuous course of the illness. Less than 10% had a history of previous treatment with neuroleptic medication. About 7% were vagrants, 9 % had a history of assaultive behaviour,and 3.8% had attempted suicide. The male to female ratio was nearly 5:1. This large community-based study differs from most previous studies in terms of higher male to female ratio, earlier age of onset in females and the predominance of negative symptoms.
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No Health Without Mental Health
Article
Full-text available
  • Oct 2007
  • LANCET
About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.
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Resources for Mental Health: Scarcity, Inequity, and Inefficiency
Article
  • Oct 2007
  • LANCET
Resources for mental health include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. We discuss here the general availability of these resources, especially in low-income and middle-income countries. Government spending on mental health in most of the relevant countries is far lower than is needed, based on the proportionate burden of mental disorders and the availability of cost-effective and affordable interventions. The poorest countries spend the lowest percentages of their overall health budgets on mental health. Most care is now institutionally based, and the transition to community care would require additional funds that have not been made available in most countries. Human resources available for mental health care in most low-income and middle-income countries are very limited, and shortages are likely to persist. Not only are resources for mental health scarce, they are also inequitably distributed-between countries, between regions, and within communities. Populations with high rates of socioeconomic deprivation have the highest need for mental health care, but the lowest access to it. Stigma about mental disorders also constrains use of available resources. People with mental illnesses are also vulnerable to abuse of their human rights. Inefficiencies in the use of available resources for mental health care include allocative and technical inefficiencies in financing mechanisms and interventions, and an overconcentration of resources in large institutions. Scarcity of available resources, inequities in their distribution, and inefficiencies in their use pose the three main obstacles to better mental health, especially in low-income and middle-income countries.
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Scale up services for mental disorders: a call for action
Article
  • Nov 2007
  • LANCET
We call for the global health community, governments, donors, multilateral agencies, and other mental health stakeholders, such as professional bodies and consumer groups, to scale up the coverage of services for mental disorders in all countries, but especially in low-income and middle-income countries. We argue that a basic, evidence-based package of services for core mental disorders should be scaled up, and that protection of the human rights of people with mental disorders and their families should be strengthened. Three questions are critical to the scaling-up process. What resources are needed? How can progress towards these goals be monitored? What should be the priorities for mental health research? To address these questions, we first estimated that the amount needed to provide services on the necessary scale would be US$2 per person per year in low-income countries and $3-4 in lower middle-income countries, which is modest compared with the requirements for scaling-up of services for other major contributors to the global burden of disease. Second, we identified a series of core and secondary indicators to track the progress that countries make toward achievement of mental health goals; many of these indicators are already routinely monitored in many countries. Third, we did a priority-setting exercise to identify gaps in the evidence base in global mental health for four categories of mental disorders. We show that funding should be given to research that develops and assesses interventions that can be delivered by people who are not mental health professionals, and that assesses how health systems can scale up such interventions across all routine-care settings. We discuss strategies to overcome the five main barriers to scaling-up of services for mental disorders; one major strategy will be sustained advocacy by diverse stakeholders, especially to target multilateral agencies, donors, and governments. This Series has provided the evidence for advocacy. Now we need political will and solidarity, above all from the global health community, to translate this evidence into action. The time to act is now.
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The Global Burden of Disease
  • C Murray
  • Lopez
Murray C, Lopez A. The Global Burden of Disease. Boston, MA: Harvard School of Public Health, World Health Organization, and World Bank; 1996.