Mental Illness: Global Challenges, Global Responses

Why a global edition of Psychiatric Times? The needs of the world's mentally ill are great; the barriers to effective treatment, extensive; and the availability of resources, limited. Still, the opportunities for international collaboration, scientific synergy and significant progress are many.

A trusted and well-read publication for mental health care professionals in the United States for more than 20 years, Psychiatric Times believes it can contribute to closing the gaps between the current global mental health situation and the provision of quality care for patients, whether in urban centers or remote villages.

The welcome increase in Internet usage throughout the world (e.g., Internet access is available in all African capital cities) permits new modes of scientific exchange. In anticipation, we have made major improvements on our Web site, such as enabling mental health care professionals worldwide to access the full-text of articles in this global edition.

We seek to facilitate global dialogues and information dissemination on issues such as mental health care policy and legislation, classification and diagnosis of mental disorders, research findings, clinical advances, treatment protocols, and prevention initiatives. All of this is being done with recognition that developing and developed countries can assist each other. Already, those in the developing countries are benefiting from the transmission of scientific technology, while those in developed countries are benefiting from knowledge of psychoactive herbal medicines used by traditional healers.

Burden of Mental Disorders

In this introduction to our first Global Watch edition, we offer glimpses of the global mental health burden, resource indicators and solution-oriented efforts.

The World Health Organization (WHO) has warned that the international burden of mental disorders is enormous and growing. As of 1990, five of the 10 leading causes of disability worldwide--measured in years lived with a disability--were psychiatric conditions: unipolar depression, schizophrenia, bipolar disorders, alcohol dependence and obsessive-compulsive disorder (Murray and Lopez, 1996). It is expected that by 2020, major depression, which is already ranked fourth among the 10, will jump to second place (Brundtland, 2001a).

More than 450 million people worldwide suffer from mental and brain disorders. This includes 121 million people with depression, 24 million with schizophrenia and 37 million with dementia (WHO, 2001). Substance use disorders are a major challenge as well, with 140 million people dependent on or abusing alcohol (Brundtland, 2001a) and an estimated 5 million people injecting illegal drugs. The high prevalence of HIV infection among intravenous drug users has accelerated the spread of HIV/AIDS.

Worldwide, nearly 1 million people commit suicide each year, and between 10 million and 20 million attempt it. The total number of youth suicides is increasing and in one-third of countries, suicide rates are higher among those under age 30 than in older age groups (Brundtland, 2001a, 2001b).

When viewed by region or country, the challenges become more specific. For example:

• In Europe, about 41 million adults are estimated to abuse or are dependent on alcohol, yet 66% receive no treatment. For some European societies, the costs of alcohol abuse and dependence have been calculated to amount to 3% of their gross domestic product (WHO/Europe, 2001).

• In China, suicide among 15- to 34-year-olds is a leading cause of death; it is the number one cause of death among young women in rural areas (WHO, 2001).

• Epidemiological studies of mental health in Latin America have shown a consistent prevalence of 18% to 25% of mental disorders in communities and up to 48% in clinical settings (Alarcon, 2003). In the year 2000, 18 million people in the region suffered financially serious setbacks (unemployment, job dismissals, eviction, homelessness) as a result of clinically significant mental disorders. Barriers and Resources

In 1959, WHO warned that efforts to have the mentally ill treated as other sick people who can be cured are likely to remain fruitless as long as the irrational fear of madness is not conquered and as long as all the influential members of the social hierarchy believe that mental health is the business of specialists rather than a concern of the whole community (Brundtland, 2001a).

Unfortunately, some 44 years later, Project Atlas, a database of WHO's Department of Mental Health and Substance Dependence, shows that 41% of 185 countries do not have a national mental health policy and 25% of 170 countries have no legislation on mental health care (WHO, 2002b). In fact, in 15% of countries worldwide mental health laws operate that are at least 40 years old (Thornicroft and Maingay, 2002). In addition, 44% of 184 countries do not have an epidemiological study or data collection system in mental health.

Several societal factors hinder the development of mental health policies. Development of such policies in India, for example, has been circumscribed by an extremely limited number of mental health care professionals, a very limited mental health care service infrastructure (about 30,000 psychiatric beds for a billion population), problems of poverty and only 60% literacy (Murthy, 2003).

Financing of mental health programs is a significant obstacle. The majority of Latin American countries "devote less than 2% of their total health budget to mental health," according to Alarcon (2003), "thus compounding a dismal picture already affected by everyday stress of all kinds (from massive internal migrations to a 'hidden epidemic' of domestic violence or from socio-political unrest to the ever-present risk of natural disasters)."

Like funding, mental health resources are in short supply. Often, the resources and services are 1% to 10% of what is needed (Brundtland, 2001a).

Throughout the world, a wide disparity exists in the type and numbers of the mental health workforce. In low-income countries, the median number of psychiatrists is 0.06 per 100,000 population and the median number of psychiatric nurses is 0.1 per 100,000. In high-income countries, the median number of psychiatrists is nine per 100,000 population and the median number of psychiatric nurses is 33.5 per 100,000 (WHO, 2001). Yet, nearly one-half of the world's population has access to one psychiatrist or less per 100,000 population; some countries (e.g., Bangladesh and Nigeria) may have access to less than one psychiatrist for every 1 million people (WHO, 2001). By comparison, the United Kingdom has one adult psychiatrist per 50,000 and the former Soviet Union has one psychiatrist per 10,000 to 20,000 (Jenkins, 2003). In Latin America, "the estimated figures of 1.6 psychiatrists, 2.7 psychiatric nurses, 2.8 psychologists and 1.9 social workers per 100,000 are far below those of Europe or the United States" (Alarcon, 2003). Some thought has been given to training traditional healers, the primary source of assistance for some 80% of rural inhabitants in developing countries, as case finders and referral sources (WHO, 2001).

Equally disturbing is the scarcity of psychotropic medications. According to WHO, at least one-fourth of countries do not have the three most commonly prescribed medications used to treat schizophrenia, depression and epilepsy at the primary care level. In Latin America, most of the countries have policies related to the supply and provision of psychotropic agents, yet more than one-third experience significant problems in implementing those policies (Alarcon, 2003). In many low-income countries, nurses are likely to be given the responsibility for prescribing and managing medicines, so it is important to make sure that they receive basic training and continuing education program support.

Although it is widely accepted that community care generally is more effective, as well as more humane, than inpatient stays in mental hospitals, community care facilities have yet to be developed in about half the countries in the African, Eastern Mediterranean and Southeast Asian regions. In other regions, these facilities are absent in at least one-third of the countries. Nearly two-thirds of the world's psychiatric beds are still in psychiatric hospitals (WHO, 2002a).

As this brief introduction indicates, the challenges are daunting, but many organizations and governments are forging partnerships and initiating change. In 2001, WHO devoted both its annual health day and annual health report to mental health. The report reviewed the burden of mental disorders and the principal contributing factors, looking at service provision and planning, obstacles to treatment, prevention approaches, and recommendations for change. As a follow-up, WHO created the Mental Health Global Action Program, a five-year, $34 million program aimed at building strategic partnerships "for sustainable capacity building for mental health action in countries." The International Mental Health Consortium is working to identify reasons for the success and failure in mental health care reform and to develop the key elements of a national mental health care policy (Abas et al., 2003). The European Commission has produced a public health framework for mental health (Jenkins, 2003; Lavikainen et al., 2001). Through its involvement and collaboration on scientific meetings throughout the world and its many publications, the World Psychiatric Association promotes the dissemination of scientific information.

Enormous progress is possible when health care professionals, international and national organizations, patients/consumers, advocacy groups, governments and media commit to proactive strategies to secure real gains in mental health care.

References:

• References1. Abas M, Baingana F, Broadhead J et al. (2003), Common mental disorders and primary health care: current practice in low-income countries. Harv Rev Psychiatry 11(2):166-173.
  2. Alarcon RD (2003), Mental health and mental health care in Latin America. World Psychiatry 2(1):54-56.
  3. Brundtland GH (2001a), Mental health in our world: the challenges ahead. Presented at the Council for Mental Health Seminar. Oslo, Norway/Dec. 11.
  4. Brundtland GH (2001b), Message from the director-general. In: The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: WHO.
  5. Jenkins R (2003), Supporting governments to adopt mental health policies. World Psychiatry 2(1):14-19.
  6. Lavikainen J, Lahtinen E, Lehtinen V (2001), Public health approach on mental health in Europe. Helsinki, Finland: Stakes.
  7. Murray CJ, Lopez AD, eds. (1996), The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 (Global Burden of Disease and Injury, Vol. 1). Cambridge, Mass.: Harvard School of Public Health.
  8. Murthy RS (2003), Mental health policy: India-towards community mental health care.
  9. Thornicroft G, Maingay S (2002), The global response to mental illness. BMJ 325(7365):608-609 [see comments].
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  11. WHO (2002a), Mental health: new WHO country data show resources fall short of needs. Available at: www.who.int/inf/en/pr-2002-30.html. Accessed Sept. 22, 2003.
  12. WHO (2002b), Project Atlas: Database. Available at: www.cvdinfobase.ca/mh-atlas/main.htm. Accessed Sept. 16, 2003.
  13. WHO/Europe (2001), Press backgrounder on the World Health Report 2001. Mental Health: New Understanding, New Hope. Available at: www.health.fgov.be/WH13/krant/krantarch2001/kranttekstock1/011008m03who-europe.htm. Accessed June 3, 2003.