Keeping mental health in the public eye
The need to address stigma is critical
Von Gabriel Ivbijaro and Elena Berger
Around the world mental illnesses attract an extraordinary amount of prejudice in society. And yet such disorders are common; one in four adults will experience mental health difficulties. Stigma and discrimination are significant barriers that deprive people of their dignity. To make dignity in mental health a reality requires that all members of society work together.
World Mental Health Day 2016, Nigeria (Photo: WFMH)
The World Federation for Mental Health (WFMH) engages in advocacy to increase awareness of the neglect of mental health in health budgets.It works to educate people about:
• The importance of mental health
• Promoting mental health and preventing mental disorders
• Improving the care, treatment and recovery of people with mental disorders
Other areas of particular focus are addressing the stigma associated with mental ill-health, advocating for dignity in the care of people with mental illness, and spreading understanding of the equal importance of mental and physical health.
Treatment for mental health is not adequately addressed
The availability of treatment in high-, medium- and low-income countries is not adequate to the need, particularly if care for substance abuse is included.In low- to middle-income countries treatment continues to be inadequate or barely available at all and we need to ask ourselves why this is the case.
Depression and anxiety alone account for a high proportion of the global burden of disease, according to statistics on years lived with disability. Examining treatment coverage for a single mental illness, major depression, the World Health Organization (WHO) found that only 36.3% of men affected by depression receive treatment in high-income countries. In low- and middle-income countries the proportion receiving treatment is far worse, standing at only 13%.Depression affects more women than men, but in high-income countries less than half of those affected receive treatment, 43.9%.Only 18.6% of women from low- and middle-income countries who experience depression receive treatment.There is a very wide gap between those who need care, and those who receive it, even in countries with the best health care resources. (World Mental Health Surveys, WHO 2014)
Why are mental illnesses neglected?
The neglect of the effect of stigma and prejudice. People are intolerant of different behaviours. Families can hide the problem – or are expected to care for an individual themselves without professional help. Health budgets are usually under pressure, so that funding for mental illnesses is chronically underfunded. But partly the neglect is caused by widespread public ignorance of the dimensions of the problem.
The size of the problem
WHO’s Global Health Estimates (2014) showed that of the years lived with disability globally in 2012, 31% were due to combined mental, neurological and substance abuse disorders.This was equal to the combined total of 31% for other major non-communicable diseases such as cardiovascular conditions, cancer, diabetes and respiratory diseases. (Global Health Estimate, WHO 2014)
In WHO’s 2012 list of the 20 leading global causes of years lost to disability, depression was at the top, accounting for 10.3% of the total. Anxiety disorders accounted for a further 3.7%. Schizophrenia and bipolar disorder each accounted for 1.8 %. (Global Health Estimates, WHO 2012)
These statistics are extraordinary,and few people are aware of them.They are also extraordinary considering how little is spent on mental health care in health budgets compared with other non-communicable diseases.The prejudice against people with mental health problems flows over into the resources assigned to medical care. Other illnesses have priority in funding and treatment.
Most people do not realise how common mental disorders are. They don’t understand that mental illness is an umbrella term covering many different disorders, ranging from less serious diagnoses to extreme disabilities.They don’t know that mental illness is treatable. Affordable and effective treatment is now available for many mental health conditions and can often be provided in primary care, by a family doctor or trained health worker. In some low-income countries, however, there are no doctors or clinic workers to provide services, and people with mental illnesses are put in chains or kept in miserable mental institutions.
The stigma surrounding mental illness and the neglect of people who experience it is particularly tragic because some major disorders can emerge at a comparatively young age. Such disorders slowly become visible in the teenage years, becoming full-blown in older teenagers or young adults. (O’Connell et al. 2009) Early treatment can result in improvement of these conditions, helping young people and their families to cope with them. Neglect can lead to a lifetime marked by severe illness. Sometimes suicide is the outcome – like mental illness, this is another subject people don’t like to talk about.WHO reports that suicide is the second leading cause of the deaths of young people worldwide. (World Health Assembly 201
World Mental Health Day, India 2016
WHO’s Department of Mental Health and Substance Abuses playing a leading role in informing the governments of its 194 member states that mental illnesses are serious and widespread conditions. In 2008 this department introduced the Mental Health Gap Action Programme (mhGAP) to draw attention to the large gap that exists in many countries between the need for mental health care and the care that is available. It has also published an “atlas” series to show, in a different form, the absence of care, country by country. Some low-income countries have only one or two psychiatrists, one or two mental health nurses, and perhaps a social worker to address the entire nation’s care.
In 2013 WHO’s major annual meeting, theWorld Health Assembly, introduced a Comprehensive Mental Health Action Plan (2013-2020) to encourage countries to adopt targets for specific improvements in mental health care and the reduction of suicide rates. Governments are gradually being prodded to address inadequate mental health services, even as they grapple with care for other important illnesses.But progress remains slow, and stigma is stubborn.
The effects of stigma
One troubling reason for the treatment gap is that the perceived shame of having a mental disorder discourages people from seeking care, even if it is available. People often feel it is difficult to go to a specialist health professional for help. One way to address the stigma associated with mental illness is to provide first-line help through family doctors and general practitioners, medical professionals who treat a variety of ailments and who can provide mental health care as part of comprehensive care. Serious mental disorders are often associated with other non-communicable diseases such as cardiovascular disease, cancer, respiratory diseases and diabetes, and people with mental illness often have shockingly shorter lifespans because these co-occurring conditions are neglected. (WHO, World Health Assembly 2013) Family doctors trained in mental health can provide overall treatment, referring individuals for specialist care as needed.
The budget problem
Because so many people are affected by mental disorders, public spending on mental health care will probably always be inadequate. Constant pressure is needed to make governments provide a higher share of health budgets for mental health. Civil society, including people with mental health problems, their families and professionals who work in the field have an important role to play in advocating for reforms, better facilities and new treatment options.These efforts should be international as well as national.
Internationally, recent civil society efforts focused on getting mental health mentioned in the new United Nations Sustainable Development Goals (SDGs), which have replaced the Millennium Development Goals (MDGs) that covered the period 2000 to 2015. Organisations and individuals pressed to have mental health targets listed among the health goals, and were successful in getting a small mention inserted in the text, which compares favourably to the MDGs, in which mental health was not mentioned at all. While this will influence the international context, more practically, organisations should press their own governments to see that spending is improved.
Civil society is constrained by its own funding problems, as mental health is not a popular cause in the competitive arena of fund-raising. Nevertheless, civil society has an important role to play in keeping the cause on the public agenda, and reframing it as government priorities change. A number of civil society organisations (CSOs) are able to raise funds to provide basic services in some low-income countries. Examples include BasicNeeds (basicneeds.org), the Peter C. Alderman Foundation (petercaldermanfoundation.org), and CBM (cbm.org).
More advocacy for mental health is needed
Key to addressing the neglect of mental health is advocacy at multiple levels to make sure the issue moves up on the political agenda. Advocates need to stress that government budgets do not provide adequate funding to cover the need for mental health services in the community. The World Federation for Mental Health and other CSOs advocate at the UN and WHO, directly with governments when the opportunity arises, and most importantly at the grassroots level where a better understanding is needed about how common mental disorders are.If grassroots knowledge about these disorders remains low, then a satisfactory level of services will never be provided.
World Mental Health Day 2008
Civil society’s objectives include pressing governments to take the broadest possible view of mental disorders, so that support is provided by a range of departments of government, and not just in the health budget. The reality is that mental illness is not just a health matter. It should be addressed in multiple departments of government, including housing, educationand justice departments. For example, in the USA, the largest government system dealing with mental illness is the prison system.
Health systems should interact with other government departments to provide the medical and social care needed to enable people with complex conditions to live in the community. Most importantly, mental health is relevant to finance departments, where decisions about funding are made.
In April 2016, to emphasise the neglect of adequate mental health funding, the World Bank and WHO held a joint meeting on mental health at the time of the World Bank’s Annual Meeting. The introduction to the meeting’s agenda noted that mental disorders were responsible for 23% of England’s total burden of disease, but received only 13 % of National Health Service health expenditures. The introduction also reported that on average, low-income countries give only 0.5% of health budgets to mental health.
To catch the ear of politicians, advocates are now stressing the economic consequences of neglecting to invest in mental health care.The costs are significant.The introduction to the World Bank/WHO meeting agenda stated that depression was estimated to cost US-$ 800 million or more in 2010 because of lost production. Depression and anxiety cause employers to lose production because of workers’ absences or poor productivity, while families lose income and governments face higher welfare costs.
The public education effort needs to be intensified
Public education is an important way to address the knowledge gap and counter unfavourable perceptions and prejudices. Campaigns to provide information about mental disorders will slowly provide a more realistic understanding of mental illness. One example is the World Federation for Mental Health’s international campaign, which sees World Mental Health Day observed each year on 10 October. This vehicle for grassroots advocacy and public education was founded by the Federation in 1992 and has wide outreach.
Each year the Board of the World Federation for Mental Health selects a current mental health issue as a theme, and organises a group of experts to write short articles about it.The material is distributed electronically, and translated into several languages (wfmh.com).The articles can also be translated individually into local languages, as needed.
The theme and materials are used by many CSOs around the world as a basis for programmes, lectures, health fairs and other public events. Government departments, hospitalsand medical schools in some places also find them useful. Programmes are widespread in some high-income countries like the UK, and also in countries with much lower levels of resources. In low- and middle-income countries the local approach can be imaginative – banners and signshave been placed alongside streets in Mongolia and Tanzania, and carried in parades in Nepal, Zambia and Zimbabwe. Slogans on banners have been carried by elephants and camels in India.
In 2015 the World Mental Health Day theme was ‘Dignity in Mental Health’, which considered the many ways in which people with mental illnesses are not accorded dignity and the many ways in which it could be provided. In 2016 the theme was ‘Psychological and Mental Health First Aid’, with the aim of increasing knowledge about the Mental Health First Aid training programme that originated in Australia.This course trains members of the public to recognise the symptoms of mental illness or a mental health crisis such as serious depression, psychosis or suicidal thoughts, and gives guidance on how to provide initial support until professional or other assistance can be obtained. For 2017, the theme is ‘Mental Health in the Workplace,’ taking place on 10th October.
People who have mental disorders or who have experienced them in the past can themselves be first-class advocates for better care.They know where there are inadequacies in mental health services, and can be forceful spokespeople on behalf of others who can’t or don’t want to take on this task.Moreover they exemplify the range of experience related to such disorders. Some people with mental disorders can be severely disabled by them. But others hold jobs and take care of families.The public as a whole may not understand that these illnesses are very variable, treatment exists, improvement can be expected – and recovery is possible.
Stigma contributes considerably to the neglect of mental disorders. Efforts must continue to address stigma through public education about mental illnesses, and civil society has a big role to play here. People who have experienced mental illness and their families can also play a major role in advocacy. Single organisations can make a difference; coalitions of organisations can be even more effective.There are many opportunities to keep the issue in the public eye.
Advocates should campaign vigorously for improved allocations of funding for mental health care in government budgets, not only in the health sector but also in multiple government departments. They should adopt a ‘whole of government’ approach.
Fundamentally, care for people with serious mental illness is a human rights issue and a matter of fairness. Alternative approaches are needed to deal with the shortage of professional staff that have specialised training and qualifications. In high-income countries training to treat mental disorders should be expanded further for general practitioners and nurse practitioners. In low- to middle-income countries appropriate training should be provided for nurses and lay clinic workers, with referrals available for specialist care.
WHO (2014). World Mental Health Surveys, 2001-2012.Introduction to the agenda, “Out of the Shadows: Making Mental Health a Global Development Priority”, World Bank-World Health Organization Meeting, Washington, D.C., 13-14 April 2016.
WHO (2014). Global Health Estimates.Introduction to the agenda, “Out of the Shadows: Making Mental Health a Global Development Priority”, World Bank-World Health Organization Meeting, Washington, D.C., 13-14 April 2016.
WHO (2014).Global Health Estimates. 20 Leading Causes of Years Lost to Disability (Global). GHE_YLD_Global_2000_2012_5.xls
Mary Ellen O’Connell, Thomas Boat, Kenneth Warner, Eds. 2009.Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities.P. 15.The National Academies Press, Washington, D.C.www.nap.edu
WHO.World Health Assembly. 2013. Draft Comprehensive Mental Health Action Plan, 2013-2020.A66/10 Rev.1, page 5.16 May 2013.
Kristian Wahlbeck.2015.Public mental health: the time is right for translation of evidence into practice.World Psychiatry, vol.14, no.1, February 2015,pp.36-42
Elena Berger, Chief Officer Governance, World Federation for Mental Health
Gabriel Ivbijaro, President, World Federation for Mental Healthand