Mental Illness, a Neglected Disease

Editors and authors from the British medical journal The Lancet called on the countries of the Americas to devote greater attention and resources to mental illness, during the North American launch of a special journal series on global mental health, held at PanAmerican Health Organization (PAHO) headquarters on May 7.

The special Lancet series on global mental health, published late last year, documents the worldwide burden of mental illness, its links to physical illness, and the widespread underfunding of prevention and treatment programs. The series represents the work of some 60 authorities on mental illness and public health, and several leading experts were on hand for the PAHO launch.

Cristina Beato, PAHO's deputy director, noted that one in four people worldwide is affected by mental illness at some point in his or her lifetime. In Latin America and the Caribbean, the burden of mental disorders has more than doubled, from 8.8 percent of disability-adjusted life years (DALYs) in 1990 to 22.2 percent in 2002.

More striking is the gap between the need for treatment and its availability. In the PAHO region, nearly 60 percent of people with major depression go untreated, as do 71 percent of people with addiction problems.

"Mental health has been neglected, and the resources for it are inadequate, insufficient, and inadequately distributed," said Beato. "This is unacceptable, and it is imperative to reduce the gaps."

Vikram Patel, of the London School of Hygiene and Tropical Medicine and lead author of one of the Lancet articles, noted that mental illness accounts for some 14 percent of the global burden of disease, more than heart disease, stroke, and cancer combined. This is true even though mental disorders are typically underreported.

In addition to direct suffering, he said, mental illness can lead to work loss, social isolation, and human rights abuses, with patients in some countries still "living in medieval conditions."

"Mental disorders are associated with great suffering in all cultures and all countries," said Patel. "Yet mental health remains a peripheral issue and has not been part of any major global health initiative since 2001."

David Satcher, former U.S. surgeon general, said that mental illnesses are as disabling as heart disease and cancer in terms of lost productivity and premature death. Yet in the United States, fewer than half of adults with mental disorders and fewer than a third of children get help, even though 80–90 percent of mental disorders are treatable.

He said stigma was partly to blame for the widespread neglect of mental health.

"Stigma deters treatment. It affects mental health at the individual, family, community, and policy levels," he said. "The key to reducing stigma is getting people to realize there is a continuum of mental health. We may be mentally healthy today, but that doesn't mean we will be mentally healthy tomorrow. One in five Americans has a diagnosable mental disorder in a given year."

The gap between the need for treatment and its availability is particularly wide in the developing world—up to 90 percent in some low-income countries, Patel noted. Chronic underfunding is the major problem. Nearly a third of countries around the world have no specific budget for mental health, and onefifth of those that do spend less than 1 percent of their national budgets on mental health.

One of the central messages in the Lancet series is that there are affordable treatments for mental disorders that have proven to be cost-effective in low- and middle-income countries. These include:

• Low-cost antidepressants and cognitive-behavioral and interpersonal therapy for depression.
• First-generation antipsychotic drugs for schizophrenia.
• Brief interventions by primary-care givers for hazardous use of alcohol.
• Pharmacological and psychosocial interventions for alcohol dependency.
• Community-based rehabilitation programs for the care of children and adults with mental disabilities.

The series also identified five main barriers to improving mental health services in low- and middle-income countries:

• The relatively low priority assigned to mental health on the public health policy agenda and, as a result, low funding.
• The complexity of, and resistance to, deinstitutionalization and decentralization of mental health services.
• The difficulties of incorporating mental health services into primary health care.
• The shortage of health workers trained in mental health care.
• The lack of a public health perspective among many mental health experts.

To overcome these, Patel called for a "global coalition for mental health" that would undertake three main actions: developing a global mental health agenda "within a human rights framework," building an evidence base for community and primary-care interventions, and building capacity to scale up mental health services. The central message of this coalition should be, "There is no health without mental health," said Patel.

Maya Zecevic, senior editor for North America at The Lancet, said the journal had published the special series to raise awareness that people with mental disorders are being neglected and to inspire new advocacy efforts among key actors around the world.

"This is all about patients.We want to let them know they are not alone.We can open the door to solutions that can only be found by the medical community, policymakers, and funders working together on this important issue," she said.