For complete reference:
New England Journal Medicine
N Engl J Med 2013;369:66-73. DOI:
When the World Health Organization (WHO) European Ministerial Conference on Mental Health endorsed the statement “No health without mental health” in 2005, it spoke to the intrinsic — and indispensable — role of mental health care in health care writ large. Yet mental health has long been treated in ways that reflect the opposite of that sentiment. This historical divide — in practice and in policy — between physical health and mental health has in turn perpetuated large gaps in resources across economic, social, and scientific domains. The upshot is a global tragedy: a legacy of the neglect and marginalization of mental health.2 The scale of the global impact of mental illness is substantial, with mental illness constituting an estimated 7.4% of the world’s measurable burden of disease.3 The lack of access to mental health services of good quality is profound in populations with limited resources, for whom numerous social hazards exacerbate vulnerability to poor health. The human toll of mental disorders is further compounded by collateral adverse effects on health and social well-being, including exposure to stigma and human rights abuses, forestallment of educational and social opportunities, and entry into a pernicious cycle of social disenfranchisement and poverty.4,5 Advances in efforts to alleviate the human and social costs of mental disorders have been both too slow and too few…
…Creating a Focused and Relevant Research Agenda
Deficits in the global delivery of mental health services reflect, in part, substantial gaps in scientific knowledge about virtually all aspects of the delivery of such care in resource-poor settings.42 Scientific publications relevant to global mental health lag behind those in other relatively well- researched and well-funded clinical domains, such as the human immunodeficiency virus–acquired immune deficiency syndrome (HIV–AIDS), malaria, and tuberculosis (Fig. 3, and the Supplementary Appendix, available with the full text of this article at NEJM.org). At the same time, studies of mental health in populations living in regions out- side high-income countries are underrepresented in the psychiatric literature,43 a problem that both perpetuates global health inequities44,45 and entails missed opportunities for important scientific research. A platform for scientific sharing and a research agenda honed to remediate deficits in the delivery of care are urgently required.46 Finally, the augmentation of research capacity on mental health in low- and middle- income countries is vital to generating an evidence base that will guide strategic planning and implementation.47
Research is needed to refine diagnostic tools and algorithms for deployment in community and primary care settings, to identify mediators and modifiers of risk and resilience, and to mea- sure the effectiveness of conventional and novel treatment-delivery strategies in a variety of health systems. Implementation and health outcomes research are particularly exigent.48 Analyses of the collateral, economic, and social effects of mental disorders may inform policymakers who are interested in understanding the relative cost- effectiveness of various mental health interventions as well as the costs of withholding them. Child and adolescent mental health is a neglected area that is of great concern given the strong evidence that mental disorders are predictors of adverse economic, social, and health outcomes in adulthood,4 resulting in costs that are difficult to measure but easy to appreciate. Because adolescents with mental illness typically have difficulty accessing mental health care, interventions that effectively address the formidable barriers confronting them — and other vulnerable sectors of the population — are essential.40 An- other highly ranked research goal is the integration, to the greatest extent possible, of culturally informed screening for mental illness into primary care services.46,48
Overcoming Barriers to Equitable Care
Even in regions in which mental health services are widely available, a sizable proportion of the population with mental illness does not receive care that is specific to the illness.1,12 Cultural practices affect the ways in which people cope with social adversity, manifest emotional distress and mental disorders, and seek care. Economic and social vulnerabilities may make medicines, appointments with health care professionals, and transportation to a clinic unaffordable and time lost from work too costly. For example, even though most low-income countries include psychotropic agents on their list of essential medicines, in 85% of those countries these medications are not available at all primary health care facilities. Moreover, the high median cost of psychotropic medicines in these countries is often prohibitive (e.g., the cost of treatment with anti- psychotic agents would equal 9% of the daily minimum wage, and antidepressants 7%) and together with the expenses of other necessary care may impose economically catastrophic costs on patients.49 Social adversity is both a risk factor and an outcome of poor mental health, and it compounds the disenfranchisement that exacerbates social structural barriers to health care.
The most basic cultural and moral barrier to the amelioration of global mental health problems continues to be the enormously negative, destructive, and almost universal stigma that is attached to mental illnesses, to patients with a mental illness and their families, and to mental health caregivers. At its worst, this stigma nullifies personhood and constitutes an abuse of human rights. But other forms of discrimination are more subtle and more structural. Psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers are not the only professionals who are targets of discrimination; it is our experience that health policy experts are also adversely affected by stigma, with the result that many shy away from making mental health care a priority. This situation may at last be undergoing positive change. The Ministry of Health in China has begun to advocate for patients with mental illness and to advance their interests, and similar agencies in other countries have be- gun to do so as well. There is other evidence that the deeply institutionalized stigma surrounding the field of mental health is being challenged and overcome. This may be the most difficult barrier to quantify and yet the most important to address…According to virtually any metric, grave concern is warranted with regard to the high global burden of mental disorders, the associated intransigent, unmet needs, and the unacceptable toll of human suffering…
- Mental health: facing the challenges, building solutions — report from the WHO European Ministerial Conference. Geneva: World Health Organization, 2005.
- Saraceno B, Dua T. Global mental health: the role of psychiatry. Eur Arch Psychiatry Clin Neurosci 2009; 259: Suppl: S109-S117.
- Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2197-223.
- Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: a global public-health challenge. Lancet 2007; 369: 1302-13.
- Mental health and development: targeting people with mental health conditions as a vulnerable group. Geneva: World Health Organization, 2010.
- Demyttenaere K, Bruffaerts R, PosadaVilla J, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291:2581-90.
- Thara R, Padmavati R, Aynkran JR, John S. Community mental health in India: a rethink. Int J Ment Health Syst 2008; 2:11.
- Razzouk D, Sharan P, Gallo C, et al. Scarcity and inequity of mental health research resources in low- and middle income countries: a global survey. Health Policy 2010; 94: -20.
- Patel V, Kim Y-R. Contribution of low and middle-income countries to research published in leading psychiatry journals, 2002-2004. Br J Psychiatry 2007; 190:77-8.
- Horton R. Medical journals: evidence of bias against the diseases of poverty. Lancet 2003; 361:712-3.
45.Tyrer P. Combating editorial racism in psychiatric publications. Br J Psychiatry 2005; 186:1-3.
- Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, Patel V. Setting priorities for global mental health research. Bull World Health Organ 2009; 87:438-46.
- Thornicroft G, Cooper S, Van Bortel T, Kakuma R, Lund C. Capacity building in global mental health research. Harv Rev Psychiatry2012; 20:13-24.
- Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS. Grand challenges in global mental health. Nature 2011; 475:27-30.
Becker, Anne E., M.D., Ph.D.,
Kleinman, Arthur, M.D.,