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Mental Health: Investing in
Mental Health: Investing in
M E N TA L H E A LT H
This publication was produced by the Department of Mental Health and Substance Dependence,
Noncommunicable Diseases and Mental Health, World Health Organization, Geneva.
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Introduction 3
Executive Summary 4
References 46
Mental health has been hidden behind a curtain of stigma and discrimination for too long. It is time to bring it out into
the open. The magnitude, suffering and burden in terms of disability and costs for individuals, families and societies
are staggering. In the last few years, the world has become more aware of this enormous burden and the potential
for mental health gains. We can make a difference using existing knowledge ready to be applied.
We need to enhance our investment in mental health substantially and we need to do it now.
Investment of financial and human resources. A higher proportion of national budgets should be allocated to develop-
ing adequate infrastructure and services for mental health. At the same time, more human resources are needed to
provide care for those with mental disorders and to protect and promote mental health. Countries, especially those
with limited resources, need to establish specifically targeted policies, plans and initiatives to promote and support
mental health.
Who needs to invest? All of us with interest in the health and development of people and communities. This includes
international organizations, development aid agencies, trusts/foundations, businesses and governments.
It should be able to provide the much-needed services, treatment and support to a larger proportion of the nearly
450 million people suffering from mental disorders than they receive at present: services that are more effective and
more humane; treatments that help them avoid chronic disability and premature death; and support that gives them
a life that is healthier and richer – a life lived with dignity. We can also expect greater financial returns from increased
productivity and lower net costs of illness and care, apart from savings in other sector outlays.
Overall, this investment will result in individuals and communities who are better able to avoid or cope with the stress-
es and conflicts that are part of everyday life, and who will therefore enjoy a better quality of life and better health.
Lee Jong-wook
3
Executive Summary
For all individuals, mental, physical abilities, cope with the normal stresses This publication aims to guide you in
and social health are vital and inter- of life, work productively and fruitful- the discovery of mental health, in the
woven strands of life. As our under- ly, and make a contribution to their magnitude and burdens of mental dis-
standing of this relationship grows, communities. Unfortunately, in most orders, and in understanding what can
it becomes ever more apparent that parts of the world, mental health and be done to promote mental health in
mental health is crucial to the overall mental disorders are not accorded the world and to alleviate the burdens
well-being of individuals, societies and anywhere near the same degree of and avoid deaths due to mental disor-
countries. Indeed, mental health can importance as physical health. Rather, ders. Effective treatments and inter-
be defined as a state of well-being they have been largely ignored or ventions that are also cost-effective
enabling individuals to realize their neglected. are now readily available. It is there-
fore time to overcome barriers and
work together in a joint effort to nar-
The magnitude and burdens of the problem row the gap between what needs to
be done and what is actually being
• As many as 450 million people suffer from a mental or behavioural disorder. done, between the burden of mental
disorders and the resources being used
• Nearly 1 million people commit suicide every year.
to address this problem. Closing the
• Four of the six leading causes of years lived with disability are due to gap is a clear obligation not only for
neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia the World Health Organization, but
and bipolar disorder). also for governments, aid and devel-
opment agencies, foundations,
• One in four families has at least one member with a mental disorder. research institutions and the business
Family members are often the primary caregivers of people with mental community.
disorders. The extent of the burden of mental disorders on family members
is difficult to assess and quantify, and is consequently often ignored.
However, it does have a significant impact on the family’s quality of life.
• In addition to the health and social costs, those suffering from mental
illnesses are also victims of human rights violations, stigma and discrimi-
nation, both inside and outside psychiatric institutions.
4
The economic burden of mental disorders
Given the prevalence of mental health and substance-dependence problems in adults and children, it is not surprising
that there is an enormous emotional as well as financial burden on individuals, their families and society as a whole.
The economic impacts of mental illness affect personal income, the ability of ill persons – and often their caregivers –
to work, productivity in the workplace and contributions to the national economy, as well as the utilization of treatment
and support services. The cost of mental health problems in developed countries is estimated to be between 3% and
4% of GNP. However, mental disorders cost national economies several billion dollars, both in terms of expenditures
incurred and loss of productivity. The average annual costs, including medical, pharmaceutical and disability costs, for
employees with depression may be 4.2 times higher than those incurred by a typical beneficiary. However, the cost of
treatment is often completely offset by a reduction in the number of days of absenteeism and productivity lost while
at work.
A combination of well-targeted treatment and prevention programmes in the field of mental health, within overall pub-
lic strategies, could avoid years lived with disability and deaths, reduce the stigma attached to mental disorders, increase
considerably the social capital, help reduce poverty and promote a country’s development.
Studies provide examples of effective programmes targeted at different age groups – from prenatal and early infancy
programmes, through adolescence to old age – and different situations, such as post-traumatic stress following acci-
dents, marital stress, work-related stress, and depression or anxiety due to job loss, widowhood or adjustment to retire-
ment. Many more studies need to be conducted in this area, particularly in low- and middle-income countries. There is
strong evidence to show that successful interventions for schizophrenia, depression and other mental disorders are not
only available, but are also affordable and cost-effective.
Yet there is an enormous gap between the need for treatment of mental disorders and the resources available. In devel-
oped countries with well organized health care systems, between 44% and 70% of patients with mental disorders do
not receive treatment. In developing countries the figures are even more startling, with the treatment gap being close
to 90%.
5
WHO’s Mental Health Global Action Programme (mhGAP)
To overcome barriers to closing the gap between resources and the need for treatment of mental disorders, and to
reduce the number of years lived with disability and deaths associated with such disorders, the World Health Organiza-
tion has created the Mental Health Global Action Programme (mhGAP) as part of a major effort to implement the rec-
ommendations of the World Health Report 2001 on mental health. The programme is based on strategies aimed at
improving the mental health of populations. To implement those strategies, WHO is undertaking different projects and
activities, such as the Global Campaign against Epilepsy, the Global Campaign for Suicide Prevention, building national
capacity to create a policy on alcohol use, and assisting countries in developing alcohol-related services. WHO is also
developing guidelines for mental health interventions in emergencies, and for the management of depression,
schizophrenia, alcohol-related disorders, drug use, epilepsy and other neurological disorders. These projects are designed
within a framework of activities which includes support to countries in monitoring their mental health systems, formulat-
ing policies, improving legislation and reorganizing their services. These efforts are largely focused on low- and middle-
income countries, where the service gaps are the largest.
Investing in mental health today can generate enormous returns in terms of reducing disability and preventing prema-
ture death. The priorities are well known and the projects and activities needed are clear and possible. It is our respon-
sibility to turn the possibilities to reality.
6
The burden of mental disorders is expected
to rise significantly over the next 20 years:
Mental health is more than the mere lack viduals and communities and enabling strands of life. As our understanding of
of mental disorders. The positive dimen- them to achieve their self-determined this interdependent relationship grows, it
sion of mental health is stressed in WHO’s goals. Mental health should be a concern becomes ever more apparent that mental
definition of health as contained in its con- for all of us, rather than only for those health is crucial to the overall well-being
stitution: “Health is a state of complete who suffer from a mental disorder. of individuals, societies and countries.
physical, mental and social well-being and Unfortunately, in most parts of the world,
Mental health problems affect society
not merely the absence of disease or infir- mental health and mental disorders are
as a whole, and not just a small, isolated
mity.” Concepts of mental health include not accorded anywhere the same impor-
segment. They are therefore a major
subjective well-being, perceived self-effica- tance as physical health. Rather, they
challenge to global development. No
cy, autonomy, competence, intergenera- have been largely ignored or neglected.
group is immune to mental disorders,
tional dependence and recognition of the
but the risk is higher among the poor,
ability to realize one’s intellectual and emo-
homeless, the unemployed, persons with
tional potential. It has also been defined as
low education, victims of violence,
a state of well-being whereby individuals
migrants and refugees, indigenous popu-
recognize their abilities, are able to cope
lations, children and adolescents, abused
with the normal stresses of life, work pro-
women and the neglected elderly.
ductively and fruitfully, and make a contri-
bution to their communities. Mental health For all individuals, mental, physical and
is about enhancing competencies of indi- social health are closely interwoven, vital
7
The magnitude and burdens
of mental disorders
A huge toll
2
Today, about 450 million people Burden of diseases worldwide: Disability adjusted life years (DALYs), 2001
suffer from a mental or behavioural
Nutritional deficiencies 2%
disorder. According to WHO’s Global
Perinatal conditions 7% Other NCDs 1%
Burden of Disease 2001, 33% of the
Maternal conditions 2%
years lived with disability (YLD) are Malignant neoplasms 5%
Respiratory infections 6%
due to neuropsychiatric disorders, a Malaria 3% Diabetes 1%
further 2.1% to intentional injuries Childhood diseases 3%
Neuropsychiatric disorders 13%
Diarrhoeal diseases 4%
(Figure 1). Unipolar depressive disor-
ders alone lead to 12.15% of years HIV/AIDS 6% Sense organ disorders 3%
Tuberculosis 2%
lived with disability, and rank as the
Other CD causes 6% Cardiovascular diseases 10%
third leading contributor to the global
Injuries 12%
burden of diseases. Four of the six
Respiratory diseases 4%
leading causes of years lived with Congenital abnormalities 2%
Digestive diseases 3%
disability are due to neuropsychiatric Musculoskeletal diseases 2%
Diseases of the genitourinary system 1%
disorders (depression, alcohol-use
disorders, schizophrenia and bipolar Source: WHR, 2002
disorder).
1
Years lived with disability (YLD): Neuropsychiatric conditions account • About 25 million suffer from
World for 13% of disability adjusted life schizophrenia;
years (DALYs), intentional injuries for
33% • 38 million suffer from epilepsy; and
3.3% and HIV/AIDS for another 6%
(Figure 2). These latter two have a • More than 90 million suffer from an
behavioural component linked to alcohol- or drug-use disorder.
mental health. Moreover, behind
The number of individuals with disor-
these oft-repeated figures lies enor-
67% ders is likely to increase further in view
mous human suffering.
Neuropsychiatric disorders of the ageing of the population, wors-
• More than 150 million persons suf- ening social problems and civil unrest.
Others
fer from depression at any point in
Source: WHR, 2002
This growing burden amounts to a
time;
huge cost in terms of human misery,
• Nearly 1 million commit suicide disability and economic loss.
every year;
8
Mental and behavioural problems
as risk factors for morbidity and mortality
9
Mental disorders and medical illness are interrelated
10
3
Prevalence of major depression in patients with physical illnesses
Hypertension up to 29%
Epilepsy up to 30%
Stroke up to 31%
Diabetes up to 27%
Cancer up to 33%
HIV/AIDS up to 44%
Tuberculosis up to 46%
General
up to 10%
population
0 10 20 30 40 50
11
Mental disorders: a significant burden on the family.
The burden of mental disorders goes beyond that which has been defined
by Disability Adjusted Life Years.
The extent of the burden of mental disorders on family members is difficult
to assess and quantify, and is consequently often ignored. However, it does
have a significant impact on the family’s quality of life.
Family members are often the primary whole can increase the family’s sense time to care for a person with a men-
caregivers of people with mental dis- of isolation, resulting in restricted tal disorder. Unfortunately, the lack of
orders. They provide emotional and social activities, and the denial of understanding on the part of most
physical support, and often have to equal participation in normal social employers, and the lack of special
bear the financial expenses associated networks. employment schemes to address this
with mental health treatment and issue, sometimes render it difficult for
Informal caregivers need more sup-
care. It is estimated that one in four family members to gain employment
port. The failure of society to
families has at least one member cur- or to hold on to an existing job, or
acknowledge the burden of mental
rently suffering from a mental or they may suffer a loss of earnings due
disorders on affected families means
behavioural disorder. In addition to to days taken off from work. This
that very little support is available to
the obvious distress of seeing a loved- compounds the financial costs associ-
them. Expenses for the treatment of
one disabled by the consequences of ated with treating and caring for
mental illness are often borne by the
a mental disorder, family members are someone with a mental disorder.
family because they are generally not
also exposed to the stigma and dis-
covered by the State or by insurance.
crimination associated with mental ill
Family members may need to set
health. Rejection by friends, relatives,
aside a significant amount of their
neighbours and the community as a
Persons with mental disorders often tions are extremely unsatisfactory. ing conditions. For example, there
suffer a wide range of human rights Inpatient places should be moved have been documented cases of peo-
violations and social stigma. from mental hospitals to general ple being tied to logs far away from
hospitals and community rehabilita- their communities for extensive peri-
In many countries, people with mental
tion services. ods of time and with inadequate food,
disorders have limited access to the
shelter or clothing. Furthermore, often
mental health treatment and care they
Violations in psychiatric people are admitted to and treated in
require, due to the lack of mental
institutions are rife mental health facilities against their
health services in the area in which
will. Issues concerning consent for
they live or in the country as a whole. Many psychiatric institutions have
admission and treatment are often
For example, the WHO Atlas Survey inadequate, degrading and even
ignored, and independent assessments
showed that 65% of psychiatric beds harmful care and treatment practices,
of capacity are not undertaken. This
are in mental hospitals, where condi- as well as unhygienic and inhuman liv-
12
In addition to the social and economic toll,
those suffering from mental illnesses are also
victims of human rights violations, stigma
and discrimination.
means that people can be locked tized along with their families. This is housing policies. In certain countries,
away for extensive periods of time, manifested by stereotyping, fear, mental disorders can be grounds for
sometimes even for life, despite hav- embarrassment, anger, and rejection denying people the right to vote and
ing the capacity to decide their future or avoidance. The myths and miscon- to membership of professional associ-
and lead a life within their community. ceptions associated with mental disor- ations. In others, a marriage can be
ders negatively affect the day-to-day annulled if the woman has suffered
lives of sufferers, leading to discrimi- from a mental disorder. Such stigma
Violations also occur outside
nation and the denial of even the and discrimination can, in turn, affect
institutions: the stigma of mental
most basic human rights. All over the a person’s ability to gain access to
illness
world, people with mental disorders appropriate care, recover from his or
In both low- and high-income coun- face unfair denial of employment and her illness and integrate into society.
tries, there is a long history of people educational opportunities, and dis-
with mental disorders being stigma- crimination in health insurance and
Human rights violations of people with mental disorders: the voice of sufferers
Caged beds
Many psychiatric institutions, general hospitals and social care homes in countries continue to use caged beds routinely
to restrain patients with mental disorders and mental retardation. Caged beds are beds with netting or, in some cases,
metal bars, which serve to physically restrain the patients. Patients are often kept in caged beds for extended periods,
sometimes even years. This type of restraint is often used when staff levels or training are inadequate, and sometimes
as a form of punishment or threat of punishment. The use of restraints such as caged beds restricts the mobility of
patients, which can result in a number of physical hazards such as pressure sores, not to mention the harmful psycho-
logical effects. People have described the experience as being emotionally devastating, frightening, humiliating, degrad-
ing and disempowering. (Caged Beds – Inhuman and Degrading Treatment in Four EU Accession Countries, Mental
Disability Advocacy Center, 2003)
August 2001: Twenty-five people were charred to death in Erwadi, India. A devastating fire broke out at 5 a.m. in the
asylum. Of the 46 with mental disorders, 40 had been chained to their beds. Erwadi had long been considered a holy
place, famous for its dargah. During the course of the “treatment”, the persons with mental disorders were frequently
caned, whipped and beaten up in the name of “driving away the evil”. During the day, they were tied to trees with
thick ropes. At night, they were tied to their beds with iron chains. (www.indiatogether.org)
13
The economic burden
of mental disorders
Given the prevalence of mental health whole is enormous, as noted earlier. work and make productive contribu-
and substance-dependence problems The economic impacts of mental ill- tions to the national economy, as well
in adults and children, the emotional, ness include its effects on personal as the utilization of treatment and
but also financial, burden on individu- income, the ability of the persons with support services (Table 1).
als, their families and society as a mental disorders or their caregivers to
Family and friends Informal care-giving Time off work Anguish; isolation; stigma
To gauge the measurable economic costs based on expenditures made or and the indirect costs derived from lost
burden of mental illness, in table 2 the resources lost. or reduced productivity in the work-
diverse economic impacts have been An important characteristic of mental place are high.
transformed into a single cost-based disorders is that mortality is relatively
measure, and organized by types of low, onset often occurs at a young age,
Indirect costs • Morbidity costs (in terms of value of lost productivity) • Value of family caregivers’ time
(resources lost) • Mortality costs
14
Mental disorders impose a range of costs on
individuals, households, employers and
society as a whole.
Estimates of costs are not available for • The estimated total burden of men- • Patel and Knapp (1997) estimated
all the various disorders, and certainly tal health problems in Canada for the aggregate costs of all mental
not for all the countries in the world. 1998 was at least Can$ 14.4 billion: disorders in the United Kingdom at
Most methodologically sound studies Can$ 8.1 billion in lost productivity £32 billion (1996/97 prices), 45% of
have been conducted in the United and Can$ 6.3 billion for treatments which was due to lost productivity.
States and the United Kingdom. At (Stephens & Joubert, 2001). This
1990 prices, mental health problems makes mental health problems one
accounted for about 2.5% of GNP in of the costliest conditions in Canada.
the United States (Rice et al., 1990).
In the Member States of the European
Union the cost of mental health prob-
lems is estimated to be between 3%
15
Mental health problems in childhood
generate additional costs in adulthood
The costs of childhood disorders can 1998). Knapp shows in figure 4 that
be both large and largely hidden children with conduct disorders gener-
(Knapp et al., 1999). Early onset of ate substantial additional costs from
mental disorders disrupts education ages 10 to 27 years. These are not
and early careers (Kessler et al., 1995). mainly related to health, as one would
The consequences in adulthood can expect, but to education and criminal
be enormous if effective treatment is justice, creating a serious challenge for
not provided (Maughan & Rutter, the social capital as a whole.
4
Costs in adulthood of childhood mental health problems
Additional costs from 10-27 years (in £)
80 000
70 000
60 000
50 000
16
High costs of mental disorders
compared to other major chronic conditions
5
NHS burdens of disease, 1996
£ million, 1992/93
Psychosis
Neurosis
Diabetes
Inpatient
Breast cancer
Outpatient
Primary care
Ischaemic
Heart Disease Pharmaceuticals
Community health
Hypertension Social services (adults)
17
Another recent study (Berto et al., for the United States, three mental
2000) presents prevalence and total disorders considered by Berto et al.
management costs of diseases such as (Alzheimer’s disease, depression and
Alzheimer’s, asthma, cancer, depres- schizophrenia) present a high preva-
sion, osteoporosis, hypertension and lence-cost ratio.
schizophrenia. As shown in figure 6
6
Prevalence and cost of major chronic conditions: United States
(in millions)
120
100
80
60
40
20
0
er
is
er
es
is
e
m
CH
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ok
io
io
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os
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as
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Al
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18
7
Even more interesting is to consider Yearly cost per patient of selected major conditions: United States
different diseases in terms of the aver- US$/patient/year
age cost per patient, as shown in fig-
ure 7: Alzheimer’s disease and 25000
schizophrenia are the two most costly
diseases, their average cost per patient 20000
being higher than cancer and stroke.
15000
10000
5000
e
a
is
n
es
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F
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a
is
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io
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In the United States, mental illness is increased 400% from 1993 to 1999, persons with two or more neurotic
considered responsible for an estimat- and that the costs of replacement, disorders had an average of 28 days
ed 59% of the economic costs deriv- together with those of salary insur- off per year compared to 8 days off
ing from injury or illness-related loss ance, amounted to Can$ 3 million for for those with one neurotic disorder
of productivity, followed by alcohol the year 2001. A survey on psychiatric (Patel & Knapp, 1997).
abuse at 34% (Rouse, 1995). A report morbidity in the United Kingdom
from a Canadian university (Université showed that people with psychosis
Laval, 2002) revealed that absences took an average of 42 days a year off
for psychological reasons had work. The same survey reveals that
19
Decreased productivity at work:
even if an employee does not take sick leave, mental health problems
can result in a substantial reduction in the usual level of activity and performance
A recent study from Harvard Medical ers. Although the effects on work loss
School examined the impact of psy- were not significantly different across
chiatric disorders on work loss days occupations, the effects on work cut-
(absence from work) among major back were greater among professional
occupational groups in the United workers. Work loss and cutback were
States (Kessler & Frank, 1997). The found to be more prevalent among
average number of work loss days those with comorbid disorders than
attributable to psychiatric disorders among those with single disorders.
was 6 days per month per 100 work- The study presents an annualized
ers; and the number of work cutback national projection of over 4 million
days (getting less done than usual) work loss days and 20 million work
was 31 days per month per 100 work- cutback days in the United States.
Photo: © WHO, P. Virot
20
Mental illness affects access
to the job market and job retention
21
The burden of substance abuse
• The government, drug abusers and which could have been prevented. dents – both pedestrians and drivers –
their families shoulder the main eco- Alcohol abuse is also responsible for had blood alcohol levels exceeding the
nomic burden of drug abuse; and neuropsychiatric disorders, domestic legal limits (Van Kralingen et al, 1991).
violence, child abuse and neglect, and Foetal alcohol syndrome is by far the
• For every dollar invested in drug
productivity loss. most common cause of mental disabil-
treatment, seven dollars are saved in
ity in the country (Department of
health and social costs. In South Africa, 25%–30% of general
Trade and Industry, 1997).
hospital admissions are directly or indi-
Abuse of alcohol and other substances
rectly related to alcohol abuse (Alber- In Asia, substance abuse is considered
continues to be one of the most serious
tyn & McCann, 1993), and 60%– the main cause in 18% of cases pre-
public health problems in both devel-
75% of admissions in specialized sub- senting problems in the workplace
oped and developing countries. World-
stance abuse treatment centres are for (EAP, 2002). In Thailand, the percent-
wide, alcohol accounted for 4% of the
alcohol-related problems and depen- age of substance abusers aged 12–65
total burden of diseases in 2000.
dence. Almost 80% of all assault years varies from 8.6% to 25% in
In Latin American countries, alcohol patients (both males and females) different regions of the country, the
was the leading risk factor for the presenting to an urban trauma unit in highest percentage being in the north-
global burden of diseases in 2000. Of Cape Town were either under the east. In New Zealand (with a popula-
an estimated 246,000 alcohol-related influence of alcohol, or injured tion of 3.4 million) alcohol-related lost
deaths in this region, about 61,000 because of alcohol-related violence productivity among the working pop-
were due to unintentional and inten- (Steyn, 1996). The majority of victims ulation was estimated to be US$ 57
tional injuries (WHO, 2002), all of of train-related accidents, traffic acci- million a year (Jones et al., 1995).
22
In the United States, the total eco- In the United Kingdom, about days are lost to hangovers and alcohol-
nomic cost of alcohol abuse was esti- 150,000 people are admitted to hos- related illnesses each year. This costs
mated at US$ 185 billion for 1998 pital each year due to alcohol-related employers £6.4 billion. One in 26 NHS
(Harwood, 2000). More than 70% accidents and illnesses. Alcohol is “bed days” is taken up by alcohol-
of this cost was attributed to lost pro- associated with up to 22,000 deaths related illness, resulting in an annual
ductivity (US$ 134.2 billion), including a year. Deaths from cirrhosis of the cost to the taxpayer of £1.7 billion.
losses from alcohol-related illness liver have nearly doubled in the last The cost of clearing up alcohol-related
(US$ 87.6 billion), premature death 10 years. A recent government report crime is a further £7.3 billion a year.
(US$ 36.5 billion) and crime shows that alcohol abuse costs the Moreover, drink leads to a further
(US$ 10.1 billion). Health care expen- country at least £20 billion a year. £6 billion in “social costs”.
ditures accounted for US$ 26.3 billion, The study found that 17 million work-
of which US$ 7.5 billion was spent on
treating alcohol abuse and depen-
dence and US$ 18.9 billion on treating 9
the adverse medical consequences of Cost of alcohol abuse in USA, billion US$, 1998
alcohol consumption. Other estimated
costs included property and adminis- 150
trative costs due to alcohol-related
automobile crashes (US$ 15.7 billion), 120
and the costs of the criminal justice
system for alcohol-related crime
90
(US$ 6.3 billion) (Figure 9).
60
30
0
lost health care vehicle crashes criminal justice
productivity system
23
Diseases related to alcohol and sub- society as a whole, including the
stance abuse are therefore a serious health system, but also social costs in
public problem. They affect develop- terms of injuries, violence and crime.
ment of the human and social capital, They also affect the well-being of
creating not only economic costs for future generations (Figure 10).
10
Excessive alcohol consumption and impaired health of the family
24
Talking about mental disorders means talking
about poverty: the two are linked in a vicious circle
Work Poverty
Unemployed persons and those who
fail to gain employment have more
depressive symptoms than individuals
who find a job (Bolton & Oakley,
Physical disorders Violence and trauma
1987; Kessler & al., 1989; Simon & al.,
2000). Moreover, employed persons
who have lost their jobs are twice as
likely to be depressed as persons who Mental disorders
retain their jobs (Dooley & al., 1994). Suicide
Alcohol
Depression
Substance Abuse
Child/adolescent development problems
Post traumatic stress disorders
25
Promoting mental health; preventing
and managing mental ill health
26
Much can be done to reduce the burdens of
mental disorders, avoid deaths and promote
mental health in the world.
Health promotion is the process of A growing body of cross-cultural evi- mothers, and significantly improves
enabling people to gain increasing dence indicates that various psycho- child development. Promotive inter-
control over their health and improve logical, social and behavioural factors ventions in schools improve self-
it (WHO, 1986). It is therefore related can protect health and support posi- esteem, life skills, pro-social behaviour,
to improving the quality of life and tive mental health. Such protection scholastic performance and the overall
the potential for good health, rather facilitates resistance (resilience) to dis- climate.
than only an amelioration of symp- ease, minimizes and delays the emer-
Among various psychosocial factors
toms (Secker, 1998). Psychosocial gence of disabilities and promotes
linked to protection and promotion in
factors influence a number of health more rapid recovery from illness
adults are secure attachment; an opti-
behaviours (e.g. proper diet, adequate (WHO, 2002). The following studies
mistic outlook on life, with a sense of
exercise, and avoiding cigarettes, are illustrative. Breast-feeding (advo-
purpose and direction; effective strate-
drugs, excessive alcohol and risky sex- cated by the joint WHO/UNICEF
gies for coping with challenge; per-
ual practices) that have a wide-rang- Baby-Friendly Hospital Initiative,
ceived control over life outcomes;
ing impact in the domain of health Naylor, 2001) improves bonding and
emotionally rewarding social relation-
(WHO, 2002). attachment between infants and
ships; expression of positive emotion;
and social integration.
27
When can interventions for
prevention of mental disorders begin?
Visits by nurses and community work- ment (Infant Health and Development For example, iodine supplementation
ers to mothers during pregnancy and Programme, 1990). Early stimulation programmes through iodination of
after childbirth, in order to prevent programmes can enable mothers to water or salt (recommended by WHO,
poor child care, child abuse, psycho- prevent the slow development often 1996; 2001) can help prevent cre-
logical and behavioural problems in seen in preterm infants, and improve tinism and other iodine-deficiency dis-
children and postnatal depression in the physical growth and behaviour of orders (Sood et al., 1997; Mubbashar,
mothers, have proved to be extremely such infants (WHO, 1998). Such pro- 1999). Moreover, it may have a posi-
effective on a sustainable basis (Olds grammes can also reduce the number tive effect on the intelligence level of
et al., 1988). Teaching mothers about of days spent in hospital (Field et al., even apparently healthy populations
early monitoring of growth and devel- 1986), and thus result in economic living in iodine-deficient areas (Ble-
opment in low-birth-weight babies, savings. Nutrient supplements to pre- ichrodt & Born, 1994).
along with proper maternal advice, vent neuropsychiatric impairment
can prevent poor intellectual develop- have also been found to be useful.
28
A stitch in time
29
How can prevention help adults and the elderly?
30
Prevention of suicidal behaviour
The prevention of suicidal behaviour It is also influenced by the availability • Control of availability of toxic sub-
(both attempted and completed sui- of methods used for that behaviour. stances (particularly pesticides in
cide) poses a series of particular chal- This diversity calls for an integration of rural areas of some Asian countries);
lenges at the public health level. On different approaches at the population
• Detoxification of domestic gas and
the one hand, subjects at risk of suici- level in order to achieve significant
car exhaustion;
dal behaviour cover a wide age range, results.
from early adolescence to later life. • Treatment of people with mental
According to the best evidence avail-
On the other hand, the risk of suicidal disorders (particularly depression,
able (WHO, 1998), the following
behaviour varies greatly according to alcoholism and schizophrenia);
interventions have demonstrated effi-
several sociocultural factors (among
cacy in preventing some forms of sui- • Reduction of access to firearms; and
which age, gender, religion, socioeco-
cidal behaviour:
nomic status) and mental status. • Toning down of press reports about
suicides.
31
Treatment of mental disorders:
effectiveness and cost-effectiveness
12
Treatment effects on disability
Percent total improvement in disability
50%
40%
30%
Psychosocial effect
20%
Drug effect
Placebo effect
10%
0%
Schizophrenia Bipolar disorder Depression Panic disorder
32
How effective are treatments for
burdensome psychiatric conditions?
50
40
30
20
10
0
0 3 6 9 12 15 18
Follow-up assessment (months)
33
What are the costs of effective treatment?
The alarmingly low level of resources a more evidence-based approach to WHO has embarked upon the world-
available in developing countries to mental health budgetary planning, wide collection of such an evidence
treat mental health problems, relative resource allocation and service devel- base by means of its WHO-CHOICE
to the affected population for which opment represents an underdeveloped project, including estimation of the
the resources are needed, has been but much needed component of cost and efficiency of a range of key
highlighted by the WHO ATLAS pro- national mental health policy in devel- treatment strategies for burdensome
ject (WHO, 2001). The generation of oping regions of the world. mental disorders. Figure 14 below
14
The annual cost per case (or episode) of evidence-based psychiatric treatment
Cost per treated case (in international dollars, I$)
Africa
Schizophrenia
Older anti-psychotic drug
+psychosocial treatment
Bipolar disorder:
Latin America Mood stabiliser drug
+psychosocial treatment
Depression:
Older anti-depressant drug
Middle East +proactive care
Panic disorder:
Older anti-depressant drug
+psychosocial treatment
Eastern Europe
SE Asia
W Pacific
34
shows the estimated cost of first-line
treatment of schizophrenia and bipo- Cost-effectiveness should be just one of several criteria used in the decision-
lar disorder on a hospital outpatient making process for funding prevention/treatment of mental disorders.
basis, and also the cost of primary
These economic evaluations should be supplemented by other arguments.
care of depression and panic disorder,
based on estimated use of health care For example:
resources that would be required to • People with mental disorders are more at risk of human rights violations
produce the expected reduction in dis-
and are more likely to be discriminated against in accessing treatment and
ability. Costs are expressed in interna-
care;
tional dollars (I$), which take into
account the purchasing power of dif- • Achievement of physical health targets, such as:
ferent countries. It is clear that more
severe psychiatric conditions such as – Infant and child mortality can be reduced through improved treatment
schizophrenia require substantially of postnatal depression;
greater resource inputs (mainly
– HIV/AIDS infection rates for the 17-24 year-old age group are reduced
because a proportion of cases need to
because improved mental health reduces unsafe sex and drug use;
be hospitalized or provided with resi-
dential care outside hospital). By con- – There is better adherence to treatments for other ailments (e.g. tubercu-
trast, the cost of effectively treating an
losis, HIV/AIDS, hypertension, diabetes and cancer treatments);
episode of depression is estimated to
be in the region of I$ 100–150. • Caregivers benefit from a lower burden of care, which means better quality
of life and fewer work days lost, and thus less loss of income;
35
The gap between the burden of
mental disorders and resources
15
Treatment gap rates (%) by disorder (world)
100
80
60
Treated
40
Untreated
20
0
Schizophrenia Major Alcohol use Child/adolescent
depression disorder mental disorders
Even though mental, brain and sub- More than 40% of all countries
stance-use disorders can be managed worldwide have no mental health
effectively with medication and/or policy and over 30% have no mental
psychosocial interventions, only a health programme. Over 90% of
small minority of patients with mental countries have no mental health policy
disorders receives even the most basic that includes children and adolescents.
treatment. Initial treatment is fre- Out-of-pocket expenditure was the
quently delayed for many years. In primary method of financing mental
developed countries with well-orga- health care in many (16.4%) coun-
nized health care systems, between tries. Even in countries where insur-
44% and 70% of patients with ance cover is provided, health plans
depression, schizophrenia, alcohol-use frequently do not cover mental and
disorders and child and adolescent behavioural disorders at the same
mental illnesses do not receive treat- level as other illnesses; this creates
ment (Figure 15) in any given year. significant economic difficulties for
In developing countries, where the patients and their families.
treatment gap is likely to be closer to
90% for these disorders, most individ-
uals with severe mental disorders are
left to cope as best they can.
36
Mental health budget in low-income countries:
non-existent or inadequate
16
Share of mental health budget in total health budget
of countries by income level (%) (World Bank classification)
100%
80%
60%
40%
20%
37
The relationship between the burden of
mental disorders and spending is clearly
inappropriate.
9%
13%
6%
3%
2%
0%
Burden of Median mental health
neuropsychiatric disorders budget as a percentage
as a percentage of total government
of all disorders health budget
Photo: © A. Mohit
38
Urgent action is needed to close the
treatment gap and to overcome barriers which
prevent people from receiving appropriate
care.
39
WHO Global Action Programme
(mhGAP)
WHO declared 2001 the Year of Men- message: mental health, neglected for As a result of the activities in 2001,
tal Health and that year’s World too long, is crucial to the overall well- the Mental Health Global Action Pro-
Health Day was a resounding success. being of individuals, societies and gramme (mhGAP) has been created.
Over 150 countries organized impor- countries, and must be universally mhGAP is WHO’s major new effort to
tant activities, including major speech- regarded in a new light. The theme of implement the recommendations of
es by political leaders and the the World Health Report 2001 was the World Health Report 2001. The
adoption of new mental health legisla- mental health, and its 10 recommen- programme is based on four strategies
tion and programmes. dations have been positively received (Figure 18) that should help enhance
by all Member States. the mental health of populations.
At the 2002 World Health Assembly,
over 130 Ministers responded posi-
tively with a clear and unequivocal
18
Mental Health Global Action Programme (mhGAP):
the four core strategies
Enhanced
mental
Reduced health of
Enhanced Reduced disease populations
mental stigma and burden
Increased health discrimination
country services
capacity
40
Advocacy, information, policy and research
are the key words underlying WHO’s new
global mental health programme, which aims
at closing the gap between those who receive
care and those who do not.
Strategy 1
Increasing and improving information for decision-making and tech-
nology transfer to increase country capacity.
WHO is collecting information about the magnitude and the burden of mental
disorders around the world, and about the resources (human, financial, socio-
cultural) that are available in countries to respond to the burden generated by
mental disorders. WHO is disseminating mental health-related technologies
and knowledge to empower countries in developing preventive measures and
promoting appropriate treatment for mental, neurological and substance-
abuse disorders.
Strategy 2
Raising awareness about mental disorders through education and
advocacy for more respect of human rights and less stigma.
41
At the Executive Board meeting in January 2002 a resolution on
mental health encouraging continued activity in this area was
adopted. The resolution strongly supports the direction of mhGAP
and urges action by Member States. The resolution was endorsed
unanimously by the World Health Assembly in May 2002.
Strategy 3
Assisting countries in designing policies and developing comprehensive and effective mental health ser-
vices. The scarcity of resource forces their rational use.
The World Health Report 2001 and the Atlas: Mental Health Resources in the World, have revealed an unsatisfactory
situation with regard to mental health care in many countries, particularly in developing countries. WHO is engaged in
providing technical assistance to Ministries of Health in developing mental health policy and services. Building national
capacity is a priority to enhance the mental health of populations.
WHO has designed a mental health policy and service guidelines to address the wide variety of needs and priorities in
policy development and service planning, and a manual on how to reform and implement mental health law.
To put plans into action, WHO is adapting the level and types of implementation to the general level of resources of
individual countries. In the particular case of developing countries, where the gap between mental health needs and the
resources to meet them is greater, WHO will offer differentiated packages of “achievable targets” for implementation
(Gap Reduction Achievable National Targets/GRANTs) to countries grouped by at least three levels of resources (low,
middle and relatively higher). These packages provide the minimum required set of feasible actions to be undertaken to
comply with the 10 recommendations spelt out in the World Health Report 2001. Achievement of the identified targets
will influence both health and social outcomes, namely mortality due to suicide or to alcohol/illicit drugs, morbidity and
disability due to the key mental disorders, quality of life, and, finally, human rights.
Strategy 4
Building local capacity for public mental health research in poor countries.
Besides advocacy, policy assistance and knowledge transfer, mhGAP formulates in some detail the active role that infor-
mation and research ought to play in the multidimensional efforts required to change the current mental health gap at
country level.
WHO is developing several projects and activities to promote this strategy at country level, including a research fellow-
ship programme targeting developing countries. A project on the cost-effectiveness of mental health strategies is being
implemented in selected countries to generate real estimates on the costs and benefits of mental health interventions.
These estimates will then be used to enhance mental health services at country level.
42
Much can be done; everyone can
contribute to better mental health
43
Schizophrenia Training to parents Human rights
Parents can help children with mental
Maintenance on antipsychotic Legislation should be modernized.
retardation to achieve their full poten-
medicines Monitoring of human rights violations
tial for development. Simple training
Once this disorder is diagnosed and should be put in place. Quality of
to parents can go a long way in ensur-
treatment is begun, most patients basic care in psychiatric settings
ing the best environment for children
need continued follow-up and regular should be improved. All this will
with mental retardation.
medicines. This costs very little, but ensure a better quality of life and
results in substantial reduction in dis- Epilepsy more dignity for patients. A substan-
ability and improvement in quality of tial component of interventions for
life. Anti-stigma campaigns mental disorders is that of enabling
The biggest barrier to treatment for patients to fully enjoy their rights of
Involvement of family in care epilepsy is stigma. Campaigns against citizenship.
Families are the most significant part- stigma result in a larger proportion of
ners in the care of chronic mental dis- those affected getting much-needed
orders. Simple interventions delivered treatment as well as reintegration into
to the families can enhance the quality schools and their communities.
of life both of the patient and of the
whole family. And relapse can be pre- Availability of medicines
vented. Antiepileptic medicines cost very little,
but their availability within health care
Mental retardation services is limited. Ensuring regular
availability of these medicines makes
Iodinization of salt
treatment possible, even in
Using iodized salt is the single most
the poorest countries: up to 70%
effective prevention activity in areas
of newly diagnosed cases can be
deficient in iodine. Millions of children
successfully treated.
can escape long-lasting intellectual
deficits by this most inexpensive pub-
lic health measure.
44
Everyone can contribute
Everyone can contribute
Foundations
Families Individuals
Mental
NGOs
Health Media
45
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47
For more information
E-mail: postmaster@paho.org
48
WHO Regional Office
for South-East Asia
E-mail: PANDEYH@whosea.org
PO Box 2932
1000 Manila
Philippines
Avenue Appia 20
ISBN 92 4 156257 9 1211 Geneva 27
Switzerland
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Website: www.who.int/mental_health