Options for Action to Transform Global Mental Health
Patricio V Marquez
After decades of neglect, there is nowadays a growing interest and commitment to “do something” about the societal burden of unattended mental and substance use disorders. The COVID-19 pandemic has accentuated the urgency of focusing on these often misunderstood and stigmatized conditions that affect people worldwide, in order to develop a better understanding of their complex biological, social, economic, and environmental determinants, the synergistic nature of mental and physical illnesses and their risk factors (e.g., contribution of mental health conditions to the non-communicable disease burden and vice-versa), and related social pathologies and impacts, and to identify ways to effectively deal with them across sectors.
This is an important step forward in a long historical journey. Throughout history, mental illness has been the subject of different interpretations and approaches to treatment. In his seminal book, “Madness and Civilization: A History of Insanity in the Age of Reason,” French philosopher Michel Foucault examined the changing meaning of “madness” in different epochs and described how, in the mid-17th Century, with the adoption of a conceptual distinction between rational and irrational behavior, those deemed “mad” began to be separated from society by gathering them, along with other outcasts, in “ships of fools” to "hit the road" to beg a living. At the end of the 18th Century, with the creation of asylums – places devoted solely to the confinement of the “mad” for the protection of society– “madness” became a mental illness to be studied and cured under the supervision of medical doctors in an institutional setting. Irrational behavior was seen as “moral error,” with individuals having freely chosen “unreason.” The “treatment” regimes of these new institutions were programs of punishment and reward aimed at causing these persons to reverse their “choice.”
Unfortunately, in the third decade of the 21st Century, not much has changed in many countries regarding how society views and deals with mental illness. As noted in the World Health Organization (WHO) Mental Health Action Plan 2013-2020, homelessness and inappropriate incarceration are far more common for people with mental disorders than for the general population, and this tends to exacerbate their marginalization and vulnerability.
We have come a long way, but much more is required to achieve physical and mental health parity—from laws and legislation to the benefits and services that must be covered under public health programs and health insurance plans. Indeed, the common reality in many countries is still one in which mental health and social workers are few, services are far and of limited access, drugs are scarce, and funds for mental health services are often inexistent.
The time has come to accept and act upon the realization that good mental health is an integral part of health and societal well-being, particularly given the growing relative importance of mental and substance use disorders and their broad impacts across population age-groups and the wider society, which demand sustained, multisectoral action.
The Problem at Hand: Complex Pathologies and Limited Access to Services
The 2022 WHO report, World Mental Health Report: Transforming Mental Health for All, released a week ago, is timely. It provides a comprehensive analysis of mental health problem and helps to shine a light on the way forward, building upon accumulated evidence.
The report shows not only that mental health needs are high, but that the societal response is still insufficient and inadequate. The seriousness and complexity of the problem is evidenced by the data and information presented in the report, as follows:
- In 2019, nearly a billion people – including 14 percent of the world’s adolescents – were living with a mental disorder. Suicides accounted for more than 1 in 100 deaths, and 58 percent of suicides occurred before age 50.
- Mental disorders are the leading cause of disability, causing 1 in 6 years lived with disability. People with severe mental health conditions die on average 10 to 20 years earlier than the general population, mostly due to preventable physical diseases.
- Social and economic inequalities, public health emergencies, war, and the climate crisis are among the global, structural threats to mental health.
- Depression and anxiety went up by more than 25 percent in the first year of the pandemic alone. Childhood sexual abuse and bullying victimization are major causes of depression.
- Stigma, discrimination, and human rights violations against people with mental health conditions are widespread in communities and care systems everywhere; 20 countries still criminalize attempted suicide.
- Across countries, it is the poorest and most disadvantaged in society who are at greatest risk of mental ill-health and who are also the least likely to receive adequate services.
- Even before the COVID-19 pandemic, just a small fraction of people in need had access to effective, affordable, and quality mental health care. For example, 71 percent of those with psychosis worldwide do not receive mental health services. While 70 percent of people with psychosis are reported to be treated in high-income countries, only 12 percent of people with psychosis receive mental health care in low-income countries. For depression, the gaps in service coverage are wide across all countries: even in high-income countries, only one third of people with depression receive formal mental health care, and minimally-adequate treatment for depression is estimated to range from 23 percent in high-income countries to 3 percent in low- and lower-middle-income countries.
The Mental Health Toll of the COVID-19 Pandemic
Besides the information conveyed in the WHO report, evidence from other sources shows that the pandemic has taken a significant toll on people’s mental health. Rising unemployment, underemployment, changes in work arrangements, loss of income, and the complications from long-COVID have disrupted daily routines. A recent global study reported a significant increase in the prevalence of both major depressive and anxiety disorders among all genders due to the pandemic—a worrisome finding because these disorders were already leading causes of disability worldwide. Social restrictions, unemployment, financial instability, and school closures are among the COVID-19-related factors that have contributed to worsened mental health outcomes.
Mental disorders are also a major risk for developing alcohol and drug dependency. Globally, 107 million people or 1.8 percent of the total population are estimated to have an alcohol use disorder. A study on mental health and alcohol use in developing countries has shown that the consumption of alcohol is heavily gendered, characterized by a high proportion of hazardous drinking among men. Hazardous drinkers not only consume large amounts of alcohol, but also do so in high-risk patterns, such as drinking alone and binging, which are associated with depressive and anxiety disorders as well as domestic violence and suicide. In terms of drug use, it is estimated that globally in 2017 around 71 million people had a drug use disorder. Most of these people are addicted to opioids, which accounts for around 55 percent of drug use disorders globally. As documented in a previous post, people are more likely to drink or use drugs as a coping mechanism "during times of uncertainty and duress," such as during the COVID-19 pandemic.
The mental health 'tail' of this global crisis will likely prove to be protracted for many people. As documented in different articles and reports, the pandemic has changed our lives, overwhelming people with anxiety about the future and feelings that it would never end despite the growing availability of vaccines and new therapies. For example, in a rare public advisory at the end of 2021, the U.S. Surgeon General warned of a “devastating” mental health crisis among adolescents that was underway before the pandemic.
Overall, it is important to keep in mind that the social costs of mental illness and substance use disorders – which compound the impact of poor physical health – are terribly high, for individuals, families, communities, and the economy. But the cost of effective treatments is surprisingly low.
Options for Action Outlined in the WHO Report
The WHO report suggests three key paths to transformation that can accelerate progress globally, focusing on shifting attitudes to mental health, addressing risks to mental health, and strengthening systems of care for mental health. As clearly discussed in the report, the suggested paths are:
- Deepen Commitment to Mental Health. Stepping up investments in mental health, not just by securing appropriate funds and human resources across health and other sectors to meet mental health needs, but also through committed political leadership and allocation of funding levels required to scale up service coverage and support, pursue evidence-based policies and practice, and establish robust information and monitoring systems. Including people with mental conditions in all aspects of society and decision-making to overcome stigma and discrimination, reduce disparities, and promote social justice, is an imperative.
- Reshape environments that influence mental health, including homes, communities, schools, workplaces, health care services, and natural environments. Intensify engagement across sectors, including to understand the social and structural determinants of mental health and intervening in ways that reduce risks, build resilience, and dismantle barriers that stop people with mental health conditions from participating fully in society. Relevant actions include stepping up action against intimate partner violence and abuse and neglect of children and older people; enabling nurturing care for early childhood development; making available livelihood support for people with mental health conditions; introducing social and emotional learning programs while countering bullying in schools; shifting attitudes and strengthening rights in mental health care; increasing access to green spaces; and banning highly hazardous pesticides, which are associated with suicides.
- Strengthen mental health care by changing where, how, and by whom mental health care is delivered and received. Build community-based networks of interconnected services that move away from custodial care in psychiatric hospitals and cover a broader spectrum of care and support through a combination of mental health services integrated in general health care, community mental health services, and services beyond the health sector. Such scale-up includes adopting a task-sharing approach that enables evidence-based care to be offered also by general health workers and community providers.
Leveraging New Technologies to Expand Access to Services
Another “entry point” to move the global mental health agenda forward, is the introduction and use of digital technologies to support guided and unguided self-help and deliver remote care. Digital care options through teletherapy and new apps have seen explosive growth during the pandemic. They offer alternative service delivery models that help overcome obstacles that hinder access to care, such as transportation barriers, stigma associated with visiting mental health clinics, personnel shortages, and high costs. These platforms, especially in mobile formats, can offer remote screening, diagnosis, monitoring, and treatment, facilitate remote training for non-specialist health care workers, and enhance online peer-to-peer support and self-care. Other tech innovations include prescription video games, that challenge children ages 8 to 12 with Attention-Deficit/Hyperactivity Disorder to focus on multiple tasks simultaneously within the game environment. Or artificial intelligence (AI) chatbots that can help patients practice cognitive behavioral therapy (CBT) to become aware of inaccurate or negative thinking so that they can view challenging situations clearly and respond to them effectively.
Online symptom tracking apps are also used to prompt patients to share data daily which are analyzed with an AI algorithm to identify patterns and alert providers in real time of any warning signs.
Several initiatives have been launched to deal with scarcity or lack of providers needed to reach people in need. The World Health Organization Academy aims to provide digital learning to health workers across the world on a range of topics, including mental health; EMPOWER, a Harvard Medical School initiative, provides digital training to support delivery of psychosocial interventions; and UNICEF’s Caring for the Caregiver program targets community workers using online and in-person training.
How to Finance this Global Effort?
A significant and sustained effort at country and international levels will require additional funding to bridge resource gaps and address low availability and quality of treatment and social support services. Rather than advocating for another siloed approach focused on individual health conditions, multi-sectoral funding must be leveraged to scale up mental health interventions while also promoting efforts to reduce duplication and inefficiencies as well as stigma and discrimination.
As highlighted at various global health events held at the World Bank Group (WBG) since 2016, these actions are doable. Governments have the responsibility to mobilize additional domestic resources to help achieve mental health parity as part of the progressive realization of universal health coverage. One way to do this is to increase tax rates on tobacco, alcohol, and sugary drinks, the pro-health taxes, which can not only provide a source of additional revenue, but also help generate public health benefits by reducing consumption and the risk of attributable chronic diseases and injuries. Elimination of fossil fuel subsidies, which impose large fiscal costs while adding to negative environmental and health impacts, could also help expand fiscal space for health.
Domestic resource mobilization should be complemented by investment and program allocations by international organizations, both multilateral and bilateral, not only in the health sector by also in other sectors that offer “entry points” to tackle mental health issues in an integrated manner.
Universal health coverage efforts can help to address community-level needs of persons with defined mental disorders and offer financial protection by covering mental health and substance use disorder services, including medicines, under public health programs funded by general revenue and health insurance arrangements.
It should be clear, however, that to move the needle and accelerate action, interventions that cut across sectors and span the life cycle are needed to address the root causes and broad manifestations and impacts of mental and substance use disorders.
Indeed, as suggested on a previous post, cooperation across sectors also will provide an opportunity for multilateral financing institutions such as the WBG, bilateral agencies, and philanthropies to use existing service platforms to support the scale-up of mental health prevention and treatment. For example, to address the critical but often overlooked association between maternal depression and childhood stunting, support could be provided as part of integrated maternal and child health interventions under platforms such as the Global Financing Facility in support of Every Woman, Every Child (GFF). Investment in other areas, including education and social protection, could be utilized to respond to the unique needs of youth and other vulnerable groups, using initiatives such as the World Bank Group’s Human Capital Project. This is an important consideration as the different dimensions of human capital complement each other, starting at an early age; e.g., proper nutrition and stimulation, in-utero and in early childhood, have been shown to improve people’s physical and mental well-being and contribute to the development of cognitive and socioemotional skills.
Similarly, integrating mental health into wellness programs in the workplace can help leverage funding from firms and enterprises as a sound investment yielding significant benefits for workers, their families, and employers and improving productivity and competitiveness. A good practice is offered by the World Bank Group, where policies and programs are in place to support individuals’ physical and mental health, including awareness building, prevention, and treatment. The launching of “Better Together: A Mental Health & Well-Being Strategy for the World Bank Group” on May 4, 2022 is a major step forward to improve the organization’s effectiveness by optimizing the physical and mental health and well-being of its staff by defining key areas of intervention to promote an overall culture of health in the workplace.
Multi-sector programs used for the reintegration of displaced populations and refugees in post-conflict and post-disaster societies, such as those funded under the World Bank Group’s IDA and IBRD windows, could help mainstream and scale up mental health interventions and related social services among these vulnerable and at-risk populations.
Microcredit schemes, such as Rise Asset Development in Canada, which provides low-interest small business loans, training, and mentorship to entrepreneurs with a history of mental health or addiction challenges (including former prisoners), can facilitate the reintegration of those with mental health conditions back into the community.
The evidence provided in the WHO report illustrates well the nature and characteristics of the global mental health challenge and makes a strong case for supporting a global effort to tackle it as a development priority. The cost of inaction is significant, as this unattended challenge undermines social and economic wellbeing of countries, and its impact is ominous. Maternal depression and trauma contribute to the intragenerational transmission of ill health, both physical and mental. As mental health conditions are the leading cause of disability in ages 9 through 29, they exert a strong negative effect on human capital development, and hence, on future employment and earning potential, poverty reduction, and improved shared prosperity in a society.
Workplace disruptions by the COVID-19 pandemic have exposed long-standing and often ignored mental stressors that sap the wellbeing and productivity of employees and managers.
At the same time, more than 20 percent of adults aged 60 and over suffer from a mental or neurological disorder, a problem that stands to grow in magnitude with the aging of the global population.
Mental disorders tend to be more acute and often unattended in conflict-affected countries where vast segments of the population are exposed to long periods of civil unrest, political and ethnic confrontations, and war, and many are or have been the subject of harassment, sexual abuse and rape, incarceration, and torture.
Another critical challenge faced in most countries is to overcome the “punishment paradigm” often found in penal systems by focusing on addressing the mental health needs of prisoners and bringing about their recovery. This requires a concerted effort to overcome the criminalization of mental illness by offering comprehensive physical and mental health services during incarceration and to support transition to community life after prisoners are released.
By drawing on the latest evidence available, the new WHO report showcases examples of good practice from around the world and the voices of people affected by mental health conditions.
Looking forward, as noted by the Dean of the Johns Hopkins Bloomberg School of Public Health, "we must start talking now about the need to invest for the long term," building upon the “brutal lessons” from the COVID-19 pandemic. The above observations presented in this post bring to the fore once again the imperative of investing in mental health not only as a development priority, but more importantly to build more resilient and healthy societies.