The global burden of mental illness and its consequences

Martin McKee European Centre on Health of Societies in Transition London School of Hygiene and Tropical Medicine

Mental illness is common

About 1 in 100 people has a severe mental health problem 1 in 4 people will experience some mental ill-health during their lifetime

The Cinderella of global health

Traditional focus on mortality fails to capture burden of disability Much disability concealed
Stigma Ignorance Marginalised populations

All change: the 1990 Global Burden of Disease Study

Introduced the concept of Disability-Adjusted Life Years Years of life lost from premature death plus years lost from disability

A very different picture

Global burden of mental and substance use disorders

Young people most affected

Looking beyond the deaths and disability

Mental illness is strongly associated with physical illness
People with severe mental illness die on average 20 years earlier than the general population For many reasons Depression
doubles the risk of coronary heart disease in adults Is an independent risk factor for stroke Is a risk factor for accidental and no-accidental injury

Prevalence of diabetes in people with schizophrenia is 5 times that in the general population

Maternal health
Mothers experiencing psychoses in pregnancy are twice as likely to have stillborn babies Maternal mental illness associated with:
Increased failure to thrive Increased infant mortality

Communicable disease
Up to 63% of HIV-positive people in low and Middle Income Countries also have depression People with co-morbid depression are 3 times less likely to comply with recommended treatment plans

Life chances
Mental illness afflicts many people at an early age As a consequence, those affected tend to:
gain fewer qualifications find it harder to obtain work and keep it have lower incomes be homeless or insecurely housed
Poverty

Unemployment Low Income Less Education

Mental Disorders

Cost of mental illness to employers

Absenteeism and Lost Productivity More workers are absent from work because of stress and anxiety than because of physical illness or injury. More days of work loss and work impairment are caused by mental illness than many other chronic conditions such as diabetes, asthma, and arthritis. In the USA, employees with depression cost employers $44 billion per year in lost productive time.2 Mental illness and substance abuse cost employers in the USA an estimated $80 to $100 billion in indirect costs annually. Overall Healthcare Costs Individuals who are depressed but not receiving care for the condition consume two to four times the healthcare resources of other employees.

Crime
Up to 90% of prisoners in some countries have a diagnosable mental health problem or a substance misuse problem

An inadequate response
Median per capita spending on mental health in Low and Middle Income countries is US$ 0.30
Far below estimated 3-4 US $ needed for a cost effective package for the treatment of common mental disorders 33% of countries have no separate budget for mental health care.

Median percentage of health budget devoted to mental health in LMIC is 2%

35% of countries do not have the minimum number of essential medications to treat common mental disorders

 and that is not all

40% of countries do not have training facilities for primary health care personnel in mental health The median number of mental health professionals per 100,000 population in Low and Middle Income Countries is only 6 Most of worlds population does not have access to minimum number of psychiatrists and other professionals required for mental health care 68.6% of the beds for mental health care are in separate mental hospitals The move from institutional to community care is slow and uneven, as inpatient care is still the predominant form of care delivered. In LAMICs there is less than one outpatient contact/visit (0.7) per one day spent in inpatient care

There are cost-effective interventions

Current mental health spending in low and middle-income countries is $ 0.30 per capita Depression treatment in primary care is as cost-effective as antiretroviral treatment for HIV/AIDS

But also barriers to effective action

Insufficient funding stemming from poor public interest, the stigma of mental illness, and insufficient patient advocacy Resources focused on centralised urban and/or institutional care, such that there is little or no access to Mental Health care in the rural and/or community settings Difficulty integrating Mental Health care into the primary health care system Poor human resources, with only a small number of Mental Health workers and inadequate Mental Health training in other health care professionals Insufficient Public Mental Health training in Mental Health leaders

What is needed?
Policy and infrastructure including legislation to protect human rights for people with mental illness Training and retention of mental health workers Funding by government, including a designated budget for mental health care Equitable allocation of financial resources including prepayment mechanisms that increase availability of mental health care by decreasing out-of-pocket expenses A mental health service that balances both community-based and inpatient care and integrates this into the Primary-Care setting Equitable access to affordable essential medications Non-Governmental Organisation support in the form of direct service provision, advocacy, mental health promotion, prevention, and mental health care in emergencies Indigenous, traditional and alternative health care Community-base rehabilitation and social services

Mobilizing a global response:

Setting the agenda
2001

2005

Helsinki

Brasilia

2007

2008

2009- 2010

2010 +

mhGAP country implementation

mhGAP: objectives
Reinforce the commitment of governments,
international organizations and other stakeholders to

increase financial and human resources

Accelerate activities to achieve significantly higher

coverage with key interventions in the resource-poor

countries

mhGAP Vision
Effective and humane care for all with mental, neurological and substance use disorders

Main strategic directions

Advocating at all levels, adopting a participatory approach ,establishing partnerships and intersectoral collaboration Identification of barriers for implementation of scaling up , realistic prioritization of needs and planning accordingly Integration into primary care and strengthening the health systems Considering various entry points based on country's health needs and services (e.g. HIV or maternal health programme) Proactive resource mobilization and appropriate reallocation of resources Constant improvement through monitoring, evaluation and application of lessons learned

Priority conditions, but can be adapted to individual country circumstances

Depression Psychosis and Bipolar disorder Self harm/ Suicide Epilepsy Dementia Alcohol use and alcohol use disorders Drug use and drug use disorders Child and adolescent mental disorders: - depression - developmental disorders - behavioural disorders

Child and Adolescent Mental Disorders Depression Developme ntal disorders Behavioural disorders

mhGAP Intervention Guide

Launched on 7th October 2010 Based on systemtic review of evidence of effective treatments for priority conditions For use by non-specialized health providers in low resource settings Includes both pharmacological and psychosocial interventions

In summary
Mental illness has been ignored for far too long This has enormous consequences for society There are many things that can be done All that is required is the willingness to do so
How can we make this happen in Georgia?