## Resources Lesson 1: Mental illness

The paper Mental Health from Our World in Data present "...estimates of mental health disorder prevalence and the associated disease burden. Most of the estimates presented in this entry are produced by the Institute for Health Metrics and Evaluation and reported in their flagship Global Burden of Disease study. For 2017 this study estimates that 792 million people lived with a mental health disorder. This is slightly more than one in ten people globally (10.7%)."The paper is worth exploring for details of each mental illness, but it makes the point that mental illnesses are under-reported and this under-reporting varies between and within countries, and diagnostic accuracy may be low.

The graph below, from the same study, shows trends over time - but how much of this is due to a real increase or is due to increased population sizes and increased reporting as the stigma of mental illness has reduced - at least in some environments?

You might want to explore the WHO site Mental health for more information about the global patterns of illness. A WHO fact sheet is also worth examining in more detail.

The Disease Control Priorities DCP3 chapter Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders combines the conditions (as MNS) since "MNS disorders, a heterogeneous range of disorders, owe their origin to a complex array of genetic, biological, psychological, and social factors". The social determinants are further explored:

"A range of social determinants influences the risk and outcome of MNS disorders. In particular, the following factors have been shown to be associated with several MNS disorders (Patel and others 2009):
1. Demographic factors, such as age, gender, and ethnicity
2. Socioeconomic status: low income, unemployment, income inequality, low education, and low social support
3. Neighborhood factors: inadequate housing, overcrowding, neighborhood violence
4. Environmental events: natural disasters, war, conflict, climate change, and migration.
5. Social change associated with changes in income, urbanization, and environmental degradation
The causal mechanisms of the social determinants of MNS disorders indicate a cyclical pattern. On the one hand, socioeconomic adversities increase the risk for MNS disorders (the social causation pathway); on the other hand, people living with MNS disorders drift into poverty during the course of their life through increased health care expenditures, reduced economic productivity associated with the disability of their condition, and stigma and discrimination associated with these conditions (the social drift pathway)."

Interventions

The Disease Control Priorities DCP3 chapter Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders further discusses the evidence for treatment and prevention. We summarise some the information here, but you can go to the chapter through the link above and download the pdf file for much more detailed information:

"Many MNS disorders can be prevented and treated effectively.
A wide variety of effective interventions can prevent and treat MNS disorders. Although some
of these interventions are also supported by evidence of cost-effectiveness, significant gaps
remain in the availability of evidence to support the scaling-up of many interventions. Some of
these interventions can have significant impacts on other global health and development priorities. For example, the effective management of maternal depression can affect child health outcomes, and the effective management of conduct disorders in children can affect adult antisocial and criminal behavior.

Best practice interventions for MNS disorders can be appropriately implemented across a range of population, community, and health care platforms.
• At the population-level platform of service delivery, best practices include legislative and regulatory measures to restrict access to means of self-harm/suicide and reduce the availability of and demand for alcohol.
• At the community-level platform, best practices include life skills training in schools to build social and emotional competencies in children and adolescents.
• At the health care platform, which covers self-care, primary health care, and hospital care delivery channels, best practices include self-management of migraine; diagnosis and management of epilepsy, headache, depression, anxiety, alcohol and illicit drug use disorders; and continuing care of schizophrenia and bipolar disorder in primary care.

Public financing of scaling-up is affordable and increases financial protection.
The costs of providing a significantly scaled-up package of specified cost-effective interventions for prioritized MNS disorders is estimated at US$3–US$4 per capita of total population per year in low- and lower- middle-income countries, and at least double that in upper-middle-income countries."

The WHO Mental Health Gap Action Programme (mhGAP) is an attempt to introduce interventions:

"Mental, neurological, and substance use disorders are common in all regions of the world, affecting every community and age group across all income countries. While 14% of the global burden of disease is attributed to these disorders, most of the people affected - 75% in many low-income countries - do not have access to the treatment they need.

The WHO Mental Health Gap Action Programme (mhGAP) aims at scaling up services for mental, neurological and substance use disorders for countries especially with low- and middle-income. The programme asserts that with proper care, psychosocial assistance and medication, tens of millions could be treated for depression, schizophrenia, and epilepsy, prevented from suicide and begin to lead normal lives– even where resources are scarce."

Although we have not talked much about suicide, Public health strategies to ensure reduction in suicide incidence in middle and low income nations concludes: "Worldwide, the incidence of suicide has increased at an alarming rate and in the year 2012 close to 1 million people died because of suicide. Although, it is a well-acknowledged fact that suicides are completely preventable, the public health authorities have failed to halt the rising trend of the suicide because of the presence of various social and health related factors. As suicide is a complex issue, in the low and middle-income nations, the most cost-effective approach is to ensure the integration of suicide prevention program into the primary health care network. To conclude, suicide is an important public health concern which is definitively preventable. However, the need of the hour is that all the stakeholders should take collective responsibility, and work in collaboration to develop and implement a comprehensive multi-sectoral suicide prevention strategy."

This paper focuses on barriers to mental health services in low- to middle-income countries, which contribute to high levels of substance use disorders as coping mechanisms. The authors present potential cost-effective strategies to improve mental health services in resource constrained settings, thereby contributing to the prevention and control of substance use disorders which may potentially reduce the burden of disease related to mental illness in these countries. Read the content under the heading "Background."

Finally, A position statement on mental health in the post-2015 development agenda reminds us that "Mental health is a cross-cutting issue, and including it in frameworks for action will increase the likelihood of achieving global priorities for development such as poverty reduction, economic development, improved health, and ensuring the most vulnerable in society are not left behind."