Inadequate MH Care Plagues Nations in All Parts of the Globe

The “disturbingly high levels of unmet need for mental health treatment worldwide” are only worsened by the fact that few people are treated effectively, according to a World Health Organization (WHO) survey of anxiety, mood, and substance disorders.

The data were based on interviews with 84,850 adults in 17 countries. These included low-income countries like Nigeria; low middle-income countries like China, Sout h Africa, Colombia, and Ukraine; high middle-income countries like Lebanon and Mexico; and high-income countries like Belgium, France, Germany, Israel, Italy, Japan, the Netherlands, New Zealand, Spain, and the United States.

Researchers led by Philip Wang, M.D., of the National Institute of Mental Health, assessed the presence of anxiety, mood, and substance disorders using DSM-IV criteria.

The results were reported in a special issue of The Lancet on September 8, accompanied by several other articles and editorials on the need for greater attention to mental health around the world.

Use of mental health services varied, but generally paralleled national income levels and spending on health care, wrote Wang. Fewer patients with mild or moderate illness severity appeared to receive services than those with more severe conditions, although the connection between severity and use of mental health specialists was inconsistent.

Furthermore, said the researchers, “Many patients who initiated treatment failed to receive follow-up care or treatment meeting minimal standards of adequacy.”

Overall, though, most treatment occurred within the general medical sector, rather than through specialty care.

That specialists do not treat many mentally ill individuals was not a surprise to Lawrence Hartmann, M.D., an APA past president, an assistant clinical professor of psychiatry at Harvard Medical School, and a member of APA's Council on Global Psychiatry. “One has to adapt one's goals to a realistic evaluation of the professional talent available,” he said in an interview.

“These results are not unexpected, but they are overdue,” said Hartmann. “The real importance of these articles is that they appear in a widely read general medical journal and provide more detail showing that mental illness is a major international public health problem.”

Wang and colleagues recommended expansion of treatment resources, backed by both governmental and private financing of mental health services. Nations will also have to decide questions like whether to focus on more severely ill patients and to use specialty rather than primary medical services.

However, many countries lack rigorous research data on services and frequently base decisions on cost or on the prejudices engendered by stigma.

A second Lancet article made clear the importance for world health of the diagnosis and treatment of mood disorders. That study looked at the connections between depression and four chronic diseases—arthritis, angina, diabetes, and asthma—among 245,404 adults in 60 countries who took part in the WHO World Health Survey.

Between 9 percent and 18 percent of persons with one of the chronic illnesses also had depression, wrote Saba Moussavi, M.P.H., and Somnath Chatterji, M.D., of WHO's Department of Measurement and Health Information Systems, and four colleagues.

Respondents with the lowest overall mean health scores had depression coupled with two or more comorbid chronic conditions, they reported. Having depression with a chronic illness was even worse than having one or more chronic illnesses without depression, they said.

The main problem in expanding care for mentally ill individuals is political, said Hartmann.

“I'd recommend that psychiatrists read this series, but even more that politicians and other physicians read it as well,” said Hartmann.“ Organizations like APA can help public health physicians and psychiatrists around the world to educate governments to do more. If we make noise and ask for a lot, maybe we'll get something.”

The series in Lancet on mental health around the world is posted at<www.thelancet.com/journals/lancet/issue?issue_key=S0140-6736(07)X6038-0>.▪