The international burden of mental disorders is enormous and growing,
according to the World Health Organization (WHO). Although mental disorders
cause fewer deaths than some other illnesses, they can be responsible for
greater disability because of their chronicity.
As of 1990, five of the 10 leading causes of disability worldwide were
psychiatric: major depression, schizophrenia, bipolar disorder, alcohol
dependence, and obsessive-compulsive disorder. By 2020, depression is
projected to become the second most disabling illness in the world.
The majority of the estimated 450 million people who suffer from
psychiatric disorders live in developing countries. Unfortunately fewer than
10 percent of these people have access to treatment. In many of these regions,
which are often torn by poverty, infectious disease, and war, mental health
care is often an unaffordable luxury.
A wide disparity exists in the type and numbers of the mental health
workforce worldwide. In sub-Saharan Africa, many countries have one
psychiatrist—if that—for every million people, compared with 137
per million in the United States. For example, Africa's most populous country,
Nigeria, has about 130 million people but only about 100 psychiatrists. With a
population of over a billion, India has fewer than 4,000 psychiatrists.
Community mental health facilities are also absent in at least one-third of
countries. Last year in Cambodia, a 10-bed inpatient psychiatric ward was
opened, the first and only one in a country of 12 million people. In most
developing nations, newer psychotropic medications are also either unavailable
or too expensive for most of those in need. Traditional healing practices and
faith healing are often the intervention of choice.
Project Atlas, a database of WHO's Department of Mental Health and
Substance Dependence, indicates that 41 percent of 185 countries surveyed lack
a national mental health policy.
Most middle- and low-income countries devote less than 1 percent of their
health expenditure to mental health. Thus, while even the most developed
countries face mental health challenges, this situation is far graver in the
rest of the world.
An important component of improving mental health throughout the world is
stepping up advocacy efforts, public education, and training of mental health
workers. Policymakers and the general public are often unaware that effective
treatment of most mental disorders is possible.
Stimulating investment in mental health services in poor countries will
require demonstrating the economic costs of untreated illness more clearly and
countering the persistent view that a person with a mental disorder will never
function at a normal level. Better mental health for the world's poor can act
as a major catalyst for economic development due to increased
It is also important to counter stigma and discrimination associated with
psychiatric conditions and promote human rights of mentally ill persons. A
mental disorder is grounds for denying the right to vote in some countries; in
others it can be grounds for annulling a marriage.
Unfortunately it sometimes takes a disaster to get mental health on the
agenda. The Asian tsunami, for example, spurred countries in the region to
improve mental health services.
The presence of mental illness often becomes apparent only after a suicide.
The WHO reports that nearly 1 million people die by suicide each year and that
these fatalities could rise to 1.5 million by 2020. Among countries reporting
suicide, the highest rates are found in Eastern Europe, where they are up to
four times that in the United States.
Hindering progress on the mental health front is that 44 percent of
countries do not have an epidemiological study or data-collection system in
mental health. Yet improved monitoring is essential for prevention and
treatment of disability. We must encourage epidemiologic research involving
data collection on mental disorders, including disability, risk factors, and
health service use in developing countries.
APA, through its Council on Global Psychiatry and representation in the
World Psychiatric Association (WPA), strives to facilitate the development of
resources to improve mental health systems in developing countries. The World
Association of Young Psychiatrists and Trainees, which usually meets during
the WPA World Congress on Psychiatry, was created to stimulate international
dialogue on mental health for residents and young psychiatrists.
The world often looks to America for guidance on how to best manage mental
health challenges. An improved diagnostic system will require international
collaboration and unified diagnostic criteria. Undoubtedly it serves our
greater interest to understand mental illness beyond our borders. ▪