"Mental health is still a peripheral issue on the global health agenda," said Vikram Patel, M.D. "Yet while most persons with mental disorders live in low- or middle-income countries, most mental health resources are found in high-income countries, reflecting a vast treatment gap."

Filling that gap requires scaling up evidence-based treatments while strengthening human rights protections for people with mental disorders, Patel told an audience at the Pan American Health Organization during APA's 2008 annual meeting in Washington, D.C., in May. The entire global health community must become involved, not just those concerned with mental health, he said." The linkages with other health problems are close, so you can't treat one without the other."

The event was the Western Hemisphere extension of the Lancet's call for new action on mental health, launched last September with a special issue of the journal.

The meeting was organized by the Department of Global Health and the School of Public Health and Health Services at George Washington University, in collaboration with the Lancet, Pan American Health Organization, Conflict Management and Resolution Section of the World Psychiatric Association, and APA. The conveners were Eliot Sorel, M.D., and Jorge Rodriquez, M.D.

"Global health is not just about infectious diseases in the developing world but chronic diseases everywhere," said Lancet North America Senior Editor Maya Zecevic, Ph.D., M.P.H. Poverty, migration, conflict, and natural disasters make matters only worse. The journal's efforts were intended to express possibilities for solutions, educate the public, and induce further research, she said. They were both a call and a move to action, backed by a commitment to measure progress.

The vast majority of persons with mental illness in the developing world reside in communities where they receive little or no care, or in" medieval" mental hospitals, said Patel, a psychiatrist and professor of international mental health and a Wellcome Trust clinical research fellow at the London School of Hygiene and Tropical Medicine in the united kingdom. He did not advocate shutting inadequate hospitals, but reforming them to permit greater access to humane care. New delivery systems might also be developed to use lightly trained, nonspecialist, village-based health workers with heavy professional backup, he said.

Early intervention might be another useful approach, said Ronald Kessler, Ph.D., a professor of health care policy at Harvard Medical School. The present approach is analogous to practicing cardiology in the 1950s, when doctors waited for a heart attack to occur before treating a patient.

"The seriously mentally ill pile up lots of problems starting in childhood," said Kessler. "The delay from earliest onset to first treatment is about 10 years. What would happen if we treated [children] with mild symptoms beginning at age 8 instead of waiting for an acute onset in their 20s?" (Psychiatric News, May 16).

Poor treatment rates also concerned former U.S. Surgeon General David Satcher, M.D., Ph.D., now director of the Center of Excellence on Health Disparities at the Morehouse School of Medicine in Atlanta.

"Although 80 to 90 percent of mental disorders are treatable with a range of therapies, only half of adults and one-third of children who need treatment are getting it," said Satcher, who reiterated his support for integrating identification and treatment of mental illness into primary care.

Mental health cannot be considered in isolation from other risk factors, he said.

"If we don't deal with the social determinants of health, we will make no progress in reducing the burden of mental illness," he said." Mental health works in both directions. It is a social determinant, and it is affected by social determinants."

Mental illness remains a burden in high-income economies too, said Thomas Insel, M.D., director of the National Institute of Mental Health (NIMH).

"These are chronic disorders of young people," said Insel." Half of all adults with mental illness experience symptom onset by age 14, and mental illness is implicated in the 30,000 suicides, 18,000 homicides, and 20,000 new AIDS cases each year [in the United States]."

Mental illness, including substance abuse, accounts for as much as 40 percent of noninfectious disease in the united States, and people with mental illness are the largest group drawing federal disability payments. The United States still lacks parity in payment for mental health services and has a geographically unequal distribution of outpatient services, while facing higher costs and increased disparities, Insel pointed out. "This is every bit as urgent as any other social problem."

Some NIMH research could be applied to low- and middle-income countries, said Insel. Collaborative care could, for example, link nurses, social workers, and lay therapists to psychiatry. Telemedicine might supplement sparse rural services. More is needed, though, he said. Resources have to be matched with the public need, and mental illness identification and treatment further integrated into general health care.

Simply implementing the existing science in the field would help, as well.

"We must take what we know and make it what we do," said Insel.

The Americas could become the model for strengthening the alliance between mental health care and primary health services, concluded Sorel, a clinical professor in the departments of global health and psychiatry and behavioral sciences at George Washington University, who introduced the speakers.

"We have focused too closely on medications for our outcomes," said Sorel. "I wish we could see more research into integrating the biological, social, and psychological approaches to treatment. We have to educate the public, policymakers, and the media about the convergence of evidence, policy, and actions we have heard today."

The Lancet special issue on global mental health is posted at<www.thelancet.com/journals/lancet/issue?issue_key=S0140-6736(07)X6038-0>. A press release for the Lancet program at the Pan American Health Organization is posted at<www.paho.org/English/DD/PIN/pr080507.htm>.▪