Developing Countries Need Expertise To Respond to Unmet MH Needs

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 productivity.

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. ▪