Why is mental illness so low on the global health agenda? | 

Flickr, by Dierk Schaefer

Seattle recently hosted a big international meeting in which many of the world’s leaders in the fight to improve health met to parse data, debate statistical methods and struggle toward consensus aimed at informing the global health agenda.

Given this focus on data, are the biggest contributors to the global burden of disease also getting the most attention and resources?

Consider two major causes of death and disability worldwide — maternal mortality and mental illness.

Today, the international community, or at least the global health community, has made reducing the number of maternal deaths and complications in childbirth worldwide a top priority. The Gates Foundation has made this a primary mission of its global health program. This priority, which really targets both mothers and children, represents two of the UN’s eight Millennium Development Goals.

Maternal health is wisely regarded as a critical, high-value goal for global health because of the important (and not always measurable) magnified benefits to a family and community that come from focusing on women’s reproductive health and the health of newborns.

Yet, surprisingly, mental illness actually kills and maims more young mothers worldwide.

For all ages and genders, the World Health Organization says mental illness is the fourth leading cause of disability and tenth leading cause of all deaths. Suicide alone kills nearly three times (nearly a million people) the number of women who die in childbirth (360,000, mostly in the developing world) every year.

“In many countries, in parts of Asia such as India and China, suicide ranks alongside maternal mortality — or, incredibly, is sometimes even higher — as the leading cause of death of young women,” said Vikram Patel, one of the leading advocates and pioneers of incorporating mental health services in poor countries.

Suicide alone kills nearly three times the number of women who die in childbirth every year.
Patel, a psychiatrist at the London School of Hygiene and Tropical Medicine, was in Seattle last week to attend a meeting of the scientific advisory board at the UW’s Institute for Health Metrics and Evaluation. Beyond sponsoring the global health metrics meeting, the UW Institute is also leading, in collaboration with the World Health Organization, the effort to update a massive report called the Global Burden of Disease.

“Given its contribution to the global burden of disease, mental illness receives nowhere near the kind of attention and resources it deserves,” Patel said.

The first Global Burden of Disease (GBD), issued in 1990 by Chris Murray (now at the UW) and Alan Lopez (University of Queensland, Australia), was a watershed moment for global health. It was a stunner, applying hard numbers to the causes of death and disability worldwide.

The GDB didn’t make everyone happy since it downgraded the status of some diseases, hurting advocates’ causes. Murray and Lopez and their Seattle colleagues, frankly, continue to make people unhappy — having recently caused a fuss by reporting that maternal mortality has declined worldwide.

But what was most stunning and disturbing about the original GBD was how high mental illness ranked as a cause of death and disability.

“That 1990 report shocked a lot of people,” said Jane Simoni, a UW psychologist who studies the use of psychotherapy as a means to help people with HIV in poor communities get the care they need.

“For some reason, people have a hard time thinking of mental illness as a disease that causes death and injuries,” Simoni said.

“For some reason, people have a hard time thinking of mental illness as a disease that causes death and injuries.”
“Among the big health problems in the world, mental illness ranks pretty high,” said Theo Vos, a former “bush doctor” in Zimbabwe and colleague of Lopez in Australia who is assisting with the current revision to the Global Burden of Disease report (due out this summer).

Mental illness in children was largely neglected in the previous analysis, Vos said, so people can expect to see the estimated mental health burden for children increase. He said some of the statistical methods are being changed (such as no longer weighting severity by age of the afflicted, and generally giving greater status to mortality statistics as opposed to morbidity, disability).

“But no matter how we end up tweaking it, mental illness will remain high,” Vos said.

High and largely untreated, largely ignored on the global health agenda. Why is that?

“Frankly, I don’t know,” said Patel. “The level of disinterest and apathy surrounding this massive problem is mysterious to me.”

Some of it clearly has to do with the stigma that still surrounds mental health, he said. Many people still tend to view mental illness as a character flaw, Patel said, as something that an individual is somehow personally responsible for having and for not being able to control their behavior.

Because of this misunderstanding, he said, many people with mental illness in poor communities (and not-so-poor, but ignorant, communities) suffer severe abuse.

“In developing countries, it is not uncommon to find people with serious mental illness chained up, locked away or subjected to regular, outright abuse, even in health care institutions,” Patel said. “If any of us saw even one individual with HIV/AIDS treated like that, there would be global outrage … But you don’t see the same outrage when it is people with mental illness.”

Road sign calling for ending abuse of mentally ill, Ghana
Flickr, Rachel Strohm

Many argue, or at least assume, that mental health treatment is too complicated and expensive — or too squishy and hard to measure? — to do in poor countries.

That’s not true, say the experts. Patel and Vos both noted studies that show that much of the burden of mental illness (which is mostly depression and anxiety) could be treated with short courses of psychotherapy and common medications.

I wrote a while back about two UW psychotherapists, Debra Kaysen and Shannon Dorsey, who are part of a global research project demonstrating that PTSD (post-traumatic stress disorder) can be treated by training locals how to do some basic talk and behavioral therapies.

They are working in Iraq with war victims, in Congo with women victims of sexual violence and among Cambodian children who were sold into sex slavery.

“There are still a lot of skeptics, but there’s been growing interest,” Kaysen said. Many professional therapists question whether poorly educated people can really provide beneficial counseling, she said, but they are showing it can work.

So there is progress being made at better incorporating mental health into the global health agenda.

There’s even a new movement aimed at doing just that, along the lines of what AIDS activists did for their cause. You can read more about it at globalmentalhealth.org.

“I think we have all the evidence we need,” Patel said. “Now, I think we need to change hearts and minds.”

Patel also spoke at the UW. His full lecture can be seen here.

  • Nancy

    Tom, great post! I’m so glad your’e on the case.

  • Thomas Weiss

    A very long time ago it would seem, those who studied the human body decided to separate the brain from studies of the rest of the body – mistake number one. Their decision to do so finds the brain as one of the least understood parts of the body.

    Mental illness is humanity’s greatest fear. People; everyone, on some level that is very deep, fear mental illness so greatly that even the thought of it terrifies us. For this reason we do everything from stigmatize those who have a form of mental illness to joke about it and belittle people who have a mental illness. We shirk mental illnesses and those who have them on a deep-seated, defensive level.

    All of this leads to the continuance of a lack of understanding of the human brain and forms of mental illnesses. Humanity has instead chosen to pursue stigma, prejudice, ignorance, hatred, bias, and more – whether these ugly things were chosen on a conscious or subconscious levels. We have chosen these things out of self-defense and because they are perceived as being somehow easier than facing our greatest fear – mental illness.

    Until studies of the human brain and forms of mental illnesses are pursued with incredible fervor, nothing will change; humanity as a whole will not advance. Instead we will have all of the ugly and hateful replacements we have chosen as placebos to real treatment and acceptance. Until we pursue studies of the brain and mental illnesses, the monster in the closet will thrive.

  • Cbeegru

    Mental illness needs a lot more attention and research funding to find better treatments and cures. If there were bona fide cures, people could feel comfortable coming forward and saying “Yes, I had depression/anxiety/bipolar disorder/etc…, and now I’m cured.”

    There is such a stigma and shame about mental illness that people, and families of people, who live with mental illness don’t talk about it. We hear about recovering alcoholics, and even though they may still be regarded with suspicion, they are OUT and visible. We can see that they’re OK. People who have recovered from depression or anxiety never share that with anyone outside they’re closest circle. As a result, we don’t hear or experience success stories of people who were severely depressed or had life altering anxiety issues, but have since recovered.

    I think for a lot of people who are treated for mental illness (anxiety and depression), it’s an ongoing struggle. Sometimes it comes back. A lot of psychotropic medications have terrible side effects that make it hard for people to keep taking them, and so they don’t. No one deserves to be abused and all people should be treated with respect. We have to acknowledge that it’s the irrationality of mentally ill folks that is so hard for others to accept. It’s disruptive and can be dangerous. Their families need resources.

    Also, there are some forms of mental illness and personality disorder for which psychotherapy and drugs are just not effective. We have a long way to go.

    • Kabra

      I disagree with what Cbeegru postulates as this is not what I find working in a community mental health free clinic. Side effects exist for lots of medications in all diseases and these are what may prompt people to change, but not necessarily discontinue treatment. What I find most commonly is that people start to feel better when on medications and after awhile feel they don’t need the medications anymore. I think people just don’t want mental illness to be considered a chronic condition, would prefer it to be more like an infection that you can take a drug and cure it like an antibiotic cures an infection. Compare that to the idea of a chronic health condition like high blood pressure or high cholesterol that the medication keeps the illness under control. Maybe it has to do with a stigma towards mental illness, it would be hard to have to accept that this is a chronic condition–something wrong with their brain, and as related in the article, implying something wrong with their character.

  • Anonymous

    As someone who has been suffering with severe depression for many years, this article has really hit home. I have recently been diagnosed with a form of bipolar disorder and after fighting the urge to commit suicide repeatedly, I am finally on medication that is helping. I have been completely open with my friends and people at my church. I am not ashamed or embarrassed and I explain my outlook that my brain is just another organ, although much more complex than a heart, a kidney, or liver each of which can produce its own set of problems.

  • http://in2mentalhealth.wordpress.com Roos Korste

    Dear Tom. Great post! Agree upon everything and thanks for advocating for these issues.