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

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.

[module align=”right” width=”half” type=”pull-quote”]Suicide alone kills nearly three times the number of women who die in childbirth every year.[/module]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.

[module align=”right” width=”half” type=”pull-quote”]”For some reason, people have a hard time thinking of mental illness as a disease that causes death and injuries.”[/module]”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.”

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.