Investing in global mental health: the time for action is now
Authors: Paul Summergrad
Journal: The Lancet Psychiatry (2016)

Despite widespread acknowledgement of the economic and global burden of mental disorders (as represented in years of life lost to disability and mortality), acting on these concerns and creating an investment plan for global mental health has been challenging.1Horton R Launching a new movement for mental health.Lancet. 2007; 370: 806Summary Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 2Patel V Saxena S Frankish H Boyce N Sustainable development and global mental health—a Lancet Commission.Lancet. 2016; 387: 1143-1145Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar This failure can be explained by many factors, including scepticism about prevalence data for mental disorders. Without precise biological measures, these disorders might be viewed as being defined culturally by high-income countries, or as having overly inclusive criteria that reject traditional ideas of normal human suffering. Additionally, a perceived absence of effective treatments in low-income countries already facing overwhelming challenges of infectious diseases and other disorders and limited infrastructure might make attention to mental illnesses less of an immediate priority. Likewise, mental disorders might be more overtly associated with disability than death, despite evidence of early mortality due to suicide or other medical disorders.3Walker ER McGee RE Druss BG Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis.JAMA Psychiatry. 2015; 72: 334-341Crossref PubMed Scopus (1490) Google Scholar Furthermore, mental illnesses are highly stigmatised. Sitting at the boundary of behaviour, neurobiology, and culture, they remain—irrespective of cause—the most intimate and personal of medical disorders, and challenge expectations for self-control and more traditional views of human nature. Irrespective of these challenges, through persistent advocacy, mental health has for the first time been formally incorporated in the United Nations Sustainable Development Goals for 2016–30.4United NationsTransforming our world: the 2030 agenda for sustainable development. United Nations, New York2015Google Scholar However, concerns about the effectiveness or feasibility of investment in mental health disorders might be continuing to impede needed wide scale interventions. Mental disorders receive a very small proportion of national health expenditures or external development support. In view of these problems, the study by Dan Chisholm and colleagues5Chisholm D Sweeny K Sheehan P et al.Scaling-up treatment of depression and anxiety: a global return on investment analysis.Lancet Psychiatry. 2016; (published onine April 12.)http://dx.doi.org/10.1016/S2215-0366(16)30024-4Google Scholar is very important. Chisholm and colleagues have, for the first time, modelled using the WHO OneHealth tool the investment needed to bring care of depression and anxiety disorders worldwide to minimally acceptable levels. They estimated the investment cost for 80% of the world's population at US$141 billion between 2016 and 2030, using the WHO Mental Health Gap Action Programme (mhGAP) intervention guide, which assumes the use of non-specialist physicians, nurses, and community health workers.6WHOmhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP). World Health Organization, Geneva2010Google Scholar They further analysed the return on investment using two endpoints: economic benefit (ie, enhanced productivity) and the imputed value of the years of improved health. Although the confidence intervals around this analysis were substantial and were dependent on the model's assumptions, they estimated that the benefit to cost ratio of the investment was 2·3–3·0 when only workforce issues were considered. That number increased to 3·5–5·7 when the implicit value of years of health gained were included. Although this number is less than that recorded in many interventions, it is important to note that other potential effects of interventions were not considered. These include the effect of treated depression and anxiety on maternal-child health, or the effect on other general health disorders that are more prevalent and costly in people with mental disorders. The Chisholm study brings rigour to the economic case, but there are many other important reasons to consider enhanced investment in global mental health, not least of which are justice, equity, human rights, and the reduction of suffering. So what should be done to support more widespread investment by governments and non-governmental organisations including foundations in advancing the global mental health infrastructure? First, there needs to be a recognition that even using a conservative estimate of the burden of mental disorders, their contribution to medical care costs, disability, lost life, and lost productivity is substantial. Indeed, in view of their high prevalence and early life onset, failure to address mental health will impede general health goals and risk other social and economic development. Second, although extensive data exist for the efficacy of both psychotherapeutic and psychopharmacological interventions for many psychiatric disorders, more extensive demonstration projects in countries with highly limited medical infrastructures are needed.7Patel V Chisholm D Parikh R et al.Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition.Lancet. 2015; (published online Oct 8.)http://dx.doi.org/10.1016/S0140-6736(15)00390-6Google Scholar Third, working with international agencies such as WHO, there needs to be an updated roadmap for investment that accounts for changes in disease burden over time. Fourth, because psychiatric disorders are highly stigmatised, the will to invest in care will require a parallel international campaign to destigmatise these disorders and, most importantly, will need to be understood as an effort to secure fundamental and inalienable human rights to care and treatment. Finally, to achieve a sustained effect on global mental health, major international organisations, governments, and foundations will need to be engaged. The publication of this report is therefore timely, coinciding with the first-ever joint meeting of the World Bank and WHO on the global economic effect of depression and anxiety on April 13–14, 2016. This is a very important initial step, but only a predicate to overdue and much needed bold action. There are many examples of the effect of such leadership, including in mental health. In the 1930s the Rockefeller Foundation invested heavily in the scientific transformation of academic psychiatry, neurology, and their related care systems in the USA, the UK, and elsewhere.8Summergrad P Hackett TP Alan Gregg and the rise of general hospital psychiatry.Gen Hosp Psychiatry. 1987; 9: 439-445Summary Full Text PDF PubMed Scopus (19) Google Scholar, 9Matysiak A Health and wellbeing. The Rockefeller Foundation Centennial Series. The Rockefeller Foundation, New York2014: 134-161Google Scholar Their leadership signalled an understanding that because infectious diseases in these countries were increasingly effectively treated, non-communicable and chronic diseases would replace them as major disease burdens. Of these, psychiatric illnesses represented the largest unmet clinical and scientific need. These investments set the stage for the post-World War 2 scientific and clinical development of psychiatry. That so many of the Rockefeller leadership also had personal experience with mental illnesses made this a profoundly courageous and visionary act.9Matysiak A Health and wellbeing. The Rockefeller Foundation Centennial Series. The Rockefeller Foundation, New York2014: 134-161Google Scholar The time has come for a similar global investment in mental health, understanding, as the Rockefeller leadership did, that as infectious, water borne, and child health illness outcomes improve, the relative burden of non-communicable diseases will increase and that mental disorders will be among the most important.10Bloom DE Cafiero ET Jané-Llopis EA et al.The global economic burden of non-communicable diseases. World Economic Forum, Geneva2011Google Scholar We will neither achieve our health or development goals if we fail to move towards those who are suffering, and we will violate the core tenets of our common humanity if we fail to help those who are ill take their rightful place among the citizens of the world. The time for open hearted and generous action is now. I receive personal fees from American Psychiatric Association and CME Outfitters, and universities and associations for non-promotional speaking outside the submitted work. Scaling-up treatment of depression and anxiety: a global return on investment analysisReturn on investment analysis of the kind reported here can contribute strongly to a balanced investment case for enhanced action to address the large and growing burden of common mental disorders worldwide. Full-Text PDF Open Access