A bleak look at mental health in the Americas
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2019)

Is it really a massive wall along the border between the USA and Mexico that the American continent needs the most today? A series of reports published in this issue of The Lancet Public Health strongly suggests that there might be more pressing issues for people living in the Americas—from North to South, these reports paint a worrying portrait for the state of mental health. In Canada, an opioid death crisis is unfolding, and Benedikt Fischer and colleagues warn in their Comment about the catastrophically high levels of drug-related mortality (about 4000 in 2017) and how current actions are simply not sufficient. In the USA, life expectancy has been falling for the past 3 years, in particular among white adults. This decline has been driven by drug poisoning deaths, but not only; mortality from alcohol use and suicides has also been rising—indicating a broader public mental health crisis in the USA—recently defined as “deaths of despair”. In an attempt to add to our understanding of this phenomenon, Meredith Shiels and colleagues' analysis dissects overall mortality and death rates from drug poisoning among people aged 25–64 years in the USA to look for patterns by ethnicity, socioeconomic status, rurality, and geography. Increasing drug poisoning mortality is not limited to poor white people. Drug overdose deaths are a national problem, increasing at an alarming rate in communities throughout the USA, regardless of ethnicity, socioeconomic status, or rurality. For Sarah Larney and Wayne Hall, writing an accompanying Comment, a sustained reduction in the unconscionable toll produced by these diseases of despair will require policies to address the structural drivers of social inequality and hopelessness. The State of Mental Health in America 2019 report, from Mental Health America, provides a snapshot of the mental health status among youth and adults by states, together with trends since the release of the first report 4 years ago. In particular, adult suicidal ideation and major depressive episodes in youth have increased. About 4% of adults reported serious thoughts of suicide—an estimated 10 million adults. Worryingly, about 13% of youth (aged 12–17 years) reported having at least one major depressive episode in the past year; this prevalence varied from 9·9 % in the District of Columbia to 15·9% in Idaho. The latest America's Health Rankings report's findings, from the United Health Foundation, echo these mental health challenges affecting the USA: the number of deaths due to intentional self-harm per 100 000 deaths increased 16% since 2012. More Americans are also reporting poor mental health, with frequent mental distress now affecting nearly one in eight adults, according to the report. When looking at the country's ability to address these issues, the report finds that mental health providers increased 8% and primary care physicians increased 5% nationwide, over the past year. Despite these increases at a national level, geographical variation continues to persist, warn the authors of the report. The proportion of mental health providers is more than six times greater in Massachusetts than in Alabama, the state with the lowest concentration of mental health providers—further worsening inequity. Similar disparities are observed on the whole continent. Too often there can be an imbalance between disease burden and health system response, as Daniel Vigo and colleagues' study, published in this issue, shows. In their study, they estimate the disease burden attributable to mental disorders, neurological disorders, substance use disorders, and self-harm, in the 35 countries in the WHO Region of the Americas. This burden constitutes 19% of total disability-adjusted life-years, ranging from 9% in Haiti to 23% in Canada. They also looked at government health spending on mental health and developed a metric to assess the disparity between disease burden and budget for mental health; they describe an imbalance in the ratio between disease burden and efficiently allocated spending, ranging from 3:1 in Canada and the USA to 435:1 in Haiti, with a median of 32:1 for the Americas. These findings certainly strengthen the case for increased investments in mental health services in the Americas. Instead of countries focusing to constructing costly barriers unlikely to solve migrations challenges, governments might consider simply improving the health of their population—in the spirit of the Plan of Action on Mental Health 2015–2020 adopted by the Pan American Health Organization and its member states. The Americas deserve a more robust response to protect and strengthen the mental health of their all-too vulnerable populations.