Overview of Mental Health Worldwide Pamela Smith, MD Fall

1) General Facts Regarding Mental Health Worldwide 2) Mental health resources available worldwide (WHO/Mental Health Atlas 2011 Analysis) 2

MENTAL HEALTH: A “state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO) 3

Global Mental Health: Refers to the international perspective on varied aspects of mental health; area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide (Koplan et al, 2009). 4

Fact 1: Mental and substance use disorders are significantly prevalent & the leading cause of disability worldwide  450 million people worldwide have some type of mental illness  Neuropsychiatric disorders contribute to approximately 13% of the global burden of disease  About 23% of all years lost because of disability is caused by mental and substance use disorders. 5

Fact 2: Stigma and discrimination against patients and families prevent people from seeking mental health care  Misunderstanding and stigma surrounding mental ill health are widespread.  Despite the existence of effective treatments for mental disorders, there is a belief that they are untreatable or that people with mental disorders are difficult, not intelligent, or incapable of making decisions.  This stigma can lead to abuse, rejection and isolation and exclude people from health care or support. Within the health system, people are often treated in institutions which resemble human warehouses rather than places of healing. 6

Fact 3: Around 20% of the world's children and adolescents have mental disorders or problems  About half of mental disorders begin before the age of 14.  Similar types of disorders are being reported across cultures.  Neuropsychiatric disorders are among the leading causes of worldwide disability in young people. Yet, regions of the world with the highest percentage of population under the age of 19 have the poorest level of mental health resources.  Most low- and middle-income countries have only one child psychiatrist for every 1 to 4 million people. 7

Fact 4: About people commit suicide every year  Over people die due to suicide every year and suicide is the second leading cause of death in year-olds.  There are indications that for each adult who died of suicide there may have been more than 20 others attempting suicide.  75% of suicides occur in low- and middle-income countries.  Mental disorders and harmful use of alcohol contribute to many suicides around the world.  Early identification and effective management are key to ensuring that people receive the care they need. 8

Fact 5: Mental disorders are important risk factors for other diseases, as well as unintentional and intentional injury  Mental disorders increase the risk of getting ill from other diseases such as HIV, cardiovascular disease, diabetes, and vice- versa. 9

Fact 6: War and disasters have a large impact on mental health and psychosocial well-being  Rates of mental disorder tend to double after emergencies. 10

World Health Organization (WHO) 2011 Report (Mental Health Atlas 2011):  Assessment of mental health resources for 184 of 196 (WHO) member states (representing 95% of WHO member states and 98% of the world’s population)  1 st report published in 2001; 2 nd in 2005  Contributors include WHO representatives & staff in country offices, MOH officials in member states, MH professionals worldwide expert in area of global MH 11

Geographic Regions (pg 76):  Africa (AFR)  Americas (AMR)  Eastern Mediterranean (EMR)  Europe (EUR)  South/South-East Asia (SEAR)  Western Pacific (WPR) 12

Income Levels (pg 76)  High (gross national per capita income of US$ 12, 276 or more)  Upper-Middle (US$ 12,275 – $3,976)  Lower-Middle (US$ $1006)  Low (US$ 1005 or less) 13

Indicators of Global Mental Health Resources (WHO, 2011) 1) Governance 2) Financing 3) Mental health care delivery of services 4) Human resources 5) Medicines for mental & behavioral disorders 6) Information systems. 14

1) Governance a) mental health policy b) mental health plan c) mental health legislation 15

1) Governance Mental Health Policy: The official statement of a government conveying an organized set of values, principles, objectives and areas for action to improve the mental health of a population.  60% of countries report having a mental health policy  Mental health policies tend to exist in high income countries (77.1%) compared to low income countries (48.7%). 16

1) Governance Mental Health Plan: scheme realizing the objectives of mental health policy  71% of countries reported having a mental health plan.  Wealthier countries had a tendency to have plans compared to countries with low income. 17

1) Governance Mental Health Legislation: Legal statutes to ensure good practice standards (i.e laws governing access to & quality of care, consent to treatment, admission/treatment w/i hospitals, etc..)  Laws aid in legally reinforcing MH policies & plans  59% of countries report having mental health legislation  Higher (i.e. high and upper-middle) income countries tended to have legislation present compared to lower (i.e. lower-middle and low) income countries. 18

2) Financing  Median mental health expenditures per capita are US$ 1.63 with large variation among income groups, ranging from US$ 0.20 in low income countries to US$ in high income countries.  Sixty-seven percent (67%) of financial resources worldwide are directed toward mental hospitals /institutions (as opposed to community-based facilities) 19

3) Mental Care Delivery of Services a) Primary health care (PHC) clinicians b) Mental health facilities (outpatient, day treatment, general hospital psychiatric ward, community residential, and mental hospital facilities) c) Other aspects of service (length of mental hospital stay, follow up care, psychosocial interventions, and distribution of beds across facilities). 20

 Higher income countries typically have more facilities and higher admission / utilization rates.  A significant majority (77%) of individuals admitted to mental hospitals remain there less than one year. However, this also implies that almost a quarter of people admitted to mental hospitals remain there longer than a year after admission. 21

4) Human Resources  Worldwide, nurses represent the most prevalent health professional group working in the mental health sector (5.8 per 100,000 population).  Greater rates of human resources are observed in higher income countries.  User and family associations are present in 64% and 62% of countries, respectively.  Both user & family associations are more prevalent in higher income countries 22

5) Medicines for mental & behavioral disorders  Worldwide, the median expenditure per person per year on medicines for mental and behavioral disorders - approx $7 ($6.81) USD.  The actual expenditure is likely to be lower, however, as fewer than 30% of countries involved in the survey reported data, with those responding being disproportionately from high income countries 23

6) Information systems  Majority of countries collect mental health care data for individuals receiving treatment from mental hospitals, general medical hospitals, day treatment & outpatient clinics.  Less data tends to be collected from primary care and community residential facilities. 24

SUMMARY  Growing burden of neuropsychiatric disease  Mental health resources remain insufficient  The burden of disease is much greater in low income countries compared to high income countries.  EMR & EUR consistently ranked high; AFR low regarding elements of MH resources  Number of beds in mental hospitals is reduced in the majority of countries (may indicate a shift from institutional care to community-based care). 25