ONLINE POST, commissioned | AMP Student 2016;1
During the last twenty years public mental health has learned some fundamental lessons.
1. Mental disorders are much more common among the poor and they, in turn, increase poverty. The stresses imposed by absolute poverty are powerful determinants of mental disorders like depression and substance abuse. Refugees or displaced persons suffer from a broad range of mental disorders. Children not receiving enough iodized salt develop mental retardation. People exposed to major economic transitions are at risk for alcohol, substance use and suicide. One of the most consistent predictors of mental disorders in low income countries is lack of education. In addition, mental and behavioural factors and disorders like depression are important for adherence and compliance to treatment of HIV/AIDS, Tuberculosis, Malaria and other diseases. Finally, mental health care for depression and substance use disorders is important for decreasing the morbidity and mortality among mothers as well as to prevent short term and long term adverse effects on neonates and children. All these facts clearly show that Mental Health should become part of global development and the public health agenda.
2. In spite of the availability of cost-effective treatment for most of those disorders, a huge gap still exists between implementation and needs worldwide. WHO-Atlas figures show that the majority of low and middle income countries have less than one psychiatrist and one psychiatric nurse per 100 000 population. The majority of low and lower middle countries allocates less than 1 % of their health budget to mental health. The treatment gap is shocking and in some countries may reach 85% untreated cases. To address this gap, it is vital that innovative mental health policies and legislation be designed and become an integral part of health systems. Promoting mental health, preventing mental disorders, mainstreaming cost-effective interventions in primary health care and engaging with local communities will be key components of these innovative policies.
3. Ten major barriers prevent the improvement of mental health services and the implementation of mental health knowledge, and corresponding challenges to overcome these barriers must be identified:
- Social stigma;
- People with mental disorders are currently not a sufficiently powerful lobby;
- Incorrect belief that care is not cost-effective;
- Vested interests of mental health professionals and workers in continuity of large hospitals;
- Need for transitional funding to shift to community-based services;
- Primary care workers already overburdened;
- Lack of incentives to work in rural areas;
- Professional establishment opposes expanded role for non-specialists in mental health workforce;
- Those who rise to leadership positions often only trained in clinical management;
- Leaders overburdened by clinical and management responsibilities and private practices.
4. Governments should make a more determined effort to put mental health in their agenda and mental health professionals, namely psychiatrists, should be more pro-change than anti-change.
There is no doubt, the most urgent and needed change is today the shift from hospital to community based care: in modern times is unacceptable that psychiatric care would be still provided in psychiatric hospitals instead than being offered in community settings with the support of beds for acute cases in general hospitals. However, shifting mental health care from hospitals to the community is often seen by some psychiatrists as a threat to their own identity and role; psychiatrists should be more engaged in promoting the respect of human rights in psychiatric facilities, the decentralization of human and financial resources to promote community mental health care and the empowerment of service users.
In conclusion, global mental health will have evolved and shifted to a new era, when the status of mental health within public health has been enhanced, resources allocated to mental health are soaring, and the allocated resources are used more effectively to strengthen service delivery and community based services in particular.