Global Mental Health in the Twenty-first Century

Overview

Global health has become an area of growing interest and concern over the past several years. To quote former Director General of the World Health Organization (WHO), Dr. Gro Brundtland, “Not only how people are dying but how they are living becomes a key ingredient in any international health planning.” Moreover, outgoing US Surgeon General David Satcher wrote in 2001 that the time for global mental health had surely arrived. One reason for this new focus was the development of an important research measure called the disability adjusted life years (DALYs) measure. The DALYs measure refers to the sum of years of life lost because of premature death in the population versus the years of life lost because of disability for incident cases of the health condition in question. As a health measurement, it extends the concept of potential years of life lost due to premature death to include equivalent years of healthy life lost due to disability. The DALYs measure becomes an overall global burden of disease single unit of measure that can be applied throughout the world.

In addition to the 13% global health burden of disease accounted for by mental illnesses, there are hidden and undefined burdens to consider. The “hidden burden” is reflected in social consequences that lead to unemployment, stigmatization, and human rights violations and not just in pathological findings. There is also the concept of “undefined burden,” which encompasses the negative impact that social and economic effects have on the families, friends, and communities of those who suffer from mental disorders. The potential casualties of mental illness related to disabilities include so-called social capital and community development.

In this chapter we will look at why mental illness is costly worldwide (e.g., it is prevalent) and provide an in-depth look at one part of the developing world, Ethiopia. Attempts to provide primary care mental health services in the developing world will be examined, along with the need for global mental health research. Then, we will summarize the WHO Mental Health Global Action Program, which attempts to respond to the world's needs in this area. Finally, we will describe new efforts aimed at reducing the global burden of disease secondary to mental illnesses.

The Cost of Mental Illness

Mental illness confers extensive disability not only in wealthy countries but also in low- and middle-income countries. In addition, recognition of mental illness appears to be on the rise throughout the world. In the WHO's 2005 report, globally, 31.7% of all years lived with disability were due to neuropsychiatric conditions. In 2004, 4.3% of all DALYs lost were due to unipolar depressive disorders. In high-income countries, Alzheimer's and other dementias were the fourth leading cause of burden of disease in 2004. It is predicted that by 2030, unipolar depressive disorders will become the number one leading cause of burden of disease, with cardiovascular diseases rising to the second leading cause of burden of disease ( Table 94-1 ).

Mental illness has increased in importance on the world public health scene for several reasons: an increased life expectancy has led to an increase in the prevalence of dementias; societal turmoil has resulted in frayed family and social bonds and to less social support; civil wars and international strife have created more refugees and cases with post-traumatic stress disorder (PTSD); and societal shifts toward technology and commercialization may have contributed to alienation and depression. Taken together, these factors can add up to a hostile environment for mental health.

The Prevalence of Mental Disorders

In 1990, a compilation of the Diagnostic Interview Schedule adjusted for both the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) nosologies, and diagnostic criteria called the Composite International Diagnostic Interview (CIDI) was designed. Later, in 1998, the International Consortium in Psychiatric Epidemiology was formed by the WHO to carry out cross-national comparative studies of the prevalence and correlates of mental diseases; it proceeded to use the CIDI throughout the world (in seven regions in North America, Latin America, and Europe) ( Table 94-2 ). Early onset of mental disorders is common, as is chronicity. This was particularly true for anxiety disorders; the median ages of onset for anxiety disorders was 15 years, while for mood disorders it was 26 years, and for substance use disorders it was 21 years. Socioeconomic measures (such as low income, little education, unemployment, and being unmarried) were all positively associated with having a mental disorder.

The International Consortium concluded that mental disorders are among the most burdensome of all disease classes. This is because of their high prevalence, chronicity, early age of onset, and resultant serious impairment. Prevention, outreach, and early intervention for people with mental disorders were recommended. The consortium called for quality assurance programs to look into the problem of inadequate treatment of mental disorders. One of these problem areas (PTSD in post-conflict societies) was investigated by de Jong and associates in 2001. PTSD was found in 37.4% of those in Algeria, 28.4% of those in Cambodia, 17.8% of those in Gaza, and 15.8% of those in Ethiopia.

Ethiopia and Mental Health in the Developing World: an Example of Global Mental Health

Ethiopia is an African country the size of Texas with a population of 75 million. Unfortunately, it has experienced a bevy of disasters (including drought, famine, human immunodeficiency virus [HIV] infection, tuberculosis, malaria, internal displacement [due to civil and border wars], abject poverty, and other stressors and traumas). Nonetheless, there are only 41 psychiatrists in the country and only one psychiatric hospital (Amanuel Hospital) with 268 beds. Additionally, there are 10 government-established outpatient psychiatric clinics available throughout the country. A new general hospital is currently being built around the Kotebe area of Addis Ababa, which will contain a number of psychiatric beds. However, these services are still woefully inadequate for the large population, and largely inaccessible to the Ethiopian population living outside of the capital city. In 2003, Addis Ababa University created a psychiatry residency training program which graduated its first class in 2006, significantly increasing the number of psychiatrists in the country. There are now 30 new Ethiopian-trained psychiatrists while the residency program continues to grow and develop. In addition to the psychiatrists now available in Ethiopia, there are 461 practicing psychiatric nurses.

In the rural Butajira region, Awas and colleagues found that the prevalence of mental distress was 17.4%. Mental distress is highest in women, in the elderly, in the illiterate, in those with low incomes, in those who abuse alcohol, and in those who are widowed or divorced. Problem drinking was found in 3.7% and use of khat (cathinone, an amphetamine-like compound found in a plant and then chewed) was found in 50%.

Using the CIDI, major mental disorders in Ethiopia have a lifetime prevalence of 31.8%. Of these, anxiety is found in 75.7%, dissociative disorders in 6.3%, mood disorders in 6.2%, somatoform disorders in 5.9%, and schizophrenia in 1.8%.

In the urban Addis Ababa region, Kebede and colleagues reported in 1999 that mental distress was prevalent (11.7%) in their sample of 10,203 individuals. Mental distress was most closely associated with women, the elderly, the uneducated, the unemployed, and those who had a small family. An under-reporting of mental illness in urban areas of Ethiopia may have occurred secondary to the impact of stigma, as well as governmental pressures applied at the time of the surveys. Tadesse and associates, in 1999, found that the prevalence of child and adolescent disorders in the Ambo district in Ethiopia was 17.7%; this is lower than the prevalence (21%) in the US.

By way of comparison, in the United States Epidemiological Catchment Area study, the lifetime prevalence of major mental disorders was 29%–38%. Anxiety and somatoform disorders ranged from 10.4% to 25%, whereas MDD was in the range of 3.7%–6.7%.

No discussion of mental health in Ethiopia would be complete without reference to the acquired immunodeficiency syndrome (AIDS) epidemic; as of 2009, there were 1,116,216 people live with HIV/AIDS in the country. This translates into the third largest population burden in the world. The overall adult prevalence of HIV infection in Addis is between 10% and 23%. No one has carried out a study of the psychiatric co-morbidity associated with this epidemic in Ethiopia, but the prevalence of depression alone in other cohorts of HIV-infected patients ranges from 11% to 35%.

The WHO's 2005 Atlas of Mental Health Resources noted that there was no mental health policy, no national mental health program, no community care in mental health, no substance abuse policy, and no applicable mental health law in Ethiopia. Another obvious barrier was the low number of psychiatrists and psychiatric nurses, and lack of psychologists or social workers. However, since 2005 drastic changes and improvements have been made in the mental health system in Ethiopia. As stated previously, the number of mental health professionals has increased due to the development of various training psychiatry programs in the past few years. Additionally, according to the National Mental Health Strategy of Ethiopia, the neurology program at Addis Ababa University has graduated 11 new neurologists.

Primary Care Mental Health Services in the Developing World

In 1974, the WHO Alma-Ata Conference established several priorities in mental health (i.e., chronic mental handicaps [including mental retardation], dementia, addictions, epilepsy, and “functional” psychoses). Remarkably, every year, up to 30% of the world's population has some form of mental disorder, and at least two-thirds of those people will not receive adequate treatment. In 2001, the WHO issued the World Health Report, which focused on mental health. It suggested solutions to the problems of world mental health: providing treatment in primary care; making psychotropic medications available; giving care in the community; educating the public; involving communities, families, and consumers; establishing national policies and legislation; developing human resources; linking with other sectors; monitoring community mental health; and supporting more research efforts.

Based on a review of mental health intervention studies, it was believed that demonstration projects with rigorous evaluation and outcomes methodologies, and appropriate mental health service models should be prioritized.

Psychiatrists can advance the cause of mental health around the world by contributing to the education of non-psychiatrists (i.e., primary care physicians, nurses, health officers, and care­givers [who are most likely to provide mental health care in the developing world]). Through education, consultation, and supervision of patient care, the scarce number of psychiatrists available can have their impact felt. A number of evidence-based studies have demonstrated that professionals in the primary health system, with the proper training, assistance and supervision, can identify, diagnose and treat those suffering from mental disorders. For this reason, practitioners of psychosomatic medicine, who commonly teach about psychiatric diagnoses and management to non-psychiatrists and provide clinical consultations, are ideal ambassadors for global psychiatry.

The 2007 Lancet series identified key barriers to the advancement of global mental health goals, accompanied by various strategies to help overcome these barriers. Among the most frequently mentioned strategies was the integration of mental health care into general health care. Treating psychiatric disorders in primary care settings is a proven and critical way to increase both access to, and quality of, comprehensive health care, as physical and mental distress are highly related. Psychiatric and neurological illnesses are frequently co-morbid with chronic physical illnesses, such as heart disease and stroke, diabetes, chronic respiratory disease, cancer, and HIV/AIDS. In the US, recent statistics from the US National Comorbidity Survey showed that 68% of individuals diagnosed with mental health disorders developed at least one physical disorder. The failure to treat co-morbid mental health issues both increases overall health care costs, while simultaneously impeding their efficacy. Furthermore, because of the stigmatization of mental illness in many cultures, those affected tend to describe mental distress somatically, and, therefore, if treatment is sought, it is often within primary care.

The 2007 Lancet series further described guidelines for innovative models that would successfully integrate mental health and primary care systems. These guidelines call for low-cost human resources, a specific mental health budget within primary health care, and the appointment and training of mental health professionals to oversee and support the primary health care staff. Since 2007, there has been some progress in developing countries towards the integration of mental health and primary care systems. Political leaders and decision-makers in some countries have increased the funding for mental health in recent years. Additionally, there has been some movement towards health care decentralization and the reorganization of mental health care into primary health care by providing primary care doctors with mental health training in conjunction with improving the availability and accessibility of psychotropic medications.

The Ethiopian Public Health Training Initiative

In 1997, the Ethiopian government, with the help of the Carter Center, established the Ethiopian Public Health Training Initiative (EPHTI), which emerged from discussion between former US President Jimmy Carter and then Ethiopian Prime Minister Meles Zenawi. The initiative had two major objectives: to strengthen the teaching capacities of the public health colleges in Ethiopia through education of their teaching staff and to collaborate with Ethiopians to develop materials specifically created to meet the learning needs of health center personnel.

Modules (e.g., on malaria, diarrhea, dehydration, pneumonia, measles, HIV infection, AIDS, syphilis, tuberculosis, trachoma, ascariasis, malnutrition, intestinal roundworms, breastfeeding, immunization, acute febrile illnesses, anemia, and family planning) have been produced to educate public health care workers, and in May 2002, the Ethiopian Council approved a program to train health care workers about mental health in Ethiopia.

This training module is used in public health colleges in Ethiopia. Interactions with primary care take place at the unit level since patients come to these health units seeking general care. Psychiatric nurses and health care workers are charged with educating primary care physicians, nurses, and health care workers about mental health. Today, more than 26,000 EPHTI-trained health care professionals serve 90% of Ethiopia's population.

The Ethiopian story is important for international psychiatry. Providing good mental services in developing countries requires a bimodal approach like that adopted by Ethiopia. Establishing an in-country psychiatry residency is also an important step. It offers a modicum of protection against the “brain drain” that often occurs when doctors train overseas, and it provides much-needed manpower and professional expertise. This model could be replicated elsewhere in the developing world. For example, in 2007 the EPHTI Replication Conference gave ministries, leaders, and workers of mental health from 10 African governments the opportunity to learn about the strategies utilized in the EPHTI model, and to discuss how these strategies could help improve the shortages of mental health professionals in their own countries. Since there will never be enough psychiatrists in countries such as Ethiopia, it is important to train other mental health professionals. In late 2010, as part of the original agreement, the Carter Center-assisted EPHTI was officially moved to Ethiopia's Federal Ministries of Health and Education.

Child and Adolescent Psychiatry

Knowledge of child and adolescent mental health problems throughout the world will be an important educational goal in the twenty-first century. Although there is limited research on child and adolescent mental health, it is known that about 10%–20% of children worldwide are affected by mental health problems. Appreciating the stresses on children and adolescents in areas engulfed by conflict and learning about the nature of their responses provides the opportunity to learn more about resiliency and about what must be done to develop more effective programs. Even in developed countries the likelihood that a psychiatrist will see a child, adolescent, or family from a different culture has significantly increased (as a result of increased immigration and migration). Cross-cultural sensitivity is crucial to recognize differences in presentation, compliance, and acceptable interventions.

Overcoming a lack of trained child and adolescent psychiatrists in developing countries requires innovative approaches for teaching and providing clinical care. Packages and manuals to guide training programs for managing childhood mental disorders are now found in low- and middle-income countries. However, extensive future research needs to be conducted in the low- and middle-income countries as the vast majority (90%) of children and adolescents of the world live in these countries. Furthermore, it is essential to integrate and form partnerships between child and adolescent mental health care and agencies outside of the health sector, such as the criminal justice, education, and social care systems.

Although some interventions have been developed and even successfully attempted in a variety of high-, middle-, and low-income countries, there are still many gaps and limitations imbedded within these particular interventions. Though child and adolescent-specific interventions are needed, it must also be recognized that maternal mental health is inextricable from child and adolescent mental health, as well as from cognitive and motor development. The effects of maternal mental disorders on child development have been studied less extensively in low- and middle-income countries than in developed countries where for example post-partum depression is known to affect 10% to 15% of women and is linked to adverse consequences in the child's development. Though less studied in low- and middle-income countries, the prevalence of maternal depression seems to be somewhat higher in these countries, which implies an even more significant impact on child and adolescent mental health. Child and adolescent psychiatry is an important area of specialization; however, effective and comprehensive child and adolescent care must also include the mental health of the entire family unit. Much can be learned by developed countries from the way in which less developed countries have supported families and individuals with mental disorders.

Psychiatry in Areas of Conflict

The psychological damage caused by violence, terror, torture, and rape during war and violent conflicts has not been adequately addressed or been made a priority in the field of psychiatric medicine. Not surprisingly, substantial research now demonstrates that mental health is a serious problem among post-conflict populations. More evidence-based research is needed to maximize the benefits of interventions (e.g., psychiatric programs and activities) for societies affected by disruptive conflicts.

Individuals (including refugees, asylum-seekers, internally-displaced persons [IDPs], and illegal immigrants) directly affected by war, civil conflict, and terrorism struggle to piece their lives together after enduring unimaginable cruelty and violence. The cruel and violent acts witnessed and experienced by these individuals come in many forms; one of the most common of these is torture. In its most recent annual report, Amnesty International concluded that in 112 countries, comprising 70% of the world, citizens are tortured. The report also states that, although there has been many successful human rights movements in the last decade, there is still “distortion of sovereignty,” meaning millions of people continue to be left behind and remain in danger. The following sections describe and define torture (as elaborated by major existing international conventions), elucidate the major physical and psychiatric effects of torture (with an emphasis on the mental health consequences of the torture experience), and present a scientifically-based and culturally-valid model for the identification and treatment of torture survivors in the health care sector.

Definitions of Torture

Though the word “torture” is commonly used without restraint in everyday language, its use should be clearly differentiated from words for inhumane and degrading actions that fail to match the true definition of “torture.” One of the most frequently cited definitions of torture is the World Medical Association's (WMA's) 1975 Declaration of Tokyo : “The deliberate, systematic, or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.”

The other frequently-cited definition comes from the 1984 United Nations Convention Against Torture that expands on this definition, distinguishing the legal and political components typically associated with torture : “Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.”

These internationally-accepted definitions of torture share two basic elements: individuals are placed in captivity and subjected to extreme mental and physical suffering, and the capturers have a political goal or agenda.

Health care providers (including primary care practitioners and mental health specialists) often do not have these international covenants in mind. However, remaining cognizant of the two central features of torture can help identify those who may have been tortured and who may not be asking for medical and psychiatric care related to torture. The majority of afflicted individuals are aware that cruel and inhumane acts have been perpetrated against them, but they cannot contextualize these actions as torture with regard to the international covenants. At times, health care practitioners are the first civilian authorities to tell the patient what is obvious: that is, that he or she has been tortured.