Mental Health

[See also page on Mental Health Services and Programmes]

Mental illness is a massive problem world wide.  It is a major burden (for individuals, families and communities) even in countries with socially enlightened policies and adequate service systems. Relatively speaking it is a much heavier burden in many L&MICs where service systems are weaker and community resources are more stretched.  

The institutional and professional separation of medical psychiatry and disabilty services is a risk in terms of policy making and program development for people living with mental illness.  Such people can sometimes benefit from medical care and pharmaceutical therapies but often their challenges need a much broader range of resources. In many respects the principles of programs and services for people living with mental illness have more in common with disability services than with medical treatment of diseases.  

The widely used distinction between serious mental illness and (what is by exclusion) 'non-serious' mental illness is a further risk to policy making. 'Serious mental illness' tends to be code for conditions where there is a significant risk of harm to self or others and where the State is under social pressure to institute various protections. By exclusion people and diagnoses which are not included in this net are at risk of being neglected in policy making, program development and service delivery.  That is, until their non-serious mental illness is complicated by alcoholism or drug misuse or gambling or other risks. In view of the huge burden of disease attributed to mental illness it is likely that even if 'non-serious' mental illness only marginally reduces people's social functioning (in family, workplace and society) it is likely to have a huge impact in aggregate. 

Decent comprehensive primary health care is fundamental for service programs for people and families living with mental illness.  Non-specialist front-line PHC practitioners have a central role to play in access to treatment, delivery of treatment, continuity of care, rehabilitation, anti-stigma campaigning, family support and addressing the social determinants of mental illness and emotional distress. In this work back-up from more specialised mental health and rehabilitation practitioners in the form of consultation, community care, crisis care and community based residential services. It is essential that the needs of mental health clients are included in any policy work on health systems strengthening and primary health care.  It is equally important that requirements, with respect to services for people with mental illness, are not addressed in  isolation from the general issues of PHC and HSS. 

Propensity for and precipitation into mental illness reflects the interplay of genes and environment although the relative roles of these vary across different conditions and different cases. However, even where genes play a major role as in schizophrenia and many cases of depression, the social environment can make a huge difference in terms of living with the illness.  Unfortunately the medicalisation and individualisation of mental illness can present barriers to clear thinking about social approaches to prevention and amelioration.  

A huge range of social experiences and environments can damage people's emotional resilience and coping skills and which may be constructed as 'causing' and exacerbating mental illness including depression and anxiety. These include growing up in dysfunctional families (including family violence); growing up in oppressed and fragmented communities; the experience of war, displacement and migration; poverty and oppression; chronic hunger and under nutrition; and various forms of alienation. These kinds of factors interplay in complex ways. For example, poverty and oppression can lead to alcohol use and family violence with devastating impacts on the identity, security and confidence of young children. For reasons which are more political than scientific the recent report of the WHO Secretariat to the EB (EB130/9) acknowledges in some detail the mental health consequences of humanitarian emergencies but fails to mention war, refugees, indigenous dispossession and a range of other equally significant issues.  

Perhaps the most dramatic absence from EB130/9 is any reference to the work of the WHO Commission on the Social Determinants of Health. If the experience of inequality and powerlessness contributes so clearly to other non-communicable diseases it seems more than likely that it contributes to mental illness. But no reference to the report of the Commission or to social determinants at all. 

The minscule budget provision for mental health in WHO's program budget (in relation to the global burden of disease) reflects the lack of enthusiasm on the part of the development banks, disease-centred foundations, private philanthropies and nation-state donors (perhaps it is not in the 'national interest') to 'buy' WHO programs under the current funding arrangements.   

Policy advocacy from the perspective of people living with mental illness and their families lacks the power of some other disease oriented constituencies.  It lacks the support of large pharmaceutical corporations because most of the high volume pharmaceuticals are now out of patent.

PHM advocacy must acknowledge the importance of mental health, both with respect to health system strengthening (including PHC) and action on the social and behavioural determinants of health. However, advocacy for care and prevention must be firmly located within the wider policy perspectives regarding comprehensive PHC and action on the SDH.  Within this framework PHM should be reaching out to the constituencies with specific concern for the experience of people and families living with mental illness. 

There is a need for the kind of expert guidelines which WHO does so well but it needs to take a broader perspective than is presently evident.