No global health without mental healthLondon School of Hygiene & Tropical Medicine https://lshtm.ac.uk/themes/custom/lshtm/images/lshtm-logo-black.png Wednesday 10 October 2018
On World Mental Health Day, the new report of the Lancet Commission on Global Mental Health and Sustainable Development offers a timely and fresh perspective on global mental health in the context of the 2030 Agenda for Sustainable Development. While the adoption of mental health and substance use targets and indicators in the Sustainable Development Goals (SDGs) reflects significant progress, the Commission underscores the need to transition from commitment to action.
This call to action, delivered to an audience of the world’s political leaders at the Global Ministerial Mental Health Summit in London, is important because mental health matters in its own right. But mental health is also particularly relevant to those of us working in global health and development, for many other reasons; for example:
The right to the highest attainable standard of physical and mental health is universal. Yet the Commission observes that there has been a global failure not only to address gaps in mental health care, but also to promote mental health, to prevent mental illness, and to protect the rights of people living with mental illness. As stated by the United Nations Special Rapporteur on Health, “Forgotten issues beget forgotten people.” Improving mental health at the population level is a human rights imperative, and we must ensure that the welfare of people in vulnerable situations is at the centre of these efforts.
The SDGs are not attainable without global action on mental health. The Sustainable Development Agenda is fundamentally about empowerment and inclusion, yet people living with mental illness are often excluded from development interventions, and mental health is rarely taken into consideration in development planning. The reciprocal relationship between social inequality and mental illness is well documented; action on mental health translates into progress on global health and development, and vice versa.
Mental health matters for global prosperity. Every year, more than 12 billion working days are lost due to mental illness and estimates suggest that mental illness will cost the global economy US$16 trillion in lost economic output in the years 2010-2030. These costs are not evenly distributed. Low- and middle-income countries (LMICs) will lose US$7 trillion, feeding what many have called a “vicious cycle” between poverty and mental illness: people living in poverty are more likely to develop mental illness, and people living with mental illness are more likely to fall into poverty.
The impact of mental health on global health is substantial. Although we agree with the Commission’s reframing of mental health as a holistic issue relevant across all sectors of development, we are naturally drawn to the public health perspective on mental health. New calculations suggest that mental illness could account for 13.0% of Disability-Adjusted Life Years (DALYs) lost, making it second only to cardiovascular and circulatory diseases (13.5% DALYs) as a leading cause of the global burden of disease. At the same time, mental health affects the risk factors, detection, treatment and outcomes of many physical illnesses. For example, as highlighted in a recent Lancet Commission, there is a strong and multifaceted relationship between mental health and HIV that starts with risky behaviours associated with mental illness (such as substance use), and ends with poorer adherence to, retention in, and outcomes of care for people living with both HIV and mental illness.
How do we respond to this important call to action?
Although the Commission does pull together compelling evidence from recent research, the argument for action is not new. Many of these arguments were introduced in the first two the Lancet Commissions on global mental health in 2007 and 2011. What is new is the clarity of vision and sense of urgency behind the agenda that the Commission outlines, with the clock starting on the Sustainable Development Goals and less than two years left to meet the objectives of the 2013-2020 Mental Health Action Plan. As global health professionals, we took away three key messages from among the many excellent recommendations of the report:
First, more investment is urgently needed. Recent estimates suggest mental health is allocated just 0.4% of overseas development assistance for health (US$132 million per annum). This is unacceptable. We know, for example, that with effective resource allocation, just US$2 per capita could extend care to nearly half of all people living with mental illness in LMICs. Better investment should be coupled with better coordination, to avoid unnecessary duplication of efforts and leave no one behind.
Second, existing solutions must be implemented. For over a decade, the focus in global mental health has been on testing innovative approaches to mental health care in low-resource settings. For example, the Centre for Global Mental Health has helped to shape a global research agenda on task sharing to overcome the shortage of 1.18 million mental health workers in LMICs. The Mental Health Innovation Network has compiled a repository of these and at least 100 other innovations from around the world. Yet very few have been taken to scale. We welcome the Commission’s call for increased funding for research and innovation to harness new opportunities, provided that this investment translates into impact and addresses the needs of people in the most vulnerable situations.
Third, we must work together. A co-ordinated, multisector response is critical. We echo the Commission’s call for mental health services to be integrated into the wider response to other global health and development priorities. We all have a role to play, particularly when it comes to bridging what the Commission calls the “prevention gap”—not only in terms of improving the resilience of individuals and communities, but also in terms of building more resilient systems. Recent experience from Sierra Leone, for example, has shown how crucial mental health systems strengthening is to disaster preparedness. Early efforts to decentralise mental health care just prior to the 2014-2015 West African Ebola outbreak meant thousands of people affected had access to services in a time of extraordinary need.
The report of the Lancet Commission on global mental health and sustainable development provides critical insight into how the global mental health agenda should evolve in response to the SDGs. It is time for the global health and development communities to afford global mental health the attention and priority it deserves. Now, it is up to us to act.
There cannot be any complacency as to the need for global action.
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