Database at a Glance: Mental health

The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” While multilateral agencies, governments, and NGOs have worked to address issues of physical and social well-being over the past several years, many continue to overlook the mental well-being of the poor and in the process, neglect what should be a growing concern in many developing countries.

According to 2010 WHO reports, in the past several years, mental illnesses have become the leading cause of DALYs worldwide and now account for nearly 25% of all Years of Life Lived with Disability (YLDs) worldwide. People in low and middle-income countries (LMICs) with mental health conditions, such as schizophrenia, major depressive disorder, drug addictions, and intellectual impairments) don’t suffer only from their mental illnesses. Rather, these mental health conditions also result in a stream of social problems, such as stigmatization and exclusion from society.

With October 10th declared as World Mental Health Day, this month’s Database at a Glance takes a look at programs in the CHMI database that work to address the growing need for mental healthcare worldwide.

Landscape of Mental Health Programs: A Look at the Facts

Government healthcare services and private sector healthcare programs in LMICs often overlook mental healthcare. With significant challenges already existing in providing primary healthcare, providing mental health services is often seen as a low priority by both governments and the international development community. In fact, though mental illnesses are the leading cause of DALYs worldwide, they receive less than 1% of health spending in low-income countries. Allocations toward mental health care are also considerably higher in European countries than they are in Africa or South Asia (WHO Mental Health ATLAS 2011). The underrepresentation of mental health in the global health space is also reflected in the CHMI database. Only 16 programs out of 1,231 programs in the database work exclusively to improve mental health.

Varying Approaches to Mental Healthcare Delivery

A number of programs in the CHMI database employ novel approaches to mental health services delivery. Providing sustainable, affordable mental health care is a significant challenge. Often, programs working in low and middle-income countries must adopt a combination of strategies to not only treat their patients, but also overcome the tremendous stigma associated with mental illnesses.

CHMI has identified three broad approaches taken by programs in the private sector to address the mental health treatment gap:

  1. Counseling Hotlines: Due to the high cost and stigma attached to mental healthcare, Many patients are ashamed to directly seek out treatment. E-Counseling PULIH, Linktam, Teen SMS Helpline to Stop Suicide, and Hotline and SMS Counseling have acknowledged this barrier to care and provide a way to access mental health services that won’t stigmatize their clients. These CHMI-profiled programs are utilizing information and communications technology (ICT). With the increasing prevalence of cellphones and the Internet, these programs now offer free counseling services through emails, texts, live chats, and phone calls. Users from all sectors of society with access to the Internet or a cellphone can discreetly contact these hotlines and receive counseling from mental health counselors at minimal or no cost. These services have greatly increased access to counseling for HIV/AIDS, suicide, mental illnesses, and traumatic events.
  2. Mental Health Training: Changing Perceptions and Treatment of Mental Health Conditions Often, the media’s depiction of mental health disorders and primary care clinician’s misunderstanding of mental health in LMIC’s contributes to added stigma. Two programs in the CHMI Database are working to improve mental healthcare delivery by training media professionals and healthcare providers to better understand mental health conditions. One such innovative program is the PULIH Foundation’s Healing Media Campaign, which trains media companies and journalists to be more aware of mental health conditions by running workshops, distributing educational material, and maintaining an active social networking presence. Health[e]Foundation focuses on primary care physicians and uses three-month training periods to provide health care providers with online courses, training workshops, and certification programs. This information is constantly updated to reflect the latest practices in mental healthcare delivery.
  3. Direct Services
    Of the mental health programs CHMI profiles, most attempt to directly treat mental health conditions by providing services at the primary level. Ten programs in the CHMI database either operate clinics or rehabilitation homes intended to help treat patients with mental illnesses. Theseprograms have taken two different approaches to treating mental health conditions. Some, like Instituto PROVE, work specifically on single issues like PTSD. Others, like Sangath, employ community health workers and operate center-based clinics providing more general therapy and care.

Expanding the Mental Health Space

A look at the CHMI database also reveals that many programs are introducing new strategies that are challenging traditional models of care. Some programs, like The Banyan or Community Based Psychological Recovery, are adopting holistic models of care. This means that patients not only receive counseling, but also vocational training, technical assistance, and access to support groups to better their lives as a whole. Other programs, like BasicNeeds, are steering away from traditional healthcare providers, instead training community health workers to recognize symptoms of mental health conditions in rural areas. Several mental health programs, including Anjali, are also exploring public-private partnerships (PPPs) to better reach poor populations. Anjali operates inside state-run hospitals in West Bengal, India and is thus able to access poor and middle class patients from rural and suburban communities who depend on public care. By forming a PPP, Anjali not only has reached a larger target population, but is also working to make mental health services a regular part of primary healthcare.

Steps Forward

So what remains to be done in promoting better global mental health? And what are practical goals that the global health community can set for itself? Despite the best efforts of the development community to address health, mental health continues to remain largely overlooked. Fortunately, several CHMI-profiled programs that have developed innovative strategies to overcome barriers are starting to offer mental health services. For example, MedicallHome is a healthcare company that provides hotline-based services to over 5 million people in Mexico. Currently, psychological counseling constitutes 1.5% of the total services the company offers. Furthermore, only 16 programs offer exclusive mental health services, but 412 work in primary healthcare. Integrating mental health services into primary healthcare, then, would significantly address the growing disparities in the treatment of mental illnesses.

What's next -- from Dr. Amir Afkhami of GWU

While writing this piece, I had a chance to speak with Dr. Amir Afkhami, a psychiatrist at the George Washington University School of Medicine and Health Sciences and a well-known proponent of global mental health. From 2008-2010, Dr. Afkhami planned and helped implement the State Department-funded Iraq Mental Health Initiative, a program that seeks to rebuild Iraq’s mental health delivery system after several years of conflict. When asked what needs to be done to improve global mental health, Dr. Afkhami stressed the need for better media campaigns to end stigmatization and promote awareness and acceptance of mental health conditions. He stated that many patients and their families often felt embarrassed to even seek treatment because of the high stigma attached to mental illnesses. In addition, he believes that training community health workers can make a dramatic difference in the early diagnosis and treatment of mental illnesses in rural areas. Though Dr. Afkhami is still keenly aware of the underrepresentation of mental health in the global health space and believes mental illnesses are drastically misunderstood, he has seen significant improvements in the coverage and quality of mental healthcare in the past decade. The WHO has also renewed its commitment to mental health through its Comprehensive Action Plan 2013-2020. And with the innovative approaches programs in the CHMI database are adopting, there are only reasons to be optimistic about the future of global mental health.

Further Reading:

  1. WHO Mental Health Atlas 2011
  2. Disease Control Priorities in Developing Countries, Chapters 31 and 32
  3. WHO Comprehensive Mental Health Action Plan 2013-2020
  4. Centre for Global Mental Health