It's a major milestone in the fight to recognize mental health and mental illness as global issues: a comprehensive report from the Lancet Commission on Global Mental Health, three years in the making, released this past week at a London summit with royals Prince William and Kate Middleton, Duchess of Cambridge, in attendance to show their support for the cause.
But it was not a celebratory event. Threaded throughout the 45-page report is a lament that the world is ignoring millions of suffering people.
That neglect is reflected in "pitifully small" levels of financial support from governments and assistance groups for research and patient care, say the 28 mental health researchers, clinicians and advocates from across five continents who authored the report. And there are far-reaching economic as well as psychological consequences, the report notes: Untreated patients are often unable to support themselves, and sometimes their caretakers can't work as well.
The situation is especially dire in low-income countries, where mental health care is often unavailable. Only one in 27 people with depression in developing countries receives adequate treatment, according to the report. Developed countries do a bit better – one in five people with depression get treatment. But overall, wealthier countries have a poor enough record of providing adequate services that the report states that "all countries can be thought of as developing countries in the context of mental health."
It's not as if the extent of the problem was unknown. In the mid-1990s, the first Global Burden of Disease study noted that of the top ten causes of disability worldwide, five were mental illnesses. Mental health researchers had little to offer at the time in terms of proven inexpensive treatments. But researchers since then have demonstrated that diseases such as depression and substance abuse can often be accurately identified and treated by community health workers with talk therapy. With light guidance from a mental health specialist, these community health workers can even help some people with schizophrenia learn to live with their disease.
The report calls for more reliance on community health workers, greater attention to stigma, a broader definition of mental illness to include mental health, a search for ways to create resilience in currently healthy people and the use of technology tools, like cellphones for diagnosis and therapy.
The big problem is money. The Commission notes the availability of funding is "alarmingly low," citing a comparison between how much was spent on other diseases in 2013 and how much was spent on mental illnesses. It found that for every year of healthy life lost because of a mental illness, global health donors provided 85 cents in assistance. But for HIV/AIDS, there was $144 for every year of healthy life lost, and $48 for TB and malaria.
So why the lack of investment?
Psychiatrist Julian Eaton, a commissioner who co-directs the global mental health division of the London School of Hygiene and Tropical Medicine, says at least part of the reason is a slow acceptance of the high incidence of mental illness and of people disabled by it. Cultural sensitivity may also be holding back investment. "In the academic world there has been an ongoing sometimes quite angry debate about whether it's appropriate to export Western ideas about mental ill health to other countries," Eaton says.
Meanwhile, what the commissioners call "multiple transitions" are creating greater need for prevention and treatment programs. Pandemics, wars, poverty, economic and political uncertainties, the increased incidence of natural disasters and the environmental disruptions of climate change are creating enormous psychological stresses that can lead to poor mental health.
Another powerful impediment to financing is stigma. It's on pretty much every commissioner's list. Janice Cooper, who runs the Carter Center's mental health center in Liberia, says it's a problem in both developed and developing countries — and on many levels. "There's ignorance, there's the perception of contagion, there's the notion that in some quarters this is not important," she says.
For commissioner Pamela Collins, who heads the global mental health program at the University of Washington, there's also an informational issue. "Many people believe these are disorders of high-income countries, and they don't think of these as problems for low- and middle-income countries," she says. And she's concerned that people forget that some of these conditions are lethal. Worldwide there are 800,000 deaths a year from suicide, most often a result of depression.
A group of 15 youth leaders from around the world, many of whom have personal experience with mental illness, were recruited by the Commission to carry its messages onto social media and get young people talking about mental health issues. Twenty-five-year-old Grace Gatera is one of the 15 members. The conflict in her native Rwanda left Gatera with PTSD that led to two suicide attempts. Gatera says governments can be blinded by other problems: "It'll be like let's deal with this crisis and deal with the crisis that comes after that and maybe when we get time we'll talk about mental health."
Other commissioners said that politicians don't feel any pressure from people with mental illnesses or their advocates, and there's no strong lobby supporting people with mental illnesses.
Vikram Patel, the co-head of the commission and head of the global mental health program at Harvard University, says it's high time for foundations to jump in. "We know how to promote mental health, we know how to prevent mental health problems and we know how to enable recovery," he says. Help couldn't come soon enough for the commissioners. They predict that between 2010 and 2030, mental illnesses will cost the global economy trillions of dollars in health-care spending as well as in lost wages and productivity.
But the nature of mental illnesses themselves may be scaring foundations away, says Julian Eaton. "People probably quite legitimately think that mental ill health is more complex than infectious diseases or broken bones." With vaccines, one shot costs a set amount, and a person is protected for life. Not so with mental illnesses. "Talking about the big funds, and the Gates Foundation is a classic example, investors want to know how much it costs," he says. While inexpensive treatments have been developed, how long people will need to use them is an open question.
The Gates Foundation (a supporter of NPR and this blog) does not fund mental illness research or care though it does fund studies on the cognitive development of children. In a statement to NPR, global health chief Trevor Mundel says, "There is no question that mental health disorders are a significant cause of death and disability, and more investment is needed." But the foundation focuses on infectious diseases, he notes, "because there is still a huge disparity between the burden of infectious disease in developing countries and wealthy countries, and we believe that our support can play a catalytic role in closing major gaps in global health equity."
With all the reasons given by the commissioners, though, there was some optimism in the room. After all, they had received support for their summit from several international and British government organizations as well as some private ones. Commissioner Julian Eaton was heartened by the increasing number of people willing to talk about mental illness and like pretty much everyone else at the meeting was thrilled when the royals showed up.
"But people are yet to sign the checks," he says.
Joanne Silberner, a former health policy correspondent for NPR, is a freelance journalist living in London.