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A Call for Integrating Mental Health into Mainstream Public Health Efforts » Women's Courage

A Call for Integrating Mental Health into Mainstream Public Health Efforts

March 3rd, 2011 by ritam1 Leave a reply »

To: World Federation for Mental Health

From: Rita Martinez, Stanford University

Subject: Integrating Mental Health Services within Broader Health Care Systems in Low and Middle-Income Countries

Date: 3/3/11

“Improvement in mental health services doesn’t require sophisticated and expensive technologies. What is required is increasing the capacity of the primary health care system for delivery of an integrated package of care,” says Dr Ala Alwan, Assistant Director-General for Noncommunicable Diseases and Mental Health at WHO

Efforts focusing on how to better incorporate mental health programs into health care systems have been both recent and challenging. The lack of integration has been most strongly felt in developing countries, where access to mental health services are offered in very limited hospital settings, resulting in an increased number of patients suffering from illnesses going untreated. Addressing this important treatment gap will require increased cross sector collaborations are needed and a strong focus on encouraging dialogues that grapple with the stigma associated with mental illness as well as different cultural beliefs.  This movement will have powerful repercussions for greater public health efforts because mental disorders are known to increase the risk of communicable and non-communicable diseases, as well as contribute to incidences of personal injury.

Mental health is an integral part of one’s overall health outcomes, and without a doubt, there can be no health without mental health. About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, substance abuse, and psychoses (1). This has drawn attention for the critical importance of mental disorders for public health. However, traditional measures for calculating the burden of disease focus on differentiating the contributions of mental and physical disorders to disability and mortality, thereby leading to the entrenched alienation of mental health from mainstream efforts to improve public health that we observe today (1). Because the reality of their interconnectedness has only recently been promoted, efforts to improve the prevention and treatment of people with mental illness have not been as successful as they could be in addressing the treatment gap.

The Global Burden of Disease report reveals that neuropsychiatric conditions account for up to a quarter of all Disability Adjusted Life Years (DALYs) lost, and up to a third of those attributed to chronic diseases (1). The conditions that contribute the most of DALYs lost are unipolar and bipolar affective disorders, substance- use and alcohol-use disorders, schizophrenia, and dementia. Despite new information, mental health remains a low priority as developing countries tend to focus on controlling infectious disease and maternal/child health, and developed countries focus on non-communicable diseases that cause early death like cardiovascular disease and cancer above those that cause years lived with disability. With that in mind, the aim of any strategy to advance mental health needs to focus on integration since if it continues to be regarded as a distinct health domain with separate budgets, the investment in mental health will be perceived to have an unaffordable opportunity cost (1).

The WHO Mental Health Gap Action Programme (mhGAP) has attempted to address the “treatment gap”- the gap between the number of people with disorders and those receiving treatment, (which is as high as 70-80% in many countries) by developing treatment packages for mental disorders that can be implemented on a large scale in low and middle-income countries. Due to limited financial resources, it becomes incumbent for any program to understand the importance of working with community-based primary care facilities when delivering these packages (2). The argument for integrating mental health services within primary care settings revolves around the reduction of associated stigma within the community and also ensuring that doctors are able to address the increasing prevalence of mental health problems.

This makes good economic sense because mental disorders account for the largest percent of DALYs lost globally. What is more, mental disorders can impact children’s learning and the ability of adults to function in families, at work, and society at large. Addressing this issue would also benefit the poorest people, whom are most likely to be suffering from mental disorders as a result of said poverty and/or the illness itself. Poverty is strongly associated with stressors that interact in complex ways, resulting unemployment, violence, social exclusion, and a sense of loss of control- all of which are closely linked to the onset of mental disorders (3). However, acknowledging that half of all countries only have one psychiatrist per 100,000 people, and a third of all countries have no mental health programs at all further supports the need for alternative approach to mental health (4). A great way to assist developing countries is to support the development of an approach that deals with mental illness in a culturally sensitive way and responds to low resources through training informal health workers. Training health workers and traditional healers to treat patients in poor countries and refer severe cases to a hospital psychiatrist may prove to be a more efficient way to treat more people suffering from mental disorders in low-resource settings.

An effective strategy for addressing mental health must focus on the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by them (5). However, this strategy cannot be adequately implemented as a stand-alone medical initiative, but must be integrated within the broader health care system or community health center in order to have the greatest impact among those affected. Because mental health is inextricably linked to one’s overall health, (having significant impact on morbidity and DALYs lost) the World Federation for Mental Health must work to facilitate its integration to mainstream public health efforts. This can only be effectively achieved by training primary care doctors in mental health issues and providing counseling services at all levels. Additionally, integration will also facilitate the removal of stigma associated with mental illness and encourage an open conversation on its effects on society at large. To have lasting effects, efforts should dually focus on advancing the status of mental heath and supporting developing countries to design unique innovative programs. With this approach, I believe we will see the greatest impact on those suffering from mental disorders but also promote a more equitable and socially conscious world.


Rita Martinez

Stanford University, Class of 2012


(1) No Health Without Mental Health-http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2807%2961238-0/abstract

(2) WHO Simplifies Treatment of Mental and Neurological Disorders-http://www.who.int/mediacentre/news/releases/2010/mental_health_20101007/en/index.html

(3) UN Enable-http://www.un.org/disabilities/default.asp?id=1545

(4) Mental Illness and the Developing World- http://www.guardian.co.uk/commentisfree/2010/may/10/mental-illness-developing-world

(5) WHO report: http://un.by/en/who/news/world/2004/04-06-04.html



  1. aherrera says:

    I think this is a nice culmination of the issues that you have been writing on. Mental health has such a tremendous impact on physical health, it is unfortunate that it is overlooked in such a large way in many regions in favor of other diseases with more apparent physical manifestations. It is often difficult to convince donors to fund mental health projects in situations where there are pressing needs in sanitation and infectious disease, however it is such a critical issue in the overall well being of people, women especially, and there is such a large need in lesser developed countries. While a large effort is needed, it is still important to make sure that it is being tailored to the belief systems and customs of individual countries, because especially in dealing with psychological disorders, there are often many culturally specific concepts and issues that are not easily translated to other societies.

  2. vaughanbagley says:

    I have a personal connection to mental health issues as my older brother is a schizophrenic. However, it is not something that I think of very often when I think of health care interventions in developing countries, making your memo very interesting to me. While I undoubtedly agree that mental health and physical health are inextricably connected, it is hard to see, realistically, how mental health interventions can be implemented in countries that cannot even handle the chronic stressers provided by poor sanitation, nutrition, water, and the spread of diseases such as HIV. Costs, being the first issue, are tiny compared to the problems involved in implementation, especially in rural areas. However, while these issues are very difficult to address, I agree that we must start with baby steps and if that means training informal health workers and traditional healers, it must be done.
    A disappearance of the stigma behind mental illness would greatly help diminish other stigmas, progressively allowing individuals in the community to seek help for anything. But again, when there is such a firm divide between public and private life, the confines of someone’s mind can remain imprisoned for a lifetime if they never feel comfortable enough to speak out. And sadly, in communities where it is not acceptable to discuss emotions with loved ones, why would an individual discuss their emotions with a strange worker or psychiatrist? Money, as I am sure you agree, should not be put forward towards a program such as this if it will not show sufficient results, and thus much research and understanding of the stigma and how to overcome it must be conducted prior to any programs.

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