Silent Suffering: Mental Health as a Global Health Priority
Coauthored with Ryan Fedasiuk, intern in the International Institutions and Global Governance program at the Council on Foreign Relations.
Today is World Health Day. Originally created to mark the founding of the World Health Organization (WHO), the day has since become an opportunity to spread awareness of a subject of major importance to global health each year. For 2017, the WHO campaign focuses on depression, the leading cause of disability worldwide. As the WHO spotlights depression and issues surrounding the illness, it is important to consider just how far the international community has to go in combating this debilitating mental disease.
World Health Organization (WHO)
In 2014, the World Health Organization published its first and only report on suicide titled Preventing suicide: A global imperative. But suicide prevention, it seems, was not quite imperative enough. Of the 169 targets specified in the United Nations Sustainable Development Goals in September 2015, mental health was mentioned just once, in target 3.4, when the leaders of the world lumped it together with “preventing noncommunicable diseases” and boldly declared that they would “promote it.” But the world has not fulfilled even this desultory ambition. Although the WHO has accelerated progress on preventing and responding to noncommunicable diseases, the same cannot be said of mental illnesses, particularly depression. Thankfully, the world health community has an opportunity to enact meaningful change at the annual Mental Health Gap Action Programme (mhGAP) conference this October in Geneva by focusing not on reinventing strategy, but on securing legal and financial commitments from countries to enact the mhGAP Intervention Guide (mhGAP-IG) as it stands.
In its 2013-2020 Mental Health Action Plan, the WHO outlined four priorities:
- Greater and more effective national leadership on mental health issues
- Improved access to comprehensive, community-based mental health care
- Increased investment in promotion and prevention strategies
- Strengthened information systems and research collection
Halfway through the timeframe, little progress has been made. As a result, the WHO is expected to fall short of its most visible mental health goal: To reduce suicide by 10 percent globally by 2020. Suicide is responsible for eight hundred thousand deaths annually, and while global morbidity has decreased, several countries have seen large spikes of up to 270 percent since the year 2000. Perhaps more hauntingly, for every person who dies by suicide, twenty people survive a suicide attempt—and these figures only reflect the sixty countries for which quality data exists.
In the natural progression of global health policy, mental health is the next frontier. In its initial sixty years of operation, the WHO focused chiefly on delivering medicines and containing the spread of outbreaks, providing hundreds of millions of mosquito nets and antiretroviral therapies to developing countries. Once our neighbors no longer looked sick, the WHO narrowed its gaze on largely invisible noncommunicable diseases (NCDs) like cancer, diabetes, and cardiovascular diseases. Governments poured resources into national health organizations and global spending on cancer quickly surpassed $100 billion. The next logical step is to focus on ailments not just of the body, but also of the mind.
World Health Organization (WHO)
Since the inaugural mhGAP conference in 2009, mental health has attracted significant international attention. The number of conference participants grew from twenty-seven in 2009 to more than fifty member states and one hundred and fifty partner organizations in 2016, when the highly-praised second version of the mhGAP-IG was unveiled. And although the recommendations outlined in the two hundred-page document are substantial, the world needs more than a plan; it needs commitments to follow through.
The mhGAP conference has been an annual occurrence for nine years, but in that time, few countries have revisited or created mental health strategies, and only twenty-eight have suicide prevention plans. Guyana, India, and Japan have taken concrete actions, but for the most part, “mental health” has been reduced to a feel-good public relations buzzword. No minister of health has ever attended an mhGAP conference. What’s more, of the six candidates running for director-general of the World Health Organization, only two mention mental health as part of their vision for WHO priorities. The public health community cannot afford stagnation on mental health. The costs—particularly to world economic prosperity and physical security—are too high.
Depression is a devastating disease. By precluding those affected as well as their caregivers from being employed, it often traps people in poverty, resulting in economic and productivity losses that exceed those of most acute physical conditions. By some estimates the costs of untreated mental illness constrain global GDP by nearly 35 percent. Accordingly, the WHO has repeatedly said that investment in mental health services is not only economically sustainable, but also generates a multiplier effect. But without concrete commitments to improving the four categories of the Mental Health Action Plan, the world is poised to regress, and least developed countries (LDCs) will be hit the hardest. More than 676 million people suffer from depression worldwide, with only 10 percent of those diagnosed receiving minimally adequate treatment in LDCs.
Mental health is also a national security issue. Nearly 73 percent of current U.S. military personnel in need of treatment are not seeking mental health care, often believing that seeking such treatment will harm their career or lead to superior officers treating them differently. Untreated mental illness creates risks in combat situations. And as the base shootings at Fort Hood and Chattanooga indicate, untreated mental health problems can put even nonactive troops in jeopardy. Finally, the costs of inadequate treatment extend to the home front. More than ninety thousand American soldiers and Marines have served multiple tours of combat, and this demographic is most at risk of developing post-traumatic stress disorder (PTSD), receiving a traumatic brain injury (TBI) which may precipitate dementia, or dying by suicide.
One of the greatest challenges to global leadership on mental health is that countries are in such disparate stages of development, which is the reason the WHO began producing the mhGAP-IG in the first place. On one end of the spectrum, suicide or attempted suicide is illegal in twenty-five countries, which leads to under-reporting and under-recording of cases of suicidal ideation and depression. On the other end, countries like the United Kingdom have established large funding guarantees for churches and local clinics to provide mental health services.
To make mental health a priority in the global development agenda, it is time for states to put their money where their mouths are. One idea is for national governments to bring policy “gift baskets” to the October meeting, akin to those they presented at the Nuclear Security Summit. Countries should focus on strengthening national capacities to improve mental health and use the multilateral forum to exchange ideas and announce new programs suited to their unique cultures and stages of development. At the national and international level, governments should commit funds to increase the supply, quality, and affordability of psychotropic medicines. By making mental health care a competitive source of national pride, states can make concrete progress toward expanding access, improving data collection, and reducing stigma.
While refocusing development on mental health, however, states should be careful to adhere to the WHO’s recommendations as well as the UN Convention on the Rights of Persons with Disabilities. By funding community-based mental health services, as opposed to standalone hospitals or shell organizations, development agencies can reduce overhead costs and curb human rights abuses that have plagued treatment in the past. To reduce stigma, media outlets should change the language they use when covering stories of suicide and self-harm. Evidence suggests that sensationalizing suicide or mental illness simply entrenches stigma and dissuades people from seeking treatment.
Addressing the global mental health crisis will be one of the greatest challenges the world health community has ever known, but success would mean prosperity and security beyond imagination. The world’s leaders should pursue peace not just among nations, but within their constituents’ minds.