Mental Health: Where Did We ‘lose it’?

December 5, 2013

The WHO refers to mental health as “A state of complete physical, mental and social well-being, and not merely the absence of disease”. Mental illnesses on the other hand, according to CDC, are “disorders generally characterized by regulation of mood, thought, and/or behavior” that affect individuals to the extent that social integration becomes problematic.

 

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photo credit: Ken State University

World mental health surveys by the WHO on the burden of mental illnesses shows an increasing burden around the world. These disorders are commonly occurring and often seriously impairing in many parts of the world. Estimates show that mental illness account for up to 14% of the global burden of disease with approximately 450 million people worldwide having some kind of a mental disorder. In Africa, 5% of the population suffers from mental illnesses and the number is expected to rise to 15% by the year 2030. It is also estimated that at any given time, 10% of adults are experiencing a current mental disorder; and that 25% will develop one at some point during their lifetime [1]. In Kenya, statistics indicate that one in four patients presenting to a primary health facility suffers from a mental illness [2, 3]. Poor mental health is increasingly becoming a big issue in urban areas in developing countries and especially in the informal settlements, majorly due to rampant poverty and the high incidences of drug abuse [4, 5].
Many mental disorders begin in childhood (and sometimes in adolescence) and may lead to significant adverse effects on subsequent role transitions in adulthood. Adult mental disorders have been found to be associated with such high role impairment to the extent they affect the quality of life the individual leads; even to death. In India and Vietnam, a study showed that there existed a relationship between high maternal Common Mental Diseases (CMD) and poor child nutritional status [6].

Capacity of Mental Health Care Systems in Developing Countries

Despite the indications of the high prevalence of mental illness, it remains low on the priority ladder in sub-Saharan Africa. Little has been done and is known about the contribution of mental disorders to other health conditions (communicable and non-communicable diseases and the intentional and unintentional injuries) as well as to disability and mortality [7]. Research has documented three main issues that are obstacles to better mental health in low and middle income countries LAMICs. These are a) scarcity of available resources; b) inequities in their distribution, and c) inefficiencies in their use [8, 9]. Another biggest impediment that adversely affects the mental health system capacity in LAMICs is the burden of group 1 diseases, commonly known as communicable diseases including HIV/AIDS) [10, 11].

Basic mental health services are unavailable to those who may require their use. The availability of health care workers in mental health in LAMICs is very limited and inequitably distributed especially within communities with high rates of  socio-economic deprivation like those living in urban informal settlements and the marginalized rural areas where there is very little economic development. The situation has greatly impacted the quality of mental health services offered in these areas. And even where such services exist, it is mostly institutionalized with an over concentration in large institutions while very little is offered in the primary healthcare facilities that serve majority of the people.

Locked up and forgotten: challenges in addressing mental health

Mental health has been neglected due to various challenges including funding and the stigma associated with it as illustrated below:

Funding challenges

Funding for mental health services is totally non-existent in developing countries; as the WHO estimates that governments around the world allocate less than 1% of their health budget to mental health services [12]. In most LAMICs, government spending on mental health is insufficient proportionate to the burden of mental disorders. In Kenya, as is the practice in most LAMICs, mental health services are severely short of resources. Less that 6% of the country’s GDP is allocated to health, against the 15% agreed in the Abuja declaration. Even less funding is available for mental health promotion; which means that there is very poor awareness of the mental health issue in the country. Cost-effective and affordable interventions for mental illnesses are unavailable.

Legal and policy infrastructure and frameworks around mental health are wanting. Where they exist, there is a gap in the implementation and the practice. In Kenya, although the Kenya Health Policy Framework (1994–2010) sets out guidelines to promote the development and implementation of effective and decentralized strategic plans in the health sector, the issue has not been accorded the necessary priority focus. This happens with the knowledge that 25% of patients seeking care at outpatient clinics have some form of mental illness. With decentralization of health services to the counties, the situation is bound to go from bad to worse.

Stigma

Stigma associated with mental illnesses is another factor that greatly affects the uptake of available mental healthcare services. Individuals suspected to be mentally sick stand a higher risk of being violated and denied their human rights. According to the Kenya National Commission on Human rights report “Silenced minds: The systemic neglect of the Mental health System in Kenya”, the policies and practices of the Government of Kenya have been inadequate and have resulted in a mental health system that is woefully under-resourced and unable to offer quality inpatient and outpatient care to the majority of Kenyans who need it. This situation is attributed to the stigma and discrimination against mental illnesses and mental disorder in the country.

In February 2011, Cable News Network (CNN) ran a documentary entitled “Locked up and Forgotten” that showed the rot and decay in the mental health infrastructure in the country as exemplified by the state at Mathare Mental Hospital, the leading mental health referral hospital in the country. The institution was referred to as ‘a sprawling complex of tortured souls, characterized by horrible conditions of neglect, filth and even death that haunts those that are committed to the facility’. This is not very far from the truth.

What can be done?

The Lancet Global Mental Health Group has put up a clarion call to the global health community as well as to governments, donors, multilateral agencies to scale up the coverage of services for mental disorders especially in LAMICs through evidence-based package of services for core mental disorders. They also advocate for the strengthening of the protection of the human rights of people with mental disorders and their families. To achieve considerable success in this quest will require setting priorities and making decisions on how best to allocate meagre resources between competing health issues. There needs to be renewed focus on mental health issues to guide focus on policy crafting and implementation. Consequently, it will be important to prioritize which issues get on the policy or legislative agenda concomitant to the policy development process, being clear on the content of policy and the development and implementation of plan of the same. Resources should also be allocated to the unmet need for screening, treatment and management of mental disorders.

Mental health promotion requires multi-sectoral action, involving a number of government sectors and non-governmental or community-based organizations. There should be concerted effort in promoting public awareness on the importance of mental health and mental disorders throughout the lifespan to ensure a healthy start in life for children and to prevent mental disorders in adulthood and old age; while encouraging reform in institutions that provide the appropriate interventions to those in need. A few organizations exist in the country in the form of The Kenya Society of the Mentally Handicapped, The Kenya Commission on Human Rights and the Africa Mental Health Foundation (AMHF) that deal with mental health issues in the country.

An integrated approach in policy and implementation strategy is also necessary. Service providers require capacity building in dealing with existing mental health issues, while healthcare workers need to be equipped with necessary knowledge and skills in managing such cases. Screening for and care of mental illnesses should be included in the primary health care package in developing countries. This will make treating mental illnesses affordable and cost effective. Primary health care facilities should integrate services for communicable and non-communicable diseases. Focus should change from investing in the specialized treatment and care of the people with mental illness and a lot invested in integrated mental health system. Last but not least, research is necessary to contribute to the formulation evidence-based policies. More research needs to be done to understand the contribution of mental disorders to other health conditions as well as to disability and mortality.

References
1. WHO, Global Burden of Disease 2004 update. 2008, World Health Organization: Geneva.
2. Kiima, D.M., et al., Kenya mental health country profile. International Review of Psychiatry, 2004. 16(1-2): p. 48-53.
3. Kiima, D. and R. Jenkins, Mental health policy in Kenya -an integrated approach to scaling up equitable care for poor populations. Int J Ment Health Syst., 2010. 4:19.(doi): p. 10.1186/1752-4458-4-19.
4. Kemppainen, J.K., et al., Antiretroviral adherence in persons with HIV/AIDS and severe mental illness. J Nerv Ment Dis., 2004. 192(6): p. 395-404.
5. Do, N.T., et al., Psychosocial factors affecting medication adherence among HIV-1 infected adults receiving combination antiretroviral therapy (cART) in Botswana. AIDS Res Hum Retroviruses., 2010. 26(6): p. 685-91. doi: 10.1089/aid.2009.0222.
6. Harpham, T., et al., Maternal mental health and child nutritional status in four developing countries. J Epidemiol Community Health, 2005. 59(12): p. 1060-4.
7. Prince, M., et al., No health without mental health. The Lancet, 2007. 370(9590): p. 859-877.
8. Saxena, S., et al., Resources for mental health: scarcity, inequity, and inefficiency. Lancet., 2007. 370(9590): p. 878-89.
9. Benedetto, S. and S. Shekhar, Bridging the mental health research gap in low- and middle-income countries. Acta Psychiatr Scand, 2004. 110(1): p. 1-3.
10. McBain, R., et al., Disease burden and mental health system capacity: WHO Atlas study of 117 low- and middle-income countries. Br J Psychiatry., 2012. 201(6): p. 444-50. doi: 10.1192/bjp.bp.112.112318. Epub 2012 Nov 8.
11. Boutayeb, A., The double burden of communicable and non-communicable diseases in developing countries. Transactions of The Royal Society of Tropical Medicine and Hygiene, 2006. 100(3): p. 191-199.
12. Bird, P., et al., Increasing the priority of mental health in Africa: findings from qualitative research in Ghana, South Africa, Uganda and Zambia. Health Policy Plan, 2011. 26(5): p. 357-365.

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