Benedetto Saraceno

The treatment gap in mental health care

Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.

Barriers to improvement of mental health services in low-income and middle-income countries

Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.

Los trastornos mentales en América Latina y el Caribe: asunto prioritario para la salud pública

OBJETIVO: La creciente carga de trastornos mentales que afecta a las poblaciones de America Latina y el Caribe es demasiado grande para hacer caso omiso de ella. Por lo tanto, es una necesidad impostergable conocer la prevalencia de los trastornos mentales y la brecha de tratamiento, que esta dada por la diferencia entre las tasas de prevalencia verdadera y las de las personas que han sido tratadas, que en algunos casos es grande pese a la existencia de tratamientos eficaces. Si se dispone de mayor informacion, se hace mas factible 1) abogar mejor por los intereses de las personas que necesitan atencion, 2) adoptar politicas mas eficaces, 3) formular programas de intervencion innovadores y 4) adjudicar recursos en conformidad con las necesidades observadas. METODOS: Los datos se obtuvieron de estudios comunitarios publicados en America Latina y el Caribe entre 1980 y 2004. En esas investigaciones epidemiologicas se usaron instrumentos diagnosticos estructurados y se estimaron tasas de prevalencia. Las tasas brutas de diversos trastornos psiquiatricos en America Latina y el Caribe se estimaron a partir de las tasas media y mediana extraidas de los estudios, desglosadas por sexo. Tambien se extrajeron los datos correspondientes al uso de servicios de salud mental para poder calcular la brecha en el tratamiento segun trastornos especificos. RESULTADOS: Las psicosis no afectivas (entre ellas la esquizofrenia) tuvieron una prevalencia media estimada durante el ano precedente de 1,0%; la depresion mayor, de 4,9%; y el abuso o la dependencia del alcohol, de 5,7%. Mas de la tercera parte de las personas afectadas por psicosis no afectivas, mas de la mitad de las afectadas por trastornos de ansiedad, y cerca de tres cuartas partes de las que abusaban o dependian del alcohol no habian recibido tratamiento psiquiatrico alguno, sea en un servicio especializado o en uno de tipo general. CONCLUSIONES: La actual brecha en el tratamiento de los trastornos mentales en America Latina y el Caribe sigue siendo abrumadora. Ademas, las tasas actuales probablemente subestiman el numero de personas sin atencion. La transicion epidemiologica y los cambios en la composicion poblacional acentuaran aun mas la brecha en la atencion en America Latina y el Caribe, a no ser que se formulen nuevas politicas de salud mental o que se actualicen las existentes, procurando incluir en ellas la extension de los programas y servicios.

Trends in mortality from suicide, 1965–99

Objective: To analyse trends in mortality from suicide over the period 1965–99.

Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis

This report reviews the evidence for the types of human rights violations experienced by people with mental and psychosocial disabilities in low-income and middle-income countries as well as strategies to prevent these violations and promote human rights in line with the UN Convention on the Rights of Persons with Disabilities (CRPD). The article draws on the views, expertise, and experience of 51 people with mental and psychosocial disabilities from 18 low-income and middle-income countries as well as a review of English language literature including from UN publications, non-governmental organisation reports, press reports, and the academic literature.

Poverty and mental illness

Objective To assess the relationship between poverty and mental illness in order to stimulate debate on future international cooperation programs in mental health. Method Epidemiological data in the international literature addressing the issue of material poverty as a risk factor for the development of mental illness and as a prognostic factor for the outcome of mental illness were reviewed. Results The international literature reviewed supports the notion that material poverty is a risk factor for a negative outcome among mentally ill people. In addition, preliminary epidemiological data suggest that service-related variables may be determinants of outcome of mental illnesses. In our view, cooperation with developing countries is a great opportunity to evaluate mental health services in a natural setting. Conclusions A new generation of programs for international cooperation in mental health is needed, in which knowledge and technology transfer is based on a service-research attitude. Attention should be focused on variables related to the poverty of services that might be linked to the course and outcome of mental illnesses.

Mental health in the aftermath of disasters: consensus and controversy.

*Department of Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland; and †Department of Mental Health and Substance Dependence, World Health Organization, Geneva, Switzerland. Reprints: Shekhar Saxena, MD, Department of Mental Health and Substance Dependence, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. E-mail: saxenas@who.int Copyright

The WHO World Health Report 2001 on mental health

OBJECTIVE 450 million people are estimated to suffer from neuropsychiatric conditions; approximately 10-20% of all children seem to have one or more mental or behavioural problems. Mental and neurological conditions account for 31% of all disability in the world. In epilepsy alone less than 25% of those affected receive treatment. In developing countries only a quarter of people suffering from schizophrenia receive treatment. Urgent action is needed to close the treatment gap and to overcome barriers. Governments need to take action with other partners to address these barriers and provide mental health services to those in need. RESULTS The World Health Report provides 10 recommendations for countries to begin taking action. These actions are divided into three scenarios: for countries with a very low level of mental health resources, for those with a medium level and for those with a high level of resources. CONCLUSIONS The Report allows every nation to recognize itself in one of three scenarios and to adopt and implement the appropriate actions.

Mental Health and Substance Abuse

This article describes the reasons why countries need to develop services for mental and substance use disorders. It also outlines key recommendations for the organization and delivery of services and discusses a number of key variables – resources, paradigm, value system, and environment – in terms of how they shape mental health services. Finally the article highlights the need to move from a biomedical model to a public health model and the role that training, mental health policy, and legislation can play in order to deliver high-quality services that respect human rights.

Bridging the mental health research gap in low- and middle-income countries

Research can and should play a substantial role in improving the mental health situation in lowand middle-income countries (in the following: nonrich countries), where the gap between burden of mental disorders and mental health resources is the largest (1, 2). Research-generated information is essential to determine mental health needs, to propose cost-effective and culturally appropriate interventions of an individual or collective nature, to monitor the process of their implementation, to evaluate the progress made, and to explore the obstacles that prevent recommended strategies from being implemented. The difference between the research information that is needed to plan the best possible services in a given setting and what is currently available can be called the research gap. All available indications are pointing towards the fact that the research gap is particularly large in the non-rich countries. It is known that mental health research publications from non-rich countries constitute a small proportion of the total research output on mental health from the world (3–5). This finding is in consonance with health literature in general (6–8) and in biomedical publications the gap between countries with low and high level of publications is widening (9). These latter findings, specially, serve as a grim reminder that inattention to inequalities will prove a severe handicap in the long run as skill and technological advantage have a self-reinforcing character. Not only is very limited research conducted in non-rich countries but the subject matter often does not answer population needs, e.g. if one follows the criterion of burden of disorders to decide on the priority for research, mental and emotional disorders as a whole (10) and affective disorders, self-inflicted injuries and mental retardation, specifically, are under-researched topics (11). In addition, new knowledge, when it exists, is seldom applied partly because of the fact that some excellent examples of research do not come to attention of policy makers and planners because of poor dissemination opportunities (12). The problems in conducting mental health research in lowand middle-income countries have been discussed by many authors (4, 12–15). A definite barrier is the low priority accorded to mental health in general and mental health research in particular. Equally important are limitations imposed by resources (e.g. funding, facilities, support staff), research capacity (e.g. trained researchers, technical support, peer network, co-operative endeavours, migration of researchers), and research environment (e.g. research culture, availability of time, incentives, bureaucracy, isolation from networks). Preferably, the research policy for a country could be developed in harmony with all other components of the national mental health policy and strategies, as research should provide to most components with the necessary scientific inputs, and with the baseline and evaluation data they require (16, 17). Research should also safeguard ethical principles in its origin (why has the research been done?), formulation (were consumers and other relevant stakeholders involved?), purpose (how the information will advance the state of mental health of the population?), target (whom will it serve?), and operation (how the rights of the individuals, families and communities will be preserved?) (16). Kleinman and Han (18) suggest that non-rich countries should focus on practical and costeffective research methods and intervention-oriented research that can be employed across many areas rather than prioritizing research according to topics. They argue for the development of population laboratories that integrate epidemiological, clinical, social science, and biomedical research through interdisciplinary research teams and international collaborations. This type of research not only brings to light the mental health burden locally and its underlying social, economic, and political constraints, but it also enables the design and implementation of relevant policies. Patel (19) suggests that Health Systems Research model that emphasizes action-oriented research, planned in close collaboration with a number of stakeholders, and disseminated in a variety of formats targeted Acta Psychiatr Scand 2004: 110: 1–3 Printed in UK. All rights reserved Copyright Blackwell Munksgaard 2004