It is time to turn our attention to mental health in poor countries, argues Priya Shetty.
Mental illness rarely features in high-profile talks about global health, possibly because of a lingering taboo or the misguided perception that it is not a cause for concern in poor countries. World Mental Health Day on 10 October was intended to set the record straight and raise awareness of mental illnesses that seriously affect the world's poor.
Depression, for example, is particularly widespread in the developing world — of the 800,000 people who commit suicide every year, 86% are in low- and middle-income countries, says the WHO.
For decades, efforts to improve health in developing countries focused on infectious diseases. Now that incidences of chronic diseases such as diabetes and cancer are rising rapidly in the developing world, they are finally being taken as seriously as HIV and malaria.
But global opinion seems divided on whether to include mental health in the fight against non-communicable diseases in developing countries. As a result, many important international initiatives to fight chronic diseases ignore mental health altogether.
The rationale behind this exclusion is that mental illness has not traditionally been included among non-communicable diseases. Considering that mental and neurological disorders are among the risk factors for non-communicable disease, and that many psychiatric illnesses such as schizophrenia that affect millions of people in the developing world are non-communicable, this is a dangerously blinkered view.
Schizophrenia, for instance, affects about 24 million people worldwide, of whom half do not get proper treatment. A staggering 90% of people without treatment live in developing countries.
A 2007 report by the WHO and the Global Forum for Health Research revealed a woeful lack of research capacity for mental health in poor countries .
The report was based on interviews with researchers, decision-makers and other stakeholders in 114 low- and middle-income countries, and shows that few countries contributed research papers on mental illness to international journals.
This low scientific output means there are large holes in the knowledge base about mental illness in some countries. It also has serious implications for national health policy. Interviewees said that few policies or programmes were based on evidence from local mental health research, because of a lack of communication between researchers and decision-makers. Most countries in Africa and South- East Asia spend just 1% of their health budgets on mental health, increasing the gap between research and policy.
The rise of chronic diseases in the developing world has driven initiatives to boost research and scale up their prevention and treatment. A UN summit in September 2011 is intended to put the fight against non-communicable diseases squarely on the global health agenda. Yet mental health is notably absent from the summit's agenda.
The 2003 Grand Challenges in Global Health initiative successfully spurred the fight against major infectious diseases, but when the Grand Challenges in Chronic Non-Communicable Diseases study was launched in 2007, it ignored mental health.
The NCD Alliance was set up in May 2009 to advocate better prevention of, and treatment for, non-communicable diseases. It is a network of international federations for diabetes, heart disease, cancer and chronic respiratory disease, which are responsible for 35 million deaths worldwide each year, 80% of them in low- and middle-income countries. But as with the UN summit, the NCD Alliance is silent on mental illness.
The exclusion of mental health from these high-profile efforts makes it harder to galvanise the necessary research into depression, schizophrenia and suicide for example.
Time for change
The first serious efforts to identify mental health research priorities in developing countries began last year. In June 2009 another alliance was created — the Global Alliance for Chronic Diseases (GACD), which, unlike the NCD Alliance, does include mental health in its remit.
This is especially important because the GACD is a collaboration between major research funding agencies, including the UK Medical Research Council, the US National Institutes of Health, the Indian Medical Research Council and the Medical Research Council of South Africa. Collectively the GACD's members control some 80% of public health research funding worldwide.
The GACD and the US National Institute of Mental Health are now leading an initiative launched this year to identify the key barriers to improving mental heath worldwide.
The initiative, which involves the Wellcome Trust, the McLaughlin-Rotman Centre for Global Health and the London School of Hygiene and Tropical Medicine, is expected to outline the Grand Challenges in Global Mental Health by the end of this year.
In addition, South Africa will host a world congress of the World Federation for Mental Health in October 2011. This is just a few weeks after the UN summit on non-communicable diseases, which will be attended by heads of state and government representatives. If ever there was a time for researchers and policymakers to engage in serious dialogue about research priorities for the developing world, this is it. And mental health needs to be on the agenda.