Engagement for and Investment in Global Mental Health

¹Invited Professor for Mental Health at Tropical Neurology and Neuroinfection Master, International University of Catalonia (UIC), Barcelona, Spain

Corresponding Author: Sabine Bahrer-Kohler, Invited Professor for Mental Health at Tropical Neurology and Neuroinfection Master, International University of Catalonia (UIC), Barcelona, Spain, Tel: + 41 (0) 61 2054477; E-Mail: [email protected]

Received Date: 18 Aug 2016     Accepted Date: 25 Aug 2016   Published Date: 07 Sep 2016   

Copyright © 2016 Kohler B S

Citation: Bahrer-Kohler S. (2016). Engagement for and Invest- ment in Global Mental Health. Mathews J Psychiatry Ment Health. 1(2): 007.

ABSTRACT Mental disorders around the globe remain low-priority, yet they concern so many people worldwide. The suffering that is caused by mental illness impacts the persons affected and their families as well as numerous aspects of life. In its Mental Health Action Plan as well as elsewhere, the WHO describes a variety of steps that should be taken worldwide, next to those that have been pointed out by actors in the field for years in publications. More must be done in the field of mental health. One important aspect in this context is stigmatization. We need differentiated statements, not arguments like the one that it is the fault of the affected persons themselves. It has been known for a long time that we need transdisciplinary collabo- ration at the national and international level, e.g. among the persons affected, their advocacy organizations, the decision- makers, and international organizations. Declarations will not do by themselves; they must be put into practice. Reports without binding commitments serve no purpose. What is needed is diversified expert competence, adequate educational facilities. On a worldwide average only a few per cent of health budgets are invested in mental health. Sustained investments from public and other funds are indispensable.

KEYWORDS

Global Mental Health; Global Engagement; Global Investment; Education; Social Determinants Of Mental Health; Stigmatization; Action Plans; Mental Health Policy.

INTRODUCTION Mental disorders around the globe are often invisible and remain a low priority, as discussed by Baxter et al. 2013 [1]. Actors and responsibilities like Jim Yong Kim, President of the World Bank and Margaret Chan, Director-General of the World Health Organization (WHO) announced that the mental health purpose has to been taken out of the shadow, has to become a priority, has to become a Global Development Prior- ity [2]. However, how to achieve these goals?

METHODS Systematic review of bibliographic databases, analyzes and extracts of key publications, inclusion of more than 320 publi- cations. The present publication includes 83 publications/pre- sentations containing data and/or statements that are based on scientific studies, surveys, considerations, analyses etc., and broad considerations and were not repetitions of con- tents outlined before. 

GLOBAL MENTAL HEALTH- STATE OF THE ART  Epidemiology/ prevalence: Many years ago the Global Burden of Disease (GBD) study published that neuro-psychiatric dis- orders account for more than 25% of all health loss due to disability, or one in four over lifetime, more than eight times greater than that attributed to heart disease and 20-fold greater than to cancer [3]. Worldwide around 10-20% of children and young adolescents experience mental disorders [4, 5]. Half of all mental illnesses begin by the age of 14 years and three-quarters by mid-20s [6]. Attention deficits, cognitive disturbances, lack of motiva- tion, and negative mood are typical manifestations [7]. Globally, about 350 million people are affected by depression, in general more women are affected than men [8]. About 60 million people worldwide are affected by bipolar affective disorder, about 21 million are affected by schizophrenia and other psychoses. Estimated over 47 million people worldwide have dementia with the majority of sufferers living in low- and middle-income countries [8, 9]. Correlations: More than 20% of adults aged 60 and over suffer from a mental or neurological disorder, excluding headache disorders with recognition that many of the broad complexi- ties of the frequent chronicity of mental disorders have an interplay and correlation with other chronic multimorbid dis- eases [9, 10].  A mental illness can contribute substantially to increased chronic disease morbidity and mortality, e.g. with chronic diseases like with Type 2 diabetes [11]. Patients with chronic medical illnesses can have two- to threefold higher rates of major depression compared with age- and gender-matched primary care patients and e.g. modifiable health risk behav- iors, like inadequate vegetable consumption, inadequate fruit consumption, smoking, physical inactivity, and alcohol risk [12,13].  Gender effects in the prevalence of common mental disor- ders (like anxiety disorders) is evident. Steel et al. document- ed that women having e.g. higher statistical rates of mood (7.3%:4.0%) and anxiety (8.7%:4.3%) disorders during the previous 12 months and men have higher rates of substance use disorders (2.0%:7.5%), with a similar pattern for lifetime prevalence [14].  The income situation of countries have several impacts. In low- and middle-income countries, between 76% and up to 85% of people with mental disorders receive no treatment for their disorder. In highincome countries, the rate is estimated between 35% and 50% of people with mental disorders [8]. Most of the people with mental, neurological, and substance use disorders, around 75%, who are affected, live in low-in- come countries [15]. Nevertheless, mental health diseases are a global phenome.  The median number of mental health beds (inpatients) per 100,000 population ranges below five in low and lower-mid- dle income countries to over 50 beds in high-income coun- tries; equally large disparities exist for outpatient services and structures (WHO, p.9) [16]. The highest rate of hospital beds - psychiatric care beds in Europe are in Belgium with around 180 beds per 100,000 inhabitants and the lowest rates are documented for Italy, Cyprus and Spain [17]. Mental Health diseases are multifactorial [18]. They need professional forms of treatment performed by e.g. general practitioners, other specialists like psychiatrists, neurologists, psychotherapists, social workers, occupational therapists, psychologists et al., and with different forms of treatment, in several in-and out- patient settings, and with the inclusion e.g. of culture and cul- tural factors [19]. Mental health diseases are often combined with an immense burden for people themselves with mental disorders and for their social networks, families and the society.  About 14% of the global burden of disease is attributed to mental health disorders and the burden of these conditions is expected to grow over the next years [15, 20].  A current study documented that 39% of caregivers in high, upper-middle, and low/lower-middle income countries with first-degree relatives themselves reported burden. Among those caregivers, 22.9-31.1% devoted time, 10.6-18.8% had financial burden, and 23.3-27.1% reported psychological dis- tress. A higher burden was reported by women than for men [21]. These data are not surprising, the percentage of family or informal caregivers who are women range from 53 to 68 percent, according to the Family Caregiver Alliance [22].  Mental health budgets: According to the World Health Orga- nization (WHO) Mental Health Atlas citated in the comprehen- sive WHO Mental Health Action Plan 2013-2020 (WHO 2016), governments around the globe spend on average 3% of their health budgets on mental health, ranging from less than only 1% in low-income countries to around 5% in high-income countries [23]. Budgets for mental health as a percentage of national health spending is approximately 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda [24]. In the US the state mental health budget trends are currently cause for urgent alarm, only 12 states have steadily increased investment from 2013 to the year 2015 [25]. Positive seems the investigation e.g. in Germany with 11% of expenditure on the account of treatment for mental and behavioral disorders [26].  Currently cuts in the budget in UK with around 8% with a real term cut of 8.25% and with the equivalent of stripping £598m from the budgets, and the originally planned cuts of £12 mil- lion from the State's mental health budget for 2016 in Ireland should receive great attention [27, 28]. In UK the Department of Health announced that the overall public health funding will be reduced by an average of 3.9% every year in real terms until 2020 [29]. Outside of Europe Errazuriz et al. 2015 sum- marized that in the Chilean National Mental Health and Psy- chiatry Plan, only three of the six mental health priorities have secure financial coverage and this in spite of the estimated high prevalence of mental health disorders in Chile [30]. Multitude of factors and influences affect an inadequate access to mental health services and treatment in Lebanon, the inef- ficient fragmentation of mental health financing among seven intermediaries seems to be one influencing factor, and a clear description of the current mental health financing system is missing [31].  Summary: Page 4 of the WHO Action Plan and the WHO Fact Sheet for mental disorders concluded, that health systems around the world have not yet adequately responded to the burden of mental disorders; as a consequence, the gap be- tween the need for treatment and counseling and its provi- sion is large all over the world [8, 23].

ENGAGEMENT IN GLOBAL MENTAL HEALTH-ASPECTS  IMPROVEMENT OF AWARENESS & KNOWLEDGE & SKILLS

First of all the individuals, professionals and the public have to be more aware about mental health or mental health dis- eases, respectively have to include the elements of awareness promotion [32].  The way to do so is e.g. with interventions provided at the pop- ulation- and community-levels, which can promote awareness and mental health [33]. Another form of awareness training can be psychoeducation (delivering of information), e.g. the Mental Health First Aid (MHFA) is a form of widespread psy- choeducation that aims to empower the public to approach and support individuals in distress by improving knowledge, attitudes and behaviours related to mental ill-mental health [34]. Mass media interventions, another form, may help to re- duce prejudice and promote awareness [35].  Information platforms like e.g. platforms to provide mental health care services via the Internet can promote knowledge and awareness, and can address the unmet need for men- tal health care [36]. Cultural competence trainings in mental health as one component for effective and culturally respon- sive services to culturally and ethnically diverse clients can be supportive to push awareness and to promote a better sensi- tivity [37].  The publications of the World Health Organization (WHO) can be supportive and innovative e.g. with the WHO agenda, WHO programs and the WHO atlas. Since 2015 and for the first time, world leaders and stakeholders are recognizing the promotion of mental health and well-being, and the preven- tion/promotion and treatment of substance abuse, as health priorities within the Global Development Agenda [38]. The leaders adopted the 2030 Agenda for Sustainable Development, which includes a set of 17 Sustainable Development Goals (SDGs). The agenda gives the international communi- ty the impetus to work together and to face and tackle the worldwide challenges [39].  The WHO with the goal to build a better health, respective- ly to ensure the highest attainable level of health/mental health for all people, delivers at the website of WHO many other publications for mental health. E.g. the mhGAP Inter- vention Guide for mental health, the WHO's flagship program on mental health, neurological and substance use disorders in non-specialized health settings or the publication: Investing in mental health- Evidence for action and the Mental Health Atlas. [40-42, 16].  To receive a better knowledge and more information about mental health and mental diseases, scientific publications are useful. Only one single databank (pubmed) shows alone 248664 publications in June 2016 for and about the topic. The first one from Macdougall about mental efficiency and health in the journal Science (1904). One of the current publications is about sustainable development and global mental health [43, 44].  Worldwide are many scientific journals in the mental health field, e.g. the journal Global Mental Health (Cambridge Uni- versity Press, 2016), or since 1982, the Canadian Journal of Community Mental Health and the Lancet series on Global Mental Health 2007 highlighted the gaps& challenges in men- tal-health worldwide [45-47].  Books can also have a high impact to promote awareness and knowledge, like the current book of Mental Health Practice in a Digital World edited by Dewan et al. in 2015 or the book about EvidenceBased School Mental Health Services written by Macklem in 2011 or the book about Essentials of Global Mental Health edited by Okpaku 2014 [48-50].  More education, training and competence, e.g. with cultur- ally informed practice moduls, multicultural counseling com- petencies linking with academic learning and virtual learn- ing environments-VLEs are needed, especially for the over a half-dozen different professions that provide services [51-55]. Mental health education has to be better included in sched- ules worldwide and in global curricula.

Stigmatization Stigmatization is an important area in the context of men- tal health and a major cause of discrimination and exclu- sion. There is a need to reduce stigmatization and increase an awareness of mental health stigmatization. Stigma can be responsible for treatment seeking delays and can reduce the likelihood that a mentally ill patient will receive adequate care and treatment [56]. Different types of stigma related to mental illness have been described so far self stigma as in- ternalization by the person with the condition, experienced stigma, public or social stigma, structural stigma, felt or per- ceived stigma [57]. Change strategies can be e.g. knowledge, education, and contact especially for challenging the public, stigma education and contact had positive effects on reducing stigmatization for adults and adolescents [58]. Also if the evi- dence that stigma interventions in reducing perceived stigma is very limited, they can support changes. Scientifically docu- mented is that current stigma interventions can be effective in reducing personal stigma [59].  The mass media's power to impact and influence public per- ception and awareness makes the mass media one of the most significant influences in societies [60]. Mass media can help to avoid continued intolerance and oppression or can be on the other hand a risk factor e.g. for the genesis or exacer- bation of mental illnesses like eating disorders and substance use disorders [60, 61].

ACTION BY INTERNATIONAL, REGIONAL AND NA- TIONAL PARTNERS: THE DEVELOPMENT AND IM- PLEMENTATION OF MENTAL HEALTH PROMOTING POLICIES AND PROGRAMS

Declarations will not change anything by themselves; they must be put into practice.  Long time ago the WHO's Alma Ata Declaration which was ad- opted in 1978, underpinned e.g. the importance of compre- hensive horizontal health/primary health care with the provi- sion of adequate health and social measures, and addressed the gross inequality in the health status [62].  One possible way to promote horizontal health/mental health is with the WHO's Mental Health Action Plan 2013-2020 [23]. The WHO's Comprehensive Mental Health Action Plan 2013-2020, endorsed by the World Health Assembly in May 2013, recognizes the essential and important role of mental health in achieving good health for all people. The plan includes four overall objectives: 

• More effective leadership and governance for mental health;
• The provision of comprehensive, integrated mental health and social care services in community based settings, which are reachable;
• The implementation of sustainable strategies for promotion and prevention; and
• strengthened information systems, evidence and research[23].

At p.7. The WHO concluded that "effective implementation of the global mental health action plan will require actions by international, regional and national partners."  For these actions e.g. partners like the civil society, including organizations of persons with mental disorders, service- as- sociations and organizations, family- members and other as- sociations, nongovernmental organizations, and community- based organizations have to be included [23].  Beside advocates, donors, commitments, foundations and initiatives engagement and action for mental health of e.g. individuals, single institutions, associations like e.g. www.glo- balmentalhealth.ch and organizations are required [40, 63].  Sustained mental health efforts are achieved through support from the community/political system-at large, organizations, institutions, federations, associations and other stakehold- ers, and from the individuals, their social networks, and with the reflection of mental health & social determinants (Bahrer -Kohler 2011) and with the transformation in political goals and sustainable aims [64]. Supportive in the context of deter- minants is the model of Dahlgren& Whitehead 1991 about determinants of health in general or the model of Evans and Stoddart (1990) of different types of factors, like physical envi- ronment and forces which can interact on very different con- ceptualizations of health [65,66].  To avoid insufficient numbers of trained providers and geo- graphic inequities, the requirement is to have enough excel- lent educated, high-qualified mental health professionals in the field of practice and research. Therefore, e.g. professional analyses are requested to improve the current situation, e.g. with the possible conclusion that e.g. primary-care physicians should be urgently trained or to receive comparable evidence or comparable information about educational standards et al. [67, 68].

DISCUSSION To reach the involved parties and persons in a more success- ful way in the future seems difficult. How to evoke emotions and cognitions with sustainable consequences, how to get e.g. public attention and the implementation in the political context? And how to integrate "data and knowledge", "emo- tions", "endorsement", "media", "community" and "why and how" in the public health context? [69]. A combination of ac- tions, health-related campains, and within professional net- works can be useful, e.g. with

• Strategies to support governments, responsibilities and community leaders to adopt mental health policies and to integrate mental health policy into public health policy and general social policy [70].
• tailored solutions for the individual situation, the individual country, and specific tasks, e.g. for addressing both- the gen- eral and/-or specific challenges and issues [70].
• Information and persuasive power clearly related to context, namely to be brief [71].
• Social media [72].
• Campains with high profile names [73].
• Social networks, platforms, and events.

To face reality it could mean that national and international engagements will not increase e.g. financial budgets or suf- ficient budgets for education & trainings or that service us- ers and providers expectations will not be fulfilled [74]. But it means that engaged parties are forced to face the reality with a vision. This vision includes e.g. more national and international ac- tions for generating finances/ generating enough cash, dis- seminating further information and evidence, and for foster- ing national & international collaborations. Supportive are key recommendations e.g. for early childhood interventions, e.g. pre-school educational and psychosocial interventions, e.g. economic and social empowerment of women, and e.g. social support to old age populations [75].

CONCLUSION The way forward. Single actions, collective actions, national & global interdisciplinary and transdisciplinary engagements, re- search for global mental health for generating and disseminat- ing are requested, to solve the challenges in the future [75]. Important is to avoid an opinion that people with a mental illness have to have control of their disabilities and are respon- sible for causing them and for their stability (Angermeyer et al. 2004 ; Corrigan et al. 2000 ; Weiner et al. 1988) [76-78].  More awareness and action for mental health prevention and promotion around the globe is necessary. E.g. there is the ur- gent need to redesign health systems, education & training systems, to integrate mental disorders, and to implement par- ity between mental and physical illness in investment into re- search, training, treatment, and prevention & promotion with the exploration of the role of sociocultural and environmental contexts (Kohn 2014, p. 36); cf. Collins et al. 2011) [79,80].  Action on all challenges will require short term and long-term engagements and investments [80]. Binding commitments are requested for e.g. the implementation of services, the access to mental health services for all, the treatment, and sufficient training structures and professional education institutions/ facilities.  Greater and sustainable investments e.g. in mental health ser- vices and in professional education in all countries and of all income levels are necessary [81]. Comparable to the state of Kleinman, who illuminated in the past the moral failure of communities in all parts of the world, mental health needs have to be much more a global humani- tarian and development priority and a priority in every coun- try in the world [81,82].  People living with mental disorders should not face cruelty, neglect and exclusion from family and community life [83].  In every national and international health budget, inappropri- ate mental health financing and funding sources have to be avoid especially as barriers to primary care, examination, and adequate treatment and counseling for people with mental diseases and for their families.

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