Investing in mental health

Mental illness has always been kept behind a wall of stigma and discrimination. People are still reluctant to talk about it, and in many respects, it remains a hidden disease.

EACH year, World Mental Health Day is celebrated on October 10. This day is significant in drawing attention to issues concerning not only mental illness, but mental well being as well.

This year’s theme is “The Great Push: Investing in Mental Health”. This theme invites a multisectoral approach in removing barriers to mental healthcare, thereby reducing the burden of neuropsychiatric disorders. It also highlights the long term cost effectivenes of investing in interventions for prevention of mental disorders and promotion of mental wellbeing.

The World Health Organisation (WHO) describes mental health as “a state of well being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

It is estimated that around 450 million people worldwide have a mental health problem. Unfortunately, in most parts of the world, mental health and mental disorders are not accorded anywhere near the same degree of importance as physical health. It is time issues concerning mental health become a global concern.

By the year 2020, the WHO has projected that depression will be the second leading cause of disability in the world. Today, depression is already ranked fourth. Mental health problems affect society as a whole and is therefore a major factor in global development

Why invest in mental health?

Globally, there is huge inequity in the distribution of skilled human resources for mental health. Shortages of psychiatrists, psychiatric nurses, psychologists and social workers are among the main barriers to providing treatment and care in low- and middle-income countries.

Low-income countries have 0.05 psychiatrists and 0.16 psychiatric nurses per 100,000 people, compared to 200 times more in high-income countries. In 40% of the countries, primary healthcare providers do not receive any training in mental health.

There are several other barriers to appropriate mental healthcare. Stigma is a major barrier. In many parts of the world, including the developed world, people with mental disorders are victimised for their illness and become targets of unfair discrimination, resulting in little or no access to housing, employment, social welfare or health insurance. People are still reluctant to talk about mental illness, and in many respects, it remains a hidden disease.

Another significant barrier to appropriate healthcare is the lack of psychotropic medication at the primary care level. While most countries have an essential drug list that includes basic psychotropic medications, 20% of countries do not have this essential package at the primary care level.

Almost half the countries in the world do not have significant mental health legislation, policy, or a national-level programme. This is a major barrier in ensuring the right to healthcare, and accountability in human rights violations.

There is also a need to strengthen the voice of users of mental health services and their role in advocacy issues, to ensure that the rights of persons with mental disabilities are fully represented.

Mental disabilities, and neurological and behavioural disorders are common in all countries around the world, causing immense suffering and staggering economic and social costs.

The gap between the burden of mental illness and the resources used to address the problem is the widest in low income countries. Closing this gap is not only the obligation of the respective governments and the WHO, but also non-government organisations, foundations, communities, families, and mental health professionals.

Investing in mental health can generate enormous returns in terms of reducing disability and preventing premature death. Besides increasing the productivity of people with mental illness and their caregivers, commitment in reducing the gap would also instill dignity in their lives and give voice to people with chronic mental illness who continue to suffer from human rights violations by being physically restrained.

The economic burden of mental disorders are huge. The core costs in terms of treatment and service fees, and usually long periods of hospitalisation, are much more compared to other types of morbidity, which are usually less chronic. In terms of indirect costs like that due to loss of productivity at work and job retention, the loss is staggering.

Since mental disorders generate huge costs in terms of long term treatment and loss in productivity, logically, they would also contribute to poverty. Conversely, insecurity, low income levels and malnutrition contribute to mental disorders. Therefore, this results in a vicious cycle of poverty and mental disorders.

Therefore, timely and appropriate investment in mental health intervention can break this vicious cycle and result in decreased overall economic burden of mental disorders.

Mental strategies

Investments in primary care services have proven to be very cost effective in treating burdensome mental illnesses like chronic schizophrenia. Such investments in service provision is not only required, but worthwhile. Commitment to prevention of mental disorders can also pay rich dividends in the long term. Detection and suitable intervention for depression, delinquent behaviour, suicidality, and substance abuse in childhood and adolescence will result in the mental well being of the potentially productive adult population.

In Malaysia, our health indices remain one of the best in the developing world. We have one psychiatrist to a population of 115,000, which is admirable, although ideally, as per the WHO recommendation, it should be one psychiatrist to a population of 50,000.

Our primary care services are being equipped to treat simple cases and make appropriate referrals to secondary and tertiary centers. Quality medications are also readily available at all levels, making our healthcare one of the most envied in the developing world.

Nevertheless, there is room for improvement. With the burgeoning urban population, and stressful environment in educational institutions and workplaces, we have witnessed an exponential increase in cases of anxiety, depression, alcohol and drug abuse, and suicide.

In recognition of the need to invest in mental health interventions, Health Minister Datuk Sri Liow Tiong Lai set up the Mental Health Promotion Advisory Council, which operates under his direct supervision. As a result of the council’s recommendation, six schools have been identified as pilot projects for the “Sekolah Minda Sihat” project.

This involves special training for school teachers to act as counselors with the capacity to detect and provide necessary intervention for students requiring help.

Another pilot project is the “Klinik Kesihatan Minda Sihat”, where several primary care clinics have been identified for capacity building that will lead to more comprehensive community mental health services.

While the government’s efforts in taking a serious view of mental health issues is laudable, the responsibility of investing in mental health falls on all of us.

Individuals, groups, charities, and businesses should also be looking to see what can be done to improve our mental health and well being. CSR or corporate social responsibility in mental health issues is dismal compared to some other countries in the region.

In addition, corporate houses have not woken up to the fact that depression at the work place, often disguised as physical complaints, can result in absenteeism and loss of productivity. It would be better for big corporations to invest in some form of Employee Assistance Programme in order to take proactive measures to prevent work-place stress and depression.

Statistics are unavailable from Malaysia, but in developed countries like the United States, it has been estimated that 35-45% of absenteeism from work is due to mental health problems, namely depression and substance abuse.

Social benefits and insurance schemes do not adequately address the needs of persons with mental illness. A caring society must be able to look after the needs of all people with disabilities, including those with mental disabilities. Non-government organisations need to be bold in advocating the needs of persons with mental disabilities, besides the promotion of mental well being for the general population.

The extraordinary transformation in ethical, legal, and political responses to the AIDS epidemic or the epidemic of tobacco-related diseases demonstrate that concerted efforts by institutions, professionals, families, and organisations can lead to positive changes in people’s lives. This courageous transformation is yet to take place for those suffering from chronic mental illness.

The great push in investing in mental health is a timely call in recognition of the huge cost in terms of human misery, disability, and economic costs due to mental illness. As a nation, we should strive to support more and better services for those with mental disabilities as we engage in promotion of mental well being for society in general, so that every Malaysian lives a life that is healthier and richer – a life that is lived with dignity .

Dr Andrew Mohanraj is a World Health Organization mental health expert and member of the Mental Health Promotion Advisory Council to the Minister of Health, Malaysia.