CLEVELAND, Ohio — Isabella was born in Barranquilla, Colombia. Isabella was raped by her uncle when she was only four years old. The traumatic incident and memories tormented Isabella through her youth and at the age of 11 she turned to drugs to escape this harsh reality. After she began to threaten suicide, she was admitted to a psychiatric hospital at the age of 15.
Following her treatment at the hospital and her continued treatment at Children International’s community center Isabella became a peer educator for the organization’s Youth Health Corps. Isabella now counsels and shares her experiences and knowledge with other youth in the area.
Isabella’s story ended positively but for other youth and adults suffering from mental illness in developing countries this is too often not the outcome. The lack of available treatment is not only a burden on the communities and people suffering from mental illness but impacts the global economy and accounts for much of the decrease in global gross domestic product.
In 2011 scholars from Harvard School of Public Health and the World Economic Forum created a report on the impact of disease on the global economy. The report estimated that noncommunicable diseases would reduce global gross domestic product by $46.7 trillion between 2010 and 2030.
While this was not a surprise to economists and global health experts the report did reveal one surprising fact, “that the largest source of those tremendous future costs would be mental disorders, which … would account for more than a third of the global economic burden of noncommunicable diseases by 2030.”
The combined direct and indirect costs of mental illness will rise to $6 trillion in 2030, up from the costs of $2.5 trillion in 2011. The team reported that this amount, adjusted for change in monetary value over time, would amount to “more than heart disease and more than cancer, diabetes, and respiratory diseases combined.” In developing countries extreme poverty and its associated lack of resources lies at the root of the problem contributing significantly to the overall burden borne by the global economy.
While first-world countries, which typically have more resources for mental health patients, contribute to the overall burden, in developing nations where mental health resources are scarce, the burden created by mental illness is much higher in terms of indirect costs. Insel, Collins and Hyman of Foreign Affairs wrote, “almost half of the world’s population lives in countries where, on average, there is only one psychiatrist for every 200,000 people; in many African countries, there is only one psychiatrist per every one million people. ”
Low-income and middle-income countries often consider mental illness to be a “first-world problem” inferring that mental health care is a luxury those in extreme poverty cannot afford. This view is thought to result in a lack of investment in mental health treatment. This is problematic because as the World Health organization reported in 2012, mental illness combined with behavioral problems is responsible for “26 percent of time lost to disability-more than any other kind of disease.”
Children International cites on their website, “The World Health Organization … estimates about 450 million people worldwide suffer from a mental health disorder, and about three-fourths of that population live in developing countries with little or no access to treatment.” The World Health Organization also reports that 800,000 people are lost to suicide on an annual basis. 75 percent of these people are from low to middle-income countries.
On a global basis the average per capita amount spent on mental health treatment is less than $2 and the average amount spent in low income countries amounts to less than 25 cents per person. Of even more concern is that approximately 85 to 90 percent of all adolescents that suffer a mental health crisis live in these same low-income countries. Despite mental illness accounting for a significant amount of lost productivity in low to lower-middle income countries, less than two percent of these countries’ total health care budgets are devoted to mental health treatment.
A woman in Johannesburg described the reality that poverty brings and how it leads to poor mental health explaining, “the thing is that where we stay, you will hear a person screaming from being beaten up in the middle of the night and there is also break-ins.” Kristin Mmari, assistant professor in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School notes, “in neighborhoods where both physical environment and social environments are considered poor, negative health outcomes become much more prevalent.” This is especially true in terms of mental health and even more so in countries that experience natural disasters.
The World Health Organization reports that mental health disorders nearly double following a natural disaster or emergency. Furthermore, in these emergency situations there are typically not enough resources to devote spending or prioritize mental health care which results in further indirect and direct costs imposed on the global economy.
Insel, Collins and Hyman of Foreign Affairs explained that this problem has not been addressed by international organizations until recently. The writers cite the health goals created by international organizations including the United Nations Millennium Development Goals had not mentioned mental health as an issue. However, treatment options are changing and offer promising results. New strategies and approaches to treatment are emerging and may provide access to mental health care for the 85 percent of untreated patients in low-income countries.
One of these new approaches is termed a task-sharing approach. Instruction by professionals in the field of psychology is utilized to educate and train nurses as well as family members in how to properly care for the mentally ill. The New England Journal of Medicine published a report in 2013 discussing the results of such a practice in the Democratic Republic of the Congo.
In 2011, the controlled trial involved 400 women in 16 different villages who were victims of sexual abuse. Trained nurses, social workers and family members counseled these women through group therapy. The results were reaffirming and showed that 90 percent of the women who were treated through the group oriented cognitive-processing therapy showed no signs of depression or anxiety symptoms after a six-month period. Compared with the 58 percent success rate of the group that received individual treatment, this was 32 percent higher. A study conducted in rural Pakistan had similar results.
The controlled trial in Pakistan that began in 2008 treated women who were suffering from prenatal and postpartum depression. The results were promising with 77 percent of women showing no symptoms of postpartum depression following treatment. This type of treatment also improved general health and well being for women in the Congo and Pakistan as well as their children. It was shown that the women who participated were much more likely to ensure that their children received vaccines vital to their health and development.
Despite the promising nature of the task-sharing approach many in government and the private sector are concerned about the cost of mental health treatment relative to the cost of other services such as vaccines and bed nets. However, due to the availability of generic medications the cost of psychiatric medicine is not nearly as high as it once was. A 2012 study by the World Health Organization of 58 low- to middle- income countries revealed that the cost of such generic medicine amounts to, on average, less than four percent of a person’s daily income.
The progression of technology has also offered the ability to treat patients at a much lower cost as well as providing access to those in rural or less populated regions of developing countries. Psychological interventions can now be carried out on mobile devices using strategies from text messaging to encouraging positive behavior incentivized through computer games.
During the Rio+20 Summit mental health advocates proposed addressing mental health issues in the Sustainable Development Goals for 2015 and beyond. Two of the proposed goals included a reduction in suicide of 10 percent and a 20 percent increase in mental health treatment of severe mental illnesses by 2020.
These developments offer hope but for those in need of treatment waiting for help can be deadly. As we understand mental health more we also understand the impact poor mental health has on both the world and especially impoverished communities. We need to take mental illness seriously as a global health problem and we should begin where it thrives most, in developing countries with little to no resources.
– Christopher Kolezynski