Mainstreaming mental health
T. Bedirhan Üstün
Group Leader, Assessment, Classification and Epidemiology, World Health Organization, 1211 Geneva 27, Switzerland
Mental health is a vitally important aspect of public health that has long been segregated and neglected (1). The articles in this months theme section signal that its time to move mental health into the mainstream of health policy and practice.
What does our science of today have to offer for dealing with mental illness? The current issue provides some good samples of recent developments. The human brain is the most complex object of investigation in the history of scientific endeavour says Hyman (pp. 455463), and gives us a useful overview of cutting-edge research issues in psychiatry. All the available evidence suggests that mental illnesses are disorders of the brain, and so for all practical purposes, such as research and service provision, these illnesses should be viewed no differently from others such as diabetes and hypertension.
In retrospect, we can see that the underlying role of brain mechanisms was already brought to light by Cades first report in 1949 on how lithium salts were effective in treating bipolar disorders. Cades article appears as our public health classic for this month, and Mitchell & Hadzi-Pavlovic discuss its repercussions (pp. 515517). It is sad to observe that even now, over 50 years later, most of the efficacious treatments that exist are still not available in most parts of the world.
Elsewhere in this issue, scientists from the International Consortium of Psychiatric Epidemiology discuss surveys carried out in different countries which show how, despite some differences in frequency, a common picture is emerging (pp. 413426). Mental disorders are very common, begin early in life, and should therefore be viewed as long-term recurring illnesses. In addition, there are long delays between the onset of a disorder and receipt of care. These findings are highly pertinent for building effective programmes and deciding on the targets and timing of interventions.
That mental disorders are a significant cause of disability (2) and account for more than 10% of the global burden of diseases (3) has come as a surprise to many. In this issue Vos & Mathers show how data obtained from a general population survey in Australia was used to calculate the part played by mental disorders in the overall burden of disease (pp. 427438). Their findings provide an independent empirical validation of the figures published three years ago by Murray et al. (3).
Recognizing a problem is only the first step towards solving it. Some research articles in the current issue take the next step and attempt to answer questions of what needs to be done. Simon (pp. 439445) shows how at least 45% of depressed patients receiving treatment in primary care appear to experience remission and this may well be an important indicator for long-term prognosis and planning. Many other successful mental health care delivery systems are emerging (4). Since 6095% of the people in the world with a mental disorder turn first to primary care facilities for help (5), this may form the basis for interventions such as primary mental health care.
Despite so much real possibility, surprisingly little is put into practice. Andrews et al. (pp. 446454) ask why the burden of disease persists when efficacious treatment is known to be available. Their answer is that nearly half of those who need treatment do not seek it, and data on those who do obtain it reveal a huge gap between efficacy in clinical trials and effectiveness in actual health care practice. The gap is similar for a wide range of medical problems, and its causes include such factors as scarce resources, poor continuity of care, and patients lost to follow-up. Mental health care also encounters specific barriers, however, such as stigma which discourages patients to seek care, and discriminatory allocation of resources.
How to bridge this gap remains the key question for policy. It is a challenge for both industrialized and developing countries. The US Surgeon General recently published a report on mental health (6) confirming that research had produced effective treatments and delivery strategies for many mental disorders, but they were not put to use effectively. We include an article on mental health practice and policy in Latin America by Alarcón & Aguilar-Gaxiola (pp. 483490), and in Africa by Gureje & Alem (pp. 475482). They are the first regional reviews of this type to be published. In addition, Jernigan et al. (pp. 491499) discuss the public health need for a global alcohol policy. Kessler, in his reflection on the future of psychiatric epidemiology, calls for a move beyond current fixation on description to developing, implementing, and evaluating interventions (pp. 464474).
Further practical considerations are put forward in a brief report by worldwide experts on their work on WHOs agenda for mental health, with commentaries on it from 10 other distinguished mental health experts working in different parts of the world (pp. 500514). The points of view expressed in this Round Table provide important input to policy discussions currently going on in WHO and around the world, and the search for sound, practical applications. We encourage readers to contribute to the debate in forthcoming issues of the Bulletin.
The universe of mental health is vast and multidimensional. Common mental disorders in primary care, reviewed by Kwame McKenzie in this issue (p. 564), indicates that a vast storehouse of knowledge and a treasury of gems of perception and description already exist. We have extensive evidence for effective treatments and interventions and their impact on human development. Now we have to make that evidence clearly and widely known, so that mental health becomes an integral part of the international health agenda.
1. Üstün TB. Global burden of mental disorders. American Journal of Public Health, 1999, 89 (9): 13151318.
2. Ormel J et al. Common mental disorders and disability across cultures. Journal of the American Medical Association, 1994, 272: 17411748.
3. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 19902020: Global burden of disease study. Lancet, 1997; 349: 14981504.
4. Gregory E et al. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. British Medical Journal, 2000, 320: 550554.
5. Üstün TB, VonKorff M. Primary mental health services: access and provision of care. In: Üstün TB, Sartorius N, eds. Mental illness in general health care: an international study. Chichester, John Wiley & Sons, 1995.