Public mental health

Prevalence of mental disorder

WHO estimates that about 450 million people worldwide suffer from neuropsychiatric conditions (WHO 2001). Mental and behavioural disorders are found in all countries, in women and men at all stages of life, amongst the rich and poor, and amongst rural and urban people.

Surveys to determine the prevalence of mental disorder have been carried out since the end of the World War II; however, the use of a range of different diagnostic instruments and methods have made it difficult to make cross-national comparisons or even assess longitudinal changes within countries. Moreover, different studies have measured ‘point prevalence’ (people who have a condition at a point in time), ‘period prevalence’ (presence of disorder in a particular time period such as one year), or ‘lifetime prevalence’ (having suffered from a disorder at some point in their lives) and, unless it is made very clear in the study what is being measured, and this has not always been the case, comparisons are difficult. Analysis by WHO in 2000 indicated a 10 per cent point prevalence of neuropsychiatric conditions in adults (WHO 2001) and that around 25 per cent of individuals will develop one or more mental or behavioural disorders in their lifetime.

Most studies have found the overall prevalence of mental disorder to be almost the same for men and women. However, almost all studies show a higher prevalence of depression amongst women than men with a ratio of between 1.5:1 and 2:1 as well as higher rates of most anxiety and eating disorders. On the other hand, men have higher rates of attention deficit hyperactivity disorder, autism, and substance abuse disorders (Hyman et al. 2006).

In the 1990s, the World Health Organization Composite International Diagnostic Interview (WHO CIDI) was used to determine both prevalence of mental disorder in countries and to assess cross-country differences. While prevalence varied widely, in most countries, more than one third of respondents were found to have had a mental disorder in their lifetime. In 1998, WHO established the World Mental Health (WMH) Survey Consortium to refine the CIDI and conduct mental health surveys around the world. The instrument was modified to measure not only prevalence but also severity, impairment and treatment (WHO 2004). Twenty-eight countries, including both high- and lower-income countries in each region of the world participated in the survey. More than 2 00 000 interviews were conducted. Results of the first 14 countries that had completed the survey were reported in 2004 (WHO World Mental Health Survey Consortium 2004). This included three countries in the Americas, seven in Europe, one in the Middle East, one in Africa, and two in Asia. Six countries were classified by the World Bank as less developed and the others developed.

As seen in Table 9.7.1, the overall prevalence varied from 4.3 per cent in Shanghai, China, to 26.4 per cent in the United States with a 9.1–16.9 per cent inter-quartile range (WHO 2004). The most common disorders found were anxiety and depression (with a high level of co-morbidity). In all but one country, anxiety disorder had the highest prevalence (2.4–18.2 per cent) followed by depression (0.8–9.6). Importantly the proportion of disorders classified as mild is substantial—from 33.1 per cent in Colombia to 80.9 per cent in Nigeria. However in cases of serious mental disorder most respondents reported at least 30 days in the past year where they were totally unable to carry out their usual activities.

It has been recognized by the designers of the WMHS that some of the variation found may be attributable to extraneous factors. For example, perceived stigma is likely to have played an important part in the lower prevalence rate observed in those countries were mental health stigma is highest (Kessler et al. 2006).

Determining the prevalence of serious mental disorder, such as schizophrenia, usually requires more specialized and specific studies than the one above and a number have been conducted. A systematic review by Saha and colleagues (Saha et al. 2005) identified 188 studies conducted between 1965 and 2002. Table 9.7.2 shows the mean estimates found.

No significant differences were found between males and females and between urban, rural, and mixed sites. In terms of economic status, the prevalence estimates from lower-income countries were significantly lower than both ‘emerging’ and high-income sites.

Not many prevalence studies have been conducted on psychotic disorders other than schizophrenia, though the lifetime prevalence of bipolar disorder, like schizophrenia is often assumed to be about 1 per cent (Perälä et al. 2007). A recent comprehensive study of psychotic and bipolar I disorders in Finland found a lifetime prevalence of psychotic disorders of 3.06 per cent. Lifetime prevalence of schizophrenia was 0.87 per cent, schizoaffective disorder 0.32 per cent, schizophreniform disorder 0.07 per cent, delusional disorder 0.18 per cent, bipolar I disorder 0.24 per cent, major depressive disorder with psychotic features 0.35 per cent, substance-induced psychotic disorder 0.42 per cent, and 0.21 per cent for psychotic disorders due to a medical condition (Perälä et al. 2007).

Mortality

Causes of mortality are sometimes used to determine priority levels of different disorders. While mental disorders in themselves have relatively low mortality rates, mental disorders, particularly depression and substance abuse, are associated with more than 90 per cent of all cases of suicide (Bertolote et al. 2004) and the incidence of suicide is substantial. WHO has reported that in 2000 around 1 million people died from suicide. The ‘global’ mortality rate was 16 per 1000—or a death through suicide every 40 seconds. Global suicidal rates for 2006 are shown in Fig. 9.7.1. Nearly 20 times this number attempt suicide. Moreover official suicide rates are usually substantially underestimated. In an Indian study using surveillance with validated verbal autopsy, the observed rates exceeded official national estimates tenfold (Aaron et al. 2004).

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Fig. 9.7.1

Map of suicide rates.

Source: WHO webpage on Suicide Prevention: http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html

According to WHO, suicide is among the three leading causes of death among 15–45-year-olds (men and women). The numbers of suicides has increased by 60 per cent over a 45-year period. In 2002, it was estimated that self-inflicted injuries were the fourteenth highest cause of all deaths. Projections to 2030 suggest that this will rise to twelfth place in the causes of death (Mathers & Loncar 2006).

Raised non-suicide-related mortality has also been found in, for example, people living with schizophrenia, bipolar disorder, and dementia (Heila et al. 2005; Ösby et al. 2001; Dewey & Saz 2001). A major investigation by the Disability Rights Commission (England and Wales) found that people with learning disabilities and mental health problems do not live as long as other citizens. Individuals with serious mental health problems were more likely to get strokes and coronary heart disease before 55 years of age and to survive for less than 5 years thereafter (Disability Rights Commission 2006). Reasons for this include the fact that people with serious mental disorder often live in social deprivation (see the subsection ‘Social determinants of mental (ill) health’), but also that the health services discriminate against people with mental health problems. They are less likely to receive medical checks and to be provided with evidence-based treatment.

Burden of disease

While morbidity and mortality are important measures for making health decisions, they fail to take into account important variables necessary for health planning. In response, a joint initiative of the WHO, the World Bank and Harvard University designed and conducted the Global Burden of Disease study. The GBD approach uses a summary measure—DALY—to quantify the burden of disease. DALYs combine the years of life lost due to premature mortality (YLL) in the population and the years lost to due to disability (YLD) for incident cases of the health condition.

The prominence of mental and neurological disorders from the GBD study relative to other disorders was a major revelation to many people and countries. When the DALY figures were first published in 1993, most countries found a major mismatch between the burden of mental health (10.5 per cent of all DALYs lost) and the prominence and attention given it. This was because traditionally only incidence/prevalence and mortality were measured in most international and national statistics. While these indices were well suited to acute diseases that either resulted in death or full recovery, mental and behavioural disorders, which more often cause disability, did not feature prominently. With the loss of ‘healthy life’ being elevated, mental and neurological disorders were catapulted into the limelight. Moreover projections showed that the burden due to mental disorders was likely to substantially increase relative to other health conditions. In 2002, mental and substance use disorders accounted for 13 per cent of the GBD (WHO 2004). When taking only the disability component of the burden of disease into account, mental and neurological conditions accounted for 30.8 per cent of all years lived with disability.

In 2006, Mathers and Loncar published an update of earlier DALY figures and projections on the burden of disease (Mathers & Loncar 2006). Estimates are now available up to 2030. Importantly for public mental health, as predicted, the relative burden of mental disorder is rising and is set to rise even further. By far the highest mental health cause of DALYs lost is unipolar depressive disorder and this disorder alone is likely to be the second-highest cause of all DALYs lost by 2030—second only to HIV/AIDS. In high-income countries, depression will become the single-highest cause of DALYs lost.

In Table 9.7.4, the three leading causes of DALYs lost, projected to 2030, by income group, are presented. Crucially unipolar depressive disorder is amongst the top three causes of DALYs lost in high-, middle-, and low-income countries.

Interrelationship between physical and mental health

Over the past 20 years, a fundamental and inseparable interconnection between mental and physical health has been established (WHO 2001) While thoughts, feelings, and behaviour have a major impact on physical health, physical health strongly influences mental health and well-being. There are two key pathways through which the physical and mental interact—firstly through physiological systems such as neuroendocrine and immune functioning, and secondly through health behaviour (WHO 2001). However, these pathways are not independent in that behaviour may affect physiology, while physiological functioning may in turn affect health behaviour.

There are numerous examples of how mental health status may impact on physical health and vice versa. At least one-third of all somatic symptoms remain medically unexplained. Common symptoms include pain, fatigue, and dizziness, while defined syndromes include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, chronic pelvic pain, and tempero-mandibular joint dysfunction (Prince et al. 2007). Somatization is present in around 15 per cent of patients seen in primary care and is independently associated with poor-health-related quality of life and increased healthcare utilization (Barsky et al. 2005).

A review by Prince et al. has shown strong evidence from population-based research for moderate to strong prospective associations between depression and anxiety and coronary heart disease outcomes including angina and non-fatal and fatal myocardial infarctions. They also showed strong evidence that depression is an independent risk factor for stroke. Depression is increased after myocardial infarction, mostly in the first month after the event. There is also strong evidence for co-morbidity between mental disorder and diabetes. The prevalence of diabetes among people with schizophrenia has consistently been found to be in the order of 15 per cent compared to a typical community prevalence of 2–3 per cent (Holt et al. 2005).

The interrelationships between physical and mental health are highly complex. Here, we illustrate five important mechanisms of this relationship through the example of mental health and HIV/AIDS.

Treatment efficacy

Having effective (including cost-effective) treatments available is another crucial component of whether a health condition should be prioritized. Most mental disorders can be effectively treated and at a cost that justifies intervention. Whiteford suggests that the burden of illness on the individual and society combined with treatment efficacy could be used as the basis of decisions to allocate resources (Whiteford 2000). Interventions that demonstrate the greatest health gain for the lowest cost would be the most highly prized. Mental health interventions fall into this category.

A recent analysis by the WHO of the comparative effectiveness and costs of pharmacological and psychosocial interventions for reducing the burden of mental disorders found the following (WHO 2006a):

The mental health service gap

Another reason to prioritize a condition is if the gap between the existence of a condition and the numbers of people being treated for it (especially if effective treatments are available), or programmes to prevent it, is high. Kohn and colleagues reviewed community-based psychiatric epidemiology studies and calculated the median rates of untreated cases of various mental disorders (Kohn et al. 2004). The median treatment gaps are found in Table 9.7.5.

These figures are major underestimates of the gaps globally as most of the data available are from high-income countries that have far greater availability of services. For example, in the only condition where a figure was available for Africa, there was a 67 per cent treatment gap for major depression compared with a 45.4 per cent gap for Europe. In the World Mental Health Survey, 35.5–50.3 per cent of serious cases of mental disorder in high-income countries and 76.3–85.4 per cent in middle- and low- income countries received no treatment in the 12 months before the interview (WHO World Mental Health Survey Consortium 2004). Clearly, the majority of people needing mental health interventions are not receiving it. Some of the reasons for the gap include a lack of identification of mental health problems by health workers; sufferers themselves not seeking treatment due to stigma, fear, or lack of knowledge that they have a treatable condition; lack of or unavailability of resources; seeking assistance elsewhere due to cultural beliefs; affordability; and poor health systems that do not allow or encourage treatment in the community. For many people, the only time they might receive treatment is if they become so disruptive in their families or communities that they are given involuntary treatment.

Personal and family impacts

The GBD study estimated that, in 2000, mental and neurological disorders accounted for 30.8 per cent of all years lived with disability—with depression accounting for 12 per cent of all disability (WHO 2004). This though does not capture the economic and psychological stress to individuals and their families resulting from this disability.

‘Days out of role’ is a very important measure of the macroeconomic impacts of mental disorder (WHO 2006a); however, for individuals and families, this very often means a direct and personal loss of income (especially where there are no or poor unemployment benefits). Moreover, a family member, often a woman spouse or parent, has to take time off from income-generating activities to care for the person with mental disorder. Income into the family is hence further eroded. Furthermore, due to the person’s mental disorder there are additional health care and usually transport costs (to get to a treatment centre) that need to be paid for (Patel & Kleinman 2003). As mental disorder is often chronic, these costs may be ongoing. In addition, in many countries, insurance payouts for mental disorder are limited (even discriminatory relative to other health problems). Thus, health care may become even less accessible and less available with time—and so the condition deteriorates and the need for care increases. The result of this cycle is often a ‘drift’ into poverty, with little chance for a person to move back to their pre-mental disorder life situation.

Being ill with any condition can be psychologically debilitating. This is exacerbated if one is forced out of work by one’s condition and one has to become dependent on others. But when this condition is also quite frightening to oneself and one sometimes feels out of control, when the condition is shrouded in stigma, where blame is often put on the ill person themselves and where appropriate treatment is not readily available (WHO 2001), the condition can become psychologically devastating to the individual concerned.

For families too, having a person develop and live with mental disorder, can be frightening, extremely disruptive, and a major economic burden. Especially where information and support are not available, family members may be inclined to just want to get rid of the person or to restrain or seclude them. Families too often become the object of discrimination. It has been found that carers who provide someone with substantial support are twice as likely to have mental health problems as those they are caring for (Singleton et al. 2007).

In many countries, access to and knowledge of treatment is so poor that it is only when the ill person becomes so disruptive in their family and community and they can no longer be dealt with, that help is sought. At this point, the patient is often unwilling or unable to co-operate and so involuntary care and treatment is required. Poor service accessibility hence results in higher proportions of people receiving care without their consent than would otherwise be the case.

Ideology of health

There is no health without mental health. This seemingly simple assertion, which flows directly from the WHO definition of health, contains a number of important inter-related meanings and has major practical implications for health and health services. Firstly, any reference to health or ill-health or any health condition invariably includes a mental health component. Hence, where a person has developed or contracted a ‘physical’ disease (communicable or non-communicable), or has even been physically injured, there is usually also a mental aspect that needs consideration. This is important—whether mental health may have been a risk factor of the presenting problem (for example, depression underlying risky sex behaviour resulting in HIV/AIDS or an alcohol problem resulting in a car accident), or is a secondary outcome. Mental health should thus be integral to all health assessments and treatment. Secondly, the assertion implies that a state of optimal health also implies a state of optimal mental health. Initiatives directed at attaining good population health should thus include considerations of mental health. Thirdly, if a state of health includes both physical and mental health, then clearly there can be no ‘health’ if mental disorder is present. Attending to mental health problems should therefore have parity with regard to treatment and prevention of physical conditions. Finally, following from the above points, health policy, health systems, and health service development should always include a mental health component. Hence, there should not only be no health without mental health, but no health service that does not provide mental health. Brundtland, a previous Director-General of the WHO, commented that ‘talking about health without mental health is a little like tuning an instrument and leaving a few discordant notes’ (WHO 2001).

The highly complex nature of human beings involves interacting biological, social, and mental components, and to accurately understand and improve human health, all three elements, and the interactions between them, need focus (WHO 2001). Critically, human beings are not mechanical automatons that ‘break down’ from time to time, but are dynamic and active beings that substantially shape their own state of health and illness. For example, a person’s eating habits, the amount of exercise they do, whether they avoid dangerous situations such as drinking and driving or having unsafe sex, and whether they take the medication that is prescribed and in the manner instructed, and whether they seek health care at an early stage of an illness are all fundamental to healthy human states and rely irrevocable on human agency—though decisions are often not taken at a conscious level and are often made without adequate information. People may also be limited in what they can do by their socioeconomic conditions.

Clearly then, mental factors, including personal volition and individual behaviour, are as important to states of health as are biological and social factors. Importantly though, mental states do not have an independent existence from the biological and the social and are in themselves shaped in interaction with these elements. Similarly, the mental states shape the biological and the social components. Hence, while it is useful to theoretically separate out the ‘contributors’ to health, this is an analytic exercise rather than an empirical one. The interacting process between the components begins at birth and stops only at death. Yet, despite this ‘empowering’ people to make ‘healthy’ decisions is seldom seen as an important health intervention (Peterson & Swartz 2002).

In addition to the impacts on health through behaviour, as previously seen, physical and mental states of well-being mutually affect each other (see the section ‘Interrelationship between physical and mental health’).

Mental disorders, like other health problems, also have physical, psychological, and social components. Hence, in treating and preventing mental disorder, all three components must also be considered. The mental aspect of health probably captures that which is ‘most human’ in health and without which much of human health care may be likened to veterinary medicine. Considering human health without mental health then is fundamentally flawed, and health policy, systems, and services that neglect the ‘mental’ side will inevitably be less effectual in improving the health status of populations than those that include mental health.

Current mental health services

Formal mental health services in many parts of the world, especially in poorer countries, are characterized by poor accessibility, inadequate resources, and far from optimal organization of services. Most people with mental disorders do not have medical care for their conditions (Funk et al. 2005). Many people rely on traditional remedies and traditional healers for their mental health care.

Availability of mental health professionals is a major inhibitor to treatment. Table 9.7.7 shows the median number of psychiatrists, psychiatric nurses, and psychologists working in mental health per 1 00 000 population per region (WHO 2005).

People with mental disorders often access health care in large isolated mental health institutions. A disproportionate proportion of most country’s mental health budget is spent in these institutions (WHO 2001). However, in Table 9.7.8, it can be seen that despite significant discharge of patients from psychiatric hospitals in higher-income countries and a concomitant development of community mental health services, there are still far more beds per capita in high-income than in lower-income countries. Hence, though the vast majority of mental health resources in low- and middle-income countries are indeed spent on psychiatric hospitals, these facilities still have far fewer beds per 10 000 population than is available in higher-income countries. Though for low- and middle-income countries, moving resources out of psychiatric hospitals is a necessity as additional resources for much needed mental health care in the community is often not available, reduction of bed numbers is from an already very low base.

Accessibility of services

There are a number of reasons why access to services may be limited. Here we consider only two issues: Geographical and financial access.

Pyramid of services—an optimal mix for mental health

WHO have put forward a ‘pyramid of services’ (Fig. 9.7.2) that provides an optimal mix of services required by people with mental disorders (Funk et al. 2004). This model is based on the premise that no single service can meet all mental health needs. In fact, without any one of these service levels, and referrals up and down the pyramid, the ‘system’ breaks down, and the other parts are unable to function effectively and efficiently.

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Fig. 9.7.2

Optimal mix of services.

Source: Funk et al. (2004).

At the bottom of the pyramid, and where most care is provided, is self-care. Most people can manage their own mental health problems themselves or with help from family or friends. However to facilitate the autonomy and ability of people to care for themselves, the health service or non-governmental organizations need to provide information to people. This should be available and accessible to all people through, for example radio shows or pamphlets that are distributed in languages and literacy levels that people understand.

Informal community mental health services are services provided in the community but that are not part of the formal health and welfare system. Examples of this are traditional healers, professionals in other sectors such as teachers, police, village health workers, services provided by non-governmental organizations, user and family associations, lay-persons, and so forth (see Box 9.7.1). Services at this level are important in preventing people who can effectively be cared for at this level from making demands further up the pyramid, however it is also an extremely important level for ‘down referral’. People who may have been treated in a hospital, for example, and discharged, often need informal support to prevent them from relapsing or needing care at a higher level. Informal services are usually accessible and acceptable to the community as they are an integral part of the community. It can be seen then that most mental disorders are dealt with outside of the medical system.

The first ‘formal’ mental health service is within primary health care. The integration of mental health care into primary health services is a critical component of comprehensive mental health care. Essential services at this level include early identification of mental disorders, management of stable psychiatric patients, referral to other levels where required, as well as promotional and prevention activities. Depending on who carries out first-level health care in a particular country, activities and interventions may be carried out by general practitioners, nurses, or other staff that provide assessment, treatment, and referral services.

Mental health services at this level greatly increases physical accessibility as first-level general health care is usually relatively close to where people live. In addition, the person can be treated as a whole person who may have co-morbid physical and mental health problems. We have previously emphasized the importance of interacting physical and mental health problems. Seeking and receiving treatments part of a general health care is also often less stigmatizing for an individual, especially where having a mental disorder is regarded as shameful. Services are therefore more acceptable to users than having to be treated in a psychiatric facility. From a clinical perspective, it has been found that most common mental disorders can be treated at primary care level. In situations where there are few trained mental health practitioners, an integrated approach substantially increases the chances of being treated for mental disorders.

Integration of mental health into primary health care requires careful training and supervision of staff. Staff needs to be equipped with knowledge and skills that enable them to provide mental health care through training provided as part of initial health worker training as well as ongoing in-service training (WHO 2003). Additionally, they have to be adequately supervised and supported. Health workers often feel ill-equipped and reluctant to undertake mental health in addition to other health care and so ongoing assistance is essential. Critically too, where psychotropic medication is needed, this must be available at this level. This means that these drugs need to become an integral part of the supply, storage, and distribution chain and provision must be made for the prescription of necessary drugs at this level.

Where there is no integrated first-level care, addition pressures are put on the higher levels of care. People are inappropriately referred to levels of care that should be dealing with more complex problems and where there is no early identification of problems, treatment or prevention, and promotion, more people become seriously ill and need to be treated at the higher levels.

The next level of the pyramid has two complementary components, the first is formal community mental health services and the second is mental health services in general hospitals.

In addition to the informal services that are commonly provided in communities for people with mental disorder, additional formal community services such as day centres, rehabilitation services, hospital diversion programmes, mobile crisis teams, therapeutic and residential supervised services, group homes, home help, assistance to families, and other support services are needed. While not all community mental health services will be able to provide all these services, a combination of some of these, based on needs and requirements, is essential for successful mental health care. Where there are no or highly inadequate community services, it becomes very difficult to discharge patients from psychiatric hospitals, thus ‘clogging up’ scarce and expensive hospital beds. Others who could avoid hospitalization if community care was available are unnecessarily (though necessary in the circumstances) hospitalized.

Without good community-level care, people often land up either in inhumane institutions or destitute and living on the streets. On the other hand, people receiving good community care have been shown to have better health and mental health outcomes and better quality of life than those treated in institutions (Anderson et al. 1993).

As part of the mental health system represented by the pyramid of care, it is important that the community mental health services have strong links with other services such as the primary care and informal and general hospital services.

The development of mental health services in general hospital settings with functions such as those shown in Box 9.7.2 is another critical element of the organization of services. Given the nature of mental disorders, for a number of people some hospitalization at some time (or times) during acute phases of their condition will be necessary. As with integrated primary mental health care, mental health care in general hospitals is more accessible and acceptable than in dedicated psychiatric hospitals. In any country, especially low- and middle-income countries, there are likely to be only a few dedicated psychiatric hospitals and these are usually situated in urban areas—albeit often somewhere out of town. These hospitals are very often not geographically or financially accessible to patients or families wishing to visit them (see the subsection ‘Accessibility of services’). There is also often high stigma associated with these facilities which are often the butt of highly discriminatory jokes or references. While clearly the issues of stigma needs to be directly dealt with, until such time as stigma around mental disorder and particularly psychiatric hospitals does change, most people prefer to get treatment in a general hospital. Any co-morbid conditions can also more easily be treated, and special investigations can be conducted.

At the peak of the pyramid, providing services at the highest cost to the least number of people are long-stay facilities and specialist services.

A small minority of people with mental disorders require more specialist care than can be provided at general hospital level. Especially in low- and middle-income countries, where there are very few mental health professionals, and certainly not enough highly skilled people to be available in every general hospital, it is necessary to refer people with therapy-resistant or complex presentations to specialized mental health centres—or hospitals where mental health specialists are available. Moreover, a small group of people require ongoing nursing care in a residential facility due to their mental disorder. This, however, is a far cry from ‘old style’ mental institutions.

Psychiatric institutions have a history of serious human rights violations, poor clinical outcomes, and inadequate rehabilitation programmes. They are also costly and consume a disproportionate proportion of mental health expenditure. The WHO have thus recommended replacing these institutions with a network of services in the community and, for the majority, care in general hospitals where hospitalization is warranted.

Social determinants of mental (ill) health

Research in mental health has tended to focus more on the psychological or the biological determinants of mental ill-health than the social determinants. This has led to an imbalanced focus on the use of biomedical interventions and/or a focus on treating the individual to the neglect of altering aspects of the wider social environment. Part of the reason for this imbalance in focus relates to the real difficulties in altering the social environment (especially the macro social environment) since, quite often, these are not within the control of public health practitioners. However, redressing this imbalance can make a highly significant contribution to public health or public mental health and in improving social development.

In this section, we examine four critical ways through which an understanding of the social determinants of mental health can improve public mental health.

1. Careful and scientific documentation of social and economic determinants informs mental health service planning.

Planners of mental health services need to know the extent of mental disorders within a country and whether there are differences between groups of people, but they also need to know what the reasons for these differences are. In addition, they need to be aware of particular ‘vulnerable’ groups so that they can put in appropriate prevention programmes where possible, identify problems at an early stage and/or allocate resources where they are most needed.

For example, poor and deprived people have a high incidence of mental and behavioural disorders (WHO 2001). Whether this is due to the impacts of poverty on the poor or to a ‘drift’ of the mentally ill into poverty is often debated, but in all likelihood both are true and in fact they are inextricable.

Patel and Kleinman reviewed 11 studies that examined the relationship between poverty and common mental disorders (Patel & Kleinman 2003). They found that the mean prevalence rates of depression and anxiety disorders varied between 20 per cent and 30 per cent with almost all studies showing a significant relationship between prevalence and various indicators of poverty. The association between poverty and common mental disorders was found to occur in all societies regardless of their levels of development, however they found no ‘absolute level’ that could be correlated with mental disorder.

Severe mental disorders such as schizophrenia are also highest in people living in lowest socioeconomic circumstances. Saraceno and Barbui showed that people with the lowest SES have eight times higher relative risk for schizophrenia than those in the highest SES groups (Saraceno & Barbui 1997).

Poverty cannot be said to ‘cause’ mental disorder as most people living in poverty do not have a mental disorder, however it does increase the risk of developing a mental disorder. Poverty and common mental disorders interact with one another in setting up a vicious cycle of poverty and mental illness (Saraceno & Barbui 1997). People are simply more likely to develop mental disorders in conditions of poverty. Moreover the ability of the person to confront or overcome their poverty condition, including getting treatment, is exacerbated if the person has a mental disorder, thus a ‘vicious’ cycle of poverty/mental health is created.

Access to treatment and rehabilitation is profoundly affected by poverty. People who can afford treatment, whose family members are able to support them financially and emotionally, who can go to rehabilitation therapy, have access to housing, job opportunities, and so forth have a considerable recovery advantage. Where a person has minimal financial means they often put an additional financial and emotional burden on the family. The need to plan services directed at people in poverty is evident.

Another example of how an understanding of social determinants can assist intervention planning is in conflict and post-conflict situations. Wars have significant mental health impacts on both soldier and civilian populations. Baingana et al. report that conflicts cause widespread insecurity due to forced displacement, sudden destitution, the break-up of families and communities, collapsed social structures and breakdown in the rule of law and may last even after the conflicts have ended (Baingana et al. 2005). People in war situations may also have experienced or witnessed killings, injuries, or amputations and gender-based violence. In addition, displaced peoples, whether internally or as refugees in other countries often have difficulties adjusting to losses incurred and the new circumstances they find themselves in. Symptoms of mental dysfunction associated with conflicts include sleeplessness, fear, nervousness, anger, aggression, depression, flashbacks, alcohol and substance abuse, suicide, and domestic and sexual violence (Baingana et al. 2005). Increased rates of PTSD and depression have consistently been found (Murthy & Lakshminarayana 2006). Most recently, Hoge et al. (2004) found that soldiers returning from combat in Afghanistan were more likely to have self-reported alcohol abuse problems than pre-deployment troops, while soldiers serving in Iraq had significantly higher rates of depression, anxiety, and PTSD than either troops that had not been deployed or were deployed in Afghanistan (Hoge et al. 2004). Differences between the troops in Iraq and Afghanistan were attributed to the higher direct combat exposure in Iraq.

Studies examining impacts on non-combatants has increased significantly in the past two decades. Table 9.7.9 summarizes studies that have addressed this issue.

Research has clearly demonstrated that war is a major social determinant of poor mental health. Although there is little that public health experts can do to prevent or stop wars, an important public mental health contribution that can be made is to assist the planning of services for people who require help as a result of the impacts of war.

2. Programmes for prevention of mental disorder and promotion of mental health can be organized around the information and knowledge about social determinants of mental health.

The mental health impacts of major social determinants of mental ill health can, to some extent at least, be mitigated through understanding these causes in a nuanced way and adapting interventions based on evidence from public health research. In their review of mental health and poverty, Patel and Kleinman (2003) showed that mental health was related to income insecurity including fear of losing employment, drop in income, and fear of land loss. High levels of hopelessness mediated by shame, stigma, and the humiliation of poverty were also found to decrease people’s psychological ability to cope. Some evidence was also found that social change through changing lifestyles, shifts from rural to urban areas, and lack of social support linked to change played an important role in the development of common mental disorders. The factor that they found had the most consistent relationship with poor mental health was low education. This level of information can be used to prevent mental health problems developing.

Taking the need for social support as an example of risk for the development of common mental disorder, it is highly feasible for public mental health practitioners to identify poor and vulnerable individuals and assist them in accessing support. In situations of rapid urbanization, for instance, many people lose contact with their support systems and often also their cultural roots and practices. Simply organizing get-togethers of people with similar backgrounds and providing transport can be highly cost effective from a mental health perspective but may also enable people who, because of their poor mental health status were unable to become economically productive, to more easily engage in work activities.

Helping people to acquire economic security has been shown to improve psychological well-being. The non-governmental organization BRAC in Bangladesh has developed programmes for poverty alleviation targeting credit facilities, gender equity, basic health care, nutrition, education, and human rights. By, amongst other things, alleviating the stress of being indebted to informal moneylenders, the mental health of many women has been improved (Chowdhury & Bhuiya 2001).

Providing literacy to women is another example where it has been shown that mental health can be promoted through social interventions. Cohen has demonstrated that providing women with information about and ideas from wider worlds, and by empowering them through literacy, it was possible to increase their sense of pride, self-worth, and purpose, and they were more able to exercise greater control of their lives (Cohen 2002).

3. Associations and impacts on mental health can be utilized by politicians, economists, and activists to advocate for social change.

The evidence for social determinants having negative mental health impacts alone is unlikely to bring about large social changes. However, when considered together with other reasons for change, the evidence for mental health impacts can add significant weight to arguments for change and can be constructively utilized in advocacy for change. A good example to illustrate this is in the field of women’s mental health.

Women have around a 1:1.5 or 1: 2 times higher levels of depression than men. While some variation is no-doubt attributable to biological factors, for example, in the case of post-natal depression, the social role that women play in most societies is critical. Freeman comments that the traditional role of women as primarily the bearers and rearers of children, inferior and obedient to men (socially and sexually), whose productive labour has been within the household and without power in social and political decisions, leaves many women feeling disempowered, dehumanized, and without dignity. Without an internal sense of worth, power, and value, many women withdraw into a depressed existence (Freeman 2007). He remarks further that even where there have been changes in labour market roles for women, rather than meaning equality with men it has usually resulted in women having to do ‘double work shift’—that is, work both at home and in formal employment. Often without recognition, and even censure from the male partner for not carrying out domestic duties adequately, this often results in severe psychological and physical stress. Given traditional gender roles, working-women may also experience guilt about neglecting their children—leading to further stress and internal conflict. Added to this are high levels of domestic violence. The impacts of abuse, especially in the longer term, are often more sorely experienced on a psychological than a physical level. Undoubtedly, gender discrimination and violence towards women have serious negative impacts on women’s mental health.

Analysis of gender discrimination and its consequences reveals numerous economic, social, and health reasons for change. However, the additional fact and evidence for increased prevalence of mental health problems as a result of gender discrimination provides more convincing evidence and reasons which politicians and activists could use in efforts to attain gender equity.

4. Information on social determinants provides the necessary information and impetus for authorities outside of health, that have an indirect responsibility with respect to health, to act accordingly.

Public mental health practitioners do not often have the means to bring about changes to improve mental health; however, they have the information necessary to inform authorities outside of health to make appropriate interventions. For example, because of the high correlation between mental disorder and poverty, special social programmes are usually needed. For example, people may require supported or subsidized housing or to be placed in special skills and job creation programmes or to be supported within the mainstream work environment. Public mental health practitioners have a major responsibility to communicate and persuade officials in departments outside of health to take direct responsibility for providing the necessary social support. Similar to public health practitioners who need to engage authorities involved in water and sanitation supplies to prevent physical diseases, public mental health practitioners too have an important role to play in conveying messages around social actions to be taken to improve people’s mental health.

Substance abuse is both a classified disorder in itself and, according to increasing evidence, certain substances such as cannabis may be a direct cause of psychosis (Fergusson et al. 2002). Factors that lead individuals to abuse substances include interacting social, psychological, and biological phenomena. Controlling the use of substances and thereby preventing mental disorder thus requires complex intersectoral collaborations involving both supply and demand characteristics. Clearly, while health must care and treat abusers—which also forms part of secondary and tertiary prevention—and must lead in prevention programmes such as media campaigns, the social determinants are linked to issues such as poverty and gangsterism that must be addressed primarily outside of the health system.