Investing in MENTAL HEALTH This publication was produced by the Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health, World Health Organization, Geneva. For further information and feedback, please contact: Department of Mental Health and Substance Dependence, Avenue Appia 20, 1211 Geneva 27, Switzerland Tel: +41 22 791 21 11, fax: +41 22 791 41 60, e-mail: [email protected], website: www.who.int/mental_health WHO Library Cataloguing-in-Publication Data World Health Organization. Investing in mental health. 1.Mental disorders - economics 2.Mental disorders - therapy 3.Mental health services - economics 4.Mental health services - economics 5.Cost of illness 6.Investments I.Title. ISBN 92 4 156257 9 (NLM classification: WM 30) © World Health Organization 2003 All rights reserved. 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Designed by Tushita Graphic Vision Sàrl, CH-1226 Thônex, Geneva Cover photo: © World Health Organization Printed by Nove Impression, Switzerland Content Introduction 3 Executive Summary 4 What is mental health? 7 The magnitude and burdens of mental disorders 8 The economic burden of mental disorders 14 Promoting mental health; preventing and managing mental ill health 26 The gap between the burden of mental disorders and resources 36 WHO Global Action Programme (mhGAP) 40 Much can be done; everyone can contribute to better mental health 43 References 46 For more information 48 Photo: © WHO, P. Virot Photo: © WHO, P. 2 Introduction by the Director-General Mental health has been hidden behind a curtain of stigma and discrimination for too long. It is time to bring it out into the open. The magnitude, suffering and burden in terms of disability and costs for individuals, families and societies are staggering. In the last few years, the world has become more aware of this enormous burden and the potential for mental health gains. We can make a difference using existing knowledge ready to be applied. We need to enhance our investment in mental health substantially and we need to do it now. What kinds of investment? Investment of financial and human resources. A higher proportion of national budgets should be allocated to develop- ing adequate infrastructure and services for mental health. At the same time, more human resources are needed to provide care for those with mental disorders and to protect and promote mental health. Countries, especially those with limited resources, need to establish specifically targeted policies, plans and initiatives to promote and support mental health. Who needs to invest? All of us with interest in the health and development of people and communities. This includes international organizations, development aid agencies, trusts/foundations, businesses and governments. What can we expect from such investment? It should be able to provide the much-needed services, treatment and support to a larger proportion of the nearly 450 million people suffering from mental disorders than they receive at present: services that are more effective and more humane; treatments that help them avoid chronic disability and premature death; and support that gives them a life that is healthier and richer – a life lived with dignity. We can also expect greater financial returns from increased productivity and lower net costs of illness and care, apart from savings in other sector outlays. Overall, this investment will result in individuals and communities who are better able to avoid or cope with the stress- es and conflicts that are part of everyday life, and who will therefore enjoy a better quality of life and better health. Lee Jong-wook 3 Executive Summary For all individuals, mental, physical abilities, cope with the normal stresses This publication aims to guide you in and social health are vital and inter- of life, work productively and fruitful- the discovery of mental health, in the woven strands of life. As our under- ly, and make a contribution to their magnitude and burdens of mental dis- standing of this relationship grows, communities. Unfortunately, in most orders, and in understanding what can it becomes ever more apparent that parts of the world, mental health and be done to promote mental health in mental health is crucial to the overall mental disorders are not accorded the world and to alleviate the burdens well-being of individuals, societies and anywhere near the same degree of and avoid deaths due to mental disor- countries. Indeed, mental health can importance as physical health. Rather, ders. Effective treatments and inter- be defined as a state of well-being they have been largely ignored or ventions that are also cost-effective enabling individuals to realize their neglected. are now readily available. It is there- fore time to overcome barriers and work together in a joint effort to nar- The magnitude and burdens of the problem row the gap between what needs to be done and what is actually being • As many as 450 million people suffer from a mental or behavioural disorder. done, between the burden of mental disorders and the resources being used • Nearly 1 million people commit suicide every year. to address this problem. Closing the • Four of the six leading causes of years lived with disability are due to gap is a clear obligation not only for neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia the World Health Organization, but and bipolar disorder). also for governments, aid and devel- opment agencies, foundations, • One in four families has at least one member with a mental disorder. research institutions and the business Family members are often the primary caregivers of people with mental community. disorders. The extent of the burden of mental disorders on family members is difficult to assess and quantify, and is consequently often ignored. However, it does have a significant impact on the family’s quality of life. • In addition to the health and social costs, those suffering from mental illnesses are also victims of human rights violations, stigma and discrimi- nation, both inside and outside psychiatric institutions. 4 The economic burden of mental disorders Given the prevalence of mental health and substance-dependence problems in adults and children, it is not surprising that there is an enormous emotional as well as financial burden on individuals, their families and society as a whole. The economic impacts of mental illness affect personal income, the ability of ill persons – and often their caregivers – to work, productivity in the workplace and contributions to the national economy, as well as the utilization of treatment and support services. The cost of mental health problems in developed countries is estimated to be between 3% and 4% of GNP. However, mental disorders cost national economies several billion dollars, both in terms of expenditures incurred and loss of productivity. The average annual costs, including medical, pharmaceutical and disability costs, for employees with depression may be 4.2 times higher than those incurred by a typical beneficiary. However, the cost of treatment is often completely offset by a reduction in the number of days of absenteeism and productivity lost while at work. Alleviating the problem: prevention, promotion and management programmes A combination of well-targeted treatment and prevention programmes in the field of mental health, within overall pub- lic strategies, could avoid years lived with disability and deaths, reduce the stigma attached to mental disorders, increase considerably the social capital, help reduce poverty and promote a country’s development. Studies provide examples of effective programmes targeted at different age groups – from prenatal and early infancy programmes, through adolescence to old age – and different situations, such as post-traumatic stress following acci- dents, marital stress, work-related stress, and depression or anxiety due to job loss, widowhood or adjustment to retire- ment. Many more studies need to be conducted in this area, particularly in low- and middle-income countries. There is strong evidence to show that successful interventions for schizophrenia,