Global Equity in Mental Health

Disability due to mental ill health is being increasingly recognized as a burgeoning problem plaguing the world. They are known to account for one in every six years lived with disability worldwide. One in eight people in the world is living with a mental illness, and this number differs across age and gender. Current mental health systems are poorly governed, resource-limited, and disproportionately distributed, with variable quality of care. The result is a worsening economic burden of mental health. With growing social and political divide, lingering civil unrest, and in the aftermath of the COVID-19 pandemic, mental health illnesses are on the rise and have only highlighted the systemic loopholes in mental health services.^[1]

In 2013, 45% of all countries had mental health policies in practice that were aligned with international human rights, and the number increased to 72% by 2024, which is still behind the fast-approaching target of 80% by 2030.^[2] Patel et al.’s study showed that low- and middle-income countries (LMICs) allocated less than 1% of their budget to mental healthcare, leading to treatment gaps higher than 75%.^[3] World Health Organization’s (WHO’s) report revealed that around half of the world’s population lives in countries where only one psychiatrist is available for a population of 200,000 people.^[1] While high-income countries have an average median number of 67.2 specialized mental health workers per 100,000 people, low-income countries and LMICs have as few as 1.1-2.4 specialized mental health workers per 100,000 people. Specialized mental health workers here included mental health nurses, who formed the largest proportion, followed by psychologists and psychiatrists.^[2] Availability of essential medications in these regions is also limited, adding to the higher burden of mental illness. This inequity in mental health is hard to ignore and has pushed global health systems to rethink mental healthcare services in LMICs and alternative evidence-based strategies towards mental health care.

The prevalence of mental illness is known to be affected by gender and age. The Global Burden of Disease Study 2021 found that the prevalence of depression and anxiety was higher in females than in males across all ages and most regions. Women had higher age-standardized disability-adjusted life years (DALY) rates than men across all ages.^[4] Differences across the genders suggest the role of social and economic factors in addition to biological factors. Additionally, LMICs contribute about 70-80% of mental health to the global pool and yet have less than 1% of their health budget towards mental health as opposed to 6-11% in high-income countries.^[5] These inequalities are driven by biological factors like gender, age, comorbidities, social factors like poverty, stigma, literacy, culture, and structural factors like rural residence and service availability.^[6] The risks for women are further compounded by gender-based violence and economic inequality, particularly for perinatal disorders.^[7]

Conversely, there is a higher prevalence of substance use disorders in men. The incidence rate for alcohol use disorders in males in 2021 was approximately 3.5 times higher than that in females, and this is expected to go up to 3.8 times by 2040.^[8] However, Ani et al.’s study only partly echoes this in Nigerian hospital-based samples, where male gender was a significant predictor for crack use only. The authors attributed this finding to limited statistical power, but it is also a revelation of the narrowing of the gender gap in LMICs for substance use disorders.^[9] This creates a demand for mental health services that are gender-sensitive – economic inclusion of women, provision of safety, better perinatal support for women, and services sensitive to the social norms about masculinity to unmask psychological distress behind substance use in men. This can aid in closing the gap that is yielded by these inequities.

The same study by Ani et al. also found that adolescents and young adults between the ages of 18 to 24 years had the highest rates of use of substances like crack, heroin, and methamphetamine.^[9] This is consistent with the finding of a large meta-analysis that estimated the median age of onset for all mental disorders to be 18 years. 50% of mental illnesses arise by the age of 14 years, and 75% of them by the age of 20.^[10] Approximately 90% of the world’s adolescents are in the LMICs, where they are exposed to poverty, conflicts, violence, poor school and family environments that intensify the risk of mental health disorders in this vulnerable age group. A systematic review similarly showed that South Asian and other LMICs had a higher prevalence of depression and anxiety among adolescents, which were linked to social and economic determinants.^[11] When mental illnesses in adolescents are unaddressed, it leads to educational, economic, and social impairment in the long term, which can perpetuate an intergenerational cycle of disadvantage and higher rates of morbidity.^[12] At the other end of the spectrum of age, central sub-Saharan Africa had the highest incidence and DALY rates for mental illness among the elderly.^[13] Addressing mental health inequities irrefutably requires age-specific approaches in addition to being gender and culture-sensitive.

The centralized tertiary mental healthcare model is definitely an integral part of mental health services, but it is insufficient to reduce the mental health treatment gap and address the inequities in LMICs. As the density of specialists is extremely low in LMICs, strengthening only the tertiary care system will not yield any benefits, especially for the poorest and remotest population.^[14] Currently, evidence has emerged that the presence of a decentralized service structure with task shifting to non-specialists and integration with primary care can be instrumental in narrowing the mental health treatment gap. The Program for Improving Mental Health Care (PRIME) and the Africa Focus on Intervention Research for Mental Health (AFFIRM) are two initiatives that exemplify how integration of mental health with primary care and task-sharing can expand access to mental health care.^[15] Alongside this, strengthening community-based platforms is particularly important, especially when stigma and poverty are strong barriers to healthcare accessibility. The systematic review on the effectiveness of community mental health delivered by lay-health workers among 4761 participants across 10 randomized controlled trials, published in the current issue, provides compelling evidence- community-based psychological interventions from lay health workers produced a pooled symptom reduction of moderate to large effect [standardized mean difference = −0.62 (95% confidence interval −0.68 to −0.56, p <0.001)].^[16] This is comparable to the SMD of -0.70 reported in a meta-analysis of specialist-delivered psychotherapy in high-income countries.^[17] This is also larger than the pooled effect size of 0.49 found in another systematic review where task-shared psychological interventions were delivered by non-specialist providers in LMICs.^[18]

A trial in Zimbabwe of the Friendship Bench intervention, i.e., delivery of primary care psychological interventions by trained lay health workers, found that such an intervention was feasible and scalable in LMICs.^[19] Similar trials modeling this intervention have also been done in Asian countries-a systematic review across 32 RCTs found that lay health workers delivered structured interventions were feasible and sustainable.^[20] Lay workers are essentially members of the same community and hence help reduce the stigma related to mental illness and ensure accessibility as well as continuity of care. The WHO-Mental Health Gap Action Programme intervention guide for non-specialist health workers aligns itself with this principle. It is structured and evidence-based that supports task-sharing and integration of mental health with primary care, routine antenatal care, HIV clinic services, and schools, and can be adapted to local contexts.^[21]

Community-based task-shared care should be the prime model of mental health service in LMICs with integration into primary care. The focus of care needs to include rapid expansion of primary care-based non-specialist delivered service, as expansion of a specialist-dependent model of care can be untenable in LMICs. Such strategies should be designed according to local relevance and with participation from community leaders and people with lived experiences. The blueprint for success in reducing the treatment gap also includes allocation of an adequate proportion of the budget, at least 5% of the healthcare budget, as suggested by the Lancet Commission of Global Mental Health and Sustainable Development, 2018.^[22] Moreover, a universal one-size-fits-all approach to the mental health system will always lead to exclusion of the vulnerable groups from care. Women require interventions that tackle structural vulnerabilities like economic agency, safety at home and at the workplace, along with amelioration of psychological distress. For adolescents, schools provide an opportune platform for mental health service delivery- specifically for early intervention and the promotion of psychological well-being before environmental and psychosocial risk factors consolidate developmental vulnerabilities into formal clinical disorders. Whereas older adults benefit most from community-based psychosocial support that recognizes their unique risk profile. At the same time, digital mental health innovations are increasingly being used to upscale mental health services. This power of technology should be leveraged to design mental health tools that are locally relevant in low-resource settings and to encourage mental health equity.

For the scientific community, it means that building up the evidence base through extensive multisite population cohort studies with integrated surveillance systems and standardized outcome measurements should be a priority. Recruitment of community-based samples over hospital-based samples will yield results that are representative of a broader population. Hence, achieving mental health equity by 2030 will need concerted efforts from all stakeholders, including researchers, specialized mental health professionals, people with lived experiences, and those from diverse backgrounds.