Mental health, NTDs and universal health coverage: no health without mental health

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Friday, 5 April 2019

Dr Julian Eaton is Mental Health Director at CBM International and Co-Director at the Centre for Global Mental Health, London School of Hygiene & Tropical Medicine

Mental health is key to wellbeing and living a good life. It is mentioned in several Sustainable Development Goals and is explicitly in the title of Goal 3 – health and wellbeing.

The WHO estimates that 1 in 4 people will experience a mental health problem that would benefit from care and support sometime in their life.

In fact, mental conditions are a leading contributor to the global burden of disease, accounting for a high proportion of total disability-adjusted life-years (13.0% of all DALYs) and are the cause of one third of all years lived with disability (YLD) – more than any other health condition. 

Links between mental and physical ill health

Yet people living with mental illness are among those most likely to be excluded from health services and other sectoral interventions, despite overwhelming evidence of the close links between mental health and virtually every major issue in development – from education and economic growth, to conflict and climate change.

There are also important associations between mental and physical ill health. In the case of neglected tropical diseases (NTDs) for example, there are increased rates of mental illness across the full range.

The mechanisms for this link might be a direct neurological effect of the disease (e.g. Chagas disease, onchocerciasis, or neuro-cysticercosis), or the psychological impact of symptoms like persistent pain, itching or blindness.

Stigma and social exclusion

Probably the most important factors leading to the commonest comorbid conditions, depression and anxiety, are stigma, social exclusion and the inability to fulfil social roles that is a consequence of some NTDs. 

Despite the high rates of disability caused by mental conditions, only 15% of people with significant needs are able to access the care they need in the poorest countries, as mental health services are grossly under-resourced. 

Given the fact that people affected by NTDs tend to be in the poorest communites, and from other marginalised groups, they are even less likely to access care.

World Health Day and universal health coverage

World Health Day on 7 April is focusing on universal health coverage (UHC) this year.

Despite the tremendous progress in the NTD field in terms of prevention through investment in mass administration of preventive chemotherapy, access to appropriate treatment, rehabilitation and support for the physical and mental health needs of people affected by NTDs is still very low. This is due to the fragility of health and social services in the countries where the majority live. 

There are challenges to ensuring good coverage for mental health of people affected by NTDs across the three domains of UHC. 

The three dimensions of universal health coverage (World Health Organization)

Populations covered: People with NTDs and mental conditions are among the most marginalised in society, often also having other vulnerabilities, which makes it less likely that they will access care. This could because they are very poor, live far from services or have other disabilities.

Services provided: In comparison to other parts of the health sector, mental health services are routinely the least well developed and resourced.

In many sub-Saharan African countries, 85% of people do not have access to mental health services, and those that do exist are of poor quality.

Affordable care: Although mental health contributes around 13% towards total burden of disease (by DALYs), national health budgets routinely allocate less than 5% (often less than 1% in the poorest countries) to mental health.

This means that many people need to pay out-of-pocket for care, even at government services, and financial protection mechanisms for physical healthcare often do not extend, or even exclude mental healthcare.

NTDs and mental health

There has been an increased interest in the links between mental health and NTDs in the last few years, and a number of research programmes are examining these mechanisms, and possible interventions to address mental health and stigma in the context of NTDs.

Many NGOs, led by those working in leprosy, now routinely include psychosocial support in their programmes. The WHO, in collaboration with the NTD NGO Network (NNN) is developing a manual to guide mental health interventions in NTDs, and Lepra is leading work on a guide to addressing health-related stigma.

Other resources have already been developed by the Disease Management, Disability and Inclusion Working Group of NNN; available online.

Despite this, mental health and wellbeing are not yet seen as an essential part of national NTD programmes.

More collaboration needed

The field of global mental health has made great progress in developing effective, feasible and cost-effective interventions for mental health in the poorest settings where that are most affected by NTDs.

RSTMH and other organisations concerned with fostering progress in NTD research and services reform can play an important role in facilitating greater collaboration for evidence generation and increased resources.

With closer collaboration between the fields of global mental health and NTDs, the mental health needs of people affected by NTDs can be addressed as part of a comprehensive approach to their care, and we can start to genuinely envisage a world with universal health coverage.

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More information

  1. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness, Lancet Psychiatry 2016; 3(2)
  2. Bailey F, Mondragon-Shem K, Haines LR, Olabi A, Alorfi A, Alvar J, Hotez P, Ruiz-Postigo JA, Adams ER, Velez I, Al-Salem W, Eaton J, Acosta-Serrano Á, Molyneux D. Cutaneous leishmaniasis and comorbid major depressive disorder: A systematic review with burden estimates. PLoS Negl Trop Dis 2019; 13(2)
  3. Litt E, Baker MC, Molyneux D (2012), Neglected tropical diseases and mental health: a perspective on comorbidity, Trends Parasitol. 28(5):195-201.Lund C et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5(4)
  4. Mackenzie J, Kesner C. Mental health funding and the SDGs: What now and who pays? London: Overseas Development Institute, May 2016.