Investment in mental health care

The World Mental Health day is being celebrated this year in October with the theme given by the World Federation for Mental Health (WFMH) of "The Great Push: Investment in Mental Health Care". This theme has been chosen with great care because of the fact that the increasing incidence and prevalence of mental illness world over is taking its toll on the economy of the world.
According to the WHO: around 450 million people in the world suffer from a mental or behavioural disorder, more than 150 million persons suffer from depression at any point in time, nearly 1 million commit suicide every year, about 25 million suffer from schizophrenia, 38 million suffer from epilepsy and more than 90 million suffer from an alcohol or drug use disorder.
According to WHO, prevalence of depression in hypertension is 29%, myocardial infarction: 22%, epilepsy: 30%, stroke: 31%, diabetes: 27%, cancer: 33%, HIV/AIDS: 44%, Tuberculosis: 46%. Mental disorders impose a range of costs on individuals, households, employers and society as a whole. In many developed countries, 35% to 45% of absenteeism from work is due to mental health problems. In United States mental illness is considered responsible for 59% of the economic costs derived from injury or illness-related loss of productivity. A report from Canada revealed absences for psychological reasons had increased 400% from 1993-1999 and the cost incurred amounted to $3 million in the year 2001. In UK, people with psychosis took an average of 42 days a year off work. In the United States 5-6 million workers between the ages of 16 and 54 years either lose, fail to seek, or cannot find employment as a consequence of mental illness.
Mental illness accounts for over 15% of disease burden in developed countries. In EU at least 83 million people suffer from mental health problems-16.7 million in UK.
Stigma may also explain the reluctance of citizens and governments to support new investment in mental health care. There is a prevailing tendency to exclude people with mental health problems from mainstream economic and social life. To counteract this, public interventions aimed at reducing the stigma attached to mental health problems are required. Political leadership may be required to bring mental health problems to the notice and attention of citizens, who may be unwilling or unable to confront such issues. Higher levels of engagement by citizens in mental health issues will, in turn, provide support and sustenance for the increase in expenditure that is required from government.
Pakistan is a country where mental health is still not a high priority area. The current background scenario about the mental health is quite gloomy keeping in view the violent political situation in the country that is causing a great increase in the incidence of mental illness. A large number of population (more than 20%) suffers from depression and its associated complications. There are a number of reasons that affect the mental health in terms of economic barriers: poor economic conditions, vulnerable currency, low priority, low willingness to pay, centralised budgets, poor co-ordination across agencies and capacity-constrained systems.
The out-of-pocket expenditure in getting treatment for mental disorders is the most prevalent pattern despite the availability of big government hospitals. Out of the total allocated budget for health, only 0.4% is being spent on mental health. According to a locally produced WHO government report, of all the expenditures spent on mental health, 11% are devoted to mental hospitals. This rate is lower than other low and middle income countries. Only 5% of the population has free access to essential psychotropic medicines.
For those who pay out-of-pocket, the cost of antipsychotic medication is 3% and antidepressant medication is 7% of the one day minimum daily wage in local currency. The cost of antipsychotic medication is 2dollars per day, and the cost of antidepressant medication is 5 dollars per day. According to the same report, there are 342 psychiatrists in the country, 478 psychologists, 3145 social workers, 22 occupational therapists and 102597 other mental health workers. In terms of research, 6% of all health publications in the country were on mental health.
The will of the government is vital in terms of allocating appropriate finances in order to develop mental health services in the country. The international organisations are taking this matter very seriously in view of morbidity of mental disorders and the tremendous economic loss associated with this. Pakistan cannot ignore the fact and should join the world community in addressing this issue.
Adequate and sustained financing is one of the most critical factors in the realisation of a viable mental health system in the country. Resources should be allocated specifically to priority underserved and at-risk populations. Prepayment systems like the general taxation and social insurance including the mental health services are one clear way to achieve these objectives. Accountability for existing mental health resources should be a critical component of planning and budgeting. Information systems for monitoring expenditures and services are crucial to ensure equity, effectiveness and efficiency. Funds should be shifted from institutions to community care and there should be better integration of mental health to primary care. The government, voluntary organisations and international agencies, along with individual pockets, could help improve the existing scenario.
(The writer is a Professor of Psychiatry, Memorial University of Newfoundland, Canada)