Closing the mental health gap

Dr Margaret Chan
Director-General of the World Health Organization

Address at the Mental Health Gap Action Programme Forum
Geneva, Switzerland

7 October 2010

Excellencies, colleagues and partners in public health, representatives of professional associations and civil society, ladies and gentlemen,

We are grateful for the support from all of you, whether financial or in the field, as researchers, practitioners, representatives of patient groups, or advocates for patient’s rights.

The magnitude of the problem we are jointly addressing can be measured, in part, by some numbers. WHO estimates that, worldwide, more than 150 million people suffer from depression. Some 125 million people are affected by alcohol-use disorders.

As many as 40 million people suffer from epilepsy, and 24 million from Alzheimer’s disease and other dementias. Every year, nearly one million people take their own lives.

WHO further estimates that mental, neurological, and substance use disorders account for 14% of the global burden of disease. Three quarters of this burden occurs in low- and middle-income countries.

But numbers alone do not measure the suffering, the isolation, the lost productivity, the brake on developing human potential, and the brake on development in general for countries.

The impact is all the more significant because so many people develop these disorders at a young age and receive no effective help, whatsoever, throughout their lives.

Today, we are moving a big step closer to addressing a central problem: the gap between the number of people with mental disorders who need, and deserve, treatment, and those who actually receive it.

In some parts of the developing world, this gap approaches 80%. How can a burden of this magnitude be ignored, when we already have the know-how? Why is the mental health gap so large?

As we all know, closing the gap faces many, sometimes interacting, barriers. Ignorance is one: public ignorance about these disorders, and political ignorance about the many ways they hold back development for countries.

People with mental disorders are stigmatized within communities and marginalized on national and international development agendas. Resources are insufficient, and they are inefficiently used, sometimes wasted on interventions that do no good, may cause harm, and have no evidence base.

Perhaps most important, efforts to close the mental health gap have been impeded by a widespread assumption that improvements in mental health require sophisticated and expensive technologies, delivered in highly specialized settings by highly specialized staff.

In other words, we face a misperception that mental health care is a luxury item on the health agenda – that care is beyond reach in resource-constrained settings where higher mortality diseases win the lion’s share of domestic and external financial support.

We now have good reason to challenge this thinking.

With publication of the mhGAP Intervention guide, we now have a simple technical tool for detecting, diagnosing, and managing the most common, and burdensome, mental, neurological, and substance use disorders, in any resource setting.

The emphasis is firmly placed on interventions that can be undertaken by busy doctors, nurses, and medical assistants working, with limited resources, at first- and second-level facilities.

Mental health problems, whether depression, epilepsy, dementia, or alcohol dependence, are real disorders. They cause death and disability. They cause suffering. They have symptoms. And they can be managed, in any resource setting.

This is the message we can now communicate with confidence.

No matter how weak the health system or how constrained the resources, something can always be done.

In a key achievement, the Intervention guide transforms a world of expertise and clinical experience, contributed by hundreds of experts, into less than 100 pages of clinical wisdom and succinct practical advice.

The guide, in effect, extends competence in diagnosis and management to the non-specialist, while respecting their busy schedules.

Medicines are effective for many of these disorders. The guide provides information on when to use, and also when not to use, specific medicines. In a balanced approach, it also covers many simple and effective psychosocial interventions, like educating the patient and family, giving advice on sleep, and linking with community sources of social support. This is feasible care, and this is first-rate care.

Development of the Guide benefitted from the work of more than 150 expert contributors and reviewers, and 20 international organizations and professional associations.

I congratulate all of you on this achievement. It has the power to change the landscape of mental health care.

Ladies and gentlemen,

Publication of the Intervention guide is the third in a logical series of steps.

First, document the mental health gap. Measure it. Make people sit up and take notice.

Second, explain what this unmet need means. Tell the story. Document the impact.

And third, show how to fill the gap. Make it feasible.

We have a simple, authoritative technical tool that extends competence to the non-specialist. But this is only the beginning.

The next critical step is to document implementation and impact with evidence gathered in countries.

WHO has initiated a programme for scaling up care for these disorders in six countries: Ethiopia, Jordan, Nigeria, Panama, Sierra Leone, and the Solomon Islands.

You will be hearing about some of these country experiences later today. You will be considering whether success can be replicated, on a much larger scale.

You will be considering the potential integration of mental health interventions into existing primary health care services. You will be looking at barriers as well as enabling factors.

Above all, you will be providing help. Help for the many millions of people debilitated by these disorders, and help to doctors, nurses, and medical assistants who want to take care of the full health needs of their patients but, up to now, lacked the knowledge and skills.

I wish you a most productive meeting.