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Chapter
The burden of mental disorders:
implications for policy
18 José Miguel Caldas de Almeida and Sergio Aguilar-Gaxiola

implementation was usually very low (Caldas de

Introduction Almeida & Horvitz-Lennon 2010). Furthermore, the
Mental disorders are commonly occurring, seriously budget allocated to mental health has traditionally
impairing, and widely under-treated in both developed been, and still is in many countries, only a very small
and developing countries. In short, they are a major part of the overall health expenditure budget; the
cause of suffering, disability, and healthcare costs and global median percentage of government health
they account for a great portion of the global burden of expenditure dedicated to mental health is 5.1% in
disease. For example, the landmark Global Burden of high-income countries and 0.5% in low-income coun-
Disease (GBD) study demonstrated that, among the tries (World Health Organization 2011). The fact is
top 10 main causes of disability, five are mental dis- that public as well as private institutions seem to lack
orders: major depression, schizophrenia, bipolar, alco- the will to invest in improving the mental health of the
hol abuse, and obsessive–compulsive disorders population. For example, a recent report documenting
(Murray & López 1996). Most notably, all of these a comprehensive assessment of development assis-
five mental disorders manifest by age 24 (Kessler tance for health (DAH) in order to promote economic,
et al. 2005). According to a 2009 report from the social, and political development in low-income and
Committee on the Prevention of Mental Disorders middle-income countries, from both public and pri-
and Substance Abuse, mental, emotional, and sub- vate institutions, included no specific information on
stance abuse disorders are common and costly. It is mental health financing, despite the fact that DAH
estimated that around one in five young people (14– grew from $5.6 billion in 1990 to $21.8 billion in
20%) have a mental disorder, representing an esti- 2007 (Ravishankar et al. 2009). Commitments to
mated annual cost of $247 billion in the USA. These global health were made to HIV/AIDS, infectious dis-
include costs to the individual and family, as well as to ease control, reproductive health care, and tuberculo-
multiple sectors such as education, justice, health care, sis control among several others, but mental health
and social welfare (National Research Council & financing was not included (Institute for Health
Institute of Medicine 2009). Metrics and Evaluation 2010).
This situation has been changing over the last 20
The costs of mental illness years, due in great part to the contributions from
Despite the individual, family, community and societal epidemiological studies showing that mental disorders
costs of mental illness, mental health continues to be a (1) are highly prevalent, (2) are associated with higher
low priority on the public health agenda and for levels of disability than chronic physical health con-
investment worldwide. Data collected by the World ditions, and (3) affect a significant percentage of peo-
Health Organization (WHO) revealed that at the ple who do not receive the treatment they need.
beginning of the new millennium 40.5% of the coun- The Global Burden of Disease study, developed by
tries in the world had no mental health policy (World the World Health Organization, the World Bank, and
Health Organization 2001a) and that in many Harvard University’s School of Public Health, showed
countries where there was a policy, the level of that neuropsychiatric disorders are responsible for a

The Burden of Mental Disorders, ed. Jordi Alonso, Somnath Chatterji, and Yanling He. Published by
Cambridge University Press. © World Health Organization 2013.

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Chapter 18: Implications for policy

significant proportion of the global burden of disease countries, this volume adds to the body of scientific
(Murray & López 1996, World Health Organization knowledge on the burden of mental illness. This chap-
2008), and this had a huge impact on policy. For the ter summarizes key findings from this volume that are
first time, it was possible to argue that there is an relevant for policy, identifies and provides an overview
enormous disparity between the real burden of mental of several components of policy development, and
disorders and the public resources allocated for mental presents implications for public policy needed to pro-
health care, based on data from a study conducted by mote the improved health and well-being of individu-
some of the most credible institutions worldwide. als with mental illness. This chapter also considers
In keeping with the same argument on the need to policy implications relevant to both developed and
invest significant resources to remedy the burden of developing countries as they grapple with the chal-
mental disorders, the landmark book World Mental lenges of the burden of mental disorders in their
Health Problems and Priorities in Low-Income populations.
Countries (Desjarlais et al. 1995), which described the
burden of mental health problems in low-income Key findings relevant for policy
countries and highlighted the need to join efforts to
The WMH survey results confirmed that, although
decrease this burden, also played a key role in the
some variations were found across countries, mental
provision of a framework for international policy
disorders are highly prevalent in both low-and high-
makers to develop a specific agenda for action and
income countries (Demyttenaere et al. 2004). Recent
further research on mental and social health.
data from the WMH surveys on mental disorders
These undertakings made major contributions and
show that low-income countries have an average
put the conditions in place to advance the WHO
12-month prevalence of mental disorders of 14.8%,
initiatives which, in 2001, gave new momentum to
while high-income countries have an average
advocacy efforts to include mental health in the public
12-month prevalence of 16.7% (Wang et al. 2011).
health agenda: the 2001 World Health Day, the World
As a result of the methodology used in the World
Health Assembly mental health meetings and the
Mental Health Survey Initiative (Kessler et al. 2012; see
World Health Report (World Health Organization
Chapter 2), the surveys’ findings also made an impor-
2001b). The subtitle of the World Health Report –
tant contribution toward better understanding of the
mental health: new understanding, new hope – high-
impact of mental disorders, showing that the costs of
lighted the urgency of developing new knowledge on
these disorders for individuals, families, and society
the nature, causes, and epidemiology of mental disor-
are extremely high, and in some areas significantly
ders, as well as on the effectiveness of interventions
higher than the costs of physical conditions (see
and services, in order to decrease the treatment gap.
Chapter 14).
It was in this context, and acknowledging that the
GBD study estimates and projections were based
largely on literature reviews in conjunction with Disability impacts
limited and isolated studies rather than on cross- Earlier research showed that mental disorders are
national epidemiological survey data, that the World associated with a significant portion of disability
Mental Health (WMH) Survey Initiative was launched caused by disease (Bijl & Ravelli 2000, Andrews et al.
in the year 2000. Its main objective was to carry out 2001). The study of disability using the WHO
rigorously implemented general population surveys in Disability Assessment Schedule (WHODAS), included
order to: (1) estimate the prevalence of mental disor- in the WMH surveys, helped to further understand the
ders, (2) evaluate risk and protective factors for pur- magnitude of this association, showing that mental
poses of targeting interventions, (3) study patterns of disorders, although less prevalent than physical disor-
and barriers to service use, and (4) validate estimates ders, explain a higher share of the disability of a pop-
of disease burden worldwide (Kessler et al. 2006). ulation than physical disorders.
Among the mental disorders included in the
WMH surveys, bipolar disorder is one of the most
Purpose of this chapter disabling illnesses, which is not surprising given that
Using population-based, cross-national epidemiolog- psychotic disorders were not considered separately.
ical data from both developed and developing Then again, other conditions, such as post-traumatic

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Section 5: Implications and future directions

stress disorder (PTSD) and panic disorder, which are (see Chapter 12). The study of the impact on partial
usually not associated with significant disability, were disability showed that “mental disorders are associated
also found to be amongst the most disabling condi- with partial disability, over and above full disability”
tions (see Chapter 14). The results of this study point (Bruffaerts et al. 2012). This study also suggests that
to the inappropriateness of a “one size fits all” mental disorders are systematically associated, across
approach to disabilities associated with mental disor- countries, with about a one-third increase in partial-
ders. That is, the patterns of disability depend both on disability days per year compared to physical disor-
the context in which these individuals live as well as on ders. As with full disability, the impact at the popula-
the nature of the mental disorder from which they tion level of major depression on partial disability is
suffer. especially important, given its high prevalence.
The assessment of disability using the Sheehan
Disability Scale (SDS) (Sheehan 1983) makes it possi-
ble to assess disability caused by a particular disorder Individual and societal disadvantages
and its interference with people’s daily functioning. In The studies included in this volume show that mental
particular, four role domains are examined with this disorders can also affect many other aspects of the lives
scale: (1) home management, (2) ability to work, of individuals and families. For example, mental dis-
(3) social life, and (4) ability to maintain relationships orders are associated with a reduction in earnings.
with family and friends. Results obtained with SDS Using the human capital approach (Becker 1994,
also showed that disability ratings for mental disorders Kessler et al. 2008) to study the adverse individual-
are generally higher than for physical disorders, and and societal-level effects of mental disorders in coun-
this was found both in high- and low-income coun- tries with different levels of income, an analysis
tries (see Chapter 13). In addition, the report by Ormel focusing on the impact of serious mental disorders
and colleagues (Chapter 13) showed that the effect of showed that, at the individual level, they are associated
mental disorders is especially pronounced in terms of with a reduction in earnings equal to 29% of the
disability in social and personal relationships, which median within-country earnings in high-income
means that mental disorders have an impact that countries and 31% in low/lower-middle-income coun-
greatly exceeds the decrease in productivity, interfer- tries (Levinson et al. 2010; see Chapter 8). At the
ing with functions that are relevant for the establish- societal level, this reduction in earnings is equivalent
ment of meaningful relationships with family and to 1.0% of all earnings in high-income countries, 0.2%
friends, and for the development of social capital. in upper-middle-income countries, and 0.4% in low/
Days out of role due to mental disorders are a lower-middle-income countries (see Chapter 8).
major source of lost human capital, as noted by Additionally, early-onset mental disorders can
Alonso et al. (2011), who provide clear evidence that contribute to a higher prevalence of adult-onset phys-
mental disorders are among the health conditions ical disorders (see Chapter 7). Taking advantage of
most strongly associated with productivity loss (see the data collected by the WMH surveys on the onset
Chapter 11). As mentioned earlier, bipolar disorder, timing of mental disorders and physical disorders, it
PTSD, and panic disorder are related to the overall was possible to investigate the influence of early-
highest degree of disability, followed by generalized onset mental disorders and childhood familial adver-
anxiety disorder (GAD) and social phobia. However, sities on adult-onset physical disorders. Scott and
major depression has a unique importance from a Von Korff’s study (Chapter 7) showed that early-
societal perspective in terms of the impact on loss of onset mental disorders were independently associ-
productivity: it is one of the most important contrib- ated with five of the six adult-onset chronic physical
utors to days out of role, combined with pain condi- disorders studied (i.e., heart disease, asthma, arthri-
tions, cardiovascular disorders, and migraine (Alonso tis, chronic back pain, severe headache), diabetes
et al. 2011). being the exception.
The effects on productivity are not limited to full Common early-onset mental disorders are also
disability, and the WMH survey findings brought to strongly associated with low current household income
light the impact of common mental disorders and after adjusting for education, in both high-income and
physical disorders on the number of days in which upper-middle-income countries (Kawakami et al. 2012),
individuals are partially unable to perform as usual and can affect the level of educational attainment (see

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Chapter 18: Implications for policy

Chapter 4). These last findings showed that the impact society. It expresses the values and the principles
on the level of educational attainment tends to be greater that each society considers fundamental in the
in high-income countries than in middle- and low- sphere of mental health care, and defines the primary
income countries, varies across countries, and is stron- goals which that society strives to attain in terms of
ger for earlier educational milestones (i.e., primary and the mental health of its population in the future.
secondary school completion) than for later milestones Moreover, a national mental health policy: (1) states
(i.e., college entry and college graduation). Lee and col- the level of priority that a government assigns
leagues (Chapter 4) emphasize that more needs to be to mental health in relation to other health and social
done in secondary schools to reach out to youth and policies, (2) helps to develop mental health services
create an opportunity for teachers to work with parents in a coordinated and systematic manner, (3) identi-
and use a multi-domain developmental approach fies key stakeholders and allows different
toward early detection to change the course of a mental stakeholders to reach agreement (World Health
disorder in children. Organization 2003).
The study by McLaughlin and colleagues that Considering that a mental health policy is the best
examined the association of parent disorders with off- instrument to define priorities (Callahan 1995) and
spring disorders provides the first population-based select the strategies indicated to systematically develop
estimates of the proportion of offspring mental disor- mental health services and other measures needed to
ders associated with parent mental disorders, suggest- address mental health problems, WHO has dedicated
ing that “parent disorders are associated with a significant efforts to support countries in their devel-
meaningful proportion of disorder onset with little opment of national mental health policies over the last
variation across country income groups in the overall 15 years.
pattern of associations” (McLaughlin et al. 2012). The The WHO Mental Health Policy and Service
implications from this study emphasize the impor- Guidance Package (World Health Organization
tance of effective interventions for treating and 2005) established the steps that governments should
improving the functioning of parents living with a take in the process of mental health policy develop-
mental disorder in order to prevent the development ment: (1) gathering information about the mental
of mental disorders in their offspring (see Chapter 3). health needs of populations, (2) gathering evidence
Taken together, these new data suggest that the for effective strategies, (3) consultation and negotia-
magnitude of the burden of mental disorders is even tion, (4) exchange with other countries, (5) setting the
higher than that estimated before the WMH Survey vision, values, principles, and objectives, (6) determin-
Initiative. At the same time, the analysis of the data on ing areas for action, and (7) identifying the roles and
the use of services has led to the realization that, responsibilities of different sectors (World Health
despite all the efforts developed in the advancement Organization 2005).
of mental health policies (World Health Organization The results of the studies in this volume have con-
2005), the treatment gap for mental disorders contin- tributed to the increasing recognition of the need to
ues to be extremely high all over the world (Wang et al. complement mental health policy formulation with a
2011). The treatment gap represents the absolute dif- mental health action plan and related performance
ference between the true prevalence of a disorder and measures, which detail the strategies, actions, and
the treated proportion of individuals affected by the metrics that are required to realize the vision and put
disorder. The treatment gap may also be articulated as the objectives of the policy into practice (World Health
the percentage of individuals who need care but do not Organization 2005). In line with this perspective, at its
receive treatment (Kohn et al. 2004). The treatment 65th session, held in May 2012, the World Health
gap is further discussed later in this chapter. Assembly adopted a resolution on mental health –
the global burden of mental disorders and the need for
Implications for mental health policy a comprehensive, coordinated response from health and
social sectors at the country level – calling on WHO to
development “develop a comprehensive global mental health action
At the country level, a national mental health policy plan with measurable outcomes, based on an assess-
is essential for the reduction of the burden of mental ment of vulnerabilities and risks, in consultation with
disorders and the promotion of mental health in and for consideration by Member States, covering

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Section 5: Implications and future directions

services, policies, legislation, plans, strategies and pro- Further efforts will now have to be made in order
grammes to provide treatment, facilitate recovery and to acquire more accurate data on the needs for care in
prevent mental disorders, promote mental health and countries and regions that have been less thoroughly
empower persons with mental disorders to live a full studied. Additional efforts are also needed to over-
and productive life in the community” (World Health come the methodological and operational limitations
Organization 2012; p.3). that have contributed to the dearth of information
The results of the studies included in this volume regarding the specific needs of some population
have relevant implications for the way in which the groups, such as people with long-term severe mental
different steps of mental health policy development are disorders.
approached, particularly the collection of information
on the needs of populations, the definition of objec- Objectives in policy development
tives, and the selection of areas for action.
The three main objectives of any health policy –
(1) improving the health of the population, (2) respond-
Information about the mental health needs ing to people’s health needs and expectations, and
of populations (3) providing financial protection against the cost of ill
health (World Health Organization 2000) – can also be
Data-driven information about a population’s need
applied to mental health policy development and
for services is a fundamental cornerstone of mental
advancement (World Health Organization 2005).
health policy formulation. Without this information,
Having confirmed that mental disorders are not
it is not possible to identify the problems that will have
only highly prevalent, but also significant drivers of
to be addressed or establish priorities for action.
disability and largely untreated, the WMH survey
One of the best ways to assess needs for care is to results make a strong case for the inclusion of improv-
collect information about the prevalence and inci- ing people’s mental health as the top priority to be
dence of mental disorders, their severity, their impact
addressed by mental health policies.
in terms of disability, and the social and economic
At the same time, the results from the WMH
costs. Based on a methodology that allows the collec-
surveys strongly suggest that mental health policies
tion of data about most of these factors in national
should also emphasize a set of specific objectives to
representative samples of the adult population, the
address the problems that proved to have a unique
results from the WMH surveys offer participating
importance in mental health, namely the treatment
countries the possibility of formulating or revising gap, comorbidity with physical disorders, and impact
their national mental health policies based on more on disability. To do so, mental health policies should
data-driven information. The new knowledge that the
include, among their main specific objectives, issues
surveys have brought to light is crucial in facilitating
such as decreasing the stigma associated with mental
agreements among stakeholders, generating the com-
disorders, the allocation of more resources for mental
mitment of policy makers in the development of
health services and making better use of existing
national mental health policies, and creating the
resources, the integration of mental health as part of
knowledge base that must be at the core of policy
primary care, the development of community-based
formulation. care, rehabilitation through cooperation between the
The number of countries that have joined the healthcare sector and other sectors, and the develop-
World Mental Health Survey Initiative illustrates the
ment of prevention and health promotion programs,
increasing recognition of the importance of sound
among others.
epidemiologic data to support policy development.
Furthermore, the fact that 76% of all countries which
had a dedicated mental health policy in 2011 have Areas for action
updated or approved new mental health policies Health policies, in general, address the various building
since 2005 (World Health Organization 2011) suggests blocks of mental health systems (World Health
that the availability of new epidemiologic data may Organization 2007). Therefore, financing, leadership
have encouraged new efforts to develop mental health and governance, organization and delivery of services,
policies based on credible, data-driven information on information systems, human resources, and essential
the needs of populations. drug procurement must be the core components of

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Chapter 18: Implications for policy

mental health policy. Other important components disorders (Von Korff et al. 2009) and a high level of
include advocacy, legislation and human rights, promo- disability associated with mental disorders
tion, prevention, treatment and rehabilitation, quality (Chapters 13 and 14), mental health services will
improvement, inter-sectoral collaboration, research have to undergo profound changes, requiring strong
and evaluation (World Health Organization 2005). leadership and adequate governance.
The results of the studies included in this volume
reinforce the need for mental health policies that
ensure the provision of financial resources commen-
Organization of services
surate with the real magnitude and impact of mental Mental health services are the means by which effec-
health problems. They also have important implica- tive interventions for mental health are organized,
tions for other areas of action, especially leadership financed, and delivered, and the way they are
and governance, organization of services, workforce organized has a strong influence on their effectiveness.
education and training, inter-sectoral collaboration, It follows that the evidence that may be used to
and prevention and health promotion. A brief descrip- support the planning of mental services is of utmost
tion of each of these key areas for action follows. importance. There are three significant challenges
highlighted by the WMH results, each with
key implications for the organization of services:
Financing, leadership, and governance (1) limited access to mental health care, (2) high
The confirmation of the high burden of mental disor- comorbidity, and (3) a high level of disability associ-
ders yielded by the results of the studies discussed in ated with mental disorders.
this volume, together with the demonstration of the Limited access to mental health care, found in
huge treatment gap in low-, middle-, and high-income both developed and developing countries, presents a
countries (Wang et al. 2011), proves that mental health significant challenge. According to the WMH surveys,
policies are urgently needed both at the national and the proportion of respondents who needed and made
the international level. use of any mental health services in the 12 months
The WMH studies also have important implica- before the interview was only 3.4% in low/lower-
tions for financing. The burden of mental disorders middle-income countries, and even in high-income
accounts for 7.9%, 9.5%, 14.6%, and 21.4% of the countries the number rose only to 12% (Wang et al.
global burden of disease in low-income, lower-middle- 2011). This high prevalence of a lack of treatment,
income, upper-middle-income, and high-income although more pronounced for the less severe mental
countries respectively (World Health Organization disorders, is also unacceptably high among the serious
2008), while in the same groups of countries, the mental disorders. For example, only 21.7%, 30.4%, and
median percentage of the health budget allocated to 44.4% of the people with severe mental disorders were
mental health is just 0.5%, 1.9%, 2.4%, and 5.1% treated in the 12 months before being interviewed in
(World Health Organization 2011). As a consequence low/lower-middle-income countries, upper-middle-
of this huge disparity between the burden of mental income countries, and high-income countries respec-
disorders and the funding allocated to mental health tively (Wang et al. 2011). It should be noted, however,
treatment, a significant increase in financial resources that because of the high prevalence of mild and sub-
for mental health is needed, particularly in low-income threshold cases, overall, the number of those who
countries. received treatment largely exceeds the number of
The allocation of more funds, however, is not untreated serious cases in every country. The treat-
enough to reduce the treatment gap of mental disor- ment gap of mental disorders is a very serious problem
ders. The analysis of barriers impeding the improve- that has no parallel with the treatment of physical
ment of mental health services shows that inadequate disorders, as shown by the study conducted by
governance and the lack of public mental health prep- Ormel and colleagues (Chapter 13). Although 47.6%,
aration of mental health leaders are also common 58.6%, and 65.3% of physical conditions were treated
obstacles to progress in this area (Saraceno et al. in low/lower-middle-income, upper-middle-income,
2007). Furthermore, to respond to some of the issues and high-income countries, only 5.7%, 13.6%, and
revealed by studies resulting from the WMH surveys, 23.7% of the respondents with a mental disorder had
such as high comorbidity between mental and physical access to treatment in the same groups of countries.

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Section 5: Implications and future directions

To address these problems, mental health policies proven to be effective and efficient for increasing
have to include a range of strategies, including the accessibility to effective mental health treatment
allocation of more resources for the development of (World Health Organization & Wonca 2008). The
mental health services, the promotion of a more task-shifting approach has been used, for example, in
rational use of available resources, and the develop- the treatment of depression, through the development
ment of models of organization for services facilitating of programs including the provision of different types
the provision of effective and efficient mental health of intervention by community health workers
care near the places where people usually live. This (Rahman et al. 2008), non-medical health workers in
means that specific measures should be adopted to primary care (Araya et al. 2003), and trained lay health
integrate mental health care into primary care services workers (Rojas et al. 2007), with clinical benefits at
and to develop comprehensive community-based least as significant as those seen with collaborative care
mental health services, in accordance with the specific programs for depression in higher-income countries.
characteristics and resources of each country. Increasing availability and decreasing costs of new
Primary care services are less stigmatizing to peo- communication technologies such as telehealth/tele-
ple with mental disorders, and are generally more medicine can also open up new opportunities for
easily accessible and acceptable than specialized men- increasing access to care for populations living in
tal health services (World Health Organization & remote areas. Mental health policies in low/lower-
Wonca 2008). Moreover, for most common and middle-income and upper-middle-income countries
acute mental disorders, they may have clinical out- should include specific strategies that promote the
comes that are as good as, or even better than, those delivery of mental health interventions through cell
of more specialized mental health services (World phones, email, and other emerging technologies such
Health Organization & Wonca 2008). as social media.
The fact that a high percentage of people with The high comorbidity found between mental and
serious mental disorders do not have access to treat- physical disorders (Von Korff et al. 2009) is the second
ment, while a significant number of people with mild key issue highlighted by the results of the WMH sur-
and subthreshold disorders do receive mental health veys with important implications for the organization
care (Wang et al. 2011) suggests that the problem is of services. The high frequency of comorbidity sug-
not only a lack of resources but also the inappropriate gests that mental health policies should include strat-
use of services and a misallocation of resources. More egies that facilitate the development of integrated
studies are needed in order to better understand the approaches to care. By diagnosing and treating both
reasons why people with no diagnosis seek mental physical and mental illnesses, integrated care considers
health care, and to better evaluate the benefits they comorbidity and its effects on the individual as a
may have received. It is very likely that, although not whole, and meets the mental health needs of people
fulfilling all the diagnostic criteria for a mental disor- with physical disorders, as well as the physical health
der, many individuals do have significant symptoms of needs of people with mental disorders.
emotional suffering which would justify the use of Furthermore, most mental and physical disorders
some kind of intervention. are chronic course and require similar approaches to
In any case, it is reasonable to think that strategies health management. There is evidence that collabora-
contributing to a more rational use of resources and a tive models of care involving combinations of phar-
better organization of services, such as a clear defini- macological and psychosocial interventions delivered
tion of responsibilities at each level of care and an in a stepped-care manner can be effective in the treat-
effective referral system, may lead to better treatment ment of people with mental and physical comorbid-
outcomes for less severe cases at the primary care level, ities (Katon & Unützer 2006, Patel 2009). This
while specialized services would be aimed at providing evidence-based model of integrated care includes six
more differentiated care in the most serious cases. key ingredients: (1) care management (i.e., patient
In low- and middle-income countries, other strat- education and empowerment, ongoing monitoring,
egies should also be adopted to tackle the problems of and care-provider coordination); (2) evidence-based
accessibility. Task shifting (i.e., the redistribution of treatments (i.e., effective medication management
clinical roles within health systems and healthcare and/or psychotherapy); (3) expert consultation for
teams) is one of the innovative strategies that has patients who are not improving; (4) systematic

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Chapter 18: Implications for policy

diagnosis and outcome tracking; (5) stepped care; and respectively (World Health Organization 2011).
(6) technology support (i.e., creating and maintaining These figures emphasize the amount of work still
registries). Katon and Unützer (2006) have shown that needed in most countries to ensure the provision of
the collaborative care model is most effective in treat- community-based services to the population and to
ing depression, anxiety, and other common mental increase access to care and reduce the treatment gap.
disorders in primary care settings. Research also indi- The high level of disability associated with mental
cates that the collaborative care model is effective in disorders, highlighted by the WMH surveys, shows
improving medical care for patients with severe men- that psychosocial rehabilitation needs to become a
tal illness (Katon & Unützer 2006). The collaborative key component of mental health care. The huge neg-
care model has been shown to reduce suicidal ideation ative impact of mental disorders on day-to-day func-
in depressed older patients, as well as to improve the tioning, together with the consequences this disability
rates of diminishing pain severity and depression in has for individuals, families, and society, shows that
patients with arthritis (Lin et al. 2003). mental health services have to be designed to offer
Currently, the integration of mental health care into rehabilitation interventions and programs tailored to
all levels of the general health system is consensually the specific challenges that people with mental disor-
recognized as necessary to improve the quality of care ders face. These programs may focus more on the
and prevent the stigma associated with mental disorders recovery of personal or social skills, vocational reha-
and mental health care (World Health Organization bilitation, employment support, or housing, and in
2001a). The results of the WMH surveys support the most cases they require a close collaboration between
principle of the integration of mental health care into mental health services and services from other sectors
the general health system, suggesting that the adoption (e.g., social services, criminal justice). Therefore, men-
of coordinated models of care addressing the needs of tal health policies should include specific strategies to
people with comorbidities should be encouraged. integrate rehabilitation programs among the different
The rigorous identification of non-affective psy- components of mental health care.
choses was not possible with the case ascertainment Overall, the results from the WMH surveys sup-
instruments used in the WMH surveys, a limitation port the principles of the organization of services
that prevents us from drawing conclusions about the recommended by WHO, underscoring the importance
services specifically dedicated to patients with those of integrating mental health care into primary care
mental disorders. Nevertheless, the high prevalence of services, developing community-based care, combin-
non-treatment found in the group of the most severe ing prevention, treatment, and rehabilitation, and sup-
mental disorders suggests that, along with the integra- porting early identification, intervention, and health
tion of mental health care into primary care services, it promotion (World Health Organization 2003).
will also be necessary to develop community-based The application of these principles must be adapted
specialized services, prepared to respond to the specific to the existing level of resources. In accordance with the
needs of people with severe mental illness in locations “balanced care model” of services proposed by
that are not significantly remote from their homes. Thornicroft and Tansella (2002), mental health policies
Data collected for the Mental Health Atlas (World should emphasize the priority of integrating mental
Health Organization 2011) show that most of the health care into primary care services and community-
available financial resources allocated to mental health based care with hospital backup. In countries with a low
care (73% in low-income countries, 74% in middle- level of resources, the large majority of mental disorder
income countries, 54% in high-income countries) con- cases should be recognized and treated within the pri-
tinue to be absorbed by mental hospitals, leaving very mary care setting, with specialist back-up to provide
limited resources for community-based services. training, consultation for complex cases, and inpatient
Therefore, community services are not regularly acces- assessment and treatment of cases that cannot be man-
sible for a significant part of the population in most aged in primary care. Meanwhile, countries with more
countries. For instance, follow-up community care is resources may additionally include community mental
provided by the majority of facilities in only 7%, 29%, health teams, acute inpatient care, community residen-
39%, and 45% in low-income, lower-middle-income, tial care, psychosocial rehabilitation programs, and dif-
upper-middle-income, and high-income countries ferentiated specialized mental health services.

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Section 5: Implications and future directions

Human resource development Inter-sectoral collaboration

The findings in this volume provide valuable insight The associations found between mental disorders and
regarding the insufficient human resources for men- physical disorders, especially non-communicable dis-
tal health in low- and middle-income countries, eases, underscore the need for moving mental health
where between 76% and 85% of people with severe policy forward, but they also suggest that mental health
and persistent mental disorders receive no treatment policies cannot be conceived and implemented without
(World Health Organization 2012). On a systems the participation of other sectors, particularly the social
level, innovative, evidence-based educational path- work and employment sectors. As the results of the
ways will need to be developed to meet the staffing WMH surveys clearly show, not only is the comorbidity
needs for the WMH countries considered in this of mental and physical disorders very high, but these
volume. For many people in these low-, middle-, two types of disorder also share many determinants,
and high-income countries, primary care professio- characteristics, and consequences in terms of disability
nals continue to be the main point of entry, and (see Chapter 14; Ormel et al. 2008). This is especially
represent the place where their mental health jour- true for common mental disorders such as depression
ney begins and often ends. Providers of primary on the side of mental disorders, and for disorders such
health care need to be trained in the current as chronic pain, arthritis, diabetes, and insomnia on the
community-defined promising practices tailored to side of physical disorders (see Chapter 14).
the general population (Aguilar-Gaxiola 2009). One solution to improving the provision of quality
Moreover, emphasis should be placed on educational care for mental disorders is to increase exposure to
policies that focus on aligning integrated health and services by entering the physical environment of the
mental health content with secondary and higher people who are the most affected by mental disorders
education curricula to ensure that a well-trained and organizing mental health care services in and
workforce will be ready and competent to serve indi- around those environments. Being aware of the soci-
viduals in different capacities (Aguilar-Gaxiola et al. etal factors related to mental disorders, especially
2011). Given that most mental disorders have their income, educational attainment, and employment
roots in childhood and adolescence, and that the first stability, may help reduce the causes of global burden
symptoms typically occur 2–4 years before the onset of disease. For example, school environments can pro-
of a full-blown mental disorder, thereby creating a vide a convenient venue for prevention and early iden-
window of opportunity when preventive programs tification, as well as for treatment programs, and this
might make a difference (National Research may help teachers to work more effectively with
Council & Institute of Medicine 2009), early identi- parents on the early detection of mental health symp-
fication and intervention (for both physical and toms in children and prevent the potential develop-
mental health) should be available for these high- ment of full-blown mental health disorders. Early
risk children in normative environments such as identification of potential mental disorders is an
school-based health programs as well as in primary important strategy, because it is during these sensitive
care settings (Aguilar-Gaxiola 2009). periods of development (Barrett et al. 2006) that prob-
A recent recommendation for capacity building by lems begin to manifest, and changing the course of a
the Latino Mental Health Concilio (Aguilar-Gaxiola mental disorder with adequate treatment early on not
et al. 2012) provides insight into workforce education only reduces health costs but also prevents unneces-
and training resources for the development of grass- sary personal and family suffering. Furthermore, there
roots community capacity-building strategies that is increasing evidence of the effectiveness and cost-
focus on: (1) strengthening outreach and engagement, effectiveness of interventions to prevent mental disor-
(2) building mental health leadership at the commun- ders, particularly in children and adolescents (World
ity level, (3) defining mental health outcomes at the Health Organization 2012). For example, evidence has
community level and in terms that matter to the pop- shown that the incidence of adolescent depression can
ulation being served, and (4) building local capacity be reduced and that full-blown schizophrenic episodes
aimed at reducing disparities and improving mental can be prevented (National Research Council &
health outcomes. Institute of Medicine 2009). Hawkins and colleagues

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Chapter 18: Implications for policy

(2008) demonstrated the long-term effects of an inter- and adolescents through the collaboration of health
vention in elementary schools in promoting positive services and schools, and to its integration with social
functioning in school, work, and community. policies related to the rights of ethnic minorities and
Specifically, teacher training in classroom instruction other vulnerable groups.
and management, child social and emotional skill One important conclusion that can be drawn from
development, and parent workshops produced a sig- the links found between mental disorders and disabil-
nificant multi-varied effect across 16 primary outcome ity, income, education attainment, and employment is
indices (e.g., preventing mental health problems, risky that it is not possible to address the prevention and
sexual behavior, substance misuse, and crime). treatment of mental disorders without an effective
Specific effects included significantly better educa- inter-sectoral collaboration, just as it is not possible
tional and economic attainment, mental health, and to implement health-related development policies
sexual health 15 years after the intervention (Hawkins without the inclusion of mental health.
et al. 2008).
Establishing these types of links and commonalities Societal investments in disease prevention
between mental and physical disorders has helped to
stimulate the development of joint approaches at the and health promotion
international level. The 2011 United Nations Summit The findings described in this volume emphasize the
on Non-Communicable Diseases represented a great important role prevention plays in the social and eco-
opportunity to include mental health as a component nomic impact of mental and later physical disorders in
of the non-communicable disease (NCDs) agenda. Due the general population. Clearly, multifaceted health
to the efforts led by the World Federation for Mental promotion strategies that focus on disease prevention
Health (WFMH), several organizations came together are essential to addressing the treatment gap for men-
to promote the inclusion of mental health in the NCD tal disorders in low- and middle-income countries.
agenda at that high-level meeting and in the global Aguilar-Gaxiola (2009) noted the importance of
health and development agenda in the future. understanding the determinants of health outcomes
Unfortunately, in the end, mental health was briefly in populations across lifespans. Specifically, he empha-
mentioned but was not formally included on the NCD sized optimizing health outcomes by balancing invest-
agenda. Nonetheless, the available evidence is compel- ments in different sectors of society (e.g., health care,
ling and the outcome of other international initiatives education, economic development). The research pre-
with the same objective may be much more successful sented in this volume suggests that a failure to invest in
in the future. At the country level, the recognition of the the treatment of children during the primary and
links between mental and physical disorders has already secondary school years increases the likelihood of
had important implications in the fields of organiza- early school dropout and termination. Lack of school-
tion, coordination, and integration of services, leading ing has been shown to be closely associated with an
to an increasing interest in the application of the inadequate adulthood combined with limited financial
chronic disease management and collaborative care opportunities, poor employment stability, low self-
models for mental disorders. efficacy, diminished marital opportunities, and other
The integration of mental health into policies later-life opportunities (Fronstin et al. 2005, Huurre
related to other sectors – e.g., social, education, and et al. 2006, Freudenberg & Ruglis 2007).
employment policies – is strongly reinforced by the Future research is needed to determine whether,
results of the WMH surveys. In fact, given the impact and to what extent, the current poor world economy
of mental disorders on total and partial disability, a will have a long-term effect on treatment, and whether
close articulation between mental health policy, social the treatment gap will continue to widen as treatment
policies, and employment policy is of crucial impor- for mental disorders becomes scarce. Kawakami and
tance to address the problems related to the recovery colleagues (see Chapter 9) suggest carrying out longi-
of people with mental disorders and to develop pro- tudinal studies examining different developmental
grams for the prevention of mental disorders in the stages and different cultures to confirm findings
workplace. The same principle applies to the integra- from this volume and find developmental pathways
tion of mental health awareness into education poli- linking early-onset mental disorders to household
cies, in order to promote the mental health of children incomes.

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Section 5: Implications and future directions

Research children’s beliefs and motivations to marry in order

to escape their stressful home environments.
The results of the studies summarized in this volume
Because the WMH survey data, examined in this
underscore the importance of inter-sectoral collabora-
comprehensive set of studies, were cross-sectional and
tive work that focuses on the prevention and treatment
did not explore causal mediators, the findings cannot
of mental disorders. Many findings are noteworthy.
be generalized to other populations. There are other
First and foremost, consistent with previous volumes
limitations that should be noted. The first of these is
that examined data from the WMH surveys, there is an
that the WMH survey data has a limited capacity to
urgent need to respond to and reduce the negative
advance our understanding of presumed causal medi-
impact that mental and physical health conditions
ators (see Kessler and colleagues in Chapter 2).
have on the lives of people from different cultural
Second, the WMH surveys did not assess which mental
and social settings. Secondly, prevention and early
disorders (e.g., psychosis, substance abuse) are signifi-
intervention strategies to address mental disorders
cantly associated with income and earnings. This is
and/or the course of a severe mental disorder lie at
important, because such an assessment might shed
the individual and also the population level, in that
light on the economic effects of early-onset mental
such strategies must be tailored to the environment in
disorders in low-income countries, where previous
which people live and interact. Third, in combination
analyses have failed. The final limitation is the cross-
with the burden of disability that mental disorders
sectional nature of the data presented in this volume.
create, low treatment rates suggest that more attention
Future research with WMH survey data should inves-
should be directed toward prioritizing health needs,
tigate inter-sectoral collaborations with an emphasis
prevention, and early intervention, and placing
on prevention and health promotion, rather than
emphasis on social determinants of health. Finally,
solely treatment, as potential solutions to the plight
several of the chapters from this volume focus on the
of mental illness. Moreover, future research should
significant associations between marital and parental
examine the social determinants of health and
factors and mental disorders.
human capital as factors associated with reducing
As noted by Breslau and colleagues in Chapter 5,
stigma and quality of care across multiple years.
mental disorders have a significant impact on the
amount of time people devote to marital relationships.
In other words, people with mental disorders have Conclusions
more difficulties managing interpersonal relationships The results of the WMH surveys included in this
over time, therefore increasing the likelihood of volume have important implications for policy. First,
divorcing or separating after marriage. As a possible they strongly reinforce evidence supporting the urgent
explanation for this negative association, previous need to invest in the development and improvement of
researchers (e.g., Raj 2010) have stated that marriages mental health systems, and they prove that this must
between adolescents may sometimes be the result of an be done across the board – in low-, middle-, and high-
escape from a stressful home environment. This find- income countries. Second, they help us to understand
ing supports the notion of exploring early preventive why it is so important to integrate mental health policy
solutions to address not only the life course of a mental into general health policy, as well as into social poli-
disorder, but the negative impact that divorce has on cies. Finally, they provide a new understanding of
the early life conditions of children and the subsequent associated factors, course, comorbidity, impact, and
risk for violence in marital relationships. Along similar treatment of mental disorders that is relevant for
lines, in Chapter 3 McLaughlin and colleagues action in several areas of mental health policy (e.g.,
explored parent psychopathology and offspring men- organization, financing and provision of services, pre-
tal disorders. Their findings that a pervasive pattern of vention, psychosocial rehabilitation, child mental
sub-additive interactions among comorbid parent dis- health services and interventions, inter-sectoral collab-
orders predicts offspring disorders contributes to the oration, workforce development and training).
literature of the WMH surveys in that parents who live The results of the surveys should strongly encour-
with a mental disorder are more likely to engage in age governments to revise, update, and develop mental
negative parenting behaviors and create a stressful health policies and plans based on the existing knowl-
environment that leads to the continuation of the edge of the burden of mental disorders, and taking into

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Chapter 18: Implications for policy

consideration the available evidence on the cost- Aguilar-Gaxiola, S., Loera, G., Méndez, L., Latino Mental
effectiveness of services and interventions. They also Health Concilio, & Nakamoto, J. (2012). Community-
call the attention of policy makers to the need to Defined Solutions for Latino Mental Health Care
Disparities Project, Latino Strategic Planning Workgroup
improve the provision of integrated mental health
Population Report. Sacramento, CA: UC Davis. http://
care, through strategies contributing to the develop- www.ucdmc.ucdavis.edu/newsroom/pdf/
ment and provision of community-based services, the latino_disparities.pdf. Accessed Dwecember 2012.
integration of mental health treatment and care into Alonso, J., Petukhova, M., Vilagut, G., et al. (2011). Days out
primary care services and general hospitals, the of role due to common physical and mental conditions:
strengthening of psychosocial rehabilitation pro- results from the WHO World Mental Health surveys.
grams, the promotion of collaborative care models Molecular Psychiatry 16, 1234–46.
Andrews, G., Henderson, S., & Hall, W. (2001). Prevalence,
with task-shifting components, and the use of
comorbidity, disability and service uitlisation: overview
e-mental health programs. The surveys’ findings also of the Australian National Mental Health Survey. British
reinforce the need to further coordinate efforts at the Journal of Psychiatry 178, 145–53.
global level to reduce the global burden of mental Araya, R., Rojas, G., Fritsch, R., et al. (2003). Treating
disorders and promote the mental health of the general depression in primary care in low-income women in
population. Santiago, Chile. Lancet 361, 995–1000.
Finally, the surveys clearly show that further deci- Barrett, P. M., Farrell, L. J., Ollendick, T. H., & Dadds, M.
(2006). Long-term outcomes of an Australian universal
sive efforts should be undertaken to increase the evi-
prevention trial of anxiety and depression symptoms in
dence base for mental health policies and plans. More children and youth: An evaluation of the Friends
epidemiological studies are needed to better under- Program. Journal of Clinical Child and Adolescent
stand the burden and associated factors of mental Psychology 35, 403–11.
disorders, as well as the use of services by those who Becker, G. (1994). Human Capital: a Theoretical and
suffer from them, while cost-effectiveness studies will Empirical Analysis with Special Reference to Education.
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Bijl, R. V., & Ravelli, A. (2000). Current and residual
sions related to the organization of mental health
functional disability associated with psychopathology:
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Global Burden of Disease study demonstrated the Incidence Study (NEMESIS). Psychological Medicine 30,
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been replicated over and over again, and brought to The role of mental and physical health in partial disability
light the significant treatment gap and lack of invest- around the world. British Journal of Psychiatry 200,
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