|Year : 2017 | Volume
| Issue : 1 | Page : 1-4
Care for mental disorders and promotion of mental well-being in South-East Asia
Nazneen Anwar1, Thaksaphon Thamarangsi2
1 Regional Adviser, Mental Health, World Health Organization Regional Office for South-East Asia, New Delhi, India
2 Director, Noncommunicable Diseases and Environmental Health, World Health Organization Regional Office for South-East Asia, New Delhi, India
|Date of Web Publication||12-May-2017|
Regional Adviser, Mental Health, World Health Organization Regional Office for South-East Asia, New Delhi
|How to cite this article:|
Anwar N, Thamarangsi T. Care for mental disorders and promotion of mental well-being in South-East Asia. WHO South-East Asia J Public Health 2017;6:1-4
|How to cite this URL:|
Anwar N, Thamarangsi T. Care for mental disorders and promotion of mental well-being in South-East Asia. WHO South-East Asia J Public Health [serial online] 2017 [cited 2017 May 27];6:1-4. Available from: http://www.who-seajph.org/text.asp?2017/6/1/1/206157
| A paradigm shift for mental health|| |
Mental, neurological and substance-use disorders are common worldwide, affecting every community and age group, and across countries of all income levels. While 14% of the global burden of disease is attributed to these disorders, almost 75% of individuals affected in many low-income countries do not have access to treatment and care. The World Health Organization (WHO) South-East Asia Region, home to just over one quarter of the world’s population, has a disproportionately large share of the global disease burden for mental disorders.
Recent mental health activities in the WHO South-East Asia Region have been strategized by the WHO Mental health action plan 2013–2020? This action plan reflects a paradigm shift in the fundamental guiding principles for prevention, management and care for people with mental disorders and recognizes the essential role of mental well-being in achieving health for all people.
The action plan is based on a life-course approach; promotes equity through universal health coverage; and underscores that mental disorders frequently lead individuals and families into poverty. It has close conceptual and strategic links to other global initiatives, including the Global strategy to reduce the harmful use of alcohol, and Workers’ health: global plan of action.
The action plan also emphasizes the need for legislation, plans, strategies and programmes to protect, promote and respect the human rights of persons with mental disorders, in line with the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child and other relevant international and regional human rights instruments.
| Primary health care for mental disorders: The new horizon|| |
In the WHO South-East Asia Region, mental illnesses have been mainly managed by a small cadre of highly skilled mental health professionals, mostly confined to a limited number of urban tertiary-care mental hospitals. The reach of this health-care delivery system has been extremely limited, as evidenced by the large treatment gap faced by patients with mental and neurological disorders. The treatment gap, defined as the proportion of patients in need who are not receiving appropriate medical care, is between 76% and 85% for mental and neurological disorders in low- and middle-income countries worldwide; the corresponding range for high-income countries is 35–50%.
Taking into account the primary health-care infrastructure that extends to almost every corner of all countries in the region, the WHO Regional Office for South-East Asia has been developing and implementing strategies to deliver care for mental and neurological disorders in the community, by empowering the existing primary health-care delivery system. The strategy is to use trained health-care workers at the community level to identify people with the most common and most disabling disorders, and then to refer these patients to primary health-care-based physicians for treatment. This mode of delivery increases access to care, taking health care to the doorsteps of the people, while also helping to reduce stigma and discrimination.
“Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”
World Health Organization, 2004
In view of scarce resources, no country in the region can provide all services for all mental health needs in all settings. Thus, prioritization and pilot projects have been critical for long-term development and success. Prioritization criteria include the magnitude of the problem, the technical feasibility of diagnosis and treatment, and potential outcomes. Surveys have indicated that Member States of the region selected epilepsy, psychosis, depression and suicide prevention when starting these initiatives. Community-based programmes were subsequently developed, based on the “five As”: availability, acceptability, accessibility, affordable medicines and assessment (see Box 1).
Pilot studies of this approach conducted in Bangladesh, Bhutan, Myanmar and Timor-Leste clearly demonstrated that strengthening the primary health-care delivery system through training of health workers and providing essential psychotropic medicines had a significant impact in reducing the treatment gap. These programmes are inherently sustainable, since they are mainstreamed into the existing national government public health-care delivery system; the only additional investment is the cost of training and ensuring a supply of psychotropic medicines. All Member States in the region can benefit from this work, whether by introducing similar strategies or by scaling up existing successful projects.
| Priorities and progress: regional activities in mental health|| |
As guided by Member States, highlighted areas of the WHO South-East Asia Regional Office mental health programmes for 2016 and 2017 include depression, epilepsy, psychosis, autism spectrum disorders, dementia care, and post-disaster mental health and psychosocial support. The emphasis has been on capacity-building to enable countries to develop and implement policies in line with the objectives of the Mental health action plan 2013–2020.
There have been several major achievements, at both regional and national levels. These include the Regional strategy on autism spectrum disorders; amendment of the Bangladesh Mental Health Act, with development of a draft national mental health policy; updating of the national mental health policy of Maldives, with development and costing of a national mental health strategy; and updating of the National mental health strategy and action plan of Timor-Leste. Technical activities have included Development of guidelines on home-based interventions for management of intellectual disability a regional workshop for strengthening capacity and preparedness for post-disaster mental health and psychosocial support; and, in India, educational resources on mental health for social workers.
These activities have been integral to the 2016–2017 programme focus on addressing the mental health elements of the Sustainable Development Goals (SDGs). Key areas are the suicide mortality rate (SDG indicator 3.4.2), and harmful use of alcohol (SDG indicator 3.5.2). A regional suicide-prevention strategy has been developed, and work has started on the development of national strategies and action plans. Country strategies, systems and interventions for disorders caused by use of alcohol have been expanded and strengthened. This work has been informed by research, including a review of the morbidity and mortality in the region related to drink-driving, and an assessment of the burden and socioeconomic cost associated with alcohol use. In addition, the regional office has been involved in a project to increase community capacity to address alcohol issues in Sri Lanka. Finally, the United Nations General Assembly Special Session on the World Drug Problem in April 2016 mandated WHO to undertake specific activities related to abuse of narcotic drugs and psychotropic substances. Thus, needs-specific country strategies and programmes are being developed for the region.
| Challenges in mental health governance: commitment, resources and management|| |
Despite these activities, major challenges persist. Revisiting mental health legislation, where needed, will help tackle the widespread prejudice, stigma and lack of awareness that hinder progress. Crucially, the centrality of dignity to all aspects of mental health must be emphasized. Dignity for those with mental health disorders will be achieved when communities, families and individuals have the confidence to seek help for mental health problems without fear and inhibition. Together, we need to ensure that mental health strategies, actions and interventions for treatment, prevention and promotion are compliant with the Convention on the Rights of Persons with Disabilities and other international and regional human rights instruments.
Mental health disorders are chronic conditions associated with high morbidity but low mortality. As a result, they do not attract donor support and are not prioritized by individual countries. Resource allocation has been scarce, which has led to disjointed projects with poor sustainability. As with other low- and middle-income countries, a large proportion of the limited funds available is directed to inpatient care. Despite overwhelming supportive evidence, the integration of mental health services within primary health care is still a challenge for most Member States of the region. There remains a significant shortfall in numbers of psychiatrists and psychologists. Although the focus has been on training of nonspecialists and implementation of the WHO Mental Health Gap Action Programme (mhGAP), which has been developed for resource-poor settings, the region has yet to embrace fully this evidence-based approach.
| Moving beyond disorders: mental well-being for all|| |
More than 70 years ago, the founding fathers of WHO incorporated in its constitution the concept of mental well-being in the definition of health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The growing body of empirical evidence for the importance of factors other than disease in human well-being has led to a greater understanding of the social determinants of health and the adoption of targeted, intersectoral initiatives such as the Millennium Development Goals and Sustainable Development Goals. In tandem, the concept of “avoiding disease” has given way to one of “promoting wellness”.
While the importance of improving physical wellness has gained traction, the full value of promoting mental well-being has yet to be exploited. A challenge is that mental well-being is contextual and subjective and therefore difficult to define and measure. Promoting factors within an individual may include absence of disease, prosperity, and happiness or contentment, which in turn may be tempered by external factors, such as cultural norms. Each person’s level of mental well-being may fluctuate and differ in family, work and other settings, owing to varying cognitive, emotional and behavioural responses. Thus, mental well-being is experienced as a spectrum, rather than as a state that is present or absent. A key component mental well-being is resilience, which is “the ability to cope with adversity and to avoid breakdown when confronted with stressors”. Indeed, WHO defines mental health overall as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.
Programme-level approaches to improving mental well-being include improving community cohesion and social capital; interventions in early childhood development; school interventions; workplace programmes for promotion of mental health; improving well-being of the elderly through improving vision, hearing, exercise and networking; reducing harm from addictive substances, including alcohol; preventing violence; preventing suicide; and promoting adolescent mental health.
Strategies to improve community mental well-being require a whole-of-society approach and broad intersectoral action, principally driven by the non-health sectors. However, the health sector can play a critical advocacy and technical role. For example, evidence shows that regular physical activity, such as walking, running or cycling, reduces depression, as well as cardiovascular disease, cancers and diabetes. Thus, initiatives to enhance opportunities for physical activity, such as pedestrian-friendly urban planning, promote not only physical but also mental health and well-being.
The challenge, therefore, is to re-imagine current concepts of mental wellness and illness, which requires, in part, a willingness to relinquish the health sector’s traditional responsibility for this domain. Partnering with the sectors that shape social, economic and environmental policies will expand our opportunities to promote mental well-being, and thereby health, for all people.
| References|| |
Noncommunicable diseases including mental health and neurological disorders. Report of the regional meeting. Yangon, Myanmar 24–26 April 2012. New Delhi: World Health Organization Regional Office for South-East Asia; 2012 (http://apps.who.int/iris/bitstream/10665/205596/1/B4889.pdf
, accessed 15 February 2017).
WHO South-East Asia regional strategy on autism spectrum disorders (ASD). New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (in press).
Development of guidelines on home-based interventions for management of intellectual disability. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (in press).
Sustainable Development Knowledge Platform. Sustainable Development Goal 3. Ensure healthy lives and promote well-being for all at all ages (https://sustainabledevelopment.un.org/sdg3
, accessed 15 February 2017).
Draft regional suicide prevention strategy. Based on the WHO mental health action plan 2013–2020. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (in press).
A review of literature on drink-driving-related morbidity and mortality in South East Asian Region (SEAR). New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (in press).
To assess the burden and socio-economic cost associated with alcohol use among individuals seeking treatment at a substance use disorder treatment centre. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (in press).
Project to increase community response and action to address alcohol issue in three selected locations in Kalutara district, Sri Lanka. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (in press).