This two-part series to mark World Mental Health Day examines some of the ways we can improve the delivery of mental health services in low- and middle-income countries (LMICs).
Read part 1 here.
At the global level, mental health has traditionally been a neglected noncommunicable disease (NCD). Before the COVID-19 pandemic, close to a billion people—70% of whom lived in a low- or middle-income country—suffered from a mental health condition. After three years of the COVID-19 pandemic, a noticeable increase in poor mental health is bringing much needed attention to this disease.
The impact of the pandemic on mental health
For Dr Amparo Elena Gordillo-Tobar, Senior Health Economist of the World Bank and leader of the mental health initiative project, the early days of the pandemic brought these grim trends to the fore.
“People were deeply affected by both the social impacts of lockdown and the mortality they were exposed to,” she says.
Research based on the global prevalence and burden of depressive and anxiety disorders in 204 countries carried out by the Institute of Health Metrics confirmed an additional 54.1 million cases of depressive disorders and 83 million additional cases of anxiety disorders globally in 2020. Though this research relates to two specific disorders, the pandemic’s effect on mental health also includes the exacerbation of addiction, self-harm and family violence, which all require specialized attention.
The pandemic caused ballooning demand for mental health services at a time when resources were already stretched far too thin, further widening the mental health treatment gap and causing particular disruption to outpatient mental health services. In LMICs, it’s estimated that there is only one mental health worker for every 100,000 people. By contrast, high-income countries have more than 50 per 100,000.
“The primary provision of health was depleted in response to the pandemic and health systems were not prepared to respond to the increased demand of mental health services, as in most cases they were not even able to respond to this demand pre-pandemic,” says Amparo
A timely response to mental health needs in Latin America
Recognizing the need for an urgent response, Access Accelerated and the World Bank launched a new project in 2020 focused on delivering community-based mental health services in Latin America and the Caribbean (LAC) in five countries: Ecuador, El Salvador, Paraguay, Peru and Uruguay.
“The timing was critical and it was high time to give focus to mental health,” says Dr Michael Fürst, Global Head of Social Business at UCB and member of the Access Accelerated Steering Committee. “Mental health disorders are very common in many countries, and it is known that many risk factors for NCDs are linked with mental health conditions. However, despite the huge disease burden caused by mental health conditions and the fact that mental health is considered under the UN SDG 3 as a key component of good health and well-being, it has long been overlooked in many discussions about NCD priorities. This should be changed as quickly as possible.”
The immediate solutions currently being implemented in the regions include mental health training for health professionals and community health workers at the primary care level, as well as the identification of mental health community champions and focal points in schools and workplaces.
In El Salvador, where an entire region may only have a single psychiatrist, nurses and community healthcare workers are being trained to better understand mental illness and identify potential violent, aggressive, or self-harming behaviours sooner. In cooperation with Chile, the project is also working on developing and reviewing protocols for depression and anxiety that will ultimately enable nurses to manage treatment at the primary care level, alleviating the demand for scarce mental health specialists.
“Bringing mental health services to primary care means that we have greater capacity,” explains Amparo. “It also means that cases are identified sooner–and often at an earlier age, when mental health conditions are likely to develop–which opens the way for more effective treatment and better health outcomes in the long run.”
Another important benefit of placing mental healthcare at the first level of care is that it can help to address stigma, particularly in Latin American cultures where there is often resistance to speak about mental health. The more accessible mental healthcare is, the less it will remain in the shadows.
One goal of the project in Paraguay is to begin to deinstitutionalize mental health patients.
“The long-term hospitalization of mental health patients is not a feasible solution,” says Amparo. “What we are learning is that integrating mental health services within the community helps to normalize the seeking of care and ultimately improves compassion for those who need that care.”
A major pillar of that approach is supporting efforts at the community level to provide needed care. The vital role of communities also extends to providing supportive environments that address stressors like isolation and loneliness. For example, in Chile and El Salvador, community recreation centers are offering safe havens and an outlet for young people–a group that has been shown to be at increased risk of mental health issues, including suicidal behaviours–to forge important social connections that tangibly improve mental health.
This work in LAC has since led to a new project in Africa, which began just two months ago, sharing experiences gained from this region with Lesotho, Rwanda and Uganda.
“In the case of Rwanda, you have a country grappling with the long-term recovery from a genocide,” says Amparo. “Much of the adult population carries trauma related to that tragedy.”
The project aims to recognize current efforts, to assess how effectively mental health services are reaching the targeted populations, and to identify potential areas for improvement. In Uganda, the project is attempting to address a sharp uptick in gender-based violence over the last three years that has badly affected maternal and reproductive health.
Just like in LAC, efforts will be made to integrate mental health at the primary care level and to incorporate it into the national noncommunicable disease agenda.
“What we need at the national level is an integrated approach to care that closely aligns mental health services with services and programs related to other disease areas, such as neurological disorders, since we often see correlation between these diseases,” Michael says. “This also means firmly embedding mental health into policy and prioritizing it when allocating government funds.”
Countries are in the process of aligning health care provision to an improved health care response, designing policies, reallocating funds, reviewing guidelines and discussing the most efficient ways to respond to the demand for mental healthcare.
Both Access Accelerated and the World Bank recognize that it’s a long game. Destigmatizing mental health, building a trained health workforce, and translating policy into action takes time. But inroads are being made and the future looks brighter.
“It is important to create evidence and to capture data in terms of what leads to the best possible outcomes for patients,” says Michael. “This will allow us to replicate those activities that have been shown as being efficient and effective and hence open a path for other countries to benefit as well.”