Grand Challenges in Global Mental Health: Integration in Research, Policy, and Practice

Abstract

More than a decade ago, the World Health Organization's (WHO) World Health Report 2001 called for the integration of mental health into primary care, acknowledging the burden of mental, neurological, and substance use (MNS) disorders globally; the lack of specialized health care providers to meet treatment needs—especially in low- and middle-income countries (LMICs); and the fact that many people seek care for MNS disorders in primary care [1]. In 2012, the Global Burden of Disease (GBD) Study 2010 confirmed the still urgent need for attention to MNS disorders: over the past 20 years, the disability adjusted life years (DALYs) attributable to MNS disorders rose by 38%, and mental and behavioral disorders account for nearly one quarter of all years lived with a disability [2],[3]. MNS disorders also contribute indirectly to mortality, through suicides and conditions like cirrhosis, which, in certain regions, both rank among leading causes of disease burden [2]. The GBD Study 2010 brought welcome news of reductions in the DALYs for communicable, maternal, neonatal, and nutritional disorders since 1990. This progress is due, in part, to coordinated, global cooperation to meet the Millennium Development Goals (MDGs) and, specifically, to achieve targets set for child survival, maternal health, and combatting HIV/AIDS and malaria by 2015. Crucial for the global public health community, investments in achieving the health-related MDGs catalyzed the development, testing, and implementation of effective health interventions for priority conditions and stimulated the development of packages of care that bundle effective interventions—whether for reduction of maternal or child mortality or for HIV care and treatment. Stakeholders recognize that “synergies in the health system must be pursued” [4], and that these packaged interventions can be delivered most effectively through integrated approaches to care [5]. The need for integrated care that addresses emerging priority conditions, like non-communicable diseases (NCDs), including MNS disorders, is acknowledged less frequently in the global context [6]. As a result of global population growth, aging, and epidemiologic and demographic transitions, NCDs account for more than 60% of deaths worldwide, with disproportionate rates of mortality among populations in LMICs [7]. Significantly, MNS disorders frequently occur throughout the course of many NCDs and infectious diseases, increasing morbidity and mortality [8]–[11]. Consequently, people suffering with co-morbid disorders, such as depression and HIV or post-traumatic stress disorder and coronary heart disease, risk poor outcomes for both disorders. Achieving desired outcomes for priority programs will be difficult without managing MNS disorders. At a minimum, packages of care for MNS disorders should be parceled with effective interventions in primary care or other priority health delivery platforms. In truth, adequate attention to the public's health requires that this integration also occur in sectors beyond health (e.g., education, justice, welfare, and labor), through collaborative partnerships of government, non-governmental organizations (NGOs), and faith-based organizations, as well as in the implementation of global health and development policy.