The importance of global mental health for the Sustainable Development Goals

Introduction

Currently the United Nations are negotiating the next generation of global development goals: the new Sustainable Development Goals (SDG) for the Post 2015 agenda. The previous 10 Millennium Development Goals (MDGs) (United Nations Millennium Declaration, 2000) have helped to accelerate development in many low- and middle-income countries (LAMICs) (United Nations, 2013). While “[t]here have been visible improvements in all health areas”, as United Nations Secretary General Ban Ki-Moon stated in the introduction to the MDG report 2013 (United Nations, 2013), mental health, although highly relevant to the MDGs, was wholly excluded from these goals. For the new SDGs, the international community now needs to recognise the evidence showing the growing burden of disease and the extensive social and economic global consequences of mental disorders and psychosocial disabilities (World Economic Forum, 2011). Mental health has for too long been a low priority in development. In the future Post-2015 agenda, mental health needs to be clearly included, with a specific mental health target and two indicators.

The significance of mental health for the global burden of disease

In recent years, mental disorders and psychosocial disabilities have been increasingly recognised as global development issues (Eaton et al., 2014). The EU and several high-income governments have acknowledged the critical importance of scaling up mental health services in LAMICs (The Council of the European Union, 2010), and the World Health Assembly has adopted a Comprehensive Mental Health Action Plan (2013–2013) as a framework for scaling up access to services, a formal recognition of WHO's 194 member states of the global relevance of mental health. The WHO and partners have developed the Mental Health Gap Action Programme (mhGAP) to provide evidence-based resources for governments and civil society to do this in a practical way. Global awareness for mental health conditions is growing, yet more commitment is needed by governments to provide sufficient prioritisation and budgets for services. The UN must react to the compelling evidence: mental health must be considered in the Post-2015 agenda.

A quarter of people in the world are affected

The WHO estimates that one in four people will experience a mental health condition in their lifetime and that approximately 600 million people worldwide are disabled as a consequence (Kohn et al., 2003). According to the World Report on Disability, 1 billion people worldwide experience a disabling condition, 60% of the causes of which are strongly linked to mental, neurological and substance abuse conditions (World health Organisation, 2011b).

Mental disorders and psychosocial disabilities are one of the most pressing development issues of our time, frustrating the aspirations of families, communities and emerging economies. Most of the people affected by mental health conditions live in low- and middle-income countries (Wang et al., 2007). Contextual factors, including poverty and hunger, conflict and trauma, poor access to health and social care, and social inequity all serve to increase their vulnerability (Kohrt et al., 2012). Yet, in these countries, between 76% and 85% of people with severe mental disorders do not receive treatment for their disorder (World Health Organisation, 2013b).

Increasing impact of mental disorders

The second reason why mental health needs to be considered as single target in the SDGs is that the burden of disease is steadily growing. Recent systematic analyses show that mental and behavioural problems account for 7.4%, and neurological conditions including dementia and epilepsy account for 3%, of the global burden of disease measured using Disability Adjusted Life Years (DALYs). Mental and behavioural problems command nearly one-quarter of the global total (Whiteford et al., 2013). This makes mental disorders and psychosocial disabilities the biggest single cause, more than cardiovascular diseases and cancer combined. By 2030, unipolar depression will be the leading contributor to years lived with disability (World Health Organisation, 2013a).

Mental health conditions can not only cause great and long-lasting disability, but also have high impact on the excess mortality. In consequence, in high-income countries, men with mental health problems die 20 years and women 15 years earlier than people without mental health problems (Lawrence et al., 2013; Wahlbeck et al., 2011). Excess mortality due to mental health conditions is likely to be much higher in low-income countries. This mortality gap is not only a life-threatening consequence of disease, but also a serious human rights challenge and development issue. Also, mental illness is a central cause of suicide (Mathers & Loncar, 2006), now the second highest cause of death among 15–29 year-olds globally (World Health Organisation, 2014).

Human rights violations, stigma and discrimination

Further, mental health must be included in the Post-2015 Development Agenda because it is a pressing case of global human rights and a moral duty (Patel et al., 2006). People with mental disorders and psychosocial disabilities often experience social exclusion, stigma and discrimination (Almazeedi & Alsuwaidan, 2014). To change societies’ perceptions, attitudes and beliefs, a public focus on human rights and stigma reduction is essential (Sartorius, 2007). In all regions of the world, people with mental disorders and psychosocial disabilities experience severe human rights violations, including being tied to beds, kept in isolation in psychiatric institutions, or chained and caged in small cells (Thornicroft & Shunned, 2006). The United Nations should recognize this failure of humanity as a global crisis requiring substantive and sustained action. Access to effective treatment can reduce stigma and exclusion, and evidence of effective interventions is now starting to emerge (Thornicroft et al., in press).

Most people do not receive effective treatment

Despite this great need, there is clear evidence that the large majority of people with mental disorders and psychosocial disabilities worldwide receive no effective treatment (Patel et al., 2013). Globally, mental disabilities and psychosocial disorders are grossly under-financed (World Economic Forum, 2011). Government spending on mental health compared with the burden of disease is creating an enormous mismatch, and substantially contributing to globally low rates of treatment of people with mental disorders (known as the “treatment gap”). Low-income countries spend about 0.5% of their very limited health budgets on psychosocial disabilities, despite their causing 25.5% of the Years Lived with Disability (YLDs) (World Health Organisation, 2011a). In many low-income countries, fewer than 10% of people are able to access services (Wang et al., 2007). Services are often non-existent, or based in large cities, far from people who may need them. In some countries, and for more severe disorders such as schizophrenia, the treatment gap is as wide as 98% (World Health Organization, 2008). In other words, this means fewer than one in 10 people with mental health conditions receive the treatment they need (Wang et al., 2007). This lack of access to treatment breaches the right to health as set out in the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2006).

Access to treatment must be improved, adherence of human rights standards needs to be secured, and we must no longer accept that the quality of life of persons with mental disorders and psychosocial disabilities should be any less than other members of society.

Mental health presents cross-cutting issues for health and development

Finally, mental health is an issue with cross-cutting impact across many of the planned SDGs, and related to many aspects of development (Thornicroft & Patel, 2014). Many aspirational global goals have strong interdependencies with mental health, for example; peaceful and inclusive societies (Goodwin & Rona, 2013) and safety in human settlements (Ouanes et al., 2014), sustainable economic growth (Cruz et al., 2013) and productive employment (Katikireddi et al., 2012), inclusive education and learning opportunities, food security and improved nutrition (Surkan et al., 2011), maternal and child health, healthy lives and well-being, the overall population level (Guszkowska et al., 2014), and a more equal society.

Mental health is not only critical to success in addressing social, political and economic development, it also has direct links to, and impact across, the majority of thematic areas for emerging priorities for the SDGs (Movement for Global Mental Health, 2013).

Call to the United Nations: make mental health a Post-2015 development target

Addressing mental health is an essential step in addressing key development issues such as social inclusion and equity, universal health coverage, a holistic and life-course approach to health, access to justice and human rights, and sustainable economic development. We, therefore, call upon the United Nations to include the following target within the Post-2015 SDG Health Goal:

The provision of mental and physical health and social care services for people with mental disorders, in parity with resources for services addressing physical health.

This target should be supported by the inclusion of the following two indicators:

(1) To ensure that service coverage for people with severe mental disorders in each country will have increased to at least 20% by 2020 (including a community orientated package of interventions for people with psychosis; bipolar affective disorder; or moderate-severe depression), and

(2) To increase the amount invested in mental health to at least 5% of the total health budget by 2020, and to at least 10% by 2030 in each low and middle income country. (#FundaMentalSDG, 2014)

Conclusion

UN Secretary General Ban Ki-Moon stated in his foreword to the 2013 MDGs report “Significant and substantial progress has been made in meeting many of the targets” (United Nations, 2013). As Jeffrey D. Sachs of the Earth Institute at Columbia University, the chief architect of the MDGs, has recently stressed, the MDGs have been a great success in engaging both LAMICs to an ambitious commitment for development, and high-income countries in exceeding their own investment promises in these countries (Sachs, 2014). Defining the goals in binding agreements has catalysed investment, economic development and political engagement, holding governments accountable will be crucial for progress (Gulland, 2013). This is why we need the United Nations to agree a clear mental health target, with two defined indicators to the new SDGs.

In the emerging global consensus on development priorities, health is increasingly seen as an essential component of overall sustainable development, and as a positive outcome of successful achievement of human rights, social and environmental initiatives (Eaton et al., 2014). Being directly linked, and having numerous interactions with other health conditions (Almas et al., 2014), mental health cannot be separated from other health domains, and is essential for sustainable human development (Prince et al., 2007). In the Constitution of the World Health Organization, mental health is an integral part of health and well-being (World Health Organisation, 2006). The case is compelling: mental health and the extensive global consequences of mental disorders and psychosocial disabilities have been neglected for too long. Such SDGs can be a major step to realising the potential contribution to the development of the quarter of the world’s population who are currently being ignored.

Declaration of interest

The authors are supporters of the #FundaMentalSDG initiative established to support the inclusion of mental health target and indicators in the SDG.