Background: Mental health accounts for an estimated 14% of the global disease burden yet receives less than 2% of health budgets in most countries, with even lower investment in low- and middle-income settings. This study examines federal mental health financing trends from 2021-2025 to assess whether legislative reform translated into fiscal prioritization. Methods: A mixed-methods policy analysis was conducted, combining quantitative analysis of federal budget appropriation documents (2021-2025) with qualitative documentary review and comparative case studies. Mental health allocations were assessed by recurrent and capital expenditure, institutional distribution, and proportional share of total federal health spending. WHO reports, national policy documents from Ghana and Kenya, and peer-reviewed literature informed comparative analysis. Results: Federal mental health allocations increased from ₦23.33 billion in 2021 to ₦88.24 billion in 2025, a 278% nominal rise. However, the sector’s share of the total health budget declined from 3.67% to 3.12%, indicating relative marginalization. Over 90% of funding supported recurrent expenditures in ten federal neuropsychiatric hospitals, with minimal investment in community-based services or primary care integration. In contrast, Ghana and Kenya more effectively leveraged legislation, fiscal decentralization, and insurance mechanisms to expand access. Conclusion: Despite legislative reform, Nigeria’s mental health financing remains centralized, hospital-focused, and misaligned with population needs. Institutional inertia, weak coordination, and delayed implementation of the Act have constrained equitable scale-up. Activating the Mental Health Fund and integrating mental health into national financing mechanisms are urgently required to prevent deepening inequities.
Pakistan confronts a severe mental health crisis that compels urgent action. Mental disorders constitute a burgeoning global burden, with depression alone accounting for a staggering 4.4% of worldwide Disability-Adjusted Life Years (DALYs) [1]. A stark inequity persists, with over 90% in low-and middle-income nations lacking access to mental health treatment, compared to over 50% receiving care in high-income countries [2]. These disparities emanate from a chronic underinvestment, with lowincome nations allocating a mere fraction, less than 1% of health budgets, to mental health [3].Pakistan mirrors these global inequities. With a paucity of just 0.19 psychiatrists per 100,000 people [4], and an underwhelming allocation of only 0.4% of the health budget for mental health [5], Pakistan grapples to meet the needs of an estimated 24 million individuals requiring mental health services [6]. Depressive, anxiety, and schizophrenia disorders are the most prevalent [7]. Stigma surrounding mental illness remains an entrenched societal challenge [8].Currently, Pakistan's mental health system operates primarily through tertiary care hospitals in major cities, with minimal integration into primary healthcare. Mental health services are largely concentrated in psychiatric departments of teaching hospitals, creating geographic and economic barriers for rural populations. The existing system relies heavily on psychiatrists and clinical psychologists, with limited involvement of general physicians, community health workers, or other non-specialist providers. Mental health education is notably absent from school curricula, and workplace mental health programs are virtually non-existent. Digital mental health solutions remain unexplored within the public sector, while community-based mental health services are severely limited. The proposed transformations would mark significant departures from this status quo through: task-sharing with non-specialist providers instead of exclusive specialist care; integration of services into primary healthcare facilities rather than tertiary hospitals alone; establishment of community clinics in place of centralized urban facilities; leveraging digital technology where traditional in-person care is the norm; and engaging community partners versus the current isolated clinical approach.To expand access, the WHO recommends strategies such as task-sharing care to nonspecialist providers, integrating services into primary care and educational institutions, developing community clinics, leveraging digital technology, and engaging community partners [9]. Pakistan could adapt approaches like training primary care workers in mental health protocols, building teacher capacity for school-based services, deploying lay counselors with specialist supervision, offering telemental health services, and engaging community health workers in outreach efforts [10].[Figure 1] telepsychiatry and digital tools, and address social determinants through campaigns on gender equity [11]. Organizations like Pakistan Institute of Living and Learning (PILL) advocate for policies, build workforce capacity, and scale up culturallyadapted interventions [12]. Digital startups like Sehat Kahani use telepsychiatry and mobile applications to bridge the workforce gap [13].A critical component in addressing Pakistan's mental health crisis is the implementation of comprehensive anti-stigma campaigns [14]. These initiatives should operate at multiple levels based on established evidence [15]:A. Community-level interventions [14,15] To comprehensively address the crisis, Pakistan must invest in scaling up its mental health workforce through training more specialists and task-sharing to non-specialists [3,16]. Integrating services into primary care and establishing community mental health centers is crucial for decentralizing access [9,10]. Increasing public mental health spending, developing sustainable financing mechanisms, and strengthening governance and policies are imperative [5,16]. Research on effective, contextuallyappropriate interventions should guide investments [14]. Developing quality monitoring mechanisms is key to ensuring standards of care [9].Addressing social determinants through multi-sectoral coordination and whole-ofsociety approaches involving government, private sector, and civil society is vital [14].Sustained political commitment and strategic investments enabling universally accessible, community-based mental healthcare are crucial for realizing wellbeing for all Pakistanis [15,16].In essence, Pakistan confronts a formidable treatment gap with escalating rates of mental illness amid extreme limitations in mental health system capacity.Comprehensive strategies are necessitated, spanning workforce expansion, service integration into communities, increased financing, anti-stigma efforts, school interventions, research, quality assurance, and multi-sectoral coordination. While challenges are immense, prioritizing community-driven, decentralized mental health systems can ensure no individual is left behind on the path to greater wellbeing.
BACKGROUND: As a consequence of the decentralization of health care provision to the different Regions (called Autonomous Communities) in Spain, different health care models and resources have been developed for psychiatric patients. It would be very useful to obtain comprehensive and comparative data on health care models, resources, and activity of acute inpatient psychiatric units (AIPUs) as a key part of mental health systems. OBJECTIVE: The aim of this study was to determine the current state of AIPUs in Spain through a national scorecard that allows the current situation to be visualized in terms of resources, processes, and outputs. METHODS: A 104-item online questionnaire was sent to all the AIPUs of the different Regions in Spain. It was divided into 11 sections, including data on the resources, processes, and outputs of the AIPUs plus general data, an indicator dashboard, and good practices. RESULTS: The questionnaire was completed by 60.0% (117/195) of the AIPUs invited to participate. The information collected has allowed us to obtain a detailed snapshot of the current situation of AIPUs in Spain at the levels of infrastructure and material resources, staffing, organization and activity of the units, coordination with other units, guidelines, processes and protocols used, participation and communication with patients and their families, teaching activity, and research linked to the units. CONCLUSIONS: This project aimed to help understand the general situation of AIPUs in Spain and its different Regions, contribute to enhancing the benchmarking and harmonization among Spanish Regions, and provide data for future comparisons with other countries. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/26214.
BACKGROUND As a consequence of the decentralization of health care provision to the different Regions (called Autonomous Communities) in Spain, different health care models and resources have been developed for psychiatric patients. It would be very useful to obtain comprehensive and comparative data on health care models, resources, and activity of acute inpatient psychiatric units (AIPUs) as a key part of mental health systems. OBJECTIVE The aim of this study was to determine the current state of AIPUs in Spain through a national scorecard that allows the current situation to be visualized in terms of resources, processes, and outputs. METHODS A 104-item online questionnaire was sent to all the AIPUs of the different Regions in Spain. It was divided into 11 sections, including data on the resources, processes, and outputs of the AIPUs plus general data, an indicator dashboard, and good practices. RESULTS The questionnaire was completed by 60.0% (117/195) of the AIPUs invited to participate. The information collected has allowed us to obtain a detailed snapshot of the current situation of AIPUs in Spain at the levels of infrastructure and material resources, staffing, organization and activity of the units, coordination with other units, guidelines, processes and protocols used, participation and communication with patients and their families, teaching activity, and research linked to the units. CONCLUSIONS This project aimed to help understand the general situation of AIPUs in Spain and its different Regions, contribute to enhancing the benchmarking and harmonization among Spanish Regions, and provide data for future comparisons with other countries. INTERNATIONAL REGISTERED REPORT RR1-10.2196/26214
BACKGROUND: (MHPF) and the mechanisms by which these reforms can be structured and financed in the context of fiscal constraint. METHODS: A situational analysis guided by a newly developed analytical framework for sustainable mental health financing was conducted. The review was followed by qualitative, indepth interviews with a range of expert national stakeholders. RESULTS: Although the MHPF is said to be consistent with ongoing efforts toward the implementation of National Health Insurance (NHI), there is clear evidence of discordance between the MHPF and the NHI. The most promising strategies for sustainable mental health financing include: increased decentralization of resources to primary and community mental health services; active integration of mental health into ongoing NHI implementation including expanding the mandate of District hospitals and drawing on the private sector; submission of costed budget bids to support a mental health conditional grant and ensuring that explicit outcomes and deliverables are in place to monitor Provincial implementation. CONCLUSION: This paper has suggested several ways in which existing reforms may be leveraged to incorporate the objectives of the MHPF and achieve better mental health outcomes for South Africans, revealing critical opportunities for mental health service scale-up to be embedded in South Africa's future health delivery strategy. The realization of a conditional grant for mental health will require technical expertise to cost existing services towards the development of an investment case for mental health service scale-up nationally, projecting potential resource requirements and returns on investment of a strong service platform. In the longer-term, the NHI benefit package must be expanded to include comprehensive mental health services at all levels. Explicit results-based financing mechanisms within the NHI Fund must also be incorporated for mental health to incentivise quality of care. Private providers engaged by the NHI must commit to make use of evidence-based mental health interventions.
Joshua Ssebunnya, S. Kangere, James Mugisha, Sumaiyah Docrat · 7 authors
BACKGROUND: In spite of the pronounced adverse economic consequences of mental, neurological, and substance use disorders on households in most low- and middle-income countries, service coverage and financial protection for these families is very limited. The aim of this study was to generate potential strategies for sustainably financing mental health care in Uganda in an effort to move towards increased financial protection and service coverage for these families. METHODS: The process of identifying potential strategies for sustainably financing mental health care in Uganda was guided by an analytical framework developed by the Emerging Mental health systems in low and middle income countries (EMERALD project). Data were collected through a situational analysis (public health burden assessment, health system assessment, macro fiscal assessment) and eight key informant interviews with selected stakeholders from sectors including health, finance and civil society. The situational analysis provided contextualization for the strategies, and was complimented by views from key informant interviews. RESULTS: Findings indicate that the following strategies have the greatest potential for moving towards more equitable and sustainable mental health financing in the Uganda context: implementing National Health Insurance Scheme; shifting to Results Based Financing; decentralizing mental health services that can be provided at community level; and continued advocacy with decision makers with evidence through research. CONCLUSION: Although several options were identified for sustainably financing mental health care in Uganda, the National Health Insurance Scheme seemed the most viable option. However, for the scheme to be effective, there is need for scale up to community health facilities and implementation in a manner that explicitly includes community level facilities.
BACKGROUND: Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15-30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective. METHODS: Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes. RESULTS: Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning. CONCLUSION: Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent.
Open access
Mental Health Treatment and Access
Child and Adolescent Psychosocial and Emotional Development
Shoba Raja, Sarah Wood, Victoria de Menil, Saju C Mannarath
BACKGROUND: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. METHODS: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. RESULTS: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. CONCLUSIONS: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.
The 2001 World Health Report made plain the global challenge posed by poor mental health. Worldwide, 20% of individuals may experience mental health problems during their lifetime, and such disorders account for approximately a third of all years lived with a disability 1. The consequences of poor mental health range far and wide, of course; they are associated with higher rates of non-mental health-related comorbidity and premature mortality. Some mental health problems are also associated with poor employment experiences, poor personal relationships, strain on families, and a higher-than-average risk of homelessness and contact with the criminal justice system. The 2001 report helped to raise awareness of the importance of mental health. The need to promote and maintain good mental health and well-being as integral elements of health policy is now quite widely recognised in high-income countries. For instance, the European Commission published in 2005 a Green Paper on mental health 2 and all 52 Member States in the European Region of the World Health Organization (WHO) endorsed a Declaration and Action Plan at Helsinki earlier that same year 3,4. In the United States, a Presidential Commission called for investment in actions to ensure that mental health receives the same level of attention as physical health problems, specifically recommending actions to tackle suicide and reduce stigma, as well as interventions to promote child mental health 5. Positive actions can also be seen in the Pacific region, where, for instance, New Zealand has a ten-year national mental health strategy 6, with implementation monitored by a separate Mental Health Commission. The picture in many other parts of the world is much less encouraging. Although there has been some recent focus on the need to tackle the mental health consequences of major disasters such as the Asian Tsunami 7, policy attention and resources in many low- and middle-income countries are still directed largely at communicable diseases. The purpose of this paper is to reflect on some of the challenges faced in low- and middle-income countries and the role that economic evidence could play in strengthening the policy case for investment in mental health. There is obviously a need to improve our understanding of the cost-effectiveness of specific interventions within the health care system. But there is also a pressing need to expand the role of economic analysis in looking at non-health sector interventions that can have a direct impact on mental health or can indirectly help with the uptake and maintenance of treatment. The ways in which services are delivered are of critical importance and also need evaluation. In particular, we shall argue that non-governmental organizations (NGOs) can be key players in the funding, coordination and delivery of services. The burden of mental illness is predicted to increase from its current level of 12% of global disease burden to approximately 15% by 2020; much of this additional burden is projected to occur in low-income countries 8. The consequences of poor mental health in low-income countries may be even worse than in high-income ones, because of the absence of social protection safety nets, compounded by the high levels of stigma and superstition 9. The cycle between poor mental health and poverty in low-income countries has been observed in several studies 10–12. Poor maternal mental health also has long-term adverse consequences for infants in low- and middle-income countries, limiting their own lifetime opportunities 13. Communicable diseases, the focus of much health policy in poorer countries, are also inextricably linked and exacerbated by poor mental health; interventions to prevent and treat mental health problems could help in the management of these conditions, as for instance in the case of HIV/AIDS 14,15. The economic costs of poor mental health are well documented in high-income countries, conservatively estimated to account for between 3% and 4% of gross domestic product (GDP). Few estimates have been made outside the developed world. One exception is a study in Kenya 16 that estimated that the total costs per patient for 5,678 individuals with mental health problems hospitalised in 1999 were US$ 2,351. This included out of pocket costs to family members of US$ 51 and productivity losses of US$ 453. Total economic costs for this group alone were more than US$ 13.3 million, equivalent to 10% of the Ministry of Health's budget; yet these figures would have been substantially larger if costs had also been included for those individuals who were not institutionalised or were treated by traditional healers. To put this in context, the average income per head of the population in Kenya is just US$ 580 per annum, and more than half the population live on less than US$ 1 per day 17. Other examples can be found in India, where the overall costs for outpatients with schizophrenia have been found to be similar to those of people living with another long-term condition, diabetes; a key difference between them, however, is the much greater contribution of indirect costs to overall costs (63% versus 29%) in the case of schizophrenia. This included not only the costs of lost opportunities to work for the individuals with the illness and their families, but also the loans taken out to meet the costs of treatment and money spent on repairing damage to property. In total the annual cost per outpatient treated for schizophrenia was estimated to be US$ 274 18. Another Indian study where free access to essential drugs was provided as part of community outreach services for people with schizophrenia reported that these led to a number of improvements in quality of life over an 18-month period. The impact on cost was modest, with the investment in community outreach services partly offset by a reduced need for caring by family members 19. This impact on family caregivers can be considerable. In Ethiopia, Shibre et al 20 looked at the impact of schizophrenia on 300 family caregivers in traditional rural communities. Relatives experienced financial difficulties, constraints on their social life, reduced opportunities to work and strained family relationships. These problems were particularly challenging for female caregivers. Similarly, a study of 66 caregivers in Zimbabwe reported that two-thirds experienced financial difficulties, especially as food consumption by their relative increased 21. Some people have argued a moral case for greater investment in mental health, given the high number of individuals affected and the ensuing profound consequences 22. Such a case obviously needs substantiating with evidence that targeting more investment on mental health will be effective in preventing or treating mental disorders, and that it represents a cost-effective use of a country's scarce resources. In turn, this generates a need for economic analyses to support clinical and strategic decision-making. Of course, decisions should never be made on the basis of cost or cost-effectiveness alone, and other factors such as fairness, human rights and ethics are usually highly relevant. There has been significant growth in the evidence base on the effectiveness and cost-effectiveness of interventions aimed at treating the consequences of poor mental health (particularly drug therapies) 23–26. Increasingly, economic analyses are being undertaken in low- and middle-income countries 27–31, but the overwhelming majority of studies are from high-income countries. This is not surprising: between 1992 and 2001 only 4% of articles in journals on the ISI Web of Science databases were on mental health issues; of these a mere 6% were from low- and middle-income countries 32. Similarly, Patel and Kim 33 found, from their review of publications between 2002 and 2004 in six leading journals, that only 3.7% of papers were from low-income countries. Unfortunately, economic evaluation findings do not transfer easily between countries, because infrastructures, resources, incentives and cultures can be very different. There is therefore a need to develop the evidence base on the effectiveness and cost-effectiveness of interventions in low- and middle-income countries through additional empirical studies. Practically, however, even with a substantial injection of funding, this evidence base will take some time to emerge, given the human and infrastructure capacity constraints within countries 34. In the meantime, how can economics best be used to inform policy making? In the absence of empirical evidence, careful use of economic “models” which seek to adapt evidence on effect to take account of different local circumstances and cost structures can play a role. The most significant such endeavour is the ongoing work of the WHO CHOICE (Choosing Interventions that are Cost Effective) Programme. CHOICE aims to assess the cost-effectiveness of a wide range of interventions for conditions that make significant contributions to the burden of disease in a range of epidemiological and geographical settings. The core aim is to feed information into the policy process 35. Thus far, the CHOICE programme has looked at schizophrenia, bipolar disorder, depression and panic disorder. It has estimated, for example, that cost-effective interventions can be provided for US$ 3–4 per capita in low-income settings of Sub-Saharan Africa and South East Asia, or around US$ 10 in middle-income regions such as Eastern Europe. These are typically a combination of older off-patent antipsychotic or mood stabilising drugs plus psychosocial therapy. It has also been estimated that, globally, between 300 and 500 million healthy years of life could be gained for each additional US$ 1 million invested. Around one third of the gains would be for severe mental disorders, schizophrenia and bipolar disorder, with the most cost-effective interventions being for depression and panic disorder 36. Welcome though the CHOICE programme is, it has largely on health care interventions to improve mental health there is in high-income countries a of evidence to the role of employment and living There is an need to assess the cost-effectiveness of and many of which outside the health for in the or There is also very evidence from low- and middle-income countries on how poverty and factors impact on the of mental health policy and these have an to mental health policy the substantial adverse impact of poor mental health and the evidence base on the of cost-effective there many in to ensure that mental health receives a level of investment in low- and middle-income countries and that, services are there is access to mental health may have to be a for national policy and of this was the that the World World Report that poor mental health was a major to the global burden of but its essential services for health services not seek to mental disorders, even though their overall burden was that of and HIV/AIDS This some and was in a of the it the case that in low- and middle-income countries the focus of much health policy has been communicable that to premature most and have been such as the by aimed at greater access to drug for The the contribution of good health economic and several health-related yet mental health is by its the of papers for the Commission which the between of economic growth and poor mental health This is exacerbated by This has to a of attention from policy and the in leading to a of resources, poor of information and if greater to mental health, a key on the of services and their as to meet needs is the of epidemiological This is not to low-income one recent review could not on mental disorders in of the European Member States Unfortunately, the infrastructure to such information is not in the of needs it is not to on epidemiological The of all need to be yet it for people with mental health problems and their to have an to in or inform the policy a there is a that policy to that can some of the of mental disorders, such as lost opportunities to work or to in There is also the risk that policy to the challenges of on the health care may the to mental health in may be not in many low-income countries One study from Zimbabwe that over of health care in the and of treatment for depression of health care may be compounded by the of mental with some studies that many that such conditions do not or be treated also that only physical or conditions are than the for more than 2 of the population less than of their total sector health care on mental health The majority of countries in Africa are in this of the world population in low-income countries have access to community care services on of mental health services is but at of people with severe mental health problems do not treatment within in some low-income countries One recent in found that only of people with disorders some of treatment for mental health problems during a In where the overwhelming majority of people with schizophrenia are by the it has been estimated that over still do not make use of services where there is a to mental health, the level of resources will be on the of the even if more than of the total health is to mental health, this will not to much in of overall resources if the overall level of national income is The need to or to make also that services have to be mental health services may be particularly in such to drug the WHO found that, by 20% of all countries were not at one one antipsychotic and one This is to be helped by the of World this can of drugs and the of drugs be by the there are some to these for national and which are life there are for mental In a number of free have been between the and some countries. These can be even than for instance the of protection There are also human especially health have to with the of high countries that can and conditions to these but challenges the middle-income countries of the a major to be the high rates of suicide and disorders, which may partly from economic and social mental health services are being put as resources for health the health by many people to in health care typically do not for long-term mental health The for mental health in many low- and middle-income countries that access to many services is on at the of Around of low-income countries reported to be the for mental health with only 3% of high-income countries this of is as it not take account of costs through with traditional healers. This on is and as it of services by those with which is especially given the between poverty and poor mental health for services may to poverty or if from at very to reduce some of the associated with poor mental health are number of challenges in use of resources have been out on by et al these may also be to health they are to be more to in mental health their impact may be in low- and middle-income countries, where human and financial resources are scarce and where there are many on resources. of these have been the of information on effectiveness and and the level of resources to mental health treatment and Another key is the poor of resources, which are in The to be to a mental health can be in one Indian study a key for the of use of antipsychotic was the need for individuals to have to more than 10 to their outreach 19. In some rural of South Africa there is only one per million population particularly from rural to can also as a to treatment. in is with the of that million people for may also be different disorders or for example, depression has been as a to schizophrenia within the health of countries There is also the that resources are used to support services that do not epidemiological needs or the of or the evidence base on effectiveness and The WHO has the of mental health where mental health is into the health countries which to on care are to be an of services. is a it may to and resources as best to meet population Health may be highly with for or local management of In countries where most resources are within a highly as in the it can be to resources from to The uptake of community outreach services also be poor because of the problems of food of and financial resources. To ensure a of treatment is may with food one in Zimbabwe that more than 10% of family could not to for the additional food for with mental health problems 21. It is therefore to ensure that resources are not and for to not only clinical but also some of the factors that the use of services. there is as in India, local structures need to have the to ensure that are to mental health. may also be by a number of different not only health, but also employment and social Poor coordination and between and local and can the of services. In for example, the of and community services for mental health was to a of coordination also need to be that of services or greater investment not that there will be improvements in mental health in may take several years to in of treatment and policy may therefore be to on of the health where more and can be even if the need for is is the need to ensure that there is a long-term to as to support individuals over time within their communities. one need is to improve access to information on effectiveness and cost-effectiveness of interventions to treat mental health understanding of population needs is also Other information that need to be and cost-effective ways to mental health to care and other and awareness and to tackle some of the consequences of the information and more use of scarce resources would some to strengthening the for mental health. a understanding of how resources are to mental health and other health would also be In many where national health are there is high on of for health Some into the ways that and organizations are in in health and other would help if a case is to be for more investment in mental health. opportunities for mental health and other to in the of would also be particularly as many of these papers to focus on physical health. that have helped the of physical and mental health in different settings also help the case for greater resources for mental health in mental health can also physical health. with that focus on physical health help their in mental health and psychosocial One review of that many they not have the to mental health needs and were in of greater with that in the mental health It is also to expand the role of economic analysis to at the cost-effectiveness of to tackle risk factors for poor mental health, such as poor living conditions, financial economic and levels of For instance, to mental health be through the of in low-income the of such will not be to mental health alone, that a all health would be The in which effective interventions are delivered to mental health-related is also of One is the and of health There is a substantial of in looking at to the of delivery and the need to services different be from care to In the to additional will be as to to services community services are developed and which seek to ensure have to be as to also mental health care as with the in may also The high on is a major to access to and countries should be health on or social major however, is that the structures for do not in low-income countries such as very local community a also need Although the CHOICE programme take into account the of uptake of economic in low- and middle-income countries have this are the to such as of it be to tackle these and if services are delivered by but there is a of information on the effectiveness or cost-effectiveness of the services they as it has been in high-income countries, services that can meet the needs of local in ways that services do with and their with local through the of greater uptake and use of services with To and how are These are key to which we now countries report that they have some in the of mental health. health services were of care in many countries, more or have also to play significant These organizations may be or support from local or other Some may also play significant in and policy it is to that specifically focus on mental health. One recent looked at that mental health services disasters as well as services. Of organizations on the United only reported being in mental health of these had in at one long-term but only were to mental health There are the mental health and the Mental Such organizations may not only raise and for mental health, but also help to services. Another is which in with health to help mental health services at care level in several programme countries in Africa and India, and can some of the to the of mental health policy and for by to raise awareness of the importance of mental health and by for access to services in low-income communities. community or which within local with key and their families, is used because of the challenges in at a high level into on the The community that can help on social in to support the work of health and health can be of to ensure use of and as well as and can also as between traditional and For example, has with traditional as one of their in where some of these have to some people with mental health problems to health services Such between the and the opportunities for health especially to their access to can help in a understanding of how to meet mental health needs in community a greater level of contact with people with mental health problems within local health care local health may make at or levels for drugs and other services to meet these local with can also be for the of mental health services. can as to to for greater In one where for example, the was that a mental health and programme would help to mental health the This has very to a of million US$ for mental health in and a World of Health developed with in to develop community in the and Mental health problems are a major to the global disease they are associated with premature and profound on and they substantial costs to the the of cost-effective interventions in high-income countries and some more but evidence in low- and middle-income countries, mental health and care have been widely with levels of investment in interventions for health where is access to and of services may be even if are of course, they are combination of some to mental health, has to these of within a highly of human rights and to of resources have a in which the to prevent and mental health problems has far largely been these challenges a analysis of the cost-effectiveness of interventions can play a role in this Such analysis needs to interventions that the of mental disorders a understanding is also of the health and the and in which interventions are to be analysis is also of more to risk factors for poor mental health, such as of access to and will have that mental health, and with other are such as those with communicable diseases. of the implementation process is In countries where health are and where mental health is a can play some of the of with can be more this help the case for investment in mental health. have with some in the of HIV/AIDS and maternal and child health. is more or different in looking at mental health problems in the same and in the same The experience from such as that even can have some which in that the of people with poor mental health in low-income countries is not as as is at the policy the key difference between mental disorders and other health is that the are more as a because they are as less mental health only to the attention of local policy a global such as the Asian Tsunami or a high local such as the in The in the of people who had been within a Commission provided the for mental health policy and by and and even the of But as these from it is for mental health to and for the that investment in mental health can economic as well as quality of life is to its on the for economic This is to effective mental health care with in the
Open access
Mental Health Treatment and Access
Health disparities and outcomes
Child and Adolescent Psychosocial and Emotional Development
Respected chair persons and members of the Indian Psychiatric Society (IPS), I am extremely happy and privileged to be here at the 59th Annual Conference, before an enlightened gathering to preside over the prestigious IPS. It is a rare honour and it shall be my endeavour to prove myself worthy of being chosen for this prestigious and highly coveted honour among the psychiatrists. I know my limitations but I am also aware of the great role that can be played by our society and I make bold to place before you many of my experiences in the field to exhort my fellow psychiatrists that we have a great responsibility ahead. From what I have observed during these years of my active practice, I have no doubt in my mind that the psychiatry as a profession is slowly gaining ground and in the years to come it will play an effective role in disabusing the minds of the public of their wrong and ill conceived notions. I shall endeavour my best with the cooperation and support of all my fellow psychiatrists. There were quite a few topics that I short listed for my presidential address. Finally, I zeroed in on this topic titled “MAKING PSYCHIATRY A HOUSEHOLD WORD” as I feel the art and science of psychiatry has a great deal to offer society apart from treating the “crazy people”. To make that contribution, psychiatrists must continue to tackle society's most pressing problems and also raise the visibility of psychiatry and its perceived relevance to solving a wide range of personal, social and family problems. The image of psychiatry has been tarnished in the eyes of common man, thanks to the battering that the profession has received at the hands of the media, not to mention the apathy of the policy makers. Here is an example to prove my point. At the recently held conference at Jaipur, I was walking outside the convention center when I heard two young women talking to each other. One said to the other: “My God!!!…. He's so weird! He really should see one of those psychiatrists who are walking around here.” “That's it!” I thought. “People think you have to be ‘weird’ to see a psychiatrist.” The public tends to view psychiatrists narrowly, associating us chiefly with our expertise in mental illness. In reality, psychiatrists can promote coping and wellness in addition to diagnosing and treating mental illness. Many people today have significant stress in their lives and we all undergo crises and life-stage transitions as a normal part of life. Psychiatrists can help people assess how they are coping with current stresses and develop new skills and strategies. A lot of people find that their stress levels have increased in this era of wars, terrorism and natural disasters. We, as psychiatrists, could do much more to prevent problems by helping people learn to cope and build their resilience. I wondered what it would take to normalize our public image, that set me thinking and I looked into dentistry, which changed the public image of its profession in the 1980s when it teamed up with Colgate toothpaste in a public education campaign that promoted the idea of the dental check-up. This campaign led to major changes not only in the public image of dentistry but also in the very nature and public impact of dental practice. Dentistry moved from a focus on restorative dentistry to an emphasis on preventive dentistry. We have all witnessed the success of this transition. People no longer wait for a toothache to visit the dentist and employers routinely include preventive examinations and cleanings as a dental benefit. I am envisaging a day when people similarly take appointments for a “psychological check-up” akin to a general health check -up and when that day comes one can rest assured that the community has truly embraced our profession. At these check-ups they could address such matters as their stress level, their relationships, how they are caring for their children and ageing parents and health basics such as diet, nutrition, sleep and exercise. In my 30 years of practising psychiatry, I have had a unique vantage point from which to both observe and reflect on, the process whereby psychiatry responds to urgent societal needs and how these needs thus influence the evolution of psychiatry. As I see it, the scope of psychiatric practice is expanding and diversifying into new areas. In short, the stage is set for the public's as well as policymakers and health care payers' full embrace of our field and for the true integration of psychiatry into health care, Only if we make them aware of our scientific knowledge and professional skills. DISABILITY AND MENTAL ILLNESS The burden of mental illness on health and productivity throughout the world has long been profoundly underestimated. Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers.[1] This Global Burden of Disease study developed a single measure to allow comparison of the burden of disease across many different disease conditions by including both death and disability. This measure was called Disability Adjusted Life Years (DALYs). DALYs measure lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, disability caused by major depression was found to be equivalent to blindness or paraplegia whereas active psychosis seen in schizophrenia produces disability equal to quadriplegia. The World Health Organization's Global Burden of Disease study reported that mental disorders comprise four of the top five sources of premature death and disability in 15-44 year olds in the Western world. Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders. The projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020. Major depression is the leading cause of disability (measured by the number of years lived with a disabling condition) worldwide among persons age 5 and older. For women throughout the world as well as those in established market economies, depression is the leading cause of DALYs. In established market economies, schizophrenia and bipolar disorder are also among the top 10 causes of DALYs for women. The above stated facts, hopefully will be an eye-opener for all the concerned parties. From our side, we should do all that we can in whichever small way to reduce this enormous disease burden. My presidential address, I hope, will serve as an initiative to formulate ways and means to achieve this objective. IMPEDIMENTS IN MAKING PSYCHIATRY A HOUSEHOLD WORD There have been a lot of impediments in making psychiatry a household word. The main culprits are the age old concept of mind-body dualism and lack of integration of mental health care into primary health care, stigma, psychiatrists themselves, the apathy of the policy makers, failure of Consultation - Liaison psychiatry and media. I will make an attempt to briefly detail what resulted in these hindrances and some plausible solutions to overcome them. MIND-BODY DUALISM The earlier concepts of health glorifying mind-body dualism are bankrupt now and mind-body dualism has an enormous negative impact on our health care system. Because of it, our health care system does not systematically attend to the many psychological risk factors for both morbidity and mortality and it virtually ignores the psychosocial pathways that lead to unnecessary utilization of medical and surgical services. In addition, the psychological impact of a medical illness is not well by the health care is the that many people from a illness have psychological illness. Finally, the share of mental health problems are by primary care take a at some of the of the top health risk factors are diet, suicide, and of the leading causes of death have significant At as much as of all to primary care medical are for problems with a psychological those who with mental health problems and those who or for problems with a psychological component those with such as those with and those with medical one study found that than of had and A number of have that health care the utilization of medical and surgical The of people mental health are for by medical with in mental is a of the of psychological in a wide range of health including both and disease system and and In addition to being these are than across a wide of and including and that mental health can be in primary health care with and on but it is whether this is true of for persons with and mental illness. There is a long of in for persons with mental disorders that would be a single system of care that to medical and mental health services. Many mental health problems are seen as and thus the general health is a natural point for and treating mental health problems. Many also continue to find care for psychiatric problems more when by their primary care The and mental health care in an system also a that common and mental disorders will be and that and among will reduce and common of of The concept of a number of that are at the of health care them are the and A significant is that not be in a highly system of As medical are to be more and they have to to each and to know the and to the of problems that Because with conditions are and to their and they will not be with disabling mental illness will have to with who more and to deal with by and of these problems has but they are not can be to and with mental but this is a and can be to increase the of health care to disabling illness, but this must with many in an of new and practice by of public and is but effective in this objective. the that mental health for ill can be into the general health a and that are on at for the The is for persons with more and disorders. - A Psychiatrists should have been seen as and as an as they are so few in In are only psychiatrists for a population of over of psychiatrists to the of is which is quite Psychiatrists are seen in negative by the of the have been are seen as disease and not are seen as being seen as are seen as a on the most in the are seen as the to as not in and thus could them of their and being a are seen as making a a to their view are seen as not scientific psychiatrists in and are seen as are seen as only and not the have been up over and mental health of of and of including have contributed to these of by help has matters The of and of view has it from the the of psychiatrists themselves, the to formulate and not the focus from negative to and not our have it We of the of mental and disease in the but are not to prevent We of mental health but do not or we do not have or for mental health at the professional or We of well being and on The and do not have psychiatrists as the but are to our We would be to of and for but not in at the to preventive and health strategies. We can be if we are to The community of which is a part would be to allow us to lead if we have for and which are effective and We would have to hands with and community with to long solutions for the population than at a of only those who have extremely and We to be for the mental health needs of the and not only the for It is only that psychiatrists in and psychiatry in general would its place and a - PSYCHIATRY of the to with are and are for the cooperation and for effective is a on the part of some to the place of factors in the of the This be to and conditions that are to observe and or to is that mental health have long had a for The or at was in the many people the field in to their psychological problems. it and such an are to The that be and the of psychiatric The on of or at in many is with and One by many including psychiatrists, is that a will come in that the has a more disorder than the one and that the is on should the for psychiatric the the moved to this is not an the two care This is to the of if the psychiatric The should that lack expertise outside of and with psychiatrists is a that must be over a of the most here is to make but when called for an This reduce by the and allow to up in the psychiatrists have a for diagnosing as or the that they be to have some psychiatric problems of their The is not as many psychiatrists and mental health in make of fellow them or their A general way to many of these is for the to be in and to the of and medical and should that the is a in which the will have the The of with psychological problems in with should be and not The should not be or or that will be as very by the He should also be aware of the of the and than a take it or it I have found that with when I am by and does not medical the can find ways to make to the medical He should with and take the of these It is also to attend medical The of knowledge of one by psychiatrists and can during before such and can lead to the also the with an to the and of with their and AND MENTAL of people with mental disorders has throughout It is by to or or people with mental disorders such as It to and and to and It the public from and to In its most and in and it people of their and with their full in for in from the mind and by of in the of the mental health system in the United from the of an influence on and in the world. In the the public mental illness as a and an of mental illness. were not to as when with of who would have been said to be ill to the professional of the The public was not at mental illness from and and to see only of mental illness. illness great social stigma, with of and a that had scientific of mental illness. the in knowledge not social in comparison with the the public's of mental illness more This was true among those who mental illness to include psychosis view held by of the The also how of those with mental illness by The public was more to an with schizophrenia as mental illness than an with This people with mental disorders truly more some public but the of is The risk of is from those who have who have a mental disorder as well as a There is a small in risk of from with mental disorders if they are with their the risk of is much for a than for a family or who is to the with mental In is very risk of or to a from with an who has a mental Because the is to whether who is has of these or in the natural is to be to this all in the of mental disorders to the total of in society is Because most people should have to from those with mental illness, in its most is of so focus on and One of found that the public's and mental illness and people to from those with mental disorders. of the common with from psychiatric disorders are listed of mental illness of of It is not that psychiatry has a in its to mental illness, but that it has also to address its current of the psychiatry in their There is a of psychiatric on and and a to the are some in psychiatry, which are in minds and a great deal to the in psychiatry. A IN PSYCHIATRY and of and and for and help for mental disorders of all people with mental disorders do not the of mental health is among the many that people from to be in in to or and for mental disorder of is in the public's to for mental health services. to for mental health or has been public held in of the public a to for for with mental such as schizophrenia and than for conditions such as and the public to support for its support the that or would be In the of the to for mental illness is to be The public for mental disorders that for There is no or single to the with mental illness. was to with increased knowledge of mental illness, but the in some ways over the years of mental illness by to knowledge be to public is to that negative mental illness can be by on the and mental to of public education and with persons with mental illness and societal way to is to find causes and effective for mental disorders. this to be of and to are of mental disorders for which has The of an infectious and of led to the of when was to a and with was the was in the developed world. with had been in mental in the before its was no one has the of public these conditions over the and of this disease of its these also a more that the mental health field was when causes and were As were each was from the mental health field to medical For over of was moved to and in and over mental disorders was moved to The of this to is that mental health field over the years the for mental disorders was This the mental health field to by their medical that psychiatry was not part of and that psychiatric practice on and that for disorders them or the mental disorders not only but be by to mental health care only those conditions causes or To point this is not to that in mental health should be should be and The here is to some of the of the the general health and mental health that will continue to effective for mental disorders to be an effective people that mental disorders are not the of or will but are that are to much of the negative to to to be developed and science has much to to the and of As a in public should People should to should more to its most they should more to the that are the of this mental health and mental illness are part of the of health and they are a for all to would be the of the to who to mental illness regardless of from the of has been a in the success of on and AND MENTAL and medical profession have been in in the media. psychiatry and psychiatrists have not been so than the profession has been by media. illness has been the for and which the in the minds of the public mental illness and the the old some of the have psychiatry in extremely Psychiatrists are as who and for the most are not in their of mental illness. as as if is not in the minds of The is not in its of psychiatry and psychiatrists. I an by the which in the on the the no longer as a the Indian Psychiatric to do of that and it a measure of the of the profession of psychiatry in if you to a This of will the most from of psychiatric have been some of mental illness, the and both of which have been into the It is to that these have been well and psychiatrists are in a of will well for the mental health profession and for psychiatrists as a There are no to tackle this It is for all of as psychiatrists, to a to this It is our responsibility to more in the mental illness. For we should no as the of this can be of you must have seen in the and for public health causes you seen psychiatry in which I think of a when mental illness and the impact that will have on the common I feel that is a and we in are some to that I all members of to the and come more with a and the psychiatry and do all that you can to the image of psychiatry, which is for the public to embrace our IN PSYCHIATRY In this I would briefly some of the success in the field of mental The that come to my mind are the by the psychiatrists in the of the The has a lot of for psychiatry and psychiatrists. This is significant as this of will a long way in making the public more and in psychiatry. The by psychiatrists during the and and the so called in the Indian of and is a in point. a long way in the with the policy and the public I also the of and that is on in the and I also the of all the psychiatrists who have in the community mental illness and to the PSYCHIATRY IN must a with a as its more than psychiatry at the of a of has such a of as psychiatry This of both and is our and we must not up one for the of the other. health must more for Indian and psychiatry do not develop in a but they develop in a social psychiatric of and and to are all on This is not a very for a with its no has the of the and the of mental the way we have in we continue to concepts and these are in our We to on these and a truly to mental from such an will more with ground in of is its and psychological well being of the community for a and of the and we as mental health should that MENTAL I of this has a to a and an which to an of and family community and care or or in the that of mental health care with primary health care into the and of mental illness and into the of and effective and overcome the with mental illness public and Health to effective must be the for people with mental illness as for medical to mental health care should be across including the and to be with and should be to and to an of psychiatrists, to the current and needs of the population I psychiatry as my profession with a lot of and I am very happy I do feel to the way in which psychiatrists are in the society A day should come when we should be to that am a and in are psychiatrists and are psychiatry. This will if we to offer solutions to a wide range of personal, family and pressing social in and and the of in some of our role in We should make the that their health the to their should be on long solutions for the population than at a of only those who are extremely and We should make the community what we are is what our minds are the which the To this the with a the is a the mind is so to it is that we it to the is the medical profession to the with such emphasis on the In this who the of by in the is by and has to a to at the of the mind and all that it has I a day not in when people make appointments for general health check We to be for the mental health needs of the community and not only the for In these of I would to the the that you to see in the we play our role as psychiatrists, I a when psychiatry in general and psychiatrists in would their place and a household word. My to all of you is that each one of you needs to in this of a household one and all IPS.