Mental health doesn’t just affect people in rich countries, it’s a global issue and makes poverty worse. We need to make it a priority, argues Professor Rachel Jenkins.

We all know that poor physical health is a barrier to the social and economic development of poor countries. This is why so much attention has been given to tackling infectious diseases – particularly malaria, HIV, cholera and infant diarrhoea. There is also concern about non-communicable (non-infectious) diseases such as heart disease, diabetes, stroke, and malignancy, but investment in these areas has, until recently, been relatively low in poorer countries. The argument is that these are largely found in rich populations. However, there is now a growing understanding of the importance of non-communicable diseases in poor countries and populations, so more attention is now being paid to them.

But there is a glaring omission. Mental illness. This vital area of non-communicable disease is still almost completely neglected – left out of the dialogue between international donors and governments of low income countries.

This is seriously bad news, because good mental health is essential if people are to participate effectively in society and the economy. Mental disorders are universal to all populations and countries. On average, common mental disorders (largely depression and anxiety) affect around 10% of people; psychosis affects 0.5-1%; dementia in people over 65 is around 5% – and there are increasing numbers of younger HIV related dementias; and alcohol abuse impacts 5% or more.

Mental disorders are disabling. They can last a long time – especially if they are left untreated. And they influence the onset, progress and outcomes of both infectious diseases such as HIV and non-infectious conditions like diabetes – they influence the core priorities of maternal and child health.

Mental disorders are not seen as major killers, but the fact is that they significantly increase the likelihood of premature death – not only from suicides and accidents – but also from infectious, respiratory, cardiovascular disease and malignancy. The infant children of depressed mothers, too, are more likely to die from infectious diseases.

Mental disorders play a significant role in perpetuating the cycle of poverty in a variety of ways. Production is lost through suicide and because people are simply unable to work. And family members cannot be fully productive either when they are caring for people with mental illness, and/or their dependents. Productivity is lost, too, when people can work, but because of their illness are unable to work very effectively.

Children with mental disorders often fail at school, which leads to unemployment and illness in adult life. Parents with mental illnesses have children whose emotional, intellectual and physical development is damaged.

Mental disorders are made worse by conflict – pre-existing illnesses become more severe, and new disorders precipitated. Mental illness may even contribute to the eruption of conflict – where violence is fuelled by substance abuse or adolescent emotional and conduct disorders.

Despite considerable efforts by WHO to raise the profile of mental health (for example the WHO 2001 Health Report), and, despite the known burden of disease and the links between mental and physical disorders, health sector reform strategies in low income countries rarely include integration of mental health concerns.

Mental health cuts across a number of sectors, including, finance, industry and employment – as well as education, social welfare and criminal justice, but the health sector needs to make significant investment. At present there is far too little attention paid to mental health needs, and the health infrastructure needed to address those needs in low and middle income countries.

On average there is only one psychiatrist for every million people in low income countries – in Malawi there is only one for over four million. And the situation is getting worse, because recruitment is not keeping pace with retirement, death and the brain drain. As a result, psychiatric services can only deal with a miniscule proportion of those in need.

Most people with mental disorders need to be seen and treated in primary care, but the general primary care health infrastructure in developing countries is fragile. It has been weakened by HIV and AIDS, conflict, the lack of continuing professional development, lack of support and supervision from the district level, lack of transport and lack of access to medicines.

Mental healthcare is not a luxury. Poor people deserve treatment for mental disorders as well as physical ones. But if they are to get access to decent mental health care, then we need to make strengthening of the primary care system a real priority, and to ensure that mental health is properly integrated into the primary care delivery system.

Professor Rachel Jenkins is Director of the World Health Organisation Collaborating Centre at the Institute of Psychiatry, King’s College, London and Director of International Affairs for the Royal College of Psychiatrists.