Authors: Caitlin Walker, Clare Donaldson, and Michael Plant
Last updated: May 2021
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This report investigates the global burden of mental illness. It sets out how big the problem is, how much spending it receives, and how those resources are allocated. It then focuses specifically on what can be done to reduce anxiety and depression in low-income countries—the assumption is that this is the part of the problem where additional resources would have the highest impact. It closes by outlining some promising donation options and career paths in the area, but does not attempt to evaluate which of these options are the most impactful, or to compare mental health to other possible global priorities—that requires further research, which HLI is undertaking regarding donations. We expect this report will be most useful for those considering putting their career or charitable donations towards improving global mental health and who therefore want to gain a better understanding of the nature of the problem and what could be done about it.
What’s the problem?
Mental illnesses are among the worst, if not the worst, of life’s common misfortunes. Depression and anxiety are associated with bigger reductions in life satisfaction than debt, divorce, unemployment, Parkinson’s, or Alzheimer’s. All over the world, those with mental illnesses suffer human rights abuses; these can be severe as being chained or caged.
Around one in every nine people lives with a diagnosable mental health disorder. These disorders are responsible for 5% of the global burden of disease, as measured in disability-adjusted life years (DALYs), and 15% of all years lived with disability. These figures are likely to be a substantial under-estimate for several reasons, for instance, that suicides and self-harm are not attributed to the burden of mental health disorders.
The vast majority of people living with mental health disorders, even in rich countries, do not receive treatment. The issue is even more acute in LICs, where mental health spending amounts to US$0.02 per person per year. In terms of development assistance, HIV receives 150 times more funding, per DALY lost to the problem, than mental and substance abuse disorders combined.
Effective interventions to improve mental health exist and can be deployed at scale. The 2016 Disease Control Priorities report noted a range of effective interventions for preventing or treating mental illnesses, and for promoting good mental health. Although there are few mental health specialists in low-income settings, one tried-and-tested way to scale-up interventions is ‘task-shifting’, where lay health workers provide therapy under the training and supervision of professionals.
While several treatments are deemed cost-effective (according to conventional standards in healthcare) the evidence-base for cost-effectiveness in low-income settings is limited. Not only are there few estimates of cost-effectiveness, these are mainly from high-income country contexts; almost no outcomes are measured in terms of subjective well-being.
Current mental health budgets could be spent more effectively. Around 80% of mental health spending in low- and middle-income countries (LMICs) goes towards psychiatric hospitals. Mental health experts argue that carefully moving to community-based care would lead to better outcomes, given fixed budgets. Further improvement could come from integrating mental health services within primary healthcare and increasing the (limited) access to cheap pharmaceutical treatments, such as antidepressants.
Stigma and misunderstanding are a major problem. These are commonplace among the general public, policymakers, and health professionals. This causes an unfortunate cycle: individuals are unwilling to seek treatment or may not even know treatment is possible; policymakers, faced with this lack of demand, prioritise other matters; as result, stigma and misunderstandings persist.
What can be done?
In light of the barriers and solutions identified from the literature, we suggest several broad avenues through which donors could fund useful work or individuals, through their careers, could undertake this work themselves. We do not attempt to prioritise between these, or between mental health and other problems; that was outside the scope of this project and is a topic for further work. We encourage interested readers to conduct their own, supplementary research.
There are many potentially valuable research directions. Examples include: identifying root causes of mental illnesses; improving preventive interventions; advancing the scale-up of existing treatments; and developing new treatments or improving existing ones.
This refers to providing individuals with interventions that prevent or treat mental disorders or promote good mental health. This direct work could be carried out by funding, founding, or joining effective non-profit or for-profit organisations. Donation advice in this area is currently quite limited; the Happier Lives Institute is working to provide some in the near future (see section 7, particularly 7.2).
Policy and advocacy work
Mental health policy and advocacy work could raise public awareness of mental health disorders and press decision-makers, such as those in governments, to provide more and better services. This might include grassroots campaigning, journalism, lobbying, or work in think-tanks at a national or international level.
The global burden of mental illness is substantial and receives scant attention. Fortunately, there are a range of ways to make progress on this problem and help people to live happier lives. We expect that improving mental health could be among the most impactful options for donors and for individuals seeking to do good with their careers.
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