Chronic underfunding and lingering stigma are significant barriers to preventive mental health care in low- and middle-income countries. Dr Julian Eaton, mental health director at CBM Global Disability Inclusion and assistant professor at the Centre for Global Mental Health, advocates a transformative approach to comorbidities, empathetic communication and cross-sector collaboration to improve outcomes.
(PART 3 of 5) Re:solve Global Health’s new Q&A series explores strategies to improve mental wellbeing. We asked five experts from diverse backgrounds (health promotion, social media strategy, public health, suicide prevention and international advocacy) to answer this key question: How can we prevent mental health problems at a population level?
What is the most effective way to prevent mental health problems in low- and middle-income countries (LMICs)?
The most important thing by far is facilitating stable economies with a reasonable amount of employment, people having decent treatment at work, access to good education and access to adequate general healthcare, including safe childbirth and early infant nutrition. These are absolutely fundamental to wellbeing because of the impact on brain health as well as social influence on mental wellbeing.
Within healthcare, what are the biggest barriers to adequate provision of preventative measures for mental health in LMICs?
Although things have really changed in the last 15 to 20 years, it remains the low prioritisation of mental health generally. We all know how little is spent on public health in general, and mental health is a tiny component of health budgets. In many low-income countries it's 1-2%, which is often spent on the national psychiatric hospital and nothing else.
The WHO is trying to persuade LMICs to reach 5%, even though the relative burden of disease of mental health is around 12-13%. There's a lack of attention and, therefore, a lack of investment in public health approaches to mental health and wellbeing.
Stigma is another significant barrier. In many LMICs, few people want to become a psychiatrist, psychiatric nurse or mental health professional because they are stigmatised professions. Anti-stigma campaigns are one of the more important things we can do, both for the broader population's mental health as well as for the very large number of people who have mental health problems.
How can we transform healthcare systems in LMICs to prevent mental health problems?
The big way forward is recognising comorbidities. There are huge numbers of people with other health problems who also have mental health problems or are at risk of mental health problems. So, the most effective way in which we can address mental health across the board is to make sure that HIV programmes have a good mental health consideration, that Neglected Tropical Disease (NTD) programmes and NCD programmes have mental health built into them.
The single most powerful thing we can do within the health system is to make health professionals realise that communication, empathy and an ability and willingness to engage in people's distress, and sometimes frank mental health symptoms, is part of their job.
People's distress is routinely ignored, either because it's socially awkward to talk about distress, or doctors are too busy, especially in primary care, and don’t have a good sense of where to seek further support for people who need it.
How important is it for public health experts and mental health professionals to collaborate and share knowledge?
It’s crucial to recognise that very few public health experts have any mental health knowledge. So they don't recognise their responsibilities in mental health in their role as the district public health officer or even at the national level in non-communicable diseases.
The other side of the coin is that mental health professionals who are often promoted to the position of national mental health advisor or district mental health focal point are entirely clinically trained.
Their advocacy tends to be for clinical services for people with severe mental health problems who make it to the hospital, rather than seeing public mental health as part of their responsibility—whether that's health systems reform, addressing housing for homeless people, drug policy or education policy. They see all of these issues as outside of their remit because they've never been trained in public mental health.
Mental health needs to be increasingly seen as an integral part of overall public health and service provision. In this way we can not only reduce prevalence, but also address the needs that do arise.