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Bridging the Treatment Gap for People with Mental Illness

RAMESH BHARDWAJ Ph.D.*

ATUL BHARDWAJ**

*Professor, George Brown College, Toronto, Canada

**Independent Researcher and Online Instructor in ‘Machine Learning’, 'Data Science'

and 'Multivariate Statistical Methods'.

Acknowledgement: Due care has been taken to cite and credit the published research

papers/sources used in this paper. Please bring to our notice any discrepancy/omission in this

regard. We apologise for any inadvertent error or omission.

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ABSTRACT

In 2010, mental and substance use disorders accounted for around 7·4% of all DALYs

(disability-adjusted life years) worldwide. The global burden of Neuropsychiatry conditions has

been found to be in a disproportionately large percentage among children and teens. The lack

of attention to the mental health of children and adolescents is known to lead to lifelong

consequences, with adverse socioeconomic effects. Mental illness has become a contributing

cause of disability claims in many developed countries. Despite these undesired effects and

costs to the nation, it is estimated that between 76% and 85% of people with serious mental

disorders receive no treatment for their disorder in low-income and middle-income nations. For

high-income nations, the corresponding estimates range between 35% and 50 %. The present

work examines the advancement and challenges in implementing evidence-based strategies

and interventions for bridging the treatment gap. The evidence shows that integration of mental

health into primary care, which has been a core recommendation for reducing the treatment

gap, is far from being fully accomplished. Access to appropriate and timely care is hindered by

several factors: inadequate resources devoted to mental health sector; the prevalence of

formalized referral procedures; inadequate emphasis on early treatment and psychiatric

diagnosis for children and adolescents; lack of appropriate training to primary health care

doctors and nurses on mental health issues; and near absence of compulsory ingredients (like

insufficient beds in residential facilities, lack of follow-up care, coordination issues etc.) for

delivering services in community settings.

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Introduction: Mental disorders, viewed in terms of prevalence, burden of disease and disability,

are one of the greatest public health challenges facing the world today. It is estimated that at

any given time, approximately 10% of the adult and child population suffers from at least one

mental disorder (Patel et al 2010). The global burden of mental and substance disorders,

assessed in terms of disability-adjusted life years (DALYs), 1 was estimated to be responsible

for 7.4% of global DALYs and 22.9% of global YLDs (years lived with disability), making them

the fifth leading cause of DALYs and the leading cause of YLDs in 2010 (Whiteford et al 2013).

This finding is confirmed by comparing the disease burden attributable to the top most common

courses of non-communicable disorders (see table 1 below). It is seen from the table that of all

the major non-communicable disorders, mental and behavioral disorders were the leading

cause of YLDs worldwide as of 2012.2 It is conjectured that by that time, common mental

disorders-like depression, anxiety, and substance-related disorders such as alcoholism- will

disable more people than complications arising from AIDS, heart disease, traffic accidents and

wars combined (Ngui et al 2010). This will impose a huge burden on public finances in terms of

large social security disbursements. According to OECD (2014), approximately one-third of new

disability benefit claims in 2008 were attributable to mental disorders (with the figure as high as

50% in some rural areas). Further, there has been a large increase in these claims in virtually all

OECD countries over the period of two decades, 1987-2008.

Notwithstanding these hard facts, a large proportion of people with mental disorders either do

not receive treatment at all owing to poor accessibility-the so-called treatment gap- or

experience long delays (WHO 2013b). It is reckoned that between 76% and 85% of people with

serious mental disorders receive no treatment for their disorder in low-income and middle-

income nations. In case of high-income countries the corresponding range falls between 35%

and 50% (WHO, 2013).

Most of the costs associated with mental health problems do not occur within the health sector,

since they take the form of reduced productivity at workplace, absenteeism, sick leave, early

retirement and receipt of disability pensions. Equally important to reckon with are the social

1 The DALY is a health metric that captures the non-fatal component of the disease burden as years live with

disability (YLDs), and the fatal component as years lost to premature mortality (YLLs). DALY (disability-adjusted life

year)=YLD(years lived with disability) + YLL(Years of life lost). See Patel et al 2010.

2 Mental disorders also contribute to mortality. The mortality numbers (as shown in the table) are almost certainly underestimated, since the WHO report attributes death by suicide to intentional injury.

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costs associated with mental illness. People with mental disorders are at high risk of poverty,

stigma and social exclusion. Because of stigmatization and discrimination, persons with mental

disorders often have their human rights violated and many face inordinate struggle with

restrictions on the rights to work and education, as well as reproductive rights and the right to

the highest attainable standard of health(WHO 2013, Ngui et al 2010).

WHO’s report (2013) acknowledged that health systems have not yet adequately responded to

the burden of mental disorders, resulting in a large gap between the need for treatment and its

provision over the world. This matter of treatment ‘gap’ is a focus of the present work.

Plan of the Study

The primary focal point of the study is to explain the treatment gap and to assess the challenges

involved in bridging the treatment gap. The treatment gap can serve as an important public

health indicator highlighting the unmet need for mental health care (Kohn et al., 2004).

This study is organized as follows. Section 2 briefly discusses about the burden of mental and

behavior disorders across broad regions across the globe. Section 3, drawing upon the work of

Kohn et al (2004), presents the estimates of treatment gaps across the Americas and European

nations for which data are usable. In section 4, the study examines the factors contributing to

the incidence and persistence of unmet mental health needs among countries. Section 5

explains the suggested measures that can effectively address the treatment gap. The study is

concluded in section 6.

2. Burden of Mental and Behavioral Disorders: 2000-2012

The following table 1 compares DALYs, YLLs and YLDs attributable to major categories of non-

communicable group of diseases. The WHO global burden of disease (GBD) measures the

burden of disease using the disability-adjusted-life-year (DALY).3 As seen from the table that

3It may, however, be noted that the burden estimated by the DALY approach does not take into

account enormous impact of mental disorders on families and communities in terms of

emotional, social and financial costs(Saraceno & Saxena (2004).

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Table 1: Estimates of the Burden of Disease in Major Non-communicable

Diseases: 2000-2012

Major

Disease(cause)

Category

DALYs

Attributable

To Cause(% of

all-Cause

Global DALYs)

YLL

Attributable

To Cause(%

of all-Cause

Global YLL)

YLD

Attributable

To Cause(%

of all-Cause

Global YLD)

Malignant

Neoplasm 8.2 10.9 0.6

Mental and

Behavioral

Disorders

7.3 0.5 25.6

Cardiovascular

Diseases 14.4 18.5 3.1

Source: Disease Burden Estimates for 2000-2012, WHO

http://www.who.int/healthinfo/global_burden_disease/estimates/en/index2.htm

mental and substance disorders were responsible for 7.3 % of global DALYs and 25.6 % of

global YLDs, making them the fifth leading cause of DALYs and the leading cause of YLDs.

Whiteford et al., (2015) further note that mental, neurological and substance abuse disorders

rarely occur in isolation, increasing one’s risk of other diseases and injuries, including high

suicide rates.

Table 2 shows that the burden of mental and behavioral disorders in Europe is higher than

found in the whole world and the region of the Americas. It is estimated that every year over

38.2% of the total EU population suffer from at least one of the 27 mental disorders covered

(Wittchen et al 2011). These authors further add that well over one third of the EU population

during any given 12 month period suffers from mental disorders alone, most of which is not

receiving any treatment.

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Table 2: Burden of Mental and Behavioral Disorders across Europe and Americas: 2012

Global and

Broad Regions

DALYs per 1000

Population

YLDs per

1000

Population

Global 28 26.8

Europe 38 34

Americas 35 32

Source: Disease Burden Estimates for 2000-2012, WHO

3. Treatment Gap

Even though, many effective interventions for the treatment of mental disorders are known and

awareness of the need for treatment of people with mental disorders has risen, yet a high

proportion of those who need mental health care do not receive it for many reasons. The

treatment gap is defined as the absolute difference between the number of individuals with a

disorder and the number of individuals who are receiving appropriate care in the health services

for that condition.

As per the methodology of Kohn et al., (2004), treatment gap (G) calculations take into account

the service utilization rate (Sc), the prevalence rate (Rc), and the population size (Pc).

G=

][

)1[(

cc

ccc

PR

PRS (i)

Utilizing data from epidemiological studies, Kohn et al., (2004) estimated the "treatment gap" to

be between 76-85% for low- and middle-income countries, and 35-50% of high-income rural

areas. The median untreated rate, or treatment gap, for schizophrenia including other non-

affective psychoses was 32.2%. For other disorders the gap was: major depression, 56.3%;

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dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD(generalized anxiety

disorder), 57.5%; and OCD(obsessive compulsive disorders), 59.5%. Alcohol abuse and

dependence had the largest treatment gap at 78.1 % (Kohn et. al., 2004). According to the

OECD report (2014), many mild to moderate mental disorders are under-diagnosed and

untreated.

The treatment gap has varied widely between countries. The treatment gap for major

depression in the WHO European Region was 45.4%, and for the Americas it was 56.9%4. The

average 12-month prevalence for major depression, weighting for the proportion of the

population over the age of 15 were: 4.7% for the WHO European Region and 6.2% for the

Americas. In the USA, 31% of people are affected by mental disorder every year, but 67% of

them are not treated. In Europe, mental disorder affects 27% of people every year, 74% of

whom receive no treatment. The lower rate of treatment gap in the WHO European Region

when compared to the Americas can be attributed in part to the wider availability of health

coverage in western European countries (Kohn e al 2004). The results reported about USA from

the ‘2012 National Survey on Drug Use and Health’, by SAMHSA (2013),5 show that among the

43.7 million adults aged 18 or older with AMI (Any Mental illness) in 2012, only 17.9 million

(41.0 percent) received mental health services in the past year. Among the 9.6 million adults

with SMI (serious mental illness) in 2012, 6.0 million (62.9 percent) received mental health

services in the past year.

One serious concern warranting policy attention is the prevalence of psychiatric disorders with

onset in childhood and adolescence (WHO 2005). Inadequate attention to the mental health of

children and adolescents can lead to mental disorders with lifelong consequences. The

following subsection focusses on the treatment gap facing children and adolescents

Children and Adolescents as Higher Risk Group in the Population Impacted by Treatment

Gap

A disproportionately large percentage of the “burden of disease”, falls in the category of

“neuropsychiatric conditions in children and adolescents ((WHO 2003a).”

4 The following contents in this para draws heavily upon Kohn et al. 5 This report (Substance Abuse and Mental Health Services Administration, 2013) presents national estimates of the prevalence of past year mental disorders and past year mental health service utilization for youths aged 12 to 17 and adults aged 18 or older.

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Prevention and early effective treatment have long-term payoffs for individuals and society.

Issues such as leaving school early, youth unemployment, youth justice involvement, bullying,

and traumatic release from care are amplified for young adults with mental illnesses. The WHO

report(2003b) highlights that: a) worldwide, up to 20% of children and adolescents suffer from a

disabling mental illness ; b) worldwide, suicide is the third leading cause of death among

adolescents ; c) major depressive disorder often has its onset in adolescence, across diverse

countries, and is associated with substantial psychosocial impairment and risk of suicide.

Evidence from US studies (US Department of Health and Human Services ,1999), reveals 1 in

5 children suffer from a mental disorder, with 1 in 10 affected by a serious mental or emotional

disorder. Only 15% to 30% of these children, however, receive the treatment they need

(WHO/WONCA, 2008). For Canada, Waddell et al (2005) has estimated that at any given time,

14% of children aged 4 to 17 years (over 800,000 in Canada) experience mental disorders, and

fewer than 25% of these children receive specialized treatment services.

4. Reasons for Treatment Gap

Barriers to mental health care, which increase the treatment gap, are originated both at the

governmental and the individual level (Kohn 2013). Barriers to care at the individual level result

from the individual’s attitudes, fear of negative impact on employment conditions, false beliefs

about mental illness, stigmatization, and lack of compliance with medicines. In Canada, the

report by Mental Health Commission (2015) found that 26.3% of people with mental disorders

attributed the reason indirectly to the stigma associated with treatment. Andrade et al., (2014),

using data are from the WHO World Mental Health (WMH) Surveys found that for among those

with a DSM-IV6 disorder in the past twelve months, the low perceived need was the most

common reason for not initiating treatment and more common among moderate and milder than

severe cases.

Governmental barriers to care emanate mostly from (i) the governments’ failure to have specific

legislation to protect the mentally ill and to provide parity for mental illness with other medical

conditions; (ii) the small amount of funds allocated to mental health in the health budget; and (iii)

6 DSM-iv is the ‘Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The psychiatric disorders

are diagnosed on the bases of Diagnostic and Statistical Manual of Mental Disorders-IV criteria. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification of

Diseases, commonly referred to as the ICD

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the type of health care coverage offered (WHO-AIMS, Kohn 2013). Furthermore, the structure of

the mental health system in the country, including the weight of mental hospitals in relation to

general hospitals with psychiatry beds, and the availability of outpatient services, also contribute

to the effectiveness and quality of the treatment (WHO 2003b). Deinstitutionalization of large

mental hospitals and decentralization of mental health services located mainly in large urban

centers remain ongoing issues for many countries, resulting in lack of access to services (Kohn

2013).

According to OECD report (2014, Ch 4), the main factors leading substantial proportion of

mental disorders under-diagnosed or an, under treated in OECD countries include under-

supply of mental health services, especially for mild-to-moderate mental disorders, combined

with the stigma and lack of awareness and understanding of mental disorders. In case of the

USA, as per the report of SAMHSA (2013, Figure 2.10), among the 5.1 million adults aged 18 or

older in 2013 who had a perceived unmet need for mental health care and did not receive

mental health services in the past year, several reasons were mentioned by respondents in the

2012 survey. These included, (i) an inability to afford the cost of care (48.3 percent), (ii)

believing at the time that the problem could be handled without treatment (26.5 percent), (iii) not

knowing where to go for services (24.6 percent), and (iv) not having the time to go for care (15.8

percent). According to the 2011 survey, over 11 million (24 percent) of US adults affected by

mental illness had no health care coverage (SAMHSA, 2012). Many individuals with co-morbid

behavioral and physical health conditions, who were relying on public insurance or safety net

systems in the USA, faced hard challenges of navigating between two or more separate and

complex systems, neither of which is well equipped to meet their needs (Croft et al., 2013). In

many European countries, marginalization and stigmatization of many disorders of the brain are

considered to be one of the serious issues leading to a treatment gap (Wittchen et al., (2011).

Even if a disorder is accurately diagnosed, provision of evidence-based treatment is far from

assured in many European countries.

Long wait times have been reported in the UK and Canada as a factor contributing to treatment

gap. For UK, survey results indicate that around two thirds of people with depression or anxiety

wait more than six months from referral to treatment, with 1 in 5 individuals waiting over a year

and 1 in 10 waiting over two years (Foley 2013, Department of Health, UK 2014).

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In Canada, the Mental Health Commission (2015), expressing concern over the mental health

quality services, noted that that over 10% of Canadians aged 15 and older who were

discharged after a mental illness–related hospitalization were readmitted within 30 days. 7 Often

readmission for patients previously hospitalized for a mental illness indicates relapse or

complications, and may reflect lack of stabilization during the previous hospitalization, poor

discharge planning, or inadequate community support.

5. Addressing Barriers to Effective Treatment

Addressing barriers to proper treatment at an individual level will require an emphasis on

educating the public on mental health issues – for example, on the harms of delaying treatment,

on the accessibility to mental health resources, as well as to the emergency and community

support facilities. To address systemic barriers that exist at the levels of government and health

care system, the following policy interventions have been advanced to deal with the treatment

gap problem:

(i) enact appropriate legislations to promote and protect mental health(WHO, ATLAS 2011);

(ii) develop and provide comprehensive, integrated, and responsive mental health and social

care services in community-based settings (WHO, ATLAS 2013);

(iii) enhance resources (financial, Infrastructural, and manpower resources) for scaling up

mental health care quality and support(Morris et al 2012); and

(iv) improve data, research, and information systems in order to support evidence-based

decision making and to monitor the quality of services(WHO, ATLAS 2011, OECD 2014).

Each of these interventions are discussed below.

5.1 Legislations to promote and Protect Mental Health

Mental health legislation is necessary to help protect the rights of people with mental disorders,

and in the absence of mental health legislation people with mental disorders become

vulnerable to abuse of their rights. Legislations and mental health plans act as mandates for

7 This report has outlined 13 indicators of monitoring the mental health of the Canadians. The purpose of these data indicators is to inform how well – or poorly – the health system is responding to Canadians’ mental health needs.

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government and relevant stakeholders to develop a comprehensive mental health, to enforce an

evidence-based decisions, to pay explicit attention to equity, to respect for the inherent dignity

and human rights of people with mental disorders and psychosocial disabilities, and to protect

vulnerable and marginalized groups.

Relevant policies and legislations can be grouped under 3 heads: (a) early detection and

intervention efforts, (b) specific legislations targeted at protecting the vulnerable population

(children, adolescents, youths, unemployed, and socially disadvantaged group), (c) programs

designed to educate public about the accessibility of mental health resources and about the ill

effects of delaying the treatment.

(a)Early detection, intervention, and treatment: The excess disability due to mental disorders

is a result of their early age of onset (WHO 2000, 2001). There is both a failure to detect mental

disorders, and failure to adequately treat mental disorders. To the extent that early intervention

can prevent progression, early treatment might be cost effective. There is considerable variation

across countries with the proportion of mental disorders detected by treating physicians varying

between 10% and 75% (see WHO and WONA 2008).

It is estimated that about half of Americans will meet the criteria for a DSM-IV disorder8

sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed

at prevention or early treatment need to focus on youth (Kessler et al 2009). The study by Wang

et al (2005) about the USA, shows that failure to make prompt initial treatment contact is a

pervasive aspect of unmet need for mental health care in the United States. In case of children

and adolescents, data collected in a number of community epidemiological surveys have

consistently found that many people wait more than a decade after first onset of a mental

disorder before seeking treatment. In view of the various issues related to treatment gap, WHO

(2004) suggests that a new focus on development and evaluation of secondary prevention

programs for the early treatment of mild cases is needed to guide rationalization of treatment

resource allocation.

8 (DSM-IV) is the Diagnostic and Statistical Manual of Mental Disorders, which defines Lifetime

prevalence of mental disorders(like mood, anxiety, impulse control, substance abuse).

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(b) Targeted Policies to Protect Socially Disadvantaged, Vulnerable and Marginalized

Groups

One of the factors attributed to the “treatment gap” is the socioeconomic barriers to accessing

available services. Redressal of this problem requires the following actions to be taken by the

government and stakeholders: (i) providing better legislative protection and social support for

teens and children against various abuses, (ii) providing better (and more) health and social

care services for currently underserved populations with unmet needs;(iii) providing better social

and financial protection for persons with mental disorders, particularly those in socially

disadvantaged and marginalized groups.

Teens and children are especially vulnerable to mental health issues, especially with regards to

the growing global problem of victimization due to bullying, a phenomenon that has significant

implications for those concerned with mental health care. Bullied children have been found to

be more at risk for developing mental health issues such as depression, self-harming, violent

behavior, psychotic symptoms, and psychosomatic problems. As well, children with depressive

symptoms are at a greater risk of being bullied. Collecting data on 4,026 children from the

ALSPAC (UK) cohort and 1,420 children from the GSMS (USA) cohort, Lereya et al. (2015)

found that childhood bullying by peers had adverse effects on the mental health of young adults.

Given both the increase in incidents of bullying and the serious, long-term adverse effects,

enforcing effective legislation to combat bullying in schools and on social media is of paramount

importance.

To address the issue of socio-economic barriers facing youths and adults, It is suggested that

the benefits of implementing mental health interventions should be equitably distributed, with a

particular focus on outcomes in key disadvantaged groups: people living in poverty, victims of

crime, women, and people with severe mental disorders. To deal with the problems of socially

disadvantaged and vulnerable people, a policy of proportionate universalism is suggested by

Marmot (2010).

(c) Mental health literacy

Andrade et al (2014), using data are from the WHO World Mental Health (WMH) surveys, found

that low perceived need and attitudinal barriers are the major barriers to seeking and staying in

treatment among individuals with common mental disorders worldwide. This points to the need

for mental health literacy programs to alter the beliefs about mental health that hinder people

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from knowing and seeking treatment for their illness (Jorm, 2000). Mental health literacy would

include a set of interconnected components: the ability to recognize disorders in order to

facilitate help seeking; knowledge of professional help and treatments available; knowledge of

effective self-help strategies; knowledge and skills to give first aid and support to others; and

knowledge of how to prevent mental disorders (Simmons and Jorm 2011). In Jorm’s (2000)

view, if the public's mental health literacy is not improved, this may hinder public acceptance of

evidence-based mental health care. The prevalence of certain mental health issues – for

example, anxiety disorders –warrants increased education about the availability of effective

treatments (Merikangas et al., 2010). Since children and youth spend a substantial part of each

day within the school setting, these communities are a natural and important venue for mental

health service delivery (Mental Health Commission of Canada 2013).

Further, behavioral research makes clear that knowledge by itself is not a sufficient inducement

to bring people into needed care. To translate need into treatment, a range of other enabling

factors is required, which include the implementation of an action plan with such steps as

specifically knowing how to call for help or where to go and overcoming barriers of payment,

transportation, embarrassments, and other disincentives to action. Public information

campaigns have to more clearly include and explain action plans (Mechanic, 2002).

5.2 Providing Comprehensive, Integrated and Responsive Mental Health and Social Care

Services in Community-based Settings (WHO 2013)

In principle, an integrated and responsive mental health care system requires that service

delivery is based on principles of accessibility, coordinated care, continuity of care,

effectiveness, equity and respect for human rights. Further, to the extent that mental disorders

and physical health problems are interwoven and as such require common services and

resource mobilization efforts, the integration of mental health in primary care can offer a more

holistic approach to mental care (Gervais 2013, WHO 2013b).

There are two evidence based approaches to integration: (i) integrating mental health into

primary care for mild-to-moderate disorders, and (ii) Integrating primary care and specialist

mental health care in an enhanced environment of a community based setting, involving

‘Community –based Mental Health Teams(CMHT)’ for patients with severe mental illness(SMI).

Both of these approaches are discussed below.

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5.2.1 Integrating Mental Health into Primary Care for Mild-to-Moderate Disorders

The term “mild-to-moderate” is described as set of mental disorders such as depression and a

range of anxiety disorders, panic disorders, phobias, somatoform disorders, eating disorders

and ADHDs (Attention Deficit and Hyperactivity Disorders) (OECD 2014)9.

Integrated or ‘Collaborative’ care models restructure the roles of health care providers, introduce

a team-based approach, in which general physicians (GPs) work in joint collaboration with

psychiatrists and trained hospital staff. Research studies, evaluating treatment models, have

shed consistent evidence that treating common mental disorders (such as depression or

anxiety) in an integrated primary care settings can lead to better patient outcomes, including

narrowing of the treatment gap, providing opportunities for reducing the stigma of mental health

problems by not clearly identifying patients who are receiving mental health care (which is often

the case if they attend specialist facilities such as psychiatric hospitals), and improving

accessibility at reduced costs (WHO and WONCA 2008, Lund et al, 2012).

In this model, general physicians (GPs) provide a prime link in the entire chain of delivering

mental health services. This model has been widely advocated, since GPs are the first point of

contact for all people in most countries. For example, OECD 2011 (Health at a Glance – OECD

Indicators) reported that for selected EU countries, the General Practitioner (GPs) was

overwhelmingly more likely to be consulted for mental health problems than psychiatrists or

psychologists. In the US, approximately 20 to 25% of primary care patients have one or more

psychiatric disorders—most commonly anxiety, depressive, and alcohol/substance abuse

disorders (Katon & Unutzer, 2013). . It is further claimed that integration of mental health into

routine health care platforms provides an effective way of delivering timely treatment in case of

co-morbid physical conditions (WHO and WONCA 2008). The following subsection presents

some details of empirical studies.

Evidence of Effectiveness: On the basis of a meta-analysis of 78 randomized trials of

collaborative versus usual care, Katon and Unutzer (2013) concluded that collaborative care

improved quality of depression and anxiety care, as well as outcomes of depressive and anxiety

disorders, for up to 2 years at either no greater costs, or in some populations, cost savings. In

9 It is estimated that 75-80% of common disorders are assumed to have mild-to-moderate symptoms, OECD 2014, Mental

health Counts. The majority of mild-to-moderate mental disorders are not disabling in an absolute sense. Rather, the majority of

people with a common mental disorder – 65-70% (OECD, 2012) – are in employment.

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their view, ‘Collaborative Care’, as a part in the USA’s health reforms (Affordable Care Act), has

become a robust example of a strategy to achieve the “triple aim” of improving health care

experiences and clinical outcomes while reducing wasteful or unnecessary medical costs. Katon

et al (2010), examining the case for collaborative care for patients with depression and chronic

physical illnesses, conducted a single blind, randomized , controlled trial in 14 primary care

clinics in Washington State with usual care. They found that as compared with usual care, the

intervention group involving nurses who provided guidelines based, patient-centered

management of depression and chronic disease significantly improved control of medical

disease and depression.

Strong et al (2008) conducted a randomized trial in a regional center in Scotland to assess the

efficacy and cost of a nurse-delivered complex complex intervention that was designed to treat

major depressive disorder in patients who had cancer (SMaRT oncology 1).10 The authors found

that the supplementation of usual care with a nurse-delivered complex intervention improved the

symptoms of depression more than did usual care alone. The study also noted that this complex

intervention was cost effective- It cost an additional (incremental cost) £5278 (US$10 556) per

quality-adjusted life-year gained (compared with a median cost per quality-adjusted life-year of

at least ￡10 000 ($20 000) for anticancer treatments).11 Sharpe et al., (2014) have suggested

for enhancing the treatment of depression in cancer patients using a collaborative practice

model—in the SMaRT Oncology-2 Trial.

Given the multifaceted nature of the co-morbidity, both physiologically and psychosocially, the

NHS (2010) report on collaborative care suggests that a significant number of people will

require complex interventions, such as collaborative care, to deliver improvements in both their

mental and physical health (Bhardwaj, A 2014).12

10 SMaRT oncology 1 refers to a randomized trial in a regional cancer center in Scotland aimed at assessing the efficacy and cost of a nurse-delivered complex intervention that was designed to treat major depressive disorder in patients who have cancer. See NHS, Collaborative Care, Primary Care Commissioning. http://www.iapt.nhs.uk/commissioning/ 11 WHO report (2013b) defines cost effectiveness in another alternative way: “A “very cost-effective”

intervention can be defined as one that generates an extra year of healthy life for a cost that falls below

the average annual income per person”(p18). 12 For details, see the report by Atul Bhardwaj, Collaborative Care Models in Mental Health: A Literature

Review of Models in Practice and a Future Potential, 2014

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Challenges in the Implementation of ‘Collaborative Care Model’: In majority of the countries

the GPs and nurses are not given training in mental health. In a survey of 184 countries, WHO

found that only in a quarter (28%) had the majority (greater than 50%) of PHC doctors received

official in-service training on mental health issues within the last five years. This figure is even

lower (22%) for PHC nurses (Morris et al., 2012, WHO 2011). Referring patients to specialists,

particularly psychiatrists, in the health care system is not sufficient or always appropriate.

Patients in most countries face considerable waiting times. Follow-up home visits and

psychosocial interventions are compulsory ingredients in community care, but follow-up care is

widespread in only one third of the countries (Morris et al 2012). To reach a reasonable

proportion of community-living individuals with common mental health problems will require

leveraging the limited number of mental health specialists as consultants to help enhance the

capacity of primary care and other care delivery settings that do not provide specialty mental

health services to address these common problems (Patel et al 2013).

5.2.2 Integrating primary care and specialist mental health care in an enhanced

environment of a community based setting, involving Community –based health teams

(CMHT) for patients with severe mental illness (SMI)

People with SMI experience increased co-morbidities with physical ill-health, and reduced life

expectancy (OECD 2014, Ch 3). Many physical disorders have been identified that are more

prevalent in individuals with SMI (De Hart et al (2011a). What is more disconcerting to note is

that there exists a high treatment gap for severe mental disorders. In a study comparing

treatment gap countries around the globe, the median treatment gap was found to be 32.2% for

schizophrenia and 50.2% for bipolar disorder (Kohn et al., 2004). A cross-national study by

WHO of 439 patients with major depression followed for 10 years found that 36% were

readmitted to hospital; 11% committed suicide; and more than 18% received a poor clinical

outcome (Kohn et al 2004). According to De Hart et al (2011b), screening and assessment of

physical health aspects are poorly managed, even in developed countries.

Because patients with SMI fare poorly in primary care, there have been calls for psychiatrists to

take primary responsibility for the overall health of their patients by expanding their task from

clinical psychiatric care to the monitoring and treatment of crucial physical parameters (De Bert

et al 2011b). But, since the treating psychiatrist may only see the patient infrequently, it has

17

been additionally suggested that this responsibility needs to be shared with the mental health

care team (Laurence, & Kisely, 2010). Multidisciplinary team consisting of psychiatrists,

physicians, nurses and other members can also help educate and motivate people with SMI to

address their lifestyle, including smoking, diet and exercise, through the use of effective

behavioral interventions (De Bert et al 2011b)

Equally important to realize is, as Anthony (1993) has stressed, that in case of serious mental

disorders, recovery from physical sickness and disability does not mean that suffering has

disappeared, all the symptoms removed, and /or the functioning completely restored. “People

with mental illness may have to retrieve from the stigma they have integrated into their very

being; from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-

determination; from the negative side effects of unemployment; and from crushed dreams”

(Anthony 1993, P 19). The case for a recovery based approach is also reinforced in several

studies, including WHO’s (2013b) and OECD’s (2014) recent recommendations. WHO has

emphasized that community-based service delivery for mental health needs to encompass a

recovery-based approach that puts the emphasis on supporting individuals with mental

disorders and psychosocial disabilities to achieve their own aspirations and goals. People with

serious mental illnesses may have multiple residential, vocational, educational, and societal

needs and requires. This realization warrants a concerted change in attitudes and behaviors on

the part of both patients and mental health care professionals, as well as the enhanced

integration of physical and mental health care (OECD 2014).

Barriers to adequate treatment of people with SMI and comorbid physical ill-health are rooted in

the organization and financing of the overall health system (OECD 2014). The increased risk of

physical ill-health among people with SMI arise due to separation of physical and mental health

care’s organizational and financing structures. It is proposed that in an enhanced integrated

model, specialist mental health care is delivered in community-based settings by multi-

disciplinary teams with inpatient care mainly reserved for people in need of high‑intensity

support (OECD 2014).

Community mental health teams (CMHTs) have been described as the basic building block for

community mental health services (Thornicroft & Tansella 2004). A common method of

18

delivering care within CMHTs is case management. ACT and ICM, are community-based case

management models (Mueser 1998, OECD 2014)13.

ACT and ICM- Case Management Approaches

ACT (‘Assertive Common Treatment’) and ICM (‘Intensive Case Management’) are multi-

disciplinary team based recovery oriented community care models. In each of these models,

‘Community-based Mental Health Teams’ (CMHT) deliver mental health care services to

patients in non-institutional environment. According to Mueser et al (1998), the ACT and ICM

models were developed to switch the locus of treatment from the hospital back into the

community by encouraging clinicians to engage and provide services for patients in their natural

living environments. Dieterich et al 2010 have mentioned that ICM evolved from two original

community models of care, Assertive Community Treatment (ACT) and Case Management

(CM). Intensive Case Management (ICM) is characterized by a small caseload and high

intensity of care (Dieterich et al., 2010), and “provides assertive outreach and services in

patients' natural environments as well as practical assistance in daily living skills” (Mueser et al

1998, P39). ICM model has been adopted in a number of OECD countries (OECD 2014, Ch 3).

While the effect of ICM on the mental state and quality of life has been found to be unclear, but

ICM has been found to be of particular value to people with SMI who are frequent users of

inpatient care. Compared to non-ICM, ICM performed better in terms of maintaining patient

contact with services (OECD 2014, Ch 3).

Given the chronic nature of most SMI, ongoing case management is needed, and this is

increasingly seen as an appropriate role for primary care practitioners (GPs). Long-stay

community residential care provides an alternative to long-stay wards in psychiatric institutions

and cater for people with SMI who require additional support to manage self-care and other

aspects of day-to-day living in the community (Thornicroft and Tansella, 2004; MacPherson et

al., 2009, OECD 2014).

Challenges in the Way of developing Effective treatment and Care Environment for SMI

13 Other prominent ‘Case Management’ models include ‘Strengths ‘ model ‘Rehabilitation’ model(Mueser et al 1998).

19

In implementing enhanced integrated models for SMI, there are two broad challenges: co-

ordination of primary general physician and community health workers with specialists (hospital)

care, and balancing of community care with institutional care. These are outlined below.

(i)Coordination Problem

Coordination among the service providers becomes a bigger issue, when care is predominantly

delivered in community settings, away from hospitals. Given the chronic nature of most SMI,

ongoing case management is needed, and this is increasingly seen as an appropriate role for

primary care practitioners. In order for such an approach to be effective, co-ordination with

specialist care, in particular for out-of-hours care is essential, and the primary care practitioner

must have the skills and support required to respond to the complex and often heterogeneous

needs of patients with SMI (OECD 2014). Coordination is essential to the process of transition

to deinstitutionalisation (Medeiroset et al 2008).

(ii) Problem of Achieving a Balanced Community-based and Institution-based mental

health care

It is suggested that directing this funding towards community-based services would allow

access to better and more cost-effective care for many more people. However, data indicate

that globally, 67% of financial resources allocated for mental health is still directed towards

mental hospitals, despite their being associated with poor health outcomes and human rights

violations (WHO, ATLAS 2011). Some countries, such as Japan, Belgium and the Netherlands,

still have relatively large numbers of beds in psychiatric hospitals, but most countries have less

than 100 beds available per 100 000 population, and many of these are located in psychiatric

units of general hospitals. The challenge in many countries has been to balance community-

based and hospital mental health care. While there is a global trend towards reduction in

psychiatric beds in mental health institutions, but there has not been a parallel expansion of

beds in a community-based inpatient units. In the coming years, it will be important to monitor

the balance as the role of community-based facilities increases (Morris et al 2012).

Tyrer et al., (2003) has warned, however, that treatment policies of those with comorbid

personality disorders and severe mental illness should not be assumed to be the same as for

those with severe mental illness alone, and that further work is needed on specific interventions

20

for this group. For this group, the authors mention that the policy of assertive outreach and care

in community settings may be inappropriate for both public and patients unless modified to take

account of the special needs of this group. There may be greater risks to the public if community

treatment for this group is pursued.

The following paragraph provides a sketchy view about the health care reform in the US in

dealing with the development of an integrated approach towards mental health.

5.3 Enhancing Resources for Scaling-Up the Quality and Effectiveness of Mental Care

Addressing unmet mental health needs will require development of better mental health

infrastructure and workforce and overall integration of mental and physical health services with

primary care. There are considerable and wide international variations in the structures and

processes14 of mental health care. These can be illustrated by differences in hospital statistics

(e.g. number and type of beds, discharge rates, and lengths of stay), care settings (specialist

hospitals, primary care, community care), numbers and skill mix of care providers and workforce

(psychiatrists, psychologists, GPs, therapists, social workers, specialist nurses, informal carers),

and rates and types of medication (e.g. defined daily doses of antidepressants, anxiolytics,

hypnotics and sedatives)(OECD 2010, Ch 2).

Public Funding of Mental Health

Mental health care is grossly underfunded as mental health spending, in many countries in the

world, is found to be less than 1% of health expenditures. Median mental health expenditures

per capita are US$ 1.63, with large variation among income groups, ranging from US$ 0.20 in

low income countries to US$ 44.84 in high income countries (Morris et al 2012). It is seldom

realized that investment in health can have broad benefits for the public purse as a whole. The

proportion of total health-system expenditure devoted to mental health needs to be weighed

against economic and social costs associated with varying range of mental illness. The

contribution of mental health problems to the overall disease burden, as well as the availability

14 Donabedian’s framework incorporates three domains of quality measurement: structure, process, and outcomes. Specifically, health care structure measures evaluate characteristics of the treatment setting’s services, including

program fidelity, staffing, and infrastructure. Process measures examine interactions between consumers and the

structural elements of the health care system. Outcome measures examine the results of these interactions for

patients, including functioning, morbidity, mortality, quality of life, and patient satisfaction (Kilbourne et al 2010).

21

of effective and cost–effective interventions for prevention and for the treatment and/or

rehabilitation of affected individuals appear to justify considering a significant increase in funding

for mental health in most countries (Knapp M et al. 2005). Greater investment in mental health

produces many benefits that occur outside the health care system, such as increased

productivity, reduced contact with the criminal-justice system and improved rates of social

inclusion. Investing in mental health actions, both within and external to the health care sector,

provides resources and opportunities to reduce the risk of social exclusion and promote social

integration (Wahlbeck and McDaid 2012, WHO 2013b).

The following table presents the information about resources in selected developed countries.

Among the European countries (covered in this table), it is found that some countries like

France, Germany, Netherlands and UK spent between 10 to 12% of their total health budget on

mental health services. Canada, USA, Italy, Finland and Japan, on the other hand, spent

relatively less. If mental health and support services are inadequately funded through public

resources and channels, the financial burden would directly fall on the households in terms of

out-of-pocket expenditures, and in the form of reduced earnings (often leading to cuts in

spending and investment in other areas or giving up household assets and savings) (WHO

2013b). According to the same WHO report, “current coverage of essential mental health care

can be characterized as inadequate, both in terms of access for those in need and in terms of

financial protection or benefit inclusion”(p20).

22

Table 3: Selected Resources for Mental Health

Country

Mental Health

Expenditure

(% of Total

Health

Budget)

Community

Residential

Facilities

Beda/Places

in

Community

Residential

Facilities:

Number

of

facilities/beds

per 1000,000

population

Number of

Psychiatrists

/nurses

Per 1000,000

Population

Canada 7.2 NA NA 12.61/65

Denmark NA 295.5 53.91 14.12/NA

Finland 3.86 9.02 133.94 28.06/NA

France 12.91 12.76 NA 22.35/86.21

Germany 11 NA NA 15.23/56.06

Iceland 8.69 17.31 119.66 19.74/37.96

Italy 5.0 2.71 46.41 7.81/19.28

Japan 4.94 1.57 16.23 10.1/102.55

Netherlands 10.65 0.12 76.27 18.77/132.26

UK 10.82 67.8 2.28 17.65/83.23

USA 6.2(2003) 0.65 22.29 7.79/3.07

Source: WHO Mental Health Atlas 2011,

http://www.who.int/mental_health/evidence/atlas/profiles/en/

23

Mental health workforce

An adequate and well-trained health workforce is a prerequisite for quality care services. The

rate of psychiatrists per 100 000 population has remained stable, on an overall average among

OECD countries at 16 between 2000 and 2011 (OECD 2014). Due to a shortage of specialists

and hospital resources, patients in most countries face considerable waiting times.

The number of mental health nurses per 100 000 population, between 2000 and 2011, stood at

50 as an overall average for 26 OECD countries (OECD 2014). A number of OECD countries

report shortages in their mental health workforce in one or more professional categories (OECD

2014). In Canada, there are shortages of psychiatrists and other mental health professionals in

certain regions of the country, in particular rural, northern and sparsely populated areas,

because of a low supply in these regions. ‘In the United States, according to the estimates by

the Health Resources and Services Administration, an additional 5 791 mental health

professionals, including psychiatrists, clinical psychologists, clinical social workers, psychiatric

nurse specialists, and marriage and family therapists, are needed to meet the current needs of

the United States population’ (OECD 2014, P 190).

In addition to the paucity of human resources, other enabling factors needed for the effective

integration of mental health treatment into primary care are lagging behind. Training on mental

health issues is weak in primary care settings in most countries. The evidence shows that in

only a quarter (28%) of countries have the majority of PHC (primary health clinic) doctors

(greater than 50%) received official in-service training on mental health issues within the last

five years (Morris et al 2012). These authors further add a disconcerting note that only one third

of the countries (36%) have officially approved manuals in the management and treatment of

mental disorders in a majority of PHC clinics.

Physical Infrastructure in Noninstitutional and Community Care

In addition to investing more resources for more facilities, it is also necessary to improve

effective utilization rates of mental services. The evidence indicates that a reduction in the

treatment gap necessitates an expansion of community-based care, but in reality 80 percent of

resources for mental health are still being spent in mental hospitals (that are commonly

associated with isolation, human rights violations and poor outcomes) in most countries covered

(Morris et al 2012, WHO 2013b). This inevitably curbs the development of more equitable and

24

cost-effective community-based services (WHO 2013b). The report of WHO (Mental Health

Atlas 2011) suggests that limited resources should be better used, i.e., redirecting resources

from institutional to community-based care

As of 2011, the global median number of facilities per 100,000 population was; 0.61 outpatient

facilities, 0.05 day treatment facilities, 0.01 community residential facilities, and 0.04 mental

hospitals. There are 7.04 psychiatric beds per 100,000 population in mental hospitals in

comparison to 1.4 psychiatric beds per 100,000 population in general hospitals (Morris et al

2012). Globally, the average number of beds per 100,000 population falls far short of the rate of

admissions to mental hospitals. In many countries downsizing of mental hospitals (and beds),

as a part of the ‘de-institutionalization’ process, has not accompanied by a parallel expansion of

beds in a community-based inpatient units.

5.4 Improving Data, Research and Information System To Support Evidence-based

Decision Making

In today’s world that which is not measured is not done. Studies have underscored the need for

better data collection by the public authorities in order to have a complete assessment of mental

health performance and gaps, including, estimates on available resources for the treatment and

prevention of neuropsychiatric disorders, mental health quality services through appropriate

indicators, and undertake cross-country performance comparisons.

There is a lack of appropriate data at the country level which inhibit the researchers to process

information about the size of the treatment gap, prevalence and severity of the mental illness ,

utilization of mental health services by age groups, socio-economic groups etc. Kohn et al

(2004) in their treatment gap study has raised some of the major concerns that are listed below.

(i) Very few countries, in their view, conduct psychiatric epidemiological studies15 that can

provide prevalence (lifetime and 12-months rates) and service use related information for

computing treatment gap. The information about treatment gap can serve as an important public

15 Epidemiology is defined as the study of the distribution and determinants of diseases in human populations.

Epidemiologic studies are concerned with the extent and types of illnesses in groups of people and with the

factors that influence their distribution. Epidemiologic studies generally proceed from studies that specify the

prevalence and distribution of a disease within a population by person, place, and time (that is, descriptive

epidemiology) to more focused studies of the determinants of disease in specific groups (that is, analytic

epidemiology) (See Merikangas & Kessler)

25

health indicator, highlighting the unmet need for mental health care (Kohn et al., 2004) -that is,

the percent of individuals who are in need of treatment and are not receiving it.

(ii) The treatment gap estimates presented by Kohn et al (2004) do not include childhood

disorders, since published data from community-based epidemiological surveys was available

only for 15 and older adults.

(iii) Due to the lack of data, the treatment gap estimates do not take into account comorbidity

cases. In the authors’ view, the treatment gap for specific disorders may be underestimated

because comorbidity is not accounted for in studies of service utilization protocols that do not

examine disorder-specific treatment (p862).

(iv)The estimates presented by Kohn et al. (2004) do not reflect the adequacy of the treatment-

the number of people who received appropriate and adequate treatment. In their view the

estimates presented may greatly overstate the utilization of services.

The inadequate identification of people who need care perpetuates under-treatment. To

understand where treatment gaps exist and improve quality, governments must improve their

data collection on prevalence. National surveys are a useful tool to estimate prevalence.

However, the design and content of such surveys vary across countries and standardized cross-

country measurement tools are limited. It is observed that only few countries systematically

measure the resources they devote to mental health. A report by the U.S. Institute of Medicine

(IOM, 2006) and others have documented substantial gaps in evidence-based care for mental

disorders citing poor quality in detection, treatment, and follow-up care (Kilbourne, Keyser,

Pincus, 2010). Atlas Project report (2011) indicates that the availability of mental health

resources is highly discrepant across countries.

5.4.1 Efforts by WHO and OECD to Harmonize the Data and to Fill Data/Information Gaps

The data sources currently most widely available across countries are hospital administrative

databases, national surveys and national registries. In order to meet the large and growing

burden of neuropsychiatric disorders and to address this information gap, the WHO and

Organization for Economic Co-operation and Development (OECD) are two international

bodies actively engaged in developing valid and comparable mental health services data today.

26

These efforts help to develop indicators that measure and evaluate characteristics of the

treatment setting’s services, including program fidelity, staffing, and infrastructure.

Project Atlas was launched by the World Health Organization (WHO) in 2000 in an attempt to

map mental health resources across the world. Mental Health Atlas-2011 (country profiles) is

the latest global picture of the resources available for mental health. The data in this publication

provide the estimates on available resources for the treatment and prevention of

neuropsychiatric disorders in 184 countries. These data can be analyzed to monitor the

progress about certain aspects of treatment gaps (like resource gaps, shift to community

facilities etc.). The OECD has initiated work to establish common mental healthcare quality

indicators (Hermann et al. 2004; Armesto et al. 2008) Studies on quality measurement normally

refer to three domains of quality measurement: structure, process, and outcomes. The rationale

underlying the framework is that health care structures, including resources and policies, can

inform processes of care provided by clinicians, which in turn can influence patient outcomes

(Kilbourne, Keyser, Pincus, 2010). Mental health quality indicators recommended by OECD

project cover the following areas: ‘Continuity of Care’, ‘Coordination of Care’, ‘Treatment’ and

‘Patient Outcomes. The codes and names for 12 indicators are presented in the table below.

OECD (2014) in its document16 has suggested the to collect information and monitor these

indicators of mental health quality. The following table is taken from OECD (Armesto et al

OECD, 2008). This table reports the availability of data on mental health quality indicators for

selected developed countries.

16 The OECD Health Care Quality Indicator (HCQI) project began work to develop indicators in the field of mental health in

2004, commencing with a survey of the availability of mental health information in OECD countries.

27

Table 4: Mental Health Quality Indicators Ranked by Availability for Selected Countries

Indicators Canada Denmark Finland France Iceland Italy Japan Sweden USA

MH7: Hospital re-

admissions for

psychiatric patients

A B B D A B D B C

MH8: Length of

treatment for

substance-related

disorders:

B B B C A D D D A

MH12:Mortality for

persons with severe

psychiatric disorders

B B A E B B E A C

MH 9: Use of anti-

cholinergic anti-

depressant

drugs among elderly

patients

B D B B B D D A E

MH2:Continuity of

visits after

hospitalization for

dual

psychiatric/substance

related conditions

C B D E B E D D C

MH 1: Timely

ambulatory follow-up

after medical health

hospitalization

B B D E B D D D C

MH4: Continuity of

visits after mental E B D E D B D D E

28

health-related

hospitalization

MH 5: Case

management for

severe psychiatric

disorders

E B C C D D D D E

MH 10: Continuous

anti-depressant

medication treatment

in acute phase

D D D E B D D E A

MH 11: Continuous

anti-depressant

medication treatment

in continuation phase

D D D E B D D A A

MH6: Visits during

acute phase

treatment of

depression

E D D E A D D D A

MH 3: Racial/ethnic

disparities in mental

health follow-up rates

E E E E C E E D C

Total (A+B+C) 6 7 5 3 11 2 0 5 9

Source: Armesto SG, Medeiros H, Wei L (2008): Information Availability for Measuring and

Comparing Quality of Mental Health Care Across OECD Countries. OECD Health technical

papers 20. OECD. (http://www.oecd.org/dataoecd/53/ 47/41243838.pdf).

Notes:

* The letter, A, means the indicator is currently collected; the letter, B, indicates that the

indicator could be constructed from available data; the letter, C, represents that a variant of this

indicator could be constructed; the letter, D, signifies that this indicator might become available

in the next three years (D); and letter, E, means unlikely to become available.

29

The three indicators dealing with the treatment of depression (MH10, MH11 and MH6) seem to

be the most challenging in terms of data availability, scoring at the bottom. These indicators

require the ability to follow-up individual patients along a time period and this information is

hardly recorded unless the patient can be individually identified. Only the indicator related to the

type of antidepressants prescribed to elderly people at discharge (MH9) seems more promising

in terms of likelihood of availability in the relative short-term. Apparently, data on prescription at

discharge would be more readily available since they do not require patient tracking.

OECD(2014) has recommended the need to improve the availability of data/information in the

following areas:(i) data on prevalence and need trough conducting epidemiological surveys; (ii)

‘Re-admission rates’ indicators17(iii)inpatient suicide or suicide after discharge(treatment

outcomes indicator),(iv) premature mortality of serious mental illness( treatment outcome

indicator);18(v) indicators for primary care(for treatment of mild-to-moderate mental disorders);

and (vi) quality measures about social outcomes(like improved labour or educational

participation). Though many OECD countries have made considerable progress in

benchmarking the quality and outcomes of mental health systems, but these initiatives pose

substantial challenges for cross-country comparisons.

6. Summary

Mental disorders are becoming quite prevalent in all countries. It is estimated that about 10% of

the adult and child population at any given time suffer from at least one mental disorder, as

defined in the ‘International Statistical Classification of Diseases and Related Health Problems’.

In most developed countries mental illness has become one of the leading causes of human

disability and premature death. Most studies have indicated that roughly half of the all lifetime

mental disorders start by mid-teens and three-fourths by the mid-20s (Kessler et al 2007).

Mental health problems among children and youth are important precursors of adult mental

disorders. Despite this known evidence, treatment does not occur until a number of years later

(Kessler et al 2007). Mental disorders if left untreated, create an enormous toll of suffering,

disability and economic loss. Evidence shows that a large percentage of people with mental

disorders (both, mild and severe) receive no treatment for their disorder around the globe. Kohn

17 commonly used indictor of the quality of inpatient care 18 Suicide and premature mortality are population mental health outcomes that are more relevant to severe mental illness (OECD

2014).

30

et al (2004), using information from epidemiological surveys, estimated the "treatment gap" to

be in the range of 76-85% for low- and middle-income countries, and 35-50% for high-income

countries. The median untreated rate, or treatment gap, for schizophrenia, including other non-

affective psychoses were 32.2%. The existence of treatment gap is considered as one of

contributory factors to the growing burden of mental disorders measured in terms of DALYs.

The available evidence points to the lack of progress made towards implementing of cost-

effective interventions. Some broad challenges and barriers in the way of reducing the treatment

gap include: insufficient resources (financial resources, trained human resources, and

infrastructural facilities), inadequate response of health and governance systems to increase

the coverage of evidence-based treatments for priority mental disorders for each demographic

stage (childhood, adolescence, adulthood and old age), slow efforts to develop information and

database for effective decision making, and inefficient allocation of resources between hospital-

based psychiatric facilities and community-based care facilities. While growing research has

favored the need for integrating mental health services with primary care and community based

settings, but in reality there remains various shortfalls. The evidence indicates that overall

mental hospitals still represent the primary mode of inpatient service. Trained manpower like

the number of psychiatrists, nurses, psychologists per 100,000 people are far inadequate

compared to the growing need for mental services. Better affordability and equality of access to

services, among other things, are needed to narrow down the treatment gap. To this end, it is

advocated that scaling up of community-based public mental health services can strongly

contribute in promoting the objective of greater equality in access because more people in need

will be served and with reduced reliance on direct out-of-pocket spending (WHO 2013b).

31

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