Global health and behavioral medicine intersect in two important ways. First, mental, neurological, and substance use (MNS) disorders affect every community in the world. We relate to MNS disorders at a local level, where they are embedded in our customs, culture, and context. MNS disorders also exert global influence, through their massive burden of disease, the human and economic costs of treated and untreated illness, and their secondary (often less visible) effects on the outcomes of other health conditions.

Second, the integration of behavioral, social, and biomedical sciences can improve health care globally. Adapting interdisciplinary lessons to tackle local problems may result in more effective, efficient, and responsive health care delivery. Similarly, understanding the interdependence of social determinants, health, and development may inform enlightened approaches to promoting health and empowering communities.

An interdisciplinary approach also has important implications for health worker training. Health workers in all settings should be trained to treat and prevent behavioral, social, and biological problems. They should be taught communication, leadership, and team membership skills. Burnout among health workers begins during training and leads to a range of dysfunctional behaviors. While learning to care for others, health workers should also be taught to care for themselves.

The intersection of global health and behavioral medicine is a complex and rapidly evolving area. With the goal of offering students a concise entry point into the relevant issues, we have organized this chapter into four sections:

1. 
   

   The global treatment gap.

   
   
2. 
   

   The need for new models of care.

   
   
3. 
   

   The importance of context.

   
   
4. 
   

   Health worker training and support.

The Problem

To appreciate the global treatment gap, we must first understand the level of need. One in four people will suffer from a mental illness in their lifetime. Major depression is the third largest contributor to the overall global disease burden and is expected to be the number one contributor by 2030. The World Health Organization (WHO) estimates that nearly 850,000 people commit suicide annually. Eighty percent of these suicides are in low- and middle-income countries. As a group, MNS disorders (including conditions such as depression, substance abuse, schizophrenia, dementia, and epilepsy) account for 14% of the overall global disease burden. According to a recent report by the World Economic Forum, the direct and indirect costs of mental illnesses totaled 2.6 trillion dollars in 2010 alone. By 2030, the cumulative costs are expected to exceed 15 trillion dollars. Underlying these staggering financial costs is a flood of measured and unmeasured human suffering.

Despite the enormous need, MNS disorders have received scant attention globally. Why is this the case? The following section presents a brief gap analysis, charting a cascade of inadequate global response from policy, to funding, to treatment.

Policy Gap

At each governance level (international, national, state/province, and local), policies influence funding priorities, timelines, and targets. It is not only health policies but also economic, trade, agricultural, educational, and environmental policies that matter. This is because health in general, and mental health in particular, is closely linked to the conditions in which people are born, grow, live, work, and age, which these policies shape. For the purposes of this gap analysis, we will focus on the prioritization of mental health in international and national health policies.

At the international level, significant strides have been made in recent years with the creation of the Mental Health Gap Action Programme (a series of evidence-based care protocols for MNS disorders), the Mental Health Atlas Project (more accurately mapping the global burden of disease for MNS disorders), and the Movement for Global Mental Health (a global advocacy group). Setbacks have also been common, with mental health too often marginalized or ignored in the international policy arena.

At the national level, many countries lack mental health policies (which services should be covered, for whom, and at what cost), plans (how these services should be implemented and evaluated), and legislation (to protect the rights of people who are mentally ill). Global disparities exist. Less than 40% of African countries have a mental health policy, compared with more than 70% of European countries. More than 70% of African countries do not have a national mental health plan, compared to more than 80% of European countries who have one. Globally less than 40% of countries have specific mental health legislation. The absence of mental health legislation (or their enforcement) encourages human rights abuses, which have been widely reported and described as a “failure of humanity.”

Funding Gap

The policy gaps described above lead to critical funding gaps. Compared to the burden of disease and economic loss they cause, the amount of health care spending targeted to MNS disorders is remarkably low. Again, global disparities exist. While high-income countries spend, on average, 5% of their health budgets on mental health, low-income countries spend around 0.5%. As a result, high-income countries spend 2.6 million dollars on psychiatric medications per 100,000 people each year, while low-income countries spend only 1700 dollars per 100,000 people each year. This funding stream is simply insufficient to build or sustain the necessary people, tools, infrastructure, or services needed to provide effective care for the one out of every four people worldwide who will suffer from MNS disorders in their lifetime.

Increased funding for mental health is needed at national and international levels. Whereas a multilateral, international funding mechanism exists for the prevention and treatment of HIV/AIDS, tuberculosis, and malaria, no such mechanism exists for noncommunicable diseases, including MNS disorders. The Grand Challenges in Global Mental Health, a joint-initiative between the US National Institute of Mental Health, Global Alliance for Chronic Disease, and other institutions seeking to fund mental health research, represents a step in the right direction.

Treatment Gap

Policy and funding gaps bear significant responsibility for the massive global treatment gap. Approximately 85% of people with MNS disorders worldwide do not receive appropriate care. Major deficits and global disparities exist in the workforce, essential medicines, and services necessary to provide effective mental health care.

There are insufficient numbers of mental health workers at all levels. These disparities are particularly pronounced in poorer countries. For example, Africa has 0.05 psychiatrists, 0.04 psychologists, and 0.61 mental health nurses per 100,000 people. Staffing levels in the United States and Europe are two to three orders of magnitude higher. New models of mental health care may be able to make better use of (and perhaps expand) the limited mental health workforce, as we discuss later. Nevertheless, the severe shortage of providers, resulting from the withering policy and funding environment, represents a major barrier to delivering safe, effective, community-centered mental health care to all who need it. Figure 8-1 shows the uneven distribution of mental health professionals globally per 100,000 population.

Similar absolute and relative disparities exist in essential medicines for MNS disorders. For example, the antipsychotic section of the WHO Essential Medicines List (EML) has not been modified since 1977. The antipsychotics currently included in the EML (chlorpromazine, fluphenazine, and haloperidol) are significantly more toxic than newer, equally efficacious agents such as risperidone. Worse still, even the outdated medicines included in the EML are often unavailable in low- and middle-income countries. A survey conducted by the WHO in 40 developing nations found that the mean availability of antidepressant medicines was 45.1% in private sector pharmacies and 27.8% in public sector pharmacies. Similar results were found for antiepileptic medicines. Though a full discussion is beyond the scope of this chapter, it bears mentioning that international policies (and the complex factors that determine them) directly shape instruments such as the EML, which profoundly influence the scope of available care in poorer countries. Millions of people live with unnecessary disability, resulting in massive economic loss and, in some cases, conflict and humanitarian crises.

In summary, one in four people suffer from MNS disorders in their lifetime; 85% of these are unable to access appropriate care; and trillions of dollars are lost as a result each year. The causes are complex but knowable. Gaps at the policy level result in insufficient funding which translates into the extreme global shortage of mental health care.

The Problem

In most of the world, mental health care consists of episodic treatments delivered by psychiatrists in specialized, often locked, facilities. This prevailing model is problematic for four reasons. First, it is too expensive. Teams of mid-level providers and community health workers can be deployed in less time and for a fraction of the cost of training and supporting a single psychiatrist. Second, it fails to achieve sufficient coverage. Even if we assume areas near specialized facilities have access to optimal mental health care (a debatable point), such concentration of resources leaves many areas too far away to maintain longitudinal care. This exacerbates the third problem, which is the overemphasis on treatment at the expense of prevention. The root causes of mental ill health are social as well as biological. If we focus only on the terrible cases that present to the psychiatric hospital, we will miss the forest for the trees. Finally, such treatment models promote stigma and fear surrounding the treatment of mental disorders. This is a particularly sensitive issue in countries where there has been a history of colonialism or violations of human rights by government authorities.