Deficiency in policies, absence of resources leads to treatment gap

More than 80% of people who need treatment do not get treatment in our region

Rawalpindi

The Institute of Psychiatry and WHO Collaborating Centre at Benazir Bhutto Hospital organised a special lecture on ‘Global and Regional Developments in Mental Health’ that mainly discussed policies and resources for research and treatment facilities available in the WHO Eastern Mediterranean Region.

The speaker on the occasion was Dr. Khalid Saeed who is the Regional Advisor at WHO Eastern Mediterranean Region (EMR) at Cairo. Consultants, residents, and house officers of psychiatry and psychologists from the twin cities of Islamabad and Rawalpindi attended the lecture.

Head of the Institute Professor Fareed A Minhas initiated the seminar by introducing Dr. Khalid as a role model for all in attendance. Since his days as a student he showed an interest and understanding of psychiatry far exceeding that of his peers, inspired by Professor Mubbashar Hussain and his dedication as a resident at the institute is remembered to this day. His choice to join the WHO as advisor, allows him to serve psychiatry at a much larger scale, he said.

Dr. Khalid began his talk by explaining that his area of responsibility extends from Pakistan in the east to Morocco in the west. He said the WHO mainly focuses on five main areas in the issue of health: the general health priorities, health system strengthening, communicable diseases, maternal and child health, prevention and control of non-communicable diseases, and emergency preparedness and response.

He elaborated that the health system relates more with policies and laws, financing, and service development. For low income countries communicable diseases are a major problem. The non-communicable diseases include cardiovascular problems, chronic respiratory illnesses, diabetes, and cerebrovascular illnesses. There has been a debate with respect to incorporating mental health under this umbrella but the inclusion has thus far been precluded due to the multi-factorial contributors leading to mental illnesses and the resulting difficulty in preventing them, he said.

He further informed the audience that an increase in the population and an aging population is resulting in a significant increase in burden of mental health. Substance use being a notable exception is increasing without any direct relation to the demographic shifts, he said.

Speaking about the mortality rate of mental illnesses, he said, that it is more appropriate to look at it from a contribution to excess deaths perspective rather than a cause specific mortality.

In the latter perspective suicide is the primary cause of death related to mental illness mortality rate and the overall contribution is a mere 0.5 %. However from the perspective of excess deaths contributed by mental illnesses the number reaches 30 million, he explained.

He shared with the audience the prevalence of mental illnesses with Oman at 13.9% and Morocco at 40.1% being the outliers and the rest of the counties falling between that range. He also alerted the audience of the fact that death and disability is not the only burden but financial cost is also to be considered. An estimated 4% of global GDP is lost due to mental illness, he said.

Speaking of emergencies he said these are tiered into three levels, with level 3 being the highest level of emergency indicating that indigenous resources of the country are insufficient to curtail the crisis. He informed the audience that the popular perception that Posttraumatic Stress Disorder (PTSD) is the significant disorder to be addressed in emergency situations is misleading as statistics reveal that an increase in the rate of depressive illness as a result of emergencies is far greater.

He then geared the discussion towards the capacity and resources in the region. He said that only half of the countries in WHO EMR have notable mental health policies but even of these there is insufficient resource allocation to ensure implementation of policies. Resultantly the policies are implemented only in piecemeal. Additionally, a few counties have laws and legislation but most of them are not in accordance with international consensus of standards, he said.

Dr. Khalid said that at average, 1-2$ per person per year are being spent on mental health and an ideal of 4-5$ is a necessity for a basic health package. In addition, he said 64% of the resources are misappropriated to the larger institutions which are not in the community and fewer people have access to them. Enhancing the resources of big institutes is not cost effective; most of the community is missing out. Not having enough people is one problem, but having them concentrated in a few institutes is a greater problem, he asserted. Most of the countries in our region have one psychiatrist per 100,000 people, he said.

Talking of research, he said that we are only contributing a dismal 15% of what is supposed to be produced. The problem is further compounded by the fact that even this corpus of research does not pertain mostly to public health. A key issue in record keeping that precludes efficient generation of statistical data is that the mental health record is not linked to the general health record, he said.

Dr. Khalid explained that the records will as a result not reflect policy. As an example, a suicide patient will have a “cardiopulmonary arrest” listed as his cause of death rather than the suicide. This leads us to use extrapolated estimates rather than more accurate research data to guide and influence effective policy making, he said.

The talk was then steered towards the treatment gap that exists. Deficiency in policies and absence of resources inevitably leads to treatment gap; More than 80% of people who need treatment do not get treatment in our region. This is not just a problem for low income countries and this gap has to be bridged by providing cost effective treatment for priority disorders, said Dr. Khalid Saeed.

He said in view of this the Mental Health Gap Action Program was launched in 2008. This has resulted in a set of publications with the mhGAP Intervention Guide being the most popular of the lot.

He said that Health and Wellbeing is now among the seventeen points in the 2030 agenda for sustainable development with mental health and substance use explicitly mentioned as specific targets. This strengthens the case of mental health professionals to influence policies as it has been identified at an international scale as a key determinant of development, said Dr. Khalid.