Part 1: Why We Need to Talk About Mental Illness
Stigma’s impact on mental health
More than a half century ago, the first Director-General of the World Health Organization (WHO) famously stated “without mental health there can be no true physical health”. Mental health has long been recognized as a critical component of an individual’s well-being, but with a staggering 14% of the global burden of disease currently attributed to mental, neurological, and substance abuse disorders — recognizing the importance of mental health is more critical now than ever before.
Not convinced?
Experts estimate that anxiety and depression alone cost the world economy a trillion dollar loss each year. But despite their demonstrated burden, mental illnesses have been consistently overlooked by governmental and international agencies alike.
Back in 2000, the World Health Assembly adopted a global strategy for the prevention and control of noncommunicable diseases (NCDs) that included four main illness types: cardiovascular disease, cancer, pulmonary disease, and diabetes. This categorization set a precedent for the exclusion of mental illness from future WHO discussions on NCDs. Just this past September, the United Nations published a set of 17 Sustainable Development Goals (SDGs). The targets include NCDs under the health goal, but there is only a minimal reference to mental health — disproportionate to the global burden of disease mental disorders for which are responsible.
The Universal Inaccessibility of Mental Health Care
Historically, limited attention given to mental health has significantly reduced accessibility to mental health care around the world. I am currently serving as a Global Health Corps fellow, working for Last Mile Health, an organization that delivers life-saving care to the world’s hardest to reach villages in Liberia. A 2008 study conducted five years after Liberia’s 14 years of civil war had ended found that 40% of Liberians had symptoms of Major Depressive Disorder (MDD) and 44% met symptom criteria for Post-Traumatic Stress Disorder (PTSD). And that was before the 2014 Ebola outbreak killed over 11,000 people and deeply affected the country’s mental health. Yet amidst Liberia’s population of four million people, only about 160 health workers have received any mental health training, and there is one psychiatrist in the entire country.
“When it comes to mental health, all countries are developing countries.” –Dr. Shekhar Saxena, Director of Mental Health and Substance Abuse at the World Health Organization
But it’s important to recognize that inaccessibility of mental health care is not an issue specific to low and middle income countries. More than 70% of people with mental illness around the world don’t receive any form of treatment from mental health care staff. Beyond limited human resources and drug shortages, accessibility of mental health care is significantly impacted by stigma — an issue that is pervasive, impactful, and universal.
Stigma: The Invisible Barrier
Misconceptions surrounding the meaning of and treatment for mental illness have encouraged a global society that discriminates against the mentally ill. There is limited common knowledge of the prevalence of mental illness, options for treatment, or the importance of understanding that mental illness is not a choice, but a life altering condition in need of appropriate treatment. Stigma manifests itself through social, religious, and cultural discrimination which is often internalized by the mentally ill, forcing them to suffer in silence.
In Liberia, stigma is so engrained in social fabrics that patients admitted to the only mental health hospital in the country are often abandoned at the facility post-treatment — a consequence of their relatives’ fear and misunderstanding of mental illness.
Although Liberia’s discrimination towards the mentally ill may appear to be an extreme example of a low-income country’s failure to recognize the importance of mental health care, it’s critical to recognize that stigma is universal. I recently had the opportunity to speak with a college mental health counselor about their experiences working with young adults in the United States, and I learned that even on a liberal college campus in North America, the barrier of stigma is as relevant as ever.
Even on a liberal college campus in the United States, the barrier of stigma is as relevant as ever.
To start, this particular campus’s mental health center is located farther off campus than the vast majority of campus-owned buildings in an effort to provide students with increased privacy. Of course, counseling is inherently personal and the ability to maintain confidentiality is important — but one could argue that a counseling center isolated from most other buildings reinforces an underlying message that any struggle with mental illness is meant to be kept hidden from view.
At a time when record numbers of students are experiencing depression and anxiety in the United States, forty percent of those struggling with mental illness do not seek treatment. For those who are able to push through the social stigma on campus to seek out care, personal stigma is often an even larger barrier to overcome. This internalized shame is often manifested through familial, cultural, or religious stigma that leaves students uncomfortable with remaining in treatment and unwilling to share their experience with peers or family members.
On a personal level, I’ve often wondered why I feel safe using social media to update my friends and family as I’ve endured four years of orthopedic ailments — reconstructive surgeries and fractures, progress and setbacks in my physical health — yet I don’t feel the same freedom to talk about my equally intense battle with depression and anxiety that have manifested themselves along the same journey. I don’t say this to solely blame my environment, but to recognize the magnitude of my own internalized stigma, despite my personal fight against it.
“Why do I feel comfortable using social media to update my friends and family as I’ve experienced four years of orthopedic issues… yet I don’t feel the same freedom to talk about my intense struggles with depression and anxiety?”
Not only is stigma a very real issue all around the world, but it is also very impactful and very dangerous. It can be easy to toss around words like ‘stigma’ without a second thought — acknowledging its presence but allowing complacency to numb our understanding of the severity of discrimination’s adverse effects. But importantly, extensive research has made clear stigma’s negative impact on people’s well-being. Not only does it decrease likelihood of those experiencing mental illness to seek help, but internalized discrimination has also been found to have strong negative impacts on hope, self-esteem, empowerment, psychiatric symptom severity, and treatment adherence.
Small Steps Forward
Fortunately, the prioritization of mental health has seen substantial progress over the last decade. Just this past April, the World Bank and the WHO brought mental health into the global spotlight when they jointly presented to ministers of finance and development agencies around the world the projected economic, health, and social returns from investing in mental health services. In Liberia, the Carter Center is utilizing a World Bank administered $2.75 million grant from the Social Development Fund to train 700 health workers and support 6,500 people in 30 communities who are in need of mental health care. In the United States, the conversation about mental health has started, and the fight against stigma has begun.
But there is so much more progress to be made.
Particularly in low and middle income countries, our understanding of the best combatants of stigma is incredibly limited. It’s critical that mental health interventions are locally customized and community based, but providing mental health services is the joint responsibility of governments, health care professionals, civil society, communities, and families.
Providing mental health services is the joint responsibility of governments, health care professionals, civil society, communities, and families.
Mental illness is a problem in every country in the world, and it’s about time that we recognize both the invisible illness that it is, as well as the impact of the invisible barriers that stand between patients and the access to health care that they deserve.
