Background

The 2010 Global Burden of Disease Study estimated that mental and substance use disorders accounted for 7.4% of all disability-adjusted life years (DALYs) globally, an increase of 37.6% over the preceding 20 years (Whiteford et al, Reference Whiteford, Degenhardt and Rehm2013). Mental and substance use disorders were the leading cause of years lost due to disability (YLDs) worldwide. Asia Pacific is a region characterised by rapid changes in economic and technological development, population growth, migration and demographics. Across this region, it is alarming that fewer than half of those affected by mental illness receive any treatment. This is despite increasing attempts by policy makers and governments to develop national mental health reforms, particularly in community mental health (Ng et al, Reference Ng, Herrman and Chiu2009). Consequently, there have been significant multilateral and global ratifications to prioritise mental health, including by the Commonwealth of Nations (54 economies) (Ng, Reference Ng2013), the Asia-Pacific Economic Cooperation (21 economies) (Ng et al, Reference Ng, Goodenow, Greenshaw, Upshall and Lam2017) and the World Health Organization (WHO, 2013).

Recently, the Economist Intelligence Unit (EIU) released the results of a regional mental health research initiative (EIU, 2016), on which this paper is based. The Asia-Pacific Mental Health Integration Index, which measures performance across a range of areas relative to integration, was devised and constructed by the EIU research team. The EIU had previously created a Europe Mental Health Integration Index in 2014 which included 30 countries. The Asia-Pacific report also drew on inputs from 20 local and international experts in mental healthcare and substantial desk research. Using quantitative and qualitative data, the study examined the extent to which community-based treatment and integration support are provided for people living with mental illness across 15 selected Asia Pacific economies. The ‘integration index’ applied a range of indicators to assess the ability of people with mental illness to lead fulfilling lives in the community. Indicators are grouped into four categories: environment (the extent to which policy supports the ability of people with mental illness to have a stable home and family life); access to treatment (the availability of mental health services and human resources); opportunities (the degree to which policy encourages those with mental illness to engage in employment); and governance (efforts to reduce stigma, increase awareness and promote the human rights of mental health patients). The aim of the index was not to provide a competitive ranking system, but to promote discourse among economies about current performance and how they can improve, and to share best practices.

General common findings

Across the Asia Pacific region, mental illness causes a significant health and socioeconomic burden, which on average accounts for more than 20% of total YLDs and 9.3% of DALYs among the economies included in this report. Moreover, the absolute age-standardised DALYs attributable to mental illness have remained virtually unchanged relative to other diseases; together with rapid population growth, this has resulted in a rising disease burden and public health and economic effects (Charlson et al, Reference Charlson, Baxter and Cheng2016). Even such advanced economies as Australia and New Zealand have gross domestic product deficits of 3.5 and 5%, respectively, linked to mental illness (The Royal Australian and New Zealand College of Psychiatrists, 2016). In the next 15 years, it is estimated that mental illness will result in a loss of $11 trillion in economic growth for India and China alone.

According to a WHO survey of 50 low- and middle-income countries, the median treatment gap was 69%; that for low-income countries (89%) was greater than for lower-middle-income and upper-middle-income countries (69 and 63%, respectively) (Demyttenaere et al, Reference Demyttenaere, Bruffaerts and Posada-Villa2004). In another study, the treatment gap was 35 to 50% in high-income countries, compared with 76–85% in lower-income countries (Lora et al, Reference Lora, Kohn and Levav2012). The EIU report cited similar figures of around 90% for those not receiving mental health treatment in middle-income countries such as China and India, whereas in higher-income countries such as Singapore and Australia, the treatment gap was above 50%. More importantly, where services are provided, most are neither patient-focused nor integrated to support those with mental illness to live a meaningful life in the community. The recovery model is gradually emerging as the standard of best practice in treatment worldwide. However, in reality, most services in the region are hospital-based and not oriented towards a recovery-focused approach that is integrated with social, housing, employment and community services.

There are also common challenges, although these may take different shapes in the different economies studied. Good epidemiological data on mental disorders are generally lacking, especially in lower-income economies where even basic data are often absent. Without an adequate mental health information system, effective service planning and resource allocation are seldom achieved. Notably, across the region, the stigma of mental illness – especially serious mental disorders – remains prevalent and a significant barrier to treatment access. This has given rise to various forms of prejudice and discrimination faced by people living with mental illness, ranging from social distance, limited employment prospects and inadequate insurance coverage to excessive use of physical restraints and human rights abuses.

The discrepancy between treatment in urban and rural areas is glaring in both high-income and low- to middle-income economies. Rural mental health services are typically under-resourced, often resulting in a disproportionately wide treatment gap and higher suicide rates. This highlights considerable nationwide variations not measured by the integration index, such as variability of services and coordination across city and rural areas, policy implementation by individual provinces or states, provisions for different sub-populations or cultural groups, and capacities of various local service providers. Therefore, having an overall country index score may not provide meaningful information about the degree of integration at the local level.

Comparison between income groups

The report found a diverse range of performance scores in all indicators across the economies, especially in terms of measures that help people with mental illness to find and sustain meaningful work, and the provision of training and vocational support programmes. Compared with a similar study in European countries conducted in 2014, the range of index scores was substantially greater (about 35%) in this Asia Pacific study, reflecting a more economically and culturally diverse region. Overall, the features of countries and territories included in this survey fall within four groups of mental health integration that are closely linked with economic development levels.

1. (a) High-income oceanic countries (New Zealand and Australia). Similar to leading European countries (e.g. the UK), both countries started mental health reform very early in the 1990s and began addressing the transition from institutional to community-based, recovery-focused care. Substantial investment in policy, resources, infrastructure and workforce (including non-governmental organisations (NGOs)) has led to a decrease in stigma against those living with mental illness.

2. (b) High-income Asian countries (Taiwan, Singapore, South Korea, Japan and Hong Kong). Backed by advanced health and social service systems, these economies have begun implementing community-based services for those with mental illness. The key challenges include lack of human resources, cross-sectoral coordination, funding incentives for community treatment and patient advocacy.

3. (c) Upper-middle-income countries (Malaysia, China and Thailand). Recent increases in national policy commitment to community-based care have been established. However, development of appropriate mental healthcare facilities and personnel remains in progress. Major issues still need to be addressed, including huge treatment gaps, inadequate mental and allied health professionals, and little coordination between healthcare providers.

4. (d) Lower-middle-income countries (India, the Philippines, Vietnam, Indonesia and Pakistan). All the above mental health challenges are huge in these countries, where treatment, resources and workforce are scarce. Resources, where available, are frequently tied up in outdated institutional facilities and treatment modalities. Health systems have an insufficient budget or lack the technical capacity to fully execute mental health expenditure. On the other hand, early signs of improvement in recent legislation, policy and programmes are encouraging.

Concluding remarks

Although guidelines are inappropriate for a highly diverse region, some lessons can be learned from this study to assist progress towards community integration. Various economies are at markedly different stages of reform in the provision of the care, services and environment necessary for integration of people with mental illness into the community. While there is a growing trend across the region in policy and plans to shift from hospital-centric treatments to community-based care, integration for people with mental illness remains slow. Overcoming the regional gap to deliver community-based care requires strong mental health policy implementation, sufficient timeframe, consistent efforts and sustainable integration of all health and non-health sectors to meet the diverse needs of people living with mental illness.

More important than funding is the question of how funds are used and applied according to policy goals. Greater emphasis is needed on developing and integrating a range of system resources, especially to build capacity among NGOs, non-health sectors and non-professionals to deliver community mental healthcare. It is obvious that more reliable data on prevalence, best practices and cost-effective treatments are required. There is a critical need across the Asia Pacific region to strengthen information systems and improve evidence and research in mental health; fundamental goals of the WHO Global Comprehensive Mental Health Action Plan (WHO, 2013).

Finally, integration depends to a large extent on the cultural acceptance of those living with mental illness. Explanatory models of mental illness and their treatments are often shaped by different cultures in the Asia Pacific region. For instance, family and societal attitudes towards mental illness are heavily influenced by cultural values, and the concept of recovery may have different meanings in Asian contexts. Along with the development of community-based infrastructure, efforts towards anti-stigma education, human rights campaigns and patient advocacy should also consider local cultural appropriateness.