Basic problems that need to be solved

The World Mental Health Report published by the WHO in June 2022 is a call for action.¹ It builds on the success of the first World Mental Health Report, which was published in 2001⁴ and has led many countries to establish national policies and programmes on mental health and to adopt international action plans to improve mental health.¹ The 2001 report showed the importance of mental health for patients, their families and societies and gave a strong global framework for action on mental health, stimulating countries to further develop treatment and prevention services, establish national policies and strengthen research. Although a lot has happened since then, many of the basic problems have not been adequately addressed. The 2022 report describes these issues, as well as areas of action that have not been tackled, but must be if progress is to be made (see below).

An important and neglected fact is that the greatest disease burden is concentrated in low- and middle-income countries (LMICs). By far the majority of people worldwide with mental disorders live in LMICs. For example, there are more people with depression in India than the total population of Spain. These countries, however, also have fewer resources to invest in mental healthcare, and materially invest less if mental health is not understood to be a health and societal priority; indeed, investment would strengthen the economies of these countries.^{Reference Chisholm, Sweeny, Sheehan, Rasmussen, Smit and Cuijpers2}

An important aspect of the further development of mental health services is to move away from large institutions and instead work on the development of community services in which people can stay in their own environment. Building on what is already available in the community is better than trying to build new community services that are unlinked and not aligned with the existing services.

It is not only a lack of resources that limits access to evidence-based treatments. Stigma is another major problem that limits progress. People with mental disorders are often assumed to be lazy, weak, unintelligent, difficult and sometimes violent and dangerous.¹ In many communities mental disorders are not considered as health issues, but as a weakness of character, a punishment for immoral behaviour or the result of illicit drug taking or supernatural forces. Reduction of stigma and campaigns to increase mental health literacy are important prerequisites to further improve mental healthcare across the world.

Unfortunately, mental disorders are associated with inequalities in several ways. Not only are structural factors such as unemployment and poverty associated with higher risks for developing mental disorders: the same groups in societies suffering most from such structural factors are also the ones who have less access to support, advocacy and effective care. Those most in need are least likely to receive care, captured in the concept of the ‘inverse care law’. And when those most in need do get support, the outcomes are often poorer¹ if the interventions are not tailored to their complex lives and situations. Improvement in mental healthcare is therefore inherently associated with reduction of inequalities and poverty across and within nations. Thus, the WHO report emphasises social determinants, as well as wider public health literacy and health promotion, and persuading decision makers and those in positions of influence that mental health is a priority for society and for health, health being an essential pathway to wealth that matters at times of adversity and in poverty.

Priorities for change

The 2022 World Mental Health Report reminds us of these essential priorities to reduce the disease burden of mental disorders in the coming decades. It also tells us how to move forward, building on the successes of the past 20 years. Important requirements for change include strengthening the political will to invest in mental healthcare and to mobilise the necessary finances with some urgency. The situation has certainly changed for the better in the past 20 years, but we are not there yet. These resources need to be invested not only in making mental healthcare available for those in need, but also in a specialised workforce that is trained to deliver evidence-based treatments, strengthen the skills of general medical staff, equip informal caregivers and optimise competencies for self-care. It is also very important to develop and implement treatments that are simple, low cost and less resource intensive than traditional treatments that have mostly been developed in high-income countries. Ensuring attention to social determinants and cultural contexts is not easy and needs skills, capabilities and coherent systems of care delivery.

The development of better mental healthcare is certainly an essential element in reducing the disease burden of mental disorders, especially in LMICs where mental healthcare is sparse or still concentrated in large psychiatric institutions. The optimal strategy is the development of community mental health services and integration of mental healthcare with general medical health services and with community services outside the health sector. For example, public health approaches include capacity for early intervention in schools, and appropriate workforce policies to protect and promote mental health in the workplace.

Unfortunately, current treatments only reduce the disease burden of mental disorders to a certain extent.^{Reference Andrews, Issakidis, Sanderson, Corry and Lapsley5} Of course, we must develop more effective care and therapeutic interventions, but it is also important to focus more on mental health promotion and illness prevention. With 700 000 people dying because of suicide, prevention is certainly one of the most important goals. However, many mental health problems start in childhood and adolescence. Investment must also target parenting and school-based programmes, which are shown to be cost-effective.

Given the COVID-19 pandemic and documented greater rates of mental illnesses, rising poverty and social isolation, and vulnerability of those living in precarity, it is clear that any future plans will need to be resilient. Those living in LMICs are most affected, and inequalities in LMICs affect the whole world. The pandemic has demonstrated that clearly. We need actions that factor in such crises, given we are facing climate change, natural disasters and conflict-related burdens, not to mention recession. The World Psychiatric Association is acting on all these fronts too, aligning closely with the WHO report's ambitions, an example of allyship to achieve significant advances in the mental health of global populations.

A call for action

The 2022 World Mental Health Report is a call for action, a line in the sand, reminding us of the incredible costs and suffering from poor mental health around the world. It not only gives a comprehensive overview of the epidemiology, disease burden and care demand, it also presents myriad exemplar projects from around the world, showing successful models of intervention to improve mental health in communities. It gives guidelines on how to increase political support and raise financial resources and how to develop seamless prevention, mental health promotion and treatment services. The report does have some weaknesses. For example, it lacks a clear analysis of why the basic problems that were noted in the previous report have not been not adequately addressed, and evidence for the effectiveness of some interventions could have been presented more clearly. However, despite these limitations, it is an important resource for policymakers, but also for clinicians and researchers working in LMICs and global mental health. The report is broad and comprehensive, but presents the needed actions in a positive and constructive way, although the success of the report in terms of changing mental health will depend very much on worldwide and national challenges inside and outside the health sector that can only be solved in the political arena.

As clinicians and researchers we should invest more in developing methods and tools to help with deinstitutionalisation and build community services. We should develop evidence-based digital tools and self-help treatments that can be easily adapted to a local context and invest more in the development of task-sharing interventions and training packages to teach nurses and lay health counsellors to use such interventions.

We commend the report and urge policymakers, politicians, clinicians, researchers and community partnerships to galvanise their collective national and international efforts. We all must act to assure progress over the next 5, 10 and 20 years.