Mental health: a stigma and neglected public health issue and time to break the barrier

INTRODUCTION

Mental well-being is an essential determinant of human prosperity, as delineated by the World Health Organization (WHO) is defined as “a state of optimal welfare wherein individuals actualize their inherent potential, effectively navigate routine life stressors, engage in productive and fruitful work, and actively contribute to the well-being of their communities.” However, a significant proportion of the global population grapples with persistent challenges in attaining this level of mental well-being, with over one billion individuals worldwide contending with mental or addictive disorders.¹

In response to this global imperative, the WHO has introduced the Special Initiative for Mental Health in 2023. This initiative is strategically poised to facilitate the provision of accessible, high-quality, and economically viable community-based mental healthcare for an additional 100 million individuals. This endeavor aligns seamlessly with the objectives outlined in the WHO's 13th general program of work (GPW13), specifically targeting the elevation of coverage for severe mental health conditions to 50% and a concomitant reduction of suicide mortality by 15%. Furthermore, the initiative is intricately designed to make substantial contributions to two key sustainable development goals (SDG) indicators: the reduction of suicide mortality (3.4.2) and the enhancement of treatment coverage for substance use disorders (3.5.1).² The overarching vision of the WHO special initiative for mental health is to envisage a scenario where every individual attains the highest standard of mental health and well-being.³

Mental health, an integral constituent of overall well-being, empowers individuals in navigating life's stressors, leveraging their cognitive capacities through effective learning and occupational endeavors, thereby fostering substantial contributions to community upliftment. Moreover, mental health is unequivocally posited as a fundamental human right essential for personal, communal, and socio-economic development. This nuanced perspective underscores the intricate interplay between mental well-being and the holistic advancement of individuals and communities alike.⁴

In 2015, global depression cases exceeded 300 million, constituting 4.3% of the world population. Depression, constituting 7.5% of global disability in 2015, is a major factor in over 800,000 annual suicides. It stands as the second leading cause of death among 15-29-year-olds, emphasizing its severe impact on public health.⁵ Approximately 4% of the world's population, totaling 301 million individuals in 2019, grapple with anxiety disorders, the most prevalent mental health conditions. Despite effective treatments, only 27.6% of those in need receive intervention. Barriers include limited awareness of its treatability, insufficient investment in mental health services, a shortage of trained healthcare providers, and societal stigma.^6,7 In India, the National mental health survey 2015-16 reported 15% of adults requiring intervention for mental health issues, with 1 in 20 suffering from depression. In 2012, India recorded over 258,000 suicides, predominantly affecting the 15-49 age group. Depression, the primary global contributor to disability (7.5% in 2015), is a significant factor in over 800,000 annual suicides, ranking as the second leading cause of death in 15-29-year-olds.^5,8

The comprehensive mental health action plan 2013-2030, originally ratified in 2013 and subsequently extended to 2030 in 2019, underwent revisions endorsed by the seventy-fourth world health assembly in 2021. This updated plan adheres to the same four principal objectives: bolstered leadership and governance in the realm of mental health, the provision of integrated community-based mental health services, the execution of promotion and prevention strategies, and the enhancement of information systems, evidence, and research. It delineates specific actions for member states, the WHO secretariat, and collaborative partners to propel mental health advancement, preempt the onset of conditions, and ensure universal coverage of mental health services.⁹

Mental health, a multifaceted construct encompassing emotional, psychological, and social dimensions, exerts profound influences on cognition, affect, and behavior. Its pivotal role extends to the adept management of stress, interpersonal relationships, and decision-making processes across the entire human lifespan, from childhood to adulthood.¹⁰

Beyond a mere absence of mental disorders, mental health manifests along a complex continuum, exhibiting distinct experiences from one individual to another. Varied degrees of difficulty and distress characterize this continuum, potentially leading to divergent social and clinical outcomes. Across the lifespan, the emergence of mental health problems can substantially impact cognitive processes, mood states, and behavioral tendencies. Contributing factors encompass biological elements such as genetic predispositions, adverse life experiences like trauma and abuse, and familial histories.

Throughout one's lifespan, a complex interplay of factors, spanning individual predispositions to broader societal and structural determinants, collaborates synergistically to either bolster or compromise mental health. This dynamic interaction significantly shapes an individual's position on the mental health continuum, elucidating the fluid and intricate nature of mental well-being.

Individual psychological and biological elements, including emotional abilities, substance utilization, and genetic factors, increase susceptibility to mental health challenges. Exposure to adverse social, economic, geopolitical, and environmental conditions—such as poverty, violence, inequality, and environmental deprivation—also heightens the risk of experiencing mental health conditions.

Risks can arise at any stage of life, with those during crucial developmental periods, particularly early childhood, being notably detrimental. For instance, negative parenting and physical punishment detrimentally impact child's well-being, while bullying stands out as a significant risk factor for mental health issues.

In contrast, protective factors foster resilience across life. These encompass individual’s social and emotional skills, positive social interactions, quality education, satisfactory employment, safe neighborhoods, and community cohesion.

Mental health risks and protective factors manifest across various societal scales. Regional threats elevate the risk for individuals, families, and communities, while worldwide threats heighten the risk for whole populations, encompassing economic downturns, disease outbreaks, humanitarian emergencies, forced displacement, and the escalating climate crisis.

Despite their limited predictive strength, individual risk and protective factors play a role. Being exposed to a risk factor does not result in a mental health condition. Conversely, individuals may develop a mental health condition without a known risk factor. Nonetheless, the interactive determinants of mental health either bolster or undermine overall mental well-being.

In recent years, there is a growing recognition of mental health's crucial role in attaining global development goals, exemplified by its inclusion in the sustainable development goals. Depression stands as a chief cause of disability, and suicide ranks as the fourth major cause of death among 15-29-year-olds. Individuals with severe mental health conditions face premature mortality, up to two decades earlier, due to preventable physical conditions.

As of 2019, around 970 million people globally, or one in every eight individuals, were living with a mental disorder, with anxiety and depressive disorders being the most prevalent. The year 2020 witnessed a significant increase in people living with anxiety and depressive disorders, largely attributed to the COVID-19 pandemic, with estimates showing a 26% and 28% rise, respectively, in just one year.¹¹

In 2017, mental disorders affected one in seven individuals in India, with their impact on the country's disease burden nearly doubling since 1990. Substantial variations exist among states concerning the burden imposed by different mental disorders, suggesting the need for targeted policies and healthcare interventions to address the mental health burden more effectively.¹²

In spite of progress in some countries, individuals with mental health conditions often face severe human rights abuses, discrimination, and stigma. Although various mental health conditions can be treated effectively at a relatively low cost, a substantial disparity still exists between those requiring care and those able to access it. The coverage of effective treatment remains notably low.

MENTAL HEALTH: A STIGMA

Mental health stigma entails negative and often unjust social attitudes directed towards individuals or groups, inducing shame for perceived deficiencies or differences in their existence.¹³ This concept comprises stereotypes, prejudice, and discrimination.¹⁴ Specifically, mental health stigma refers to societal disapproval or the imposition of shame on individuals living with mental illnesses or seeking help for emotional distress, such as anxiety, depression, bipolar disorder, or post-traumatic stress disorder (PTSD).

Individuals grappling with mental health conditions may face stigma, entailing negative perceptions, disparate treatment, and feelings of shame or inadequacy. This stigmatization can result in discriminatory actions, exacerbating the severity of mental illnesses.¹⁵ Stigmatized individuals often encounter differential treatment, exclusion, and social marginalization, rendering them vulnerable to prejudice and discrimination.

Addressing the repercussions of bias and discrimination can be distressing and may worsen mental illness, posing a challenge greater than coping with the illness itself. People with mental health issues may internalize prejudiced views, impacting self-esteem and potentially leading to treatment avoidance, social withdrawal, substance abuse, or suicidal tendencies.¹⁶

The term "prejudice" typically denotes preconceived judgment, where individuals interpret situations based on outdated and often erroneous ideas rather than evaluating them on their present merits.¹⁶ In popular culture, the term carries a more specific meaning related to hateful attitudes and discriminatory practices held by one group toward another based on factors like skin color, religious beliefs, cultural heritage, family structure, sexual orientation, and socioeconomic status.

Mental health stigma, originating from various sources such as family, friends, coworkers, and societal influences, can be exploited by groups and hampers individuals with mental illness from seeking assistance, integrating into society, and leading fulfilling lives.

Different types of stigmas have been identified- public stigma: refers to negative or discriminatory attitudes exhibited by others towards an individual's mental illness; self-stigma: entails an individual's self-perception of their mental health condition, characterized by negative attitudes and feelings of shame^; and institutional stigma: relates to policies formulated by governmental or private organizations, whether knowingly or unknowingly, that restrict the opportunities and support available to individuals dealing with mental illness.¹⁷

Insufficient awareness, education, perception, and fear surrounding individuals with mental illness contribute to heightened stigma. According to the mental health foundation, nearly nine in ten people with mental illness perceive the negative impacts of stigma and discrimination on their lives. This challenge is evident within healthcare sectors, where stigma and discrimination manifest across various organizational levels.¹⁸

Systemically, mental illness may face detrimental effects, including reduced investment, compromised standards, and the influence of biased cultural factors within healthcare systems. At the individual healthcare practitioner level, patient interactions may be swayed by pre-existing stereotypical beliefs, discriminatory behavior, and negative attitudes. Patients frequently express feelings of being undervalued, disregarded, and dehumanized by a notable portion of health professionals.¹⁹ Healthcare professionals may inadvertently display unfavorable attitudes toward individuals with mental illness, including exclusion from decision-making processes, a lack of seriousness in addressing symptoms, inadequate provision of information about conditions (whether physical or mental), and the manifestation of paternalistic or demeaning behavior.^19,20 Despite numerous attempts to establish scales for stigma assessment, achieving a universal consensus remains challenging due to the intricate and multifaceted nature of stigma and prejudice.²¹

MENTAL HEALTH: A NEGLECTED PUBLIC HEALTH

Mental health, often neglected in the realm of public health, holds significance due to its impact on individuals' physical and social well-being, aligning with the broader goals of public health initiatives.²² Presently, a substantial portion of public spending on mental health primarily caters to individuals dealing with psychosis, numbering a quarter of a million. In contrast, clinical depression affects a million people, while clinical anxiety afflicts four million more.²³

Civil society mobilization presents a stark contrast between low-income and high-income nations, with advocacy entities for mental health issues existing in 49% and 83%, respectively.²⁴ Globally, specific demographics, including women, people in poverty, refugees, and asylum seekers, face disproportionate challenges. Refugees are five times more likely to experience mental health issues, with over 61% expected to undergo a mental health crisis. Mental health conditions, a universal concern, are influenced by various social, political, and economic factors, encompassing disadvantage, deprivation, low education, unemployment, discrimination, and violence.

In India, a recent survey by the National Institute of Mental Health and Neurosciences (NIMHANS) highlights a substantial gap between the mental health care needed and the actual utilization of services. Despite nearly 150 million Indians requiring mental health care, less than 30 million seek assistance. The economic burden on individuals with mental disorders is substantial, with families spending Rs. 1,000-1,500 per month on treatment and travel.²⁵ The World Health Organization estimates that mental health problems in India contribute to 2443 disability-adjusted life years (DALYs) per 100,000 population, with an age-adjusted suicide rate of 21.1 per 100,000. The economic losses attributed to mental health conditions from 2012-2030 are estimated at USD 1.03 trillion.²⁶ Vulnerable groups, marked by lower income, education, and employment, bear a disproportionate burden, exacerbated by limited resources and the absence of state services and insurance coverage.

The treatment gap for mental illnesses in less-developed countries is significant, ranging from 76% to 85%.²⁷ Inadequate resources, both in infrastructure and human resources, contribute to this gap in countries like India.²⁸ Despite improvements in various health indicators, India faces challenges in delivering quality care, leading to a substantial population experiencing impoverishment due to high out-of-pocket healthcare expenditures.²⁹ Task-shifting to non-specialist community health workers is recommended to address the shortage of mental health professionals.³⁰ Given the dire shortage in numbers of psychiatrists, psychologists, psychiatric nurses, and social workers; piggybacking on primary care systems and employing innovative force multipliers are future courses of action.

TIME TO BREAK THE BARRIER

Studies suggest that familiarity and interactions with individuals facing mental health challenges significantly contribute to reducing stigma. Public education plays a pivotal role in dispelling misconceptions and fears, as a lack of understanding is a major source of stigma. An effective strategy involves individuals openly sharing their experiences, making mental health more tangible and relatable to the broader population. Efforts to reduce stigma can operate at both individual and population levels, with the most robust evidence supporting anti-stigma initiatives that involve contact with individuals who have lived experiences with mental illness and efforts with long-term commitments.

Celebrities such as Demi Lovato, Dwayne "The Rock" Johnson, Michael Phelps, Taraji P. Henson, and Lady Gaga have contributed significantly by sharing their personal stories of mental health challenges, bringing the discussion into mainstream media and everyday conversations, particularly appealing to the younger generation seeking information and personal narratives online.

Organizations like the National Alliance on Mental Illness (NAMI) provide actionable suggestions for individuals to contribute to stigma reduction. These include sharing personal mental health experiences, educating oneself and others with accurate knowledge, using language carefully to promote understanding, advocating for equality regardless of one's health status, showing empathy, boosting self-confidence, and, perhaps most importantly, fostering connections and sharing experiences.³¹

To create a mentally healthy community, everyone can play a vital role by: disseminating accurate information about mental health within society to foster awareness and understanding; practicing empathy towards individuals dealing with mental health challenges, without discrimination or bias; sharing personal experiences of mental illness to dispel myths and encourage others to do the same; and providing proper training for healthcare professionals to address unintentional stigma-related attitudes.²¹

Implementing ''what to do'' and ''what to say'' programs, delivered by trained instructors who have recovered from mental illness, aiming to target subconscious myths and biased judgments while making healthcare professionals aware of their role in facilitating recovery from mental illnesses.²²

Promotion and prevention interventions aim to identify and address individual, social, and structural factors influencing mental health. These programs mitigate risks, enhance resilience, and foster a supportive environment.

Reshaping these determinants often requires a cross-sectoral approach, involving education, labor, justice, transport, environment, housing, and welfare. The health sector plays a significant role by integrating promotion and prevention efforts into health services and advocating for multisectoral collaboration.

Global efforts prioritize suicide prevention, aligning with sustainable development goals. Effective approaches involve restricting access to methods, responsible media reporting, social and teaching social and emotional skills to adolescents, and early intervention. Prohibiting highly dangerous pesticides stands out as a cost-efficient measure to decrease suicide rates.

Child and adolescent mental health are a key focus, involving policies promoting mental health, caregiver support, school-based programs, and fostering positive community and online environments. School-based social and emotional learning programs prove effective across various income levels.

The growing interest in promoting and protecting mental health at work can be facilitated through legislation, organizational strategies, manager training, and worker interventions.

India's mental healthcare act of 2017, replacing the 1987 Act, emphasizes the rights and agency of those with mental illness. Recognizing access to mental healthcare as a 'right,' it establishes Central and State Mental Health Authorities, focusing on infrastructure development, practitioner registration, and service-delivery norms.³²

CONCLUSION

In a nutshell, mental health, a critical component of overall well-being, has been underscored as a global public health priority. Despite initiatives and frameworks addressing mental health challenges, stigma remains a pervasive barrier, impeding access to care. The neglected status of mental health in public health agendas, coupled with the substantial treatment gap, necessitates urgent action. Breaking the stigma requires concerted efforts at individual, societal, and systemic levels, emphasizing education, empathy, and dismantling discriminatory practices. By integrating mental health into broader public health strategies, fostering awareness, and ensuring equitable access to care, the global community can strive towards a future where mental well-being is universally prioritized and protected.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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