Mental health in Africa: A neglected link in the development chain
Historically, mental health has been neglected on Africa’s health and development policy agenda. Faced with many challenges – including intractable poverty, infectious diseases, maternal and child mortality, and conflict – African political leaders and international development agencies frequently overlook the importance of mental health. This trend is often compounded by ignorance about the extent of mental health problems, stigma against those living with mental illness and mistaken beliefs that mental illnesses cannot be treated.
Yet there are many good reasons to give greater priority to mental health in Africa. The first relates to the definition of mental health itself. The World Health Organization (WHO) defines health as “a complete state of physical, mental and social wellbeing, and not just the absence of disease or infirmity”.
This definition has a strong basis in the epidemiological evidence, as mental and physical illnesses are strongly linked. People living with mental illness or substance use disorders are more likely to become infected with HIV. Conversely, people living with HIV are twice as likely to be depressed as the general population. Treating depression not only improves adherence, but also improves immune system functioning in people living with HIV. Maternal depression has been shown to have a significant impact on subsequent infant growth and development.
Similarly, chronic non-communicable diseases such as hypertension and diabetes have high levels of co-morbidity with mental illness. This co-morbidity doesn’t only influence disability but also has direct consequences on mortality: in a study from Ethiopia, people living with severe mental illness (schizophrenia, bipolar mood disorder and severe depression) have been found to die 30 years earlier than the general population, mainly from infectious causes. Mental health, the health of the brain, is therefore inseparable from physical health.
Secondly, mental health is also inseparable from social and economic development. In 2010 we conducted a large systematic review of 115 studies from 36 low- and middle-income countries, including several African countries, and found compelling evidence that poverty is strongly associated with common mental disorders, namely depression, anxiety and somatoform disorders5. The relationship between poverty and mental illness is cyclical: on the one hand, the conditions of poverty increase the risk of mental illness through the stress of food and income insecurity, increased life events (such as trauma, illness and injuries) and the lack of resources to cushion the blow of such life events. On the other hand, people who live with mental illness tend to drift into or remain in poverty during the course of their lives because of increased health care expenditure, disability and stigma, which limit income-generating opportunities.
The third reason to take mental health seriously relates to human rights. People living with mental illness (particularly severe mental illness) are frequently stigmatized, shunned and excluded from mainstream African society, as they are in societies around the world. Cast aside by beliefs that psychosis or epileptic seizures are signs of demonic possession or evil spirits, people living with conditions like schizophrenia, bipolar disorder and epilepsy are frequently subjected to human rights abuses and denied access to life-changing treatment. In fact absence of treatment is the norm rather than the exception in Africa. The “treatment gap”, defined as the proportion of people who live with a mental illness who do not receive treatment, ranges from 75% in South Africa, to in excess of 90% in Ethiopia8 and Nigeria.
The fourth reason to give greater priority to mental health is the good news part of this story. Since the early 2000s, a series of randomized controlled trials (RCTs) in African countries have provided compelling evidence that mental health interventions, including pharmacological and psychological interventions, are highly effective. Many of these interventions have made innovative use of non-specialist health providers in local communities, greatly reducing the cost of care. For example, in northern Uganda, Paul Bolton and colleagues demonstrated significant improvements in depression and daily functioning using group inter-personal therapy, delivered by local non-specialist facilitators10. Recently, Dixon Chibanda and colleagues in Zimbabwe showed that a counselling intervention delivered by lay health workers in primary care clinics in Harare, called the “Friendship Bench”, led to significant improvements in depression, anxiety, disability and health-related quality of life.
The other good news is that many mental health interventions don’t only lead to clinical improvements. They also tend to improve the economic circumstances of individuals and households affected by mental illness. In 2011, we conducted a systematic review of interventions that break the cycle of poverty and mental illness. We found that most studies that evaluated the economic impact of mental health interventions in low- and middle-income countries showed that clinical improvements went hand-in-hand with economic improvements. In other words, there are good economic reasons for investing in mental health care. Recently, WHO health economist Dan Chisholm and colleagues conducted a return on investment analysis, and found that, for every dollar invested in care for depression and anxiety disorders globally from 2015 to 2030, there is a $2.30 to $3.00 return on investment when economic benefits are considered, and a $3.30 to $5.70 return on investment when health returns are also included.
As this new evidence emerges, the tide is beginning to turn for development policy on mental health. In April 2016, the World Bank and WHO held a high level meeting in Washington, DC entitled “Out of the Shadows: Making Mental Health a Global Development Priority”. At this meeting, the President of the World Bank, Dr Jim Kim, and the Director General of WHO, Dr Margaret Chan, committed themselves and their organizations to giving greater priority to mental health. This commitment is reflected in the WHO global Mental Health Action Plan (2013-2020) and in the World Bank’s recently established Mind, Behaviour and Development Unit (eMBeD).
Now that a robust evidence base is emerging, we know more than ever about what works. But a critical remaining question is the “how” question: how can we take evidence-based interventions to scale and cover large populations using existing health care systems, while maintaining quality? This is a question that has occupied the Programme for Improving Mental health carE (PRIME) since 2011. PRIME is a DFID-funded research programme consortium working in Ethiopia, India, Nepal, South Africa and Uganda15. In each country we have established a district demonstration site, where we are integrating mental health care for psychosis, depression, epilepsy and alcohol abuse disorders into routine primary care. Simultaneously, we are evaluating impacts on treatment coverage, primary care detection and individual clinical, social and economic outcomes. During the final phase (2015-2019), we are scaling up this model to other districts, and working with other countries that are interested in using our tools and service delivery model.
In a similar vein, in the “Emerging mental health systems in low- and middle-income countries” (EMERALD) study, we are working in the five PRIME countries, plus Nigeria, to strengthen information systems, improve governance and calculate the costs of scaling up integrated packages of care. PRIME, EMERALD and other innovations described earlier share many features: they focus on the delivery of low-cost, effective interventions that make use of existing cultural and social resources.
As we move forward, a key gap remains in care for children and adolescents. Africa has a youthful demographic profile compared to other regions of the world, and many mental, neurological and substance abuse disorders have their origins in childhood and adolescence. It is vital that we intervene early, to prevent mental illness and promote the mental health and well-being of the next generation. A good example of an African innovation in child and adolescent mental health is Farm Radio in Malawi, a mental health promotion programme working with young people.
It is also vital that we integrate mental health into poverty alleviation and violence reduction strategies. Several RCTs have shown improvements in mental health and subjective well-being through the delivery of cash transfers, for example in Kenya. The power of these poverty-alleviation strategies could be greatly enhanced by including a mental health component, building the human capital that improves and sustains the impact of poverty reduction.
To conclude, improving mental health is a means of unlocking development potential; a neglected link in the development chain in Africa. By neglecting mental health, it will be difficult to attain many of the Sustainable Development Goals related to poverty, HIV, malaria, gender empowerment and education. By investing in mental health – the cognitive, affective and behavioural capacity for dealing with adversity – we can promote resilience on the African continent. Mental health is both a means to social and economic development, and a worthy goal in itself.