Elsevier

The Lancet

Volume 370, Issue 9590, 8–14 September 2007, Pages 859-877
The Lancet

Series
No health without mental health

https://doi.org/10.1016/S0140-6736(07)61238-0Get rights and content

Summary

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

Introduction

The WHO proposition that there can be “no health without mental health”1 has also been endorsed by the Pan American Health Organisation, the EU Council of Ministers, the World Federation of Mental Health, and the UK Royal College of Psychiatrists. What is the substance of this slogan?

Mental disorders make a substantial independent contribution to the burden of disease worldwide (panel 1).2 WHO's 2005 estimates of the global burden of disease provide evidence on the relative effect of health problems worldwide.3, 4 Non-communicable diseases are rapidly becoming the dominant causes of ill health in all developing regions except sub-Saharan Africa (table 1).4 The Global Burden of Disease report has revealed the scale of the contribution of mental disorders, by use of an integrated measure of disease burden—the disability-adjusted life-year, which is the sum of years lived with disability and years of life lost.4 The report showed that neuropsychiatric conditions account for up to a quarter of all disability-adjusted life-years, and up to a third of those attributed to non-communicable diseases, although the size of this contribution varies between countries according to income level (table 1).4 The neuropsychiatric conditions that contribute the most disability-adjusted life-years are mental disorders, especially unipolar and bipolar affective disorders, substance-use and alcohol-use disorders, schizophrenia, and dementia. Neurological disorders (such as migraine, epilepsy, Parkinson's disease, and multiple sclerosis) make a smaller but still significant contribution. Of the non-communicable diseases, neuropsychiatric conditions contribute the most to overall burden (figure 1 and table 1),4 more than either cardiovascular disease or cancer.

Despite these new insights, ten years after the first WHO report on the global burden of disease, mental health remains a low priority in most low-income and middle-income countries. Developing countries tend to prioritise the control and eradication of infectious diseases and reproductive, maternal, and child health, whereas developed countries prioritise non-communicable diseases that cause early death (such as cancer and heart disease) above those that cause years lived-with-disability (such as mental disorders, dementia, and stroke). If mental disorders are regarded as a distinct health domain, with separate services and budgets, then investment in mental health is perceived to have an unaffordable opportunity cost.

Our first aim is to critically appraise the way that the burden of disability and premature mortality is apportioned, in WHO's estimates of global burden of disease, between underlying conditions within groups of disorder, and, specifically, to assess whether these estimates account for the full contribution of mental disorder to mortality and disability. Our second aim is to review available evidence for interactions between mental disorders and other health conditions (such as medically unexplained somatic symptoms, communicable diseases, maternal and perinatal conditions, non-communicable diseases, and injuries). Our third aim is to discuss the implications of these links for the future orientation of health policies, health systems, and services.

Section snippets

Contributions of mental disorders to disability and mortality

Mental disorders are an important cause of long-term disability and dependency. WHO's 2005 report attributed 31·7% of all years lived-with-disability to neuropsychiatric conditions: the five major contributors to this total were unipolar depression (11·8%), alcohol-use disorder (3·3%), schizophrenia (2·8%), bipolar depression (2·4%), and dementia (1·6%).4 However, the interaction between mental disorder and disability is more complex and extensive than the WHO report suggests. Depression

Medically unexplained somatic symptoms

Typically, at least a third of all somatic symptoms remain medically unexplained, both in the general population35 and in general medical-care settings.36 Common medically unexplained symptoms include pain, fatigue, and dizziness. Syndromes that represent characteristic organ-specific groups of medically unexplained symptoms have also been defined: irritable bowel syndrome, fibromyalgia, chronic-fatigue syndrome, chronic pelvic pain, temporomandibular joint dysfunction, and sexual-discharge

Reproductive and sexual health

Women are at heightened risk for common mental disorders: a female to male sex ratio of 1·5 to 2·0 is typical.195, 196 In Pakistan, the prevalence of common mental disorders in men is similar to that in other regions, but women are two to three times more likely than men to suffer from such disorders.197 Gender affects many of the determinants of mental health, including socioeconomic position, access to resources, social roles, rank, and status; and gender differences in mental disorders

Maternal and child health

Maternal psychosis affects infant growth and survival. Maternal schizophrenia is consistently associated with preterm delivery204, 205 and low birthweight.204, 205, 206 The effect of maternal psychosis on child survival has also been investigated—a meta-analysis linked maternal psychosis with a two-fold increased risk of stillbirth or infant mortality.207 Postpartum depression affects 10% to 15% of women in developed countries,208 with adverse consequences for the early mother–infant

Injuries

Injury and violence are important causes of death and disability worldwide. The 2005 WHO report estimated that 5·4 million deaths from injury accounted for 9% of deaths worldwide and 12% of the global burden of disease, and that such deaths would increase substantially by 2030.4 Mental health problems are both a cause and a consequence of injury. Injury and mental disorder also have many determinants in common, such as poverty,234, 235 conflict, violence, and alcohol use. Any public-health

Implications for policy, practice, and research

WHO estimates of the global burden of disease have helped to raise awareness of the enormous effect of mental disorders, both in their own right and relative to other health conditions. Much of this effect arises from the commonest disorders, especially depression and alcohol-use disorder. However, the Cartesian dualism that is implicit in the methods used to generate these estimates has meant that what began as a blessing is now, in some respects, a bane. In reality, the interactions between

Search strategy

We searched relevant databases (Medline, PubMed, Embase, and the Cochrane Library of systematic reviews and clinical trials) with the following Mesh terms: “mental disorders”, “substance-related disorders”, “cardiovascular diseases”, “cerebrovascular disorders”, “diabetes mellitus”, “diabetes complications”, “HIV infections”, “malaria”, “tuberculosis”, “genital diseases”, “female”, “infant nutrition disorders”, “and accidents”, together with the PubMed clinical queries algorithms for

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