Global Mental Health Perspectives from the Eastern Mediterranean Region

Professor Unaiza Niaz is the Advisory Board Member of The Lancet Psychiatry International and a Commissioner on the Lancet Commission on Global Mental Health and Sustainable Development. In this blog, Dr. Niaz shares her perspective on the status of mental health within the Eastern Mediterranean Region as well as the efforts of the World Health Organization's Eastern Mediterranean Regional Office's with updates to their Regional Framework to Scale Up Action on Mental Health within the Region. 

Given current political unrest, protracted humanitarian crises and the challenges associated with displaced populations on the move, the burden of mental health disorders within countries in the Eastern Mediterranean Region are significantly higher as compared to the global average¹.

Data from the 2015 Global Burden of Disease also shows how prevalent mental health conditions (such as depression, anxiety and substance abuse) were in the EMR. Depressive (42.1% of total Disability-Adjusted Life Years - DALYs) and anxiety disorders (21.5% of total DALYs) are the third and ninth leading cause of Years Lived with Disability for instance, with higher rates in countries experiencing complex emergency situations².

The EMR region contributes to 16% of the global prevalence of depression and 12% of global prevalence of anxiety disorders in the world³. Rates in women are up to twice as higher as those in men⁴ and while recent years have seen significant changes in the field of mental health in the countries of the Region,  several problems still exist.

Negative attitudes toward mental health are still observed among policymakers and administrators, possibly stemming from a lack of knowledge about recent developments in the field of mental health. This is often because of the lack of collaboration between university departments and ministries of health.

Oftentimes health administrators are ill-informed on prevention, treatment and management of mental health and psychosocial disorders and the cost-effectiveness of their benefit to the economy. Investing in targeted engagement and stigma reduction activities for medical trainees, nurses and other health professionals is key to incentivizing young medical professionals towards mental health specialization and training. Brain drain is another major and multi-faceted challenge associated with the mental health workforce within the EMR region. In addition to motivating medical professionals to specialize in the mental health field, further incentives need to be built into teaching and trainee programmes and reflected in the policies of health care facilities for there to be a significant impact in reducing brain drain.

There is a shortage of qualified mental health professionals in almost all the countries within the EMR. Multiple reasons for the limited human resources include brain drain, lack of respect given to professionals within the field amongst others. This is often exacerbated by the ambiguity over the roles of the members of the mental health care team and whether the clinical responsibilities of psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses can be task shared with more general medical or community-based service providers

Many countries within the EMR still host outdated mental health laws which do not have adequate provisions for treatment, care and rehabilitation of persons suffering from neuropsychiatric illnesses, at the same time respecting human and civil rights

The Lancet Commission on Global Mental Health posits mental health as a basic human right. Moreover, from a social justice perspective, it emphasizes the rights of vulnerable populations who are at greater risk for poor mental health (such as those who are fleeing conflict) as well as the rights of people already living with mental health problems. To address the problem, it is vital that locally-driven and appropriate mental health objectives should be defined in each country. An extensive account of the nature, extent and consequences of mental health disorders noted and the resources available identified. The objectives should be realistic and need to be formulated in terms of the effects to health or service delivery to be achieved for a stated proportion of the population in a defined area.

Another key public health priority identified was to empower and integrate mental health into primary health care services under the ambit of the Sustainable Development Goals within the region to address the burgeoning burden of both common and disabling mental health conditions. The PHC approach is rooted in system strengthening and has become the foundation for health systems development within the 21^st century. The WHO Report on PHC in the EMR (2018) proposed seven strategic priorities aligned towards the successful implementation of mental health within the PHC approach: 1) move towards UHC, 2) strengthen leadership and governance in health, 3) strengthen health information systems, 4) promote a balanced and well managed health workforce, 5) improve access to quality health care services, 6) engage with the private health sector, and 7) ensure access to essential technologies.

Given that refugees and populations on the move are frequently moving across multiple routes and destinations within the EMR; it is important to implement functioning mental health services within primary health care through efficient coordination mechanisms and information systems. Ensuring that care pathways link to teaching, secondary and tertiary hospitals with a well-trained team of mental health professionals, is vital, in the delivery of appropriate and high quality collaborative care.

Paving the way for progress and best practice in the EMR

In 2015, the World Health Organization’s Regional Office for the Eastern Mediterranean published the regional framework to scale up action on mental health in the EMR that highlighted proposed indicators and strategic interventions for 1) Governance, 2) Healthcare, 3) Promotion and Prevention and 4) Surveillance, Monitoring and Research. In September 2019, the Department of Non-Communicable Diseases and Mental Health will hold a meeting to review the implementation of the Regional Framework for Scaling up action on Mental health in the Eastern Mediterranean Region and the amendments to the appendices of the WHO’s comprehensive mental health action plan 2013–2020. The goals of this intercountry meeting are to:

• Review Member States’ progress on the EMRO Regional Framework and highlight the challenges and best practice solutions identified in mental health implementation to take forward as priorities
• Provide a regional forum and space for discussion where Member States’ can share lessons learned, perspectives and valuable input on the amendments to the appendices of WHO’s Comprehensive Mental Health Action Plan 2013-2020
• Share lessons from the Lancet Commission Report on Global Mental Health and Sustainable Development

The forum seeks to bring together a unified voice within key actors dedicated to improving mental health care in the region. WHO’s role as convener seeks to bolster and strengthen networks and collaboration between Member States’ as well as to identify the technical support needed to best pave the best way forward for implementing priority country actions according to the EMRO Regional Framework to scale up action on mental health in the Eastern Mediterranean Region.

References

1. Charara R, Forouzanfar M, Naghavi M, Moradi-Lakeh M, Afshin A, Vos T, Daoud F, Wang H, El Bcheraoui C, Khalil I, Hamadeh RR. (2017) The burden of mental disorders in the eastern Mediterranean region, 1990-2013. PloS one. Jan 17;12(1):e0169575.
2. Mokdad AH, Charara R, El Bcheraoui C, Khalil I, Moradi-Lakeh M, Afshin A, Kassebaum NJ, Collison M, Krohn KJ, Chew A, Daoud F. (2018) The burden of mental disorders in the Eastern Mediterranean region, 1990-2015: findings from the global burden of disease 2015 study. International journal of public health. May 1;63(Suppl):25-37.
3. World Health Organization (2017) Depression and other common mental disorders: global health estimates. World Health Organization.
4. World Health Organization (2011) Strategy for mental health and substance abuse in the Eastern Mediterranean Region 2012–2016.

Photo Credit: A Syrian woman carrying her child by Rostyslav Savchyn on Unsplash