The Alma Ata Declaration on Universal Healthcare (WHO 1978) was a clarion call for nations to focus on health for all their peoples. The mental health movement also acknowledged the inadequacy of care for people with mental illness living in the community. The World Health Organization (WHO) led the effort to incorporate mental healthcare within primary healthcare in developing countries. This resulted in pilot projects in different parts of the developing world (WHO 1984). Evidence from these endeavours was then employed to establish national mental health policies and programmes in many countries (DGHS 1982).
In India, pilot projects in Raipur Rani (Chandigarh) and Sakalwara (Bengaluru) were scaled-up for the Bellary District Mental Health Programme (Karnataka) in 1988. The district programme then became the blueprint for similar plans rolled out in over 123 districts across the country (Goel 2011). But patchy and variable implementation, lack of human resources, limited budgets, inability to utilise available funding and the failure to integrate mental healthcare into primary care resulted in poor delivery of mental health services in most areas (Sarin and Jain 2013).
It was the tragedy in Erwadi, Tamil Nadu, in 2001—where people treated in a religious facility died in an accidental fire—that brought the plight of those with mental illness into national consciousness. The subsequent directives of the Supreme Court and the National Human Rights Commission temporarily refocused the country’s attention on the care of people with mental disorders. Yet, today, mental healthcare in the community and in primary care remains a distant dream in India.
Similar situations in many low- and middle-income countries (LMIC) spawned international concern. The Movement for Global Mental Health (MGMH), launched in 2007,renewed the national and international efforts at improving care for people with mental illness. The movement recognised the burden of mental illness, identified limitations in service delivery, highlighted the gap in treatment and services and attempts to bridge the void. It initiated many research projects and coordinated resources to achieve its objectives and goals.
Support for the movement also came from the WHO, which attempted to take the 65th World Health Assembly resolution on mental health and care forward. The Mental Health Gap Action Programme (mhGAP), launched by the WHO in 2008, produced an intervention guide for common psychiatric disorders and their management in primary care (WHO 2008). Further, its Comprehensive Mental Health Action Plan 2013–20 includes elaborate and diverse objectives to scale up services for national populations (WHO 2013). Despite these much-hyped efforts, the reality on the ground for people with mental illness has hardly changed across many LMIC.
An analysis of the status quo related to poor mental healthcare delivery suggests a complex interaction with the changing international political and economic environment. The ideal of Universal Healthcare, as argued by the Alma Ata Declaration, soon came under intense political and economic pressure. Its critics argued that it did not have clear targets, was too broad, expensive and hence unattainable. The programmes gradually morphed into a more circumscribed Selective Primary Health Care with its specific focus on growth monitoring, oral rehydration therapy, breastfeeding, immunisation and female education, family spacing, and food supplements (GOBI–FFF) (Walsh and Warren 1979).
The collapse of the Soviet Union resulted in a reduction in emphasis on egalitarian ideals and increased focus on capitalistic economic systems. Many LMIC, in their efforts to quickly increase their gross domestic product, reduced importance of public sector institutions and encouraged private enterprises. Reductions in national health budgets significantly affected the already meagre finances available for mental health services. The original aims and methods of strengthening primary healthcare systems are all but forgotten (WHO 2008).
Despite long and systematic campaigns by mental health professionals, activists and the WHO, mental health did not reach critical international political consciousness. The United Nations’ ambitious Millennium Development Goals (2000) failed to mention mental health objectives, suggesting its relatively limited role and impact on humanity compared with priority physical, social and economic concerns. Recent campaigns attempted to highlight the need to include mental disorders in the more detailed Sustainable Development Goals (SDG) (2015) (Thornicroft and Patel 2014). However, mental illness does not directly feature in SDGs. The promotion of mental health is listed under SDG 3.4, which supports the reduction of premature mortality from non-communicable diseases (NCDs) through their prevention and treatment and through the promotion of mental health and well-being. SDG 3.5 suggests the need to strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
The WHO and some other international organisations have taken these goals to argue for the integration of mental healthcare with NCDs and some are even suggesting that mental illness be included as an NCD in its own right. They are currently championing the linkage between NCDs and common mental disorders (for example, depression and anxiety), shared underlying causes, associated risk factors, co-occurrence, complex interdependencies and interactions, and their far-reaching and overarching consequences (WHO and Calouste Gulbenkian Foundation 2014a). They suggest integrated, effective and efficient care for chronic conditions not just within transformed health systems but also scaled up within communities. Mental health professionals and activists have been suggesting the inclusion of specific objective mental health indicators (for example, reduction in suicide rates and increase usage of services for psychosis) to measure SDGs and their change over time.
The failure of the international community to highlight the need to focus on mental disorders and their treatment despite robust evidence of contribution to the global burden of disease (Ferrari et al 2013) demands analysis. The limited resources and expertise on the ground to manage mental disorders in primary care and in the community call for introspection. The issues include problems in primary care, failure of public health and psychiatric overreach and are briefly discussed below.
Problems in Primary Care
The problems in primary healthcare in India and LMIC are multiple and diverse (Jacob 2011). Poor infrastructure and overburdened primary care systems are common. Limited finances and poor utilisation of available funds do not help improve impoverished environments nor raise the morale of demoralised healthcare staff.
Significant differences in primary and tertiary care settings, patient profiles and physician perspectives influence clinical practice. Unsuitable tertiary care concepts and classification complicate diagnosis and consequent care. Traditionally, physician training emphasises medical diagnosis. Consequently, the inability to recognise the diagnostic label prevents the initiation of treatment. Non-specific symptoms, milder, mixed and sub-syndromal presentations, associated with psychosocial stress and physical adversity make the use of classical tertiary care concepts and categories (for example, major depression and generalised anxiety) difficult to employ in primary care. Yet, common clinical presentations in primary care (for example, mixed anxiety depression) are not recognised or accepted as psychiatric labels even in psychiatric classifications for use in primary care (Jacob and Patel 2014).
Physicians recognise the importance of psychosocial context (for example, stress, personal resources, coping, social supports and culture) and their effect on mental health. They prefer not to use mental disorder labels because of the high rates of spontaneous remission and placebo response and the absence of improvement with antidepressant medication in those with mild disorders (Kirsch et al 2008). General practitioners are seriously concerned about the medicalisation of all personal and social distress (PLoS Medicine Editors 2013). They argue that the use of symptoms to diagnose mental disorders, without consideration of context, in particular psychosocial hardship, essentially flags non-clinically significant distress, especially at lower degrees of severity.
Many physicians and general practitioners are uncomfortable with the use of the concept of mental disorder, with its disease halo, which sidesteps the disease–illness dichotomy while attempting to encompass both disease and distress (Jacob and Patel 2014). A disease portrays structural and functional abnormality, while illness is used to depict subjective experience of suffering. Consequently, they often do not use psychiatric categories at all, preferring to avoid potentially stigmatising and meaningless labels. Consequently, the International Classification of Primary Care-2 (WONCA 2003) focuses on reasons for clinical encounters, patient data, and clinical activity. “Mixed anxiety depression” and “adjustment disorders” are preferred to the traditional psychiatric categories of major depression and generalised anxiety. Consequently, the training of physicians in psychiatry in LMIC, often set in specialist facilities rather than in primary and secondary care settings, is inappropriate and disempowers physicians. The diluted tertiary care concepts and classifications and management strategies, enforced top down, are seldom practised. Consequently, such efforts are more in the realm of advocacy than technical input.
Piggybacking mental health programmes requires robust primary health systems for success. Revitalising primary care in LMIC, currently systematically underfunded and impoverished, will not aid the goal of integrating mental health into primary care or with NCDs. The capitalistic orientation of governments and the failure to support universal health coverage suggest the need to increase political pressure. The inability to scale up projects to national programmes in LMIC mandates the need for bottom-up concepts and classification, restructuring medical and nursing education, revamping mental health training, and the strengthening of primary healthcare (Jacob 2011).
Failure of Public Health
There is hard evidence to suggest that mental distress and illness are linked to social determinants of health (WHO and Calouste Gulbenkian Foundation 2014a, b). The failure to meet basic needs (for example, clean water, sanitation, nutrition, housing, immunisation) due to poverty impacts mental health (Jacob 2012). Patriarchy results in gross gender injustice and significantly affects the health of girls and women. Low education and unemployment are common causes of mental distress. Structural violence, discrimination, social exclusion, political oppression, ethnic cleansing and forced migration are common in poorer countries. Armed conflicts and war take their toll. These risk factors for poor mental health work through insecurity, hopelessness, rapid social change, risk of violence, and poor physical health (Patel and Kleinman 2003).
Nevertheless, mental health in LMIC is often addressed through urgency driven medical solutions, which are preferred to public health approaches (Jacob 2007). Public health is therefore reduced to a biomedical model. Primary care is mistaken for public health, and the focus is on outreach clinics rather than a concerted multisectoral public health response (that is provision of basic needs, healthcare, employment, justice, etc).
The absence of gold standards and laboratory tests, lack of pathognomonic symptoms, use of individuals’ perception of unpleasant feelings and phenomena within the normal range of emotions, and the discounting of stress and context makes it difficult to separate normal human distress from mental disorders (Jacob 2015). Psychiatric labels medicalise mental distress.
Stress and trauma can be acute (for example, bereavement), recurrent (example, domestic violence) or chronic (for example, poverty); physical disease and disability, interpersonal difficulties and other social determinants are associated with symptoms of depression and anxiety. Clinically and statistically significant relationship between psychosocial adversity and mental ill-health (that is distress, illness and disease) complicates the simplistic “atheoretical” approach to psychiatric diagnosis. The current classifications provide labels by arbitrarily dividing the many complex dimensions of mental health, distress, illness and disease into dichotomous normal/abnormal (disorder) categories (Jacob 2015). The discipline with its biomedical framework transfers the disease halo reserved for severe mental illness to all psychiatric diagnoses. It locates primary pathology in the individual when causal mechanism can lie in the environment. Medication-based solutions for problems of living are controversial.
The vast evidence base, which demonstrates the correlation of depression and anxiety with NCDs, is based on observational studies, and cohort and case-control designs. However, such investigations are prone to bias. On the other hand, there is very limited evidence that treatment of depression and anxiety impact NCD outcomes as demonstrated by the SADHART (Sertraline AntiDepressant Heart Attack Randomised Trial) and ENRICHD (Enhancing Recovery in Coronary Heart Disease Patients) trials (Glassman et al 2002; ENRICHD 2003).
Tactical Advance and Strategic Failure
The linkage raises many questions: Is the current push to highlight linkage between mental disorders and NCD tactical? Does it acknowledge the strategic failure of incorporating mental illness management in primary care? Will such tactical packaging with NCD prove effective, particularly in the context of impoverished, emasculated and demoralised primary healthcare systems? Will it change the ground reality and overcome the barriers to universal health and mental healthcare?
The failure of individual vertical programmes to deliver argues for the integration of mental healthcare into primary healthcare. However, such incorporation at the front line of healthcare requires massive inputs to strengthen health systems to allow for successful horizontal integration of different aspects of health service delivery.
An analysis of recent history argues that much of the effort by mental health professionals is essentially advocacy rather than technical input to integrate mental healthcare into primary healthcare or even into the care of chronic NCDs. Rhetoric needs to match reality. It also suggests that mental health advocacy may not significantly affect secular trends in population mental health and care.