MENTAL HEALTH by GRØSET™

MENTAL HEALTH IN DEVELOPMENT WORK COMPASSIONATE SOCIETIES

Can the poor afford to think about their mental health? Can society afford not to?

MENTAL HEALTH – FORGOTTEN IN DEVELOPMENT WORK Over 400 million people suffer from mental disorders, of whom 80% live in low or moderate income nations. Approximately 85% of these individuals do not have access to treatment. Mental health and social development People suffering from mental disorders are often the most vulnerable in society. There is a proven correlation between reduced mental health and important indicators for development such as education, social engagement, and business development. In countries where there are few options for treatment, people who suffer from psychosis or dementia can risk being locked up, physically restrained, caged, or imprisoned. These patients are not able to advocate for themselves, and all too often, they end up at the back of the line when resources are distributed. Many experience stigmatization and discrimination. “Mental health problems are widespread. Yet it is very difficult to talk about the subject. This makes it harder for those affected. That is why it is so important to take up the challenge of de-stigmatizing mental health issues. We must normalize mental health problems. They are widespread and common, in all walks of life. Many thanks to everyone taking part in de-stigmatizing this issue.” Kjell Magne Bondevik, former prime minister of Norway

Still, not everyone working in the field of mental health are granted the resources needed for their work. Few international development organizations are aware of the mental health perspective in their work. This is apart from a trauma focus in work in war and conflict areas. The other exception is the preventative methods for HIV and AIDS.

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With permission from National Academies Press © (2010), National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.

Read more: • Report on Mental Health Development. Targeting people with mental health conditions as a vulnerable group (2010). WHO • “Mental health in a global perspective”. HimalPartner conference of March 8, 2012 in Oslo

WHO AND NORWEGIAN DEVELOPMENT WORK WHO Resolution and Action plan (2013-2020) WHO – the World Health Organization – defines mental health as “a state of wellbeing where each individual realizes his potential, is able to deal with the normal challenges of life, is able to work productively, and is in a position to contribute to the local environment”. WHO has adopted a resolution (2012) and an action plan for mental health (2013). In this initiative, WHO has included mental disorders, neurological illnesses, and substance abuse. This is abbreviated to MNS; “Mental, Neurological, and Substance abuse”. Vision A world in which mental health is valued, promoted, and protected. A world in which mental disorders are prevented. A world in which those affected by mental disorders are guaranteed their human rights. A world in which these individuals have access to quality professional care that is adapted to the local culture. A world in which these individuals have access to health care services that promote rehabilitation. A world in which these individuals are given the best possible conditions for good health and the opportunity to participate in society and the workforce without stigmatization or discrimination. Goal Promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity and disability for persons with mental disorders. General principles Universal health coverage – Human rights – Evidence-based practice – Life-course approach – Multisectoral approach – Empowerment of individuals with mental disorders On the Norwegian agenda Awareness of mental health as a global challenge is increasing in the context of Norwegian development work. NORAD published a report in 2014 called “Mental health as a global challenge”. Mental health has been prioritized in a target under the health goal in Norway’s stand on the United Nations new Sustainable Development Goals from 2015 till 2030.

Read more: • Mental Health Action Plan 2013-2020 (2013). • WHO Mental Health Gap Action Programme: www.who.int/mental_health/mhgap/en • Taking action for the world’s most pressing challenges: www.action2015.org

KOSHISH MEANS “TO MAKE AN EFFORT” A boy of 15 lives in the mountains of Nepal. His family is like any other high-caste family in the district of Ghurka. He lives in a mud house, like everyone else in his village, and is happy to be able to go to school. The boy begins to change over the course of the autumn months. He withdraws from his friends, and can no longer stand to be with them. He is sad, depressed, and has no energy. Despite these difficulties, he pushes himself to complete secondary school. He becomes more ill and does poorly in social settings. Others in his village believe his problems are caused by evil spirits. Today Matrika Devkota is 43 years old. He leads the Nepalese organization “Koshish”. The name means “to make an effort”. This is exactly what Koshish wants to do for those suffering from mental illness in Nepal. Matrika has himself experienced stigmatization and knows the prejudice that mental illness elicits in others. He lived eight years in total isolation when problems had become too great for him to handle. Neither he nor his mother, the only other person with whom he had contact, knew that there was treatment for mental illness, or that they had any rights. Matrika works very hard so that people with mental disorders in Nepal don’t have to experience what he went through. The goal for Koshish is to influence the authorities in Nepal by showing what potential there is in helping people with mental problems. Koshish calls this “Action Based Advocacy”. “I often think that I can better understand others who suffer from these disorders because I have one of them too” says Matrika. “I am well as long as I take my medicine.” In October 2013, Matrika was invited to Delhi to receive Dr. Guislain’s Award, an award for his untiring efforts to bring an end to discrimination of individuals with mental disorders. In this context, he made the following comment: “I receive back so much from my work with helping patients who encounter stigmatization and obstacles due to their mental illness. Through intensive effort, we are beginning to see significant changes in Nepal’s politics relating to health care and mental disorders.” Koshish is a member of the National Mental Health Network – Nepal. The network is a group of organizations working in the field of mental health and psychological services, rights and inclusion for people living with mental health problems and psychological disabilities in Nepal. Read more: • www.koshishnepal.org • National Mental Health Network - Nepal: www.mhnetworknepal.org

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The UN Convention on the Rights of Persons with Disabilities By the Atlas Alliance The UN Convention on the Rights of Persons with Disabilities (CRPD) went into effect in 2008. Persons with disabilities include “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.” (Article 1) The purpose of the convention is “to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity.” The Convention’s overarching principles are “respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons, non-discrimination and full and effective participation and inclusion in society”. Further the Convention calls for respect for difference and acceptance of persons with disabilities as part of human diversity and humanity. Force and public guardianship are not alternatives in line with the Convention, as the Convention stresses the right to live in, and participate, in the community. In order to accomplish this, a comprehensive development of systems and solutions must be in place, which build upon cooperation, trust, and support of mental health. Local solutions must be explored that are in line with the principles of the CRPD. CommunityBased Rehabilitation (CBR) is a holistic strategy that has been developed to support the duty bearers in their obligations to ensure human rights for each individual as well as access to services for persons who are marginalized for any reason. Therefore, CBR might be a useful tool for implementing the Convention in countries where institutional capacity is weak, including the health care system, which also may lack resources and human expertise to meet every person’s needs. Read more: • CRPD can be downloaded at UN Enable: www.un.org/disabilities/ • www.atlas-alliansen.no

Photo: Hanneck Mdoka- PODCAM/NFU

NO HEALTH WITHOUT MENTAL HEALTH Mental health is not a peripheral aspect of societal development and health, rather it is a central element that affects everything else. Downward spiral The WHO Report of 2010 points to the fact that there is a clear connection between poverty and mental health. To have a serious mental disability in an impoverished country makes an individual greatly vulnerable. Stigmatization leads to many individuals being excluded from the job market as well as from options for housing. Poverty in and of itself creates vulnerability, which further erodes mental health through despair, discouragement, and fear of the future. If one cannot afford treatment, one is quickly caught up in a vicious cycle. Mental symptoms contribute to a reduced ability to work, and a lack of income creates greater poverty. Such is the downward spiral.

Mental disability Reduced economic development in society

Increased vulnerability

Reduced mental health in the individual

Consequences of reduced mental disability on the individual and societal levels. Consequences of reduced mental disability on the individual and societal levels. • Depression has a negative effect on the course of a number of physical diseases, for example HIV/AIDS. • Those affected by serious mental disorders experience discrimination, violations of their human rights, and early death. • The mentally ill often do not complete their education, are not able to take higher education and are consequently forced to the back of the line when applying for employment. • Those with mental disorders are often excluded from projects relating to social development. • Due to stigmatization, many are excluded from income-generating activities. • In the case of physical illness it is less likely that those with mental disorders will be given treatment than those who don’t have mental disorders, for example in the case of coronary disease. • Approximately one million people commit suicide annually, many of whom are of working age. • All levels of the population experience stigma. Read more: • The Lancet Series on Global Mental Health 2007 and 2011. • Resources on alcohol, drugs and development: www.add-resources.org

INVESTING IN MENTAL HEALTH A Global Syndrome The World Economic Forum offers new perspectives when they argue that a lack of mental well-being is becoming a global syndrome in the 21st century. They state that this is a result of global economic systems, lifestyle, and how trends in development have evolved over time. The costs related to a lack of mental well-being are significant both for the public and private sector. As an example, five percent of the annual global gross national product are related to costs associated with mental disorders and non-communicable diseases. “The costs associated with mental disorders and non-communicable disease make up 5% of the world’s annual GNP.” World Economic Forum On the other hand, mental well-being enable an individual to work effectively and productively in society, as well as engenders a personal quality of life. Underestimated This “invisible” epidemic is an underestimated cause of poverty and impediment to economic development in many countries. It is not just the health sector that is affected by a lack of mental well-being. There is a need for interdisciplinary cooperation in the public and private sectors in order to effectively deal with this challenge. “This invisible epidemic is an underestimated cause of poverty and impediment to economic development in many countries.”

World Economic Forum

As the world moves toward a new agenda in line with the millennial goals, health and well-being for people will increasingly become the collective responsibilities for governments as well as for other cooperating entities.

Read more: • World Economic Forum, Global Agenda Council on Well-being and Mental health www.weforum.org • Investing in Mental Health. Evidence for Action (2013). WHO

A MORE COMPASSIONATE SOCIETY: MENTAL WELL-BEING Prevention should be prioritized Prevention of mental disorders is about preventing greater numbers of individuals from being afflicted, as well as promoting mental health in the general population. Interventions should be implemented before individuals become sick or receive a diagnosis. “It is important to remember that health services do not produce health, they can only repair health.” (Arne Holte). This means that prevention must take place where people are most: in school, at work, in the family, etc. “In contrast to what most people believe, prevention is not about some advanced technology that only mental health experts can carry out. Rather, prevention is about creating a society in which people have the opportunity to develop themselves and their abilities.”

Arne Holte, Assistant Director, Norwegian Institute of Public Health

Mental disorders are as common as the flu. Most people experience some kind of mental disorder during the course of their lifetime, but just in the same way that the common cold can occasionally develop into something more serious like pneumonia, or in extreme cases can become life-threatening, in the same way mental disorders develop differently for different people. Today we see that it is both possible and cost effective to prevent mental disorders (WHO Resolution 2012). This includes depression, anxiety, and alcohol abuse.

Rate of return to investment in human capital

Invest in the children If one is to invest strategically, there is now strong evidence to suggest that the first signs of mental disorders can be seen in childhood or in adolescence. James J. Heckman was awarded the Nobel Prize in economics for his research which showed a high rate of investment return for disadvantaged pre-school children. International Child Development Programme (ICDP) is a program for caregivers, which Rate of return to investment of human capital sensitize them towards the child’s needs. The program promotes children’s mental health Programs targeted toward the earliset years and may prevent mental disorders. Preschool programs

Opportunity cost of funds

Job training

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Heckman, James J. “Skill Formation and the Economics of Investing in Disadvantaged Children, Science, 312(5893): 1900-1902.

Read more: • Arne Holte, Preventing mental disabilities: Ten suggestions. Presentation March 7, 2012 • International Child Development Programme: www.icdp.info

MENTAL ILLNESS Mental disorders and substance abuse are as important factors as physical illness to the global burden of disease. WHO operates with the concept of Disability-Adjusted Life Years (DALYs). The purpose for using this means of measurement is to quantify the global burden of disease. Mental disorders and substance abuse account for 7.4% of the global DALYs, and are the leading causes for years lived with disability. These DALYs are further broken down accordingly: Depression (40.5%), anxiety disorders (14.6%), substance abuse (10.9%) and alcohol abuse (9.6%). In other words, depression is the leading cause of disability in the world. It is estimated that by 2030, depression will top the DALY statistics.

Other mental disorders

Depression

24,4% 40,5% Alcohol abuse

9,6% 10,9%

Substance abuse

14,6%

Anxiety disorders

What are mental disorders? A mental disorder or a mental health problem is considered present when challenges with thoughts, feelings, and behavior adversely affect social relationships, work, or school. Previously, there has been speculation whether these disorders are the same the world over. Studies show that this is the case, although some disorders may be expressed differently in different countries. Recommended treatments for mental disorders are psychotherapy and psychotropic drugs. Research and experience show that mental illness increases the risk for physical ailments, substance abuse, divorce, and instability in the workplace. Research in developing countries has shown that there is a correlation between postpartum depression and reduced growth in the child. Additionally, poor quality of life, insecurity, and trauma in childhood lead to greater risk for mental disorders later in life. A diversity of illnesses It is difficult to generalize mental disorders and what needs patients may have for treatment and follow up. This is due to the fact that there are a number of illnesses in the area of mental health which affect people in different ways. The duration of different disorders vary as well, some disorders are lifelong, while others appear for a shorter period of time. Everyone has a mental health • Everyone is stressed, tired, or sad from time to time. Mental disorders differ from this in terms of severity and duration. • Everyone can be affected, not just particularly “vulnerable” individuals • Everyone’s mental health can be challenged by traumatic events Read more: • The Global Burden of Disease Study. 2010 • Visualizing of the Global Burden of Disease Study. • The Norwegian Council for Mental Health: www.psykiskhelse.no

Photo: Atlas-alliansen

WHERE THERE IS NO PSYCHIATRIST

(or other mental health professionals) Mental health for everyone, by everyone

By Vikram Patel, London School of Hygiene and Tropical Medicine, and Sangath Center, Goa, India

With regard to the distribution of resources and options for treatment, mental health problems are clearly the most neglected of all medical conditions. The inability of society to be able to shed light on these needs in terms of promoting health and social services has been described as “failure of humanity.” There is a need for a new way of thinking and innovative solutions. In many countries today, treatment for mental disorders focuses heavily on medication, by highly skilled professionals, offered in expensive institutions where one uses language that alienates the local population. All too often personal and local resources are not sufficiently taken into account. At the heart of this new approach is the need to ask the question of who is offering mental health treatment. In most countries, the only way mental health services can be offered on a large scale is through primary health care services, such as through maternal and child health care. Proximity and accessibility Primary health care workers would be able to deliver services closer to the patient and offer a wide spectrum of contextualized interventions, tailor-made to the needs of the individual. We also see an increased number of facilities that aim to de-professionalize and increase accessibility to services. Examples of these types of options would include mentor follow-up care and selfhelp interventions which can be given through manuals and on the internet.

EXPERTS LOCAL SERVICES

“Quite simply, health is too important to be left to health professionals alone, and this is arguably even more true for mental health care.” Vikram Patel

SELF-HELP

Read more: • The book “Where There is No Psychiatrist” by Vikram Patel (2003) • The organization Sangath in India focuses on various methods of treatment. www.sangath.com • See TED-talk video with Vikram Patel.

INTERDISCIPLINARY GLOBAL COMMITMENT The “be careful” banner

By Heidi Westborg Steel, General Secretary HimalPartner

Mental health is connected to the most private sphere of our life; how we were raised, the culture in which we live, and our faith. Culture and faith can influence us both positively or negatively, and we are not always aware of how this takes place. We therefore must not underestimate the differences of culture. Along with all of the good intentions, the “be careful” banner must be hoisted high. “Adapt, not adopt” Our partners indicate a need for help. The challenge for us in the West is to work together with our partners for appropriate solutions defined by those who know the issues at hand. We not only have our own cultural background, beliefs, and upbringing, but as professionals we also have our own structures and systems. A simple direct translation can never adequately meet the challenges of other cultural contexts. Therefore, the expression “adapt, not adopt” reflects the need to preserve knowledge and good ideas, but adapting them to local conditions. That is why the ability to listen, taking the time, and do research are so important. In confronting a topic like mental health, the dimension of faith is also a challenge. In many parts of the world, mental disorders are understood as possession by evil spirits. People try to find help by consulting medicine men or priests. Information dissemination is no doubt needed. However for those of us from the secularized world, we need to be open towards other worldviews. Establishing a network We must find some new keys. 1) Ensure interdisciplinary cooperation and educate primary health care services. 2) Give space for the voices of those people who know the challenges firsthand, whether affected directly, or closest kin. 3) Ensure networking. Issues related to mental health will be given greater attention. There are many small, local players, and it is tempting to keep ones cards to oneself. Read more: • Internationally. Movement for Global Mental Health. Become a member. www.globalmentalhealth.org • Nepal: National Mental Health Network – Nepal. www.mhnetworknepal.org • Norway: Network for Global Mental Health in Norway. In cooperation with the Norwegian Health Network for Development. Join us. • Network for Global Mental Health in Norway: www.globalmentalhelse.no

Network for global mental health in Norway is a loosely affiliated group of professionals connected to the Norwegian Health Network for Development. We work together to put mental health on the agenda of development work. HimalPartner serves as administrator, and sends out regular email updates and invitations to meetings. Sign up at: www.globalmentalhelse.no

Compassionate societies

• promotes mental health • prevents mental disorders • includes people with mental disorders

Mental health in development work • WHO’s mental health action plan 2013-2020 • www.action2015.org

HimalPartner is a small mission organization with 75 years of experience in working in the Himalayan region. Our workers know the local languages, cultures, and contexts well. We support local partner organizations. HimalPartner is also known for its hydropower work in Nepal. www.himalpartner.no

Can the poor afford to?

• Treatment options for those with mental disabilities are absent in developing countries. • Treatment must be made cheaper and more accessible for all levels of society. • Treatment must be given locally by primary healthcare services.

Digni is an umbrella organization for the long-term development work of 19 mission organizations and denominations in Norway. Digni’s most important task is to manage and ensure quality control of funds given to member organization projects by NORAD (Norwegian Agency for Development Cooperation). Digni supports mental health work through professional development and project funding. www.digni.no

Can society afford not to?

• Costs related to mental health comprise 5% of the world’s global GNP. • Mental disorders is an underestimated cause of poverty that impedes economic development in many countries. • Therefore it is profitable to invest in mental health.

Editor: Ingunn Dreyer Ødegaard Photos: Pål Brenna

Translation: Randal C. Frivold Design and print: GRØSETTM