Combining health and social protection measures to reach the ultra ...

Access to healthDiscrimination as a barrier toaccessing mental health careArticle by Graham ThornicroftAlthough each year up to 30% of the populationworldwide has some form of mental illness, at leasttwo thirds receive no treatment. This under-treatmentoccurs even in countries with the best resources 1 . In the USA,for example, 31% of the population are affected by mentalillness every year, but 67% of these individuals are nottreated 2 . Moreover, in Europe mental illness affects 27% ofpeople every year, 74% of whom receive no treatment 3 . Theproportions of people with mental illness who are treated inlow- and medium-resource countries (LAMIC) are far less, forexample a recent worldwide survey found that the proportionof respondents receiving mental health care over 12 monthswas as low as 1.6% in Nigeria, and that in most of the 17countries studied only a minority of people with severedisorder received treatment 4 .A WHO review of 37 studies across the world, for example,found that the proportion of people untreated for particularconditions is: schizophrenia 32.2%; depression 56.3%;dysthymia 56.0%; bipolar disorder 50.2%; panic disorder55.9%; generalized anxiety disorder 57.5%; and obsessivecompulsive disorder 57.3%; alcohol abuse and dependence78.1% 5-7 . Indeed in one particular study of depressed peoplein St Petersburg only 3% were treated 8 , both because of thelow level of coverage of services, and because of demandlimiting factors such as the need for out-of-pocket paymentsto afford treatment.Two contributory factors towards this degree of neglect are(i) the reluctance of many people to seek help for mentalillness related problems because of their anticipation ofstigma should they be diagnosed, and (ii) the reluctance ofmany people who do have a diagnosis of mental illness toadvocate for better mental health care for fear of shame andrejection if they disclose their condition 1 .Stigma: a combination of ignorance,prejudice and discriminationStigma is a term which has evaded clear, operationaldefinition 9-12 . It can be considered as an amalgamation ofthree related problems: a lack of knowledge (ignorance andmisinformation), negative attitudes (prejudice), and excludingor avoiding behaviours (discrimination) 13-17 . The combinationof these three elements has a powerful force for socialexclusion 13 . Indeed there is no known country, society orculture in which people with mental illness with a diagnosisare considered to have the same value and to be asacceptable as people who do not have mental illness.Second, the quality of information that we have is relativelypoor, with very few comparative studies between countries orover time. Third, there do seem to be clear links betweenpopular understandings of the meaning of a diagnosis ofmental illness, if people in mental distress want to seek help,and whether they feel able to disclose their problems 18 . Thecore experiences of shame (to oneself and one’s family) andblame (from others) are common everywhere stigma hasbeen studied, but to differing extents. Where comparisonswith other conditions have been made, then people with adiagnosis of mental illnesses are more, or far more,stigmatized 19,20 , and have been referred to as the “ultimatestigma” 21 . Finally, rejection and avoidance of people with adiagnosis of mental illness appear to be universalphenomenon, and a recent study of terms used by schoolchildren to refer to mental illness revealed 250 differentwords and phrases, none of which are positive 22 .Limited access to mental health careIt is only recently that the full potency of such barriers tofinding treatment and care have been recognized 23 . Forexample, studies from several countries have consistentlyfound that even after a family member has developed clearcutsigns of a psychotic disorder, on average it is over a yearuntil the unwell person first receives assessment andtreatment 24-26 . A survey of almost 10 000 adults in the USAhas added more detail to this picture. The results showed thatthe majority of people with mental disorders eventuallycontact treatment services, but they often wait a long timebefore doing so: with average delays before seeking help ofeight years for mood disorders, and at least nine years foranxiety disorders. People who wait longer than average beforereceiving care are more likely to be young, old, male, poorlyeducated, or a member of a racial/ethnic minority 27 .Where do people go to try to find help? The detailed USsurvey just mentioned also asked this question and producedsome surprising answers. Only about one third (41%) ofpeople who had experienced mental illness in the previousyear had received any treatment: 12% from a psychiatrist,16% from a non-psychiatric mental health specialist, 23%treated by a general medical practitioner, 8% from a socialservices professional and 7% from a complementary oralternative medical provider. In terms of treatment adequacy,mental health specialists provided care that was at least062 ✜ Global Forum Update on Research for Health Volume 4