AMA SPEECH MENTAL HEALTH
AMA
Global Mental Health: Giving it its Place on the Map
Jeremy A. Lazarus, MD
President
American Medical Association
Health and Human Services Global Mental Health Conference
Nov. 15, 2012
Italian Embassy
Washington, D.C.
Thank you for that warm welcome, and I’m honored to be here. It’s been a busy couple of weeks here in Washington. In the days leading up to the U.S. election, we saw extreme joy, despair, obsessive checking of the polls, compulsive television watching and other behaviors I’m pretty sure could be classified in the DSM.
We might joke a little about that, but those of us who live in prosperous nations are lucky in that if we are indeed obsessive-compulsive, manic, depressed or suffering from any number of mental health issues that may or may not be exacerbated by politics, we generally have access to mental health services.
We were heartened to see that with the re-election of President Obama, the nation affirmed its support for the Affordable Care Act, which strengthens that access. Most Americans recognize what the ACA can do for the care of the body. But it also does a lot for the mind. We’re proud to have had a hand in making sure that people with pre-existing conditions, mental as well as physical, won’t be denied insurance. And other protections mean that if a patient has forgotten to mention a minor bout of depression or made another honest mistake while filling out an insurance application, the insurance company can’t retroactively cancel the policy and refuse to pay for that patient’s cancer treatment. That can literally be a life-saver.
While not perfect, the ACA builds on mental health parity legislation passed in 2008, it stresses preventative care, and it improves access to psychiatric medications prescribed under Medicare.
While we still have a way to go in giving mental health care the prominence and resources it deserves, we’ve been making great strides here in the United States.
Yet we all know that not all parts of the world are managing to move so firmly ahead. Especially the developing world. Global mental health is a huge issue, and it’s one that’s very worth our attention—and our action.
That’s why I’m here today. I’ve been the president of the AMA for about six months now. And I’ve been a psychiatrist for about 40 years.
As the president of the AMA, I know how what a difference strong physician leadership can make in improving a nation’s health. As a physician, I know what a difference we can each make in a single patient’s life.
[PAUSE]
As physicians and as nations, we spend considerable time, effort and money combatting communicable diseases in the developing world—things like HIV/AIDS and malaria that do indeed affect millions.
We also recognize the growing threat of noncommunicable diseases, which have become the leading cause of disability around the world, and are adding to the disease burden on top of those communicable illnesses.
But mental illness takes a huge toll as well.
Today, neuropsychiatric conditions are the leading causes of disability worldwide, accounting for 37% of all healthy life years lost from disease.
And there are huge co-morbidities with noncommunicable diseases as well.
We all know that we see a lot of patients who are coping with both mental and physical issues. Sometimes a physical problem has caused or contributed to a mental or behavioral disorder. Sometimes we think it’s the other way around. Either way, there’s no getting around it: Patients with mental illness tend to have shorter lives, whether due directly to mental illness or due to things like heart disease, diabetes and other illnesses that we often see in our psychiatric patients.
But as societies, we tend to treat those mental and physical ailments very differently.
Break a leg, and it’s a pretty good bet that you’ll be able to get it set. But the mentally ill aren’t always getting so much as a crutch.
The reasons include lack of resources, lack of training, cultural factors and stigma.
Tending to mental health is a challenge even in nations like ours, but it’s far worse in low-income countries.
We see it in the treatment rates. It’s thought that up to 85 percent of people with severe mental disorders in low-income countries receive no treatment whatsoever. In high-income countries, the figure is estimated at between 35 and 50 percent. In countries where initial treatment rates are low, so too are the instances of even minimally acceptable aftercare.
We see it, too, in the dollars spent. Low-income countries spend about half of one percent of their health care dollars on mental health services. In comparison, high-income countries spend about 5 percent.
We even see it in the number of psychiatrists. On average, in low-income countries, there are only two psychiatrists per 2 million inhabitants. In the U.S., we have about 47,000 serving our population, and we still don’t think it’s nearly enough.
There are many mental disorders that merit our attention. But let’s look for a moment at one: depression, the focus of this year’s World Mental Health Day.
Indeed, depression is a huge problem, affecting some 350 million people around the world. As a point of comparison, that’s slightly more than the population of the entire United States. It is also roughly the population Germany, France, the UK, Italy and Spain all put together. That could make for some pretty grim soccer matches.
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Depression is such a big problem that it’s been projected that by 2030, unipolar depression will be the leading cause of good health lost worldwide, ahead of even heart disease, COPD and HIV/AIDS.
And with so few psychiatrists and other resources, no wonder that in some countries, as few as 10 percent of those who need treatment for depression receive it.
[PAUSE]
We hope that this is the year that some of that changes.
The World Health Organization has issued a resolution on mental health, with the aim of improving care, lifting stigma and developing resources worldwide.
And already, it’s more than merely resolution. The WHO Mental Health Gap Action Program aims at ramping up treatment services around the world, especially in low- and middle-income countries.
There have been some promising developments.
In Nigeria, for instance, a study on the cost of treatment for schizophrenia and depression showed that older, less expensive anti-psychotic drugs and anti-depressants offered effective treatment, in combination with psychosocial treatment and effective treatment and case management.
And in Uganda, there’s been support for training of non-specialized clinicians to provide and improve care to those suffering mental, neurological and substance use disorders.
And in Sierra Leone, they’re putting nurses through mental health care training.
We at the AMA support that kind of broadening of resources, and we’ve been addressing similar issues ourselves.
Some of it is in our work with disaster medicine.
We know that disasters, natural or man-made, can exact a huge mental toll on affected populations. And when those disasters do strike, as with the case of tsunamis, earthquakes and hurricanes in recent years, physicians are always among the first to pack their bags and offer assistance.
We’ve supported that, but we also offer ways for our physicians to go even beyond that.
In an AMA report from 2009, we emphasized the need for mental health resources for victims and responders.
We suggested that it was important to help create a local infrastructure to address mental health needs in areas experiencing a disaster or crisis, including interventions and programs to promote community resilience as well as actual treatment for acute and long-term effects of trauma.
We provide our members with resources to that end, and we promote awareness with our journal, “Disaster Medicine and Public Health Preparedness.” Recent articles have covered psychological distress among Sri Lankan nurses dealing with war victims, tsunami trauma, and creating community resilience.
[PAUSE]
But examining global mental health isn’t just about looking at other, poorer countries and saying, “You’ve got a problem.” We’ve been tending to our own back yard as well.
After all, we in the developed world face some of the same challenges less affluent nations do. Namely, not every person who needs care has been getting it.
Here in the U.S., it was hard to miss last week’s sentencing of Jared Loughner, who went on a 2011 shooting rampage that killed six people and injured more, most famously now-former Arizona congresswoman Gabriella Giffords. Loughner’s arrest and subsequent trial raised questions regarding the forced administration of anti-psychotics, which is another matter, but apparently it took exactly that much intervention to get him on medication for schizophrenia.
As I mentioned before, even high-income countries still only manage to deliver care in any given year to a portion of the people who need it. And you don’t have to be a Jared Loughner to slip through the cracks.
Sometimes all you have to be is African-American. Or Asian. Or part of our native population.
Here in the U.S., African-Americans are 20 percent more likely to report having serious psychological distress than Non-Hispanic Whites. And older Asian-American women have the highest suicide rate of all women in the United States older than 65. Adolescent American Indian and Alaska natives die from suicide at twice the rate as whites. Obviously, there are big disparities in health care even here in the United States. We don’t think that’s right, and we’re trying to even the playing field.
Our AMA Minority Affairs section has been working to address those disparities in a variety of ways, from raising awareness to offering continuing education opportunities to our physicians.
We also support continuing efforts to find the best ways to treat mental disorders. And this is one of those areas where we hope our leadership and advocacy can be of help to our international peers.
One of the benefits of the Affordable Care Act is that it stresses something that we’ve known all along: That coordinating care, effectively sharing information, and treating the whole person, is vitally important if you want better outcomes.
We’ve long been active in helping our members, most of whom are not psychiatrists, recognize and treat common mental health issues. Whether it’s guidelines on dealing with eating disorders, or sharing research on depression, we try to give all of our physicians, especially primary-care providers, tools they need.
But a lot of the work around the ACA has been about figuring out what really works—evidence-based medicine. We think that we will eventually build a body of research that will be hugely helpful to health organizations around the world, and we’re eager to be stewards in that process.
We’ve also done a lot of work to shape new models of health care delivery, along with payment models. Such things as accountable care organizations and medical homes should bring a more holistic, integrated approach to mental and physical health.
Part of improving payment models is about making it more attractive for physicians to deliver care in poorer or more rural areas, which are typically under-served. That’s something with worldwide implications.
Ultimately, we hope our efforts will help improve treatment while combatting the stigma that has long accompanied mental illness. We in the U.S. have come a long way since the 1840 census first started tracking and categorizing mental disorders with a single classification: “Idiocy/Insanity.”
Today, we know a lot more about neurochemical and psychological processes. We’ve obviously come up with much better models of treatment since the not-so-golden age of trans-orbital lobotomies and madhouses.
There’s still a lot of stigma surrounding mental disorders, but we’re doing a better job of keeping people in their communities and supporting the families of the mentally ill.
But I don’t want to talk too much about what we’ve been doing right here, or pat ourselves on the back too heartily for our good global intentions. Because we’ve been here before.
In 2001, JAMA published an article by the U.S. Surgeon General entitled, “Global Mental Health. Its Time Has Come.” That was largely in response to the WHO’s year-long mental health campaign of the same year.
In some ways, things haven’t changed much. Or at least not nearly enough.
We still labor under incomplete data. Mental health is a tough study to begin with, and we don’t have the kind of measurement and country-to-country comparisons that would be truly helpful.
We still need far more training and resources for mental health care providers around the world.
We still have challenges regarding best practices.
And globally, we still rely too much on institutional care, though that is getting better. Italy, by the way, has been a great leader in that.
[PAUSE]
At the AMA, we like to say, “Together we are stronger.”
That’s true in our communities, and it’s true in our professional alliances.
We can grow stronger only by honoring the insights of care providers from all cultures.
We in higher-income countries can share our resources and teach others. But we can learn a lot from those in lower-income countries as well.
Ultimately, one of our missions at the AMA is to improve health outcomes. I know it’s been my mission all along.
I found my inspiration in medicine after my brother died in an accident when I was in college.
Maybe it made me extra-aware of how minds can be nearly shattered by depression, personality orders or crushing changes in circumstance. I know it made me want to help.
I think we’re all driven by that desire to help, no matter where in the world we live, work or bring our expertise. Even when the challenges seem nearly insurmountable.
Now, those of you who know me know may know that I’ve completed 13 triathalons.
Global mental health is a bit like a triathalon. At the beginning, the finish line feels like it’s a long, long way away. Conditions are often challenging, and you have to use many means to convey yourself toward your goal.
But if you’ve trained well, and you keep at it, you will likely see that finish line come into view.
In the end, in medicine, as in so many things, it’s persistence that will win the race.
But faster is better. And no one really wants to be last.
This is a great time for us to come together and pick up the pace.
Let’s make sure that in this race, no one gets left behind.
Thank you.
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