Mental Health Among Displaced People and Refugees: Making the Case For Action Under Humanitarian Response and Development Programs Discussion Brief Mental Health Among Displaced People and Refugees Prepared by Patricio V. Marquez, Lead Public Health Specialist and Coordinator of the Global Mental Health Initiative, Health, Nutrition and Population Global Practice (HNP GP), The World Bank Group (WBG). Contributions and comments were provided by Sheila Dutta, Senior Health Specialist, and Jaime Bayona, Senior Health Specialist, HNP GP, WBG, as well as by Giuseppe Raviola, Director, Mental Health, Partners in Health (PIH), Inka Weissbecker, Senior Global Mental Health and Psychosocial Support Advisor, International Medical Corps, Shekhar Saxena, Director, Department of Mental Health and Substance Abuse, World Health Organization (WHO), Mark van Ommeren, Public Mental Health Adviser, WHO, Eliot Sorel, Senior Scholar in Healthcare Innovation and Policy Research, George Washington University School of Medicine & School of Public Health, Pamela Collins, Associate Director for Special Populations, Office for Research on Disparities & Global Mental Health/Director, Office of Rural Mental Health Research, US National Institute of Mental Health, and Melanie Walker, Senior Adviser to the President of the World Bank Group. Aakanksha Pande, Senior Health Economist, and Ana Holt, Senior Health Specialist, HNP GP, WBG, also contributed as part of policy discussions. Overall guidance and support provided by Tim Evans, Senior Director, and Enis Baris, Program Manager, Health, Nutrition and Population Global Practice, The World Bank Group, as well as by Colin Bruce, Senior Adviser, Fragility, Conflict and Violence, The World Bank Group. Edited by Alexander Irwin. Operational support from Akosua Dakwa. Support for the preparation of the original discussion brief produced in 2017 was provided under the World Bank Group’s Global Mental Health Program at the Health, Nutrition and Population (HNP) Global Practice, cofinanced by the Rockefeller Foundation. Financial support for the preparation of this abridged version was provided by the Public Health Agency of Canada. Washington, D.C. July 2018 2 Making the Case for Action at The World Bank Group Contents Executive Summary 5 1. The challenge 6 2. Mental Disorders: An “Invisible” Burden 6 Box 1: Social Determinants of Mental, Neurological, and Substance Use Disorders 7 Figure 1: Global distribution of non-fatal disease burden of disease 8 3. The Economic and Social Impact of Mental Disorders 9 Table 1: Direct and indirect costs of mental disorders: Results from selected studies 9 4. Mental Health of Displaced Populations and Refugees 10 5. How Should We Address Mental Health Needs in Conflict- and Post-Conflict-Related Situations? 11 6. Collaborative, Multi-Sectoral Approaches 12 7. Essential Mental Health Interventions at the Community Level 12 Table 2: Mental Health Value Chain 14 8. Treatment Settings and Integration with Health and Social System 16 Figure 2: Intervention Pyramid for Mental Health and Psychosocial Support in Emergencies 16 Box 2: Mental Health Care Efforts in Syria 18 9. Are Mental Health Interventions Affordable and Cost-Effective? 19 Figure 3: Ratio of (economic and social) benefit to cost for scaled-up treatment 19 10. Dealing with Malnutrition in Conflict and its Psychological Causes 20 11. Dealing with Multidrug-resistant Organisms among Refugees and Hosting Populations. 20 12. Mental Health Care Over the Long Term 21 Box 3: Country/Regional Examples of Sustainable Mental Health Care after Conflicts and Emergencies 22 Box 4. Bringing Mental Health Services to Those Who Need Them Most: Peru’s Carabayllo Experience 25 13. Key Lessons Learned 27 14. The Way Forward 27 Endnotes 29 References 31 3 Mental Health Among Displaced People and Refugees "It was as if God had decided to put to the test every capacity for surprise and was keeping the inhabitants of Macondo in a permanent alteration between excitement and disappointment, doubt and revelation, to such an extreme that no one knew for certain where the limits of reality lay." Gabriel García Márquez “One Hundred Years of Solitude” 1982 Nobel Prize in Literature-winning Colombian author And Ive always been strong But Ive never felt so weak And all my prayers have gone for nothing Ive been without love But never forsaken Now the morning sun The morning sun is breaking Bruce Springsteen “The Depression” “Every day, millions of men, women and children around the world are burdened by mental illness. Yet mental health too often remains in the shadows, as a result of stigma and a lack of understanding, resources, and services. Two decades ago, we faced a similar situation with HIV and AIDS. People affected by AIDS faced severe stigma, and there was a widespread failure of policymakers to acknowledge or address the growing number of people dying in the world – especially in Africa – from the lack of access to affordable treatment. It was unjust, it was wrong, and it was unleashing a health and development catastrophe. So a group of us decided to raise our voices and bring HIV and AIDS out of the shadows, and we demanded action. Today, we are here to bring mental health into the spotlight and squarely on the global development agenda where it belongs.” Jim Yong Kim, President, World Bank Group High-Level Opening Panel “Out of the Shadows: Making Mental Health a Global Development Priority” Flagship Event at 2016 IMF/WBG Spring Meetings Washington D.C., April 13-14, 2016 "I decline to accept the end of man. It is easy enough to say that man is immortal simply because he will endure: that when the last dingdong of doom has clanged and faded from the last worthless rock hanging tideless in the last red and dying evening, that even then there will still be one more sound: that of his puny inexhaustible voice, still talking. I refuse to accept this. I believe that man will not merely endure: he will prevail. He is immortal, not because he alone among creatures has an inexhaustible voice, but because he has a soul, a spirit capable of compassion and sacrifice and endurance.” William Faulkner “Speech at the Nobel Banquet at the City Hall in Stockholm, December 10, 1950” 1949 Nobel Prize in Literature-winning United States author "Our goal is to create a society where people can access health and social services without fear of discrimination and prejudice." The Honourable Ginette Petitpas Taylor, Minister of Health, Canada Addressing the “Moving the Needle” Symposium, World Bank Group International Monetary Fund Spring Meetings, April 19, 2018 4 Making the Case for Action at The World Bank Group Executive Summary Projects funded by the World Bank Group (WBG) and other organizations utilize a bottom-up, The current global crisis of forced displacement multidisciplinary approach to re-integrate poses multiple humanitarian and development displaced populations after conflicts and natural challenges. Forcibly displaced people’s mental disasters. As part of this approach, development health needs have often been neglected in efforts in post-conflict and post-disaster societies response plans. Yet meeting these needs is should include mental health services integrated critical to help displaced persons overcome into primary health care structures. Priority trauma and rebuild their lives. Without mental health interventions in these contexts: appropriate mental health care, forcibly displaced (a) have a strong evidence base; (b) aim to people will often be unable to benefit fully from improve people’s daily functioning; and (c) help other forms of support that are provided to them. protect the most vulnerable from further trauma. Examples exist of how disaster and emergency In 2010, mental, neurological, and substance contexts have been used to make sustainable use disorders (MNS) were the leading cause of improvements in mental health systems in years lived with disability in the world. These low- and middle-income countries. Investing disorders also impose high costs on economies. in mental health as part of early recovery can While they are prevalent in all settings, mental strengthen the long-term availability of services disorders can be triggered or exacerbated by for survivors—and improve development extreme adversity, including violence and forced outcomes. displacement. Common mental health diagnoses among refugee populations include depression, A shared commitment is needed from national post-traumatic stress disorder (PTSD), and and international actors to champion mental generalized anxiety disorder. Refugee children health parity in the provision of health and social and adolescents suffer most, with studies finding services, including in humanitarian emergencies. PTSD rates from 50-90 percent in this population. High priority should go to identifying alternative sources of financing for mental health parity in MNS disorders can be successfully treated. health systems. For example, raising tobacco Evidence-based treatments for depression taxes can expand a country’s resources to and anxiety disorders include time-limited fund essential services for the population and psychosocial therapies and antidepressant strengthen human capital, including among medications. Anti-stigma campaigns can be displaced people. By investing in care for MNS powerful tools in confronting barriers to support disorders, we can help ensure that relief and for people with mental disorders. development programs yield the greatest benefits for refugees and host communities over Mental health and psychosocial support services the short-and medium-terms. at the community level, including for displaced people and refugees, should not be stand- alone interventions. They work best as part of an integrated platform of social, educational, and health services. Evidence shows that non- specialist workers in primary-care and community settings can deliver mental health services successfully. MNS services are cost-effective. 5 Mental Health Among Displaced People and Refugees 1. The Challenge 2. Mental Disorders: An “Invisible” Burden The current crisis of forced displacement is posing serious humanitarian and development Mental, neurological, and substance use disorders challenges across the world. The World Bank (MNS) account for a significant proportion of Group and the international community at large the global disease burden. Yet MNS illnesses cannot ignore these challenges, given their scale often remain “invisible.”2 3 MNS disorders include and complexity. As documented in a recent a heterogeneous range of conditions that owe World Bank report,1 about 65 million people – one their origin to genetic, biological, psychological, percent of the world’s population – live in forced and social factors. They can have their onset displacement and extreme poverty. In contrast to across the life course. MNS disorders often run economic migrants, who move in search of better a chronic course, are highly disabling, and are opportunities, and to persons affected by natural associated with significant premature mortality.4 disasters, the forcibly displaced are fleeing conflict These forms of illness also hamper development and violence. Forcibly displaced people include in countries around the world.5 6 MNS disorders refugees and asylum-seekers (currently about 24 include anxiety disorders, autism, dementia, million people) and internally displaced persons depression, epilepsy, illicit drug use and alcohol (about 41 million). These are the highest numbers use disorders, intellectual disability, migraine, and of forcibly displaced people since World War II. psychotic conditions (schizophrenia and bipolar disorders), among others. Host countries often have limited resources even before taking in refugees. The refugee influx can Within the MNS spectrum, mental disorders are quickly overwhelm existing capacities, including syndromes characterized by clinically significant health, housing, educational, and social welfare disturbance in an individual's cognition, emotion, systems and services. Inflows of displaced people regulation, or behavior that reflects a dysfunction can cause social and economic challenges and in the psychological, biological, or developmental disruptions to host communities. However, processes underlying mental functioning.7 As refugees can also bring skills, expertise, and labor such, these disorders affect mood, thinking, and that can benefit communities in the longer term. behavior. They contribute to behavioral or mental patterns that may cause suffering or a poor The international community can act to reduce ability to function in life. Such features may be vulnerabilities among the forcibly displaced persistent, relapsing and remitting, or occur as a during a crisis and then help them rebuild their single episode. lives. Such action can also mitigate the impact of forced displacement on host communities and The World Health Organization (WHO) estimates governments. This requires action to support that mental disorders account for 30% of non- economic activity, job creation, and social fatal disease burden worldwide (Figure 1) and cohesion, as well as to strengthen and expand 10% of overall disease burden, including death essential services. and disability.8 Some researchers argue that the global burden of mental illness tends to be underestimated because of five main causes: overlap between psychiatric and neurological disorders; the grouping of suicide and self-harm as a separate category; conflation of all chronic 6 Making the Case for Action at The World Bank Group pain syndromes with musculoskeletal disorders; Box 1: Social Determinants of Mental, exclusion of personality disorders from disease- Neurological, and Substance Use Disorders burden calculations; and inadequate consideration of the contribution of severe mental illness to A range of social determinants influences the risk and mortality from associated causes.9 outcome of MNS disorders. In particular, the following factors have been shown to be associated with several MNS disorders: According to a recent report,10 absolute disability-adjusted life years (DALYs) caused by MNS disorders increased by 41 percent increase 1. Demographic factors, such as age, gender, and ethnicity between 1990 and 2010: from 182 million to 258 2. Socioeconomic status: low income, million DALYs. The proportion of the global disease unemployment, income inequality, low education, burden caused by these disorders increased and low social support from 7.3 to 10.4 percent. With the exception of 3. Neighborhood factors: inadequate housing, substance use disorders, which increased because overcrowding, neighborhood violence of changes in prevalence over time, this increase 4. Environmental events: natural disasters, war, was largely caused by population growth and conflict, climate change, and migration. aging. The report also indicates that, in 2010, MNS 5. Social change associated with changes in income, disorders were the leading cause of years lived urbanization, and environmental degradation with disability (YLDs) in the world. The causal mechanisms of the social determinants of MNS disorders indicate a cyclical pattern. On the one In 2010, DALYs for MNS disorders were highest hand, socioeconomic adversities increase the risk for during early to mid-adulthood, explaining 18.6 MNS disorders (the social causation pathway); on the percent of total DALYs for individuals aged 15 to other hand, people living with MNS disorders drift 49 years, compared with 10.4 percent for all ages into poverty during the course of their life through combined. Within the 15-49 age group, mental increased health care expenditures, reduced economic and substance use disorders were the leading productivity associated with the disability of their condition, and stigma and discrimination associated contributor to the total burden caused by MNS with these conditions (the social drift pathway). disorders. For neurological disorders, DALYs were highest in the elderly. Overall, males accounted for Understanding the vicious cycle of social determinants 48.1 percent and females for 51.9 percent of DALYs and MNS disorders provides opportunities for for MNS disorders. The relative proportion of DALYs interventions that target social causation and social for MNS disorders to overall disease burden was drift. In relation to social causation, the evidence for estimated to be 1.6 times higher in high-income the mental health benefits of poverty-alleviation countries (HICs) (15.5 percent of total DALYs) than interventions is mixed but growing. In relation to social drift, the evidence for the individual and household in low- and middle-income countries (LMICs) (9.4 economic benefits of the prevention and treatment percent of total DALYs), largely because of the of MNS disorders is compelling, and supports the relatively higher burden of other health conditions, economic argument for scaling up these interventions such as infectious and perinatal diseases, in LMICs. (Lund and others 2011). However, because of the larger population of LMICs, the report noted that absolute DALYs for Source: Adapted from Patel, Vikram, Dan Chisholm, Tarun Dua, Ramanan Laxminarayan, and Maria Elena Medina- MNS disorders are higher in LMICs compared Mora. 2016. Disease Control Priorities, Third Edition: Volume with HICs. 4. Mental, Neurological, and Substance Use Disorders. Washington, DC: World Bank. Mental Health Among Displaced People and Refugees The 2015 Global Burden of Disease (GBD) studies diabetes, HIV, and obesity, as well as a host of risky also confirm the large contribution of mental behaviors.15 Those with mental disorders are more and substance use disorders to global disability. likely to engage in unhealthy behaviors such as Depressive disorders and anxiety disorders are smoking, alcohol use, poor nutritional choices, and among the ten leading causes of global years lack of physical activity. Mental disorders greatly lived with disability (YLDs) for both sexes. (These increase the risk of a person’s developing another two types of conditions ranked fourth and eighth, chronic disease,16 and are associated with reduced respectively, as sources of YLDs.11) Depressive health care-seeking and poorer compliance disorders and anxiety disorders are also among with medical regimens. At the same time, those the 30 leading causes of global disability-adjusted suffering from chronic diseases are also more likely life years (DALYs) for both sexes (ranking 15th and to develop mental health problems. 28th).12 13 Suicide, which is frequently caused by mental disorders, also exacts an enormous toll The WHO “Mental Health Action Plan 2013-2020” 17 on society. In India, for example, it has overtaken emphasizes that homelessness and inappropriate complications from pregnancy and childbirth as incarceration are far more common for people with the leading cause of death among women aged mental disorders than for the general population, 15 to 49.14 and this tends to exacerbate their marginalization and vulnerability. It is clear that mental disorders There is also frequent comorbidity and a notable are closely linked with physical health and affect link between mental disorders and other costly, both a significant portion of the overall population chronic medical conditions. Relevant chronic and disproportionate numbers of the vulnerable conditions include cancer, cardiovascular disease, and underserved. 17% Communicable, maternal, perinatal and nutritional conditions 6% Injuries 31% Mental, neurological Figure 1 and substance use Global distribution disorders of non-fatal disease 10% Depression burden of disease8 4% Anxiety disorders 31% (years lived with disability) 4% Alcohol use disorders Other non- 14% Other disorders communicable diseases (e.g. CVD, cancer, diabetes, respiratory diseases) 14% Musculoskeletal 8 diseases Making the Case for Action at The World Bank Group 3. The Economic and Social Impact of Spending on mental health can be among the Mental Disorders highest areas of health expenditure, representing between 5 and 18 percent of total health Not only do mental disorders represent a expenditures for a selection of countries able to significant disease burden, they are also very costly break down total spending (Germany, Hungary, to country economies. The global cost of mental Korea, the Netherlands, and Slovenia). While these disorders was estimated at approximately $2.5 figures suggest high spending on mental health, trillion in 2010; by 2030, that figure is projected the investments are still likely insufficient, given to rise by 240 percent, to $6 trillion.18 In 2010, 54 the high prevalence of mental health conditions percent of that burden was borne by low- and and the social and economic burden they inflict. middle-income countries; by 2030, the proportion The proportion of total public health expenditure is projected to reach 58 percent. Worsened by allocated to mental health care is often very small. low levels of investment and effective treatment For example, mental disorders are responsible for coverage, mental disorders have serious economic 23 percent of England’s total burden of disease, consequences and may limit the impact or but receive 13 percent of National Health effectiveness of development assistance. Service expenditures. Studies done in high-income countries have The indirect costs of mental health are particularly found that the costs associated with mental high. These include the economic consequences disorders total between 2.3 and 4.4% of gross attributable to disease but which are not domestic product (GDP) (Table 1).19 Roughly captured in the cost of medical services directly two-thirds of those costs are indirect, associated related to the disease. Calculations of indirect with the loss of productivity and income due to costs incorporate, for example, the value of lost disability or death. production due to unemployment, absences from work, and “presentism” (the loss in productivity that occurs when employees come to work, but are unwell and consequently function at less than full capacity). These calculations also include the losses associated with premature mortality. Table 1: Direct and indirect costs of mental disorders: Results from selected studies19 Direct Costs Indirect Costs Total Costs Country Year % of GDP (Billions) (Billions) (Billions) CANADA 2011 CAD 42.3 CAD 6.3 CAD 48.6 4.40 ENGLAND 2009/10 GBP 21.3 GBP 30.3 GBP 51.6 4.10 FRANCE 2007 EUR 22.8 EUR 21.3 EUR 44.1 2.30 GLOBAL 2010 USD 823 USD 1,670 USD 2,493 4.00 9 Mental Health Among Displaced People and Refugees 4. Mental Health of Displaced disability, and a positive association between conflict Populations and Refugees and depression and anxiety disorders. Traditionally the refugee experience is divided into Most of those exposed to emergencies suffer three stages: preflight, flight, and resettlement.20 some form of psychological distress. Accumulated evidence24 shows that the prevalence of common The preflight phase may include, for example, losses mental disorders such as depression, anxiety, and of family members, livelihoods, and belongings, post-traumatic stress disorders (PTSD), increases paired with possible physical and emotional from a baseline of 10 percent to 15-20 percent trauma to the individual or family, the experience of among crisis-affected populations, while severe witnessing extreme violence, and social upheaval. mental disorders, such as psychosis or debilitating Adolescents may also have participated in violence, depression and anxiety, can increase from 1-2 voluntarily or not, as child soldiers or militants. percent to 3-4 percent. Such mental health problems have especially severe consequences in Flight involves an uncertain journey from the humanitarian settings, where they affect the ability home area to the resettlement site and may involve of affected populations to function and survive. arduous travel, refugee camps, and/or detention centers, often including further losses and traumatic The more common mental health diagnoses stressors. Children and adolescents are often associated with refugee populations are depressive separated from their families and at the mercy of and anxiety disorders, including PTSD, generalized others for care and protection. anxiety, panic attacks, adjustment disorder, and somatization.25 The incidence of disorders varies The resettlement process includes challenges such with different populations and their experiences. as the loss of culture, community, and language, Researchers studying settled refugees have found as well as the need to adapt to a new and foreign rates of PTSD and major depression of 5-15 percent environment. Children often straddle the old and or 10-40 percent, depending on the study. Children new cultures, as they learn new languages and and adolescents often have higher prevalence, with cultural norms more quickly than their elders. All of various investigations revealing rates of PTSD from these experiences may play a role in the acquisition 50-90 percent and major depression from 6-40 of, or protection from, mental health conditions in percent. Risk factors for the development of mental each individual within a refugee population. health problems include the number of traumas, delayed asylum application process, detention, and Mental disorders can be triggered by extreme the loss of culture and support systems. On the adversity, such as massive displacement. Conflict other hand, protective factors include a supportive exposes displaced populations and refugees to environment where affected populations can violence and high levels of stress,21 causing dramatic access basic needs, maintain or form new social rises in mental illness that can continue for decades connections and relationships, and are supported in after armed conflict has ceased, as documented pursuing educational and economic opportunities. in multiple studies.22 Armed conflict and violence disrupt social support structures and expose civilian If mental health issues are not effectively addressed, populations to high levels of stress. Consistent with the long-term mental health and psychosocial the findings of earlier Global Burden of Disease (GBD) wellbeing of the displaced population and refugees studies, GBD 201523 confirmed the large contribution may be affected. Many Cambodians, for example, of mental and substance use disorders to global continue to suffer mental disorders and poor health almost four decades after the Khmer Rouge-led genocide of the late 1970s.26 10 Making the Case for Action at The World Bank Group 5. How Should We Address Mental about available services; lack of transport or other Health Needs in Conflict- and Post- resources to access services; language and cultural Conflict-Related Situations? barriers between refugees and service providers; and limited follow-up supports. Mental health is an integral part of overall health, but has received inadequate attention from Addressing mental health needs is important at all health care planners and from society in general, times. But it is critical in times of crisis and recovery. worldwide. Despite their enormous social burden, Examples exist of how disaster and emergency mental disorders continue to be driven into the contexts have successfully been used to make shadows by stigma, prejudice, and people’s fear sustainable improvements in mental health of disclosing an affliction because a job may be systems in low- and middle-income countries.28 lost or social standing ruined. In other cases, these diseases go untreated because health and social Displaced people have not only experienced support services are either not available at all, or traumatic events, but have also lost many of are out of financial reach for the afflicted and their their assets and risk further depletion of human families. The vast majority of low- and middle- and social capital. People may have experienced income countries allocate less than 1 percent of the killing of loved ones, family separation, their health budgets for mental health. abandonment of children and the elderly, and may have been subjected to torture, rape, and other Mental disorders tend to be more acute and forms of violence that can leave deep mental scars. often unattended in conflict and post-conflict situations, where large segments of the Refugees in host communities also face population may have lived through long periods continuing hardships that may affect their mental of armed conflict and ethnic confrontations.27 health. Ongoing stressors such as lack of access to Many have been the subject of harassment, employment, disruption of educational aspirations, sexual abuse and rape, incarceration, and torture. bullying of children at school, as well as social isolation and uncertainty, can increase mental Unlike physical wounds and losses, conditions illness risks. Some studies of conflict-affected such as depression, anxiety (including post- populations have shown that daily stressors in the traumatic stress disorder), and traumatic host environment were actually more predictive of brain injuries, which affect mood, thoughts, developing mental health problems than was and behavior, are often invisible. They persist past trauma.29 unrecognized, unacknowledged, or ignored in humanitarian and development-assistance programs, undermining efforts to help rebuild and sustain the lives of displaced populations. Most countries are ill-equipped to deal with this “invisible” challenge – which is amplified today by conflict and refugee crises in the Middle East and other parts of the world. Refugees and displaced populations often face significant barriers in accessing quality mental health services. Obstacles include lack of knowledge 11 Mental Health Among Displaced People and Refugees 6. Collaborative, Multisectoral reintegration of affected persons into social and Approaches economic activities. An example is Canada’s RISE Asset Development program, which provides WHO’s Mental Health Gap Action Plan (mhGAP) seed capital and lends at low-interest rates to aims to scale-up mental health services in low- people with a history of mental health and income and middle-income countries.30 The addiction challenges.36 mhGAP plan, together with the report and commentary prepared after the 2016 WBG/ 7. Essential Mental Health WHO “Out of the Shadows” event,31 32 emphasize Interventions at the Community Level that evidence-based interventions have been effective in promoting, protecting, and restoring Effective, scaled-up responses to improve the mental health—far more effective than the mental health and psychosocial wellbeing of institutionalization approaches of the past. conflict-affected populations require adaptation to specific contexts. The most successful Mental health and psychosocial interventions approaches mobilize multi-layered systems of and programs can improve economic, social, services and supports. They encompass the and human development, and strengthen provision of food, shelter, water, sanitation, basic health systems. Properly implemented, these health care, and other essential services; action interventions represent “best buys” for any society, to strengthen community and family supports; with significant returns both in terms of health emotional and practical support through and economic gains. Some key interventions are individual, family or group interventions; and deployed within the health sector (e.g., treatment ongoing care through community-based primary with medicines or psychological interventions), health care systems. others outside it (e.g., psychological interventions delivered through social services, or providing Most common mental disorders, such as anxiety timely humanitarian assistance to refugees). A and depression, are prevalent and disabling. growing focus on mental health and psychosocial Fortunately, these illnesses also respond to a program implementation is consistent with their range of safe and effective treatments. However, inclusion in Sustainable Development Goal 3,33 owing to stigma and inadequate funding, these ensuring healthy lives and promoting wellbeing disorders are not being treated in most primary- for all ages, and in Priority 4 of the 2015 Sendai care and community settings. The Interagency Framework, which identifies mental health as an Standing Committee37 has provided guidance essential aspect of disaster risk reduction.34 on tiered action in emergency settings, including for camp coordination and management, A collaborative response is required to tackle that is human rights-based and takes a “do no mental health as a development challenge. harm” approach. This allows a focus on affected Such a response would involve multidisciplinary individuals as whole persons, addressing both approaches that integrate health services at the their physical and mental health needs, while community level,35 in schools, and in workplaces reducing the risk of stigma and discrimination to explicitly address the mental health and among families and communities. This is psychosocial needs of displaced people and host important since mental disorders are highly communities. The model would include services co-morbid with other priority conditions (e.g., to address alcohol and other drug use problems. maternal and child health conditions, HIV/AIDS, It would also include innovative social protection and non-communicable diseases such as cancer and employment schemes that facilitate the and diabetes). 12 Making the Case for Action at The World Bank Group To inform the design of context-specific to achieve universal health coverage. This matrix interventions in emergency settings, the mapping includes a care delivery “value chain,” adapted of the problem is of paramount importance. from the business literature. The resulting “Total Mapping includes gathering information on Health For All” 41 approach integrates primary mental health as part of current governmental care, mental health, and public health. The model policies and plans. It also requires assessment supports understanding of how various activities of mental health and psychosocial information fit together as part of a coherent care delivery about the affected population (e.g., access and process. Implemented at community and facility utilization of mental health services, culturally levels, the interventions can be grouped into an specific understandings of mental health essential package of services that includes: problems, and help-seeking behaviors). The mapping exercise must include both persons • Promotion and prevention, including stigma with disorders induced by the crisis and those reduction interventions with preexisting disorders.38 Such assessments • Case finding (e.g., psychological assessment, can also clarify the current availability of mental diagnosis) health services in affected settings. • Treatment (e.g., counseling, psychosocial interventions such as cognitive behavioral New kinds of tools are offering program therapy, and treatment with essential implementers additional guidance on how to medicines such as antidepressant and consider the complex articulation of systems antipsychotic medications) of care in contexts with especially limited • Follow-up (e.g., monitoring of symptoms) resources and potentially competing priorities. • Reintegration (e.g., social and economic The continuum of action spans service-delivery interventions). science, quality-improvement methods, implementation science, and “mixed” qualitative Core, cross-cutting components of the system and quantitative methods, along with formal include sustained supervision in clinical, randomized controlled trials and anthropological programmatic, and academic spheres for local research. All these approaches contribute implementation teams, as well as a focus on patient to our knowledge of what works in context. safety, quality of care, outcomes measurement Implementing organizations such as Partners In (monitoring and evaluation), and the use of data Health (PIH), International Medical Corps (IMC), to drive performance improvement. or World Vision are actively adapting this kind of knowledge to practice in post-disaster and There are examples from refugee countries as emergency settings. well. For example, IMC has successfully scaled up mental health services within primary health care As illustrated in Table 2 below, PIH experience in response to the Syrian crisis. The program spans in countries such as Haiti, Liberia, Peru, and several countries, including Iraq, Jordan, Lebanon, Rwanda39 40 shows that many effective, evidence- Syria, and Turkey. IMC’s approach includes: using based interventions can be implemented at the the WHO mhGAP Intervention Guidelines to train community and facility levels to deal with anxiety general health care staff; mobilizing community and depression—two of the most common health workers for outreach and follow-up; forms of mental disorder—along with psychosis. assigning psychosocial workers to clinics to address Adapting knowledge from WHO’s mhGAP and multiple needs and deliver scalable psychosocial existing evidence, PIH has worked to develop a interventions; and establishing networks and mental health service-delivery planning matrix referral pathways among service providers.42 13 Mental Health Among Displaced People and Refugees Table 2: Mental Health Value Chain40 Training and Supervision: Clinical, Programmatic, Academic/Research Safety, Quality, Outcomes Measures (M&E) and Performance Improvement Prevention Case-Finding Enrollment Treatment Follow-up Reintegration Health facility Health facility Health facility Health facility Ongoing clinical care: • Psychoeducation • Diagnosis • Monitoring of • Choosing • Formulation symptoms and treatment plan • Mental status functioning • Screening • Medication exam • Med adherence • Referral management • medical exam support and • Community • Evaluation • Psychotherapy laboratory/ monitoring of side stigma • Hospitalization imaging effects • Staff and reduction • Crisis Management • triage severity • Social interventions community • School/ • Social interventions • Psychotherapy education religious based • Social activities Community Community Community Community interventions • Staff and Ongoing: • Peer support community Referral to health • Coordiation groups education center by: • Symptom • Intersectional • Parent • CHW • Home visits monitoring collaborations and family • Community • Psychoeducation • Assignment • Medication education member • Psychotherapy of sick role monitoring • Traditional • Social • Case finding • Adhereence healer interventions (passive and support • Family • Monitoring active) • Psychosocial members (medication) support • Church • Psychotherapy • School • Observation Anti-stigma campaigns can be powerful tools in stigma associated with mental disorders also confronting barriers to support for people with influences how these disorders are prioritized mental disorders. Stigma and discrimination in and contributes to some clinicians’ discriminatory relation to mental illnesses have been described attitudes toward people with mental illnesses.45 as having worse consequences than the Thus, stigma has adverse consequences for the conditions themselves.43 Stigma associated with quality of mental health services delivered.46 mental disorders can result in social isolation, Anti-stigma campaigns as well as peer-to-peer low self-esteem, and limited opportunities in support models can help break down stigma and areas such as employment, education, and raise awareness. Peer-to-peer models engage housing. Stigma can also hinder patients from those recovering from mental health problems in seeking help, thereby increasing the treatment helping others and encourage them to take on gap for mental disorders.44 What is more, visible, proactive roles in their communities. 14 Making the Case for Action at The World Bank Group A recent global review47 provides evidence and inter-personal mechanisms. For example, that social contact is the most effective type of a recent study48 assessed the effectiveness of a intervention to improve stigma-related knowledge brief multicomponent intervention incorporating and attitudes in the short term. However, the behavioral strategies delivered by lay health evidence for longer-term benefit of social contact workers to adults functionally impaired by in reducing stigma is weak. The review’s main symptoms of psychological distress in a conflict- findings are the following: (1) At the population affected setting. The study examined a lay level, there is a fairly consistent pattern of short- worker–administered intervention consisting term benefits for positive attitude change, and of five weekly 90-minute individual sessions some lesser evidence for knowledge improvement; that included empirically supported strategies (2) for people with mental illness, some group- of problem solving, behavioral activation, level anti-stigma inventions show promise and strengthening social support, and stress merit further assessment; (3) for specific target management. Researchers found that, compared groups, such as students, social-contact-based to enhanced usual care, the intervention may interventions usually achieve short-term (but less be a practical approach for treating adults with clearly long-term) attitudinal improvements, and psychological distress in conflict-affected areas. less often produce knowledge gains; (4) this is The application of this intervention resulted in a heterogeneous field of study with few strong clinically significant reductions in anxiety and study designs with large sample sizes; (5) research depressive symptoms at 3 months. from low-income and middle-income countries is conspicuous by its relative absence; (6) caution “Task-sharing” models, by which non-specialist needs to be exercised in not overgeneralizing providers deliver care, have been adapted from lessons from one target group to another; (7) there the global HIV/AIDS care movement to the mental is a clear need for studies with longer-term follow- health field over the past two decades. These up to assess whether initial gains are sustained models are now offering hope for the spread and or attenuated, and whether booster doses of the scaling of mental health services in high- as well intervention are needed to maintain progress; (8) as low-income countries. There is also a growing few studies in any part of the world have focused body of evidence49 demonstrating that non- on either the service user's perspective regarding specialist workers in primary-care and community stigma and discrimination or on the behavior settings can deliver mental health care with great domain of behavioral change regarding stigma, effectiveness to a variety of populations. whether in people with or without mental illness. In view of the magnitude of challenges that result As for pharmacological therapies, several major from mental health stigma and discrimination, groups of antidepressants are in common use the review finds a need for new, methodologically today, including tricyclic antidepressants and strong research that will support decisions on selective serotonin reuptake inhibitors (SSRIs).50 investment in stigma-reducing interventions. Studies have found strong evidence for the efficacy of antidepressant pharmacotherapy and Current evidence-based treatments for moderate no evidence of an advantage for any specific drug to severe depression and anxiety disorders over another. Antidepressants generally, and SSRIs include structured, time-limited psychological in particular, have well-documented efficacy in treatments and antidepressant medications. the treatment of anxiety disorders, trauma-related Numerous randomized trials support the efficacy disorders like PTSD, and other disorders related to of psychological treatments, especially in the form depression. Similarly, evidence for psychosocial of brief treatments based on cognitive, behavioral, and psychopharmacological interventions for psychosis is adequate. 15 Mental Health Among Displaced People and Refugees 8. Treatment Settings and Integration participatory approaches, and strengthen coping with Health and Social Systems mechanisms. An integrated service model seeks first of all to improve people’s daily functioning and Displaced people and refugee populations protect the most vulnerable from further adversity. are confronted with extraordinary stresses and It addresses, for example, the specific needs of challenges to their physical and psychological vulnerable constituencies, including women, health. Whether mobile or in a camp setting, they children, adolescents, the elderly, and those with can easily fall through the cracks of assistance severe mental disorders. In addition, a successful mechanisms. For this reason, the articulation of holistic service model can empower affected mental health and psychosocial services within people to take charge of their lives. other government programs, as well as with the development and NGO sector, can provide a critical Mental health planners and policy makers need safety net for these vulnerable populations. to support, through public awareness and community engagement, care delivery systems The provision of mental health and psychosocial that are sensitive to local social, economic, and support services at the community level cannot cultural contexts. This will help ensure that mental be seen as a vertical or free-standing intervention health care is appropriately sought and utilized by offered in a health facility. Rather, it needs to be part potential beneficiaries. of broad, integrated platforms offering a range of community, health, social, and educational services. The Inter-Agency Standing Committee (IASC) Such platforms provide basic services and security, intervention pyramid for mental health and promote community and family support through psychosocial support, presented in Figure 2 below, illustrates task responsibility by levels of care. Figure 2: Intervention Pyramid for Mental Health and Psychosocial Support in Emergencies51 Clinical Services Example: Clinical mental health care (whether by PHC staff or by mental health professionals) Focused Psychosocial Supports Example: Basic emotional and practical support to selected individuals or families Strengthening Community and Family Supports: Example: Activating social networks Supportive child-friendly spaces Social Considerations in Basic Services and Security: Example: Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and 16 that protect dignity Making the Case for Action at The World Bank Group Efforts at collaborative, integrated care – an mutual goal-setting as interventions to improve TB evidence-based approach to care for chronic treatment adherence by reducing psychological illness applied in primary care settings – should stress.56 57 guide the effective use of resources for delivery of quality mental health care. Such efforts emphasize There is significant evidence that integrated systematic identification of patients, self-care, and delivery of mental health and psychosocial active care management by clinical providers, support services can be effective for these blended with other medical, mental health, and complex health problems. For example, community supports.52 psychiatric diagnoses are more common in HIV patient groups than other populations and are Given that anxiety and depression play large associated with poor ART adherence. However, roles in the health of expectant and new mothers antidepressant treatment for depressed HIV and their children, maternal care settings can patients is associated with improved antiretroviral be a viable platform for delivering depression medication adherence,60 61 62 and psychological care, where early and effective intervention interventions in this population can lead to for maternal depression can be implemented. improved immune status.63 64 65 66 Depressive symptoms in mothers are associated with preeclampsia, preterm birth, intrauterine The reality of comorbidity in affected populations growth retardation, and low birth weight in implies the need to develop and implement infants. The prevalence and severity of antenatal coordinated mental health promotion, protection, anxiety and depression are higher in low-and illness prevention, screening, and interventions. middle-income countries.53 54 Interpersonal These services can be delivered by integrated psychotherapy, however, is associated with a primary-care, mental-health, and public-health reduction in depressive symptomatology in teams in an effective TOTAL Health model, pregnant women.55 Importantly, mothers with supporting collaboration among public, private, high levels of psychological distress exclusively and NGO partners.67 breastfeed for a shorter duration. However, WHO considers exclusive breastfeeding the safest and The collaborative care approach has proven most effective intervention to reduce infant effective in general population samples and morbidity and mortality. Cognitive behavioral vulnerable sub-populations in high-income counseling delivered in the postpartum period countries, and increasingly in LMICs.68 Evidence can reduce the risk that a mother will stop from low-income countries demonstrates the exclusive breastfeeding.56 57 effectiveness of care delivery by community or lay health workers. In addition to their impact on overall physical health, mental disorders can exacerbate As shown in Box 2,69 recent efforts in Syria illustrate common co-occurring diseases, such as diabetes, the types of investments and activities required hypertension, cardiovascular disease, and cancer, to build a mental health system responsive to communicable diseases such as HIV and TB, population needs during a crisis. and major health challenges affecting mothers and children in the pre- and post-partum periods. Mental disorders are also a barrier to patient adherence to TB treatment, and WHO recommends therapeutic relationships and 17 Mental Health Among Displaced People and Refugees Box 2: Mental Health Care Efforts in Syria69 Key achievements to date include the following: The reality of the conflict: • Mental health is now seen as a public health 4.8m Registered Syrians refugees abroad, priority in Syria. according to the UNHCR • A team of Syrian mental health professionals play 6.6m Registered refugees inside the a leadership role in prevention and treatment of country, according to UNHCR mental health conditions in Syria. 450,000 People killed in the fighting • Mental health services are provided for people in Syria with mental disorders at primary-care facilities in Damascus, Rural Damascus, Homs, Aleppo, In Syria, the World Health Organization (WHO) is Hamma, Lattaki Hasaka, and Tartus. These services working with partners to cope with the emerging are provided by non-specialist general needs of the population. Despite the challenges practitioners under the supervision of specialists, presented by the ongoing conflict, mental health all trained through the WHO mhGAP program. services are becoming more widely available in Syria. Mental health care is now being offered in primary and • A team of psychologists is providing a wide secondary health facilities in some of the most affected range of psychotherapeutic interventions Syrian governorates (Damascus, Rural Damascus, Homs, through multidisciplinary teams at the primary Suwayda, Aleppo, Al Hassakeh, Hama, Tartous, and and secondary care levels. Lattakia). This is in contrast to the situation before the conflict, at which time mental health care was provided • Psychotropic medication provided through WHO in at only three hospitals, and only in Damascus and and partners is available at primary and secondary Aleppo. care levels for the first time in the country. Key to addressing this gap was training and continuous • An inpatient unit for mental disorders has been technical supervision of primary health care physicians established for the first time in Syria, in a general on the management of stress, depression, psychosis, hospital in Damascus. Two more inpatient facilities suicide, and psychosomatic disorders. The WHO are expected to open soon. mhGAP Intervention Guide, an integrated guide for the management of priority mental health conditions, was the main tool used. WHO recruited a team of field-based national supervisors to support this process. mhGAP training materials were translated into Arabic and adapted for use in the Syrian context by Syrian mental health professionals, with support from WHO. WHO supported the training of Syrian health professionals and provision of psychotropic medicines, not only through its Damascus office, but also its sub- offices in Homs and Aleppo, and its field presence in Gaziantep/Turkey. 18 Making the Case for Action at The World Bank Group 9. Are Mental Health Interventions management and administration, training and Affordable and Cost-Effective? supervision, drug safety monitoring, health promotion and awareness campaigns, and A WHO-led study70 estimated the cost of strengthened logistics and information systems. treatment interventions at the community level The latter were estimated as on-cost to the for moderate to severe cases of depression. estimated direct healthcare costs. The baseline Prepared for the WBG/WHO global mental health value for on-cost was 10 percent (and therefore event at the 2016 WBG/IMF Spring Meetings, the grows in absolute terms during scale-up). study examined a range of treatment options. These included basic psychosocial treatment for The results of the estimation, which would need mild cases and either basic or more intensive to be adapted to the particular conditions of psychosocial treatment plus antidepressant drug given emergency contexts, show that the cost therapy for moderate to severe cases. of scaling up the delivery of these interventions is relatively low. The average annual cost during The study incorporated key categories of resource 15 years of scaled-up investment is $.08 per use, including: person in low-income countries, $0.34 in lower middle-income countries, $1.12 in upper middle- • Medication, with six months of continual generic income countries, and $3.89 in high-income antidepressants for moderate to severe cases countries. Per-person costs for treatment of anxiety disorders are approximately half those • Outpatient and primary care, including regular for depression. Across country income groups, visits for all cases, with frequencies ranging from resulting benefit-to-cost ratios amount to 2•3–3•0 four per case per year for basic psychosocial to 1 when only economic benefits are considered, treatment, up to 14–18 visits for moderate to and 3•3–5•7 to 1 when the value of health returns severe cases receiving antidepressant medication is also included (Figure 3). and intensive psychosocial treatment • Inpatient care, with only a few cases expected to be admitted to hospital (2–3 percent of moderate to severe cases only, for an average Figure 3: Ratio of (economic and social) length of stay of 14 days). benefit to cost for scaled-up treatment70 An assumption of the study was that care and Depression Anxiety follow-up would largely be undertaken in non- specialist health care settings by doctors, nurses, 5.7 5.4 5.3 and psychosocial care-providers trained in the 4.2 4.0 identification, assessment, and management of 3.8 3.9 3.3 depression and anxiety disorders. Estimations also included expected levels of program costs and shared health-system resources needed to deliver interventions Low-income Lower Upper High-income countries middle-income middle-income countries as part of an integrated model of chronic (N=6) countries countries (N=10) (N=10) (N=10) disease management. These included program 19 Mental Health Among Displaced People and Refugees 10. Dealing with Malnutrition in Overall, besides adequate nutrition, psychosocial Conflict and its Psychological Causes stimulation from a caregiver is required to support a child’s optimal physical, motor, cognitive, In a study of the 2013 outbreak of violence in and language development, as well as mental Bangui, Central African Republic,71 researchers health. Psychosocial stimulation refers “to the found that dealing with malnutrition in such a extent that the environment provides physical crisis is more complex than simply curing disease stimulation through sensory input (e.g., visual, and providing children with therapeutic foods. auditory, tactile), as well as emotional stimulation The reason is clear: often, post-traumatic stress provided through an affectionate caregiver- disorder hinders treatment success among a large child bond.”72 It is recommended that nutrition number of children suffering from life-threatening programs targeting displaced populations malnutrition. combine nutrition, maternal mental health, and psychosocial stimulation interventions.73 The humanitarian relief organization Action Against Hunger collected data on more than 11. Dealing with Multidrug-resistant 1,000 parents of malnourished children between Organisms among Refugees and July 2013 and March 2014. The researchers Hosting Populations. reported that, in 75 percent of cases studied, the parents presented symptoms of post- As discussed in a new study,74 displaced traumatic stress linked to their exposure to populations and refugees pose additional, extreme violence. It was found that this condition often overlooked, challenges to the social and contributed to behavioral changes, flashbacks, healthcare systems in receiving countries. In fatigue, isolation, excessive irritability, and feelings addition to good hygiene practices, safe food, of hopelessness and despair, which in turn had and sanitary and vaccination programs that are a temporary but disabling impact on many needed to control the risk of infectious diseases mothers’ ability to nurse and feed their children. outbreaks in refugee camps and their spread In some cases, this resulted in early weaning to receiving communities, findings from the that can be deadly in an already challenging study suggest the importance of strengthening environment. Some mothers had also reportedly screening procedures and infection control attempted suicide and infanticide. It was found measures in hospitals where refugees are that children, while too young to fully understand admitted to prevent the spread of multidrug- what they have witnessed, may develop physical resistant organisms (MDRO). For example, symptoms such as continuous crying, refusing the study evidences that refugees tested in to eat, bed wetting, sleep disturbances, and poor some receiving countries showed prevalence interaction. of methicillin-resistant staphylococcus aureus To recognize these signs, malnourished children (MRSA) infection of up to of up to 13.5%--MRSA is and their caretakers need to receive psychological caused by a type of staph bacteria that becomes and social support from specialized counseling resistant to many of the antibiotics used to teams. Regular feeding times, medical monitoring, treat ordinary staph infections. This observed and psychological and motor activities also need prevalence rate was found to be far higher than to be included as part of daily routines. those of “traditional risk groups” for MRSA, such as hemodialysis patients and patients depending on outpatient home-nursing care or residing in nursing homes. The adoption of screening and 20 Making the Case for Action at The World Bank Group special infection control measures is therefore Nor, in fact, are they truly separable. As discussed required to ensure the provision of adequate above, untreated mental disorders can negatively medical care and safety for all hospital patients affect risk, patient management, and outcomes regardless of country of origin and of the staff in in such co-occurring diseases as tuberculosis the health facilities. and HIV, diabetes, hypertension, cardiovascular disease, and cancer. 12. Mental Health Care Over the Long Term In moving forward, a firm commitment is needed from national and international actors to Projects funded by the World Bank Group champion mental health parity in the provision and other organizations utilize a bottom-up, of health and social services, as part of dedicated multidisciplinary approach to re-integrate development support and assistance programs displaced population groups after conflicts (see Box 4 on Peru’s recent experience). This is and natural disasters. Incorporating integrated crucial in order to help displaced people and care and treatment for mental illness into these refugees overcome their vulnerabilities, build existing projects would help to overcome barriers mental resilience, and take full advantage to securing employment among the poor and of poverty-reduction programs, economic vulnerable. Further investment in education, opportunities and legal protections, particularly social protection, and employment training with regard to stigma and discrimination.76 would help prevent social exclusion and build social resilience by serving the unique needs of If the World Bank and WHO are to fully embrace vulnerable groups. and support the progressive realization of universal health coverage, we must work to To the above end, development efforts in post- ensure that prevention, treatment, and care conflict and post-disaster societies should include services for mental disorders at the community expanding mental health services that are well level, along with psychosocial support mechanisms, integrated into primary health care systems. are integrated into existing service delivery Box 3 provides case examples of countries/ platforms, are accessible, and are covered under regions that have seized opportunities during financial protection arrangements.77 and after emergencies to build better mental health care.75 They represent a wide range of emergency situations and political contexts, and provide evidence that it is possible to take action in emergencies to create better mental health systems for the long term. Building out mental health services that are well integrated into primary care and public health in countries hosting refugees, and in post-conflict and post-disaster societies, would require treating mental and substance use disorders like other chronic health conditions. After all, these are disorders of the brain, an organ of the human body just as important as the heart, liver, or lungs. 21 Mental Health Among Displaced People and Refugees Box 3: Country/Regional Examples of Sustainable Mental Health Care after Jordan: The influx of displaced Iraqis into Jordan Conflicts and Emergencies75 drew substantial support from aid agencies. Within this context, community-based mental health care Afghanistan: Following the fall of the Taliban was initiated. The project’s many achievements built government in 2001, mental health was declared a momentum for broader change across the country. priority issue and was included in the country’s Basic New community-based mental health clinics helped Package of Health Services. Much progress has been more than 3550 people in need from 2009 to 2011. made. For example, since 2001, more than 1,000 health workers have been trained in basic mental health care, Kosovo: After conflict, rapid political change generated and nearly 100,000 people have been diagnosed and an opportunity to reform Kosovo’s mental health treated for mental health conditions in Nangarhar system. A mental health taskforce created a new Province alone. strategic plan to guide and coordinate efforts. Today, each of Kosovo’s seven regions offers a range of Burundi: Modern mental health services were almost community-based mental health services. non-existent prior to the past decade, but today the government supplies essential psychiatric medications Somalia: The governance structure in Somalia has through its national drug distribution center, and been fragmented for more than 20 years, and during outpatient mental health clinics are established in most of that time the country has been riddled with several provincial hospitals. From 2000 to 2008, more conflict and emergencies. Despite these challenges, than 27,000 people were helped by newly established mental health services have improved. From 2007 mental health and psychosocial services. to 2010, chains were removed from more than 1700 people with mental disorders. Indonesia (Aceh): In a matter of years following the tsunami of 2004, Aceh’s mental health services were Sri Lanka: In the aftermath of the 2004 tsunami, Sri transformed from a single mental hospital to a basic Lanka made rapid progress in the development of basic system of mental health care, grounded by primary mental health services, extending beyond tsunami- health services and supported by secondary care affected zones to most parts of the country. A new offered through district general hospitals. Now, 13 of 23 national mental health policy has been guiding the districts have specific mental health budgets, compared development of decentralized and community-based with none a decade ago. Aceh’s mental health system is care. Today, 20 of the country’s 27 districts have mental viewed as a model for other provinces in Indonesia. health services infrastructure, compared with 10 before the tsunami. Iraq: Mental health reform has been ongoing since 2004. Community mental health units now function Timor-Leste: Building from a complete absence of within general hospitals, and benefit from more stable mental health services in 1999, the country now has resources. Since 2004, 80–85 percent of psychiatrists, a comprehensive community-based mental health more than 50 percent of general practitioners, and system. Today, the Timor-Leste National Mental Health 20–30 percent of nurses, psychologists, and social Strategy is part of the Ministry of Health’s overall long- workers working in the country have received mental term strategic plan. Mental health-trained general health training. nurses are available in around one-quarter of the country’s 65 community health centers, compared with Japan: A series of catastrophic earthquakes in Japan, none before the emergency. including the 1995 Hanshin-Awaji earthquake, the 2006 Niigata Chuetsu earthquake, and the 2011 Great East West Bank and Gaza Strip: Significant improvements Japan earthquake, has provided evidence that mental in the mental health system have been made over health and psychosocial support can also be effectively the past decade, towards community-based care and integrated into humanitarian response and disaster risk integration of mental health into primary care. In 2010, management. more than 3000 people were managed in community- based mental health centers across the West Bank and Gaza Strip. 22 Making the Case for Action at The World Bank Group In the United States, as well as countries such as The framework for action is structured around Chile, Colombia, and Ghana, attempts to promote four pillars that are geared to improve the mental treatment equality for mental disorders including health and well-being of people in Canada and addiction programs have run up against clauses the services they need: that deny health insurance coverage for pre- existing conditions, a common barrier. When this • Leadership and funding: the mobilization hurdle is overcome, the next barrier has included of commitment and support from the highest determination of what is covered and funded at political level is critical to better resource the the provider level. This leads to a host of additional mental health response and increase the capacity questions, such as what conditions to cover, how to deliver quality, evidence-based, and integrated to select a menu of evidence-based treatments to services and better meet the needs of diverse be offered by service providers at different levels population groups. While funding is important, of care (as is commonly done for other health it is emphasized that leaders need to focus on conditions), and how these services will be funded achieving parity between physical and mental and reimbursed without perpetuating indirect health care, better integrating mental health and medical discrimination through high deductibles, physical health, and fostering collaboration across copayments, and lifetime limitations in coverage. the health, social, education, and justice sectors. There are countries, such as Canada, that show • Promotion and prevention: given the that well-designed frameworks, built upon broad multisectoral nature of mental health problems consultations involving local, regional, and national and illnesses, upstream efforts are needed, placing groups, agencies, governments, and vulnerable more emphasis on holistic prevention strategies, population groups such as Indigenous peoples promotion of mental wellness, increased and people with lived experience, and that awareness and education about positive mental enjoy the highest level of political commitment, health across the lifespan, and a more refined can serve as good roadmaps for advancing the focus on the social determinants of health in a mental health agenda over the medium term. culturally competent and safe manner. Promotion The “Changing Directions, Changing Lives: The and prevention must be complemented with Mental Health Strategy for Canada”, along with efforts to uphold human rights, social inclusion, the “Advancing the Mental Health Strategy for and eliminate stigma and discrimination. Canada: A Framework for Action (2017–2022)” adopted to accelerate uptake and implementation • Access and services: making timely access of the strategy, offer some lessons for designing to evidence-based, integrated, person-centered, and implementing comprehensive national holistic, high-quality mental health services mental health strategies. across the continuum of care should be a priority. People with lived experience and their caregivers A key aspect of the Canadian mental health must be engaged at all service points and in the strategy is its humanistic orientation. It positions policy development process to truly improve the people living with mental health problems and availability and quality of mental health services. illnesses and their families as the drivers of change in mental health. It also recognizes that success • Data and research: aside from developing depends on the commitment of governments to benchmarks and ongoing evaluation of system set policies and fund services, as well as of other performance, as well as the translation of actors to regulate, accredit, monitor, evidence-based mental health knowledge into and deliver services. policy and practice, this pillar includes support 23 Mental Health Among Displaced People and Refugees for comprehensive, innovative, interdisciplinary illustrate that broad social goals are the basic research and evaluation on mental health parameters that ultimately guide and shape problems and illnesses and mental health policy and institutional decisions concerning programs and treatments; facilitating the the most appropriate and contextually relevant involvement of people living with mental illnesses organizational forms, financing arrangements, in research; improving data collection systems and service delivery mechanisms. The strategy and population-level monitoring to collect also clearly distinguishes the intermediate comprehensive information on mental health, goals (improved access, quality, efficiency, wellness, illness, service access, and wait times and and fairness) from the ultimate goals of ensure that publicly-funded data is available to integrated mental health and social systems researchers and policy makers. (improved social and mental and physical health conditions, financial protection, and user These pillars are in line with WHO’s Mental Health satisfaction with the services received), avoiding Action Plan 2013-2020, adopted by the World the risk of confusing the means and ends of Health Assembly, consisting of all ministers of policy action. health, including of Canada. While recognizing that heterogeneous social, Canada has also established itself as a leader on economic, and cultural country contexts global mental health. Many Canadian agencies preclude the mechanical adoption of other have been collaborating with international countries’ experiences, the transnational sharing and national partners. For example, since 2012, of knowledge and adaptation of relevant aspects Grand Challenges Canada (GCC) has invested of those international experiences to specific more than 35 million Canadian dollars to fund country realities is one of the benefits of living in over 70 innovative mental health projects in an interconnected, globalized world. If inclusive more than 28 low-and middle-income countries. mental health policy, programs, and services These innovations have led to tens of thousands are going to thrive across the world to improve people receiving mental health care; GCC health outcomes for people with mental health funded grants have the potential to improve problems and illnesses and their families, we will thousands of additional by 2030. GCC has also do well in recognizing that more than technical supported the establishment of Mental Health processes, their realization will depend, as Innovation Network, which shares information Canada’s experience shows, on social and political and knowledge for decision making to innovators, decisions as to what kind of society a country researchers, civil society and policy makers. wants to have. Canada’s contributions at the international level, also set an example for other By defining a broad, multi-stakeholder, social countries to contribute to global mental health. compact to support mental health promotion and mental illness prevention and treatment, Canada’s mental health strategy and the framework for action show the importance of alternative “distributive social ethics” or “moral values” in developing ­public policies. That is, the well-articulated, socially inclusive goals and participatory mechanisms of the strategy 24 Making the Case for Action at The World Bank Group Box 4. Bringing Mental Health Services Anxiety and depression are common problems in to Those Who Need Them Most: Peru’s Peru. In Carabayllo, as in other districts with high Carabayllo Experience levels of poverty, social problems like domestic violence, sale and consumption of drugs, gangs, prostitution, assaults, and robberies are common. “Welcome to my house!” said World Bank Group Community organizations in Carabayllo are trying to President Jim Yong Kim during his opening remarks implement a comprehensive approach to deal with to the Peruvian President, First Lady, Minister of these complex challenges. Health, and Mayor of the district of Carabayllo. Dr. Efforts in Carabayllo include opening the first Kim felt like he was at home, because he had been a home for people with severe mental disorders regular visitor to Carabayllo since 1994, when he led in socially neglected situations. Six therapeutic an initiative to implement the first community-based caregivers, who are community health workers with approach to control multidrug-resistant tuberculosis ad-hoc training, are taking care of eight women, (MDR-TB) in a resource-poor setting. ranging from 21 to 63 years old. Health workers are responsible for overseeing residents’ treatment, for This time, Carabayllo was making history again. Peru’s providing new skills training, and for enabling the President had recently signed a law that protects socialization and reintegration of patients into the the rights of people with mental health problems. community. The National Institute of Mental Health is The regulation includes a set of community mental providing technical advice, training, monitoring, and health services integrated at the primary health care therapeutic support to caregivers. level, which require the direct involvement of the community and the family of the patients. It is a first As we left the district of Carabayllo, I thought about step to decentralize mental health services through the great challenges the community is still facing the implementation of the new model of community to become a healthy society. Undoubtedly, the care for mental health, including general and lessons from the past allow for active community specialized mental health care services. participation, creating a platform for true collaboration among government bodies and Across six regions in Peru, there are 21 community community-based organizations. centers for mental health. The coordinated effort— by the Ministry of Health, the National Institute of Source: Bayona, J. 2015. “Bringing Mental Health Services Mental Health, local government in Carabayllo, and to Those Who Need Them Most”. The World Bank Blogs, several international and national organizations—is October 30, 2015. Available at http://blogs.worldbank.org/ promoting social participation and is strengthening health/bringing-mental-health-services-those-who-need- the network of community-based mental health them-most. approaches to implement psychosocial interventions in families with mental disorders. In the past, mental health patients were hospitalized; now, in this new model of health care delivery, patients are ambulatory. Community health workers conduct home visits to beneficiaries and provide psycho- education, support adherence to treatment, and encourage the participation of family members in the recovery of the patient with mental health problems. Mental Health Among Displaced People and Refugees This is not an easy task. Strategies and plans can be substantial. In the United States, for for the medium term are required to integrate example, as part of the 2009 reauthorization of mental health care into health services delivery the Children’s Health Insurance Program, a 62 platforms that focus on the whole person, percent per-pack increase in the federal cigarette rather than an aggregation of diseases. Even if tax was adopted to help fund the program. The these policy and service delivery changes were measure increased the total federal cigarette tax adopted, the need would remain for unrelenting to about $1 a pack. Federal cigarette tax revenue efforts to support affected persons and their rose by 129 percent, from $6.8 billion to $15.5 families, empowering them to defy stigma, access billion, in the 12 months after the tax, while services, and adhere to prescribed treatments. cigarette pack sales declined by 8.3 percent in There is an ongoing imperative to identify entry 2009 – the largest decline since 1932.80 points across sectors to address the social and economic factors that contribute to the onset and In the Philippines, the adoption of the 2012 Sin perpetuation of mental disorders. Tax Law confirmed that substantial tax increases on tobacco and alcohol can yield both direct High priority should go to identifying alternative public health impact and new resources for sources of financing for mental health parity in health investments. In the first three years of the the health system, and to mainstreaming mental law’s implementation, $3.9 billion in additional health across system entry points. Development fiscal revenues were collected. The additional lifts lives, and new and innovative funding fiscal space multiplied the Department of Health approaches for development are “game changers.” budget threefold. The Department was able to Recalling the 2015 Financing for Development expand the number of families whose health Addis Ababa Action Agenda,78 one can argue that insurance premiums were paid by the National the development community needs to redouble Government. The number of primary recipients its advocacy with national governments to raise benefiting rose from 5.2 million in 2012 to 15.3 “sin taxes”: including on tobacco, alcohol, and million in 2015. In total, counting family members, sugary drinks. These taxes represent a win-win for about 45 million poor Filipinos benefited— public health and domestic revenue mobilization. roughly half of the country’s total population. For example, taxing tobacco is one of the most Both these country initiatives show that cost-effective measures to reduce consumption increasing taxes on tobacco and alcohol is “low of products that kill prematurely, make people ill hanging fruit,” a high-yield strategy for raising with diverse diseases (e.g., cancer, heart disease, domestic resources to reach development and respiratory illnesses), and burden health goals, including expanding mental health systems with enormous costs. Hiking tobacco care coverage.81 taxes can expand a country’s tax base to fund essential public services for the entire population and strengthen human capital. One clear example is the progressive realization of universal health coverage, including mental health care.79 Data from different countries indicate that the annual tax revenue from excise taxes on tobacco 26 Making the Case for Action at The World Bank Group 13. Key Lessons Learned82 14. The Way Forward • Mental health and psychosocial problems Jim Y. Kim, President of the WBG, has called are extremely common in major crises. There is for a collaborative response to tackle mental always a need for mental health and psychosocial health as a development challenge by pursuing support services (MHPSS) in humanitarian crises. multidisciplinary approaches.84 Successful During a humanitarian crisis, prevalence surveys approaches encompass integrated health are not needed to justify investing in MHPSS. In services at the community level, in schools and some exceptional cases, prevalence surveys, if done in workplace programs, and initiatives to address well, can be justified for advocacy and scientific the mental health and psychosocial needs of knowledge. The dire situation of displaced person displaced populations. and refugees in the world today demands that investments be made to support their mental Addressing mental health as an integral part of health and wellbeing. An area that requires priority the global development agenda adds value by attention is the mental health and psychosocial increasing the effectiveness of programs in other needs of children and adolescents. This issue has sectors such as health, maternal and child health, been prominent on the southern border of the nutrition, education, social protection, and jobs. United States and also in the recent large migration Mental health problems are especially common in Europe. in conflict- and crisis-affected populations. They may impair the ability of affected persons and • Activities and programming should be their families to take advantage of any type integrated into wider systems (for example, development program. Addressing mental health existing community support mechanisms, formal/ alongside other sectors can unlock additional non-formal school systems, general health systems human potential, contribute to a more inclusive and services, social services, trusted protection rights-based approach, and help accelerate networks). This reaches more people, is more the positive impact of programs on affected sustainable and carries less social stigma. communities. • Relative priority should be given to those The WBG could bring four primary comparative MHPSS projects that (a) have a relatively advantages to support scaling up mental health strong evidence-basis; (b) seek to demonstrate services for displaced people and refugees: improvements in people’s daily functioning; and (c) (1) Strong influence on the global development are likely to protect the most vulnerable, including agenda; (2) involvement in virtually all sectors, people with severe mental disorders, by reducing including health, nutrition and population; their exposure to further adversity. education; social protection; fragility, conflict and violence; macroeconomics; and finance; (3) ability • Investing in mental health as part of early to support scale-up of effective programs as part of recovery can make a substantial difference in the broader development action under IDA18 funding; long-term availability of services for the most and (4) public-health and economic expertise. severely affected survivors—and ultimately in development outcomes. Emergencies are unique An effective response to the mental health needs opportunities to build back/up sustainable mental of the displaced and refugees would require health care (See the Resources section, below). strengthening partnerships between the WBG, WHO, UNHCR, UNICEF, Public Health Agency of • Practical tools and guidelines exist for assessment and response. 27 Mental Health Among Displaced People and Refugees Canada, and other international and national partners, such as PIH and IMC. Because mental health affects so many aspects of development, external actors must work in partnership with civil society and the private sector, under the leadership of governments, to harness the comparative advantage of each. Support must be well planned and coordinated to enhance synergy and avoid duplication of effort. Bureaucracy should be minimized and processing of aid dramatically accelerated. Most of all, a concerted effort to break the silence surrounding mental health needs is required, and consolidated action must be taken early in crisis and post-crisis situations to ensure timely and effective support for people affected, including displaced persons and refugees. If this is done, as Toluwalola Kasali observed, we will be helping affected people regain “the ability to dream, desire and work for a future, one very different from their present circumstances.” 85 28 Making the Case for Action at The World Bank Group Endnotes al. 2004; Silove, D., et al. 2008. 1 World Bank 2016. 23 GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016. 2 Marquez, P.V. 2015b; Evans, T., Marquez, P.V., and Saxena, S. 24 WHO & UNHCR 2012; WHO & UNHCR 2015; WHO, UNICEF, 2015. UNFPA, UNHCR, & UN Action n.d. 3 Mnookin S., et al. 2016. 25 Studies cited at Refugee Health Technical Assistance Center (http://refugeehealthta.org/physical-mental-health/ 4 Patel, V., Chisholm, D., Parikh, R., Charlson, F.J, Degenhardt, mental-health/): include: Birman, D., Beehler, S., Harris, E. et L., Dua, T., et al. 2015. al. 2008; Carswell, K., Blackburn, P., Barker, C. 2011; Lustig, S., Kia-Keating, M., Kight, W. et al. 2004; Murray, K., Davidson, G., 5 Marquez, P.V. 2015; Evans, T, Marquez, P.V., and Saxena, S. Schweitzer, R. 2010. 2015. 26 Mollica, R.F., et al. 2014. 6 Mnookin, S., et al. 2016. 27 Marquez, P.V. 2014. 7 American Psychiatric Association 2013. 28 Epping-Jordan JE, Ommeren MV, Nayef Ashour H, Maramis 8 World Health Organization (WHO ) n.d. A, Marini A, Mohanraj A, Noori A, Rizwan H, Saeed K, Silove D, Suveendran T, Urbina L, Ventevogel P, Saxena S. 2015. 9 Vigo, D., Thornicroft, G., and Atun, R. 2016. 29 There are several studies by Ken Miller on this, e.g. Miller, K. Patel, V., Chisholm, D., Dua, T., Laxminarayan, R., Medina- 10 E., Omidian, P., Rasmussen, A., Yaqubi, A., Daudzai, H., Nasiri, Mora, M.E. 2016. M., Bakhtyari, M.B., Quraishi, N., Usmankhil, S., & Sultani, Z. 2008. GBD 2015 Disease and Injury Incidence and Prevalence 11 Collaborators 2016. 30 WHO 2010. 12 GBD 2015 DALYs and HALE Collaborators 2016. 31 World Bank Group, WHO 2016. 13 The 2015 GBD Study uses the disability-adjusted life-year Kleinman, A., Lockwood Estrin, G., Usmani, S., Chisholm, D., 32 (DALY), combining years of life lost (YLLs) due to mortality Marquez, P.V., Evans, T.G., and Saxena, S. 2016. and years lived with disability (YLDs) in a single metric. One DALY can be thought of as one lost year of healthy life. 33 United Nations. Sustainable Development Goals, Goal 3. Available at: http://www.un.org/sustainabledevelopment/ 14 Patel, V., et al. 2012. health/ 15 See for example Sorel, E. 2016. 34 United Nations Office for Disaster Risk Reduction (UNISDR) 2015. 16 Bloom, D.E., et al. 2011; Marquez, P.V. and Farrington, J. 2013. 35 American Psychiatric Association (APA) 2016. 17 WHO 2013. 36 See Rise Asset Development: http://www. riseassetdevelopment.com/. 18 Bloom, D.E., et al. 2011. 37 Interagency Standing Committee 2014. This 19 Hewlett, E. and Moran, V. 2014. and other documents accessed at: https:// interagencystandingcommittee.org/product-categories/ 20 Studies cited at Refugee Health Technical Assistance mental-health-and-psychosocial-support Center (http://refugeehealthta.org/physical-mental-health/ mental-health/) include: Birman, D., Beehler, S., Harris, E. et See WHO & UNHCR 2012; WHO & UNHCR. 2015; WHO, 38 al. 2008; Carswell, K., Blackburn, P., Barker, C. 2011; Lustig, S., UNICEF, UNFPA, UNHCR, & UN Action n.d. Kia-Keating, M., Kight, W. et al. 2004; Murray, K., Davidson, G., Schweitzer, R. 2010. 39 Marquez, P.V. and Walker, M. 2016. 21 Mnookin S., et al. 2016; Sorel, E.R., et al. 2005. 40 See Partners in Health Mental Health site: http://www.pih. org/priority-programs/mental-health. Cf. Partners In Health 22 Mnookin S., et al. 2016; Bolton, P., et al. 2002; Chung, R. and (PIH) 2016. Also see PIH Mental Health Planning Matrix Kagawa-Singer, M. 1993; De Jong, J., et al. 2001; De Jong, to Achieve UHC. Discussed in personal communication J., et al. 2003; Dubois, V., et al. 2004; Karam, E.G., et al. 2008; Mollica, R.F., et al. 1997; Mollica, R.F., et al. 2004; Pham, P.N, et 29 Mental Health Among Displaced People and Refugees with Giuseppe Raviola, MD, MPH, Director, Mental Health, Based on Partners In Health (PIH), Four Zeros Strategic Plan, 66 Partners In Health, October 21, 2016. analysis and references compiled by Alexandra Rose, MSc GMH. 41 Sorel, E. 2015. 67 Personal communication with Prof. Eliot Sorel, George 42 See International Medical Corps (IMC) 2015. Washington University School of Public Health, December 7, 2016. 43 Thornicrofts, G., et al. 2016. Layard, R., et al. 2007; Ngo, V., et al. (in press); Pemjean, A. 68 44 Quinn, N., et al. 2013. 2010; UK Department of Health 2012. 45 Sartorius, N. 2007. 69 Personal communication with Shekhar Saxena, Director, Department of Mental Health and Substance Abuse, and Sartorius, N. 2002; Sartorius, N. 2007; Magliano, L., et al. 46 Mark van Ommeren, Public Mental Health Adviser, WHO, 2004; Magliano, L., et al. 2011. November 11, 2016. Syrian conflict data from the Financial Times’s article ‘It felt like the last goodbye’, by Erika Solomon 47 Thornicrofts, G., et al. 2016. and Geoff Dyer, December 17, 2016, p.6. 48 Rahman, A., et al. 2016. 70 Chisholm, D., Sweeny, K., Sheehan, P., et al. 2016. 49 Chowdhary, Neerja; Anand, Arpita; Dimidjian, Sona; Shinde, 71 Duvergé, S. 2014. Sachin; Weobong, Benedict; Balaji, Madhumitha; Hollon, Steven D.; Rahman, Atif; Wilson, G. Terence; Verdeli, Helena; 72 WHO 2006. Araya, Ricardo; King, Michael; Jordans, Mark; Fairburn, Christopher; Kirkwood, Betty; Patel, Vikram 2016. 73 McGrath, M. and Schafer, A. 2014. 50 Mnookin S., et al. 2016. 74 Heudorf, U. 2016. 51 Inter-Agency Standing Committee (IASC) 2007. 75 WHO 2013b. 52 Druss, B., and Reisinger, E. 2011; Katon, W., et al. 2006; Marquez, P.V. 2016d. 76 O’Neil, A., et al. 2015; Patel, V., et al. 2013; Jamison, D. (in press). 77 Marquez, P.V. 2016a. 53 Verbeek, T., et al. 2015. Marquez, P.V., and Moreno-Dodson, B. 2016; Marquez, P.V. 78 2016b. 54 Kim, D.R., et al. 2013. 79 Marquez, P. V. 2015a. 55 Spinelli, M.G., Endicott J. 2003. 80 Marquez, P.V. 2016c. 56 Wachs, T.D, Black, M.M., Engle, P.L. 2009. 81 Marquez, P.V. 2016c. 57 Sikander, S., et al. 2015. Personal communication with Shekhar Saxena, Director, 82 58 Pachi ,A., Dionisios, B., Moussas, G., Tslebis 2013. Department of Mental Health and Substance Abuse and and Mark van Ommeren, Public Mental Health Adviser, WHO, 59 WHO 2003. 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