The latest issue of the open access Public Library of Science - Medicine journal includes a provocative article with a relatively staid title: "Achieving the Millennium Development Goals: Does Mental Health Play a Role?" The authors, J. Jaime Miranda (Wellcome Trust Research Training Fellow) and Vikram Patel (reader in International Mental Health, London School of Hygiene and Tropical Medicine), argue that the likelihood of successfully meeting the Millennium Development Goals is dramatically undercut by the lack of recognition of mental health as a factor in a number of development arenas. For the authors, by not addressing mental health, the MDGs miss an important aspect of sustainable community development.
Miranda and Patel assert that, in developing countries, mental-health-related conditions are among the the most important causes of sickness, disability and (in some age groups) premature mortality. Although this seems on its face a surprising claim (one might expect physical diseases to play the greatest role), they point out that mental health conditions contribute to the likelihood of seeking out care for physical illnesses, reduce the incidence of mothers breast-feeding their children (in turn reducing their overall physical health), and increase the likelihood of risky behavior that could lead to harm.
The authors tie mental health conditions to three of the Millennium Goals in particular: goal 1, the eradication of extreme poverty and hunger; goal 4, the reduction of child mortality; and goal 5, the improvement of maternal health. While the direct causal links from mental health to these conditions is often less clear than the authors claim, they do make a good case that there's a strong correlation between these issues and mental health. Claims that mental health issues exacerbate existing health and economic conditions are much better-supported (an argument that one of the authors, Vikram Patel, has written about for the World Health Organization).
Even if their analysis is occasionally shaky, their policy prescriptions are on-target:
Our prescription for global policy is to urge those involved with implementing and funding programs aimed at achieving the MDGs to take a broad and holistic approach to the targets. This approach would imply an explicit focus on strengthening basic health-care systems, for example, by strengthening the availability and skills of health workers, not only to deliver babies in hygienic circumstances but also to counsel mothers about stresses and provide effective psychological interventions. Another example of strengthening health-care systems is to ensure that while district health managers are sourcing antiretrovirals for people with HIV/AIDS, effective treatments for depression are also being made available for those who need them. [...]
...most important of all is to advocate effectively to challenge the nihilism of global health planners, regarding the role of mental health. ... Undoubtedly, stigma plays a key role in explaining the lack of acceptance of mental health as a legitimate health concern of people in developing countries. We must challenge this both through research evidence and through ensuring more opportunity for local voices from developing countries to acknowledge their needs and agendas.
Mental health issues, especially depression, are a touchy subject. When Alex wrote about "A World Without Depression" in May, the ensuing discussion was both extensive and heated. There is clearly a cultural component to how mental health issues are perceived and expressed, and it's important that specialists don't try to apply textbook Western expectations of behavior. Nonetheless, certain mental health-related issues -- such as suicide and alcohol abuse -- cut across social boundaries. Miranda and Patel are on their firmest ground when they argue that it's irresponsible for the Millennium Development Goals not to include at least a discussion of mental health characteristics and conditions. They don't claim that efforts to improve the emotional states of people trapped in poverty will in any way be sufficient to end that privation; what they do claim -- and what I think has some significant merit -- is that efforts to end poverty will not be as successful if they don't also include a recognition of the emotional aspects of life in extremely poor conditions.
The reason they wont include mental health is its never good to run a test where everyone fails with an f- .