MENTAL HEALTH IN LOW-INCOME COUNTRIES

By Jen Zhu
INTRODUCTION
Mental health disorders are a global issue, affecting every country, community, and age group. People with mental disorders die prematurely and experience disproportionately higher rates of disability. Mental health disorders frequently lead individuals and families into poverty, causing problems that extend beyond just health. The World Health Organization is calling upon its delegates to specifically address the issue of mental health in low-income developing countries. Many things can be done to improve mental health in these settings. Mental health disorders are often heavily stigmatized. 75% of people suffering from mental health disorders in low-income countries do not have access to treatment, and those who receive treatment experience poor quality of care. There is a lack of both health workers dealing with mental health and available basic medicines for mental disorders. Through your policymaking, you have the power to make a tremendous difference in many lives. Countries with low and lower middle incomes have most of the global burden, and because they have limited human and financial resources, a strategy that focuses on these countries has the potential for maximum impact (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.)

EXPLANATION OF THE PROBLEM

The World Bank defines low-income countries as $1,035 or less Gross National Income (GNI) per capita, which is the dollar value of a countrys final income in a year, divided by its population (The World Bank: How We Classify Countries.) Mental disorders is used to refer to a range of mental and behavioral disorders that fall within the International Statistical Classification of Diseases and Related Health Problems. These include disorders that cause a high burden of disease such as depression, bipolar affective disorder, schizophrenia, anxiety disorders, dementia, substance use disorders, intellectual disabilities, and developmental and behavioral disorders with onset usually occurring in childhood and adolescence, including autism (Comprehensive mental health action plan 20132020.) Mental health is fundamental to health. The World Health Organization Constitution defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Mental health and physical health are very interconnected and affect each other. Good 1

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mental health is necessary for a more complete state of wellness (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) Mental, neurological and substance use disorders are 13% of the total global burden of disease in the year 2004 (6), and about 30% of the total burden of non-communicable diseases is due to these disorders (8). Depression alone is 4.3% of the global burden of disease and is among the largest single causes of disability worldwide, particularly for women (Comprehensive mental health action plan 20132020.) Persons with major depression and schizophrenia have a 40% to 60% greater chance of dying prematurely than the general population, due to physical health problems that are often left unattended (such as cancers, cardiovascular diseases, diabetes and HIV infection) and suicide. Suicide is the second most common cause of death among young people worldwide (Comprehensive mental health action plan 20132020.) Between 76% and 85% of people with severe mental disorders in low-income and middle-income countries receive no treatment for their disorder (Comprehensive mental health action plan 20132020.) Only 11% of severe cases of mental disorder in China received any treatment in the previous 12 months. Among the people who received treatment for severe mental health disorders in Nigeria, only 10% received adequate treatment (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) low-income countries is a key barrier to public access to mental health care. Approximately one-third of all countries, and almost half of all African nations, do not have a comprehensive mental health care policy or plan. Out of the countries with mental health care policies, nearly 40% have not been revised since 1990, thereby failing to address recent developments in mental health care (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) 36% of people living in low-income countries are covered by mental health legislation, compared with 92% in high-income countries (Comprehensive mental health action plan 20132020.) One in four people need mental health care at some point in their lives (7), but one-third of the worlds population lives in countries that allocate less than 1% of their health budget to mental health, and 31% of countries have no specific public budget for mental health (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) The average spending for mental health care in low-income countries can be as low as $0.25 per person per year (WHO highlights global underinvestment in mental health care.) Governments often spend the majority of their scarce mental health resources on services that serve relatively few people. 70 percent of mental health spending is on psychiatric institutions. If more resources were spent at a primary care level, more people would be reached and at an early enough stage of the mental health care disorders to reduce the need for expensive hospital care (WHO highlights global underinvestment in mental health care.) Only 52% of low-income countries offer community-based mental health care programs, compared to 97% of highincome countries (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) The lack of prioritization for mental health has been reflected in national and international priorities. The United Nations

Lack of policy, plan, and legislation on mental health

Comprehensive mental health policies are essential for implementing and coordinating mental health services. The lack of a policy, plan, and legislation on mental health in many

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chose to exclude mental health from the Millennium Development Goals, which was very controversial with mental health advocates (Millennium Development Goals Report 2011.) continuous training of health workers so that their knowledge and skills remain up to date on recent developments in medicine (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.)

Lack of Mental Health Professionals Lack of Accessible Medications

There is unequal distribution of and few trained, available health workers in most countries with low and middle incomes (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) Half of the world's population lives in a country where there is an average of one or less psychiatrists to serve 200,000 people. Other mental health care providers trained in the use of psychosocial interventions are significantly scarcer (Comprehensive mental health action plan 20132020.) In many low-income countries, there is less than one mental health specialist per one million people (WHO highlights global underinvestment in mental health care.) The situation is even more severe for children and adolescents: most low- and middle-income countries have only one child psychiatrist for every one to four million people in 2005 (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) Additionally, mental health professionals are mostly located in urban areas (1), while more than three quarters of lowincome countries population live in rural areas. Very few services, including mental health human resources, reach these rural areas (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) The lack of health care professionals is further exacerbated by brain drain, the emigration of trained health care professionals to other countries that may offer higher salaries. For health care professionals who remain in low-income countries, there is a lack of infrastructure, facilities, and resources for Essential medicines that treat psychological disorders are significantly unavailable in low-income countries. According to the World Health Organization, approximately 20% of countries do not have at least one common antidepressant, one antipsychotic, and one antiepileptic medication available in primary care settings (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) Coupled with the lack of qualified health workers with the necessary authority to prescribe these medications (6), this results in severely restricted access to treatment for mental health disorders. High medication prices further make mental health care unaffordable and inaccessible (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.)

Social Stigma
Attitudes toward mental illness vary among individuals, families, ethnicities, cultures, and countries (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) In many low-income countries, a significant amount of stigma surrounds mental disorders, and mental health is not a topic that is frequently discussed. Mental illnesses are often seen as a source of shame (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) For example, Latino patients often viewed clinical diagnoses of mental health disorders as potentially very socially damaging, preferring to refer to their conditions very generally as nervios (Cultural

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Perspectives on Mental Health; Barriers to Mental Health Care.) Mentally ill individuals and their families often face social disapproval and devaluation. The diagnosis of a mental health disorder in a marriage commonly leads to marital separation and divorce (Stigma towards people with mental illness in developing countries in Asia.) Women in India often do not seek treatment for mental health because they fear the dishonor that having a mental health disorder would bring to their families and the possibility of greatly reduced marriage prospects (In India Stigma of Mental Illness Hinders Treatment.) People may also regard individuals with a mental disorder as dangerous and aggressive, which distances them further from others in society (Stigma towards people with mental illness in developing countries in Asia.) Some stigma derives from misunderstandings of the causes of mental illnesses or misperceptions that mental illnesses are contagious or associated with HIV/AIDS (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) Stigma surrounding mental health can negatively affect patients readiness and willingness to seek and adhere to medical treatment (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) Additionally, stigma negatively affects major funding to mental health. Because mental health is so highly stigmatized worldwide, the major funders of global health initiatives have not traditionally made mental health a significant priority (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) with depression will report his or her physical symptoms, such as headache, and be treated for those physical symptoms but not for his or her depression (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.)

Cultural Explanations
Cultural and religious teachings shape attitudes toward individuals with mental disorders and also influence beliefs about the origins and nature of mental illness. Common cultural explanations for mental illness are supernatural, religious, and magical (Stigma towards people with mental illness in developing countries in Asia.) In eastern Uganda, for instance, many illnesses are attributed to witchcraft, curses, or sorcery done by living or dead individuals who felt wronged by the afflicted individual. In India, the powerful Hindu deity, an incarnation of Shiva, has the ability to purge evil spirits. As a result, many worshippers travel for significant lengths of time, sometimes by foot, to arrive at temples associated with this deity and seek treatment for their mental illnesses. Faith healers and temple doctors are by far the most socially acceptable way to try to cure mental illness in India (In India Stigma of Mental Illness Hinders Treatment.)

Human Rights Violations

Because of stigmatization and discrimination, persons with mental disorders frequently have their human rights violated. They are denied economic, social, and cultural rights. They are limited on their right to work and education, their right to reproduce, and especially their right to the highest quality of health. People with mental health conditions also are denied civil and political rights: the right to marry and have a family, personal liberty, the right to vote, the right to exercise their legal capacity on issues pertaining to them

Misdiagnosis
Because mental disorders are stigmatized and subsequently socially disadvantageous, the somatization of psychiatric disorders is widespread. For example, a patient

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such as their treatment and care, and the right to participate effectively and fully in public life. Health facilities in low-income countries have engaged in various human rights violations, such as unhygienic and inhuman living conditions, physical and sexual abuse, neglect, and harmful and degrading treatment practices. Even outside of mental health facilities, people with mental disorders often are excluded and marginalized from society and live in very vulnerable situations. In the context of traditional medicine, abuses of human rights are common as well. An example of this was the 2001 incident in Erwaddi, South India in which several people with mental health conditions burned to death because they were chained to their beds and unable to escape the fire that engulfed their healing temple (Mental health in low- and middle-income countries.) 22% of countries do not have laws that offer legal protection of the human and civil rights of people with mental illnesses (Cultural Perspectives on Mental Health; Barriers to Mental Health Care.) 2011 and 2030 (Comprehensive mental health action plan 20132020.)

People Particularly at Risk

Certain groups of people are at a significantly higher risk of experiencing mental health problems. These vulnerable groups include the poor, minority and indigenous groups, lesbian, gay, bisexual, and transgender individuals, people experiencing discrimination and human rights violations, infants and children subjected to abuse and neglect, adolescents exposed to substance use, people exposed to conflict, natural disasters, or other humanitarian emergencies, prisoners, and people with chronic health conditions. Poor mental health is strongly influenced by various social and economic determinants. Low socioeconomic status, alcohol use, and stress are some of the many risk factors common to mental disorders (Comprehensive mental health action plan 20132020.) Poverty and its associated psychosocial stressors (e.g. violence, unemployment, social exclusion, and insecurity) are especially associated with mental health problems. This extends beyond absolute poverty: relative poverty, low education, and inequality within communities are correlated with increased risk of poor mental health (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) Exposure to adversity at a young age is an established preventable risk factor for mental disorders (Comprehensive mental health action plan 20132020.)

Economic Consequences
Mental health conditions frequently lead individuals and families into poverty (Comprehensive mental health action plan 20132020.). Poor mental health and poverty interact in a perpetuating cycle: poor mental health impedes peoples ability to learn and to be a productive member of their economy, and poverty increases the risk of developing mental health disorders as well as restricts peoples ability to access health care (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.). The economic consequences of mental health disorders are tremendous: a recent study estimated that the cumulative global impact of mental disorders in terms of lost economic output will equal US$16.3 million between

WORLD HEALTH ORGANIZATION ACTIONS

Mental Health Gap Action Programme (mhGAP)

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World Health Organization launched the Mental Health Gap Action Programme (mhGAP) in 2008 to help countries scale up their services for mental, neurological, and substance disorders. The program strengthens capacity of the countries health care systems by providing knowledge and skills to primary health care providersranging from general doctors to nursesto identify and manage the disorders (WHO highlights global underinvestment in mental health care.) Ethiopia, Nigeria, and Panama have started to train their primary health care personnel to identify and treat priority mental disorders (WHO highlights global underinvestment in mental health care.) An epilepsy project in rural China has successfully delivered services through existing local primary care health systems. Town clinic physicians and rural doctors were given basic training and were able to administer anticonvulsant to epilepsy patients. With the success of the initial study, the government extended the epilepsy project to 34 counties in China with 19 million people, training 1500 local physicians, and treating more than 10,000 people with epilepsy (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) Large, developing countries like Brazil, India, and Thailand are planning to make rapid advancements by scaling up care through their national health programs (WHO highlights global underinvestment in mental health care.) and communication material and provides technical assistance for advocacy campaigns in countries (World Mental Health Day.)

QualityRights Project
The World Health Organization QualityRights Project works to improve the service quality and human rights conditions in mental health and social care facilities and to empower organizations to advocate for the rights of persons with mental and psychosocial disabilities. The QualityRights Project aims to develop a movement of people with mental disabilities to provide mutual support, advocate, and influence policy-making processes and to reform national policies and legislation (WHO QualityRights Project addressing a hidden emergency.)

Project Atlas
In Project Atlas, the World Health Organizaitons Department of Mental Health and Substance Abuse collects, compiles, and disseminates data on mental health and neurology resources in the world. These resources include policies, programs and best practices, financing, services, professionals, treatment and medicines, information systems and related organizations. The primary aim of the project is to raise public and professional awareness of the inadequacies of existing resources and services and the large inequities in their distribution at the national and global level. Project Atlas provides information that facilitates and encourages the enhancement of resources. It allows for easy access to global, regional, and country data and comparisons of countries and regions (Project Atlas: Resources for Mental Health.) However, routine information systems for mental health in most low-income countries are lacking or nonexistent, which makes it

World Mental Health Day

Every year, October 10 is World Mental Health Day, an initiative that the World Health Organization supports through raising awareness on mental health issues. The World Health Organization raises awareness by mobilizing its strong relationships with Ministries of Health and civil society organizations around the world. The World Health Organization also develops technical
th

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difficult to understand and address the needs of local populations (7.) The International Federation of Red Cross is the worlds largest humanitarian network that works to meet the needs and improve the lives of vulnerable people before, during, and after disasters and health emergencies. Its health activities include emergency response, addressing stigma, programs in health promotion and prevention, providing psychosocial care, and community empowerment (20. International Federation of Red Cross and Red Crescent Societies.) Red Cross recognize mental health as a state of wellbeing and works in collaboration with government, service providers, and communities to improve mental health, remove the stigma around mental health issues, and promote participation of people with mental health conditions in the community. The American Red Cross officially recognized the need for disaster mental health services beginning in 1989 and developed the Red Cross Disaster Mental Health Services Program to treat disaster victims with a multidisciplinary team of mental health professionals (The American Red Cross disaster mental health services: development of a cooperative, single function, multidisciplinary service model.)

INTEREST GROUPS
International Medical Corps
International Medical Corps is one of the few international relief organizations that make mental health a priority, particularly focusing on addressing the mental needs of communities hit by disaster and identifying and treating people with pre-existing mental health disorders. Its comprehensive mental health care initiatives recently include the launch of a large-scale, regional initiative that will bring mental health and psychosocial support to Iraqi refugees in Lebanon, Jordan, and Syria and train medical professionals to handle the increased demands for mental health and psychosocial services, and the completion of a pilot study in northern Uganda and a Somali refugee camp in Ethiopia that exhibited faster recovery in malnourished children through a program that integrated feeding programs, improvement of maternal mental health, and improved mother-child interaction (Mental Health.)

Amnesty International
Amnesty International is an organization that works in over 150 countries and territories to campaign for the end of serious human rights abuses. Amnesty International regards mental health as a human rights issue. Its current priorities include driving the reform of mental health services, challenging mental health prejudice and discrimination, and advocating for children and young peoples right to mental health (Amnesty International: Who We Are.)

Doctors Without Borders

Doctors Without Borders, otherwise known as Mdecins Sans Frontires, is an international medical humanitarian organization that provides emergency medical care to people in wars, famines, epidemics, natural disasters, and other crises in more than 60 countries. The organization realized on the killing fields of Bosnia in the 1990s that it was essential to address the psychological and emotional needs of people caught in conflict. Doctors Without Borders has conducted mental health interventions in more than 40 countries since the Bosnian War, along with interventions Doctors Without Borders launched before the war in the Gaza Strip,

Red Cross

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Uganda, and India. Interventions include the establishment of counseling centers, training of local counselors to build the communitys capacity to deal with ongoing conflict, radio programs for psychological education, walk-in clinics, home-based care, and group therapy (Doctors Without Borders: Mental Health.) of Persons with Mental Illness and for the Improvement of Mental Health Care.)

POSSIBLE SOLUTIONS
In determining solutions to improve mental health in low-income countries, you may consider community-based solutions, a comprehensive approach integrating mental health and social services, empowerment of people with mental disabilities, fostering a culture more accepting of mental health disorders, and improved treatment. There are many more possible solutions that you may think of, including solutions that address some of the various problems that low-income countries currently face regarding mental health. You must think about what can be achieved with the available funds and may find that you need to prioritize the most urgent areas for action.

United Nations
The United Nations is an international organization founded to maintain international peace and security, develop friendly relations among nations and promote social progress, and better living standards and human rights (UN at a Glance.) It has recently begun to regard mental health as an essential part of development. The United Nations faced criticism for omitting mental health in its Millennium Development Goals, which have been referred to as the most politically important pact ever made for international development. Mental health advocates worldwide claim that the omission of mental health from the Millennium Development Goals has negatively affected mental health as a global health issue (Mental Health Not Getting Enough Attention from UN.) The United Nations now acknowledges that mental health is one of the most neglected development issues in achieving the Millennium Development Goals (MDGs.) The United Nations Department of Economic and Social Affairs collaborated with the World Health Organization in a policy analysis document titled: Mental Health and Development: Integrating Mental Health into All Development Efforts including MDGs (Mental Health and Development.) The United Nations also supports World Mental Health Day to raise awareness about mental health issues worldwide and published the United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care in 1991 (United Nations Principles for the Protection

Human Resource Development

By introducing mental health into undergraduate and graduate curricula in lowincome countries and training and mentoring health workers in the field, particularly in nonspecialized settings, you can build the knowledge and skills of general and specialized health workers to deliver evidence-based, culturally appropriate and human rightsoriented mental health care. Health care workers would also be better equipped to identify people with mental disorders, offer appropriate treatment and support, and refer individuals to higher levels of care if necessary (Comprehensive mental health action plan 20132020.) Where doctors and nurses are in short supply, community health workers can be trained to deliver mental health care. Community-based mental services include outreach services, home care and support, emergency care, community-based

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rehabilitation and supported housing. Family members and caregivers of people with mental health conditions can be better engaged as peer support workers (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.) designing, planning and implementing policies, laws and services can result in more effective policies surrounding mental health (Comprehensive mental health action plan 20132020.) Rights advocacy will also greatly help people with mental health conditions to lead lives of a much higher quality. These rights include the rights of people with mental disorders to receive government disability benefits, gain access to housing and livelihood programs, and to participate in work and community life and civic affairs.

Integration of Mental Health Care into Other Services

Mental health care can be incorporated into existing and prevalent general health care services such as maternal, sexual, reproductive and child health, HIV/AIDS and chronic noncommunicable disease programs. Because mental health, like other aspects of health, is affected by socioeconomic factors such as poverty, an integrated approach that addresses mental health through comprehensive strategies for promotion, prevention, treatment and recovery will take into consideration other relevant factors to ensuring good mental health. An example of this is nonprofit organization Partners in Health paying for transport for patients because they realized the cost of transport to their clinics was keeping patients from attending appointments and adhering to their treatment plans. Community and economic development programs that work to reduce poverty, empower women and help them obtain economic independence, reduce malnutrition, increase literacy and education, and empower the underprivileged contribute to the prevention of mental and substance use disorders and promote mental health (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.)

Federal Laws
If enforced, federal laws improving rights and opportunities significantly ensure human rights of people with mental disabilities. Federal laws can also include antidiscrimination laws and address and prevent human right violations associated with mental disorders.

Information Campaigns
Information campaigns encompass antistigma campaigns, cultural campaigns, and psychological education campaigns. They can raise awareness of issues, help people better manage their mental health, and combat misperceptions and discrimination. Campaigns can be TV, radio, online, mobile, press, and grass-roots community engagement activities.

Partnerships
International, regional, and national partnerships can supplement available resources. These partners include 1) international, regional, and sub-regional development agencies such as the World Bank and United Nations; 2) academic and research institutions such as the network of World Health Organization collaborating centers; 3)

Empowerment of People with Mental Health Conditions

Giving people with mental disorders a formal role and authority in the process of

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civic organizations of people with mental disorders and disabilities and family members; 4) mental health nongovernmental organizations, community-based organizations, human rights-based organizations, and faithbased organizations; 5) associations of health care professionals and service providers. These organizations can provide technical support on the planning and implementation of best practices for promoting mental health, reducing stigma and discrimination, promoting human rights, and preventing mental disorders. They can provide research for mental health and strengthen information systems. These partners represent a variety of perspectives. The needs and capacity of different partners and the government will vary country to country, so specific country-based assessments is necessary to better understand the current situation and the best roles and actions for key stakeholder groups (Comprehensive mental health action plan 20132020.)
me to have a stake in implementation, I may not value it the way you value it. .. so I think the stakeholders should be involved at all levels of policy; formulation, implementation, evaluation. (SSI, a health manager at district level, Uganda country report, 2008)

Financing
How will policy implementation be financed? Will you allocate additional resources to mental health, and if so, what will be the source of the additional funds? Should low and middle-income countries to demonstrate their commitment to mental health through financing policies for their own country, or is it the responsibility of countries or international organizations with more funds to help finance this? (Resources for delivery of services for these disorders can be mobilized from various sources by attempts to increase the proportion allocated to these conditions in national health budgets; by reallocation of funds from other activities; and from external funding, such as that provided through developmental aid, bilateral and multilateral agencies, and foundations (Mental Health Gap Action Programme: Scaling up care for mental, neurological, and substance use disorders.)

QUESTIONS FOR POLICYMAKERS

Stakeholder Involvement
Who are the relevant stakeholders from both inside and outside the health sector (i.e. mental health service users, welfare, religious sectors, family organizations, social services)? You should identify them and think about how to involve these stakeholders during the policy development. Extensive consultation with stakeholders will facilitate a more complete understanding of the complexities surrounding mental health, which will help you construct a more effective policy. It will also cause all stakeholders required for successful implementation of the policy to be much more invested in your policy and its outcomes.
if I dont have a stake in the development of the policy, and you want

GUIDE TO FURTHER RESEARCH

It is encouraged that policymakers review the resources listed in the bibliography of this briefing to become more knowledgeable on the topic of mental health in low-income countries, but there are also additional resources you can use to research. There are many ways to improve mental health in low-income settings. Researching the costs and benefits of various methods of improving mental health will allow legislators to better understand the situation and to draw upon different ideas and different models to compile an ideal solution.

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http://www.bmj.com/content/329/7475/1138 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 2948731/ http://www.who.int/mediacentre/news/notes/20 07/np25/en/index.html http://in2mentalhealth.com/2011/04/21/canelearning-boost-the-mental-health-capacity-inlow-income-countries/ http://www.uniteforsight.org/mentalhealth/module8 It is also important to have a more complete understanding of the barriers to mental health in developing countries in order to arrive at more effective solutions. http://www.thelancet.com/journals/lancet/article /PIIS0140-6736(07)61263-X/abstract http://www.who.int/bulletin/volumes/89/3/10082784/en/index.html http://apps.who.int/globalatlas/default.asp http://www.uniteforsight.org/mentalhealth/module6 It could be additionally helpful to gather more information on the intricacies and options of financing mental health policy changes in countries with limited resources. http://heapol.oxfordjournals.org/content/21/3/1 71.abstract http://www.icmpe.org/test1/journal/issues/v6pdf /6-145_text.pdf World Health Organization cannot wait to learn of your solutions.

GLOSSARY
evidence-based - rooted in scientific evidence and/or best practice, taking culture into account human rights - inalienable fundamental rights to which a person is inherently entitled simply because she or he is a human being mental health - a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community Millennium Development Goals - eight goals agreed to by all the worlds countries and all the worlds leading development institutions that mobilize efforts to meet the needs of the worlds poorest by the target date of 2015 Service user - anyone who is a patient or other user of health and/or social services Somatization the experience and communication of psychological distress in the form of physical bodily symptoms and to seek medical help for them Stakeholder - a person, group, organization, member or system who affects or can be affected by an organization's actions Stigma - devaluing, disgracing, and disfavoring by the general public Treatment Gap - percentage of individuals who need mental health care but do not receive treatment

CONCLUSION
The focus of the debate is which solution or solutions you will prioritize. You must think about what realistically can be achieved and how, while aiming to make the biggest possible impact that you can. Be specific in describing your objectives and how those objectives will be achieved, and explain which measurable results will be used to determine success of your initiative. Negotiations must be made, compromises must be proposed, and skillful policymakers must step to the challengethe

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Vulnerable groups - individuals or groups of individuals who are made vulnerable by the situations and environments that they are exposed to (as opposed to any inherent weakness or lack of capacity) http://www.theworld.org/2011/09/mentalhealth-not-getting-enough-attention-from-un/ 3 July 2013. United Nations. Mental Health and Development. <http://www.un.org/disabilities/default.asp?id=1 545> 1 July 2013. United Nations. Millennium Development Goals Report 2011. New York: United Nations, 2011. < http://www.un.org/millenniumgoals/11_MDG% 20Report_EN.pdf>18 Oct 2011 United Nations. UN at a Glance. <http://www.un.org/en/aboutun/index.shtml> 2 July 2013. United Nations General Assembly. United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care. 17 December 1991. <http://www.health.wa.gov.au/mhareview/report s/synthesis/15%20MHA%20Synthesis%20%20%20Appendices%201.pdf> 1 July 2013. Unite for Sight. Cultural Perspectives on Mental Health; Barriers to Mental Health Care. <http://www.uniteforsight.org/mentalhealth/module6> 1 July 2013. Weaver JD, Dingman RL, Morgan J, Hong BA, North CS. The American Red Cross disaster mental health services: development of a cooperative, single function, multidisciplinary service model. Aug 2000. <http://www.ncbi.nlm.nih.gov/pubmed/109324 44> 2 July 2013. World Bank. How We Classify Countries. <http://data.worldbank.org/about/countryclassifications> 5 July 2013. World Health Organization. Mental Health Gap Action Programme: Scaling up care for

BIBLIOGRAPHY
Amnesty International. Amnesty International: Who We Are. <http://www.amnesty.org/en/who-we-are> 3 July 2013. Doctors Without Borders. Doctors Without Borders: Mental Health. <https://www.doctorswithoutborders.org/news/is sue.cfm?id=2399&cat=issue-page> 2 July 2013. International Federation of Red Cross and Red Crescent Societies. <http://www.ifrc.org/> 4 July 2013. International Medical Corps. Mental Health. <https://internationalmedicalcorps.org/mentalh ealth> 3 July 2013. Kennedy, Miranda. In India Stigma of Mental Illness Hinders Treatment National Public Radio. 11 Aug 2011. < http://www.npr.org/templates/story/story.php? storyId=129091680 > 16 Oct 2011 Lauber, C. Rossler, W. Stigma towards people with mental illness in developing countries in Asia. Apr 2007. <http://www.ncbi.nlm.nih.gov/pubmed/174647 93> 2 July 2013. Patel, Vikram. Mental health in low- and middle-income countries. 14 Mar 2007. <http://bmb.oxfordjournals.org/content/8182/1/81.full> 3 July 2013. The World. Mental Health Not Getting Enough Attention from UN. 19 Sept 2011.

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mental, neurological, and substance use disorders. 2008. <http://whqlibdoc.who.int/publications/2008/97 89241596206_eng.pdf> 2 July 2013. World Health Organization. Project Atlas: Resources for Mental Health. <http://www.who.int/mental_health/evidence/atl as/en/> 1 July 2013. World Health Organization. WHO highlights global underinvestment in mental health care. Geneva. <http://www.who.int/mediacentre/news/notes/2 011/mental_health_20111007/en/index.html> 11 Oct 2011. World Health Organization. WHO QualityRights Project addressing a hidden emergency. <http://www.who.int/mental_health/policy/quali ty_rights/en/index.html> 2 July 2013. World Health Organization. World Mental Health Day. <http://www.who.int/mental_health/world_ment al_health_day/en/index.html> 1 July 2013. World Health Organization Executive Board. Comprehensive mental health action plan 2013-2020. 27 May 2013. <http://apps.who.int/gb/ebwha/pdf_files/WHA 66/A66_R8-en.pdf> 3 July 2013.

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