Social Science Series #5: Mental health in developed vs developing countries

A person’s health includes both physical and mental wellbeing and they can impact one another. There has been increasing acknowledgment of the importance mental health plays in a healthy and happy life. Within mental wellbeing, depression is one of the leading causes of disability. Furthermore, suicide is the second leading cause of death between 15- and 30-year-olds. Mental health conditions can have a substantial effect on all areas of life, such as school, work performance, relationships with family and friends as well as the ability to participate in the community. In 2021, mental health disorders have been found to affect 13% of the world’s population and therefore it is imperative to understand and appropriately treat mental disorders.

Source: Mental health Atlas; Department of mental health organization.

Developed countries vs developing countries

Mental health problems are found in almost every country. However, reports suggest that perception and availability of treatments are varied in different regions, particularly between developed and developing countries.

A developed country is characterized to have a high quality of life, a well-to-do economy, and advanced technological infrastructure. Currently, 148 countries are classified as developed with the United States and the United Kingdom being the most developed countries in the world with a ranking higher than 0.9 in the Human Development Index. Characteristics of a developed country include:

  • Guaranteed security guaranteed health
  • Low unemployment rate
  • High level of science and technology
  • The level of exports is higher than imports

A developing country is characterized by widespread chronic poverty and has poor economic development compared to other nations. There are 47 countries classified as a developing country with South Sudan and Chad ranking less than 0.4 in the Human Development Index. Characteristics of a developing country include:

  • Not guaranteed security
  • Minimal health facilities
  • Uncontrolled population development
  • High unemployment rate
  • Imports are higher than exports

Attitudes/perceptions toward mental illness vary among individuals, families, ethnicities, cultures, and countries. Cultural and religious teachings often influence beliefs about the origins and nature of mental illness and shape attitudes towards mental health.

Source: Data sources, country classification and aggregation methodology, United Nations.

Perception of mental health in developed countries

Firstly, richer countries have higher rates of mental health issues compared to poorer countries. For example, Australia and New Zealand, both identified as high-income countries, had the highest lifetime prevalence rates of anxiety — 8% and 7.9%, respectively. Nigeria (0.1%) and Shenzhen, China (0.2%), had the lowest rates reported; both were categorized as low-income areas.

A study conducted in England and Wales (developed countries) found that:

  • Men and women alike with general mental health problems went up by 20% between 1993 to 2014.
  • The percentage of people reporting severe mental health symptoms has risen from 7% in 1993 to over 9% in 2014.
  • People reporting self-harm went up by 62% between the years 2000–2014 (which means reported self-harm more than doubled).
  • People reporting having had suicidal thoughts went up by 30% between the years 2000–2014.

Source: What are mental health problems, Minds in Wales.

Other than the fact these statistics are concerning, the number of people reporting their mental health struggles also suggests that openly talking about and seeking help regarding mental health has become less stigmatized and taboo in developed countries.

One of the main problems faced by people with mental health problems even in rich countries is discrimination. The report demonstrates the varying levels of acceptance of those with mental health problems and that widespread perceptions of prejudice still exist. For example, only around 5 in 10 people say they would be willing to socialize with someone with schizophrenia.

However, in wealthier countries, there have been mental health campaigns to educate the public and diminish misinformation regarding mental health, and therefore reduce stigma. Social media platforms and celebrities opening up about their own mental health struggles have also helped to shift negative perceptions regarding mental disorders.

Source: Global mental health: a new global health field comes of age, JAMA, 2010.

Perception of mental health in developing countries

Public knowledge about mental disorders as medical conditions and their evidence-based treatment strategies in developing countries, are generally poorly or inaccurately understood.

In Asia, where many cultures value “conformity to norms, emotional self-control, and family recognition through achievement”, mental illnesses are often stigmatized and seen as a source of shame. The negative perception of mental illness can be influenced by other factors, such as the perceived cause of the illness. 

China is considered a developing country although this country has one of the world’s largest economies today. This is because there is a huge income gap, widespread poverty, and a slower urbanization rate than that of developed countries.

In a 2003 study, Chinese Americans and European Americans were presented with a vignette in which an individual was diagnosed with schizophrenia or a major depressive disorder. Participants were then told that experts had concluded that the individual’s illness was “genetic”, “partly genetic” or “not genetic” in origin, and participants were asked to rate how they would feel if one of their children dated, married or reproduced with the subject of the vignette. Genetic attribution of mental illness significantly reduced unwillingness to marry and reproduce among Chinese Americans, but it increased the same measures among European Americans supporting previous findings that developing countries have a negative perception of mental illness.

There are also negative attitudes towards health care professionals in Africa (developing country) noting that stigma, religious beliefs, distrust of the medical profession, and communication barriers may contribute to African individual’s wariness of mental health services. Approximately 63% of Africans viewed depression as a “personal weakness”, 30% reported that they would deal with depression themselves, and only one-third reported that they would accept medication for depression if prescribed by a medical professional.

Although the reasons for stigmatization are not consistent across communities or cultures, perceived stigma by individuals living with mental illness is reported internationally. For instance, the World Mental Health Surveys showed that stigma was closely associated with anxiety and mood disorders among adults reporting significant disability. The survey data, which included responses from 16 countries in the Americas, Europe, the Middle East, Africa, Asia, and the South Pacific, showed that 22.1% of participants from developing countries and 11.7% of participants from developed countries experienced embarrassment and discrimination due to their mental illness. Notably, these figures likely underestimate the extent of the stigma associated with mental illness since they only evaluated data on anxiety and mood disorders.

Finally, presenting mental health care services in culturally sensitive ways may be essential to increasing access to and usage of mental health care services, as local beliefs about mental health often differ from the Western biomedical perspective on mental illness. For example, one study comparing Indian and American attitudes toward mental illness surveyed students at a university in the Himalayan region of Northern India and at a university in the Rocky Mountain region of the United States. The Indian students were more likely to view depression as arising from personally controllable causes (e.g. failure to achieve goals) and to “endorse social support and spiritual reflection or relaxation” as ways to deal with depression. This highlights that treatment plans in varied countries for mental disorders should take into account diverse perspectives on mental illness in order to maximize the effectiveness of mental health care delivery programs.

Source: Indigenous perspectives on depression in rural regions of India and the United States, Transcultural Psychiatry, 2011; World Health Organization; Major depressive disorder in the African American population, J Natl Med Assoc, 2011.

A health system is a way in which all health services are provided. From how they are financed, to the workforce, facilities, and supplies available, a strong health system will ensure that everyone is able to access high-quality healthcare without financial difficulty. In developing countries, health systems for providing mental health services are underfunded and overstretched. In contrast, developed countries provide extensive mental health services, such as England, which provides free health care, making it easily accessible to all.

Source:  Poverty and access to health care in developing countries, Ann N Y Acad Sci, 2008.

Mental healthcare is 50 times more accessible in developed countries compared to developing countries. High-income countries have on average nearly 20 times more beds available to treat mental health patients than low-income countries. The Mental Health Atlas report 2020 of the World Health Organization (WHO) showed that mental health treatment in wealthy countries averaged 62.2 mental health workers for every 100,000 people. This may be due to the fact that mental health is less taboo in wealthier countries that people perceive jobs catering to mental health issues as being valid, and therefore more people are studying to become psychiatrists, psychologists, and counsellors.

Additionally, government expenditure on mental health is more than $50 per capita in high-income countries whereas low and lower middle-income countries spend less than $1. The investment in mental health also offers opportunities for return on investment for individuals, families, and communities as individuals can return to meaningful work. Some of the strategies established by high-income countries include paying general practitioners to deliver mental health services and hire mental health staff; usage of telehealth platforms to assess and treat mild-to-moderate symptoms virtually; deploying community health workers to screen people and help them navigate the health system processes; as well as creating and strengthening the non-profit organizations to address mental health symptoms and diagnosis.

Source: Mental Health Atlas, World Health Organization, 2020; The Commonwealth Fund.

In developing countries, government health expenditure that goes to mental health is less than 2%. Nearly 1 in every 10 people has a mental health disorder, but just 1% of the global health workforce is working as psychiatrists, occupational therapists, or social workers. On average, the world’s poorest countries have less than 1 mental health worker for every 100,000 people.  Funding and resources allocated to mental health are almost non-existent in many health systems around the world; 80% of people with mental health problems live in low and middle-income countries, where fewer than 1 in 5 get any treatment. When mental health services do exist, they are often not adequate or appropriate. They are rarely integrated well with other health services, and the stigma attached to mental health issues prevents many people from seeking and accessing services. It is a silent epidemic, and those suffering are often not in a position to demand action.

A weak mental health system can mean that:

  • Mental healthcare facilities do not exist where they are most needed. This is especially true in rural and remote areas where the distance to travel to a facility – or the cost to do so – is too much.
  • Mental health facilities that do exist are understaffed and under-resourced. This means they are unable to provide high-quality culturally appropriate healthcare or vital services such as those for mental health.
  • Poor quality mental health services give rise to mistrust and suspicion, which deter people from seeking healthcare when it is needed.
  • Mental health service users are charged a fee for seeking healthcare to fill the funding gap. This pushes many people into poverty or again deters people from seeking healthcare when it is needed.

Source: World Health Organization.

Improving mental health in developing countries

For the improvement of mental health in developing countries, it is necessary for national governments to work with international organizations to support them. Many innovative projects in the mental health sector are funded by organizations such as the World Federation for Mental Health, the World Health Organization, Grand Challenges Canada, the Pan American Health Organization, the Columbia University Global Mental Health Program based in New York, among others. Some of the developing countries in which these pioneering projects have been established are:

  1. Pakistan: the Family Networks for Kids project, shifts tasks from health workers to relatives, neighbors; creates strong networks of new recruits that care for youths with behavioral difficulties.
  2. Kenya: an innovative model enlists African traditional healers, faith healers, and community health workers to help detect mental illness.
  3. Zimbabwe: the Friendship Bench project creates a safe space and a sense of belonging in communities, to enhance mental wellbeing and improve people’s’ quality of life.

Another strategy that can improve mental health in developing countries is the World Health Organization Quality Rights Toolkit, which provides countries with practical information and tools that helps assessing and improving quality and human rights standards in mental health and social care facilities. It provides practical guidance on:

  • Human rights and quality standards that should be respected, protected and fulfilled in both inpatient and outpatient mental health and social care facilities;
  • Preparing for and conducting a comprehensive assessment of facilities; and
  • Reporting findings and making appropriate recommendations on the basis of the assessment.

Any of the actions to promote, protect and restore mental health must include: better information, awareness and education about mental health and illness; improved health and social services for persons with mental disorders; and enhanced legal, social and financial protection for persons, families or communities adversely affected by mental disorders.

Source: Nations for Mental Health-WHO; World Federation for Mental Health; World Health Organization.

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