Mental health needs our attention

Mental health is neglected, in Canada and globally. As an area of high unmet need, mental health requires champions to illuminate its substantial burden and to make it more visible to policy-makers. This is why CMAJ has chosen mental health as one of four special areas of focus, alongside sepsis, health services and vulnerable populations.

The prevalence and burden of mental illness is high — 20% of Canadians will experience a period of mental illness — yet spending on mental health care as a percentage of total health spending remains woefully inadequate.1 A 2016 update of the Global Burden of Disease Study showed just how high the burden of mental and substance abuse disorders continues to be worldwide.2 Major depressive disorder and anxiety disorder ranked among the top 10 conditions accounting for years lived with disability in 2016. Seven mental illnesses are among the 30 most burdensome conditions. The economic burden of mental illness in Canada is estimated at a staggering $51 billion per year.3 Mental health and substance use disorders may begin early in life and a relapsing course is the norm, which helps to explain this high estimate that includes costs of health care, lost productivity and reduced health-related quality of life. Given that mental illness has such a large effect on society, the resources devoted to provision of mental health services are truly pitiful.

But services are not the only area of unmet need. Mental health lags behind physical health in research, too. The diagnosis of mental illness remains syndromic in an era of genetic- and molecular-level diagnosis for many physical illnesses. Case definitions for mental illnesses are clinical, and a lack of clear biomarkers hampers our ability to research mental illness well. Census data often do not include sufficient markers for mental health. Many mental and substance use disorders are more prevalent among those who are economically and socially disadvantaged through greater relative exposure to clusters of social and environmental risk factors. This is why interventions to prevent and treat mental illness must involve coordination between health and nonhealth sectors. However, research into complex, multisector interventions is difficult — to plan, to conduct and to fund.

In the decades since the first publication of the Global Burden of Disease Study, which highlighted burden of illness beyond mortality, mental health has received more attention. As countries battle greater burdens of noncommunicable diseases, many of which show high comorbidity with mental illness, we have begun to embrace the concept of “no health without mental health.” As a result, mental health advocacy has increased, and much work has been done to reduce stigma surrounding mental health and draw attention to the rights of people living with mental illness. The 2015 Sustainable Development Goals, by including mention of mental health in health-related goals, brought mental health to the global development agenda. Yet, there is still much to be done to level the playing field. Because research in mental illness lags, service and policy choices are limited and resources directed toward mental health remain inadequate.

Recent developments in genomics and functional magnetic resonance imaging have allowed us to begin to understand diseases of the brain more clearly. Neurobiology may give us useful insights into the causes of mental illness, which are still largely unknown. Epidemiologic studies have shed considerable light on individual- and population-level risk factors, and the interaction of personal and environmental factors that predispose susceptible individuals to develop a mental disorder at a particular time. For Canada to ensure a mentally healthy population, we will need even more innovative research to inform mental health sector planning and general government policy.

The most cost-effective treatment for any illness is to prevent its onset. Yet, our understanding of how to prevent mental illness is limited. To fill this gap, we will need studies of complex interventions that span several sectors — not just the health sector — informed by neurobiological and genomic research, and parallel evaluations of cost-effectiveness.

Knowledge translation is our business. Consistent with our mission to champion knowledge that matters, CMAJ is committed to supporting innovative knowledge generation in the area of mental health. Globally, this is an exciting time for mental health research. We encourage submissions of research, thoughtful analyses and clinical reviews in this important area of focus.