Mental health, largely ignored in the past, today constitutes one of the most important public health issues worldwide.
This change is mainly due to the evidence accumulated in the last 20 years on the high prevalence of mental illnesses and the impact they have in various areas of people's lives, families and society. Thanks to advances in psychiatric epidemiology, we know today, for example, that, every year, 23% of Portuguese suffer from a mental disorder, and that these disorders not only cause enormous individual suffering, but are associated with high levels of disability in activities of daily living, work and relationships with others, and are responsible for economic costs for society of enormous magnitude.
The Global Burden of Disease Study (WHO), carried out by WHO, the World Bank and Harvard University, played a decisive role in this field, as it developed new concepts and methods that enabled it to measure impact of mental disorders on society, not only through the effects of disease on mortality, but also on the level of disability associated with them.
It was these new methods of analysis that made it possible to know that, worldwide, mental illnesses are responsible for 13% of all years of life lost due to premature death or serious disability due to any disease, and that cause more years of life with disability (32,4%) than any other type of illness.
This impact is further amplified by the fact that people with mental illnesses are at a greater risk of suffering from physical health problems, thus contributing through this co-morbidity to increased levels of mortality and disability. And because many people, although not suffering from a mental illness, have milder mental health problems (usually symptoms of anxiety and depression associated with life difficulties), which cause them suffering and interfere with their ability to relate to others, in their productivity and creativity.
For all these reasons, mental health is, in fact, a primary health issue. But its impact goes far beyond health, because, as we know today, it is also a fundamental factor for the sustainable development of societies.
Mental health: an essential issue for sustainable development
Although explicitly mentioned in Objective 3 (Good health and well-being), mental health is relevant to all Sustainable Development Goals.
One of the main reasons for this relevance has to do with the close relationship between mental illness and poverty.
It is a circular relationship that is self-perpetuating. Lower levels of income, education, housing and social support increase the risk of suffering from a mental illness. But, at the same time, the occurrence of mental illness leads to a cascade of events that ends up aggravating poverty and other socioeconomic variables associated with it.
The literature shows that the evidence for this association is very robust, particularly with regard to the association with low social and economic status, low education, unemployment, financial concerns, social isolation and deteriorated housing.
A similar phenomenon occurs with social capital. Societies with higher levels of civic participation and reciprocity rules that facilitate cooperation for mutual benefit protect people from the risk of suffering from mental illness, either through its structural components (social cohesion, belonging to organizations) or through its components cognitive (confidence, feeling of belonging, sharing values). At the same time, a high prevalence of mental illness can have a negative impact on social capital, thus compromising economic development and its sustainability.
Another reason that explains the importance of mental health for sustainable development has to do with the enormous costs that mental illness entails for the economy.
An estimate of the costs of mental illness for the world economy between 2011 and 2030 points to a cost of $ 16 trillion - more than the combined costs of cancer, diabetes and respiratory diseases.
A 2012 European study on the costs of mental illness estimated, for Portugal, a total annual cost of 7.615 million euros, with 37% of this amount (2.818 million) related to direct costs associated with healthcare, 23% (1.752 million) ) related to direct non-medical costs and 40% (3.046 million) resulting from indirect costs.
An important part of the indirect costs derives from the high impact that mental illnesses have on the country's productivity, as a result of absenteeism and presentism that result from the especially significant association of mental illnesses with disability. According to the results of the National Mental Health Study, people who suffer from any mental disorder in our country missed work in the previous year, 22,5 days on average, because of their mental disorder, estimating themselves although the partial disability resulting from mental disorders is responsible, in countries with the level of development of Portugal, for about 23 days / year of presentism.
In conclusion, the existence of very close links between mental health and most of the key development issues - from economic growth to education, through inequalities, work and climate change - is now widely proven. However, people suffering from mental illness are among those most likely to be excluded from development interventions and remain one of the groups with the least voice to defend their rights, which brings us to the issue of human rights. .
Mental health and human rights
As Arthur Kleinman of Harvard Medical School said, the continued neglect of the health and human rights needs of people with mental illness is a “failure of humanity” and represents one of the biggest public health scandals of our time.
Despite the progress already made in these areas, a large number of people with mental illnesses continue to be ostracized and isolated from society around the world, living for long periods of time in institutions with inhuman living conditions, being subjected to unnecessary coercive treatments, without your informed consent and without access to mechanisms to protect your rights, to be denied your civil and political rights, and to be discriminated against in relation to employment, education and physical health care.
The adoption, in 2006, of the Convention on the Rights of Persons with Disabilities (CRPD), and its ratification by 181 countries, including Portugal, represented a fundamental milestone in the defense of the rights of people suffering from psychosocial disability associated with illness mental, by linking all these countries to doing everything so that a series of rights that are especially important for these people are effectively respected. Among these, the right to access quality care, the right to non-discrimination in education and employment, the right to an independent life and inclusion in the community, and the recognition of the legal capacity of these people on equal terms deserve special mention. with all the others.
Many steps have already been taken in our country to ensure that these rights are respected. For example, the Mental Health Act, passed in 1998, regulated for the first time among us the procedures to be followed in situations of compulsory internment of people with mental illness and defined the general principles of a national mental health policy clearly based on the principles of inclusion of people with mental illness in the community.
The National Mental Health Plan, approved in 2008, ensured, until its interruption in 2011, significant advances in the reform of mental health services in accordance with the principles defined in the aforementioned Law. And the new Legal System for the Most Accompanied, approved in 2019, which already incorporates the recommendations of the CRPD, enshrines the adoption of a new approach with profound implications for the respect of the rights of people with psychosocial disabilities.
However, much remains to be done. The National Mental Health Study showed that over 40% of severe mental illness cases still lack access to mental health care. Another European study showed that residential structures for people with mental illness in our country have a much lower level of quality than the European average in key dimensions of care. And an assessment of psychiatric institutions carried out in the context of a WHO-Europe initiative revealed significant weaknesses and frequent human rights violations in some of the institutions studied.
This situation is further aggravated by the high stigma associated with mental illness in our country, by the scarcity of services in the community, and by the difficulties experienced by people with mental illness in defending their interests.
Time for action
Over the past few decades, several mental health laws, policies, plans and programs have been developed in Portugal, with the aim of implementing reforms in mental health services that have long been known to be indispensable.
Thanks to these efforts, important advances have been made - for example, in the transition from care centered in psychiatric hospitals to care in general hospitals, in the improvement of mental health services for children and adolescents, in the preparation of the bases of the National Network of Continuing Care of Mental Health and launch of the first services of this network. However, the development of community mental health teams and psychosocial rehabilitation programs, which are the key elements of a modern system, fell far short of what was initially planned.
The truth is that, until today, it has never been possible to implement a policy and plan for long enough to achieve solid results in a reform that requires time and strong and continued political support.
The current Government's program and some measures already taken - that would highlight the constitution of a group to review the mental health law - show that there is beginning to be a greater recognition of the importance of mental health by the political power. However, due to the financial constraints in force in recent years, the implementation of the National Mental Health Plan - interrupted in 2011 - continued to be delayed.
The current crisis triggered by the Covid-19 epidemic is a unique opportunity to change this state of affairs and for mental health to be, in fact, seen as what it is: one of the greatest public health challenges of our day.
After six months of experience with the Covid-19 epidemic, there is no one in Portugal who is not aware of the impacts that this crisis is having on the mental health of the population, and who does not realize that it is playing a decisive role in overcoming the crisis. that we are living. With the economic and unemployment problems ahead, these problems will certainly worsen even more, and there is now a consensus that it is necessary to take measures now to mitigate the effects they will have on the most vulnerable populations.
On the other hand, if the right policy choices are made, the resources that will be available under the Portugal 2020-2030 Recovery and Resilience Plan will make it possible to make investments in improving mental health services that have long been postponed. If this happens, the mental health of the populations will improve, the human rights of people with mental illness will be better protected. And the sustainable development of our society will certainly be facilitated.
José Miguel Caldas de Almeida signs this text as the author of the essay “The mental health of the Portuguese”, within the scope of the partnership between Jornal Económico and the Francisco Manuel dos Santos Foundation.