October 10 marks World Mental Health Day. This year's campaign theme, developed by WHO, United for Global Mental Health, and the World Federation for Mental Health, recognises that investment in mental health has not matched rising global awareness of the scale of the problem in recent years. The campaign slogan—“Move for mental health: Let's invest” —calls the world to action and, for the first time, will be accompanied by a global online advocacy event.

From addiction to dementia to schizophrenia, almost 1 billion people worldwide suffer from a mental disorder. Lost productivity as a result of two of the most common mental disorders, anxiety and depression, costs the global economy US$ 1 trillion each year. In total, poor mental health was estimated to cost the world economy approximately above $2·4 trillion per year in poor health and reduced productivity in 2010, a cost projected to rise to $6 trillion by 2030.

Yet, despite substantial advances in research, demonstrating the clinical and cost-effectiveness of pharmacological and psychosocial interventions to prevent and treat common mental disorders, delivery at scale and translation into real-world benefits has been slow. The costs involved in mental health care are many and can involve social services, primary, secondary, and tertiary care. In addition to direct intervention costs, expenditure can be expected to cover facilities, staff, administration, management, training, supervision, advocacy and outreach activities. The diversity of services and care providers can complicate estimates of national mental health expenditure.

The WHO Mental Health Atlas 2017 requested that countries estimate their government's total spend on mental health, using subnational and national data. They found that, on average, mental health expenditure accounted for less than 2% of government budgets for health.

The report highlighted how care and treatment for severe mental disorders is not included in national health insurance or reimbursement schemes in 27% of 169 responding countries. When asked how people pay for services, 17% of 168 responding member states said that service users paid out-of-pocket. Indeed, out-of-pocket payments for mental health services account for above 42% of mental health expenditure in the African region and 40% in the South-East Asia region. While a combination of bilateral, multilateral, private, and philanthropic donations have contributed somewhat to filling the funding gap, development assistance for mental health has never been more than 1% of global development assistance for health.

The economic case for investment in mental health

The economic case for investment in mental health is strong: for every $1 invested in scaled-up treatment for depression and anxiety, there is a $4 return in better health and productivity. The Lancet Commission on global mental health and sustainable development, published in 2018, called for a partnership including academic institutions, UN agencies, development banks, the private sector, and civil society organisations to mobilise, disburse, and invest funds to transform mental health, stating that “When it comes to mental health, all countries can be thought of as developing countries.”

For these purposes, Mental health focuses on the services involved in providing assessment and treatment for people with mental illness, rather than those that may provide wider support (such as activities that contribute to the wellbeing and quality of life of people experiencing mental health problems, and their carers). This report focuses on services for people with mental illness, rather than neurodevelopmental conditions such as learning disabilities, as those are areas with unique considerations and issues. The exception is where those are illustrative of a wider issue.

Helen Gilburt

Mental health does not provide detailed insights into services provided by the independent sector or VCSE organisations. This may change in future years as efforts to capture the provision of mental health support in other settings are reflected within national datasets.

Context

Less than 50 years ago, most people who received care or treatment for mental illness in England did so in an institutional care setting known as an asylum. In 1974, 100,000 people were housed in mental health institutions, and although people attended outpatient clinics to receive medication, there were few community services. Today, advances in the understanding of mental illness, alongside the development of pharmacological and psychological treatments, mean that most people who access mental health care do so within a community setting.

Successive policies have led to the development of a range of services: to deliver specific types of treatment (such as NHS Talking Therapies for people with anxiety and depression); to provide evidence-based treatment for people with particular illnesses (such as early intervention in psychosis); and to provide intervention at critical points of need (such as support for people experiencing a mental health crisis in the community). NHS providers and commissioners have also contributed to the current services landscape through locally led decision-making about the types of services that are provided, for whom, and how those services are organised and work together.

A commitment to achieving parity of esteem between mental and physical health care was enshrined in the Health and Social Care Act 2012. This was followed by the establishment of the Mental Health Taskforce by NHS England in 2015 and led to the Five Year Forward View for Mental Health in 2016. This national strategy focused on improving access to a number of specific community-based services. The subsequent NHS Long Term Plan and associated Mental Health Implementation Plan continued the policy focus on increasing access, targeting support to a number of key pathways. Most notably, though, it sought to enhance support for people with severe mental illness across primary and secondary care and within communities, encompassing and extending the role of the voluntary, community and social enterprise (VCSE) sector.

The result is that more people than ever are now able to access support for mental health problems. As of November 2023, 1.86 million people (including those referred and those seen) were in contact with NHS-funded secondary mental health services. There were also 162,250 referrals to NHS Talking Therapies. This is partly due to increased investment and a larger overall workforce. However, this investment and expansion in workforce has not covered the full range of services available and has not been at sufficient scale to reflect population need, which means that provision in many areas of care remains far from comprehensive. For example, current plans only go as far as providing support for mental health within schools and colleges to at least 50% of pupils in schools and learners in further education. Although other forms of support may be available, there remains a considerable gap in access. At the same time, issues with quality of care (such as lack of therapeutic care in inpatient settings) have become more prominent, while workforce capacity, as well as the availability of meaningful data, continues to limit progress in improving services. For many people who seek or provide care, the notion of parity is as relevant now as it was when it was first legislated in 2012.