Indices of Inadequate Mental Wellbeing in High-income and Low-income Countries: A Comparative Analysis

Introduction Mental Health, as defined by the World Health Organization (WHO), is a state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities. Mental health disorders account for about 13% disability-adjusted life years and 32% of disability globally.[1] According to the Global Burden of Disease Study in 2017, about 790 million people reported impaired mental wellbeing, which represents about 11% of the global population.[2] The WHO estimated that mental health disorders produce economic depletion to the ton of 1 trillion USD, with depression being the leading cause of ill health and disability.[2] People with mental illness are at higher risk of inadequate standards and outcomes of care and this is even worse in the ethnic minorities and those with low socioeconomic status.[1] Based on recent World Bank statistics and categorization, all the countries in the world are classified into four according to the level of their gross national income (GNI). GNI is the total income earned by a nation’s people and businesses, including investment income, regardless of where it was earned. It also covers money received from abroad, such as foreign investment and economic development aid. GDP is the total market value of all finished goods and services produced within a country in a set time period. GNP includes the income of all of a country’s residents and businesses, whether it flows back to the country or it is spent abroad. It also adds subsidies and taxes from foreign sources.[3] Low-income economies (1,045 USD or less), for example, Afghanistan, Chad, Liberia, Sudan, and South Sudan. Lower-middle income economies (1,046 USD – 4,095 USD), for example, Nigeria, Haiti, Morocco, Nepal, and Vietnam. Upper-middle income economies (4096 USD – 12,695 USD), for example, Botswana, Brazil, Malaysia, Mauritius, and Romania. High-income economies (12,696 USD or more), for example, the UK, the USA, Germany, Canada, and Bahamas.[3] Mental Wellbeing and National Economy The economy of a nation has a lot to do with the degree of mental wellbeing of the people, the prevalence of, quality of care, and the level of social support available to people with mental illness. On the other side, mental wellbeing is paramount to the productivity of individuals, successful contributions to the society, optimal national development, and the formation of adequate interpersonal relationships.[4] Mental ill health interacts with poverty in a complex manner. Mental illness impairs people and interferes with their abilities to participate fruitfully and meaningfully in their economies, while poverty increases the risk for mental ill health and limits access to adequate health care services. It has been reported that people with mental illness are 3–7 times more likely to be unemployed than those without mental illness.[5] This is the basis for the mental health gap action program among the low- and middle-income nations developed by the WHO in 2002. The resources available to handle the enormous burden of these disorders are insufficient, poorly distributed, and inefficiently used, resulting in a treatment gap of 75%–84% in low- and middle-income countries as against that of 35%–50% in high-income countries.[4] Although multidimensional, poverty varies depending on the social, cultural, and political systems in a particular region. From the standpoint of epidemiology, poverty can be defined as a state of low socioeconomic status (measured by social and or income class), unemployed, and low level of education.[1] The United Nations defines poverty as a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education, and information. It depends not only on income but also access to social services. Globally, there’s been a rising trend of poverty after the COVID-19 pandemic.[2] For countries with low and middle income, the battle against mental illness is fierce, with inadequate quality of care premised on poverty and rising rates of unemployment. With about 70% of the global burden of mental illness in these countries, shortage of resources for the funding of treatment and research among the mentally ill limit their effective participation in meaningful areas of national development.[6] As a result of these, the menace of stigma towards the mentally ill is deeply ingrained in the fabric of the society, leading to poor quality of life among them and affecting national economies negatively. Stigma promotes poor health-seeking behavior, long history of untreated illness, social deprivation, and social exclusion.[1] In addition, another determinant of mental well-being in low-and middle-income countries is the socio-cultural values and stereotypes. For example, in sub-Saharan Africa, much emphasis is placed on spiritism, punishment from unseen forces as being the origin of mental illness, which negates the biopsychosocial approach in orthodox care.[7] This makes a lot of people seek medical help from inappropriate quarters. However, religion, which is held in high esteem in these countries, has been shown to improve the quality of life of the mentally ill if leveraged duly. This is because it provides and promotes a source of social support and sense of togetherness, which gives a feeling of being in control of situations and links an individual with adequate treatment facilities in case of relapse or recurrence.[8] Furthermore, the communal living pattern in the low- and middle-income countries (LMICs) also favorably enhances good social support. For example, in the international pilot study of schizophrenia conducted by the WHO in 1973, it was reported that patients in Nigeria, India, and Colombia had better outcome from the illness, and one of the reasons adduced was the early presentation of patients with acute symptoms in these countries which was indirectly linked to communal living style.[8] Optimal social support from communal living improves rapid response and rehabilitation of the mentally ill, leading to better quality of life and consequently improved community participation, and societal and national productivity.[7] The effects of poverty on mental wellbeing are not only confined to the LMICs as they also affect countries with high economy. In a study conducted among low-income participants in the United States, food insecurity was associated with 257% higher risk of anxiety and 253% higher risk of depression, while income stability was found as a protective factor for depression.[2] In Spain, profound decline in mental wellbeing among men was reported during a period of economic crisis and those with low socioeconomic status were more affected. Also, significant increase in the prevalence of many mental health disorders especially depression was reported among primary care attendees between 2006 and 2010 during the period of economic crisis with difficulty in paying mortgage and unemployment the major risk factors.[7] Globally, the rates of suicide have been reportedly increased at the extremes of national economies – both during economic boom and economic depression.[8] Because of the design of work and social paradigms, the rate of loneliness is higher in high-income countries when compared with the LMICs. This increases the risk for mental illness like anxiety disorder and depressive disorder.[6] Furthermore, due to the proper implementation of national minimum wage for all workers irrespective of skill level in industrialized countries, people tend to take on more shifts with the view of the financial gain. This inadvertently increases the risk for burnout, work stress and psychological disorders like adjustment disorder, posttraumatic stress disorder from interpersonal conflicts at work.[4] Another point to note is the issue of universal health coverage which is more available in high income countries relative to the LMICs. As a result of universal health coverage, the mental health gap in high income countries is not as wide as what obtains in low- and middle-income countries.[9] For instance, the National Health Service in the United Kingdom enables people to access healthcare on need basis, irrespective of the cost implication of their health needs and their socioeconomic status. However, in many LMICs, universal health coverage is not available and this affects the life expectancy of the residents and the quality of life of the mentally ill. In Nigeria for instance, over 70% of healthcare needs are funded from out-of-pocket payments and this worsens the multidimensional poverty associated with mental illness in the country.[10] In addition, because of the high economy, many psychiatrists, psychiatric nurses, psychologists and other mental health practitioners migrate from low- and middle-income countries to the high-income countries. This depletion of personnel in LMICs has negative multifactorial effects on the mental healthcare of the available populace, while that of the high-income countries is enhanced.[5] Recommendations Since strong communal relationship through participation in religious groups and activities, and deeply-ingrained family ties in low- and middle-income countries promote mental wellbeing, these practices should be properly reinforced and consolidated on through thorough population mental health promotion and advocacy. This can be done in public places such as religious centers, organized symposia, mass, and social media. However, as multidimensional poverty, which is a notable cause of poor mental wellbeing is more prevalent in the low- and middle-income countries; intentional measures should be put in place to overcome it. One way to get this done is to ensure improved national welfare system, hence more accessible mental healthcare for the residents through the provision of universal health coverage. For the high-income countries, the good wage implementation for workers should be maintained as good remuneration is an important aid to optimal mental wellbeing. Although there may be a need for the re-design of work and schedules for people in these countries to make allowance for better community participation to cater for improved mental wellbeing of workers. Conclusion The dynamics of mental wellbeing are quite different in high-income countries from low- and middle-income countries. Although socioeconomic status affect people in both categories, lack of availability of required fund for accessible mental healthcare and higher rates of unemployment are drawbacks to optimal mental wellbeing in low- and middle-income countries. Loneliness and higher work rates are contributing factors to suboptimal mental wellbeing in high-income countries. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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