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THOMAS R. INSEL is Director of the National Institute of Mental Health.
PAMELA Y. COLLINS is Director of the Oice for Research on Disparities and Global
Mental Health at the National Institute of Mental Health.
STEVEN E. HYMAN is Director of the Stanley Center for Psychiatric Research at the
Broad Institute of Harvard and MIT.
January/February 2015 127
Darkness Invisible
The Hidden Global Costs o Mental Illness
Thomas R. Insel, Pamela Y. Collins, and
Steven E. Hyman
Four years ago, a team o scholars from the Harvard School
o Public Health and the World Economic Forum prepared a
report on the current and future global economic burden o
disease. Science and medicine have made tremendous progress in
combating infectious diseases during the past ve decades, and the
group noted that noncommunicable diseases, such as heart disease
and diabetes, now pose a greater risk than contagious illnesses. In
2010, the report’s authors found, noncommunicable diseases caused
63 percent o all deaths around the world, and 80 percent o those
fatalities occurred in countries that the World Bank characterizes as
low income or middle income. Noncommunicable diseases are partly
rooted in lifestyle and diet, and their emergence as a major risk,
especially in the developing world, represents the dark side o the
economic advances that have also spurred increased longevity, urban-
ization, and population growth. The scale o the problem is only going
to grow: between 2010 and 2030, the report estimated, chronic non-
communicable diseases will reduce global by $46.7 trillion.
These ndings reected a growing consensus among global health
experts and economists. But the report did contain one big surprise:
it predicted that the largest source o those tremendous future costs
would be mental disorders, which the report forecast would account
for more than a third o the global economic burden o noncommuni-
cable diseases by 2030. Taken together, the direct economic eects o
Thomas R. Insel, Pamela Y. Collins, and Steven E. Hyman
128
mental illness (such as spending on care) and the indirect eects (such
as lost productivity) already cost the global economy around $2.5 trillion
a year. By 2030, the team projected, that amount will increase to around
$6 trillion, in constant dollars—more than heart disease and more than
cancer, diabetes, and respiratory diseases combined.
These conclusions were dramatic and disturbing. Yet the report
had virtually no impact on debates about public health policy, mostly
because it did not manage to dislodge persistent and harmful misper-
ceptions about mental illness. In wealthy countries, most people
continue to view mental illness as a problem facing individuals and
families, rather than as a policy challenge with signicant economic
and political implications. Meanwhile, in low-income and middle-
income countries and within international organizations, ocials tend
to view mental illness as a “First World problem”; according to that
view, worrying about mental health is a luxury that people living in
severe poverty or amid violent conict cannot aord.
In reality, in countries o all levels o wealth and development,
mental illness aects almost every aspect o society and the economy.
And far from lacking relevance or urgency in poor and war-torn
countries, mental illness often contributes to the very dysfunctions
that plague such places. Moreover, breakthroughs in therapy and
treatment have signicantly improved the ecacy—and lowered the
cost—o caring for people who suer from mental illness, even in
places that have traditionally lacked access to mental health services.
Policymakers, mental health professionals, and advocates for the
mentally ill should take advantage o this progress. To do so, they
rst must change the way people—including they themselves—think
about and talk about mental illness.
BRAIN DRAIN
People underestimate the costs and signicance o mental illness for
many reasons. At the most basic level, policymakers and public health
ocials tend to view mental illness as fundamentally dierent from
other medical problems. But just like other diseases, mental illnesses
are disorders o a bodily organ: the brain. In this respect, they are no
dierent from other noncommunicable diseases.
Most people also do not realize just how common mental disorders
are, in part because such illnesses are stigmatized and thus often hidden.
The U.S. Department o Health and Human Services estimates that
Darkness Invisible
January/February 2015 129
in 2012, 43.7 million Americans over the age o 18 suered from some
kind o mental disorder—18.6 percent o the country’s adult population.
Nearly ten million o those people, or 4.1 percent o adult Americans,
struggled with serious mental illnesses, such as psychotic disorders.
Even in the United States, where treatment for such problems is
relatively accessible, many people do not seek or receive care until
their disorders have become chronic and disabling, a length o time
that one recent study found to be 11 years, on average.
Mental disorders are also far more disabling than most people real-
ize, often preventing the aicted from working, studying, caring for
others, producing, and consuming. In a 2012 report on the global
economic burden o disease, the World Health Organization noted
that mental illnesses and behavioral disorders account for 26 percent
o the time lost to disability—more than any other kind o disease.
The impact o mental illnesses is magnied by the fact that such
disorders aict mostly young people, in contrast to other chronic
noncommunicable diseases, such as heart disease or cancer, which
generally appear later in life. A 2005 study conducted by researchers
at Harvard Medical School, the University o Michigan, and the
National Institute o Mental Health found that 75 percent o adults
suering from mental illness reported that their symptoms began
REUTERS / STRINGER
The hidden epidemic: in a mental hospital in Shanxi Province, China, October 2010
Thomas R. Insel, Pamela Y. Collins, and Steven E. Hyman
130
before they turned 25. The rst signs o psychosis in people with
schizophrenia typically arrive between the ages o 18 and 23; autism
begins to aect people before the age o three. Such early onset explains
why mental disorders represent by far the largest source o disability—
and hence lost productivity—for people between the ages o 15 and
44, a crucial period in life during which people transition from school
to work, nd partners, start families, and build careers.
Another little-understood aspect o mental disorders is that they
are not merely disabling; they are deadly. Although many factors lead
people to end their own lives, the American Foundation for Suicide
Prevention estimates that mental illness plays a role in 90 percent
o suicides. The World Health Organization estimates that some
800,000 people commit suicide every year, 75 percent o them in
low-income and middle-income countries. Globally, more than twice
as many people die from suicide as die from homicide each year, and
suicide is the second-largest source o mortality for people aged 15 to
29, topped only by trac accidents.
Finally, mental disorders act as a gateway to a range o other costly
public health problems. Suering from a mental illness increases one’s
chances o contracting and o developing heart disease, pulmonary
diseases, and diabetes; it also raises one’s risk o homelessness, poverty,
and institutionalization, including imprisonment—all o which
represent further burdens on society.
ATTENTION DEFICIT
Despite these profound costs, mental illness receives surprisingly
little attention and resources from governments and international
organizations. Globally, annual spending on mental health amounts
to less than $2 per person; on average, low-income countries spend
less than 25 cents per person. The median amount that countries
spend on mental health equals less than three percent of the
median amount that they spend on all health care, even though mental
illness accounts for over 20 percent o all health-care costs. And
the poorer the country, the worse the problem: the World Health
Organization estimates that the majority o countries at low and
lower-middle levels o income devote less than two percent o their
health budgets to treating mental disorders. In such countries, up
to 85 percent o people with severe mental illness receive no treat-
ment at all.
Darkness Invisible
January/February 2015 131
Even wealthy countries devote few resources to mental disorders
relative to the economic costs they impose. According to the Centre
for Economic Performance at the London School o Economics,
mental illness costs the British economy around 70 billion pounds
in lost productivity and health-care expenditures every year and
accounts for 23 percent o the burden that disease places on the
United Kingdom, and yet the National Health Service devotes only
13 percent o its expenditures to mental disorders. Nor are interna-
tional organizations any better attuned to the problem: mental illness
went completely unmentioned in the ’s Millennium Development
Goals (s), and until recently, most o the major organizations
addressing global health and disaster relie paid little attention to the
mental health needs o the populations they served.
Owing to this lack o attention and awareness, the costs o treating
mental illness often fall outside health-care sectors. In the United
States, for instance, most states have almost completely dismantled
the system o mental hospitals that once oversaw care for the mentally
ill. As a result, Americans with serious mental illness are ten times
as likely to be imprisoned as to be in hospitals. In a sense, through
welfare programs, social services, and jails and prisons, many countries
Losing It
Top Ten Sources of Time Lost to Disability Globally From All Medical
Causes, by Percentage
: World Health Organization, 2012.
Mental and behavioral disorders
Musculoskeletal diseases
Nutritional deficiencies
Respiratory diseases
Injuries
Cardiovascular diseases
Genitourinary diseases
Neurological and sense-
organ conditions
Infectious diseases
Endocrine, blood, and
immune disorders; diabetes
26%
14%
13%
8%
7%
7%
6%
4%
3%
3%
Thomas R. Insel, Pamela Y. Collins, and Steven E. Hyman
132
wind up spending on the eects o mental illness—such as unemploy-
ment, homelessness, and incarceration—rather than the underlying
causes. In the United States, such indirect costs represent two-thirds
o the economic burden o mental health problems—a gure that
makes sense considering that 30 percent o the country’s chronically
homeless and more than 20 percent o the people incarcerated in the
United States suer from a mental disorder.
A FIRST WORLD PROBLEM?
Compared with wealthy countries, low-income and middle-income
countries face an even starker challenge when it comes to mental
health: a lack o expertise and a shortage o professionals. Residents o
wealthy countries enjoy a relatively high concentration o mental health
specialists: high-income countries have, on average, nine psychiatrists
for every 100,000 people. But almost hal o the world’s population
lives in countries where, on average, there is only one psychiatrist for
every 200,000 people; in many African countries, there is only one
psychiatrist per every one million people.
In the short term, these numbers are not likely to improve much.
But people suering from mental illness in poorer places could benet
from a relatively new trend in the eld: the so-called task-sharing
approach, in which professionals train a range o providers—from
nurses and social workers to peers and family members—to care for
those with mental illness. Controlled trials have already demonstrated
the promise this approach holds, even in places with few established
mental health resources. In a report published in The New England
Journal of Medicine in 2013, a team led by Judith Bass, a mental health
specialist at Johns Hopkins University, described a controlled trial
it had carried out in 2011 involving around 400 women in 16 villages
in the Democratic Republic o the Congo who had suered sexual
violence and exhibited symptoms o posttraumatic stress disorder,
depression, or anxiety. To test the ecacy o a task-sharing ap-
proach to caring for these women, clinical experts from the United
States spent ve or six days training local women in how to provide
cognitive-processing therapy, which focuses on helping people to
stop avoiding their problems and instead solve them by changing
their behavior.
The local assistants used that approach to treat one set o the
victims o violence, 70 percent o whom suered from symptoms o
Darkness Invisible
January/February 2015 133
depression and anxiety disorders before the trial began. A control
group o other victims, 83 percent o whom were experiencing such
symptoms, received only individual support from the assistants.
The results were remarkable: after six months, only ten percent o the
women who had received the cognitive-processing therapy still appeared
to be suering from depression or anxiety disorders, compared with
42 percent o those who had received just individual support.
In a 2008 article in The Lancet, a team o researchers reported
similar results from a controlled trial in rural Pakistan, in which the
team trained community health workers to provide a form o treat-
ment resembling cognitive-behavioral therapy to women struggling
with prenatal or postpartum depression. Women in 20 rural areas
received treatment from the trainees; a control group o women in
20 other areas received care from workers who had not been trained.
When the treatment period ended, only 23 percent o the women
who had received care from the trained workers showed symptoms
consistent with prenatal or postpartum depression, compared with
53 percent o those in the control group.
The results in Congo and Pakistan suggest that task-sharing
approaches can produce results equal to or even better than those
achieved by such treatments in wealthy countries, where they
have been used, to cite one example, to care for U.S. military vet-
erans struggling with posttraumatic stress disorder. And in both
Congo and Pakistan, women who received psychotherapeutic
treatment showed not only substantial decreases in symptoms but
also improvements in overall health and well-being. Nor were
they the only beneciaries: the women who received such treatments
in Pakistan were also more likely to obtain crucial vaccines for
their children.
PAGING BILL GATES
Another obstacle hindering mental health care in the developing world
is that many donors, public health specialists, and government ocials
believe that mental illness cannot be addressed with the kinds o
low-cost, simple interventions that have made such a dierence in
the ght against other diseases in poor countries—think o polio
vaccines and bed nets to prevent the spread o malaria, for example.
In fact, similarly safe, eective, and inexpensive treatments exist for
the most prevalent mental disorders.
Thomas R. Insel, Pamela Y. Collins, and Steven E. Hyman
134
Medications that relieve the most disabling symptoms o depres-
sion, psychosis, anxiety, and bipolar disorder have been available
for ve decades and now exist in relatively inexpensive generic for-
mulations. A 2012 World Health Organization study showed that
among 58 low- and middle-income countries, a typical course o such
psychiatric medications costs, on average, approximately four percent
o an individual’s daily income. Although such treatments must be
prescribed and managed by medical professionals, the paucity o
psychiatrists in poorer countries would not necessarily present an
obstacle to making psychiatric medications more widely available.
After all, even in the developed world, most antidepressants and
anti-anxiety medications are prescribed not by psychiatrists but by
primary-care practitioners.
But perhaps the most promising new treatments for the most
common mood and anxiety disorders have emerged thanks to tech-
nological innovation. As the Internet and mobile technology have
spread, psychological treatments are no longer limited to those who
can visit a psychotherapist’s oce. More than ve billion people all
over the world now have access to mobile devices that could allow
them to receive psychotherapeutic interventions ranging from text
messages that provide self-help strategies to computer games that
incentivize positive changes in behavior. A group o psychiatric
researchers in Australia recently found that a Web-based program
reduced depressive and anxiety symptoms by allowing users to
complete interactive modules on topics such as “managing fear and
anxiety” and “tackling unhelpful thinking.” And even in places
where few people have smartphones, the spread o basic cellular ser-
vice means that providers can still reach far more potential patients
by phone than ever before.
OUT OF THE SHADOWS
Even i donors, international organizations, and governments came to
better understand the massive costs associated with mental illness and
the feasibility o treatments, genuine progress would still rely on a
number o systemic changes. First, there is a basic need for increased
awareness o the scope o the problem. In rich and poor countries
alike, mental health advocates must do a better job o explaining to
ocials and the public the true costs o mental illness, encouraging
people to understand how the problem aects not only individuals and
Darkness Invisible
January/February 2015 135
families but also entire communities and economies. “No health with-
out mental health” has become a rallying cry for reformers, but such
slogans frequently fall on dea ears. Mental health advocates could
win more allies within the medical profession by drawing attention to
the fact that improved mental health leads to better overall health.
Second, countries at every economic level must better integrate
mental health care into their broader health-care systems. In wealthy
countries, two simple steps would help: preparing more primary-care
providers to treat mental disorders and creating incentives for mental
health specialists and general medical practitioners to share facilities
and establish partnerships, which would make it easier for people to
get psychiatric and psychological care. In poorer countries, one step
toward better integration would be to give community health workers,
who already monitor basic health needs, the ability to screen for com-
mon mental disorders, as well. For example, nurses who help patients
stick to their medication regimens could incorporate mental
health screening into their routines.
Finally, the international community needs to make a formal com-
mitment to reducing the global economic burden o mental illness.
Although mental illness aects the achievement o several o the
’s s, such as empowering women, reducing child mortality,
improving maternal health, and reversing the spread o , the
goals made no mention o mental health. Now, the process o drafting
successors to the s, the so-called Sustainable Development
Goals, is well under way. Mental health advocates involved in the pro-
cess are pushing for the establishment o specic targets, including a
ten percent reduction in suicide by 2020 and a 20 percent increase in
treatment for severe mental disorders by the same date. These are
achievable goals, but meeting them will require political will, public
and private investment, and coordination among the health, nancial,
social-service, and educational sectors.
Such steps will go a long way toward reducing the damage mental
disorders inict on societies and economies all over the world. But for
such measures to succeed, policymakers and experts must rst pull
mental illness out o the shadows and into the center o debates about
global public health.∂
