Mental health indicators in APEC

Abstract

Background:

The World Economic Forum (2011) concluded that the economic impact of mental illness is the single most important contributor among all non-communicable diseases to loss of productivity. The 21 economies represented by Asia Pacific Economic Cooperation (APEC) responded to that information with efforts to address mental health as an integral component of economic development.

Aim:

In order to help assess the progress of APEC region compared to other regions of the world, the World Health Organization (WHO) granted us access to a subset of the 2014 Mental Health Atlas database containing health indicators from all 21 APEC economies.

Methods:

APEC-specific data were extracted using the same format used by WHO in its Mental Health Atlas to compare/contrast data in APEC versus the six WHO regions of the world.

Results:

It was observed that mental health workforces in APEC include a higher number of psychiatrist providers compared with WHO regions. Suicide rates reported in three APEC economies are among the highest in the world. All APEC economies continue their individual and coordinated efforts to support their ‘APEC Roadmap to Promote Mental Wellness in a Healthy Asia Pacific (2014–2020)’.

Conclusion:

Significant challenges for APEC members exist to coordinate regional efforts to improve mental health due to highly variable income levels, existing health infrastructures and social preferences. The findings in this report may serve as a helpful baseline for measuring success within the APEC region by 2020, the year in which progress in support of economic development will be reassessed.

Keywords

APEC disability adjusted life years Asia Pacific mental illness WHO

Background

Asia Pacific Economic Cooperation (APEC) is a consensus-based inter-government voluntary forum for 21 Pacific Rim member economies. APEC’s strengths include its tremendous convening power and direct involvement of both political leaders and finance ministers. Collectively APEC includes the world’s largest economies, approximately 41% of the world’s population, 54% of the world’s total gross domestic products and 44% of the world’s trade. In 2011, the World Economic Forum reported that the direct and indirect costs of mental illness represented the single most important contributor to loss of productivity and generation of disability adjusted life years among all non-communicable diseases (Bloom et al., 2011). In response to that report, APEC organized a 2013 multinational mental health workforce committee and sponsored a 2-day workshop to formulate a 5-year plan which APEC economies could agree upon and institutionalize, thus facilitating adoption of the World Health Organization (WHO) Comprehensive Mental Health Strategic Action Plan (WHO, 2013).

A key document produced from the 2014 APEC workshop and endorsed by APEC leadership was the ‘APEC Roadmap to Promote Mental Wellness in a Healthy Asia Pacific (2014–2020)’ (APEC, 2014). Swift economic changes, aging populations and frequent natural disasters raise special challenges for APEC member economies that require a proactive and concerted response (APEC, 2012). A major milestone for APEC’s Mental Health Roadmap initiative was reached in 2016 by establishment of a Digital Hub for Best and Innovative Practices in Mental Health Partnerships (Ng, Goodenow, Greenshaw, Upshall, Lam, 2017). The University of British Colombia and the University of Alberta, Canada, in cooperation with the Mental Health Commission of Canada and the Mood Disorders Society of Canada were selected as principle hosts for this Digital Hub which collaborates with all APEC economies via a multinational APEC Mental Health Taskforce.

In May 2013, the 66th World Health Assembly adopted the WHO Comprehensive Mental Health Action Plan (2013–2020) (WHO, 2013), in which core mental health indicators were articulated to measure changes and achievements by member states. Collection of mental health indicators by WHO has occurred on a regular basis beginning in 2001 through collaboration between WHO Headquarters Office, Geneva, in collaboration with its six regional offices. A Mental Health Atlas survey was sent to all country representatives by WHO and responses were published after comparing data for the six WHO defined regions of the world: Western Pacific Region (WPRO), European Region (EURO), Americas (AMRO), Eastern Mediterranean Region (EMRO), South-East Asia Region (SEARO) and Africa (AFRO).

Aim

To facilitate the formal entry of APEC financial ministries into regional mental health improvement operations, APEC leadership requested access to a sample of the WHO 2014 Mental Health Atlas database to compare mental health data in the APEC region to global and WHO regional data. The results of this study provide a historical perspective and baseline on which to measure the impact of future APEC initiatives in mental health by the year 2020 as stipulated in the APEC Mental Health Roadmap.

Methods

The 2014 WHO Mental Health Atlas contains information collected from 171 countries that responded to a survey conducted by the Department of Mental Health and Substance Abuse, WHO (Geneva) in collaboration with its six WHO regional offices. Data from each country are self-reported and supporting documentation for each statistic is not routinely requested by WHO. Information specific to APEC countries was provided by WHO headquarters in Geneva. Data provided for APEC economies were organized around a subset of four queries to see how the APEC region compared with WHO regions that contain a mix of low, lower-middle, upper-middle and high-income countries. The APEC economy–specific queries included the following: availability of mental health data, sources of funding for mental health services and the composition of mental health workforces and suicide rates. The WHO Mental Health Atlas groups mental health data into four categories: no mental health data compiled in the last 2 years, data compiled only for general health statistics, data compiled in the last 2 years only for the public sector and data compiled in the last 2 years for public and private sectors. Countries were asked about the percentage of their population that has medical services derived from the government (national insurance), non-governmental organizations, employers (social health insurance) and private out-of-pocket costs or insurance. Each country was asked to calculate the numbers of their mental health workforce in eight categories: psychiatrists, other doctors, nurses, psychologists, social workers, occupational therapists and other mental health workers. Workforce numbers are reported per 100,000 population.

Ethical clearance

This project was reviewed by the Institutional Review Board of the Medical College of Wisconsin, Milwaukee, Wisconsin under project number PRO 000 29,692. This project was approved as ‘Not Human Subject Research’ because information extracted from the 2014 WHO Mental Health Atlas is not individually identifiable, does not involve intervention or interaction with living individuals, and does not involve human biological specimens or human information/data that will be used to support the marketing of a regulated drug, biologic or device product.

Results

APEC populations

In 2017, there are 21 country members of APEC (Supplementary file Table 2). Income levels and populations for APEC members at the time of the WHO Mental Health survey in 2014 varied greatly. China reported the largest population of 1.4 billion and the smallest APEC economy was Brunei Darussalam with a population of 423,207. APEC did not include any low-income countries, but does include four lower-middle countries (Indonesia, Papua New Guinea, Philippines and Vietnam), five upper-middle income countries (China, Malaysia, Mexico, Peru and Thailand) and 10 high-income economies (Australia, Brunei Darussalam, Canada, Chile, Japan, New Zealand, the Republic of Korea, The Russian Federation, Singapore and United States).

Data availability and reporting

Mental health data were available in the 2014 Mental Health Atlas from all APEC member economies, although data specific to Taiwan and Hong Kong were included in overall data reported by the People’s Republic of China (Figure 1).

Figure 1.

Availability of mental health data from APEC and WHO regions.

No mental health data were available from the last 2 years from two APEC countries. In all, 42% of APEC compiled mental health data for only general health statistics. A total of 37% of APEC countries compiled mental health–specific data in the last 2 years from the public sector, and 11% of APEC had mental health–specific data compiled in the last 2 years for the public and private sectors.

Funding sources

In contrast to SEARO where primary funding for mental health services was virtually 100% from national health insurance, the APEC region had a mix of funding sources (Table 1).

Table 1.

Sources of funding for mental health services.

WHO regions and APEC	N	Government (national insurance)		NGOs (for profit or not for profit)		Employers (social health insurance)		Households (private insurance, out-of-pocket)
WHO regions and APEC	N	Primary funding source	Secondary funding source	Primary funding source	Secondary funding source	Primary funding source	Secondary funding source	Primary funding source	Secondary funding source
Global	122	79%	14%	2%	22%	2%	33%	18%	31%
APEC	19	68%	5%	0%	16%	0%	26%	5%	21%
AFRO	28	67%	19%	4%	30%	7%	30%	22%	22%
AMRO	25	78%	13%	0%	26%	0%	48%	22%	13%
EMRO	14	77%	15%	8%	23%	0%	23%	15%	38%
EURO	32	86%	14%	0%	14%	0%	26%	14%	46%
SEARO	10	100%	0%	0%	22%	0%	44%	0%	33%
WPRO	13	77%	15%	0%	15%	0%	38%	23%	31%

WHO: World Health Organization; APEC: Asia Pacific Economic Cooperation; NGO: non-governmental organisation.

Within APEC, national insurance was the primary source of funding in only 68% of countries. Households (private insurance, out of pocket) contributed as a secondary funding source in 21% and as a primary funding source in only 5%. Employers (social health insurance) served as a secondary funding source in 26%. The composition of mental health workforce varied greatly from region to region, although in APEC economies, psychiatrists comprised the largest segment of mental health services (18.3/100,000 population). Overall, APEC included a substantially larger mental health workforce of 58/100,000 population, compared with the global average of only 11.3/100,000 population.

Mental health workforce

The breakdown of mental health workforce by WHO region (per 100,000 population) varied dramatically between APEC and non-APEC countries (Figure 2).

Figure 2.

Mental health workforce.

In APEC, psychiatrists provided the largest percentage of mental health services at 18.3/100,000, compared with AFRO (1/100,000), AMRO (5.9/100,000), EMRO (1.4/100,000), EURO (1.4/100,000), SEARO (1.5/100,000) and WPRO (6.2/100,000). Nurses represented the second largest group of mental health service providers within APEC at 16.5/100,000 compared with AFRO (0.6/100,000), AMRO (5.3/100,000), EMRO (3.1/100,000), EURO (24.1/100,000), SEARO (2.6/100,000) and WPRO (5.7/100,000). Psychologists comprised the third largest group of mental health service providers within APEC at 8.06/100,000. The number of psychologists per 100,000 providing mental health services is higher than within any other WHO region: AFRO (not provided), AMRO (1.4/100,000), EMRO (0.4/100,000), EURO (2.7/100,000), SEARO (0.1/100,000), WPRO (0.9/100,000) and globally (0.7/100,000).

Suicide rates

Global median suicide rates in 2014 in data compiled by WHO were calculated as 11 per 100,000 population based on self-reporting by each country. The average suicide rate in APEC lower-middle income countries (4/100,000) was much lower than the global suicide rate, and three countries (Philippines, Malaysia and Peru) reported rates at only 3/100,000 (Supplementary file Table 3). In contrast to the lower middle-income APEC economies, average APEC high-income economy suicide rates were about the same in Canada (10/100,000), Australia (11/100,000), Chile (12/100,000) and the United States (12/100,000). However, three high-income APEC economies reported the worlds’ highest suicide rates – Japan (19/100,000), the Russian Federation (21/100,000) and the Republic of Korea (29/100,000).

Discussion

The WHO media center fact sheet on suicides states that close to 800,000 suicides occur each year and in 2015, 75% of global suicides occurred in low- and middle-income countries (WHO, 2017). In this study, the three APEC members with the highest suicide rates were all high-income economies. These statistics are not necessarily contradictory because numbers and rates are subject to population variability. In addition, there is the possibility of reporting bias that affects the accuracy and validity of self-reported data. If that were the case, relatively lower suicide rates may be a function of incomplete reporting or the absence of recent data. Alternatively, this observation may truly highlight the principle that high incomes alone do not translate into an optimum personal sense of well-being.

Globally, suicide is the second leading cause of death among 15- to 29-year-olds (WHO, 2017). In the United States, suicide rates have not substantially decreased over the past 20 years, despite major advances in the treatment of other diseases such as HIV/AIDS, cardiovascular disease and pediatric cancers. Suicide in the United States remains the fourth ranking cause of years of potential life lost before age 65. Age-adjusted suicide rates also are higher among North American Indian/Alaska and Canadian Natives and Whites than among Hispanics, Blacks and Asians/Pacific (Caetano et al., 2015). Alcohol and other substance abuse problems are important confounding variables shared by high and low-income economies. In addition, APEC demonstrates a wide array of country and/or culturally specific issues such as the high rates of post-partum depression and adolescent mental illnesses recorded in rural areas of Vietnam (Fisher, Tran, & Tran, 2012; Le, Holton, Nguyen, Wolfe, & Fisher, 2016).

The observation of high rates of psychiatrist providers in APEC may reflect cultural preferences. A study by the US National Institutes of Health (Mchugh, Whitton, Peckham, Welge, & Otto, 2013) examined patient preference for psychological (non-pharmacological) and pharmacological treatment. Results yielded a significant threefold preference for psychological treatment, with adolescents and women significantly more likely to choose non-pharmacological therapy. Because APEC does not include any low-income countries, this may lead to a much higher perceived percentage of psychiatrist providers. Depending on the individual economy, there may be insufficient numbers or distributions of psychiatrists in low-income countries to provide pharmacological therapy even if it were desirable. WHO reported that only 1% of the global health workforce is employed in mental health (WHO, 2015). According to the WHO Mental Health Atlas (2014), on average, there is less than one mental health worker per 10,000 people globally, which varies between high- and low-income countries where rates can drop as low as 1 per 100,000 and as high as 1 per 2,000. The mental health workforce shortage is a worldwide concern.

The APEC Digital Hub website detailing sponsors, partnerships and programs was released at the start of the 2016–2017 season in which Vietnam hosted the year-long APEC annual meetings (Ng, Goodenow, Greenshaw, Upshall, Lam, 2017). The purpose of this website is to strengthen mental health communities in support of sustainable economic growth by sharing information, best practices, pilot collaborations and by promoting innovative research. It prioritizes multi-sector collaborations and international best practices to ensure the recognition of workforce mental wellness as a pillar of economic growth. Core partners involved in the Digital Hub extend across the Asia-Pacific and include The University of Melbourne Department of Mental Health, the Ministry of Health in Chile, Peking University APEC Health Sciences Academy in China, the Directorate of Mental Health, Ministry of Health in Indonesia, the National Institute of Mental Health, National Centre of Neurology and Psychiatry in Japan, the National Centre for Mental Health in Korea, Ministry of Health in Malaysia, National Institute of Psychiatry in Mexico, The University of the Philippines and National Center for Mental Health in The Philippines, the Institute of Mental Health in Singapore, and The Research and Training Center for Community Development in Vietnam. These Core Partners provide leadership and are responsible for Digital Hub initiatives reporting and identifying innovative projects. The Digital Hub focuses on seven priority areas: workplace wellness and resilience, integration of mental health care with primary care in community settings, advocacy and public awareness, vulnerable communities and children, mental wellness of indigenous communities, disaster resilience and trauma and data collection and standardization.

Strengths and limitations

It was not possible to access the entire 2014 WHO Mental Health Atlas for this pilot study of APEC-specific mental health indicators and thus this report does not present a comprehensive picture of mental health indicators within the APEC region compared with WHO regions. Therefore, the types of comparative analyses made in this study are limited and were not meant to be comprehensive given the limitations of the data and WHO templated information. Nonetheless, this report does clearly illustrate several significant challenges that APEC must address in providing best practice models for its member economies, given the obvious differences in income levels, governments, populations, cultures, health care delivery models and available workforce. Mental health care delivery models that require large numbers of psychiatrists as seen in high-income countries are unlikely to be transferable to lower-income economies with a large percentage of its population in rural settings or where physicians do not deliver most primary health care. Data present in the 2014 WHO Mental Health Atlas are self-reported by each participating country.

To understand the potential impact of APEC in promoting improved global mental health care, it is important to recognize that first and foremost APEC is concerned with economic productivity and development. Many/most committees, dialogues and fora within APEC (e.g. Business Advisory Committee, Life Science Innovation Forum) include private sector representatives as active and equal participants sitting aside health care providers, academics, non-governmental organizations and government representatives. This composition can be viewed either as a plus (involvement of key private sector leaders) or a minus (concern about bottom line over individual well-being). But even if the latter perspective is the ultimate motivation, one should not dismiss the potential benefit of high-profile involvement of the private sector and Ministers of Finance.

Conclusion

It is likely that return on investment arguments will be most persuasive (Chisholm et al., 2016). The 2016 joint WHO-World Bank-International Monetary Fund spring meeting in Washington DC was the first time that APEC leadership was invited to sit aside leadership of the United Nations, WHO and the World Bank and together emphasized the magnitude of the economic impact of mental illness, highlighting the urgent need to develop cooperative efforts and policies. The global economic community was united in recognizing the urgency to address this historic problem and collaborate on scaling up a broad multi-sectorial response for an ‘invisible disability’. The April 2016 World Bank meeting theme was entitled ‘Out Of The Shadows: Making Mental Health a Global Development Priority’ (World Bank, 2016).

APEC is committed to promoting and supporting implementation of the WHO Mental Health Action Plan. APEC has committed its resources, political and financial capital to promote and facilitate advances in mental health services as a unique and critically important measure of economic development. The participation of such a high-profile multinational economic organization as APEC in the mental health arena is unique and historic, but its ability to substantively impact the global problem of mental illness remains to be seen. Analysis of best practice models for mental health care delivery and resource allocation must remain a work in progress, taking into consideration the demographic variability within APEC. In addressing the stark reality of high suicide rates in three high-income APEC economies, APEC leadership could serve as an exemplary and inspirational model of how a balanced portfolio, sharing elements of social justice with financial return on investment incorporates best and innovative practices in mental health for a common economic good (Chisholm et al., 2016; Victoria Institute of Strategic Economic Studies, 2016). It is anticipated that efforts to improve mental health infrastructure and the results of model APEC collaborations will continue to be important deliverables announced yearly by each APEC host economy including Papua New Guinea in 2018.

Supplemental Material

Revised_supplementary_Table_2_for_IJSP – Supplemental material for Mental health indicators in APEC

Supplemental material, Revised_supplementary_Table_2_for_IJSP for Mental health indicators in APEC by Michael Kron, Rupinder Grewal, John Idso, Michael Prough, Cassandra Sundaram, Scott Klein, John Nida, Desmond Jumbam and Kaya Garringer in International Journal of Social Psychiatry

Supplemental Material

Supplementary_File_Table_3 – Supplemental material for Mental health indicators in APEC

Supplemental material, Supplementary_File_Table_3 for Mental health indicators in APEC by Michael Kron, Rupinder Grewal, John Idso, Michael Prough, Cassandra Sundaram, Scott Klein, John Nida, Desmond Jumbam and Kaya Garringer in International Journal of Social Psychiatry

Footnotes

Acknowledgements

We wish to acknowledge the World Health Organization, Department of Mental Health through Dr. Dan Chisholm for access to data from the 2014 WHO Mental Health Atlas.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

ORCID iD

Michael Kron

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Supplementary Material

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