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STUDY GUIDE FOR AMSA-UNDIP MINI MUN

TOPIC: RESPONDING MENTAL DISORDERS AND DEPRESSION AS GLOBAL


PUBLIC HEALTH CHALLENGE1
A. INTRODUCTION TO WORLD HEALTH ORGANIZATIOINS
When diplomats met to form the United Nations in 1945, one of the things they
discussed was setting up a global health organization. World Health Organization (WHO)
firmly committed to the principles set out in the preamble to the Constitution. It was adopted
by the International Health Conference held in New York from 19 June to 22 July 1946 by
the representatives of 61 States and entered into force on 7 April 1948 – a date we now
celebrate every year as World Health Day.
As a specialized agency of the UN system, WHO is firmly committed to the following
ethical principles:
 Integrity: To behave in accordance with ethical principles, and act in good faith,
intellectual honesty and fairness.
 Accountability: To take responsibility for one’s actions, decisions and their
consequences.
 Independence and impartiality: To conduct oneself with the interests of WHO only
in view and under the sole authority of the Director-General, and to ensure that
personal views and convictions do not compromise ethical principles, official duties
or the interests of WHO.
 Respect: To respect the dignity, worth, equality, diversity and privacy of all persons.
 Professional Commitment: To demonstrate a high level of professionalism and
loyalty to the Organization, its mandate and objectives (WHO, 2018).

More than 7000 people from more than 150 countries work for the Organization in
150 WHO offices in countries, territories and areas, six regional offices, at the Global Service
Centre in Malaysia and at the headquarters in Geneva, Switzerland. In addition to medical
doctors, public health specialists, scientists and epidemiologists, WHO staff include people
trained to manage administrative, financial, and information systems, as well as experts in the
fields of health statistics, economics and emergency relief.
WHO is the directing and coordinating authority on international health within the United
Nations’ system. It is done by:

1
Composed by Indra Setiawan, Amelia Titisari, and Ester Elisabeth.
 Providing leadership on matters critical to health and engaging in partnerships where
joint actions is needed;
 Shaping the research agenda and stimulating the generation, translation and
dissemination of valuable knowledge;
 Setting norms and standards and promoting and monitoring their implementation;
 Articulating ethical and evidence-based policy options;
 Providing technical support, catalyzing change, and building sustainable institutional
capacity; and
 Monitoring the health situation and assessing health trends (WHO, 2018).

In terms of areas of work, WHO have several concentration. Those concentration and
focuses are:
1. Health systems
WHO’s priority in the area of health systems is moving towards universal health coverage.
WHO works together with policy-makers, global health partners, civil society, academia and
the private sector to support countries to develop, implement and monitor solid national
health plans. In addition, WHO supports countries to assure the availability of equitable
integrated people-centered health services at an affordable price; facilitate access to
affordable, safe and effective health technologies; and to strengthen health information
systems and evidence-based policy-making.
2. Non-communicable diseases
Non-communicable diseases (NCDs), including heart disease, stroke, cancer, diabetes and
chronic lung disease, and mental health conditions - together with violence and injuries - are
collectively responsible for more than 70% of all deaths worldwide. Eight out of 10 of these
deaths occur in low- and middle-income countries. The consequences of these diseases reach
beyond the health sector and solutions require more than a system that prevents and treats
disease.
3. Promoting health through life-course
Promoting good health through the life-course cuts across all work done by WHO, and takes
into account the need to address environment risks and social determinants of health, as well
as gender, equity and human rights. The work in this biennium has a crucial focus on
finishing the agenda of the Millennium Development Goals and reducing disparities between
and within countries.
4. Communicable diseases
WHO is working with countries to increase and sustain access to prevention, treatment and
care for HIV, tuberculosis, malaria and neglected tropical diseases and to reduce vaccine-
preventable diseases. MDG 6 (combat HIV/AIDS, malaria and other diseases) has driven
remarkable progress but much work remains.
5. Preparedness, surveillance and response
During emergencies, WHO’s operational role includes leading and coordinating the health
response in support of countries, undertaking risk assessments, identifying priorities and
setting strategies, providing critical technical guidance, supplies and financial resources as
well as monitoring the health situation. WHO also helps countries to strengthen their national
core capacities for emergency risk management to prevent, prepare for, respond to, and
recover from emergencies due to any hazard that pose a threat to human health security.
6. Corporate services
Corporate services provide the enabling functions, tools and resources that makes all of this
work possible. For example, corporate services encompass governing bodies convening
Member States for policymaking, the legal team advising during the development of
international treaties, communications staff helping disseminate health information, human
resources bringing in some of the world’s best public health experts or building services
providing the space and the tools for around 7000 staff to perform their work in 1 of WHO’s
more than 150 offices (WHO, 2018).

On May 26 2017, WHO has made extraordinary progress in its bold reform agenda
over the past decade. Innovative leadership, managerial structures and systems have resulted
in increased effectiveness, efficiency, responsiveness, transparency and accountability. WHO
is reforming to be better equipped to address the increasingly complex challenges of health in
the 21st century. From persisting problems to new and emerging public health threats, WHO
needs the capability and flexibility to respond to this evolving environment. Reform has three
aims: programmatic reform to improve people’s health; governance reform to increase
coherence in global health, and; managerial reform in pursuit of organizational excellence.

B. BACKGROUND PROBLEM OF DEPRESSION AND MENTAL DISORDERS


For many years mental health and mental illness have been left unattended due to
relentless stigma which only recently has begun to subside. With an increasing number of
approximately 450 million people suffering from some sort of mental illness it has become
obvious issues with mental health and mental disorders are now one of the leading causes of
disability and ill-health across the globe (NAMI: 2015). Mental disorders affect a myriad of
parties, ranging from individuals, families and government, in particular. Due to the
aforementioned stigma, two thirds of people with a mental disorder never seek proper
medical care (WHO: 2001) . Consequently, properly acting upon this issue has become
progressively harder over the years despite unprecedented development in varying kinds of
treatments and medical knowledge. Effective treatment however is often very difficult for the
average person to afford as it is more often than not, supplied by the private sector in the
form of rehabilitation centers/programs, prescription drugs, and service form psychiatrists
and psychologists. Low-income families often deal with the issue of not being able to afford
these forms of treatment (WHO: 2001). Government provided treatment is often inadequate
as they tend to create large mental institutions, which fail to treat individuals sufficiently.
Each case of a mental disorder is different to the next thus grouping together patients is
highly ineffective and quite often, counter productive, as it often has adverse effects on their
health and often isolates them from their families and the rest of society.

Prior to 1991, the issues of mental were not widely discussed of. At that time and
prior to the 90s, talking about mental health was avoided to the point patients with mental
illnesses did not receive proper medical treatment as they should have. Besides conversation
on mental health being “taboo” there also was an extensive lack of medical and scientific
research on the matter, which meant patients who were being treated were often being treated
incorrectly. Throughout the 18th century and up until the mid to late 19th century treatment
of mental disorders was inhumane. Conducted in what was called at the time “Insane
asylums” ,treatments were drastic ranging from electroshock therapy to lobotomies. With a
massive influx of mentally ill individuals after World War 1 and World War 2 the asylums
quickly flooded and experimentation on a vulnerable population continued until the mid to
late 19th century where asylums started getting shut down due to public outcry about the
horror stories coming out of them. Around this time proper scientific theories began to
emerge about how to help mentally ill people, predominantly because of the work of figures
such as Sigmund Freud6 and B. F. Skinner. By the 20th century, enough groundwork had
been laid to set the path for more scientifically supported and effective methods of treatment.
(ABC: 2016)

The number of Mental illness cases has been steadily increasing over the years at a
relatively concerning rate affecting people of all ages, incomes, and backgrounds
indiscriminately. The the vast majority of chronic cases of mental illness are manifesr by age
of 24 (75% of all cases to be exact) meaning that the majority of the young global population
suffers from some sort of mental illness, be it a mood disorder, anxiety disorder or behavioral
disorder (NAMI: 2015). Naturally this has an adverse effect on their education and
subsequently their overall future as mental illness tends to prevent active contribution to
society, lead to difficulty with employment, and challenge their physical health and
relationships (Corrigan: 2014) .With evidence showing that a mental illness in someone's
early life may possibly lead to substance abuse later on in their life, it goes without saying
that the effects of mental illness have a broad and deep effect on someone's life. Additionally,
90%10 of the roughly 800,00011 suicides every year involve an individual with some kind of
underlying mental illness (WHO: 2013). These numbers are only escalating day by day and
renders preventive measures and proper medical treatment urgent needs.

One of the main contributors to the growth of this issue is lack of action and
legislation for nations governments (WHO: 2001). Despite the burden that mental disorders
befall all nations, communities and societies - 40% of countries don't have any sort of mental
health policy, 30% don't have a mental health program and roughly one-fourth doesn't even
have mental health legislation. Out of the nations that do have the necessary programs and
legislation, 66% spend just or less than 1% of their annual budgets on mental health, and 25%
of countries don't even have the three most common prescription drugs for depression and
schizophrenia. Ultimately, this signifies that without state provided care or proper legislation
in place to make this kind of treatment and medication affordable, 50.1% of the people
simply cannot afford to acquire the medication they need (WHO: 2013). As mentioned
beforehand,due to lack of government support or even old fashioned practices, treatment is
now generally provided by the private sector be it though rehabilitation centers/programs or
services through psychiatrists and psychologists and prescription medication. The existence
of this sector stands to benefit the public as it provides specialized treatments, access to more
types of medications and even priority support where you won't be put on a waiting list. Yet,
the expense still remains, only emphasizing the need for improved government support and
legislation.
C. GUIDE ON DEFINING THE PROBLEM

To limit the discussion, this simulation will refer on three main issues in regards to
mental health: depression, anxiety disorders and other common mental. The definition of
each issue is as follow:

a. Depressive Disorder: characterized by sadness, loss of interest or pleasure, feelings


of guilt or low selfworth, disturbed sleep or appetite, feelings of tiredness, and poor
concentration. Depression can be longlasting or recurrent, substantially impairing
an individual’s ability to function at work or school or cope with daily life. At its
most severe, depression can lead to suicide. Depressive disorders include two main
sub-categories:
a. major depressive disorder / depressive episode, which involves symptoms
such as depressed mood, loss of interest and enjoyment, and decreased
energy; depending on the number and severity of symptoms, a depressive
episode can be categorized as mild, moderate, or severe; and
b. dysthymia, a persistent or chronic form of mild depression; the symptoms of
dysthymia are similar to depressive episode, but tend to be less intense and
last longer.
b. Anxiety disorders refer to a group of mental disorders characterized by feelings of
anxiety and fear, including generalised anxiety disorder (GAD), panic disorder,
phobias, social anxiety disorder, obsessive-compulsive disorder (OCD) and post-
traumatic stress disorder (PTSD). As with depression, symptoms can range from
mild to severe. The duration of symptoms typically experienced by people with
anxiety disorders makes it more a chronic than episodic disorder.
c. Common mental disorders refer to a range of anxiety and depressive disorders.

D. THE CURRENT STATUS QUO OF DEPRESSION AND OTHER COMMON


MENTAL DISORDERS
I. Statistics on People with Depression and Other Common Mental Disorders

The discussion in this simulation will focus on three main issues in regards to mental
health: depression, anxiety disorder, and other common mental discussion. Therefore, each
countries representative is expected to narrow any topics or questions to those three types of
issue. This section will further explain the comparison of each issue statistically to define the
current situation of the problem and eventually to be considered as the basis to formulate
appropriate actions and solutions to be implemented. However, this section will merely
emphasize on the statistic of depression, as the explanation on anxiety disorder and other
common mental disorders are most likely the same as depression. The differences are merely
found on the definition of each issue and the number of people who suffer that slightly
different.

The latest data from World Health Organization (WHO) estimates that the total
number of people suffered from depression exceed 300 million or 4.4% of total global
population. This number has increased gradually from previous findings and in 2020,
according to Reddy (2010), depression is projected to reach second place in the ranking of
Disability Adjusted Life Years (DALY)2 calculated for all ages. He further explained that
currently depression is the second cause of DALYs in the age category 15-44 years. This data
has certainly proven that the issue of public health, especially those regards with depression
and mental disorders will get even more challenging in the next few years.

Of 300 million people suffering depression, nearly half of these people live in the
South-East Asia Region and Western Pacific Region, reflecting the relatively larger
populations of those two Regions (WHO 2017). Other than those aforementioned regions, the
high number of depression cases is found in Mediterranean region and African region. The
former comprises about 16 % of total people with depression and the latter about 9 % of the
total. One of the reasons behind the prominent finding of depression and mental disorders in
those regions is the socioeconomic condition of the countries. Those regions mostly consist
of developing countries where the healthcare conditions are not as advanced as what
developed countries possess. Sami et al. explains the correlation between socioeconomic
condition in developing countries with the rate of depression and mental disorders as follow,

“Major increase in mental health problem will occur in the low-and-middle-


income countries (LMICs) (Prince et al., 2007), due to the unavailability and
inaccessibility of mental health treatment. Furthermore, lack of data available
to aid in the evaluation of the quality or effectiveness of treatments among the
minorities who received mental health care especially in low-and middle-
income countries (LMICs). This is also accompanied by the shortage of mental
healthcare professional, trainings, inaccurate empirical evaluation of
innovative, scalable models of care delivery as well as the inadequate political

2
The disability-adjusted life year (DALY) is a summary health measure that combines mortality and
morbidity into a single measure as a way to estimate global disease burden and the effectiveness of
health interventions (Chen et al., 2015).
will to substantiate research, policy, training and infrastructure development
as a priority at national, regional and multinational level leads to the mental
health problems (Becker & Kleinman, 2013). Less emphasis and priority is
given on mental health care in LMICs, including Asia (Sharan et al., 2009;
World Health Organization, 2007).” (Sami et al., 2015)
The chart below shows the division of number of depressive disorder found in each region,

Figure 1. Cases of Depressive Disorder by WHO Region (WHO 2017)

Depression can also be perceived through gender-based perspective. WHO found that
females are more prone to depression and mental disorder than male. According to the study
undertaken by Prof. Daniel Freeman, a professor of Psychology in Oxford University, women
are approximately 75% more likely than men to report having recently suffered from
depression, and around 60% more likely to report an anxiety disorder (The Guardian 2017).
The rationale on why women possess higher prevalence of depression is explained by Albert
(2015) who argues that it stems from biological sex differences and depend less on race,
culture, diet, education and numerous other potentially confounding social and economic
factors. The chart below shows the prevalence of depressive disorders among male and
female,
Figure 2. Global Prevalence of Depressive Disorders by Age and Sex (WHO
2017)

II. The Global Cost of Depression and Mental Disorders

Depression and mental disorders is indeed the health problem that is usually perceived
as a personal or individual problem. However, it is undeniable that high number of people
with depression or mental disorders in a society can potentially be detrimental to many
aspects of life in a country. Mental disorders are therefore by no means limited to a small
group of predisposed individuals but are a major public health problem with marked
consequences for society (Trautmann et al., 2016). One of the common consequences that is
widely discussed and debated is the economic consequences of mental disorders.

In order to give an in-depth understanding on the economic consequences of mental


disorder, various approaches are being introduced. The first approach is human capital
approach, which is most commonly used to quantify the economic costs of mental disorders
and disease in general, distinguishes between direct and indirect costs (Trautmann et al.,
2016). The major idea behind this approach is that economic growth depends on labor and
capital, both of which can be negatively influenced by disease. Capital is depleted by
healthcare expenditures, and labor is depleted by disability and mortality. Based on data from
2010, the global direct and indirect economic costs of mental disorders were estimated at
US$2.5 trillion. Importantly, the indirect costs (US$1.7 trillion) are much higher than the
direct costs (US$0.8 trillion).

The second approach is economic growth approach that mainly argues that mental
disorders in society causes lost economic growth in a country. The major idea behind this
approach is that economic growth depends on labor and capital, both of which can be
negatively influenced by disease. Between 2011 and 2030, the cumulative economic output
loss associated with mental disorders is thereby projected to US$ 16.3 trillion worldwide,
making the economic output loss related to mental disorders comparable to that of
cardiovascu-lar diseases, and higher than that of cancer, chronic respiratory diseases, and
diabetes.

The broadest approach used for calculating the economic impact of mental disorders
is the value of statistical life (VSL) method. This method assumes that tradeoffs between
risks and money can be used to quantify the risk of disability or death associated with mental
disorders. Using the VSL approach, the global economic burden of mental disorders was
estimated at US$8.5 trillion in 2010. Similar to the impact on economic growth, this estimate
is comparable to that of cardiovascular diseases and higher than that of cancer, chronic
respiratory diseases, and diabetes. This economic burden is also expected to almost double
until 2030.

Figure 3. Determining the Economic Consequences of Mental Disorders


III. Special Case: Depression and Mental Disorders in Conflicted Areas

In the contemporary era, wars and conflicts are still waging in many part of the world,
causing chaotic situations and continuous suffering among human beings. In such situation,
depression and mental disorders are certainly health problems that can commonly be found.
WHO estimates that, during emergencies, the prevalence of severe mental illnesses, such as
psychosis and severe forms of depression increases by 3–4%, and the prevalence of mild to
moderate mental disorders, such as depression and anxiety, increases by 15–20% (WHO
2016). With limited health access caused by risky and critical situations, the treatment of
depression and mental disorder during the conflict can be very problematic.

The problem of depression and mental disorders in conflicted area are usually found
in refugees. The United Nations estimate that over 65 million persons worldwide are
currently displaced by war, armed conflict or persecution (Silove et al., 2017). Several studies
have clearly demonstrated that refugees are at an increased risk of mental health disorders,
particularly post-traumatic stress disorder (PTSD) and depression (Naja et al., 2016).
Exposure to torture and the total number of trauma events experienced emerged as the
strongest predictors of PTSD and depression, respectively (Silove et al., 2017). One of the
examples of refugees suffering from depression and mental disorder is Syrian refugees. The
study undertaken by Naja et al. (2016) has concluded that 40-45% Syrian war migrants are
suffering depression during their time of settlement. The situation is getting worse as the host
countries are usually giving limited health access to the refugees, including the access to seek
help for depression.

The impediment in giving mental health care to refugees is not only caused by limited
health access, but also other factors such as language and culture. Giacco and Priebe from
European Union review some of the challenges faced in providing mental health care to
refugees as follow,

a. Language barriers: many refugees have a poor command of the language of the
host country, requiring an interpreter during consultations. Even if interpretation is
available, the lack of direct communication may complicate proper assessments.
b. Belief systems: different belief systems may hinder mental health assessments and
conflict with the practitioners’ understanding, such as the possible tendency to
seek physical explanations for psychological problems.
c. Cultural expectations: refugees may have different views on what to expect from
mental health care and on what kind of information they want to disclose. This
may impact on whether they accept a mental health diagnosis and the consequent
treatment.
d. Establishing trust: Refugees may be particularly distrustful of services and
authorities because of previous experiences in their country of origin. Moreover,
they may be unfamiliar with the health care system in the host country, in
particular with the way mental health care works.

E. PAST INTERNATIONAL ACTIONS

The WHO has done numerous actions in addressing the global issue of depression and
other mental disorders through international health campaigns, programs, and researches.

WHO Mental Health Gap Action Programme (mhGAP)

Mental, neurological, and substance use disorders are common in all regions of the
world, affecting every community and age group across all income countries. While 14% of
the global burden of disease is attributed to these disorders, most of the people affected - 75%
in many low-income countries - do not have access to the treatment they need. The WHO
Mental Health Gap Action Programme (mhGAP) aims at scaling up services for mental,
neurological and substance use disorders for countries especially with low- and middle-
income. The programme asserts that with proper care, psychosocial assistance and
medication, tens of millions could be treated for depression, schizophrenia, and epilepsy,
prevented from suicide and begin to lead normal lives– even where resources are scarce. The
mhGAP Forum was held on October 9-10, 2018 in the WHO Headquarter at Geneva. The
two days of activities in the Forum provided an opportunity for a diverse group of
stakeholders to discuss a variety of themes, all related to the implementation of WHO’s
Mental Health Action Plan 2013-2020. The Forum also discussed specific commitments from
partners towards implementing the Action Plan. There also was time available for informal
networking. (WHO 2018)
mhGAP Intervention Guide

The mhGAP Intervention Guide (mhGAP-IG) for mental, neurological and substance
use disorders for non-specialist health settings, is a technical tool developed by WHO to
assist in implementation of mhGAP. The Intervention Guide has been developed through a
systematic review of evidence followed by an international consultative and participatory
process. The mhGAP-IG presents integrated management of priority conditions using
protocols for clinical decision-making. The priority conditions included are: depression,
psychosis, bipolar disorders, epilepsy, developmental and behavioral disorders in children
and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and
other significant emotional or medically unexplained complaints. The mhGAP-IG is a model
guide and has been developed for use by health-care providers working in non-specialized
health-care settings after adaptation for national and local needs. (WHO 2018)

Mental Health Action Plan 2013-2020

The 66th World Health Assembly, consisting of Ministers of Health of 194 Member
States, adopted the WHO’s Comprehensive Mental Health Action Plan 2013-2020 in May
2013. The action plan recognizes the essential role of mental health in achieving health for all
people. It is based on a life-course approach, aims to achieve equity through universal health
coverage and stresses the importance of prevention. Four major objectives are set forth: more
effective leadership and governance for mental health; the provision of comprehensive,
integrated mental health and social care services in community-based settings;
implementation of strategies for promotion and prevention; and strengthened information
systems, evidence and research. (WHO 2018)

Preventing Suicide: A Global Imperative (Publication)


Every 40 seconds a person dies by suicide somewhere in the world. Over 800 000
people die by suicide every year. Yet suicides are preventable. “Preventing suicide: a global
imperative” is the first WHO report of its kind. It aims to increase awareness of the public
health significance of suicide and suicide attempts, to make suicide prevention a higher
priority on the global public health agenda, and to encourage and support countries to
develop or strengthen comprehensive suicide prevention strategies in a multi-sectoral public
health approach. The report provides a global knowledge base on suicide and suicide attempts
as well as actionable steps for countries based on their current resources and context to move
forward in suicide prevention. (WHO 2018)

World Health Day 2017 Campaign


World Health Day, celebrated on 7 April every year to mark the anniversary of the
founding of the World Health Organization, provides WHO with a unique opportunity to
mobilize action around a specific health topic of concern to people all over the world. The
theme of WHO’s 2017 World Health Day campaign is depression. The interest has been
phenomenal, with close to 2 million visits to the campaign’s website and more than 300
activities in 76 countries was registered on the campaign’s app. The overall goal of this one-
year campaign, beginning on 10 October 2016, World Mental Health Day, is that more
people with depression, in all countries, seek and get help. At the core of the campaign is the
importance of talking about depression as a vital component of recovery. The stigma
surrounding mental illness, including depression, remains a barrier to people seeking help
throughout the world. Talking about depression, whether with a family member, friend or
medical professional; in larger groups, for example in schools, the workplace and social
settings; or in the public domain, in the news media, blogs or social media, helps break down
this stigma, ultimately leading to more people seeking help. (WHO 2018)

QUESTIONS A RESOLUTION MUST ANSWER

1. How can the international community contribute in lowering the number of


depression?
2. What is the most appropriate strategy to eliminate stigma surrounding mental health
while also increase access to the medical treatment thereof?
3. What is the loophole of previous actions? How can international community
overcome the loophole?
4. What is the suitable strategy to cope with depression and mental disorders in
conflicted areas?

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