Toward a Paradigm Shift on Mental Health in Latin America
Improving care, expanding access, and supporting resilience
An issue brief produced by FP Analytics with support from Viatris.
FP Analytics retained control of the research direction and findings.
The COVID-19 pandemic has exposed and exacerbated existing health challenges across the globe, demonstrating the need for resilient health systems to address communicable and non-communicable diseases (NCDs). NCDs represent the greatest challenge facing health systems globally, projected to account for 75 percent of all deaths by 2030. In Latin America and the Caribbean (LAC), the proportion is even higher, with research suggesting that the top four NCDs alone—cardiovascular disease, cancer, chronic respiratory diseases, and diabetes—will account for 81 percent of all deaths by 2030. While physical ailments are the most commonly recognized NCDs, mental health conditions are increasingly acknowledged as a significant portion of the global NCD burden. Mental illness, neurological disorders, substance abuse, and suicide (MNSS) levy an immense, often undercounted, cost to people’s health. Measured in years lived with a disability (YLDs), mental illness is responsible for nearly one-third of all disability globally, and yet the 194 World Health Organization (WHO) member states devote an average of just 2 percent of health budgets to mental health. In short, mental health is an inextricable and underfunded part of the NCD challenge, with far-reaching social, economic, and health implications. Strategically and sustainably addressing NCDs will therefore require concomitant efforts to improve access to, and the outcomes of, mental health care. Given Latin American countries’ aging populations and economic stagnation, as well as COVID-19’s acute negative impact on health systems, the region warrants closer examination and understanding of the scope of mental illness and the multifaceted benefits of strengthening mental health care.
As with other NCDs, effective strategies for treating mental illness are known but generally underfunded or unavailable to many people around the world, particularly in lower- and middle-income countries (LMICs)—which constitute 17 of Latin America’s 21 economies—and in poor regions of high-income countries. This gap in mental health care represents a major impediment to adequately addressing the basic needs and human rights of people everywhere. Supporting better mental health is fundamental to achieving universal health coverage (UHC), as laid out in initiatives such as UHC2030 and the UN High-Level Meeting on UHC 2023, which seek to ensure quality health care for all, without risk of financial burden. But addressing mental illness is not just a health-specific goal—it is integral to achieving all 17 of the United Nations’ Sustainable Development Goals (SDGs), as well as to the rights outlined in landmark international commitments such as the Universal Declaration of Human Rights and the Convention on the Rights of Persons with Disabilities.
Efforts to address mental health can be reconceptualized as not just a sound investment in the future but as inseparable from tackling the greater NCD challenge and providing quality health care to all.
Beyond the moral and ethical rationales for investing in mental health, there are strong economic and social cases driven by higher quality of life, more resilient communities, and restored productivity—critical elements of healthy, sustainable societies. Mental health can no longer be relegated to an afterthought in efforts to address the global NCD challenge. In Latin America, as elsewhere, mental health can be elevated with continued advocacy, targeted resourcing, comprehensive policies, and cross-sectoral cooperation. As this issue brief demonstrates, efforts to address mental health can be reconceptualized as not just a sound investment in the future but as inseparable from tackling the greater NCD challenge and providing quality health care to all.
The Scope of the Mental Health Burden
Alongside major NCDs that drive early mortality, such as cardiovascular disease and cancer, mental health is often treated as a secondary or less-pressing priority, but data increasingly shows the true scale of the mental health burden. While prevalence estimates of mental illness generally rely on national surveys and studies of variable quality, they are enough to produce a rough image of the burden of mental illness worldwide, though these figures may still represent an undercount. According to the WHO, close to one billion people around the world had a diagnosable mental disorder in 2022, 82 percent of whom were in LMICs. As of 2019, this included an estimated 280 million people living with depression, and 300 million people living with anxiety, and as of 2021, more than 700,000 deaths each year could be attributed to suicide. COVID-19 only increased these impacts, with the WHO estimating that the pandemic increased the prevalence of anxiety and depression by 25 percent worldwide during its first year. This global burden is made worse by the knowledge that fairly effective treatments exist but are often not available to those who need them. In low-income countries, as much as 75 percent of people who have a mental disorder do not receive treatment, and in some counties, the treatment gap for people with severe mental health conditions, such as schizophrenia and bipolar disorder, reaches as high as 90 percent. Together, mental health conditions levy an enormous cost in terms of poor health and reduced productivity, projected to reach as high as $6 trillion annually by 2030 globally—more than the costs of cancer, diabetes, and chronic respiratory diseases combined.
Together, mental health conditions levy an enormous cost in terms of poor health and reduced productivity, projected to reach as high as $6 trillion annually by 2030 globally—more than the costs of cancer, diabetes, and chronic respiratory diseases combined.
Mental Health Disease Burden in Latin America, 2020
Mental illness accounts for roughly a third of all YLDs in the region, with the most acute impacts reported in Brazil, Chile, and Argentina.
A Note on Measuring the Impact of Mental Health: YLDs vs. DALYs: Studies vary on the metrics used to gauge the impact of mental illness. Years lived with disability (YLDs) often show a higher disease burden than disability-adjusted life years (DALYs), a measure that combines YLDs with years of life lost (YLLs). The Pan-American Health Organization (PAHO) argues that DALYs tend to underestimate the disease burden from mental illness, because death is rarely attributed to mental illness, and that YLDs therefore provide a less-biased means of comparison for disability across diseases. For example, although mental illness is a common driver of suicide, suicide is often classified as an “injury” rather than a death due to a mental illness.
Mental Health as Percentage of All YLDs and DALYs in Latin America, 2020
Data source: PAHO, Burden of Mental Health Disorders in the Americas: Country Profiles, 2020.
These trends hold true in the Americas. In 2019, 15.6 percent of people in the Americas, including North and South America, had a mental health disorder, the highest proportion of any WHO region, and MNSS accounted for one-third of total YLDs in the region as well as a fifth of all disability-adjusted life years (DALYs) (see note above). In Latin America specifically, MNSS exhibits a varied prevalence reflective of the diverse country contexts at play. In a 2017 study, the WHO concluded that Brazil had the highest rates of anxiety in the world (9.3 percent of the population) and the fifth-highest rates of depression (5.8 percent of the population). Data from the Pan-American Health Organization (PAHO) shows that as of 2020, 37.6 percent of all YLDs in Brazil can be attributed to MNSS, the highest proportion in Latin America, followed by Chile (37.0 percent), Argentina (36.4 percent), and Nicaragua (36.2 percent). When measured in DALYs, Chile leads the region (23.9 percent), followed by Costa Rica (21.9 percent), Nicaragua (21.2 percent), and Cuba (19.6 percent). As in other global regions, the most impacted demographic groups include adolescents, women (particularly during pregnancy), older adults, LGBTQI+ individuals, and groups experiencing traumatic life events, such as displacement or conflict.
Increasing Access to Mental Health Professionals across Brazil
Amid some of the world’s highest prevalence rates of anxiety and depression, Brazil suffers from a continued deficit of mental health care professionals. In Brazil and many other LMICs, a number of factors deter medical professionals from specializing in mental health, including poor remuneration, stigma against the profession, high job dissatisfaction, inadequate training opportunities, and lack of resources. The WHO’s Mental Health Atlas estimated that there were just 3.7 psychiatrists for every 100,000 people in Brazil in 2020. While historic projections suggested that 10 psychiatrists per 100,000 people was the minimum level needed to address mental illness in any given country, that baseline is thought to be far higher today as awareness of low mental health indicators and inadequate access grows. Many OECD countries have more than 20 psychiatrists per 100,000 people, but that still may be insufficient to address gaps in care and safeguard mental health alongside prevention of NCDs or strengthening of primary health care. Brazil further suffers from an uneven distribution of mental health care professionals, with some regions in the north having as few as 0.7 psychiatrists per 100,000 inhabitants, according to one 2014 estimate. The Brazilian government has been working to address this shortage, including through the More Doctors Programme (Programa Mais Médicos)). At its launch in 2013 the program provided resources to recruit 16,000 primary care doctors, including psychiatrists, and it was recently relaunched by the Lula administration, with 15,000 new vacancies for physicians. This effort was supplemented in 2020 with the launch of the Doctors around Brazil Programme (Programa Médicos pelo Brasil), which specifically targets vulnerable and remote populations. Through its support to Brazil’s Unified Health System (SUS), which is responsible for the country’s psychosocial care centers (Centros de Atenção Psicossocial, or CAPS), the program is set to serve 4,875 municipalities and 34 special Indigenous health districts, which will expand access and capacity significantly once they are implemented.
Percentage of Physicians with Specialties in Psychiatry in Select Countries, 2019
Data source: Demografia Médica no Brasil 2020.
Like other regions, Latin America experiences substantial treatment gaps for MNSS, largely due to a lack of adequate funding. In 2018, PAHO found that the proportion of disease burden attributable to MNSS in the Americas is six times the proportion of public health funds devoted to mental health issues. For adults with moderate and severe disorders, the median treatment gap—meaning the median percentage of people with mental illness who do not get treatment—is 47.2 percent in North America but 77.9 percent in Latin America and the Caribbean. The gaps for specific diseases include 56.9 percent for schizophrenia, 73.9 percent for depression, and 85.1 percent for alcohol abuse. Some 60 percent of funding for mental health services in Latin America still goes toward psychiatric hospitals, which modern best practices regard as generally ineffective for treating mental illness, and which in some cases may even exacerbate mental conditions.
Mental Health and UHC in Chile
As part of broader health reforms in 2005, Chile introduced Acceso Universal con Garantías Explícitas (GES), a UHC package that includes both medical and psychosocial benefits. It guarantees access to quality health coverage for over 85 diagnoses, with attention paid to providing equal access to beneficiaries in public and private health care settings and to integrating mental health with primary care at the local level. Today, 80 percent of those who seek mental health care from GES receive treatment from primary care providers, and mental health coverage for the lowest income quintile has increased by 20 percent.
Number of Psychiatrists in Chile per 100,000 people, 2010–2021
In the context of the dual challenge posed by mental illness and other NCDs in Latin America and around the world, it is also critical to highlight the close, bidirectional relationship between such diseases. People with NCDs often suffer from co-morbidities, with the presence of NCDs such as cardiovascular disease, cancer, and diabetes increasing the likelihood of mental illness, and the presence of mental illness linked to higher rates of NCDs. For example, adults who have an NCD have been found to be two to three times more likely to develop depression, and individuals who have anxiety disorders are 2.2 times more likely to have heart disease. As a result, effective UHC is contingent upon addressing both elements simultaneously. To change the narrative on mental illness, the world needs to recognize the immense costs it levies alongside other NCDs, and to reconceptualize the cost of treatment as an investment in overall well-being and health with straightforward, substantial returns.
The Economic and Social Returns of Investing in Mental Health
Fully grasping the scope of mental illness requires looking beyond the immediate health impacts to understand the varied economic and social costs that it poses. These costs most obviously accrue to individuals, as they suffer from lower quality of life, unemployment and underemployment, stigma, exclusion, loss of opportunity (including forgone education), and risks of falling into poverty. However, families and caregivers also face costs due to the time, stress, and resources involved in providing care, as do larger communities and societies, which, in the absence of adequate preventative care for mental health, must spend additional resources for health care and support systems and end up with lower overall productivity. A 2022 study by The Lancet Clinical Medicine estimated that mental disorders may lead to as much as $5 trillion in annual economic losses worldwide, including the equivalent of 7.6 percent of GDP in Tropical Latin America, 5.7 percent in Central Latin America, and 5.0 percent in Andean Latin America.
Given such high costs, a compelling economic case for investing in mental health emerges. When conceptualized as a return on investment (ROI), each dollar spent on mental health could more than pay for itself. For example, investments to scale up treatment for anxiety and depression globally are likely to yield an ROI of around 4 to 1, a result of restored healthy years of life and economic productivity gains. In Latin America, like elsewhere, these efforts most clearly entail expanding community-based access to basic mental health resources, trained mental health professionals, and medication, which are lacking in the region. Diagnosing and treating mental health challenges earlier in the life course can yield even greater, multifold benefits. For example, investing in parenting programs for children who are at risk of developing a mental health condition has been shown to yield a return of up to 9 to 1. Elsewhere, interventions in the most severe cases of mental illness, such as hospital-presenting cases of self-harm, can yield returns as high as 15 to 1.
Peru’s Success in Adopting Community-Based Care
As much as 60 percent of mental health spending in Latin America still goes to psychiatric hospitals, despite extensive evidence and research showing that such institutions are almost always ineffective at addressing mental health issues, and may actually serve to exacerbate them. Recognizing this, Peru began shifting funding from such institutions to community-based care in 2013, including the incorporation of mental health services in Peru’s Integrated Health Insurance scheme (SIS) and a 10-year budget put in place by the Ministry of Economy and Finance in 2014 to support community-based mental health services and expand mental health resources more broadly. Mental health service coverage has expanded as a result. In 2009, 9 percent of Peruvians were receiving the mental health care they needed. By 2018, that figure had risen to 26 percent. Additionally, the country went from just 23 community mental health centers in 2015 to 208 in 2021.
Peru’s Mental Health Workforce per 100,000 people, 2015–2021
Data source: WHO, World Mental Health Report, 2022.
Addressing mental health benefits an individual’s life, their household and community, and society at large. At an individual level, treating mental illness and improving quality of life, for patients and caregivers alike, can help ensure fulfilling and happy lives. Mental health is tied to society-wide development goals, such as SDG 1 (eliminating poverty), SDG 4 (access to quality education), and SDG 10 (reduced inequality), as well as universal human rights such as the right to an adequate standard of living, enshrined in the UN Declaration on Human Rights. Effective mental health treatment doubly improves economic outcomes by reducing spending on health and enabling higher earnings, helping to alleviate the vicious cycle between mental illness and poverty. In Mexico and Colombia, for example, studies have shown that multidimensional poverty leads to higher rates of depressive symptoms. Investments in mental health can help break this cycle, forming the foundation for wider change.
Preventative care for mental illness can also help reduce overall health care utilization by reducing the prevalence and severity of cases, freeing up resources for other priorities. It can lead to more effective responses to other health challenges, such as communicable diseases, or more resources spent on other public goods, such as infrastructure, education, and research. Because the global health care industry accounts for around 4.4 percent of global greenhouse gas emissions, preventative mental health care can also help reduce carbon emissions and aid in the fight against climate change, which has been identified as a social determinant of mental health. Together, these varied benefits demonstrate the whole-of-society nature of the struggle against mental illness, as well as the vast scope of potential benefits.
Mental Health Challenges among Venezuelan Refugees
The plight of the millions of Venezuelan refugees who have moved across Latin America in the last decade helps demonstrate the region’s mental health challenges due to political upheaval. Displaced persons—fleeing political, economic, climatic, and other shocks—are likely to suffer acute and potentially long-term effects absent support for mental health services for both routine and extraordinary circumstances. For example, a 2020 study found that more than 20 percent of Venezuelan migrants living in Bogotá, Colombia, demonstrated signs of post-traumatic stress disorder (PTSD), compared to an estimated prevalence in the wider Colombian population of below 3 percent. Americares, a global health and disaster relief organization, has responded by operating 10 clinics to address the health concerns of Venezuelans travelling across the Colombian border, particularly focusing on mental health support and reproductive health services. In coordination with Colombia’s Ministry of Health and Social Protection, USAID, and the U.S. Department of State, Americares has administered 863,000 primary care and mental health consultations since August 2018.
Pathways to Improve Mental Health Outcomes
Given the society-wide impacts of mental illness, and the compounding benefits of better mental health care, there are clear imperatives for tackling this major health priority. Mental health needs to be reconceptualized as inseparable from the fight against other NCDs, such as cardiovascular disease, cancers, and diabetes, and therefore inseparable from the drive for UHC. Increased momentum for achieving UHC, led by efforts such as UHC2030 and the UN High-Level Meeting on UHC 2023, upholds the principle that everyone deserves access to the health care they need, when and where they need it, without suffering financial hardship, as outlined in SDG 3.8. The urgency of better mental health in this broader mission is perhaps best captured by the title of a recent report from the Global Mental Health Action Network: No Health Without Mental Health. Because treatment gaps for mental illness reach as high as 90 percent in some places, particularly in LMICs, and because of the prevalence of co-morbidities between mental disorders and other NCDs, making progress on the world’s largest driver of mortality will require parallel efforts through UHC programming to tackle chronic physical ailments hand in hand with mental illness.
There are several pathways that can be prioritized in Latin America, and beyond, to achieve a paradigm shift in the fight against mental illness and to bolster efforts on UHC worldwide:
Expand domestic resources for mental health: Above all else, countries in Latin America and around the world can devote more resources to mental health care and ensure that money is being well spent. In Latin America, countries such as Peru and Brazil have made efforts to shift from centralized, poorly equipped psychiatric institutions toward community-based care at a local level, buttressed by supportive communities. In addition to repurposing funding toward more effective strategies, governments should consider other means of domestic resource mobilization to fund mental health programs, such as taxes on substances like tobacco and alcohol, which also help to combat other NCDs. Expanded resources are critical for ensuring adequate availability of trained mental health professionals as well as access to low-cost pharmacological solutions.
Catalyze change through international donors: While local funding will form the foundation for long-term, sustainable health solutions, international funding from external donors can act as a catalyst to spur action in target areas. For example, the Health4Life Fund is a UN financing mechanism established in 2021 to help LMICs fight mental illness and other NCDs and strengthen health systems. By providing grants and encouraging changes to legislation, policies, and regulations, the fund seeks to save 39 million lives and realize $2.7 trillion dollars in economic benefits via an effort to mobilize and invest $250 million over its first five years.
Prioritize at-risk groups: Similar to the treatment of other NCDs, investment in mental health can yield the greatest impacts by targeting populations that are most at risk, such as pregnant women (one in five of whom will experience a mental health condition), Indigenous groups (for whom the treatment gap in Latin America is 80 percent), the elderly (one in four of whom experiences a mental disorder), adolescents (for whom the early development and mismanagement of mental illness can yield life-long impacts), and LGBTQI+ individuals (for example, lesbian, gay, and bisexual individuals are more than twice as likely to experience anxiety and depression as the heterosexual population). In these groups, there are often synergies between mental health and other health goals, such as providing mental support for mothers alongside maternal health services, monitoring for anxiety and depression among older adults suffering from other NCDs, or providing mental health services to refugees and internally displaced persons in tandem with other social support services.
Provide care through a multisectoral, life-course approach: Mental illness can appear in different forms throughout the life course—from infancy to old age—and health systems need flexible, dynamic options for providing comprehensive effective mental health services as part of primary care. As the WHO’s Comprehensive Mental Health Action Plan 2013–2030 acknowledges, a successful multisectoral approach to mental health will draw from across sectors, including health, education, housing, and employment, as well as from private-sector actors and international efforts. One such initiative is Singapore’s Response, Early Intervention and Assessment in Community Mental Health (REACH) program, which mobilizes multisectoral networks of care for youth at risk of mental illness. REACH teams of medical doctors, psychologists, therapists, and social workers work to build clinical expertise in mental health provision across a range of contexts, including hospitals, schools, and non-profits that provide community services.
Invest in data and research: Progress on mental health, as with other NCDs, is contingent on well-developed, standardized practices for gauging the scale of disease burden and the effectiveness of different responses. There is a dearth of quality data in Latin America and around the world, and the true impact of mental illness is often thought to be undercounted. Furthermore, not only is research in mental health grossly out of proportion with its overall disease burden, but just 10 percent of such research focuses on LMICs—which include 17 of Latin America’s 21 countries—and half of that research is still conducted by high-income countries. More resources are needed for localized research in LMICs—conducted by professionals in LMICs—to build a clear picture of the scope of mental illness across varied country, regional, and community contexts. One such effort, the Latin American Treatment and Innovation Network in Mental Health (LATIN-MH), coordinates research and training hubs in São Paulo, Brazil, and Lima, Peru, specializing in the comorbidities between chronic physical and mental diseases.
Expand education and awareness: To make sustainable, community-based care maximally effective and to leverage society-wide resources to respond to mental illness, concomitant efforts to expand awareness of mental health issues and counter stigmas are essential. In Latin America, for example, social stigma can stop patients from receiving care or living fulfilling lives and may also discourage medical professionals from working in mental health. Public campaigns, such as PAHO’s #DoYourShare campaign (called #FaçaSuaParte in Brazil), to educate people about disease can help shift perceptions, as can private-sector actors like Yo Quiero Yo Puedo, an NGO in Ciudad Juarez Mexico that works to fight stigma and encourage Mexicans to access care for mental illness.
Mental illness presents a major challenge to health system resilience, economic growth, and societal wellbeing in Latin America. These interventions represent just some of the options available to governments and health services on the continent to address, prevent, and treat mental illness. The rebuilding and strengthening of health systems in the wake of the devastating impacts of the COVID-19 pandemic, represent a pivotal moment to integrate mental health care, and NCD care more broadly, into Latin American health sectors.
Publication date: September 2023
By Phillip Meylan (Affiliate Researcher), Isabel Schmidt (Senior Policy Analyst), and Dr. Mayesha Alam (Vice President of Research). Illustration by Harol Bustos.
This issue brief was produced by FP Analytics with support from Viatris.
FP Analytics retained control of the research direction and findings. Foreign Policy’s editorial team was not involved in the creation of this content.