Mental health is an integral part of the sustainable development goals

This article draws attention to the role of mental health in most, if not all, of the 17 Sustainable Development Goals (SDGs). Reducing mental health problems and suffering is important in itself. In addition, good mental health is related to the ability to reach the SDGs, as the very definition of mental health reflects. The SDGs are universal, and mental health concern all, whether rich or poor. Moreover, the need for interdisciplinary and intersectoral solutions to reach the SDGs is highlighted, which provides a window of opportunity for mental health as this is a field where cooperation across sectors and professions is central. We argue that efforts to eradicate poverty, prevent conflicts and disasters, and promote education will not be successful unless mental health is prioritized. Poor mental health and unfulfilled human potential pose major risks to the changes that are needed if we are to reach the SDGs. Poverty, marginalization, violence, complex emergencies and violations of human rights threaten both human development and sustainable economic development, and constitute an important context for global mental health. For the first time, mental health is explicitly included in universally agreed goals, providing an opportunity to enhance mental health and wellbeing across countries and professional disciplines. To fully use this opportunity, care for people with mental illness and psychosocial disabilities, as well as promotion of resilience and mental health generally, must be prioritized.


Background
Mental health and psychosocial wellbeing were defined as an integral part of health by the WHO in 1978, and have been addressed in many UN resolutions. However, it is only recently that mental health has been included on the unified global agenda. When world leaders adopted the Sustainable Development Goals (SDGs) in 2015, they also committed to prioritize "prevention and treatment of non-communicable diseases, including behavioral development and neurological disorders, which constitute a major challenge to sustainable development" (http://www. who.int/mental_health/SDGs/en/).

The sustainable developmental goals
Built on the experiences of the Millennium Development Goals, the aim of the SDG agenda is to eradicate poverty and hunger; promote inclusion, human dignity and equality; protect the planet, promote growth; and foster peace and justice. The SDGs (Figure 1) consist of 17 goals with 169 targets. Specific reference is made to mental health and substance abuse under goal 3. Target 3.4 on premature mortality from non-communicable diseases aims for a reduction by "one third through prevention and treatment and promotion of mental health and wellbeing", and target 3.5 addresses prevention and treatment of substance abuse. Moreover, as pointed out by Izutsu et al. [1], the rights of people with disabilities are referred to specifically in goals 4, 8, 10, and 11, which is relevant for people with mental, intellectual, and psychosocial disabilities. The SDGs provide a rationale and a framework to address mental health from many perspectives with renewed urgency.
Universal goals that concern us all One aspect of the SDGs that is new is their universality, not merely being goals for poor countries. Likewise, mental health concerns us all. Even the richest countries, richest people, and most privileged families experience mental health problems and are confronted with the suffering associated with depression, suicide, or substance abuse. Another prominent aspect of the SDGs is that they are multisectoral, and that innovations and progress in one sector will impact another. In addition, in order to reach the goals, it will be necessary to collaborate across sectors and disciplines. Similarly, reaching the goals of promoting good mental health and wellbeing for all, and providing good and dignified treatment for those in need, require multidisciplinary cooperation. The solution will not only be found in the health sector. The final SDG goal is to ensure good partnerships. Partners for mental health include civil society, private sector, governments and nongovernmental organizations. Lessons from these partnerships may be applied for the overall SDG agenda.
The aim of this paper is therefore to review the SDGs from a mental health perspective, and discuss how improved mental health may support the efforts to reach all SDGs, and how progress towards the 17 goals might impact mental health.

Goals 1, 2 and 6: Eradicating poverty, hunger and poor sanitation
Mental health problems constitute an enormous burden to individuals and societies, both in terms of human suffering and economy. Depression alone has been estimated to affect 350 million persons, being the single largest contributor to years lived with disability [2]. More than 80% of people with mental disorders live in low and middle income countries (LMICs). Mental illness and substance abuse are major causes of disease burden, accounting for nearly 9 % and 17 % of the total burden of disease in LMICs [2]. At the same time it is estimated that approximately 80 % of people in LMIC with severe mental disorders receive no treatment (http://apps. who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf), often labelled the "mental health treatment gap".
Poverty directly affects mental health, for example through malnutrition which can impair brain development (e.g. growth of neurons) and function (e.g., neurotransmitter syntheses, the maintenance of brain tissue [3]. Deficiencies can inhibit intellectual and physical potential, and cause lifelong disability. Iodine deficiency in pregnancy increases the risk of irreversible brain damage, and nearly a quarter of all children under age five are physically stunted, which is linked to numerous risks to development and health [4,5].

Goals 3 and 4: Good health and education
Physical, mental and social sides of health are interrelated, and improvements in physical health will impact mental health and vice versa. Examples include how substance abuse can cause liver cancer, and that depression may increase risk for not seeking treatment or taking medicine. Mental health and psychosocial wellbeing are important for children's education and school attendance. Humanitarian crises, whether caused by natural disasters or conflicts, not only destroy schools, but may negatively impact the ability to learn. Quality education can promote and protect mental health through knowledge and life skills, provision of safety and meaningful activities, and social networks.
Interrelatedness is the case throughout the life span, and is very evident in early childhood. Similar to mental health, Early Childhood Development (ECD) is an integral part of reaching the SDGs, and mentioned specifically under goal 4 on education. Early deprivation and toxic stress can impair physical and mental health, education, and other important developmental areas. Poor parenting can change brain chemistry and architecture, also for subsequent generations [4]. ECD interventions early in life set a trajectory for good lifelong health, and can lead to lower incidence of non-communicable diseases [5].

Goals 5, 10 & 16: Promoting equality, peace and justice
Although all humans are born equal in dignity and rights, and should not be subject to discrimination; inequality, discrimination and stigma are salient when it comes to global mental health. One of the challenges in implementing mental health services is the stigma -a community's negative perceptions towards people with mental disorders -that often is attached to mental health problems. Mental illness stigma is common in all countries, both LMIC and high income countries [5,6], negatively impacts the lives of people, and increases the burden of disease [7]. The negative effects of stigma towards people with mental illness can influence all areas of life, including life expectancy, learning, working, and social relationships [8]. In addition to the scarcity of resources for prevention, care and treatment, negative attitudes towards mental health can also limit access to treatment [9]. Moreover, negative attitudes are often coinciding with negative practices, such as hiding or punishing people with mental health problems.
Humanitarian crises, such as war, are associated with heightened prevalence of mental disorders and distress. Violence is a major threat to mental health. For example, one meta-analysis of studies of conflict affected populations found prevalence rates of 15.4% for PTSD and 17.3% for depression [9,10]. The global partnership to end violence against children estimate that 120 million girls and 73 million boys have been victims of sexual violence, and almost one billion children are regularly subjected to physical punishment; all of which pose serious risks to mental health (http://files7.webydo.com/92/9216880/ UploadedFiles/AB4FCF9F-566D-151A-84D9-A2237991AE82.pdf).
However, good mental health and reduced substance abuse might contribute to reducing violence, and psychosocial interventions are part of conflict transformation as a way to break the cycle of violence. Psychosocial support is often included in rehabilitation following atrocities.

Goals 8, 9 & 11: Economic prosperity, sustainable communities, and jobs
Poor mental health and substance abuse threatens economic prosperity. The global cost of mental disorders was estimated to be approximately $2.5 trillion in 2010; and more than half of this burden was borne by LMICs [2]. Maternal depression can affect poverty, and also have negative consequences for children, for example higher risk of not being vaccinated, or improper treatment for childhood diseases. Maternal health can also have direct and indirect effects on poverty and prosperity.
Mental health is important for people's ability to work, and therefore for their productivity and economy. However, work also plays a crucial role for people's mental health. Work places provide opportunities for promoting dignity, equality and health. Strengthening people's ability to work also promotes economic growth and inclusion. Sustainable cities and communities will require behavior change and innovation. Whether these concern clean energy or responsible consumption, wellbeing, social networks and realizing the full human potential are factors that will influence people's ability and will to adapt and learn.

Goals 7, 12, 13, 14 & 15: Protecting the planet and natural resources
Whether on land or at sea, natural resources and the survival of the planet impact people's health, and people's health will have consequences for their ability to manage the changes necessary for a more sustainable environment. Strengthening people's and communities' resilience, including their mental health, is an important step towards disaster risk reduction [11].
Natural and climate change related disasters already seriously impact global health [12]. People in low-and middle-income countries are at particular risk, which places them at increased risk for mental health problems. A recent study [13] examined the mental health and functioning of people living in an area of Vietnam characterized by high risk for natural disasters and poverty. The results showed elevated rates of PTSD, somatic problems, and functional impairment but not depression or anxiety. It is interesting that financial stress was the strongest predictor of mental health problems [13] illustrating the complexity of the issues, and why the SDGs are interlinked, and that the solutions will require widespread partnerships and cooperation.

Humanitarian emergencies, mental health, mental illness and resilience
The SDGs address the root causes of humanitarian emergencies, as poverty, natural disasters and conflicts often represent critical threats to the health and safety of a community. Emergencies often occur in low-and middle-income countries, for example, LMICs accounted for 88% of the global reported disaster mortality [14,15]. There is substantial experience and evidence on mental health and psychosocial interventions in and after emergencies which is valuable in the efforts to reach the SDGs. The community context is crucial for promoting mental health in and for the SDGs, including identifying and using available resources.
Both from a human rights perspective and an economic perspective it is clear that mental health must be prioritized. If we are to reach the SDGs we will need to develop the human potential so that more people can contribute to the work and changes needed. To achieve this, increased resilience is central. Resilience points both towards promoting mental health in communities, families, schools and work places, and to prevent and treat mental health disorders and substance abuse. Both must therefore be global priorities and responsibilities. In fact, the WHO definition of mental health -a state of wellbeing where individuals realize their potential, can cope with normal challenges in life, can work productively, and contribute to their community -sums up much of what is needed if we are to reach the SDGs by 2030.