In low- and middle-income countries, such as Thailand, notable disparities persist in the treatment and attendance rates for mental illnesses [25]. While health system factors, particularly financial and medical resources, critically influence the coverage and effectiveness of mental health service interventions, mental health systems in these countries remain insufficiently investigated. The global consequences of the COVID-19 pandemic have cast a shadow on public mental health. In Thailand, the observed decline in the number of patients seeking mental health services during the pandemic is potentially associated with the adaptation of psychiatric facilities and outpatient departments for outbreak management. This adaptation may have deterred individuals with mental health concerns from accessing health facilities due to heightened infection-related anxieties [26]. Nevertheless, amid the ongoing COVID-19 pandemic, the intersection of equality and poverty has emerged as a crucial factor influencing the increasing prevalence of mental health problems, particularly in low- and middle-income countries, underscoring the escalating concerns related to mental health and psychosocial well-being in Thailand and these regions [27,28,29].
Moreover, studies have shown the pandemic’s worsening impact on psychopathological and socioeconomic factors, contributing to a new burden of mental illnesses [30,31,32]. These circumstances highlight the imperative to reorganize existing mental health services, addressing unmet needs and preparing for post-pandemic challenges, especially in LMICs [33]. Addressing high levels of unmet need is acknowledged to be extremely complex, as outlined by the World Mental Health Report, which urgently calls for the transformation of mental health and underscores collaborative efforts among various stakeholders, including professionals [34].
Despite the central role of promoting mental health and preventing mental health conditions in the public mental health approach, this domain remains under-researched and challenging to change [35]. The report navigates the uncertainty surrounding the approach to social determinants of mental health, delineating roles and responsibilities between the health sector and other domains [34]. Additionally, the transformation of mental health services necessitates the integration of mental health considerations into discussions addressing social determinants such as poverty alleviation and violence prevention [35].
The findings of this study underscore the spatiotemporal heterogeneity in the attendance rates for mental illness in Thailand, reflecting a complex interplay of factors. Assessment of unmet need has been conducted across diverse and vulnerable populations, including minority ethnic groups and individuals grappling with specific health conditions, notably mental illnesses [36]. In 2019, the Thai Ministry of Public Health reported that there were only 25 community-based psychiatric units with 0.4 beds per 100,000 population, limiting the accessibility of minority groups such as hill tribe people [36]. Our study also identified several areas of significance for mental health in the north of Thailand, where most hill tribes are located in rural areas, particularly along the borders of neighboring countries.
The hill tribe communities in Thailand may face specific challenges related to mental health, which could include various factors such as cultural practices, certain health behaviors, economic conditions, and educational resources [25, 37]. Additionally, a significant portion of hill tribe individuals may experience limited access to healthcare services and medical assistance [38]. Moreover, the existing mental health screening tools available in peripheral healthcare units in remote areas might not be fully tailored to the specific needs of the hill tribe communities. Therefore, it is plausible that the prevalence of mental health issues in these communities could be underrepresented in the available data. Consequently, there is a need for an enhanced healthcare system to more accurately identify mental health concerns and provide appropriate care and monitoring, with a particular focus on addressing depression. Public health interventions should be directed at improving awareness about mental health among hill tribe communities, exploring culturally suitable methods or channels for communication in local hill tribe languages [38].
Through community-based participatory research, a depression care model tailored for the hill tribe population was developed and demonstrated clear effectiveness when tested in a hill tribe community [39]. This model can be applied to other hill tribe communities in northern Thailand to enhance depression care. Additionally, the stateless and hill tribe population in Thailand relies on accessing all public services, including healthcare [40]. Stigma significantly impacts their lives, given their existence as an invisible population and the negative treatment they receive. Addressing this issue through access to public health resources and education is considered effective under the implementation schemes of relevant organizations. Furthermore, stigma related to drug use has multifaceted impacts on physical and mental health, influenced by personal traits, community dynamics, and socio-economic factors, including culture and tribes. Implementing a program to reduce drug and substance use among hill tribes holds the potential to minimize this stigma [41].
Another region with disease clusters was the northeast, which is the largest region of the country consisting of 20 provinces, where many migrant workers from neighboring countries live. Most of these migrants reside in semi-urban and semi-rural communities, where they might encounter various environmental problems that put them under stress. The socioeconomic factors prevalent in this region may also contribute to the development of depressive symptoms in many individuals without access to proper assistance [42]. Additionally, there has been an increase in illegal drug use in Thailand [43], causing extensive economic and social problems, with the northeastern part seen as a drug trafficking area [43, 44].
A nationally representative face-to-face household survey was conducted in the USA using a fully structured diagnostic interview. The results revealed that anxiety disorders were the most prevalent, affecting almost 20% of the population, followed by mood disorders, impulse control disorders, and substance use disorders. These findings suggest a similar pattern of mental illness prevalence in Thailand. In addition, the study identified a strong correlation between anxious depression (major depressive episode with generalized anxiety disorder) and comorbid substance disorders (both alcohol abuse and dependence with drug abuse and dependence) [45].
Moreover, common mental disorders, such as depression and anxiety, significantly contribute to the burden of disease and disability in low- and middle-income countries [46]. Investigating the social determinants of mental disorders in LMICs, including Thailand, is crucial as recognized key factors such as poverty, low education, social exclusion, gender disadvantage, conflict, and disasters are major determinants of mental disorders in LMICs [47]. Thus, research exploring the impact of these determinants on mental health outcomes in Thailand can inform targeted interventions and policies, mitigating risk factors associated with mental disorders. This effort can also contribute to a comprehensive understanding of prevalence and associated risk factors, guiding the development of effective strategies to enhance mental well-being of the population in the country.
Nevertheless, the imperative task of reducing the costs associated with mental illness is a highly complex issue, compounded by the challenge of addressing substantial unmet needs. Considering the limitations of current treatment options for certain diagnoses, it becomes important to explore potential protective factors unique to specific groups. Within the Thai cultural context, the communal living patterns in rural villages foster robust social networks, potentially enabling individuals with mental disabilities to lead successful lives. Studies suggested that, with the support of family and community, along with medication, self-regulation, essential self-management skills, and occasional intervention by psychiatric-mental health practitioners, those living with schizophrenia can engage in daily activities, work, and contribute to the well-being of others [48, 49]. Thus, leveraging the support of families and communities can serve an alternative social resource in the rehabilitative process of mental health support in Thailand.
There are several limitations to this study, including the potential stigmatization of mental disorders, which might prevent patients from seeking treatment altogether. The stigmatization of mental illness can be influenced by factors such as media and education [50]. Moreover, the number and location of mental health services in each province may affect how easily people can access the service, leading to an underestimation of the actual number of patients with mental illness. The analysis used the data available from the Thai government which did not include the numbers of new diagnoses by condition. Instead, the available metric was annual numbers of individuals visiting mental health services. Thus, conditions with longer duration of more frequent episodes for which the same person attends services over multiple years e.g., schizophrenia may be over-represented compared to conditions with shorter duration or less frequent episodes.
In our study, we aimed to explore the spatiotemporal distribution of visits at mental health facilities. However, it is important to acknowledge a limitation in our correlation analysis, where the pairing of disorders may seem unconventional. While the correlations observed in our results are based on real-world data, it is important to recognize that the reported number of visits may be influenced by various factors. Despite these unconventional pairings, our findings offer exploratory insights into the utilization patterns of mental health services, which can inform hypotheses for future research. Additionally, we acknowledge that the Spearman spatial maps may not directly inform complex resource allocation decisions. While our research provides valuable insights into mental health service utilization patterns, future studies could enhance our findings by incorporating additional factors such as demographic characteristics, socioeconomic status, and healthcare infrastructure to develop more nuanced models for resource allocation.
Moreover, there are overarching challenges in estimating the prevalence of mental disorders and mental health-related service contacts. These estimates are crucial for policy formulation, research, advocacy, and resource allocation. However, the burden of mental illness may be potentially underestimated at various geographical locations and scales [2, 51]. Contributing to this underestimation are socio-economic factors, including stigma and prejudice, particularly pronounced in LMICs [8, 52]. An alternative approach involves combining various data sources to enhance the accuracy of estimates, although there is currently no standardized method for this [53]. Nonetheless, it is important to note that the main analysis focused on the relative spatial distribution rather than comparing absolute measures of disease occurrence between diagnoses, potentially limiting the impact of this aspect on the findings. Despite these acknowledged limitations, this study provides valuable evidence that can serve as a baseline for addressing the high need and persistent scarcity of financial resources, workforce, and infrastructure for mental health services in the country.
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