Global Health and Mental Health

Global health has been described as a field that places a priority on improving health and achieving equity in health for all people worldwide (Koplan 2009). Broadly, low- and middle-income countries have made extraordinary progress over the past two decades in health care delivery and population health through global and national programming targeting diseases such as HIV/AIDS, tuberculosis, and malaria, and through basic interventions such as immunization. Mental health, however, remains overwhelmingly unaddressed, and represents an opportunity for the global health community given the significant burden of illness, the glaring treatment gap, the common co-morbidity of mental disorders with other conditions, and the proven effectiveness of treatments for mental disorders.

The World Health Organization (WHO) has defined “mental health” as “more than the mere lack of mental disorder,” but rather as “a state of well-being” (WHO Fact File 2018). Mental health therefore encompasses a broad conception of health that includes wellness, ameliorating poverty and social determinants of mental illness, addressing early childhood development and preventive approaches to care, and providing clinical treatments that encompass psychological, pharmacologic and other approaches, for a broad range of mental and neurological disorders. Severe mental disorders, including schizophrenia and other psychotic illnesses; common mental disorders, encompassing major depression, anxiety, and stress-related conditions and post-traumatic experiences; and epilepsy together compose a significant proportion of the untreated global burden of mental disorders that current global health efforts are seeking to creatively address.

The focus of an emergent field of global mental health over the past several decades has been on reducing mental health disparities between and within nations, and seeking innovative community-based and systemic solutions to increasing access to care (Patel and Prince, 2010). The field of global mental health has primarily reflected significant research efforts showing evidence that mental health treatments originally developed in higher-income settings can be adapted and delivered in low- and middle-income countries. Overcoming the significant challenges that relate to bridging the treatment gap, and developing functional, sustained mental health systems, remains a significant challenge in global health. It requires a deep appreciation of the ways in which local culture and belief systems inform understandings of health and illness in communities; knowledge of the burden of illness; awareness of the effectiveness of various mental health treatments; familiarity with best practices in community health, including the engagement of nonspecialist providers such as community health workers; and skills in effective advocacy to also transform health systems and policy responses that can help lay the groundwork for interventions to be successfully embedded within local community, cultural, and biomedical contexts.

The Global Burden of Illness

Mental disorders represent the greatest collective cause of disability globally today. Over the past two decades, new methodologies and information on the prevalence of mental disorders have highlighted the global burden of illness. Recent estimates suggest that the disease burden of mental disorders accounts for 32.4 percent of years lived with disability (YLDs) and 13.0 percent of disability-adjusted life-years (DALYs) (Vigo et al., 2016). Mental disorders account for almost one in three years lived with disability globally. Depression, the most common mental disorder, affects an estimated 350 million people globally and represents the leading cause of disability (as measured by DALYs) around the world. Severe mental disorders, including schizophrenia, affect approximately 1 in 100 people globally, across cultures, with significant severity of illness, morbidity, low life expectancy, and economic impact on families. Mental disorders significantly impact people in low-and middle-income countries, with 80 percent of the world’s population living in these regions; however, most formal, health system-based mental health resources are spent inhigh-income countries.

The Mental Health Treatment Gap

Resources that do get spent on mental health services, particularly in low- and middle-income countries, are often highly centralized and tend to be funneled toward national-level institutional facilities instead of being “decentralized” to create services at primary care clinics and in communities. In high-income countries socioeconomic disparities also limit the availability of mental health services within and across communities, particularly in rural areas, leading to similar challenges across low resource settings. Furthermore, the “treatment gap” for people with mental disorders exceeds 50 percent in all countries worldwide, approaching rates as high as 90 percent in the least resourced countries (Patel, Maj, et al. 2010). Epilepsy, for example, the most common serious neurologic disorder, could be treated in 70 percent of people if treatments were available; however, 76 percent of epilepsy remains untreated globally in all areas, with upwards of 90 percent in rural areas in low-income countries (Meyer et al. 2012). Neurological and neurodevelopmental services are also so limited in many contexts that within government ministries of health in low-income countries neurological care falls under the aegis of “mental health,” with even greater gaps in the availability of neurologists.

With regard to child and adolescent mental health, more than 50 percent of mental disorders start before the age of 14, and 75 percent start before the age of 24 (Kessler 2005). One quarter of DALYs for mental disorders and substance abuse is borne by those 24 years old or younger, the age group that accounts for more than 40 percent of the world population (Mundi 2017, GBD 2017). Most children and young people in low-income countries do not have access to mental health care, with child mental health considered the “orphan’s orphan” of health care across low-, middle-, and high-income countries (Lu et al. 2018, Mind Your Mind 2018). Even in high-income countries, there exists a crisis in child mental health service delivery and access. In Canada, for example, often cited as having a highly evolved health care delivery system, only one in five children who need mental health services receive them (CAMH 2018, Huffington Post 2018).

Reasons for the mental health treatment gap are numerous and include inadequate government budgets to fund adequate human resource, facility, and medication costs; the deleterious effects of locked hospitals in promoting stigma and fear and poor quality of care; limited access to care for a significant proportion of the population due to geographical distance for those living in rural or remote areas; the significant emotional costs of seeking care for people living with illness and their families; a general lack of sustained community-based care models that exist in context; lack of families’ ability to pay for medications and exclusion of psychiatric medications from insurance payment plans if they exist; general lack of specialists trained in the provision of quality care practices; and community-wide stigma and fear of people living with mental disorders.

Human Rights and Institutional Care

An ongoing challenge for global health has remained a poor standard of clinical care delivered in resource-constrained, public institutional psychiatric facilities, combined with a lack of human rights protections for people living with mental disorders. This generally has reflected the limited resources allocated for mental health services by governments, which have tended to spend less than one percent of their budgets on mental health care despite the high disease burden, spending the limited funding on maintaining dilapidated facilities with inadequate human resources, and over-reliance on powerful neuroleptic medications. In higher-income countries, while more mental health services may be available in communities than in lower-income countries, people living with mental disorders can also find themselves incarcerated or homeless without social protections.

Of grave concern, in many low- and middle-income countries, asylums, mental and psychiatric hospitals continue to be the primary form of mental health care, a dire situation. Such facilities continue to be the sites of human rights abuses, also perpetuating economies of ineffective alternative healers in communities (Cohen and Minas, 2017). While traditional healing systems, and religious and spiritual practices, should ideally be integrated with more formal biomedical interventions for truly holistic, patient-centered care, in many instances local community providers drain the financial resources of families desperate to heal a family member living with a severe mental illness (often attributed to a culturally specific or spiritual cause). The promise of healing, and no other alternative, draws families to seek care at the psychiatric facility. Solutions to such facilities include the development of community-based services, the gradual opening of small acute psychiatric units in general hospitals, which can reduce admissions to centralized notional facilities, and legislation protecting the rights of people living with mental disorders. Greater investments need to be made in integrating care within primary care, and engaging additional cadres of providers in the health care system in various aspects of care, while not allowing centralized facilities to degrade and serve as monuments to fear and stigma related to mental illness in contexts where safe, effective and evidence-based clinical mental health services have not previously existed.

“Task Sharing” and Nonspecialist Care Delivery

Increasingly, and in response to the complete lack of formal, decentralized mental health services across most of the globe, over the past decade, a research evidence base has been developed for the effectiveness of provision of nonspecialist-delivered, community-based care for mental disorders in low-resource settings. Nonspecialists include community leaders, community health workers, nurses, physicians, and other members of the community and providers who can support the provision of certain mental health care tasks. Growing evidence about effective “task sharing” of psychosocial and psychological interventions – care delivered by nonspecialist providers – may be the most important advance made by an emergent field of Global Mental Health over the past decade (Whitley 2015). This was supported by a landmark Lancet series in 2007 (Chisholm 2007, Patel Araya 2007, Patel Flischer 2007, Prince Patel 2007), launching “a new movement for mental health” (Horton 2007), and subsequently followed with a 2011 Lancet series (Kakuma 2011, Lund 2011, Patel Boyce 2011), a 2011 Nature publication (Collins 2011), and a 2013 PLOS series on Grand Challenges in Global Mental Health (Kaaya 2013, Ngo 2013, Patel 2013, Rahman 2013, Whitley 2015). New funders also came onto the scene – the Wellcome Trust (UK), Grand Challenges Canada, and in 2011 a new US National Institutes of Mental Health (NIMH) Office for Research on Disparities and Global Mental Health (a title implying the relevance of solving disparities in mental health care provision in high-income countries as well, and the possibility of “reverse innovation” from low- to high-income settings such as in the United States). This movement itself, with its own history, has had as its stated aim “to improve services for people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income countries where effective services are often scarce” (GMHM website 2018). This aim distinguishes the global mental health movement from the decades of work within cultural psychiatry and medical anthropology that sought to understand local conceptions of mental distress and healing (Kirmayer and Pedersen 2014). The development of the field of global mental health reflected the historical neglect of mental health as a component of the global health agenda, what Arthur Kleinman called “a failure of humanity,” as well as a historical overemphasis on the practices of the field of psychiatry as the main solution to the perceived problem: the aforementioned treatment gap (Kleinman 2009).

Since the early twenty-first century, significant work has been done to evaluate interventions and systems to address the treatment gap, and to build momentum toward identifying cost-effective, evidence-supported practices and services that could feasibly be made more widely available in low-income countries, leading to a “scale-up” of services. The World Health Organization (WHO) has taken an important role in this process through its Mental Health Gap Programme, which in 2011 published an Intervention Guide (IG) for “mental, neurological and substance use disorders in nonspecialized health settings” based on extensive literature review – emerging international consensus on best practices that can potentially be adapted to context, and acknowledgment of certain “universal” aspects to the way mental disorders present regardless of cultural context (WHO 2011). The WHO mhGAP-IG materials provide guidance for the treatment of depression, psychosis, bipolar disorder, and other conditions, suggesting social, psychosocial, psychological, and pharmacological interventions, and have been most relevant to the training and support of generalist physicians in delivering basic components of mental health care. A subsequent second edition was unveiled in 2016, and an additional version was developed for use in humanitarian emergencies (WHO 2016, WHO 2015). These guidelines to support the development of services for the long-term have intersected with the concurrent development of guidance for health sector agencies in providing support to populations during humanitarian crises, embodied by the 2007 Interagency Standing Committee Guidelines (IASC) on Mental Health and Psychosocial Support in Emergency Settings (IASC 2007). Taken together, these documents seek to ensure that the most appropriate actions are taken and resources expended at the right time and in the right way in the process of moving from acute emergencies to longer-term responses so that sustainable mental health systems can be “built back better” (WHO 2013). At a policy level, the WHO has been deeply involved in supporting governments in strengthening mental health care, including with a WHO Comprehensive Mental Health Action Plan 2013–2020 (DeSilva et al. 2013, WHO MHAP 2013).