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Global Mental Health - Friend or Foe?

Presentation at the launch of the MSc Global Mental Health, University of Glasgow, 26th March 2012

Ross White

on 2 June 2016

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Transcript of Global Mental Health - Friend or Foe?

The top five leading causes of burden (DALYs) for all ages were:
Mental health difficulties are set to become a leading global cause of disability (Mathers & Loncar, 2005).
4 out of 5 people in low and middle-income countries who need services for mental, neurological and/or substance use disorders do not receive them (MH-Gap, 2008).

Greater than 90% of global mental health resources are located in high-income countries (WHO, 2005).

Globally, spending on mental health is less than $2 (US) per person, per year. It is 25 cents in low income countries. (WHO, 2011)

Only 36% of people living in low income countries are covered by mental health legislation vs. 92% in HIC (WHO, 2011).
The preoccupation with trying to find universal ways of classifying different types of mental illness may have limited our understanding of the important role that culture plays in understanding mental illness.

Mental health services should reflect the needs of local communities and be sustainable without being tied to dependency on funding agencies driven by pharmaceutical and insurance industries.

One size does not fit all: The models of mental health care that will evolve through a bottom-up approach will vary from place to place
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 behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and other significant emotional or medically unexplained complaints (WHO, 2010).
Fifty-seven per cent of the 114 LMICs were found to contribute fewer than five
articles to the international mental health indexed literature for a 10-year period
Global Mental Health

Friend or Foe?

Dr Ross White, University of Glasgow
By 2030 Unipolar depression will be the No. 2 contributor to total years lived with disability globally.
WHO Mental Health Atlas (2005) - data received from all 192 WHO Member States.

Aggregate results (region/income group) and country profile information provided.
WHO Mental Health Atlas (2011). It presents data from 184 WHO Member States: covering 98% of the world’s population.

Divided into 6 sections:
•Mental Health care delivery
•Medicines for mental and behavioural disorders
•Information systems
The Global Burden of Disease Update (WHO, 2004)
Steps for addressing the mh-GAP (mh-GAP, 2008):
•Political commitment
•Assessment of needs and resources
•Development of a policy and legislative infrastructure
•Delivery of the intervention package
•Strengthening of human resources
•Mobilization of financial resources
•Monitoring and evaluation
But does this 'epidemic in depression' really exist?

A meta-analysis of 56 published studies of refugees’ mental health (totaling 67 294 participants) found the strongest moderating factor to be social conditions after displacement. Resolution of the conflict that had displaced them also had positive effects. The mental phenomena being identified as satisfying criteria for a mental disorder (typically depression or post-traumatic stress disorder) were mostly incidental and a 'normal' reaction to their circumstances (Porter and Haslam, 2005).

The danger with medicalising everyday life is that it deflects attention from what millions of people worldwide might cite as the basis of their distress for example, poverty and lack of rights (Summerfield, 1998).
Is Global Mental Health actually about ‘mental health’ or is it about ‘ill-health’ (‘illness’).

Mental health has been defined as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease"’ (WHO, 2008).

Historically notions of mental 'illness' have been inextricably linked to the roll-out of psychiatric services. In the last 40 years biological explanations for mental 'illness' have risen to the fore.

Key questions:
Is the evidence there to support hypothesised biological undepinnings of mental illness?
Are psychiatric services effective at treating mental illness?
Are psychiatric systems of services appropriate and sustainable in low and middle income countries?
The principal classification systems, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) 'are Western cultural documents par excellence' (Mezzich et al., 1999).
Psychiatry has a disproportionately loud voice in determining what are deemed to be cultural attitudes toward mental health problems in high-income countries. In effect, attitudes toward mental illness in high income countries could be thought of as reflecting "a culture of the minority" (Fernando, 2012).
The World Health Organisation has called for the ‘scaling up’ of services for mental health in LMIC (WHO, 2008; 2010).

Scaling up involves:
Increasing the number of people receiving services
Increasing the range of services offered
Ensuring these services are evidence-based
Using models of service delivery that have been found to be effective in a similar contexts
Sustaining these services through effective policy, implementation, and financing (Eaton et al., 2011).

But are we really in a position to know what to scale up?
Global Mental Health has been defined as the ‘area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide' (Patel & Prince, 2010).

Global Mental Health is predominantly a 'western' endeavor.

Lancet series on Global Mental Health (2007).
2nd Lancet series on Global Mental Health (2011).

The emergence of Global Mental Health has occurred in the context of persisting dominance of biological psychiatry in high income countries.

Mental illnesses were to have universal biological causes, and standard treatments can be readily applied across the world irrespective of local differences.
The continued absence of definitive evidence to support biological processes that are causal in mental illness has led to the suggestion that biological psychiatry is ‘a practice in search of a science’ (Wyatt & Midkiff, 2006)
If evidence­based practices lead to positive outcomes in high-income countries, then similar positive outcomes will be observed in LMIC.

What is considered to be ‘evidence-based practice’ can serve powerful economic and political interests (Kirmayer & Minas, 2000).

In 2007, US citizens spent £25 billion on antidepressants and antipsychotics (Whitaker, 2010).
The evidence base

Despite the exponential rise in sales of psychotropic medications, the evidence for biological causes for mental illnesses such as depression and schizophrenia remain fairly weak (Stahl, 2000; Nestler et al., 2002; Wyatt & Midkiff, 2006)
Claims about drug effectiveness are at times overstated, and that pharmaceutical companies have been found to employ questionable research methodologies (Glenmullen, 2002; Valenstein, 1998; Whitaker, 2010).
Positive Outcome

There is currently no accepted consensus on what constitutes positive outcome for individuals with mental illness.

Traditionally, psychiatry has been concerned with eradicating symptoms of mental illness.

But clinical symptoms do not improve in parallel with social or functional aspects of service users’ presentation (Liberman et al., 2002). Functional outcome relates to variables such as cognitive impairment, residential independence, vocational outcomes, and/or social functions (Harvey & Bellack, 2009).

Using symptomatic remission as an indicator of recovery can yield better rates of good outcome than using indicators of functional recovery (Robinson et al., 2005).
The evidence base suffers from a lack of cultural inclusion.

Black and minority ethnic groups are under-represented in mental health related research.

As such, there is a lack of adequate evidence supporting the use of ‘evidenced-based’ psychological therapies with individuals from Black and Minority Ethnic populations in the US (Hall, 2001).

The evidence-base is seriously limited in its capacity to take into account cultural diversity (Kirmayer, 2012).
Stakeholders among community workers and service users in LMI countries were excluded.

The biological and psychiatric conceptualisation of mental health problems ignored the experiences of ordinary people who access a variety of services including indigenous healing, social support networks, rights-based organisations and family support for problems.
The evidence-base is heavily skewed towards research conducted in high-income countries. The costly standards of psychiatric epidemiology and randomized clinical trials, it can be difficult for clinicians or researchers in LMIC to contribute to the accumulation of knowledge (Kirmayer, 2006)

The lack of mental health related research being conducted in LMIC countries is very evident in the finding that over 90% of papers published in a three year period in six leading psychiatric journals came from Euro-American countries (Patel & Sumathipala, 2001).

Derek Summerfield (2008) expresses concerns about the validity of the evidence base underlying GMH. In a review of 183 published studies on the mental health of refugees, four fifths of the studies relied exclusively on measures of psychopathology developed with Western populations (Hollifield et al., 2002).
Researchers often refer to non-Western populations’ “limited knowledge of mental disorders,” their lack of “mental health literacy,” or the need to “teach” health workers and the people they serve about mental health.

This is medical imperialism, similar to the marginalisation of indigenous knowledge systems in the colonial era, and is generally to the disadvantage of local populations (Said, 1993; Summerfiled, 1999).

New research ideally needs to engage with participants in a way that carries no preformed notions about what is “mental” or “health” in their world: local concepts must be the starting point for the creation of valid instruments for screening or diagnosis.
Global Mental Health - Friend or Foe?

The answer depends very much on how the process of how distress in different parts of the world is conceptualised, researched, and subsequently addressed.

We have to be wary of the potential for enabling easy access to psychotropic drugs and promoting narrow, rigid systems of diagnosis.

Awake to the possibility that 'therapeutic' models of understanding and working with mental health problems may not be the way forward.
Deprivation is a key issue for people living in LMIC.

Mental Health services should reflect the needs of local communities and be sustainable. Community development may be a key strategy for reducing psychological distress. Focusing on communities.

Services should be ethical and sustainable (Gasper, 2004; Warburton, 1998), rather than postcolonial notions of social improvement and ‘catching up’ (Gasper, 2004). Self-defining subjects’ rather than ‘objects of concern’, people ‘entitled to choose their way of life themselves’ both as individuals and communities (Gasper, 2004).
Research has failed to conclusively show that outcome for complex mental illnesses (such as psychosis) in high-income countries are superior to outcomes in LMIC (where populations may not had access to medication-based treatments) (Hopper, Harrison, Janka & Sartorius, 2007; Cohen et al., 2008; Alem et al., 2009).

It will be important for clinicians and academics working in high-income countries to critically reflect on their own practice and question how wise the accepted wisdom about mental health provision actually is. In this sense ‘Global’ means global; people learning from each other about how to improve mental health provision across the globe.
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