As the global health community become increasingly aware of a significant gap in mental health care access in high-income countries (HICs) and low- and middle-income countries (LMICs), mental health leaders must decide if and how to address the inequity. However, because of varied cultural understandings of mental illness and a historic power imbalance between the Global North and the Global South, this task is fraught with controversy. Proponents of the “Global Mental Health Movement” believe that lack of mental healthcare is a human rights issue and call for increased mental health access in LMICs. Opponents, on the other hand, argue that cultural variation in understandings of mental health are too significant, and a Global Mental Health Movement would inevitably lead to the imposition of the Western biomedical approach in communities that do not ascribe to it. Various mental health interventions, including PRIME and Dr. Lambo’s Aro Village program, respond to the mental health treatment gap and these concerns in different ways. Ultimately, the mental health treatment gap is a global health issue that must be addressed, but steps should be taken to ensure this is done in a way that is respectful and effective in a variety of contexts.

Executive Summary

Undeniably, there is a gap in access to mental health treatment between Low- and Middle-income countries (LMICs) and High-income countries (HICs). Neurological diseases account for 14% of the global burden of disease, yet mental health is still neglected worldwide; generally, countries prioritize healthcare efforts that target physical diseases without addressing their interactions with mental health (WHO, 2001). Low-Income and Middle-Income countries are particularly lacking in access to mental healthcare, with four out of every five people with a mental illness going without any care (PRIME, n.d.). Since mental health is understood differently across different cultures, addressing or even acknowledging this lack of mental healthcare means answering challenging questions about global mental health and differences in across the North-South political and socioeconomic divide: How do understandings and definitions of mental health from the Global North impact the efforts to close the treatment gap in the Global South? How can we move past cultural differences to provide respectful and effective interventions globally? Leading specialists, governments, and NGOs have proposed varied intervention strategies, each with their own strengths and weaknesses, but the issue of how best to address mental illness is still filled of controversy.

Two opposing viewpoints characterize the controversy surrounding cross-cultural issues in the movement for global mental health. On the one hand, opposition to the global mental health movement argues that mental health is locally defined and that scaling up mental health in LMICs inevitably means imposing a Western understanding of mental illness on other cultures. Indeed, views of mental illness, including labels like “depression”, differ across cultures. On the other hand, proponents of the global mental health movement argue that inequality in access to mental health care is a violation of human rights, and they advocate for scalable but localized interventions.

Ultimately, considering the controversy as well as the research on global mental health, it is clear that further steps need to be taken to address the mental health treatment gap, but that policies and programming need to speak to ethical concerns. Four key goals need to be emphasized as the global health community addresses this issue: (1) Expand interventions focusing on mental health, (2) Increase reliance on partnerships (3) Increase focus on research, and (4) Bolster mental health education. Mental healthcare is often deprioritized because of its relative “invisibility” compared to physical illnesses and particularly infectious diseases. However, it is now clear that mental illness is a serious public health concern that contributes significantly to quality of life globally. Through these four strategies, public and private organizations can begin the hard work of tackling the issue ethically and effectively.

Since mental health is understood differently across different cultures, addressing or even acknowledging this lack of mental healthcare means answering challenging questions about global mental health and differences in across the North-South political and socioeconomic divide.

Key Findings

1. Mental Health and the Treatment Gap:

Although it is now clear that issues of mental wellbeing have significant impacts on the emergence of disease, social relationships, and even global and local economies, the WHO only started seriously looking into the topic as a global health concern in the 1990s (WHO, 2001). Their work opened a conversation that inspired an increased interest in mental health. This conversation eventually led to a decisive series of articles in The Lancet in 2007, which inspired the “Movement for Global Mental Health” (Movement for Global Mental Health, n.d.).

Although this issue is now at the forefront of conversations in global health, mental illness as a concept – even as a term – is contentious, complex, and confusing. The personal nature of psychological health problems makes mental health challenging to define, measure, and address across cultural contexts. According to the WHO, “There is a widely shared but mistaken idea that all mental health interventions are sophisticated and can only be delivered by highly specialized staff” (WHO, 2010), and this attitude has led to a large gap in mental health resources in HICs with access to these specialized services versus LMICs with fewer resources. Whereas 80% of the world’s population lives in LMICs, 80% of mental health care resources are concentrated in HICs.

Now that we know mental health care is feasible even in LMICs, the question becomes how and if we will address the gap. Generally, those who control resources also control its allocation, so, in line with colonial histories, the decisions of the high-income Global North impact the future of the low-income Global South in this topic. With this historical power imbalance, the WHO and The Lancet’s call to action, which challenges actors to narrow the gap, inevitably entails answering complex questions like: Does mental illness exist, and if so, what is it? How do we address the issue when the definition of mental illness is variable? How HICs talk about mental health directly impacts the interventions supported in LMICs, ethically challenging questions regarding implementation necessarily come to the forefront.

Although there are discrepancies in cross-cultural understandings of mental illness, there is no doubt that mental health impacts overall health, and that we must do something to ameliorate mental health care in LMICs considering the gap in resources. According to the WHO’s 2003 report, “While the prevalence of major depression in the general population can go from an average 3% up to 10%, it is consistently higher in people affected by chronic disease” (WHO, 2003, p.10). So, even when data adjusts for inconsistencies in research, and even taking into account issues of labeling (not every culture uses the term “depression,” for example), we can generally conclude that there is a correlation between physical and mental illness. According to this report, major depression is associated with increased prevalence of some chronic disease up to 44% (WHO, 2003, p.11). While this research follows a Western, medicalized model for understanding mental illness (it depends on questionnaires and similar criteria to determine who has a disease), the results make sense across cultures. When a person undergoes psychological distress, they are less likely to take their medications or follow through with treatment plans for other, unrelated health issues (WHO, 2003, p.10). In fact, because of this correlation, lack of access to mental health care can be considered a form of structural violence Johan Galtung, the founder of the discipline of peace and conflict studies, defines violence as “the cause of the difference between the potential and the actual, between what could have been and what is” (Galtung 1969, p. 168). In this case, people in countries without mental health care services are not able to achieve full potential because of physical and mental the physical and mental results of that lack of access. Therefore, this is not a simple issue of quality of life, but rather of systemic injustice towards people in LMICs.

Similar results exist across many mental illnesses, and this data likely underestimates the impact of the mental health treatment gap because it does not take into account the way mental illness affects communities, not just the afflicted individuals. When a person has a mental illness, or a comorbid physical illness, it affects the family and larger community that must support them, especially in LMICs. With respect to mental illness, “the burden of care falls heavily on women, as they are usually the primary caregivers, and on the poor, who do not possess adequate resources” (Desjarlais, 1995, p.220). These secondary effects of mental illness are hard, if not impossible to measure, but can be assumed to be extensive.

Most importantly, it is well established that LMICs are severely lacking in mental health care resources. From the number of beds in clinical settings, to the number of mental health professionals, to the availability of medicines, to the prevalence of advocacy organizations, to the level of government funding, LMICs do not have support for the mentally ill (Saxena, Thornicroft, Knapp, Whiteford, 2007). The data on this lack in resources is drastic: overall, despite the fact that mental illness disproportionately afflicts LMICs, “The poorest countries spend the lowest percentages of their overall health budgets on mental health” (Saxena, Thornicroft, Knapp, Whiteford, 2007, p. 878). For example, in Africa and Asia, most countries spend less than 1% of their total health budget on mental health (Saxena, Thornicroft, Knapp, Whiteford, 2007, p. 881). The Declaration of Alma Ata in 1978 established health as a human right, and considering the obvious impact of mental health on physical wellbeing and quality of life, the mental health resource gap between HICs and LMICs is a human rights issue that must be addressed.

2. The “Global Mental Health” Controversy

It is clear from widespread research that mental health care in LMICs is a problem, and yet how this data is interpreted and how to address the problem are sources of major controversy. At the most basic level, there is controversy over whether the labels we use to define “mental illness” are culturally based. Understanding mental illness, just like understanding any other disease with social risk factors, is complex. In a speech at the 2012 Advanced Study Institute Conference, David Summerfield, an honorary senior lecturer at the Institute of Psychaitry, King’s College in the UK and the a leading opponent of the global mental health movement, discusses a particular refugee from Zimbabwe diagnosed with depression. The woman wondered why she had been referred to a medical team; she did not think she had a mental illness. She was HIV-positive, risking deportation back to Zimbabwe “where she would die,” and living in an unpleasant home. Instead of depression, she diagnosed herself with “Kufungisisa,” which means “thinking too much;” in other words, she was leading a hard life and was understandably upset (Summerfield, 2012). Not only did she use a different word to describe her psychological status, she attributed it to external factors rather than internal ones. The external contributors to her “Kufungisisa” are overwhelming, so Summerfield denies that the woman’s symptoms warrant a diagnosis of depression, a medical disorder. However, the narrow, medicalized mental health model that Summerfield criticizes here limits his assessment of mental health in general. This woman was likely experiencing “depression” as one part of a co-existing and related factors including poverty and refugee status, among others. That is, experiencing other life problems exacerbates the experience of psychological distress, but does not minimize that experience. Rather, it underscores the importance of taking a holistic approach to mental health care and recognizing the intersections between mental health as a medical illness and mental health in a social context.

The idea of a “global” health movement suggests that we are implementing something around the world, yet we still do not have mental health treatments figured out, even in HICs like the U.S.

However, even if we recognize that it is possible to define mental health cross-culturally by resisting labels and acknowledging different social factors, Summerfield points out the challenges involved with implementation. The idea of a “global” health movement suggests that we are implementing something around the world, yet we still do not have mental health treatments figured out, even in HICs like the U.S. For example, Summerfield highlights the overuse of pharmaceuticals and suggests that pharmaceutical companies have too much incentive to over-expand their drugs into LMICs that often have non-medical understandings of mental illness, thus imposing a medical model where it may not exist otherwise. Furthermore, Summerfield points out that scaling up evidence-based treatments from the Global North is not a good idea because we do not yet have evidence that such treatments work in high-income contexts, let alone LMICs. Overall, David Summerfield is concerned that scaling up mental health care will result in the imposition of western understandings of mental health on LMICs, too reminiscent of imperialist attitudes.

In opposition to Summerfield, Vikram Patel, a leader in the global mental health movement, claims that injustice due to lack of access to mental health care in LMICs is undeniable and reprehensible, and we must find effective ways to scale up global mental health care (Patel, 2012). He argues that the pitfalls Summerfield outlines are avoidable by rooting interventions in local understandings of mental health care. He emphasizes that although there is a specific understanding of mental health in the Global North, mental health as a concept did not originate in any one part of the world, mental health has existed for centuries in LMICs and HICs alike. He addresses controversy over the Mental Health Gap Action Programme (mhGAP), an extensive explanation of interventions proposed by the WHO in 2010 to address the mental health treatment gap. It includes flow charts and descriptions to help health care providers choose mental health treatments. Patel describes this sort of resource as a toolkit rather than a prescription, intended to be adapted to different contexts. He advocates for the use of randomized control trials to assess the efficacy of interventions (which use randomly selected groups and probability to determine whether an intervention is effective), task-shifting to address lack of human resources, among other strategies. Overall, Patel sees this issue as too important to pass up due to concerns about implementation.

III. Innovative Interventions:

A wealth of innovative interventions have been implemented, each with their own strengths and weaknesses with regard to addressing cross-cultural concerns. Two strategies in particular depict differing but successful approaches to this issue: Dr. Lambo’s Aro village system in Nigeria and PRIME (Programme for Improving Mental health carE). Dr. Lambo, a Western-trained Nigerian psychiatrist and scholar, founded the village-based mental health program in Western Nigeria in 1954. Patients, accompanied by a family member who took care of them, were temporarily integrated into particular villages with a hospital and smaller clinics. Family members were paid to compensate for time off work. As the patients underwent traditional and locally appropriate mental health treatment, they participated in community activities. In exchange, the hospital awarded the village with grants to improve water and sanitation issues (Desjarlais, 1995). By partnering with the village and patient family members and providing traditional care, the project benefited from the pre-existing village structure socially, medically, and economically while simultaneously treating patients and fostering their personal support system. This is an example of a project that depends entirely on the “local.” Without intimate knowledge of the village structure, hierarchies, and medical practices, it would not have been possible.

The project was extremely successful and managed to treat three times the number of patients compared with the traditional hospital that existed before (Sheid, Brown, 2010). The project therefore increased access to mental health care without imposing external understandings of medicine. However, due to globalization and development, the Aro Village Project was not scalable. The structure only worked in a small, agrarian village and Western models expanded in other parts of the country as development increased. Also, in this case, the leader of the project was Nigerian (albeit educated in the UK). His intimate knowledge of Nigerian culture likely helped him better meet the needs of the patients, families, and village partners. But considering current global distribution of resources, in most cases, funding and medical professionals will often come from the West, which makes partnership even more important. Although the project was a good example of strong partnership and localized efforts without much influence from the North, its impact was limited.

On the other hand, PRIME’s main objective is to implement the WHO’s mhGAP, a much more standardized implementation strategy than the village health project. PRIME works in five LMICs: Ethiopia, India, Nepal, South Africa, and Uganda. The very fact that one organization works in multiple countries and communities reveals that PRIME is part of the global health movement. The mhGAP provides detailed diagnostic tools and suggests treatment plans for twelve neuropsychological disorders, including depression, alcohol abuse, and dementia. However, this structure is intended to empower health care providers in the context of pre-established primary health systems, not establish hard-and-fast rules. This allows local healh systems to adjust implementation based on local understandings of mental health to some extent. PRIME works with the WHO, partners in the UK, and local leaders and organizations in the LMICs it serves to generate research and implement interventions based on expanding primary health care (PRIME, n.d.). This is a scalable project that focuses on local interventions by integrating standardized strategies on a case-by-case basis in primary care settings. It creates partnerships that give LMIC leaders a voice while harnessing the resources of HICs, the WHO, and other powerful entities. It creatively addresses the issue of a human resource gap through task-sharing and task-shifting, educating primary health care providers enough so they can provide counseling and psychiatric services usually only provided by specialists.

However, PRIME’s strategy as well as the mhGAP’s depends at least to some degree on research methods, language, and definitions of mental illness from the Global North. For example, the mhGAP uses language like “depression,” and as Summerfield pointed out in his talk, this term may not be locally relevant in some LMICs. Gotlib and Hammen’s Handbook of Depression (2010) extensively expounds why even this one word has Western underpinnings. Among other reasons, decreases in self-esteem are only viewed as abnormal in cultures that assume that having positive emotions and feeling good about oneself is a normal and healthy way of being.” And this means that “conceptions of depression are influenced by the Western view of the individual” which doesn’t translate in cultures that “view individuals as interdependent, connected with others, and defined by the social context” (p. 468). Further, PRIME and other global mental health organizations often depend on randomized controlled trials. Among other ethical concerns, some question whether complex interventions across different cultural groups can be assessed using objective measurements as a predictor of future success (Allen, Barn, Lanphear, 2015).

Recommendations

Although there are limitations that impede accurate assessment and implementation of global mental health interventions, the inequity in mental health support between HICs and LMICs is undeniable, and we must make efforts to close that gap. However, keeping in mind the unequal power relationship due to imbalanced resource distribution in the Global North and Global South, these efforts must thoughtfully address concerns about cross-cultural understandings of mental health and imperialistic attitudes. In order to approach this project holistically, global entities and smaller organizations should focus on four key areas: (1) Mental health interventions, (2) Partnerships (3) Research, and (4) Education.

First and foremost, global health agencies and organizations should fund more localized mental health interventions that create sustainable, equitable, and economically responsible projects. They should give priority to interventions that promote task shifting and task sharing in order to maximize the number of health care providers in low-resource settings. These projects should provide financial support to all health care providers and have a plan for substantial, long-term training and support to non-professional providers in order to ensure they are effective and that the project is sustainable. They should also give priority to interventions that provide long-term strategies for integrating the broader community where the interventions are implemented. At minimum, this means the project must build off any pre-existing primary care structure in the community. However, especially if there is no strong healthcare system in place, this could also mean partnering with community members to build off the community’s social, economic, or other structure (as in the Aro village scheme). By building off pre-existing health infrastructure, projects can use a diagonal approach (strengthening health systems and addressing the particular issue of mental health) that allows room for expansion into new areas of mental health or public health in general and reduces costs. In addition to these benefits, by including the community in some capacity, effective interventions can increase awareness in the community and reduce stigma surrounding mental health. Further, this kind of partnership minimizes the tensions and mistrust associated with West-imposed interventions.

As established at the Alma Ata Conference, health is a human right, and across the board, research, case studies, and fieldwork substantiate the idea that mental health contributes to overall health of populations. Therefore, despite complex ethical challenges that must be considered and addressed thoughtfully, it is a moral imperative to narrow the gap in mental health care between HICs and LMICs.

Next, governments (and NGOs when applicable) should help fund increased anthropological research in mental health as opposed to research using quantitative measurements and randomized controlled trials. Anthropological research is certainly more long-term and less intervention-focused, however, it is a better way to achieve the knowledge necessary to implement truly localized interventions and avoid an imposition of Western understandings reminiscent of imperialism. Anthropological research should specifically address issues of stigma and local medicine in order to understand the local history and current beliefs surrounding mental health. When appropriate, if traditional healing or treatment exist, research should investigate the efficacy of those practices in comparison to Western models. The WHO should deemphasize the dependence on mhGAP interventions, since these are based on the Western model, except in cases where these models are locally appropriate and accepted, as determined by anthropological studies and research into existing health infrastructure.

Finally, governments should provide incentives to medical and nursing schools in LMICs to strengthen their education on mental illness and encourage careers in mental health care in order to minimize the gap in mental health care professionals between HICs and LMICs. More generally, as a long-term strategy to address issues of stigma, awareness, and to increase participation in finding effective interventions, international agencies like the WHO should encourage discussions surrounding mental health care in a variety of educational settings, both in HICs and LMICs. Widespread understanding of mental health as part of broader health issues (and acknowledgement of The Lancet’s claim that there is “no health without mental health” (Prince et al, 2007)) will inevitably lead to increased interest and activism with respect to closing the mental health care gap between HICs and LMICs.

Considering the vast number of organizations committed to this cause – from relatively large-scale programs like PRIME to global and governmental entities to small projects by NGOs – the WHO should serve as a supportive liaison connecting organizations and sharing knowledge. By incentivizing partnerships between countries and organizations, specifically between entities from the North and South, the WHO can provide a low-cost service to improve communication so that LMICs have a real say in intervention implementation.

Essentially, organizations and larger entities focused on mental health should (1) scale up local and global support for mental health care and (2) emphasize local contexts in the implementation of mental health care. As established at the Alma Ata Conference, health is a human right, and across the board, research, case studies, and fieldwork substantiate the idea that mental health contributes to overall health of populations. Therefore, despite complex ethical challenges that must be considered and addressed thoughtfully, it is a moral imperative to narrow the gap in mental health care between HICs and LMICs.

 

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