Promoting Global Mental Health:The Role of Contextual Science

Dr Ross WhiteUniversity Teacher/Clinical Psychologist

Mental Health and Well-beingUniversity of Glasgow

Global Mental Health

• 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 ‘a failure of humanity’ (Kleinman, 2009): “The fundamental truth of global mental health is moral: individuals with mental illness exist under the worst of moral conditions”.

Income Groups

Inequalities in Mental Health Provision

• Despite the fact that around 80% of the world’s population live in LMIC (Saxena et al., 2006), it is estimated that greater than 90% of global mental health resources are located in high-income countries (WHO, 2005).

• Countries in Africa, Latin America, and south/south-east Asia spend under 2% (and often less than 1%) of health expenditure on psychiatric conditions compared to over 10% in the USA (Kleinman, 2009).

Leading causes of burden of disease (DALYS) 2004

Issues with Epidemiology

• Representativeness of the studies (the EURO region had studies relating to 15 out of 52 countries compared to the AFRO region which had studies relating to 3 out of 52 countries) (Brhlikova et al. 2010).

• This may be indicative of true discrepancies in prevalence, however it is important to note that the cross-cultural reliability and validity of the CIDI are not well established (Simon et al. 2002; Wang et al. 2007; Bromet et al. 2011).

mhGAP(WHO)

• The Mental Health Gap – Action Programme (mhGAP-AP) outlines key steps in scaling-up of services in LMIC: secure political commitment, assess needs and resources, develop policy and legislative infrastructure, deliver intervention packages, strengthen human resources, mobilize financial resources, and monitor and evaluate services.

• The Mental Health Gap – Intervention Guide (mhGAP-IG): Presents integrated management plans for priority conditions including: Depression, Psychosis, Bipolar disorders, and Epilepsy in LMIC.

Issues with mhGAP

• Absence of an evidence base to inform us about what exactly to scale up.

• “Scaling up is defined as a deliberate effort to increase the impact of health-service interventions that have been successfully tested in pilot projects, so that they will benefit more people…However, pilot or experimental projects are of little value until they are scaled up to generate a larger policy and programme impact” (WHO, 2008; P13).

Issues with mhGAP

• There is no acknowledgement of how scaling up psychiatric services might serve to inhibit the development and use of other forms of healing and/or treatment.

• Summerfield (2012): the more that people think that they are not expected to cope through their own recourses and networks, then the greater the risk that time honoured ways of enduring and coping may be lost.

Issues with mhGAP

• The central weakness of global mental health programmes such as mhGAP is their assumption that mental health problems are the same the world over, that these are ‘diseases’ of the brain.

• At present, within these programmes, there is very limited focus on the potential role that social and cultural factors play in mental health problems across the globe.

Globalising Mental Illness

• The evidence for biological causes for mental illnesses such as depression and schizophrenia remain fairly weak (Nestler et al., 2002; Stahl, 2000).

• Biological psychiatry ‘a practice in search of a science’ (Wyatt & Midkiff, 2006).

• Antipsychotic medications can contribute to metabolic disorders, cardiovascular conditions, and risk of premature mortality linked to sudden cardiac death (Alvarez-Jiminez et al., 2008; Ray et al., 2009; Weinmann et al., 2009).

Globalising Mental Illness• WHO studies: International Pilot Study for

Schizophrenia (IPSS), Determinants of Outcome of Severe Mental Disorders (DOSMeD), International Study of Schizophrenia (ISoS).

• High rates of chronic disability and dependency associated with schizophrenia in high-income countries, despite access to costly biomedical treatment, suggests that something essential to recovery is missing in the social fabric (Jablensky & Sartorius, 2008).

Globalising Mental Illness

• The predominance of ‘Western’ frames of reference for categorising and measuring mental health difficulties mean that the evidence-base for mental health interventions is not universally valid for the global population (Summerfield, 2008) .

• The cross-cultural validity of the diagnosis of depression is questionable. The apparent rise in prevalence of depression across the globe is a ‘pseudo-epidemic’ (Summerfield, 2006) .

Globalising Mental Illness

• Tanzania: Biomedical explanations of mental health difficulties led to the emergence of the criticism, hostility and over-involvement in families (high expressed-emotion) which had not previously been observed in this cultural context (McGruder, 1999).

• Ghana: psychotropic medications synonymous with “modern” medical treatment and little consideration is therefore given to psychosocial interventions within psychiatric services. In spite of treatment approaches supporting the resumption of a social role being most valued (Read, 2012).

The Role of Functional Science

• ACT can empower individuals to tolerate distress and commit to value-consistent behaviors (which are in part culturally defined).

• Consequently, ACT may translate well across different cultures.

• ACT has been used successfully in a non-Western middle-income country i.e. Iran (Mo’tamedi et al., 2012) and Sierra Leone.

The Vision

• Rather than focusing on psychiatric diagnoses, focus on specific types of difficulties that impact on their mental wellbeing (e.g. sexual and gender-based violence, poverty, social exclusion, migration and physical health problems such as HIV/AIDS).

• Target local resources in culturally appropriate ways to moderate or modify the impact of structural inequality and social injuries.

The Vision

• Mental health practitioners, social scientists, anthropologists, politicians and community leaders engaging in constructive dialogue aimed at developing culturally appropriate ways of understanding and supporting mental health needs.

• Contextual formulations: narrative accounts of individuals’ difficulties and strengths understood within their local setting; a values-based approach to understanding the individual’s life and how they want to move forward; and an examination of local resources that are available to support this journey.

Conclusions

• Mental health services in low and middle income countries are under-resourced.

• The WHO are scaling up psychiatric systems.• Outcome for complex mental health problems may

be better in LMIC than HIC.• We must embrace more nuanced, culturally

appropriate approaches (work globally, think locally).• Contextual science has a role to play.

Ross.White@glasgow.ac.uk