Global Mental Health: Title and subTitle BreakA New Global Health Field Comes of Age

Global health is “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”¹ Global mental health is the application of these principles to the domain of mental ill health. The most striking inequity concerns the disparities in provision of care and respect for human rights of persons living with mental disorders between rich and poor countries. Low- and middle-income countries are home to more than 80% of the global population but command less than 20% of the share of the mental health resources.² The consequent “treatment gap” is a contravention of basic human rights—more than 75% of those identified with serious anxiety, mood, impulse control, or substance use disorders in the World Mental Health surveys in low- and middle-income countries received no care at all, despite substantial role disability.³ In sub-Saharan Africa, the treatment gap for schizophrenia and other psychoses can exceed 90%.⁴ Even where treatment is provided, it often is far below minimum acceptable standards. Failure to provide basic necessities such as adequate nourishment, clothing, shelter, comfort, and privacy; unauthorized and unmonitored detention; and shackling and chaining are all well-documented abuses, described recently as a “failure of humanity.”⁵

Three critical foundations of evidence account for the emergence of the new field of global mental health. First, a large body of cross-cultural research and, equally important, the narratives of health care workers and persons living with mental disorders have put to rest any notion that mental disorders were a figment of a “Western” imagination and that the imposition of such concepts on traditional and holistic models of understanding amounted to little more than an exercise in neocolonialism. Second, an increasing amount of epidemiological research has attested to the considerable burden of mental disorders in all world regions. The Global Burden of Disease⁶ indicated that 5 of the top 10 contributors to years lived with disability globally were mental disorders. The vicious circle of disadvantage, social exclusion, and mental disorder was a key message of the World Health Report 2001.⁷ Third, evidence has shown that efficacious drug and psychological treatments are available for a range of mental disorders and that nonspecialist health care workers can deliver psychological treatments or multicomponent stepped care interventions for mental disorders, with large treatment effect sizes that are sustained for extended periods.⁸ With severe and persistent shortages of personnel and the spiraling costs of specialist mental health care, such evidence counters the nihilistic view that nothing can be done.⁹

The recent rapid increase in the visibility of the field can be seen in several articles on global mental health that suggested scaling up services for persons with mental disorders on the twin principles of scientific evidence and human rights.⁹ This has now been adopted as a focus of action in global mental health, such as with the World Health Organization's (WHO’s) mhGAP (Mental Health Global Action Program) and the Movement for Global Mental Health.¹⁰ WHO has declared mhGAP as its flagship program in mental health and will publish evidence-based guidelines for nonspecialist health care workers to provide treatments for 8 mental, neurological, and substance use disorders in routine health care settings. The Movement for Global Mental Health is a coalition of individuals and institutions committed to actions to close the treatment gap. It derives its inspiration from the success of the Treatment Action Campaign in transforming the lives of persons living with human immunodeficiency virus (HIV) infection worldwide by campaigning to ensure access to antiretroviral medicines.

Scaling up services can take 2 distinct paths. Integrating mental health care into programs already in place for other health conditions is a pragmatic and efficient approach that may require only marginally additional resources; HIV/AIDS, chronic diseases, and maternal and child health are some examples. However, the most vulnerable individuals with mental disorders are those living with serious, enduring, and disabling conditions: intellectual disabilities, schizophrenia, and dementia are hallmark examples of such conditions across the life course. For these individuals, there is an urgent need for deinstitutionalization and provision of acute and continuing care services closer to the communities where those affected live.

There is a critical need for more research. While the essential ingredients of packages of care have already been identified,⁸ there is uncertainty as to precisely how these should be delivered. Hence, much attention needs to be directed to the implementation science. This needs to focus particularly on the most effective interaction between specialist and nonspecialist care providers, such as the extent to which tasks can be shifted and the duration, type, and frequency of training and supervision that are required. So far, the field of global mental health has been largely focused on the large treatment gaps in low- and middle-income countries, a clear moral and ethical priority. However, the field will reach maturity only when it recognizes its potential to bring about improved care and outcomes and reduced inequities in all world regions. There are many underserved subpopulations in high-income countries too, and the provision and quality of mental health care has been shown to vary widely. In a globalizing world, the field will increasingly need to address transnational influences on mental health; migration, conflict, disasters, and the effects of global trade policies are notable examples.

Knowledge can and must flow in both directions between high-income countries and low- and middle-income countries. Researching mental disorders and treatments in diverse populations and translating advances in neuroscience to the benefits of patient care in the global mental health context are major challenges for the field. Ultimately, the search for a better understanding of the causes of mental disorders and affordable and effective treatments is of importance to improving the lives of individuals living with these disorders in all countries. This is the ultimate goal of global mental health.