Global Mental Health: Where are we heading?
Special note from the editors: This is the fifth blog of our new series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months.
Global mental health is a term that describes the practices, research and policies delivered and enacted worldwide to improve the mental health of the world's citizens. I have chosen today to discuss global mental health because it is a topic I feel most passionately about.
I am of Ugandan heritage, a low-income country in East Africa, and it was my learning of the stark contrast in the services and unique experiences and challenges faced by patients and mental health professionals, in comparison to our services here in the United Kingdom, that first led me to become interested in transcultural psychiatry and global mental health.
Although it is not perfect, the United Kingdom benefits from an incredible National Healthcare Service, including brilliant mental health services, and this is in part why I decided to study medicine and it has inspired me to pursue psychiatry as a career.
However, this also means for many of us it can be easy to forget to consider the lived realities and struggles of those at home and that of others in what can feel like half a world away.
Mental illness and substance misuse are leading causes of disability globally and account for just under 15% of annual deaths worldwide.
By 2030 it is projected that mental health problems, particularly depression, will be the single leading cause of mortality and morbidity universally. The presence of a worldwide treatment gap in mental health services has been described wherein people in need are not receiving care. This division is large and is described across many mental health conditions including depression, anxiety disorders and schizophrenia, whilst being the greatest in those experiencing alcohol abuse and dependence.
These inequalities vary throughout the globe and are most pronounced in less economically developed nations where services are scarcer and less accessible, with up to an estimated 76–85% of mental disorders going untreated in less developed nations, in comparison to 35–50% in more developed nations. This failure to implement public mental health interventions leads to largely preventable suffering at a population level.
What issues is Global Mental Health facing?
It is increasingly recognised that the conditions in which individuals are born, grow, live and work, impacts both their physical and mental health. These circumstances are heavily influenced by the division of power, finances and resources from the local to the global level, creating health disparities between communities.
A number of structural barriers within countries contribute to the global treatment gaps observed including a lack of human resources, fragmented service delivery models and poor service funding. Compounding these difficulties is a lack of knowledge in identifying mental illness features within communities, coupled with stigma and fear towards mental illnesses and their treatment.
A great number of factors influence the mental health of individuals worldwide. It is felt some of the most prominent changes to global mental health in the coming years will come to head in the face of heightening political instability, increasing war and conflict, rising urbanicity and migration, the mounting effects of climate change, and most recently, the COVID-19 global pandemic.
In 2019, 79.5 million people were forcibly displaced globally. Most people remain displaced within their home country but 26 million people worldwide have fled to other countries as refugees.
In 2018 there were over 125,000 refugees and 45,000 pending asylum applications in the UK alone. It is known that asylum seekers and refugees face unique and complex mental health challenges and are more likely to experience mental distress, including higher rates of depression, PTSD and anxiety disorders. Despite this, refugees are less likely to receive the appropriate support than the general population.
Recent history has borne witness to individuals crossing borders to flee their homes and countries in situations of political instability and war, and it is these often harrowing pre-migration experiences that contribute to this vulnerability, alongside issues faced later such as poor housing, family separation and difficult asylum processes.
Climate change is set to be the largest cause of mass migration and displacement of all time and with it bringing untold difficulties for affected citizens globally.
Loss of land, homes, livelihoods and worsening food and water insecurity and poverty due to extreme weather is thought to be driving disease burden, including worsening of mental health concerns, particularly an increase in depression, substance abuse and PTSD.
The effects of climate change pose an extreme threat to the wellbeing and mental health of the worlds citizens, disproportionately affecting the worlds least economically developed nations. Global action and collaboration to tackle both the immediate and long-term outcomes is urgently needed.
The emergence of the COVID-19 pandemic has had an overwhelming impact on individuals mental health and has disrupted the delivery of mental health services globally, particularly impacting low and middle-income countries, where services are already fragile.
Those in need are finding it harder to get the support they need in an age where it was already difficult to receive the support they needed even prior to the pandemic, and even in more developed countries.
The long-term psychosocial manifestations of COVID-19 are still unclear but the impact of physical distancing, loneliness, death of friends and family members, and job losses is likely to be tremendous.
In addition, it is becoming more apparent that those having endured significant illness are experiencing new onset chronic disease and disability bringing with it mental distress. It is also recognised that intensive care hospitalisation can lead to the development of anxiety disorders, depression and PTSD.
There is substantial evidence that ethnic minorities are being disproportionately affected by the COVID-19 virus. This is in addition to the fact that in the UK, those of African and Caribbean backgrounds are already consistently over-represented within mental health service admissions whilst also experiencing disproportionate cases of compulsory detention, coercive treatment and adverse care incidents.
Structural racism, economic disadvantage, social exclusion, barriers to service accessibility and misdiagnosis are some of the major factors that contribute to the poor experience of services reported by some minority populations.
How is global mental health moving forward?
Governments are the most commonly cited source of mental health service funding worldwide, followed by non-governmental and non-profit organisations and finally employers and private expenditure.
A growing interest in global mental health issues over the last decade has seen funding opportunities for global health activities increase, echoed by a growth in research initiatives, such as the UK’s £1.5 billion Global Challenges Research Fund to support cutting-edge research that addresses the challenges faced by developing countries.
Year by year this field expands, and it is precisely this developing awareness and interest from academics, clinicians, activists, citizens and alike that will encourage further funding from government and non-governmental bodies, greater opportunities for healthcare professionals and researchers and a wealth of real global change.
Researchers have considered possibilities for the future of global mental health, most pertinently calling for worldwide co-ordination of research and a universal consensus concerning the minimum standards of care for patients with mental disorders. In response to shortages in service delivery, the 2018 Lancet Commission on global mental health and sustainable development recognised mental health as a fundamental element of universal health coverage.
The Commission stressed the need to scale up services and highlighted the promising capacity of digital health solutions in improving accessibility of services globally. For example, the widespread adoption of mobile phones in low-income countries has led to their increasing use for health interventions given their potential for increasing access and coverage in hard-to-reach areas.
Global concern regarding the psychosocial effects of COVID-19 has led major funding bodies and governments to increasingly appeal for proposals and solutions to tackle these outcomes. In addition to this, it is understood that treatment interventions alone are insufficient to reduce the burden of mental illness and a call for research to further understand the social determinants of global mental health is being made.
The development of public health strategies for the prevention of mental illness in global communities will be hugely impactful and will reduce the need for mental health services utilisation, increasingly vital in nations for whom services are scarce and fragile.
Although the picture I have painted today is perhaps a difficult one, improving the quality and accessibility of care is ongoing, particularly in low-resource settings. The future of global mental health is rapidly evolving under challenging circumstances, particularly in light of the COVID-19 pandemic.
We are all global citizens sharing the same planet and I believe the provision of equitable, accessible mental health services for all those who may need it, regardless of location or personal characteristics, alongside the implementation of supportive health policies, should be of paramount importance in addressing what is a largely preventable global disability and mortality issue.
I consider it extremely important for all healthcare professionals to be knowledgeable about global mental health issues and the inequalities that divide our societies, regardless of whether they work in mental health services, as these issues permeate all areas of medicine, life and beyond.
It reminds me of the poignant words of Dr Brock Chisholm, the first Director-General of the WHO:
“Without mental health there can be no true physical health”
In the next few decades, I hope to see the much-needed changes come to fruition, ultimately leading to fewer people suffering unnecessarily and definitively receiving the care they deserve.
I am optimistic that I will see this brighter future in my lifetime and hope to be a part of this incredibly important global change.
NOTE FROM THE EDITORS: If you enjoyed today’s blog by Cecilia, be sure to head over to InSPIre the Mind and check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, and gender inequality in psychiatry.