” There is no health without mental health”
Global Mental Health, is in my experience, a topic that can get a lot of very intelligent people confused stumped or in heated argument around different issues within this area. While no expert, mental health and care of people with mental illness in different contexts is one of the first topics that got me interested in Global Health. As a neuroscience undergraduate I was fortunate to work at Grand Challenges Canada, one of the first granting agencies to meet the Grand Challenge in Global Mental Health sent out by the leader of the field, Vikram Patel. I wanted to study the brain as an undergraduate because there is so much we do not understand about it. I feel the same can be said for Mental Health. Again, speaking as only an interested lay person there is great debate around the best approaches to providing care in high resource contexts let alone low resource settings. The majority of trial in mental illness treatment have been conducted in high resource settings, which raises the question if the results can be applied in another context. The impact of treatments across different religious and social context is not known. Of course this lack of research does not meant we should ignore mental health needs or that mental health solutions should not be attempted in low resource settings. I personally feel ay global health intervention focusing on mental health must be undertaken with great care and implemented and informed by local people with an understanding of the biosocial context along with available evidence. That mental illness may present differently in specific cultural and social context is a challenge for surveillance , diagnosis and treatment. Of course, this should be true for any GH intervention. Somatosphere has an excellent blog piece going into greater depth on the critiques of the Global Mental Health movement
As such it was with great enjoyment and relief to hear Dr. Harms speak. Right from the start Dr. Harms openly address the controversy and complexity of delivering mental health care in different cultural contexts. Dr. Harms started with an overview of the Global Mental Health landscape. While definitions of health have long understood a person’s health is more than their physical condition, mental health has long been neglected. Personally, I wonder if this is due to the challenge of offering effective treatment. Prior to the use of DALYs even measuring the burden of mental illness would have been difficult. Even still, Mental Illness must be addressed
More than 75% of people with serious mental illness in less developed countries do not receive treatment , and for those who receive treatment there it little study to the effectiveness or quality. For low resource settings there is an almost overwhelming number of issues that have lead to this situation. There are few healthcare professional with the training to provide mental health care, models of care delivery are needed as is more research, policy and political support and infrastructure. Even more difficult is that advances are needed in these areas simultaneously for mental health care to progress in low resource settings.
In my opinion mental health care in low resource settings can lead the way in innovative methods to provide low cost, scalable but effective care. Task shifting and working with traditional healers or using non-specialists to provide mental health care is one suggested approach.
One of the common argument against global mental health is one of cultural relativism and that the GMH movement is a form of medical imperialism. Personally, I believe many people working in the field take efforts to prevent this from happening. Dr. Harms raised an example scenario from her experiences in the field and asked us what we though about the psychiatrists decision. While our class was able to understand why a psychiatrists may have made the suggestion they did based on the social context they were in, I feel many people were uncomfortable at first with the decision the psychiatrist made.
Vikram Patel has an interesting mnemonic to guide global mental health interventions which I very much support:
S: simplify the messages used to convey mental health issues e.g. avoid using psychiatric labels which can cause shame and misunderstanding
U: unpack interventions into components which are easy to deliver
D: care should be Delivered as close as possible to people’s home
A: should recruit and train the Available manpower within a local community. –working within the local context.
R: Reallocate the skills of specialized manpower to supervise and support community health agents.
TED talk on GMH by Vikram Patel
Fascinating discussion on the challenges facing GMH
McGill’s division of social and trans cultural psychiatry there are great online lecture on culture and mental health
Prince M, Patel V, Saxena S, et al. No health without mental health. The Lancet. 2007; 370: 859-77.
Grosse SD, Lollar DJ, Campbell VA, Chamie M. Disability and disability-adjusted life years: not the same. Public Health Reports. March-April 2009; 124: 197-202.