There are huge inequalities in the
availability of resources to support mentalhealthneeds across the globe. It is
estimated that greater than ninetypercent of global mentalhealth resources are
located in highincomecountries (WHO, 2005). This is all the more alarming when
we consider that around eightypercent of the world’s population live in low-
and middle-incomecountries (LMIC: Saxena et al., 2006). In countries inAfrica, latin
America, and south/southeastAsia under twopercent (and often less than onepercent)
of expenditure on health tends to go to services for psychiatric conditions
(compared to over tenpercent in theUSA) (Kleinman, 2009). And there is a
gathering mentalhealth storm: it is projected that by2030, depression will be
the second biggest cause of disease burden across the globe (Mathers &
Loncar, 2006), second only toHIV/AIDS.
When
four out of five people inLMIC who need services for mental, neurological
and/or substance-use disorders do not receive them (WHO, 2008), we have a clear
"treatmentgap", the difference between the levels of mentalhealthservices
required by LMICpopulations and what is actually available on the ground.
Prominent clinicians and academics, as well as international organisations such
as theWorldHealthOrganization (WHO, 2008, 2010), have called for the
"scaling up" of services for mentalhealth inLMIC. "Scaling up"
involves increasing the number of people receiving services, increasing the
range of services offered, ensuring these services are evidence-based, using
models of service delivery that have been found to be effective in a similar
contexts, and sustaining these services through effective policy,
implementation and financing (Eaton et al., 2011). Yet in light of the limited
resources available to support mentalhealth, it is pertinent to ask whether it
makes sense to try to export systems of service delivery that have been
developed in highcountries toLMIC. Will this venture be sustainable in the
longer term? More importantly, will these systems actually deliver added value
for the increase in budgetary expenditure that will be required?
The seductive allure of biologicalPsychiatry
In
highcountries, mentalhealth services tend to gravitate aroundPsychiatry, the
branch ofMedicine that is concerned with the study and treatment of mentaillness,
emotional disturbance, and abnormal behaviour. BiologicalPsychiatry is an
approach toPsychiatry that aims to understand mentalillness in terms of the
biological function of the nervoussystem.
The
rise of biologicalPsychiatry promised great things. Biological explanations of
mentalillness permeated the public consciousness, and the hunt was on to
discover the magical compounds that could redress the chemical imbalances that
were purported to cause mentaillness. Various different medications have been
developed and the marketed. In the past fortyyears, the sales of psychotropic
medications have increased dramatically. Yet despite the exponential rise in
sales of these medications, the evidence for biological causes for mentaillnesses
such as depression and schizophrenia remain fairly weak (Nestler et al., 2002;
Stahl, 2000). The continued absence of definitive evidence to support
biological processes that are causal in mentaillness has led to the suggestion
that biologicalPsychiatry is ‘a practice in search of a science’ (Wyatt &
Midkiff, 2006). Despite these concerns, biologicalPsychiatry continues to exert
a strong influence on the delivery of mentalhealthservices in
highincomecountries such as theUK and America [US].
The
seductive allure of the rationale underlying biologicalPsychiatry is plain to
see. If mentaillnesses were to have universal biological causes, then standard
treatments could be readily applied across the world irrespective of local
differences and associated cultural differences. If evidencebased practices lead
to positive outcomes in highincomecountries, then similar positive outcomes
will be observed in LMIC. Right?
This
is where the picture gets a bit more complicated. Before we can answer this
question, we need to be clear on what we mean by: (1) ‘evidencebased practices’
and (2) ‘positive outcomes’. What is considered to be ‘evidencebased practice’
can serve powerful economic and political interests (Kirmayer & Minas,
2000). In 2007, US citizens alone spent twentyfivebillionspounds on
antidepressants and antipsychotics (Whitaker, 2010). All this in spite of the
fact that claims about drugeffectiveness are at times overstated, and that
pharmaceutical companies have been found to employ questionable research
methodologies (Glenmullen, 2002; Valenstein, 1998; Whitaker, 2010). Professor
DavidHealy (Psychiatrist, University of Cardiff) has stated that a ‘large
number of clinical trials done are not reported if the results don’t suit the
companies’ sponsoring (the) study’ (tinyurl.com/dxlh55w). The evidencebase is
heavily skewed towards research conducted in highincomecountries. Since
producing hard evidence depends on the costly standards of psychiatric
epidemiology and randomised clinical trials, it can be difficult for clinicians
or researchers inLMIC to contribute to the accumulation of knowledge (Kirmayer,
2006). The lack of mentalhealth related research being conducted inLMIC
countries is evident in the finding that over ninetypercent of papers published
in a threeyear period in sixleading psychiatric journals came from euroamerican
countries (Patel & Sumathipala, 2001). An inductive, ["]bottomup
approach["] to research emphasising the importance of local
conceptualisations of mentalhealth difficulties and focusing on local
priorities in different LMIC is required.
Even
if the research capacity inLMIC can be increased, difficulties remain. The
issue of what constitutes ‘positive outcomes’ in relation to mentaillness has
plagued clinical practice and research for manyyears. There is currently no
accepted consensus on what constitutes positive outcome for individuals with mentaillness.
Traditionally, Psychiatry has been concerned with eradicating symptoms of
mentaillness. However, it is important to
appreciate that clinical symptoms do not improve in parallel with social or
functional aspects of service users’s presentation (Liberman et al., 2002).
Functional outcome relates to variables such as cognitive impairment,
residential independence, vocational outcomes, and/or social functions (Harvey
& Bellack, 2009). In this sense, using symptomatic remission as an
indicator of recovery can yield better rates of good outcome than using
indicators of functional recovery (Robinson et al., 2005).
Another
important consideration relating to outcome in mentalillness relates to the
extent to which particular outcomes are culturally sensitive and inclusive
(Vaillant, 2012). Marked disparities have been highlighted between
ethnicminoritygroups and whitepeople in outcome, serviceusage and servicesatisfaction
(Sashidharan, 2001). The lack of culturally inclusive understandings of
positive outcome in mentalillness is compounded by the underrepresentation of
black- and minority-ethnicgroups in mentalhealthrelatedresearch. This has led
to some concluding that there is a lack of adequate evidence supporting the use
of ‘evidencebased’ psychological therapies with individuals from black- and
minority-ethnicpopulations (Hall, 2001). Considering these issues, it seems
that ["]the jury["] is in no position to deliver a ["]verdict["]
on whether ‘evidencebased’ practices for mentaillness developed in highincomecountries
deliver positive outcomes inLMIC.
Diagnosis and culture
Despite
the question marks that remain about the causes of mentaillness, the veracity
of the evidence base, what constitutes good outcome, and how inclusive mentalhealth
services are to cultural diversity within the population, the Psychiatryheavyperspective
has a powerful say in how mentalhealth difficulties are understood inLMIC.
Dissenting voices have questioned the wisdom of this approach. One particular
source of dissention relates to the process of psychiatric diagnosis. The
international classification systems for diagnosing mentaillnesses (such as
depression and schizophrenia) have been criticised for making unwarranted
assumptions that these diagnostic categories have the same meaning when carried
over to a new cultural context (Kleinman, 1977, 1987). This issue has
potentially been obscured by the fact that the panels that finalise these
diagnostic categories have been criticised for being unrepresentative of the
global population. Of the 47 psychiatrists who contributed to the initial draft
of themostrecent WorldHealthOrganization diagnosticsystem (ICD-10: WHO, 1992), only
two were fromAfrica, and none of the fourteenfieldtrialcentres were located in
subSaharanAfrica. Inevitably this led to the omission of conditions that had
been described for many years inAfrica (Patel & Winston, 1994), such as
‘brain fag syndrome’. (This was initially a term used almost exclusively in
westAfrica, generally manifesting as vague somatic symptoms, depression and
difficulty concentrating, often in male students.)
ICD10
does at least acknowledge that there are exceptions to the apparent universality
of psychiatric diagnoses by including what are called culturespecific
disorders. One such example is koro, a form of genital retraction anxiety which
presents in parts ofAsia. Prior toICD10, symptompresentations such as koro
tended to be subsumed into existing diagnoses such as delusional disorder
(Crozier, 2011). But the inclusion of culturespecific disorders only serves to
perpetuate a skewed view of the impact of culture on mentalhealth; ‘cultural’
explanations seem to be reserved for nonWestern patients/populations that show
koro(-like) syndromes, and not for diagnoses that are more prevalent in
highincomecountries (e.g. anorexianervosa). Indeed, it has been suggested that
many psychiatric conditions described in these diagnostic manuals (such as
anorexianervosa, chronicfatiguesyndrome) might actually be largely culturebound
to euroamerican populations (Kleinman, 2000; Lopez & Guernaccia, 2000).
Because people living in "western" countries tend to see the world
through a cultural lens that has been tinted by psychiatric conceptualisations
of mentaillness, they are blind to how specific to "western"
countries these conceptualisations actually are.
TransculturalPsychiatry
Culture
has been defined as "a set of institutional settings, formal and informal
practices, explicit and tacit rules, ways of making sense and presenting one’s experience
in forms that will influence others" (Kirmayer, 2006, p.133). Interest in
the potential interplay between culture and mentaillness first arose in
colonialtimes as psychiatrists and anthropologists surveyed the phenomenology
and prevalence of mentaillnesses in newly colonised parts of the world. This
led to the development of a new discipline called transculturalPsychiatry, a
branch ofPsychiatry that is concerned with the cultural and ethnic context of mentaillness.
In
its early incarnation, transculturalPsychiatry was blighted by the racist
attitudes that prevailed at that time about the notion of naive "native"
minds. However, over time, this began to change as people began to understand
that Psychiatry was itself a cultural construct.
In1977, ArthurKleinman proposed a "new crossculturalPsychiatry" that
promised a revitalised tradition that gave due respect to cultural difference
and did not export psychiatric theories that were themselves culturebound.
Transcultural (or crosscultural)Psychiatry is now understood to be concerned with
the ways in which a medicalsymptom, diagnosis or practice reflects social,
cultural, and Moral concerns (Kirmayer, 2006).
Tensions
exist in transculturalPsychiatry. Clinicians, who are motivated to produce good
outcomes for serviceusers, may work from the premise that there is crosscultural
portability of psychiatric or psychological theory and practice. Although well
intended, this approach can be met with disapproval from socialscientists who
are focused on advancing medicalAnthropology as a scholarly discipline.
However, it is becoming clear that in this era of rapid globalisation, mentalhealthpractitioners,
social scientists and anthropologists need to come together and engage in
constructive dialogue aimed at developing crosscultural understanding about how
best to meet the mentalhealth needs of people across the globe.
The
need for interdisciplinary working in promoting improved understanding about
the interplay between culture and mentaillness has been demonstrated by a
growing body of evidence indicating that exporting Western conceptualisations
of mentalhealth difficulties intoLMIC can have a detrimental impact on local
populations. EthanWatters’s book CrazyLikeUs cites examples from different parts of the world (including China,
Japan, Peru, SriLanka, and Tanzania) where the introduction of psychiatric
conceptualisations of mentaillness has potentially changed how distress is
manifested, or introduced barriers to recovery (e.g. the emergence of expressed
emotion in the families of individuals with psychosis inTanzania). Watters (2010)
cites the work ofGaithriFernando who has written extensively
about the aftermath of the tsunami that struckSriLanka in2006. Fernando claims
that "western" conceptualisations of trauma and the diagnostic
criteria forPTSD were not appropriate for a srilankan context. Fernando found
that srilankan people were much more likely to report physical symptoms
following distressing events. This was attributed to the observation that the
notion of a mindbodydisconnect is less pronounced inSriLanka. Sri lankans were
also more likely to see the negative consequences of the tsunami in terms of
the impact it had on social relationships. Because sri lankan people tended not
to report problematic reactions relating to internal emotional states (e.g.
fear or anxiety), the rates ofPTSD following the tsunami were considerably
lower than had been anticipated. Fernando concluded that western techniques for
conceptualising, assessing and treating the distress that people were
experiencing were inadequate.
Watters
also explores the way in which understanding about depression has changed inJapan
over thelasttwentyyears. This sobering tale allowsWatters to explore how
the interplay between cultural factors and notions of mentaillness can be
manipulated for financial gain. In the1960s, HubertTellenbach had introduced the notion of a personality type called TypusMelancholicus. This idea heavily influenced psychiatric thinking in Japan. Typus
melancholicus had substantial congruence with a respected personality type
inJapan; "those who were serious, diligent and thoughtful and expressed
great concern for the welfare of others dotdotdot prone to feeling overwhelming
sadness when cultural upheaval disordered their lives and threatened the
welfare of others" (Watters, 2010; p.228). Although at the end of thetwentiethcentury
there had been a psychiatric term in the japaneseLanguage for depression
(utsubyô), this tended to relate to a rare and very debilitating condition.
Prior to2000, there had been no real market for prescribing antidepressant
medications in Japan. However, shifting public perception about
TypusMelancholicus closer toward the western conceptualisation of depression
would have huge implications for antidepressant prescribing inJapan. Watters (2010) claims that GlaxoSmithKline’s enthusiasm to
build a market for its new antidepressantmedication inJapan dovetailed
conveniently with a GlaxoSmithKline sponsored "international consensus
group" of experts on culturalPsychiatry discussing crosscultural
variations in depression (Ballenger et al., 2001) concluding that depression
was vastly underestimated inJapan. Depression is now conceptualised inJapan as
affecting individuals (particularly men) who are too hardworking and have overinternalised
the japaneseEthic of productivity and corporateloyalty. In the last few
years, the market for antidepressants in Japan has grown exponentially. An
important consequence of this "aggressive pharmaceuticalisation", is
that psychological and social treatments for depression are being ditched
(Kitanaka, 2011).
Globalisation of mentalhealth
There
is a growing willingness to explore ways of addressing inequalities in the
provision made for mentaillness across the globe, but translating this
willingness into effective action is fraught with potential danger. We must
guard against assumptions that indigenous concepts of mentalhealth difficulties
inLMIC and strategies used in these contexts to deal with it are based on
ignorance (Summerfield, 2008). Despite the apparent sophistication of-Laws, -policies,
-services and -treatments for mentaillness in highincomecountries, outcomes for
individuals with mentalhealth problems may not actually be any better than inLMIC.
Research has failed to conclusively show that outcome for complex mentaillnesses
(such as psychosis) in highincomecountries are superior to outcomes inLMIC
(where populations may not had access to medicationbased treatments) (Alem et
al., 2009; Cohen et al., 2008; Hopper et al., 2007). The lack of academic and
political engagement with alternative nonwestern perspectives means that "western"
narratives about "mentaillness" continue to dominate over local
understanding (Timimi, 2010), yet we in highincomecountries have much to learn
about mentalhealthprovision, particularly in relation to promoting inclusion of
black- and ethnic-minoritymembers of the population.
To
conclude, I would like to come back to the title. Rather than the globalisation
of mentalillness, perhaps what we should be aiming for is the globalisation of
mentalhealth. This is an immensely more inclusive aspiration. By promoting
global mentalhealth, there is the potential for clinicians, academics, service
users and policy makers from across the world to work together with a shared
purpose. By exchanging knowledge, LMIC can benefit from hard lessons learned in
highincomecountries, and highincomecountries can look afresh at how mentalhealth
difficulties are understood and treated. It will be important for clinicians
and academics working in highincomecountries to critically reflect on their own
practice and question the accepted wisdom about mentalhealthprovision.
To
assist with this knowledge exchange, a new MSCGlobalMentalHealthprogramme has
been launched at theUniversityOfGlasgow. Global mentalhealth has been defined
as the "area of study, research and practice that places a priority on
improving mentalhealth and achieving equity in mentalhealth for all people
worldwide" (Patel & Prince, 2010). The programme seeks to develop
leaders in mentalhealth who can design, implement and evaluate sustainable
services, policies and treatments to promote mentalhealth in culturally
appropriate ways across the globe. Global mentalhealth is an emergent area of
study. Momentum is building. Although the challenges are both numerous and
complex, the prize is a worthy one. The cost of not acting can be counted in
the everincreasing number of people whose lives are being affected by mentalhealthproblems
across the globe. [Compromise cowardic at thelastparagraph.]
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