Global Mental Health and Social Determinants

In addition to the aforementioned association with transcultural psychiatry, the emergence of GMH has been linked to developments in the field of GH (Patel 2012, 2014).[1] Global health has been defined as: ‘the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide’ (Koplan et al. 2009, p. 1994). Patel (2014) points out that GH initiatives are guided by three central tenets: (1) reducing disease burden, (2) increasing equity and (3) being global in its reach. The development of GH has served to propagate economic metrics that have been used to highlight the considerable impact that mental health difficulties cause globally. A key example of this was the introduction of the Disability Adjusted Life Year in the World Development Report: Investing in Health (Jamison et al. 1993). This metric, which measures the impact of health conditions on morbidity and mortality, led to mental health difficulties being highlighted as a considerable cause of burden in the Global Burden of Disease study (Murray and Lopez 1996). Results from the GBD metrics on mental health were used to strengthen the call to address mental health as a worldwide problem in the book entitled World Mental Health: Problems and Priorities in Low-Income Countries (Desjarlais et al. 1995). The development of GMH is thus linked to epidemiological enquiry into disease burden and the assumption that mental health difficulties and their impact are standardizable across the globe (Bemme and D’Souza 2014; Baxter et al. 2013). This in spite of the fact that mental health-related epidemiological data are absent or only partial for much of the world’s population (particularly the 80% who live in low- and middle- income countries), making it inadequate for planning and policy at a global or local level (Baxter et al. 2013).

Recently, Susser and Patel (2014) have argued that GMH should be regarded as partly distinct from GH, as otherwise mental health difficulties will continue to receive lower levels of priority relative to physical illnesses (including communicable and non-communicable diseases). GMH is also vulnerable to criticisms that have been levelled at GH in recent years, particularly the risk of mental health initiatives being disengaged from environmental, political and economic factors which impact health. These factors form part of the public health concept of ‘social determinants’ as drivers of health inequalities (Marmot 2014) and which were influential in the development of the GH concept. However, social determinants are often narrowed down to proximal or ‘downstream’ factors such as lifestyles or family structure, with much less focus on broader ‘upstream’ determinants which operate on a global scale such as economic policies. For example, Richard Horton has suggested that the field of GH has ‘built an echo chamber for debate that is hermetically sealed from the political reality that faces billions of people worldwide’ (Horton 2014, p. 111). Specifically, Horton (2014) points out that global institutions systematically ignore the social chaos in which people live their lives, that is, ‘the disruption, disorder, disorganisation, and decay of civil society and its institutions’ (p. 111). According to Horton, social chaos can arise from three major sources: armed conflict, internal displacement and fragile economies. The narrow focus of GH may in part stem from the ways in which roles and responsibilities relating to health care have historically been designated. Professionals have tended to operate within the narrow confines of ‘vertical’ approaches, which have restricted their efforts to working within the competency-specific boundaries of the health sector ‘silo’. Whereas health care professionals may feel sufficiently skilled to intervene in medical problems, they may feel less competent at recognizing and addressing factors related to other sectors such as education and criminal justice, let alone national and global policy. An additional complication may relate to the extent to which matters relating to health and mental health can become political issues that are susceptible to the competing political interests of different protagonists. In such circumstances, ignoring ‘social chaos’ may be a strategic necessity to ensure that the provision of some form of support remains possible, albeit partial. The concern here is that unresolved sources of social injustice and ‘structural violence’ (Farmer et al. 2006) continue to perpetuate physical and mental health difficulties and limit access to sources of support. It is hoped that the specific inclusion of mental health in the Sustainable Development Goals (UN 2015), and initiatives such as the Out of the Shadows: Making Mental Health a Global Priority launched by The World Bank in April 2016, will be helpful for creating momentum for addressing structural factors that may be serving to limit mental health and wellbeing.

The WHO (2014) has highlighted the need to specifically address social determinants of mental health, and recognition of the influence of social determinants on mental health has been claimed as one of the foundations of GMH (Patel 2012). Kirmayer and Pedersen (2014) argue that GMH initiatives need to place greater emphasis on forms of social inequality and injustice. Indeed, it has been suggested that: the hallmark of GMH is to emphasize the simultaneous need for social interventions alongside biomedical interventions as appropriate for the individual.

(Patel 2014, p. 782)

However, there has not always been consensus on how a balance might be struck in addressing social, as well as medical, influences on mental health. In addition, efforts to address ‘social determinants’ have tended to be focused at the micro level of the individual and/or the community, rather than tackling wider structural determinants at a macro level (Das and Rao 2012). Reflecting this uncertainty, Joop de Jong has expressed concerns that the purpose of GMH is unclear because it lacks a guiding (meta-)theory (cited in Bemme and D’Souza 2012). It is perhaps debatable how much of a drawback this overarching lack of consensus is. On the one hand, it may contribute to the bogging down of GMH advances and initiatives in repetitive arguments over theoretical perspective and appropriate interventions. On the other hand, a diversity of theoretical positions may actually be a stimulating and valuable feature that continually challenges GMH as a field of study and practice to engage with the complex social realities and uncertainties in which people live.

Since the latter part of the twentieth century, mental health services in the West have increasingly professed allegiance to the ‘biopsychosocial approach’ (Engel 1977). The impetus for proposing this approach stemmed from a concern that the biomedical approach had left ‘no room within its framework for the social, psychological, and behavioral dimensions of illness’ (Engel 2004, p. 53). Whilst commentators acknowledge that the biopsychosocial approach has made an important contribution to clinical science, concerns have been raised about the extent to which the approach has been able to bring about meaningful change in clinical practice (Alvarez et al. 2012). Sadler and Hulgus (1990) highlighted that a lack of consideration of the ‘practical and moral dimensions of clinical work’ (p. 185) means that the biopsychosocial approach is largely redundant for guiding specific actions in the clinical encounter. Alvarez et al. (2012) suggested that the absence of concrete guidelines about applying the biopsychosocial approach in practice means that it weakens in the face of biomedical approaches. Rather than leading to a holistic, integrative way of addressing mental health difficulties, Ghaemi (2009) raises the possibility that the biopsychosocial approach can lead to ‘cherry picking’ of treatment options, whereby different professionals revert to their specialist training to decide which particular interventions to recommend. This may lead to the emergence of a monoculture of treatment in particular professional groupings. For example, Steven Sharfstein (the former president of the American Psychiatric Association), reflecting on the dominant role that biological approaches to mental health difficulties had assumed in the USA, urged psychiatrist colleagues to:

examine the fact that as a profession, we have allowed the biopsychosocial model

to become the bio-bio-bio model. (Cited in Read 2005, p. 597)

To some extent, concerns about the risk of professional parochialism (among psychiatrists, psychologists, nurses etc.) can be offset by a multidisciplinary team approach that aims to collectively harness expertise in different forms of treatment and intervention. However, in low-income settings such approaches may be limited by restricted resources and limited diversity of professional expertise, resulting in a reliance on more easily delivered pharmaceutical interventions (Jain and Jadhav 2012).

  • [1] Readers interested in learning more about the historical context of the emergence of Global MentalHealth should consult Bemme and D’Souza (2014), Lovell (2014), and Lovell and Susser (2014).
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