II Globalising Mental Health: Challenges and New Visions
'Global Mental Health Spreads Like Bush Fire in the Global South': Efforts to Scale Up Mental Health Services in Low- and Middle-Income Countries
China Mills and Ross G. White
In 2003, the World Health Organization (WHO) reported that over 650 million people worldwide are estimated to meet diagnostic criteria for common mental disorders such as depression and anxiety (2003a, p. 17). Furthermore, WHO have estimated that by 2030, depression will be the second biggest disease burden across the globe (Mathers and Loncar 2006), second only to HIV/AIDS. Despite this global ‘burden’ of mental disorders and their growing prevalence, the 2001 World Health Report stated that ‘[m]ore than 40% of countries have no mental health policy and over 30% have no mental health programme’, meaning that ‘there is no psychiatric care for the majority of the population’ (WHO 2001a, pp. 3, xvi). Most of the countries that do not have a mental health policy are low- and middle-income countries (LMICs).
In light of this, the Movement for Global Mental Health (MGMH)—an increasingly influential international network of individuals and organizations—was launched in 2008 (see www.globalmentalhealth.org). The MGMH aims ‘to close the treatment gap for people living with mental disorders worldwide’ (Patel et al. 2011, p. 88)—‘the gulf between the huge numbers who
This is a quote from a personal communication between China Mills and Mohamed Ibrahim, a PhD student at Simon Fraser University, Canada, and a nurse and social worker in Kenya.
C. Mills (*)
University of Sheffield, Sheffield, UK R.G. White (*)
Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
© The Author(s) 2017
R.G. White et al. (eds.), The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health, DOI 10.1057/978-1-137-39510-8_10
need treatment and the small minority who actually receive it’ (WHO 2001, p. 6). To achieve this, it aims ‘[t]o scale up the coverage of services for mental disorders in all countries, but especially in low-income and middle-income countries’ (Lancet Global Mental Health Group 2007, p. 87) and believes that this scale-up is ‘the most important priority for global mental health’ (Lancet Global Mental Health Group 2007, p. 87).
Scaling-up has been defined as the process of 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 similar contexts, and sustaining these services through effective policy, implementation, and financing (Eaton et al. 2011). What is meant by ‘mental health services’ tends to involve (dependent on the type of ‘disorder’) both pharmacological and psychosocial interventions, though medication seems to be given priority as first- line treatment in certain circumstances, for example, for schizophrenia and psychotic disorders, and in areas seen as being resource poor (Lancet Global Mental Health Group 2007). In an effort to outline strategies for scaling up mental health provision in LMICs, WHO published two key documents: the Mental Health Gap—Action Programme (mhGAP-AP) and the Mental Health Gap—Intervention Guide (mhGAP-IG). The mhGAP-AP outlines key steps for scaling up mental health services in LMICs, while the mhGAP-IG presents integrated management plans for priority conditions, including depression, psychosis, bipolar disorder, and epilepsy, in LMICs.
Concerns have been expressed that the mhGAP initiatives are largely based on mental health services in high-income countries (HICs) that have been heavily shaped by biomedical psychiatry (White and Sashidharan 2014a). This is occurring at a time when ‘psychiatry is under criticism as a basis for mental health service development’ (Fernando and Weerackody 2009, p. 196). As such, calls to scale up services in LMICs are co-occurring with calls to scale down the role of psychiatry in many HICs. Fernando voices this concern when he asks: ‘Has psychiatry been such a success here [in HICs] to entitle us to export it all over the world?’ (2011, p. 22).
This chapter asks a number of pertinent questions aimed at facilitating critical reflection on efforts to scale up mental health services in LMICs in order to explore the complexities of this endeavour. In part, this involves paying attention both to more general critiques of psychiatry in HICs—for such critiques may still apply or magnify when exported globally—and to critiques that are focussed more specifically on the export of mental health services dominated by psychiatry to LMICs. The questions to be considered include:
Is the validity of psychiatric diagnosis being overemphasized? Is a preoccupation with eliminating symptoms of illness obscuring understanding about what constitutes ‘positive outcomes’ for individuals experiencing mental health difficulties? Is the ‘treatment gap’ in LMICs as large as it is reported to be? Are alternative forms of support being neglected? Are social determinants of mental health being sufficiently considered? Is the evidence base for GMH sufficiently broad, and has the efficacy of ‘task-shifting’ been sufficiently demonstrated?