Is the 'Treatment Gap' in LMICs as Large as It Is Reported to Be?
Much of the call to scale up mental health services is based on the assumption that there is a ‘treatment gap’—that there is a high need for mental health services in LMICs and that this need is not met. Within GMH literature, this partly seems to imply that current services and resources for mental health simply do not exist, and partly that what does exist is inadequate, particularly in respect to being ‘unscientific’. As Kasujja (2014, p. 3) puts it—‘scaling- up implies that LMIC mental health systems need some kind of upgrading, which implies, in other words, that they are rotten, inadequate, insufficient or in a state that causes concern’. Such assumptions are problematic and need to be addressed. Patel et al. (2011, p. 1442) call for the Mental Health Gap Action Programme (mhGAP) guidelines (specifically developed to aid treatment decisions in non-specialized health care settings in LMICs) to ‘become the standard approach for all countries and health sectors’, meaning that ‘irrational and inappropriate interventions should be discouraged and weeded out’. Here ‘scaling up’ also involves a process of ‘weeding out’. That which is being scaled up is constructed as rational and appropriate, and that which needs weeding out is ‘irrational’. However, the question of who decides what counts as appropriate or irrational is overlooked. Drawing on the work of Fernando (2012) and Sax (2014), Kirmayer and Pedersen (2014) suggest that the notion of a treatment gap ‘privileges mental health services and interventions by mental health professionals and ignores or downplays community- based and grass-roots approaches’ (p. 764).
The assumption that GMH is scaling up psychiatry onto an empty terrain (i.e. that few resources currently exist in LMICs) is problematic because, as with the assumption that alternatives do exist but are ‘irrational’, it overlooks the potential cultural validity of alternative forms of support, which may range from informal support within a community, to other forms of healing. Moreover, a number of LMICs already have psychiatric systems in the form of large asylums, often as legacies of colonialism (Ernst 1997), and that continue as sites where multiple human rights abuses occur (WHO 2003b, p. 23). Such abuses are acknowledged by the MGMH, which calls for a move away from large-scale institutions and encourages community and out-patient forms of care. However, the MGMH does this with (1) little discussion of the problems that care in the community has run into in the HICs where it is enacted and (2) little acknowledgement of how the MGMH’s activities may reproduce (neo)colonial power relations (see Fernando 2014; Mills 2014a; Mills and Fernando 2014).