Developments in global mental health

A home visit by a CBM community mental health programme worker in Sierra Leone (Credit: CBM)
A home visit by a CBM community mental health programme worker in Sierra Leone (Credit: CBM)

Mental health is gaining increasing attention in Australia, with Beyond Blue and other campaigns contributing to bringing this previously taboo issue gradually out of the shadows. People have started to feel able to talk about the issue, assisted by prominent individuals in the public eye disclosing a personal history of mental health problems. While there remains a huge disparity between investment in physical and mental health care services, and a massive treatment gap for people with mental health conditions, there is a growing recognition of mental health needs, and political will to address the issue is increasing.

This increase in profile in the domestic agenda is not reflected in the proportion of funds allocated to mental health in overseas aid, where on average mental health sees less than 1% of total overseas aid for health. Ironically, this is roughly the proportion of health budgets allocated to mental health in the poorest countries in sub-Saharan Africa. The international development community has a long way to go.

It was in the late 1990s that key epidemiological studies started to include disability associated with mental conditions, and the result surprised everyone. Mental illness overall turned out to be the single greatest contributor to the non-communicable global burden of disease, with depression alone set to dwarf other causes of disability. At the same time, the World Health Organisation found that in low income countries, over 85% of people with severe mental illness did not receive the care they need, and even in high income countries the figure is between 35% and 50%. Together, these studies put credible figures to what had been known for a long time; that there is a huge unmet need. This was one of the factors that has encouraged a significant growth in interest in global mental health as a discipline aiming to address this treatment gap. Significant scientific effort was put into working towards a better understanding of how to translate the best evidence for effective care into a variety of resource-poor contexts round the world. There is now a substantial body of evidence to guide implementation of innovative service models available to implementers, for example on the Mental Health Innovation Network. CBM has worked closely with the World Health Organisation to inform development of practical resources like the mental health gap action programme (mhGAP) and WHO MiNDbank. It is only by making such practical guidance available that we can ensure that the best international evidence is able to be properly translated and used for effective programs in low-resourced settings.

Global mental health, even more than other global health initiatives, has had to engage in issues of local contextual understanding of mental health and illness, and avoid the risk of applying inappropriate models of care in diverse settings. All cultures have their own traditions around mental health care, and engaging with populations’ understanding of mental health, as well as that of traditional and religious healers, is essential. The history of psychiatry and the legacy of colonisation in many countries is one of narrowly biomedical and often abusive practice in institutions. Accessible and culturally appropriate mental health services embedded in communities or decentralised health systems must not only take account of evidence for effective treatment, but the crucial issues of human rights abuse and social exclusion that many people with mental health problems encounter. At CBM, we have found that engaging with people affected by mental illness and psychosocial disability so they are at the heart of processes of change is the best way to ensure that the focus remains on issues that really matter to them. Fostering growth of self-help groups and disabled persons’ organisations can be transformative in changing negative attitudes of communities towards people with mental health problems. CBM’s community mental health programs help develop leadership skills and opportunities for people with psychosocial disabilities and carers, facilitating self-help groups and supporting them to advocate for their rights and influence policy direction.

Working with government is also important. CBM‘s mental health programs in West Africa and Indonesia aim to support governments to integrate and strengthen mental health services in primary health care systems, together with community-based work that builds the confidence and collective voice of service users and carers and reduces the social barriers often faced by people with psychosocial disabilities.

The programs in West Africa build the knowledge and skills of mental health service providers using mhGAP. These providers become a sustainable resource for their own countries and go on to train and supervise mental health services in primary health care settings. This is done alongside work with government; for example, in Benue State, Nigeria, partnering with the Ministry of Health helps improve access and quality of mental health provision and ensure that respect for the rights of people with psychosocial disabilities underpins service.

In under-resourced regions, including significant parts of the Indo-Pacific, the few services that do exist are outdated, and very hard to access. There is an over-reliance on a few hospitals to provide treatment, and few opportunities for people with mental health problems to find the support they need in their own communities. Recent efforts to address these problems involve reviewing the existing services using the QualityRights toolkit, using local service users, professionals, government and other stakeholders to collectively measure the quality of the existing services against international human rights standards, and working together towards service reform.

A rights-based approach has been a powerful way of framing mental health work, and is a cross-cutting issue, alongside placing the voice of users of services at the centre of mental health reform, in the UN’s global Mental Health Action Plan. This plan lays out specific areas where NGOs are best placed to promote reform, and CBM has engaged in many countries in Africa, Asia, and Latin America to work in health system strengthening, as well as promoting access to human rights. Psychosocial disabilities associated with mental health problems are specifically included in the Convention on the Rights of Persons with Disabilities. This opens up an important mechanism for mainstreaming work in mental health and disability, and applying important accountability mechanisms to efforts to address the needs of this particularly vulnerable and historically neglected group.

Mental health is uniquely applicable to many aspects of international development, across health, education, environment, and other areas. Mental health was formally included in several Sustainable Development Goals, and an important emphasis in future will involve thinking beyond the medical focus on treatment towards recognising the contribution that good mental health can make to overall wellbeing and the achievement of other development objectives. At the same time, achievement of many of these development objectives will positively influence the population’s mental health.

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Julian Eaton

Julian Eaton, a British psychiatrist, is Senior Mental Health Advisor for CBM International.

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