What is global mental health?
Authors: Pamela Y. Collins
Journal: World Psychiatry (2020)

Looking back at 2020, historians will acknowledge the inescapable reality of global interconnectedness. Every country will have witnessed the health, social and emotional effects of the COVID-19 pandemic. For others, the outpouring of pent up anger, sadness and frustration due to generations of social inequities, exclusion, racism and discrimination – apparent both in the disparities in mortality revealed by COVID-19 and the persistent acts of structural and physical violence (highlighted among people of African descent in the US) – will be most vivid in retrospect. That these events have an emotional impact or more enduring effects on mental health will not be disputed. The appropriate responses to them – social, clinical, political, or some combination – can be debated. Such questions are ideally suited for the field of global mental health. Global mental health is an evolving field of research and practice that aims to alleviate mental suffering through the prevention, care and treatment of mental and substance use disorders, and to promote and sustain the mental health of individuals and communities around the world1. It prioritizes equity, and is informed by many disciplines, including neuroscience, genomics, social sciences (especially psychology, medical anthropology and sociology), epidemiology, health services research, and implementation science. Advocacy plays a central role in the dissemination and translation of evidence into actionable policies and plans for communities, health systems and policy-makers to implement. Global mental health activities are wide-ranging and intend to integrate a "reframed" mental health agenda into the 2030 Agenda for Sustainable Development2. This reframed agenda rests on four foundational pillars. The starting point is to recognize mental health as a global public good that requires action and intervention beyond the health sector. The second is adopting a dimensional approach that conceptualizes mental health as a continuum from wellness to illness, allowing equal emphasis on the prevention and treatment of mental disorders alongside the promotion and maintenance of mental health. The third pillar underscores the convergence of sociocultural experience and environmental context, genetics, neurodevelopment and psychology on brain biology to produce subjective experiences of mental health or distress. Consequently, our understanding of mental health and our ability to intervene lie at the intersection of multiple sources of knowledge. The fourth makes human rights a central tenet of global mental health action, and emphasizes the critical role that people with lived experience of mental health conditions must play in shaping prevention, care and research. To achieve the aims of global mental health, several actions are proposed for policy-makers, funders, health system managers, advocates, and communities. Among these are the use of policies to address upstream social determinants of mental health; the scaling of mental health services and the integration of mental health into other global health priorities, from HIV/AIDS to non-communicable disease care; targeting sensitive periods of development by investing in the mental health and well-being of young people; the application of innovative approaches to extend mental health care; and the call for more financial investment in the sustained implementation of preventive mea-sures and treatment interventions as well as in research across the relevant disciplines. Research funding of the past decade shaped many of the current dominant themes in the field, such as task-sharing to extend human resources for mental health, and integrating mental health into global health priorities via community-based platforms both in and outside of the health care sector. The Grand Challenges in Global Mental Health, a research priority-setting exercise, distilled the insights of more than 400 participants from 60 countries around the world and specified the need for science along the translational continuum from discovery to policy research3. The most frequently espoused of the 40 challenges calls for primary prevention of mental disorders. Others speak to the need to enable family and community environments that support mental health, understand adaptive and resilient responses to daily life stressors, and establish cross-national evidence on factors underlying mental health disparities – all of which are relevant to the urgencies of 2020. The authors of the Grand Challenges emphasized its global relevance, distinct from a focus on low- and middle-income countries, acknowledging the challenges that high-income countries also face when it comes to addressing mental health. Global health (and global mental health) attempts to recognize and change the power dynamics inherent in international relationships founded on colonial legacies and contemporary economic relationships. It identifies as "global" anything that concerns multiple countries, including shared determinants of health, and communicates the value of shared learning across countries and economies. "The global in global health refers to the scope of the problems, not their location"4. In the context of global mental health, shared determinants of health include poor investment in mental health care, inadequate attention to prevention as well as treatment of mental disorders, insufficient human resources, and consequently, limited access and quality of care. Equally important are transnational upstream determinants of mental health such as racial and other forms of discrimination, gender inequality, poverty, unplanned rapid urbanization, global economic downturns, forced migration, and complex humanitarian emergencies due to natural disasters and conflicts. Deficits in quality education, investment in early child development, safe and affordable housing, though local in their manifestations, are prevalent in many countries and ultimately affect mental health and well-being. Global mental health recognizes a vastly interconnected world and values nurturing that interconnectedness for solving difficult problems through a diversity of perspectives. It operates on the supposition that suffering and well-being are shared aspects of our humanity and, although distinct social, political, historical and economic drivers shape daily experience, there is promise in collective action. Without deliberate steps toward mental health equity through multiple routes, the global mental health project falters. One route to global mental health equity is through quality mental health research. The increased investment in mental health research in low- and middle-income countries has led to an expanded evidence base on effective interventions now being implemented in diverse sociocultural settings. Greater resources for research and research capacity-building provide opportunities for more diverse ethnic and cultural populations to contribute to the evidence base, to shape research questions and the approaches to answering them, thereby increasing the likelihood that research outcomes will be of relevance to all of us. Global diversity in mental health research participants will also permit more progress in the search for etiologies of mental illness. Our understanding of the genetic architecture of schizophrenia and bipolar disorder relies largely on Northern European data5. Funding flows, partnerships, and opportunities to engage new populations and pursue locally relevant research are far from equitable and this must remain a goal of global mental health. Equity in improving population mental health outcomes will require a commitment to designing interventions to tackle social problems that limit the effectiveness of care oriented to the individual6. Community leadership and empowerment, alongside engagement of service users to help transform service delivery, could be hallmarks of these interventions. Equity in the production and dissemination of global mental health knowledge requires prioritization of local cultural perspectives. Leveraging global relationships need not negate local experience. Rather, one strategy of the global mental health community should be to make known the innovation and ideas that come from communities which seldom find a global audience. In a recent initiative on suicide prevention among Arctic Indigenous people, a method was developed to build consensus across a diverse group of international stakeholders7. Some members of the team called for a parallel process that would use culturally acceptable methods to relay the particular experiences of specific Indigenous communities. The group applied both methods and integrated the findings in the final report7. Even widely experienced processes, such as deinstitutionalization, provide context-specific lessons about leveraging political opportunities into gains for mental health8. In many settings, deinstitutionalization and innovations in community mental health coincided with the establishment of post-colonial governments, the end of military dictatorship, or the entry of democracy. For example, the expansion of community mental health services in Jamaica after its independence developed in alignment with local cultural values, distinct from the colonial era8. These creative approaches to mental health care are valued, though not always widely disseminated. Nevertheless, the influence of innovative approaches to mental health from settings with scarce resources pervades global mental health. Integrating peers, lay health workers, primary care providers, as well as technology, into mental health care adds flexibility to mental health service delivery, breaks down traditional hierarchies, and makes care more accessible9. Diverse ethnic and cultural groups in high-income countries that face challenges in access to and engagement in care can make use of such varied approaches. It is possible that the global reach of the social, emotional and economic shocks of 2020 will thrust communities around the world into innovation that benefits mental health. If so, the movements, resources and networks that represent people and projects engaged in global mental health may become increasingly widely accessible. The field offers a transnational community for diverse stakeholders with distinct perspectives who value its aims.