Globalization and mental health: a WPA perspective

Globalization may be defined as a process in which the traditional boundaries separating individuals and societies gradually and increasingly recede. The process has clearly both negative and positive results and is likely to create both losers and winners. Globalization has promised to grant the world instant communication, fast and efficient means of travel, a widened access to technology, cross border cultural interaction and globalized approaches to environmental issues. However, it also entails deregulation of commerce and the creation of supernational political and economic bodies. As a result, the gap is widening between societies which enjoy knowledge, technology and the ability to control events and others which are still backward, ignorant, frustrated, helpless and unable to follow progress and self-actualization.

Critics point out that the internet, for example, remains the realm of a privileged minority, as most of the world's population have never made a telephone call, let alone sent an e-mail.

The global village allegedly created by globalization is not that global after all. If we assume that 100 people are living on earth, 57 of them are Asians, 21 are Europeans, 8 are Africans, 6 are Americans; 48 are men and 52 are women; 30 are white and 70 are non-white; 30 are Christians and 70 are non-Christians. On the other hand, six people own 59% of the community wealth and they are all North Americans. Eighty live in poverty, 70 cannot read, 50 die in famine, 1 has a higher education and 1 has a computer. It is obvious that power and resources do not seem to follow the majority/minority pattern of the world population, i.e., globalization has failed until now to democratically represent the world it has claimed to globalize (1).

GLOBALIZATION OF MENTAL HEALTH: AN UNMET CHALLENGE

Mental health is a state of well-being whereby individuals recognize their abilities, are able to cope with normal stresses of life, work productively and fruitfully and make a contribution to their communities.

The prevalence of mental disorders is closely related to social, economic and cultural conditions. If we consider all the previously mentioned changes in information technologies, we can easily foresee that the shape and content of mental disorders, and consequently of psychological and psychotherapeutical treatments, will undergo serious changes.

Mental ill health is occupying an increasingly larger space within the world disease burden. Saraceno (2) has shown that poverty and mental disorders feed into each other, one leading to another in a vicious circle that has to be broken by either the eradication of poverty or adequate intervention with patients with mental disorders or preferably both. More alarmingly, he showed that the gap between the treated and untreated is higher for child and adolescent disorders than for major depression or schizophrenia (i.e., the coming generations which will hold the responsibility of the world are the ones which are the most marginalized in the provision of mental health care).

Rapid changes provide both a threat and an opportunity for psychiatry. Cuts in government spending represent the most obvious risk, since most psychiatric services are largely either directly or indirectly dependent on government funding. On the other hand, demand for psychiatric services, both quantitatively and qualitatively, is increasing.

In psychiatry, the most important aspect of globalization is delivering mental health services in an equitable pattern, providing equal treatment and establishing equal outcome to our patient population, no matter which part of the world they come from (1).

So far, globalization has affected psychiatric clinical practice in a multitude of ways, which unfortunately do not include a worldwide provision or access to mental health care services:

• Increased ethnic and cultural diversity of service users has led to a wider range of attitudes and beliefs in relation to mental illness.

• Increased ethnic and cultural diversity of service providers has led to a wider range of approaches and beliefs in relation to mental health care.

• In developed countries, increased rates of inward migration have led to increases of migration-associated mental disorders. In rapidly developing countries, socioeconomic

• changes and life events have led to increases in rates of mental disorders.

• In all countries, the development of technology has led to increased information on a range of health care services, resulting in increased demand.

• Finally, globalization has contributed to an increased emphasis on the implementation of international protocols in psychiatric training, mental health policy and the protection of human rights of mental patients. It has also resulted into a thorough examination of the concept of social capital and its influence on the mental health of populations.

In fact, globalization, as it has been implemented to this very day, highlights several crises of different natures: a leadership crisis (where wealth is allowed to be concentrated in fewer and fewer hands so that the world's three richest individuals have assets exceeding the gross domestic product of the poorest 48 countries); a democratic crisis (where 1.3 billion people live on incomes of less than 1$/day); an economic crisis (where nearly 1.5 billion people have no access to clean water, and 1 billion live in miserably substandard housing); a spiritual crisis (where many people are so poor that they can only see God in the form of bread), and, last but not least, a moral crisis (where 40 thousand children die each day from malnutrition and disease) (3).

ROLE OF PSYCHIATRISTS

As health professionals, we are bound by our commitment to the health of our patients; as psychiatrists, we are especially concerned with their mental health.

The Declaration of Madrid states that psychiatrists "must advocate for fair and equal treatment of the mentally ill, for social justice and equity for all". They should thrive for the continued provision of high-quality, evidence- based mental health care.

In the field of diagnosis, globalization of ICD-10 and DSM-IV criteria will provide our patients with a global up-to-date tool for diagnosis, which should be linked with management and outcome.

Evidence-based psychiatry will ensure better services even for poorer countries, by filtering out the unnecessary affluent therapies and leave the essential necessary parts for implementation in developing countries.

ROLE OF THE WPA

In response to the problems caused or highlighted by globalization, it is necessary to address issues in psychiatric training, service provision and social policy and to increase the emphasis placed on transcultural psychiatry in mental health curricula. Furthermore, one does not need financial resources to be able to respect human rights. The best way to ensure that human rights are respected on a global scale is to increase awareness and implementation of the United Nations principles regarding people with mental illnesses.

The WPA has developed an under- and post-graduate core curriculum that places significant emphasis on transcultural issues. The cultural variability of nations does not have to be paralleled by discrimination in accessibility to services. Globalization in psychiatry can be implemented in the field of human rights of mental patients. Of special concern in that regard are migrant mental health and political abuses of psychiatry.

There is no excuse for denying mental patients access to therapy and management. Even from an economic point of view, Mumford et al (4) have shown that the treatment of every diagnosable affective disorder would lead to a 2% increase in health expenditure and a 20% decrease in health care expenditure per capita.

In 2002, the WPA General Assembly in Yokohama endorsed a consensus statement on globalization and mental health (5). This statement called upon all WPA components to raise public and government awareness that the effects of globalization will be optimized only when improvements in health and well-being become central objectives of national economic policies and of the design and management of the international economic system; and that mental health is part of public health. It called upon psychiatrists to be in a position to actively shape policy, to form national alliances, to lobby internationally for a more equitable distribution of resources and quality of care, and to ensure that governments are aware of the implications of globalization on human rights and mental health. It appealed to them to advocate for fair and equal treatment of the mentally ill, for social justice and equity for all, and to serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles. Even when challenged by the obstacles imposed by globalization, psychiatrists should remain committed to their mandate and the Declaration of Madrid.

To achieve globalization of mental health services, we need more studies on the psychological variables affecting mental illness, the provision of a better structure for psychosocial intervention for both developing and developed countries, and a more equitable distribution of world resources.