A renewed agenda for global mental health

4 years ago, The Lancet published a Series of articles highlighting the global health crisis due to an astonishingly large treatment gap: up to nine of ten people with a mental health problem do not receive even basic care in some countries. The Series showed that this gap was not due to insufficient evidence about the effect of mental health problems or their effective treatment, but to a range of barriers operating at all levels of the health system, from global policies through to local health-care provision. The Series ended with a call to action to scale up services for people with mental health problems, especially in low-income and middle-income countries where the gaps are the largest, and where some of the most serious human rights abuses against affected people are perpetrated.¹ 4 years on, we take stock of what progress has been made.

The themes of this new Series were selected by the members of the Movement for Global Mental Health, a coalition of 95 institutions and over 1700 individuals from more than 100 countries, representing professionals and civil society, and working together to advocate for the necessary conditions for a better life for people affected by mental health problems. In this respect, the Series represents a unique example of agenda setting for scientific publications by a social movement. The Movement chose themes about tracking progress in achievement of the goals of the call to action, and filling in gaps in the knowledge synthesised in the first Series.

There is cause for us to celebrate the emergence of global and national responses to mental health care. Several global initiatives have been launched in the past 4 years, notably: WHO's mhGAP intervention guidelines, which provide the symbolic bednets for priority mental, neurological, and substance misuse disorders for use by non-specialists in routine healthcare settings;² the Grand Challenges in Global Mental Health that support a new generation of research;³ and the Movement for Global Mental Health itself.⁴ At national and local levels, we see concrete examples of countries making bold steps to develop mental health policies and plans to step up care;⁵ an impressive growth in the evidence base for treatments and delivery systems (eg, for children’s mental health⁶ and in humanitarian settings⁷); new programmes for building capacity;⁵ and an increasing presence of diverse stakeholder communities, particularly from low-income and middle-income countries, in leadership roles. In this context, we are delighted that 40% of the 52 authors in the Series are based in low-income and middle-income countries and another 15% are based in UN or international development agencies. In view of the need to involve diverse stakeholder communities, we are also pleased to note that more than a third of authors are drawn from outside academia, including representatives of user groups in low-income and middle-income countries. Exciting new evidence points to the effectiveness of task sharing with non-specialist and lay health workers to address the massive shortage of specialists.⁸ Scaling up such innovations will require a substantial redefinition of the role of specialist personnel which, in turn, will need the strong buy-in of the professional bodies that lead these specialists.⁵ In this context, we welcome the engagement of the World Psychiatric Association leaders with the challenges posed by the shortage of specialists.⁹

However, there is still a long way to go, with many challenges to face. First and foremost, the issue of the human rights of people with mental health problems should be placed at the foreground of global health— the abuse of even basic entitlements, such as freedom and the denial of the right to care,¹⁰ constitute a global emergency on a par with the worst human rights scandals in the history of global health, one which has rightly been called a “failure of humanity”.¹¹ People with mental health problems, particularly serious mental disorders and disabilities, who bear a disproportionate burden of human rights abuses, should be empowered to ensure a life of dignity. Second, health systems need increased resources to scale up care. Budgetary allocations for mental health care are still grotesquely out of proportion to the burden posed by mental health problems, resulting in slow progress in scaling up of care.⁵ Furthermore, there is a need to ensure that the increasing resources for developing mental health services account for the unique needs of people who are particularly vulnerable, notably children and those affected by serious mental disorders and disabilities. The mental health needs of children and adolescents, a demographic group comprising more than a third of the global population, have been neglected, even though addressing their needs might alleviate suffering, improve educational attainment in childhood, and potentially reduce the burden of mental disorders in adulthood.⁶ Third, much is still to be learned about how to deliver effective treatments in the real world. The mhGAP guidelines should become the standard approach for all countries and health sectors; irrational and inappropriate interventions should be discouraged and weeded out. Use of scarce resources for ineffective treatments and inefficient models of care is unacceptable. Delivery of effective treatments depends crucially on the development of human resources, especially among the frontline health workforce, often using innovative solutions.⁸ Furthermore, a review of research into interventions that can break the vicious cycle of poverty and mental health problems has shown evidence that effective mental health interventions can lead to a reduction in poverty.¹² We need to ensure that all development assistance for global health specifically tracks mental health-related funding and assesses the effect of development activities on mental health problems in the population.¹² Fourth, natural disasters and conflicts provide not only a high need but also a unique opportunity to scale up care to the affected population.⁷

This new Series on global mental health reaffirms our conviction that the provision of appropriate mental health services is intrinsic to the development of prosperous, humane societies worldwide.