Challenges and opportunities in global mental health: a perspective from WHO

Abstract

This paper enumerates and briefly discusses WHO’s recent contributions to global mental health and the current challenges and opportunities in this area. It briefly discusses response to diversity across countries and communities, the need for innovations and global exchange of information, evidence and knowledge and raises issues like psychological interventions and human rights related to mental health.

Introduction

Global mental health can quite simply be conceptualised as the highest attainable mental health for all, which is consistent with the World Health Organization (WHO) conceptualization of the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being (WHO, 2014a). WHO's definition of health itself includes mental and social wellbeing, recognising mental health quite clearly, as an integral component of health and wellbeing. This editorial presents, in summary form, some of the recent contributions that WHO is making in global mental health including some challenges and opportunities.

WHO has contributed to mental health objectives right from the inception of WHO. These contributions are consistent with the overall core functions of WHO, which include the following:

• •providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
• •shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
• •setting norms and standards and promoting and monitoring their implementation;
• •articulating ethical and evidence-based policy options;
• •providing technical support, catalysing change, and building sustainable institutional capacity; and
• •monitoring the health situation and assessing health trends.

WHO being the lead United Nation (UN) agency for health, it has several core strengths to fulfil its role. These include its ability to influence health policies with the countries and also its capacity to convene a variety of diverse stakeholders in health. These core functions and strengths have been utilised in advancing the global mental health agenda. WHO's work during the last three decades has demonstrated that mental disorders are present and indeed common in all regions of the world and can be identified and diagnosed using standard descriptions, criteria and instruments. This work also demonstrated the commonalities and differences in the long term outcome of disorders- identifying some critical variables related to socio-cultural environment. In addition, estimates for burden from mental, neurological and substance use disorders were made (WHO, 2008).

WHO's mental health action plan

Political commitment is quite essential for global mental health. The World Health Assembly provided this in a strong way in 2013, when it adopted the Comprehensive Mental Health Action Plan (WHO, 2013a). This plan is global in its scope, incorporates a clear and ambitious vision, precise objectives and also measurable indicators and time-bound global targets. The vision of the Action Plan is ‘a world in which mental health is valued, promoted and protected, mental disorders are prevented and persons affected by these disorders are able to exercise the full range of human rights and to access high quality, culturally-appropriate health and social care in a timely way to promote recovery, all in order to attain the highest possible level of health and participate fully in society and at work free from stigmatisation and discrimination.’ The plan has six cross-cutting principles- universal health coverage, human rights, evidence-based practice, life course approach, multi-sectoral approach and empowerment of persons with mental disorders and psychosocial disabilities. The action plan focuses on four key objectives; to strengthen effective leadership and governance for mental health, to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; to implement strategies for promotion and prevention in mental health, and; to strengthen information systems, evidence and research for mental health. Specific global targets to be achieved by 2020 relate to policy and law, service coverage, prevention and promotion programmes, suicide rate and collection and reporting of core data.

Some of the specific activities of WHO to strengthen global mental health and to achieve the objectives of the mental health action plan are briefly described below.

Mental health atlas

WHO published the first Atlas on mental health in 2001 and since then has published updates periodically, the last one being in 2015 (WHO, 2015a). Atlas publishes key information on resources for mental health within all countries allowing a global and regional stocktaking and also comparisons over time. WHO's mental health atlases have been widely used by policymakers, academics and civil society and have advanced a global dialogue and discussion.

Evidence on disease burden and economic aspects

WHO assists in preparing and disseminating evidence on burden due to mental disorders and associated conditions e.g., suicide (WHO, 2014b), treatment gap (Kohn et al. 2004) and workforce gap (Bruckner et al. 2011). It has also published cost-effectiveness of services (Chisholm & Saxena, 2012) and return on investment estimates (Chisholm et al. 2016). These are pertinent and persuasive data for advancing the global mental health agenda.

Mental health gap action programme (mhGAP)

This technical programme, launched by WHO in 2008 has, as its objective, scaling up of care for priority mental, neurological and substance use disorders by non-specialised health care providers. This programme has established a framework and an evidence-based intervention guide for general doctors and nurses to be trained in identifying and treating priority conditions. mhGAP is one of the most successful global programmes in mental health, with more than 90 countries using it in one way or the other. mhGAP Intervention Guide (WHO, 2010) is available in 19 languages.

Disease specific initiatives

Though, WHO encourages strengthening of the mental health care systems as a whole, some disorders require specific efforts. Developmental disorders including autism is one of these. Based on a resolution from the World Health Assembly (2014), WHO has developed a parents’ skills training manual (http://www.who.int/mental_health/maternal-child/PST/en/) to enhance the contribution that parents can make in the fullest possible development of their children, even if the health care system is weak. Similarly, WHO is developing iSupport, an online portal for caregivers of persons with dementia. Based on reports that persons with severe mental disorders suffer from early and excess mortality, WHO has convened an expert group to advise it on the risk factors for excess mortality and on interventions to offer to countries to avert this serious consequence of severe mental disorders. Findings of this expert group are in press (Liu et al., in press).

Emergency mental health

Conflicts, wars and natural disasters increase the need for mental health and psychosocial care while decreasing the capacity of health systems to do so. Most communities that suffer these unfortunate events anyway have rudimentary mental health care systems; hence, WHO's attempt is to use these events as an opportunity to ‘build back better’ (WHO, 2013b). Many countries and communities have made substantial progress in developing their community mental health services after a humanitarian emergency and WHO has supported these efforts.

Mental health in the development agenda

For the first time, global leaders have included ‘mental health and wellbeing’ within the UN Sustainable Development Goals (https://sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals). This is likely to have a major influence on the priority given to mental health within the health and development plans of all countries. This may also lead to increased resources being made available for mental health interventions. World Bank and WHO organised an event on Making Mental Health a Global Development Priority, in April 2016 as a part of the World Bank Group Annual Meeting (http://www.who.int/mental_health/advocacy/WB_event_2016/en/). The event not only reemphasised the need for greater attention to mental health but also provided a number of evidence based innovative solutions to tackling these issues.

Some relevant issues in global mental health

Diversity across countries and communities

Diversity and inequality among countries and communities for mental health systems and resources is wide and not decreasing sufficiently quickly. This raises the question- whether global recommendations can be applied to all countries and communities. WHO's Mental Health Action Plan 2013–2020 has taken a position that its objectives and actions are relevant to all countries, but the options for implementation can be varied, to suit the level of development of mental health, health and social systems and resource availability. These options for implementation are provided in appendix 2 of the Action Plan but even this list is indicative and other options can be deployed by countries and communities. Similarly, most of the technical material from WHO is expected to be used with appropriate adaptation and many cases, explicit instructions are provided for doing this.

Innovations

Remaining somewhat isolated and secluded from the mainstream health, mental health has not benefitted sufficiently from innovations. However, this is changing. A variety of innovative ways are being tried to reform mental health services, including deinstitutionalisation (WHO and Gulbenkian Global Mental Health Platform, 2014), delivery of services using non-specialists or even lay workers and in the use of technology (http://mhinnovation.net/). This certainly is a good direction, but large scale adoption and integration of innovations into routine practice is still an exception rather than the norm. Much more efforts and resources are needed to scale up the coverage of effective innovative practices.

Global exchange of information, evidence and knowledge

When it comes to mental health, all countries are developing countries (Collins & Saxena, 2016). None of the countries have a mental health system that is satisfactory enough for there being no need to develop further. This also translates into the need for learning from all possible sources and not relying on information, evidence and knowledge from those that are ‘developed’. Innovations can come from anywhere- and can be useful even in settings that are widely different. Global mental health needs to become more open to information, experience and knowledge from diverse and unconventional sources.

Psychological interventions

Though, WHO's formal recommendations for treatment of priority mental, neurological and substance abuse conditions include pharmacological and psychosocial interventions, the actual use of psychosocial interventions is extremely weak in the majority of low resource settings. The reasons for this include lack of specialists and other qualified trainers, difficulties in accessing training manuals and other material and lack of time on the part of trainers and trainees. WHO has recently taken forward the urgent task of scaling up psychosocial interventions. This includes developing manuals for evidence-based low intensity psychological interventions to be delivered by non-specialists. WHO's Psychological First Aid (WHO, War Trauma Foundation and World Vision, 2011) is now available in multiple languages and is being used very widely. Thinking Healthy (WHO, 2015b) is a manual for psychological interventions for perinatal depression. WHO is also providing evidence for problem solving and self-help interventions for depression and anxiety problems (WHO, 2016). WHO's contribution is significant, since it makes all these material available in public domain for unrestricted and free-from-cost use globally.

Human rights related to mental health

Though, there are strong arguments for global mental health on the basis of disability, death and also the economic evidence, human rights related to mental health still remains an important issue (Drew et al. 2011). Persons with mental disorders remain very vulnerable to abuse of their basic human rights within mental hospitals and other institutions but also in the community. Though mental disabilities are explicitly covered within the scope of the UN Convention on the Rights of Persons with Disabilities, majority of countries still do not have their mental health policies and law complying with it (WHO, 2015a, b). Global mental health needs to pay a higher level of attention to this aspect. WHO's QualityRights project (WHO, 2012) aims to improve the quality and human rights conditions in inpatient and outpatient mental health and social care facilities and empower organizations to advocate for the rights of people with mental and psychosocial disabilities.

Conclusion

Global mental health has advanced during the last decade as a discipline but also as an activity of public health significance. WHO continues to provide technical material and guidance to advance global mental health working closely with many partners. However, much more efforts are needed to achieve satisfactory progress especially in low and middle resource settings.

Disclaimer

S.S. is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

Financial support

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Conflict of interests

The authors declare no competing interests.