The Routledge Handbook of International Development, Mental Health and Wellbeing 9780429397844, 9780367027735

Citation preview

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GOOD HEALTH AND WELL-BEING

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The Routledge Handbook of International Development, Mental Health and Wellbeing Edited by Laura Davidson

THE ROUTLEDGE HANDBOOK OF INTERNATIONAL DEVELOPMENT, MENTAL HEALTH AND WELLBEING

Mental health has always been a low priority worldwide. Yet more than 650 million people are estimated to meet diagnostic criteria for common mental disorders such as depression and anxiety, with almost three-quarters of that burden in low- and middle-income countries. Nowhere in the world does mental health enjoy parity with physical health. Notwithstanding astonishing medical advancements in treatments for physical illnesses, mental disorder continues to have a startlingly high mortality rate. However, despite its widespread neglect, there is now an emerging international imperative to improve global mental health and wellbeing. The UN’s current international development agenda finalised at the end of 2015 contains 17 Sustainable Development Goals (SDGs), including SDG3 which seeks to ensure healthy lives and promote wellbeing for all at all ages. Although much broader in focus than the previous eight Millennium Development Goals (MDGs), the need for worldwide improvement in mental health has finally been recognised. This Handbook addresses the new UN agenda in the context of mental health and sustainable development, examining its implications for national and international policymakers, decision-makers, researchers and funding agencies. Conceptual, evidence-based and practical discussions crossing a range of disciplines are presented from the world’s leading mental health experts. Together, they explore why a commitment to investing in mental health for the fulfilment of SDG3 ought to be an absolute global priority. Laura Davidson is a London Barrister at No.5 Chambers and a noted authority on human rights, mental health, disability, and capacity matters. She has both an LLM. in international law and a PhD. from the University of Cambridge, and is a regular visiting academic Fellow at the University of Cape Town, South Africa. Her academic study has included qualitative research on psychosocial disability and trauma in northern Uganda. Dr Davidson is also an international development consultant, and in 2013 drafted Rwanda’s first mental health legislation. She provides expert advice and training to law firms, NGOs, and governments on all aspects of health care, human rights, justice, and the rule of law.

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THE ROUTLEDGE HANDBOOK OF INTERNATIONAL DEVELOPMENT, MENTAL HEALTH AND WELLBEING

Edited by Laura Davidson

First published 2019 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 A GlassHouse book Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 selection and editorial matter, Laura Davidson; individual chapters, the contributors The right of Laura Davidson to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Davidson, Laura (Lawyer), editor. Title: The Routledge handbook of international development, mental health and wellbeing / Laura Davidson. Description: Abingdon, Oxon ; New York, NY : Routledge, 2019. | Includes index. Identifiers: LCCN 2019003040 (print) | LCCN 2019009347 (ebook) | ISBN 9780429397844 (ebk) | ISBN 9780367027735 (hbk) Subjects: LCSH: Mental health laws. | Sustainable development—Law and legislation. | United Nations. General Assembly. Transforming our world: the 2030 Agenda for Sustainable Development (2015). 3, Good health and well-being. Classification: LCC K3608 (ebook) | LCC K3608 .R68 2019 (print) | DDC 344.04/4—dc23 LC record available at https://lccn.loc.gov/2019003040 ISBN: 978-0-367-02773-5 (hbk) ISBN: 978-0-429-39784-4 (ebk) Typeset in Bembo by Apex CoVantage, LLC

This book is dedicated to John Grace QC, with whom I co-founded Mental Health Research UK in 2008 – the UK’s first charity dedicated to funding research into the causes of mental illness in order to develop better treatments with fewer side-effects. Our joint vision was to make a long-term difference. His kindness, loyalty, and good humour continue to be greatly missed.

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CONTENTS

List of figures and tables List of contributors Foreword: The New UN Health Agenda Jeffrey D. Sachs

xi xii xvii

PART I

The global imperative 1

2

1

The global mental health imperative and the role of the World Health Organization within the UN 2030 Agenda Shekhar Saxena and Laura Davidson The rights to mental health and development Lawrence O. Gostin and Laura Davidson

3

21

PART II

Economic perspectives

43

3

Meeting SDG3: The role of economics in mental health policy Martin Knapp and Valentina Iemmi

45

4

The relationship between mental health and poverty in low- and middle-income countries Judith Bass

5

Mental health and economic development in Vietnam Chris Underhill,Victoria K. Ngo, and Tam Nguyen vii

58

69

Contents

6 Social entrepreneurship and systems thinking about mental illness in low- and middle-income countries Sean A. Kidd and Kwame McKenzie

81

PART III

Demographic and cultural perspectives

95

7 Understanding traditional and other culture-based approaches to mental illness in lower- and middle-income contexts Joseph D. Calabrese 8 Addressing mental health from a gender perspective: Challenges and opportunities in meeting SDG3 Carol Vlassoff 9 Men’s mental health and wellbeing: The global challenge Svend Aage Madsen

97

109

128

10 The mental health and wellbeing of migrants in the context of the 2030 Sustainable Development Agenda Guglielmo Schininà and Karoline Popp

138

11 The Sustainable Development Goals and child and adolescent mental health in low- and middle-income countries Cornelius Ani and Olayinka Omigbodun

152

12 The global challenge of mental health and ageing, and scalable innovations in mental health services for older adults Stephen J. Bartels

171

PART IV

Policy

185

13 Strengthening government policy to achieve Target 3.4 of SDG3 Rachel Jenkins

187

14 Mental health, disability rights, and equal access to employment: Global challenges in light of the Sustainable Development Goals Aart Hendriks

viii

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Contents

15 Prioritising rights-based mental health care in the 2030 Agenda Dainius Pu¯ras and Julie Hannah

222

16 Natural and humanitarian disasters, and mental health: Lessons from Haiti Giuseppe Raviola

235

17 Paradigm shift: Treatment alternatives to psychiatric drugs, with particular reference to low- and middle-income countries Peter Lehmann

251

PART V

Legal perspectives

271

18 Mental disability, the European Convention on Human Rights and Fundamental Rights and Freedoms, and the Sustainable Development Goals Peter Bartlett 19 The Sustainable Development Goals, psychosocial disability, and the meaning of wellbeing in SDG3: Towards an approach that combines the subjective and objective David Bilchitz 20 International monitoring and enforcement mechanisms for human rights violations in the global mental health context Laura Davidson 21 The law as sword and shield: Realising the rights of those with psychosocial disability through international, regional, and national complaints systems Laura Davidson

273

291

305

331

PART VI

Country perspectives

359

22 A case study: Colombia, conflict, and the peace process, from a user-perspective Salam A. Gómez

361

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Contents

23 Legislating on mental health in India to achieve SDG3 Amita Dhanda 24 Breaking the restraints: Civil society’s struggle to abolish human rights violations in Israel’s psychiatric system Sharon Primor and Dahlia Virtzberg Afterword: Joining up for our future in global mental health Vikram Patel Index

x

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385

396 401

FIGURES AND TABLES

Figures 9.1 9.2 16.1 21.1

Registered diagnoses around the world (%) Suicides around the world (per 100,000) The depression care pathway developed in Haiti by Zanmi Lasante and Partners In Health Social and cultural determinants of mental disorders and the Sustainable Development Goals: a conceptual framework. Reprinted with permission from Crick, L., Brooke-Sumner, C., Baingana, F., et al. (2018), Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews, Lancet Psychiatry, 5: 357–369.

130 134 244

356

Tables 9.1 Symptoms traditionally associated with depression in men 9.2 Reactions and state-patterns seen more often in men than in women 12.1 Summary of scalable innovations in global delivery of mental health services tailored to older adults 16.1 Summary of lessons on developing comprehensive, community-based mental health care from disasters and emergency contexts (adapted from Epping-Jordan, et al. (2015)) 20.1 Key human rights treaties and their monitoring and enforcement bodies 20.2 International human rights monitoring and enforcement mechanisms

xi

131 132 181

237 310 316

CONTRIBUTORS

Cornelius Ani is a Consultant Child and Adolescent Psychiatrist in Surrey, UK, an Honorary Clinical Senior Lecturer at Imperial College London, and an Associate Lecturer in Child and Adolescent Mental Health (CAMH) at the University of Ibadan, Nigeria. His research includes projects in Africa, Asia, UK and North America. He was instrumental in setting up the first post-graduate training in CAMH in West Africa. Stephen J. Bartels, MD, MS is the Herman O. West Professor of Geriatrics, Professor of Psychiatry, Professor of Community & Family Medicine, and Professor of Health Policy at the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth’s Geisel School of Medicine, USA. He is also the Director of the Dartmouth Centers for Health and Aging. Peter Bartlett is Nottinghamshire Healthcare NHS Trust Professor of Mental Health Law at the Institute of Mental Health and the School of Law at the University of Nottingham. With Oliver Lewis and Oliver Thorold, he is author of Mental Disability and the European Convention on Human Rights (2006) (Leiden: Brill/Martinus Nijhoff ). He has published extensively on mental health and mental disability law. Judith Bass is an Associate Professor of Global Mental Health at the Johns Hopkins Bloomberg School of Public Health who holds degrees in both economic development and public health. Her research interests involve the intersection between mental health and economic development, with a particular focus on programmes that impact both domains. David Bilchitz is a Professor of Fundamental Rights and Constitutional Law in the Faculty of Law at the University of Johannesburg, and Director of the South African Institute for Advanced Constitutional, Public, Human Rights and International Law (SAIFAC). He is also Secretary-General of the International Association of Constitutional Law (IACL). Having been awarded a Von Humboldt Foundation Fellowship, in 2018 he conducted research at the Humboldt University in Berlin. Joseph D. Calabrese is Reader of Medical Anthropology at University College London. He holds a PhD from the University of Chicago, where he combined training in anthropology and xii

Contributors

clinical psychology. He completed postdoctoral clinical training at the Cambridge Hospital/ Harvard Medical School, subsequently holding research fellowships at Harvard Medical School and the University of Oxford. His research explores diverse approaches to treating mental illness. Laura Davidson is a London Barrister, a noted authority on human rights and mental disability law, and co-founder of Mental Health Research UK. She has an LLM in international law and a PhD in mental health law and human rights, both from the University of Cambridge, UK. A regular visiting academic Fellow for a number of years at the University of Cape Town, South Africa, she has undertaken empirical qualitative research on psychosocial disability and trauma in northern Uganda. She is also an international development consultant, and in 2013 drafted Rwanda’s first mental health legislation and advised the government on its health policy. Amita Dhanda is a Professor of Law who heads the Centre for Disability Studies at the National Academy of Legal Studies and Research, Hyderabad, India. She represented civil society in the UN CRPD negotiations surrounding legal capacity, and has been actively engaged in reform efforts to harmonise Indian law with the Convention. Salam A. Gómez is a person with lived experience of pychosocial disability; he Co-chairs and is the Executive Director CEO of FundaMental Colombia, the Co-chair and CEO of the World Network of Users and Survivors of Psychiatry (WNUSP), and Colombia’s representative in the International Organization of Physiotherapy and Mental Health (IOPTMH). Since 2010 he has been a national disability counsellor representing people with psychosocial disabilities. He is a team representative on the Colombia Committee for the Elimination of All Forms of Discrimination against Persons with Disabilities (CEDDIS/OAS), and the Colombian Network of Higher Education Institutions for Disability (RCIESD). Lawrence O. Gostin is University Professor and the O’Neill Chair in Global Health Law, Georgetown University, Washington, DC, and a Professor of Public Health at Johns Hopkins University, Baltimore, USA. He is also the Director of the World Health Organization Collaborating Center on National and Global Health Law. He has served on numerous WHO expert advisory committees, including the WHO/Global Fund Blue Ribbon Expert Panel to develop a global health equity framework. He co-chairs the Lancet Commission on Global Health Law and holds multiple international academic professional appointments. Julie Hannah is the Director of the International Centre on Human Rights and Drug Policy. Her work in human rights and drug control, including the right to health, has been internationally recognised. She is a member of the Human Rights Centre at the University of Essex where she is an advisor to the UN Special Rapporteur on the right to health, supporting the mandate’s thematic research and civil society engagement. She has over ten years’ experience leading humanitarian and human rights projects for marginalised communities, particularly in Southeast Asia. Aart Hendriks is a health and human rights lawyer attached to Leiden Law School as Professor in health law. He is also a surrogate judge and member of the Board of Supervisors of the Erasmus Medical Centre in Rotterdam, the Netherlands. He regularly serves as a consultant for regional and international health and human rights organisations. Valentina Iemmi specialises in global mental health policy and has a particular interest is in the economic aspects of policy and practice in relation to mental health and mental disabilities. xiii

Contributors

She trained as a clinical psychologist at the University of Paris, subsequently obtaining her MSc in Health Policy, Planning and Financing at the London School of Economics where she is now a Research Fellow. Rachel Jenkins is Professor Emeritus at Kings College London. She is a psychiatrist, epidemiologist and international mental health policy-maker with 20 years’ experience of working in low- and middle-income countries on research, training, and mental health policy development and implementation. She was Director of the WHO Collaborating Centre on Mental Health, Institute of Psychiatry, Kings College London, UK, from 1997 to 2012. Sean A. Kidd is a Senior Scientist and Division Chief of Psychology at the Centre for Addiction and Mental Health (CAMH), and an Associate Professor in the Department of Psychiatry at the University of Toronto, Canada. The focus of his career has been upon marginality and service enhancement, particularly relating to homeless youths and individuals with severe mental illness. Martin Knapp is Professor of Social Policy and Director of the Personal Social Services Research Unit, London School of Economics and Political Science, UK. He is also Director of the School for Social Care Research funded by the National Institute of Health Research. His research interests are mainly in the areas of child and adult mental health, dementia, autism, and long-term care. Peter Lehmann is a certified pedagogue and an independent publisher, author and freelance activist in Berlin, Germany. He survived psychiatric treatment in the 1970s and regularly speaks and publishes on alternatives to the psychiatric biomedical model, as a person with lived experience, for the human rights of psychiatric patients. In 2010 he was awarded an Honorary Doctorate by the Aristotle University of Thessaloniki, and in 2011 the Order of Merit of the Federal Republic of Germany. Svend Aage Madsen is the Head of Research and former Head of Department at Copenhagen University Hospital. A Postgraduate Fellow, he heads the research programmes, ‘Screening Mothers and Fathers for Perinatal Depression’, ‘The Fatherhood Research Program’, and ‘Men’s Health’. He has a PhD in Clinical Psychology from the University of Copenhagen, and is licensed as a psychotherapist. He is also the President of the Men’s Health Forum in Denmark. Kwame McKenzie is a psychiatrist, researcher and policy adviser. Born in the UK and trained in psychiatry at the Institute of Psychiatry, London, he has also worked in Belgium, the Caribbean, and the USA where he was a Harkness Fellow and visiting senior scholar at Harvard University. He is a Professor of Psychiatry at the University of Toronto, Canada, and the CEO of The Wellesley Institute, a policy think-tank. Victoria K. Ngo is an Associate Professor of Community Health and Social Sciences at the City University of New York Graduate School of Public Health & Health Policy (CUNY SPH), USA, where she is Deputy Director of the Center for Innovations in Mental Health. She is also an adjunct behavioural scientist at the RAND Corporation. Her research as a clinical psychologist focuses on task-shifting mental health care and the development of implementation strategies to increase access to and the quality of depression services in global low-resource settings. Since 2001 she has been developing mental health research infrastructure and clinical capacity in Vietnam where she leads depression care capacity-building programmes. xiv

Contributors

Tam Nguyen is the country director for mental health NGO BasicNeeds, and founder of the Research Center for Mental Health and Community Development in Vietnam. She has over 15 years of experience in the NGO sector, managing and developing projects and organisations supporting mental health service development for marginalised and vulnerable people. She is a nationally recognised community leader for mental health service and policy development in Vietnam. Olayinka Omigbodun is Professor and Head of Psychiatry at the University of Ibadan, Nigeria and Consultant in Child & Adolescent Psychiatry, University College Hospital, Ibadan. She is Pioneer Director of the University’s Centre for Child and Adolescent Mental Health (CCAMH) funded by the MacArthur Foundation. She is also a previous President of the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP). Vikram Patel is The Pershing Square Professor of Global Health and Wellcome Trust Principal Research Fellow at Harvard Medical School, USA. He holds Honorary Professorships at the Harvard T. H. Chan School of Public Health, the Public Health Foundation of India, and the London School of Hygiene & Tropical Medicine, UK. He is a co-founder of the Indian mental health NGO, Sangath. His work has focused on the burden of mental disorders, their association with social disadvantage, and the use of community resources for their prevention and treatment. Karoline Popp is a migration specialist with a decade’s worth of experience in policy, research and international cooperation in the field of migration. She worked for the International Organization for Migration (IOM) in Geneva and Cairo after obtaining degrees from the University of Oxford and the School of Oriental and African Studies in London, UK. She is currently a researcher at the Expert Council of German Foundations on Integration and Migration. Sharon Primor is a prominent human rights lawyer and advocate, specialising in the rights of people with disabilities. She is the legal counsellor of Bizchut (the Israeli Center for Human Rights for People with Disabilities), Israel’s leading disability rights NGO. She is the head of the organisation’s project on human rights within psychiatric facilities, having previously specialised in children’s rights. Dainius Pu¯ras is a Professor and the Head of child psychiatry and public mental health at Vilnius University, Lithuania. In 2014 he was appointed by the UN Human Rights Council and serves as a Special Rapporteur on the right to health. From 2007 to 2011 he was a member of the UN Committee on the Rights of the Child. He is actively involved in regional and global activities promoting evidence-based and rights-based health policies and services, with a focus on mental health and child health. Giuseppe Raviola, MD MPH, is an Assistant Professor of Psychiatry and of Global Health and Social Medicine at Harvard Medical School. He is Director of Mental Health for Partners In Health, Director of the Program in Global Mental Health and Social Change at Harvard Medical School, and an attending physician at Boston Children’s Hospital. Shekhar Saxena is a psychiatrist by training who has published widely in high impact journals, authoring more than 300 scientific papers. He is currently a Visiting Professor at the Harvard xv

Contributors

T. H. Chan School of Public Health. He has 20 years’ experience working at the World Health Organization, where he was the Director of the Department of Mental Health and Substance Abuse from 2010 to 2018. Guglielmo Schininà is the Head of Mental Health, Psychosocial Response and Intercultural Communication at the International Organization for Migration (IOM) and co-directs the Summer School ‘Psychosocial Interventions in Migration, Emergency and Displacement’ at the Scuola Sant’Anna in Pisa, Italy. Over the last 20 years he has designed programmes providing psychosocial support for displaced and migrant populations, including refugees and victims of trafficking in more than 60 countries worldwide. Chris Underhill is a global expert in the delivery of health and rehabilitation systems to those in poverty who has founded numerous successful global NGOs promoting mental health and development for marginalised communities, including BasicNeeds and citiesRISE. He has received numerous prestigious awards for his social impact, including the Ashoka Senior Fellowship, the Skoll Foundation Award for Social Entrepreneurship, and the Schwab Foundation Award for Social Entrepreneurship. In 2000 he was made an MBE by her Majesty the Queen for his services to disability and development. Dahlia Virtzberg is a linguistic and literary editor and a doctoral candidate in culture studies with a focus on the social and political history of the psychiatric establishment in Israel. She is a well-known ex-patient activist and advocate for the human rights of people with psychosocial disabilities, and was significantly involved in the Israeli ‘Break the Restraints’ project. Carol Vlassoff is an Adjunct Professor with the School of Epidemiology and Public Health, University of Ottawa, Canada, with 20 years’ experience working with the World Health Organization, including seven years in senior positions with the Pan American Health Organization. She has considerable research experience in the areas of gender, sexual and reproductive health, global health systems, and HIV/AIDS.

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FOREWORD Jeffrey D. Sachs

The Routledge Handbook on International Development, Mental Health and Wellbeing is a seminal contribution to sustainable development and the first compendium of its kind. This superb collection of chapters, written by over 30 leading experts around the world including the editor, Laura Davidson, comprehensively surveys mental health in the context of international development. Bringing together a range of multidisciplinary and interdisciplinary perspectives, it draws on different areas of importance relating to mental health, such as economics, anthropology, demography and culture, law and policy. This key reference takes up a challenge of inestimable importance, seeking to highlight the need for incorporating mental health into health policies, national budgeting and planning, international development, and global diplomacy. Its interest to academics is obvious, but for those in the development arena, its practicality makes it an essential read—particularly for those working in public health and/or human rights. Few world topics are more pertinent to human wellbeing. Mental illness constitutes one of the decisive sources of preventable and treatable human suffering. Yet, for reasons of ignorance, social stigma, shortterm governmental goals, and burdens of poverty, mental illnesses have long been chronically under-addressed in national and global health policies and have failed to figure prominently in global diplomacy until very recently. The chapters in this remarkable volume make painfully clear that mental health has never been accorded its rightful place in health promotion and disease control. The highest profile global disease control campaigns in recent decades have focused on infectious diseases (in particular, HIV/AIDS, TB, malaria, and polio), maternal and child survival, and expanded vaccine coverage, rather than mental health. This was evident in the scale-up of health coverage in the era of the Millennium Development Goals (MDGs) between 2000 and 2015.1 During this period, mental health professionals at the WHO, in academia, and in wider civil society built the case for expanding the global focus on health to include the prevention and treatment of mental disorders. These valiant efforts finally met with success in the incorporation of mental health within Agenda 2030 and the Sustainable Development Goals (SDGs), adopted unanimously by all 193 UN member states in September 2015. Agenda 2030 envisions ‘[a] world with equitable and universal access to quality education at all levels, [and] to health care and

1 See MDG4, MDG5, and MDG6.

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social protection, where physical, mental and social well-being are assured’.2 SDG3 requires all states to ‘[e]nsure healthy lives and promote well-being for all at all ages’. Target 3.4 in particular (explored in detail in Chapter 13 of this book) calls for the promotion of ‘mental health and well-being’ and the reduction ‘by one-third of premature mortality from non-communicable diseases’. In a variety of fascinating and pertinent contexts, The Routledge Handbook on International Development, Mental Health and Wellbeing gives us invaluable guidance on how these bold objectives might best be met. Even in the richest countries, only a fraction—sometimes a shockingly small number—of individuals suffering from mental illnesses such as depression, anxiety disorders, post-traumatic stress disorder (PTSD), and substance use disorders are able to benefit from high-quality mental health services. The shortfall in quality mental health services is worldwide and deep. As numerous chapters of this book emphasise, the situation is, of course, far graver in low- and middle-income countries (LMICs) where pervasive poverty and the shortage of trained health care workers often lead to a near-complete absence of mental health services, as Chapter 2 highlights. The massive challenge, therefore, is one of ‘scale-up’ to ensure that skilled, sensitive, well-trained and well-supervised mental health professionals are available when and where they are needed. In most developed nations, the solution involves a new awareness of the urgency of mental health services; in LMICs, it is not only awareness that is vital, but also new financing for mental health interventions, along with innovative approaches such as task-shifting (explored in numerous chapters of this volume), perhaps involving collaborations. Wealthier countries have an explicit responsibility under SDG17 to assist those countries facing a financial shortfall in meeting their SDG commitments, including mental health services (as Chapter 2 in particular emphasises). Governments of all states, rich and poor, have a duty both under international human rights law and under the 2030 Agenda to prioritise and budget for mental health prevention, support and treatment. This volume contains an in-depth consideration of what the world should aim for in terms of the quality and coverage of mental health services, and how states should meet their obligations under SDG3 in a responsible and sustainable manner. As discussed in Chapter 1, mental disorders can arise as a result of chronic stress and deprivation. Extreme poverty is one major cause of mental disorders such as depression and substance use disorders, while mental illnesses in turn can lead to poverty, thereby giving rise to a vicious spiral in which economic deprivation and mental disorders exacerbate each other. When mental illnesses occur, the burdens on society can be enormous. Individuals and families face great stresses and dislocation. The economy suffers from lower productivity, absenteeism, unemployment, school drop-outs, and the multiple social burdens of substance use disorders. Chapters 3 to 4 of this book focus on the economics of mental health. These illuminate with great clarity the overwhelming evidence that untreated mental disorders have costs far greater than the cost of effective treatment. The book also includes several interesting economic perspectives such as the chapter on women’s economic empowerment in Vietnam, and the consideration of a social enterprise approach to mental health in LMICs. Other forms of deprivation and stress, such as unemployment, lack of access to schooling, and forced migration (caused by wars, poverty, and environmental catastrophes, as examined in Chapters 10 and 16 of this book) also raise the incidence and prevalence of mental illnesses such

2 UN GA, RES/70/1, Transforming our world: the 2030 agenda, Declaration, para.7.

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Foreword

as depression, anxiety disorders and post-traumatic stress disorder (PTSD). These factors are explored in a number of the chapters within this volume in absorbing ways, illustrated by the authors’ experiences in countries as varied as Bhutan, Haiti, and Colombia. A significant increase in worldwide research into different mental illnesses is crucial for the development of more effective treatments. Nonetheless, one vital message of this book is that certain low-cost and proven interventions, appropriately adapted to local circumstances, already exist. Mental disorders can often be prevented and treated, even in poor countries. Mental health support and treatment must be tailored not only to different countries and cultures, however, but also to differing demographics during the life-cycle, and ultimately, to individuals. Chapters 7 to 12 of this volume consider important demographic considerations in the treatment of mental illness, and include an anthropological perspective by a chartered psychologist on sociocultural constructions of illness and Native American therapeutic ritual use of peyote. The mental health needs of children and young people and also gender-based needs are examined in depth. Two pressing challenges of our globalised, modern age are also explored: the mental health of migrants, and our worldwide ageing population and the inevitable surge in dementia. A clear message emanating from this book is the interconnectedness of SDG3 with many of the other SDGs. For example, achieving SDG1 (ending poverty), SDG2 (ending hunger), SDG4 (ensuring universal access to schooling), and SDG16 (creating peaceful societies) will reduce the burdens of mental illness at the same time. Not only is the holistic nature of mental health abundantly apparent, but to meet SDG3 effectively, a deeply multidisciplinary approach will be needed—one which takes into account the multifaceted biological, social, and environmental factors related to mental illness. A simple biomedical model of mental ill-health is inadequate for the complexities of the modern age, and we must move beyond the stark insensitivities and abuses of power of the past. Importantly, several authors of chapters within this book have lived experience of mental illness themselves. Their profound insights are vital if we are to make real inroads into reducing the global epidemic of mental illness. Individuals with mental disorders often face stigma, discrimination, and coercion (such as forced hospitalisation or harsh physical restraints) which can be highly traumatic and destructive of human dignity and basic human rights. All health care providers need training and supervision to ensure that patients are accorded their right to dignity, and to decent, effective, and appropriate treatment in accordance with best health practices and with international human rights law. The potentially crucial contribution that the law can make to achieving SDG3 is considered from various perspectives in the legal section (Chapters 18 to 22). These contributions vividly illuminate how the law may not only redress rights violations, but also alter perceptions and result in normative changes, impacting on mental health both directly and indirectly. A country case study on Israel in Chapter 24 which outlines how civil society pressure resulted in changes to national law and policy on enforced treatment is an excellent complement to this section. The Routledge Handbook on International Development, Mental Health and Wellbeing is therefore an indispensable and unique tool for what ought to be one of the highest priorities of the SDG era. We have the opportunity to prevent mental illnesses and treat them effectively when they arise. In the classic definition of health championed by the World Health Organization (WHO)—‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’—mental health has an obvious and central role. The definition includes not only the prevention and treatment of mental disorders, but also the promotion of

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positive wellbeing, as seen, for example, within the field of positive psychology. By embracing the critical messages in this volume and mobilising the resources needed to ensure high-quality mental health services around the world, we can achieve a historic breakthrough in human wellbeing globally. Through this book, we are now richly guided; the time for action is at hand. Jeffrey D. Sachs (Special Advisor to UN Secretary-General Antonio Guterres on the Sustainable Development Goals; Director of the UN Sustainable Development Solutions Network; University Professor and Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University, New York)

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PART I

The global imperative

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1 THE GLOBAL MENTAL HEALTH IMPERATIVE AND THE ROLE OF THE WORLD HEALTH ORGANIZATION WITHIN THE UN 2030 AGENDA Shekhar Saxena* and Laura Davidson† The burden One in four: an oft-repeated statistic representing the number of people globally who will suffer from mental illness at some time in their lives. The alarmingly high figure has been stated so frequently that it has, perhaps, lost its sting. Yet, more recently the true figure has been recognised as being probably even higher.1 In a 2014 survey in England, for example, 37% of adults between the ages of 16 and 74 (one in three) were in receipt of treatment for their mental health.2 Given the growing elderly population worldwide, it is plain that the mental health burden is set to increase yet further, with approximately 9.9 million new cases of dementia globally each year.3 To this must be added the widespread comorbidity of mental illness with substance use worldwide,

* Shekhar Saxena is a psychiatrist and Professor of the Practice of Global Mental Health at the Harvard T. H. Chan School of Public Health, and the former Director of the Department of Mental Health and Substance Abuse at the World Health Organization (2010 to 2018), where he worked for 20 years. † Laura Davidson is a London Barrister specialising in health care law and human rights, an international development consultant, and co-founder of Mental Health Research UK. She is a recognised authority on mental disability law. 1 See, e.g., New Zealand research (Moffitt, T. E., Caspi, A., Taylor, A., et al. (2010), How common are common mental disorders? Evidence that lifetime rates are doubled by prospective versus retrospective ascertainment, Psychological Medicine, 40: 899–909. A 2005 study in the US found that an estimated lifetime rate of 50.8%; see Kessler, R. C., Berglund, P., Demler, O., et al. (2005), Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication, Arch Gen Psychiatry, 62(6): 593–602. 2 The survey also found that every week 1 in 6 people in England reported a mental health issue (with many failing to seek help, often due to stigma); see S. McManus, P. Bebbington, R. Jenkins, & T. Brugha (eds) (2016), Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey 2014 (Leeds: NHS Digital). Available at: http://content.digital.nhs.uk/catalogue/PUB21748/apms-2014-prelims.pdf; WHO (2017), Depression and Other Common Mental Disorders: Global Health Estimates. Available at: apps.who.int/ iris/bitstream/10665/254610/1/WHO-MSD-MER-2017.2-eng.pdf ?ua=1. 3 There are 9.9 million new cases of dementia every year, with almost one new case every three seconds; see further WHO (2017), A70/28, Global Action Plan on the Public Health Response to Dementia

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particularly amongst men. In 2010, 10% of the total global burden of disease was held attributable to mental, neurological, and substance use disorders.4 However, globally, the mental health burden is almost certainly underestimated too, perhaps by more than a third.5 Whatever the true figure, it is clear that mental illness affects an enormous number of lives, and the burden is rising. There was a 37.6% increase in mental and substance use disorders combined in the 20 years between 1990 and 2010.6 A year after the UN’s Millennium Development Goals (MDGs) were finalised, the World Health Organization (WHO) estimated that by 2020 depression would be the second leading cause of world disability.7 Seven years later, the WHO predicted depression to be the largest contributor to disease burden by 2030.8 It is now apparent that these were underestimates; in its report of 30 March 2017,9 the WHO announced that depression was already the leading cause of ill-health and disability worldwide, with over 300 million sufferers; an increase of over 18% between 2005 and 2015. Data suggests that the global disease burden of mental illness accounts for 32.4% of years lived with disability (YLDs) and 13% of disability-adjusted life-years (DALYs)10 (an increase on earlier estimates suggesting 21.2% of YLDs and 7.1% of DALYs).11 The highest proportion of DALYs are amongst young people aged ten to 29.12 Tragically, every year nearly 800,000 people die from suicide, which equates to one death every 40 seconds, every hour, each day.13 Whilst worldwide

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2017–2025, 3 Apr, adopted at the 70th World Health Assembly in May 2017. See also Chapter 12 of this book by Stephen J. Bartels on mental health and the elderly. Murray, C. J. L., Vos, T., Lozano, R., et al. (2012), Disability-Adjusted Life Years (DALYs) for 291 Diseases and Injuries in Twenty-one Regions, 1990–2010: A Systematic Analysis for the Global Burden of Disease Study 2010, The Lancet, 380(9859): 2197–2223, at 2204 and 2207. See also Vos, T., Flaxman, A. D., Naghavi, M., et al. (2012), Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010, The Lancet, 380(9859): 2163–2196. See also World Health Assembly, RES/WHA66.8, Comprehensive Mental Health Action Plan 2013–2020, 27 May 2013, p.4. See Vigo, D., Thornicroft, G., & Atun, R. (2016), Estimating the true global burden of mental illness, The Lancet, 3(2): 171–178. Whiteford, H. A., Degenhardt, L., Rehm, J., et al. (2013), Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010, The Lancet, 382(9904): 1575–1586. WHO (2001), The World Health Report 2001: Mental Health: New Understanding, New Hope. Available at: www.who.int/whr/2001/en/whr01_en.pdf?ua=1. WHO (2008), Global Burden of Disease: 2004 Update. Available at: www.who.int/healthinfo/global_ burden_disease/2004_report_update/en/. WHO (2017), Depression and Other Common Mental Disorders: Global Health Estimates. Available at: www.who.int/mental_health/management/depression/prevalence_global_health_estimates/en/. In 1993 the World Bank introduced the concept of the disability-adjusted life year (DALY) as a measure of disease burden by combining premature death with loss of healthy life years; see World Development Report (1993), Investing in Health. Available at: documents.worldbank.org/curated/ en/468831468340807129/World-development-report-1993-investing-in-health. See the Global Burden of Disease Study 2013 Collaborators (2015), Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013, The Lancet, 386: 743–800. For more on life expectancy and the increased mortality rate of those with mental disorder, see Chapter 17 of this book by Peter Lehmann. Whiteford H. A., Degenhardt L., Rehm J., et al. (2013), Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010, The Lancet, 382(9904): 1575–1586. WHO (2014), Preventing Suicide: A Global Imperative, p.83. Available at: apps.who.int/iris/bitstr eam/10665/131056/1/9789241564779_eng.pdf.

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suicide rates are highest in people aged 70 and over, suicide is the second leading cause of death amongst 15 to 29 year olds, and the leading cause in deaths of girls aged 15 to 19 years old. Seventy-five per cent of suicides occur in low- and middle-income countries (LMICs),14 such as Sri Lanka, which in 2017 had the highest suicide rate in the world—58.8 suicides per 100,000 population.15 The mortality rate for those with severe mental illness is startling: they die up to 20 years younger than those with physical illnesses.16

Human rights Yet, despite immensely high death rates, mental health receives a fraction of the development aid allocated to the combat of cancer or HIV/AIDS.17 Medical advancements in terms of treatment for those illnesses have been astonishing, concomitant with the level of research funding provided to them over the past 30 years. However, those with serious mental illnesses, particularly in the lower socioeconomic bracket, have no better quality of life and little better treatment than had they been born decades ago. Most psychotropic medications have side-effects which can be very debilitating.18 Sufferers are disproportionately represented in prisons, and amongst the homeless. Human rights abuses (physical, sexual, emotional and psychological) against those with mental illness around the globe is rife, exacerbated by stigma. In many LMICs, physical restraint is still used as a method of ‘treatment’ for those with mental illness, including the barbaric use of chains and metal leg cuffs.19 Some acts perpetrated amount to torture, such as alleged treatment in so-called ‘prayer camps’ in Ghana, with reports of victims being chained without shade in high temperatures for days, starving and dying of thirst.20 The widespread incarceration of people with

14 See, e.g., Deshpande, R. S. (2002), Suicide by farmers in Karnataka: agrarian distress and possible alleviatory steps, Economic and Political Weekly, 37(26): 2601–2610. For more on the burden of suicide, particularly in young men, see Chapter 9 of this book by Svend Aage Madsen. 15 According to the WHO’s age-standardised suicide rates compiled from global suicide data. Available at: www.who.int/gho/mental_health/suicide_rates/en/. See also Guyana, which had the highest suicide rate in 2012, and is not far behind with 46 suicides per 100,000 population. See further the BBC report, ‘How Guyana is trying to combat its high suicide rate’, by Gemma Handy, 16 Oct 2016. Available at: www.bbc.com/news/world-latin-america-37618854. 16 See, e.g., Liu, N. H., Daumit, G. L., Dua, T., et al. (2017), Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas, World Psychiatry, 16(1): 30–40; Lawrence, D., Hancock, K. J., & Kisely, S. (2013), The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population-based registers, BMJ, 346; Walker, E. R., McGee, R. E., & Druss, B. G. (2015), Mortality in mental disorders and global disease burden implications: a systematic review and metaanalysis, JAMA Psychiatry, 72: 334–341; and Fekadu, A., Medhin, G., Kebede, D., et al. (2015), Excess mortality in severe mental illness: 10–year population-based cohort study in rural Ethiopia, Br J Psychiatry, 206: 289–296. Available at: doi.org/10.1192/bjp.bp.114.149112. 17 See, e.g., Charlson, F. J., Dieleman, J., Singh, L., & Whiteford, H. A. (2017), Donor Financing of Global Mental Health, 1995–2015: An Assessment of Trends, Channels, and Alignment with the Disease Burden, PLOS ONE, 12(2): e0172259. Available at: https://doi.org/10.1371/journal.pone.0169384; Gostin, L. O. (2015), A Tale of Two Diseases: Mental Illness and HIV/AIDS, Milbank Q., 93(4): 687–690. Available at: www.ncbi.nlm.nih.gov/pubmed/26626982. 18 See further on this topic Chapter 17 of this book by Peter Lehmann. 19 See, e.g., UN GA, A/HRC/25/60/Add.1, Juan E. Mendez, Report of the Special Rapporteur on Torture and Other Inhuman or Degrading Treatment or Punishment: Mission to Ghana, 25th session, 5 Mar 2014, Agenda Item 3, Part IIID. 20 See, e.g., Edwards, J. (2014), Ghana’s mental health patients confined to prayer camps, The Lancet, 383(9911): 15–16. Available at: www.ncbi.nlm.nih.gov/pubmed/24400332. See also Arias, D. Taylor, L., Ofori-Atta, A., & Bradley, E. H. (2016), Prayer Camps and Biomedical Care in Ghana: Is Collaboration

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mental illness in hospital continues, despite its being contrary to Article 12 of the Convention on the Rights of Persons with Disabilities (CRPD) in the opinion of its Committee.21 This is so even where there is either no legal basis for it—in almost two thirds of the world—or where mental health legislation over ten years old exists which does not accord with current international human rights standards.22 As Patel et al. observed in 2011, 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,23 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’.24

The treatment gap There is also an immense and unconscionable ‘treatment gap’ in mental health (the percentage of people with an illness who receive no treatment). Whilst it varies across regions, for mental disorders it is universally large.25 Thirteen years ago, a review of community-based psychiatric epidemiology studies suggested that the median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For depression, the gap was 56.3%, and for bipolar disorder 50.2%. The gap was 55.9% for panic disorder, and 57.3% for obsessive compulsive disorder (OCD). It is likely that such reported gaps were underestimated due to the unavailability of community-based data from LMICs, which often have grossly inadequate service provision. The treatment gap has probably widened further since 2004, when alcohol abuse and dependence had the largest treatment gap at 78.1%.26 By 2013, the UN’s online Sustainable Development Knowledge Platform reported that ‘only about 1 in 6 people worldwide suffering from drug-use disorders received treatment . . . [and] [a]pproximately 1 in 18 people with drug-use disorders received treatment in Africa that year, compared with 1 in 5 in Western and Central Europe’.

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in Mental Health Care Possible?, PLoS ONE, 11(9): e0162305. Available at: journals.plos.org/plosone/ article?id=10.1371/journal.pone.0162305. See General Comment 1 on Art.12 (Equal recognition before the law), UN Doc.CRPD/C/GC/1. However, one or other or both of the jurisdictions under consideration are signatories to the Conventions mentioned. Unfortunately the UN’s 2030 agenda does not require the implementation of mental health legislation to enforce obligations, such as the right to access appropriate treatment. In 2017, 111 countries reported having a stand-alone law for mental health (57% of the 194 WHO member states). The African and South-East Asian regions had the lowest percentage (44–50%). However, 40% of responding countries claimed to have updated their mental health legislation since 2013. Thirty-four countries had no mental health legal provisions whatsoever (i.e., not even integrated into general health or disability law): see further WHO (2018), Mental Health Atlas 2017 (Geneva: WHO), para.2.2. Available at: www.who. int/mental_health/evidence/atlas/mental_health_atlas_2017/en/. For more on justiciable human rights complaints under international law, see Chapters 20 and 21 of this book by Laura Davidson. Patel, V., Boyce, N., Collins, P. Y., et al. (2011), A renewed agenda for global mental health, The Lancet, 378(9801): 1441–1442. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(11) 61385-8/abstract. Kleinman, A. (2009), Global mental health: a failure of humanity, The Lancet, 374: 603–604. With regard to India, for example, see Sagar, R., Pattanayak, R. D., Chandrasekaran, R., et al. (2017), Twelve month prevalence and treatment gap for common mental disorders: findings from a large-scale epidemiological survey in India, Indian Journal of Psychiatry, 59(1): 46–55. See further Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004), The treatment gap in mental health care, Bulletin of the WHO, Nov, 82(11): 811–890.

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A recent large-scale review found that only a minority of persons with major depressive disorders received minimally adequate treatment, equating to 1 in 5 people in high-income countries and 1 in 27 in low- and lower-middle-income countries.27 Why does the treatment gap persist? Apart from a failure to diagnose, there is a global deficit of mental health service providers to meet need. For example, almost a third of the US population lacks adequate access to mental health care, with similar shortages in many others including Australia, Canada, Finland, and Japan. On average globally, there are only nine mental health providers per 100,000 people.28 The position in LMICs is appalling, with an estimated extra 1.71 million mental health workers required.29 To illustrate the scale of the problem, in Afghanistan ten million people rely on one psychiatrist, compared to one per 5,000 people in Belgium.30 Between 76% and 85% of people with mental disorders in LMICs receive no treatment at all for their disorder, as opposed to 35% and 50% respectively for those in high-income countries.31 However, the figures with respect to more developed countries are still poor —all countries are ‘developing’ when it comes to mental health.

The link between physical and mental health Mental health has always been marginalised within the global public health agenda, and (inexplicably) viewed as a discrete health concern.32 Yet, ‘without mental health there can be no true physical health’, as the WHO’s first Director-General, psychiatrist Brock Chisholm, famously stated. As Kolappa et al. noted, ‘[h]alf a century later, we have strong evidence elucidating the bidirectional relationship between mental illnesses—specifically depression and anxiety—and physical health outcomes’.33 Exercise has been proven to have a positive effect on such mental disorders as depression, anxiety and stress.34 Paradoxically, stress and anxiety can exacerbate

27 Thornicroft, G., Chatterji, S., Evans-Lacko, S., et al. (2016), Undertreatment of people with major depressive disorder in 21 countries, BJ Psych, 1–6. Available at: doi.org/10.1192/bjp.bp.116.188078. 28 Collins, P. Y. & Saxena, S. (2016), Action on mental health needs global cooperation, Nature, 6 Apr, 532(7597) (Comment). 29 Scheffler, R. M., Bruckner, T. A., Fulton, B. D., et al. (2011), Human resources for mental health: workforce shortages in low- and middle-income countries, Human Resources for Health Observer, 8, Executive Summary (Geneva: WHO). p.VII. This workforce estimation was made in 2011 with regard to 2015, and thus the need for more workers is likely to be even greater. Available at: apps.who. int/iris/bitstream/10665/44508/1/9789241501019_eng.pdf. See also Collins & Saxena (2016), ibid.; Bruckner, T. A., Scheffler, R. M., Shen, G., et al. (2011), The mental health workforce gap in low- and middle-income countries: a needs-based approach, Bulletin of the World Health Organization, 89: 184–194. Available at: doi.org/10.2471/BLT.10.082784. 30 WHO Mental Health Atlas 2014 Country Profile for Afghanistan. Available at: www.who.int/mental_ health/evidence/atlas/profiles-2014/afg.pdf?ua=1; WHO Mental Health Atlas 2014 Country Profile for Belgium. Available at: www.who.int/mental_health/evidence/atlas/profiles-2014/bel.pdf?ua=1. 31 Kohn et al. (2004), op. cit., nt.26. 32 Prince, M., Patel, V., Saxena, S., et al. (2007), No Health Without Mental Health, The Lancet, 370(9590): 859–77. Available at: dx.doi.org/10.1016/S0140-6736(07)61238-0. 33 Kolappa, K., Henderson, D. C., & Kishore, S. P. (2013), No Physical Health Without Mental Health: Lessons Learned, Bulletin of the WHO, 91: 3–3A. Available at: doi.org/10.2471/BLT.12.115063. 34 See, e.g., Stathopoulou, G., Powers, M. B., Berry, A. C., et al. (2006), Exercise Interventions for Mental Health: A Quantitative and Qualitative Review, Clinical Psychology, Science and Practice, 13(2): 179–193. Available at: doi.org/10.1111/j.1468-2850.2006.00021.x; Callaghan, P. (2004), Exercise: a neglected intervention in mental health care?, Journal of Psychiatric and Mental Health Nursing, 11(4): 476–483. Available at: doi:10.1111/j.1365-2850.2004.00751.x; Hamer, M., Stamatkis, E., & Steptoe, A. (2009), Dose-response relationship between physical activity and mental health: the Scottish Health Survey,

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physical conditions through reduced immune functioning. Mental illness may also manifest itself somatically.35 Further, it is moot that those with physical health conditions have an increased risk of developing a mental disorder such as depression. Mental illness contributes to unintentional injury and self-harm, and increases risk in communicable and non-communicable diseases (NCDs).36 Comorbidity (either with a physical illness or another mental disorder) complicates help-seeking, diagnosis, and treatment, and adversely influences prognosis, with untreated or inadequately treated mental illness leading to less favourable health outcomes. The prognosis of those treated for chronic physical illnesses such as cancer, diabetes, cardiac disease and HIV/ AIDS is worse when there is comorbid, untreated depression.37 In addition, people with severe mental illness have up to 60% higher chances of dying prematurely from NCDs that are neglected because of the underlying mental condition,38 sometimes due to lack of compliance with medication, or (more often in LMICs) its erratic availability. In addition, those with mental disorder are more prone to unhealthy behaviours which result in obesity or cancer.39 The US Center for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration found that the mentally ill smoke at a 70% higher rate than the rest of the population, and consume a third of all cigarettes.40 This habit can worsen due to anxiety, and often arises from boredom, both during in-patient hospital stays and in the community due to a lack of access to employment because of stigma and/or relapse. As Kolappa et al. have highlighted, despite the clear interconnection between mental and physical health, ‘policy continues to lag behind the evidence’.41 Research by Becker and

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British Journal of Sports Medicine, 43(4): 1083–1084. Available at: doi:10.1136/bjsm.2009.069187; Ten Have, M., de Graaf, R., & Monshouwer, K. (2011), Physical exercise in adults and mental health status: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), Journal of Psychosomatic Research, 71(5): 5342–5348. Available at: doi.org/10.1016/j.jpsychores.2011.04.001. See, e.g., Henningsen, P., Zimmermann, T., & Sattel, H. (2003), Medically Unexplained Physical Symptoms, Anxiety, and Depression: A MetaAnalytic Review, Psychosomatic Medicine, 65(4): 528–533. Underestimation of mental illness globally is suggested by the researchers as due to (1) the overlap between psychiatric and neurological disorders; (2) the grouping of suicide and self-harm as a separate category in statistics; (3) the conflation of all chronic pain syndromes with musculoskeletal disorders; (4) the exclusion of personality disorders from disease burden calculations; and (5) the inadequate consideration of the contribution of severe mental illness to mortality from associated causes. See, e.g., Whang, W., Shimbo, D., Kronish, I. M., et al. (2010), Depressive symptoms and all-cause mortality in unstable angina pectoris (from the Coronary Psychosocial Evaluation Studies [COPES]), Am J Cardiol, 106: 1104–1107. Available at: doi:10.1016/j.amjcard.2010.06.015 pmid: 20920647. The psychotropic medications used to treat the majority of mental illnesses can also trigger serious physical health problems; see further Chapter 17 of this book by Peter Lehmann. WHO (2013), Mental Health Action Plan 2013–2020 (Geneva: WHO), p.7, para.11. Many psychotropic medications also cause weight gain. See, e.g., The NSDUH Report (2013), Adults With Mental Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes Smoked, 20 Mar 2013 (Rockville: Substance Abuse and Mental Health Services Administration); Centers for Disease Control and Prevention (2013), Vital Signs: Current Cigarette Smoking Among Adults Aged 18 Years With Mental Illness—United States, 2009–2011, Morbidity and Mortality Weekly Report, 62(05): 81–87. Another US survey which interviewed 138,000 adults in their homes from 2009 to 2011 found that 1 in 3 adults with mental illness smokes, compared with 1 in 5 adults without mental illness (see Substance Abuse and Mental Health Services Administration (2012), Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12–4725 (Rockville: Substance Abuse and Mental Health Services Administration). Available at: www.samhsa.gov/data/sites/default/files/2011MHFDT/2k11 MHFR/Web/NSDUHmhfr2011.htm#4.1 Kolappa, K., Henderson, D. C., & Kishore, S. P. (2013), No physical health without mental health: lessons unlearned?, Bulletin of the World Health Organization, 91: 3–3A. Available at: doi: 10.2471/BLT.12.115063.

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Kleinman has shown how historically there has been ‘a cavernous divide between physical and mental health—in resources, political commitment, and human compassion’.42 Health services are not provided equitably to the mentally ill, and the quality of care for both the mental and physical health conditions of such patients is often inadequate.

Global mental health and development Biological, socioeconomic, and environmental factors all contribute to mental illness. Those who live in poverty are disproportionately affected by mental disorders.43 In one study, children in abject poverty in Brazil had a fivefold increased likelihood of having a mental illness.44 In Brazil, India, Chile and Zimbabwe, the rate of mental illness suffered by the poor is approximately double that of the wealthy.45 Socioeconomic disadvantage appears to be both a cause and consequence of depression, and a likely barrier to treatment.46 Mental illness (and trauma in particular) can increase significantly in the wake of upheavals47 such as natural disasters, forced migrations, conflict, persecution and war,48 which tend to be more prevalent and/or exacerbated in LMICs with severe resource constraints. In addition, whilst the cumulative lost economic output due to mental illness over the next 20 years will be US$16 trillion (£11 trillion),49 there is non-parity in budgetary provision between mental and physical health globally, with spending on mental health less than 2.5% of the health budget.50 In 2017, the WHO found that only just over half of responding states had allocated a budget in accordance with assessed mental health need, and less than 30% on the African

42 Becker, A. E. & Kleinman, A. (2013), Mental health and the Global Agenda, New England Journal of Medicine, 369(1): 66–73, at 66. 43 See Chapter 3 of this book by Martin Knapp and Valentina Iemmi, and Chapter 4 by Judith Bass. See also Lund, C., Breen, A., Flisher, A. J., & Patel, V. (2010), Poverty and Common Mental Disorders in Low and Middle Income Countries: A Systematic Review, Social Science & Medicine, 71(3): 517–528. See also ECOSOC/WHO (2009), ‘Addressing noncommunicable disease and mental health: major challenges to sustainable development in the 21st century’, ECOSOC meeting/WHO Discussion paper, Mental Health, Poverty and Development, July. Available at: www.who.int/nmh/publications/discussion_paper_en.pdf. 44 See Fleitlich, B. & Goodman, R. (2001), Social factors associated with child mental health problems in Brazil: cross sectional survey, British Medical Journal, 323: 599–600. 45 Patel V., Araya, R., de Lima, M., Ludermir, A., & Todd, C. (1999), Women, poverty and common mental disorders in four restructuring societies, Social Science & Medicine, 49: 1461–1471. 46 Folb, N., Lund, C., Fairall, L. R., et al. (2015), Socioeconomic predictors and consequences of depression among primary care attenders with non-communicable diseases in the Western Cape, South Africa: cohort study within a randomised trial, BMC Public Health, 15: 1194. Available at: doi:10.1186/ s12889-015-2509-4. 47 L. O. Gostin (2014), Global Health Law (Cambridge: Harvard University Press), p.390. See further Chapter 16 of this book by Giuseppe Raviola, and Chapter 22 by Salam A. Gómez. 48 See further Chapter 10 of this book by Guglielmo Schininà and Karoline Popp. Chapter 22 by Salam A. Gómez also provides a perspective on how prolonged conflict and war can adversely affect the mental health of a nation. 49 Report of the World Economic Forum & the Harvard School of Public Health, The Global Economic Burden of Non-communicable Diseases, Sept 2011. Available at: www3.weforum.org/docs/WEF_Harvard_ HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf. See also Chisholm, D., Sweeny, K., Sheehan, P. (2016), Scaling-up treatment of depression and anxiety: a global return on investment analysis, The Lancet Psychiatry, 3(5): 415–424, who estimate that the net value of investment needed over the period 2016–2030 to substantially scale up effective treatment coverage for depression and anxiety disorders is US$147B. Available at: dx.doi.org/10.1016/S2215-0366(16)30024-4. 50 See further WHO (2018), op. cit., nt.22.

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continent.51 Although the situation has improved slightly, in 2017 the global median mental health expenditure per capita was only US$2.5: less than 2% of the global median of government general health expenditure. These amounts are entirely inadequate for the provision of even basic mental health care. In view of the interrelationships between mental illness and physical illness as well as poverty, it is obvious that to sustain all facets of development, mental health must be prioritised, particularly in low-resource settings. Yet, despite the clear global crisis in mental health, in modern global health discourse ‘most high-level attention to NCDs has entirely excluded mental illness’.52 Financial and human resources to address mental illness are inadequate and unequally distributed, and those that exist frequently fail to focus on culturally appropriate evidence-based treatments.53

The Millennium Development Goals The enormous influence of the UN and its development agenda should not be underestimated, with international development budgets intended to assist LMICs swayed by its priorities. For 15 years, such budgets focused on the eight areas set out in the MDGs adjudged by the UN to be priorities. Whilst almost half of the eight MDGs focused on physical health and achieved considerable progress over their span, mental health was conspicuously absent. That exacerbated the huge deficit in terms of investment and improvement in mental as opposed to physical health. Funding for mental health projects around the world was practically non-existent.54 Widespread trauma in war-torn states or recovering post-conflict countries such as South Sudan, Rwanda, Uganda, and Colombia55 remained largely untreated. The MDGs also failed to close the gaps between the rich and poor. As Gostin has pointed out, [a]lthough security [against infectious diseases] is important, the deepest global health challenges have little to do with cross-border threats. The primary challenge is to significantly reduce the enduring and unconscionable burdens of endemic disease and early death among the world’s poor.56 Accordingly, for those of us working in the field of mental illness, the successors of the MDGs were long-awaited.

The Sustainable Development Goals A consortium of mental health advocates which included clinicians, research institutions and NGOs advocated strongly for the inclusion of mental health within the new UN agenda, along with meaningful targets and indicators.57 The need to achieve ‘optimal health, equitably

51 Ibid., p.24. 52 Gostin (2014), op. cit., nt.47, p.44. 53 Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007), Resources for mental health: scarcity, inequity, and inefficiency, The Lancet, 370: 878–889. 54 Charlson et al. (2017), op. cit., nt.17. See also Laura Davidson (2016), ‘Mental health laws would diminish stigma and improve the lives of millions’, The Guardian, 26 Apr. Available at: www.the guardian.com/global-development-professionals-network/2016/apr/26/mental-health-law-diminishstigma-improve-lives. 55 For an account of the mental health issues in Colombia, see Chapter 22 of this book by Salam A. Gómez. 56 Gostin (2014), op. cit., nt.47, p.414. 57 For more on the advocacy efforts during the SDG development stage, see Thornicroft, G. & Patel, V. (2014), Including mental health among the new sustainable development goals, British Medical Journal,

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distributed’58 has never been more vital. Yet only one of the 17 Sustainable Development Goals (SDGs) relates to health—broadly drafted SDG3—by which states must aim to ‘[e]nsure healthy lives and promote well-being for all at all ages’. The promotion of wellbeing might include, for example, nutrition, sport, or educational activities, and so on a practical level, evidence-based support programmes for those with psychosocial disability must compete for funding with all manner of projects much less directly related to mental health. Nonetheless, the inclusion of ‘mental health and well-being’ in SDG3—and target 3.4 which repeats the need for states to ‘promote mental health and well-being’59—provides a new opportunity to raise the bar in terms of the best attainable state of health globally.

Monitoring and evaluation To advance global mental health, every country must not only improve resources, but also enhance progress monitoring to ensure that improvement in wellbeing is concrete, incremental, and continuing. Unfortunately, in many if not all LMICs, clinics and health systems lack the funds, capacity, protocols and sometimes motivation60 to record and monitor information on the impact of services, let alone to evaluate results in order to effect improvement. Although the 13 SDG targets and the 241 indicators61 barely mention mental health,62 states which have genuine intent to meet the SDGs and improve population quality of life must commit to monitoring and evaluation regardless. Furthermore, funding bodies must recognise the importance of regular training for mental health professionals to enable meaningful monitoring and evaluation on both established and new approaches.

The role of the WHO in meeting SDG3 The WHO is a UN agency and inter-governmental organisation comprised of 194 member states with a unique normative mandate. The protection of global health was heralded as its primary function in its 1946 Constitution.63 It was also to ‘act as the directing and co-ordinating authority

58 59 60

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62 63

349. Available at: doi.org/10.1136/bmj.g5189. See also Mills, C. (2018), From ‘Invisible Problem’ to Global Priority: The Inclusion of Mental Health in the Sustainable Development Goals, Development and Change, 49(3): 843–866. Available at: doi.org/10.1111/dech.12397. Gostin (2014), op. cit., nt.47, p.72. The first requirement under SDG target 3.4 is ‘by 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment’. E.g., only 33% of member states regularly compile mental health service activity data covering at least the public sector—see WHO (2018), op. cit., nt.22, p.9. Also, ‘burn-out’ of professionals in low resource settings is common: see, e.g., para.3.9 of Davidson, L., Liebling, H., Akello, G. F., & Ochola, G. (2016), The experiences of survivors and trauma counselling service providers in northern Uganda: implications for mental health policy and legislation, Int J of Law and Psych, 49(A): 84–92, at 88. However, since nine indicators repeat under two or three different targets (see below), the actual total number of individual indicators in the list is 230: Final list of Proposed Sustainable Development Goal Indicators, Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators, E/CN.3/2016/2/Rev.1. For more on the SDG targets and indicators see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson. For an in-depth discussion of the WHO’s origins, including its founding ideals, core functions, normative powers, and governing structures, as well as internal institutional tensions, see Gostin (2014), op. cit., nt.47, Chapter 4, p.72.

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on international health work’,64 and develop international health law.65 Its legislative body, the World Health Assembly (WHA), makes decisions and provides policy direction,66 supported by technical advisory and administrative expertise from a Secretariat led by its Director-General. It has six regional offices assisted by 147 country offices,67 with governance defined by one country, one vote. In its 1978 Alma-Ata Declaration on Primary Health Care,68 the WHO called for ‘health for all’ by the end of the millennium to enable everyone to ‘lead a socially and economically productive life’. Unfortunately its timeframe to meet the goals of affordable, accessible, evidence-based, and socially acceptable primary health care was too optimistic. In the WHO’s 2008 World Health Report,69 four public health care reforms were highlighted: equitable universal coverage, people-centred health systems, public policy to integrate public health into primary health care, and leadership to engage public participation.70 In addition, a universal health coverage resolution adopted by the WHA in 201171 was passed by the UN General Assembly in 2012.72

Conventions and soft law Under Articles 2 and 19 of its Constitution, the WHO has powers to adopt legally binding ‘conventions, agreements and regulations’ through the WHA. Despite this mandate, only two such treaties have been adopted,73 neither of which relates to mental health. A state must report

64 Art.2(a) of the Charter of the United Nations, which entered into force on 24 Oct 1945. Following ratification by the necessary 26 states, the Constitution entered into force on 7 Apr 1948, which has become World Health Day. The most recent version is the 45th ed., Supplement, Oct 2006. Available at: www.who.int/governance/eb/who_constitution_en.pdf. 65 To date, this has mostly been through soft norms such as Recommendations to member states under the rarely invoked Art.23, although two binding international treaties have been significant: the WHO Framework Convention in Tobacco Control (2003), and the International Health Regulations (2005). For more on international human rights legal obligations with respect to those with disability, see Chapter 20 of this book by Laura Davidson. 66 The WHA convenes every May in Geneva, Switzerland to decide on policy and approve the WHO budget. It appoints the Director-General every five years, approves reports from the Assembly, and instructs the Board on necessary actions. See further WHO Resolutions WHA 8–26 and rule 9 of WHA 8–27, ‘Rules of Procedure of the World Health Assembly’ (1955). 67 The WHA is empowered by articles 44–54 of Chapter XI of the WHO Constitution to create regional organisations to meet the health needs of a particular geographical area. Each such organisation consists of a regional committee which formulates health policy specific to the region and is comprised of state representatives and a regional office—the administrative organs of the regional committees. The six regional offices are based in Washington, DC (Region of the Americas), Copenhagen (European Region), Cairo (Eastern Mediterranean Region), Brazzaville (African Region), New Delhi (South-East Asia Region) and Manila (Western Pacific Region). 68 WHA, RES/WHA/30.43, ‘Technical Co-operation’, 19 May 1977. 69 WHO (2008), The World Health Report 2008: Primary Health Care (Now More Than Ever). Available at: www.who.int/whr/2008/en/. 70 In its 2010 World Health Report, the WHO noted that health spending drove 100 million people below the poverty line annually. Its proposed solution was for direct payments for health to be no more than 15–20% of total health spending, with earmarked funds through taxes or other revenue essential. 71 WHO RES/WHA/64.9,‘Sustainable Health Financing Structures and Universal Coverage’, 24 May 2011. 72 UN GA RES/67/81, Global Health and Foreign Policy, 12 Dec 2012. 73 The 2003 WHO Framework Convention on Tobacco Control, and the supplementary 2012 Protocol to Eliminate Illicit Trade in Tobacco Products. The WHO’s reluctance to adopt binding norms has been criticised; see, e.g., Taylor, A. L. (1992), Making the World Health Oganization Work: A Legal Framework for Universal Access to the Conditions for Health, American Journal of Law and Medicine, 18: 301–346;

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annually on the implementation of any treaty to which it is bound following national accession.74 If it makes reservations to a treaty, it remains a party provided that the reservation is compatible with the convention’s overall purpose.75 Article 21 provides the WHA with quasi-legislative powers to adopt regulations on health topics.76 Unusually in international law, unless states opt out, they are automatically bound. Gostin et al. have long proposed a legally binding convention on health, including mental health, and the WHO has both the mandate to develop international health law, and the influence to make that a reality.77 However, this would require considerably more political will globally than is presently apparent. The WHO may also pass resolutions to adopt international policy frameworks, and it has the power to draw up guidelines and codes and to ‘make recommendations with respect to international health matters’.78 Known as ‘soft law’, these have considerable persuasive power, such as the (revised) 2005 International Health Regulations (IHR) and the 2010 Global Code of Practice on the International Recruitment of Health Personnel.79 If the WHA grants authority, the Secretariat can set a norm or standard. The Secretariat may also convene expert committees to receive formal expert advice on areas that are controversial.80 All of these mechanisms offer the WHO substantial scope to make an impact in terms of positive global change in mental health.

Monitoring What powers does the WHO have to ensure that states adhere to their health commitments?

Annual national reports In terms of the treaty signatories’ duty to report annually on implementation, the WHO’s Director-General has a monitoring authority.81 Chapter XIV of the WHO’s Constitution sets out member state reporting requirements. Article 61 requires the provision of annual reports ‘on the action taken and progress achieved in improving the health of its people’. Under Article 62, each member must report annually on its actions regarding WHA recommendations pursuant to Article 23, and with respect to conventions, agreements, regulations, and Recommendations (including Global Strategies).82 Article 63 requires states to ‘communicate promptly to the Organization important laws, regulations, official reports, and statistics pertaining to health which have been published in the State concerned’. Statistical and epidemiological reports are to be supplied

74

75 76 77 78 79 80 81 82

Fidler, D. P. (1998), The Future of the World Health Organization: What Role for International Law?, Vanderbilt Journal of Transnational Law, 31(5): 1079–1126. Unusually in international law, Art.20 requires states to act, either in accepting or refusing the treaty, within 18 months of adoption by the WHA, informing the Director-General of the action it has taken, and if it does not accede to the treaty within that period, it must provide a statement of reasons. See Art.21 of the Vienna Convention on the Law of Treaties, adopted 23 May 1969 (Treaty No.18232), and entering into force on 27 Jan 1980. By way of Art.22, these enter into force after due notice is given. Gostin, L. O., Friedman, E. A., Buse, K., et al. (2013), Towards a framework convention on global health, Bulletin of the World Health Organization 2013, 91: 790–793. Available at: dx.doi.org/10.2471/BLT.12.114447. See Art.12 and Art.19 of the WHO Constitution. Available at: www.who.int/hrh/migration/code/WHO_global_code_of_practice_EN.pdf. See, e.g., www.who.int/substance_abuse/expert_committee_alcohol_trs944.pdf. By way of Art.20, a state which accepts a Convention or agreement adopted by the WHA must make an annual report to the Director-General in accordance with five Articles within Chapter XIV. Such as the Global Code of Practice on the International Recruitment of Health Personnel, developed by the Secretariat at the behest of the WHA.

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under Article 64. Additional health information may be requested by the Board under Article 65, provided it is ‘practicable’. The WHO’s International Digest of Health Legislation (IDHL) is a library of domestic health law, but unfortunately it is incomplete due to the failure of many member states to adhere to Chapter XIV.83 If such requirements had a legal basis, this would be an important monitoring and evaluation resource. However, the WHO’s regional offices report to the relevant member state as well as to the Director-General, and this decentralised structure has been criticised for inhibiting global strategy-implementation.84

The WHO and mental health The WHO is rightly respected, has an impressive history and vast expertise, and a broad health remit.85 Given that almost every country worldwide is a member, it is plain that the WHO has a crucial role in creating global impetus for change in mental health. In May 2012, the WHO adopted a resolution at the 65th WHA Assembly on the global burden of mental disorders and the need for a comprehensive, coordinated response from national health and social sectors.86 Recognising that both socioeconomic and behavioural factors have an impact on mental health, the WHO adopted a Mental Health Action Plan 2013–2020 (the Action Plan),87 with multidisciplinary guidance on national promotion, implementation, and prevention strategies for mental disorders in each tier of care. It calls for national leadership and governance for mental health, research (including in LMICs), and improved information systems. Progress under the Action Plan is monitored by states via six measurable targets to be achieved globally by 2020:88 1.1 80% of member states to develop or update their mental health policy in accordance with international and regional health instruments;89 1.2 50% of member states to develop or update their mental health law in accordance with international and regional health instruments; 2A 20% increase in service coverage for severe mental disorders; 3.1 80% of countries . . . [to] have at least two functional national, multisectoral mental health promotion and prevention programmes; 3.2 10% reduction in suicide; 4 80% of countries to be routinely collecting and reporting at least a core set of mental health indictors every two years through their national health and social information systems. These targets are intentionally practical. For example, only a modest 50% of member states are expected to update archaic mental health legislation90 and/or non-internationally compliant

83 See Gostin (2014), op. cit., nt.47, p.114. 84 Ibid., p.72. 85 According to Gostin, ‘the WHO is the only institution with the legitimacy to rationalize global health funding and activities and to advocate for health in the trade, intellectual property, and environmental sectors’, ibid., p.127. 86 WHA, RES/WHA/64.5, The global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level, 25 May 2012. 87 WHA, RES/WHA/66.8, ‘Comprehensive Mental Health Action Plan 2013–2020’, 27 May 2013. Available at: www.who.int/mental_health/publications/action_plan/en/. 88 See further Saxena, S., Funk, M., & Chisholm, D. (2013), World Health Assembly Adopts Comprehensive Mental Health Plan 2013–2020, The Lancet, 381(9882): 1970. 89 For more on the importance of mental health policy, see Chapter 13 of this book by Rachel Jenkins. 90 For consideration of how international human rights legal requirements can result in challenge to archaic mental health legislation (with Zambia as a case study), see Chapter 21 of this book by Laura Davidson.

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law over the next seven years, because the legislative process takes time.91 The Action Plan’s goal of a 10% global reduction in suicide rates is lower than the SDGs’ aspiration. Under SDG target 3.4, a reduction ‘by one third’ of premature mortality from NCDs is required, with the suicide mortality rate a monitoring tool in terms of mental illness under indicator 3.4.2. However, this difference can be explained by the timeframe (20 years under the Action Plan, rather than 30 under the SDGs). Notably, the Action Plan’s proposed 20% increase in service coverage for severe mental disorders by 2020 is considerably more concrete than any targets or indicators under SDG3. To achieve SDG3 and leave no-one behind,92 states must commit to that at the very least.

Other monitoring tools Already used in more than 80 countries, the 2009 WHO Assessment Instrument for Mental Health Systems (WHO-AIMS)93 is an information-collecting tool on countries’ mental health systems, providing a baseline for monitoring improvements. Similarly, the WHO’s Mental Health Atlas94 collates baseline mental health data for member states to measure progress towards the objectives of the Action Plan.95 However, compliance with both is voluntary, thereby weakening their utility. If SDG3 has any prospect of being met, states must commit to adherence.

mhGAP Recognising the need to expand mental health services, particularly in LMICs, the WHO launched the Mental Health Gap Action Program (mhGAP) in 2008.96 International consultation on mhGAP’s implementation resulted in resources like the mhGAP Intervention Guide (mhGAP-IG) for mental, neurological and substance use disorders for non-specialist health settings. This evidence-based tool facilitates integrated management of priority conditions through clinical decision-making protocols.97 The Guide is currently being used in over 100 countries, and is available in more than 20 languages.

Multi-stakeholder cooperation The global health arena in the twenty-first century is vastly different from when the WHO was created. In the last decade there have been fundamental changes in the health landscape.

91 The WHO is currently preparing a mental health legislation manual to help countries adopt international human rights norms into domestic legislation, but at the time of writing, this was not yet available. 92 ‘Ensuring that no one is left behind’ was the theme of the 2016 High Level Political Forum (the UN central platform for follow-up and review of the 2030 Agenda for Sustainable Development), as well as a central promise of the 2030 Agenda for Sustainable Development. 93 Version 2.2. See also the WHO-AIMS report (2009), Mental health systems in selected low- and middle-income countries: a WHO-AIMS cross-national analysis. Both available at: www.who.int/ mental_health/evidence/WHO-AIMS/en/. 94 The most recent version is the 2017 Atlas. Available at: www.who.int/mental_health/evidence/atlas/ mental_health_atlas_2017/en/. 95 The Lancet announced its new Countdown Global Mental Health initiative as this book was going to press, described as building on the WHO’s Mental Health Atlas and Mental Health Action Plan; Saxena, S., Kestel, D., Sunkel, C., et al. (2019), Countdown Global Mental Health, The Lancet, 393(10174): 858–859. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30424-6/fulltext. 96 Available at: www.who.int/mental_health/publications/mhgap_pubs/en/. 97 The priority conditions included are: depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and other significant emotional or medically unexplained complaints.

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The remit of financial institutions like the World Bank and the International Monetary Fund has widened to include the provision of conditional loans and the promotion of certain specific health reforms. A global economy has led to the contribution by other significant bodies to public health. In 2000, the Global Alliance for Vaccines and Immunization Alliance (GAVI) and the Joint UN Programme on HIV/Acquired Immune Deficiency Syndrome (UNAIDS)98 entered the health arena. Other global strong-holders have emerged, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund).99 In its collaborative model, low-income applicant countries themselves select the level of funding and interventions they need.100 In addition, wealthy health philanthropists have created charitable bodies which have formed major new health partnerships, influencing health-related agendas through selective early-stage funding. For example, the Bill & Melinda Gates Foundation has prioritised the combat of specific diseases through technology innovation and research.101 Although such private organisations often lack the transparency and accountability of multi-state organisations,102 they appear to be making practical inroads into intractable health issues.

Health partnerships Plainly, in a complex, globalised world, multi-stakeholder partnerships are essential to meet the challenges in public health. By 2010, there were more than 100 such partnerships worldwide,103 many of which continue to have close relationships with the WHO.104 New public-private partnerships in mental health incorporating appropriate monitoring mechanisms should be nurtured and embraced.

Innovation In the 1970s and 1980s, global collaborative research led by the WHO enabled the comparison of the incidence, prevalence and management of mental disorders in different countries.105 Whilst this facilitated some cross-cultural conceptualisations of mental illness, treatment and

98 The Global Fund and GAVI have provided the most finance for governance. 99 An independent Swiss Foundation originally administered through the WHO, but autonomous since 2009. The Global Fund was established in 2002. 100 Proposals must include measurable outcome targets, with performance reviewed biennially by a Technical Review Panel of scientific experts. Poor performance would be likely to lead to corrective action and more frequent reporting. Successful projects would only receive additional funds if performance was adequate. By 2011 the Global Fund had approved US$22.9B in grants to 151 countries. As of May 2017, it had disbursed US$33.8B. Further information available at: www.theglobalfund.org/en/financials/. 101 Further information available at: www.gatesfoundation.org/What-We-Do. 102 As Gostin has queried, ‘[h]ow can global governance capture the immense resources and ingenuity of towering figures such as Bill Gates, Bill Clinton, and Michael Bloomberg while ensuring they do not skew priorities or divert attention from the underlying drivers of inequality?’, see Gostin (2014), op. cit., nt.47, p.166. See Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson for an interesting perspective and discussion about the public health agenda influence of private donors. 103 For an indication of high-income country commitment to international development in terms of health, see, e.g., Action for Global health (2011), Aid Effectiveness for Health: Towards the Fourth Highlevel Forum, Busan 2011: Making Health Aid Work Better, Apr 2011 (Brussels: Action for Global Health). Available at: afgh.ukno.org/uploads/media/English_01.pdf. 104 E.g., despite general and deep mistrust of the pharmaceutical industry, it is obvious that the development of vaccines requires its input and assistance. 105 See, e.g., Sartorius, N., Shapiro, R., & Jablensky, A. (1974), The International Pilot Study of Schizophrenia, Schizophrenia Bulletin, 1(11): 21–34. Available at: doi.org/10.1093/schbul/1.11.21; Leff, J., Sartorius, N.,

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management, in general there has been a dearth of culturally appropriate evidence-based mental health research.106 Partnerships between researchers in LMICs and high-income countries have tested feasibility and provided implementation support, but inevitably they remain unequal colleagues. Further, limited infrastructure for community mental health care in LMICs and paltry budgetary allocations are significant obstacles to the implementation of research findings. Nonetheless, more intensified innovation in mental health research has been apparent since 2011. An estimated US$79.3 million was invested by three of the largest funders of mental health initiatives between 1995 and 2015: Grand Challenges Canada in Global Mental Health (Grand Challenges), the UK Department for International Development (DfID), and the US National Institute of Mental Health (NIMH).107 The former initiative,108 funded by the NIMH and supported by the Global Alliance for Chronic Diseases (GACD),109 has identified 40 ‘grand challenges’ for global mental health over ten years.110 The aim is to improve the lives of those with mental, neurological and substance use disorders by facilitating an equitable and global approach to reducing the burden of mental disorders.111 The 40 research priorities identified include the need to ‘foster resilience and enhance protective factors for mental, neurological and substance use disorders across developmental and life course stage’. Pioneering, practical strategies have been funded and piloted in LMICs, such as care delivery by non-specialists (peers, community health workers, or primary care providers) to capacity build and compensate for the deficit of trained mental health professionals.112 The use of electronically delivered interventions and also the development and testing of applications on smartphones and tablets to extend screening and treatment access has been fêted,113 although the cost of such technology can prove prohibitive in

106

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108 109 110 111 112

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Jablensky, A., et al. (1992), The International Pilot Study of Schizophrenia: Five Year Follow-up Findings, Psychological Medicine, 22: 131–145; Sartorius, N., Davidian, H., & Ernberg, G. (1983), Depressive disorders in different cultures: report on the WHO Collaborative Study on Standardized Assessment of Depressive Disorders (Geneva: WHO). See further the joint report of the Global Forum for Health Research/WHO (2007), Research Capacity for Mental Health in Low- and Middle-income Countries: Results of a Mapping Project. Available at: www.who.int/mental_health/MHRC_FullText.pdf. See Charlson, F. J., Dieleman, J., Singh, L., & Whiteford, H. A. (2017), Donor Financing of Global Mental Health, 1995–2015: An Assessment of Trends, Channels, and Alignment with the Disease Burden, PLoS ONE, 12(1): e0169384. Available at: doi.org/10.1371/journal.pone.0169384. See further Collins, P. Y., Patel, V., Joestl, S. S., et al. (2010), Grand challenges in global mental health, Nature, 475: 27–30. Available at: doi:10.1038/475027a. The GACD has its headquarters in London. The 40 ‘grand challenges’ in mental health are available at: www.nimh.nih.gov/about/organization/ gmh/grandchallenges/index.shtml. Although there is no timeline set for this. See further on this subject Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson. See also, e.g., Patel, V., Weiss, H. A., Chowdhary, N., et al. (2011), Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months, The British Journal of Psychiatry, 199(6): 459–466. Available at: doi:10.1192/bjp.bp.111.092155. See also Patel, V., Weobong, B., Nadkarni, A., et al. (2014), The effectiveness and cost-effectiveness of lay counsellor-delivered psychological treatments for harmful and dependent drinking and moderate to severe depression in primary care in India: PREMIUM study protocol for randomized controlled trials, Bio Med Central, 15: 101; Condo, J., Mugeni, C., Naughton, B., et al. (2014), Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives, Hum Resour Health, 12: 71. Available at: doi.org/10.1192/bjp.bp.111.092155. For a somewhat sceptical discussion of such apps, see Anthes, E. (2016), Mental health: there’s an app for that, Nature, 532: 20–23. Available at: doi:10.1038/532020a. See also Naslund, J. A., Aschbrenner, K. A., Araya, R., et al. (2017), Digital technology for treating and preventing mental disorders in

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LMICs.114 There is also the risk of technology being viewed as a low-cost (but less efficacious) alternative to providing professional help, and it may not translate well due to language or cultural barriers.115 A true global commitment to mental health must support intervention-sharing between poor and wealthy settings, whilst acknowledging local and cultural needs.116 Innovators use technology not only for new approaches, but also to publicise their ideas. Useful though they are, journal publications and databases are insufficient. Unsuccessful trials or evaluations ought to be published to prevent substantial duplication of effort. Information dissemination on evidence-based interventions, including project weaknesses, must become the norm. There are now several open-source networks and virtual communities for idea-sharing in mental health, aspiring to speed improvement in prevention, treatment, and support. Such networks facilitate a global conversation not only amongst professionals, but patients themselves, carers, and social entrepreneurs. The WHO has an established network of collaborating centres in all of the WHO regions (research institutes and universities), over 40 of which relate to mental health.117 These collaborating centres assist the WHO in data collection, policy advice, training and research. In addition, the Mental Health Innovation Network (MHIN), which is managed by the WHO’s Department of Mental Health and Substance Abuse and a research team from the London School of Hygiene & Tropical Medicine,118 was created with the aim of developing new solutions to local problems. The WHO has also established the Global Clinical Practice Network (GLPN)—an online platform used by over 12,600 mental health and primary care professionals from 150 countries who assist in research by participating in internet-based field trials.119 It tests guidelines for the WHO’s diagnostic manual,120 including for the long-anticipated classification of mental and behavioural disorders (the International Classification of Diseases and Related Health Problems (ICD-11)).121 The ICD-11 has a helpful standardised form for compiling national morbidity and mortality statistics, with diseases classified from records such as death certificates. This can feed into data describing and monitoring population health collected by states under national reporting responsibilities to the WHO. The WHO QualityRights initiative aims to improve the quality and human rights conditions in inpatient and outpatient mental health and social care facilities.122 It also seeks to empower

low-income and middle-income countries: a narrative review of the literature, Lancet Psychiatry, 4(6): 486–500. Available at: doi.org/10.1016/S2215-0366(17)30096-2. 114 As Naslund et al. (2017), ibid., conclude, many individuals will remain without access . . . [and] might include individuals in the most impoverished settings, women who have less access to mobile devices than men, individuals in rural areas without electricity or reliable network coverage, and those living in regions without access to mobile phones or the internet because of governmental policies and strict regulation of telecommunications sectors.

115 116 117 118 119 120 121 122

See also Howard, P. N. & Mazaheri, N. (2009), Telecommunications reform, Internet use and mobile phone adoption in the developing world, World Dev, 37: 1159–1169. For more on the use of culturally inappropriate technological treatment solutions, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson. See further Collins et al. (2010), op. cit., nt.107. See more on the WHO’s collaborating centres at: www.who.int/collaboratingcentres/en/. Shekhar Saxena, co-author of this Chapter, was the director of the WHO’s Department of Mental Health and Substance Abuse from 2010–2018. The MHIN is funded by Grand Challenges Canada. See further at: www.globalclinicalpractice.net/en/. The manual is intended for epidemiological health management and clinical purposes. The 1994 ICD-10 has just been updated to the ICD-11. Available at: icd.who.int/. Available at: www.who.int/mental_health/policy/quality_rights/en/.

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organisations to advocate for those with mental disabilities to implement a human rights and recovery approach in accordance with international human rights standards, including the CRPD. The associated Tool Kit is intended to support countries in doing so. In 2017, the WHO produced pilot version materials intended to transform the Tool Kit recommendations into practical solutions, reviewed by global mental health stakeholders. Sixteen CRPD-compliant training and guidance materials have now been finalised.

Conclusion The 2000 UN Millennium Declaration declared that, ‘in addition to our separate responsibilities to our individual societies, we have a collective responsibility to uphold the principles of human dignity, equality and equity at the global level’.123 That duty remains. Whilst the SDGs have major shortcomings, the close association between mental health and social determinants (particularly poverty and employment disadvantage) means that states which improve the quality of mental health education, services, and prevention strategies will meet not only SDG3, but also numerous other goals. For example, efforts made to meet SDG1 (which requires states to reduce poverty) will benefit mental health, as will commitment to SDG10 (which relates to reducing inequality), and the provision of quality education in order to meet SDG4. The need to address global mental health is gaining increasing traction. In April 2016, the World Bank and the WHO co-hosted a two-day series of events, billed as aiming to ‘move mental health from the margins to the mainstream of the global development agenda’ through investment and engaging ‘finance ministers, multilateral and bilateral organizations, the business community, technology innovators, and civil society’.124 There has been a subtle shift towards a multidisciplinary, multi-sector, and multi-agency approach. Recently, the Lancet Commission on Global Mental Health and Sustainable Development argued for a unified global vision for action on mental health, epmhasising the need for increased monitoring and accountability.125 To achieve SDG3, joint health and social policy and health-system planning is essential. The integration of mental health in every healthcare tier is vital, as are multi-sector suicide prevention strategies. All states, including LMICs, need to establish partnerships between Ministries of Health, hospitals and clinics, NGOs, and national and international research centres of excellence. A multi-state approach is also crucial to prevent the ‘brain drain’ which occurs when health workers from LMICs train in western countries and remain (or return) there, pursuing higher salaries and more comfortable lives.126 Global advocacy for mental health and substance use issues must be stepped up. The WHO’s Action Plan rightly calls for adequate ringfenced funding, plus stronger national leadership and governance for mental health.

123 UN GA RES/55/2, UN Millennium Declaration, 8 Sept 2000, para.2. 124 The series, Out of the Shadows, took place during the World Bank–International Monetary Fund Spring Meetings. The goal was to educate stakeholders about ‘the expected returns in terms of health, social and economic benefits’ through ‘urgent investments’ in mental health services—see the report by the World Bank Group and the WHO (2016), Out of the shadows: making mental health a global development priority. Available at: documents.worldbank.org/curated/en/270131468187759113/ pdf/105052-WP-PUBLIC-wb-background-paper.pdf. 125 See Patel, V., Saxena, S., Lund, C., et al. (2018), The Lancet Commission on global mental health and sustainable development, The Lancet, 392(10157):1553–1598. Available at: doi: 10.1016/S01406736(18)31612-X. 126 SDG target 3.c. is partly aimed at changing this (with health worker density and distribution set as an indicator (3.c.1)), as is the 2010 WHO’s Global Code of Practice on the International Recruitment of Health Personnel.

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In March 2017 the UN High Commissioner for Human Rights published a report at the behest of the UN Human Rights Council. It advocates for the integration of a human rights perspective in mental health, and the realisation of those rights.127 It implores stakeholders to reflect on the practical ways in which the right to mental health can be upheld through the design and delivery of mental health laws, policies, and services.128 The High Commissioner questions whether or not the current approach to mental health which uses a biomedical model with its inherent vast power imbalance is supported by evidence, medical ethics, and human rights. States are challenged to reconsider the very basis of their current mental health care model. A radical change of approach is needed to improve health systems and transform the way mental wellbeing is addressed in a holistic manner. To overcome limited human resources and to serve isolated rural populations, LMICs must be open to innovation, such as through the delivery of care by non-specialised health care providers and the use of technology.129 New and innovative public-private partnerships must be created, and links between academic institutions established or strengthened. The translation of ideas and interventions between poor and wealthy states must be facilitated, whilst taking into account local cultural needs. NGOs working in the mental health field must be supported and nurtured. To track progress, governments must implement systemic monitoring mechanisms, and provide prompt and reliable country-level data. Poor population mental health affects progress generally. The world must recognise that good mental health is crucial for development through economy-strengthening and poverty reduction. As will be argued elsewhere in this book, the economic argument for investment in mental health is overwhelming.130 It is hoped that by considering how states might meet their responsibilities under SDG3 from various in-depth perspectives, the imperative of a multi-disciplinary approach to mental health will hit home. The inclusion of SDG3 in the new UN Agenda provides mankind with an opportunity to improve mental health and wellbeing for all at all ages. The era of the invisibility of those suffering from mental ill-health must end. In the words of the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, we must ‘harness the momentum of the 2030 Agenda to address mental health’131. The opportunity to better it must be grasped with both hands, with universal commitment to promoting holistic wellbeing by ensuring that both the mental and physical health needs of all people globally are met.

127 UN GA, A/HRC/34/32, Report of the UN High Commissioner for Human Rights, Mental Health and Human Rights, 34th session, 27 Feb–24 Mar 2017 (31 Jan), Agenda items 2 and 3. 128 Ibid. 129 See further Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, and Chapter 6 by Sean A. Kidd and Kwame McKenzie. 130 For a detailed discussion of the economic arguments for investment in mental health, see Chapter 3 of this book by Martin Knapp and Victoria Iemmi. 131 See para.14 of the Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (2017), 3 Mar 2017, UN Report A/HRC/35/21 to the Human Rights Council, 35th session, 6–23 June 2017, p.5, Agenda item 3. Available at: documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/pdf/G1707604.pdf OpenElement.

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2 THE RIGHTS TO MENTAL HEALTH AND DEVELOPMENT Lawrence O. Gostin* and Laura Davidson†

Introduction It is often argued that there is a ‘right’ to mental health, but what does (or should) it mean? At present the right to mental health is insufficiently robust, but greater conceptual and normative clarity could make the right easier to identify, operationalise, and litigate, in parity with the right to physical health. A rights approach requires advancing the dignity and welfare of persons with mental disabilities, simultaneously helping to fulfil the UN health-related Sustainable Development Goal 3 (SDG3) within the new UN Agenda.1 Vital, too, is monitoring international mental health obligations and measuring their impact. In this chapter, ideas are offered for comprehensive strategies to help states respect, protect, and fulfil the right to mental health, and to implement and enforce such strategies within available resources.

The mental health burden Despite close to a third of all disability worldwide arising from mental illness,2 it remains almost invisible in modern global health discourse, policy, funding, and action. Yet, mental disability causes untold misery for countless millions, and accounts for approximately 7% of disability-adjusted life years (DALYs) worldwide,3 with young people aged ten to 29 most

* Lawrence O. Gostin is University Professor and O’Neill Chair in Global Health Law, Georgetown University and directs the World Health Organization Center on National and Global Health Law. † Laura Davidson is a London Barrister specialising in health care law and human rights, an international development consultant, and co-founder of Mental Health Research UK. She is a recognised authority on mental disability law. 1 Transforming our world: the 2030 Agenda for Sustainable Development, Resolution Adopted by the UN General Assembly, 70th Session, 25 Sept 2015, A/RES/70/1 (Agenda items 15 and 16). Available at: www.un.org/ ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. 2 See, e.g., Vigo, D., Thornicroft, G., & Atun, R. (2016), Estimating the true global burden of mental illness, The Lancet Psychiatry, 3(2): 171–178. 3 See, e.g., WHO (2014), Global Health Estimates: Deaths, Disability-adjusted Life Year (DALYs), years of life lost (YLL) and years lost due to disability (YLD) by cause, age and sex, 2000–2016. Available at: www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html. Developed in the 1990s, the DALY is a measure of overall disease burden expressed as the number of years lost due to

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affected.4 Suicide results in an estimated 2,160 deaths daily.5 Scandalously, those with mental disorder are twice as likely as others to die prematurely,6 and there has been a lamentable failure to improve life expectancy. In 2018, the aetiology of all mental illnesses remains largely unknown. Psychotropic medication is outdated, crude, untailored to the individual, and frequently ineffective. Where efficacious, it often results in debilitating and stigmatising side-effects, such as tardive dyskinesia.7 Even the newer, second-generation psychotropic medications cause obesity, metabolic syndrome, and cardiovascular disease. Worldwide, many psychiatric hospitals, particularly in low- and middle-income countries (LMICs), have grossly inadequate facilities for care and treatment. Hospital conditions frequently denigrate dignity and exacerbate mental disorder, rather than improve it. Human rights abuses are rife, perpetrated by family members, wider civil society, and even mental health professionals—mostly unwittingly, but at times maliciously. Resource constraints and weak or non-existent accountability structures proliferate abuse through inadequate monitoring of standards of care in psychiatric institutions—or no monitoring at all.8 Non-communicable diseases (NCDs) including mental disabilities are the primary contributor to the global economic burden.9 Despite the overwhelming economic argument for investment,10 mental health remains neglected in development assistance and health financing. Between 2007 and 2013, only 1% of international health assistance went to mental health.11 The exclusion of mental health from the UN Millennium Development Goals (MDGs) exacerbated the problem. Further, national budgets for mental health are ‘still grotesquely out of proportion to the burden posed by mental health problems, resulting in slow progress in scaling up of care’,12 as Patel et al. point out. Indeed, whilst mental illness accounts for approximately 13% of health care costs globally, it receives on average only 3% of healthcare funding, with

4 5 6

7 8 9 10 11

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ill-health, disability or early death, to compare the overall health and life expectancy in different countries. See also Whiteford, H. A., Degenhardt, L., Rehm, J., et al. (2013), Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010, The Lancet, 382(9904): 1575–1586. Whiteford et al. (2013), ibid. WHO (2014), Preventing Suicide: A Global Imperative. Available at: apps.who.int/iris/bitstream/ 10665/131056/1/9789241564779_eng.pdf. See, e.g., Walker, E. R., McGee, R. E., & Druss, B. G. (2015), Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis, JAMA Psychiatry, 72(4): 334–341. Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2110027. For more on the effects of psychotropic medication, see Chapter 17 of this book by Peter Lehmann. For a consideration of international monitoring systems intended to protect against human rights abuses, see Chapter 20 of this book by Laura Davidson. Bloom, D. E., Cafiero, E. T., Jané-Llopis, E., et al. (2001), The Global Economic Burden of Noncommunicable Diseases (Geneva: World Economic Forum). See further Chapter 3 of this book by Martin Knapp and Victoria Iemmi, and Chapter 4 by Judith Bass. See para.39 of the Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, UN Report A/HRC/35/21 to the Human Rights Council, 35th session, 6–23 June 2017 (28 Mar), pp.5–6, Agenda item 3. Available at: documents-dds-ny.un.org/ doc/UNDOC/GEN/G17/076/04/pdf/G1707604.pdf?OpenElement. See also the report by the World Bank Group and the WHO (2016), Out of the shadows: making mental health a global development priority. Available at: documents.worldbank.org/curated/en/270131468187759113/pdf/105052-WPPUBLIC-wb-background-paper.pdf. Patel, V., Boyce, N., Collins, P. Y., et al. (2011), A renewed agenda for global mental health, The Lancet [online], 22 Oct, 378(9801): 1441–1442.

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only 0.5% spent in low income countries.13 Even the World Health Organization (WHO), with its remit to protect global health and co-ordinate international health work,14 devotes only a tiny fraction of its budget to mental health.15 Major investment is crucial to strengthen mental health systems.16 Furthermore, the treatment gap between rich and poor is stark, and often a privilege of the wealthy, who have 50 times greater access to mental health care.17 Health insurance frequently excludes or limits coverage for mental illness, thereby exacerbating impoverishment or leaving the most vulnerable untreated.

The parameters of the right to mental health In an era of cavernous health inequalities, the rights approach has not gained the traction it deserves. Is the right to health readily identifiable? The WHO’s definition of ‘health’ is an aspirational ‘right’ that is virtually impossible to achieve: ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.18 In 2010 the European Community stated that a ‘right to health’ has ‘no single definition. It is about worldwide improvement of health, reduction of disparities, and protection against global health threats’.19 Without an agreed definition, is it meaningless? How might the right to health be given conceptual and normative clarity, thereby becoming an identifiable, operational, justiciable and enforceable human right? Is there a separate right to mental health, rather than a general right to health which includes, but does not guarantee or prioritise, mental health?

13 WHO (2003), Investing in Mental Health (Geneva: WHO), p.38; WHO (2013), Investing in Mental Health: Evidence for Action (Geneva: WHO), p.15. 14 See Article 55, Charter of the United Nations, which entered into force on 24 Oct 1945. The most recent version of the Constitution is the 45th edn (Supp), Oct 2006. Available at: www.who.int/governance/ eb/who_constitution_en.pdf. For more consideration of the WHO, see Chapter 1 of this book by Shekhar Saxena and Laura Davidson. For an in-depth discussion of the WHO’s origins, including its founding ideals, core functions, normative powers, and governing structures, as well as internal institutional tensions, see L. O. Gostin (2014), Global Health Law (Cambridge: Harvard University Press), Chapter 4. 15 The WHO’s approved Programme budget for it in 2018–2019 was US$47 million; only just over a quarter of the budget for NCDs, and a tiny fraction of the approved overall budget of US$4,421.5 million. Available at: https://apps.who.int/iris/bitstream/handle/10665/272406/WHO-PRP-17.1-eng.pdf ? sequence=1&isAllowed=y. 16 See, e.g., Chisholm, D., Sanderson, K., Ayuso-Mateos, J. L., & Saxena, S. (2004), Reducing the global burden of depression: population-level analysis of intervention cost-effectiveness in 14 world regions, Br J Psychiatry, 184: 393–403. Available at: doi.org/10.1192/bjp.184.5.393. See also Eaton, J., McCay, L., Semrau, M., et al. (2011), Scale up of services for mental health in low-income and middle-income countries, The Lancet, 378(9802): 1592–1603. Available at: doi.org/10.1016/S01406736(11)60891-X. 17 See WHO (2015), Mental Health Atlas 2014. Available at: www.who.int/mental_health/evidence/ atlas/mental_health_atlas_2014/en/. See also ‘Mental healthcare 50 times more accessible in wealthy countries’, The Guardian, 20 July 2015. Available at: www.theguardian.com/global-development/ datablog/2015/jul/20/mental-healthcare-world-health-organisation. 18 See the introductory declaration in the WHO Constitution. Available at: www.who.int/governance/ eb/who_constitution_en.pdf. 19 Council of Europe (2010), The EU Role in Global Health, Communication from the commission to the council, the European parliament, the European economic and social committee and the committee of the regions, Brussels, 31 Mar 2010, COM(2010)128 final; SEC(2010)380–382, para.1.

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The right to health is rooted in economic, social, and cultural rights protected by numerous international Conventions. First articulated in the Universal Declaration on Human Rights (UDHR),20 Article 25(1) affirms that [e]veryone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Notably, mental health is not mentioned.21 Indeed, despite the recognition of the right to health in international law for over 50 years, mental health does not feature in most treaties—a major global obstacle to mental health service improvement. Yet, like the mandate of the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, clearly the right to health encompasses both physical and mental health.22 The intersectionality of the right to mental health should also be noted. The 1986 UN Declaration on the Right to Development23 describes that right in its Preamble as a comprehensive economic, social, cultural and political process, which aims at the constant improvement of the well-being of the entire population and of all individuals on the basis of their active, free and meaningful participation in development and in the fair distribution of benefits resulting therefrom.24 The UN International Covenant on Economic, Social and Cultural Rights (ICESCR) is unusual in that it explicitly includes mental health and provides the most comprehensive protection of the right to health in international law.25 Article 12(1) states that everyone has the right to the ‘enjoyment of the highest attainable standard of physical and mental health’.26 General Comment 14 of the ICESCR is the most authoritative statement on the scope and meaning of the right to health.27 It observes that Article 12 embraces a wide range of socioeconomic conditions necessary for healthy lives, including the underlying determinants of health, such as nutrition, sanitation, housing, potable drinking water, safe workplaces and a healthy environment.28 However,

20 Universal Declaration on Human Rights, UN GA RES/217 (III)A, UN Doc.A/810 (adopted 10 Dec 1948). 21 Although ‘disability’ is mentioned generally. 22 Hereafter, ‘the UN Special Rapporteur on health’. The current UN Special Rapporteur, Dainius Pu¯ras, on health has co-authored a chapter of this book; see Chapter 15, also by Julie Hannah. See also his recent report on mental health, Report of the Special Rapporteur, op. cit., nt.11. 23 UN GA A/RES/41/128, UN Declaration on the Right to Development, 4 Dec 1986. The right to development is now within the mandate of several UN bodies. It was first articulated in the 1981 African Charter on Human and Peoples’ Rights, Art.22(1) of which provides that ‘[a]ll peoples shall have the right to their economic, social and cultural development with due regard to their freedom and identity and in the equal enjoyment of the common heritage of mankind’, and insists that ‘[s]tates shall have the duty, individually or collectively, to ensure the exercise of the right to development’. 24 Emphasis added. 25 International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted by UN GA RES/2200A (XXI) of 16 Dec 1966, and entered into force 23 Mar 1976. 26 Emphasis added. 27 Committee on Economic, Social and Cultural Rights (CESR), General Comment No.14 (2000), The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/2000/4, adopted at the 22nd session, 11 Aug 2000. 28 Ibid., para.4.

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a US Court of Appeals decision has described Article 12 as ‘nebulous’, ‘infinitely malleable’, ‘boundless and indeterminate’, and ‘devoid of articulable or discernible standards and regulations’.29 Such breadth and imprecision in a right makes it difficult to implement and enforce. Article 12(1) of the ICESCR demands that states realise the right to health by (inter alia) taking steps to prevent and treat ‘endemic . . . and other diseases, and [ensure] . . . access to medical services for all’, which plainly applies to mental disorders and those suffering from them.30 General Comment 14 explains the normative need for availability, accessibility, acceptability, and quality of care within facilities, medicines, and health services.31 Accordingly,‘availability’ requires sufficient quantities of health facilities, plus access to essential medicines and trained healthcare professionals. For health services to be ‘accessible’, no access barriers such as cost or discrimination must exist; health care should be practically, financially, and geographically obtainable.32 ‘Acceptability’ requires ethical, culturally appropriate, and gender-sensitive health services that meet people’s needs. ‘Quality of care’ means states must provide appropriately trained professionals to run health services of a decent standard.33 Sceptics argue that Article 12(1) only requires the ‘highest attainable’ standard of mental health.34 The right to health is further weakened by the General Committee’s concession that ‘both the individual’s biological and socio-economic preconditions and a State’s available resources’ may be taken into account.35 More importantly, states need only progressively realise the right,36 as exemplified in the approach of the African Commission on Human and Peoples’ Rights in Purohit and Moore v. The Gambia.37 Article 16 of the African ‘Banjul’ Charter states that ‘[e]very individual shall have the right to enjoy the best attainable state of physical and mental health’, with signatory states required to ‘take the necessary measures to protect the health of their people and to ensure that they receive medical attention when they are sick’. In addition to a violation of the right to liberty and security of the person, the Commission found a breach of Article 1638 with respect to psychiatric patients detained at the Royal Victoria Teaching Hospital39 under the Gambia’s Lunatic Detention Act 1917, due to the absence of detention review.40 However, despite emphasising the crucial nature of the right to health, the Commission noted that African countries had significant financial constraints. Thus, regrettably, it interpreted the Charter

29 Flores v. Southern Peru Copper Corporation, 203 F.R.D. 92 (S.D.N.Y. 2001). 30 Art.12(2)(c). Steps required by Art.12(2) largely relate to child health, environmental hygiene, and epidemic control. 31 See para.12. of CESCR General Comment No.14, op. cit., nt.27. 32 In many LMICs in rural communities, the cost of taking public transport to a health centre is prohibitive. 33 General Comment No.14, op. cit., nt.27, para.12(c)–(d). 34 Emphasis added. 35 General Comment No.14, op. cit., nt.27, para.9. 36 This means that states have an unspecified period of time to improve services incrementally in order to protect the right to health. It is a concept created by treaty Committees and the courts, and does not appear in Convention texts. 37 (2003) No.241/2001. 38 The right of people with disabilities to special measures of protection in keeping with their physical and moral needs under Article 18(4) was also found to have been violated. 39 Ironically, in Banjul, where the treaty was signed—The Gambia’s capital city. 40 Further, the Commission reminded the Gambia that psychiatric patients should be accorded special treatment to enable them to reach and sustain their optimum level of independence and functioning, in accordance with Art.18(4) and the (now outdated) MI Principles. It was also held that the legislation violated respect for human dignity as it used dehumanising terminology such as ‘idiots’ and ‘lunatics’ to describe persons with mental illness.

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as merely requiring provision of the maximum available resources—despite the absence of such qualification within Article 16. Although setting the standard too high risks rendering the right to health meaningless, all states, including LMICs, ought to be held accountable by concrete goals and timelines. The Convention on the Rights of Persons with Disability (CRPD) adopts a more robust approach.41 The definition of ‘disability’ in Article 1 clarifies that those with ‘long-term . . . mental, intellectual or sensory impairments’ are included within the scope of its protection.42 Whilst Article 25 protects only the right to ‘the enjoyment of the highest attainable standard of health’,43 states cannot discriminate on the basis of disability.44 Equal quality of service must be ensured, including ‘raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical standards for public and private health care’. This represents a significant parity requirement; a challenge, given that ‘nowhere in the world does mental health enjoy parity with physical health in national policies and budgets or in medical education and practice’, as noted recently by the UN Special Rapporteur on health.45 Article 25 also requires prevention services, prompt diagnosis and intervention, and community service provision. Thus, transferring rural dwellers to a city hub as a first resort would breach the Convention.46 Additionally, Article 25(e) of the CRPD requires states to ensure the availability of affordable health insurance which covers mental disorder.

Strengthening the right to mental health If health is a human right, it must be actionable. Unfortunately, no rigorous international implementation and enforcement obligations exist.47 The majority of outcome measurement indices, treaty reporting systems, and court adjudication processes are voluntary, with many states abstaining. How, then, can accountability improve?

Measuring improvements in the right to health via the SDGs It is noteworthy that the right to health continues to evolve. Further, the inclusion of SDG3 in the new UN Agenda48 (under which states must ‘promote healthy lives and enhance well-being for all at all ages’) has finally brought mental health sharply into focus. Despite the UN’s dogged

41 For an in-depth discussion of the impact of this, see Chapter 20 of this book by Laura Davidson. The CRPD is considered in detail in Part V of this book pertaining to legal perspectives. 42 It is unclear how the phrase ‘long-term’ might be interpreted by a national court in terms of mental disability. 43 Emphasis added. 44 Art.25(a) requires states to ‘provide persons with disabilities with the same range, quality and standard of free or affordable health care and programmes as provided to other persons’. 45 Report of the Special Rapporteur (2017), op. cit., nt.11, para.6. 46 This is common in LMICs where psychiatric care is often only available at the tertiary level. However, high-income countries are not exempt—the UK has been criticised for this very recently: see, e.g., Ben Kentish (2017), ‘Number of mental health patients treated hundreds of miles from home hits new high’, The Independent, 5 Mar. Available at: www.independent.co.uk/news/mental-health-patients-out-ofarea-placements-theresa-may-psychosis-anorexia-schizophrenia-a7611571.html. 47 For a discussion of how to realise rights when violated, see Chapter 21 of this book by Laura Davidson. 48 UN Resolution (2015), op. cit., nt.1.

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avoidance of the words ‘mental health’ in the SDGs and the unnecessarily broad terms of SDG3, states now have a global responsibility to eliminate gross and unconscionable health inequities between the rich and poor, the urban and the rural. Health must be promoted and improved for everyone, but particularly for the marginalised. So how might the new UN Agenda strengthen the right to mental health?

SDG targets The UN Secretary-General’s synthesis report rightly emphasises that implementation, monitoring and evaluation of the SDGs will require ‘[e]nhanced national and international statistical capacities, rigorous indicators, reliable and timely data sets, new and non-traditional data sources, and broader and systematic disaggregation to reveal inequities’.49 Targets set under each goal measure whether states are meeting their SDG commitments. Focused, evidence-based, actionable, and inclusive targets and indicators ought to strengthen the right to health, and evidence its impact on social and economic determinants and development. However, disappointingly, mental health is referred to in only two of the 13 targets under SDG3. Whilst three others are also relevant (targets 3.4, 3.5, 3.850 and 3.b51 and 3.c52 pertaining to the availability of medication, the training of professionals, and universal health coverage), those are all equally applicable to physical health.53 Only target 3.4 is specific to mental illness, requiring states by 2030 to ‘reduce by one third premature mortality from non-communicable diseases through prevention and treatment’ and ‘promote mental health and well-being’. The latter requirement unnecessarily repeats SDG3, rather than setting a specific and concrete aim to help achieve the goal. Disappointingly, no positive target to ensure a healthy life expectancy was included. Decreasing premature mortality is imperative, but reducing disability and improving quality of life are equally important objectives. Target 3.5 requires states to ‘strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol’.54 Although subject to debate,

49 United Nations (2014), United Nations Secretary-General Synthesis Report of the Secretary-General on the Post-2015 Agenda (New York: UN). 50 Target 3.8 requires states to ‘[a]chieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’. This is a particular challenge since traditionally many health insurance policies worldwide have excluded mental health unfairly from coverage. 51 Target 3.b repeats the need to ‘provide access to affordable essential medicines and vaccines . . . and, in particular, provide access to medicines for all’. It is clear that this is already a struggle in LMICs, despite the prevalence of generic medicines in the twenty-first century. Target 3.b is stated as in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which ‘affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-related Aspects of Intellectual Property Rights regarding flexibilities to protect public health’. 52 In accordance with target 3.c, states must ‘[s]ubstantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States’. If this was achieved in the mental health field, it would be a coup—although the word ‘substantially’ is open to interpretation. Further, the difficulties in meeting this target will be exacerbated in LMICs, as professionally trained staff are much more likely to be enticed abroad by higher salaries and better working conditions. 53 See further targets 3.8, 3.b, and 3.c. 54 SDG indicator 3.5.1 relates to ‘[c]overage of treatment interventions (pharmacological, psychosocial and rehabilitation and aftercare services) for substance use disorders’. SDG indicator 3.5.2 concerns

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substance use is defined as a mental illness in the two main psychiatric diagnostic manuals, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association,55 and that of the WHO (the ICD-11).56

The SDG indicators SDG progress requires monitoring by clear indicators that promote multi-sector approaches and inter-SDG integration, along with sustainable funding. There are 241 indicators drafted to help states evaluate improvements in reaching targets.57 A Final List of proposed Sustainable Development Indicators can be found in the Report of the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (the SDG Indicator Report).58 The right to mental health could have been made more explicit and meaningful,59 but, like the targets, the indicators barely refer to mental health. It may be that the lack of global consensus on how best to measure ‘wellbeing’ inhibited the incorporation of additional indicators for SDG3. Only three of 26 indicators under SDG3 pertain to mental health. The only indicator related to mental illness (rather than addiction) is indicator 3.4.2 concerning the population suicide mortality rate. A further five indicators apply both to mental and physical health: 3.5.1 Coverage of treatment interventions (pharmacological, psychosocial and rehabilitation and aftercare services) for substance use disorders 3.5.2 Harmful use of alcohol, defined according to the national context as alcohol per capita consumption (aged 15 years and older) within a calendar year in litres of pure alcohol 3.8.1 Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include . . . non-communicable diseases and service capacity and access, among the general and the most disadvantaged population) 3.8.2 Number of people covered by health insurance or a public health system per 1,000 population

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‘[h]armful use of alcohol, defined according to the national context as alcohol per capita consumption (aged 15 years and older) within a calendar year in litres of pure alcohol’. ‘Addiction’ is not considered a specific diagnosis in the fifth edition of the DSM-5. Updated in 2013, the manual replaced the categories of substance abuse and substance dependence with a single category: ‘substance use disorder’. The symptoms associated with a substance use disorder are of four main types: impaired control, social impairment, risky use, and pharmacological criteria (in other words, tolerance and withdrawal). First drafted in 1994, the new 2018 version has combined ‘substance abuse’ and ‘substance dependence’ so that they are interchangeable, which aligns with the DSM-5. The term ‘disorder’ is used in the classification rather than ‘disease’ and ‘illness’, and describes a clinically recognisable set of symptoms or behaviour generally associated with interference with personal function and distress. Since 9 indicators repeat under several different targets, the actual total number of individual indicators in the list is 230. See E/CN.3/2016/2/Rev.1, Annex IV. Available at: https://sustainabledevelopment.un.org/content/ documents/11803Official-List-of-Proposed-SDG-Indicators.pdf. It is debatable whether or not the SDG targets and indictors are now final or remain flexible. Although the SDG Indicator Report uses the word ‘proposed’ in terms of indicators despite reference to the list being ‘final’, the prevailing view appears to be that there is little likelihood of change at this stage, since the General Assembly would need to adopt such amendments.

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3.b.1 Proportion of the population with access to affordable medicines and vaccines on a sustainable basis 3.b.2 Total net official development assistance to medical research and basic health sectors 3.c.1 Health worker density and distribution

Indicator 3.4.2 Currently, suicide mortality rates are highest in the WHO European Region (14.1 per 100,000 population) and lowest in the WHO Eastern Mediterranean Region (3.8 per 100,000 population).60 However, national data on suicide rates from many countries (particularly LMICs) is often incomplete, inaccurate, or delayed.61 To measure progress towards meeting SDG3 and its targets, indicator 3.4.2 ought to require records not only of completed suicides, but also attempted suicides and self-harm, as recommended in 2014 in the WHO’s first global report on suicide prevention.62 In view of the weak UN monitoring tools, mental health advocates (including those with lived experience) must pressurise governments and seek involvement in tracking progress towards relevant targets and indicators.63 The importance of data collection to improve standards and quality of life for those with mental disability should be emphasised in professional training. The UN, European Union, and Commonwealth Secretariat64 should provide technical assistance to LMICs to help strengthen data systems and build monitoring and evaluation capacity.

Disaggregation The SDG Indicator Report states that the indicators ‘should be disaggregated, where relevant, by income, sex, age, race, ethnicity, migratory status, disability and geographic location, or other characteristics’.65 The words, ‘where relevant’, are unhelpful, since states may take differing views on relevance, complicating data comparison. Furthermore, regrettably the generic term ‘disability’ makes no distinction between mental and physical disability. National data disaggregation by mental disability could prove extremely useful, not least in advocacy. For example, the proportion of the population below the international and national poverty lines

60 WHO (2016), Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2015. Available at: www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html. 61 See, e.g., Hagaman, A. K., Maharjan, U., & Khort, B. A. (2016), Suicide surveillance and health systems in Nepal: a qualitative and social network analysis, Int J Ment Health Syst, 10: 46. Available at: doi. org/10.1186/s13033-016-0073-7. 62 WHO (2014), Preventing Suicide: A Global Imperative, pp.7 and 25–27. Available at: apps.who.int/iris/ bitstream/10665/131056/1/9789241564779_eng.pdf?ua=1&ua=1. 63 Guidance on advocacy is available from the WHO via its QualityRights initiative, which has published 15 key training and guidance materials (see guidance tool ‘Advocacy actions to promote human rights in mental health and related areas’. Available at: www.who.int/mental_health/policy/quality_rights/ guidance_training_tools/en/. 64 For Commonwealth states, a Commonwealth Fund for Technical Cooperation exists at the UK’s Commonwealth Secretariat in London, but access to it is dependent upon state contributions. 65 In accordance with the Fundamental Principles of Official Statistics (UN GA, RES/68/261); see the rubric prior to the list of indicators in the final indicator list, op. cit., nt.58. The Lancet’s Countdown for Global Mental Health initiative may help assist with disaggregation; see further nt.67 below.

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(covered by indicators 1.1.1 and 1.2.1), or the population living in households with access to basic services under indicator 1.4.1 could be disaggregated according to mental disability. As the right to health includes a right to the underlying determinants of health, such data would illuminate where LMICs require support. However, it remains to be seen whether or not states will undertake such disaggregation. Given the weakness of the indicators, the WHO’s more technically rigorous indicators within its NCD and Mental Health Action Plans 2013–2020,66 careful recording of Years of Life Lost (YLDs) and Years Lived with Disability (YLDs), and data collected and published under The Lancet’s new Countdown for Global Mental Health initiative will perhaps enable more precise progress monitoring.67

Strategies for protecting the right to mental health and meeting SDG3 Human resources for health Sufficient human resources are crucial for the delivery of effective treatment. Social support from trained mental health professionals can improve psychosocial disability. However, the worldwide dearth of mental health professionals remains a global health crisis. Trained mental health professionals account for just 1% of the global health workforce. In 2014, the WHO estimated that 45% of the world’s population had less than 1 psychiatrist for 100,000 people.68 Globally, there was an average of only 7.7 mental health nurses per 100,000 population. The reasons for the exacerbation of the global shortage of health care workers working in mental health are multifaceted. Like mental health patients, psychiatric professionals frequently are stigmatised, with nurses sometimes lacking wage parity with those nursing physically ill patients, even in high-income countries.69 Thus, psychosocial specialists are less easy

66 WHO (2013), Global Action Plan for the Prevention and Control of NCDs 2013–2020; WHA (2013), Resolution WHA66.8, ‘Comprehensive Mental Health Action Plan 2013–2020’, 27 May. 67 The WHO’s Mental Health Atlas is used to track progress in the implementation of WHO’s Mental Health Action Plan 2013–2020 As this book was going to Press, The Lancet announced its Countdown for Global Mental Health initiative-an independent, multi-stakeholder monitoring collaboration for mental health. It plans to develop a robust comparative country index, with biennial reports tracking national, regional, and global progress from 2020 to 2030 published in The Lancet. It will work closely with existing Countdowns to ensure the integration of mental health across other global health domains. See further Saxena, S., Kestel, D., Sunkel, C., et al. (2019), Countdown Global Mental Health, The Lancet, 393(10174): 858–859. Available at: www.thelancet.com/journals/lancet/article/PIIS01406736(19)30424-6/fulltext. See also Whiteford, H. A., Ferrari, A. J., Baxter, A. J., et al. (2013), How did we arrive at burden of disease estimates for mental and illicit drug use disorders in the Global Burden of Disease Study 2010?, Curr Opin Psychiatry, 26(4): 376–383. 68 However, it should be noted that out of 194 countries, over a third of the world (69 countries) provided no data: see http://gamapserver.who.int/gho/interactive_charts/mental_health/psychiatrists_nurses/ atlas.html. 69 See, e.g., Morrissette, P. J. (2011), Recruitment and retention of Canadian undergraduate psychiatric nursing faculty: challenges and recommendations, Journal of Psychiatric and Mental Health Nursing, 18(7): 595–601. Available at: doi.org/10.1111/j.1365-2850.2011.01708.x. See also Wells, J. S. G. & McElwee, C. N. (2000), The recruitment crisis in nursing: placing Irish psychiatric nursing in context—a review, Journal of Advanced Nursing, 32(1): 10–18. Available at: doi.org/10.1046/j.1365-2648.2000.01460.x. For a consideration of South Africa, see Jansen, R. (2014), Psychiatric nursing: an unpopular choice, Journal of Psychiatric and Mental Health Nursing, 22(2): 142–148. Available at: doi.org/10.1111/jpm.12138.

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to recruit, and staff shortages in combination with stigma contribute to exceptionally high burnout and attrition rates.70 Further, typically, psychiatrists and psychologists are scarce in rural areas, preferring to reside and work in cities. Yet the right to health demands local health care services. A policy solution might involve the relocation of mid-level mental health workers to more rural areas. Without the support of family and/or community, those posted for lengthy periods may lose enthusiasm or suffer swift burnout, resulting in lacklustre care. Accordingly, hardship placement incentivisation is vital, such as higher salaries, meaningful career development, or the provision of cheap or free family accommodation—perhaps with geographical employment freedom upon successful completion of such service.71

Recruitment policy and global retention strategies There are also worldwide inequalities in the distribution of health care workers. Shortages in human resources for health lead to uneven distribution of staff, gaps in skills and competencies, poor motivation, and low retention.72 Despite frequently having greater health needs, LMICs often suffer most. Indeed, of the 57 countries with critical shortages in 2013, 39 are in Africa, with 25% of the world’s disease burden, yet only 3% of its health workers and 1% of its health financing.73 Of the countries that provided data to the WHO in 2014, Eritrea (with a population larger than Scotland or Norway) and the Marshall Islands had no psychiatrists at all. Afghanistan, Burundi and Tanzania were little better, with only 0.01 per 100,000 people.74 Although also inadequate in comparison with the disease burden, Monaco had 40.98 psychiatrists per 100,000 people, and Norway, 29.69.75 The Maldives had no mental health nurses, with only 0.01 per 100,000 people in Togo.76 Most were in Norway (123.08 per 100,000 people) and France (90.86).77 Clearly, not one state meets the availability requirement extrapolated in General Comment No. 14 on the Article 12 ICESCR right to health. Further, people’s needs cannot be met by insufficient numbers of trained professionals. Such dearths prevent states from meeting the acceptability requirement. Regrettably, there is no SDG indicator demanding the creation of training infrastructure. However, the WHO has adopted several resolutions aimed at universal health coverage and improving equitable access to health professionals, which would also help states meet the SDGs.78 The

70 See, e.g., Davidson, L., Liebling, H., Akello, G. F., & Ochola, G. (2016), The experiences of survivors and trauma counselling service providers in northern Uganda: implications for mental health policy and legislation, Int J of Law and Psych, Part A, Nov–Dec (49): 84–92, at 88. 71 Naturally, this is more difficult for LMICs, where transport costs can be prohibitive, yet arguably the need is greater in rural areas of LMICs. 72 See further Dal Poz, M. R., Quain, E. E., O’Neil, M., et al. (2006), Addressing the health workforce crisis: towards a common approach, Hum. Resour. Health, 4: 21. 73 Gostin (2014), op. cit., nt.14, p.342. 74 Liberia and Niger were little better with 0.02 psychiatrists. Next in line were Laos, Sierra Leone and South Sudan, each with 0.03 psychiatrists per 100,000 people. 75 Belgium had 20.32 psychiatrists per 100,000 people, with 20.10 in The Netherlands. 76 Côte D’Ivoire was close behind with 0.02, and Mali and South Sudan with only 0.08 and 0.09 respectively. 77 Slovenia had 89.56 per 100,000 people, and Australia, 70.91. 78 See also the WHO Global Code of Practice on the International Recruitment of Health Personnel (2010) WHA63.16; Health workforce strengthening (2011), WHA64.6; Strengthening nursing and midwifery (2011) WHA64.7; Transforming health workforce education in support of universal health coverage (2013), WHA66.23; and Follow-up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coverage (2014), WHA67.24. See also Chapter 3 of the WHO Mental Health Atlas 2014 on

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WHO Human Resources for Health Action Framework assists governments in developing and implementing a comprehensive strategy for a sustainable health workforce.79 Six interconnected components for the development of human resources are proposed: policy, health workforce management, finance, education, partnerships, and leadership. Recognising that health specialist shortages in LMICs are exacerbated by migration to richer countries, in 2016 the WHO adopted the Global Strategy on Human Resources for Health: Workforce 2030.80 It promotes international collaboration on ethical recruitment in conformity with the WHO Code of Practice on International Recruitment of Health Personnel.81

Increasing capacity—recruitment and training In view of the human resource health crisis, SDG target 3.c requires the training of health professionals generally, with indicator 3.c.1 focused on worker density and distribution. Naturally, LMICs cannot be expected to provide the same level of care as more developed nations instantaneously.82 However, protecting the right to health and meeting SDG3 are international duties, which, even at their weakest, require progressive realisation and progress. Thus, all states must plan and implement national health policies which fund training for sufficient numbers of psychiatric professionals to ensure adequate countrywide support.83 High-income countries have a responsibility to assist LMICs in this regard. Many such international development partnerships already exist, with specific hospitals or university departments pairing with LMIC counterparts for regular in-country training (sometimes enabling exchange placements in the partner country).84

Human rights training Providing health care of a range, quality and standard equivalent to that for physical disorder requires increased awareness and understanding from health care professionals on ‘the human rights, dignity, autonomy and needs of persons with disabilities’, as the CRPD states.85 Article 25(d) of the CRPD proposes that this be accomplished through ‘training and the promulgation

79 80 81

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funding/human resources. Available at: apps.who.int/iris/bitstream/10665/178879/1/9789241565011_ eng.pdf?ua=1&ua=1. WHO (2006), The World Health Report 2006: Working Together for Health. Available at: www.who. int/whr/2006/whr06_en.pdf. WHO (2016), WHA69.19, 69th World Health Assembly, 28 May. WHO (2010), WHO Global Code of Practice on the International Recruitment of Health Personnel, Resolution WHA63.16, 63rd World Health Assembly, Geneva, 17–21 May, in Resolutions and decisions, annexes, WHA63/2010/REC/1, p.31. On the Code, see further Siyam, A., Zurn, P., Christian Rø, O., et al. (2013), Monitoring the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, Bull World Health Organ, 91(11): 816–823. Available at: doi. org/10.2471/BLT.13.118778. For further discussion about the difficulties inherent in surmounting the resource gap in LMICs, see, e.g., Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007), Resources for mental health: scarcity, inequity, and inefficiency, The Lancet, 370: 878–889. On LMICs, see further Patel, V. (2009), The future of psychiatry in low- and middle-income countries, Psychol Med, 39: 1759–1762. E.g., Butabika National Referral Hospital in Kampala, Uganda has collaborated with East London NHS Foundation Trust in London, UK, since 2004; see further www.butabikaeastlondon.com. Art.25(d).

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of ethical standards for public and private health care’. Such standards should be integrated into training for new recruits, and added to ongoing career development. The WHO has now finalised 16 training and guidance materials under its QualityRights initiative to assist mental health stakeholders in the implementation of a CRPD-compliant human rights and recovery approach.86 These useful materials are freely available to high-income countries and LMICs alike. Six core mental health and human rights modules and four advanced modules (on, for example, supported decision-making and the elimination of seclusion and restraint) complement a service improvement instrument and four guidance tools. An important objective of the WHO QualityRights initiative is to persuade governments to adopt international human rights norms and reform policies, laws, and programmes.87 However, the UN’s 1991 guidance, The protection of persons with mental illness and the improvement of mental health care (known as the MI Principles),88 is now hopelessly out of date. So, too, is the WHO Resource Book on Mental Health, Human Rights and Legislation, drafted prior to the adoption of the CRPD. Due to its non-compliance with the CRPD, it has been withdrawn. To plug this gap, the WHO is currently revamping its mental health legislation guidance to help countries adopt current international human rights norms into domestic legislation. At the date of publication of this book, there was still no indication as to when it might be available. However, this is not an excuse for an impasse by states with no—or inadequately protective—mental health legislation.

Lay support and task-shifting Given the psychiatric expertise gap in LMICs, numerous NGOs have piloted innovative strategies.89 Short-term training and supervision of non-specialist health workers with monitoring by psychiatrists, neurologists, and psychosocial workers can meet mental health need effectively where professionals are either absent (such as in rural communities) or too few.90 For example,

86 WHO, op cit., nt.63. 87 It also seeks to improve quality of mental health care and human rights, create community-based and recovery-oriented services that respect and promote human rights, promote independent living in the community, and to develop a movement of people with mental disabilities to provide mutual support, conduct advocacy, and influence policy-making processes. 88 UN GA, A/RES/46/119, adopted at the 75th plenary meeting, 17 Dec 1991. 89 Kakuma, R., Minas, H., van Ginneken, N., et al. (2011), Human resources for mental health care: current situation and strategies for action, The Lancet, 378: 1654–1663. Available at: www.thelancet.com/ journals/lancet/article/PIIS0140-6736(11)61093-3/fulltext?code=lancet-site. 90 For more on the use of mental health lay workers, see, e.g., V. Patel, D. Chisholm, T. Dua, et al. (2015), Mental, Neurological, and Substance Use Disorders: Disease Control Priorities (3rd edn), Vol.4 (Washington, DC: World Bank); Patel, V., Belkin, G. S., Chockalingam, A., et al. (2013), Grand Challenges: Integrating Mental Health Services into Priority Health Care Platforms, PLoS Med, 10(5): e1001448. Available at: doi.org/10.1371/journal.pmed.1001448. See also van Ginneken, N., Tharyan, P., Lewin, S., et al. (2013), Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries, Cochrane Database Syst, 19 Nov (11): CD009149. Available at: doi.org/10.1002/14651858.CD009149.pub2. In addition, see Araya, R., Rojas, G., Fritsch, R., et al. (2003), Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial, The Lancet, 361: 995–1000; Rojas, G., Fritsch, R., Solis, J., et al. (2007), Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial, The Lancet, 370: 1629–1637; Ran, M. S., Xiang, M. Z., Chan, C. L., et al. (2003), Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia: a randomised controlled trial, Soc Psychiatry Psychiatr Epidemiol, 38: 69–75; and Chatterjee, S., Pillai, A., Jain, S., et al.

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simple case management in rural settings at the primary care level by peer-trained support workers has proved successful in Goa, India,91 and in Rwanda (utilising community health workers).92 Such systems free clinicians to assist with more complex psychiatric cases.93 Another answer to the health worker drought in LMICs is task-shifting (also known as task-sharing),94 defined as ‘delegating tasks to existing or new cadres with either less training or narrowly tailored training’.95 For example, mental health care providers may be employed in various different sectors, or intersectoral collaborations with schools, prisons or other entities introduced. This both improves mental health awareness and ensures accurate and swift detection of mental disorders, triggering referrals and earlier treatment, thereby avoiding chronicity. It also leads to improved follow-up care and overall service delivery. Tools such as the WHO’s mhGAP intervention guidelines on mental, neurological, and substance misuse disorders,96 specifically created for use by such non-specialists in primary or secondary healthcare settings, are an excellent resource. Further, a broader set of workforce categories is likely to facilitate scaling-up mental health care in LMICs. Fulton et al. suggest LMICs take a ‘skill-mix’ rather than a staff-mix approach.97 However, as Kukuma et al. observe, whilst task-shifting seems to be ‘an effective and feasible approach . . . it too will entail substantial investment, innovative thinking, and effective leadership’.98

Research Compared to the size of budgets for equally debilitating physical health problems such as cancer and HIV/AIDS, the amount spent on mental health research globally is paltry. The US’s National

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(2009), Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India, Br J Psychiatry, 195: 433–439. See, e.g., Patel, V., Weiss, H. A., Chowdhary, N., et al. (2011), Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months, The British Journal of Psychiatry, 199(6): 459–466. Available at: doi.org/10.1192/bjp.bp.111.092155. See further Patel, V., Weobong, B., Nadkarni, A., et al. (2014), The effectiveness and cost-effectiveness of lay counsellor-delivered psychological treatments for harmful and dependent drinking and moderate to severe depression in primary care in India: PREMIUM study protocol for randomized controlled trials, Trials, 15: 101; and Shinde, S., Andrew, G., Bangash, O., et al. (2013), The impact of a lay counselor-led collaborative care intervention for common mental disorders in public and private primary care: a qualitative evaluation nested in the MANAS trial in Goa, India, Social Science & Medicine, 88: 48–55. See, e.g., Condo, J., Mugeni, C., Naughton, B., et al. (2014), Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives, Hum Resour Health, 12: 71. Available at: doi.org/10.1186/1478-4491-12-71. For consideration of strategies to counter lack of human resources in relation to mental health in LMICs, see, e.g., Saraceno, B., van Ommeren, M., Batniji, R., et al. (2007), Barriers to improvement of mental health services in low-income and middle-income countries, The Lancet, 370(9593): 1164–1174. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61263-X/fulltext. See Chapter 4 of this book by Judith Bass for a discussion of how the task-sharing model has expanded and improved upon the task-shifting approach. Fulton, B. D., Scheffler, R. M., Sparkes, S. P., et al. (2011), Health workforce skill mix and task shifting in low income countries: a review of recent evidence, Hum Resour Health, 9: 1. See also Chapter 4 of this book by Judith Bass, Chapter 6 by Sean A. Kidd and Kwame MacKenzie, Chapter 11 by Cornelius Ani and Olayinka Omigbodun, and Chapter 12 by Stephen J. Bartels. WHO (2010), mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Nonspecialized Health Settings: Mental Health Gap Action Programme (mhGAP) (Geneva: WHO). Ibid. Kakuma, R., Minas, H., van Ginneken, N., et al. (2011), Human resources for mental health care: current situation and strategies for action, The Lancet, 5 Nov, 378(9803): 1654–1663.

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Institute of Mental Health (NIMH) is the largest mental health research funder in the world, yet its 2015 budget for research was on a par with that of 1999.99 In the UK, no research charity with an exclusive mental health research remit even existed until as recently as 2008.100 However, the dearth of research and investment in mental health cannot be blamed on its intractability or the complexity of the brain, since HIV/AIDS also affected a vulnerable, marginalised, and unfairly stigmatised community, and seemed equally obdurate. Yet by 2011, unprecedented scientific progress due to research commitment meant that the seemingly unstoppable 1980s HIV/AIDS epidemic had been almost eradicated in only two decades. Indeed, a newly diagnosed 20-year-old who receives treatment is now likely to live another 50 years.101 Presently, complete understanding of the aetiology of mental illness is a distant hope. However, both SDG3 and the need for the progressive realisation of the right to mental health demand that states invest in scientific research. Although there are some affordable and efficacious prevention and treatment interventions in existence,102 new innovations remain vital. Despite the frequent call for evidence-based research on effective treatments in LMICs, little has been undertaken on culturally appropriate mental health interventions;103 in the words of the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health in 2017, ‘[t]he scaling-up of care must not involve the scaling-up of inappropriate care’.104 Additionally, the world’s many ineffective treatments and inefficient models of care must not be replicated in LMICs. Furthermore, treatments developed and effective in high-income countries do not necessarily translate well into LMICs. For example, most research on post-traumatic stress disorder (PTSD) occurred in high-income countries’ military populations. Virtual reality headsets have been shown to

99 For a critique of this funding gap, see the Post by Former NIMH Director Thomas Insel (2015), Funding Science, 23 Jan. Available at: www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/fund ing-science.shtml. 100 Mental Health Research UK, which was co-founded by Laura Davidson, one of the co-authors of this chapter. A subsequent UK charity, MQ: Transforming Mental Health, was founded in 2013, with initial funding from the Wellcome Trust. Whilst it has a similar remit, it funds research projects globally (unlike Mental Health Research UK, which seeks to capacity-build research within the UK). 101 See, e.g., May, M. T., Gompels, M., Delpech, V., et al. (2014), Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy, AIDS, May, 28(8): 1193–1202. For more on the lessons mental health should take from the successful battle against HIV/ AIDS, see Gostin, L. O. (2015), A Tale of Two Diseases: Mental Illness and HIV/AIDS, Milbank Q, Dec, 93(4): 687–690. Available at: doi.org/10.1111/1468-0009.12161. 102 See, e.g., Patel, V., Simon, G., Chowdhary, N., et al. (2009), Packages of care for depression in lowand middle-income countries, PLoS Med, 6(10): e1000159. Available at: doi: 10.1371/journal. pmed.1000159. See also Tol, W. A., Barbui, C., Galappatti, A., et al. (2011), Mental health and psychosocial support in humanitarian settings: linking practice and research, The Lancet, 378(9802): 1581–1591. Available at: www.ncbi.nlm.nih.gov/pubmed/22008428. In addition, see Chisholm, D., Lund, C., & Saxena, S. (2007), Cost of scaling up mental healthcare in low- and middle-income countries, Br J Psychiatry, 191: 528–535. Available at: doi.org/10.1192/bjp.bp.107.038463. See further Chisholm, D. & Saxena, S. (2012), Cost effectiveness of strategies to combat neuropsychiatric conditions in sub-Saharan Africa and South East Asia: mathematical modelling study, BMJ, 344: e609. Available at: doi.org/ 10.1136/bmj.e609. 103 For a consideration of traditional healing and cultural approaches in the contexts of Bhutan and the native American Indian population, see Chapter 7 of this book by Joseph D. Calabrese. 104 See the Report of the Special Rapporteur (2017), op. cit., nt.11, para.55. See also para.77, where caution is urged against LMICs following the lead of high-income countries, which have ‘[t]he largest concentration of mental hospitals and beds separated from regular health care’.

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reduce PTSD symptoms105—an entirely impractical treatment for resource-strapped, post-conflict in possession of neither the necessary funds nor the energy sources in rural areas of great need.106

Multilateral cooperation Massive global social, economic, and political changes over numerous decades have resulted in transnational health hazards beyond the field of health care.107 Increasing industrialisation and urbanisation are causing serious environmental issues. Migration, international drug trafficking, and international corporations selling tobacco, food, and medicine all influence health. Today, multilateral cooperation in the field of public health is essential. Cooperation on the right to health is an international legal obligation now set out in SDG17, thus reinforcing the responsibility of commitment to global partnerships.108 The international community rallies upon a natural disaster or conflict when,‘in both the relief and recovery stages, international support must include psychosocial support to strengthen resilience in the face of enormous adversity and suffering’.109 Whilst such crises provide a unique opportunity to scale up care to affected populations,110 collaborations between LMICs and wealthier states with global development budgets to respect, protect, and fulfil the right to mental health are just as necessary during peace and stability. A systemic approach is needed. Wealthy nations should help fund research into culturally appropriate evidence-based interventions and assist in cost-effectiveness, affordability and feasibility analysis to inform scale-up prioritisation of the most promising strategies, as various targets under SDG17 require.111 Further, to aid research and policy-making, mental health funding and the effect of development activities on mental illness (both positive and negative) should be tracked.112

Public-private partnerships Major international organisations and partnerships exist for infectious diseases, such as UNAIDS, the Global Fund, and the GAVI Alliance. Yet, there is no single equivalent international agency or public-private partnership devoted to ending mental illness. At least there is now a funding stream. Valuable lessons can be gleaned from the global fight against HIV/AIDS, where networks of funders, researchers, clinicians, and patients shared information that led to standardised care protocols created by international working groups, civil society, and UNAIDS.113 The remarkable advances in funding, care, and rights in the HIV/AIDS sphere were due in large part to powerful mobilisation by civil society groups.

105 See, e.g., Lake, J. (2015), The integrative management of PTSD: a review of conventional and CAM approaches used to prevent and treat PTSD with emphasis on military personnel, Advances in Integrative Medicine, 2: 13–23. 106 Furthermore, the virtual reality scenes developed for the western military are unlikely to resonate or assist in the recovery of civilian LMIC populations. 107 The UN General Assembly deliberated upon such issues when considering the post-2015 Agenda. 108 SDG17 requires states to ‘[s]trengthen the means of implementation and revitalize the global partnership for sustainable development’. 109 See Report of the Special Rapporteur (2017), op. cit., nt.11, para.39. 110 Tol et al. (2011), op. cit., nt.102. 111 See, e.g., targets 17.2, 17.3, 17.6. 17.9, 17.14, 17.16, 17.18 and 17.19. 112 See, e.g., Lund, C., De Silva, M., Plagerson, S., et al. (2011), Poverty and mental disorders: breaking the cycle in low-income and middle-income countries, The Lancet, 378(9801): 1502–1514. Available at: www.ncbi.nlm.nih.gov/pubmed/22008425. 113 Similar networks exist in vaccine and contraception research.

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Happily, several global mental health initiatives have been launched more recently. The US National Institute for Mental Health ‘Grand Challenges in Global Mental Health’ initiative supports a new generation of research. Grand Challenges Canada also has a global mental health programme which provides funding to improve treatments and expand access to care via six goals.114 The initiative invested Can$42 million in 85 projects in 31 countries in 2016–2017.115 The Movement for Global Mental Health116—a network aimed at improving services worldwide (particularly in LMICs) for those with psychosocial disabilities via scientific evidence and human rights—had its genesis in 2007. Its online platform enables idea-sharing amongst 200 institutions and 10,000 individuals.117 Very recently, The Lancet unveiled its Countdown Global Mental Health initiative, described as an independent, multi-stakeholder monitoring collaboration for mental health, within an initial timeframe of the UN SDGs. It aims to increase accountability and decrease population-level disparities for mental health by developing a country comparison index. It has partnered with the WHO, Global Mental Health at Harvard, the Global Mental Health Peer Network, and United for Global Mental Health (UnitedGMH) – a major new civil society organisation founded in late 2018 which aims to mobilise political and financial resources for mental health worldwide.118 Such collaboration is key to making the right to mental health meaningful, and in meeting not only SDG3, but also SDG1 which seeks to ‘end poverty in all its forms everywhere’.

State commitment The breadth of the right to health requires governments to assure both quality mental health services and the determinants of good mental health. The concept of progressive realisation does not apply to some international freedoms and core obligations and thus must be implemented immediately, such as the elaboration of a national public health strategy and non-discriminatory access to services.119 Under international law, states must eliminate discrimination against those with psychosocial disabilities and ensure they are treated with dignity. This is also specified in

114 This is separate from the Grand Challenges in Global Mental Health Initiative. Its six goals are to (i) provide effective and affordable community-based care; (ii) develop treatments for use by nonspecialists; (iii) improve children’s access to evidence-based care; (iv) reduce cost and improve supply of medication; (v) integrate screening and services into primary care; and (vi) develop mobile and IT technologies. It supports the online Mental Health Innovation Network, which facilitates the development and uptake of effective mental health innovations by enabling learning, enhancing linkages, disseminating knowledge and leveraging resources. 115 For further information see: www.grandchallenges.ca/programs/global-mental-health/. 116 It began with a Call for Action published in the first Lancet series on global mental health. It is a network of individuals and organisations that aim to improve services for those with mental health issues and psychosocial disabilities worldwide, especially in LMICs, through scientific evidence and human rights. 117 The Movement’s organisation is the joint responsibility of the Secretariat based at the South African Federation for Mental Health, and an international Advisory Board has a mandate through the Movement’s Charter. 118 The Countdown initiative will work closely with existing Countdowns to ensure the integration of mental health across other global health domains. See further nt.67 above. For a considered approach to mental health collaboration published as this book was going to press, see Vigo, D. V., Patel, V., Becker, A., et al. (2019), A partnership for transforming mental health globally, The Lancet, 6(4): 350–356. Available at: www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30434-6/ fulltext#articleInformation. 119 Committee on Economic, Social and Cultural Rights, General Comment No.14 (2000) on the right to the highest attainable standard of health, paras.43–45.

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SDG16, with target 16.b requiring states to ‘[p]romote and enforce non-discriminatory laws and policies for sustainable development’. A multifaceted approach is necessary, involving national interdisciplinary and multi-sectoral collaborations amongst government ministries, researchers, NGOs, health professionals, patients, caregivers, and local communities. However, providing a basic mental health service package globally would require six to eight times more investment than currently—an estimated US$6.6 to US$9.33 billion in lower middleincome countries, and approximately US$1.6 billion in low-income countries.120 Proposed action number 36 of the WHO’s Mental Health Action Plan 2013–2020121 requires states to ensure ‘a budget across all relevant sectors that is commensurate with identified human and other resources required to implement agreed-upon evidence-based mental health plans and actions’. Whilst a sound intention, how is this achievable in countries with pitiful and/or no ring-fenced mental health budgets? Despite the WHO’s history, enormous expertise, and broad remit,122 surprisingly, it has had little influence in ensuring respect for the right to mental health. Its resources are ‘entirely incommensurate with the scope and scale of global health needs’.123 In 2010 the WHO had a US$300 million deficit. Its two year US$4 billion budget fell sharply from 2010 to 2012, and then did not increase until 2016. A non-mandatory ‘assessed contribution’ was requested from member states, with the balance (77%) from voluntary contributions provided by the wealthiest states and foundations. Pledges varied as much as 30%.124 More recently, the WHO’s limited funds have been spent on emergencies such as humanitarian disasters, SARS (severe acute respiratory syndrome), and the Ebola outbreak. Despite the contemporaneity of the latter, few states provided additional funding for the new Health Emergencies Programme. Such a non-enforceable funding model was wholly inadequate for the global age. Fortunately, member states voted in favour of major modernising budgetary reforms in May 2013, and now there are fixed voluntary contributions, rather than pledges.125 This may ensure that the WHO has more influence upon its member states. However, the WHO itself has failed to prioritise mental health. Indeed, the WHO’s budget for mental health and substance abuse in 2018–2019 was a paltry US$4.7—an increase of only US$1 million from 2016–2017—compared to US$351.4 million earmarked for the NCD category as a whole.126

120 Gilbert, B. J., Patel, V., Farmer, P. E., et al. (2015), Assessing Development Assistance for Mental Health in Developing Countries: 2007–2013, PLoS Med, 12(6): e1001834. Available at: doi.org/10.1371/ journal.pmed.1001834. 121 WHO (2013), op. cit., nt.66. 122 According to Gostin, ‘the WHO is the only institution with the legitimacy to rationalize global health funding and activities and to advocate for health in the trade, intellectual property, and environmental sectors’; see Gostin (2014), op. cit., nt.14, p.127. 123 Ibid. 124 See Butler, D. (2013), Agency gets a grip on budget, Nature, 6 June, 498(7452): 18–19. Available at: doi.org/10.1038/498018a. Another innovation was an ability to move up to 5% of one budget line to another, providing flexibility in addressing unforeseen needs. 125 The WHO’s total Programme budget 2018–2019 represented an increase of US$81 million from that of 2016–2017, but a reduction of US$24.6M for NCDs. Available at: apps.who.int/gb/ebwha/ pdf_files/WHA70/A70_7-en.pdf?ua=1. 126 WHO (2017), Programme Budget 2018–2019, WHO/PRP/17.1. Available at: https://apps.who.int/ iris/bitstream/handle/10665/272406/WHO-PRP-17.1-eng.pdf?sequence=1&isAllowed=y.

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Suicide prevention strategies To meet SDG indicator 3.4.2, the systematic implementation of suicide prevention strategies is crucial,127 yet at present such strategies exist in only 28 countries worldwide.128 As the WHO extols, policies should emphasise early identification and treatment of both mental disorders and substance use disorders, with input from both health and social sectors, from ministerial to community level.129 Accessible psychosocial support and rehabilitation must be provided by doctors, nurses and mental health professionals who have received suicide training.130 Firearms, hanging, and pesticide poisoning are the most common methods used for suicide globally.131 Gun control laws must be tightened. Seventy-five per cent of suicides occur in LMICs, where widespread agriculture and subsistence farming make pesticides widely available.132 Restricting ease of access can reduce impulsive suicide attempts arising from crisis.133 In Guyana, which had the highest suicide rate in the world in 2012134 (five times higher than the world average),135

127 For further information on suicide prevention, see WHO (2014), Preventing Suicide: A Global Imperative. Available at: www.who.int/mental_health/suicide-prevention/world_report_2014/en/. See also WHO (2016), Preventing suicide: a community engagement toolkit. Available at: https://apps.who. int/iris/handle/10665/272860 128 WHO (2014), op. cit., nt.5. 129 Ibid., pp.8–9. 130 Regarding the high suicide rate in men, see Chapter 9 of this book by Svend Aage Madsen, and particularly the section on the Men’s Shed movement. 131 WHO (2014), op. cit., nt.5, p.7. 132 Ibid., p.11. The proportion of pesticide suicides amongst all suicides is over 60% in Guyana, Dominica, El Salvador, Honduras and Suriname); see further WHO (2016), Safer Access to Pesticides for Suicide Prevention: Experiences from Community Interventions, WHO/MSD/MER/16.3, p.6. Available at: www. who.int/mental_health/suicide-prevention/pesticides_community_interventions/en/. According to a systematic review, fatal pesticide self-poisoning is also a method of suicide in some African countries; see Gunnell, D., Eddleston, M., Phillips, M. R., & Konradsen, F. (2007), The global distribution of fatal pesticide self-poisoning: a systematic review, BMC Public Health, 7: 357. Available at: doi. org/10.1186/1471-2458-7-357. See also WHO (2016), Safer Access to Pesticides for Suicide Prevention: Experiences from Community Interventions, WHO/MSD/MER/16.3. Available at: www.who. int/mental_health/suicide-prevention/pesticides_community_interventions/en/. 133 WHO (2014), op. cit., nt.5, p.11. See also Deshpande, R. S. (2002), Suicide by farmers in Karnataka: agrarian distress and possible alleviatory steps, Economic and Political Weekly, 37(26): 2601–2610; and WHO (2016), Safer Access to Pesticides for Suicide Prevention: Experiences from Community Interventions, WHO/MSD/MER/16.3, pp.8–23, which discusses a pilot study of the use of lock boxes in suicide prevention in China, India and Sri Lanka. Available at: www.who.int/mental_health/ suicide-prevention/pesticides_community_interventions/en/. 134 Guyana has 44.2 suicides per 100,000 people compared to a global average of 16, and has an estimated 1,500 to 2,000 attempted suicides annually, or about one attempt every five hours. Only one out of every four suicides is carried out by a woman, and most are in the age 15 to 34 bracket. 135 The head of psychiatry at Georgetown Public Hospital estimated that for each successful suicide, there were up to 25 more attempted cases. See further G. Handy (2016), ‘How Guyana is trying to combat its high suicide rate’, BBC News, 16 Oct. Available at: www.bbc.com/news/worldlatin-america-37618854.

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pesticide lock boxes have been introduced with some success.136 Responsible media reporting also has a role to play in decreasing suicide.137

A global health convention A right to health lacking clarity hinders accountability. How might the global community forge a more meaningful right, particularly when international treaty bodies and courts promulgate the concept of progressive realisation? The WHO, with a mandate and powers to draft health Conventions,138 has the global influence to persuade states to opt into a new framework treaty incorporating the right to the highest attainable standard of physical and mental health. This would help states not only to meet SDG3, but also to bring clarity to norms and standards surrounding the right.139 Legal and policy implementation and analysis could improve health equity and justice across all socioeconomic groups. State accountability via mandatory monitoring, reporting and enforcement mechanisms through domestic judicial systems would empower citizens to claim their right to health. An ambitious treaty could require positive social determinants within every environment, including the most remote and impoverished communities. For example, it might demand quality health care and treatment, access to a nutritious diet, safe drinking water, and a healthy environment (including clean air). An enforceable duty could ensure economic and social conditions conducive to good health, such as employment, safe work environments, decent housing, income support, and gender equality. Importantly, a responsibility to build capacity to fulfil the right to health would require adequate funds to be ring-fenced. A treaty could boost confidence in national governments through the incorporation of high standards of good governance, involving inclusive participation, transparency, anti-corruption strategies, accountability, and stewardship. This would encourage high-income countries to increase commitment to help overcome challenges in global governance for health. Conversely, increased national investment in health would be more likely in states confident of international financing, leading to a more genuinely equal partnership. Instead of a profitability model, incentives could be provided for research and development based on global health needs with flexibility to adapt global standards to local priorities, systems and knowledge, ensuring local ownership and accountability.140

136 Personal communication between the Ambassador to Guyana (Frederick Hamley Case) and Laura Davidson, Nov 2016. See also Farahnaz Mohammed (2015), ‘Guyana: mental illness, witchcraft, and the highest suicide rate in the world’, The Guardian, 3 Jun. Available at: www.theguardian.com/global-de velopment-professionals-network/2015/jun/03/guyana-mental-illness-witchcraft-and-the-highestsuicide-rate-in-the-world. The WHO’s 2016 suicide rates for Lithuania and Russia slightly surpassed that of Guyana. See further, http://apps.who.int/gho/data/node.main.MHSUICIDE?lang=en. 137 The WHO has published suicide prevention guidance: see WHO (2014), Preventing Suicide: A Global Imperative. Available at: www.who.int/mental_health/suicide-prevention/exe_summary_english. pdf?ua=1. 138 For more on the powers of the WHO see Chapter 1 of this book by Shekhar Saxena and Laura Davidson. 139 See Gostin, L. O, Friedman, E. A. Buse, K., et al. (2013), Towards a framework Convention on global health, Bulletin of the World Health Organization, 91: 790–793. Available at: dx.doi.org/10.2471/ BLT.12.114447. See also Friedman, E. A., Gostin, L. O., & Buse, K. (2013), Advancing the right to health through global organizations: the potential role of a framework Convention on global health, Health Hum Rights, 15: 71–86. 140 For discussion of several innovative approaches to mental health care and treatment in LMICs, see Chapter 6 of this book by Sean A. Kidd and Kwame McKenzie.

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There is already a broad civil society movement for a Framework Convention on Global Health.141 Advancing a rights-based approach to global mental health could be transformative. Partnering with national stakeholders to highlight in-country health needs, an international body—perhaps akin to the Intergovernmental Panel on Climate Change—could be mandated to modernise treaty norms and standards where necessary. Such a Convention could adjust in the future to new international structures and changes in the global burden of disease.

Conclusion Inaction and indifference to improving mental health services have always been inexcusable, and the UN must take some responsibility for its regrettable MDG focus on physical health alone. Almost 20 years on, mental disabilities continue to affect us all individually, nationally, and globally. It is abundantly plain that there can be no health without mental health.142 The need to include mental health in the UN’s new goals was compelling. However, the disappointingly lacklustre focus on mental health encourages continued non-prioritisation by governments. The tools for ensuring monitoring, evaluation and, more importantly, the achievement of improved wellbeing under SDG3 are hopelessly flawed. Neither the current SDG3 targets nor the indicators adequately set out steps required to improve mental health. The UN’s belligerent failure to include mental health in clear terms in the SDGs was another missed opportunity which cannot have been by chance. Did stigma and perceived intractability dissuade UN actors from including the term? Was the comparative weakness of mental health advocacy compared to that of other sectors a factor? This book is an attempt to counterbalance the failure. More positively, the inclusion of SDG3 within the new UN Agenda creates a global duty to tackle the misery caused by mental disorder and its enormous burden.143 It is time that the right to health was taken seriously as an international responsibility binding on all countries. As Patel et al. advocated in 2011, 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,144 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’.145 In the words of the UN Special Rapporteur on health, the global community must ‘harness the momentum of the 2030 Agenda to address mental health’. In 2017, the UN High Commissioner for Human Rights called for the integration of a human rights perspective in mental

141 The Framework Convention on Global Health Alliance (FCGHA). More information available at: www.fcghalliance.org/. See also Gostin, L. O. & Friedman, E. A. (2013), Towards a Framework Convention on Global Health: A Transformative Agenda for Global Health Justice, Yale J. Health Policy, Law & Ethics, 13(1): 1–75. Available at: http://ssrn.com/abstract=2273749. Further argument can be found in Gostin, L. O., Friedman, E. A., Buse, K., et al. (2013), Towards a Framework Convention on Global Health, WHO Bulletin, 91(10): 790–793. Available at www.who.int/bulletin/volumes/ 91/10/12-114447.pdf. 142 See, e.g., Prince, M., Patel, V. Saxena, S., et al. (2007), No Health Without Mental Health, The Lancet, 370(9590): 859–877. Available at: dx.doi.org/10.1016/S0140-6736(07)61238-0. 143 The global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level, 65th World Health Assembly, WHA65.4, 25 May 2012. 144 Drew, N., Funk, M., Tang., S, et al. (2011), Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis, The Lancet, 378(9803): 1664–1675. Available at: doi. org/10.1016/S0140-6736(11)61458-X. 145 Kleinman, A. (2009), Global mental health: a failure of humanity, The Lancet, 374: 603–604.

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health, and the realisation of those rights,146 questioning whether or not the current approaches to mental health, which use a biomedical model involving a vast power imbalance, are supported by evidence, medical ethics, and human rights. Those with psychosocial disability (and serious mental disorders particularly) bear a disproportionate burden of human rights abuses, and must be empowered to live lives of dignity. As recently highlighted, the right to quality mental health ‘compels going beyond the idea of users as mere recipients of care towards their full consideration as active holders of rights’.147 Efficient systems and institutions staffed by highly trained, empathetic professionals respectful of human rights must be the worldwide norm. Governments committed to health and good governance strategies are a prerequisite for making the right to mental health meaningful. To scale up mental health care, significant budgetary, systemic and human resources are required.148 Naturally, domestic law and policy must ensure the enforceability of the right. The WHO has an important role in persuading states to take their commitment to SDG3 and the protection of the right to mental health seriously. It must embrace a renewed monitoring role, admonishing country failures in adhering to Conventions, Recommendations, annual reporting requirements, and even soft law. Such obligations and the quest for global social justice in mental health would be greatly enhanced by the adoption of a binding international framework Convention on global health. Will the WHO use its mandate? The new Director-General of WHO, Dr Tedros Adhanom Ghebreyesus,149 began his five-year term on 1 July 2017. It remains to be seen whether or not he has the courage, with the WHO behind him, to fill the gap created by the weak SDG target and indicator process. The right to health and SDG3 both demand increased research capacity to develop better, culturally appropriate, evidence-based mental health interventions. Innovation through online and in-country collaborations should be embraced. The provision of robust research, training and capacity-building support to LMICs from high-income countries can help both the supporting and supported countries to meet their SDG3 obligations, thereby upholding the right to the highest attainable standard of health. International collaborations and intersectoral multistakeholder discussions are essential at all stages. Public-private partnerships should be developed and nourished. States must appreciate the importance of accurate data, and disaggregate it according to mental disability to illuminate where expert support is required. All mental health stakeholders must come together to invest in social and economic rights that protect the international right to health, improve global mental health, narrow worldwide health inequities, ensure healthy lives, and promote wellbeing for all at all ages.150

146 See Report of the Special Rapporteur (2017), op. cit., nt.11. 147 Ibid., para.61. 148 Patel, V., Boyce, N., Collins, P. Y., et al. (2011), A renewed agenda for global mental health, The Lancet, 378 (9801): 1441–1442. 149 Elected by the World Health Assembly on 23 May 2017. 150 Gostin (2014), op. cit., nt.14, p.72.

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PART II

Economic perspectives

C\ Taylor & Francis �-

Taylor & Francis Group

http://taylora n dfra ncis.com

3 MEETING SDG3 The role of economics in mental health policy Martin Knapp* and Valentina Iemmi†

Introduction In today’s global world, economic issues are of the utmost importance—even more so than previously. There is a pervasive scarcity of resources worldwide. Mental health has often lost out in battles to access those scarce resources, particularly in low- and middle-income countries (LMICs). This chapter will focus on four specific aspects. It will discuss the relationship between mental health issues and economic performance, with effects such as unemployment, work absenteeism, education disruption (consequently affecting human capital) and economic growth. The ways in which economic considerations can affect mental health and wellbeing will be explored, including the effect of poverty, unemployment and unsecured debt on common mental disorders. Given that resources are in scarce supply, it is also necessary to analyse economic evaluation methodology, such as the tools available to assess cost-effectiveness. Finally, using several case studies, the chapter will explore how various methods can inform decision-makers, and particularly those in LMICs, in order to help them meet relevant Sustainable Development Goals (SDGs) in the mental health context.

Why are economic issues important? Most mental health problems are complicated and distressing. They have negative consequences for individuals who are unwell, as well as for their families, their peers at school, college or work, employers and in wider society. They can cause temporary or permanent incapacity, abject misery, self-loathing and personal shame, and lead to public stigma and discrimination in many different settings. They can prompt violent behaviour, self-harm and suicidal ideation,1 leading societies to impose restrictions on individual liberty because of assumed or confirmed risks to

* Martin Knapp is Professor of Social Policy and Director of the Personal Social Services Research Unit based in the Department of Health Policy at the London School of Economics and Political Science. † Valentina Iemmi is a Research Fellow in the Personal Social Services Research Unit, based in the Department of Health Policy at the London School of Economics and Political Science. 1 For statistics on suicide and self-harm, see Chapter 1 of this book by Shekhar Saxena and Laura Davidson.

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these individuals themselves, or to others. They are associated with poor health behaviours and premature mortality.2 There may also be some positives: mental illnesses may give people new insights, help them to embrace change, and may even energise them.3 Overwhelmingly, however, the negatives outweigh any positives. These wide-ranging and largely deleterious consequences make mental illness appear ‘expensive’ in the sense that scarce resources must be devoted to respond to them, often over long periods. As a result, decision-makers controlling health care and other budgets often look for ways to reduce these resource impacts, with careful thought about how to deploy resources in order to meet needs associated with mental illness or, better still, how those needs can be prevented from emerging in the first place. Evidence from economic evaluations help decision-makers think through the options. When considering whether a health care intervention warrants support, the core ‘clinical’ question is whether it reduces symptoms or improves functioning. The equivalent for preventive strategies is whether the target illness is prevented or its impact lessened. If one were to adopt a recovery focus,4 the equivalent question would be the degree to which personally defined goals have been achieved, whether in terms of objective indicators of social roles or subjective indicators of personal goals. However, resources are always scarce, so decision-makers will face a second question: are the resources employed to deliver the intervention or strategy justified by the effects (outcomes) that are achieved? Those decision-makers include government ministers, elected politicians, chief executives and boards of major corporations, owners of small enterprises, health insurance fund managers, and almost every purchaser, provider and professional in health, social care, housing, education and other systems. Scarcity is everyone’s everyday reality. In the next section of this chapter the ways in which mental health issues can influence economic performance will be considered. The third section will discuss connections in the other direction, such as how economic considerations and experiences can affect mental health. Methods of economic evaluation will then be examined (the best known of which is costeffectiveness analysis), and how evidence from evaluation studies can inform decision-makers in LMIC contexts. In the final section, these economic arguments will be evaluated in the context of the UN SDGs, along with illustrations.

Mental health affects economic performance Wide-ranging costs Mental health issues—when recognised and responded to—can have sizeable impacts on health care budgets, associated with treatments delivered in inpatient, outpatient, community and primary care settings. Of course, as other chapters in this book have shown,5 the vast majority of people with mental health needs in LMICs do not have access to treatment: a few years ago,

2 For more on these aspects, see ibid. 3 See, e.g., Galvez, J. F., Thommi, S., & Ghaemi, S. N. (2011), Positive aspects of mental illness: a review in bipolar disorder, Journal of Affective Disorders, 128(3): 185–190. 4 Ramon, S., Healy, B., & Renouf, N. (2007), Recovery from mental illness as an emergent concept and practice in Australia and the UK, International Journal of Social Psychiatry, 53(2): 108–122. 5 See, e.g., Chapter 1 of this book by Shekhar Saxena and Laura Davidson, and Chapter 2 by Lawrence O. Gostin and Laura Davidson.

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the World Health Organization (WHO) estimated that between 76% and 85% of people with severe mental, neurological and substance use disorders had received no treatment in the previous 12 months.6 Even in high-income countries, the ‘treatment gap’ between those requiring treatment and those receiving it is wide. When treatment services are available, patients and families may need to make high out-of-pocket payments to access them, either in cash or kind. Very commonly there will be wider consequences of poor mental health, so that some people will need support in relation to housing, social care or employment, whilst others may exhibit behaviours that lead to contact with criminal justice agencies. Difficulties with employment as a result of mental illness may generate productivity losses for the economy, and income losses for the individual. Consequently, there will be both direct and indirect costs arising from mental health issues, many of them lasting for many years, and ranging widely across different services and systems. A few years ago the World Economic Forum (WEF) estimated the global costs of the most common non-communicable diseases (NCDs), making projections to 2030.7 For mental health issues, the global cost in 2010 was calculated to be almost US$2.5 trillion, two-thirds of which was accounted for by indirect costs. By 2030, these mental health-related costs were projected to increase to US$6 trillion. In relative terms, the estimated costs of mental health exceed current costs in relation to cardiovascular disease, chronic respiratory disease, cancer or diabetes. By 2030, mental health issues are projected to account for more than half of the overall global economic burden attributable to NCDs. As the authors of the WEF report emphasise, people with mental health issues are at above-average risk of other NCDs (such as cardiovascular disease and diabetes), so that the global economic impact is actually much higher. This treatment-related cost would be considerably higher if there was universal health coverage which extended health care to everyone with mental, neurological and substance use (MNS) disorders, although such calculations are always fraught with difficulties.8 On the other hand, recognising and responding to the mental health needs of a much wider group of people would bring enormous improvements in quality of life. In terms of the economic effects of mental illness, the high costs borne by families are often overlooked. These include payments for health care treatments and the opportunity costs of providing unpaid care and support which can disrupt employment and damage earnings for those family members.9 Calculations in the World Alzheimer Report 2010 suggested that unpaid care from family members and others represented more than half the total costs of dementia in low-income countries, and almost two-thirds in lower-middle-income countries.10

6 WHO (2008), mhGAP: Mental Health Gap Action Programme: Scaling up Care for Mental, Neurological and Substance Use Disorders (Geneva: WHO). 7 Bloom, D. E., Cafiero, E. T., Jané-Llopis, E., et al. (2011), The Global Economic Burden of Noncommunicable Diseases (Geneva: World Economic Forum). See also Chapter 1 of this book by Shekhar Saxena and Laura Davidson. 8 Chisholm, D., Johansson, K. A., Reykar, N., et al. (2015), ‘Universal health coverage for mental, neurological, and substance use disorders: an extended cost-effectiveness analysis’, in V. Patel, D. Chisholm, T. Dua, et al. (eds) (2015), Mental, Neurological, and Substance Use Disorders. Disease Control Priorities (3rd edn), Vol.4 (Washington, DC: World Bank). 9 Hamber, B. E. (1997), The Burden of Care: An Analysis of the Burden of Care on the Caregivers of Psychiatric Outpatients (Johannesburg: Centre for Health Policy, Department of Community Health, University of the Witwatersrand). 10 Wimo, A. & Prince, M. (2010), World Alzheimer Report 2010: The Global Economic Impact of Dementia (London: Alzheimer’s Disease International).

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The enduring nature of most mental health issues means that there will be economic impacts across the life-course for many people: a need for support in school, but still under-achievement in terms of educational qualifications; poor employment chances, frequent absences from work, low wages and slow career progression; heavy use of both generic and specialist health services through childhood and adulthood; perhaps continuing behavioural problems that result in antisocial and criminal activity, or possibly in substance use; and difficulties with personal relationships. One UK study found that adulthood economic impacts that could be traced back to childhood mental health issues were much greater than the impacts of physical illnesses, and occurred earlier in adulthood.11

Employment, productivity and economic growth Employment is an especially important sphere,12 because of its key roles in both national economic growth and personal economic circumstances, as just noted. In fact, there are multiple, complex, two-way links between mental health issues and employment difficulties. On the one hand, people with mental health issues are at greater risk of unemployment, job insecurity, absenteeism, presenteeism (reduced productivity when at work due to debilitating symptoms), low salaries, and early retirement.13 This is partly because of their episodic or more permanent state of ill-health, partly because their history of disrupted employment (and education) leaves them less well placed to compete with others for paid work or promotion, and partly because of endemic social stigma and widespread discrimination by employers and others.14 Although documented most robustly in high-income countries,15 these adverse impacts have been reported in other countries across the world.16 Psychoses, which are most likely to emerge when people are in their late teenage years or early 20s, can be especially damaging, given that the typical age of onset is precisely the time when many individuals are looking to make key investments in their human capital.17 On the other hand, experiences of stress, bullying and other difficulties in the workplace can cause or exacerbate mental health issues such as anxiety and depression.18 Given the close links between employment, income, personal debt and poverty (as discussed further below), the

11 Goodman, A., Joyce, R., & Smith, J. P. (2011), The long shadow cast by childhood physical and mental problems on adult life, Proceedings of the National Academy of Sciences of the United States of America, 108 (15): 6032–6037. 12 For an in-depth consideration of mental health and employment see further Chapter 14 of this book by Aart Hendriks. 13 Organisation for Economic Co-operation and Development (2012), Sick on the Job? Myths and Realities about Mental Health and Work (Paris: OECD). 14 For more on this topic, see, e.g., G. Thornicroft (2006), Shunned: Discrimination against People with Mental Illness (Oxford: Oxford University Press). 15 OECD, op. cit., nt.13. 16 Kawakami, N., Abdulghani, E., Alonso, J., et al. (2012), Early-life mental disorders and adult household income in the World Mental Health Surveys, Biological Psychiatry, 72(3): 228–237. 17 Fleischhacker, W., Arango, C., Arteel, P., et al. (2014), Schizophrenia: time to commit to policy change, Schizophrenia Bulletin, 40(33): S165–S194. 18 Harvey, S. B., Modini, M., Joyce, S., et al. (2017), Can work make you mentally ill? A systematic metareview of work-related risk factors for common mental health problems, Occupational and Environmental Medicine, 74(4): 301–310.

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complex downward spiralling relationship between mental health issues and work-related difficulties can be hard to break down. The overall effect is that lost productivity tends to be the biggest contributor to the costs of mental health issues, with implications for household income, community prosperity and national economic growth. Moreover, employment generally confers more than just individual and national economic benefits, although these are clearly of considerable importance. Employment also generates status and social roles, it fosters social networks, and it is a key source of self-concept. Consequently, many individuals will gain over the longer term from the social capital that such roles and networks create, helping to build resilience to future shocks as well as sources of support at times of crisis. For these reasons, in a few Organization for Economic Cooperation and Development (OECD) countries, legislation has been introduced to ensure that mental health issues are, at least in principle, addressed in the same way as physical health problems in terms of employment rights.19 Most people with mental health issues want to work and are perfectly capable of doing so with the appropriate support.

Economic factors affect mental health There are close links between mental illness and economic disadvantage; indeed there is commonly a vicious circle.20 Two main explanations have been offered. The social causation hypothesis is that economic and social disadvantage such as poverty increases the risk of mental illness through augmented risk factors (for example, financial stress such as unsecured personal debt, social stigma, isolation, social exclusion, food insecurity, and malnutrition) and decreased protective factors (such as low levels of social capital or poor education). In contrast, the social selection or ‘drift’ hypothesis is that people with mental health issues have higher risks of remaining in or falling into poverty thanks to high treatment costs, disrupted or poorly remunerated employment, and hence lower individual or household income.21 The social causation explanation may be more pertinent when considering conditions such as depression and anxiety, whilst the drift explanation is probably more relevant to more severe mental health issues such as those experiencing symptoms associated with chronic schizophrenia; but in either case the causal pathways are complex and probably bi-directional.

Poverty Studies in high-income countries have shown that poverty and unemployment are associated with the maintenance, but apparently not necessarily the onset, of common mental disorders such as depression and anxiety, whereas financial strain (unsecured or problematic personal debt) appears to be associated with both.22 Poverty is associated with, or leads to, many forms of disadvantage,

19 See, e.g., Thornicroft (2006), op. cit., nt.14. 20 See, e.g., Lund, C., De Silva, M., Plagerson, S., et al. (2011), Poverty and mental disorders: breaking the cycle in low-income and middle-income countries, The Lancet, 378(9801): 1502–1514; Iemmi, V., Bantjes, J., Coast, E., et al. (2016), Suicide and poverty in low-income and middle-income countries: a systematic review, The Lancet Psychiatry, 3(8): 774–783. 21 See, e.g., Patel, V. & Kleinman, A. (2003), Poverty and common mental disorders in developing countries, Bulletin of the World Health Organization, 81(8): 609–615; Funk, M., Drew, N., & Knapp, M. (2012), Mental health, poverty and development, Journal of Public Mental Health, 11(4): 166–185. 22 Weich, S. & Lewis, G. (1998), Poverty, unemployment, and common mental disorders: population based cohort study, BMJ, 317(7151): 115–119.

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including limited educational and employment opportunities, bad housing, homelessness and violence.23 Living in poverty also makes it very difficult for individuals to afford treatment for their mental or other health issues.24

Recession and debt The recent global economic crisis exposed the close relationships between mental health issues, personal debt and financial instability. The effects on suicide rates have been most clearly demonstrated through a number of studies, given the availability of national-level indicators. For example, one study analysed data for more than 50 European and American countries and found that suicide rates increased significantly after the 2008 global economic crisis, more so for men than women, and more noticeably in countries where recession bit deepest (as measured by job losses).25 The Asian economic downturn in the late 1990s was associated with an increase in suicide rates, as well as a widening of income-related mental health inequalities.26 Socioeconomic upheaval in the Russian Federation in the 1990s was followed by increased rates of suicide and alcohol-related deaths.27 In low-income country contexts, one study in India found higher rates of distress and suicide amongst farmers who fell into debt following a national agricultural crisis,28 and another study in Pakistan demonstrated the close association between personal debt problems and suicide attempts.29 The impact of personal financial difficulties on mental health depends partly on the type of debt and whether it is considered by the individual to be ‘manageable’. The effects are mainly seen with respect to depression, rather than anxiety or non-specific mental disorders.30 Economic conditions can have wider effects too: recession in the wider economy has been found to affect the mental health not only of adults, but also of children,31 and has been linked to higher levels of youth substance use and drug-dealing.32 How governments respond to prevailing

23 See, e.g., Patel, V., Kirkwood, B., Pednekar, S., et al. (2006), Risk factors for common mental disorders in women. Population-based longitudinal study, British Journal of Psychiatry, 189(6): 547–555; Havenaar, J., Geerlings, M., Vivian, L., et al. (2008), Common mental health problems in historically disadvantaged urban and rural communities in South Africa: prevalence and risk factors, Social Psychiatry and Psychiatric Epidemiology, 43(3): 209–215. 24 Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007), Scarcity, inequity and inefficiency of resources: three major obstacles to better mental health, The Lancet, 370(9590): 878–889. 25 Chang, S., Stuckler, D., Yip, P., & Gunnell, D. (2013), Impact of 2008 global economic crisis on suicide: time trend study in 54 countries, BMJ, 347: f5239. 26 Hong, J., Knapp, M., & McGuire, A. (2011), Income-related inequalities in the prevalence of depression and suicidal behaviour: a 10-year trend following economic crisis, World Psychiatry, 10(1): 40–44. 27 Men, T., Brennan, P., Boffetta P., & Zaridze, D. (2003), Russian mortality trends for 1991–2001: analysis by cause and region, BMJ, 327(7421): 964. 28 Deshpande, R. S. (2002), Suicide by farmers in Karnataka: agrarian distress and possible alleviatory steps, Economic and Political Weekly, 37(26): 2601–2610. 29 Haider, S. I. & Ijaz, H. (2002), Deliberate self-poisoning (unemployment and debt), Pakistan Journal of Medical Sciences, 18(2): 122–125. 30 Fitch, C., Hamilton, S., Bassett, P., & Davey, R. (2011), The relationship between personal debt and mental health: a systematic review, Mental Health Review Journal, 16(4): 153–166. 31 Solantaus, T., Leinonen, J., & Punamäki, R. L. (2004), Children’s mental health in times of economic recession: replication and extension of the family economic stress model in Finland, Developmental Psychology, 40(3): 412–429. 32 Arkes, J. (2007), Does the economy affect teenage substance use?, Health Economics, 16(1): 19–36.

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macroeconomic circumstances is clearly important. One line of argument is that ‘austerity fiscal policies’ may well exacerbate the negative impacts of recession on mental health issues.33

Economic interventions To improve global mental health—and indeed to meet SDG3—it is clear that policies need to target both the causes of mental health issues and the causes of poverty. Studies in a range of LMICs have demonstrated how mental health interventions such as medications, psychotherapy and community rehabilitation can help to prevent the drift into poverty, even though focused primarily on tackling psychiatric symptoms.34 In contrast, the evidence of the effect on mental health issues of poverty alleviation interventions such as cash transfers and microcredit is inconclusive. Asset promotion programmes appear to have clear mental health benefits. For example, the evaluation of the conditional cash transfer (CCT) programme Oportunidades in Mexico found a significant reduction in both depressive symptoms in mothers and behavioural problems in children of families having benefited from the programme for three to five years.35 Oportunidades is a national CCT programme for poor households, including a cash transfer of about 25% of household income conditional on compliance with activities (such as pre-natal care, immunisation, nutrition supplementation, and educational workshops). Another evaluation of a microcredit intervention in South Africa found an increase in perceived stress levels amongst recipients of small loans (both in men and women), but a decrease in depressive symptoms in men.36 Debt advice and counselling services can decrease the risk of developing or exacerbating mental disorders.37 Plainly, more research is required.

Economic evaluation When evaluating a specific intervention—whether one targeted at addressing mental health issues or at poverty alleviation, or with any other objective—there is a strong need to consider not just whether the objectives are met, but also the cost of doing so. In a clinical context, for example, the core effectiveness question will be whether an intervention such as medication or a community support programme alleviates symptoms or meets individuals’ needs in another way, such as lessening the impacts of poor mental health on quality of life or functioning. The economic question also needs to be asked: are the resources needed to deliver the specific intervention justified by the outcomes achieved? There are three main types of health-based economic evaluations, each sharing some features, but differing in how they conceptualise outcomes. When comparing two or more interventions targeted on a particular condition (such as depression), the most relevant outcomes will be

33 D. Stuckler & S. Basu (2013), The Body Economic: Why Austerity Kills (London: Basic Books). 34 For a detailed discussion of the economics of mental health and poverty in LMICs, see Chapter 4 of this book by Judith Bass. 35 Ozer, E. J., Fernald, L. C., Weber, A., et al. (2011), Does alleviating poverty affect mothers’ depressive symptoms? A quasi-experimental investigation of Mexico’s Oportunidades programme, International Journal of Epidemiology, 40(6): 1565–1576. 36 Fernald, L. C., Hamad, R., Karlan, D., et al. (2008), Small individual loans and mental health: a randomized controlled trial among South African adults, BMC Public Health, 8(1): 409. 37 See, e.g., Wahlbeck, K. & McDaid, D. (2012), Actions to alleviate the mental health impact of the economic crisis, World Psychiatry, 11(3): 139–145.

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specific to the disorder (for example, reducing depressive symptoms). A cost-effectiveness analysis would be most appropriate here: it looks at disorder-specific outcomes and the resources required to achieve or prevent them.38 If the decision context is broader (such as whether to invest in the treatment of depression, rather than in HIV), then outcomes must be measured in a common unit relevant to both disease areas. The two most frequently used such generic outcome measures are changes in qualityadjusted life years (QALYs) and disability-adjusted life years (DALYs). When economists measure outcomes using QALYs or DALYs, this is often called a cost-utility analysis (although it must be noted that the terminology used is inconsistent). A cost-utility analysis tells the strategic decision-maker where they will achieve most impact from their available resources by showing which of the two or more interventions achieved greater QALY or DALY gains from a given amount of money.39 If a decision-maker needs to choose how to allocate resources across a much wider canvas (such as between health care, education and defence) then the only feasible generic outcome measures would be monetary valuations of what is achieved, or perhaps a high-level wellbeing measure such as happiness.40 Health economists call this a cost-benefit analysis. It is hard to calculate monetary values of mental health outcomes, so cost-benefit analyses are rare. An exception might be where the primary aim is something like improving employment outcomes (more people in paid jobs and lower absenteeism rates, for example), because then the effectiveness measure could be monetised in terms of productivity gains.41

Cost and outcome measurement Many mental health issues have broad cost impacts, spread across different sectors. An evaluation of a mental health intervention, therefore, usually will need to measure impacts on multiple budgets. In fact, the breadth of cost and outcome measurement in an evaluation depends on the purpose of the study: is it intended to inform resource allocation within a single agency (such as a community mental health service) or a wider system (such as health care) or a particular sector (such as government) or a whole society? Broader questions need broader measures of costs and outcomes. This is easier said than done, as it may be difficult practically to measure all impacts, and even more problematic to bring different systems together to coordinate their actions. Naturally, it is difficult to persuade decision-makers to invest their resources when the pay-offs (economic or otherwise) are mainly in another sector, and/or when they take many years to be achieved. On the outcome side of an evaluation, the most relevant measures assess changes in symptoms, behaviour, functioning and quality of life. QALYs or other generic measures are also

38 Petrou, S. & Gray, A. (2011), Economic evaluation alongside randomised controlled trials: design, conduct, analysis, and reporting, BMJ, 342: d1548. 39 Luyten, J., Naci, H., & Knapp, M. (2016), Economic evaluation of mental health interventions: an introduction to cost-utility analysis, Evidence-based Mental Health, 19(2): 49–53. 40 For more on this topic, see, e.g., O’Donnell, G. (2013), ‘Using Well-being as a Guide to Policy’, in J. Helliwell, R. Layard, & J. Sachs (eds) (2013), World Happiness Report 2013 (New York: UN Sustainable Development Solutions Network). See also Chapter 7 of this book by Joseph D. Calabrese, which considers mental health in Bhutan—a country famous for its ‘happiness’ index. 41 Knapp, M., Patel, A., Curran, C., et al. (2013), Supported employment: cost-effectiveness across six European sites, World Psychiatry, 12(1): 60–68.

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likely to be recommended by economists alongside clinical measures, because QALYs make it easier to consider resource allocation across a range of different disease areas. The most widely used tool for obtaining QALYs is the EQ-5D.42 This is a simple, five-dimensional tool that covers mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Item scores are aggregated using preference weights that reflect societal perspectives on what drives health-related quality of life. Ideally, these costs and outcomes would be measured for long periods. This is because mental health issues are often chronic due to their underlying biology, low rates of recognition and treatment, and because therapies mainly address symptoms, rather than curing underlying diseases. Furthermore, good interventions are often more likely to generate long-term positive impacts, as has been shown with some psychological therapies.43 In practice, however, it is hard to conduct evaluations over long periods because it is infeasible (due, for example, to a lack of interest by the participants in staying in a clinical trial), expensive or unethical.

Trade-offs When one intervention is found to be more effective than another, but also to have higher costs, the question then arises as to which represents the most efficient use of available resources. The answer depends on the value attached by the decision-maker to the effectiveness gains and whether or not they are considered to be ‘worth’ the additional costs. In these circumstances there is a need to decide how effectiveness gains are traded off against higher cost, which is a value judgement. The usual approach employed by health economists to highlight the nature of the trade-off is to calculate the incremental cost-effectiveness ratio (ICER): the difference in cost between the two interventions being evaluated, divided by the difference in effectiveness.44 If the primary outcome is, for example, preventing suicides, then the ICER might represent the additional cost of avoiding one additional suicide. If the outcome is to reduce depressive symptoms, then the ICER might show the cost of achieving a one-point gain in the symptom measure. Calculated ICER values can be discussed with decision-makers, who then must judge whether or not they consider this value to be an amount ‘worth paying’. In England and Wales, the National Institute for Health and Care Excellence (NICE) goes one step further in seeking to advise on resource deployment in the National Health Service (NHS). It employs a threshold value as a point of reference to guide discussion and decision. In its technology appraisals, NICE calculates the ICER as cost per additional QALY and compares it with a threshold of £20,000 per QALY.45 If the ICER exceeds this threshold, the argument is

42 EuroQol Group (1990), EuroQoL: a new facility for the measurement of health-related quality of life, Health Policy, 16(3): 199–208. 43 See, e.g., Wiles, N. J., Thomas, L., Turner, N., et al. (2016), Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial, The Lancet Psychiatry, 3(2): 137–144; Isasi, A. G., Echeburua, E., Liminana, J. M., & Gonzalez-Pinto, A. (2014), Psychoeducation and cognitive-behavioral therapy for patients with refractory bipolar disorder: a five-year controlled clinical trial, European Psychiatry, 29(3): 134–141. 44 M. Drummond, M. Sculpher, G. W. Torrance, et al. (2005), Methods for the Economic Evaluation of Health Care Programmes (3rd edn) (Oxford: Oxford University Press). 45 National Institute for Health and Clinical Excellence (2008), Guide to the Methods of Technology Appraisal (London: National Institute for Health and Clinical Excellence).

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that resources (represented by cost) could be better spent elsewhere in the NHS (on other interventions) where it costs less than £20,000 to achieve one additional QALY. However, the NICE threshold is a guide, not a rigid rule. It reminds everyone that resources are scarce and that choices must be made before using them. Two things need to be emphasised. First, for an intervention to be cost-effective it does not need to generate savings; it must simply represent a better use of resources. Second, economic evaluations examine the efficiency of use of available resources, but there are other criteria that will concern decision-makers, such as equity of access or prioritisation of certain population subgroups.

Study design A randomised controlled design—where people are allocated to treatments by chance—is undoubtedly the most robust study design to answer many clinical questions. As Sibbald has observed, it ‘ensures no systematic differences between intervention groups in factors, known and unknown, that may affect outcome’.46 Such a design is widely used in clinical research, and can easily accommodate economic evaluation. However, randomised trials are not always feasible, and might sometimes be considered unethical because some participants are being denied access to treatment. Furthermore, decision-makers may not want to wait for a randomised trial to be completed, as they can often take three years or more. An alternative to the randomised trial is some form of mathematical modelling, populated with data from previous trials, observational studies or routine management information systems (in other words, secondary data). Models are simulations of what might happen in reality—for example, tracing pathways through care for individuals with particular needs, or estimating and comparing outcomes and costs associated with two or more interventions.47 Model-based economic evaluations are more easily generalised and flexible than trials, and much quicker to carry out (thus providing earlier answers to decision-makers), but they are clearly simplifications of reality, and their usefulness depends fundamentally on the quality of the data used to populate them.

Global aspirations and resource realities Mental health issues represent significant and growing economic challenges across the world, but unfortunately they have not been very prominent on global policy agenda until relatively recently. The WHO focused its 2001 World Health Report on mental health,48 and has subsequently taken a global lead in addressing the endemic neglect of mental health issues across large parts of the world.49 Amongst other things, it regularly updates a Mental Health Atlas,50 has developed the WHO

46 Sibbald, B. (1998), Understanding controlled trials: Why are randomised controlled trials important?, BMJ, 316: 201. 47 A. Briggs, K. Claxton, & M. Sculpher (2006), Decision Modelling for Health Economic Evaluation (Oxford: Oxford University Press). 48 WHO (2000), The World Health Report 2001: Mental Health: New Understanding, New Hope (Geneva: WHO). 49 For more on the role of the WHO, see Chapter 1 of this book by Shekhar Saxena and Laura Davidson. 50 WHO (2015), Mental Health Atlas 2014 (Geneva: WHO).

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Assessment Instrument for Mental Health Systems (WHO-AIMS) to facilitate more systematic mapping of activities,51 and drafted guidelines for mental health policy, planning and service development.52 The WHO has played a major role, too, in the Mental Health Gap Action Programme (mhGAP),53 set up in 2008 to guide treatment of mental health issues in low-resource settings,54 and a few years later launched the Mental Health Action Plan (MHAP) 2013–2020, which set out objectives, targets and proposed actions at both global and country levels.55 In contrast to these influential efforts by the WHO, other international bodies have shown less interest in mental health issues. For reasons that are hard to fathom, the United Nations (UN) omitted all reference to mental health in its Millennium Development Goals (MDGs), launched in 2000.56 Recognition—albeit still rather modest when viewed in their wider context— eventually followed when the SDGs were adopted by the UN at its General Assembly in September 2015.57 Two of the health-related targets explicitly mention mental health: • •

Target 3.4: ‘By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.’ Target 3.5: ‘Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.’

The mental health-related indicators associated with these targets—suicide mortality rates, coverage of treatments (pharmacological, psychosocial, rehabilitation, aftercare) for substance use disorders, and a measure of alcohol consumption—are somewhat narrow, given the wide-ranging effects of poor mental health. However, other health-related targets (such as target 3.8 on universal health coverage) and SDGs with more general aims (such as SDG8 to ‘promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all’, and SDG10 seeking to ‘reduce inequality within and among countries’) have relevance for or can be linked to mental health issues. In addition, the principle of ‘no one being left behind’ that spans the SDG agenda emphasises the inclusion of people with disabilities, including those with mental disabilities.

Conclusion There are a number of economic considerations to take into account when considering mental health issues. One of those considerations is how to respond to the pervasiveness of scarcity.

51 WHO (2005), WHO-AIMS (Version 2.2) World Health Organization Assessment Instrument for Mental Health Systems (Geneva: WHO). 52 See, e.g., WHO (2003), Organization of Services for Mental Health (Geneva: WHO). 53 WHO (2008), op. cit., nt.6. 54 WHO (2010), mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Nonspecialized Health Settings: Mental Health Gap Action Programme (mhGAP)—version 2.0. (Geneva: WHO). 55 WHO (2013), Investing in Mental Health: Evidence for Action (Geneva: WHO). For more on the role of WHO in relation to mental health, see Chapter 1 of this book by Shekhar Saxena and Laura Davidson. 56 Miranda, J. J. & Patel, V. (2005), Achieving the Millennium Development Goals: does mental health play a role?, PLoS Medicine, 2(10): e291. 57 United Nations (2015), Transforming our World: the 2030 Agenda for Sustainable Development (New York: UN).

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Policy-makers, funding bodies and service providers all face difficult decisions about how to use the resources for which they are responsible—which are always more limited than they would wish—in order to achieve the best mental health and wider outcomes. It would seem to make enormous sense to try to prevent mental issues from emerging in the first place. That said, a prevention programme must be rigorously tested to ensure it makes the best use of societal resources. Modest or very uncertain benefits from delivery of a particular programme may not be cost-effective. Further pilot studies may be necessary first. Similarly, it may appear obvious that efficacious treatments alleviating the often very distressing symptoms and pervasive functional limitations of a mental disorder should be made available as widely as possible. Again, however, economic issues need to be taken into consideration: the outcomes achieved from the investment in such treatments may be relatively modest when set alongside the costs of achieving them. Economic evaluations—cost-effectiveness and similar analyses—are tools that decisionmakers can use to inform the difficult choices that, inevitably, they must make. Those evaluations do not themselves make the decisions, but they offer a logical framework and a set of empirical findings to feed into the ethical judgements that decision-makers will have to make. Those decision-makers will rightly also take other criteria into consideration when choosing between the various courses of actions open to them, particularly equitable access to effective treatments. Yet, even then there will be an economic dimension: what, for example, is the cost of achieving fairness, and what are the economic consequences of persisting with a system that is unfair? A second important economic consideration is the set of often quite complex interconnections between the economic status of individuals and communities and the risk of mental health issues. In this chapter, some of those links have been highlighted. For example, there are clear links between personal and societal economic ‘adversity’—such as poverty, lengthy periods of unemployment, and problematic debt—and the emergence, prolongation or exacerbation of poor mental health. When national economies get into difficulty, such as during a prolonged recession, there is a higher prevalence of common mental disorders, and higher rates of suicide. Third, mental health issues themselves have economic consequences. Someone experiencing a period of poor mental health may have difficulty performing to their full potential at work or in the household, for example. This may lead to lower productivity for the economy and lower income for the individual. They may need support from their family, which could in turn cause those other family members employment disruption or income loss. The individual experiencing mental health issues will generally need treatment from the health care system or perhaps services from other systems, such as social care or welfare benefits (if they exist), with concomitant costs to the system and/or the individual and/or their family. Although modest, the SDGs represent the first time that mental health issues have been recognised by world leaders as part of the global development agenda. The obvious challenge is to convert those global aspirations into action on the ground through well-designed, broadly spanned prevention programmes and evidence-based, affordable, feasible treatments and services. For that conversion to be realised, substantial additional resources will need to be generated and invested wisely. Nonetheless, there is every chance that many of the possible prevention and treatment initiatives would, in due course, generate sufficient monetary savings to pay for themselves, or contribute importantly to economic growth, such as through increased employment and

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productivity rates.58 Success in pursuit of the mental health-related SDG targets discussed above can therefore be linked not only to better individual and societal wellbeing, but also to improved individual and national economic performance. This is a most persuasive factor which those advocating with governments and other bodies in relation to the rights of those with mental health issues should emphasise when seeking additional resources.

58 McDaid, D., Park, A., & Knapp, M. (2017), Commissioning Cost-effective Services for Promotion of Mental Health and Wellbeing and Prevention of Mental Ill Health (London: Public Health England).

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4 THE RELATIONSHIP BETWEEN MENTAL HEALTH AND POVERTY IN LOW- AND MIDDLE-INCOME COUNTRIES Judith Bass* Introduction Much of our understanding of the relationship between poverty and mental health problems is couched in the two opposing hypotheses of social causation and social selection. The former posits that the stress and social conditions associated with living in poverty are causes of, or more correctly risk factors for, the development of mental illness. The latter hypothesis, in contrast, suggests that the presence of a mental illness causes an individual to drift into poverty due to limitations in functioning and the frequent stigma and social isolation associated with this class of disorders. Whilst some disorders fit better with one or other of these hypotheses, the reality is that for most individuals living with a mental illness in low- or middle-income countries (LMICs), poverty is an endemic situation that is both a cause and an effect of the condition. This chapter will explore how, in the context of poverty, with limited economic resources for health and social and educational programming, a situation is created in which large segments of the population are at risk of developing a mental health problem. Once present, a lack of services results in the exacerbation of the problem for the individual, their family, and often their whole community, contributing to a continued cycle of poverty and ill-health. Examples will be drawn from populations in both LMICs and more stable nations, as well as those affected by conflict (either historical or ongoing). The chapter will also consider the potential impact of the Sustainable Development Goals (SDGs)1 in breaking the poverty cycle, and methods by which this might be possible, given appropriate investment.

* Judith Bass is an Associate Professor of Global Mental Health at the Johns Hopkins Bloomberg School of Public Health Maryland, USA, whose research focuses on the intersection between mental health and economic development. 1 UN GA RES/70/1 adopted on 25 Sept 2015: Transforming our world: the 2030 Agenda for Sustainable Development. Available at: www.un.org/sustainabledevelopment/development-agenda/.

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Defining the constructs of poverty and mental health The need to address poverty is addressed in SDG1 of the new UN Agenda which requires states to ‘end poverty in all its forms everywhere’. The construct of poverty has traditionally been defined in economic terms, using income (at the individual level), or Gross Domestic Product (GDP) (at the national level) to define individuals or countries as poor.2 Common reference to individuals living on less than a dollar a day has reinforced the concept of poverty as synonymous with income (or lack thereof). However, the use of income as a proxy for poverty is problematic. First, the meaning and utility of individual and household income can vary by context. For example, living on a dollar a day may mean something quite different in urban and rural settings. In urban areas, individuals need money for purchasing power, whilst in the latter, other options may exist for barter or exchange. This variation can result in a potential lack of comparability of what a dollar a day means across contexts.3 To understand the impact of poverty on health outcomes, many researchers have moved to multi-dimensional conceptualisations of poverty that emphasise deprivation rather than solely monetary indicators. Factors such as availability of and access to a safe environment, nutritional food, health care, education and social services are also part of the conceptualisation of poverty,4 particularly as it relates to the opportunity for an individual, or a population, to reach their social, economic, and political potential. As stated by the United Nations with reference to the SDGs, [p]overty is more than the lack of income and resources to ensure a sustainable livelihood. Its manifestations include hunger and malnutrition, limited access to education and other basic services, social discrimination and exclusion as well as the lack of participation in decision-making.5 Whilst mental health was absent from the Millennium Development Goals (MDGs),6 SDG3 requires states to ‘[e]nsure healthy lives and promote well-being for all at all ages’, and includes two specific targets related to mental health: ‘[b]y 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and well-being’ and ‘[s]trengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol’ (target 3.4 and target 3.5 respectively).7 The construct of mental health has been defined in the Diagnostic and Statistical Manual (DSM-5) as a reference to a positive state of emotional, psychological and social wellbeing, with a ‘clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior’ (referred to as a mental ‘disorder’). Researchers who take a wellbeing perspective often focus on mental health promotion which includes the aim of stimulating positive mental health and

2 Bhutan has famously questioned the utility of GDP, and has adopted a ‘happiness index’ instead. For more on this, see Chapter 7 of this book by Joseph D. Calabrese. 3 Burns, J. K. (2015), Poverty, inequality and a political economy of mental health, Epidemiol Psychiatr Sci, 24(2): 107–113. 4 On the social determinants to the right to health, see Chapter 2 by Lawrence O. Gostin and Laura Davidson. 5 SDG1, UN Sustainable Development Goals. Available at: www.un.org/sustainabledevelopment/poverty/. 6 UN Millennium Development Goals. Available at: www.un.org/millenniumgoals/. 7 US Sustainable Development Goal 3. Available at: www.un.org/sustainabledevelopment/health.

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enhancing quality of life factors.8 This perspective is gaining popularity, including a proposal to create a wellbeing-adjusted life year (WALY) to complement the existing metric of qualityadjusted life year (QALY) which is frequently applied to health improvements realised over a oneyear period of life extended.9 In contrast, researchers whose emphasis is on mental illness often specify disorders (such as schizophrenia or major depressive disorder) or categories of disorders (such as common mental disorders, severe mental disorders, or substance use disorders). The definition of disorder is often, although not always, driven by Western-based models of mental illness as defined in the DSM or International Classification of Disease (ICD) schema.10 Regardless of whether or not a wellbeing or disorder-based approach is taken, fundamental to all definitions of mental health are factors related to functionality. The domains of functioning that are most often associated with mental health are social functioning (such as interpersonal interactions and relationships and participation in community, social and civic life) and occupational functioning (work and employment).11 Thus, being mentally healthy and/or free from a mental disorder would result in an individual having the opportunity to participate and function fully in the context in which they live. This is particularly important when we consider a resource-poor context (in other words, one in which poverty is prevalent at the individual and societal level), in which opportunities for engaging in social and occupational functioning may be diminished.

Prevailing theories linking poverty and mental health The link between poverty and mental health is well established; globally, people living in poverty have higher rates of mental disorder, and individuals with mental disorders are over-represented amongst populations living in poverty.12 As indicated above, the ‘social causation’ hypothesis states that the conditions of poverty increase the risk of poor mental health through increased exposure to adverse conditions and stress, and the ‘social selection’ hypothesis suggests that individuals with mental illness tend to drift down into poverty or fail to advance out of poverty due to their impaired functioning and experiences of discrimination and stigma.13 Whilst these theories have largely been tested in high-income countries, a review by Lund et al. indicated that both social

8 Barry, M. M. & Jenkins, R. (2007), Implementing Mental Health Promotion (Oxford: Elsevier Health Sciences). See also Herrman, H., Moodie, R., & Vic, A. S. S. (2010), ‘Mental health promotion’, in V. Patel, A. Woodward, V. Feigin, et al. (eds), Mental and Neurological Public Health: A Global Perspective (Cambridge: Academic Press), p.450; Yankovskyy, S. (2016), Political and economic transformations in Ukraine: the view from psychiatry, Transcult Psychiatry, 53(5): 612–629. 9 Johnson, R., Jenkinson, D., Stinton, C., et al. (2016), Where’s WALY? A proof of concept study of the ‘wellbeing adjusted life year’ using secondary analysis of cross-sectional survey data, Health and Quality of Life Outcomes, 14(1): 1–9. 10 For a critique of the Western construct of mental health, see further Chapter 17 of this book by Peter Lehmann. See also Chapter 7 by Joseph D. Calabrese, and Chapter 15 by Dainius Pu¯ras and Julie Hannah. 11 Üstun, B. & Kennedy, C. (2009), What is ‘functional impairment’? Disentangling disability from clinical significance, World Psychiatry, 8(2): 82–85. 12 See, e.g., Haushofer, J. & Shapiro, J. (2013), Household Response to Income Changes: Evidence from an Unconditional Cash Transfer Program (Boston: Massachusetts Institute of Technology); Lund, C., De Silva, M., Plagerson, S., et al. (2011), Poverty and mental disorders: breaking the cycle in low-income and middle-income countries, The Lancet, 378(9801): 1502–1514. 13 Dohrenwend, B. P., Levav, I., Shrout, P. E., et al. (1992), Socioeconomic status and psychiatric disorders: the causation-selection issue, Science, 255(5047): 946–952.

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causation and social selection processes operate to create the observed associations between poverty and mental disorders in LMICs.14 At the population level, there is also evidence of the link between poverty and mental health. Haushofer & Fehr have shown that within and across countries, higher incomes and higher GDP were both associated with increased happiness and life satisfaction.15 In their work, together with the wide body of research on the link between poverty and mental health, it is clear that the relationship between these two constructs is cyclical, creating a feedback loop which may reinforce the relationship over time. In low-resource countries where much of the population is living in poverty, the resources that could be accessed if individuals had more income (such as general health care, education, social support, and mental health policy and treatment) are minimally available. This cycle of poverty and ill-health can be quite pronounced, and the impacts of individual and contextual poverty are felt across the life course.

Childhood Mental health is negatively affected when general physical health services are not available or are limited and of questionable quality, as is common in many LMICs. Starting during gestation and in early childhood, the physical, cognitive and neurological development of the child is directly related to the mental health and wellbeing of the mother.16 In contexts where there are many risks for poor child development, starting life with a healthy mother is quite important. However, the prevalence of depression and other common mental disorders amongst pregnant women in LMICs is high, and women who are in the lower socioeconomic stratum are amongst those at highest risk. For example, a cross-sectional study amongst 831 pregnant women attending antenatal clinics in Sao Paulo in Brazil found an estimated 20% prevalence of common mental disorders, with key indicators of low socioeconomic status (SES) (in other words, living in a crowded home and having a lower occupational status) being amongst key risk factors.17 Whilst access to prenatal care may exist generally, services to treat mental health problems often are unavailable, and this is even more pronounced in relation to alcohol and drug treatment. Although alcohol and drug use tends to be less during pregnancy, such use exists and women who use alcohol or drugs put themselves and their developing foetus at risk of a wide range of health problems. A study conducted in a resourcepoor peri-urban area of South Africa found that current alcohol and other drug use prevalence was 18%, with food insecurity, co-occurring depression, anxiety, suicidality, and relationship violence all predictive of alcohol and other drug use.18 These high rates persist into the postpartum period. A study of women with young infants in Malawi found a greater than 30% prevalence of major or

14 Lund, C., Breen, A., Flisher, A. J., et al. (2010), Poverty and common mental disorders in low and middle income countries: a systematic review, Soc Sci Med, 71(3): 517–528. 15 Haushofer, J. & Fehr, E. (2014), On the psychology of poverty, Science, 344(6186): 862–867. 16 Liu, Y., Kaaya, S., Chai, J., et al. (2017), Maternal depressive symptoms and early childhood cognitive development: a meta-analysis, Psychol Med, 47(4): 680–689; Herba, C. M., Glover, V., Ramchandani, P. G., & Rondon, M. B. (2016), Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries, The Lancet Psychiatry, 3(10): 983–992. 17 Faisal-Cury, A., Menezes, P., Araya, R., & Zugaib, M. (2009), Common mental disorders during pregnancy: prevalence and associated factors among low-income women in São Paulo, Brazil: depression and anxiety during pregnancy, Arch Womens Ment Health, 12(5): 335–343. 18 Onah, M. N., Field, S., van Heyningen, T., & Honikman, S. (2016), Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting, Int J Ment Health Syst, 10(38).

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minor depression, with increased risk for women of lower socioeconomic status, women who lack support systems, and women whose infants have recently experienced illness.19 Untreated mental health problems amongst mothers during infancy and early childhood, which are quite prevalent in low-resource settings,20 can have a long-lasting effect on child development. This is because infants and young children are dependent on their mothers for managing their feeding, hygiene and general health care, including receipt of regular immunisations and care when they are sick. Mothers and caregivers who are mentally unwell may be less able to perform these caregiving tasks. In their recent review of postnatal depression and its effects on child development in LMICs, Parsons et al. found high rates of depression, with poverty and economic adversity increasing the risk.21 There was also evidence from a limited number of studies that children whose mothers had postpartum depression were at risk of poorer social and cognitive development, compared with children whose mothers were depression-free.22 Beyond the perinatal depression literature, longitudinal studies in LMICs demonstrate that children born into poverty are more likely to experience impairments in cognitive development.23 This may emanate from exposure to poverty-related risks in early childhood which can directly affect brain development through limited opportunity for cognitive stimulation and inadequate nutrition, with detrimental impact on the infant’s cognitive and emotional developmental trajectory. In a review of risk factors for adverse child development outcomes in LMICs, Walker et al. identified inadequate cognitive stimulation as one of four key risk factors in need of urgent intervention with children aged 0–5.24 In particular, children in poverty can experience diminished language inputs and enter school at a disadvantage, with disparities persisting throughout their education, leading to reduced future earnings and adult poverty. Investments in early education, therefore, will help states to meet not only SDG4 (quality education), but also SDG1 on poverty and SDG3 on good health and wellbeing.

Adolescence and early adulthood The interconnectedness of poverty, HIV and mental health problems is particularly relevant in adolescence and early adulthood. In poor, urban contexts within LMICs, the increased rates of depression, aggressive behaviour, and substance use amongst youth often result from a lack of real or perceived life chances due to poverty and unemployment. This is exemplified most starkly in the experience of homeless youths, and in particular young people living on the streets. In their

19 Stewart, R. C., Bunn, J., Vokhiwa, M., et al. (2010), Common mental disorder and associated factors amongst women with young infants in rural Malawi, Soc Psychiatry Psychiatr Epidemiol, 45(5): 551–559. 20 Fisher, J., Cabral de Mello, M., Patel, V., et al. (2012), Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review, Bull World Health Organ, 90(2): 139G–149G. 21 Parsons, C. E., Young, K. S., Rochat, T. J., et al. (2012), Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries, Br Med Bull, 101: 57–79. 22 Ibid. 23 See, e.g., Grantham-McGregor, S. (2007), Early child development in developing countries, The Lancet, 369(9564): 824; Escueta, M., Whetten, K., Ostermann, J., & O’Donnell, K. (2014), Adverse childhood experiences, psychosocial well-being and cognitive development among orphans and abandoned children in five low income countries, BMC Int Health Hum Rights, 14: 6; Walker, S. P., Wachs, T. D., Grantham-McGregor, S., et al. (2011), Inequality in early childhood: risk and protective factors for early child development, The Lancet, 378(9799): 1325–1338. 24 Ibid.

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review of the literature from high-, middle-, and low-income countries, Embelton et al. found that 60% of street youth in LMICs reported lifetime drug use (most commonly inhalants, tobacco, alcohol, and marijuana), with substance use being associated with a host of other poor health outcomes including high-risk sexual behaviours and increased risk for HIV infection, as well as increased rates of depressive symptoms.25 In the general population, there is often an elevation in the incidence and prevalence of mental health problems in the period of adolescence and early adulthood, with poverty being an added factor increasing risk for mental disorders. A study from Zimbabwe, where more than half the population lives in extreme poverty and the prevalence of HIV infection is nearly 15%, found that amongst 18 to 22 year old women, lower socioeconomic status was associated with less education, earlier marriage, increased rates of depression and anxiety, and more risky sexual behaviours associated with increased risk of HIV infection.26 Even with the recognition that mental health problems amongst children and adolescents are prevalent and impact upon their ability to develop cognitively and behaviourally, the resources for treatment are woefully lacking in most LMICs. The World Health Organization attempted a systematic collection of information from LMICs on their existing services and resources for child and adolescent mental health.27 Despite the lack of data from many LMIC settings, funding for child and adolescent mental health services was found to be rare, with a general lack of child mental health policy implementation, even in countries which possessed such policies.28

Adulthood The association between poverty and mental health may be particularly pronounced for women, often already vulnerable to higher rates of discrimination in terms of education and access to employment, particularly in LMICs.29 In their now classic 1999 report on women, poverty and common mental disorders in four LMICs, Patel et al. confirmed that female gender, low education and poverty were all associated with increased risk for mental health problems.30 These associations were evident even when the general population’s level of poverty was less pronounced, suggesting that it is not merely poverty, but relative poverty that increases the risk of mental health problems. A study from a resource-poor area of Ethiopia found that beyond the context

25 Embleton, L., Mwangi, A., Vreeman, R., et al. (2013), The epidemiology of substance use among street children in resource-constrained settings: a systematic review and meta-analysis, Addiction, 108(10): 1722–1733. 26 Pascoe, S. J., Langhaug, L. F., Mavhu, W., et al. (2015), Poverty, food insufficiency and HIV infection and sexual behaviour among young rural Zimbabwean women, PLoS ONE, 10: 1. 27 WHO (2005), Atlas Child and Adolescent Mental Health Resources: Global Concerns: Implications for the Future (World Psychiatric Association; WHO; International Association for Child and Adolescent Psychiatry and Allied Professions). Available at: www.who.int/mental_health/publications/ atlas_child_ado/en/. 28 Belfer, M. L. (2008), Child and adolescent mental disorders: the magnitude of the problem across the globe, J Child Psychol Psychiatry, 49(3): 226–236; Kieling, C., Baker-Henningham, H., Belfer, M., et al. (2011), Child and adolescent mental health worldwide: evidence for action, The Lancet, 378(9801): 1515–1525. 29 For a comprehensive consideration of the link between gender (and particularly women) and mental health, see Chapter 8 of this book by Carol Vlassoff. 30 Patel, V., Araya, R., de Lima, M., et al. (1999), Women, poverty and common mental disorders in four restructuring societies, Soc Sci Med, 49(11): 1461–1471.

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of general poverty, women of a reproductive age who lived in particularly poor economic conditions were at increased risk of depression.31 Having poorer socioeconomic status was associated with increased risk for common mental disorders, whilst having more education and a permanent job were associated with decreased risk. A recent study in India32 found that amongst adult women attending health services, more than 20% screened positive for common mental health problems, but nearly all (81.9%) reported not previously having been diagnosed, despite having received services from a health care provider within the past year. Those women who did screen positive had worse self-reported health, had received more health care visits in the prior year, and reported spending more money on health care, worsening their already poor economic status. In addition to the general risks associated with poverty, women living in poverty in LMICs are frequently at increased risk of experiencing gender-based and intimate partner violence. In LMICs, women often have fewer social and economic opportunities compared with men, based on unequal access to education, fewer employment opportunities and often restrictive gender roles based on male control and female subservience.33 Multiple studies in LMICs highlight the interrelationship between poverty, violence and poor mental health.34 A population-based study of married women in rural India found that low education, low standard of living, and recent intimate partner violence (IPV) were all related to increased risk for common mental disorders, along with husbands’ alcohol use and women’s tobacco use.35 In a study of perinatal women in Timor Leste, regression analyses showed that IPV and traumas related to historical mass conflict were significantly associated with the presence of depression symptoms. It also found that human rights-related trauma and IPV were related to post-traumatic stress disorder (PTSD) symptoms, as well as continuing adversity.36 Although female gender is an important correlate of increased risk for mental health problems in LMICs, the association between poverty-related factors and increased risk of mental health problems is also relevant for men in such countries.37 In their study from South Africa, Ardington et al. found that for both men and women, socioeconomic status was a strong predictor of depression, with correlates being reduced income, fewer assets, and lower educational attainment.38

31 Deyessa, N., Berhane, Y., Alem, A., et al. (2008), Depression among women in rural Ethiopia as related to socioeconomic factors: a community-based study on women in reproductive age groups, Scand J Public Health, 36(6): 589–597. 32 Soni, A., Fahey, N., Byatt, N., et al. (2016), Association of common mental disorder symptoms with health and healthcare factors among women in rural western India: results of a cross-sectional survey, BMJ Open, 6(7): e010834. 33 See, e.g., Jewkes, R., Flood, M., & Lang, J. (2015), From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls, The Lancet, 385(9977): 1580–1589; Michau, L., Horn, J., Bank, A., et al. (2015), Prevention of violence against women and girls: lessons from practice, The Lancet, 385(9978): 1672–1684. 34 Ellsberg, M., Jansen, H. A., Heise, L., et al. (2008), Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study, The Lancet, 371(9619): 1165–1172. 35 Shidhaye, R. & Patel, V. (2010), Association of socio-economic, gender and health factors with common mental disorders in women: a population-based study of 5703 married rural women in India, Int J Epidemiol, 39(6): 1510–1521. 36 Silove, D., Rees, S., Tay, A. K., et al. (2015), Pathways to perinatal depressive symptoms after mass conflict in Timor-Leste: a modelling analysis using cross-sectional data, The Lancet Psychiatry, 2(2): 161–167. 37 For a consideration of men and mental health, see Chapter 9 of this book by Svend Aage Madsen. 38 Ardington, C. & Case, A. (2010), Interactions between Mental Health and Socioeconomic Status in the South African National Income Dynamics Study, Journal for Studies in Economics and Econometrics, 34(3): 69–84.

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Promising strategies for breaking the cycle of poverty and mental ill-health Prevention of mental health problems in the first place is one way to interrupt the cycle of poverty and poor mental health. Prevention strategies that intervene during a child’s first few years of life set the stage for promoting neurological and social development, and form the physical, social, cognitive, and emotional foundations for subsequent development. For children in extreme circumstances (such as those living in severe poverty), research has found that weak foundations in early childhood increase the risk of difficulties with learning, problematic behaviours, and potentially long-term physical and mental health problems.39 As noted above, children who are delayed in their cognitive development in early childhood are at risk of not fulfilling their educational potential, which puts them at a disadvantage for later employment.40 Programmes targeting cognitive development and neurodevelopment in early childhood can reduce mental health problems and improve wellbeing in later life. One study found that a standard deviation cognitive gain in pre-school-aged children would confer the benefits of an estimated minimum of an additional two-thirds of a year of schooling.41 Thus, parenting programmes that target child development outcomes are a promising prevention approach increasingly being implemented and evaluated in low-resource countries such as Bangladesh,42 South Africa,43 and Uganda.44 An example is the Mediational Intervention for Sensitizing Caregivers (MISC). The MISC model teaches caregivers to use materials they already have in their home and general environment to engage in specific activities with their child. These are intended to improve attention and focus, help the child to relate different objects with different activities (thereby improving depth and meaning in interactions), encourage the child to try new things, and expand upon the activities in which they regularly engage. They can also assist the child in regulating their emotions and reactions when frustration and conflict arise. This parenting intervention has been tested in Uganda amongst HIV-infected children45 and HIV-exposed but uninfected children,46 and in Ethiopia amongst urban poor families.47 It was found to be effective for improving a range of child cognitive and developmental outcomes, including expressive and receptive language skills and attention.

39 Shonkoff, J. P. (2010), Building a new biodevelopmental framework to guide the future of early childhood policy, Child Dev, 81(1): 357–367. 40 Knudsen, E. I., Heckman, J. J., Cameron, J. L., & Shonkoff, J. P. (2006), Economic, neurobiological, and behavioral perspectives on building America’s future workforce, Proc Natl Acad Sci USA, 103(27): 10155–10162. 41 Engle, P. L. (2007), Parenting programme for child development, J Health Popul Nutr, 25(1): 1–2. 42 Aboud, F. E., Singla, D. R., Nahil, M. I., & Borisova, I. (2013), Effectiveness of a parenting program in Bangladesh to address early childhood health, growth and development, Soc Sci Med, 97: 250–258. 43 Dowdall, N., Cooper, P. J., Tomlinson, M., et al. (2017), The Benefits of Early Book Sharing (BEBS) for child cognitive and socio-emotional development in South Africa: study protocol for a randomised controlled trial, Trials, 18(1): 118. 44 Singla, D. R., Kumbakumba, E., & Aboud, F. E. (2015), Effects of a parenting intervention to address maternal psychological wellbeing and child development and growth in rural Uganda: a communitybased, cluster randomised trial, Lancet Glob Health, 3(8): e458–469. 45 Boivin, M. J., Nakasujja, N., Familiar-Lopez, I., et al. (2017), Effect of Caregiver Training on the Neurodevelopment of HIV-exposed Uninfected Children and Caregiver Mental Health: A Ugandan Cluster-randomized Controlled Trial, J Dev Behav Pediatr, 38(9): 753–764. 46 Bass, J. K., Opoka, R., Familiar, I., et al. (2017), Randomized controlled trial of caregiver training for HIV-infected child neurodevelopment and caregiver well-being, AIDS, 31(13): 1877–1883. 47 Klein, P. S. H. R. (2004), Interaction-oriented early intervention in Ethiopia: the MISC approach, Infants and Young Children, 17(4): 340–354.

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Historically, one of the limiting factors in the availability of mental health services in LMICs is the lack of mental health professionals to provide care.48 Where human resources exist, they are generally based in central, urban centres, limiting access by a majority of the country’s population. The WHO Mental Health Atlas, which reports on the policy, financial and human resources devoted to mental health services globally, estimated that the median number of mental health workers is below 1 per 100,000 population in low-income countries.49 To address this challenge, the field has moved towards practical, task-sharing approaches. The task-sharing model has expanded and improved upon the task-shifting approach; task-sharing has been proposed as a solution to the limited health care access in LMICs through the training of non-medical healthcare workers to provide services traditionally provided by medical professionals.50 For mental health services, task-sharing utilises non-mental health professionals to provide direct mental health services under the supervision of, and with referral to, professionals with more mental health training. Thus, the care of the patient is shared by the non-professional and the professionals. This fits with SDG target 3.c: ‘to increase . . . the recruitment, development, training and retention of the health workforce in developing countries’ by expanding the categories of those who can be considered part of the mental health workforce in LMICs. To provide mental health services where no mental health professionals exist, evidence is growing that task-sharing can be an effective strategy, together with continued training and strengthening of mental health care professionals.51 Bass et al. implemented a task-sharing approach in the trial of a cognitive behaviour-based therapy for the treatment of depression and post-trauma symptoms amongst female survivors of gender-based violence in eastern Democratic Republic of Congo.52 Prior to initiation of the study, there was already a system of care in the villages through local NGOs which had provided psychosocial assistants for basic counselling and case management for survivors. For the study, these psychosocial assistants, most of whom had some secondary school education, were trained by US-based clinicians in a specific talk therapy, Cognitive Processing Therapy. Concurrent to the training of the psychosocial assistants, local staff from the collaborating international NGO, International Rescue Committee, were trained to be supervisors in this therapy. These supervisors had more experience with psychosocial and mental health programming, but were not mental health professionals. To provide one more level of mental health support during the study, a US-trained social worker originally from West Africa provided overall supervision and support for all of the supervisors and providers of the therapy. Once they completed the two week in-person training, the psychosocial assistants participated in

48 For more on the problem of human resource shortages, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson. 49 WHO (2015), Mental Health Atlas 2014. Available at www.who.int/mental_health/evidence/atlas/ mental_health_atlas_2014/en/. 50 Joshi, R., Alim, M., Kengne, A. P., et al. (2014), Task shifting for non-communicable disease management in low and middle income countries—a systematic review, PLoS One, 9(8): e103754. For more on task-shifting and task-sharing approaches, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, Chapter 5 by Chris Underhill, Victoria K. Ngo, and Tam Nguyen, Chapter 11 by Cornelius Ani and Olayinka Omigbodun, and Chapter 12 by Stephen J. Bartels. 51 van Ginneken, N., Tharyan, P., Lewin, S., et al. (2013), Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries, Cochrane Database Syst Rev, 19(11): Cd009149. 52 Bass, J. K., Annan, J., Murray, S. M., et al. (2013), Controlled trial of psychotherapy for sexual violence survivors in DR Congo, New England Journal of Medicine, 368: 2182–2191.

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an apprenticeship model of training,53 where they received ongoing training through role play and supervision support as they provided the treatment to women in their own communities. Results of the study indicated that the intervention was successful in reducing the burden of mental health problems and improving functioning, so the psychosocial assistants from the control villages received training in the therapy, and received regular support and supervision to provide it to the women in their communities. Whilst multiple studies have shown that task-sharing is a promising approach to reducing the treatment gap, Padmanathan & de Silva point out that there are sometimes barriers to the acceptability and feasibility of task-sharing models which would need to be overcome if such intervention strategies are to be sustainable.54 Amongst these barriers are the stress and burden experienced by the task-sharing providers, their own perceived level of competence and confidence in the appropriate provision of services, and acceptance of the task-sharing providers by other health care professionals. In addition, financial and career incentives are frequently inadequate to retain the task-sharing providers in their defined roles. In addition to task-sharing, some countries are working to expand the availability of the professional mental health workforce, with a particular focus on nurses.55 For example, Ethiopia developed a psychiatric nursing training programme to facilitate the dispersion of trained nurses throughout the country. Their activities include being able to prescribe and monitor psychotropic medicine, as well as to provide early identification and prevention services for mental and behavioural disorders.56 Another approach taken by service providers and researchers to try to address the link between poverty and mental health problems has been to implement poverty reduction programmes. Such a strategy would have the dual advantage for states of meeting SDG1 (the requirement to end poverty), and SDG2 (the need to end hunger) at the same time as SDG3. An early study by Fernald et al. in South Africa found that a loan programme that improved access to credit did not improve depressive symptoms in the sample overall, although amongst men, increased access to credit did result in reduced depressive symptoms.57 Research into cash transfer programming has found positive mental health impact, with a study by Ozer et al. of a conditional cash transfer programme for Mexican women resulting in reduced self-reported depression scores.58 Research by Haushofer & Shapiro relating to an unconditional cash transfer programme in Kenya resulted in improved self-reported distress and depression.59

53 Murray, L. K., Dorsey, S., Bolton, P., et al. (2011), Building Capacity in Mental Health Interventions in Low Resource Countries: An Apprenticeship Model for Training Local Providers, International Journal of Mental Health Systems, 5(1): 30. 54 Padmanathan, P. & De Silva, M. J. (2013), The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: a systematic review, Soc Sci Med, 97: 82–86. 55 Barrett, T., Boeck, R., Fusco, C., et al. (2009), Nurses are the key to improving mental health services in low- and middle-income countries, Int Nurs Rev, 56(1): 138–141. 56 Araya, M., Mussie, M., & Jacobson, L. (2009), Decentralized psychiatric nursing service in Ethiopia—a model for low income countries, Ethiop Med J, 47(1): 61–64. 57 Fernald, L. C., Hamad, R., Karlan, D., et al. (2008), Small individual loans and mental health: a randomized controlled trial among South African adults, BMC Public Health, 8: 409. 58 Ozer, E. J., Fernald, L. C., Weber, A., et al. (2011), Does alleviating poverty affect mothers’ depressive symptoms? A quasi-experimental investigation of Mexico’s Oportunidades programme, Int J Epidemiol, 40(6): 1565–1576. 59 Haushofer, J. & Shapiro, J. (2013), Household Response to Income Changes: Evidence from an Unconditional Cash Transfer Program (Boston: Massachusetts Institute of Technology).

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However, studies that have utilised other economic intervention strategies have not found such impacts. A study by Green et al. of a general village-based poverty alleviation programme in Uganda that included business training, start-up capital, and follow-up support found that after 16 months, cash earnings had increased substantially, yet there was no impact on depressive symptoms.60 Similarly, a study by Bass et al. of a Village Savings and Loan Association (VSLA) programme amongst rural female Congolese survivors of sexual violence found increases in financial savings, but no impact on reduction in depression, anxiety or PTSD symptoms in comparison to women who were on a waiting list to participate in the VSLA programme after the study was complete.61 It may be that these latter interventions did not have a strong enough financial impact to influence mental health directly, or that other contributing factors such as trauma exposure may limit the ability of economic programming alone to reduce mental health problems. The evidence to date would suggest that there ought to be a combined approach to meeting SDG3, with economic assistance provided at the same time as mental health support and treatment.

Conclusion The evidence continues to mount that poverty and mental health problems are intricately linked, and that populations in many LMICs suffer disproportionately from that dual burden due to the contextual nature of poverty and the accompanying risk factors associated with mental health problems. The UN SDGs are the latest global initiative to try to address systematic development issues in all countries, and the inclusion of mental health within the wellbeing construct in SDG3 and its targets following the MDGs (in which they received no mention) provides hope that mental health issues will be better addressed. To do so, mental health must be included in the health and economic programmes developed by different states to meet the SDG targets. Mental health problems have a direct impact on the functioning of individuals, as well as on their families and, at the group level, on the communities in which affected people live. Although more research is needed to understand how addressing poverty-related factors can impact upon mental health, it is clear that addressing mental health effectively will have economic benefits across the person’s lifespan—from improving educational chances to increasing positive work-related outcomes.

60 Green, E., Blattman, C., Jamison, J., & Annan, J. (2016), Does poverty alleviation decrease depression symptoms in post-conflict settings? A cluster-randomized trial of microenterprise assistance in Northern Uganda, Global Mental Health, 3(e7). Available at: doi: 10.1017/gmh.2015.28. 61 Bass, J., Murray, S., Cole, G., et al. (2016), Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo, Global Mental Health, 3(e19): 1–12.

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5 MENTAL HEALTH AND ECONOMIC DEVELOPMENT IN VIETNAM1 Chris Underhill*, Victoria K. Ngo†, and Tam Nguyen‡

Introduction Depression is the leading mental health burden worldwide,2 and women are at particular risk of depression, with prevalence rates ranging from one to three times that of men.3 Growing epidemiological evidence from around the world shows that poverty and mental illness, including depression, interact in a negative spiral, especially for women in low-income countries where cultures and norms are more patriarchal, gender roles more restrictive, and gender inequalities more pervasive. Although the link between poverty and depression is well established,4 few interventions exist to break this cycle. This chapter will provide background on the link between depression and poverty, and describe how the 2030 United Nations Sustainable Development Goals (SDGs), and particularly SDG3 which is focused on health and wellbeing, might be met through community-based interventions that address both poverty and mental health. A number of innovative programmes developed in Vietnam will be reviewed, and lessons learned from the implementation of these programmes will be discussed.

* Chris Underhill is a global mental health expert and social entrepreneur who has founded and directed numerous organisations to promote mental health for marginalised peoples, including BasicNeeds and citiesRISE. † Victoria K. Ngo is a behavioural scientist and Deputy Director of the Center for Innovations in Mental Health at the City University of New York Graduate School of Public Health & Health Policy (CUNY SPH), where she is an Associate Professor. ‡ Tam Nguyen is the Director of BasicNeeds Vietnam. 1 We are grateful to Trung Tu Lam of MD Da Nang Psychiatric Hospital who co-directed the LIFE-DM program for his valuable insights and input into this chapter. 2 Murray, C. J., Vos, T., Lozano, R., et al. (2013), Disability-Adjusted Life Years (DALYS) for 291 Diseases and Injuries in 21 Regions, 1990–2010: A Systematic Analysis for the Global Burden of Disease Study 2010, The Lancet, 380(9859): 2197–2223. 3 WHO (1997), Nations for Mental Health: Gender Differences in Epidemiology of Affective Disorders and Schizophrenia (Geneva: WHO), pp.4–13. 4 On the link between poverty and mental health, see further Chapter 3 of this book by Martin Knapp and Valentina Iemmi, Chapter 4 by Judith Bass, and Chapter 8 by Carol Vlassoff.

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Mental health and development One of the key challenges associated with sustainable development is the rise of non-communicable diseases (NCDs) which are often chronic in nature, including heart disease, diabetes, cancer, and mental illnesses. Each year, NCDs cause 16 million premature deaths before the age of 70, and they affect disproportionately low- and middle-income countries (LMICs).5 Therefore, the reduction of NCDs is a major development challenge. An ageing population, longer life expectancy, population growth, urbanisation, and globalisation of risk factors have made NCDs a threat to worldwide development and economic growth, and an urgent global health priority.6 It is estimated that NCDs pose a substantial economic burden that will evolve into a staggering global output loss of US$47 trillion over the next two decades, with mental illness and heart disease accounting for the highest cost. The cost of mental illness alone is expected to reach US$6 trillion globally over the next 15 years.7 Yet, on average, governments spend less than US$2 per person per year on mental health care, with a 200-fold difference in per capita expenditures between high-income and low-income countries.8 Although effective and simple treatments exist,9 the treatment gap exceeds 50% in all countries in the world, and approaches 90% in the least resourced countries.10 Around the globe, mental illness is highly stigmatised, misunderstood, and neglected. Government investment in mental health services remains low, and therefore mental health human resource capacity and services remain limited, particularly in LMICs11 (one of the major reasons for the large treatment gap in such countries). Depression is particularly harmful as it can cause unproductivity in those who suffer from it who otherwise would be productive. In addition to depression diminishing work capacity, it increases mortality from comorbid health conditions12 and suicide.13 The WHO conducted a study using data from 36 countries showing the high return on investment for scaling-up of evidence-based depression care.14 It is estimated that if depression were left untreated, it would

5 WHO (2016), Non-communicable Diseases Progress Monitor 2015 (Geneva: WHO). 6 Ngo, V., Rubinstein, A., Ganju, V., et al. (2013), Grand Challenges: Integrating Mental Health Care into the Non-communicable Disease Agenda, PLoS Medicine, 10(5): 1–5. 7 Bloom, D., Cafiero, E., Jane-Llopis, E., et al. (2011), The Global Economic Burden of Non-communicable Diseases (Geneva: World Economic Forum). For more on the economic argument for increased spending on mental health, see Chapter 3 of this book by Martin Knapp and Valentina Iemmi. 8 WHO (2015), Mental Health Atlas 2014 (Geneva: WHO). 9 WHO (2008), mhGAP: Mental Health Gap Action Programme: Scaling up Care for Mental, Neurological and Substance Use Disorders (Geneva: WHO). 10 Kohn R., Saxena, S., Levav, I., & Saraceno, B., et al. (2004), The treatment gap in mental health care, Bull World Health Organization, 82(11): 858–866; Thornicroft, G., Chatterji, S., Evans-Lacko, S., et al. (2017), Undertreatment of people with major depressive disorder in 21 countries, British Journal of Psychiatry, 210(2): 119–124; Lora, A., Kohn, R., Levav, I., et al. (2012), Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries, Bull World Health Organization, 90(1): 47–54. 11 WHO (2015), op. cit., nt.8. 12 Prince, M., Patel, V., Saxena, S., et al. (2007), No health without mental health, The Lancet, 370(9580): 859–877. 13 Cavanagh, J., Carson, A., Sharpe, M., & Lawrie, S. (2003), Psychological autopsy studies of suicide: a systematic review, Psychol Med, 33: 395–405. 14 Chisholm, D., Sweeny, K., Sheehan, P., et al. (2016), Scaling-up treatment of depression and anxiety: a global return on investment analysis, Lancet Psychiatry, 3: 415–424.

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cost 50 million years of life in a year globally; a loss of an estimated US$925 billion.15 Investing in adequate depression care in the next 15 years would cost US$91 billion (if limited to only US$1.50 per person annually),16 and result in a return of US$480 billion when considering both health and economic returns over this period; a high yield with a five-to-one return.17 Left untreated, depression heightens the risk of poverty by negatively affecting economic productivity and impairing behavioural functioning, social interaction, and access to resources. Stressors associated with poverty contribute to the risk of depression development and its continuation. These two challenges act in a synergistic fashion to exacerbate each other, increasing feelings of hopelessness, the risk of other health problems,18 and greater exposure to negative life events—such as violence and trauma—which increases the risk of mental health problems. The existence of this negative downward cycle is supported by extensive epidemiological data showing a bi-directional association between poverty and depression.19 The need for increased development of mental health services represents a major challenge to sustainable development, and is a cross-cutting issue that is central to SDG3 on health and wellbeing, as well as to other Sustainable Development Goals such as poverty eradication (SDG1), the empowerment of girls and women (SDG5), and reduced inequality. The critical role of mental health in development was recognised by the United Nations in a historic move in the autumn of 2016 with the inclusion of wellbeing in the 2030 Agenda for Sustainable Development.20 One of the 17 SDGs, SDG3 focuses on ‘ensuring healthy lives and promoting well-being for all at all ages’, and now this goal includes a commitment to prevention and treatment of NCDs, including behavioural, developmental and neurological disorders. Specifically, target 3.4 requests that countries ‘[b]y 2030, reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being’. Given the central role of mental health and social determinants in the prevention and treatment of NCDs, in order to meet SDG3 and target 3.4 specifically, the development of comprehensive community-based models that integrate mental health and poverty alleviation strategies are essential. One such strategy, developed by RAND, Da Nang Psychiatric Hospital, and the NGO BasicNeeds in Vietnam, is a programme called LIFE-DM.21 It combines skill-based psychological interventions with microfinance services to break the downward cycle of depression and poverty for impoverished women. This programme may offer an innovative solution to other LMICs that integrates established evidence-based interventions for depression22 with poverty alleviation

15 16 17 18 19 20 21

22

Ibid. Ibid. Ibid. For more on the comorbidity of mental and physical health, see Chapter 1 of this book by Shekhar Saxena and Laura Davidson. Lund, C., Breen, A., Flisher, A. J., et al. (2010), Poverty and common mental disorders in low and middle income countries: a systematic review, Soc Sci Med, 71: 517–528. United Nations (2017), Transforming Our World: The 2030 Agenda for Sustainable Development, p.18. Available at: https://sustainabledevelopment.un.org/post2015/transformingourworld/publication. LIFE-DM was developed with funding from the US National Institute of Mental Health (NIMH R34MH094648–01A1; PI Victoria Ngo), a community-academic partnership between Da Nang Psychiatric Hospital, the Da Nang WU, the Da Nang Department of Health, the Da Nang People’s Committee, and BasicNeeds Vietnam. Ngo, V., Weiss, B., Lam, T., et al. (2014), The Vietnam Multicomponent Collaborative Care for Depression Program: Development of Depression Care for Low- and Middle-income Nations, Journal of Cognitive Psychotherapy, 28: 156–167.

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strategies that currently exist in many of them. The application of depression self-management skills (such as stress management and problem-solving strategies) on poverty stressors is particularly powerful, as it addresses key drivers that impact upon mental health and can empower the most vulnerable populations to have more control and self-efficacy to manage their health and livelihood. A community-based approach where these interventions can be task-shifted to non-mental health providers, such as primary care providers and lay health workers, is particularly useful to extend the reach of mental health services, particularly in settings where mental health human resources are limited.23 Efforts to task-shift depression care and support holistic programmes that teach skills to manage both mental health and livelihood stressors are needed to promote mental health and wellbeing for high risk populations.

Mental health in Asia and Vietnam Asia’s rapid development and large population make it a strategic and key player in global mental health and development due to its growing political and economic influence on the world stage. In the past decade, Asia has distinguished itself as the world’s most rapidly developing region, with Vietnam’s economy one of the fastest growing in the world. The region now accounts for more than 35% of world gross domestic product (GDP) in purchasing power parity terms, and rapid economic expansion is expected to continue. About 19% of Asia survives on less than US$1 daily.24 Further, human resource shortages, inadequate infrastructure across most sectors, and social and dramatic cultural shifts tax the emotional health of individuals, families, and communities, increasing the risk of stress-related mental health conditions. Unaddressed depression can cripple this emerging market through its detrimental impact on work functioning, days lost from work, and elevated health care costs. Although a number of Asian countries have been successful at establishing mental health policies, including Vietnam, these plans focus on severe mental health conditions, and are extremely underfunded. In Vietnam, only 0.44% of the health budget is allocated to mental health care, which is similar to allocations in Africa.25 Closing this treatment gap in Asia will have lasting development gains, as well as an economic and health impact beyond its borders, as successes here may serve as models for other countries which are also in transition. Vietnam is reported to be the 14th most populous country in the world. It currently has a population of more than 92 million people. The per capita annual gross domestic product (GDP) is US$1,596, which has resulted in a change from poor to LMIC national status.26 Hailed by many in the international community as an ‘economic success story’, the social consequences of such rapid growth are becoming ever more apparent in Vietnam. Due to the lack of investment in infrastructure relating to health, increased privatisation of services, geographical disparities, and a lack of suitably trained personnel, access to health care (particularly mental health care) has become more difficult for many. Despite the economic progress of the country, mental health services continue to lag behind and largely focus on institutionalisation of severe mental illness in psychiatric settings.

23 For more on task-shifting, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, Chapter 4 by Judith Bass, Chapter 6 by Sean A. Kidd and Kwame MacKenzie, Chapter 11 by Cornelius Ani and Olayinka Omigbodun, and Chapter 12 by Stephen J. Bartels. 24 World Bank (2014), Vietnam: World Development Indicators. Available at: data.worldbank.org/country/ vietnam. 25 Vuong, D. A., Van Ginneken, E., Morris, J., Ha, S. T., & Busse, R. (2011), Mental health in Vietnam: burden of disease and availability of services, Asian Journal of Psychiatry, 4: 65–70. 26 World Bank (2014), op. cit., nt.24.

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However, via recent revisions of the National Mental Health Plan,27 the government of Vietnam has focused increasingly on developing a community-based mental health system through the Ministry of Health (MOH) and Ministry of Labour, Invalids, and Social Affairs (MOLISA). The Plan introduces community mental health through the primary care system, which consists of four tiers: central (which includes national hospitals), provincial, district, and commune (which represents approximately 10,000 people).28 The Commune Health Station (CHS) is the primary point of entry into the health system. Access to mental health services is provided through a network of 27 provincial psychiatric hospitals distributed across the 63 provinces, or through mental health departments in district-level general hospitals. These facilities focus mainly on schizophrenia and epilepsy, with little emphasis by the government to date on more common mental health problems, such as depression and anxiety.29 In 1998, a move towards community-based mental health services was initiated that resulted in the country’s psychiatric hospitals supporting CHS management of mental health problems. As a result, limited pharmacological treatments are now available in some primary health care centres in Vietnam. However, mental health service delivery in these primary care clinics have continued to focus primarily on medication management for severe mental illness, with only a handful providing behavioural or psychosocial management of depression and anxiety. The latter is funded largely by international research or demonstration projects, such as those introduced by RAND and BasicNeeds, and their programmes are explored in the following section.

Community-based mental health service development in Vietnam Three major service development initiatives have been progressed in Vietnam that have shaped the evolution of community-based mental health services. These are the Multicomponent Collaborative Care for Depression model in Da Nang and Khanh Hoa province, the BasicNeeds Vietnam Mental Health Development project in the province of Thua Thien-Hue, and the Livelihood Integration for Effective Depression Management (LIFE-DM) in Da Nang.

Multicomponent Collaborative Care for Depression In early 2009, the Vietnam Veterans of America Foundation was funded by Atlantic Philanthropies to develop a community-based model of depression care for Vietnam. The authors’ team, including local implementation partners from Da Nang Psychiatric Hospital, Khanh Hoa Psychiatric Hospital, Vanderbilt University, and RAND, developed a stepped collaborative care programme called the Multicomponent Collaborative Care for Depression (MCCD), which was based on the Partners in Care collaborative care programme for depression developed in the United States,30 and the MANAS programme developed in India.31 During the

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Decision 1215/QDTTG, 22 July 2011. Vuong (2011), op. cit., nt.25. Ibid. Wells, K., Sherbourne, C., Schoenbaum, M., et al. (2000), Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial, JAMA, 283(2): 212–220. 31 Patel, V., Chisholm, D., Rabe-Hesketh, S., et al. (2003), Efficacy and cost-effectiveness of drug and psychological treatments for common mental disorders in general health care in Goa, India: a randomised, controlled trial, The Lancet, 361(9351): 33–39.

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formative phase of the demonstration project (from January to December 2009), the model was adapted for use in Vietnam.32 MCCD was based on a collaborative task-shifting model,33 where non-specialised personnel, such as primary care providers, are supported by mental health specialists to deliver depression care. This has been found to be an effective model for addressing human resource limitations in LMICs.34 CHS providers screen and assess for depression and provide psycho-education and guideline antidepressant medications, and/or individual therapy. The MCCD therapy sessions teach patients about the relationship between mood and activities, how to monitor the link between the two, and skills to identify and increase pleasurable and healthy activities. They also teach participants how to balance life demands and problem-solve, and to achieve goals. The programme trained psychiatrists and psychologists from the provincial psychiatric hospital to provide supportive supervision to primary care providers and lay community health workers at the commune health stations to implement MCCD in 12 communes. Across the programme, more than 40,000 individuals were screened for depression, with more than half of those who screened positive (2,541) followed up on the referral for assessment at the CHS. Of these, 914 were formally diagnosed with a depressive disorder, 92% of patients recommended for treatment accepted it, and 73% of patients completed treatment.35 A randomised control study of 475 participants comparing MCCD to guideline antidepressant medication found superior results for MCCD, showing significant improvements across mental health and functioning outcomes.36 The results suggest that a more comprehensive approach to depression that focuses on psychoeducation and behavioural skills appears to increase patients’ knowledge about their depression, problem-solving skills to resolve stressors, and ultimately self-management of mood problems relative to medication alone.

BasicNeeds Vietnam mental health and development model BasicNeeds is an international non-governmental organisation (NGO) which focuses on mental health. It has developed a comprehensive ‘mental health and development’ model for addressing the needs of people living with mental illness in poor communities in low-income countries. Established in 2000, BasicNeeds now has 16 programmes in 14 low-income countries,37 and was first introduced to Vietnam in 2011. BasicNeeds Vietnam sought to introduce an innovative and relevant model of community-based mental health and development, and aimed to assist with both the mental health and livelihood needs of the target groups in Thua Thien-Hue province.

32 33 34 35

Ngo (2014), op. cit., nt.22. See nt.23 above. Ngo (2014), op. cit., nt.22. Ngo, V. (2012), ‘Effectiveness of Depression Care for Vietnam’, paper presented to the ASEAN Mental Health Congress, Singapore, Nov. 36 Ngo, V., Lam, T., Weiss, B., Dang, T., Nguyen, M., & Nguyen, T. (2016) ‘The Incremental Value of Behavioral Activation Treatment Relative to Anti-depressant Medication for Depressed Patients in Vietnam: A Cluster Randomised Controlled Trial’, poster presented at Solving the Grand Challenges in Global Mental Health: Partnering for Impact at Scale, Toronto, Canada, June 2015. 37 See further at: www.mhinnovation.net/innovations/basicneeds-mental-health-and-development-model.

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BasicNeeds Vietnam worked with the CHS and the Women’s Union (WU), a quasigovernmental organisation that supports community-based social services for women throughout Vietnam, to set up five self-help groups for people with schizophrenia, epilepsy and anxiety. The groups offered peer support, psychoeducation, and livelihood support (including access to microfinance loans, and funds from a rotating credit in the group during times of crisis), advocacy in relation to entitlements, and training in enterprise activities.38 Many of the participants reported a reduction in their anxiety and stress about money, and reduced feelings of isolation.39 Some of the key achievements of the programme have included shifting the focus of treatment for mental illness away from the psychiatric hospital to CHS—the lowest level of the health system—making mental health services more accessible in Thua Thien-Hue. The introduction of a referral and treatment pathway for a more common mental health condition such as General Anxiety Disorder (GAD) has supported the continued evolution of the collaborative care model by extending it to anxiety disorders. This has facilitated significant learning and capacitybuilding in terms of training primary care providers to utilise a broader range of therapeutic interventions. The use of ‘task-shifting’ in relation to the diagnosis and treatment of anxiety has made the MHD model possible. People suffering from anxiety, schizophrenia and epilepsy were linked to livelihood support and opportunities. The strategy worked, bringing income into households where it had not existed previously, and having a significant impact upon the quality of care and support available to people previously viewed as capable of very little. The programme has challenged stereotypes and stigma by encouraging people to work together, and by making people with mental health difficulties more visible in their communities in a positive way. The programme, similar to MCCD, has provided further evidence that simple and brief sessions (usually three to seven) of manualised psychological therapy can be delivered by non-mental health professionals in the primary care system. Manualised treatments are psychotherapy treatments guided by a manual. Session goals and exercises are clear and explicit, making the therapy process highly transparent. This approach is ideal for task-shifting mental health by making it easier for providers without specialised mental health training to deliver mental health interventions.40 It contrasts with a more process-oriented supportive therapy approach where sessions tend to be free-flowing and guided by broader principles, rather than following a more rigid process. The introduction of such psychological treatments provides a viable alternative to medication for some people. Although initially challenging to set up, discussions with staff members at the CHS and district hospital suggested that their capacity to manage the programme and to provide the service improved significantly with supportive supervision. The promotion of a ‘stepped care’ or tiered approach to the treatment of mental health led to more effective use of existing resources in the community, particularly at the CHS, which reduced travel costs to the provincial psychiatric hospital—a major treatment barrier for clients. Lastly, payment for therapy at the CHS was made available to some patients from the Universal Insurance Fund, which made psychological treatment more accessible in the community. There have been a number of ongoing challenges for the programme, however. These have included a lack of leadership and support from the psychiatric hospital in Hue, capacity gaps at

38 Hand in Hand International. Available at: www.handinhandinternational.org/hand-in-hand-teams-upwith-care-to-fight-poverty-in-rwanda/. 39 See further BasicNeeds Vietnam Independent Final Evaluation Reports, BasicNeeds Annual Reports 2011–2014. Available at: www.basicneeds.org/resources/. 40 See nt.23 above.

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each level of the system and within the WU organisation, and ongoing training and supervision needs. The implementation experience with this programme highlighted the importance of setting up a collaboration between multiple organisations to create a network of care, and emphasised the need for continued and appropriate levels of funding. Despite these challenges, these task-shifting efforts utilising a collaborative care model demonstrated to all stakeholders, including those within the MoH—and those who were sceptical—that the integration of a mental health and development model is possible within the existing system.

Development and implementation of LIFE-DM In LMICs, a focus on women is a strategic and necessary high priority. They are a vulnerable population due to the gender inequities in education, economic opportunities, and social discrimination. They represent a high-risk group for both poverty and depression.41 Furthermore, poverty alleviation programmes such as microfinance which frequently target women have been found to have positive impacts on women’s socioeconomic status and social and emotional wellbeing.42 However, few microfinance programmes have integrated evidence-based mental health interventions, or evaluated such integration in a controlled study. To address the dual challenge of poverty and depression, RAND, Da Nang Psychiatric Hospital, and BasicNeeds Vietnam developed a programme called Livelihood Integration for Effective Depression Management (LIFE-DM); an innovative intervention that integrates evidence-based depression treatment with microfinance services to address both depression and poverty simultaneously. The programme expanded the MCCD model to include a community development approach,43 with the intervention focusing on both mood management and economic empowerment. Using the team-based model previously used in Vietnam, the programme was delivered by both health providers from CHS and microfinance providers from the WU. Like the BNVN MHD project in Thua Thien-Hue, CHS and the WU work together and are supported by local psychiatrists (or other mental health specialists) and a district level microfinance manager to facilitate the group-based depression treatment and microfinance services. In LIFE-DM, the integrated model offers 12 sessions of group therapy that uses two wellestablished evidence-based psychotherapies for depression, including behaviour activation (BA) and problem-solving therapy to address both depression and poverty simultaneously. BA focuses on increasing adaptive activities whilst decreasing activities that maintain depressed mood or inhibit adaptive activities through mood monitoring, activity scheduling, and engagement in pleasurable and healthy activities. Problem Solving Therapy is a cognitive-behavioural intervention using a systematic approach. It helps individuals increase their awareness and control of their problems by teaching skills to define and prioritise problems accurately, generate solutions, and take steps to solve those problems. The LIFE-DM group teaches skills to improve coping, encourage engagement in healthy activities, problem-solve stressors, and support communications and relationships to improve overall quality of life and functioning. Sessions on BA are introduced

41 See, e.g., Chapter 8 of this book by Carol Vlassoff; Patel, V., Lund, C., Hatherill, S., et al. (2009), Social Determinants of Mental Disorders. Priority Public Health Conditions: From Learning to Action on Social Determinants of Health (Geneva: WHO). 42 Lund, C., De Silva, M., Plagerson, S., et al. (2011), Poverty and mental disorders: breaking the cycle in low-income and middle-income countries, The Lancet, 378: 1565–1576. 43 Raja, S., Underhill, C., Shrestha, P., et al. (2012), Integrating mental health and development: a case study of the BasicNeeds Model in Nepal, PLoS Medicine, 9: e1001261.

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first to teach patients about the relationship between their activities and mood. The impact of lack of activity or social isolation on mood is discussed, including how this affects the ability to work and generate income. Participants are helped to identify behaviours which can improve their mood (such as a trip to the market to get some fresh air), as well as behaviours or activities in which they can engage to ensure and increase their livelihood (such as visiting the market to find out how much other vendors charge for their goods). In sessions where problem-solving skills are taught, the group discusses strategies to problem-solve barriers to activities that can help mood, as well as those related to income-generation. In addition, participants are offered small microfinance loans and encouraged to start a saving plan. Each participant develops a livelihood plan, learns personal finance management skills, such as budgeting and savings, and how to take small steps towards their financial goals. After the end of the 12-session LIFE-DM programme, women are encouraged to continue to meet monthly to support one another in their livelihood plans, and their loan repayment is collected. Led by the RAND Corporation, a controlled study was conducted comparing LIFE-DM with usual care (guideline antidepressant treatment) provided to 166 women.44 The programme was found to be more effective in improving depression, social support, self-efficacy, functioning, and economic outcomes for participants compared with usual care conditions at six and 12 months follow-up. Participants also reported family benefits, increased confidence, and improvements in mood management. Examples of treatment benefits found in the qualitative interviews included statements such as, ‘I feel like I’m 20 years younger’; ‘I have energy to do things I never thought I could do’; ‘I have more confidence to make money’; ‘The group is the most supportive thing in my life. Even my husband and son remind me to come to group every week because they notice how much happier I am.’45 Qualitative interview observations of group sessions found that stressors most discussed in groups were family issues, such as marital conflicts with husbands, lack of support from husbands, conflicts with in-laws, and challenges with child behaviour management. Nearly 25% of participants lived with in-laws, which is not unique to Vietnam, but characteristic of many collectivistic and traditional family structures in developing countries. In addition, nearly a third of the women reported domestic violence, which is generally more common in patriarchal societies.46 Many of the women complained about lack of support from their husbands, and feeling fatigued and overwhelmed as a result of responsibility for generating income as well as managing household duties. The latter concern arose from the expectation that the women must carry the larger load of the family burden, especially when married to husbands with poor functioning due to health issues, or to those unemployed or without an income. Although the study did not assess outcomes for husbands, women in the groups did express frustration about husbands’ alcohol consumption and the impact of intoxication on their wives’ wellbeing, and on overall family functioning. This is an issue commonly talked about, yet it is largely under-studied and should be considered when

44 The study was funded by the US National Institute of Mental Health (NIMH R34MH094648–01A1; PI Victoria K. Ngo), ClinicalTrials.gov registration NCT02069301. On mental health interventions for women in LMICs, see further Chapter 8 of this book by Carol Vlassoff. 45 Ngo, V., Trung, L., & Nguyen, T. (2016), ‘LIFE-DM: Breaking the Cycle of Depression and Poverty’, paper presented at the Innovations Fair Out of the Shadows: Making Mental Health a Global Health Priority, convened by the World Bank and the WHO, Washington, DC, Apr. 46 Do, K., Weiss, B., & Pollack, A. (2013), Cultural Beliefs, Intimate Partner Violence and Mental Health Functioning among Vietnamese Women, Int Perpective Psychology, 2(3). Available at: www.ncbi.nlm.nih. gov/pmc/articles/PMC3866026/.

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developing future programmes. The next phase of this programme will be extended in order to refer men to mental health services, and a family session will be added to the LIFE-DM group so that patients can invite their partners and adult care-givers to the group to support their mental health goals and livelihood plans.

Implementation and sustainability challenges Despite these successes, the programme also encountered numerous implementation challenges, including barriers to multi-sectoral collaborations which required intensive communitypartnered efforts to identify positive solutions for each sector. It was important to obtain political buy-in at all levels (local, provincial, and national) whilst simultaneously working top-down from national to provincial to commune level leadership, as well as bottom-up with local community members themselves to engage all levels of stakeholders. Although the programmes discussed were effective, it required tremendous human resources to engage, train, supervise, and support providers across the health system. Such difficulties were magnified, as BasicNeeds Vietnam and RAND were not national organisations, and supported the programme with outside funding. For this reason, it was essential to leverage other multi-ministry policy initiatives, such as health insurance plans, ministry collaborative policies, and other national priorities to integrate the programme fully into the existing health and social systems. Although these community-based programmes were designed to dovetail with the government system through the primary care system and poverty alleviation programmes offered by the WU, the sustainability of the existing system will require ongoing commitments in relation to loan availability, particularly for depressed women. The ongoing shortage of health providers and the common practice in Vietnam (and in other LMICs) of promoting effective health providers to serve in leadership positions, especially those who had received training from MCCD, BNVN, and LIFE-DM, is a challenge to the sustainability of community-based services. Other challenges to sustainability included the poor level of local capacity in this regard. Across these programmes, local teams of providers received ‘Trainers of Trainers’ workshops, although this had mixed results, as high-quality trainers required longer-term specialised training, rather than the project-based training opportunities available. A further issue that is likely to impact on sustainability is the degree to which local leaders become involved in the programme. The programme’s efforts to engage the wider community and local leaders was somewhat mixed and resulted in an over-reliance on the community collaborators (the village health worker and the WU commune collaborator) to refer people to the system and to support the intervention. Although this increased access to services, the village health network was relatively weak, with huge variation in ability and commitment. Sustainability also requires an increased awareness of the available services within the community, and an improved willingness to request access to therapy and livelihood/microfinance support.

Lessons learned Important lessons were learned during the development and implementation of these communitybased programmes which can further improve the support of mental health services in Vietnam. First, despite the many challenges, it has been possible in the Vietnamese context to develop and implement successfully a collaborative stepped-care model for Common Mental Disorders in general, and for depression specifically. Whilst the LIFE-DM programme has been successful, the service capacity of the system was less than originally thought, with an under-estimation of the level of resistance to change, particularly at the higher levels of the system. Future programmes 78

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intend to carry out a very detailed assessment of the personalities of those in leadership positions within the local psychiatric hospital and the WU, including their style of leadership and their previous record in relation to supporting and leading innovation within the system. In addition, the selection of the CHS and its staff, in addition to health collaborators to work in the programme, needs to take into account their passion, dynamism, and willingness to engage with the community, as opposed to their medical training and expertise. For the most part, training in mental health can be provided and skills for mental health tasks can be developed with supportive supervision. However, ‘soft’ skills to engage and retain mental health patients are essential to develop the new services that focus on patient self-management and empowerment, versus the usual drug-based treatments provided in primary care settings. Similarly, key criteria for the WU staff at lower levels who work directly with psychiatric patients are communication, community and family engagement, problem-solving orientation, and a supportive attitude. In LIFE-DM, the role of the WU expanded from simple screening of referrals and loan collection to a more central role in the delivery of the depression groups. Therefore, on-going supervision needs to focus more on supporting mental health as well as helping workers to generate ‘soft’ skills. Across all programmes, the role of key personnel from the CHS and the WU in taking initiatives and leading the local efforts was critical to the sustainment of the services. Thus, it is suggested for other such programmes that there should be a greater emphasis upon developing champions of the programme itself who are internal to the system. When it comes to creating structures which are aimed at increasing collaboration and dialogue within the system, the LIFE-DM team found it essential to be very involved in the process and to advocate for the inclusion of other stakeholders, such as relevant government departments, as well as representatives from the business and NGO sectors. The choice of the WU as a partner in the current programme has been very effective in ensuring that women, and economic issues affecting women, are treated as priorities. Improving the situation of women simultaneously improves the situation of the family.47 Furthermore, by improving mental health, the economic development of the nation is also advanced. With interventions such as LIFE-DM and BNVN, it is possible to break the cycle of depression and poverty, and to do so in settings where resources are limited. The programmes have been designed and developed in a way that aims to maximise sustainability and integration into the existing structures, whilst at the same time trying to change these very structures for the better. However, the work of the programmes has only begun, and it will require support for many more years. It will be important to engage continuously with all stakeholders to raise awareness about the relationship between mental health, health, and poverty, particularly for women, in order to make mental health a more central and strategic priority for economic development. The current convergence of international efforts to address mental health goals provide the global health community with a great opportunity to further improve promising communitybased service models and implement innovative solutions to reach SDG3 and meet wellbeing target 3.4. This series of mental health programmes in Vietnam provides a way to address the worrisome human resource shortages in mental health services in LMICs through simple, evidence-based interventions, easily transferrable for use by non-clinicians. The key is the utilisation of existing health infrastructure such as primary care services. The methods used within the

47 There is a considerable body of evidence that assisting women into income-generating activities is much more effective in reducing poverty for this reason. For more on this, see Chapter 8 of this book by Carol Vlassoff.

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programmes draw from a wealth of practices that already exist, but in Vietnam they have been simplified and restructured so that they can be more easily adapted to the low-resource setting. The clinical interventions themselves also address broader issues that impact mental health and wellbeing by teaching skills of self-management of mental health symptoms, coping and problemsolving strategies for life stressors, as well as providing livelihood support through microfinance loans. For individuals in LMICs, it is particularly critical that interventions are holistic, integrative, and address the psychological, sociocultural, and economic pressures that influence mental health and wellbeing. It is to be hoped that the Vietnamese model can be reproduced in other LMICs with appropriate cultural adaptations in order to meet SDG3 and other crosscutting UN goals.

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6 SOCIAL ENTREPRENEURSHIP AND SYSTEMS THINKING ABOUT MENTAL ILLNESS IN LOW- AND MIDDLE-INCOME COUNTRIES Sean A. Kidd* and Kwame McKenzie† Introduction Ensuring healthy lives and promoting wellbeing for all at all ages in accordance with UN Sustainable Development Goal 3 (SDG3) cannot be accomplished without close attention being paid to threats to mental health leading to mental illness or addiction. This is a globally relevant point, given the high burden of mental illness,1 and investments in mental health-related care and prevention that are badly out of proportion to that burden.2 This is a challenge pertinent to most countries, as there is an under-resourcing in high income contexts also.3 However, in lowand lower-middle-income countries (LMICs) this disparity is compounded both with respect to investment, and insufficiencies in broader infrastructure.4 As the burden of mental illness in LMICs has become better articulated, so too has the response to it, the most prominent of which has been a movement towards generating evidence for clear and replicable approaches, designed through models such as stepped care and

* Sean Kidd is the Division Chief of Psychology at the Centre for Addiction and Mental Health (CAMH) and an Associate Professor in the Psychiatry Department of the University of Toronto who co-founded the Social Entrepreneurism in Mental Health (SEMH) research group. † Kwame McKenzie is the CEO of the Wellesley Institute, Toronto, a Professor of Psychiatry at the University of Toronto, and the Director of Clinical Health Equity at CAMH. 1 WHO (2013), Mental Health Action Plan 2013–2020 (Geneva: WHO). 2 See, e.g., Patel, V., Chisholm, D., Parikh, R., et al. (2016), Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, The Lancet, 387(10028): 1672–1685. 3 See, e.g., Kidd, S. A. & McKenzie, K. J. (2014), Social Entrepreneurship and Services for Marginalized Groups, Ethnicity and Inequalities in Health and Social Care, 7(1): 3–13. 4 Jacob, K. S., Sharan, P., Mirza, I., et al. (2007), Mental health systems in countries: Where are we now?, The Lancet, 370: 1061–1077. doi:10.1016/S0140-6736(07)61241-0; Patel, V., Chisholm, D., Parikh, R., et al. (2016), Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, The Lancet, 387(10028): 1672–1685; and Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007), Resources for mental health: scarcity, inequity, and inefficiency, The Lancet, 370: 878–889. Available at doi:10.1016/S0140-6736(07)61239-2.

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task-shifting to accommodate resource limitations in LMICs.5 Such approaches go through formal tests of feasibility and outcome, randomised controlled trials, and subsequent ‘scaling up’ of the intervention by implementing it in more sites whilst continuing to investigate and compare outcomes.6 This paradigm, if it might be referred to as that, was catalysed into a global mental health (GMH) movement in 2007 following the publication of an influential series of papers in The Lancet journal and a call to action.7 This led to unprecedented activity and investment in global mental health, including the development of hundreds of initiatives that follow the GMH model8 and the creation of funding mechanisms structured to support it, such as Grand Challenges Canada.9 This emphasis upon standardisation, clinical trials, and scaling-up has not been without some controversy. Some have suggested that the GMH movement is imposing a Western, biomedical conceptualisation of mental illness and treatment that pathologises individuals for normal reactions to social determinant-driven problems.10 There are also concerns that the GMH model obscures or discourages grassroots types of approaches, and leads to interventions lacking local and cultural relevance. As argued by Kirmayer and Pederson,11 the most productive path would appear to lie in a balanced approach that considers the many benefits of scaled-up, evidence-based approaches, whilst carefully attending to the social determinant, cultural and contextual processes in which they are implemented. The challenge is that, unlike the task of articulating and manualising the core technical aspects of a given intervention, capturing and replicating ‘non-technical’ factors such as leadership, partnership, and local understandings of mental illness and intervention is relatively difficult. Social entrepreneurship is an umbrella concept which has some value in articulating non-technical considerations in the generation of solutions to mental health challenges in LMICs.12 Social entrepreneurs have been characterised as individuals and groups who develop highly flexible, grassroots approaches to solving social problems that effectively bridge gaps between multiple sectors and systems.13 They focus on problems minimally addressed by others, build social value and capital, continuously modify and iterate, are highly embedded in

5 For more on task-shifting, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, Chapter 4 by Judith Bass, 5 by Chris Underhill, Victoria K. Ngo, and Tam Nguyen, Chapter 11 by Cornelius Ani and Olayinka Omigbodun, Chapter 12 by Stephen J. Bartels. 6 Eaton, J., McCay, L., Semrau, M., et al. (2011), Scale up of services for mental health in low-income and middle-income countries, The Lancet, 378(9802): 1592–1603. 7 Chisholm, D., Flisher, A. J., Lund, C., et al. (2007), Scale up services for mental disorders: a call for action, The Lancet, 370(9594): 1241–1252; Patel, V. (2012), Global mental health: from science to action, Harvard Review of Psychiatry, 20(1): 6–12. 8 Such as www.mhinnovation.net. 9 For more on Grand Challenges Canada, see Chapter 1 of this book by Shekhar Saxena and Laura Davidson. 10 See, e.g., Whitley, R. (2015), Global Mental Health: concepts, conflicts and controversies, Epidemiology and Psychiatric Sciences, 24(4): 285–291. See also Chapter 15 of this book by Dainius Pu¯ras and Julie Hannah and Chapter 17 by Peter Lehmann. 11 Kirmayer, L. J. & Pedersen, D. (2014), Toward a new architecture for global mental health, Transcultural Psychiatry, 51(6): 759–776. 12 Kidd, S. A., Madan, A., Rallabandi, S., et al. (2016), A Multiple Case Study of Mental Health Interventions in Middle Income Countries: Considering the Science of Delivery, PLOS ONE, 11(3): e0152083. 13 Drayton, W., Brown, C., & Hillhouse, K. (2006), Integrating social entrepreneurs into the ‘health for all’ formula, Bulletin of the World Health Organization, 84(8): 591; D. Bornstein (2007), Change the World: Social Entrepreneurs and the Power of New Ideas (Oxford: Oxford University Press).

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networks related to their work, and generate sustainable approaches.14 Such frameworks have been extensively employed by organisations such as Ashoka15 and the Skoll Foundation16 to identify interventions that may seem radically different from standard approaches, yet are viable or show promise of viability. Social entrepreneurship is often confused or conflated with social enterprise. A social enterprise is a business in which social impact is the primary (or otherwise emphasised) objective rather than financial gain—and is operated by a social entrepreneur.17 Social entrepreneurship refers more broadly to social entrepreneur-driven interventions that may or may not involve social enterprises/businesses. Studies examining social entrepreneurship globally have found that much of this type of work has focused directly or indirectly upon health,18 albeit less so on mental health.19 In contexts where more standard biomedical approaches have not been developed or where implementation has failed, social entrepreneurs have had considerable success through the application of a systems lens to mental illness, generating culturally and contextually relevant interventions that engage complex social determinants of illness. Moreover, through leveraged approaches that maximise the impact of scarce resources, and intensive policy and public engagement, social entrepreneurs in mental health have demonstrated many viable initiatives. Such a tailoring of approach, with close attention paid to technical and non-technical aspects of intervention not bound to a primarily biomedical conceptualisation of the problems addressed, encapsulates the system dynamics frame which it is argued herein is a hallmark of social entrepreneurship in LMIC mental health. This chapter describes such models for social entrepreneurship in mental health in LMICs which grew out of intensive case studies with some of the leading examples globally,20 and a review of expert perspectives and the relevant literature.21 This model of practice describes the kind of non-specific, culturally and contextually driven approaches that, arguably, are the best enablers of scaled, technical interventions propagated in the GMH movement. Furthermore, it is argued that this type of conceptualisation for addressing mental health challenges is essential to the aspirations of SDG3. The chapter provides case studies to illustrate the key emerging elements of social entrepreneurship. Finally, a system dynamics model of mental health intervention in LMICs is proposed.

14 Bornstein (2007), ibid.; Myers, P. & Nelson, T. (2011), ‘Considering social capital in context of social entrepreneurship’, in A. Fayolle & H. Matley (eds), Handbook of Research on Social Entrepreneurship (Cheltenham: Edward Elgar); Shaw, E. & Carter, S. (2007), Social entrepreneurship: theoretical antecedents and empirical analysis of entrepreneurial processes and outcomes, Journal of Small Business and Enterprise Development, 14: 418–434. 15 More information at: www.ashoka.org. 16 More information at: www.skoll.org. 17 Galera, G. & Borzaga, C. (2009), Social enterprise: an international overview of its conceptual evolution and legal implementation, Social Enterprise Journal, 5(3): 210–228. 18 Cukier, W., Trenholm, S., Carl, D., & Gekas, G. (2011), Social entrepreneurship: a content analysis, Journal of Strategic Innovation and Sustainability, 7(1): 99–119. 19 Kidd, S. A., Kerman, N., Cole, D., et al. (2015), Social Entrepreneurship and Mental Health Intervention: A Literature Review and Scan of Expert Perspectives, International Journal of Mental Health and Addiction, 13(6): 776–787. 20 Kidd et al. (2016), op. cit., nt.12. 21 Kidd et al. (2015), op. cit., nt.19.

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Social entrepreneurship in mental health Just as the concept of recovery (and the recovery movement) have been criticised as being vague and poorly operationalised in a care context driven by clinical trials,22 criticism might be aimed at social entrepreneurship as it relates to mental health as lacking in clarity.23 Nonetheless, a fairly coherent model exists—both from the perspective of those considered to be social entrepreneurs working in mental health, and the relatively modest literature on the topic. Along with the more general characteristics outlined above, there are specific points of emphasis as to how such work is defined. For example, the model includes the use of a social justice framework, consideration of the kind of leadership necessary, embeddedness within the communities and cultures served, and actions ranging from specific interventions through to public and policy engagement.24 These key themes which emerged in the study undertaken of several internationally recognised social entrepreneurs and their organisations will be highlighted below.25 The following five organisations were selected for the case studies.26 BasicNeeds, Vietnam and Ghana.27 Amongst the most extensively scaled comprehensive interventions to address mental illness globally, BasicNeeds has 12 sites with over 600,000 beneficiaries to date. Acid Survivors Foundation, Bangladesh.28 The organisation provides a range of services from plastic surgery to psychosocial rehabilitation—for Bangladeshi people who have survived acid violence. The Banyan, Chennai, India.29 The Banyan provides an intensive array of services for homeless individuals with severe mental illness, and through its sister organisation, the Banyan Academy of Leadership in Mental Health, engages in research, education, and advocacy. ADVANCE, Egypt.30 The organisation provides specialised, education-based services for children and adolescents with autism spectrum disorders to support social integration. Fundacion Colectivo Aquí y Ahora, Colombia.31 This organisation addresses youth addiction through a focus on personal meaning, with engagement at the family, school, workplace and public levels.

22 Davidson, L., O’Connell, M., Tondora, J., et al. (2006), The top ten concerns about recovery encountered in mental health system transformation, Psychiatric Services, 57(5): 640–645. 23 Peredo, A. & McLean, M. (2006), Social entrepreneurship: a critical review of the concept, Journal of World Business, 41(1): 56–65. 24 Kidd et al. (2015), op. cit., nt.19; Kidd et al. (2016), op. cit., nt.12. 25 Kidd et al. (2016), ibid.; Kidd, S. A., Madan, A., Rallabandi, S., et al. (2016), Social Entrepreneurship and Mental Health in Low and Middle Income Settings (Toronto: Centre for Addiction and Mental Health). Available at: www.porticonetwork.ca/web/semh. 26 The Social Entrepreneurism in Mental Health (SEMH) research group has examined social entrepreneurship in high and low-income contexts in close collaboration with Ashoka (see further: www.ashoka. org). The research presented in this chapter was supported by a grant from Grand Challenges Canada, and the authors have written it on behalf of the SEMH group that includes Athena Madan, Susmitha Rallabandi, Donald C. Cole, Elisha Muskat, Shoba Raja, David Wiljer, and David Aylward. 27 See further: www.basicneeds.org. For more on the work being undertaken by Basic Needs in Vietnam, see Chapter 5 of this book by Chris Underhill, Victoria K. Ngo, and Tam Nguyen. 28 See further: www.acidsurvivors.org. 29 See further: www.thebanyan.org. 30 See further: www.advance-society.org. 31 See further: colectivoaquiyahora.org/.

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Understanding the problem and guiding principles It was clear from conversations with internationally recognised mental health social entrepreneurs in LMICs (in this case, Ashoka Fellows and their colleagues) that when it came to developing an understanding of the in-country problem and what needed to be done, the organisations had to undertake a deep inquiry and engage with complex issues. As one Banyan senior staff member stated, When you reintegrate them [the patient] back to their family, then you will know the problems they face there. So, you have high stigma in the community, you have high stigma in that particular family itself. They don’t know where they have to go, so access of [sic] treatment is another issue and even if they have access, their quality of care is a big issue. So, even if they have treatment, what happens to their functionality? Whether they have any employment opportunities? What happens to the family burden? Who is there to really support them? So, all these questions made us to think what our programme should be. These are the learnings that we got from this group—we started exploring various aspects and now coming back and connecting these dots to really give them a proper intervention package so that we can prevent somebody from going into mental illness or prevent them from being homeless. Indeed, all the social entrepreneurs studied appeared to go to great lengths to try to understand the problems they sought to address. All of them described spending significant time with everyone affected, such as sitting on the street with a person diagnosed with schizophrenia, having meals with families, or having tea with government officials. Such deep and strategic analyses led to a set of approaches that shared many commonalities across countries and contexts. These included a diverse array of interventions that flexed to client need and simultaneously built family and community alliances and capacity. The organisations also worked hard to reduce stigma and break down policy barriers by cultural and legal means, whilst generating social capital, partnerships, and investment around the issue being addressed. Clearly there is a complexity to this type of work and a risk of diffusion and drift. There are, however, some ways of maintaining focus. One way was to focus on a specific population. The second method involved the use of a social justice framework (essentially, a recovery model of care),32 with decision-making carried out via principles of respect, compassion, and individualised support.

Leadership A considerable amount of time was spent during the research discussing the kind of people attracted to, and the kind of work that constituted, socially entrepreneurial leadership. As described above, one key characteristic was the willingness to be rigorous in efforts to understand the problems that were being addressed and the systems in which they were embedded. A second characteristic noted was resilient determination, which appears essential to tackling problems that might seem intractable to others. For example, the Acid Survivor’s Foundation in Bangladesh

32 Davidson, L., Tondora, J., O’Connell, M. J., et al. (2007), Creating a recovery-oriented system of behavioral health care: moving from concept to reality, Psychiatric Rehabilitation Journal, 31(1): 23–31.

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addressed acid violence in a country with major systemic barriers to intervention. One Ashoka Fellow and organisation founder stated that, to succeed, leaders in this space must have a ‘dogged determination to work in a field, quite frankly, that most people don’t want to work in’. Another commented that it was ‘like a mission’, and a ‘duty, responsibility, and obligation to society’. Along with this type of determination and a deep knowledge of the problem under focus, the ability to engage and align a diverse range of people was also emphasised by the social entrepreneurs studied. As one founder put it, it was necessary to have an ‘innate ability to command attention, respect, and sometimes leadership, even from . . . elders’. A highly developed sense of empathy and the ability to understand others’ needs and modes of communicating and operating is essential. Values identified by the organisation as essential to its success were integrity, the cultivation of trust, and a recognition of the importance of culture that is arguably more robust than is typical. Finally, socially entrepreneurial leaders were described by colleagues and collaborators as highly skilful in recognising the potential of everyone who works in the organisation in any capacity. From volunteers to leaders, having every individual engaging to their full potential was seen as essential to impact in resource-lean settings. In a related manner, cultivating a community of mutual support was described as essential to reducing burnout and the loss of skilled staff— further contributing to sustainability. The organisation leaders set up this culture of practice and engagement from the beginning. As one organisational founder stated, I developed a culture in [the organisation] from the very beginning where everyone was equal. It did not matter if it was an executive director or a ward boy. We all were equal and all had a contribution to make. That culture was very different to the country’s culture.

Specific activities Cutting across a wide range of organisations varied in scope, context and mental health focus, there were four types of activity noted as essential to successful endeavours. These were attention to the livelihoods of service recipients, the creation of empowerment cultures, a particular model of stakeholder engagement, and early consideration of expansion and scaling-up methodology.

Livelihoods Livelihoods—having the means to secure life’s necessities—have been firmly established as central to community-based interventions generally.33 The social entrepreneurs in our research had similarly come to understand this pivotal and concurrent need in addressing mental illness in LMICs. This worked in two ways: first, recognition that any form of intervention would have much less impact without attention to livelihoods, and second, that attention to livelihoods delivered many benefits. As one organisation founder intimated: Treatment for many, many poor mentally ill people is secondary to survival. Although in the West we might think that the two are uniform or equally important, I think to many people in [the] developing world, the most important is: livelihood, survival,

33 WHO (2010), Community-based Rehabilitation (CBR) Guidelines. Available at: www.who.int/disab ilities/cbr/guidelines.

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making [sic] a pay, trying to turn a penny for your family, and it’s only then that you feel you can present yourself to the medical practitioner and see what’s wrong with you. For impoverished people, in most instances the treatment of mental illness will be viewed as less important than the tasks necessary for basic survival, and people have serious concerns about the cost of treatments. Involvement in care can pose immediate burdens on families, even if the care holds the promise of greatly lessening that burden in the long term. A Banyan service provider referred to the importance of attending to family needs as well, stating: . . . for the patients who were reintegrated, we developed this programme of disability allowance, a very small nominal amount, but we recognised that helped the families a lot, [and] increased the service utilisation. It supported the families to support the cost of travel [to care facilities] which is a very important factor. The beautiful thing about helping a person become more productive is that it inverts the problem of being unproductive. In essence, it makes it easier for families to support their loved ones with mental illness, improves mental health in a range of ways, and demonstrates productivity (which usually involves getting out into the community more) whilst also reducing stigma. As Freire states: False charity constrains the fearful and subdued, the ‘rejects of life’, to extend their trembling hands. True generosity lies in striving so that these hands—whether of individuals or entire peoples—need to be extended less and less in supplication, so that more and more they become human hands which work and, working, transform the world.34 The importance of the concept of social entrepreneurship is obvious in this context, both in this particular research project and globally.35 Working from a deep understanding of individual strengths, challenges, as well as market needs in local contexts, the social entrepreneurs in our study generated ingenious and sustainable sources of income. These ranged from the creation of formal social enterprises to informal revenue generating activities.36 Social enterprise creation engaged the full skill set of social entrepreneurship, from assessing needs and market gaps, co-creating feasible businesses, empowering clients, and cultivating space (and social capital) in community markets that generated business for the enterprise whilst reducing resistance from business competitors. The latter was managed through raising competitor awareness about the social mission of the new enterprise.

Empowerment A social entrepreneurship frame for addressing mental health in LMICs is fundamentally one of empowerment. Some of the ways in which staff are empowered by organisational leaders have been mentioned above, but the empowerment of those individuals being supported was also vital.

34 Freire, P. (1989 [1968]), Pedagogy of the Oppressed (M.B. Ramos, trans.) (New York: Continuum), p.29. 35 J. Elkington & P. Hartigan (2013), The Power of Unreasonable People: How Social Entrepreneurs Create Markets That Change the World (Boston: Harvard Business Publishing). 36 Raja, S., Underhill, C., Shrestha, P., et al. (2012), Integrating mental health and development: a case study of the BasicNeeds Model in Nepal, PLoS Medicine, 9(7): e1001261.

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The case studies clearly emphasised that it was essential for mental health services to address the systemic dehumanisation experienced by individuals with mental illness.37 One powerful comment made by a BasicNeeds service recipient was that ‘[c]ommunity initiatives restore status and visibility. They give us an increased sense of pride. We are seen.’ The discussion of empowerment was ubiquitous across the case studies. Flowing from an empathetic, humanising, and equitable approach to this work, the people interviewed actively sought out and recognised the ‘inner strength’ and potential of those they served. Invoking Freire, several of the participants used the word ‘conscientisation’ with reference to their work with service recipients.38 Roughly defined, this means helping people become more aware of the entirety of their situation, what they ‘need’, and their potential to take action to improve their lives and the lives of others. One ADVANCE staff member commented pertinently: Again this notion of reducing stigma through humanising the problem: I don’t think we can call them special needs. We all have special needs. I have special needs in something. You have special needs in something. So, we shouldn’t label them as special needs. Everyone can do what they can do . . . If people can understand that we all have special needs, we don’t have to advocate for inclusion. The organisations studied found many benefits in using an empowerment framework. As described above, it fostered inclusion through exposing communities not only to de-stigmatising ways of conceptualising mental health problems, but also through the active advocacy of those affected themselves, which had an impact on stigma, policy, and fundraising efforts. People felt empowered when they were able to demonstrate to themselves and others of what they were capable across a range of contexts, including contributing to efforts to help others. These were not narratives of individuals being ‘used’ to raise funds or to carry out unpaid work, but rather of organisations that fundamentally created spaces for people to realise their full potential and make a difference. A particular service manager with the Acid Survivors Foundation explained it this way: Another strength I would say is that we provide quality services so that [acid attack] survivors cannot only get instant support, but can rehabilitate to the society, so that they can survive, they can be a leader. Before the attack, maybe she was a normal person, but after the attack she became a leader to the community. Another thread of import here was the quality and availability of services, enabled through peer support which was described as very helpful in several domains, including empowerment and hope-building. It also informed organisations, helping them to develop deep insight into community resources and local culture. This information came from the narratives of peers themselves, those receiving peer support, and staff. For example, a BasicNeeds peer support worker at one initiative stated: We feel this work is better done by us because it is we who are sick and should therefore support each other . . . Village mobilisers are more familiar with the participants

37 Drew, N., Funk, M., Tang, S., et al. (2011), Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis, The Lancet, 378(9803): 1664–1675. 38 Freire, P. (1970), Cultural action and conscientization, Harvard Educational Review, 40(3): 452–477.

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in their community, have a vested interest in the project, have experience of treatment and are aware of the benefits of the project to participants’ lives.

Engaged stakeholders, space to work, and brand The need to create space in which to operate and develop resources emerged strongly in the narratives of those interviewed. The rationale was simple, whether at the beginning of a single intervention or scaling globally. Growth and improving lives are impossible if the issue is not seen as important or relevant, if there are no facilitative policies, or if existing policies limit actions and if families will not reach out for help with their loved one. Media was one method used to cultivate awareness about an issue and to influence policy. Those interviewed had cultivated relationships with a range of media outlets and created compelling stories about their work and the problems that they were addressing. For example, a senior staff member at The Banyan commented: For social awareness, we used lot of media initially. Most of them are aware about us. It’s for homeless mentally ill women. So, all our rescue calls are from the public and there, the social media had actually done programmes, they have conducted events with famous personalities, they have conducted interviews with famous personalities who had actually visited here, so that the news had spread to the public in a very different way. Everybody knows about the organisation. Beyond the media, stakeholder engagement extended into the realm of formal education. ADVANCE opens up its staff trainings (which are highly regarded) free of charge to personnel from the Ministries of Education and Social Affairs in Egypt. The Acid Survivor’s Foundation holds yearly workshops for panel and staff lawyers and the police, recognising that it is essential to engage the justice system in the dialogue about acid violence. The Banyan similarly engages in formal training of the local and state judiciary. This intersectoral approach is essential for success in improving the lives of those with mental disability and hence SDG3.39 The provision of concrete and mutually beneficial paths to address mental health challenges extended to policy-makers as well. Engaging policy-makers and political systems was clearly important to generate resources, create helpful (or remove problematic) policies, and to gain greater exposure. One founder put it thus: . . . [I]t’s absolutely essential . . . that we work with government. We’ve got to be able to work with the people or the institutions at least which are likely to be the longest stayers. All I mean by long stayer, that the government in one shape, form, or another will be there now, tomorrow, and in the future. They have to have knowledge about best practice in mental ill-health, they have to at least bless best practice in mental health and organisational practice by NGOs, CBOs [community-based organisations], and international NGOs. All of this engagement work was helped through increasing the support of the public— leveraged through the media, strong branding and messaging, and the support of famous and

39 For more on this, see Chapter 2 by Lawrence O. Gostin and Laura Davidson.

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influential people. Important ingredients were sufficient operational space in which to work, a profile as high as possible, and a range of connections. These had clear implications for greater success in raising funds through grants, government support, and philanthropy. Whilst all of the above strategies were important, a challenge remained: unless organisations were able to educate, raise awareness, and successfully engage communities and families at ‘grassroots’ level, their work would be stalled. One Fundacion Colectivo Aquí y Ahora staff member described this effort as the Consentidos approach: ‘If you educate the family together, they will know how to support each other and recognise what makes them vulnerable—to becoming addicted, being exposed to drugs, knowing how to recover—that’s a good approach.’ It was clear that knowledge of the requisite population was crucial to the success of the work in social entrepreneurship—understanding how to engage diverse communities which may be facing poverty and have had little formal education. This required both persistence and an understanding of what is important to people—such as the enhancement of the livelihoods of people with mental illness. Here, a thread of creativity and flexibility came out as well; the recognition that traditional ways of raising awareness would have worked poorly in impoverished contexts. An example of this was in Vietnam, where the authors were informed that written brochures often ended up being used as coasters for teapots.40 Such difficulties with traditional awareness-raising were compounded where mental illness was viewed supernaturally. Participants described employing a range of strategies in such circumstances, from direct meetings with key individuals such as local chiefs, to using radio advertisements. As one BasicNeeds staff member noted, ‘wherever we’ve ever been, they tend to come to us because they hear us on the radio’. Finally, building collaborations with communities and families was not always described as reaching out. A big part of it was inviting people in; learning from and engaging with communities and supporting clients in community-based activities and advocacy. This took place in a range of ways. Organisations curated activities and resources that were helpful for both clients and the community. This reduced stigma, raised awareness, educated the community about the work of the organisation, and helped staff better understand what the community needed—and by proxy, assisted with fundraising and volunteerism. This appeared essential even at the most basic level—understanding in a culturally and context-relevant way that mental illness is something with which the organisation can help. This was not expansion in the sense of extending one’s walls outwards. Rather, this might be understood better as diffusion into geographic, cultural, service, and social spaces without clear boundaries between the services and those being served. A senior ADVANCE staff member stated thus: ‘Here in Egypt we make four events—art expression, sports day, a conference and a round table seminar . . . [W]e invite other societies to share in this, to exhibit art, to join us in our events.’ The topic of branding and marketing was also one that emerged prominently in the study. The social entrepreneurs interviewed discussed how it was essential to become much more strategic in their ‘branding strategy’. This was not only about their specific organisation, but also branding and marketing the issue that they sought to address. The founder of one organisation put it like this: We devised the plan and . . . developed responses which were much more strategic and less immersed in social sciences. So, it was more a branding strategy, more a management

40 Personal communication with a BasicNeeds service leader (2015).

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strategy. How do I get my team in place, how do I position myself, how do I market the issue, not so much of our organisation but the issue. The ‘brand’ of the service—its leaders, staff, approaches, and the issue it addressed—were developed in a number of ways. For example, an organisation might cultivate an ethos or set of values and an approach seen by all stakeholders as distinctly different, valuable, and admirable. Impact was also important. This included developing a reputation for having great skill at making gains with and for individuals whose challenges were widely regarded as profound or otherwise ‘hopeless cases’. Scale, too, was pertinent. These were organisations that served very large numbers of service recipients, on a local to an international scale. Effective branding was also woven into being connected from local to global levels with other prominent and relevant organisations and being an active training site for learners from a range of disciplines, regions, and countries. One founder stated, For capacity building, we have partnered with several prominent national organisations. They are [the] biggest services in the world and these join together and [are] working with the government to improve services. We have a training programme which is supported by [a prominent British charity]. We do training based on their curriculum. They train our staff and then we train local service care providers. Brand development emerged in these narratives as catalytic to exponential recognition. Partnerships and resource generation became intertwined in a way that made growth and sustainability possible. Strong branding also supported expansion of an intervention—either through an aspect of it being taken up by another organisation (such as the provision of intensive training by The Banyan) or through a franchise model (as provided by BasicNeeds). In the latter scenario, a service model is manualised with a clear and replicable design that receives support in implementation from a central site and sustains fidelity to the approach. Along with implementation support, the brand in this instance helps to legitimise the local effort—which has implications for funding, policy influence, and collaborations at local and global levels.

Scaling-up All those interviewed had varying degrees of experience in expanding the reach of their work. This was described as a balance between establishing a set of ‘minimum specifications’ or core approaches which were effective whilst being adaptable to other settings—a process that certainly created some dilemmas. These included concerns about fidelity—when scaling up, how can an organisation be certain that the newly developed service holds true to the same approaches and values that defined quality for the initial model? As mentioned above, others grappled with the question whether or not to scale using a franchise-type approach or, rather, to advise other groups on service enhancement based upon their model to help other organisations grow. The approach taken by one of the founders interviewed was as follows: ‘Our strategy in scaling up is we set models, we study them, we fine-tune them, we develop protocols, then we impact policy and through policy and advocacy, projects are scaled up.’ Another founder indicated: The other part of scaling up is to work through civil society players, get them to replicate, but we are not following the franchisee model. We believe that we can share and capacity-build, but not follow the franchisee model. Towards that, we worked with two NGOs and replicated parts of our work . . . So, we are looking at scaling up by sharing 91

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our resources and expertise both within the country (that’s of course . . . our primary focus), but [also] . . . in [the] South Asian and South East Asian region with these partners, and [we] look at it as a mutual learning sort of exercise. Lastly, there was some discussion about what was needed to facilitate and support scaling-up, in terms of ensuring that the scaled endeavour was run well and had the contextual elements, policy and otherwise, that made it sustainable. This took the form of building capacity as well as taking considerable care in vetting potential sites and the partners therein. In at least one instance this involved setting formal criteria for potential franchise sites.41 This work was described as a balancing act to ensure not overly ‘stretching allegiances and materials’, and fostering growth and independence at a local level as well as nationally or globally. The next phase in these efforts (which many of our participants were entering) was the ‘stabilisation’ of the resulting ‘alliance of organisations’. That required the generation of a network supportive of continued growth to ensure quality and maintain relational connections. This ‘second generation movement’, as it was framed by one organisation leader, would in turn become much less linear. This reference to a less linear second generation movement reflected scaling patterns of organisations such as Alcoholics Anonymous42 and microfinance initiatives, which indeed became more a movement than a coordinated approach to scaling up. Whilst having challenges, particularly in the area of fidelity, such movements radically increase reach and scale.

Conclusion—systems science as the way forward What has been attempted in this chapter is an examination of the ‘non-technical’ aspects of very successful organisations and interventions that address mental health in LMICs, all of which have been highlighted as exceptionally strong examples of social entrepreneurship. The non-technical approaches that were examined here included models of leadership, particular approaches to the problem addressed, organisational values and culture, attention to livelihoods, and stakeholder engagement. What has not been covered in this chapter are details about the technical aspects of their work, such as specific models of social enterprise, group psychotherapy, assessment, pharmacotherapy, and family education—all of which are discussed to some degree in various chapters of this book. A full consideration of non-technical elements of interventions through which technical strategies are implemented, along with the social, cultural, and political contexts in which they are embedded, represents a systems orientation to mental health in LMICs. The authors of this chapter and others suggest that such a systems orientation, particularly the rigorous study of non-technical aspects of intervention, has received insufficient attention in the GMH field.43 Social entrepreneurship is arguably a helpful lens through which to identify and understand the work of individuals who, and organisations which, are exceptionally strong systems-thinkers.

41 BasicNeeds (2009), Community Mental Health Practice: Seven Essential Features for Scaling Up in Low- and Middle-income Countries (Bangalore, India). Available at: www.basicneeds.org/resources. 42 Substance Abuse and Mental Health Services Administration (2009), The NSDUH Report: Mental Health Support and Self-help Groups (Rockville: Substance Abuse and Mental Health Services Administration). Available at: www.oregon.gov/oha/amh/recovery/mh-selfhelp-guides.pdf. 43 Kirmayer & Pedersen (2014), op. cit., nt.11; Whitley, R. (2015), Global Mental Health: concepts, conflicts and controversies, Epidemiology and Psychiatric Sciences, 24(4): 285–291.

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Whilst hazy in definition and perhaps requiring modification,44 social entrepreneurship is a construct that captures the types of innovative, flexible, culturally embedded approaches that bridge gaps between sectors and generate social capital essential to the success and sustainability of the GMH effort. This point is evidenced in the observation that individuals identified as leading social entrepreneurs, such as Ashoka Fellows, are doing some of the most impactful and viable work in developing contexts. Building on the research presented here which used social entrepreneurship as a contextual framework, and the associated literature that has been reviewed, it would seem clear that for work in the GMH field to make a major difference in the daunting task that SDG3 represents, better theory and science are required. As the authors have proposed previously,45 as well as others in areas such as public health,46 until the field moves towards more rigorous methods that better map onto ‘wicked’ systemic problems47 such as mental illness and addictions in LMICs, many promising interventions will be of limited impact and viability, and divisive debates on best practice will continue. A complex systems approach holds promise in capturing both technical and non-technical aspects of interventions with more exactitude. Specific methods worth examining in this context might include system dynamics analysis, network analysis, and agent-based modelling. Such methodologies and the methodological shortcomings that they seek to address are emergent topics in development contexts,48 and will likely emerge as the next generation of methods underpinning better coordinated and coherent efforts to improve the health and wellbeing of people in LMICs. In conclusion, there is sufficient evidence to suggest that non-technical methods of intervening in LMICs, captured through a social entrepreneurship lens, should be developed along with more technical, circumscribed approaches currently dominating the global conversations about clinical effectiveness and scale. Both are essential in developing sustainable, locally relevant support for mental health in low resource settings, thereby meeting SDG3. Indeed, social entrepreneurship as a broad concept has relevance to progress on all of the SDGs,49 and this breadth is readily reflected in the diverse activities of Ashoka Fellows globally. Improved impact in this effort will, however, require better theory and research—perhaps growing from the systems considerations and methods which have been described in this chapter.

44 Peredo, A. & McLean, M. (2006), Social entrepreneurship: a critical review of the concept, Journal of World Business, 41(1): 56–65. 45 Kidd et al. (2016), op. cit., nt.12. 46 Luke, D. A. & Stamatakis, K. A. (2012), Systems science methods in public health: dynamics, networks, and agents, Annual Review of Public Health, 33: 357–376. 47 For more on this public health concept, see, e.g., Newman, J. & Head, B. W. (2017), Wicked tendencies in policy problems: rethinking the distinction between social and technical problems, Policy and Society, 36(3): 414–429. 48 See, e.g., Hjorth, P. & Bagheri, A. (2006), Navigating towards sustainable development: a system dynamics approach, Futures, 38(1): 74–92. 49 Just as mental health is a cross-cutting issue; a basic tenet of this book. Likewise, all of the SDGs require a consideration of wellbeing if they are to be met fully.

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PART III

Demographic and cultural perspectives

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7 UNDERSTANDING TRADITIONAL AND OTHER CULTURE-BASED APPROACHES TO MENTAL ILLNESS IN LOWER- AND MIDDLE-INCOME CONTEXTS Joseph D. Calabrese* Introduction Those working to improve the treatment of mental illness in diverse cultural contexts often deal with a complex landscape of religious interpretations of illness, ritual interventions, alternative systems of plant medicines, and various claims of efficacy.1 These voices and claims must be balanced with a commitment to actually enhancing wellbeing, in line with UN Sustainable Development Goal 3 (SDG3) to ‘ensure healthy lives and promote well-being for all at all ages’. Evaluating each context independently is crucial, as some alternatives to ‘Western’ medicalised interventions enhance patient health, whilst others impede it or even cause harm. In attempting to illuminate this landscape, this chapter will draw on the author’s decades of experience as a medical anthropologist and clinical psychologist researching mental illness and its treatment, whilst also personally treating patients in several different societies. Case examples will be drawn primarily from fieldwork and clinical practice in Native North American communities and in Bhutan. It is a familiar refrain for many medical anthropologists that health care must be delivered in a manner that is culturally appropriate and that existing therapeutic traditions must be respected, thus avoiding cultural imperialism. In line with this sentiment, the World Health Organization (WHO) has encouraged the use of traditional medicine and its integration into health systems.2

* Joseph D. Calabrese is a Chartered Psychologist and Reader of Medical Anthropology, Department of Anthropology, University College London, and a prior Visiting Professor, University of Medical Sciences of Bhutan, Thimphu, Bhutan. 1 For an example in the Ugandan context, see Davidson, L., Liebling, H., Akello, G. F., & Ochola, G. (2016), The experiences of survivors and trauma counselling service providers in northern Uganda: implications for mental health policy and legislation, Int. J. Law Psychiatry, Nov–Dec, 49(A): 84–92, at 86. 2 WHO (2013), WHO Traditional Medicine Strategy 2014–2023. Available at: www.who.int/medicines/ publications/traditional/trm_strategy14_23/en.

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There are significant potential benefits attached to this strategy, especially the fact that integration may facilitate clinical evaluation of traditional treatments, oversight of practitioners (some of whom have been known to chain or beat patients, or restrict food),3 and minimisation of risks (such as organ damage from the use of toxic herbs or potions, or wound sepsis from chaining), all of which are imperative.4 However, such a blanket policy tends to de-emphasise the particularities of local contexts, the problems being addressed, and the nature of the medicines and procedures involved. Worse, it may give the appearance of having more to do with economic limitations, including the lack of trained personnel, or indeed with political correctness, than with a desire to undertake serious research and improve contexts of care. This top-down approach has been critiqued in some WHO studies, such as those that compare the course of psychotic disorders in ‘developing’ versus ‘developed’ countries—a dichotomy that tends to reduce complex intersocietal variations to economics—when a careful study of local factors at particular sites would have been much more illuminating.5 Supporting traditional treatments makes sense when the local interventions can be shown to be effective, or at least beneficial to society, and are not harmful. In other cases, traditional understandings (such as those that attribute severe mental illness to sin or to a spiritual entity) can simply impede and delay effective health care delivery. When reviewing ethnographic research on traditional health care approaches, certain things become clear. Sociocultural constructions of illness relate to local understandings of the person and cosmology, which tend to be embedded in spiritual frameworks. Aetiological understandings are often personalistic, finding the cause of illness in the actions of a witch, an angry deity, or a spirit who has possessed the person’s body or captured their soul.6 Illness may also be understood in terms of sin, spiritual pollution or an imbalance of humours. It is crucial to understand that when these understandings of illness are present, therapeutic intervention will address these postulated causes, taking the form of witch detection/nullification, ritual exorcisms, shamanic spirit flights to retrieve the soul, prayer, or various forms of purification or re-balancing of humours.7 Traditional healing approaches thus may relate more to postulated—but evidentially unsupportable—religious entities, rather than to the actual causes of illness.

3 For example, see Sorketti, E. A., Zainal, N. Z., & Habil, M. H. (2013), The treatment outcome of psychotic disorders by traditional healers in central Sudan, International Journal of Social Psychiatry, 59: 365–376; Adelekan, M. L., Makanjuola, A. B., & Ndom, R. J. E. (2001), Traditional Mental Health Practitioners in Kwara State, Nigeria, East African Medical Journal, 78(4): 190–196. 4 The risks associated with chaining were also made apparent when 28 patients of a faith-based mental asylum in Erwadi, Tamil Nadu, died in a fire, unable to escape due to their chains. See Krishnakumar, A. (2001), Escape from Erwadi, Frontline, Sept, 18(18): 1–14. Available at: www.frontline.in/static/html/ fl1818/18180270.htm. 5 Calabrese, J. D. & Corrigan, P. W. (2005), ‘Beyond Dementia Praecox: Findings from Long-term Followup Studies of Schizophrenia’, in R. Ralph & P. Corrigan (eds), Recovery in Mental Illness: Broadening Our Understanding of Wellness (Washington, DC: American Psychological Association). See also Cohen, A., Patel, V., Thara, R., & Gureje, O. (2008), Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World?, Schizophrenia Bulletin, 34(2): 229–244. 6 Foster, G. M. (1976), Disease Etiologies in Non-Western Medical Systems, American Anthropologist, 78(4): 773–782. 7 B. M. Knauft (1985), Good Company and Violence: Sorcery and Social Action in a Lowland New Guinea Society (Berkeley: University of California Press); Herdt, G. (1990), ‘Sambia Nosebleeding Rites and Male Proximity to Women’, in J. W. Stigler, R. A. Shweder, & G. Herdt (eds) (1997), Cultural Psychology: Essays in Comparative Human Development (Cambridge: Cambridge University Press), pp.366–400; A. Fadiman (1997), The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures (New York: Farrar, Straus & Giroux).

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The confusion of illness with religious phenomena, although fascinating anthropologically, can lead to tragedies and atrocities. For example, in 2015 in Nepal, Kodai Harijan consulted a local shaman, seeking help for his sick son. The diagnosis was spirit possession. The shaman told Harijan that his son could be cured, but that it would require a human sacrifice. According to testimony given to police, Harijan and his relatives found the ten-year-old boy Jivan Kohar playing with friends in the village and lured him away with a packet of biscuits and the promise of 50 rupees (around 30 pence). The boy was taken to a temple on the outskirts of the village where the shaman performed a religious ritual. The boy was then taken to a field nearby, where three people held him down as Hirijan slit his throat with a sickle. When police found him, the boy’s head had almost been severed from his body.8 In another case, described in detail by Fadiman,9 a three-month-old Hmong girl, Lia Lee, began experiencing epileptic seizures, which her parents understood as a spiritual condition involving her soul being ‘caught’ by a spirit. The Lees worried about their child’s health, but also considered the illness to be a positive sign that she may have spiritual gifts. Lia’s doctors changed her anticonvulsant medication over 20 times in an effort to control her seizures. They could not determine whether Lia was convulsing despite her drugs, or because she was no longer receiving them. Confused by the doctor’s regimen of drugs that seemed to make Lia worse, the parents had reduced Lia’s anticonvulsant drugs and employed their own traditional remedies, including herbal medicines, massage, and treatment by a Hmong shaman. If a drug seemed to make her better, the dose was increased. Lia eventually had a massive seizure that left her brain-dead. Plant medicines, often assumed to be harmless because they are ‘natural’ or because they have been used for generations, can also cause harm. It cannot be assumed that ‘natural’ means safe. Lead, mercury and arsenic are natural, but are also potent poisons.10 According to a study published by the Centers for Disease Control and Prevention,11 these substances can be found in various Ayurvedic medicines.12 An interesting table is included in the study listing various medicines with trustworthy sounding manufacturers such as ‘Vyas Pharmaceuticals’ or ‘Research

8 Dunn, J. (2015), Desperate father kidnapped and murdered a ten-year-old boy in religious ritual after a holy man told him a human sacrifice would save his ailing son in Nepal, Daily Mail, 27 July. See www. dailymail.co.uk/news/article-3176306/Desperate-father-kidnapped-murdered-ten-year-old-boyreligious-ritual-holy-man-told-human-sacrifice-save-ailing-son-Nepal.html. 9 Fadiman (1997), op. cit., nt.7. 10 According to the WHO, [m]ercury is a naturally occurring element that is found in air, water and soil . . . Exposure to mercury—even small amounts—may cause serious health problems, and is a threat to the development of the child in utero and early in life (see WHO (2017), Mercury and Health (fact sheet). Available at: www. who.int/mediacentre/factsheets/fs361/en/) The WHO also states that ‘[l]ead is a cumulative toxicant that affects multiple body systems and is particularly harmful to young children . . . There is no known level of lead exposure that is considered safe’ (see WHO (2016), Lead Poisoning and Health (fact sheet). Available at: www.who.int/mediacentre/ factsheets/fs379/en/). 11 Hore, P., Ahmed, M., Ehrlich, J., et al. (2012), Lead poisoning in pregnant women who used ayurvedic medications from India—New York City, 2011–2012, Morbidity and Mortality Weekly Report (Centers for Disease Control and Prevention), 61: 641–646. Available at: www.cdc.gov/mmwr/preview/ mmwrhtml/mm6133a1.htm. 12 Ayurveda is an ancient medical system that originated in India. Ayurvedic medicines may include herbs, minerals, metals or other materials, some of which are known to be toxic. However, in the US these medicines are regulated as dietary supplements and thus are not required to meet safety and effectiveness standards required of conventional medicines.

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Drugs & Pharmaceuticals’—yet they were found to have concentrations of mercury as high as 10%, of arsenic as high as 5.2%, and of lead as high as 4.7%. In the early 1990s in Brussels, around 100 otherwise healthy young women started presenting with advanced kidney disease that would ultimately require dialysis or renal transplantation.13 An investigation revealed that they had all attended the same weight-loss programme which gave them Aristolochia, a Chinese herb used for millennia. It was found to cause both irreversible kidney damage and cancer. There may be many other commonly used traditional medicines which are toxic, and additional scientific studies are required before their use is encouraged. The situation is complicated further by the fact that reports of therapeutic improvement by patients may be inaccurate. In their study of the outcomes of patients seeing a particular Taiwanese traditional healer, Kleinman and Sung demonstrate that efficacy cannot be established based on patients’ self-reports.14 As the authors point out, most efficacy studies in anthropology do not carry out later follow-ups, but rely on reports soon after ritual treatment. This is problematic because patients may be constrained by cultural norms to discuss ritual outcomes in exclusively positive terms. In their follow-up study of 12 patients treated by a ritual healer, Kleinman and Sung found that ten people rated themselves at least partially cured. However, they write that this occurred despite the lack of any significant symptom change in several cases, and in the face of ‘considerably worsened symptoms in one case’.15 As these examples make clear, ritual treatments and traditional medicines can be ineffective or even deadly, even when believed by the local population—and reported by specific patients—to be effective. Traditional practices and other culture-based approaches, such as attempted healings in evangelical churches, typically target a different metaphysical domain and view of the body from that which can be demonstrated empirically. This especially tends to be the case when dealing with mental illnesses. However, traditional approaches sometimes discover and perpetuate a therapeutic methodology, even though the local supernatural rationalisation of the procedures clashes with science-based understandings of the therapeutic. As is described in the following case study from the author’s work with Native Americans, there may be unacknowledged therapeutic processes at work that can nevertheless be analysed and which result in measurable therapeutic outcomes.

Native American ritual peyote use Native North American communities can be considered internal colonies of the United States, and they face similar problems to lower and middle income countries (LMICs), such as health disparities, poverty, war-related historical trauma, environmental risks, racism, healing systems that conflict with scientific biomedicine, and a significant burden of mental illness. Thus, the focus of this chapter encompasses lower and middle income contexts rather than countries. By one calculation, as many as 100 million indigenous people died as a result of the European colonisation of the Americas, which constitutes a genocide.16 Today, according to government statistics,

13 Grollman, A. P. & Marcus, D. M. (2016), Global Hazards of Herbal Remedies: Lessons from Aristolochia, EMBO Reports, 17(5): 618–626. 14 Kleinman, A. & Sung, L. H. (1979), Why do Indigenous Practitioners Successfully Heal?, Social Science and Medicine, 13B: 7–26. 15 Ibid., 7. 16 D. E. Stannard (1992), American Holocaust: Columbus and the Conquest of the New World (New York: Oxford University Press).

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over one in four Native Americans live in poverty.17 In terms of health disparities, in 2014 Native American deaths from alcoholism were 520% greater than the 2008 US average, deaths from tuberculosis were 450% greater, deaths from chronic liver disease and cirrhosis were 368% greater, deaths from diabetes mellitus were 177% greater, and suicide rates for Native American youth were over three times the national average.18 During two years of anthropological fieldwork living amongst the Navajos of the southwestern United States, the author was immersed in a context disrupted by genocidal colonialism and came to focus on a post-colonial healing tradition called the Native American Church (NAC).19 The NAC is a ritual-based healing tradition within many Native North American tribes that addresses alcoholism and other mental health issues. The tradition has been subject to attacks by the US Government as well as tribal governments,20 given its therapeutic use of peyote, a psychedelic cactus used by Native Americans for six millennia, within a symbolically structured ritual process. Fieldwork in Navajo communities was combined with a year-long clinical psychology placement treating adolescent patients at a Navajo treatment programme. This programme incorporated traditional healing rituals into the treatment process in response to the local demand for culturally appropriate health care.21 The project came about in response to legal attacks on NAC members, motivated by the ‘War on Drugs’, and specifically the case of Oregon v. Smith.22 The US Supreme Court decided that followers of the NAC, which was previously protected by the Free Exercise Clause,23 could now be found guilty of a class B felony. The research revealed that it was standard practice at the federally funded clinical facility at which the author treated Native American adolescents to include Peyote Ceremonies in treatment and aftercare plans (when approved by their parents). In fact, the US Government reimbursed practitioners of the ceremony for clinical services.24 The research indicated that addictive behaviours were often changed and wellbeing enhanced due to participation in the Peyote Ceremony. An experience at a Peyote Ceremony, such as a symbolically structured vision, was often the catalyst for recovery mentioned in interviews. Continued participation operated as aftercare, providing a supportive community since alcohol use is viewed as a sin.25 To seek scientific clarity on these apparently positive outcomes, the author was involved in setting up an independent controlled study of mental health outcomes of NAC members through

17 US Census Bureau (2015), American Community Survey 1-year Estimates. Available at: https://fact finder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. 18 Indian Health Service (2014), Trends in Indian Health. Available at: www.ihs.gov/dps/includes/themes/ newihstheme/display_objects/documents/Trends2014Book508.pdf; Surgeon General of the US Public Health Service (2005), Statement on Suicide Prevention among Native American Youth before the Indian Affairs Committee, US Senate. Available at: www.ihs.gov/newsroom/includes/themes/newih stheme/display_objects/documents/testimony/109/2005-06-15Carmona.pdf 19 J. D. Calabrese (2013), A Different Medicine: Postcolonial Healing in the Native American Church (New York: Oxford University Press). 20 O. C. Stewart (1987), Peyote Religion: A History (Norman: University of Oklahoma Press), pp.128–147, 203–208 and 296–310. 21 Complete findings are reported in Calabrese (2013), op. cit., nt.19. 22 Employment Division of Oregon v. Smith, 494 US 872 (1990). Also see Calabrese, J. D. (2001), The Supreme Court versus Peyote: Consciousness Alteration, Cultural Psychiatry and the Dilemma of Contemporary Subcultures, Anthropology of Consciousness, 12(2): 4–19. 23 The Free Exercise Clause of the First Amendment of the US Constitution specifies that Congress shall make no law prohibiting the free exercise of religion. 24 Calabrese (2013), op. cit., nt.19, pp.38–39. See also S. J. Kunitz & J. E. Levy (1994), Drinking Careers: A Twenty-five Year Study of Three Navajo Populations (New Haven: Yale University Press), p.202. 25 Calabrese (2013), ibid., Chapter VI.

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the Harvard Medical School.26 The study, published in Biological Psychiatry, compared mental health and neuropsychological test results of a group of Navajos who regularly used peyote with a group reporting minimal use of peyote, alcohol or other substances, and another group of recovered alcoholics from the Navajo community. Results indicated that the former alcoholic group showed significant deficits on every scale of the Rand Mental Health Inventory (RMHI)27 and on two neuropsychological measures.28 However, the peyote group showed no significant differences from the abstinent comparison group on most scales and scored significantly better on two scales of the RMHI. Furthermore, amongst NAC members, greater lifetime peyote use was associated with significantly better RMHI scores on five of the nine scales, including the composite Mental Health Index. Although the Native American participants tend to explain these outcomes in spiritual terms, they can be analysed in terms of known and measurable communicative, social and psychological processes. This sort of analysis can illuminate processes that are often reduced to ‘the placebo effect’. The therapeutic efficacy can be considered in terms of the symbolically structured ritual process, including the strategic use of the psychoactive medicine, as well as the broader cultural ontology that is built up as an experiential reality for participants. That ontology focuses on the individual’s relationship with peyote, experienced as a conscious entity that can monitor one’s thoughts and behaviours (and especially intervening to prevent or punish alcohol use), in addition to its status as a sacred medicinal substance. Peyote is used in an all-night ritual that takes place in a tipi that opens to the east to face the rising sun. Inside, an altar of earth is made in the shape of a half moon. A line is sketched along the top, called ‘the Road’, which represents the path of one’s life, beginning at birth on the left and rising to its highest potency in adulthood; then decreasing in potency as one approaches old age and death. Thus, the moon symbol functions, on one level, as a symbol of one’s life, implying a process of critical self-reflection on one’s life path during the ritual. At another level, the moon is a symbol of transformation because it is said that the moon changes by growing and shrinking once a month.29 Navajos also view the moon as representative of the natural process of human gestation, as it takes nine moons (or months) to create life. Accordingly, in this one ritual symbol, the participant’s life course is embedded symbolically within natural transformative processes. The multiple meanings of the moon symbol weave a plot involving the transformative regestation of the self. The tipi also plays a part in this gestation symbolism. Navajos explained that the tipi represents a pregnant female with a blanket facing east, and the beating of the peyote drum replicates the sound of a mother’s heartbeat as heard from inside the womb. The timing of the ritual is another component of the symbolic process. The ritual begins at nightfall, at the ending of one day, and moves the patient symbolically to the dawning of a new day, accompanied by many symbols of rebirth, renewal, and natural transformation. At dawn the participants emerge from the tipi and greet the new day in a symbolic rebirth from the maternal

26 Halpern, J. H., Sherwood, A. R., Hudson, J. I., et al. (2005), Psychological and Cognitive Effects of Long-term Peyote Use among Native Americans, Biological Psychiatry, 58: 624–631. 27 The RMHI measures anxiety, depression, and other aspects of psychological distress and wellbeing. See Veit, C. T. & Ware, J. E. (1983), The structure of psychological distress and well-being in general populations, Journal of Consulting and Clinical Psychology, 51: 730–742. 28 These neuropsychological measures were reported as the ‘immediate condition’ of the Rey-Osterreith Complex Figure Test (it is assumed that the authors meant the ‘immediate recall’ condition) and total perseverations on the Wisconsin Card Sort Test. 29 Calabrese (2013), op. cit., nt.19, pp.124–136.

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image of the tipi. The ingestion of the peyote cactus supports this narrative intervention not only through its ability to produce impressive visions (interpreted as divine communications), but also through its pharmacological ability to enhance suggestibility.30 This quality was established in experimental studies undertaken at Stanford University by Sjoberg and Hollister in 1965 which found that mescaline, the main psychoactive ingredient of peyote, enhanced primary suggestibility to the level of a hypnotic induction.31 Therefore the plant medicine is used to enhance the delivery of therapeutic messages, making them, in effect, post-hypnotic suggestions. Even though peyote is itself a serotonergic substance,32 this is, admittedly, a very different understanding of psychopharmacology from that found in Euro-American psychiatry, which often provides psychopharmacological intervention without much work being carried out on the patient’s meaningful interpretation of the intervention. Modern clinical disciplines separate the pharmacological and meaning-related approaches into the disciplines of psychiatry and clinical psychology. This results in psychiatric medicines being administered in a technical manner, with little effort devoted to ‘emplotting’ their use in a meaningful way.33 In contrast, within Native American contexts that are not mind/body dualist in the same way, psychoactive plant medicines are used to transform self-awareness and enhance emplotment in a narrative. Psychopharmacological intervention to facilitate creative shifts in perspective, therapeutic emplotment or insight is not the standard usage of psychiatric medicines in Euro-American psychiatry. The dominant agonist/antagonist (materialist) paradigm of Euro-American psychiatry focuses on fixing discrete neurochemical imbalances within a mechanistic medical model. The Peyote Ceremony represents an entirely different paradigm of psychopharmacological intervention focused on higher-order mental processes such as experience, emotion, insight, creativity, and planning. It goes beyond the synapse and neurotransmitter to the levels of meaning, self-reflection, and social interaction. The author refers to this approach as a semiotic/ reflexive paradigm of psychopharmacology, as opposed to the agonist/antagonist model of Euro-American psychiatry.34 This case study demonstrates that a particular local intervention can be extremely effective for a particular set of mental health issues, even though the approach clashes strongly with standard biomedical theories and practice and tends to be rationalised in spiritual terms. Perhaps an intervention with this depth of psychological impact is needed, given the history of trauma and radical disruption of Native American communities. The case foregrounds the importance of getting past centuries of ethnocentric dismissal (currently in the form of a ‘War on Drugs’) in order to recognise an alternative and viable system of psychopharmacological intervention, incorporating

30 Suggestibility as used here is the ability to have one’s perceptions, cognitions and behaviours influenced by suggestions, such as hypnotic suggestions. Levels of suggestibility can be measured using various tests, such as the Stanford Suggestibility Scale. 31 Sjoberg, B. M. & Hollister, L. E. (1965), The Effects of Psychotomimetic Drugs on Primary Suggestibility, Psychopharmacologia, 8: 251–262. 32 Serotonin is a neurotransmitter. Serotonergic substances are substances that produce their effect by interacting with the serotonin system. E.g., several antidepressant medications currently in use are serotonergic substances that have an effect by selectively inhibiting the reuptake of serotonin. 33 Calabrese (2013), op. cit., nt.19, pp.29–35. To ‘emplot’ something, as used here, means simply to place it into a story or narrative. 34 Ibid., pp.25–26 and 137. The existence of two very different paradigms of psychopharmacology creates a paradigm clash in which Euro-Americans perceive Native American peyote use not as part of a therapeutic intervention, but in an ethnocentric manner, i.e., as substance misuse.

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cognitive and social interventions with demonstrable therapeutic outcomes.35 The proper ethical response is to support this indigenous intervention to treat the particular mental health issues for which it is effective.

Severe mental illness and public psychiatry in Bhutan Bhutan is a Buddhist Kingdom in the eastern Himalayas wedged between China and India. It has an officially recognised population of around 750,000. Given various factors, not least its location across several high mountain valleys, Bhutan has remained very isolated for most of its history. The government permitted television and the internet only in 1999. Bhutan has become famous for its Gross National Happiness (GNH) policy,36 which resonates with SDG3 and implies a critique of exclusively economic development goals. Bhutan measures happiness and wellbeing, seeking to improve them. The GNH Index incorporates subjective and objective indicators of wellbeing across nine domains: psychological wellbeing, health, education, cultural diversity and resilience, time use, good governance, community vitality, living standard, and ecological diversity and resilience. However, even in Bhutan there are people coping with mental illness who remain at special risk of unhappiness. A mental health system was launched in Bhutan very late in comparison with most other countries, with the Psychiatry unit at Jigme Dorji Wangchuck National Referral Hospital only opening in 1997. An inpatient psychiatry ward was opened in April 2004. There are only two psychiatrists and a few psychiatric nurses for the entire country.37 There are no clinical psychologists and very little psychotherapy of any kind exists. The system relies heavily on medication, with some psycho-education for detoxing drug and alcohol patients. Modern mental health practices did not previously exist in Bhutan. Until then, communities had relied solely on traditional forms of treatment for problems that developed nations would have described as mental illness. These were mainly pujas, which are rituals led by Buddhist monks or shamans. The author’s research was undertaken over four summers spent mainly in the capital city of Thimphu, combining volunteer clinical practice as a psychologist with anthropological fieldwork on local understandings of mental illness. Bhutan is undergoing a high level of rural to urban migration, which is changing patterns of work, gender roles and illness. With its growth, Thimphu is experiencing many new problems, such as disruptive youth and significant alcohol and substance abuse. Patients with psychiatric disorders are also referred to Thimphu from regions

35 The findings of this research have been used by the National Health Service Corps (a part of the US Department of Health and Human Services) to train health professionals to provide culturally competent primary health care services to under-served populations. See R. T. Trotter (1999), National Health Service Corps Educational Program for Clinical and Community Issues in Primary Care: Cross-cultural Issues in Primary Care Module (Washington, DC: US Department of Health and Human Services). The ethnographic material on the Peyote Ceremony gathered during this research has been used in the training module to challenge clinicians to see beyond their ethnocentrism and provide culturally appropriate care to Native American patients. However, there has been no rethinking of peyote’s Schedule I status (designating a dangerous drug of abuse with no known therapeutic uses). 36 K. Ura, S. Alkire, T. Zangmo, & K. Wangdi (2012), An Extensive Analysis of GNH Index (Thimphu: The Centre for Bhutan Studies). Available at: www.grossnationalhappiness.com/wp-content/uploads/ 2012/10/An%20Extensive%20Analysis%20of%20GNH%20Index.pdf. 37 See WHO and Ministry of Health, Thimphu, Bhutan (2007), WHO-AIMS Report on Mental Health System in Bhutan. Available at: www.who.int/mental_health/evidence/bhutan_who_aims_ report.pdf.

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throughout the country, so there is a very diverse patient mix to observe. Initial research questions were very broad: are the understandings of psychiatric illness developed in the West valid for Bhutan, a geographically isolated country in which cultural influences from other countries have been rigidly controlled? Or is the local situation unique (as relativist anthropologists would tend to assume)? Do Bhutanese patients respond to standard psychological and psychiatric treatments? Or are standard approaches completely irrelevant? An investigation into the effects of healing ceremonies and traditional medicine (Sowa Rigpa) was considered necessary to test whether there were healing practices already in place that might be useful and effective. This case study indicated that the same sorts of psychiatric illnesses that are found around the world occur in Bhutan, though they are often interpreted as spiritual afflictions.38 Mental illness is most often explained in terms of spirit possession, being punished or attacked by a spirit or deity or, ultimately, as due to karma (the effect of something one did in a previous existence). However, regardless of the local interpretations, there were many classic presentations of familiar disorders. Even though the population has not been ‘indoctrinated’ into modern psychiatric interpretive frameworks, the author’s research and clinical practice reveal that clearly identifiable cases of depression, suicide, psychotic disorders, panic disorders, OCD, epilepsy, developmental disabilities, alcoholism, and substance misuse are found throughout the country.

Patient case study The author treated a young man from a relatively isolated area of Western Bhutan. Initially, he complained of distressing thoughts causing pain inside his body, making him weak. In a later therapy session, he admitted to rumination if he had negative thoughts about another person. When he saw friends smoking, chewing doma (betel and areca), or acting in a way of which he disapproved, he had negative thoughts about them. He obsessed about these negative thoughts and felt that he had to neutralise them. Thus, when he had the thought, ‘That’s a negative person, not acting true to their cultural values’, he tried to neutralise this thought by pairing this person with a positive person in his mind. He often ordered a group of people in his mind as follows: bad person—good person—bad person—good person (so that each bad person was paired with a good person to expunge the anxiety-provoking ‘badness’). This is a clear case of Obsessive Compulsive Disorder (OCD) with a mental ritual; classic symptoms, despite occurring in a relatively isolated population within Bhutan with little knowledge of modern psychiatry. It would appear that such a pattern of behaviour (which was distressing to the patient) is not simply a construct of the West, but rather much more general to the human condition. Many other classic presentations were witnessed, including the tragic case of a man with psychosis who, responding to command auditory hallucinations, stabbed his wife to death. There were some differences observed in this context, such as more episodes of brief remitting psychosis encountered at the hospital than chronic schizophrenia. However, that was a possible by-product of higher death rates for Bhutanese with schizophrenia, or of home confinement (including chaining) of more disturbed individuals as sometimes practised in Bhutan, which is often encountered when an inadequate mental health system is in place. The opinion of the Bhutanese

38 Calabrese, J. D. & Dorji, C. (2014), Traditional and Modern Understandings of Mental Illness in Bhutan: Preserving the Benefits of Each to Support Gross National Happiness, Journal of Bhutan Studies, 30: 1–29.

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chief psychiatrist was that traditional treatment was ineffective in treating severe mental disorders such as schizophrenia.39 In terms of treatments, patients generally responded as expected to modern psychiatric drugs and to psychotherapy,40 even when the illness seemed very ‘spiritual’ to them. This depended on patient engagement and the quality of the medications that were available. It is noteworthy that in Bhutan at times there can be substandard or otherwise ineffective batches of medicine. This became very apparent when several patients with mania were on the ward and none were calming after several weeks of treatment with a mood stabilising medication. Upon analysis, there was some level of local knowledge of the psychopharmacological properties of plants in Bhutan. The author investigated the composition of seven Bhutanese Sowa Rigpa medicines associated with the treatment of mental illness symptoms. Six of the seven contain Myristica fragrans and five contain Aquilaria agallocha.41 Myristica fragrans (nutmeg) is psychoactive in high doses because it contains myristicin, which, like some antidepressant medications, is a monoamine oxidase inhibitor. Aquilaria agallocha has been found to contain a central nervous system depressant. However, a modern psychiatric practitioner would find the availability of only a weak monoamine oxidase inhibitor and a general central nervous system depressant for the treatment of all psychiatric illness very limiting. Nothing was witnessed to indicate that traditional ritual interventions or local medicines were effective for severe mental disorders such as psychoses. Instead, many patients went through years of ritual treatments that were ineffective and, when finally brought to the hospital after all else had failed, were either catatonic or had developed a treatment-resistant chronic mental illness. Such catatonia was then effectively treated by psychotropic medicine and symptoms of severe mental illness were often, though not always, ameliorated. The evidence pertaining to this clinical ethnographic study of Bhutan does not support a relativist argument, but instead one for species-wide patterns of severe mental illness and the need for a greater availability of modern treatment approaches, including not only authentic and potent medicines, but also psychotherapy and psychosocial rehabilitation (which are more focused on increasing social functionality than on simply eliminating symptoms).42 As the chief psychiatrist stated, acceptance of modern medical approaches, particularly in relation to psychiatric treatment, is a huge challenge in a society such as Bhutan, where most people are used to traditional forms of treatment.43 However, Bhutan does have valuable cultural resources for mental wellbeing. The spirituallymotivated practice of compassion and kindness in Bhutan, along with the interpretation of life

39 Personal communication expressed to the author during research. The doctor had qualified in psychiatry in Sri Lanka and India. 40 This is taking into account the individual differences in insight, motivation and responsiveness to treatment that are typically encountered when treating mental illness in any context. 41 Calabrese & Dorji (2014), op. cit., nt.38, at 15–17. Data was analysed on ingredients and uses of various medicines listed by the Institute of Traditional Medical Services in Bhutan. 42 See Farkas M. & Anthony, W. A. (2010), Psychiatric rehabilitation interventions: a review, International Review of Psychiatry, 22: 114–129; McGurk, S. R., Twamley, E. W., Sitzer, D. I., et al. (2007), A meta-analysis of cognitive remediation in schizophrenia, American Journal of Psychiatry, 164: 1791–1802; Mueser, K., Corrigan, P. W., Hilton, D. W., et al. (2002), Illness management and recovery: a review of the research, Psychiatric Services, 53(10): 1272–1284; Durham, R. C, Guthrie, M., Morton, R. V., et al. (2003), TaysideFife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms: results to three-month follow-up, The British Journal of Psychiatry, 182(4): 303–311. 43 Personal communication expressed to the author during research.

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in terms of karma, results in a generally very sane and peaceful society. Bhutan’s violent crime rate is relatively low. Stray dogs and cows nap in the middle of busy streets, since drivers will avoid the bad karma that would result from hitting them. Even taxis will sound their horn and slow down to avoid hitting a pigeon. Human and animal life is seen as more valuable there than in many other places globally. This way of valuing life and prioritising compassion, whilst not eliminating the reality of severe mental illness, is an important resource for mental health at a societal level that Bhutan would do well to preserve and perhaps integrate more explicitly into the care of people with mental illnesses. Furthermore, other states seeking to meet SDG3 could learn from this value-system.

Conclusion The case studies discussed above indicate that, when faced with diverse claims about traditional and other culture-based forms of treatment, simplistic relativist arguments and blanket policies that encourage traditional medicines because they are ‘cultural’ (or economically expedient) ought to be avoided. Similarly, anti-relativist ethnocentric viewpoints are not always appropriate, since a very effective local intervention may exist. The specifics of the local context matter. As such, a more flexible meta-relativist approach is advocated, by which is meant a relativised relativism— one that remains open to finding pan-human continuities as well as local particularities.44 An acceptable form of cultural relativism is the assumption that there can be different, yet equally accurate or effective views of the world or approaches to health. For many anthropologists, however, the optimality of the existing local frameworks of meaning and practice is a quasi-religious assumption, often buttressed by extremely questionable theory. When combined with a lack of clinical knowledge and appropriate evaluation, this assumption can miss the actual clinical realities of the local context entirely. Relativism ought not to be an automatic assumption that, when faced with two different worldviews or medical systems, both must be equally valuable. It would be wrong and contrary to achieving SDG3 to refuse to judge a society as failing in terms of mental health provision in comparison to others out of alleged respect for its culture. Local treatments should be assessed in a way that is culturally informed and deeply self-reflective (in terms of questioning potential ethnocentrism), as well as being clinically informed and using appropriate empirical methodology. Health effects of local treatments should be assessed objectively, both in terms of the therapeutic effects and the actual or potential anti-therapeutic effects. Promises of effective treatment that do not deliver, but rather impede or delay demonstrably more effective treatments, are anti-therapeutic and should not be supported. Further, approaches that uncritically advocate for them are manifestly unethical. However, one should always be ready to be surprised by treatment approaches which come from a radically contrasting paradigm, yet still work very well, as in the case of peyote use by Native Americans. Such openness requires an on-going critical examination of personal ethnocentric biases: what part of our understandings and the interventions developed and/or used in our own countries simply derive from our own local cultural convictions and are thus, when imposed on other cultures, manifestations of imperialism? A global ‘War on Drugs’ (which frequently means indigenous plant medicines that happen to be psychoactive in nature) in the absence of real data that they are dangerous is clearly ethnocentric and imperialist: it is a manifestation of a quasi-religious belief local to Western cultures and energised by the interests

44 Calabrese (2013), op. cit., nt.19, p.16 and pp.60–61.

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of pharmaceutical corporations, for-profit prisons, the political utility of scapegoating cultural others, and a host of other factors to do with neither safety nor efficacy.45 That said, where an effective medical intervention is introduced to a different culture because there are no effective alternatives, it will not be imperialistic. This is because, despite any treatment flaws (such as side-effects), it is the best intervention empirically demonstrated to help people with a particular form of illness. To meet SDG3, states have a duty to provide the most effective treatments possible and enhance local health care. Whether a particular mental health intervention works, or is ineffective or dangerous, is an empirical question requiring intensive field research and honest clinical evaluation. It cannot be concluded that, generally, traditional treatments are effective or ineffective. Each case of treatment and each country’s heritage, culture and history is different—both in terms of the local interventions involved and the problems treated. The Navajo case study revealed that an indigenous intervention that clashed strongly with Euro-American sensibilities, expectations and understandings of the treatment process is effective treatment for substance misuse, and supports general psychological wellbeing and a harmonious family life.46 In the context of Bhutan, examining severe mental illness specifically, what stood out were the hundreds of clinical cases inadequately treated with ritual interventions for years, resulting in chronic illness, catatonia, and severely diminished life chances.47 Nonetheless, a very compassionate and peaceful social milieu appeared to function to support mental health and prosocial behaviour. Finally, it is unnecessary to choose between a biologically reductionist, medication-based approach to public psychiatry and group-based relational approaches, which often have the benefit of mobilising local networks of social support. How can local support networks be utilised without at times reinforcing problematic beliefs about the nature of illness? Mutual support groups for patients and their communities can be extremely valuable when their ideologies do not undermine effective clinical services.48 This has been observed in the collective ceremonies used within Native American communities which provide significant support, increase resilience, and aid healing. In addition, group psychotherapy, therapeutic milieu approaches, and psychiatric rehabilitation can be extremely useful in the treatment of mental illness, and their drawbacks are minimal in comparison to the side-effects associated with psychiatric drugs.49 Individualism, as manifested in the reduction of mental illness to individual biology and the limiting of treatment to one medicated patient at a time, is potentially an aspect of the ethnocentrism of the West that should be critically examined in efforts to promote wellbeing and meet SDG3 effectively.

45 D. Nutt (2012), Drugs—Without the Hot Air: Minimising the Harms of Legal and Illegal Drugs (Cambridge: UIT Cambridge); American Civil Liberties Union (2011), Banking on Bondage: Private Prisons and Mass Incarceration. Available at: www.aclu.org/files/assets/bankingonbondage_20111102.pdf. 46 Calabrese (2013), op. cit., nt.19, pp.18–23 and pp.139–198. 47 Calabrese & Dorji (2014), op. cit., nt.38. 48 Corrigan, P. W., Calabrese, J. D., Diwan, S. E., et al. (2002), Some Recovery Processes in Mutual-help Groups for Persons with Mental Illness I: Qualitative Analysis of Program Materials and Testimonies, Community Mental Health Journal, 38(4): 287–301; Pistrang, N., Barker, C., & Humphreys, K. (2008), Mutual Help Groups for Mental Health Problems: A Review of Effectiveness Studies, American Journal of Community Psychology, 42(1–2): 110–121. 49 Calabrese & Corrigan (2005), op. cit., nt.5. Also see R. P. Liberman (2008), Recovery from Disability: Manual of Psychiatric Rehabilitation (Washington, DC: American Psychiatric Publishing, Inc). For a comprehensive critique of the Western biomedical model in the treatment of psychosocial disability, see Chapter 17 of this book by Peter Lehmann.

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8 ADDRESSING MENTAL HEALTH FROM A GENDER PERSPECTIVE Challenges and opportunities in meeting SDG3 Carol Vlassoff * Introduction This chapter explores the relationship between gender and mental health and the importance of this relationship for meeting Sustainable Development Goal 3 (SDG3). The overall goal of ensuring health and wellbeing for all throughout the life cycle includes the targets of promoting mental health and wellbeing, of strengthening prevention and treatment of substance abuse, and of reducing the suicide mortality rate.1 This chapter will argue that incorporating a gender approach into the promotion of mental health and wellbeing is essential in the attainment of SDG3, particularly in lower and middle-income countries (LMICs). Gender refers to ‘socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women’.2 Gender affects people’s control over the circumstances influencing their lives and health, including their social status and treatment by society, and their ability to shape or alter these conditions. At birth, men and women are entitled to enjoy their human rights and to be fulfilled and healthy. However, the roles attributed to them are often rooted in unequal power relationships, with women subordinated. Such inequalities can have negative consequences for women’s lives, health and wellbeing. Unequal gender relations are prevalent in most societies to some degree, but they are particularly prominent in LMICs where cultural factors often reinforce male-female hierarchies. People of the lesbian, bisexual, gay, and transgender (LBGT) community also face widespread discrimination globally, and are at risk of

* Carol Vlassoff is a demographer specialising in the social and economic aspects of global health with expertise in gender and development, and Adjunct Professor at the School of Epidemiology and Public Health, University of Ottawa. 1 United Nations, Department of Social and Economic Affairs, Sustainable Development Goal 3. Available at: https://sustainabledevelopment.un.org/sdg3. 2 WHO (2017), Gender, Women and Health: What Do We Mean by Sex and Gender? Available at: www. legal-tools.org/doc/a33dc3/pdf/.

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mental illness because of their repeated exposure to psychosocial stressors, including anti-LBGT attitudes, stigmatisation, and violence.3 A considerable amount of epidemiological literature has focused on biological gender differences in mental conditions, but most of the research on sex and gender differences in mental disorders is from high-income countries (HICs). Common mental disorders (CMDs) in LMICs have begun to be investigated only recently, and little is known about how specific risk factors vary by gender, as well as by other demographic and socioeconomic factors. The remainder of this chapter will therefore focus on what is known about gender and mental health issues in LMICs, in terms of challenges and opportunities to address them. Whilst taking a gendersensitive approach, it will concentrate on women, as a companion chapter in this book deals with male mental health concerns.4 It should be noted that this chapter does not discuss biomedical interventions for medical disorders, such as medicines and psychiatric therapies, although research and practice are increasingly recognising that men and women often respond differently to medical treatments and thus that gender influences should also be considered when prescribing treatment.5 A prevailing gap in the literature on gender differences in mental health in LMICs has been the failure to include perspectives of LBGT populations (with the exception of the HIV literature and specific LBGT journals). The relative lack of attention to LBGT issues in this chapter is due to the paucity of studies available from LMICs.

Sex differences in the burden of mental disorders It is widely accepted that men and women have similar rates of severe mental disorders, but that they have different patterns of CMDs.6 Women suffer more from depression, ranked by the WHO as the leading contributor to disability globally.7 Anxiety disorders, such as posttraumatic stress disorder (PTSD), are also reported more frequently amongst women, as well as panic disorders and phobias (from which women suffer up to three times more than men).8 Women have more comorbidity and concomitant increased disability (compared to the disability resultant from a single illness).9 Older women are reported to suffer disproportionately from mental disorders, including dementia, depression, and organic brain syndromes.10 By contrast,

3 See Willging, C. E., Salvador, M., & Kano, M. A. (2006), Brief Reports: Unequal Treatment: Mental Health Care for Sexual and Gender Minority Groups in a Rural State, Psychiatric Services, 57(6): 867–870. 4 See Chapter 9 of this book by Svend Aage Madsen on men’s mental health. 5 See, e.g., Fitzgerald, P. & Dinan, T. G. (2011), ‘Biological Sex Differences Relevant to Mental Health’, in D. Kohan (ed.), Oxford Textbook on Women and Mental Health (Oxford: Oxford University Press), Chapter 5, and Farr, S. L., Dietz, P. M., Williams, J.R., et al. (2011), Depression, Screening and Treatment among Nonpregnant Women of Reproductive Age in the United States, 1990–2010, Preventing Chronic Disease [online], 8(A): 122. Available at: www.ncbi.nlm.nih.gov/pubmed/22005615. 6 WHO (undated), Gender and Women’s Mental Health: Gender Disparities and Mental Health: The Facts. Available at: www.who.int/mental_health/resources/gender/en/. 7 WHO (2017), Common Mental Disorders, Global Health Estimates. Available at: apps.who.int/iris/ bitstream/10665/254610/1/WHO-MSD-MER-2017.2-eng.pdf. 8 Kadri, N. & Alami, K. M. (2009), ‘Depression and anxiety among women’, in P. S. Chandra, H. Herrman, J. Fisher, et al. (2009), Contemporary Topics in Women’s Mental Health: Global Perspectives (Chichester: John Wiley & Sons), pp.37–64. 9 Ibid. 10 Whilst older age is associated with increased risk of mental disorders, there is evidence that gender differences remain, even after controlling for age. However, more in-depth, disorder-specific, longitudinal

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men are described as suffering more from alcohol dependence, antisocial personality disorder, and substance use disorders.11 Accepted wisdom as to sex differences in the prevalence of mental disorders has been challenged by Hill and Needham,12 who note that national studies of overall psychopathology have been limited to a narrow range of conditions, and that there has been no comprehensive test of male-female differences across all known mental health conditions. They also question the tendency to group women and men into a simple dichotomous category of affective disorders (traditionally considered to be more common in women) and behaviour disorders (considered to be more common in men), due to a lack of consistent evidence that women and men respond to stress in different ways. They argue that an overemphasis on ‘gendered responsivity’ distorts the fact that negative emotions and risky behaviour (such as substance abuse and antisocial behaviour) are associated with stress for both sexes. The implications of their argument for the present analysis is that more attention should be paid to understanding the different stressors affecting the susceptibility and responses of both sexes, rather than to quantifying which sex suffers more or less from different mental disorders.

Gender-related stressors for women in LMICs This section highlights the main gender-related stressors that particularly affect women’s mental health.

Common perinatal and postnatal disorders Maternal health concerns dominate most of the literature on women’s mental health, especially disorders during the perinatal period. Stressors related to this period are both physical and socially derived. In HICs it is estimated that about 10% of pregnant women, and 13% of post-partum women, experience some type of mental disorder—mainly depression or anxiety,13 but also psychosis. In a systematic review of research on non-psychotic common perinatal mental disorders (CPMD), Fisher et al. found them to be even more prevalent in LMICs, where about one in six pregnant women and one in five postpartum women experience a CPMD.14 This finding, as the authors note, counters the widely held supposition that women’s mental health in LMICs is protected by culturally appropriate social support mechanisms. For example, the network of female relatives in extended family situations in South Asian countries was thought to provide women with much greater support than that received by women in nuclear families without other adult females to help care for them and their infants.

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research is needed in both HICS and LMIC to confirm these differences over the lifespan, and the influence of factors such as pre-existing conditions and frequency of symptoms. Steel, Z., Marnane, C., Iranpour, C., et al. (2014), The Global Prevalence of Common Mental Disorders: A Systematic Review and Meta-analysis 1980–2013, International Journal of Epidemiology, 43(2): 476–493. Hill, T. D. & Needham, B. L. (2013), Rethinking Gender and Mental Health: A Critical Analysis of Three Propositions, Social Science & Medicine, 92: 83–91. Fisher, J., Cabral de Mello, M., Patel, V., et al. (2012), Prevalence and Determinants of Common Perinatal Mental Disorders in Women in Low- and Lower-middle-income Countries: A Systematic Review, Bulletin of the World Health Organization [online], 90: 139–149H. Available at: www.who.int/bulletin/ volumes/90/2/11-091850.pdf. Ibid., p.5.

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Gender plays an important role in how women respond to perinatal stressors in both HICs and LMICs. Domestic abuse and lack of partner support for a pregnancy increase women’s stress and the probability of CPMDs. In societies with male sex progeny preference, women may be blamed for bearing a female child and may even feel guilty for doing so. In South Asia, for example, women often admit to feeling ‘unfulfilled’ if they do not produce a son.15 In the modern context of Asia’s declining fertility, most couples will be content with a small family if they have at least one son, and will forgo having daughters entirely.16 In India, the widespread availability of sex selective technologies (amniocentesis and ultrasound) in the 1970s and of legal abortion (since 1971) have had the combined effect of allowing couples to determine the sex composition of their families. Sex selection in favour of males has continued, particularly in South Asia, North Africa, and the Middle East, despite economic growth and development in other spheres of society.17 Importantly, where women have access to better education and employment opportunities, risk of CPMDs is lower.18 This is also the case where women have access to reproductive health services and a supportive family environment.19 CPMDs have deleterious effects not only upon mothers themselves, but also on the mental health and wellbeing of their children. Due to the stigmatisation associated with mental illness, women suffering from CPMDs are less likely to participate in essential preventive health care,20 and because infants are dependent on their mothers for their survival and wellbeing, their development is compromised if a mother is insensitive or unresponsive to their needs.21 In LMICs, maternal depression is associated with higher rates of neonatal malnutrition and stunting, diarrhoeal and infectious illnesses, hospital admissions, lower birth weight and incomplete compliance with immunisation schedules.22 Whilst research on the impact of men’s mental health during the perinatal period on childcare is lacking,23 the burden on mothers is likely to be disproportionately greater. More research concerning women’s (and men’s) mental health in the perinatal period in LMICs is needed to increase understanding and properly address the issues in culturally and gender-sensitive ways.

Violence and victimisation Domestic violence (by which is meant in this chapter ‘any behaviour within an intimate relationship that causes physical, psychological or sexual harm’)24 is a common hidden problem

15 This issue is discussed in detail in C. Vlassoff (2013), Gender Equality and Inequality in Rural India. Blessed with a Son (New York: Palgrave Macmillan). 16 Seth, S. (2010), Skewed Sex Ratio at Birth in India, Journal of Biosocial Science, 43(1): 83–97; Vlassoff (2013), op. cit., nt.15. 17 See, e.g., Hesketh, T., Li Lu, M. D., & Wei Xing, Z. (2011), The Consequences of Son Preference and Sex-selective Abortion in China and other Asian Countries, Canadian Medical Association Journal, 183(12): 1374–1377. 18 Fisher et al. (2012), op. cit., nt.13. 19 Ibid. 20 Fisher, J., Tran, T., Buoi, L. T., et al. (2010), Perinatal Mental Disorders and Health Care Use in Northern Viet Nam, Bulletin of the World Health Organization [online], 88(10): 737–745. Available at: www.scielosp. org/scielo.php?pid=S0042-96862010001000010&script=sci_arttext&tlng=pt. 21 See also further Chapter 11 of this book by Cornelius Ani and Olayinka Omigbodun. 22 Stewart, R. C., Umar, E., Kauye, F., et al. (2008), Maternal Common Mental Disorder and Infant Growth – A Cross-sectional Study from Malawi, Maternal and Child Nutrition, 4(3): 209–219. 23 See further on this Chapter 9 of this book by Svend Aage Madsen. 24 Hegarty, K. (2011), Domestic Violence: The Hidden Epidemic Associated with Mental Illness, The British Journal of Psychiatry, 198(3): 169–170.

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for women globally, and a major cause of mental ill health.25 Injurious physical and mental health sequelae of intimate partner violence (IPV) include injury and death, chronic pain, gastrointestinal and gynaecological problems, depression, and PTSD.26 Many women also suffer rape and violence during pregnancy, causing harm to both mothers and children. Although it varies significantly between countries, about 30% of women experience physical or sexual IPV during their lifetime globally.27 In LMICs, the prevalence of physical IPV against women varies from 14% in Cambodia to 71% in Ethiopia.28 Men also experience IPV, but it is less prevalent and severe.29 To date, most research in this area has focused on physical and sexual violence,30 leaving the area of emotional and mental anguish (unrelated to physical abuse) largely undocumented. Gender-based violence (GBV) against women is widely condoned in many LMICs where patriarchal values are the norm.31 A recent analysis examined approval for ‘wife-beating’ under five different circumstances.32 The first was where a wife goes out without telling her husband. The second related to a wife who neglects the children. The third category was a wife who argues with her husband, and the fourth, where a wife refuses to have sexual intercourse with him. The fifth and final category was where a wife burns the family’s food. This survey was carried out amongst 53,538 men and 439,614 women in a sample of households from 39 countries, including 23 LMICs. The questions assessed attitudes only concerning physical abuse, and did not investigate attitudes about sexual or emotional violence toward women. Approval by women of physical chastisement in relation to any one or more of the five categories varied from 2% in Argentina to 90% in Afghanistan. Only one-third of the countries provided data from men’s perspectives. For those countries which included men’s attitudes, approval varied from 5% in Belarus to 75% in the Central African Republic.33 Africa and South Asia were the regions where physical chastisement was most accepted, whereas Europe, Latin America, and the Caribbean were the least accepting. Acceptance was more prevalent amongst those with low household income, those of rural residence, and the less educated, as well as (perhaps surprisingly) amongst younger adults (the latter finding being consistent with prior evidence). In the countries with high acceptance of physical chastisement, women were more likely to justify it than men, but in the countries with low acceptance, the opposite was true. The authors noted that those countries with higher approval tend to be also higher in gender inequality, and hence men in such countries are better educated, and have greater access to employment and other opportunities than women. The authors concluded that policies are needed urgently to improve gender equality and women’s economic status and education in the countries where acceptance of physical chastisement is most widespread, and that interventions need to be orientated to those most approving of IPV

25 Ibid. 26 Campbell, J. C. (2002), Health Consequences of Intimate Partner Violence, The Lancet, 359(9314): 1331–1336. 27 Devries, K. M., Mak, J. Y., Garcia-Moreno, C., et al. (2013), The Global Prevalence of Intimate Partner Violence against Women, Science, 340 (6140): 1527–1528. 28 Tran, T. D., Nguyen, H., & Fisher, J. (2016), Attitudes towards Intimate Partner Violence against Women among Women and Men in 39 Low- and Middle-income Countries, PLoS ONE [online], 11(11): 1–14 e0167438. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0167438. 29 Ibid., p.2. 30 Ibid. 31 Carter, J. (2015), Patriarchy and Violence against Women and Girls, The Lancet [online], 385(9978): e40-e41. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62217-0/fulltext. 32 Tran et al. (2016), op. cit., nt.28, p.3. 33 Ibid., p.4.

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(such as women, youth, those living in rural areas, and the poor). Given the consequences of these problematic attitudes, the authors conclude that changing accepting attitudes toward violence against women should be national priorities within the context of the SDGs. In terms of the mental health implications from this study, it would appear that female victims of IPV are most at risk of mental health problems because they lack social support and tend to blame themselves for causing the violence.34 IPV against women is strongly associated with suicide attempts. Based on analysis of a large 2000–2003 World Health Organization (WHO) study of women aged 15 to 49 in 13 sites, including seven LMICs, Devries et al. found that IPV, physical violence from non-partners, divorce, separation, widowhood, childhood sexual abuse, and having a mother who experienced IPV were the most consistent predictors for suicide attempts.35 The study recommended that health workers in LMICs should receive training to recognise and respond to the consequences of violence in order to reduce the health burden associated with suicidal behaviour. Poly-victimisation means exposure to a variety of forms of aggression, including maltreatment, vandalism, physical assault, peer, sibling and cyber victimisation, and witnessing family or community violence. Gender differences in the rates and effects of victimisation and polyvictimisation, particularly amongst children and adolescents, are receiving growing attention in HICs. The types of victimisation appear to vary by sex, with females more subject to sexual abuse, whereas males are subjected to more physical abuse.36 Evidence of long-term mental health consequences for children who experience victimisation remains insufficient, and more research is needed to elucidate the effect of gender and age on the nature of the victimisation and their relation to psychiatric outcomes. In LMICs, there has been limited investigation of the association between experiences of violence (including poly-victimisation) amongst children and adolescents.37 A recent study amongst adolescent girls and boys in Vietnam,38 however, found different effects on health-related quality of life by sex: female adolescents suffered worse effects than males on all outcomes, except for disability. However, for those who experienced poly-victimisation, both girls and boys suffered equally ill-effects, including lower levels of self-esteem and increased levels of anxiety, depression and pain.

Social and economic stressors Socioeconomic status, including education, employment, and income, has been widely shown to affect mental health, especially that of women. In a study based on the WHO’s World Health Surveys (2002–2003), the analysis of data from 53 countries including 29 LMICs found depression to be higher in women. This gender association increased according to the economic development

34 Ibid., pp.11–12. 35 Devries, K., Watts, C., Mieko, Y., et al. (2011), Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women’s health and domestic violence against women, Social Science and Medicine, 73(1): 79–86. 36 See Gershon, A., Minor, K., & Hayward, C. (2008), Gender, Victimization, and Psychiatric Outcomes, Psychological Medicine, 38(10): 1377–1391. 37 Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007), Poly-victimization: A Neglected Component in Child Victimization, Child Abuse & Neglect, 31: 7–26. 38 Le, M. T. H., Holton, S., Nguyen, H. T., et al. (2016), Victimisation, Poly-victimisation and Health-related Quality of Life among High School Students in Vietnam: a Cross-sectional Survey, Health and Quality of Life Outcomes [online], 14(1): 155. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5097374/.

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of countries.39 It was suggested that women in HICs may be more likely to report symptoms of depression, or that changes in traditional gender roles, including assuming multiple roles, may partly explain this finding. There is, in fact, some evidence that changing gender roles are narrowing the widely reported differences in CMDs between men and women. Cohort analysis of part of the epidemiological data from subsequent WHO World Mental Health Surveys found that female-male differences in major depression, intermittent explosive disorder, and substance disorders were smaller amongst younger cohorts than older ones.40 These differences were considered to be partly related to changes in conventional female roles, whereby younger women had more access to equalising opportunities, such as employment, birth control and resources that protect against traditional stressors, such as financial dependence. The link between poverty and the prevalence of mental health disorders has been widely discussed in the research literature,41 both at country and individual levels. These associations at the country level are still being debated, partly because the studies have used different indicators of poverty and mental health.42 At the individual level, associations between being female, poverty and CMDs are strong, but the underlying reasons for this require further study, especially in LMICs. For example, in low income communities in Karachi, Pakistan, it was observed that financial worries were more important stressors for males, whereas family concerns were more important amongst females.43 Gender roles were thought to explain this difference, men having primary responsibility for providing for their families, and women, for the management of relationship issues. The authors observed that low income or low education may increase vulnerability to social challenges that, in turn, are linked to distress. Further, poor women are more likely to live in crowded conditions, to have fewer occupational opportunities, and to suffer from chronic illnesses, all of which are known risk factors for CMDs.44

Multimorbidity Globally, multimorbidity (suffering from two or more chronic physical or mental illnesses simultaneously) is associated with other adverse physical and mental health outcomes, including

39 Rai, D., Zitko, P., Jones, K., et al. (2013), Country- and Individual-level Socioeconomic Determinants of Depression: Multilevel Cross-national Comparison, British Journal of Psychiatry, 202(3): 195–203. 40 Seedat, S., Scott, K. M., Angermeyer, M. C., et al. (2009), Cross-national Associations between Gender and Mental Disorders in the World Health Organization World Mental Health Surveys, Archives of General Psychiatry, 66(7): 785–795. 41 See, e.g., Lund, C., Breen, A., Fisher, A. J., et al. (2010), Poverty and Common Mental Disorders in Low And Middle Income Countries: A Systematic Review, Social Science & Medicine, 71(3): 512–528, which reviewed 115 community and facility-based studies in LMICs that strongly suggested that poorer people have poorer mental health. However, data from LMICs remain more limited than that from HICs. 42 For example, in Patel, V. & Kleinman, A. (2003), Poverty and Common Mental Disorders in Developing Countries, Bulletin of the World Health Organization [online], 81(8): 609–615. Available at: www.who.int/ bulletin/volumes/81/8/Patel0803.pdf. Table 1 reviews a variety of different measures for poverty, as well as different measures of psychiatric morbidity. 43 Kidwai, R. (2014), Demographic factors, Social Problems and Material Amenities as Predictors of Psychological Distress: A Cross-sectional Study in Karachi, Pakistan, Social Psychiatry and Psychiatric Epidemiology, 49(1): 27–39. 44 Patel, V., Kirkwood, B. R., Pednekar, S., et al. (2006), Risk Factors for Common Mental Disorders In Women. Population-based Longitudinal Study, British Journal of Psychiatry, 189: 547–555.

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depression.45 It has been found to be significantly higher in females in several HICs,46 and in a few LMICs where studies have been carried out.47 Whilst previously thought to be more prevalent in the ageing population, recent research has shown that multimorbidity also affects younger people.48 The links between multimorbidity, gender, and mental disorders plainly require further investigation.

Gender, coping and care-seeking Many studies of gender differences in the use of health services, especially in HICs, have found that women consult services more than men. Possible explanations have included differences in socialisation, knowledge, sensitivity to symptoms because women are more likely to be in care-giving roles, and health status. Studies on gender and care-seeking for general health problems in LMICs agree that women are more frequent users of rural health clinics than men,49 but findings suggest that women attend clinics more for others, especially their children, than for themselves.50 For their own problems, women tend to first consult traditional healers, partly because they have less available cash to pay for formal services, and healers are more likely to accept payment in kind.51 Healers are also more accessible and tend to provide explanations within cultural frameworks of daily experiences that women understand.52 Moreover, perhaps in part due to the focus of the Millennium Development Goals (MDGs) on maternal health, LMIC

45 Mercer, S. W., Gunn, J., Wyke, S., & Guthrie, B. (2012), Managing Patients with Mental and Physical Multimorbidity, British Medical Journal [online], 345: e5559. Available at: www.bmj.com/content/350/ bmj.h176. 46 See, for example, Agborsangaya, C. B., Lau, D., Lahtinen, M., et al. (2012), Multimorbidity Prevalence and Patterns across Socioeconomic Determinants: A Cross-sectional Survey, BMC Public Health [online], 12: 201. Available at: bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-201; and Marengoni, A., Angleman, S., Melis, R., et al. (2011), Aging with Multimorbidity: A Systematic Review of the Literature, Ageing Research Reviews, 10(4): 430–439. 47 See, for example, Arokiasamy, P., Uttamacharya, U., Jain, K., et al. (2015), The Impact of Multimorbidity on Adult Physical and Mental Health in Low- and Middle-income Countries: What Does the Study on Global Ageing and Adult Health (SAGE) Reveal?, BMC Medicine [online], 13: 178. Available at: www. ncbi.nlm.nih.gov/pmc/articles/PMC4524360/; and Alaba, O. & Chola, L. (2013), The Social Determinants of Multimorbidity in South Africa, International Journal for Equity in Health [online], 12: 63. Available at: equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-12-63. 48 See, for example, Arokiasamy, P., Uttamacharya, U., Jain, K., et al. (2015), The Impact of Multimorbidity on Adult Physical and Mental Health in Low- and Middle-income Countries: What Does the Study on Global Ageing and Adult Health (SAGE) Reveal?, BMC Medicine [online], 13: 178. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4524360/. See also Taylor, A. W., Price, K., Gill, T. K., et al. (2010), Multimorbidity—Not Just an Older Person’s Issue. Results from an Australian Biomedical Study, BMC Public Health [online], 10: 718. Available at: bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-10-718. 49 See, e.g., Yamasaki-Nakagawa, M., Ozasa, K., Yamada, N., et al. (2001), Gender Difference in Delays to Diagnosis and Health Care Seeking Behaviour in a Rural Area of Nepal, The International Journal of Tuberculosis and Lung Disease, 5(1): 24–31; and Allotey, P. & Gyapong, M. (2005), The Gender Agenda in the Control of Tropical Diseases: A Review of Current Evidence. Special Topics No. 4 (Geneva: UNICEF, UNDP, World Bank, WHO Special Programme for Research and Training in Tropical Diseases (TDR/WHO)). 50 Vlassoff, C. (2008), ‘Gender in Health and Illness’, in K. Heggenhougen & S. R. Quah (eds) (2008), The International Encyclopedia of Public Health (1st edn) (Boston: Elselvier), pp.26–35. 51 Allotey, P. (1995), The Burden of Illness in Pregnancy in Rural Ghana: a Study of Maternal Morbidity and Interventions in Northern Ghana (thesis; Perth: University of Western Australia). 52 Allotey & Gyapong (2005), op. cit., nt.49, p.49.

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health services pay more attention to maternal-child health, rather than to women’s health issues outside of the reproductive age.53 Further, gender stereotyping identifies females as prone to emotional problems, and men to alcohol problems, thus hindering accurate treatment. A lack of sufficient numbers of female personnel may further inhibit women from using medical services for themselves. Compared to HICs, there is relatively little knowledge on health-seeking behaviour for those with CMDs in LMICS. However, a recent analysis of sex differences in utilisation of mental health services from 62 LMICs using WHO’s Assessment Instrument for Mental Health Systems (WHO-AIMS) found that women used fewer mental health services than men.54 The authors attributed this difference primarily to gender-based factors, such as women’s lack of decision-making power and financial resources, a lack of free time to seek care, and restrictions on their mobility outside the domestic sphere. They also mentioned the possibility that women use more services from traditional healers (as noted above, in relation to general health issues), but that the hypothesis required substantiation. Some studies in LMICs have found that, because of stigma attached to mental disorders, women tend to report their psychological stress in terms of physical ailments (somatisation). In Indian studies, for example, women often describe poor mental health as gynaecological concerns.55 Women may hesitate to report culturally deviant behaviour, such as alcohol or drug abuse, especially in societies where substance use is more prevalent and accepted amongst males. Failure to talk about these concerns with health professionals impedes rapid and accurate diagnosis, appropriate treatment, and referral. Studies on client-provider relations in LMICs have found that women who attend health services are often the subject of blame and are treated as inferior. For example, they may be blamed for reporting late, or for not taking their children for regular immunisations.56 This exacerbates their reluctance to access health care for themselves, even when other access barriers, such as transportation and economic constraints, are absent. There is some evidence that women sometimes use the opportunity of bringing their children to health facilities to have themselves examined as well, but this is an issue that has received little research attention.57 Insensitive treatment by health personnel can also be a problem for women in HICs, but more options for restitution are available to them. In mental health consultations, however, men appear to be more affected than women by negative treatment. A recent systematic review of 144 studies from both HICs and LMICs found that stigma had a disproportionate effect on men’s help-seeking behaviour, perhaps due to the disconnect between men being typified as

53 For a discussion of this issue, see Vlassoff (2008), op. cit., nt.50. 54 Paula de los Angeles, C., Watkins, W., McBain, L. R., et al. (2014), Use of Mental Health Services by Women in Low And Middle Income Countries, Journal of Public Mental Health, 13(4): 211–223. 55 See, for example, Maitra, S., Brault, M. A., Schensul, S. L., et al. (2015), An Approach to Mental Health in Low- and Middle-income Countries: A Case Example from Urban India, International Journal of Mental Health, 44(3): 215–230; and Parkar, S. R., Nagarsekar, B., & Weiss, M. G. (2009), Explaining Suicide in an Urban Slum of Mumbai, India: A Sociocultural Autopsy, Crisis, 30(4): 192–201. 56 See, e.g., Percival, V., Richards, E., MacLean, T., & Theobald, S. (2014), Health Systems and Gender in Post-conflict Contexts: Building Back Better?, Conflict and Health, 20(8): 19. Available at: conflictandhealth.biomedcentral.com/articles/10.1186/1752-1505-8-19. See also WHO (2010), Gender, Women and Primary Health Care Renewal: A Discussion Paper. Available at: apps.who.int/iris/bitstr eam/10665/44430/1/9789241564038_eng.pdf. 57 See Vlassoff, C. & Bonilla, E. (1994), Gender-related differences in the impact of tropical diseases on women: what do we know?, Journal of Biosocial Science, 26: 37–53.

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strong and stoical, as opposed to dependent on others by seeking care.58 In general, it can safely be said that both women and men suffer from gender-related constraints in consulting health professionals for psychological problems. In terms of coping with mental disorders, emotional and logistical support, such as help with medication and adherence from family, community members and health workers, has been found to play an important buffering role. For example, a study of adherence to treatment for schizophrenia in the United States found that most patients with supportive families remained in treatment longer and had better outcomes than those without such support.59 Evidence from LMICs on this subject is limited, and there is even less information on gender differences with respect to coping with mental disorders. However, there is growing evidence that spousal and family support are important in their prevention.60 Providing support for family members or others affected by mental illness can be stressful for care-givers who often lack guidance on appropriate care practices. Hence, it is important that public health programmes provide assistance and counselling to them as well as to patients.

Gender and the response of health systems The integration of gender into health policies and programmes is a necessary first step in improving the gender-sensitivity of health services. However, its translation into practical guidelines for implementation in LMIC health care settings remains a challenge, due partly to the inexperience of the health sector in this area, and partly to the lack of appreciation as to how traditional gender norms may affect health. In addition, the hierarchy in the health system itself, where men are viewed as decision-makers and women mainly as subordinates, reproduces itself at all levels of the services.61 Hence, nurses and others may treat lower-level staff and patients in a condescending way, and this pattern is perpetuated in health worker-client interactions, especially with respect to poor women where gender inequality, race and social class often intersect. Gender inequalities in the health services have also been found to influence the quality of data produced, and the reporting of data and trends.62 Most women and men experiencing

58 Clement, S., Schauman, O., Graham, T., et al. (2014), What is the Impact of Mental Health-related Stigma on Help-seeking? A Systematic Review of Quantitative and Qualitative Studies, Psychological Medicine, 45(1): 11–27. 59 Glick, I. D., Stekoll, A. H., & Hays, S. (2011), The Role of the Family and Improvement in Treatment Maintenance, Adherence, and Outcome for Schizophrenia, Journal of Clinical Psychopharmacology, 31(1): 82–85. 60 See, e.g., Qadir, F., Khalid, A., Haqqani, S., et al. (2013), The Association of Marital Relationship and Perceived Social Support with Mental Health of Women in Pakistan, BMC Public Health [online], 13: 150. Available at: bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-1150. See also Fisher, J., Cabral de Mello, M., Patel, V., et al. (2012), Prevalence and Determinants of Common Perinatal Mental Disorders in Women in Low- and Lower-middle-income Countries: A Systematic Review, Bulletin of the World Health Organization [online], 90: 139–149H. Available at: www.who.int/bulletin/ volumes/90/2/11-091850/en/. 61 See, e.g., Vlassoff (2008), op. cit., nt.50; Glick et al. (2011), op. cit., nt.59; Percival et al. (2014), op. cit., nt.56, 19, and WHO (2010), Gender, Women and Primary Health Care Renewal: A Discussion Paper. Available at: apps.who.int/iris/bitstream/10665/44430/1/9789241564038_eng.pdf. 62 Morgan, R., George, A., Ssali, S., et al. (2016), How to Do (or Not to Do) Gender Analysis in Health Systems Research, Health Policy and Planning, 31(8): 1069–1078.

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emotional distress and/or psychological disorders are never identified, for several reasons. These include the stigma attached to mental illness, the tendency to ignore its signs and symptoms, on the part of both the sufferer and society, and the failure of health systems to recognise these symptoms. Disorders triggered by violence are under-diagnosed because women hesitate to disclose their victimisation unless directly questioned about it by their providers. In many LMICs, hospital statistics are used for general surveillance purposes, such as where it is generalised to the whole population because of the lack of vital registration data. However, inferences from hospital data may be erroneous because they are based on a selective sample, and may miss out women disproportionately because of their greater economic and social constraints in seeking mental health care.63 Gender stereotypes affect providers’ perceptions of clients’ health needs and the way they counsel them.64 Women are more likely than men to be diagnosed with depression, whilst depression in men is more often ignored.65 Thus, women are more often treated with psychotropic drugs and they are less likely to be diagnosed as suffering from alcohol abuse. Male providers tend to be more authoritative than female providers, give less time to patients, and are less likely to engage in two-way dialogue with them.66 This lack of sensitive communication between health workers and female patients makes it difficult for women to disclose psychological and emotional distress; a health issue that is often stigmatised. When women do disclose their problems, many health workers tend to either over-treat or under-treat women.67 Acute shortages of trained mental health professionals are widely reported in LMIC studies.68 Where such facilities, trained professionals and treatments are unavailable, the specific needs of men, women and LBGT populations remain largely unaddressed. Health workers in LMICs are often unequipped to counsel clients on sensitive health issues because they lack training in how to deal with often stigmatised matters such as domestic abuse, unwanted pregnancies, HIV and

63 Ibid. 64 A large body of literature articulates the oppression and discrimination that women have faced at the hands of psychiatric practice from the earliest days of the field’s history (Burgess, R. A. (2016), ‘Dangerous Discourses? Silencing Women within “Global Mental Health” Practice’, in J. Jasmine Gideon (ed.), Handbook on Gender and Health (Cheltenham: Edward Elgar Publishing), Chapter 5, pp.79–97; L. Appignanesi (2011), Mad, Bad and Sad: A History of Women and the Mind Doctors from 1800 to the Present (London: Hachette); Ussher, J. M. (2010), Diagnosing difficult women and pathologising femininity: gender bias in psychiatric nosology, Feminism & Psychology, 23(1): 63–39). Since early psychiatric thinking was dominated by male practitioners (such as Philippe Pinel and Sigmund Freud), women’s concerns were categorised according to gendered perceptions of females whose emotional stresses were seen as hysterical or perverse. For more on this subject see Hirshbein, L. (2010), Sex and Gender in Psychiatry: A View from History, Journal of Medical Humanities, 31(2): 155–170. 65 Percival et al. (2014), op. cit., nt.56, p.19. Available at: conflictandhealth.biomedcentral.com/articles/ 10.1186/1752-1505-8-19. 66 Jefferson, L., Bloor, K., Birks,Y., et al. (2013), Effect of Physicians’ Gender on Communication and Consultation Length: A Systematic Review and Meta-analysis, Journal of Health Services Research and Policy, 18(4): 242–248; and WHO (2010), op. cit., nt.56. 67 WHO (2010), op. cit., nt.56. 68 Baron, E. C., Hanlon, C., Mall, S., et al. (2016), Maternal Mental Health in Primary Care in Five Lowand Middle-income Countries: A Situational Analysis, BMC Health Services Research [online], 16(1): 53. Available at: bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1291-z. See also Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson; and Bruckner, T. A., Scheffler, R. M., Shen, G., et al. (2011), The Mental Health Workforce Gap in Low- and Middle-income Countries: A Needs-based Approach, Bulletin of the World Health Organization [online], 89(3): 184–194. Available at: www.who.int/bulletin/volumes/89/3/10-082784/en/.

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mental health. Similarly, many health professionals are either unsympathetic to, or find it difficult to address, sexual issues with people with minority sexual orientations, especially in settings where LBGT populations are severely stigmatised. Such weaknesses in the health services inadvertently contribute to the worsening of health problems, as well as the spread of infections. For example, people at risk of sexually transmitted infections, such as men who have sexual intercourse with men, may avoid health facilities when they view them as unresponsive to their needs.

Promising gender-related interventions in LMICS According to the WHO, three main factors are helpful in preventing the development of mental health problems, especially depression: autonomy (described as the ability to exercise some control in the face of severe events), access and control over some material resources, and support from family, friends, or health providers.69 With these factors as a guide, this section reviews a number of interventions that have shown at least some success in LMICs in preventing and treating CMDs, especially amongst women.

Interventions to increase autonomy vis-à-vis severe events Several well-established interventions are available for women in the areas of maternal mental health, domestic violence, and substance misuse in HICs. However, less is known about interventions to assist women in LMICs in coping with their mental health. Few psychological interventions for survivors of GBV in LMICs have been rigorously evaluated, as Dawson et al. observe.70 Further, as noted earlier, the assumption that women are protected by traditional cultural practices in the perinatal period impedes attention to this problem. In most LMICs it is difficult to provide dedicated GBV services because of a combination of resource constraints and stigma.71 Ideally, these services would be delivered as part of the general health programmes that provide psychological help for survivors of GBV without specifically highlighting it. This would ensure that the situation was not exacerbated either by stigmatising the person further in the community, or by causing further intimate partner GBV should it be discovered that women attended services. A feasibility randomised control trial of one such intervention in Kenya, ‘PM+’ (Problem Management Plus), demonstrated promising results and the potential for further research on the approach.72 The intervention was conducted by trained community health workers (CHWs) amongst women living in poor peri-urban villages in Nairobi, and used problem-solving counselling to address symptoms of CMD, such as depression, anxiety and stress. However, it did not specifically select for women affected by GBV. The results were reduced PTSD symptoms amongst women affected by adversity, including GBV. The study also suggested that the generic screening approach was effective in reaching those suffering from GBV, and that non-specialised CHWs could be trained to deliver the intervention successfully.

69 WHO (2017), op. cit., nt.7. 70 Dawson, K. S., Schafer, A., Anjuri, D., et al. (2016), Feasibility Trial of a Scalable Psychological Intervention for Women affected by Urban Adversity and Gender-based Violence in Nairobi, BMC Psychiatry [online], 16: 410. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5116169/. 71 Ibid. 72 Ibid.

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Childhood and adolescence are crucial phases for nurturing healthy mental and physical development.73 Evidence, mainly from HICs, indicates that comprehensive mental health promotion interventions, in collaboration with families, schools and communities, can lead to many positive outcomes in mental health, social functioning, school and work performance, and healthy behaviours.74 However, even though LMICs are home to 90% of the world’s young people, empowermentoriented interventions for adolescents and their effects by gender and socioeconomic status are relatively unexplored.75 Several studies report gender differences for interventions provided in political conflict situations, but findings are inconsistent. A study of classroom-based interventions (CBI) in conflict-affected rural Nepal reported significant reductions in psychological difficulties and aggression amongst males, with improved pro-social behaviour only amongst females.76 A CBI designed to alleviate post-conflict distress amongst youth in the West Bank and Gaza, Palestine, found that both sexes responded positively in terms of maintaining hope, but that boys experienced greater benefits than girls in relation to enhancing belief in personal responsibility and control.77 A later study of an intervention for Palestinian children in Gaza using recovery techniques also found more impact upon males in reducing clinically significant PTSD, whilst only those girls who had low post-conflict trauma (‘peritraumatic dissociation’) benefited.78 As the authors noted, this result contradicts the belief that psychological and social help is more attuned to female needs than to those of men. A systematic review of school and communitybased mental health promotion interventions for youth in LMIC settings found mixed results, mainly positive, but some negative mental health outcomes. An intervention encouraging students to write about their experiences to help them cope with PTSD led to significantly increased depression symptoms subsequent to the intervention.79 Findings regarding gender and age differences in response to the various interventions were also unclear, two studies reporting positive impacts for girls, whilst another found a positive impact only for boys, and younger children (especially males) seemed to benefit more from the interventions than older adolescents.80 The lack of consistency in findings across these interventions highlights the necessity of further

73 For an in-depth consideration of this issue, see Chapter 11 of this book by Cornelius Ani and Olayinka Omigbodun. 74 See, e.g., Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2013), A Systematic Review of the Effectiveness of Mental Health Promotion Interventions for Young People in Low and Middle Income Countries, BMC Public Health [online], 13(1): 835. Available at: bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-13-835. See also Salam, R. A., Das, J. K., Lassi, Z. S., & Bhutta, Z. A. (2016), Adolescent Health Interventions: Conclusions, Evidence Gaps, and Research Priorities, Journal of Adolescent Health, 59(4): S88–S92. 75 Salam et al. (2016), ibid. 76 Jordans, M. J. D., Komproe, I. H., Tol, W. A., et al. (2010), Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: a cluster randomized controlled trial, Journal of Child Psychology and Psychiatry, 51(7): 818–826. 77 Khamis, V., Macy, R., & Coignez, V. (2004), The Impact Of The Classroom/Community/Camp-based Intervention (CBI) Program On Palestinian Children (New York: Save the Children and USAID). Available at: citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.510.9759&rep=rep1&type=pdf. 78 Qouta, S. R., Palosaari, E., Diab, M., & Punamaki, R. (2012), Intervention Effectiveness among Waraffected Children: A Cluster Randomized Controlled Trial on Improving Mental Health, Journal of Traumatic Stress, 25(3): 288–298. 79 Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2013), A Systematic Review of the Effectiveness of Mental Health Promotion Interventions for Young People in Low and Middle Income Countries, BMC Public Health [online], 13(1): 835. Available at: bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-13-835. 80 As the authors note, this finding is consistent with research from HICs which emphasises the importance of reaching children when they are young to sustain their resilience and strengthen coping abilities.

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investigation into mental health promotion programmes for youth which allow for a more in-depth analysis of the differential impacts of demographic factors such as sex and age. There are very few studies of promising, empowerment-focused interventions for LBGT populations, with the exception of some related to HIV and AIDS. However, a study of the Pehchan programme in India which uses a rights-based approach to help communities and systems provide HIV, health, legal, and social services to transgender communities found significant improvement in both demand and access to services nationwide, as well as in ‘self-efficacy’ and ‘collective identity’—a model to respond to the unique health needs of transgender communities.81 Such programmes do not seem to have been extended to mental health, but they could have similar benefits for people in mental distress, given their frequent marginalisation from society.

Interventions focusing on control over resources In recent years there has been growing interest in the impact of special financing initiatives on mental health and wellbeing, especially for orphans and young people affected by HIV in Africa.82 Cash may be provided to beneficiary households, sometimes contingent upon the fulfilment of certain conditions (‘conditional’ cash transfers), or unconditionally, to improve the welfare of the participating households and to encourage desired changes in behaviour related to economic activities, nutrition, education, and health. Results generally show positive outcomes with respect to cash transfers. For example, in an evaluative report on (mostly unconditional) cash transfers to households in eight African countries (using a rigorous scientific mixed-methods approach with both qualitative and quantitative research methods including control households, positive outcomes were found.83 These included increased school enrolment of both girls and boys (especially secondary enrolment), improved educational attainment, and reduced illness from diarrhoea amongst children. In five countries (Kenya, Malawi, South Africa, Zimbabwe, and Zambia) the transfer evaluation also contained a module dedicated specifically to adolescents (with face-to-face interviews) which included some questions on mental health. Results showed that programme participants had later sexual debut, made greater use of condoms, had fewer sexual partners, and had lower pregnancy rates. There is very little discussion of mental health in the report, although a separate paper by Handa et al. on the Kenyan study84 noted that by lifting homes out of severe poverty, these programmes may improve mental health and increase hope

81 Shaikh, S., Mburu, G., Arumugam, V., et al. (2016), Empowering Communities and Strengthening Systems to improve Transgender Health: Outcomes from the Pehchan Programme in India, Journal of the International AIDS Society [online], 19(3) (Suppl 2): 20809. Available at: www.ncbi.nlm.nih.gov/pmc/ articles/PMC4949313/. 82 See, for example, Ssewamala, F. M. & Ismayilova, L. (2009), Integrating Children’s Savings Accounts in the Care and Support of Orphaned Adolescents in Rural Uganda, Social Service Review, 83(3): 453–472; and Ssewamala, F. M., Karimi, L., Chang-Keun, H., & Ismayilova, L. (2010), Social Capital, Savings, and Educational Performance of Orphaned Adolescents in Sub-Saharan Africa, Children and Youth Services Review, 32(12): 1704–1710. 83 B. Davis, S. Handa, N. Hypher, et al. (eds) (2016), From Evidence to Action. The Story of Cash Transfers and Impact Evaluation in Sub-Saharan Africa (Rome/New York/Oxford: Food and Agriculture Organization/ UNICEF/Oxford University Press). 84 Handa, S., Halpern, C. T., Pettifor, A., & Thirumurthy, H. (2014), The Government of Kenya’s Cash Transfer Program Reduces the Risk of Sexual Debut among Young People Age 15–25, PLoS ONE [online], 9(1): p.e85473. Available at: journals.plos.org/plosone/article?id=10.1371/jour nal.pone.0085473.

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for the future.85 However, it is apparent that future evaluations of these initiatives are needed to explore these mechanisms in relation to mental health. Cash transfer schemes appear to be especially effective when combined with gender and HIV training, such as the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) programme to empower women in the face of HIV, using a combination of microfinance, gender/ HIV-awareness training, referred to as ‘Sisters for Life’, in combination with community mobilisation. In a cluster randomised trial in South Africa, significant positive effects in household economic wellbeing, social capital, and women’s empowerment, as well as in reducing IPV, were reported. However, two other risk factors for HIV—the rate of unprotected sexual intercourse with a non-spousal partner and HIV incidence—were not reduced in all cohorts.86 Findings regarding gender differences in youth-oriented cash incentive programmes were inconsistent: in Kenya, only young men received significant benefits from the programme, whereas amongst Ugandan orphans, girls benefited more than boys in terms of self-esteem. However, the reasons for these differences were not explored, and hence it is difficult to understand the specific pathways involved. More research clearly is required on this, including how access to financial resources affects not only self-esteem, but also mental health.

Interventions focusing on support from family, friends, or health providers In HICs, social support has been identified as a contributor to resilience and the reduction of depression in the face of severe events and circumstances,87 especially amongst women.88 There is still limited evidence of the impact of successful social support interventions on resilience and mental health in LMICs, and more analysis is required regarding type and stage of intervention (whether preventive, using support/resilience/coping strategies, or providing treatment), population, and age and gender specific targets (such as of children, women, men, and LBGT groups). The robustness of the findings regarding outcomes in studies to date is unclear—some rely on self-reporting, which may skew the results, and other studies are randomised control trials. The majority of studies have focused on maternal mental health and on HIV-affected individuals where the positive effects of social support seems well documented. Evidence of the impact of family and community-based interventions on the rehabilitation of patients with mental illness

85 The authors also noted that young women participating in the cash transfer programme entered into sexual relations later than male participants and non-participants. The authors hypothesised that the cash transfer programmes may reduce women’s dependence on males, and reduce unwanted sexual relationships and unprotected sex. 86 Pronyk, P. M., Hargreaves, J. R., Kim, J. C., et al. (2006), Effect of a Structural Intervention for the Prevention of Intimate-Partner Violence and HIV in Rural South Africa: A Cluster Randomised Trial, The Lancet, 368(9551): 1973–1983. 87 See, e.g., Thoits, P. A. (2011), Mechanisms Linking Social Ties and Support to Physical and Mental Health, Journal of Health and Social Behavior, 52(2): 145–161; and Maulik, P. K., Eaton, W. W., & Bradshaw, C. P. (2011), The Effect of Social Networks and Social Support on Mental Health Services Use, Following a Life Event, among the Baltimore Epidemiologic Catchment Area Cohort, Journal of Behavioral and Health Services Research, 38(1): 29–50. 88 Taft, A. J., Small, R., Hegarty, K. L., et al. (2011), MOthers’ AdvocateS in The Community (MOSAIC)— Non-professional Mentor Support to Reduce Intimate Partner Violence and Depression in Mothers: A Cluster Randomised Trial in Primary Care, BMC Public Health [online], 11: 178. Available at: bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-178.

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remains weak, with only modestly optimistic results for interventions such as family education, crisis interventions, counselling, and skills training with psychosocial support.89 However, there is growing evidence from South Asia that social support significantly reduces the risk of depression and increases resilience in women. In a study of urban Indian women living in a Mumbai slum, those who received social and emotional support from friends and family reported significantly fewer days with depression, even after adjusting for husbands’ recent violence and alcohol abuse.90 Similarly, in Pakistan, higher perceived social support from family, friends, and significant others amongst married women reduced the likelihood of depression and anxiety, and was positively associated with the resolution of marital problems. Neither study described in detail the type of social support received, but community support played a key role, whereas that of family members was less clear. In India, the presence of family members in the home did not affect the degree of depression women reported whereas, in Pakistan, living in a nuclear family increased the risk of CMD symptoms. In South Asia, studies have found that the presence of in-laws in the household often reduces women’s freedom and exacerbates their abuse and suffering.91 Burgess discusses the impact of the Movement for Global Mental Health (MGMH),92 a community-based approach often recommended for LMICs, initiated in 2007 within the South African mental health care service. It implements primary mental health care in district hospitals, supported by higher levels of care involving partnerships with stakeholders across multiple sectors. Despite efforts of service providers to offer gender-sensitive treatment—viewing female clients as autonomous and learning about the broader socioeconomic constraints of their daily realities—the services were unable to offer sufficient support for the many issues underlying their distress. Based on the challenges identified in the South African experience, Burgess recommends a community health competency approach using a participatory framework involving dialogue between service providers, researchers, and communities. These competencies include enhancing the ability of community members to identify and refer serious cases of mental disorder and to respond to others in a culturally appropriate manner. The researchers also recommend helping communities develop (or expand existing) skills to address mental difficulties. The importance of safe social spaces and dialogue on challenging issues amongst mental health professionals and local mental health service sectors was emphasised. Finally, the study suggested the development of partnerships with others with experience in tackling similar problems in other global or local contexts. Such partnerships could connect women in need of support to existing resources, such as income-generating activities or skills training, to create opportunities to mitigate wider social problems that impact upon women’s experiences of mental distress. LBGT youths are known to be at risk of compromised health, both physical and emotional.93 Most research has focused on negative factors associated with such risks, especially in adolescence and young adulthood, including adverse reactions of parents around the time of their child’s

89 Weinmann, S. & Koesters M. (2016), Mental Health Service Provision in Low and Middle-income Countries: Recent Developments, Current Opinion in Psychiatry, 29(4): 270–275. 90 Dasgupta, A., Battala, M., Saggurti, N., et al. (2013), Local Social Support Mitigates Depression among Women Contending with Spousal Violence and Husband’s Risky Drinking in Mumbai Slum Communities, Journal of Affective Disorders, 145(1): 126–129. 91 Raj, A., Sabarwal, S., Decker, M. R., et al. (2011), Abuse from In-laws During Pregnancy and Postpartum: Qualitative and Quantitative Findings from Low-income Mothers of Infants In Mumbai, India, Maternal and Child Health Journal, 15(6): 700–712; Parkar, S. R., Nagarsekar, B., & Weiss, M. G. (2009), Explaining Suicide in an Urban Slum of Mumbai, India: a Sociocultural Autopsy, Crisis, 30(4): 192–201. 92 Burgess (2016), op. cit., nt.64. 93 Ryan, C., Stephen, T., Russell, S. T., et al. (2010), Family Acceptance in Adolescence and the Health of LBGT Young Adults, Journal of Child and Adolescent Psychiatric Nursing, 23(4): 205–213.

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disclosure of sexual identity.94 A few studies that have examined the association between parental reactions to sexuality disclosure and the youths’ mental health found, perhaps unsurprisingly, that LGBT youths who experienced more rejecting responses to disclosure report poorer psychological adjustment.95 Rosario, Schrimshaw, and Hunter (2009) examined substance use amongst LGB youth to consider whether or not there was a connection between misuse and how the young people perceived the reactions of family members and others to their LGB identity. They found that the number of perceived negative reactions was associated with more substance use, although accepting reactions did not directly reduce it. Another study of the relationship between family rejection in adolescence showed clear associations between parental rejection during adolescence and illegal drug use, risky sexual behaviour, depression, and attempted suicide amongst young LGB adults.96 Nonetheless, it has also been found that family relationships improve after parents become sensitised to the needs and wellbeing of their LGBT children.97 Whilst the reasons for this were not specifically investigated, D’Augelli et al. hypothesised that parents with outwardly LGB children may have suspected their sexual orientation before their children disclosed it to them, and disparaging comments may have elicited disclosure from their LGB child.98 However, children whose parents were aware of their sexual orientation were less fearful about parent’s future reactions, and indicated that they had more parental support than those who had not told their parents. Similarly, an in-depth study of young LBGT adults concerning family acceptance during their adolescence found clear links between family acceptance in adolescence and health status in young adulthood. Participants who had low family acceptance as adolescents were more than three times as likely to report both suicidal ideation and suicide attempts, compared to those reporting high levels of family acceptance. Females reported more suicidal ideation and attempts than males.99

Conclusions and recommendations In this chapter it has been repeatedly observed that global attention to gender issues relating to health is inadequate. This is particularly the case in LMICs (which frequently have cultural practices adverse to women) because of the paucity of research and the absence of data. This results in lack of knowledge about the experience of mental health and illness by gender (and other characteristics), and in how services are provided. As referred to earlier in the chapter, there are often differential perceptions and assumed interventions for male and female clients, leading to

94 Weinmann & Koesters (2016), op. cit., nt.89; D’Augelli, A. R., Grossman, A. H., & Starks, M. T. (2005), Parents’ Awareness of Lesbian, Gay, and Bisexual Youths’ Sexual Orientation, Journal of Marriage and the Family, 67(2): 474–482. 95 See, e.g., Elizur, Y. & Ziv, M. (2001), Family Support and Acceptance, Gay Male Identity Formation, and Psychological Adjustment: A Path Model, Family Process, 40(2): 125–144; D’Augelli, A. R. (2001), Mental Health Problems among Lesbian, Gay, and Bisexual Youths Ages 14 to 21, Clinical Child Psychology and Psychiatry, 7(3): 433–456. 96 Rosario, M., Schrimshaw, E. W., & Hunter, J. (2009), Disclosure of sexual orientation and subsequent substance use and abuse among lesbian, gay, and bisexual youths: critical role of disclosure reactions, Psychology of Addictive Behavior, 23(1): 175–184; Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009), Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay and Bisexual Young Adults, Pediatrics, 123(1): 346–352. 97 Ryan et al. (2010), op. cit., nt.93; D’Augelli (2001), op. cit., nt.95. 98 D’Augelli (2005), op. cit., nt.94. 99 Ryan, C., Stephen, T., Russell, S. T., et al. (2010), Family Acceptance in Adolescence and the Health of LBGT Young Adults, Journal of Child and Adolescent Psychiatric Nursing, 23(4): 205–213.

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different treatments which are not necessarily individually or gender appropriate, or indeed optimal. As evidenced by many of the studies referred to in this chapter, whilst more recently there has been increasing international attention paid to the mental health needs of LMIC populations, it is essential to avoid the automatic replication of Western psychiatric models of treatment in the developing world. Such models frequently are not only culturally inappropriate, but also not necessarily effective in improving outcomes. It is therefore important that in expanding women’s mental health services and promoting their mental health in LMICs, new models are explored. Such models must ensure that at all stages of an intervention, women, men, and LBGT communities are active partners in terms of being consulted as advisors or participants, and that their authentic experiences are recognised from a holistic perspective, including their health concerns, within the context of their own lives and experiences.100 In this chapter several constraints in addressing gender issues holistically in both HICs and LMICs have been considered; constraints which may seem overwhelming in terms of fulfilling SDG3 which requires the promotion of mental health and wellbeing for all. However, in identifying interventions with the potential for the greatest impact, two main entry points seem most promising in LMICs: addressing and reducing depression amongst women (which could have a major impact on disability worldwide), and school and community-based programmes for children and adolescents. Focusing on depression, an important first step would be increasing the gender-sensitivity of health services. Affirmative gains in health status have been observed where gender-sensitive services are provided, using a participatory and problem-solving approach that explores the experiences of mental difficulties within the realities of clients’ lives.101 This would entail a new approach to the capacity-building of health personnel at all levels of health services in LMICs.102 In line with gender mainstreaming programmes globally, training would need to be rolled out over a period of time under the leadership of experienced gender trainers responsible for overseeing the process. Many trainers are available within government and academic institutions and non-governmental organisations (NGOs) in LMICs who could be seconded for this purpose. This training would necessarily consider the factors identified by the WHO as important for preventing mental disorders,103 especially those promoting empowerment and social support. Increasing access to material resources, such as via employment and income, is also necessary, but this may be a longer-term goal as it extends beyond the mandate of the health sector alone. However, further exploration and validation of income-generating and skills training programmes with the active engagement of clients, cash transfers for vulnerable people in special circumstances (such as children’s savings plans for orphans resulting from HIV), and economic support for survivors of traumatic events is required to determine their influence on mental health. Training should raise awareness amongst health workers concerning periods in the lifecycle when people are most vulnerable to depression, such as the stressors associated with maternal mental health, adolescence, and ageing, when the importance of paying special attention to client

100 Taft et al. (2011), op. cit., nt.88. 101 Dawson et al. (2016), op. cit., nt.70. For a new approach to improving gender sensitivity in health systems, see Vlassoff, C. & St. John, R. (2019), A human rights-based framework to assess gender equality in health systems: the example of Zika virus in the Americas, Global Health Action, 11(3). Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC6427496/. 102 For more on the need to capacity-build human resources, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson. 103 WHO (2017), op. cit., nt.2.

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need is elevated. Addressing possible GBV in a sensitive way, perhaps using a problem-based approach to allow it to emerge within discussions of general health challenges, also seems a promising intervention that can be used by CHWs. Health workers can collaborate with NGOs, community groups, leaders, and clients themselves as partners in untangling and responding to the stressors of daily life for those in the community. This consultative and participatory approach should also help strengthen social support mechanisms, as care-givers are often left alone to struggle with the challenges they face in providing help to loved ones with mental health problems. The potential for expanding the community competency framework in LMICs, discussed by Burgess and outlined above,104 deserves further testing and evaluation as a holistic response to clients with mental health challenges, including both their physical treatment needs and their broader environmental concerns. Youth is the second recommended entry point for accelerating progress toward the achievement of SDG3. Although school and community-based programmes require further evaluation in LMICs, they offer key opportunities for reaching children and adolescents with information on health risks, prevention and empowerment strategies, and can assist with stigma reduction which is a barrier to help-seeking. Training in counselling on adolescent sexuality and preparation for marriage with an emphasis on gender equality would be likely to prove useful for teachers, health workers and family members to help reduce potential stressors for young people. Due to the lack of evidence of efficacious interventions, evaluative research should accompany the testing and scaling up of the interventions suggested here. Throughout this process, the involvement of those from LMICs is essential, including research capacity-building where necessary. This will ensure that both programmes and their evaluations can be developed and led by LMIC professionals and those affected themselves, thus enabling their authentic contributions to the achievement of health and wellbeing for all.

104 Burgess (2016), op. cit., nt.64.

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9 MEN’S MENTAL HEALTH AND WELLBEING The global challenge Svend Aage Madsen* Introduction An overview of the statistics on men’s mental health internationally shows that men’s depression and other mental health problems are under-detected and under-treated all over the world. This can be explained in part due to men’s tendency not to seek help. Further, health services appear to have a limited capacity to reach out to men due to men’s unique presentation of symptoms. There may also be a reluctance to do so, with higher levels of substance abuse, anger, withdrawal, and challenging behaviours in men than in women. Yet, more than three times as many men as women commit suicide, and the difference increases to up to five times in single men and in older age. The higher suicide rates in men are linked to undiagnosed (and untreated) mental health problems. This chapter will make recommendations for action in terms of men’s mental health to enable states to meet SDG3. Such action will also help countries to meet other SDGs, such as SDG1 and SDG2 (goals to end poverty and hunger) and SDG16 (which requires states to promote peaceful and inclusive societies). The first essential challenge is for men’s mental health-related problems to be detected. In addition, it will be crucial for states to create methods for swift referral, as well as treatment models better suited to men. Some suggestions for how such strategies and models might be developed which fit culturally and are effective will be provided in the chapter, with case studies where appropriate. The higher prevalence of substance abuse in men will also be considered; there is often such co-morbidity along with psychosocial disability,1 with substances abused either as a means of self-medication, due to personality propensities, or related to changes in perceived traditional male roles (such as the loss of a job and subsequent lack of employment). There are five main difficulties in relation to men’s mental disorder issues. First, men are under-diagnosed and under-treated. Second, men are less likely than women to seek help when it comes to mental health difficulties. Third, it appears difficult for men themselves, as

* Head of Research at the Copenhagen University Hospital, and President of the Men’s Health Forum, Denmark. 1 Wahlbeck, K., Westman, J., Nordentoft, M., & Gissler, M. (2011), Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders, The British Journal of Psychiatry, 199: 453–458.

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well as health professionals, to identify their problems as mental disturbances. Fourth, there is a lack of adequate assessment tools suitable for men’s symptomatology. Finally, suitable referral pathways are often unavailable for men who are not used to referring themselves to health services and who do not have adequate language for communicating their mental states. Finally, there is a lack of gender-specific treatment and knowledge about the kinds of treatment that are more suitable for men.

Gender differences When health, and not least mental health, is the topic, gender-related research and information about it seldom relates to men. A search in PubMed for ‘Women AND Psychology’ and ‘Men AND Psychology’ brings up four times as many research articles on psychology containing the word ‘women’ on its own as articles with the word ‘men’ only. There are far fewer studies on men and mental health than on women and mental health. However, it is very important to acknowledge that mental health issues can be different for men, which is seldom mentioned. One reason for this might be that the picture is complex. In a study by Zachary et al.,2 a consistent ‘gender effect’ was seen in the prevalence of common mental disorders. Remarkable gender differences were observed in the study, with more than twice as many men diagnosed with substance abuse and twice as many women as men diagnosed with mood and anxiety disorders (see Figure 9.1). The study also reveals some regional variation, such as in Sub-Saharan-African and North and South East Asian countries, which appear to have lower rates of mental disorders than other regions of the world. This is especially so in English speaking countries3—although there are significant difficulties in obtaining data from many low-income countries. The gender differences shown in Figure 9.1 may indicate that there are clear differences in the mental states of men and women. However, the research may also indicate that mental illness in men and women is detected differently, with men more easily diagnosed based on their actions—behaviour such as abuse, violence, and anti-social acts—rather than based on how they feel and express their state of mind. Women are more often diagnosed according to how they feel, and depression and anxiety disorders are diagnoses encompassing states of mind. In general, it would appear that women are more open to talking to others about their emotional state of mind.4 There also appears to be a gender difference in help-seeking behaviour, with men much more reluctant to seek help from health services, both for physical symptoms, and even more when it comes to mental health difficulties. Very often men visit health care services only when they are urged to, or are sent by their family, employer, or the police. Furthermore, epidemiological

2 Steel, Z., Marnane, C., Iranpour, C., et al. (2014), The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013, International Journal of Epidemiology, 43(2): 476–493. 3 There are many challenges in obtaining reliable results when measuring mental health, especially in low-resource settings. Worldwide, there are numerous cultural and other barriers against openness about mental disorders, often seen as taboo, and thus they are frequently denied in order to avoid stigmatisation. To ensure accurate reporting when obtaining data, in-country researchers with in-depth knowledge of the culture and traditions of a particular area are essential. 4 See, e.g., N. Chodrow (1978), The Reproduction of Mothering (Los Angeles: University of California Press); Pollack, W., ‘No Man is an Island’, in R. Levant & W. Pollack (1995), A New Psychology of Men (New York: Basic Books), pp.32–57.

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Figure 9.1 Registered diagnoses around the world (%)

and other studies5 have shown that gender differences in terms of the prevalence of depression are much smaller than the 2:1 ratio which is generally seen upon hospital admission and in attendees at general medical practices. This suggests that men are under-diagnosed with, and under-treated for, depression. As it has been shown that men of different ages, ethnicities, and social backgrounds access physical and mental health services less frequently than women,6 it is necessary to find new ways for men to access such services to identify and refer the large number of men with depression and other mental health problems for treatment. Therefore there is a need to develop ‘male-friendly’ primary mental health care services where the barriers to men’s access have been addressed. Those barriers have been identified as, for example, opening hours, inappropriate information and communication for men, and inaccessible services far away from the workplace.7

Depression According to the World Health Organization (WHO), depression is now the leading cause of disease burden globally.8 This makes it crucial to dig deeper into the causes of the apparent gender

5 Olsen, L. R. (2006), Measurements of depressive illness and mental distress in the Danish general population, Danish Medical Bulletin, Feb, 5(1): 101; Madsen, S. Aa. (2013), Mænds skjulte depressioner [Men’s Hidden Depressions], Månedsskrift for Almen Praksis, 91(6): 537–545. 6 A. White, R. Hogston, S. Aa. Madsen, et al. (2011), The State of Men’s Health in Europe, The European Commission (Brussels: DG Sanco Publications). 7 I. Sabaj-Kjær & S. Aa. Madsen (2016), Manden og lægen [The Man and the GP] (Copenhagen: Forum for Mænds Sundhed); S. Aa. Madsen (2014), Mænds sundhed og sygdomme [Men’s Health and Diseases] (Copenhagen: Samfundslitteratur). 8 WHO (2017), Depression and Other Common Mental Disorders: Global Health Estimates (Geneva: WHO), Licence: CC BY-NC-SA 3.0 IGO.

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Global challenge of men’s mental health Table 9.1 Symptoms traditionally associated with depression in men • • • • • • • • • •

Acting out, aggressiveness Low impulse control Anger attacks Irritability Tendency to blame others and to be implacable Low stress threshold Restlessness Risky and socially unacceptable behaviour Abuse, especially alcohol General dissatisfaction with oneself and one’s own behaviour

disparity in terms of depression. One of the reasons why men appear under-represented in the data on depression is that men may exhibit symptoms not traditionally associated with the illness. In recent decades, more studies have focused on whether men show different symptoms of depression than women. Men often exhibit quite different symptoms that are not typically connected with depression or psychological difficulties at all. In most classification and diagnostic systems, depression is usually defined as a passive and inwardly directed reaction with elements of self-deprecation and guilt feelings.9 Yet, in men suffering from depression, studies have shown that anger attacks, affective rigidity, self-criticism and alcohol and drug abuse are symptoms that more often occur.10 In the Gotland Study, Rutz et al. suggest the existence of such a male-specific syndrome.11 Startlingly, the study showed that education and training of general practitioners about depressive illness resulted in a statistically significant reduction in the number of female suicides, but left the rate of male suicides almost unaffected. These experiences led to the development of the Gotland Male Depression Scale12 which lists some of the symptoms or states of mind more often seen in men which are quite different from those traditionally associated with depression (see Table 9.1). Other researchers in the field have used the term ‘masked depression’ to designate male symptoms.13 Such research forms part of the psychological studies on gender-specific conditions in societal and cultural connection, such as work and family roles and responsibilities, and in socialisation and development (with mothers being the first attachment and identification figure for both boys and girls). In the gender roles that historically men have adopted, it has been important to keep fear and emotions at bay in order to be able to act, defend, fight, toil for food, and hunt.

9 See, e.g., A. Beck (2008), Beck Depression Inventory (2nd edn) (Davie: Nova Southeastern University Center for Psychological Studies); Beck, A. T., Ward, C. H., Mendelson, M., et al. (1961), An inventory for measuring depression, Archives of General Psychiatry, 4: 561–571; Hamilton, M. (1960), A Rating Scale for Depression, J Neurol Neurosurg Psychiat, 23: 56. 10 See Winkler, D., Pjrek, E., & Kasper, S. (2006), Gender specific symptoms of depression and anger attacks, J Men’s Health Gender, 3: 19–24, and S. Cochran & F. Rabinowitz (2000), Men and Depression (New York: Academic Press). 11 See Rutz, W. (2001), Preventing suicide and premature death by education and treatment, Journal of Affective Disorders, 62(1–2): 123–129; Rutz, W., von Knorring, L, Pihlgren, H, et al. (1995), Prevention of male suicides: lessons from Gotland study, The Lancet, 345(8948): 524. 12 Zierau, F., Bille, A., Rutz, W., & Bech, P. (2002), The Gotland Male Depression Scale: a validity study in patients with alcohol use disorder, Nord J Psychiatry, 56(4): 265–271. 13 S. Cochran & F. Rabinowitz (2000), Men and Depression (New York: Academic Press), and Pollack, W. (2005) ‘Masked men’, in G. Good & G. Brooks (eds), The New Handbook of Psychotherapy and Counselling with Men (San Francisco: Wiley), pp.203–216.

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Svend Aage Madsen Table 9.2 Reactions and state-patterns seen more often in men than in women1 • • • • • 1

Withdrawal from relationships Over-involvement with work Denial of pain Rigid demands for autonomy Rejection of getting help See, e.g., ibid., and Madsen (2013), op cit., nt.5.

This has led to a channelling of emotional problems into anger, avoidance and self-reflection, disregard for one’s own condition, and non-communication of feelings. Boys and men therefore have encountered pressure to conform to social norms encapsulated by beliefs such as ‘big boys don’t cry’, ‘beware of weakness’, ‘you must be able to take care of yourself ’, and ‘it’s important not to be dependent on others’. In this connection, men appear to have difficulty in defining and expressing their internal condition and feelings. This has led to a focus on the specific reactions and state-patterns set out in Table 9.2 above, which, together with those mentioned previously, are seen more often in men than in women. When such states as ‘acting-out’, substance abuse and/or withdrawal symptoms are predominant, the man’s suffering is very often not identified. When statistics on depression (and possibly other mental disturbances too) show a twofold higher prevalence in women than in men, it may be that this is because depression and other mental disorders in half of the men are not detected and consequently remain untreated. Magovcevic & Addis14 have developed The Masculine Depression Scale as an instrument for detecting men with depression with (inter alia) traditional, externalising and withdrawal symptoms.

Perinatal depression One distinct disorder in many countries which affects men as well as women is not even recognised as existing in the male gender—namely, perinatal mood disorder. This is often also called post-natal or post-partum depression. Whilst the impact of women’s transition to parenthood has been recognised and acknowledged for several decades, with many mental health studies focusing on psychiatric and psychological perinatal suffering in women, men’s transition to parenthood has not been met with much attention. However, men’s transition to fatherhood can have a major psychological impact on men’s lives, identities and states of mind. This can also lead to mental disturbances which are, essentially, a feature of perinatal depression. Perinatal mood depression, as measured by the Edinburgh Postnatal Depression Scale (EPDS),15 affects approximately 10% to 14% of women.16 A growing number of studies on post-partum depression in women also take

14 Magovcevic, M. M. & Addis, M. E. (2008), The Masculine Depression Scale: Development and Psychometric Evaluation, Psychology of Men and Masculinity, 9: 117–132. 15 J. Cox & J. Holden (2003), Perinatal Mental Health: A Guide to the Edinburgh Post-natal Depression Scale (London: Gaskell). 16 Cox J., Connor, Y., & Kendell, R. (1982), Prospective study of the psychiatric disorders of childbirth, Br J Psychiatry, 140: 111–117.

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note of the father’s psychological wellbeing. Meta-analyses of studies around the world17 report rates of 7% to 10% in men suffering from perinatal mood disorders, with the highest rates in the US (approaching 13%).18 However, the importance of raising awareness of men’s post-partum depression has been emphasised in research which has found that paternal depression has a specific and detrimental effect on children’s early behavioural and emotional development.19

Suicide The UN Secretary-General Report, ‘Progress towards the Sustainable Development Goals’, states that [t]he most common [mental disorders] are anxiety and depression, which, not infrequently, can lead to suicide. In 2012, an estimated 800,000 people worldwide committed suicide, and 86% of them were under the age of 70. Globally, suicide is the second leading cause of death among those between the ages of 15 and 29.20 Women globally are considered to have a higher prevalence of mood and anxiety disorders— around twice as high as men—and thus more suicides should be expected in women. However, suicide rates reveal a paradox; the WHO identifies in its report, ‘Preventing suicide: a global imperative’,21 that globally, men’s suicide rate is 15 per 100,000, whereas it is around half that for women (namely, 8 per 100,000). This inconsistency is an eye-opener, further revealing the complexities of men’s mental health. Plainly, a gender perspective is essential in understanding mental health data. With meeting SDG3 in mind, SDG target 3.4 requires states to,‘[b]y 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and

17 Paulson, J. F. & Bazemore, S. D. (2010), Prenatal and postpartum depression in fathers and its association with maternal depression, Journal of the American Medical Association, 303: 1961–1969; Cameron, E., Sedov, I., & Tomfohr-Madsen, L. (2016), Prevalence of Paternal Depression in Pregnancy and the Postpartum: An Updated Meta-analysis, Journal of Affective Disorders, 206: 189–203. Madsen, S. Aa. (2019), Men and Perinatal Depression, Trends in Urology and Men’s Health, 10(2): 7–9. Recently a special guide for treating men with perinatal depression has been developed in Denmark: Madsen, S. Aa. (2018), Guide til behandling af fædre med fødselsdepressioner [Guide for Treatment of Fathers with Perinatal Depression] (Copenhagen: Rigshospitalet’s Fatherhood Research Programme). 18 There are studies included from four continents, but none are from Africa. Although there is a fastgrowing body of research on men and perinatal depression around the world, there still are very few studies from low-income countries. 19 Junge, C., Garthus-Niegel, S., Slinning, K., et al. (2016), The Impact of Perinatal Depression on Children’s Social-emotional Development: A Longitudinal Study, Matern Child Health J, Aug, 21(3). Available at: DOI 10.1007/s10995-016-2146-2; Paulson, J., Dauber, S., & Leiferman, J. (2006), Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behaviour, Pediatrics, 118: 659–668; Ramchandani, P., Stein, A., Evans, J., & O’Connor, T. (2005), Paternal depression in the postnatal period and child development: a prospective population study, The Lancet, 3652: 2201–2205. 20 United Nations (2016), Progress towards the Sustainable Development Goals, Report of the Secretary General, United Nations, Economic and Social Council 2016 session, 3 June 2016, E/2016/75. 21 WHO (2014), Preventing Suicide: A Global Imperative. Available at: www.who.int/mental_health/ suicide-prevention/world_report_2014/en/.

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Figure 9.2 Suicides around the world (per 100,000)

promote mental health and well-being’).22 There are only two indicators associated with target 3.4, and one is the suicide mortality rate (indicator 3.4.2).23 Figure 9.2 shows the suicide rate per 100,000 in the population according to the WHO’s 2014 report. The figure suggests that, on average, globally, approximately twice as many men as women commit suicide. However, as the WHO remarks, we must read these figures cautiously: . . . since suicide is a sensitive issue, and even illegal in some countries, it is very likely that it is under-reported. In countries with good vital registration data, suicide may often be misclassified as an accident or another cause of death. Registering a suicide is a complicated procedure involving several different authorities, often including law enforcement. Moreover, in countries without a reliable registration of deaths, suicides simply go uncounted.24 Together with studies from countries with reliable vital registration data,25 this suggests that men commit suicide around three times as often as women. Furthermore, in some countries there is a high prevalence of the elderly committing suicide, such as in Europe where elderly men commit suicide five times as often as women of the same age.26 In comparison, in China and Greenland it is younger people who most often commit suicide (young women in the former, and young men in the latter).

22 UN-GA (2015), A/RES/70/1, Transforming our world: the 2030 agenda for sustainable development. 23 The other is indicator 3.4.1: the ‘[m]ortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease’. 24 Ibid. 25 White et al. (2011), op. cit., nt.6. 26 Ibid.

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Suicide is generally considered to be an act arising out of intense mental suffering. The much higher rate of suicides in men are, amongst other things, likely to be due to a lack of detection of men’s mental suffering. Suicide risk in men also arises from psychosocial and/or economic pressure, as well as problems related to age, such as the loss of a partner, loss of reduced functional capacities, and loss of employment.27 Although these stressors also apply to women, research suggests that such negative social determinants have an increased negative impact on men’s physical and mental health.28 Suicide prevention in men can be strengthened through better detection of depression in men, in combination with improved social factors such as reduction of poverty and unemployment, and improvement in access to health care. Thus, both mental health treatment and social changes are needed to reduce suicide rates in men.

The burdens In its 2012 report, ‘Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level’, the WHO emphasises that untreated mental disorders are a heavy burden globally.29 Burdens arising from men’s mental disturbances are violence, sexual abuse and intimate partner violence, as well as alcohol and drug abuse, in which men are more often the offenders, perpetrators, and abusers. These disturbances cost lives, cause illness and disabilities, and increase mental health problems not only in the person who is abused, but also in the wider family. In addition, men’s mental health problems often arise from trauma. As men form the majority of the workforce globally and tend to undertake much more manual labour than women, they are more at risk of workplace accidents which can cause injury. This means they will require time off work, with associated reduced self-esteem, not to mention increased stress and anxiety about supporting their families. Furthermore, men are much more likely than women to be conscripted into the military, with the higher risk of post-traumatic stress disorder (PTSD). Such risk is higher in lower-income countries compared with high-income countries, and especially prevalent in post-conflict areas. Trauma can also produce various physical illnesses related to unhealthy living, which are a heavy health burden, especially in low and middle-income countries (LMICs) with little access to professional mental health workers.30 Men’s violence against women is a very serious worldwide problem. However, it should also be recognised that intimate partner violence is a phenomenon occurring between people in intimate relationships—heterosexual and/or same-sex relationships—and that domestic violence can also take place against men, including emotional, sexual and physical abuse and threats of abuse. This is still not well recognised, or accepted as a real problem, about which there have been very few studies.31

27 Suicide rates for men increased in the years after the economic crisis in 2008. 28 Madsen (2014), op. cit., nt.7. 29 WHO (2012), Global Burden of Mental Disorders and the Need for a Comprehensive, Coordinated Response from Health and Social Sectors at the Country Level, Report by the Secretariat (Geneva: WHO). 30 Atwoli, L., Stein, D. Koenen, K., & McLaughlind, K. A. (2015), Epidemiology of posttraumatic stress disorder: prevalence, correlates and consequences, Curr Opin Psychiatry, 28(4): 307–311. 31 See, e.g., Hines, D. & Douglas, E. (2010), Intimate Terrorism by Women against Men: Does it Exist?, Journal of Agress Confl Peace Res, 2(3): 36–56; Barber, C. (2008), Domestic violence against men, Nursing

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It is well known that differences in life expectancy are immense for people with a mental disorder diagnosis. The decrease in life expectancy that poor mental health causes is marked. Those diagnosed with a mental illness have a two to three times higher mortality rate than the general population.32 There is a gender disparity in this increased mortality rate, however: on average, men with mental disorders die 20 years earlier than the general male population (measured as life expectancy from the age of 15). In comparison, women with mental disorders die on average 12 years earlier than the general population.33 Plainly, the causes of this difference warrants further investigation.

Prevention In order to improve men’s mental health, it is obvious that prevention is needed. However, there are very few examples of goal-directed mental health prevention programmes for men. The exception to this poor state of affairs is the Men’s Shed movement around the world.34 A ‘Men’s Shed’ is an open, autonomous and friendly place where men can come together for a variety of self-decided activities such as handicraft work, gardening, physical training, painting, and cooking. Men’s Sheds are open to men of all ages and backgrounds. The movement began in Australia in the 1990s and spread to Europe, Africa, and America more recently. Men’s Sheds have been shown to have a positive impact on men’s mental as well as physical health.35

Conclusion and recommendations It is time for the world to recognise that in order to meet SDG3, gender differences in terms of mental health must be addressed. Governments and health professionals must develop detection, referral, and treatment models better suited to men. Men use health services less, and tend to be reluctant to take their health issues seriously or to look after their health properly. The barriers to help-seeking observed in men are often related to a culture of masculinity, such as male embarrassment arising from a perception of emasculation. Indeed, this may result in additional stigma for men with mental health issues compared with women.36 To meet SDG3, states have a duty to create mental health policies and treatment strategies which take into account gender differences. The duty of states under target 3.5 of SDG3 to ‘strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol’ requires policy and treatment initiatives which recognise the prevalence of substance abuse in men (often a method of self-medication) and the connection between alcohol abuse and depression. In addition, men are more often victims of violence than women, and of severe traffic and workplace accidents. Their higher involvement in military conflicts can

32

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36

Standard, 22(51): 35–39; and Kumar, A. (2012), Domestic Violence against Men in India: A Perspective, Journal of Human Behavior in the Social Environment, 22(3): 290–296. Wahlbeck et al. (2011), op. cit., nt.1. This study covers men and women treated at a psychiatric hospital in the Nordic countries, and it is not possible to predict if this is an international trend. However, most of the data on mental health related to gender is very much alike around the world. Ibid. B. Golding (2015), The Men’s Shed Movement: The Company of Men (Champaign: Common Ground Publishing). See Lefkowich, M., Richardson, N., & Robertson, S. (2015), If we want to get men in, then we need to ask men what they want: pathways to effective health programming for men, American Journal of Men’s Health [online], ii: 1557988315617825; P. Flood & S. Blair (2013), Men’s Sheds in Australia: Effects on Physical Health and Mental Well-being (Hawthorne: UltraFeedback Pty Ltd.). Although there has been no research on this.

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also cause severe trauma, making PTSD more prevalent in men than in women. National policies need to recognise this and prepare for it. Clearly, mental health policies must include prevention strategies which take account of gender differences. The Men’s Shed movement has been shown to have a supportive and positive preventive effect on men’s mental and physical health. States should also prioritise as a matter of urgency much more extensive prevention of men’s suicides—especially in older men. The scaling up of the Men’s Sheds initiative in countries where it exists currently ought to assist with this. It is recommended that similar initiatives are rolled out and piloted in LMICs (with culturally appropriate adaptations), and their efficacy carefully researched. Furthermore, in order to meet SDG3, the under-detection of men’s mental health problems must be recognised as a reality, both in national health strategies and at international level. More research on the symptoms of male mental health issues is necessary, both in high-income countries and LMICs. To help reduce the current global mental health treatment gap, governments need to develop appropriate screening tools to detect the 50% of male depression that remains undiagnosed. Earlier detection of men’s depression through the development of identification programmes and evidence-based strategies is essential. In line with states’ responsibilities under target 3.8 of SDG3 to ‘ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes’, the stress of having a young family (particularly on the birth of a first child) should be recognised not only for women, but also for men. The fact that men, too, can suffer from perinatal depression should be widely disseminated. Thus, men should be included in pre-natal preparation courses and screening programmes, with the goal of identifying the 7% to 10% of new fathers who suffer from perinatal depression. Further, culturally sensitive screening instruments suited to men’s depression and other mental health problems in men should be devised for them, especially for those in vulnerable groups such as older or single men. Also crucial is for GPs and other mental health service professionals to receive training on understanding men’s mental health, and to improve their engagement and communication with male patients. Furthermore, populations in general and mental health professionals in particular need to understand that men as well as women can be the victim of violence and psychological and emotional abuse from their intimate partner, with mental health consequences. The development of specialised education programmes on men’s mental health and the integration of modules on gender and men’s mental health into the training syllabi of all health courses is essential in this regard. In addition, the development of training protocols and short training courses on men’s mental health which target the existing service providers in the health, allied health, and community sectors is imperative. Target 3.7 of SDG3 also requires states to ‘achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’. There is a stark lack of appropriate treatment services for men worldwide. This is, of course, interlinked with a failure to detect men’s disturbances, as well as insufficient engagement and communication strategies. To address the under-treatment of men’s mental health problems, it will be important for states to develop ‘male-friendly’ primary mental health care services that provide flexible opening hours (and in particular which provide later opening hours after work). They should also have the capacity to be offered in workplace settings and in more accessible community settings. Only if a comprehensive, multipronged and multidisciplinary approach is taken to men’s mental health in terms of research, policy, and treatment will states be able to meet the requirements of SDG3.

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10 THE MENTAL HEALTH AND WELLBEING OF MIGRANTS IN THE CONTEXT OF THE 2030 SUSTAINABLE DEVELOPMENT AGENDA Guglielmo Schininà* and Karoline Popp† Introduction This chapter will consider the relationships between migration, mental health and wellbeing, and development in the context of the Sustainable Development Goals (SDGs). In doing so, the chapter will examine two relationships within this triangle: migration and mental health and wellbeing, as well as migration and development.1 The chapter argues that an inclusive and human rights-based approach that guarantees the availability and accessibility of appropriate mental health care for all migrants (irrespective of their status) will contribute to optimal development outcomes for migrants themselves, their families, communities, and also the societies of both origin and destination countries. In this chapter, a migrant is broadly defined as any person who is moving or has moved across an international border or within a State, away from his or her habitual place of residence, regardless of the person’s legal status, whether the movement is voluntary or involuntary, what the causes for the movement are, or what the length of the stay is.2 This umbrella definition can include a diverse set of individuals, such as labour migrants, cyclic or seasonal migrant workers, foreign students and domestic workers, people who are displaced

* Guglielmo Schininà is Head of Mental Health, Psychosocial Response and Intercultural Communication at the International Organization for Migration (IOM). † Karoline Popp is a migration policy specialist and researcher with the Expert Council of German Foundations on Integration and Migration in Berlin who previously worked for the International Organization for Migration (IOM) in Geneva and Cairo. 1 The third relationship—between mental health and development—constitutes the overarching argument of this book and will not be specifically treated in this chapter. 2 IOM (2016), Global migration trends 2015 factsheet (Geneva: IOM).

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within their country due to wars or disasters, refugees and asylum seekers, mobile and travelling populations, transnational families, and maritime workers.3 As will be explained later, however, the type of migration and associated conditions make an important difference to developmental and mental health outcomes. Counting both international and internal migrants, the International Organization of Migration (IOM) estimates that roughly a billion individuals in the world are migrants, which corresponds to 14% of the global population.4 The number of international migrants reached 258 million in 2017,5 but this figure is probably an underestimate, since it does not include all irregular migrants. According to this estimate, international migrants represent 3.4% of the global population. Their relevance for development, however, has to be seen in light of the fact that they are for the most part of working age and economically active. Many migrate with upward social mobility objectives in mind, support families and communities back home, or facilitate the labour market participation of others—for example, when the presence of migrant domestic helpers allows women in developed countries to pursue formal employment.6 Their movement therefore affects, positively or negatively, the social, economic and cultural futures of societies of origin, transit and destination. From the reasons for departure, to the stay and integration in the new countries, to a possible return to the country of origin, development is inherent to the entire migration cycle.7

The 2030 Sustainable Development Agenda: the context for migration, mental health and wellbeing Analysing the connections between mental health and wellbeing, migration and development requires a broad reading of the 2030 Agenda.8 Whilst SDG3 (‘[e]nsure healthy lives and promote well-being for all at all ages’),9 and specifically target 3.4 (‘[b]y 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’),10 are especially relevant to this chapter, an understanding of the implications of the 2030 Agenda for mental health policy and practice cannot be derived from a single goal or target. At the outset, several principles and features of the 2030 Agenda are worth recalling. First, the 2030 Agenda has universal clout, unlike the predecessors of the SDGs (the Millennium Development Goals (MDGs)) which focused on extreme poverty and applied primarily to the world’s poorest countries. It was created by and for all countries of the world in the recognition that sustainable development is the responsibility of all states, as noted in the accompanying declaration

3 Organization for Economic Co-operation and Development (OECD) (2015), International migration outlook 2015 (Paris: OECD). 4 IOM (2016), Migration key terms. Available at: www.iom.int/key-migration-terms. 5 UN DESA (2017), International migration report 2017: highlights (ST/ESA/SER.A/404). 6 Department for International Development (2007), Moving out of poverty-making migration work better for better for poor people, London. See also UNDESA (2015), Trends in international migration, 2015. Available at: www.un.org/en/development/desa/population/migration/publications/populationfacts/docs/ MigrationPopFacts20154.pdf. 7 IOM (2016), op. cit., nt.4. 8 United Nations (2015), Transforming our world: the 2030 agenda for sustainable development, UN-GA (2015), A/RES/70/1 (Geneva: UN). 9 Ibid., p.16. 10 Ibid.

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of the UN General Assembly:‘It is accepted by all countries and is applicable to all.’11 This matters from the point of view of migration, as migration affects developing12 and developed countries alike, and indeed some of the most economically advanced countries are also amongst the world’s most popular destination countries for migration.13 Second, the 2030 Agenda is ‘integrated and indivisible’,14 not a menu of isolated silos and stand-alone options. This is made explicit at various points throughout the declaration and particularly in the Agenda’s Preamble which emphasises that ‘the interlinkages and integrated nature of the Sustainable Development Goals are of crucial importance in ensuring that the purpose of the new Agenda is realized’.15 In his analysis of the level of integration amongst the SDGs, Le Blanc asserts that the ‘goals and targets can be seen as a network, in which links among goals exist through targets that explicitly refer to multiple goals’.16 SDG3, for example, contains nine targets (13 if the targets relating to means of implementation are counted). Le Blanc notes that an additional seven targets under SDGs 2, 6, 11 and 12 also explicitly refer to health in their wording,17 whilst many more can be read to imply or contribute to wellbeing. Third, inclusiveness is a guiding principle of the Agenda as a whole. The Agenda’s motto, ‘leaving no one behind’,18 is reiterated throughout, and inclusion is a key theme of numerous goals. This principle is instrumental in any argument concerning the applicability of the 2030 Agenda in its entirety to migrants, as it subtly, but effectively, counters lingering notions that states are accountable solely to their citizens, or that migrants in an irregular situation can be deprived of fundamental rights. Therefore, whilst substantial and explicit targets on mental health are few—and not directly linked to migration—the overall spirit of the 2030 Agenda supports a broad interpretation in which most provisions would be applicable to migrants. Its integrated nature and some of its most important guiding principles—inclusiveness, in particular—validate the argument that efforts to improve and support migrants’ mental health and wellbeing are well justified under the Sustainable Development Agenda.19

Migration and development A great deal has been written about the relationship between migration and development, and it is beyond the scope of this chapter to summarise the literature and growing empirical evidence surrounding migration and development exhaustively. Nevertheless, a short recapitulation of a few key points in the discussion is necessary here. In simplified terms, the academic debate can be divided into two camps: on the one hand, those working within a structuralist paradigm and influenced by dependency theory and for whom migration is an inherent expression of structural inequalities and systems of exploitation, and on the other hand, neoclassical approaches in which

11 12 13 14 15 16

UN-GA (2015), op. cit., nt.8, p.1. ODI (2016), Leaving no one behind. Available at: www.odi.org/events/4320-leaving-no-one-behind. IOM (2016), op. cit., nt.2. UN-GA (2015), op. cit., nt.8, p.1. Ibid., p.2. Le Blanc, D. (2015), ‘Towards Integration at Last? The Sustainable Development Goals as a Network of Targets’, Working Paper No. 141 (New York: UN DESA), p.1. 17 Ibid., p.9. 18 ODI (2016), op. cit., nt.12. 19 Tulloch, O., Machingura, F., & Melamed, C. (2016), Health, migration and the 2030 agenda for sustainable development (Bern: ODI).

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migration is a manifestation of market forces at work to match supply and demand of labour.20 Beyond these tensions, it is widely recognised that there are two-way linkages between migration and development: development (and the lack of it) influences migration patterns, types and volumes, whilst migration can also affect development outcomes. At the same time, any relationship and its quality or impact must be assessed at the micro-level of the individual migrant (and his or her immediate family or community), as well as at the macro-level of the societies and economies of origin and destination with whom migrants interact. For example, migration impacts upon development via the labour and skills migrants bring to their destination labour markets, through financial and social remittances,21 and the creation of transnational trade links. Conversely, migration can result in the temporary or permanent loss of skilled workers by the country of origin. At the level of the individual, from a human capital and social mobility perspective, migration can lead to up-skilling and gains in income and status for an individual, or to precariousness, de-skilling and the underuse of skills. It also has social, economic and emotional consequences for families staying behind in the origin country. Put simply, whether the outcomes of migration are positive or negative depends very much upon whom you ask. In the other direction of causality, development differentials, manifesting, for example, in wage differences between countries, are a powerful driver of migration. The linkages are often complex and non-linear—for example, whilst poverty is a driver of migration, it is generally not the poorest who are able to muster the financial, personal and informational resources and networks to migrate.22 As a result, migration rates tend to increase with increasing prosperity, at least initially.23 With a few exceptions, the migration–development nexus has traditionally been examined from a macro(-economic) perspective with a focus on aggregate socio-economic effects.24 Migrants are often portrayed as factors in production and units of labour—as workers, purveyors of skills, or senders of remittances—especially in migration literature influenced by liberal economic theory.25 The present analysis, instead, starts from the premise that migrants are first and foremost individuals with a complex set of strengths, vulnerabilities, needs, motivations, and desires. With respect to development, this means that migrants are above all agents of their own development and that of their families, and should be respected and supported as such, before being ‘instrumentalised’ for utilitarian development purposes. At the same time, whilst migrants have agency, they are not free agents; the conditions under which migration takes place (dictated by policies and laws and underlying political, economic and social structures) crucially determine the outcomes for migrants in terms of their wellbeing, mental health and human development. Those same conditions, and the policies that countries put in place, also determine the developmental,

20 See, e.g., M. Clemens (2014), Does Development Reduce Migration? (Washington, DC: Centre for Global Development); S. Castles, H. De Haas, & M. J. Miller (2013), The Age of Migration (Basingstoke: Palgrave Macmillan Higher Education); H. De Haas (2008), Migration and Development: A Theoretical Perspective (Oxford: International Migration Institute); J. F. H. Moraga & H. Rapoport (2011), Tradable Immigration Quotas (Stanford: Stanford University); D. McKenzie & D. Yang (2015), Evidence on Policies to Increase the Development in Impacts of International Migration (Oxford: Oxford University). 21 Levitt, P. & Lamba-Nieves, D. (2010), ‘It’s Not Just About the Economy, Stupid’—Social Remittances Revisited (Washington, DC: Migration Policy Institute). Available at: www.migrationpolicy.org/article/itsnot-just-about-economy-stupid-social-remittances-revisited. 22 IOM (2016), op. cit., nt.2; Castles et al. (2013), op. cit., nt.20; De Haas (2008), op. cit., nt.20. 23 IOM (2013), World migration report: migrant well-being and development (Geneva: IOM). 24 De Haas (2008), op. cit., nt.20; IOM (2013), op. cit., nt.23. 25 Dustmann, C., Frattini, T., & Glitz, A. (2007), The impact of migration: a review of the economic evidence, File No.102, Contract No.36/2006 (London: Centre for Research and Analysis of Migration).

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social, economic and political consequences of migration for societies of origin and destination.26 In essence, voluntary migration through safe and regular channels (for example, in order to take up a desired job in another country) can be assumed to bring greater benefits to the migrant and his or her surroundings than undocumented migration forced by war, instability and desperation, which frequently results in risks, human rights violations, and precarious social, economic, and legal conditions. The 2030 Agenda has set a milestone in its recognition of migration as an integral component of development. After the complete omission of migration in the MDGs,27 migrants and migration are now explicitly included in the declaration, and in at least five goals:28 Goal 5, Target 5.2: Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation. Goal 8, Target 8.7: Take immediate and effective measures to eradicate forced labour, end modern slavery and human trafficking and secure the prohibition and elimination of the worst forms of child labour, including recruitment and use of child soldiers, and by 2025 end child labour in all its forms.29 Goal 8, Target 8.8: Protect labour rights and promote safe and secure working environments for all workers, including migrant workers, in particular women migrants, and those in precarious employment. Goal 10, Target 10.7: Facilitate orderly, safe, regular and responsible migration and mobility of people, including through the implementation of planned and well-managed migration policies. Goal 10, Target 10.C: By 2030, reduce to less than 3 per cent the transaction costs of migrant remittances and eliminate remittance corridors with costs higher than 5 per cent. Goal 16, Target 16.2: End abuse, exploitation, trafficking and all forms of violence against and torture of children. Goal 17, Target 17.18: By 2020, enhance capacity-building support to developing countries, including for least developed countries and small island developing states, to increase significantly the availability of high-quality, timely and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts. In addition to the explicit references to migration, there is an emphasis on the principle of non-discrimination in SDG16: Goal 16, Target 16.B: Promote and enforce non-discriminatory laws and policies for sustainable development. This is relevant in the context of international migration and the fulfillment of migrants’ rights and their access to services.

26 IOM (2015), Migration governance framework (Geneva: IOM). Available at: governingbodies.iom.int/ system/files/en/council/106/C-106–40-Migration-Governance-Framework.pdf. 27 Mental health was similarly sidelined and excluded from the MDGs. 28 UN GA (2015), op. cit., nt.8. All emphases are added unless otherwise stated. 29 It should be noted that human trafficking can, but does not necessarily, involve the crossing of an international border. For the purpose of a chapter on the mental health consequences of migration it is important to highlight human trafficking which can be bound up in other patterns of international migration.

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Migration, mental health, and wellbeing The Preamble of the 2030 Agenda recognises the necessity to achieve ‘a world with equitable and universal access to quality . . . health care and social protection, where physical, mental and social well-being are assured’,30 and ‘to promote physical and mental health and well-being’.31 Further, ‘no one must be left behind’ by ensuring (inter alia) the ‘prevention and treatment of non-communicable diseases, including behavioural, developmental and neurological disorders, which constitute a major challenge for sustainable development’.32 This important recognition of the promotion of mental health and wellbeing as a factor of sustainable development in the Agenda’s Preamble is further developed, as mentioned, in target 3.4. The target requires states to ‘reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’.33 International commitments to mental health have, however, existed before the SDGs. The International Covenant on Economic, Social and Cultural Rights (ICESCR)34 enunciates the right of all to the highest attainable standard of mental health in Article 12(1). Other conventions, legal instruments and soft law or legal guidelines stipulate the right of specific categories of migrants to mental health care and psychosocial support, such as for victims of trafficking35 and separated and unaccompanied minors.36 In 2016, the UN Human Rights Council adopted a resolution promoting universal access to mental health care within a human rights framework.37 These international legal instruments provide a basis on which to build universal access to mental health care, including for migrants. Their application, however, has been hampered by economic and political constraints, and mental health care remains a disproportionately underfunded domain of public investments.38 Since both migration and mental health are considered important factors of sustainable development under the 2030 Agenda, it is imperative to look at the relation between them more closely. According to the World Health Organization (WHO), mental health is a ‘state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’.39 Migration is often associated with psychological vulnerabilities, resulting from difficulties experienced by migrants in countries of origin and during migration,40 or the challenges of adapting to new surroundings and a new way of living.41 Thus, migration can

30 31 32 33 34 35

36 37 38 39 40 41

UN GA (2015), op. cit., nt.8, p.3. Ibid., p.7. Ibid., p.8. Ibid., p.16. UN GA (1966) RES/2200A (XXI), International covenant on economic, social and cultural rights. Available at: www.ohchr.org/Documents/ProfessionalInterest/cescr.pdf. UN GA (2000), Protocol to prevent, suppress and punish trafficking in person, especially women and children, supplementing the United Nations convention against transnational organised crime (New York: UN). UNHCR (1997), Guidelines on policies and procedures in dealing with unaccompanied children seeking asylum. Available at: www.unhcr.org/3d4f91cf4.pdf. UN GA (2016), A/RES/32/L.26, Mental health and human rights. J. Mackenzie & C. Kesner (2016), Mental Health Funding and the SDGs (London: ODI). Available at: www.odi.org/sites/odi.org.uk/files/resource-documents/10573.pdf. WHO (2016), Mental health included in the UN sustainable development goals. Available at: www. who.int/mental_health/SDGs/en/. Kaya, B. & Efionayi-Mäder, D. (2007), Migration and Health: A Basic Document on the Issues (Neuchatel, Promotion Santé Suisse and the Federal Office of Public Health). Loue S. & Sajatovic, M. (2009), Determinants of Minority Mental Health and Wellness (New York: Springer).

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challenge the mental health of migrants, confronting them with abnormal stressors,42 such as precarious legal and working conditions, uncertainty, isolation, separation from family and support networks, discrimination, or cultural, social and linguistic barriers.43 These stressors, either individually or via accumulation, can induce psychological problems, including anxiety, toxic stress,44 sadness, a sense of disassociation, anger, maladaptation,45 and nostalgic disorientation.46 The WHO definition of mental health specifically refers to an individual’s ability to work and be productive. The relationship between work or livelihood activities and mental health is significant: in several rapid psychosocial assessments conducted by the IOM with war-affected displaced populations, participants consistently identified the lack of means to support themselves and their families as they had been able to do before the displacement as a central cause of their distress and other negative feelings.47 They also cited the engagement in livelihood activities of any sort as one of the best ways of coping with their general distress.48 A study conducted in Bangladesh with poverty-stricken female-headed households found a highly significant correlation between livelihood activities and subjective wellbeing, and a negative correlation between livelihood activities and distress.49 The ability to provide for one’s livelihood and engage in work therefore seems to be critical to good mental health. Yet for a range of reasons, migrants and refugees often struggle to work to their full potential using their level of qualification, or have to take on ‘dirty, dangerous and demeaning’ jobs,50 particularly when lacking documentation. In some countries, refugees are not allowed to work altogether. Moreover, certificates and degrees obtained in the countries of origins are often not recognised by the host country.51 Some of the migration-specific targets of the 2030 Agenda (such as targets 5.2, 8.7, 8.8, 10.7, 10.C, 16.2, and 16.B), when reached, will reduce some of the above-mentioned stressors that affect the mental

42 Bhugra, D. & Becker, M. A. (2005), Migration, cultural bereavement and cultural identity, World Psychiatry 4(1): 18–24. 43 Ibid. 44 National Scientific Council on the Developing Child (2005), Excess Stress Disrupts the Architecture of the Developing Brain (Cambridge: Harvard University). 45 See, e.g., Potochnick, S. R. & Perreira, K. M. (2010), Depression and anxiety among first-generation immigrant Latino youth: key correlates and implications for future research, Journal of Nervous and Mental Disorders, 98(7): 470–477. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3139460/. See also Kirmayer, L. J., Narasiah, L., Munoz, M., et al. (2011), Common mental health problems in immigrants and refugees: general approach in primary care (Canadian Collaboration for Immigrant and Refugee Health (CCIRH)), CMAJ, 183(12): E959–E967. Available at: doi.org/10.1503/cmaj.090292. 46 Papadopoulos, R. K. (2015), Failure and success in forms of involuntary dislocation: trauma, resilience, and adversity-activated development, Jungian Odyssey Series, 7: 25–49. 47 See further Giardinelli, L., Kios, G., Abubakar, B., et al. (2015), An Assessment of Psychosocial Needs and Resources in Yola IDP Camps: North East Nigeria (Abuja: IOM); Schininà, G. & West, H. (2014), A rapid assessment of psychosocial needs and resources in South Sudan following the outbreak of the 2013/2014 conflict (Juba: IOM); Ataya, A., Duigan, P, Louis, D., & Schininà, G. (2010), Assessment on Psychosocial Needs of Haitians Affected by the January 2010 Earthquake (Port Au Prince: IOM Haiti); and Schininà, G., Bartoloni, E., & Nuri, R. (2008), Assessment on Psychosocial Needs of Iraqis Displaced in Jordan and Lebanon (Beirut: IOM Lebanon). 48 Ibid. 49 Chowdhury, J. S. B., Frongillo, E., & Warren, A. (2015), Food insecurity mediates the effect of a poverty alleviation program on psychosocial health among the ultra-poor in Bangladesh, The Journal of Nutrition, 145: 1934–1941. 50 Benach, J., Muntaner, C., Delcos, C., et al. (2011), Migration and ‘low-skilled’ workers in destination countries, PLoS Med, 8(6): e1001043. Available at: doi.org/10.1371/1001043. 51 IOM (2013), Recognition of Qualifications and Competencies of Migrants, Brussels, IOM Regional Office for EU, EEA and NATO.

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health of migrants, and improve their prospects of working and being productive under the WHO’s wider definition of mental health.52 Looking at the more specific domain of mental disorders and their treatment, the existing research on mental illness amongst migrants is weak due to obstacles relating to data collection, sample size and selection, and comparisons between contexts and populations that are very different around the globe.53 However, existing research suggests that some categories of migrants to varying degrees are more vulnerable to certain mental disorders than are non-migrant populations. Post-Traumatic Stress Disorder (PTSD), for example, tends to be more prevalent in refugees and asylum seekers,54 internally displaced persons,55 victims of trafficking,56 migrant detainees,57 and unaccompanied minors.58 Furthermore, according to some studies, incidences of anxiety and depression are slightly higher amongst various categories of labour migrants59 and victims of trafficking compared with the average population.60 Psychoses, too, can occur more frequently in the general migrant population,61 and to an even larger extent amongst refugees.62 However, these differences in the prevalence of severe mental disorders between migrant and non-migrant populations are, whilst statistically significant, quite small in size. In addition, some comparative studies show that the prevalence rates of certain mental disorders can differ for populations of the same national origin and similar migratory characteristics in different host countries. This hints at the fact that the main determinants of migrants’ vulnerability to these disorders are

52 WHO (2016), Mental health included in the UN sustainable development goals. Available at: www.who. int/mental_health/SDGs/en/. 53 M. Knipper & Y. Bilgin (2009), Migration und Gesundheit (Berlin: Konrad Adenauer Stiftung). Available at: www.kas.de/wf/doc/kas_16451-544-1-30.pdf?100422141713. 54 Knipscheer, J. W., Sleijpen, M., Mooren, T., et al. (2015), Trauma exposure and refugee status as predictors of mental health outcomes in treatment-seeking refugees, BJPsych Bull, 39(4): 178–182. Available at: doi. org/10.1192/pb.bp.114.047951. 55 Salah, T. T., Abdelrahman, A., Lien, L., et al. (2013), The mental health of internally displaced persons: an epidemiological study of adults in two settlements in central Sudan, Int J Soc Psychiatry, 59(8): 782–788. Available at: doi.org/10.1177/0020764012456810. 56 Zimmerman, C., Hossain, M., Yun, K., et al. (2006), Stolen smiles: a summary report on the physical and psychological health consequences of women and adolescents trafficked in Europe (London: The London School of Hygiene and Tropical Medicine). 57 Robjant, K., Hassan, R., & Katona, C. (2009), Mental health implications of detaining asylum seekers: systematic review, The British Journal of Psychiatry, 194(4): 306–312. Available at: doi.org/10.1192/bjp. bp.108.053223. 58 Jensen, T. K., Skårdalsmo, E. M. B., & Fjermestad, K. W. (2014), Development of mental health problems—a follow-up study of unaccompanied refugee minors, Child and Adolescent Psychiatry and Mental Health, 8:29. Available at: doi.org/10.1186/1753-2000-8-29. 59 Breslau, J., Borges, G., Saito, N., et al. (2011), Migration from Mexico to the US and conduct disorder: a cross-national study, Arch Gen Psychiatry, 68: 1284–1293. Available at: www.ncbi.nlm.nih.gov/pmc/ articles/PMC3739443/. See also Schweizerische Eidgenossenschaft, Department des Inneren (2010), Migranten in der Schweiz. Wichtigste Ergebnisse des zweiten Gesundheitsmonitorings der Migrationsbevölkerung in der Schweiz (Bern: BAG). 60 Ottisova, L., Hemmings, S., Howard, L. M., et al. (2016), Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review, Epidemiology and Psychiatric Sciences, 25(4): 317–341. 61 Hollander, A. C., Dal, H., Lewis, G., et al. (2016), Refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden, BMJ, 352: i1030. Available at: dx.doi.org/10.1136/bmj.i1030. 62 See, e.g., ibid.; Cantor-Graae, E. & Selten, J. P. (2005), Schizophrenia and migration: a meta-analysis and review, Am J Psychiatry, 162: 12–24.

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linked to the social challenges of integration in the new country.63 These factors include, but are not limited to, isolation, discrimination, poverty, difficulty in accessing services, experiences of detention, and bureaucratic procedures, including the time spent in limbo waiting for status determination.64 The Agenda’s Preamble, as stated above, advocates for the prevention and treatment of behavioural, developmental and neurological disorders in a way that does not leave anyone behind. It is therefore essential that migrants are not excluded from relevant care services. However, migrants’ inclusion in existing mental health systems is likely to be difficult or inefficacious whenever those systems are not adequately serving the local population in any event. This is particularly true in, but not limited to, LMICs where economic constraints and higher stigmatisation of mental disorders have limited the development of national mental health services. The inclusion of migrants in mental health care cannot be divorced from the development of good mental health systems for the local population. In some countries, efforts by international organisations to provide mental health care to emergency-affected displaced populations or to particular groups of vulnerable internal or international migrants have brought about better mental health services for all, which have then become embedded in the national health systems. This was the case in Moldova through support programmes for victims of trafficking compliant with the requirements of the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children.65 In Jordan, thanks to mental health training and initiatives aimed at providing psychosocial support to Iraqi and Syrian refugees, mental health care improved generally.66 Similarly, in Cambodia following the fall of the Khmer Rouge regime which had destroyed all existing mental health services, the attention given to the mental health needs of internally displaced and returnee populations led to the re-establishment of a psychiatry curriculum in the country.67

Human trafficking and its effect on mental health As mentioned at the outset, it is difficult to do justice to the diversity of migration experiences in a macro-level analysis of mental health, development, and migration. However, victims of trafficking constitute one category for whom negative mental health outcomes are more consistently documented. Human trafficking by definition involves the ‘threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability’, as well as exploitation, including for sexual purposes.68 As a result, victims of trafficking are prone to an array of emotional consequences which can persist long after the trafficking episode. In a 2016 meta-review of existing studies on the subject, Ottisova and

63 Kaya & Efionayi-Mäder (2007), op. cit., nt.40. 64 Schininà, G. & Zanghellini, T. E. (2018), ‘Internal and International Migration and its Impact on the Mental Health of Migrants’, in D. Moussaoui, D. Bhugra, & A. Ventriglio (eds) (2018), Mental Health and Illness in Migration. Mental Health and Illness Worldwide (Singapore: Springer) 65 UN GA (2000), op. cit., nt.35; IOM (2017), Preventing trafficking and protecting victims in Moldova. Available at: www.iom.int/preventing-trafficking-and-protecting-victims-moldova. The Republic of Moldova signed the UN Convention against Transnational Organized Crime and the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children on 14 Dec 2000 and ratified both on 16 Sept 2005; see UN Treaty Collection. Available at: https://treaties.un.org/. 66 Schininà et al. (2008), op. cit., nt.47. 67 See, e.g., Savin, D. (2000), Developing psychiatric training and services in Cambodia, Psychiatric Services, 51, 935; Somasundaram, D. J., Van de Put, W. A. C. M., & Eisenbruch, M. (1999), Starting mental health services in Cambodia, Social Science and Medicine, 48: 1029–1046. 68 UN GA (2000), op. cit., nt.35.

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colleagues arrived at the conclusion that although the available research generally is not of high quality, most studies on human trafficking nevertheless suggest a higher prevalence of symptoms of depression, anxiety, PTSD and suicidality than in other populations, as well as psychoses in male victims.69 In general, as for other categories of migrants, the mental health outcomes of trafficking in human beings cannot be generalised. Although emotional suffering is present and is a normal consequence of the events most victims of trafficking experience, the majority of former victims will not develop mental disorders. The pathological outcomes depend on a range of factors, including pre-existing vulnerabilities, the type of trafficking, the frequency of violence perpetrated against them, and the type of exploitation. Factors related to their rehabilitation and reintegration after the trafficking experience also play a role, including whether individuals are able to access services, or whether and to what degree they suffer from stigma as a result of having been trafficked. The Palermo Protocol stipulates that states should take steps to support ‘the physical, psychological and social recovery of victims of trafficking’ and provide ‘medical, psychological and material assistance’.70 Yet, whilst some attempts have been made to measure the prevalence of mental disorders amongst victims, little has been done globally to evaluate response services and identify best clinical practices.71 In addition, in cross-border trafficking cases, the laws of the destination country typically require that former victims return to their country of origin, often to circumstances in which appropriate mental health services are poorly developed or non-existent. The need to eliminate human trafficking, as noted above, also features in the SDGs. Whilst target 8.7 refers to human trafficking in the context of forced labour, target 5.2 under SDG5 (‘[a]chieve gender equality and empower all women and girls’) subsumes trafficking under violence against women and girls. This gives rise to a broader issue whereby common assumptions about a certain (migrant) group—in this case, gender-related assumptions about the risk of human trafficking—can have consequences for victim assistance and policymaking, including in relation to mental health responses. With respect to human trafficking, the IOM has seen a marked increase in the identification of male victims of trafficking compared with female victims (from 16% in 2006 to 57% in 2016).72 Human trafficking was long perceived to be primarily a crime against women. These biases have caused the ‘invisibility’ of trafficking of men and boys, as a result of which the mental health needs of male victims of trafficking have been overlooked.73

69 Ottisova et al. (2016), op. cit., nt.60. 70 UN GA (2000), op. cit., nt.35, Art.6. 71 Craggs, S. & Schininà, G. (2016), Mental health of victims of trafficking: a right, a need and a service, Epidemiology and Psychiatric Sciences, 25: 345–346. 72 IOM (2017), Global Trafficking: Trends in Focus—IOM Victims of Trafficking Data 2006–2016. Available at: www.iom.int/sites/default/files/our_work/DMM/MAD/A4-Trafficking-External-Brief.pdf. It is important to note that this data refers to the identification of male or female victims of trafficking in IOM’s victim assistance operations. It does not necessarily reflect the sex distribution amongst victims of trafficking globally, although the growing prevalence of male victims has also been acknowledged by other actors: see, e.g. Paul, C. (2017), UN Reports on Changing Face of Human Trafficking, 10 Jan 2017. Available at: sdg.iisd.org/news/un-reports-on-changing-face-of-human-trafficking/. 73 US Department of State (2017), Assisting Male Survivors of Human Trafficking (fact sheet), Office to Monitor and Combat Trafficking in Persons, 27 June 2017. Available at: www.state.gov/j/tip/rls/ fs/2017/272004.htm. See also Duger, A. (2015), SDG SERIES (2015): SDGs Adopting a Rights-based Approach to Human Trafficking, Health and Human Rights Journal, 10 Sept 2015. Available at: www. hhrjournal.org/2015/09/sdg-series-sdgs-adopting-a-rights-based-approach-to-human-trafficking/. See also IOM (2008), Trafficking of Men—A Trend Less Considered: The Case of Belarus and Ukraine, Migration Research Series No.26 (Geneva: IOM). For more on men’s mental health, see Chapter 9 of this book by Svend Aage Madsen.

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It will be important for future efforts to correct this bias in policy, services and assistance, in line with the spirit of the 2030 Agenda. There is therefore a subtle, but important, distinction to be made: whether migrants’ mental health issues are due to inherent personal and biographical characteristics, or rather a result of external structural conditions and social challenges encountered during migration and integration. Clearly, there is no universally applicable answer, given the diversity of individual migration experiences. There is a tendency in policy, public and sometimes even medical discourse—however well-intentioned—to assume that migrants will experience vulnerability to mental health disorders by definition, with an overemphasis on ‘trauma’. Whilst this assumption is not necessarily wrong, it is certainly overstated. The resulting risks are twofold: first, it can mean that there is no acknowledgement of migrants’ agency and resilience, leading to (further) disempowerment. Second, it shifts the onus onto the migrant, rather than questioning the structural, legal and policy issues and social environment that may have contributed to or even triggered mental health challenges. Here, the SDGs’ emphasis on inclusiveness and non-discrimination set the framework for a more structural approach to ensuring migrants’ mental health and wellbeing.

Structural challenges to universal mental health care Turning then to the structural challenges facing migrants in destination countries, migrants are often overlooked entirely in the organisation of national mental health care systems. In many countries, mobile populations and irregular migrants are excluded altogether from existing health care systems.74 In some countries where primary health care is available for all, migrants’ right to secondary and tertiary health care services can be complicated by the administrative and legal procedures regulating access. In numerous countries, mental health care is positioned at the second and tertiary level of care,75 which decreases ease of access. Furthermore, a lack of outreach and information, language and cultural barriers, and the stigma attached to mental disorders, paired with discrimination against migrants, can jeopardise migrants’ access to the existing services.76 There is a need for all states to consider these obstacles and provide relevant responses to make mental health services legally available, factually accessible, and technically efficacious for migrants.77 This will make a contribution to two interconnected objectives of the 2030 Agenda: the promotion of mental health and wellbeing for all, under SDG3 (without which sustainable development is hampered), and the consideration of migration as a driver of development.

74 See, e.g., European Year of Development (2015), Refugees and internally displaced persons: right to health, right to life. Available at: www.europarl.europa.eu/meetdocs/2014_2019/documents/deve/dv/refugees_/ refugees_en.pdf. See also Schininà, G., Zuodar, S., & Blake, C. (2011), Citoyennetés, culture et santé mentale en Europe; un aperçu des pratiques en France, en Allemagne, en Grande-Bretagne, en Italie et en Suisse, TranSfaire & Cultures, 4: 13–30. 75 Drew, N., Faydi, E., Funk, M., & Saraceno, B. (2008), Integrating mental health into primary healthcare, Ment Health Fam Med, 5(1): 5–8. 76 Morris, M. D., Popper, T. P., Rodwell, T. C., et al. (2009), Healthcare barriers of refugees post-resettlement, J Community Health, 34(6): 529–538. Available at: doi.org/10.1007/s10900-009-9175-3. 77 IOM (2017), ‘Migration health in sustainable development goals: “leave no one behind” in an increasingly mobile society’, a position paper (Geneva: IOM).

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Recommendations A series of practical steps can be taken by states to foster migrants’ integration in different mental health care services and make them migrant-friendly. The premise is that segregated mental health care services for migrants are best avoided as they are liable to contribute to stigma, and risk being unsustainable.78 Instead, existing services need to be strengthened and developed for the target population as a whole. Services and therapeutic approaches need to become more cognisant of a range of diversity characteristics, including those relevant to migrants and migration. In most countries, mental health care is mainly offered at the secondary and tertiary care level, whilst migrants, especially those in irregular situations, are typically given access only to primary health care services, if at all.79 The first recommendation, therefore, relates to mainstreaming mental health care at the primary health care level, and to granting migrants access to all levels of health care, including secondary and tertiary. A second recommendation is that states should mainstream mental health care in multiple sectors. Migration can create major stressors, and the prevalence of mental disorders in migrants is often correlated with social problems in the integration phase. The relationship between mental health and mobility should be considered in all the concerned systems, and especially those that can actively shape a migrant’s initial in-country experience. Capacity-building of service providers and practitioners and integrated models of service involving all affected stakeholder groups should be considered for educational settings, social care, health care, religious communities, social services, security and law enforcement, and community services. Third, needs will differ substantially between different contexts and migrant groups, and even within the same group. This requires flexible systems that can deal with diverse groups, but training should also be available for those providers and institutions that are likely to interact with the most vulnerable individuals, such as victims of trafficking. More generally, attention and responses to the mental health needs of migrants must be age- and gendersensitive to prevent barriers and exclusion. The fourth recommendation relates to the establishment of linguistically and culturally appropriate forms of outreach in different migrant communities. Even if mental health services are open to migrants, a lack of information, language barriers, and stigma can de facto exclude immigrants from existing mental health services.80 Culturally and linguistically appropriate outreach, including information campaigns, information points, and training of mental health promoters within the migrants’ communities can reduce these challenges. Even when migrants do access the existing services, language and cultural barriers can continue being an obstacle in the actual provision of therapy and in the therapeutic relationship. This is particularly true in western systems, since talking therapies dominate western therapeutic models. Mental health services, in particular in areas with large migrant populations, should always consider whether or not interpretation is necessary, and if so, provide appropriate training for the interpreters. This is likely to prove particularly difficult, however, in LMICs where resources are stretched. Reliance may be necessary not only upon health workers themselves, but also upon community volunteers, or through health promoters or advocates within the services offered by international organisations to refugees and victims of trafficking.

78 Schininà et al. (2018), op. cit., nt.64. 79 Schininà et al. (2011), op. cit., nt.74. 80 Ibid., p.23.

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In the same vein, the understanding of cultural differences is essential to achieve good therapeutic results and avoid misdiagnoses when therapists and clients come from different cultures. The formation of a taskforce of cultural or mental health mediators who come from migrant communities and who are trained to fulfil this function has proved effective in some countries.81 There are, however, sustainability problems with this model, especially since migrant communities are increasingly diverse. The management of cultural diversity in supporting and developing a therapeutic relationship should, in any case, be made part of the national curricula for psychiatrists, clinical psychologists, clinical social workers, and nurses, especially in countries experiencing high rates of immigration.

Conclusion Whilst the 2030 Agenda is a major step forward in bringing migration and mental health into the development context, a word of caution is necessary. The actual impact of the SDGs depends largely upon their translation into national development plans and dedicated follow-up and review of their implementation at national, regional and global levels. The appropriateness of indicators and available resources for data collection and analysis will also shape the influence of the SDGs. The agreed global indicators for target 3.4 are 3.4.1 (‘[m]ortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease’) and 3.4.2 (‘[s]uicide mortality rate’).82 As indicators for mental health, these are disappointingly limited, particularly since suicide mortality rates can be a weak indicator of the general mental health status of a population. Thus, global progress will depend majorly upon national development plans, and the measurement and monitoring (by specialised organisations and other actors) of progress on mental health beyond suicide rates—including that of migrants. The commitments recently set out in the 2030 Agenda have been further reinforced by the UN General Assembly’s 2016 New York Declaration for Refugees and Migrants,83 which makes numerous references to the right of migrants and refugees to health, access to health services and psychosocial support. In the Declaration, states have committed on the one hand to developing a Comprehensive Refugee Response Framework, and on the other, to a Global Compact for Safe, Orderly and Regular Migration.84 It remains to be seen to what extent mental health aspects will be reflected in the two frameworks, but they do offer the global community an opportunity to build awareness of the mental health dimensions of migration, strengthen existing hard and soft norms in this area, and make recommendations for policy and practice. At the time of writing, the intergovernmental thematic consultations in preparation for the Global Compact on Migration

81 Ibid., p.40. 82 United Nations (2017), SDG Indicators: Global Indicator Framework for the Sustainable Development Goals and Targets of the 2030 Agenda for Sustainable Development (Geneva: UNSTATS). Available at: unstats.un.org/ sdgs/indicators/indicators-list/. See also United Nations (2017), The Sustainable Development Goals Report 2017 (New York: UN). Available at: unstats.un.org/sdgs/files/report/2017/thesustainabledevel opmentgoalsreport2017.pdf. 83 UN GA (2016), RES/A/71/7, Resolution adopted by the General Assembly on 18 September 2016: New York Declaration for Refugees and Migrants. Available at: www.un.org/en/ga/search/view_doc.asp?symbol=A/ RES/71/1. 84 Ibid., Annex I and Annex II. See also: http://refugeesmigrants.un.org. The intergovernmental negotiations on the Global Compact for Safe, Orderly and Regular Migration and the consultation process for the Global Compact on Refugees concluded in late 2018 after the editorial deadline for this chapter. Although neither of the Compacts are binding, there are minor references to mental health aspects in both Compacts. Further information available at: https://refugeesmigrants.un.org.

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had made a passing reference to mental health under the thematic consultations on the ‘[h]uman rights of all migrants, social inclusion, cohesion, and all forms of discrimination, including racism, xenophobia and intolerance’.85 However, although the official summary of the session discusses health at length,86 no specific mention is made of mental health. This chapter has considered the relationships between migration and development, and between migration and mental health. It has described how migration can have negative repercussions for mental health, but cautions against making assumptions about or ‘over-pathologising’ the migrant condition. Attention to vulnerabilities is as important as an active promotion of individual agency, strength and resilience. Likewise, attention to the needs of an individual should not distract from efforts to address the structural factors that increase the risk of mental health concerns. The 2030 Agenda acknowledges that migration is an essential component of sustainable development, and that mental health is an essential factor of sustainable development. Protecting, promoting and ensuring the mental health of migrants therefore is an end in itself and a means to achieving the Agenda’s goals. Both the development and the mental health outcomes of migration are a function of the conditions and challenges that migrants encounter on their way to, and particularly on their arrival in, destination countries. The responsibility, therefore, is on policymakers and practitioners to transform policies, systems and approaches concerning physical health and mental health, as well as development and labour market and migration policies, in a way that puts migrants’ rights and wellbeing at their heart.

85 Global Compact on Migration (2017), Thematic Session on ‘Human rights of all migrants, social inclusion, cohesion, and all forms of discrimination, including racism, xenophobia and intolerance’, 8–9 May 2017. The issue brief is available at: refugeesmigrants.un.org/sites/default/files/issue_brief_for_first_ thematic_session.pdf. 86 Ibid. The Co-facilitators’ Summary is available at: refugeesmigrants.un.org/sites/default/files/summary_0.pdf.

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11 THE SUSTAINABLE DEVELOPMENT GOALS AND CHILD AND ADOLESCENT MENTAL HEALTH IN LOW- AND MIDDLE-INCOME COUNTRIES Cornelius Ani* and Olayinka Omigbodun† Introduction The Sustainable Development Goals (SDGs) present new drivers for improving quality of life and the environment worldwide. The Millennium Development Goals (MDGs) which preceded the SDGs were credited with some progress such as reduction in Infant Mortality Rates (IMR) in Low and Middle Income Countries (LMICs).1 Whilst the MDGs impacted upon mental health, there were no specific mental health goals. The SGDs, on the other hand, have one explicit goal with mental health content (SDG3) and many other SDGs with mental health as an overarching interface. This reveals the improving profile and priority of mental health in the global development agenda.2 Despite some warranted critiques of the MDGs, it is nonetheless recognised that they helped many LMICs to improve some developmental milestones such as substantial reduction in the mortality of under-fives.3 With longer life expectancy, attention is now shifting to the quality of life and reduction in morbidity from non-communicable diseases (NCDs) amongst the millions

* Dr. Cornelius Ani is an Honorary Clinical Senior Lecturer at the Centre for Psychiatry, Imperial College London, and a Consultant Child and Adolescent Psychiatrist for Surrey and Borders Partnership NHS Trust in the UK. † Olayinka Omigbodun is a Consultant in Child and Adolescent Psychiatry at the University College Hospital, Ibadan, Nigeria, Head of Psychiatry at the College of Medicine, and Director and the Principal Investigator at the Centre for Child & Adolescent Mental Health, University of Ibadan. 1 UN (2015), We Can End Poverty. Millennium Development Goals and Beyond 2015. Available at: www.un.org/ millenniumgoals/childhealth.shtml. 2 Votruba, N., Thornicroft, G., & the FundaMentalSDG Steering Group (2016), Sustainable development goals and mental health: learnings from the contribution of the FundaMentalSDG global initiative, Global Mental Health, 3, e26. Available at: doi.org/10.1017/gmh.2016.20. 3 UN (2015), op. cit., nt.1.

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of children who are now surviving into school age and adolescence.4 The World Health Organization (WHO) estimates that 10% to 20% of children and adolescents are affected by diagnosable mental disorders.5 The contribution of some Child and Adolescent Mental Disorders (CAMDs) such as anxiety, depression, substance misuse and conduct disorders to global age-standardised Disability Adjusted Life Years (DALYs) has increased in the past 15 years.6 LMICs have higher proportions of young people with vulnerabilities that increase their likelihood of mental illness.7 These include those with chronic medical conditions (such as haemoglobinopathies), infections (such as HIV/AIDS), and being an orphan, refugee or internally displaced person. LMICs also have a younger demographic profile, with 31% to 43% of the population younger than 15 years compared to 17% in High Income Countries (HICs) in 2016.8 With a youthful population combined with reducing youth mortality and high fertility rates, it is projected that the population burden of CAMDs will increase in LMICs over time, even if the incidence of specific disorders remains unchanged.9 Given that 50% of adult mental disorders start in childhood or adolescence,10 the long-term mental health burden in these regions is likely to be high. This chapter will explore the interface between specific SDGs and Child and Adolescent Mental Health (CAMH) in LMICs. In addition to SDG3 which has a specific focus on mental health, other SDGs with overarching relevance for CAMH, including poverty (SDG1), hunger and nutrition (SDG2), education (SDG4), gender inequality (SDG5), and the reduction of violence (SDG16), will also be explored. The SDGs are used as platforms to discuss determinants of CAMH in LMICs and explore interventions to prevent onset and/or support affected children and young people. Programmatic policy measures as well as specific targeted interventions with a good evidence base are discussed. The potential role of the SDGs as catalysts for governments to improve CAMH in LMICs will be highlighted. Finally, a case study from Nigeria is used to highlight human capacity development which is part of SDG3.

The burden of CAMDs in LMICs A meta-analysis of studies in LMICs estimates that 10% of children and adolescents are affected by mental disorders.11 Using Nigeria and depression as examples, it is estimated that between

4 The Global Burden of Disease Child and Adolescent Health Collaboration (2017), Child and Adolescent Health From 1990 to 2015. Findings from the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study, JAMA Pediatr, 171(6): 573–592. Available at: doi.org/10.1001/jamapediatrics.2017.0250. 5 WHO (2017), Mental Health—Child and Adolescent Mental Health. Available at: www.who.int/ mental_health/maternal-child/child_adolescent/en/. 6 The Global Burden of Disease Child and Adolescent Health Collaboration (2017), op. cit., nt.4. 7 Owen, J. P., Baig, B., Abbo, C., & Baheretibeb, Y. (2016), Child and adolescent mental health in subSaharan Africa: a perspective from clinicians and researchers, B. J. Psych. International, 13(2): 45–47. 8 The World Bank (2017), World Development Indicators: Population Dynamics. Available at: wdi.world bank.org/table/2.1. 9 Scott, J. G., Mihalopoulos, C., Erskine, H., et al. (2015), ‘Childhood Mental and Developmental Disorders’, in V. Patel, D. Chisholm, T. Dua, et al. (eds) (2015), Mental, Neurological, and Substance Use Disorders: Disease Control Priorities (3rd edn), Vol.4 (Washington, DC: The International Bank for Reconstruction and Development/The World Bank). Available at: www.ncbi.nlm.nih.gov/books/NBK361945/. 10 Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S, et al. (2007), Age of onset of mental disorders: a review of recent literature, Current Opinion in Psychiatry, 20(4): 359–364. Available at: doi.org/10.1097/ YCO.0b013e32816ebc8c. 11 Cortina, M. A., Sodha, A., Fazel, M., & Ramchandani, P. G. (2012), Prevalence of Child Mental Health Problems in Sub-Saharan Africa: A Systematic Review, Arch Pediatr Adolesc Med, 166(3): 276–281. Available at: doi.org/10.1001/archpediatrics.2011.592.

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6% to 12% of Nigerian children and adolescents have a depressive disorder.12 Using the more conservative estimate of 6% still suggests that about 4 million Nigerian adolescents could be affected by depression. This is consistent with the suggestion that depression was the greatest contributor to the global burden of disease worldwide in 2013, affecting more than 10% of ten-to-24-year-olds.13

The impact of CAMDs The most serious consequence of CAMDs for affected children is increased mortality. This can be from suicide which is one of the significant causes of youth death in LMICs.14 Death of affected children and others can also result from accidents related to impulsive actions due to untreated Attention Deficit and Hyperactivity Disorder (ADHD) and/or impaired judgement from substance misuse.15 Young people with conduct disorder are also at higher risk of being victims or perpetrators of serious crimes, including homicides.16 Other consequences of CAMDs for affected children include school exclusions, academic failure, antisocial behaviour, teenage pregnancy and young parenthood, occupational and relationship failures, poverty, substance abuse, and involvement with the criminal justice system.17 Intergenerational transmission of childhood conduct disorders resulting from inadequate parenting and the failure to attain necessary life skills is common, with the children of the affected young people at increased risk of developing CAMDs.18 Families of children and adolescents affected by CAMDs experience increased burden of care19 which can result in various detrimental effects. These include secondary mental disorders in siblings and parents, adverse parenting practices such as the use of harsh physical discipline, economic stresses from loss of work by parents and/or out-of-pocket expenditure for treatment, and ultimately family breakdown. The community-wide impact of CAMDs includes the cost

12 See, e.g., Adeniyi, A. F., Okafor, N. C., & Adeniyi, C. Y. (2011), Depression and Physical Activity in a Sample of Nigerian Adolescents: Levels, Relationships and Predictors, Child and Adolescent Psychiatry and Mental Health, 5: 16. Available at: doi.org/10.1186/1753-2000-5-16. See also Adewuya, O. A., Ola, B. A., & Aloba, O. O. (2007), Prevalence of major depressive disorders and a validation of the Beck Depression Inventory among Nigerian adolescents, European Child Adolescent Psychiatry, 16: 287–292; Omigbodun, O., Dogra, N., Esan, O., & Adedokun, B. (2008), Prevalence and Correlates of Suicidal Behavior Among Adolescents in South West Nigeria, International Journal of Social Psychiatry, 54: 34–46. 13 Patton, G. C., Sawyer, S. M., Santelli, J. S., et al. (2016), Our future: a Lancet commission on adolescent health and wellbeing, The Lancet, 11 June, 387(10036): 2423–2478. Available at: doi.org/10.1016/ S0140-6736(16)00579-1. 14 WHO (2017), Mental Health – Suicide Data. Available at: www.who.int/mental_health/prevention/ suicide/suicideprevent/en/. 15 Dalsgaard, S., Østergaard, D., Leckman, J. F., et al. (2015), Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study, The Lancet, 30 May; 385(9983): 2190–2196. 16 Hagelstam, C. & Hakkanen, H. (2006), Adolescent homicides in Finland: offence and offender characteristics. Forensic Science International, 164: 110–115. 17 See, Scott et al. (2015), op. cit., nt.9. 18 D’Onofrio, B. M., Slutske, W. S., Turkheimer, E., et al. (2007), Intergenerational Transmission of Childhood Conduct Problems: A Children of Twins Study, Archives of General Psychiatry, 64(7): 820–829. Available at: doi.org/10.1001/archpsyc.64.7.820. 19 Al-Dujaili, A. H. & Al-Mossawy, A. A. J. (2017), Psychosocial burden among caregivers of children with autism spectrum disorder in Najaf province, Curr Pediatr Res, 21(2): 272–282.

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of special or remedial education (if available), economic deprivation from lost productivity, costs related to criminal justice, and threats to community cohesion.20 Thus, using the impetus provided by the SDGs to promote positive mental health for young people in LMICs could have important positive ecological and cross-sectoral benefits that not only support the young people in achieving their developmental potential, but also enhance family stability, as well as community social and economic development and justice. Historically, mental health has been much neglected compared to physical health—but this appears even worse for CAMH than it does for adult mental health.21 It is therefore important to use the catalytic value of the SDGs to bridge this huge gap in the recognition, prevention, and treatment of CAMDs in LMICs and elsewhere. There are 17 SDGs with 169 targets. SDG3 is a specific goal for health with two targets specifically focused on mental health (targets 3.4 and 3.5).22 In addition to SDG3, five other SDGs (1, 2, 4, 5, and 16) have clear interfaces with CAMH. The relationships between these relevant SDGs and CAMH are now discussed. Evidence-based policies and interventions required to transform the SDGs from lofty aspirations to measures with positive practical impact on CAMH in LMICs are discussed.

SDG1: End poverty in all its forms everywhere Despite varying definitions, evidence from both HICs and LMICs strongly indicate that poverty is a crucial multi-dimensional social determinant of CAMH.23 Brazilian children living in abject poverty are at least five times more likely to have a diagnosable mental disorder compared with their middle class peers.24 Poverty overarches many of the other SDGs such that children and adolescents who live in low-income households are not only more likely to be in poor physical and mental health (which involves SDG3), but also to be malnourished (which affects SDG2), out of school or poorly educated (governed by SDG4), suffer gender and other discrimination (dealt with by SDG5), and violence and abuse (covered by SDG16).25 They are also less able or less likely to seek help, especially if services require out-of-pocket payment (as is the case in the majority of LMICs). Given the pervasive link between poverty and children’s health and development, it follows that interventions to reduce poverty can be predicted to have a positive impact upon their health.

20 Scott, S., Knapp, M., Henderson, J., & Maughan, B. (2001), Financial cost of social exclusion: follow up study of antisocial children into adulthood, BMJ, 323(7306): 191. 21 World Psychiatric Association, WHO, & International Association for Child and Adolescent Psychiatry and Allied Professions (2005), Atlas: Child and Adolescent Mental Health Resources (Geneva: WHO). Available at: www.who.int/mental_health/publications/atlas_child_ado/en/. 22 Sustainable Development Knowledge Platform. Available at: https://sustainabledevelopment.un.org/sdgs. 23 See, e.g., Sadler, K., Vizard, T., Ford, T., et al. (2017), Mental Health of Children and Young People in England, 2017, Health and Social Care Information Centre. Available at: https://digital.nhs.uk/data-and-infor mation/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017. See also Fleitlich-Bilyk, B. & Goodman, R. (2004), Prevalence of Child and Adolescent Psychiatric Disorders in Southeast Brazil, Journal of the American Academy of Child & Adolescent Psychiatry, 43(6): 727–734. See also Chapter 13 of this book by Rachel Jenkins. 24 Ibid. 25 Cluver, L. D., Orkin, F. M., Meinck, F., et al. (2016), Can Social Protection Improve Sustainable Development Goals for Adolescent Health?, PLOS ONE, 11(10): e0164808. Available at: doi.org/10.1371/ journal.pone.0164808.

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Cluver et al. tested this hypothesis in South Africa.26 As the third target (1.3) under SDG1 calls for the implementation of nationally appropriate social protection systems, the authors conducted a longitudinal analysis of the impact of the provision of household economic assistance and psychosocial support on children across several SDG domains. They found that the social protection measures which included poverty alleviation strategies, such as cash transfer, were associated with better outcomes in several SDG domains including reduced substance misuse amongst both boys and girls. The addition of psychosocial interventions (for example, parenting support) produced synergistic benefits in some domains.27 However, not all studies find that poverty alleviation results in improved mental health.28 This may be due to other variables that simultaneously affect mental health which may not be amenable to poverty alleviation alone. For example, the study by Cluver et al. found significant association between poverty alleviation and reduced mental disorders in boys, but not in girls.29 This suggests that in addition to social protective measures, more specific targeted interventions may be required to support mental health, especially for girls. The reciprocal relationship between poverty and mental health suggests that addressing the disabling effects of mental health symptoms could reduce poverty and economic deprivation. Consistent with this hypothesis, systematic reviews have shown largely consistent positive associations between mental health interventions and economic outcomes.30 Although these studies are amongst adults, a positive impact of the improved economic prospects of the wider family on children’s wellbeing is not an unreasonable hypothesis.

Recommendations The strong evidence of a bidirectional relationship between poverty and CAMH suggests that dual and synergistic policies addressing both problems should be a priority in LMICs.31 Governments should be encouraged to pursue policies and interventions to promote the economic security of families and individual children as one of the means to promote CAMH. Such policies include cash and asset transfers, microfinance, agriculture starter packs, and exemptions from financial obligations that would otherwise push families into debt and poverty, such as school fees and the purchase of school uniforms.32 Equally, policies to improve the identification and treatment of CAMDs are crucial to reducing the poverty-driving effect of mental disorders. Such measures, which are discussed in more detail in later sections of this chapter, include CAMH capacity-building, task-shifting, access to essential CAMH drugs, and integration of CAMH into primary care and educational settings.

26 Ibid. 27 Ibid. 28 Lund, C., De Silva, M., Plagerson, S., et al. (2011), Poverty and mental disorders: breaking the cycle in low-income and middle-income countries, The Lancet, 378: 1502–1514. 29 Cluver et al. (2016), op. cit., nt.25. 30 Ibid. 31 For more on the interrelationship between poverty and mental health, see Chapter 4 of this book by Judith Bass. 32 Handley, G., Higgins, K., & Bhavna, S., et al. (2009), ‘Poverty and Poverty Reduction in Sub-Saharan Africa: An Overview of the Issues’, Working Paper 299 (Overseas Development Institute (ODI): results of research presented in preliminary form for discussion and critical comment). Available at: www.odi. org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/860.pdf.

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SDG2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture Hunger and poor food security can affect children’s mental health in several ways.33 First, the children’s diet may be lacking in adequate calories and/or important micronutrients such as iron and iodine which are directly required for optimum mental health. Second, food insecurity could create additional stressors within family relationships, leading to parental distress which can spill over to their children.34 Both chronic under-nutrition and acute hunger are associated with adverse impact on children’s mental health. Stunting, which is a consequence of chronic under-nutrition, provides a good example of the adverse impact of poor nutrition on children’s mental health. Studies in many countries have consistently found an association between stunting and poor child development and longer-term sub-optimal mental health. An important early randomised controlled study by Grantham McGregor et al. in Jamaica35 with subsequent longitudinal follow-up36 found that compared with non-stunted children, stunted children achieved poorer early developmental quotients, had reduced cognitive abilities whilst of school age, and had a poorer emotional wellbeing and behaviour in late adolescence, including anxiety, depression, and lower self-esteem. They also exhibited more hyperactive behaviour and had a tendency towards more oppositional behaviour. Significantly, stunted children in the study who received both nutritional supplementation and psychosocial stimulation achieved improved early development almost matching those of the non-stunted children.37 Further evidence of the adverse impact of chronic under-nutrition on children’s socioemotional development comes from an analysis by McCoy et al. of a large data set involving over 900,000 children in 35 LMICs. The study found a positive correlation between height-for-age (HFA) and the early childhood development index (ECDI) (which measured characteristics such as the ability to regulate aggressive behaviours, and relate well to peers). The correlation was observed across the whole HFA spectrum. Additionally, a strong positive correlation was found between the prevalence of stunting and the percentage of children who scored low on the ECDI.38 Given that in 2016 there were 154 million five-year-olds in LMICs estimated to be stunted in growth,39 the potential impact of chronic under-nutrition on these children’s emotional wellbeing and behaviour could be very high.

33 Weaver, L. J. & Hadley, C. (2009), Moving Beyond Hunger and Nutrition: A Systematic Review of the Evidence Linking Food Insecurity and Mental Health in Developing Countries, Ecology of Food and Nutrition, 48: 263–284. 34 Ibid. 35 Grantham-McGregor, S. M., Powell, C. A., Walker, S. P., & Himes, J. H. (1991), Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study, The Lancet, 338(8758): 1–5. 36 Walker, S. P., Chang, S. M., Powell, C. A, et al. (2007), Early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation, J Nutr, 137(11): 2464–2469. 37 Handley et al. (2009), op. cit., nt.32. 38 McCoy, D. C., Peet, E. D., Ezzati, M., et al. (2016), Early Childhood Developmental Status in Lowand Middle-income Countries: National, Regional, and Global Prevalence Estimates Using Predictive Modeling, PLoS Med, 13(6): e1002034. Available at: https://doi.org/10.1371/journal.pmed.1002034. 39 UNICEF, WHO, & The World Bank Group (2017), Global Database on Child Growth and Malnutrition. Joint Child Malnutrition Estimates—Levels and Trends. Available at: www.who.int/nutgrowthdb/estimates 2016/en/.

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In addition to stunting, poor food security can affect children’s mental health through lack of specific micronutrients such as iron, zinc, Vitamin A, Vitamin D, Vitamin B12, folate, and iodine. These micronutrient deficiencies often occur together and more commonly amongst children under the age of five years.40 They can be associated with several medical complications and premature death.41 Iodine and iron deficiencies are also associated with developmental and mental health difficulties. Apart from classic cretinism associated with intrauterine iodine deficiency, children lacking iodine can show intellectual deficits without the other features of cretinism.42 Studies have also shown that chronic iron deficiency in the school age period is linked to more behavioural problems, poorer cognition, and school under-achievement.43 In addition to chronic under-nutrition, acute hunger is also associated with an adverse effect upon children’s mental health, both in the general population and amongst children with other vulnerabilities. A recent study of adolescent suicidal behaviour in 32 LMICs found an association between going to bed hungry and suicidal ideation, with the highest population attribution fraction of 6.4% found in the African region.44 A study of children orphaned by HIV/AIDS in Tanzania found that going to bed hungry was a predictor of anxiety and depressive symptoms over and above other factors associated with being an orphan.45

Recommendations Food security impacts upon children and young people’s mental health; hence implementing the strategies built into SDG2 is likely to result in improved child mental health. Given that one of the main mechanisms is insufficient intake of energy and micronutrients, policy actions should be aimed at increasing the quantity and quality of food available to children. Some of these strategies are discussed later in this chapter. However, studies also suggest that providing food alone may not be enough to mitigate the adverse mental health effect of under-nutrition on children unless this is paired with psychosocial intervention such as cognitive stimulation.46 The impact of food security on child mental health is also intertwined with other important non-biological parameters, such as social inequality. This, for example, may explain the practice

40 Saleem, A. F. & Bhutta, Z. A. (2015), Micronutrient Deficiencies in Children, World Rev Nutr Diet, 113: 147–151. Available at: doi.org/10.1159/000375276. 41 Stevens, G. A., Bennett, J. E., Hennocq, Q., et al. (2015), Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys, Lancet Glob Health, Sept, 3(9): e528–e536. Available at: doi. org/10.1016/S2214-109X(15)00039-X. 42 Delange, F. (2009), The Disorders Induced by Iodine Deficiency, Thyroid, 4(1): 107–128. The medical term ‘cretinism’ is used to describe the physical and neurodevelopmental consequences of children born to mothers who are iodine-deficient during pregnancy, the consequences of which include intellectual disability. 43 Grantham-McGregor, S. M. & Ani, C. (2001), A review of the effect of iron deficiency anaemia on child development and cognition, Journal of Nutrition, 131: 649S–668S. 44 McKinnon, B., Gariépy, G., Sentenac, M., & Elgar, F. J. (2016), Adolescent suicidal behaviours in 32 low- and middle-income countries, Bulletin of the World Health Organization, 94(5): 340–350F. Available at: doi.org/10.2471/BLT.15.163295. 45 Makame, V., Ani, C., & Grantham-McGregor, S. (2002), Psychosocial function of orphans in Tanzania, Acta Paediatrica, 91(4): 459–465. 46 See, e.g., Handley et al. (2009), op. cit., nt.32; Grantham-McGregor (1991), op. cit., nt.35.

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of preferential male feeding in some communities,47 even when food security for all the children is adequate. This suggests that wider social justice mechanisms are also required to ensure that not only is adequate food available, but that access to it is fair and equitable.48 This links to SDG5, the goal of which is to achieve gender equality and female empowerment.

Supplementation Where lack of food is the main reason for childhood under-nutrition, food supplementation is one option for meeting their nutritional needs. Schools provide a framework for universal nutritional supplementation. This can be offered in the form of school meals. The fact that most children in LMICs attend primary school49 makes this a potential mechanism for providing many children with both nutritional support and cognitive stimulation. However, universal school meals are very expensive and unaffordable by many LMICs. A cheaper alternative is to focus on children who are already undernourished or at risk of under-nutrition—although the recipients may feel stigmatised.

Fortification Micronutrient deficiencies can be mitigated more widely by way of food fortification. This can be done centrally by manufacturers of food widely consumed by children. The WHO recommends fortification of wheat and maize flour where possible.50 Central fortification of salt with iodine has been shown to be effective in reducing iodine deficiencies and the resulting neurodevelopmental consequences in children.51 However, universal fortification may not be of benefit to children whose parents are too poor to afford the fortified food, or who feed mainly from their own home-grown food. In such circumstances, targeted fortification could be pursued by providing the families with micronutrient powders (MNPs) such as ‘sprinkles’.52 Nonetheless, it is vital to note that universal or targeted fortification requires quality control to reduce the risk of side-effects and toxicity from overdose of nutrients such as iron.53 The risks can be further reduced by adhering to evidence-based fortification guidelines such as those issued by the WHO.54

47 Fledderjohann, J., Agrawal, S., Vellakkal, S., et al. (2014), Do Girls Have a Nutritional Disadvantage Compared with Boys? Statistical Models of Breastfeeding and Food Consumption Inequalities among Indian Siblings, PLoS ONE, 9(9): e107172. Available at: doi.org/10.1371/journal.pone.0107172. 48 Cluver at al. (2016), op. cit., nt.25. 49 The World Bank, Millennium Development Goals, GOAL 2: Achieve Universal Primary Education by 2015. Available at: www5.worldbank.org/mdgs/education.html. 50 WHO, Fortification of wheat and maize flours. Available at: www.who.int/elena/titles/guidance_ summaries/flour_fortification/en/. 51 UNICEF/WHO/The World Bank Group (2017), op. cit., nt.39. 52 Schauer, C. & Zlotkin, S. (2003), Home fortification with micronutrient sprinkles—a new approach for the prevention and treatment of nutritional anemias, Paediatrics & Child Health, 8(2): 87–90. 53 Pasricha, S., Drakesmith, H., Black, J., et al. (2013), Control of iron deficiency anaemia in low and middle-income countries, Blood. Available at: doi.org/10.1182/blood-2012-09-453522. 54 See, e.g., WHO (2016), Guideline: Use of Multiple Micronutrient Powders for Point-of-use Fortification of Foods Consumed by Infants and Young Children aged 6–23 Months and Children aged 2–12 Years (Geneva: WHO); Licence: CC BY-NC-SA 3.0 IGO; WHO (2016), Guideline: Fortification of Maize Flour and Corn Meal with Vitamins and Minerals (Geneva: WHO). Licence: CC BY-NC-SA 3.0 IGO.

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Other measures to reduce the risk of childhood under-nutrition and the consequent adverse impact on child mental health include promoting breast-feeding. Breast milk can provide all of a baby’s nutritional needs in the first six months, and meet half of the child’s needs up to the age of 12 months, and a third up to the age of two years.55

SDG3: Ensure healthy lives and promote well-being for all at all ages SDG3 focuses on health and includes specific targets for mental health (targets 3.4 and 3.5). There is a reciprocal relationship between mental and physical health. For example, young people with chronic medical conditions are at increased risk of anxiety and depression both in childhood and adulthood.56 On the other hand, mental disorders such as schizophrenia are associated with increased risk of metabolic disorders such as Type 2 diabetes mellitus—although some of the risk factors may relate to medication side-effects.57 In relation to children, acute medical conditions such as cerebral malaria, and chronic medical disorders such as haemoglobinopathies, are associated with increased risk of mental disorders. Other physical health conditions such as HIV/ AIDS, and injuries from war and road traffic accidents, are also associated with increased risk of childhood mental illness. These factors have obvious implications for LMICs, and are discussed further below. Children are at increased risk of cerebral malaria due to the shorter time they have had to acquire immunity against malaria.58 Up to 24% of children who survive cerebral malaria are at higher risk of long-lasting mental health problems.59 Even children with less severe malarial infections experience difficulties with attention, memory, language and spatial skills.60 Despite progress in many parts of the world to slow the spread of HIV/AIDs, this condition recorded the most significant increase in DALYs amongst 25 leading causes of DALYs in children between 1990 and 2005, and maintained its ranking in 2015.61 Although mortality from HIV/ AIDS has dramatically reduced due to the widespread availability of Highly Active Antiretroviral Therapy (HAART), the condition remains associated with increased risk of childhood mental disorders.62

55 WHO, Infant and Young Child Feeding (fact sheet). Available at: www.who.int/mediacentre/fact sheets/fs342/en/. 56 Secinti, E., Thompson, E. J., Richards, M., & Gaysina, D. (2017), Research review: childhood chronic physical illness and adult emotional health—a systematic review and meta-analysis, J Child Psychol Psychiatr, 58: 753–769. Available at: doi.org/10.1111/jcpp.12727. 57 De Hert, M., Schereurs, V., Vancamofort, D., & Van Winkel, R. (2009), Metabolic syndrome in people with schizophrenia: a review, World Psychiatry, 8(1): 15–22. For more discussion of the side-effects of medication, see Chapter 17 of this book by Peter Lehmann. 58 WHO (2018), Malaria in children under five, 26 Jan. Available at: www.who.int/malaria/areas/high_ risk_groups/children/en/. 59 Carter, J. A., Ross, A. J., Neville, B. G. R., et al. (2005), Developmental impairments following severe falciparum malaria in children, Tropical Medicine & International Health, 10: 3–10. Available at: doi.org/ 10.1111/j.1365-3156.2004.01345.x. 60 Kihara, M., Abubakar, A., & Newton C. R. J. C. (2014), ‘Cognitive Impairment and Behavioural Disturbances Following Malaria or HIV Infection in Childhood’, in M. Bentivoglio, E. Cavalheiro, K. Kristensson, & N. Patel (eds) (2014), Neglected Tropical Diseases and Conditions of the Nervous System (New York: Springer). 61 See The Global Burden of Disease Child and Adolescent Health Collaboration (2017), op. cit., nt.4. 62 Betancourt, T., Scorza, P., Kanyanganzi, F., et al. (2014), HIV and Child Mental Health: A Case-control Study in Rwanda, Pediatrics, 134(2): e464–e472. Available at: doi.org/10.1542/peds.2013-2734.

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Sickle Cell Disease (SCD) is the most common of the haemoglobinopathies.63 The condition affects mainly people of black African origin, but there are also areas of high prevalence in the Mediterranean region and parts of Asia. Whilst studies of the mental health of affected children who live in HICs show conflicting results, the two studies from Nigeria (the country with the highest prevalence of SCD in the world) both show a threefold increase in emotional and behavioural difficulties amongst affected children, compared with unaffected peers.64 Road traffic accidents (RTAs) are a major cause of death and disability amongst young people worldwide.65 RTAs and childhood mental health can have a bidirectional relationship. On the one hand, certain mental disorders which start in childhood (such as ADHD) increase the risk of the affected person being involved in RTAs due to lack of concentration and impulsive behaviour.66 On the other hand, RTAs are associated with risk of acquired brain injury which can manifest itself by cognitive dysfunction, personality change, impulsive and aggressive behaviour, and mood swings.67

Mental health interventions There are now many evidence-based interventions for CAMDs.68 These include a wide range of psychological and social interventions such as Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT), and Family Therapy, and medications such as antipsychotics, antidepressants, mood stabilisers, and stimulants (such as for ADHD).69 However, children and young people with CAMDs in LMICs have limited access to these interventions. The reasons for lack of access include the lack of locally adapted psychological interventions and/or the expertise to deliver them, the absence of relevant medications, and/or limited expertise in their prescription and monitoring. An inability to pay for medication and long travel distances to access centres where diagnosis and treatment could be provided also impede access to psychological interventions. Furthermore, when medications are accessible in some LMICs, the bio-availability is sometimes uncertain due to adulteration and poor quality control.70 Most evidence-based psychological interventions for CAMDs, such as CBT, were developed in HICs. However, the authors’ experience in Nigeria has been that, when appropriately adapted,

63 The Global Burden of Disease Child and Adolescent Health Collaboration (2017), op. cit., nt.4. 64 See, e.g., Bakare, M. O., Omigbodun, O. O., Kuteyi, O. B., et al. (2008), Psychological complications of childhood chronic physical illness in Nigerian children and their mothers: the implication for developing pediatric liaison services, Child and Adolescent Psychiatry and Mental Health, 2: 34. Available at: https://doi.org/10.1186/1753-2000-2-34; Iloeje, S. O. (1991), Psychiatric morbidity among children with sickle-cell disease, Dev Med Child Neurol, 33(12): 1087–1094. 65 The Global Burden of Disease Child and Adolescent Health Collaboration (2017), op. cit., nt.4. 66 WHO (2017), op. cit., nt.14. 67 Schretlen, D. J. & Shapiro, A. M. (2003), A quantitative review of the effects of traumatic brain injury on cognitive functioning, Int Rev Psychiatry, 15(4): 341–349. Available at: doi.org/10.1080/095402603 10001606728. 68 Rutter, M. & Stevenson, J. (2012), ‘Developments in Child and Adolescent Psychiatry over the last 50 years’, in M. Rutter, D. Bishop, D. Spine, et al. (eds), Rutter’s Child and Adolescent Psychiatry (5th edn) (Oxford: Wiley-Blackwell). 69 Although the nomenclature sounds counterintuitive, stimulants such as Methylphenidate are effective in reducing ADHD symptoms. 70 WHO (2005), Improving access and use of psychotropic medicines. WHO mental health policy and service guidance package—module 10. Available at: www.who.int/mental_health/policy/services/ essentialpackage1v10/en/.

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psychological interventions developed in HICs can be effective for children and young people in LMICs.71 Examples of crucial adaptions include the use of locally and culturally nuanced language, group-based formats to increase reach and cost-effectiveness, the inclusion of pre-existing helpful religious and cultural coping strategies, and delivery in settings such as school to improve access and reduce stigma.

Training The World Mental Health Atlas72 evidences extremely limited numbers of mental health professionals in LMICs compared with HICs. Many LMICs have less than one psychiatrist to a million population. The situation with CAMH is even more challenging, with many regions having no formal training programme to develop clinicians with expertise in this field. The situation is further worsened by the ‘brain drain’ of qualified mental health professionals from LMICs to HICs.73 It has been estimated that sub-Saharan African countries have lost US$2 billion-worth of training costs through migration of doctors from the region to HICs.74 In these circumstances, CAMH service provision based on models used in HICs is unlikely to be sustainable in LMICs. Thus, the WHO and others recommend task-shifting whereby other categories of workers who are more readily available are trained and supervised by more qualified professionals to provide frontline service delivery.75

Case study on training from Nigeria In 2011, the Centre for Child and Adolescent Mental Health (CCAMH) at the University of Ibadan, Nigeria, established the first post-graduate training in CAMH in West Africa. The programme set up an 18-month Master of Science Degree in CAMH (MSc. CAMH).76 The project was led by a multidisciplinary group from the University of Ibadan, supported by local and international collaborations. The latter included Imperial College London, Harvard Medical School (through the Children’s Hospital Global Partnerships in Psychiatry at

71 See, e.g., Bella-Awusah, T., Ani, C., Ajuwon, A., & Omigbodun, O. (2016), Effectiveness of brief schoolbased, group cognitive behavioural therapy for depressed adolescents in South West Nigeria, Child and Adolescent Mental Health, 21: 44–50; Abdulmalik, J., Ani, C., Ajuwon, A., & Omigbodun, O. (2016), Effects of problem-solving skills for aggressive primary school children in Ibadan Nigeria, Child and Adolescent Psychiatry and Mental Health, 10(1): 31. Available at: doi.org/10.1186/s13034-016-0116-5. See also Adeniyi, Y. C. & Omigbodun, O. O. (2016), Effect of a classroom-based intervention on the social skills of pupils with intellectual disability in Southwest Nigeria, Journal of Child and Adolescent Psychiatry and Mental Health, 10(29): 1–12; and Bello-Mojeed, M., Ani, C., Lagunju, I., & Omigbodun, O. (2016), Feasibility of parent-mediated behavioural intervention for behavioural problems in children with Autism Spectrum Disorder in Nigeria: a pilot study, Child and Adolescent Psychiatry and Mental Health, 10(1): 28. Available at: doi.org/10.1186/s13034-016-0117-4. 72 WHO (2015), Mental Health Atlas 2014. Available at: www.who.int/mental_health/evidence/atlas/ mental_health_atlas_2014/en/. 73 For more on this, see Chapter 2 by Lawrence O. Gostin and Laura Davidson. 74 Mills, E., Kanters, S., Hagopian, A., et al. (2011), The financial cost of doctors emigrating from subSaharan Africa: human capital analysis, BMJ, 343. Available at: doi.org/10.1136/bmj.d7031. 75 For more on task-shifting, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, Chapter 4 by Judith Bass, Chapter 5 by Chris Underhill, Victoria K. Ngo, and Tam Nguyen, and in the context of geriatric mental health, Chapter 12 by Stephen J. Bartels. 76 Supported by a grant from the John D. and Catherine T. MacArthur Foundation.

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Children’s Hospital Boston), and Sangath, in Goa, India. Many of the international faculty were originally from Nigeria and so familiar with the nuances of the local culture, teaching, and medical ecology. To promote programme sustainability, topics were jointly taught and assessed by overseas-based and Nigeria-based faculty members over many years. Students gain both theoretical and clinical experiences in CAMH, including regular supervised exposure to practice in the CAMH and paediatric clinics. Each student receives a period of supervised individual psychological intervention with a child or adolescent with mental disorder. Fieldwork is undertaken in residential special schools, and a residential facility for homeless children and/ or those remanded by the criminal justice system. Students who have prescribing authorisation in their own countries receive in-depth exposure to psychopharmacology relevant to CAMH. The development of leadership skills is infused into the programme so that graduates can implement task-shifting. Thus far, 72 students have graduated from the programme from nine different African countries including Gambia, Liberia, Sierra Leone, Ghana, Kenya, Eritrea, Zambia, Zimbabwe, and Nigeria. In addition to clinical and leadership training, the Masters programme offers high-level research training, with each student completing a project publishable in peer reviewed journals, with 12 such publications to date. In 2016, the programme established a shorter 12-month Postgraduate Diploma course in CAMH,77 with the first four diploma students graduating in 2017.

Recommendations Given the direct link between many acute and chronic medical conditions and poor mental health amongst children and adolescents, efforts to prevent some of these medical conditions are highly recommended. Universal childhood immunisations can prevent some infections such as measles which can have mental health complications such as encephalitis. Other strategies to prevent malaria and reduce the risk of cerebral malaria are also crucial. The progress made in limiting the spread of HIV/AIDS needs to be sustained, in addition to the availability of HAART for those who need it. Prevention of RTAs is crucial and will require multi-level interventions78 that include road and vehicle safety measures, and treatment of children and adults with ADHD. Improving manpower resources requires widened training opportunities, as well as incentives to prevent professionals migrating to HICs and to encourage those who have migrated to return. Some LMICs such as the Philippines have implemented forms of ‘bonding contracts’ requiring health professionals to work a certain number of years in their home country before being allowed to emigrate.79 Although such policies have been criticised as unfair because other professional groups are exempt, this approach deserves some consideration. It has the potential to benefit patients, and could be seen as a fair return if the doctors’ training was funded by public taxation. In addition, CAMH will need to be integrated into primary care and to include schools in order to improve access. School-based interventions have the additional advantage of being less

77 PgDip.CAMH. 78 Staton, C., Vissoci, J., Gong, E., et al. (2016), Road Traffic Injury Prevention Initiatives: A Systematic Review and Metasummary of Effectiveness in Low and Middle Income Countries, PLoS ONE, 11(1): e0144971. Available at: doi.org/10.1371/journal.pone.0144971. 79 Dussault, G. & Franceschini, M. C. (2006), Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce, Human Resources for Health, 4: 12. Available at: doi.org/10.1186/1478-4491-4-12

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stigmatising compared with psychiatric clinics. Further, once capacity for diagnosis and treatment has improved, access to essential psychiatric medications will become crucial. However, unfortunately the WHO failed to include specific medication for ADHD in the 2017 WHO Essential Drugs List,80 which might have led to increased availability. Furthermore, despite good evidence that methylphenidate is a relatively cheap and highly effective intervention for ADHD that can reduce educational failure and accidents,81 access to this medication is still very limited in many LMICs. Thus, governments themselves must take the lead to ensure that crucial medications used for treating the most common and/or severe CAMDs are on the Essential Drug List and available to front-line CAMH clinicians in their respective countries. There is also a need to adapt evidence-based psychological interventions in LMICs further, taking into account the varying cultural, and socio-economic realities of the populations. Adapted interventions with good efficacy and proven cost-effectiveness should be supported by governments and scaled up for wider reach. Mental health remains highly stigmatising worldwide, but particularly in many LMICs, so access to support and treatment may still be limited even in the face of improved service provision unless simultaneous strategies are introduced to tackle stigma. Examples might include delivery of mental health interventions in schools using non-mental health professionals such as school counsellors and teachers, and stigma-reducing educational classes, both of which have been found to be effective.82 Finally, the need for out-of-pocket expenses to access CAMH assessment and/or treatment is likely to limit access significantly, especially for the most vulnerable families in LMICs. Help-seeking in these settings is already cost-laden as parents have to miss paid work and spend money on transport to facilitate the child’s attendance at a health facility. To add extra expense for assessment and/or medications would make access beyond the reach of vast members of the population in LMICs. Therefore, policies to reduce the cost of access, such as the ring-fencing of budget and development aid to fund or subsidise CAMH, are crucial.

SDG4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Education is one of the most effective population-wide measures that can improve CAMH even more than direct health intervention.83 Every extra year spent in education after the age of 12 is associated with reduced risk of mortality for both males and females, and less teenage pregnancy.84 In particular, educating girls can yield huge intergenerational advantages.85

80 WHO, Essential medicines and health products; WHO Model Lists of Essential Medicines. Available at: www.who.int/medicines/publications/essentialmedicines/en/. 81 Chang, Z., Lichtenstein, P., D’Onofrio, B. M., et al. (2014), Serious Transport Accidents in Adults With Attention-Deficit/Hyperactivity Disorder and the Effect of Medication: A Population-based Study, JAMA Psychiatry, 71(3): 319–325. Available at: doi.org/10.1001/jamapsychiatry.2013.4174. 82 See, e.g., Bella-Awusah, T., Adedokun, B., Dogra, N., & Omigbodun, O. (2014), The impact of a mental health teaching programme on rural and urban secondary school students’ perceptions of mental illness in southwest Nigeria, Journal of Child and Adolescent Mental Health, 26(3): 207–215; Oduguwa, A., Adedokun, B., & Omigbodun O. (2017), Effect of a mental health-training programme on Nigerian school pupils’ perception of mental illness, Journal of Child and Adolescent Psychiatry and Mental Health, 11(19): 1–10. 83 Adeniyi et al. (2011), op. cit., nt.12. 84 Ibid. 85 Ibid.

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Despite these potential advantages of education, and evidence of improving enrolment, 61 million children of primary school age were out of school in 2014.86 The situation is more difficult for girls in LMICs who are 100 times less likely than boys to be enrolled in schools.87 The mix of female gender and severe poverty carries a particularly high vulnerability regarding education. For example, a study in South Africa found that girls living in severe poverty were more likely to drop out of education.88 This suggests that even when education is free, girls living in severe poverty may not be able access it as, instead, they may have to engage in incomegenerating activities to meet more immediate pressing needs for themselves and their families. Another group with limited education enrolment in LMICs are children with disabilities, 98% of whom are not enrolled in schools.89 The reciprocal interaction between education and CAMH is exemplified by the fact that mental illness is a significant cause of poor school achievement and drop-out. Mental disorders such as ADHD can directly impair concentration and result in educational failure. On the other hand, the hyperactivity and impulsivity associated with ADHD can cause classroom management difficulties resulting in school exclusion. In addition to their primary role of offering education, schools can offer advantages as sites for the delivery of CAMH services. Children accessing CAMH interventions in school do not have to incur extra travel costs to visit a clinic for similar intervention, and their parents need not take time off work to accompany them to clinic, thereby losing income. Also, school mental health intervention may be less stigmatising, compared with visiting a psychiatric clinic.90

Recommendations Governments in LMICs should prioritise equitable and inclusive access to education for all children. Specific promotion of female education is important due to the positive multiplier and intergenerational advantages. Given the inhibiting effect of poverty on school enrolment, especially for girls, additional social and economic support such as stipend or other forms of cash transfer may be required (as well as free education) in order to sustain enrolment and prevent drop-out. In addition to girls, special attention is required to promote educational access by other vulnerable children, including those with disabilities. Finally, in light of the reciprocal relationship between education and health and the interfaces between these and other important macro and meso-level socio-economic and cultural influences, an integrated multi-sectoral, and multi-agency approach is required in each country and region to maximise the benefits of education on young peoples’ mental health.

86 Sustainable Development Knowledge Platform, Sustainable Development Goal 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all. Available at: sustainabledevelopment.un.org/sdg4. 87 See Grantham-McGregor & Ani (2001), op. cit., nt.43. 88 Cluver et al. (2016), op. cit., nt.25. 89 UNESCO Policy Brief on Early Childhood, Inclusion of Children with Disabilities: The Early Childhood Imperative. Available at: unesdoc.unesco.org/images/0018/001831/183156e.pdf. 90 WHO (1997), Promoting Health through Schools. Report of a WHO Expert Committee on Comprehensive School Health Education and Promotion, Technical Report Series 870 (Geneva: WHO).

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SDG5: Achieve gender equality and empower all women and girls Young females are much more likely to experience emotional difficulties and self-harm than boys of the same age in both HICs and LMICs.91 Similarly, the prevalence of depression is higher amongst adolescent girls compared with boys.92 Whilst there are putative biological contributory factors to this excess prevalence, it is also likely that many socio-cultural and economic factors are involved.93 One possible factor is gender inequality.94 As already outlined, gender inequality and female discrimination interface with other SDGs including poverty (SDG1), nutrition (SDG3) and education (SDG4)—all of which are also interrelated with CAMH. Male preference is still a factor in many LMICs, with major consequences for females that include, in severe cases, infanticide.95 Young girls in LMICs are disproportionately impacted by poverty. In some LMICs, boys may be preferentially fed over girls.96 Even when education is free, girls may not be able to access it due to poverty which requires them to take on caring or income-generating activities to support the family. In some cases, cultural and/or religious beliefs may hinder girls’ access to education compared with boys. The adverse impact of lack of education on mental health has already been explored in this chapter. The mental health of female children and adolescents is further threatened by gender-based violence. An international review estimates that, globally, up to 46% of girls experience physical dating violence in adolescence.97 Girls exposed to physical and/or sexual violence are at increased risk of not only post-traumatic stress disorder (PTSD), but also anxiety, depression, self-harm, and suicidal behaviour.98 Evidence from some regions in LMICs such as the state of Kerala in India shows that promoting gender equity through public policy can produce clear positive outcomes for girls resulting in the highest female literacy rate and lowest maternal mortality rates of all states in India.99

Recommendations Gender inequality is associated with so many risk factors for adverse CAMH amongst female children and adolescents that concerted efforts are required in all countries to address this

91 World Psychiatric Association, WHO, & International Association for Child and Adolescent Psychiatry and Allied Professions (2005), op. cit., nt.21. 92 Wade, T. J., Cairney, J., & Pevalin, D. J. (2002), Emergence of gender differences in depression during adolescence: national panel results from three countries, Journal of the American Academy of Child and Adolescent Psychiatry, 41: 190–198. 93 Kuehner, C. (2003), Gender differences in unipolar depression: an update of epidemiological findings and possible explanations, Acta Psychiatr Scand, 108(3): 163–174. 94 Piccinelli, M. & Wilkinson, G. (2000), Gender differences in depression: critical review, Br J Psychiatry, 177: 486–492. 95 Fuse, K. & Crenshaw, E. M. (2006), Gender imbalance in infant mortality: a cross-national study of social structure and female infanticide, Soc Sci Med, 62(2): 360–374. 96 Fledderjohann, J., Agrawal, S., Vellakkal, S., et al. (2014), Do Girls Have a Nutritional Disadvantage Compared with Boys? Statistical Models of Breastfeeding and Food Consumption Inequalities among Indian Siblings, PLoS ONE, 9(9): e107172. Available at: doi.org/10.1371/journal.pone.0107172. 97 Leen, E., Sorbring, E., Mawer, M., et al. (2013), Prevalence, dynamic risk factors and the efficacy of primary interventions for adolescent dating violence: an international review, Aggression and Violent Behavior, 18(1): 159–174. 98 For more on this topic, see Chapter 8 of this book by Carol Vlassoff. 99 Sanneving, L., Trygg, N., Saxena, D., et al. (2013), Inequity in India: the case of maternal and reproductive health, Global Health Action, 6: 10.3402/gha.v6i0.19145. Available at: doi.org/10.3402/gha.v6i0.19145.

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challenge. Whilst progress is being made in some areas (such as reducing rates of child marriage), the situation is worsening in others, such as gender-based violence. Public education is essential to address cultural and religious practices promoting gender inequality. However, legislative processes are also required to ensure the adoption of such changes. Kerala state in India presents a good example of government programmes to promote gender equality and the transformative impact on the wellbeing of girls.100

SDG16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels The first two targets of SDG16 are to reduce all forms of violence (target 16.1), and end abuse, exploitation, trafficking and all forms of violence against and torture of children (target 16.2). Large numbers of children and young people in LMICs are exposed to a wide range of individual and community level violence. Children experience individual violence at home, in schools, in their local communities, and over the internet. Unfortunately, children can experience harsh physical discipline, emotional and psychological abuse, and sexual abuse at home or at school. In relation to physical discipline, parents and teachers may be using it, in good faith, to manage a child’s defiant behaviour. However, this practice can be psychologically harmful to the children. Whilst studies show cultural variations in the impact of physical discipline on children’s mental health, it is generally accepted that harsh and severe corporal punishment is harmful to children’s wellbeing in all cultures; hence better avoided.101 Many studies in HICs have demonstrated effective non-physical disciplinary methods, and evidence for similar strategies in LIMCs is starting to emerge.102 The internet is a relatively new, but rapidly expanding, source of violence against children and young people. Internet harm on children can take the form of cyber-bullying or sexual exploitation. Social media present a particularly risky platform for vulnerable children. The risk of online violence arising from social media is increased where children have their own private internet-enabled devices, which reduces the opportunity for parental supervision. Thus, children now are more likely to be exposed to unedited and unfiltered graphic images sent directly to their online devices, with risk of vicarious trauma. Although this may be less likely in LMICs due to lower internet access, the risk is likely to increase over time. All these forms of violence are associated with increased risk of child and adolescent mental illnesses. Children and young people are increasingly being exposed to various forms of community violence. These range from bullying by peers and gang-related activities to more extreme

100 Bhutta, Z., Nundy, S., & Abbasi, K. (2004), Is there hope for South Asia? Yes, if we can replicate the models of Kerala and Sri Lanka, British Medical Journal, 328(7443): 777–778. 101 Lansford, J. E., Chang, L., Dodge, K. A., et al. (2005), Physical Discipline and Children’s Adjustment: Cultural Normativeness as a Moderator, Child Development, 76(6): 1234–1246. Available at: doi. org/10.1111/j.1467-8624.2005.00847.x. 102 See, e.g., Furlong, M., McGilloway, S., Bywater, T., et al. (2013), Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Review), Evid Based Child Health, 7 Mar, 8(2): 318–692. Available at: doi. org/10.1002/ebch.1905; Mejia, A., Calam, R., & Sanders, M. R. (2012), A Review of Parenting Programs in Developing Countries: Opportunities and Challenges for Preventing Emotional and Behavioral Difficulties in Children, Clin Child Fam Psychol Rev, 15: 163–175. Available at: doi.org/10.1007/ s10567-012-0116-9.

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violence due to military conflicts and terrorist activities. The vast majority of wars since 1950 have been in LMICs.103 Some young people are abducted and forced to become child soldiers, or are forced into marriage with soldiers, which can result in significant post-conflict mental health difficulties.104 The child mental health impact of war and community violence is wide-ranging and includes PTSD, anxiety, depression, and regressive behaviours. The loss of education, reduced access to health care, and safe recreational opportunities engendered by large-scale conflicts adversely affects children’s short- and long-term development.105

Recommendations Protecting children from violence requires a multi-layered ecological approach that includes measures at the family, school, and wider community levels. Children’s experience of violence in the home or school in the form of physical discipline could be reduced by educating the adults on alternative and effective non-physical disciplinary strategies and on the risks and negative impacts associated with physical chastisement. Legislation already exists in most jurisdictions against serious violence towards children, although enforcement is sometimes questionable. Other newer forms of violent crimes against children, such as internet-based violence, may require new or updated legislation, coupled with robust enforcement.

The need for an integrated approach It is clear that multiple factors influence the onset, course and resolution of CAMDs. These factors map onto several SDGs, as this chapter has shown. Accordingly, an integrated multiagency approach with close partnerships targeting multiple layers simultaneously is required if the SDGs are to be used as a catalyst for supporting the prevention and treatment of CAMH in LMICs. One South African study106 illustrates this need for a multi-layered and multipronged approach by examining the impact of social protective interventions on the wellbeing of young people in South Africa. In this study, social protection included economic support such as cash and asset transfers, and psychosocial support. The social protective activities map across many SDGs including poverty (SDG1), hunger (SDG2), mental health (SDG3), educational access (SDG4), sexual exploitation (SDG5), and violence (SDG16). The study showed that the social protective interventions were associated with improvements across many SDGs. However, the researchers also make the wider point that even one multi-layered intervention such as social protection may not be enough to meet children’s health and developmental goals in LMICs. For example, the mental health of girls in the study was not significantly improved by the social protective measures, which suggests that additional measures—and/or research—are required.

103 Max Roser (2016), War and Peace. Available at: ourworldindata.org/war-and-peace/. 104 Betancourt, T. S., Brennan, R. T., Rubin-Smith, J., et al. (2010), Sierra Leone’s former child soldiers: a longitudinal study of risk, protective factors, and mental health, Journal of the American Academy of Child and Adolescent Psychiatry, 49(6): 606–615. Available at: doi.org/10.1016/j.jaac.2010.03.008. 105 For more on the effect of war on the mental health of child soldiers see Chapter 22 of this book by Salam A. Gómez. 106 Cluver et al. (2016), op. cit., nt.25.

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Resource limitations in LMICs make integrated approaches particularly important as they can be more cost-effective. Another example is the potential multiple roles that schools can play in supporting young people. Not only do schools provide education, which is crucial for human development and mental health, but they can also serve as a venue for mental health prevention, identification, and targeted intervention. Based on the principle of task-shifting, teachers and school counsellors could be up-skilled to support the delivery of mental health interventions. In addition, for children with mental disorders such as autism and intellectual disability, and who can have very high care needs, schooling can provided much needed respite for parents. This may help reduce the prevalence of parental physical abuse arising from frustration and an inability to cope. Also, schools can be venues for support groups, as parental peer-to-peer support can be crucial in these cases. Given that traditional and faith healers are often the first sources of help that families in LMICs approach for CAMDs, a pragmatic engagement with these important members of the local health ecology is essential. The goal of the engagement could include supporting the traditional healers to improve case identification, enhancing their own practice such as better provision of emotional support to CAMDs, eradicating harmful practices such as female genital mutilation cutting (FGM/C) and scarification marks, and agreeing to referral pathways for severe cases such as psychosis.107 Whilst the SDGs provide important impetus for promoting CAMH, further advantage can be gained by drawing synergy between the SDGs and other international frameworks that also promote CAMH. Examples include the WHO Mental Health Action Plan (2013–2020)108 and the United Nations Convention on the Rights of the Child 1989.109 The objectives of the former include the provision of comprehensive community-based integrated mental health and social care services, and the implementation of strategies to promote mental health and prevent the onset of mental disorders. The Convention on the Rights of the Child has clearly stated rights relating to mental health such as, for example, the right to the best possible health and education, and protection from violence and abuse.

Conclusion CAMDs are common in all countries and are associated with increased mortality from suicide and accidents, and considerable morbidity and suffering. In LMICs, many bio-environmental, cultural and political factors linked with several SDGs militate against CAMH, including poverty, under-nutrition, poor education, gender inequality, and violence. Concerted multi-sectoral programmes cutting across these SDGs are required to mitigate the adverse effects on CAMH. The SDGs also provide a framework for developing or adapting evidence-based interventions to help children already affected by CAMDs. Investment in intervention programmes is often driven by evidence, based on efficacy, costeffectiveness and acceptability. Many CAMH interventions developed in HICs meet these

107 Ae-Ngibise, K., Cooper, S., Adiibokah, E., et al. (2010), ‘Whether you like it or not people with mental problems are going to go to them’: a qualitative exploration into the widespread use of traditional and faith healers in the provision of mental health care in Ghana, International Review of Psychiatry, 22: 558–567. 108 WHO (2013), Mental health action plan 2013–2020. Available at: www.who.int/mental_health/ publications/action_plan/en/. 109 The United Nations Convention on the Rights of the Child (signed on 20 Nov 1989, and in force on 2 Sept 1990). Available at: www.unicef.org.uk/what-we-do/un-convention-child-rights/.

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criteria, but their evidence base in LMICs is not as good. It is therefore crucial to support research aimed at adapting existing evidence-based interventions to the local realities in LMICs. Due to severe shortages in professionals with CAMH skills, the vast majority of CAMDs in LMICs are not diagnosed, and so children in need do not receive any formal evidence-based intervention. Manpower development requires building specialist CAMH expertise for some staff who can train and supervise others. Incentives are required to prevent locally trained specialist staff leaving for better paid jobs in HICs. Supporting most children with mental disorders in LMICs requires integration with primary care through task-shifting, and involvement of other professionals with experience of working with children, such as teachers and school counsellors. Building pragmatic alliances with traditional and faith healers is also important. Finally, whilst CAMH can be promoted by judicious application of each SDG discussed in this chapter, ultimately the actual implementation depends very much on having stable societies governed by the rule of law, justice and human rights. Wars and other forms of organised violence cause such dislocation of all the societal frameworks that support promotion of CAMH in LMICs that pursuit of peace and respect for human rights addressed by SDG16 could arguably be the most important overarching determinant of CAMH in LMICs.

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12 THE GLOBAL CHALLENGE OF MENTAL HEALTH AND AGEING, AND SCALABLE INNOVATIONS IN MENTAL HEALTH SERVICES FOR OLDER ADULTS Stephen J. Bartels* Introduction Between 2015 and 2050 the World Health Organization estimates that the world’s population of adults aged 60 and older will almost double from 12% to 22%—an absolute increase from 900 million to approximately 2 billion.1 Increasing life expectancy across the globe due to improvements in basic public health measures have spawned a new era for older adults who can now expect to live longer and pursue a common goal of ‘ageing in community’. However, a paradoxical downside of this increase in longevity is the rapidly growing burden of an older population with complex health and long-term care needs associated with escalating costs, potentially threatening the viability and financial sustainability of health care systems across the world. In the absence of developing affordable and sustainable innovative approaches to the challenge of an ageing population, regional economies are at risk of diverting core resources away from other pressing needs such as preventive, medical, behavioural, and substance abuse services for young adults, as well as investments in education, and regional infrastructure. This demographic challenge disproportionately affects low-income countries. The proportion of older adults living in low and middle-income countries (LMICs) is estimated to increase from 65% in 2015, to 71% in 2030 and 76% in 2050.2 Health care systems around the world are unprepared for the workforce challenges of caring for this ageing demographic, as the number of adults who are of employment age is also falling, reducing both the numbers

* Stephen J. Bartels is the Herman O. West Professor of Geriatrics and Professor of Psychiatry, Community and Family Medicine, and of Health Policy at the Geisel school of Medicine at Dartmouth College, USA. 1 WHO (2017), Mental health of older adults (fact sheet). Available at: www.who.int/mediacentre/ factsheets/fs381/en/. 2 Prince, M., Wimo, A., Guerchet, M., et al. (2015), The Global Impact of Dementia: An Analysis of Prevalence, Incidence, Cost and Trends (London: Alzheimer’s Disease International). Available at: www.alz.co.uk/ research/world-report-2015.

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of available caregivers, and the revenue needed to support ageing health and social services. Further complicating this picture is the growing number of older adults living alone, with the waning of traditional configurations in which extended, multi-generation family caregivers could be relied on to provide family-based, long-term care to parents and grandparents. This chapter will highlight how the increasing demand for mental health services for the elderly will dramatically outstrip capacity, and consider how states worldwide might create innovative and unconventional solutions to service provision in order to plug the gap and meet their obligations under the UN Sustainable Development Goals (SDGs), and particularly SDG3 relating to health and wellbeing.

The challenge and impact of common mental health disorders in older adults Approximately 20% of adults aged 60 and older suffer from a mental disorder, accounting for 6.6% of total disability and over 17 years of disability for this age group. This changing demographic will substantially challenge health and social services due to a dramatic workforce shortfall and a lack of appropriate services to address the mental health and medical needs of this high-risk population. Estimates of the worldwide prevalence of major mental disorders in adults aged 60 and older include dementia (5%) depression (7%) anxiety disorders (4%) and substance abuse (1%). Under-detection and under-diagnosis is common.3 Psychiatric disorders are often obscured due to the presence of comorbid chronic health conditions, misattribution of mental health symptoms to physical disorders, and the inaccurate perspective that mental disorders are a ‘normal’ consequence of ageing. The picture is further complicated by under-reporting of mental health symptoms by older adults due to stigma.4 Older adults experience additional challenges compared with younger adults, making them vulnerable to depression and anxiety disorders. Age-related physical limitations or loss of independence, mobility, vision, hearing, or cognitive capability are associated with increased risk of depression, anxiety disorders, and other mental health conditions. The impact of mental health conditions in older adults is often compounded by the common presence of chronic health conditions and the interaction between physical and mental health.5 For example, chronic health conditions that are associated with impaired functioning, chronic pain, and physical symptoms can worsen the course and severity of a mental health condition. Conversely, mental illness can worsen the outcomes of common disorders such as heart disease, diabetes, and cancer. The interaction between physical and mental health in older adults is a common dynamic that adds to the social, economic, and overall health burden of mental disorders. Finally, older adults have the highest suicide rate of any age group. For example, in the United States, over 6,000 older adults take their lives each year, with the highest rate represented by

3 WHO (2017), op. cit., nt.1. 4 See e.g., J. Eden, K. Maslow, M. Le, & D. Blazer (eds) (2012), The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Committee on the Mental Health Workforce for Geriatric Populations, Board on Health Care Services, Institute of Medicine (Washington, DC: National Academies Press US); and Bharadwaj, P., Pai, M. M., & Suziedelyte, A. (2015),‘Mental health stigma’, National Bureau of Economic Research Working Paper 21240. Available at: www.nber.org/papers/w21240. 5 For more on the relationship between physical and mental health, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson.

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white males over the age of 85 with 51.4 deaths by suicide per 100,000.6 In China, where suicides constitute one-fifth of all recorded suicides in the world, adults over age 65 have a suicide rate ranging from 44–200 per 100,000—four to five times greater than the general population.7 A comparison of the characteristics amongst older adults who died by suicide in Australia found that suicide in the ‘young’ old (age 65–74) is more likely to be associated with legal, financial, and relationship stressors, whereas suicide in the ‘oldest’ old (85 and older) is more likely to be associated with declining physical health and bereavement.8 SDG target 3.4 requires states, by 2030, to ‘reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’, including through indicator 3.4.2—the suicide mortality rate. A substantial body of worldwide research identifies five primary domains associated with increased risk of suicide in older adults: psychiatric illness, personality traits and coping styles, medical illness, life stressors and social disconnectedness, and functional impairment.9 In contrast to young adults, older adults are more likely to experience the loss of spouses, siblings, and friends, potentially triggering prolonged bereavement and increased risk of depression, substance use disorders, and suicide. Loss of valued work and socially related roles, and declining ability to participate in leisure activities, are additional age-related stressors. Age-related sensory, mobility, and functional limitations also contribute to an increased risk of social isolation and declining social support, setting the stage for greater vulnerability to mental illness. In summary, no single factor has been identified to account for the disproportionately high rate of suicide in older adults across the globe. However, it is noteworthy that there are some isolated exceptions. In some indigenous cultures, rates amongst older adults are relatively low compared with younger adults, suggesting that factors associated with traditional cultural structures and support may serve as potential protective factors.10 This is worth further research, given that states must consider what policy changes they need to make in order to ensure that they meet SDG3 ‘for all at all ages’.

The emerging challenge of ageing adults with serious mental illness The ageing of the population is also resulting in an unprecedented increase in the number of older adults with ‘serious’ or ‘severe’ mental illnesses (SMI) such as schizophrenia, schizoaffective disorder, and bipolar disorder. Across all age groups, it is estimated that over three-quarters of people with serious mental illness in LMICs and approximately half in high-income countries

6 Conwell, Y. (2014), Suicide later in life: challenges and priorities for prevention, American Journal of Preventive Medicine, 47(3): S244. 7 Dong, X., Chang, E. S., Zeng, P., et al. (2015), Suicide in the Global Chinese Aging Population: A Review of Risk and Protective Factors, Consequences, and Interventions, Aging and Disease, 6(2): 121–130. 8 Koo, Y. W., Kolves, K., & De Leo, D. (2017), Suicide in older adults: a comparison with middle-aged adults using the Queensland Suicide Register, International Psychogeriatrics, 29(3): 419–430. 9 See, e.g., Conwell (2014), op. cit., nt.6; Sachs-Ericsson, N., Van Orden, K., & Zarit, S. (2016), Suicide and aging: special issue, Aging & Mental Health, 20(2): 110–112; Stanley, I. H., Hom, M. A., Rogers, M. L., et al. (2016), Understanding suicide among older adults: a review of psychological and sociological theories of suicide, Aging & Mental Health, 20(2): 113–122. 10 Hunter, E. & Harvey, D. (2002), Indigenous suicide in Australia, New Zealand, Canada, and the United States, Emergency Medicine, 14(1): 14–23.

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receive no treatment for their mental illness.11 The health care workforce is particularly unprepared to address the special needs of this complex population. In addition to experiencing substantial challenges in independent functioning, middle aged and older adults with serious mental illness experience a significant health disparity with respect to reduced life expectancy. Whilst life expectancy for the general population has increased in the majority of countries across the globe, it has decreased for those with a serious mental illness (SMI).12 The life expectancy of people with SMI such as schizophrenia, bipolar disorder, or chronic depression is an alarming 11 to 30 years less than that of the general population.13 A meta-analysis consisting of 203 studies conducted in 29 countries determined that people with mental illness have a mortality rate that is 2.22 times higher than the general population without mental disorders. Two-thirds of these deaths were due to natural causes and a median ten years of life lost, accounting for 14.3% of deaths worldwide.14 Major causes of early mortality for this high-risk group include cardiovascular disease (associated with high rates of obesity), diabetes, and hypertension, with increased levels of sedentary behaviour, poor nutrition, and tobacco use evident.15 SMI is not only devastating for individuals and families through its impact on functioning, productivity, and early mortality, but it also exerts a considerable burden on national economies. For example, in high-income countries such as the US, people with SMI (including older adults) have aggregate health care costs that are two to three times greater than those of people with physical illness alone.16 The ageing of this subgroup is likely to overwhelm mental health and primary care services that lack the capacity, competency, and services required to meet the special needs of this rapidly growing group with unique psychiatric and medical care needs.

The global dementia epidemic Global ageing will also dramatically increase the burden of providing care to adults with dementia. In aggregate, the total number of people with dementia is projected to increase from 46.8 million people worldwide in 2015, almost doubling every 20 years, to 74.7 million in 2030 and 131.5 million in 2050.17 Much of this increase is attributable to an increase in the number of those with dementia in LMICs: in 2015, 58% of all people with dementia lived in LMICs, which is projected to rise to 63% in 2030 and 68% in 2050.18 Dementia and cognitive impairment are

11 See, e.g., Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., et al. (2007), Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys, The Lancet, 370(9590): 841–850. 12 Saha, S., Chant, D., & McGrath, J. (2007), A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time?, Arch Gen Psychiatry, 64(10): 1123–1131. 13 See, e.g., De Hert, M., Correll, C. U., Bobes, J., et al. (2011), Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care, World Psychiatry, 10(1): 52–77; Druss, B. G., Zhao, L., Von Esenwein, S., et al. (2011), Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey, Med Care, 49(6): 599–560. 14 Walker, E. R., McGee, R. E., & Druss, B. G. (2015), Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis, JAMA Psychiat, 72(4): 334–341. 15 See, e.g., Druss et al. (2011), op. cit., nt.13. 16 Bartels, S. J., Clark, R. E., Peacock, W. J., et al. (2003), Medicare and medicaid costs for schizophrenia patients by age cohort compared with costs for depression, dementia, and medically ill patients, Am J Geriatr Psychiatry, 11(6): 648–657. 17 Prince et al. (2015), op. cit., nt.2. 18 Ibid.

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the leading contributors of disability and dependence on care amongst older people worldwide. The global burden of Alzheimer’s disease alone will substantially challenge health care economies with respect to caregiving, long-term care and social costs. The worldwide costs of dementia have increased from US$604 billion in 2010 to US$818 billion in 2015; an increase of 35.4%, representing 1.09% of global GDP—with future projections amounting to approximately US$1 trillion in 2018 and US$2 trillion in 2030.19

The growing shortfall in the mental health and ageing service workforce The increasing demand for mental health services for older adults will dramatically outstrip capacity, requiring innovative and unconventional solutions to service provision around the globe. The World Health Organization Mental Health Atlas 2014 dramatically illustrates the profound gap per capita in expenditure for mental health services in LMICs which make up 80% to 90% of the world’s population (US$1.53) compared with high income countries (US$58.73). With respect to outcomes and provision of basic mental health services, the gap is especially alarming. Over 95% of individuals in LMICs fail to receive minimally adequate treatment for depression, compared with over 75% of those in high income countries. Outside of highincome countries, psychiatrists, psychologists, and social workers are almost non-existent. Indeed, the World Health Organization estimates that there is a shortage of over 4.5 million mental health clinicians across the globe, which is mostly concentrated in 57 of the world’s poorest countries.20 In addition to the impact on health care services and costs, there are substantial indirect costs associated with caregiving, in conjunction with impact on the mental health and wellbeing of caregivers. For example, caregivers of people with chronic health conditions and Alzheimer’s disease have higher rates of depression, substance use disorder, and stress-related health conditions such as hypertension and cardiovascular disease. Caregiving is also associated with absenteeism and lost days at work, as well as significant economic hardships for families.21 With the related ageing of the health care workforce, there is an inadequate capacity to provide needed health care and social support services to this rapidly growing population. The global challenge of addressing the mental health needs of older adults might be described as a ‘perfect storm’ disproportionately affecting LMICs. Many such countries have an unprecedented global ageing demographic, and thus an increased burden arising from the special needs of older adults with mental health conditions. Yet, they also have a growing workforce shortfall of providers with expertise in older adult mental health interventions.22 Such persons have high rates of multi-morbidity, physical disability, cognitive impairment, functional limitations, and poverty.

19 Ibid. 20 WHO (2015), Mental Health Atlas 2014. Available at: www.who.int/mental_health/evidence/atlas/ mental_health_atlas_2014/en/. 21 For more on mental health and employment, see Chapter 14 of this book by Aart Hendriks. See also Chapter 3 by Martin Knapp and Valentina Iemmi on the economic impact of mental health, and Chapter 4 by Judith Bass which considers the issue in LMICs. 22 For more on the global shortage of mental health workers generally, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson.

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Scalable innovations in global delivery of mental health services tailored to older adults Addressing these challenges will require innovative approaches that are specifically tailored to the needs of older adults, whilst also being scalable, affordable, and sustainable. Key examples of innovations with special application to older adults include collaborative care, task-shifting, and integrated mental and physical health self-management. Other approaches involve prevention of late-life mental disorders and suicide, and distress-focused interventions. The social determinants of health and integrated ageing social services need to be considered. Further, caregiver support interventions in dementia care require development, and digital health expansion may assist with this (see summary in Table 12.1 at the end of the next section).

Collaborative care Over 75 studies document the effectiveness of the collaborative care model for treatment of depression in primary care across all age groups. The model consists of an embedded depression care manager providing systematic screening, care coordination and follow-up for mental health problems.23 A recent systematic review of 29 studies focused on older adults (age 60+) confirms that collaborative care is effective in treating late-life depression in primary care settings, and also of potential value in improving dementia care outcomes. Collaborative care may be particularly beneficial in providing access to mental health care for older adults in countries with disproportionately large and growing populations of older adults. For example, a recent study of collaborative care in China found that patients in the depression care management group achieved a remission rate that was over six times greater than usual care.24

Task-shifting Although collaborative care models have been shown to be effective by combining embedded depression care managers within primary care delivery settings, in LMICs and high-income rural settings, specialty mental health providers are virtually non-existent. This necessitates the use of alternative providers to make such models scalable. Community health workers or peers often take on the role of mental health providers within primary care settings or in social service organisations.25 They are trained to follow stepped care protocols which include systematic screening, monitoring of outcomes, and altering treatment for individuals not responding to basic initial interventions. Lay health workers and peers have also been shown to be effective in delivering basic problem-solving therapy and other evidence-based cognitive-behavioural interventions.26

23 Archer, J., Bower, P., Gilbody, S., et al. (2012), Collaborative care for depression and anxiety problems, The Cochrane Database of Systematic Reviews, 10: Cd006525. 24 Bartels, S. J. (2015), Why collaborative care matters for older adults in China, The Lancet Psychiatry, 2(4): 286–287. 25 For more on task-shifting, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, Chapter 4 by Judith Bass, Chapter 5 by Chris Underhill, Victoria K. Ngo, and Tam Nguyen, and Chapter 11 by Cornelius Ani and Olayinka Omigbodun. 26 Patel, V. & Saxena, S. (2014), Transforming lives, enhancing communities—innovations in global mental health, NEJM, 370(6): 498–501.

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Home and community-based older adult mental health services A series of randomised trials dating back over two decades document the effectiveness of home and community-based mental health outreach interventions for common mental health conditions affecting older adults.27 High rates of mental illness (40.5%) have been identified by home care services for home-bound disabled older adults in high-income countries.28 This is due to the expansion of home-based, long-term care services as alternatives to institution-based nursing home settings. Although prescriptions for antidepressants have risen sharply in some regions of the world few homebound older adults receive formal mental health services despite proven models of care associated with improved outcomes. For example, a randomised trial testing the effectiveness of integrating depression care management into routine home health care for homebound medical/surgical patients with co-occurring depression proved that it was effective in reducing depression severity and hospitalisation.29

Integrated mental and physical health self-management ‘Integrated illness self-management’ is based on the premise that the interaction of physical and mental health in older adults with mental health conditions warrants self-management of both domains.30 For example, Integrated Illness Management and Recovery (I-IMR) is a recoveryoriented intervention which combines training and coaching in both psychiatric and physical illness self-management into a single integrated curriculum and programme aimed at improving outcomes for older adults (age 50+) with SMI and chronic health conditions. I-IMR combines four evidence-based psychosocial interventions shown to be effective amongst people with serious mental illness: psychoeducation (which improves knowledge about mental illness management), behavioural tailoring (which improves medication adherence), relapse prevention training (which decreases relapse and re-hospitalisation), and coping skills training (which reduces symptomrelated distress).31 A synthesis of integrated evidence-based models of care for older adults with serious mental illness found four approaches to be effective: psychosocial skills training, integrated illness self-management, collaborative care, and ‘behavioural health homes’ (a mental health agency that partners with primary care and integrates it into community mental health

27 See, e.g., Bruce, M. L., Van Citters, A. D., & Bartels, S. J. (2005), Evidence-based mental health services for home and community, The Psychiatric Clinics of North America, 28(4): 1039–1060; Van Citters, A. D. & Bartels, S. J. (2004), A systematic review of the effectiveness of community-based mental health outreach services for older adults, Psychiatr Serv, 55(11): 1237–1249. 28 See, e.g., Li, L. W. & Conwell, Y. (2007), Mental health status of home care elders in Michigan, The Gerontologist, 47(4): 528–534; Qiu, W. Q., Dean, M., Liu, T., et al. (2010), Physical and mental health of homebound older adults: an overlooked population, Journal of the American Geriatrics Society, 58(12): 2423–2428. 29 See, e.g., Bruce, M. L., Lohman, M. C., Greenberg, R. L., et al. (2016), Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-day Hospitalization: The Depression Care for Patients at Home Cluster-randomized Trial, Journal of the American Geriatrics Society, 64(11): 2196–2203; Bruce, M. L., Raue, P. J., Reilly, C. F., et al. (2015), Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial, JAMA Internal Medicine, 175(1): 55–64. 30 Bartels, S. J. (2004), Caring for the whole person: integrated health care for older adults with severe mental illness and medical comorbidity, Journal of the American Geriatrics Society, 52(12 Suppl): S249–S257. 31 Bartels, S. J., Pratt, S. I., Mueser, K. T., et al. (2014), Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with serious mental illness, Psychiatr Serv, 65(3): 330–337.

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clinics). Innovative models of care building on these approaches that incorporate telehealth, mobile health, and peer support hold specific promise for addressing the needs of this high-risk group in LMICs.32

Prevention Recent advances have also been achieved in prevention for older adults with mental health conditions. For example, indicated prevention consisting of brief interventions for subsyndromal or minor depression has been demonstrated as effective in preventing progression to major depression.33 For example, a current trial is underway in Goa, India, evaluating indicated prevention of depression in later life (DIL) aimed at older adults with mild (subsyndromal) symptoms of depression and anxiety with the aim of preventing transitioning to major depression and anxiety disorders.34 This study builds on the MANAS trial of Patel and colleagues which used lay health counsellors in a multicomponent stepped care depression intervention, providing problemsolving therapy and addressing additional sleep challenges and social casework needs in conjunction with self-management of chronic health conditions.35 This is the first randomised clinical trial addressing prevention of depressive disorders in LMICs, and the intervention is both extremely novel with respect to focusing on prevention of geriatric mental health conditions, whilst also incorporating a highly scalable population-based approach through delivering both screening and the intervention through lay health counsellors.36 As older adults have the highest suicide rates of any age group, late-life suicide is a critical target for prevention. In contrast to an extensive research literature on risk factors, there are few studies on preventive interventions for late-life suicide. Noteworthy examples include trials of integrated collaborative depression care management in primary care in the US;37 a programme of community-based outreach and in-home support for isolated, frail older adults in Italy;38 and a multi-level suicide prevention programme in rural Japan consisting of systematic depression screening for older adults and referral for treatment in conjunction with community-based support, social services, and patient education.39

32 Bartels, S. J., DiMilia, P. R., Fortuna, K. L., & Naslund, J. A. (2018), Integrated Care for Older Adults with Serious Mental Illness and Medical Comorbidity: Evidence-based Models and Future Research Directions, The Psychiatric Clinics of North America, 41(1): 153–164. 33 Reynolds, C. F. 3rd, Thomas, S. B., Morse, J. Q., et al. (2014), Early intervention to preempt major depression among older black and white adults, Psychiatr Serv, 65(6): 765–773. 34 Dias, A., Azariah, F., Health, P., et al. (2017), Intervention development for the indicated prevention of depression in later life: the ‘DIL’ protocol in Goa, India, Contemporary Clinical Trials Communications, 6: 131–139. 35 Patel, V., Weiss, H. A., Chowdhary, N., et al. (2010), Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial, The Lancet, 376(9758): 2086–2095. 36 Dias & Azariah, et al. (2017), op. cit., nt.34. 37 Bruce, M. L., Ten Have, T. R., Reynolds, C. F. 3rd, et al. (2004), Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial, Journal of the American Medical Association, 291(9): 1081–1091. 38 De Leo, D., Dello Buono, M., & Dwyer, J. (2002), Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy, The British Journal of Psychiatry, 181: 226–229. 39 Oyama, H., Sakashita, T., Ono, Y., et al. (2008), Effect of community-based intervention using depression screening on elderly suicide risk: a meta-analysis of the evidence from Japan, Community Mental Health Journal, 44(5): 311–320.

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A proposed framework to guide research and programme development for reducing suicide risk in older adults identifies four key ‘drivers’: developing effective early detection strategies, enhancing general health promotion for older adults, increasing access to mental health care, and programmes to improve social connectedness.40 Examples of early detection measures include systematic screening in primary care and training of individuals who regularly come in contact with older adults in the community (such as social service providers, senior housing workers, and home delivered meal programmes), to identify at-risk older adults and engage in helpful action. General health promotion measures aimed at maximising physical and mental health include the promotion of healthy behaviour, provision of routine preventive care, ensuring effective pain management, and access to community-based services and support to optimise functioning. Improving access to mental health care for at-risk older adults necessitates delivering care where older adults live and seek services, and ensuring that mental health is included as a covered component of general health care. Finally, increasing social connectedness and resilience at the individual level can take place by providing psychosocial behavioural activation interventions and facilitating social networks. At the community level, this can be facilitated by promoting ageing social services, subsidised congregated living opportunities, and elder-friendly communities.41 Admittedly, although such interventions may have an evidence-base for reducing suicide in the elderly, expecting such labour-intensive and costly interventions to be provided country-wide in LMICs may be unrealistic at this stage. However, SDG17 requires that states ‘[s]trengthen the means of implementation and revitalise the Global Partnership for Sustainable Development’. Thus, wealthier states have a duty to assist with appropriate development funding. Given the global ageing population, this would be an apposite area for such support. Finally, and importantly, the alarming projected global health and economic burden of dementia is potentially amenable to health promotion and prevention measures. A 2013 G8 Summit on Dementia determined that there is sufficient evidence to suggest that approximately half of all cases of Alzheimer’s disease are attributable to seven modifiable risk factors: depression, diabetes, midlife obesity, midlife hypertension, smoking, low educational attainment, and physical inactivity.42 It is estimated that a 25% reduction in these seven factors could result in 3 million fewer cases worldwide.43

Distress-focused interventions and integrated ageing social services Due to the heterogeneity of mental health conditions in older adults, and the frequency of comorbidity with physical health symptoms, treatment should be tailored to the individual’s needs and preferences, rather than in accordance with a universal diagnostic label. In this respect, focusing on addressing ‘distress’ and the social determinants of health is central to engaging the individual with mental health treatment, as is providing services acceptable and relevant to the individual.

40 Conwell (2014), op. cit., nt.6. 41 Ibid. 42 For more on the 2013 G8 Dementia Summit, see: www.gov.uk/government/publications/g8-dementiasummit-agreements. 43 Baumgart, M., Snyder, H. M., Carrillo, M. C., et al. (2015), Summary of the evidence on modifiable risk factors for cognitive decline and dementia: a population-based perspective, Alzheimer’s & Dementia, 11(6): 718–726.

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Caregiver support interventions in dementia care The majority of personal health care services for older adults is provided by family members. Effective support services for family caregivers have been associated with decreased nursing home admissions and use of acute care services. Dias and colleagues conducted a randomised trial of a home care programme for caregivers of persons with dementia in developing countries based in Goa, India. This study consisted of a community-based intervention provided by a team consisting of ‘home care advisors’, and supervised by a counsellor with personal experience as the caregiver of a family member with dementia with consultative support from a psychiatrist. The team was focused on supporting the caregiver of the individual with dementia via four key strands: education, strategies for behavioural management, access to a one-time psychiatric assessment, and medication interventions as needed. This approach was associated with a significant reduction in overall distress as measured by the General Health Questionnaire and the Neuropsychiatric Inventory measure of distress.44 In addition to enhancing caregiver skills to address the special needs of older adults with mental disorders, family members provide critical support and are at increased risk of mental health and physical health disorders in their own right due to caregiver stress. For example, being a caregiver of a family member with a chronic health condition or a mental health disorder is associated with increased risk of depression, anxiety disorders, sleep disorders, substance use disorders and stress-related health conditions such as hypertension, obesity, and cardiovascular disease.45 Providing early detection, prevention, and interventions aimed at family caregivers of the older person with a mental health condition can be essential to maintaining the older adult successfully in the community and preventing or delaying institution-based long-term care.

Technology, telehealth, and digital platforms Other novel solutions capitalise on the emerging role of web-based and mobile health technologies in detection, monitoring, and self-management of chronic health conditions. Older adults are amongst the fastest-growing users of the internet,46 providing opportunities for screening and treatments that are otherwise poorly accessed due to lack of transportation, limited mobility, social isolation, and perceived stigma. Mobile health technologies in telehealth have been shown to be effective in identifying early symptoms of either psychiatric or medical complications and supporting early intervention.47 Automated telehealth approaches include providing in-home monitoring of medical and psychiatric symptoms in conjunction with automated educational and support instructions for common physical and mental health symptoms. When early signs of either psychiatric or medical relapse are detected, automated algorithms can alert nurses

44 Dias, A., Dewey, M. E., D’Souza, J., et al. (2008), The effectiveness of a home care program for supporting caregivers of persons with dementia in developing countries: a randomised controlled trial from Goa, India, PloS ONE, 3(6): e2333. 45 See, e.g., Brodaty, H. & Donkin, M. (2009), Family caregivers of people with dementia, Dialogues in Clinical Neuroscience, 11(2): 217–228; Collins, L. G. & Swartz, K. (2011), Caregiver care, American Family Physician, 83(11): 1309–1317. 46 Charness, N. & Boot, W. R. (2009), Aging and information technology use: potential and barriers, Current Directions in Psychological Science, 18(5): 253–258. 47 Pratt, S. I., Bartels, S. J., Mueser, K. T., et al. (2013), Feasibility and effectiveness of an automated telehealth intervention to improve illness self-management in people with serious psychiatric and medical disorders, Psychiatric Rehabilitation Journal, 36(4): 297–305.

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Table 12.1 Summary of scalable innovations in global delivery of mental health services tailored to older adults Innovation

Description

Older adult-specific application

Collaborative care

Embedded care managers or lay health workers in primary care provide screening, brief interventions, follow-up, and referrals using stepped care algorithms.

Task-shifting

Lay health workers, peers, and caregivers with brief training and supervision by mental health specialists detect diagnose, treat, and monitor symptoms.

Home and community-based older adult mental health services

Mental health and substance abuse services are delivered in home and community-based settings where older adults reside or seek services.

Integrated mental and physical health self-management

Middle aged and older adults with serious mental illness have disproportionately high rates of multi-morbidity, and experience a ten–25-year reduced life expectancy. Combined mental health and physical health self-management supports both mental health and physical illness self-efficacy and self-management. Prevention of depression: Brief cognitive-behavioural interventions can prevent conversion from minor (subsyndromal) depression to major depressive illness. Prevention of suicide: Key approaches to reducing suicide risk in older adults include providing screening and mental health services in primary care and in the community; enhancing health promotion to improve overall health and functioning; and programmes to improve social connectedness. Prevention of dementia: Reduction of seven modifiable risk factors: depression, diabetes, midlife obesity, midlife hypertension, smoking, low educational attainment, and physical inactivity.

Older adults are more likely to engage in mental health care and receive treatment in primary care. Collaborative care addresses the common comorbidity of chronic health conditions and mental illness in older adults. The rapidly growing older adult demographic, coupled with an inadequate (and ageing) workforce has spawned a variety of effective lay, peer, and caregiver-delivered interventions with an emphasis on home and community-based services. The need to deliver services in the community due to transportation and mobility limitations (especially in rural and LMICs) necessitates delivery of mental health services to older adults where they reside and seek services. Integrated mental and physical selfmanagement training and support delivered to middle aged and older adults with serious mental illness is associated with improved psychiatric and medical self-management, chronic disease outcomes, and reduced acute service use. Older adults are at increased risk of depressive symptoms and suicide associated with physical illnesses, chronic pain, social isolation, loneliness, and loss. Effective approaches to prevention require screening and delivery of preventive interventions where older adults reside and seek social services, and primary health care including home and community-based outreach. In addition, efforts focused on health promotion and social connectedness are key elements of mental health preventive strategies for older adults.

Prevention of late-life mental disorders and suicide in older adults

(Continued)

Stephen J. Bartels Table 12.1 (Continued) Innovation

Description

Older adult-specific application

Distress-focused interventions and integrated ageing social services

In contrast to diagnosis-specific interventions, distress-focused approaches are more likely to be viewed as acceptable, culturally appropriate, and generalisable to diverse populations. Integrated mental health and ageing social services have the potential to address key social determinants of older adult health and independent functioning.

Caregiver support interventions in dementia care

Caregiver support interventions assist in delaying nursing home placement, reducing psychiatric symptoms, and reducing caregiver depression and stress-related conditions.

Technology, telehealth, and digital platforms

Automated telehealth interventions can provide in-home monitoring and self-management support for medical and psychiatric conditions. Evidencebased brief psychotherapies can be delivered through telehealth or webbased programmes for prevention and treatment of depression and other common mental health conditions.

Older adults are more likely to perceive and experience stigma associated with mental illness and have comorbid mental and physical health symptoms causing ‘distress’ affecting overall functioning. Growth in community-based social services to support successful ageing in the community has the potential to provide integrated mental health and social services by lay professionals working in home-based care programmes and other support services. Caregiver support interventions are a mainstay of community-based dementia, leveraging the crucial role of family caregivers, and supporting home and communitybased services for older adults with dementia. Family caregivers provide the majority of at-home support for older adults with dementia, with a major impact on the overall cost of dementia care. Older adults are amongst the fastest growing users of the internet, potentially helping to overcome access barriers to screening and treatments due to lack of transportation, limited mobility, social isolation, and perceived stigma. Tailoring digital technology to the needs of older adults includes coaching support along with modifications and accommodations for visual, hearing, and cognitive limitations.

or community health workers to intervene and pre-emptively address illness relapse before it occurs.48 Brief evidence-based psychotherapies can be delivered effectively through telehealth

48 Naslund, J. A., Aschbrenner, K. A., Araya, R., et al. (2017), Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature, The Lancet Psychiatry, 4(6): 486–500.

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or automated web-based programmes for both the treatment and prevention of depression and other common mental health conditions.49 Use of social media also has the potential to provide lay peer support and older adult volunteers as a potential solution to overcoming the profound social isolation experienced by many older adults following the death of a spouse, or due to physical disabilities associated with chronic illness. Access to health care information was identified as a key determinant in reaching the Millennium Development Goals (MDGs) and also the post-2015 Sustainable Development Goals.50 Despite the potential for web-based and mobile health technologies to help overcome the dramatic shortfall in trained mental health providers and the potential for telehealth to improve access to services in rural settings, significant barriers remain. The rapid growth in the use of web-based and mobile health technologies is substantially limited in populations within LMICs due to persistent economic and infrastructure barriers.51 Improving access to mental health interventions and services for older adults across the globe will require significant economic reforms—and, where necessary, international cooperation in accordance with SDG17—that support innovation in delivery, including enhanced access to trained lay health outreach workers52 and health-related technology.

The key role of implementation science in future strategies and research Perhaps the greatest challenge in future research addressing the global challenge of mental health conditions in older adults will relate to implementation. There is a multitude of evidence-based practices for late-life mental health conditions. Implementation science is the scientific study of methods to promote the systematic uptake of research findings into the routines of local, regional or national health care delivery systems. In addition, implementation science improves the development of new treatments and practices by informing how they are designed in order to maximise usability, reach, spread, and sustainability. Many of the current innovations in global mental health and ageing are adaptations of existing evidence-based practices to improve implementation outcomes, including uptake, spread, reach, scalability, and sustainability. A dynamic tension has developed in implementation science regarding two imperatives: fidelity of implementation— the delivery of a manualised intervention programme, and programme adaptation—the modification of a programme to improve the fit for a specific consumer group, local organisation, and/ or setting. Intensive training, supervision, fidelity monitoring, and use of optimal providers and circumstances for delivering interventions are frequently impractical, and may present barriers to effective implementation in real-world settings. Chambers and colleagues (2013) suggest a ‘Dynamic Sustainability Framework’, and propose that both fidelity and adaptation are essential elements of effective and sustainable programme implementation to ensure that interventions evolve to respond to different ethnicities, cultures, settings, environments, resources, providers,

49 See, e.g., Pratt & Bartels, et al. (2013), op. cit., nt.47. See also Sandoval, L. R., Buckey, J. C., Ainslie, R., et al. (2017), Randomized controlled trial of a computerized interactive media-based problem solving treatment for depression, Behavior Therapy, 48(3): 413–425. 50 Royston, G., Hagar, C., Long, L. A., et al. (2015), Mobile health-care information for all: a global challenge, The Lancet Global Health, 3(7): e356–357. 51 Ibid. 52 For more on the use of lay health workers, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson.

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and financing structures.53 In this construct, fidelity-consistent modifications are viewed as meeting the intent of adaptations when defined as a deliberate and thoughtful alteration to the design or delivery of an intervention with a goal of improving its fit, effectiveness, and potential sustainability within a specific context or culture. Such modifications are essential to meet the needs of the ageing population globally, particularly in LMICs with different cultures and resource constraints.

Conclusion: addressing the global challenge of older adults with mental health needs The worldwide ‘silver tsunami’ of older adults with mental health needs will soon overwhelm an inadequately prepared and poorly resourced health care system due to the dearth of mental health providers with expertise on adult mental health conditions. Addressing the mental health needs of an ageing population will require a paradigm shift and innovative approaches to treatment and community-based services. In addition to the use of community health workers and lay providers, a growing literature is documenting the potential benefits and acceptability of using telehealth and digital health platforms as well as social media. This could be used to engage peers and family to help older adults with depression by, for example, reducing social isolation and providing social support following the death of a spouse, or to those with functional limitations associated with chronic illness and immobility. This challenge is compounded for older adults with mental illness who are likely to be dually affected by disability arising from both their mental health and their physical health.54 Following the principles of the World Health Organization, mental health services for older adults need to be developed which reflect evidence-based practices, but which are adapted to optimise acceptability and scalability.55 This applies in particular to LMICs due to their resource constraints. To be specific, this means identifying and reducing existing evidence-based practices to their core essential components and implementing them through competency-based training that identifies the core basic fundamental components of evidence-based practices and ensures that the requisite skills to provide the appropriate care, support, and treatment have been acquired by community-based members of the treatment team. In this respect, the priority for future research is likely to lie in the growing field of implementation science focused on identifying optimal approaches to achieving practical, generalisable, scalable, and sustainable implementation, and on the spreading and utilisation of effective interventions which meet the needs and preferences of the rapidly growing global population of older adults with mental health needs.

53 Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013), The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change, Implementation Science, 8: 117. 54 Bartels, S. J., Naslund, J. A. (2013), The underside of the silver tsunami—older adults and mental health care, NEJM, 368(6): 493–496. See also Beard, J. R., Officer, A., de Carvalho, I. A., et al. (2016), The World report on ageing and health: a policy framework for healthy ageing, The Lancet, 387(10033): 2145–2154. 55 WHO (2017), Mental health of older adults (fact sheet). Available at: www.who.int/mediacentre/ factsheets/fs381/en/.

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PART IV

Policy

C\ Taylor & Francis �-

Taylor & Francis Group

http://taylora n dfra ncis.com

13 STRENGTHENING GOVERNMENT POLICY TO ACHIEVE TARGET 3.4 OF SDG31 Rachel Jenkins*

Introduction: international advocacy on mental health The importance of mental health as an integral part of overall health has long been recognised,2 and was reaffirmed in the Declaration of Alma-Ata.3 Calls for action on mental health have increased over the past decades, such as the annual World Mental Health Day on 10 October, which has been celebrated every year since 1992.4 Multiple high level meetings, conferences and publications have raised awareness of the need for strategies to improve global mental health. The Millennium Development Goals (MDGs) did not include mental health as an identifiable objective, although mental health was relevant to most of the MDGs, especially those relating to physical health, education, and economic development.5 During the design of the post-2015 global framework for poverty eradication and sustainable development, mental health increasingly

* Rachel Jenkins is a psychiatrist, epidemiologist and international mental health policy-maker, with 20 years’ experience of working in low- and middle- income countries on research, training, and mental health policy development and implementation. 1 I am very grateful to Annabelle Metzner and Cornelius Oepen who provided comments on the draft chapter and helped with references, and to Pam Brown for formatting the references. Some of the material and arguments presented in the chapter were also given in a joint commissioned consultancy for the EU (2015): HAS 25, ‘Improving mental health care in resource poor settings’. 2 WHO (1946), Constitution of the World Health Organization. Available at: www.who.int/governance/ eb/who_constitution_en.pdf. 3 WHO (1978), Declaration of Alma-Ata. Available at: www.who.int/publications/almaata_declaration_ en.pdf. 4 R. Desjarlais, L. Eisenberg, B. Good, & A. Kleinman (1995), World Mental Health: Problems and Priorities in Low Income Countries (New York: Oxford University Press); WHO (2001), The World Health Report 2001—Mental Health: New Understanding, New Hope. Available at: www.who.int/whr/2001/en/; see further WHO (2008), Mental Health Gap Action Programme (mhGAP). Available at: www.who.int/ mental_health/mhgap/en/; and Institute of Medicine (2001), Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge (Washington, DC: Institute of Medicine). More recently, see Patel, V., Saxena, S., Lund, C., et al. (2018), The Lancet Commission on global mental health and sustainable development, The Lancet, 27 Oct, 392(10157): 1553–1598. Available at: www.thelancet.com/journals/lancet/ article/PIIS0140-6736(18)31612-X/ppt. See also Jenkins, R. (2019), Global mental health and sustainable development, International Psychiatry, 16: 34–37. 5 United Nations (2000), United Nations Millennium Declaration, RES/55/2 adopted by the General Assembly on 18 Sept 2000. Available at: www.un.org/millennium/declaration/ares552e.pdf.

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entered discussions which paved the way for the inclusion of mental health in the Sustainable Development Goals (SDGs). The SDGs are not legally binding, but countries are expected to take ownership and establish a national framework for achieving the 17 Goals. Implementation and success will rely on countries’ own sustainable development policies, plans and programmes, and the countries themselves have the primary responsibility for follow-up and review of progress made in implementing the Goals and targets over the next 15 years.6

The Sustainable Development Goals In order to achieve the SDGs recently established by the United Nation member states, governments are likely to seek to strengthen their health and social systems.7 SDG 3 aims to ‘ensure healthy lives and promote well-being for all at all ages’. Target 3.4 aims to, ‘by 2030, reduce by one third premature mortality from non-communicable disease (NCDs) through prevention and treatment and promote mental health and well-being’, and target 3.5 requires states to ‘strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol’. Both mental illness and substance abuse contribute to premature mortality from NCDs. This is due partly to suicide, partly to non-suicidal trauma and accidents, and partly to premature physical mortality arising from comorbidity between mental illness and physical illness, between mental illness and substance abuse, and from the physical consequences of substance abuse as well as most psychiatric drugs (which have physical health side-effects).8 Thus, target 3.5 and the first part of target 3.4 require policy attention to be given to prevention and treatment of mental, neurological, and substance-use (MNS) disorders, whilst the second part of target 3.4 requires policy attention to mental health promotion. Other SDGs (especially 1, 5, 8, and 10 relating to poverty reduction, gender, economic development, and reducing inequalities respectively) also require attention to be given to mental health promotion, and the prevention and treatment of MNS disorders, as MNS disorders are strongly associated with poverty, financial hardship and debt, and low productivity.9 Such disorders are more common generally in women, ethnic minorities, people with disabilities, and other marginalised groups.10 This chapter will consider mental health and mental disorder for policy-makers; the rationale for the need for increased attention to mental health in order to achieve the SDGs; the reasons why adequately addressing mental health is a core asset for health system strengthening; the resource constraints of low- and middle-income countries (LMICs); and the key dimensions of mainstreaming mental health in all sectors. The relevance of primary care for health promotion, prevention, and treatment of mental disorders is discussed, together with key principles for the incorporation of these components into primary mental health care as an essential component of achieving universal health coverage (UHC). The chapter argues that health and social systems

6 UN GA, A/Res./70.1, adopted by the General Assembly on 25 Sept 2015: Transforming our World: The 2030 Agenda for Sustainable Development. Available at:www.un.org/sustainabledevelopment/development-agenda/. 7 WHO (2007), Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes WHO’s Framework for Action. Available at: www.who.int/healthsystems/strategy/everybodys_busi ness.pdf. 8 For more on this topic, see Chapter 17 of this book by Peter Lehmann. 9 See, e.g., Jenkins, R., Bhugra, D., Bebbington, P., et al. (2008), Debt, income and mental disorder in the general population, Psychological Medicine, 38: 1485–1494. 10 Ibid. See also Foresight Mental Capital and Wellbeing Project (2008), Final Project Report (London: The Government Office for Science). Available at: assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/292453/mental-capital-wellbeing-summary.pdf See also Beddington, J., Cooper, C., Field, J., et al. (2008), The Mental Wealth of Nations, Nature, 445(7216): 1057–1060.

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will be strengthened significantly by further integrating mental health into existing health, social, educational, and criminal justice policies. This is a direct requirement of target 3.4 and would greatly assist the achievement of many of the other SDGs.

Concepts of mental health and mental illness Misconceptions about mental illness amongst policy-makers, donors, health workers and other professionals, and the wider community are widespread and hinder appropriate action to address mental disorders and their health, social, and economic consequences. Such misconceptions include beliefs that mental disorders are not real illnesses, but rather just a cultural issue or a social problem; and that they cannot be treated or that they are merely caused by addiction. Other common erroneous beliefs are that mental illness is contagious and that the burden of mental illness is minor compared to that of physical illnesses. A particular fallacy is that addressing mental disorders will damage efforts and resource availability to treat physical illness.11 It is time to address these misconceptions head on at international and national policy and donor levels, so that equivalent policy attention is paid to mental and physical disorders.12 According to the WHO’s 2001 definition, mental health is ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’.13 Thus, mental health is more than the absence of symptoms or distress and refers to a positive sense of wellbeing, the ability to have mutually satisfying relationships, and to cope with adverse life events (in other words, to develop resilience). This positive conceptualisation of mental health is often referred to as ‘positive mental health’.14 It has an important societal value, contributing to the functions of society—including overall productivity. Furthermore, it presents an important resource for individuals, families, communities and nations, increasing human, social and economic capital.15 Mental illness or mental disorder refers to suffering and morbidity due to mental or behavioural problems (for example, disturbances in perception, beliefs, mood, concentration, as well as irritability, abnormal personality traits or excessive consumption of alcohol, drugs or tobacco). Major categories include depression, anxiety, somatisation, post-traumatic stress disorder (PTSD), psychosis, autism, attention deficit hyperactivity disorder (ADHD), childhood emotional and conduct disorders, learning difficulties such as dyslexia, and intellectual retardation. Common neurological disorders include epilepsy, Parkinson’s disease and dementia (both age-related and HIV-related). Culture and religion influence the value placed by society on mental health, access to services, and pathways through care. They also impact upon the degree of stigma and discrimination there is towards people with MNS disorders, diagnosis, and the presentation of symptoms such as low mood, anxiety and fatigue, and illness behaviour. Culture and religion may affect illness behaviours such as the propensity to take bed-rest, whether or not over-the-counter medications

11 12 13 14

Jenkins, R. (2003), Supporting Governments to Adopt Mental Health Policies, World Psychiatry, 2: 14–19. Jenkins et al. (2008), op. cit., nt.9. WHO (2001), Strengthening Mental Health Promotion (fact sheet No.22) (Geneva: WHO). Barry, M. (2009), Addressing the Determinants of Positive Mental Health: Concepts, Evidence and Practice, International Journal of Mental Health Promotion, 11(3): 4–17. 15 Beddington, J., Cooper, C., Field, J., et al. (2008), The Mental Wealth of Nations, Nature, 445(7216): 1057–1060.

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are taken, recourse to traditional healers, whether or not formal health care is accessed. Thus, context-specific mental health strategies and locally tailored solutions are crucial.16

Rationale for action on mental health The rationale for action on mental health arises first from the positive contribution of good mental health to physical health, family life, education, the economy, and social participation.17 Second, it arises from our growing understanding of the risk factors for mental disorders.18 Third, action ought to be taken on mental health due to its prevalence, and the large degree of disability, personal suffering and the wider negative impact that mental illness can have on human, social and economic capital. Lastly, it is humane to take such action since effective interventions are available for the promotion of mental health as well as the prevention and treatment of mental disorders which can reduce premature mortality.19

Positive mental health and its beneficial impact on health and social outcomes Positive or good mental health20 is associated with improved educational outcomes, greater productivity, and improved cognitive ability. It also leads to increased resilience to adversity, better physical health, less sickness absence, and reduced mortality. There is evidence that it leads to increased social interaction and participation, reduced risk-taking, and of course reduced mental illness and suicide.21 Additionally, positive mental health is important for the educational achievement of children and their future prospects,22 for the physical health of the population, for

16 R. Jenkins, A. McCulloch, L. Friedli, & C. Parker (2002), Developing Mental Health Policy, Maudsley Monograph 43 (Abingdon: Psychology Press, Taylor and Francis Group), pp.1–213; Jenkins, R. (2003), Supporting Governments to Adopt Mental Health Policies, World Psychiatry, 2: 14–19. 17 The Foresight Report (2008), op. cit., nt.10, p.75. 18 See, e.g., the Foresight Report (2008), op. cit., nt.10, pp.76–81; Bebbington, P., Dunn, G., Jenkins, R., et al. (1998), The Influence of Age and Sex on the Prevalence of Depressive Conditions: Report from the National Survey of Psychiatric Morbidity, Psychol Med, 28: 9–19; Brugha, T. Morgan, Z. Bebbington, P., et al. (2003), Social Support Networks and Type of Neurotic Symptom among Adults in British Households, Psychol Med, 33: 307–318; Cooper, C., Bebbington, P., Meltzer, H., et al. (2008), Depression and Common Mental Disorders in Lone Parents: Results of the 2000 National Psychiatric Morbidity Survey, Psychol Med, 38: 335–342; Targosz, S., Bebbington, P., Lewis, G., et al. (2003), Lone Mothers, Social Exclusion and Depression, Psychol Med, 33: 715–722; Vostanis, P., Brugha, T., Goodman, R., et al. (2006), Relationship Between Parental Psychopathology, Parenting Strategies and Child Mental Health: Findings from the GB National Study, Soc Psychiatry Psychiatr Epidemiol, 41: 509–514; and Jenkins et al. (2008), op. cit., nt.9. 19 See further the Foresight Report (2008), op. cit., nt.10., pp.14–31. See also Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), Should Development Agencies Care about Mental Health?, Mental Health in Family Medicine, 8(2): 65–67. 20 See the Foresight Report (2008) for a definition, op. cit., nt.10, pp.52–97. 21 Silva, M. J. D., McKenzie, K., Harpham, T., & Huttly, S. R. A. (2005), Social capital and mental illness: a systematic review, Journal of Epidemiol Community Health, 59: 619–627. 22 Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2013), A Systematic Review of the Effectiveness of Mental Health Promotion Interventions for Young People in Low and Middle Income Countries, BMC Public Health, 13(1): 835.

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community development, and for the economy. In other words, good mental health is essential for human, economic and social capital.23

Risk factors associated with mental, neurological and substance-use disorders At different stages in life, various factors affect and interact with mental health. In children, risk factors associated with higher rates of mental disorder are child abuse, parental psychopathology, physical health problems, low income, and lone parents.24 Childhood disorders are associated with reduced school attendance and health and social skills outcomes, smoking, alcohol and drug use, as well as higher rates of subsequent adult mental disorder, unemployment, low earnings, teenage parenthood, marital problems, criminal activity and imprisonment. Risk factors associated with higher rates of mental disorders amongst adults include comorbidity with other non-communicable and communicable diseases, sexual violence, injuries, unemployment, debt, and poverty. Mental disorder is also associated with homelessness, antisocial behaviour, imprisonment, smoking, and alcohol and drug abuse. In addition, those suffering from mental disorder are more likely to indulge in sexual risk-taking, to have a poor diet and a lifestyle involving physical inactivity, and experience marital breakdown.25 Some risk factors are especially prevalent in LMICs, particularly poverty and its associated psychosocial stressors (such as violence, unemployment, social exclusion and insecurity).26 Knowledge of risk factors27 should inform clinical assessments in the health system (both at primary care and secondary care levels) as part of an overall biopsychosocial approach, and similarly it should inform national and local intersectoral prevention strategies.

23 Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), Mental Health and the Global Agenda: Core Conceptual Issues, Mental Health in Family Medicine, 8(2): 69–82. 24 Bebbington, P., Jonas, S., Kuipers, E., et al. (2011), Childhood Sexual Abuse and Psychosis: Data from a Cross-sectional National Psychiatric Survey in England, British Journal of Psychiatry, 199(1): 29–37; Vostanis et al. (2006), op. cit., nt 18. For a thorough review of the impact of childhood mental disorders, see further the Foresight Report (2008), op. cit., nt.10. 25 Bebbington et al. (1998), op. cit., nt.18; Brugha et al. (2003), op. cit., nt.18; Jonas, S., Bebbington, P., McManus, S., et al. (2011), Sexual Abuse and Psychiatric Disorder in England: Results from the 2007 Adult Psychiatric Morbidity Survey, Psychol Med, 41(4): 709–719; Cooper et al. (2008), op. cit., nt.18; Targosz et al. (2003), op. cit., nt.18; Jenkins et al. (2008), op. cit., nt.9. 26 United Nations (2013), Inequality Matters—Report of the World Social Situation 2013 (New York: UN). 27 See, e.g., Jenkins, R., Othieno, C., Ongeri, L., et al. (2015), Attention Deficit Hyperactivity Disorder Symptom Self-report in Adults in Kenya and its Associated Risk Factors, an Analysis from a Household Survey in a Demographic Surveillance Site, Glob Mental Health (Camb), 2: e14. Available at: doi: 10.1017/gmh.2015.14; Jenkins, R., Othieno, C., Ongeri, L., et al. (2015), Adult Psychotic Symptoms, Their Associated Risk Factors and Changes in Prevalence in Men and Women Over a Decade in a Poor Rural District of Kenya, International Journal of Environmental Research and Public Health, 12(5); Jenkins, R., Njenga, F., Okonji, M., et al. (2012), Psychotic Symptoms in Kenya—Prevalence and Risk Factors, including their Relationship with Common Mental Disorders, Int J Environ Res and Public Health, 9: 1748–1756; Jenkins, R., Njenga, F., Okonji, M., et al. (2012), Prevalence of Common Mental Disorders in a Rural District of Kenya, and Socio-demographic Risk Factors, Int. J. Environ. Res. Public Health, 9: 1810–1819. Available at: doi:10.3390/ijerph9051810; Jenkins, R., Mbatia, J., Singleton, N., & White, B. (2010), Prevalence of Psychotic Symptoms and their Risk Factors in Urban Tanzania, International Journal of Environmental Research and Public Health, 7: 2514–2525; and Jenkins, R., Mbatia, J., Singleton, N., & White, B. (2010), Common Mental Disorders and Risk Factors in Urban Tanzania, International Journal of Environmental Research and Public Health, 7(6): 2543–2558.

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Mental disorders and their damaging impact on overall health and social outcomes There have been numerous epidemiological studies of rates of mental disorder across the world. Whilst rates vary within and between countries, a global picture emerges of roughly 0.5–2% prevalence for adult psychosis, 5–15% prevalence for adult depression and anxiety, and 10% for childhood mental disorders.28 Although mental disorders may be brief, lasting only a few weeks, half are more chronic, extending for many months or even years. They are frequently accompanied by difficulties in fulfilling activities of daily living (otherwise termed ‘disability’), caused by the common mental illness symptoms of fatigue, poor concentration, and irritability, as well as by mood, thought and perception disturbance.29 Thus, MNS disorders have detrimental effects not only on individuals and families, but also on communities, the wider health system and the economy. Just as important as these is, of course, the internal suffering caused by the illness, which is now also the subject of intensive research.30

Comorbidity between mental and physical illness MNS disorders are often comorbid with, or act as risk factors for, NCDs (such as cardiovascular disease and cancer), communicable diseases (such as HIV/AIDS and tuberculosis), the sexual and reproductive health of mothers, and injuries.31 Furthermore, mental disorders are independent risk factors for NCDs,32 communicable disease, injury and deliberate self-harm and suicide. Research has indicated that depression and substance-use disorders also adversely affect treatment adherence for other disorders.33 Furthermore, there is diagnostic confusion between mental and physical illness due to shared symptoms, such as headache, fatigue or poor concentration, leading to erroneous diagnostic data and treatments, especially at the primary care level.34 Mental disorders contribute to premature mortality in two ways, namely deliberate self-harm (including suicide), and premature death from physical disorders.35 First, mental disorders are

28 Institute of Medicine (2001), Neurological, Psychiatric and Developmental Disorders—Meeting the Challenge in the Developing World (Washington, DC: National Academy Press). See also Kessler, R. & Ustun, T. (eds) (2008), The World Health Organization World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders (New York: Cambridge University Press). 29 Ormel, J., Petukhova, M., Chatterji, S., et al. (2008), Disability and Treatment of Specific Mental and Physical Disorder across the World, British Journal of Psychiatry, 192: 368–375. 30 Schulz, R., Herbert, R., Dew, M., et al. (2007), Patient Suffering and Caregiver Compassion: New Opportunities for Research, Practice, and Policy, The Gerontologist, 47(1): 4–13. 31 Oni, T. & Unwin, N. (2015), Why the Communicable/Noncommunicable Disease Dichotomy is Problematic for Public Health Control Strategies: Implications of Multinationality for Health Systems in an era of Health Transition, International Health, 15 July. Available at: doi: 10.1093/inthealth/ihv040. 32 Buist-Bouwman, M., de Graaf, R., Vollebergh, W., & Ormel, J. (2005), Comorbidity of Physical and Mental Disorders and the Effect on Work Loss Days, Acta Psychiatrica Scandinavica III, 36–43. 33 DiMatteo, M., Lepper, H., & Croghan, T. (2000), Depression is a Risk Factor of Noncompliance in Medical Theatres, Arch-Internal Medicine, 160(14): 2101–2107. 34 See, e.g., Sartorius, N., Ustün, T., Costa e Silva, J., et al. (1993), An International Study of Psychological Problems in Primary Care. Preliminary Report from the World Health Organization Collaborative Project on Psychological Problems in General Health Care, Archives of General Psychiatry, 50: 819–824; Dowrick, D., Katona, C., Peveler, R., & Lloyd, H. (2005), Somatic Symptoms and Depression: Diagnostic Confusion and Clinical Neglect, The British Journal of General Practice, 55(529): 829–830. 35 Harris, E. & Barraclough, B. (1998), Excess Mortality of Mental Disorder, British Journal of Psychiatry, 173: 11–53.

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the principal risk factor for suicide; well over 90% of people committing suicide have been reported to have been diagnosed with a psychiatric disorder in the past.36 In addition, experiencing conflict, disaster, violence, abuse or loss, as well as a sense of isolation, are all associated strongly with suicidal behaviour. Worldwide, over 800,000 people die due to suicide every year, and many more people attempt to kill themselves, or commit self-harm. However, most LMICs currently lack methodical and thorough methods for national collection of data on suicides, suicide attempts and self-harm. Further, suicide is an intensely sensitive issue, and even illegal in some countries,37 so suicides are likely to be under-reported or misclassified. Suicide is the 15th leading cause of death worldwide, and amongst 15 to 29 year olds it is the second leading cause of death.38 Globally, 75% of suicides occur in LMICs, and certain cultural traditions have even encouraged it, such as the practice of sati in India.39 In addition to suicide, MNS disorders contribute to mortality rates because comorbid physical health problems are a major cause of premature death in people with mental disorders,40 and people with physical illness have a much worse prognosis if they are also depressed.41 This

36 Bertolote, J. & Fleischmann, A. (2002), Suicide and Psychiatric Diagnosis: a Worldwide Perspective, World Psychiatry, 1(3): 181–185. 37 In England and Wales, for example, suicide was illegal until the Suicide Act 1961 was passed. 38 WHO (2014), Preventing Suicide: A Global Imperative. Available at: www.who.int/mental_health/ suicide-prevention/world_report_2014/en/. 39 For further information on this practice which has now been made illegal, see, e.g., The Commission of Sati (Prevention) Act 1987 (No.3 of 1988); The Ministry of Woman and Child Development, Government of India. Available at: www.wcd.nic.in/commission-sati-prevention-act-1987-3-1988-excluding-admin istration-criminal-justice-regard-offences/ 40 Harris, E. & Barraclough, B. (1998), Excess Mortality of Mental Disorder, British Journal of Psychiatry, 173: 11–53. 41 See, e.g., Prince, M., Patel, V., Saxena, S., et al. (2007), No Health without Mental Health, The Lancet, 370: 859–877, which reported evidence from systematic reviews of population-based research that there are moderate to strong prospective associations between depression, anxiety and coronary heart disease, Type II diabetes, and fatal and non-fatal stroke. Studies also support a strong association between mental disorder and risk factors for chronic diseases, such as smoking, reduced activity, poor diet, obesity and hypertension. See also, e.g., Glassman, A. (2008), Depression and Cardiovascular Disease, Pharmacopsychiatry, 41: 221–225; Katon, W. (2008), The Comorbidity of Diabetes Mellitus and Depression, American Journal of Medicine, 121: S8–S15; Gadalla, T. (2009), Association of Obesity with Mood and Anxiety Disorders in the Adult General Population, Chronic Diseases in Canada, 30: 29–36; Ormel, J., Von Korff, M., Burger, H., et al. (2007), Mental Disorders among Persons with Heart Disease: Results from World Mental Health Surveys, General Hospital Psychiatry, 29: 325–334; Sherwood, A., Blumenthal, J., Trivedi, R., et al. (2007), Relationship of Depression to Death or Hospitalization in Patients with Heart Failure, Archives of Internal Medicine, 167: 367–373; Baingana, F., Thomas, R., & Comblain, C. (2005), ‘HIV/AIDS and Mental Health’, Working Paper (Washington, DC: The World Bank); Pence, B. (2009), The Impact of Mental Health and Traumatic Life Experiences on Antiretroviral Treatment Outcomes for People Living with HIV/AIDS, Journal of Antimicrobial Chemotherapy, 63: 636–640; Husain, M., Dearman, S., Chaudhry, I., et al. (2008), The Relationship between Anxiety, Depression and Illness Perception in Tuberculosis Patients in Pakistan, Clinical Practice and Epidemiology in Mental Health, 4:4; Harris, E. & Barraclough, B. (1998), Excess Mortality of Mental Disorder, British Journal of Psychiatry, 173: 11–53; Peet, M. (2004), Diet, Diabetes and Schizophrenia: Review and Hypothesis, British Journal of Psychiatry, 47: S102–S105; Gupta, A. & Craig, T. (2009), Diet, Smoking and Cardiovascular Risk in Schizophrenia in High and Low Care Supported Housing, Epidemiology and Psychiatric Sciences, 18: 200–207; Husain, M., Dearman, S., Chaudhry, I., Rizvi, N., & Waheed, W. (2008), The Relationship between Anxiety, Depression and Illness Perception in Tuberculosis Patients in Pakistan, Clinical Practice and Epidemiology in Mental Health, 4(4): 4.

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co-relationship is not fully understood, but may be due partly to the impact of depressed mood on the immune system.42 Mental disorder, as a risk factor for physical health problems, increases the mortality rate of cardiovascular disease almost as much as smoking does.43 For instance, people with schizophrenia die 16 to 20 years earlier and have a 3.2 times increased rate of mortality from respiratory disease, 3.4 times increased rate from infectious disease, and 2.3 times increased rate from cardiovascular disease.44 Harmful alcohol use is a component cause of more than 200 disease and injury conditions such as liver cirrhosis, cancers and injuries.45 Furthermore, studies from both high- and low-income countries have shown that people with depression have a 50% greater risk of cardiovascular disease and a 60% increased risk of diabetes.46

The Global Burden of Disease studies The latest Global Burden of Disease Study, carried out in 2013,47 has shown that overall, mortality is declining faster than both disease prevalence and disability. Thus, people are living longer, but with more diseases and disability—and there is a major transition from prevalence of communicable diseases to non-communicable diseases, for which health systems are inadequately prepared.48 Between 1990 and 2013, years of life lived with disability (YLDs) rose globally by 42.3%, due to ageing and population growth. The leading causes of YLD in 2013 were low back pain (first in 1990 and 2013), major depression (third in 1990 and second in 2013), iron deficiency anaemia (second in 1990 and third in 2013), neck pain (fourth in 1990 and 2013), hearing loss (fifth in 1990 and 2013), anxiety (seventh in 1990 and ninth in 2013) and schizophrenia (12th in 1990 and 11th in 2013). Indeed, MNS disorders account for 10.4% of global disability-adjusted life years (DALYs), 2.3% of global years of life lost due to premature mortality (YLLs) and 28.5% of YLDs. In addition, MNS disorders account for four out of the ten leading causes of disability, with depression being the most disabling disorder worldwide measured in YLDs.49 By 2030,

42 Dowlati, Y., Herrmann, N., Swardfager, W., Liu, H., Sham, L., Reim, E. K., & Lanctôt, K. L. (2010), A meta-analysis of cytokines in major depression, Biological Psychiatry, 67(5): 446–457. Available at: www. ncbi.nlm.nih.gov/pubmed/20015486. 43 Frasure-Smith, N. & Lesperance, F. (2010), Depression and Cardiac Risk: Present Status and Future Directions, Heart, 96: 173–176. 44 Ösby, U., Correia, N., Brandt, L., et al. (2000), Mortality and Causes of Death in Schizophrenia in Stockholm County, Sweden, Schizophrenia Research, 45(1–2): 21–28. 45 WHO (2014), Global Status Report on Alcohol and Health 2014. Available at: apps.who.int/iris/bitstr eam/10665/112736/1/9789240692763_eng.pdf ?ua=1. 46 See, e.g., Glassman, A. (2008), Depression and Cardiovascular Disease, Pharmacopsychiatry, 41(6): 221–225; Katon, W. (2008), The Comorbidity of Diabetes Mellitus and Depression, American Journal of Medicine, 121 (11 Suppl 2): 8–15. 47 Mathers, C. & Loncar, D. (2005), ‘Updated Projections of Global Mortality and Burden of Disease, 2002–2030: Data Sources, Methods, and Results’, Evidence and Information for Policy Working Paper. Available at: www.who.int/healthinfo/statistics/bod_projections2030_paper.pdf. See also WHO (2013), WHO Methods and Data Sources for Global Burden of Disease Estimates 2000–2011. Available at: www.who.int/healthinfo/statistics/GlobalDALYmethods_2000_2011.pdf ?ua=1. 48 Atun, R. (2015), Transitioning health systems for multimorbidity, The Lancet, 386(9995): 721–722. 49 Whiteford, H., Degenhardt, L, Rehm, J., et al. (2013), Global Burden of Disease Attributable to Mental and Substance Use Disorders: Findings from the Global Burden of Disease Study 2010, The Lancet [online], 29 Aug.

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depression is expected to be the leading cause of disability in high-income countries (HICs), the second leading cause of disability after HIV/AIDS in middle-income countries (MICs), and the third leading cause of disability after HIV/AIDS and perinatal conditions in low-income countries (LICs).50 Though these figures give a good oversight of the global burden of MNS disorders, it is important to note that they do not reflect the high proportion of actual suicides which are not officially recorded, the premature mortality of people with mental disorder from physical disease, or the caregiver burden arising from the physical, emotional and financial toll of providing care. The toll of MNS disorders is especially high in LMICs, where three-quarters of the global burden of disease arising from neuropsychiatric disorders is located.51 In LMICs where children and adolescents form a very high proportion of the population, suicide is of particular concern. As life expectancy increases worldwide, dementia is expected to become increasingly common.52 Ninety per cent of the burden of HIV/AIDS is located in LMICs, and since treatments have improved significantly since the 1980s, survival rates are much improved. This means that HIV-related dementia is likely to become a significant issue in such countries.53 In addition, alcohol abuse presents a growing problem in sub-Saharan Africa.54 Further, LMICs are particularly susceptible to disasters—including both natural and industrial disasters, major ferry and road traffic accidents and plane crashes—with 85% of global disasters occurring in such countries.55 Finally, there is a high prevalence of war and civil violence, which have an adverse impact on mental health, and in particular contribute to PTSD and anxiety disorders.56

The economic impact of mental, neurological and substance-use disorders57 MNS disorders cause loss of economic productivity due to inability to work, absence from work, and accidents at work. Premature death due to suicide or worsened physical health contributes to productivity loss and reduction in family income. All of these can lead to poverty. Out-of-pocket spending by family members for people with MNS disorders is high in LMICs, as treatment in specialist hospitals is rarely free and often expensive. Furthermore, people with unrecognised and untreated psychological comorbidities utilise health services significantly more often, which

50 Mathers & Loncar (2005), op. cit., nt.47. 51 Lund, C., Tomlinson, M., De Silva, M., et al. (2012), PRIME: A Programme to Reduce the Treatment Gap for Mental Disorders in Five Low- and Middle-income Countries, PLOS Medicine, 9(12). 52 Ferri, C., Prince, M., Brayne, C., et al. (2005), Global Prevalence of Dementia: a Delphi Consensus Study, The Lancet, 336(9503): 2112–2117. Available at: www.ncbi.nlm.nih.gov/pubmed/16360788. 53 Bell, J. (2004), An Update on the Neuropathology of HIV in the HAART era, Histopathology, 45: 549–559. Available at: www.ncbi.nlm.nih.gov/pubmed/15569045. 54 Baingana, F., Alem, A., & Jenkins, R. (2006), ‘Mental Health and the Abuse of Alcohol and Controlled Substances’, in D. Jamison, R. Feacham, M. Makgoba, et al. (eds) (2006), Disease and Mortality in SubSahara Africa (2nd edn) (Washington, DC: The International Bank for Reconstruction and Development, and The World Bank). 55 Roy, N., Thakkar, P., & Shah, H. (2011), Developing-World Disaster Research: Present Evidence and Future Priorities, Disaster Medicine and Public Health Preparedness, 5: 112–116. 56 De Jong, J., Komproe, I., & Van Ommeren, M. (2003), Common Mental Disorders in Postconflict Settings, The Lancet, 361(9375). 57 For detailed consideration of the economic arguments for increased mental health investment, see Chapter 3 of this book by Martin Knapp and Valentina Iemmi, and Chapter 4 by Judith Bass.

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increases costs for the health service as well as for individuals and families.58 In 2011 the World Economic Forum predicted that the lost economic output due to mental disorders will amount to US$16.3 trillion globally between 2011 and 2030.59 Mental health conditions and cardiovascular diseases combined contribute 70% of that lost output, which consequently will also limit efforts to combat poverty and achieve sustainable development.60

Policy to enable achievement of SDG3 In order to enable progress on SDG target 3.4, it is important to support governments with the integration of mental health policy into public health policy and general social policy. Developing and following a systematic biopsychosocial approach to policy on health promotion, prevention, and treatment to improve quality of life and decrease mortality is crucial for the achievement of target 3.4. An individual’s life course can be improved significantly if mental health promotion has resulted in increased resilience and coping skills, and if prevention has reduced some risk factors through, for example, good parenting, school education, and positive life experience. The burden due to MNS disorders can be greatly reduced or removed by thorough biopsychosocial assessment, biopsychosocial treatment, and community-based rehabilitation.61

Policy on multisectoral mental health promotion to achieve SDG3 An individual’s resilience can be strengthened by promoting coping skills, emotional and social skills, increasing physical activities, improving nutrition, and by developing and maintaining strong social networks.62 This might take place in schools, in the workplace, at home, in primary care, or within communities. Mainstreaming mental health in the educational setting is essential as it presents the most important arena outside the family for the development of child mental health. Similarly, children often constitute half the population in LMICs, and yet receive too little policy attention. Specific learning difficulties in schools (including dyslexia) lead to educational failure, school drop-out, unemployment and over-representation in prisons. It is therefore important for policy to address specific learning difficulties in schools. Large numbers of children across the world are looked after in orphanages and children’s homes, which often contain those who have been abused and neglected, as well as those whose home life has broken down. However, there are also children in such institutions with developmental delay and retardation, speech delay, and epilepsy. Others suffer from hyperactivity and aggression, or have chronic physical illness, disability or handicap. Ensuring adequate mental and physical health promotion and care for children ‘looked after’ by the state, which will help to prevent their subsequent overrepresentation in the prisons, is a policy imperative. The provision of mental health promotion in

58 R. Kessler & D. Stafford (eds) (2008), Collaborative Medicine Case Studies: Evidence in Practice (New York: Springer). 59 World Economic Forum, the Harvard School of Public Health (2011), The Global Economic Burden of Non Communicable Diseases (Geneva: WEF). 60 Gureje, O. & Jenkins, R. (2007), Mental Health in Development: Re-emphasising the Link, The Lancet, 369: 447–449. 61 Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), How Can Mental Health be Integrated into Health System Strengthening?, Mental Health in Family Medicine, 8(2): 115–117. 62 The Foresight Report (2008), op. cit., nt.10.

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schools using the whole school approach is a crucial area for action,63 especially in LMICs, where often half the population is aged under 16. Like the education sector, the employment sector offers several entry-points for mainstreaming mental health, such as through the promotion of safe working conditions, healthy management styles, good diet, increased exercise, a focus on the importance of wellbeing, promoting work-family reconciliation, and improving access to stress management programmes. Such strategies are highly likely to lead to widespread health, social and productivity benefits.64 Workplaces are key settings where all too often health and safety policies do not include mental health promotion and prevention, or prompt detection and management of disorders.65 This results in damage to both health and productivity. Thus, workplace health policies should consider and reference mental health promotion, as well as prevention, diagnosis, early treatment, and rehabilitation for those suffering from mental health and substance-use disorders.66 Prisons are another key setting of concern for mental health policy. Mental illness is exceptionally common in prisons, and in some countries suicide rates for prisoners are very high.67 Clear and effective guidelines for health care staff in prisons are crucial for the systematic prevention of and treatment for anxiety and depression in prison, to ensure that people with psychosis are treated in hospital rather than prison, and to prevent self-harm and suicide.68 Furthermore, it would make sense to tackle dyslexia and educational failure in prisoners, which will contribute to improved health and social outcomes after their release. Finally, it is clear that since mental health has an impact on numerous interconnected social and economic areas of life, government policy needs to integrate mental health promotion strategies not only into health, but also into education policy, employment policy, criminal justice policy (including the courts, police and prisons), and community development policy.69

Policy on multisectoral prevention to achieve SDG3 Some preventive strategies that have been shown to improve mental health and reduce the risks for mental disorders involve physical factors, such as improving nutrition70 and increasing exercise,71 and environmental factors such as improved housing.72 Social factors such as increasing

63 Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2013), A Systematic Review of the Effectiveness of Mental Health Promotion Interventions for Young People in Low and Middle Income Countries, BMC Public Health, 13(1): 835. 64 See, e.g., WHO (2000), Mental Health and Work: Impact, Issues and Good Practices. Available at: www.who.int/mental_health/media/en/712.pdf; WHO (2010), Mental Health and Well-being at the Workplace: Protection and Inclusion in Challenging Times. Available at: http://ec.europa.eu/health/ mental_health/docs/who_workplace_en.pdf. 65 Jenkins, R. (2013), Mental Health of People at Work, Occupational Health Practice, 73. 66 Department of Health (1995), ABC of Mental Health in the Workplace-a guide for employers (London: HMSO). 67 Matschnig, M., Fruhwald, S., & Frottier, P. (2006), Suicide Behind Bars—an International Review, Psychiatric Praxis, 33: 6–13. 68 See World Health Organization Collaborating Centre (2001), Prison version of World Health Organization Guide to Primary Care (London: Royal Society of Medicine). 69 Jenkins et al. (2008), op. cit., nt.9. 70 Jacka, F. N., Sacks, G., Berk, M., & Allender, S. (2014), Food Policies for Physical and Mental Health, BMC Psychiatry, 14: 132. Available at: doi.org/10.1186/1471-244X-14-132. 71 Penedo, F., Dahn, J., & Jason, R. (2005), Exercise and Well-being: A Review of Mental and Physical Health Benefits Associated with Physical Activity, Current Opinion in Psychiatry, 18(2): 189–193. 72 Harris, J., Hall, J., Meltzer, H., et al. (2010), Health, Mental Health and Housing Conditions in England (London: National Centre for Social Research).

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access to education,73 reducing economic insecurity, tackling personal unmanageable debt,74 and strengthening community networks and reducing harm from addictive substances use are also important. Additionally, various studies have found that mental illness can be reduced through a combination of actions: promoting a healthy start in life and reducing child abuse and neglect, providing support for those coping with parental mental illness, enhancing resilience, reducing risky behaviour in schools, dealing with family disruption which impacts on the workplace, and supporting refugees.75 Major risk factors for mental disorder appear to be child abuse and neglect, personal debt, and poor nutrition, and therefore government policy needs to address these in particular. As well as the non-health sectors of education, employment, communities, and criminal justice, primary health care is a crucial setting76 for the implementation of prevention as well as mental health promotion across the life course, because it is more easily accessed. Furthermore, primary care provides major opportunities for mental health promotion during opportunistic consultations at every stage of the life course.77

Policy on prevention of premature mortality to achieve target 3.4 The prevention of premature mortality from physical disease in people with mental disorder should be implemented using a systematic biopsychosocial approach in primary care to address multiple morbidity systematically. The key components of national policy on suicide prevention78 should be derived from an understanding of the pathway to suicide,79 from low resilience, to mental disorder, to development of suicidal thoughts, to development of suicidal plans, to actual suicide attempts. Thus, the key prevention steps generally include mental health promotion to increase resilience, the reduction of key risk factors to reduce the prevalence of mental disorders, and improved assessment and management of mental disorders (especially depression) in primary care to reduce their duration and severity. In addition, regular systematic training for all public sector employees (those working in health and social welfare, as well as teachers, the police, and prison staff ) on the assessment and management of suicidal risk is essential, so

73 The Foresight Report (2008), op. cit., nt.10. 74 Wahlbeck, K. & McDaid, D. (2012), Actions to Alleviate the Mental Health Impact of the Economic Crisis, World Psychiatry, 11(3): 139–145. 75 WHO (2004), Prevention of Mental Disorders: Effective Interventions and Policy Options. Available at: www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf. See also C. Hosman, E. Jane-Llopis, & S. Saxena (eds) (2005), Prevention of Mental Disorders: Effective Interventions and Policy Options (Oxford: Oxford University Press), and M. Knapp, D. McDaid, & M. Parsonage (2011), Mental Health Promotion and Mental Illness Prevention: The Economic Case, Report 15972 (London: Department of Health). 76 Educational Trust for Health Improvement through Cognitive Strategies (2015), Cultivating Mental Health Promotion in General Practice (London: Royal College of General Practitioners & London Journal of Primary Care). Available at: ethicscharity.files.wordpress.com/2015/10/rcgp_keymsg_150925_v4.pdf. See also Thomas, S., Jenkins, R., Burch, T., et al. (2016), Promoting Mental Health and Preventing Mental Illness in General Practice, Journal of Primary Care, 8(1): 3–9. 77 Educational Trust (2015), ibid. 78 United Nations (1996), Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies, ST/ESA/245 (New York: U.N. Department of Policy Coordination and Sustainable Development). See also WHO (2013), Mental Health Action Plan 2013–2020. Available at: www.who.int/ mental_health/action_plan_2013/en/. 79 Jenkins, R. & Singh, B. (2000), ‘General Population Strategies of Suicide Prevention’, in K. Hawton & K. van Heeringen (eds) (2000), The International Handbook of Suicide and Attempted Suicide (Chichester: John Wiley), Chapter 34.

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that suicidal people are recognised and supported. Important, too, is the support of high risk groups with high rates of suicide (such as people with severe mental illness and those within particular high-risk occupational groups such as doctors, dentists, veterinarians, pharmacists and farmers). Finally, governments should ensure reduced access to means of suicide (including guns, car exhausts, pesticides, and certain medicines such as paracetamol) and cooperation with the media to avoid inadvertent glamorisation of suicide and reporting of suicide methods, in order to reduce copycat suicides.80

Health system strengthening Health systems in many countries, and particularly in LMICs, are often under-resourced, and there are significant obstacles to the scaling-up of services and the provision of equitable and sustainable health services and health outcomes for all. Globally, health systems are unprepared for the major transition from a communicable to non-communicable disease burden, and for the growing disease and disability burden.81 This anticipated problem underlies the recent major focus on health system strengthening, although adequate resources have yet to be applied to generic health system strengthening by donors and governments in LMICs.

Low- and middle-income countries: human and financial resource constraints Despite the major contribution made by MNS disorders to the global burden of disease, disability and mortality, it is striking that MNS disorders remain marginalised in health policy and health budgets. According to the WHO, funding for MNS disorders accounts for only 0.05% of the total health budget in LICs, 2.4% in MICs, and 5.1% in HICs.82 Furthermore, these scarce mental health resources are distributed unequally between countries, regions and communities, with inefficiency in their use a widespread problem.83 Besides financial resource constraints, LMICs face a scarcity in the mental health workforce, with 0.9 psychiatrists per 100,000 population in LICs, 3.2 in lower MICs, and 15.9 in upper MICs, compared to 52.3 in HICs.84 In LMICs, specialist psychiatric services are extremely rare and are often largely restricted to a national hospital in the capital city with occasional private practice. In addition, there may be some degree of decentralisation of specialist services to regional levels (with inpatient beds and outpatient services) or even at the district level—although usually this will be restricted to outpatient services, perhaps with a small number of inpatient beds.85

80 Gould, M., Kleinman, M., Lake, A., et al. (2014), Newspaper Coverage of Suicide and Initiation of Suicide Clusters in Teenagers in the USA, 1988–96: A Retrospective, Population-based, Case-control Study, The Lancet Psychiatry, 1: 34–43. 81 Atun (2015), op. cit., nt.48. 82 WHO (2011), Mental Health Atlas 2011 (Geneva: WHO). 83 Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007), Resources for Mental Health: Scarcity, Inequity, and Efficiency, The Lancet, 370: 878–889. 84 WHO (2015), Mental Health Atlas 2014. Available at: www.who.int/mental_health/evidence/atlas/ mental_health_atlas_2014/en/. 85 Jenkins, R., Heshmat, A., Loza, N., et al. (2010), Mental Health Policy and Development in Egypt— Integrating Mental Health into Health Sector Reforms 2001–9, International Journal of Mental Health Systems, 24 June, 4: 17; Mbatia, J. & Jenkins, R. (2010), Development of a Mental Health Policy and System in Tanzania: An Integrated Approach to Achieve Equality, Psychiatric Services, 61(10): 1028–1031;

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Generally, the number of people graduating from a course training mental health professionals in LMICs is low and, of those, a significant proportion emigrate to HICs.86 In a concerted effort to address the long-standing serious damage to LMICs’ health workforces,87 the WHO Code of Practice on the International Recruitment of Health Personnel was adopted by the 63rd World Health Assembly on 21 May 2010.88 The Code recognises the interconnectedness of human resources for health actions in national and global health labour markets, and therefore the need for a systemic approach to health workforce development. It recommends that member states discourage active recruitment from LMICs facing critical shortages of health workers, and that steps are taken to create a sustainable health workforce. Member countries are expected to provide effective workforce planning, education, training and retention strategies that will reduce their need to recruit migrant health personnel. They should encourage and support health personnel to utilise work experience gained abroad for the benefit of their home country. Accordingly, the Code seeks to redress the imbalances in the supply of health workers around the world by raising important human rights issues, including access to health, equity and social justice. In the context of migration, the Code encourages receiving countries to consider the impact of their policies and actions on the countries from which health workers migrate. There have also been strong calls for mechanisms of compensation to donor countries, including a restitution fund to strengthen the health systems in LMICs and to increase the remuneration of local health workers.89 Mackey & Liang have argued that HICs should assume responsibility for the costs they have inflicted on resource-poor populations and should provide equitable resource-sharing to those countries most adversely affected by shortages of healthcare workers.90 They argue for the establishment of a global health resource fund, in conjunction with an international framework for health worker migration. The objective would be to provide global governance to encourage equitable migration pathways and to establish data collection mechanisms in order to provide a clearer picture of how those pathways are changing over time. The primary care workforce in LMICs is also highly constrained, with roughly one nurse and one clinical officer per 10,000 population, compared to one doctor and 0.5 nurses per 1,700 people in the UK.91 Some disorders, such as psychosis, are usually readily visible even to lay people, so they are often already diagnosed and treated by primary care teams in LMICs. Other disorders, especially childhood disorders and adult depression, rarely receive diagnosis and treatment unless primary care workers undergo effective training on mental disorders.92

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Kiima, D. & Jenkins, R. (2010), Mental Health Policy in Kenya—an Integrated Approach to Scaling Up Equitable Care for Poor Populations, International Journal of Mental Health Systems, 4(1): 19. Jenkins, R., Kydd, R., Mullen, P., et al. (2010), International Migration of Doctors, and its Impact on Availability of Psychiatrists in Low Income Countries, PLOS One, 5(2): e9049. Available at: dx.plos. org/10.1371/journal.pone.0009049. Jenkins, R. (2016), Brain Drain, International Psychiatry, 13: 53–55. WHO (2010), Global Code of Practice on the International Recruitment of Health Personnel. Available at: apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R16-en.pdf. Chen, L., Evans, T., Anand, S., et al. (2004), Human Resources for Health: Overcoming the Crisis, The Lancet, 364(9449): 1984–1990; Mensah, K., Mackintosh, M., & Henry, L. (2005), The ‘Skills Drain’ of Health Professionals from the Developing World: A Framework for Policy Formulation (London: Medact UK). Available at: www.medact.org/2005/resources/reports/health-worker-migration-medact-reportpolicy-formulation/. Mackey, T. & Liang, B. (2013), Restructuring Brain Drain: Strengthening Governance and Financing for Health Worker Migration, Global Health Action, 6: 1–7. Jenkins (2016), op. cit., nt.87. Kiima & Jenkins (2010), op. cit., nt.85; Kauye, F., Jenkins, R., & Rahman, A. (2014), Training Primary Health Care Workers in Mental Health and its Impact on Diagnoses of Common Mental

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Health systems worldwide are strained by repeat consultations, misdiagnosis and mistreatment of people complaining of physical symptoms who actually have MNS disorders (usually depression or anxiety). Commonly, in LMICs such persons will be diagnosed by health workers as suffering from malaria, amoebiasis, and typhoid.93 Despite investigations proving negative, they are erroneously treated for such physical conditions, resulting in drug resistance, unnecessary costs, and further repeat consultations as the symptoms remain untreated. In order to reduce such repeat consultations, misdiagnosis and mistreatment, as well as meet population need for treatment and care of mental disorders and reduce premature mortality, it is crucial to integrate biopsychosocial assessment, treatment and care into the existing health system at each level; from primary care (with its community linkages) to district, regional and national levels. This will result in the overall strengthening of health systems. Furthermore, such integration will be strengthened if accompanied by integration of a holistic biopsychosocial approach to all clinical consultations into primary care in order to make use of available, effective and affordable interventions to promote mental health, prevent mental illness, tackle MNS disorders and their accompanying disability, and prevent excessive mortality. It will also improve the prognosis of existing physical illness (since comorbid depression worsens it) and contribute towards achieving universal health coverage as required by SDG target 3.8. To support the integration of a holistic biopsychosocial approach to all clinical consultations into primary care, it is important to include organisational and training programmes for primary care and for the district level staff who supervise those working there—as well as for those to whom they may make referrals. The training programmes need to cover the diagnosis and physical, psychological and social management of mental disorders, as well as the use of psychological interventions and medicines in primary care.94 It is also vital to include dialogue with traditional health practitioners since they are so frequently consulted by those with mental health difficulties (particularly in LMICs).95 However, further research is needed to understand how best to

Disorders in Primary Care of a Developing Country, Malawi: A Cluster-randomized Controlled Trial, Psychological Medicine, 44(03): 657–666; Jenkins, R., Othieno, C., Okeyo, S., et al. (2013), Short Structured General Mental Health in Service Training Programme in Kenya Improves Patient Health and Social Outcomes but Not Detection of Mental Health Problems—a Pragmatic Cluster Randomised Controlled Trial, International Journal of Mental Health Systems, 7(1): 25. 93 D. Kiima (1987), Psychiatric Morbidity among Patients Attending a Primary Health Care Facility from a Deprived Community in Nairobi (Nairobi: Department of Psychiatry, University of Nairobi). 94 See WHO (2010), mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings: Mental Health Gap Action Programme (mhGAP). Available at: www.who.int/mental_health/publications/mhGAP_intervention_guide/en/; see also the guidance from the national Institute for Health and Care Excellence. Available at: www.nice.org.uk/. In addition, see Kauye et al. (2014), op. cit., nt.92; Jenkins et al. (2013), op. cit., nt.92; Jenkins, R., Kiima, D., Okonji, M., et al. (2010), Integration of Mental Health in Primary Care and Community Health Workers in Kenya— Context, Rationale, Coverage and Sustainability, Mental Health in Family Medicine, 7(1): 37–47; Jenkins, R., Kiima, D., Njenga, F., et al. (2010), Integration of Mental Health into Primary Care in Kenya, World Psychiatry, 9: 118–120; Jenkins, R., Othieno, C., Okeyo, S., et al. (2013), Health System Challenges to Integration of Mental Health Delivery in Primary Care in Kenya—Perspectives of Primary Care Health Workers, BMC Health Services Research, 13(1): 368; Othieno, C., Jenkins, R., Okeyo, S., et al. (2013), Perspectives and Concerns of Clients at Primary Health Care Facilities Involved in Evaluation of a National Mental Health Training Programme for Primary Care in Kenya, International Journal of Mental Health Systems, 7: 5; Jenkins, R., Othieno, C., Okeyo, S., et al. (2013), Exploring the Perspectives and Experiences of Health Workers at Primary Health Facilities in Kenya Following Training, Int J Mental Health System, 7(1): 6. 95 Gureje, O., Nortje, G., Makanjuola, V., et al. (2015), The Role of Global Traditional and Complementary Systems of Medicine in the Treatment of Mental Health Disorders, The Lancet Psychiatry, 2(2): 168–177. See also Chapter 7 of this book by Joseph D. Calabrese.

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strengthen the contribution made by traditional health practitioners, and to prevent practices harmful to health and wellbeing. Essential, too, for integrating a holistic biopsychosocial approach in primary care clinical consultations is the mainstreaming of mental health into the WHO Community Based Rehabilitation Strategy (CBR). This is a useful tool to support general intersectoral community development for rehabilitation, poverty reduction, and the equalisation of opportunities and social inclusion of all people with disabilities.96 To be effective in improving wellbeing and meeting SDG3, wider intersectoral collaboration on mental health will also be required at national, provincial, district and local levels. A biopsychosocial approach will result in improved general health outcomes and quality of care, as the complexity of clinical needs from multi-morbidity is better understood and managed. Contrary to common expectation, the integration of a biopsychosocial approach into all clinical consultations also results in a rapidly decreased workload for health staff because psychosocial disorders are more effectively treated. Hence, they are no longer a major contribution to the repeat consultation load of untreated or poorly treated disorders (as well as side-effects from inappropriate medication), and the cost of unnecessary treatments will reduce. When health workers have received comprehensive training in core concepts (mental health, mental illness diagnoses, disability, risk factors, consequences of illness, illness behaviour, mental health promotion, prevention, treatment, rehabilitation, and prevention of mortality), biopsychosocial assessment and management, they should be competent and confident in their ability to address problems that may otherwise be difficult to understand, or indeed frightening. Further, such training will enable health workers to give adequate support to family care-givers who have themselves a propensity to increased rates of depression and anxiety unless well supported. Indeed, this holistic approach to health care is reflected in the Hippocratic Oath and its modern interpretations.97 Health systems will be strengthened if mental health is adequately addressed. The key steps for including mental health in health system strengthening are integration of mental health into primary health care, and mainstreaming mental health into programmes for communicable and non-communicable diseases as well as health system strengthening initiatives. Mainstreaming mental health in programmes on communicable and non-communicable disease and public health is crucial in order to address the comorbidity between mental and physical illness, and to strengthen the positive links between good mental health and good physical health. It is also essential to mainstream mental health within the national Ministry of Health, including programmes on human resource development, Health Management Information Systems (HMIS)— which aim to record and analyse data at each level in the health care system on consultations, diagnoses, treatments, and outcomes—financing, and health sector strategic planning. HMIS is usually inadequate in relation to mental illness, and rarely contains enough illness categories to enable adequate planning for medicine supplies, or to enable monitoring of different conditions.98 At a minimum, this would include data on depression, anxiety, somatisation, conversion disorder, PTSD, acute psychosis, chronic schizophrenia, bipolar disorder, substance abuse, ADHD, childhood emotional disorders including conduct disorders, dementia, and toxic confusional states (delirium).

96 See WHO (2010), Community Based Rehabilitation Guidelines, pp.1–70. Available at: www.who.int/ disabilities/cbr/en/. 97 World Medical Association (2006), WMA Declaration of Geneva. Available at: www.wma.net/-post/ wma-declaration-of-geneva/. 98 Ndeti, D. M. & Jenkins, R. (2009), The implementation of mental health information systems in developing countries: challenges and opportunities, Epidemiologia e Psichiatria Sociale, 18(1): 12–16.

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Integration of mental health into primary care will require the inclusion of mental health competencies for assessment, diagnosis and management in basic training and continuing professional development (CPD) for primary care workers post-basic training, and for district level staff and supervisors, with human resource expansion where possible. This should include sufficient support and supervision of primary health care staff on assessment, diagnosis and management of mental disorders. Furthermore, mental health and mental illness must be incorporated into the agenda of local health and social committees, and their local annual planning and budgeting cycle, as well as into the essential health care package (the guaranteed minimum health care coverage that the government agrees to supply to the population).99 It will be important to include basic psychotropic medicines in local medicine supplies, not only to district hospitals, but also to primary care clinics, in order to avoid relapse and unnecessary transfers to specialist psychiatric hospitals far from the local community of the individual suffering from mental illness.100 In particular, medicine supplies are needed for moderate to severe depression, psychosis and epilepsy. Mainstreaming mental health by including it within the national Ministry of Health will ensure that there is a knowledgeable and experienced mental health section visible within that Ministry. Such a division should have good links to those responsible for health sector reform, primary care, prevention, HMIS, medicine supply, other NCDs and communicable diseases, and with other relevant government ministries including social welfare, education, criminal justice, employment, and culture. Furthermore, links with key non-governmental, community-based and faith-based organisations can be fostered by the mental health team in the Ministry to ensure adequate analysis and input on mental health strategies by key stakeholders. Examples of mainstreaming mental health in the Ministry of Health and across other sectors are documented for several countries, such as Tanzania, Malawi, Zanzibar, Kenya, Egypt and Russia.101 To be successful, integration efforts need to be tailored to the country and cultural context, and human and financial resources. Furthermore, successful integration of mental health care into primary care relies first on a contextual and situational analysis to understand the current context, structure and functioning of the primary care system in the specific country under consideration.102 Leadership and strong governance will be required to implement

99 See WHO (2008), Technical Brief [Essential Health Packages: What are they for? What do they change?]. Available at: www.who.int/healthsystems/topics/delivery/technical_brief_ehp.pdf. 100 Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), How can Mental Health be Integrated into Health System Strengthening?, Mental Health in Family Medicine, 8(2): 115–117; Jenkins, R., Othieno, C., Okeyo, S., et al. (2013), Health System Challenges to Integration of Mental Health Delivery in Primary Care in Kenya—Perspectives of Primary Care Health Workers, BMC Health Services Research, 13(1): 368. 101 Jenkins, R., Lancashire, L., McDaid, D., et al. (2007), Mental health reform in Russia: an integrated approach to achieve social inclusion and recovery, Bulletin of the World Health Organization, 85: 858–866; Jenkins et al. (2010), op. cit., nt.85; Mbatia & Jenkins (2010), op. cit., nt.85; Kiima & Jenkins (2010), op. cit., nt.85. 102 Jenkins, R. (ed.) (2004), International Project on Mental Health Policy and Services. Phase 1: Instruments and Country Profiles., International Review of Psychiatry, 16(1–2): 1–176. See also Jenkins, R., McDaid, D., Brugha, T., et al. (2007), ‘The evidence base in mental health policy and practice’, in M. Knapp, D. McDaid, E. Mossialos, & G. Thornicroft (eds), Mental Health Policy and Practice Across Europe (Buckingham: Open University Press), pp.100–125; Jenkins, R. (2007), ‘Health services research and policy’, in K. Bhui & D. Bhugra (eds), Culture and Mental Health: A Comprehensive Textbook (London: Hodder Arnold), pp.70–86.

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effective change in the system.103 In addition, relevant legislation and the inclusion of mental health in general health policy and health sector reform strategies will be necessary in order to provide the overall policy framework under which systematic change can be driven.104 Also essential is a mental health coordinating unit in the Ministry of Health to oversee strategy implementation, as well as policy dialogue within the Ministry of Health and with other sectors.105 Finally, multisectoral stakeholder collaboration is required, as well as engagement between other health programmes where mental health is relevant, such as infectious diseases, non-communicable diseases, and maternal and child health.106 Collaboration with non-health sectors such as employment, social welfare and education should not be forgotten.107 Furthermore, consideration of development and sustainability of human resources (including capacity), training, and supervision are all vital components of integrating mental health into primary care.108 Improved HMIS is highly important so that mental disorders and their outcomes can be adequately recorded in primary care. There should also be good practice guidelines provided for the assessment, diagnosis and treatment of mental disorders, and universal population access to treatments, including medicines and psychological therapies.109 Finally, the financing of primary care services must be ensured.110

Disasters and conflicts No country can afford to ignore the possibility of disasters, whether man-made or natural. It is clear that all countries need major disaster plans at national and local level that include integration of mental health into frontline care, support and supervision from specialists, and intersectoral

103 Jenkins, R. (2003), Supporting Governments to Adopt Mental Health Policies, World Psychiatry, 2: 14–19; Jenkins, R. (2013), How to Convince Politicians that Mental Health is a Priority, World Psychiatry, 12(3): 266–268; Jenkins, R. (2015), Whither Mental Health Policy – Where does it Come From and does it go Anywhere Useful? Comment on Cross-national Diffusion of Mental Health Policy, International Journal of Health Policy and Management, 4(x): 1–2. 104 Jenkins, R., Heshmat, A., Loza, N., et al. (2010), Mental Health Policy and Development in Egypt— Integrating Mental Health into Health Sector Reforms 2001–9, International Journal of Mental Health Systems, 24 June, 4: 17; Mbatia, J. & Jenkins, R. (2010), Development of a Mental Health Policy and System in Tanzania: An Integrated Approach to Achieve Equality, Psychiatric Services, 61(10): 1028–1031; Kiima, D. & Jenkins, R. (2010), Mental Health Policy in Kenya—An Integrated Approach to Scaling Up Equitable Care for Poor Populations, International Journal of Mental Health Systems, 4(1): 19. 105 Jenkins et al. (2008), op. cit., nt.9. 106 Jenkins, R., Bobyleva, Z., Goldberg, D., et al. (2009), Integrating Mental Health into Primary Care in Sverdlovsk, Mental Health in Family Medicine, 6: 29–36. 107 Nikiforov, A., Bobylova, Z., Gafurov, V., et al. (2007), Mental Health Reform in Russia: an Integrated Approach to Achieve Social Inclusion and Recovery, Bulletin of the World Health Organization, 85: 858–866; Jenkins, R., McDaid, D., Nikiforov, A., et al. (2010), Mental Health Care Reforms in Europe: Rehabilitation and Social Inclusion of People with Mental Illness in Russia, Psychiatric Services, 61(3): 222–224. 108 WHO (2007), Integrating mental health services into primary health care. Available at: www.who.int/ mental_health/policy/services/3_MHintoPHC_Infosheet.pdf. 109 WHO (2010), op. cit., nt.96; R. Jenkins (ed.) (2004), WHO Guide to Mental and Neurological Health in Primary Care (2nd edn) (London: Royal Society of Medicine Press), pp.1–305. 110 Dixon A., McDaid D., Knapp M., & Curran C. (2006), Financing mental health services in low- and middle-income countries, Health Policy Plan, 21(3): 171–182; WHO (2005), Mental Health policy and service guidance package—Mental Health Financing. Available at: www.who.int/mental_health/ resources/en/Financing.pdf.

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coordination. Conflicts are much more common in poor countries, and nearly all LICs have experienced war in the last 50 years or are adjacent to a country that has. This means that they frequently bear the largest burden in caring for refugees.111 Women and children are particularly vulnerable to war, frequently witnessing or being forced to participate in murder, which can cause PTSD. They are often abducted as child soldiers, victims of rape and forced marriage, and infected with AIDS. Such countries have the difficult task subsequently of attempting to rehabilitate these child soldiers and victims of war. Often psychosocial issues remain neglected in post-conflict situations, despite the fact that the presence of psychosocial disorders contributes to low compliance with vaccination, nutrition, oral rehydration, antibiotic intake, and to risky sexual behaviour. Thus, there is high morbidity and mortality from preventable and treatable infectious diseases in refugee populations.

Intersectoral coordination at national, regional and local levels For all the above reasons, in order to meet SDG3 there needs to be a permanent cross-government committee on mental health in every country, as well as regional and local mental health committees to monitor and facilitate collaboration across sectors. There will also need to be policy consideration of operational geographic boundaries relevant for health and social care,112 education and criminal justice so that the various sectors can work together, synchronise, and communicate. This must be facilitated in terms of policy and planning cycles, lines of accountability for joint working with respect to financial and information systems, shared good practice guidelines, and the removal of perverse incentives against cooperation between agencies. Mental health promotion, prevention of morbidity and mortality, and integration of mental health into primary care are the core approaches for achieving target 3.4, as well as being major contributors to SD3 as a whole. They will also contribute to economic development and reduction of poverty (SDG1), and to the reduction of gender inequality (SDG5) as well as other inequalities (SDG10). However, they will be most effective if placed within an overall mental health policy framework, as each SDG is interrelated with and must support the others. An overarching mental health policy framework113 ought to include the following. First, the national components should include the construction of a national strategy to promote mental health, reduce morbidity, and reduce mortality. It should also establish policy links with other government departments, including home affairs, criminal justice, education, housing, and finance. Also vital is the updating or drafting of new mental health legislation in order to set the overall philosophy of approach to the care of people with mental disorders, together with precise provision for assessment and treatment without consent under certain defined conditions.114 Such legislation is essential for safeguarding the health and human rights of people with mental illness, as well as for ensuring

111 See further Chapter 16 of this book by Giuseppe Raviola. 112 Such as, e.g., local authority boundaries in the UK which are responsible for social care and which may differ from the geographical area for which the health authority is responsible, thus adversely impacting upon joined-up care. 113 For an in-depth discussion of these important concepts, see further R. Jenkins, A. McCulloch, L. Friedli, & C. Parker (2002), Developing Mental Health Policy, Maudsley Monograph 43 (London: Psychology Press, Taylor and Francis Group), pp.1–213. 114 For consideration of General Comment No.1 on Art.12 of the CRPD, see Chapter 15 by Dainius Pu¯ras and Julie Hannah. For a critique of the assumption that compulsory treatment of those with mental illness is appropriate and lawful, see Chapter 17 of this book by Peter Lehmann.

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public safety. Also necessary will be mechanisms to ensure sustainable local financing and removal of perverse financial incentives, implementation plans, and the inclusion of an overall system of accountability and governance.115 In addition, the supportive infrastructure components of an overarching mental health policy framework should include strategies in relation to human resources, service user involvement, research and development, and health information. The latter should include local and national systematic collection of indicators of context, mental health needs, service inputs, service processes, and the health and social outcomes achieved by the services. Finally, the service components of mainstreaming mental health through a cohesive policy include the health components of primary care, specialist care, ensuring links between the two, and good practice guidelines to assist the high quality assessment, diagnosis and management of people with mental disorders. It will also require the intersectoral components of health service liaison with NGOs, police, the prison service, the social sector, and dialogue with traditional healers. The non-health service components of direct mental health promotion in schools, workplaces and the community should also be included.116 There is a need for a partnership rather than competition for resources between those working on NCDs and infectious diseases.117 For example, mental health promotion is essential in schools if we are to reduce the risk of AIDS from unprotected intercourse and drugs, and support should be given to girls to be assertive and confident in ensuring their own sexual health and safety. Further, mental health policy needs to be linked with generic health policy. It is particularly important that any general public health strategy addresses mental as well as physical health, so that national mortality indicators include death from suicide for all countries. States must also improve accuracy in recording suicides in order to comply with SDG indicator 3.4.2, and ensure that national morbidity indicators include relevant measures of morbidity due to mental illness. In addition, health impact assessments for proposed policies should explicitly include mental health. Some of the generic health policy issues that will impact on mental health include primary care funding, training and incentive arrangements, and general government health targets. It is essential to ensure mental health is included in generic health reforms, such as the development of health information systems, hospital optimisation programmes,118 quality standards, basic training standards, and accreditation procedures. Governments need to ensure that all relevant agencies are aware of the importance of mental health for the population; that they are aware of the influence that their activities can have on mental health; and that appropriate coordination between relevant agencies takes place. This coordination is often in place for action on alcohol and drugs, and for AIDS programmes, but as yet rarely occurs in relation to mental health programmes, despite mental illness forming the greatest burden across the population.

115 See, e.g., Dixon et al. (2006), op.cit., nt.110, pp.121–127. 116 Ibid., at 97–99 and 101–114. See also Jenkins, R. (2003), Supporting Governments to Adopt Mental Health Policies, World Psychiatry, 2: 14–19. 117 See, e.g., Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), Scaling Up Mental Health Services: Where Would the Money Come From?, Mental Health in Family Medicine, 8(2): 83–86; Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), Social, Economic, Human Rights and Political Challenges to Global Mental Health, Mental Health in Family Medicine, 8(2): 87–96; Jenkins, R., Baingana, F., Ahmed, R., et al. (2011), Health System Challenges and Solutions to Improving Mental Health Outcomes, Mental Health and Family Medicine, 8(2): 119–127. 118 E.g., hospital decentralisation and refurbishment (according to the amount of funding available).

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Conclusion This chapter has summarised overall strategies of mental health promotion, prevention and health system strengthening to achieve SDG target 3.4 in order to build mental capital for sustainable social and economic development.119 The steps described in this chapter will also contribute to meeting many other SDGs such as SDG1, 5, 8, and 10 relating to poverty reduction, gender, economic development, and reducing inequalities respectively. What is crucial in order for states to meet SDG3 is the mainstreaming of mental health not only in the health system, but also in all relevant non-health sectors of education, social welfare, criminal justice, employment, and community development. This will require intersectoral buy-in and collaboration at national, regional and local levels.

119 The Foresight Report (2008), op. cit., nt.10, pp.45–97.

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14 MENTAL HEALTH, DISABILITY RIGHTS, AND EQUAL ACCESS TO EMPLOYMENT Global challenges in light of the Sustainable Development Goals Aart Hendriks* Introduction The relationship between medicine and disability rights is everything but unproblematic.1 This particularly holds true with respect to persons with mental illness and persons with mental disabilities (henceforth, persons with mental health disabilities). Traditionally, they are assumed (wrongly) to be unable to participate as equals in society, particularly in the labour market. In fact, their legal capacity is regularly taken away arbitrarily, leading to a high degree of dependency and vulnerability.2 These prejudices and practices affect persons with mental health disabilities even more in low- and middle-income countries (LMICs); countries that cannot provide basic facilities in various aspects of life. In such countries, people with mental health disabilities often have no access to evidence-based health care and may, for a number of reasons, experience even more exclusion and physical and social violence than in other parts in the world.3 People with mental health disabilities often experience additional hardships in LMICs—not merely economic

* Aart Hendriks is a health and human rights lawyer and Professor in Health Law at Leiden University, The Netherlands. 1 Hendriks, A. C. & Lewis, O. (2015), ‘Disability’, in Y. Joly & B. M. Knoppers (eds), Routledge Handbook of Medical Law and Ethics (Abingdon: Routledge), pp.78–97. 2 Lewis, O. (2015), Legal Capacity in International Human Rights Law (Leiden: Leiden University). See also the Committee on the Rights of Persons with Disabilities (CRPD), 9 Sept 2013, Communication No.4/2011 (Zsolt Bujdosó, et al.), UN Doc.CRPD/C/10/D/4/2011. In this case, the authors of the complaint successfully contended that their automatic disenfranchisement, regardless of the nature of their disability and their individual abilities, was discriminatory and unjustified. 3 Humphrey, M. (2016),‘The intersectionality of poverty, disability, and gender as a framework to understand violence against women with disabilities: a case study of South Africa’, International Development, Community and Environment (IDCE), Paper 36; Kirakosyan, L. (2014), An Examination of Violence Practiced against Disabled Brazilians in Relation to Sustainable Development, Disabilities Studies Quarterly, 34(4). Available at: dx.doi.org/10.18061/dsq.v34i4.3989. See also Patel, V. (2007), Mental health in low- and

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poverty, but regular and severe physical, emotional and psychological abuse, often by their own families.4 These practices most certainly have a negative impact on their overall health and wellbeing.5 Unfortunately, mental health legislation, often aimed at protecting society against persons with mental health disabilities rather than the opposite, may contribute to the segregation of people with mental health disabilities from others in society.6 From an economic perspective, unemployment and segregation are a waste of economic resources; people with the potential to generate an income for themselves independently, be it with or without workplace adaptations, are made dependent on benefits, welfare and health care.7 The economic situation of persons with mental health disabilities is often much worse in countries that cannot afford to support them financially, as is the case in many LMICs. In these countries, people with mental health disabilities are completely dependent on family, friends and charity. From a human and human rights perspective this is catastrophic; a large group of persons who may be highly motivated to participate in the labour market8 is forced to live in economic deprivation. It is important to realise that the unemployment rate of people with mental health disabilities is, in all parts of the world, sometimes as high as 90%.9 Whilst it should be stressed that mental health issues can be both a root cause and the result of poverty and social exclusion,10 unnecessary unemployment deprives those with mental health disabilities of status within their community—thus also adversely affecting their wellbeing. The adoption of the United Nations (UN) Sustainable Development Goals (SDGs) in 2015 provides an excellent opportunity to reflect upon health and health care as human rights. It is also a good reason to examine the way these rights can contribute to rights-based disability policies that—in the words of target 3.4 of SDG3—‘promote mental health and well-being’. In doing so, this chapter will focus particularly on the importance of enhancing equal access

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middle-income countries, British Medical Bulletin, 81–82(1): 81–96. Available at: doi.org/10.1093/ bmb/ldm010. See, e.g., Ssengooba, M. (2012), ‘Like a Death Sentence’: Abuses against Persons with Mental Disabilities in Ghana, Human Rights Watch, Kwesi Kassah, A., Lind Kassah, B. L., & Kobla Agbota, T. (2012), Abuse of disabled children in Ghana, Disability & Society, 27(5): 689–701. Available at: dx.doi.org/10.1080/09 687599.2012.673079. See also Kheswa, J. G. (2014), Mentally Challenged Children in Africa: Victims of Sexual Abuse, Mediterranean Journal of Social Sciences, 5(27): 959–965. See, e.g., Kirk, D. S. & Hardy, M. (2012), The Acute and Enduring Consequences of Exposure to Violence on Youth Mental Health and Aggression, Justice Quarterly, 31(3): 539–567. Available at: dx.doi. org/10.1080/07418825.2012.737471. See also Hecker, T., Hermenau, K., Maedl, A., et al. (2013), Does Perpetrating Violence Damage Mental Health? Differences Between Forcibly Recruited and Voluntary Combatants in DR Congo, Journal of Traumatic Stress, 26(10): 142–148. Available at: doi.org/10.1002/ jts.21770. WHO (2005), WHO Resource Book on Mental Health, Human Rights and Legislation. Stop Exclusion, Dare to Care (Geneva: WHO), Publication No. WHO/MSD/MER/06.2. WHO (2006), Economic Aspects of Mental Health: Key Messages to Health Planners and Policy-makers (Geneva: WHO). Saunders, S. L. & Nedelec, B. (2014), What Work Means to People with Work Disability: A Scoping Review, Journal of Occupational Rehabilitation, 24(1): 100–110. Available at: doi.org/10.1007/s10926013-9436-y. Harnois, G. & Gabriel, P. (2000), Mental Health and Work: Impact Issues and Good Practices (Geneva: WHO and International Labour Organisation), p.9. Weich, S. & Lewis, G. (1998), Material standard of living, social class and the prevalence of common mental disorders, Journal of Epidemiology and Community Health, 52: 8–14. Available at: doi.org/10.1136/ jech.52.1.8.

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to employment, probably one of the most important means to reduce poverty and isolation, whilst at the same time promoting mental health and wellbeing. In discussing this relationship, SDG3 will be examined (relating to good health and wellbeing) and SDG8 (which requires a healthy work environment and economic growth), as well as the Convention on the Rights of Persons with Disabilities (CRPD). The ultimate aim of this chapter is to examine the changes that are needed to enable the full and effective participation and inclusion in society of persons with mental health disabilities, notably through the enjoyment of equal employment opportunities in the spirit of the SDGs. In so doing, there will be a particular focus on LMICs, where access to, and the quality of, mental health care is most problematic, despite about 80% of the total number of people with mental health disabilities living in these countries.11 Thus, these countries deserve special attention and support in terms of sustainable development, SDG3 and SDG8.

Health and health care rights Terminology Health is one of our most precious assets, often underestimated until it is compromised and affecting our wellbeing. Even though there is a general layman’s understanding of the meaning of ‘health’, it is a concept that is extremely difficult to define. The world’s leading description of health can be found in the Preamble to the Constitution of the World Health Organization (WHO), as adopted in 1946. According to its first principle, ‘[h]ealth is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Admittedly, this definition is heavily contested. It is contended that it is obsolete, too vague, unachievable given the emphasis on ‘complete wellbeing’, and dependent on how individuals subjectively interpret their wellbeing, thus lacking operational value.12 Despite this, the WHO’s definition of health remains until today the most authoritative definition of health in the absence of a better alternative. As a corollary, health care can be defined as the maintenance or improvement of the health of individuals and communities. In industrialised countries it is often taken for granted that specially trained medical and paramedical professionals, acting within the realm of their competence, play a crucial role in the provision of health care. In LMICs, access to these professionals is not uncommonly restricted to a selective number of citizens from the highest income groups. Health is not merely dependent on access to health care and the quality of health care. Important as health care is, it should be noted that health—as well as a complete state of

11 De Boer, H. M., Mula, M., & Sander, J. W. (2008), The global burden and stigma of epilepsy, Epilepsy & Behavior, 12: 540–546. Available at: doi.org/10.1016/j.yebeh.2007.12.019. 12 Callahan, D. (1973), The WHO definition of health, The Hastings Center Studies, 1(3): 77–87. Available at: doi.org/10.2307/3527467. See also Jadad, A. R. & O’Grady, L. (2008), How should health be defined?, British Medical Journal, 337(a2900): 1363–1364. Available at: doi.org/10.1136/bmj.a2900. See also Huber, M., Knottnerus, J. A., Green, L., et al. (2011), How should we define health?, British Medical Journal, 343(d4163): 235–237. Available at: doi.org/10.1136/bmj.d4163.

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wellbeing—is influenced by a large number of factors, including individual behaviour, biology and social and economic conditions.13

Health and health care as rights The right to health is one of the most essential human rights,14 and was first recognised as a human right in 1946. This occurred on the adoption of the Constitution of the WHO.15 According to the Preamble of this document, ‘[t]he enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition’. Thus seen, the right to health is closely interconnected with other individual and social human rights, including the right to employment.16 It also transpires from the WHO provision on the right to health that this right is intimately connected to the principles of equality and non-discrimination, with states expected to take measures to enhance the health of all and guarantee access to health care services on the basis of non-discrimination.17 Similar provisions on the right to health were included in 1965 in the International Convention on the Elimination of All forms of Racial Discrimination (ICERD);18 the following year in the International Covenant on Economic, Social and Cultural Rights (ICESCR);19 in 1979 in the Convention on the Elimination of All forms of Discrimination against Women (CEDAW);20

13 Kawachi, I. & Kennedy, B. P. (1997), Socioeconomic determinants of health: health and social cohesion: why care about income inequality?, British Medical Journal, 314: 1037–1040. Available at: www.ncbi. nlm.nih.gov/pmc/articles/PMC2126438/. See also von Rueden, U., Gosch, A., Rajmil, L., et al. (2006), Socioeconomic determinants of health related quality of life in childhood and adolescence: results from a European study, Journal of Epidemiology and Community Health, 60(2): 130–135. Available at: doi. org/10.1136/jech.2005.039792. 14 B. C. A. Toebes (1999), The Right to Health as a Human Right in International Law (Antwerp/Oxford: Intersentia/Hart); Hendriks, A. C. (1998), The Right to Health in National and International Jurisprudence, European Journal of Health Law, 5: 389–408; A. Clapham & M. Robinson (eds) (2009), Realizing the Right to Health (Zurich: Rüffer & Rub); B. C. A. Toebes, R. Ferguson, M. Markovic & O. Nnamuchi (eds) (2014), The Right to Health—A Multi-country Study of Law, Policy and Practice (The Hague: T.M.C. Asser Press/Springer). 15 Grad, F. P. (2002), The Preamble of the Constitution of the World Health Organization, Bulletin of the World Health Organization, 80(12): 981–982. 16 Toebes, B. C. A. (2012), ‘The Right to Health and Other Health-related Rights’, in B. C. A. Toebes, M. Hartlev, A. Hendriks, & J. Rothmar Herrmann (eds), Health and Human Rights in Europe (Cambridge, Antwerp and Portland: Intersentia), pp.83–110. 17 M. San Giorgi (2012), The Human Right to Equal Access to Health Care (Antwerp/Oxford: Intersentia/Hart). 18 Art.5 of the ICERD states: In compliance with the fundamental obligations laid down in article 2 of this Convention, States Parties undertake to prohibit and to eliminate racial discrimination in all its forms and to guarantee the right of everyone, without distinction as to race, colour, or national or ethnic origin, to equality before the law, notably in the enjoyment of the following rights: . . . (e) Economic, social and cultural rights, in particular: . . . (iv) The right to public health, medical care, social security and social services; . . . 19 Art.12(1) of the ICESCR states that ‘States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. 20 Art.12 of the CEDAW states that States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning.

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in 1989 in the Convention on the Rights of the Child (CRC);21 and more recently in 2006 within the CRPD,22 as well as in national constitutions.23 All these international provisions, in addition to those under national law, build on the broad definition of health, as defined by the WHO in 1946. This implies that state obligations in relation to respecting, protecting and promoting health should not be confined to guaranteeing access to health care, but should be extended to improving the underlying determinants of health gradually, such as access to water, sanitation and food, housing, healthy occupational and environmental conditions, and access to education and information.24 Thus, the right to health should be interpreted as an inclusive right, covering both health care and the underlying determinants to health.25 This comprehensive view of health is also reflected in targets listed under SDG3 on good health and wellbeing which require UN member states (inter alia) to strive towards a reduction of the maternal mortality ratio, end a number of communicable diseases, and reduce global deaths for road accidents. These targets cannot be achieved merely by improving health care, but require policies to enhance income-raising opportunities with the participation not only of individuals, but also civil society groups and organisations. This will require the promotion and enforcement of equal employment opportunities (as required by SDG8), and thus increase the participation of people with mental health disabilities and all others in the labour market.

Interim conclusions The importance of health for one’s wellbeing (which states must ensure under SDG3) and one’s societal opportunities is reflected in the fact that health has been acknowledged universally as a human right. Even though the right to health should not be understood as a right to be healthy,26 it imposes an obligation upon states to take a range of measures to meet it, and to respect relevant essential freedoms, in order to enable individuals to enjoy the highest attainable level of health and allow economic growth as required by SDG8. Although health care may play an important role with respect to an individual’s health, it has been acknowledged that health and wellbeing are dependent on many more determinants than the accessibility and quality of health services. Not all of these factors fall within the scope of the roles and duties of health professionals, to the extent that they are available and accessible

21 Art.24(1) of the CRC states that States parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services. 22 Art.25 of the CRPD states that States Parties recognize that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. States Parties shall take all appropriate measures to ensure access for persons with disabilities to health services that are gender-sensitive, including health-related rehabilitation. 23 Heymann, J., Cassola, A., Raub. A., & Mishra, L. (2013), Constitutional rights to health, public health and medical care: the status of health protections in 191 countries, Global Public Health, 8(6): 639–653. Available at: dx.doi.org/10.1080/17441692.2013.810765. 24 UN CESCR, General Comment No.14: The Right to the Highest Attainable Standard of Health, UN Doc.E/C.12/2000/4, 11 Aug 2000, para.11. 25 Ibid. 26 Ibid., para.8.

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to individuals and society at large. Moreover, not all determinants of health can be properly addressed by state policies (such as biological factors). Furthermore, certain state interventions might be inappropriate, as they might lead to unacceptable interferences with individual freedoms associated with health rights (such as the right to choose one’s own lifestyle). Nonetheless, to comply with SDG8 states can develop and enforce occupational health laws to protect the health of employees and to promote decent work conditions. In addition, to ensure nondiscrimination states ought to take measures to protect individuals from harassment and violence by others. States must recognise, therefore, not only the need to create policies to meet their obligations to ensure good health, but also of necessary restrictions on such obligations due to competing rights.

Mental health and disability rights Terminology Following the WHO’s 1946 definition of health, mental health was subsequently defined by the WHO in 2005 as ‘a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’.27 A temporary mental health problem does not necessarily equate to a long-term mental disability.28 Both conditions, however, have in common that they are generally perceived as unhealthy, and sufferers are thought to be in need of medical assistance to solve their so-called ‘medical problems’ and to lack the capacity to take decisions for themselves. As a result of the latter assumption, their legal capacity is often partially or even totally denied,29 making it difficult for persons whose mental health is impaired to exercise such rights as the right to be free from unwanted medical treatment (the right to physical and mental integrity), the right to freedom from unwanted institutionalisation (the right to freedom) and the right to decide where to live and with whom.30 In other words, mental health problems and mental health disabilities are commonly seen as medical conditions that are inherent to an individual and that need to be addressed by treatment and rehabilitation provided by medical professionals.31 In the traditional medical model on mental health disability, it is commonly taken for granted that health care and medical professionals are accessible and available. This, however, is far from the reality in LMICs.

27 WHO (2001), Strengthening Mental Health Promotion (fact sheet No.220) (Geneva: WHO), p.1. 28 The CPRD and other legal instruments differentiate between short and long-term impairments now that individuals are commonly only eligible to benefits in case of long term or lasting inhibitions. Cf. ECJ, 1 Dec 2016, Case C-395/15 (Mohamed Daouidi), ECLI:EU:C:2016:917. In this judgment the European Court of Justice emphasised the importance of distinguishing between a temporary incapacity and a long-term limitation that constitutes a disability. 29 For a consideration of the legal provisions permitting psychiatric treatment on the basis of the assumed mental incapacity of psychiatric patients in the UK and South Africa, see Davidson, L. (2017), Capacity to consent to or refuse psychiatric treatment: an analysis of South African and British law, South African Journal on Human Rights, 32(3): 457–489. See further Lewis (2015), op. cit., nt.2. 30 Robertson, G. B. (2015), ‘Mental Health’, in Joly & Knoppers, op. cit., nt.1, pp.98–111. See also ECtHR 23 Mar 2017, AM-V v. Finland, Application No. 53251/13. 31 Hendriks & Lewis (2015), op. cit., nt.1, p.79.

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A rights-based perspective Mental health and disability rights emerged in response to the massive violations of the rights of persons with mental health disabilities, notably in the context of psychiatry.32 The recognition of persons with mental health disabilities as subjects of rights instead of recipients of care and charity, and subjects of coercion, required a fundamental change in the thinking surrounding mental health. In the traditional, ‘individual’ or ‘medical model’ of disability, a health disability essentially denoted an individual’s inability to function in a conventional way due to a health impairment.33 Scholars in favour of the ‘social model’ of disability34 argue that the solution to problems relating to disability should not be centred on individuals, but that attention should be paid to the interaction between individuals and their environment. It is argued by the proponents of the social model of disability that many obstacles faced by persons with mental health disabilities are erected, imposed and exacerbated by their physical and social environment, often designed by able-minded persons who fail to take into account the needs of differently abled persons. In addition, mental health problems may be the effect of or exacerbated by such factors as unemployment, work-related stress, and uncertainty about one’s income.35 Therefore, it is contended, mental health disabilities are not merely individual characteristics, but a social construct that partially reflects the systematic denial of human rights to a group of individuals deemed less able to function in our society, or at least who do not function in a conventional way, due to individual health impairments. This shift from the individual towards the social model of disability has been reflected in the definition of disability in the CRPD adopted in 2006. According to Article 1 of this human rights Convention, ‘[p]ersons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others’.36 A similar shift towards

32 P. Bartlett, O. Lewis, & O. Thorold (2007), Mental Disability and the European Convention on Human Rights (Leiden and Boston: Martinus Nijhoff), pp.5–7. See also M. Perlin (2012), International Human Rights and Mental Disability Law. When the silenced are heard (Oxford: Oxford University Press); Dudley, M., Silove, D. M., & Gale, F. (2012), ‘Mental health, human rights and their relationship: an introduction’, in M. Dudley, D. Silove, & F. Gale (eds), Human Rights and Mental Health: Vision, Praxis and Courage (Oxford: Oxford University Press), pp.1–50; Slobogin, C. (2015), Eliminating mental disability as legal criterion in the deprivation of liberty cases: the impact of the Convention on the Rights of Persons with Disabilities on the insanity defence, civil commitment and competency law, International Journal of Law and Psychiatry, 40: 36–42. 33 Oliver, M. & Barnes, C. (2010), Disability studies, disabled people and the struggle for inclusion, British Journal of Sociology of Education, 31(5): 547–560. Available at: dx.doi.org/10.1080/01425692.2010.500088. See also Meekosha, H. & Soldatic, K. (2011), Human Rights and the Global South: the case of disability, Third World Quarterly, 32(8): 1383–1397. Available at: dx.doi.org/10.1080/01436597.2011.614800. 34 See, e.g., C. Barnes & G. Mercer (2005), The Social Model of Disability (Leeds: Disability Press); S. French & J. Swain (2012), Working with Disabled People in Policy and Practice. A Social Model (Basingstoke: Palgrave Macmillan); and Oliver, M. (2013), The social model of disability: thirty years on, Disability and Society, 28(7): 1024–1026. 35 Barr, B., Taylor-Robinson, D., Stuckler, D., et al. (2015), First, do no harm: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study, Journal of Epidemiology & Community Health, 70(4). Available at: dx.doi.org/10.1136/jech-2015-206209. See also Milfort, R., Bond, G. R., McGurk, S. R., & Drake, R. E. (2015), Barriers to Employment Among Social Security Disability Insurance Beneficiaries in the Mental Health Treatment Study, Psychiatric Services, 66(12): 1350–1352. Available at: dx.doi.org/10.1176/appi.ps.201400502. 36 Emphasis added. The Committee on the Rights of Persons with Disabilities (CRPD) is very critical of states parties embracing the medical model of disability. See, e.g., CRPD, 4 Apr 2014, Communication No.2/2010 (Liliane Gröninger), UN Doc.CRPD/C/D/2/2010:

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the recognition of the environmental components impacting upon an individual’s functional opportunities underlies the decision by the WHO to replace the 1980 International Classification of Impairments, Disabilities, and Handicaps (ICIDH) by the International Classification of Functioning, Disability and Health (ICF) in 2001. It was maintained by the drafters of the ICF that a diagnosis reveals little about a person’s functional abilities. Whereas the ICIDH was a framework for classifying the (individual) health components of functioning and disability, the ICF looks into factors of relevance for functional abilities more generally. Therefore, the ICF takes into account all aspects of a person’s life (development, participation and environment), instead of solely focusing on the person’s diagnosis. The SDGs tacitly build upon the social model of disability, now that SDG3 sets as a goal the need to ensure ‘healthy lives’ and the promotion of ‘well-being for all at all ages’. However, this approach in no way suggests that the achievement of good health and wellbeing is dependent upon access to and the quality of health care services. The 2030 Agenda for Sustainable Development largely leaves it to UN member states to decide on the measures to be taken which they deem most appropriate to achieve the goals to which they must commit. In so doing, they must abide by the principles to which they have committed in General Assembly Resolution 70/1 (2015),37 including the eradication of poverty, the fostering of social inclusion and the combatting of inequality.38 SDG8 is closely related to these principles, requiring member states to promote ‘full and productive employment and decent work for all’. There are other targets attached to SDG8 (with which SDG3 is interrelated) which are likely to be instrumental in eradicating poverty, fostering social inclusion and combatting inequality.39

Interim conclusions Important as (mental) health care is, increasingly over the course of the last few decades it has been acknowledged that mental health disabilities cannot be equated to mere medical conditions in need of treatment and rehabilitation. In fact, for there to be full participation in society of individuals with mental health disabilities on an equal basis with others—goals which underpin the CRPD and the SDGs—states must take an array of measures not confined to the field of health care, and not restricted to individuals. Such measures are aimed instead at the interaction between individuals and their environment. This idea underlies the recognition of persons with mental health problems and intellectual disabilities as holders of rights, and not mere objects of care and treatment.

Provision of an integration subsidy that only applies to persons with disabilities whose full working capacity may be restored within 36 months [. . .], according to the Committee, seemed to respond to the medical model of disability, because it tends to consider disability as something that is transitional and that, in consequence, can be ‘surpassed or cured’ with time. For a critique of the biomedical model of recovery for those with mental disability, see Chapter 17 of this book by Peter Lehmann. See also Chapter 15 by Dainius Pu¯ ras and Julie Hannah. 37 See A/RES/70/1, Transforming our World: The 2030 Agenda for Sustainable Development, 25 Sept 2015. Available at: www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. 38 Ibid., para.13. 39 Such as achieving full and productive employment and decent work for persons with disabilities, reducing unemployment in young people, and increasing the number in education or training.

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From mental health problems to equal employment opportunities Introduction Like the CRPD and its underlying general principles,40 the SDGs acknowledge the importance of societal participation and equal opportunities for persons with mental health disabilities. They uphold the view that health care can contribute to equal opportunities41 and that full and productive employment for all is not merely a way to achieve sustainable economic growth, but an important means to enable people with mental health disabilities fully and effectively to participate in society, respecting their dignity and inherent human rights. It must, however, also be acknowledged that mental health disabilities frequently obstruct the integration in the workforce of persons who have them, not least because of societal prejudices and discriminatory stereotypes. Disability policies may improve the equal employment opportunities of persons with mental health disabilities.42 These are discussed below.

Policies promoting inclusion and preventing exclusion Article 27 of the CRPD recognises the right of those with disabilities to work on an equal basis with others, including the opportunity to gain a living by work freely chosen, or to be accepted in the labour market and in a work environment that is open, inclusive and accessible to those with disabilities. Education as well as vocational training are probably the strongest tools to promote equal employment opportunities for all and to prevent the exclusion of individuals and groups from the labour market. Given that unemployment, poverty and other forms of exclusion may themselves lead to mental illness,43 measures aimed at promoting equal employment opportunities also contribute to mental health and wellbeing. It is therefore crucial that persons with mental health disabilities are offered equal educational and vocational training opportunities which adequately cater for their needs. This will help to enable persons with mental health disabilities to compete on an equal basis with others in the labour market and prevent their exclusion. Whilst the UN Principles for the Protection of those with Mental Illness (the MI Principles)44 prohibit forced labour of psychiatric patients under Principles 13.3 and 13.4, outside the confines of the hospital, there have been many documented instances of the abuse of those with mental and physical disabilities in employment. Such abuse may involve financial exploitation— underpaid or unpaid work (sometimes due to human trafficking)—or excessive working hours, often in poor or inhumane workplace conditions.45 Whilst the criminal law may apply in such circumstances, an important means of promoting inclusion in the labour

40 Art.3 of the CRPD. 41 Art.25 of the CRPD and SDG3. 42 See OECD (2015), Fit Mind, Fit Job. From Evidence to Practice in Mental Health and Work (Paris: OECD Publishing). Available at: www.oecd.org/els/fit-mind-fit-job-9789264228283-en.htm. See also Koslowski, N., Klein, K., Arnold, K., et al. (2016), Effectiveness of interventions for adults with mild to moderate intellectual disabilities and mental health problems: systematic review and meta-analysis, The British Journal of Psychiatry, 209(6): 469–474. Available at: doi.org/10.1192/bjp.bp.114.162313. 43 See, e.g., Funk, M., Drew, N., & Knapp, M. (2012), Mental health, poverty and development, Journal of Public Mental Health, 11(4): 166–185. Available at: doi.org/10.1108/17465721211289356. 44 UN GA A/RES/46/119), 17 Dec 1991. The MI Principles are now outdated. 45 See, e.g., Balderian, N. (1991), Sexual abuse of people with developmental disabilities, Sexuality and Disability, 9(4): 323–335; Poreddi, V., Ramachandra, R. K., & Math, S. B. (2013), People with mental illness and human rights: a developing countries perspective, Indian J Psychiatry, Apr–June, 55(2): 117–124.

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market is the adoption of comprehensive non-discrimination legislation. However, such laws are meaningless if they are not enforced. Therefore there should be effective dissuasive penalties that deter employers, employees, occupational health professionals and all others in the labour market from discriminating against a person with mental health disabilities. In this respect, it is crucial that non-discrimination laws should not confine themselves to promoting equal treatment (formal equality), but instead focus on equally favourable treatment for all (material equality). The latter implies that individual and group differences, like mental health disabilities, are taken into account and may imply that individuals are treated differently to the extent that they are different to ensure that they are eventually equally well-off. Non-discrimination laws based on material equality, like the CRPD, thus embrace a broad concept of discrimination that stipulates that the denial of a ‘reasonable accommodation’ is also seen as a form of discrimination.46 ‘Reasonable accommodations’ are defined in the CRPD as ‘necessary and appropriate modifications and adjustments, not imposing a disproportionate or undue burden on others, where needed in a particular case, to ensure persons with disabilities can enjoy or exercise their rights on an equal basis with others’.47 Reasonable accommodations for persons with mental health disabilities in the labour market might be the modification of a regular work schedule or more flexibility in working hours to avoid stress or to take into account the effects of medication. Similarly, a job might be restructured by reallocating marginal job functions an individual is unable to do due to an anxiety disorder, or adjusting supervisory methods to allow an otherwise qualified individual who experiences problems in concentration to receive more detailed day-to-day guidance than others.48 Such accommodations might be essential in various situations to enable persons with mental health disabilities to access the labour market.49 States and employers have a certain degree of liberty to decide on the adjustment to be made.50 However, it remains of the utmost importance in all cases to ensure that a reasonable accommodation meets an individual’s needs. In other words, reasonable accommodations should be tailor-made.51 Inclusion and equal opportunities can also be promoted by the provision of information on mental health disabilities to employers, employees, occupational health professionals and others in the labour market, to address concerns and reduce negative stereotypes. Measures such as these are not focused upon individuals with mental health disabilities, but upon their environment; an approach fully in line with the social model of disability according to which there should

46 Waddington, L. & Hendriks, A. (2002), The Expanding Concept of Employment Discrimination in Europe: From Direct and Indirect Discrimination to Reasonable Accommodation Discrimination, International Journal of Comparative Labour Law and Industrial Relations, 18(4): 403–428. 47 Art.2 of the CRPD. 48 Center, C. (2010), ‘Law and Job Accommodation in Mental Health Disability’, in I. Z. Schulz & E. S. Rogers (eds), Work Accommodation and Retention in Mental Health (New York: Springer), pp.17–18. 49 See further on this topic Bell, M. (2015), Mental Health at Work and the Duty to Make Reasonable Adjustments, Industrial Law Journal, 44(2): 194–221. Available at: doi.org/10.1093/indlaw/dwv009. 50 See CRPD, Communication No. 5/2011 (Marie-Louise Jungelin), 2 Oct 2014, UN Doc.CRPD/C/ 12/D/5/2011: 10.5 The Committee considers that, when assessing the reasonableness and proportionality of accommodation measures, State parties enjoy a certain margin of appreciation. It further considers that it is generally for the courts of States parties to the Convention to evaluate facts and evidence in a particular case, unless it is found that the evaluation was clearly arbitrary or amounted to a denial of justice. 51 See Bond, G. R. & Drake, R. E. (2014), Making the case for IPS supported employment, Administration and Policy in Mental Health and Mental Health Services Research, 41(1): 69–73. Available at: doi. org/10.1192/bjp.bp.114.162313. See also Ellison, M. L., Klodnick, V. V., Bond, G. R., et al. (2015), Adapting Supported Employment for Emerging Adults with Serious Mental Health Conditions, The Journal of Behavioral Health Services & Research, 42(2): 206–222.

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be concentration on the interaction between an individual and his or her environment. In this respect, research suggests that an integrated inclusion and equal opportunities approach is the best way successfully to address the impact of mental health disability upon work commitments and productivity.52 This requires a combination of the improvement of knowledge and skills, the specification of responsibilities for the involved actors, financial incentives, and the rigorous implementation and policing of such policies.53 Although contested, inclusion in the labour market for persons with mental health disabilities can also be advanced by the introduction of a quota system.54 Levying a quota means requiring employers to employ a certain number or percentage of employees with health problems or disabilities. However, equal rights and disability rights scholars often deem quota systems to be incompatible with the principles of equality and non-discrimination,55 because they may, unintentionally, reinforce the incorrect assumption that persons with mental health disabilities would otherwise not be eligible for employment due to their lack of competencies or productivity.56 Last but not least, another way to promote the integration and prevent the exclusion of persons with mental health disabilities from the labour market is by integrating mental health into primary health care to prevent mental health problems being neglected by primary health providers, and enable early and effective treatment where possible.57

Interim conclusions Policies enhancing equal employment opportunities for persons with mental health disabilities are largely human rights-based. This reflects the idea that human rights violations arising from poverty or discrimination negatively impact upon mental health. Conversely, respecting human rights can improve mental health, and promote wellbeing.58 Enhancing equal employment opportunities for persons with mental health disabilities requires states and other actors to take a range of measures. Some of these measures are health and health care rights-related (such as occupational health strategies), whilst others are not (such as non-discrimination laws and

52 LaMontagne, A. D., Martin, A., Page, K. M., et al. (2014), Workplace mental health: developing an integrated intervention approach, BMC Psychiatry, 14(1): 1–11. Available at: doi.org/10.1186/1471244X-14-131. See also OECD (2015), op. cit., nt.42. 53 See also Lockwood, G., Henderson, C., & Thornicroft, G. (2014), Mental health disability discrimination: law, policy and practice, International Journal of Discrimination and the Law, 14(3): 168–182. 54 Waddington, L. (1996), Reassessing the employment of people with disabilities in Europe: from quotas to antidiscrimination laws, Comparative Labor Law & Policy Journal, 18: 62–101. 55 See further C. Barnes (1991), Disabled People in Britain and Discrimination: A Case for Anti-discriminatory Legislation (London: Hurst and Co./University of Calgary Press); Waddington, L. (1996), Reassessing the employment of people with disabilities: from quotas to anti-discrimination laws, Comparative Labor Law & Policy Journal, 18: 61–101; and Waddington, L. (2016), Positive Action Measures and the UN Convention on the Rights of Persons with Disabilities, International Labor Rights Case Law, 2: 396–401. 56 For discussion of case studies which challenge this notion, see, e.g., WHO (2009), ‘Mental health, poverty and development’, discussion paper, July; ECOSOC meeting, ‘Addressing noncommunicable disease and mental health: major challenges to sustainable development in the 21st century’, para.6.3 (Interventions for poverty reduction and income generation). 57 Daar, A. S., Jacobs, M., Wall, S., et al. (2017), Declaration on mental health in Africa: moving to implementation and mental disability, Global Health Action, 7: 24589. Available at: dx.doi.org/10.3402/gha. v7.24589. 58 Mann, S. B., Bradley, V. J., & Sahakian, B. J. (2016), Human Rights-based Approaches to Mental Health: A Review of Programs, Health and Human Rights [online], 18(1). Available at: www.hhrjournal. org/2016/05/human-rights-based-approaches-to-mental-health-a-review-of-programs/.

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enforcement measures). Also, it must be emphasised that some such measures should be aimed at individuals with mental health disabilities themselves (such as the provision of reasonable accommodation), but efforts should also be made to influence the environment of these persons to promote equal employment opportunities effectively.

Conclusions and agenda for policy and research In this chapter it has been maintained that promoting equal employment opportunities for persons with mental health disabilities is a human rights requirement which underlies several of the SDGs (notably SDG3 and SDG8) as well as the CRPD. Promoting equal employment opportunities is also related to health and health care. Employment enhances the health and wellbeing of individuals, whilst (mental) health care can lead to an improvement in job opportunities. The latter principle illustrates the importance for LMICs of promoting mental health and strengthening mental health care programmes,59 particularly in view of disproportionately high numbers of persons with mental health disabilities in these countries who have been excluded from the labour market, and who frequently are exposed to many forms of inhuman and degrading treatment.60 The deprivation of employment can impact upon mental health detrimentally, and may eventually lead to social isolation and poverty. Thus, it is in the economic interest of all individuals as well as all states to ensure that nobody is excluded from the labour market. Indeed, the costs of mental ill-health are enormous, for the individuals concerned, for employers (due to job absenteeism and loss of productivity), and for society at large.61 Equal employment opportunities and mental health thus need to be promoted in tandem. It is also well known that employment may cause or exacerbate mental health problems such as stress, anxiety, depression, bipolar disorder, and attention deficit hyperactivity disorder (ADHD), affecting wellbeing and productivity.62 It is therefore important that more research is done on the interrelationship between mental health and employment, including in LMICs, and that employers appropriately consider this issue. Investing in occupational health care will assist in this regard.63 In this chapter a range of measures have been described that are likely to promote the integration and prevent the exclusion of persons with mental health disabilities from the labour market. Such strategies will contribute to the achievement of the SDGs and their targets. It is, therefore, most regrettable that to date very few countries have comprehensive employment policies and laws in place with respect to persons with mental health disabilities. In fact, knowledge about how best to promote equal employment opportunities for this group is still relatively limited.64

59 Semrau, M., Evans-Lacko, S., Alem, A., et al. (2015), Strengthening mental health systems in low- and middle-income countries: the Emerald programme, BMC Medicine, 13(79): 1–9. Available at: doi. org/10.1186/s12916-015-0309-4. 60 Daar et al. (2017), op. cit., nt.57. See also Funk et al. (2012), op. cit., nt.43; WHO (2003), Investing in Mental Health (Geneva: WHO). 61 OECD (2015), op. cit., nt.42. 62 See, e.g., Bilsker, D., Wiseman, S., & Gilbert, M. (2006), Managing depression-related occupational disability: a pragmatic approach, Canadian Journal of Psychiatry, 51(2): 76–83; Chopra, P. (2008), Mental health in the workplace: issues for developing countries, International Journal of Mental Health Systems, 3(4): 1–9. 63 Saunders, S. L. & Nedelec, B. (2014), What Work Means to People with Work Disability: A Scoping Review, Journal of Occupational Rehabilitation, 24(1): 100–110. Available at: doi.org/10.1007/ s10926-013-9436-y. 64 Anderson, R., Wynne, R., & McDaid, D. (2007), ‘Housing and employment’, in M. Knapp, D. McDaid, E. Mossialos, & G. Thornicroft (eds), Mental Health Policy and Practice across Europe (Buckingham: Open University Press/McGraw-Hill Education), p.264.

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Similarly, little research has been conducted on job adaptations (‘reasonable accommodations’) for persons with mental health disabilities. In fact, it appears that people with disabilities are reluctant to ask for a reasonable accommodation, fearing that this may affect their success adversely when applying for jobs, or result in their dismissal or redundancy.65 This emphasises the importance of the enforcement of comprehensive non-discrimination legislation. There are various reasons for the dearth of knowledge with respect to evidence-based employment strategies for those with mental health disabilities. As aforementioned, mental health disabilities have been viewed under the medical model as individual medical issues, and not as a focus for human rights efforts requiring steps to be taken to promote societal integration on the basis of dignity, autonomy and respect, taking into account the contextual factors that lead or contribute to exclusion (as under the social model). The traditional approach towards people with mental health disabilities has hampered research into the employment rights of these persons and the need to design integrated policies, the focus of attention having been upon individuals and their impairments, rather than the interaction between individuals and their environment. Second, mental health disabilities are often considered intractable due to the diversity of mental health conditions and the lack of research and understanding of the aetiology (in relation to the brain) compared with other branches of medicine. Legislatures and policy-makers prefer to design laws and policies that offer solutions for groups, and are less likely to prescribe tailor-made solutions for ‘deviant’ individuals. The reality is, however, that a reasonable accommodation for one person within a group is not always useful to others, and vice versa. This also holds true with respect to persons with the same mental health disability; each person is unique and different. With regard to personalised medicine,66 more research is needed on adaptations, prevention and rehabilitation, with a focus on individuals and their particular needs, instead of seeking to meet the needs of groups. This requires a new approach in the field of employment research; an approach that is still in its infancy. Whilst this may be very costly, particularly for LMICs, it should be a human rights goal to be achieved progressively. From the above analysis it becomes clear that health and health care rights are important preconditions for the enhancement of equal employment opportunities for persons with mental health disabilities, and accordingly, their wellbeing. A broad range of measures will be needed to achieve the aspiration set down in SDG3, and these cannot be confined to the field of health care. Realising the goals laid down in SDG3 and SDG8, as well as meeting the obligations of the CRPD, requires not merely a set of policy measures, but above all research into the effectiveness of the measures described above in this chapter, with a focus on the interaction between individuals and their environment. The lack of research evidence with respect to many relevant employment issues relating to those with mental health disabilities will hinder the systematic implementation of the SDGs through human rights and disabilities policies. However, such absence of knowledge must not deter states from taking further measures in pursuit of achieving the SDGs, whilst simultaneously undertaking much needed research in this area. All states must attempt to improve the mental wellbeing not only of groups, but also of individuals, in order to ensure the sustainable development of our societies. In view of the imbalance between the industrialised and developing worlds, the achievement of these goals—and particularly SDG8 in terms of decent workplace

65 Center, C. (2010), ‘Law and Job Accommodation in Mental Health Disability’, in Schulz & Rogers (2010), op. cit., nt.48, pp.3–32. 66 Hamburg, M. A. & Collins, F. S. (2010), The Path to Personalized Medicine, New England Journal of Medicine, 363: 301–304. Available at: doi.org/10.1056/NEJMp1006304.

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standards—will be an even greater challenge for LMICs.67 At the same time, it should not be forgotten that international human rights law also requires states to assist one another and to cooperate in order to realise human rights worldwide.68 This is another message to be taken from this chapter: the promotion of mental health and the integration of persons with mental health disabilities into the employment market requires the sharing of information, the definition of common goals and plans of action, and collaborative international efforts.

67 Chopra, P. (2009), Mental health and the workplace: issues for developing countries, International Journal of Mental Health Systems, 3(4). Available at: doi.org/10.1186/1752-4458-3-4. 68 Art.2(1) of the ICESCR and Art.32 of the CRPD.

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15 PRIORITISING RIGHTS-BASED MENTAL HEALTH CARE IN THE 2030 AGENDA Dainius Pu¯ras* and Julie Hannah†

Introduction The 2030 Agenda for Sustainable Development signals an ambitious political commitment towards transforming our world into a more just, peaceful and inclusive global community. The 17 Sustainable Development Goals (SDGs) contained in this Agenda centralise health, both as an outcome and as a means to achieving sustainable human development. The SDGs give more prominence to mental health than their predecessors, the Millennium Development Goals (MDGs), signalling a universal commitment to mental health for the second and third decades of the millennium. Other high-profile international processes recognising the imperative of mental health for socio-economic development have complemented this commitment.1 The global mental health crisis has emerged from the shadows and the vibrant community of mental health activists, service users and survivors, scholars, and practitioners have a historic opportunity to advance wellbeing and sustainable human development for all. Regrettably, the SDGs, their targets and indicators lack the specificity required to inform that shift. Many of the targets and indicators are reductive in content and fail to recognise critical right to health elements.2 This is the unfortunate inevitability of international political processes,

* Dainius Pu¯ras is Professor at Vilnius University and UN Special Rapporteur on the right to physical and mental health. † Julie Hannah is the Director of the International Centre on Human Rights and Drug Policy and is based at the Human Rights Centre, University of Essex. 1 National Institute of Mental Health (2016), Out of the Shadows: Making Mental Health a Global Priority, World Bank Organisation and WHO joint meeting, Apr; Mental Health and Human Rights, HRC, Res.A/ HRC/32/L.26 (June 2016); Global Challenges in Global Mental Health (USA). Available at: www.nimh.nih. gov/about/organization/gmh/grandchallenges/index.shtml. Since this chapter was written, two important documents emerged from the UN human rights machinery as vital contributions to the broader international debates discussed herein. See UN GA, HRC, Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (2017), UN Doc.A/HRC/35/21, 35th Session, 6–23 June 2017 (28 Mar), pp.5–6, agenda item 3. Available at: documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement. See also UN GA, HRC, 36th Session, Mental health and human rights, A/HRC/RES/36/13, 11–29 Sept 2017 (9 Oct) (see further p.328 in Chapter 20 of this book by Laura Davidson). 2 UN Special Rapporteur on the right to health, Dainius Pu¯ras, The right to health and the Sustainable Development Goals, A/71/304 (Aug 2016) (hereafter, ‘Right to health and SDG report’).

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where rich substance is watered down in the swim towards consensus.3 It is at this critical juncture that the important work of leveraging these commitments (however vague and insubstantial) into concrete, rights-based mental health strategies lines the road ahead. How to take forward implementation is also where the mental health community fractures.4 How policy-makers are influenced by this fractured community to chart a path towards achieving the SDGs, specifically in relation to mental health, has significant implications for the full and effective realisation of human rights for individuals living with serious psychosocial difficulties. This chapter recognises the importance of the consensus that mental health is a human development imperative, in addition to the need for scaled-up investments to promote health and wellbeing for all. The focus will be on where this consensus fractures, using human rights, including the right to health, both to locate the debates on closing the mental health treatment gap, and to contextualise the urgent need to address the current systemic human rights crisis of contemporary mental health care. The chapter will argue that the dominant biomedical model is no longer compliant with the right to health, examining how the evolving normative, social and scientific landscape demands a paradigm shift to uphold international legal obligations, strengthen the practice of medicine, and improve health and wellbeing.

The emergence of mental health in the global development agenda The political recognition now afforded to mental health is thanks to the efforts of an indefatigable community of advocates over many years. Without wishing to simplify or trivialise the diverse array of important contributions, the chapter will focus specifically upon the global efforts to prioritise closing the treatment gap for mental health. That movement, particularly in low- and middle-income countries (LMICs), has attracted the attention and buy-in of various powerful stakeholders and is poised to be a priority issue in future policy implementation. The movement is amorphous and evolving, but is firmly rooted in conventional psychiatry, with much support from the organised professional psychiatric community, the World Bank, and the World Health Organization (WHO)—all wielding enormous influence with policy-makers in governments around the globe.5 In combination, these stakeholders have established both the moral and economic imperatives for addressing mental health with the shared priority to scale up investment to enable access

3 Here, the authors wish to draw attention to the key difference between human rights and the Sustainable Development Goals: whereas the SDGs are political commitments, human rights give rise to binding and enduring legal obligations to realise the right to mental and physical health. 4 Freeman, M. C., Kolappa, K., Caldas de Almeida, J. M., et al. (2015), Reversing hard won victories in the name of human rights: a critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons with Disabilities, The Lancet Psychiatry, 2(9): 844–850; P. Bartlett (2014), Implementing a Paradigm Shift: Implementing the CRPD in the Context of Mental Disability Law, Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture’s 2013 Thematic Report (Washington, DC: Centre for Human Rights and Humanitarian Law, American University Washington College of Law), pp.169–180; O. Lewis (2014), The Role of Global Psychiatry in Advancing Human Rights’ Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture’s 2013 Thematic Report (Washington, DC: Centre for Human Rights and Humanitarian Law, American University Washington College of Law), pp.247–262; Campbell, C. & Burgess, R. (2012), The Role of Communities in Advancing the Goals of the Movement for Global Mental Health, Transcultural Psychiatry, 49(3–4): 379–395. 5 Patel, V., Garrison, G., de Jesus Mari, J., et al. (2008), The Lancet’s Series on Global Mental Health: 1 Year On, The Lancet, 372(9646): 1354–1357; WHO (2008), Mental Health Gap Action Programme. Available at: apps.who.int/iris/bitstream/10665/43809/1/9789241596206_eng.pdf; Chisholm, D., Sweeny, K., Sheehan, P., et al. (2016), Scaling-up treatment of depression and anxiety: a global return on investment analysis, The Lancet Psychiatry, 3(5): 415–424; World Bank and WHO (2016), Out of the Shadows: Making Mental Health a Global Development Priority,

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to treatment. Such top-down, internationally driven initiatives, whilst of vital utility in placing mental health on the global agenda, will not guarantee policies that benefit the interests and rights of individual users and survivors of mental health services, particularly in parts of the world where outdated and abusive services are the norm.6 In a worst-case scenario, the misuse of scaled-up investment could further drive widespread human rights violations in mental health care systems.7 The loosely aligned movement to close the treatment gap has articulated the case to expand treatment in LMICs and offered a research agenda and the beginning of an operational framework to advance large-scale implementation.8 However, this broad agenda obscures the complexity of the issue, and thus is not without highly credible criticism.9 Points of departure are both conceptual and operational in nature and are worthy of consideration. A few notable critiques are of vital importance to ensure human rights become more firmly rooted within the mental health policy landscape.

Medicalisation of psychosocial disability and mental ill-health Many of the stakeholders calling for the prioritisation of the treatment gap have embraced a diagnostic model to assess the current crisis in mental health, and thus overemphasise interventions to remedy mental illness as a biological phenomenon.10 Much of the literature, particularly publications consolidated in two Lancet series on global mental health, develops the case for clinical interventions that are curative, which lead to improved health, and thereby ensure socio-economic vitality.11 Alarming statistics to indicate the scale and economic burden of ‘mental disorders’ are used to highlight the urgency of the need to expand and develop appropriate treatment.12 The use of such numbers deserves criticism,13 but it is uncontroversial that people experiencing mental ill-health are without access to adequate care and services. This conceptual framing firmly roots the global crisis within a biomedical model (albeit perhaps inadvertently).14 This is situated in direct opposition to the social model of disability promoted by the human rights community and indeed required under the Convention on the Rights of Persons with

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10 11 12 13

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13–14 Apr. Available at: iamhrf.org/sites/iamhrf.org/files/uploads/publication/files/summaryreport_ global_mental_health_event.pdf. Rosen, A., Rosen, T., & McGorry, P. (2012), ‘The Human Rights of People with Severe and Persistent Mental Illness: Can Conflicts between Dominant and Non-dominant Paradigms be Reconciled?’, in M. Dudley, D. Silove, & F. Gale (eds) (2012), Mental Health and Human Rights: Vision, Praxis and Courage (Oxford: Oxford University Press), p.299. To be discussed in more detail in the following section. Chisholm, D., Sweeny, K., Sheehan, P., et al. (2016), Scaling up Services for Mental Health Disorders: A Call to Action, The Lancet, 2007(370): 1241–1252; see also Lancet Series 2011. R. White, S. Jain, D. M. R. Orr, & U. Read (eds) (2017), The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health (Basingstoke: Palgrave Macmillan); C. Mills (2014), Decolonising Global Mental Health (Abingdon: Routledge); Lewis (2014), op. cit., nt.4; Summerfield, D. (2012), Against Global Mental Health, Transcultural Psychiatry, 49(3–4): 519–530. The authors do not dispute that mental illness does indeed exist. Global Mental Health Lancet Series 2001 and 2007. See also Lancet Series 2011. Available at: www.thelan cet.com/series/global-mental-health-2011. Ibid.; see also nt.4. However, see nt.10. See also Summerfield (2012), op. cit., nt.9; Kleinman, A. (2009), Global mental health: a failure of humanity, The Lancet, 374(9690): 603–604. See also the report of UN Special Rapporteur on the right to health, Dainius Pu¯ras, The right to mental health, A/HRC/35/21 (Mar 2017), para.16. Campbell, C. & Burgess, R. (2012), The Role of Communities in Advancing the Goals of the Movement for Global Mental Health, Transcultural Psychiatry, 379: 379–395.

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Disabilities (CRPD).15 Perhaps even more problematic is the way in which a medical framing narrows the full and effective integration of human rights. By emphasising treatment of medical conditions, the inevitable policy arrangement will focus on a basket of services and interventions that achieve a narrow outcome. Prioritising the expansion of curative treatment, typically based on biomedical interventions that still too often rely upon inpatient care and institutionalisation, will leave mental health systems in a state of arrested development.

Subsidiary and selective treatment of rights A primary motivation to close the treatment gap is the protection of the human rights of persons living with psychosocial disabilities.16 Human rights are routinely deployed (and narrowly interpreted) to establish an entitlement to access health services—medicines and other interventions—in order to treat mental illness. Whilst the right to health17 establishes a range of entitlements, including access to health services, it also concurrently guarantees certain freedoms, including freedom from discrimination, forced medical interventions, coercion, violence, torture, and other forms of inhuman or degrading treatment.18 Stakeholders have yet meaningfully to articulate how proposals to scale up treatment will ensure that persons receiving such treatment are free from these abuses endemic in many countries around the globe, particularly in institutional settings.19 Worryingly within this movement, operational references to human rights are often reduced to the requirement of establishing mental health laws20 to protect the rights of persons with disabilities and to establish monitoring mechanisms.21 To conflate human rights with establishing mental health legislation (far too often focused on instituting ‘exceptions’ to legal capacity and the right to be free from deprivation of liberty and any form of violence) is misleading and contributes to a legal environment that enables human rights violations.22 Likewise, reducing the applicability of human rights in mental health to establishing monitoring mechanisms—whilst a critical component in an accountable and rights-protective health system—does nothing to address structural failures within a health system to respect, protect and fulfil the rights of service users. This subsidiary and selective approach to human rights fails to place the rights and experiences of users at the forefront of service design and delivery.

15 CRPD, Art.2. See also Chapter III on the ‘Global burden of obstacles’ which frames this issue in the 2017 report by the UN Special Rapporteur on the right to health, op. cit., nt.1, paras.16–29. 16 Patel, V., Boyce, N., Collins, P. Y., & Horton, R. (2011), A Renewed Agenda for Global Mental Health, The Lancet, 378(9801): 1441–1442. Available at: doi.org/10.1016/S0140-6736(11)61385-8. 17 For more on the right to health, and specifically the right to mental health, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson. 18 International Convention on Economic, Social and Cultural Rights, Art.12; The Right to the Highest Attainable Standard of Health, General Comment No.14, E/C.12/2000/4 (2000) (hereafter GC 14), para.11. 19 Human Rights Watch (2014), ‘Treated Worse than Animals’—Abuses against Women and Girls with Psychosocial or Intellectual Disabilities in Institutions in India; Human Rights Watch (2016), ‘It is My Dream to Leave This Place’—Children with Disabilities in Serbian Institutions. 20 For a consideration of how human rights can be realised whether or not mental health legislation exists, see further Chapter 21 of this book by Laura Davidson. 21 See table of indicators, and specifically, the secondary indicators in Lancet Global Mental Health Group (2007), Scale up Services for Mental Disorders: A Call to Action, The Lancet, 1244. See also WHO (2010), Mental Health and Development: Targeting People with Mental Conditions as a Vulnerable Group (Geneva: WHO), pp.49–52. 22 E.g., through forced treatment, institutionalisation/hospitalisation, and the arbitrary loss of legal capacity.

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Accordingly and regrettably, the world’s psychiatric community has appropriated human rights discourse that is regressive in posture and effect.23 There is a troubling and unhelpful tendency to manufacture a hierarchy of rights, of which the right to access a professional who can provide a person diagnosed with mental illness with treatment is primary. There are numerous practical and legal problems with this position, particularly when it comes to establishing sustainable mental health strategies, policies, and programmes. It places the psychiatric community—gatekeepers to services for people with psychosocial disabilities—at odds with the range of freedoms and entitlements patients are guaranteed under medical ethics and human rights. Likewise, this misconception of rights glosses over the very real and systemic scale of human rights abuse occurring in the name of treatment, at the hands of psychiatric professionals, across the world. It charts a dangerous course that will continue to perpetuate abuse, and, if expanded, will do so exponentially.

Stigma and discrimination World psychiatry and other stakeholders seeking to close the treatment gap have identified stigma as a leading obstacle to the health and wellbeing of people with mental illness.24 There is rich literature within the sciences linking stigma and discrimination to poor health.25 Equality and non-discrimination are essential determinants for mental and physical health and a failure to respect these tenets leads to enduring challenges for people with mental illness.26 From an operational perspective, mere calls from the psychiatric community for an end to stigma and discrimination in health care are insufficient. Stigma reduction requires concrete and targeted steps to make meaningful progress. The right to health requires an understanding of the drivers of stigma and the development of appropriate policy and practices to end discrimination as an immediate priority.27 The field of conventional psychiatry has failed formally to consider the role psychiatric professionals have played and continue to play in perpetuating stigma. Much of the scholarship produced by the profession limits discussion on stigma and discrimination, focusing narrowly on discriminatory actions of health professionals outside of the mental health sector. Whilst this is certainly an important issue,28 it addresses only one key challenge to overcoming discrimination in order to improve health outcomes. Meaningful reflection and policy reform to address the ways in which stigma is fuelled by the asymmetrical power relationship between mental health professionals and patients, and by paternalistic attitudes from psychiatrists and other stakeholders toward users of services, should be central to the psychiatric community’s agenda. Outside of the clinical relationship, psychiatric professionals wield enormous power over an individual at legislative and policy levels. Mental health legislation—for which the psychiatric

23 Maj, M. (2011), The rights of people with mental disorders: a WPA perspective, Lancet Series 2011, 378: 1502 and 1515; Lewis (2014), op. cit., nt.4. 24 See Randall, J., Thornicroft, G., Rohan, E., et al. (2010), ‘Stigma and Discrimination: Critical Human Rights Issues for Mental Health’, in Dudley et al. (2016), op. cit. nt.6, Chapter 5; World Psychiatric Association: Stigma and Mental Disorders. Available at: www.wpanet.org/uploads/Sections/Stigma_and_ Mental_Health/Section%20on%20Stigma%20&%20Mental%20Health%20-%20Report.pdf. 25 See, e.g., McDaid, D. (2008), ‘Countering the Stigmatisation and Discrimination of People with Mental Health Problems in Europe’, Research Paper (Brussels: European Commission). Available at: ec.europa.eu/ health/ph_determinants/life_style/mental/docs/stigma_paper_en.pdf. 26 WHO (2001), Mental Health: New Understanding, New Hope (Geneva: WHO). 27 Right to health and SDG report, para.43. 28 Op cit., nt.21; see also Committee of Experts on Rights of Persons with Disabilities, Council of Europe ‘Developing a Disability Action Plan 2016–2020’, EDF analysis paper, p.37.

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community often lobbies—concentrates and embeds psychiatric authority to override a person’s legal capacity. It is psychiatrists who are empowered as custodians of the state to recommend and administer treatment to people without their consent. In most if not all countries, this legal framework is implemented within a paternalistic culture of health services, further depriving users of their autonomy and participation in their recovery. Within the existing status quo of conventional mental health care, many service providers, including psychiatrists, view people who have lost their legal capacity as not competent, or unable to participate in a range of social, political or economic pursuits. Without better recognition from the psychiatric community of the role of the profession in perpetuating stigma and discrimination—not merely in individual cases, but systematically—and advocacy to develop policy solutions in consultation with the user community, the treatment gap for which this same group of stakeholders so stridently pushes will fail to be closed.

Contemporary mental health care as a systemic human rights issue: historical reflection, root conditions, and a call for change The clinical practice and delivery of mental health services is a history of both scientific achievement and tremendous human suffering.29 Psychiatry as a field of medicine is replete with paternalistic and abusive care practices mostly carried out with the noble desire to reduce suffering and improve the human condition. From the asylums of the 1800s, to the era of psychotropic medicines in the late twentieth century, and up to now with the assertive community care of the new millennium, mental health treatment has been characterised by coercion, restraint, and even sterilisation. The pendulum swings from ‘brainless mind’ to ‘mindless brain’, and it is now back to the excessive reliance on pathologisation and medicalisation.30 Women, and in particular women from racial or ethnic minorities and women who fail to conform to patriarchal gender constructs, have disproportionately suffered throughout this history.31 Treatment has not liberated the world of human suffering, instead producing a legacy of violence where generations of individuals with real or perceived psychosocial disability have been starved of choice, dignity, and community. The award of a Nobel Prize for the lobotomy is a classic illustration of how an egregious human rights violation can be presented as treatment, heralded as scientific achievement, and rapidly integrated into everyday clinical practice.32 It is a chilling warning that the desire both

29 E. Shorter (1997), History of Psychiatry (London: John Wiley & Sons). 30 Report of the UN Special Rapporteur on the right to health, Dainius Pu¯ras (2017), The Right to Mental Health, A/HRC/35/21, para.9. 31 See Committee of the Rights of Persons with Disabilities (2016), General Comment 3, Women and Girls with Disabilities: CRPD/C/GC/3, Aug 2016; Franklin, S. S. (2014), African-American Girls in Foster Care & Psychotropic Medication: Her Right to Survival & Development, Bodily Integrity & Self-determination, ICERD Shadow Report. Available at: tbinternet.ohchr.org/Treaties/CERD/Shared%20Documents/ USA/INT_CERD_NGO_USA_17736_E.pdf; Ortoleva, S. & Lewis, H. (2012), ‘Forgotten Sisters – A Report on Violence Against Women with Disabilities: An Overview of its Nature, Scope, Causes and Consequences’, Research Paper No.104-201221, Aug 2012 (Boston: Northeastern University School of Law); Johnson, M. & Kilty, J. (2014), ‘Power, Control and Coercion: Exploring Hyper-masculine Performativity by Private Guards in Psychiatric Ward Setting’, in D. Holmes, J. D Jacob, & A. Perron (eds) (2014), Power and Psychiatric Apparatus (London and New York: Ashgate). 32 Gross, D. & Schafer, G. (2011), Egas Moniz (1874–1955) and the ‘invention’ of modern psychosurgery: a historical and ethical reanalysis under special consideration of Portuguese original sources, Neurosurgery Focus, 30(2): E8, 1–7. Available at: www.ncbi.nlm.nih.gov/pubmed/21284454; Yong Tan, S. & Yip, A.

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to provide and expand treatment can subordinate the ethical principle of the medical profession to ‘do no harm’ and fundamentally fail to safeguard the human rights and dignity of individuals in vulnerable situations. Likewise, the persistent global problem of institutionalising children is a modern example of how a narrowly conceived social project to protect children with developmental and psychosocial disabilities gives rise to more harm than amelioration.33 Whilst the history of psychiatry has been to a large extent one of systemic human rights violations, it is also a history of progress. As the policy and clinical landscapes of mental health have evolved, scientific evidence and stronger human rights protections have continuously been integrated. With each evolution in treatment and care protocols—be it unchaining people with mental disabilities,34 the rise of psychodynamic therapies, or the arrival of psychotropic medicines—there has been increasing political space for evidence-based treatment, dignity in treatment and recovery, and the beginnings of a human rights-friendly framework of medical ethics to support the everyday practice of psychiatry.35 Despite progress, human rights violations of users of mental health services remain at unacceptably high rates of prevalence and signal the need for a paradigm change. It is not disputed that the lack of resources allocated to mental health is a primary driver of human rights violations, but an equal scale of abuse occurs when resources are invested in stagnant and outdated mental health systems.36 There are numerous examples of significant financial and human resources pouring into mental health services that are, by design, constructed to violate human rights.37 For example, segregated long-term social care institutions and psychiatric hospitals common in Central and Eastern Europe still exist today, with significant investment from EU structural funds.38 Thus, it is vital to advance the global mental health agenda with an understanding of these historical failures and, importantly, to recognise the structural drivers of abuse in the name of psychiatry and medicine. Several root conditions of note are discussed below.

Power asymmetry rooted in coercion A principal factor obstructing progress towards better mental health care services is the monopoly of power in decision-making both at the policy level and in care relationships. Conventional psychiatry has consolidated tremendous influence in determining the clinical direction of mental health treatment. This authority hinges on the premise that psychiatry has specialised scientific insight—and yet it is one that is largely based on poorly understood biological processes. This has concentrated decisions about mental health, policy priorities, and the organisation of care in

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(2014), António Egas Moniz (1874–1955): lobotomy pioneer and Nobel laureate, Singapore Medical Journal, Apr, 55(4): 175–176. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4291941/. See also Schlich, T. (2015), Cutting the body to cure the mind, The Lancet, 2 May: 390–392. Available at: www.thelancet.com/pdfs/journals/lanpsy/PIIS2215-0366(15)00188-1.pdf. WHO and the Gulbenkian Global Mental Health Platform (2015), Promoting Rights and Community Living for Children with Psychosocial Disabilities (Geneva: WHO). Although this is still occurring today throughout the world. Mann, S. P., Bradley, V. J., & Sahakian, B. J. (2016), Human Rights-based Approaches to Mental Health: A Review of Programs, Health and Human Rights, June, 18(1): 263–275. WHO (2001), Mental Health: New Understanding, New Hope (Geneva: WHO). WHO (2014), Mental Health Atlas (Geneva: WHO), p.30. Open Society Foundations (2015), Community Not Confinement: The Role of the European Union in Promoting and Protecting the Rights of Persons with Disabilities to Live in the Community. See also WHO (2013), WHO Comprehensive Mental Health Action Plan (2013–2020) (Geneva: WHO), p.8: 67% of global financing for mental health is directed towards institutions.

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spaces inaccessible to users and without their meaningful input. Likewise, the prevailing paternalistic culture in mental health care undermines patient autonomy and fuels coercive and toxic care relationships.39 Psychiatrists have become formalised gatekeepers of the health and dignity of individuals with psychosocial disabilities, legally entrusted to assess legal capacity and able to administer treatment without consent, often in violent and extremely degrading circumstances. A redistribution of power can fortify protections against systemic abuse, but also strengthen, if not liberate, the practice of psychiatry and mental health care. With shared responsibility amongst a broader landscape of health care professionals, psychiatrists are empowered to support patients with more treatment pathways.40 There is much evidence to support the nourishing effect social science and other disciplines, as well as community and social psychiatry, have had on the field of conventional psychiatry throughout the twentieth century.41

Neurobiological paradigm There is an obvious need to review the neurobiological paradigm that has dominated investments in psychiatry and mental health services during the last three decades. Organising mental health care services around timeworn notions of illness, cure, and excessive medication has proved ineffective in supporting individuals in their recovery. Whilst the biological model was conceived as a means to fight stigma by finding a cure to mental illness, it has backfired, perpetuating rather than ending stigma. Likewise, the over-reliance on pharmaceutical solutions to mental illness has fostered a troublesome partnership between the pharmaceutical industry and psychiatric treatment.42 This is not to say that the future of psychiatry will be without a biomedical component, but it must be recalibrated to enable a bio-psychosocial model based on user-driven concepts of recovery and modern public health.

Selective conceptualisation and implementation of human rights The presumption in favour of certain rights has been at the heart of the psychiatric profession since its inception. From the desire to unchain the mad in prison dungeons43 to the push for deinstitutionalisation today, psychiatry has an enduring blind spot for the holistic nature of rights. In much the same way as the biomedical paradigm is reductive in its clinical approach to mental health, hierarchical concepts of rights reduce their protection and fulfilment in mental health care.

39 Rosen et al. (2012), op. cit., nt.6. 40 See World Psychiatric Association (1996), Madrid Declaration on Ethical Standards for Psychiatric Practice; Shekhar, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007), Resources for mental health: scarcity, inequity, and inefficiency, The Lancet, 370: 878–889. 41 See, e.g., Priebe, S., Burns, T., & Craig, T. K. J. (2013), The future of academic psychiatry may be social, BJP, 202: 319–320; Shorter (1997), op. cit., nt.29; Braken, P. (2014), Towards a Hermeneutic Shift in Psychiatry, World Psychiatry, 13(3): 241–243. 42 Harrison, J. N., Cluxton-Keller, F., & Gross, D. (2012), Antipsychotic Medication Prescribing Trends in Children and Adolescents, Journal of Pediatric Healthcare, 26(2): 139–145; Olufson, M. King, M., & Schoenbaum, M. (2015), Treatment of Young People With Antipsychotic Medications in the United States, JAMA Psychiatry, 72(9): 867–874; P. Gøtzsche (2013), Deadly Medicines and Organised Crime: How Big Pharma has Corrupted Healthcare (London: Radcliffe Publishing); Tyrer P. & Kendall T. (2009), The spurious advance of antipsychotic drug therapy, The Lancet, 373: 4–5. 43 See, e.g., Dr Philippe Pinel’s work in Bicêtre Hospital in Paris, and Shorter (1997), op. cit., nt.29, pp.1–12.

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Prioritising certain rights over others leads to unsustainable policy models, both because they do not enable the realisation of rights, and because they create financially unsound services. One cannot help but draw parallels with the financial and human rights travesties seen in some orphanages.44 Many such institutions arose during an era of charity and paternalism, intending to protect children’s essential needs, including nutrition and shelter. Indeed, the model was a positive advancement for its time. However, in Central and Eastern Europe, countless institutionalised children had at least one parent. The choice to prioritise one category of fundamental rights meant the right to healthy development and a supportive family environment was completely neglected, both as a policy and in practice. The failure to recognise these children as rights-holders requiring holistic responses caused them irreparable psychosocial and physical harm.45 Psychiatric treatment also responds to the needs of persons with psychosocial and intellectual disabilities paternalistically, deciding for users what entitlements they need—hence the evolving phenomena of institutionalisation, forced placement and treatment. The contemporary arrangement of mental health services is a model that has undermined systematically the rights of persons with psychosocial disabilities in open, democratic societies, and has produced historic injustices when applied in closed, authoritarian contexts. The human rights legal framework has responded to this systemic failure with the ratification of the CRPD, shifting the normative landscape substantially. This will be discussed further below.

Human rights and mental health at a crossroads By the end of the twentieth century, convincing evidence had been accumulated in support of a public health framework to address mental health. This was embodied by a 2001 publication from the WHO, establishing a clear consensus reiterated in the 2005 Helsinki WHO Ministerial Conference that mental health must be liberated from outmoded attitudes, stigma, and professional, geographical, and political isolation.46 Nearly two decades have passed since the publication of this landmark report, and yet the global state of mental health remains hostage to the same outdated attitudes with wholly inadequate services. The inadequacy of services remains concentrated in two equally problematic dimensions: parts of the world where no services are available, and parts of the world where services are narrowly constructed and delivered in stigmatising, coercive and inhospitable environments. A reconsideration of the extent to which human rights as an operational framework can add practical value to this health crisis requires urgent attention, particularly as implementation strategies for achieving the SDGs take shape, including strategies around mental health. This chapter provides an introduction to several core operational right to health elements that might contribute towards advancing a paradigm shift in mental health, as well as assist states in meeting SDG3.

44 Report of the UN Special Rapporteur on the right to health, Dainius Pu¯ras (2015), The right to health in early childhood, A/70/213, July, para.73. See also the Annex in UN GA, RES.64/142, Guidelines for the Alternative Care of Children. 45 Ibid. 46 WHO (2001), Mental Health: New Understanding, New Hope (Geneva: WHO).

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Towards a broader understanding of health The WHO’s Constitution defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.47 Mental health must therefore be understood to consist of a range of interconnected elements: biological, social, political, cultural, and environmental.48 Likewise, the CRPD reframes disability, and moves away from a rigid medical model to a more nuanced, social model of disability, thus calling for the full integration of human rights in all health-related policies and services.49 The right to health enshrined in the International Covenant on Economic, Social and Cultural Rights (ICESCR) and enriched by Article 24 of the CRPD establishes a range of obligations, freedoms, and entitlements, which must serve health in the widest sense. This expansive definition of health indicates that a narrow, biomedical approach to mental health care is not compliant with the right to health and is no longer fit for its purpose in practice.

Rights-based mental health treatment: expanding universal health coverage and leaving no one behind General Comment 14 on the ICESCR on implementing the right to health requires states to ensure accountable health systems based on non-discrimination, equality, and participation.50 Strengthening health systems based on these principles is of vital importance for people experiencing and living with severe and persistent mental and psychosocial disability, as they are likely to come into prolonged and repeated contact with services throughout their lives. The right to health explicitly guarantees that health systems provide a number of services to promote mental health and to prevent and treat mental ill-health. Similarly, SDG3 requires states to ‘ensure healthy lives and promote well-being for all at all ages’. Since the ratification of the ICESCR decades ago, advances in the neurological, biological and social sciences have increasingly evidenced that both the mental and physical health of persons experiencing psychosocial difficulties are intimately tied to their physical and psychosocial environment.51 This understanding must become central to modern mental health care, specifically in identifying cost-effective treatment interventions and support which must be made available. This is particularly important when defining the core package of services under universal health coverage schemes expected to be rolled out across the globe by 2030.52 Whilst the 2030 Agenda affirms that universal health coverage and access to quality health care are necessary to

47 Constitution of the World Health Organization, 45th edn, Basic Documents, Supplement, Oct 2006. Available at: www.who.int/governance/eb/who_constitution_en.pdf. 48 WHO (2013), op. cit., nt.38, p.8. The WHO defines mental health as: as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Available at: www.who.int/features/factfiles/mental_health/en/. 49 The Preamble to the Convention on the Rights of Persons with Disabilities states: ‘. . . disability is an evolving concept and that disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others.’ 50 UN Committee On Economic, Social & Cultural Rights, E/C.12/2000/4 (2000), General Comment No.14, The Right to the Highest Attainable Standard of Health. 51 WHO (2013), op. cit., nt.38; WHO (2013), Investing in Mental Health: Evidence for Action (Geneva: WHO). 52 SDG3.8; Right to health and the SDG report; A. Chapman (2016), Human Rights, Global Health, and Neoliberal Policies (Cambridge: Cambridge University Press).

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promote mental health,53 it fails to address specifically the grossly unmet need for rights-based mental health services. Whilst target 3.8 reflects a specific commitment to ‘achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines for all’, a core package of services limited to or overly reliant upon biomedical interventions must be understood as non-compliant with the right to health.54 The biomedical gatekeepers using power to define a limited basket of mental health services must be challenged by a more expansive understanding of health (not to be confused as a more costly understanding of health), incorporating advances in scientific evidence, to ensure that comprehensive public health and psychosocial services are ensured via policy and secured in practice.55 If the treatment gap is to be closed in conformity with the right to health, the global movement for mental health must also make strident demands for community-based and culturally appropriate psychosocial treatment, in addition to evidence-based biomedical care.56 Universal models advanced by the global movement to close the treatment gap, particularly those based on traditional biomedical models of care, run the risk of ignoring the exceedingly important cultural contexts in which real users of services experience their lives.57 Whilst the right to health is instructive in normatively advancing a bio-psychosocial treatment paradigm, there still remains the need to confront the entrenched power imbalance in how mental health services are delivered, and to understand the extent to which the evolving human rights framework tolerates coercion and violence in mental health care. The legal framework—both internationally and domestically—to ensure the health and wellbeing of persons with psychosocial disabilities has developed within a protective construct.58 Issues of consent, intimately tied to legal capacity, are framed by a paternalistic duty to protect. Over the years, this protective paradigm has evolved to include legal standards intended to safeguard legal capacity and informed consent.59 However, these standards permit a range of exceptions and qualifications that, in practice, render safeguards virtually meaningless. Coerced treatment and/or confinement become the rule rather than the exception for many individuals, particularly those with serious mental illness.60 Two underlying principles—medical necessity and dangerousness—continue both to justify and normalise exceptions, perpetuating the protective framework and reinforcing the monopoly of power in decision-making. Authority to assess medical necessity and whether or not a patient is dangerous remains concentrated in the hands of psychiatric professionals who espouse the concepts as watertight safeguards, despite the

53 See SDG3.8. 54 Right to health and the SDG report, paras.86–88. 55 For further elaboration see Hunt, P. & Bueno de Mesquita, J. (2006), Mental Disabilities and the Human Right to the Highest Attainable Standard of Health, Human Rights Quarterly, 28: 332–356. 56 Ibid. 57 White et al. (2017), op. cit., nt.9. 58 Arstein-Kerslake, A. & Flynn, E. (2016), The General Comment on Article 12 of the Convention on the Rights of Persons with Disabilities: a roadmap for equality before the law, The International Journal Of Human Rights, 20(4): 471–490. 59 E.g., Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (1991) (the MI Principles), UN GA RES.46/119, UN GAOR Doc.A/RES/46/119; World Programme of Action Concerning Disabled Persons, GA RES.37/51, adopted 3 Dec 1982, UN Doc(2013).A/37/51 (1982); Declaration of Caracas on the Restructuring of Psychiatric Care in Latin America (1990) (PAHO/WHO). 60 George, S. (2015), UN CRPD: equal recognition before the law, The Lancet Psychiatry, 2(11): e29.

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subjective nature of both.61 Contrary to the myth of dangerousness is the evidence that people with psychosocial disabilities are much more likely to be victims of violence than perpetrators.62 This must be reassessed if stakeholders are serious about the elimination of violence and human rights abuse in mental health care, in order for states to meet obligations on the right to health. The CRPD confronts this protective framing, introducing an enabling legal framework that redistributes (and restores) decision-making power to the individual rights-holders with appropriate protections.63 A critical protection is the requirement to end institutionalisation, where many have been left far behind.64 Fulfilling the commitment in the 2030 Agenda to leaving no one behind (including when meeting SDG3) requires a foundational shift that prioritises those furthest behind first.65 The SDG targets and indicators developed to guide states in achieving this shift are insufficient.66 The right to health is a tool that can help to fill this gap, set priorities, and shape holistic implementation.67 General Comment 14 on implementing the right to health places priority on meeting the health needs of the most marginalised. In particular, it points to the need to prioritise and scale up investment to address the global health crisis of persons with psychosocial disabilities languishing in institutions.68 General Comment 14 also establishes an obligation to refrain from applying coercive medical treatments unless on an exceptional basis, including during the treatment of mental illness.69 Drafted in the 1990s, the right to health (with the General Comment following in 2000) must be understood within this contemporary, shifting normative paradigm.70 To respond to this shift and to ensure the right to health and other corresponding rights of persons with psychosocial

61 Joint Statement from the American Psychiatric Association and the World Psychiatric Association in response to the report of the Special Rapporteur on torture (2014), Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture’s 2013 Thematic Report (Washington, DC: Centre for Human Rights and Humanitarian Law, American University Washington College of Law), pp.141–142; Peterson, J. K., Kennealy, P., Skeem, J., et al. (2014), How Often and How Consistently do Symptoms Directly Precede Criminal Behavior Among Offenders With Mental Illness?, Law Human Behav, 38(5): 439–449. 62 Hiday, V. A., Swartz, M. S., Swanson, J. W., et al. (1999), Criminal Victimisation of Persons with Severe Mental Illness, Psychiatric Services, 50(1): 62–68; Dolan, M. C., Castle, D., & McGregor, K. (2012), Criminally Violent Victimisation in Schizophrenia Spectrum Disorders: the Relationship to Symptoms and Substance Abuse, BMC Public Health, 12: 445; Hiroeh, U., Appleby, L., Mortensen, P. B., & Dunn, G. (2001), Death by Homicide, Suicide, and Other Unnatural Causes in People with Mental Illness: A Population-based Study, The Lancet, 358(9299): 2110–2112; Choe, J. W., Teplin, L. A., & Abram, K. M. (2008), Perpetration of violence, violent victimization, and severe mental illness: balancing public health outcomes, Psychiatr Serv, 59: 153–164; Maniglio, R. (2009), Severe mental illness and criminal victimization: a systematic review, Acta Psychiatr Scand, 119: 180ı191; and Latalova, K., Kamaradova, D., & Prasko, J. (2014), Violent victimization of adult patients with severe mental illness: a systematic review, Neuropsychiatr Dis Treat, 10: 1925–1939. 63 CRPD, Arts 12, 2, and 24. 64 CRPD, Art.19. 65 Right to health and SDG report, para.41. 66 Ibid. 67 Ibid. 68 General Comment No.14, CRPD Committee; The Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, adopted 22 Apr 2002, UN Doc E/CN.4/RES/2002/31 (2002), para.18, 43 (hereafter GC14; Right to health and SDG report), para.44. 69 GC14, para.34. 70 See, e.g., Legal Consequences for States of the Continued Presence of South Africa in Namibia (South West Africa) notwithstanding Security Council Resolution 276, [1971] ICJ Reports 16; Roger Judge v. Canada (2003) Communication No.829/1998, UN Doc CCPR/C/78/D/829/1998, para.10.7; General Comment No.14.

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disabilities, both legislative and programmatic reforms are necessary to enable users of mental health services to make decisions about their health with appropriate support as and when needed. The changing normative paradigm and systemic human rights risk inherent in contemporary mental health services also calls for the elimination of the coercive medical treatment of persons with psychosocial disabilities. In particular, this requires the immediate action to reduce radically coercive medical practices, and the progressive move towards an end to all forced psychiatric treatment and confinement.71

Conclusion The biomedical model has failed in its promise both to cure mental illness with effective treatment and to end stigma and discrimination against persons with mental or psychosocial disabilities. This futile pursuit of cure and salvation has created tremendous human suffering, leaving a pattern of systemic human rights abuses in its wake. Since the start of the millennium, the public health and human rights community have made courageous attempts to transform mental health care, with recommendations to abandon outmoded, discriminatory practices. To date, the prevalence of human rights violations against persons with psychosocial disabilities, particularly those who have resided in institutions, remains unacceptably high. A shift in paradigm is crucial. The normative framework has changed rapidly since the ratification of the CRPD, and there is a need for better commitment to end this unacceptable human rights crisis. Whilst the path ahead is uncertain, one thing is patently clear: scaled-up investments in global mental health can advance only with a human rights-based approach as an obligatory component in all policies and services related to mental health. Any attempts to close the treatment gap that fail to incorporate such an approach are at risk of creating more harm rather than eliminating it. This chapter has attempted to consider ways in which human rights, specifically the right to health, can address harmful power asymmetries and recalibrate the spectrum of treatment and support provided to those with mental ill-health. It has also sought to examine ways of establishing an enabling legal and social policy environment to empower users of services to access acceptable mental health services in the community, with dignity, and on a basis that is equal to that of everyone else. Only if the world changes its paternalistic and neurobiological approach to mental health to one that is grounded in a holistic human rights framework can real progress towards SDG3 be achieved.

71 CRPD General Comment No.1; Report of Special Rapporteur on right to health, Anand Grover, A/64/272 (Aug 2009); Human Rights Commissioner, Council of Europe (2012), ‘Who Gets to Decide? Right to Legal Capacity of Persons with Intellectual and Psychosocial Disabilities’, CommDH/ IssuePaper 2 (Feb).

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16 NATURAL AND HUMANITARIAN DISASTERS, AND MENTAL HEALTH Lessons from Haiti Giuseppe Raviola* Introduction Disasters and emergencies have significant impacts on economic, social, and human development. Natural and humanitarian disasters promote illness and disease in ways proximal and distal to the immediate event, such as through direct physical injury, destruction of infrastructure, worsening of poverty, disruption of primary health care services, increased vulnerability to communicable diseases such as cholera through poor sanitation and lack of preventive resources such as vaccines, and the triggering of psychological and emotional distress. Disasters worsen poor health outcomes at the intersection of communicable diseases and non-communicable diseases (NCDs), including mental health. Complex mechanisms promote comorbidity of mental disorders with other NCDs such as cardiovascular, lung and liver diseases, diabetes, and cancer.1 In the context of natural disasters all of these problems compound one another when co-occurring. Disasters therefore increase the need to directly address and promote mental health and wellbeing, and to minimise greater morbidity and mortality from co-occurring NCDs, infectious disease outbreaks or transmission, and other problems such as substance abuse which can be sequelae of the experience of living through the crisis, stress and grief related to disasters and humanitarian emergencies. In addition, in contexts where there is a lack of services for people living with disabilities, either those pre-existing or caused by the disaster, individuals with disabilities are left particularly vulnerable, including to mental health problems but also other significant psychosocial challenges. Sustainable Development Goal 3 (SDG3), which seeks to ‘ensure healthy lives and promote wellbeing for all at all ages’, is therefore highly relevant in the context of humanitarian emergencies, whether related to the impacts of poverty, natural disasters (such as earthquake or hurricanes), wars or violence, and displacement.2 Broadly, among other health targets, SDG3 seeks to reduce global maternal mortality, end preventable deaths of newborns and children under

* Giuseppe Raviola is Director of the Program in Global Mental Health and Social Change (PGMHSC) at Harvard Medical School, Director of Mental Health for Partners In Health (PIH), and Attending Physician at Boston Children’s Hospital. 1 Patel, V. & Chatterji, S. (2015), Integrating Mental Health In Care For Noncommunicable Diseases: An Imperative for Person-centered Care, Health Affairs, 34(9): 1498–1505. 2 Available at: www.who.int/sdg/targets/en/.

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five years of age, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases while combating hepatitis, water-borne diseases and other communicable diseases, reduce premature mortality from non-communicable diseases through prevention and treatment, promote mental health and wellbeing, and strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol. Regarding health systems, SDG3 seeks to increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing states, and to strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks.3 This chapter explores the relationship of SDG3 to mental health and wellbeing in the context of natural and humanitarian disasters, and offers some strategies for reduction of stress-related conditions and improvement of mental health systems based on a case study of Haiti following its 2010 earthquake, the subsequent ongoing cholera outbreak, and the 2016 hurricane.

Disasters provide opportunities to improve on SDG3 targets Disasters and emergencies offer critical opportunities for systems and policy leaders to reflect upon gaps in health care and to strengthen national health systems consistent with SDG3. This is because mental health has been such a neglected area in health systems globally, regardless of income. There exists a direct relationship between the targets of SDG3 and the strengthening of health systems to provide access and deliver comprehensive, community-based, human rights-centred mental health care for the greatest number of people. In fact, disaster and emergency situations have been used to make substantial and sustainable improvements in mental health systems in low- and middle-income countries (LMICs), and have yielded significant lessons over the past 20 years (see Table 16.1).4 The WHO has worked to raise awareness about this type of opportunity.5 Thus, aside from necessary short-term responses, in important ways actions taken during post-disaster planning can contribute to generating new political support and investment in mental health services and policy development.

International guidance and support during disasters Significant evidence exists regarding the positive impacts of integrated delivery of mental health and psychosocial support with major global health priorities, all of which can be exacerbated in disasters in the context of compromised health systems. Evidence-based interventions exist that are adaptable to cultural contexts, can strengthen mental health care in the post-disaster context, and can reduce morbidity and mortality of comorbid medical conditions. What is essential in the immediate disaster-aftermath is the delivery of timely, community-based, human rights-focused response services as outlined in the 2007 Interagency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings.6 The IASC, created in 1992, has served as an interagency forum and organising structure for coordination, policy development,

3 Available at: www.un.org/sustainabledevelopment/health/. 4 Epping-Jordan, J. E., Ommeren, M. V., Nayef Ashour, H., et al. (2015), Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective, International Journal of Mental Health Systems, 9(15). Available at: doi.org/10.1186/s13033-015-0007-9. 5 WHO (2013), Building Back Better: Sustainable Mental Health Care after Emergencies (Geneva: WHO). 6 Available at:interagencystandingcommittee.org/product-categories/mental-health-and-psychosocialsupport.

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Disaster effects on mental health Table 16.1 Summary of lessons on developing comprehensive, community-based mental health care from disasters and emergency contexts (adapted from Epping-Jordan, et al. (2015)) 1. Mental health reform is supported through planning for long-term sustainability from the outset. 2. The broad mental health needs of the emergency-affected population are addressed, with reforms generally covering a wide range of mental health problems, as opposed to only one disorder (e.g., post-traumatic stress disorder). 3. The government’s central role is respected, with an emphasis on working with the government to enact reform, and within existing government infrastructures. 4. National professionals play a key role, with international experts and agencies involving themselves in mental health reform only to the extent that they are invited to do so. 5. Coordination of actors interested in long-term mental health development typically is crucial when working towards mental health reform, so as not to duplicate efforts. 6. Mental health reform involves review and revision of national policies and plans, with an overall integrated public health approach that involves mental health policy reform and an emphasis on increasing political will for improved mental health care. 7. The mental health system is considered and strengthened as a whole, from community to tertiary care levels. 8. Health workers recruited from local communities are reorganised, trained and supervised so that they are better equipped to manage mental health problems, and to ensure long-term sustainability, and culturally appropriate acceptable interventions. 9. Demonstration projects offer proof of concept and attract further support and funds for mental health reform, and help to ensure momentum for longer-term funding. 10. Advocacy helps maintain momentum for change, with key individuals and groups playing crucial roles in advocating for broader mental health reform, and maintaining momentum for change after the acute emergency.

and decision-making involving key UN and non-UN humanitarian partners in disasters. The UN Office for the Coordination of Humanitarian Affairs (OCHA) was created in 1998 to assist governments in mobilising international assistance when the scale of a disaster exceeds national capacity. OCHA manages several tools to facilitate coordination of multiple actors and resources through the UN Cluster approach—a forum of the most experienced relief agencies. Its aim is to strengthen partnerships and ensure more predictability and accountability in international responses to humanitarian emergencies by clarifying division of labour amongst organisations, and better defining their roles and responsibilities within the key sectors of response. Initiated in 1997, the Sphere Standards describe a set of minimum standards, endorsed by a wide range of humanitarian agencies, to be attained in disaster assistance in each of five key sectors: water supply and sanitation, nutrition, food aid, shelter and health services, with the inclusion of indicators for both mental and social aspects of health.7 All of these initiatives have placed a greater focus upon responsible, community-based, human rights-based interventions relating to mental health and psychosocial support in post-disaster settings. In addition, the WHO and the UN High Commissioner for Refugees have developed a set of recommendations representing emerging consensus on evidence-based practices in mental health care that can be adapted to the context of humanitarian settings—the mhGAP Humanitarian Intervention Guide (mhGAP HIG). This guide includes attention to acute stress, grief, depression, post-traumatic stress disorder, psychosis and other mental health problems, which may worsen during humanitarian crises, and for which services may be lacking.

7 Available at: www.sphereproject.org.

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More recently with regard to development goals, health and disasters, the adoption of the Sendai Framework in 2015 has sought to reduce disaster risks and improve post-disaster responses, rehabilitation and reconstruction through systematic efforts to analyse and reduce the causal factors of disasters.8 The Sendai Framework outlined a broad set of challenges and identified new priorities with regard to disaster risk reduction, with Priority 4 emphasising the need for ‘enhancing disaster preparedness for effective response, and to “Build Back Better” in recovery, rehabilitation and reconstruction’. As part of Priority 4, the Framework describes the need, amongst other priorities, to promote the resilience of new and existing hospitals and other health facilities, to train the existing workforce and voluntary workers in disaster response, to promote the cooperation of diverse institutions, and to ‘enhance recovery schemes to provide psychosocial support and mental health services for all people in need’.9 Therefore the UN and its member states have explicitly recognised through the Sendai Framework the importance of mental health and psychosocial support as part of effective disaster preparation and response, with the hope of informing national, regional and global strategies, policy and commitments that also promote the targets under SDG3.

Mental health and co-occurring health challenges in humanitarian disasters The SDG3 requires the reduction of maternal mortality and preventable deaths of newborns and children under the age of five, the reduction of HIV, tuberculosis (TB) and other communicable diseases, and the achievement of universal health coverage.10 Given the particular vulnerability of certain populations (such as people living in poverty, or women and children) to such conditions, particularly in the context of natural disasters, a social justice and human rights-based approach is essential. In light of common comorbidities of mental health and other medical conditions, research has shown that integrating mental health services into other clinical areas can have significant impacts on a number of health indicators, and this is particularly true in the context of natural disasters. For example, regarding the prevention of maternal death in childbirth, the prevalence and severity of antenatal anxiety and depression may be higher in low- and middle-income countries (LMICs) than in developed countries.11 Disasters will exacerbate problems related to access to quality health care during childbirth. Stress-related and depressive symptoms in mothers, which can increase due to the uncertainties involved with natural and humanitarian disasters, are associated with pre-eclampsia, pre-term births, intrauterine growth retardation, and low birth weight in infants.12 Prioritisation of integrated maternal mental health care, before disasters occur or during the long-term response to a disaster, represents a critical intervention. A number of interventions such as those recommended in the mhGAP HIG (psychoeducation, stress management

8 United Nations Office for Disaster Risk Reduction (2009), UNISDR Terminology on Disaster Risk Reduction (Geneva: UNISDR). See also Tsutsumi, A., Izutsu, T., Ito, A., et al. (2015), Mental health mainstreamed in new UN disaster framework, Lancet Psychiatry, 2(8): 679–680. 9 United Nations (2015), Sendai Framework for Disaster Risk Reduction 2015–2030 (New York: UN). 10 Available at: www.un.org/sustainabledevelopment/health/. 11 Verbeek, T., Arjadi, R., Vendrik, J. J., et al. (2015), Anxiety and depression during pregnancy in Central America: a cross-sectional study among pregnant women in the developing country Nicaragua, BMC Psychiatry, 15(1): 292. 12 Kim, D. R., Sockol, D. E., Sammel, M. D., et al. (2013), Elevated risk of adverse obstetric outcomes in pregnant women with depression, Archives of Women’s Mental Health, 16(6): 475–482.

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skills, basic psychological support, and psychological treatments), can directly address the risks of worse health outcomes. Following depression screening, interpersonal psychotherapy has been observed to reduce depressive symptomatology in pregnant women.13 Regarding the reduction of infant morbidity and mortality, and particularly deaths from malnutrition in the under-fives, exclusive breastfeeding is considered by the World Health Organization (WHO) to be the safest and most effective intervention. Mothers with high levels of psychological distress exclusively breastfeed for a shorter duration; however, a cognitive behavioural counselling intervention delivered in the post-partum period has been shown to reduce the risk of a mother stopping exclusive breastfeeding.14 The development of primary care systems through delivery of services for HIV/AIDS has led to a fundamental shift in global health toward the strengthening of health systems. The more sound the health system, the more prepared the system can be to deliver mental health services. With regard to transmission of HIV in the context of disasters, many issues can co-occur. There exists a greater risk of lack of access to antiretroviral therapy (ART) medication treatments during disasters. Psychiatric diagnoses are more common in HIV patient groups than other populations and are associated with poor ART medication adherence. However, antidepressant treatment for depressed HIV patients is associated with an improvement in ART adherence, and there is also evidence that psychological interventions can lead to improved immune status.15 Therefore, disruptions in treatment for either set of conditions can have a deleterious effect on both conditions. As with HIV and many other diseases, mental health comorbidities are a barrier to patient adherence in TB treatment. The WHO recommends establishing strong therapeutic relationships and mutual goal-setting as interventions to improve TB treatment adherence which will help reduce psychological stress.16 Disruptions in disasters of community-based treatment and support programmes that address co-occurring psychosocial, psychological and infectious disease challenges can lead to significantly worsened outcomes for people living with these conditions, and can disrupt the ability of health systems to address them in a coordinated way.

The 2010 Haiti earthquake response and the emergency response of Zanmi Lasante On 12 January 2010, a major earthquake struck the country of Haiti, resulting in an estimated 300,000 deaths, and leaving approximately 1.5 million people homeless. In the same year, a cholera epidemic began which has continued to the present day, and which worsened as a result of Hurricane Matthew in 2016. For a low-income country, the post-earthquake situation of

13 Spinelli, M. G. & Endicott, J. (2003), Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women, American Journal of Psychiatry, 160(3): 555–562. 14 Wachs, T. D., Black, M. M., & Engle, P. L. (2009), Maternal Depression: A Global Threat to Children’s Health Development, and Behavior and to Human Rights, Child Development Perspectives, 3(1): 51–59. See also Sikander, S., Maselko, J., Zafar, S., et al. (2015), Cognitive-behavioral Counseling for Exclusive Breastfeeding in Rural Pediatrics: A Cluster RCT, Pediatrics, 135(2). 15 See Gaynes, B. N., Pence, B. W., Eron, J. J., & Miller, W. C. (2008), Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV+ patient population, Psychosomatic Medicine, 70: 505–511; Kumar, V. & Encinosa, W. (2009), Effects of Antidepressant Treatment on Antiretroviral Regimen Adherence among depressed HIV-infected patients, Psychiatric Quarterly, 80: 131–141. 16 Available at: dx.doi.org/10.1155/2013/489865. See also WHO (2003), Adherence to Long-term Therapies: Evidence for Action. Available at: apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdf.

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Haiti from 2010 to the present provides a case study in the major challenges involved in ‘building back better’ with regard to mental health care and services, policy and financing, and to the broader strengthening of health systems in highly resource-constrained contexts. In countries where there are few systems leaders and policy-makers with experience in mental health care delivery or service planning, the efforts of Partners In Health (PIH) in Haiti offers an example of priority-setting within the context of SDG3. The case study shows how strategic opportunities can be optimised to demonstrate effectiveness, to develop systems to measure outcomes, and how effective advocacy might lead to greater resources for mental health and psychosocial programme development, albeit operating in a context where mental health systems development and protection for those living with mental illness have not previously been a priority of government policy leaders. Even if productive actions occur in developing a community-based system of care, there is no guarantee that the necessary commitments will be made by governments in planning and financing community-based mental health systems. For this reason, even in the context of disasters, advocacy with governments to develop components of a mental health system is essential. Such advocacy must include demonstration projects with keen government ministry involvement, a national mental health policy and plan, efforts at poverty reduction, convening of key stakeholders into coalitions, and financial and human resource commitments to the replication and spread of proven interventions.17 Prior to the 2010 earthquake, Haiti was the poorest nation in the Western hemisphere, with the country characterised by high levels of rural and urban poverty, weak governance structures, sporadic outbreaks of violence, significant environmental degradation, and poor quality public health systems (particularly for mental health).18 There was no government planning in the development of formal mental health services and systems, aside from two poorly resourced, locked psychiatric facilities in the capital, Port-au-Prince. Culturally, the main community resource for addressing mental health problems historically had been churches or traditional healers. In the context of long-standing social, political, and economic conditions that promoted health crises such as the ongoing cholera epidemic, the development and scaling-up of formal mental health services that were safe, effective and culturally sound was going to present a very significant challenge. Also, the relative disenfranchisement of the Haitian Government, based upon years of foreign intervention and an excessively powerful non-governmental sector, put at risk the capacity of the Ministère de la Santé Publique et de la Population (MSPP—the Haitian Ministry of Health) itself to participate in a process of mental health system reform. Planning processes, therefore, would have to seek to overcome a long-standing lack of trust between government and NGO partners. Founded in 1987, Zanmi Lasante (ZL) is a local NGO that has collaborated for more than 25 years with PIH, an international health care organisation today working in ten countries in close partnership with in-country government officials and leading medical and academic institutions to build local capacity to delivery health care and to strengthen health systems.19 PIH works to

17 Hann, K., Pearson, H., Campbell, D., et al. (2015), Factors for success in mental health advocacy, Global Health Action, 8: 28791. 18 United Nations Development Programme (2011), Table 1: Human Development Index and its components. Available at: hdr. undp.org/en/statistics/hdi/. See also Binder, A. & Grunewald, F. (2010), Haiti: IASC Cluster Approach Evaluation, 2nd Phase Country Study, Apr. Available at: www.unicef.org/eval uation/files/IASC-Haiti-USA-2010-016-2.pdf. See also Sontag, S. (2010), In Haiti, mental health system is in collapse, New York Times, 20 Mar. Available at: www.nytimes.com/2010/03/20/world/americas/ 20haiti.html. 19 Partners In Health (2016), Our Mission. Available at: www.pih.org/pages/our-mission.

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build hospitals, strengthening health centres, and linking community health services to primary and tertiary care resources in low-resource settings in collaboration with government ministries of health. PIH’s main strategic priorities include reduction of maternal deaths in childbirth, child deaths from malnutrition, deaths from HIV, and deaths from tuberculosis—all consistent with major SDG3 targets.20 When Haiti was struck by the devastating earthquake of 12 January 2010, PIH and ZL together became involved in responding to the emergency. At that time, ZL had a staff of approximately 5,400, including 2,500 community health workers (CHWs), and 11 hospitals and health centres working in partnership with MSPP and serving 1.3 million people. The capacity to support government health care delivery efforts therefore pre-dated the natural disaster in the areas where ZL was working. Soon after the earthquake, the Haitian Minister of Health directly asked for the support of ZL and PIH in developing a national mental health response to the postearthquake situation, acknowledging that attention to formal mental health services had not been a priority for the government previously. ZL and PIH proposed a process by which the ZL/PIH NGO team would use the emergency response as a launching point for a long-term investment in developing a community-based model of care that potentially could be emulated by the Ministry if proof-of-concept was demonstrated at the ZL sites. Immediately following the earthquake, PIH therefore became engaged in three primary activities: first, finding, supporting, and treating both the basic psychosocial and acute mental health needs of internally displaced persons (IDPs); second, building capacity for overall psychosocial and mental health services, both preventive and clinical, at ZL sites; and third, supporting the Haitian Ministry of Health in developing a national mental health plan.21 The team drew from current evidence and best practice recommendations to provide an initial mental health and psychosocial response to the emergency, consisting of support to staff members, the launching of child and family-specific social activities, the development of community programmes, training in psychological first aid (adapted to the Haitian context for use by psychologists and social workers), and the implementation of enhanced mental health services at all ZL sites, including the training of primary care physicians in managing acute distress states and in using psychopharmacology. The psychopharmacologic formulary utilised by the organisation was expanded to contain a range of options for managing acute distress states and more chronic mental illness, and all of these interventions helped to stabilise individuals and communities during the early phases of the emergency. This included ongoing coordination and collaboration with a ZL rehabilitation team for those who had been injured physically in the earthquake, as well as ongoing collaboration with a new orphanage, Zanmi Beni, that was developed following the earthquake to meet the needs of children living with physical and intellectual disabilities. These children had been abandoned in the back rooms of the national university hospital prior to the earthquake, reflecting a lack of pre-existing services to support families with children with disabilities, and adults living with disabilities. Bearing in mind that there was no dedicated mental health programme prior to the 2010 earthquake, in the aftermath for the first year and a half ZL and PIH served the mental health needs of thousands of people, both within and travelling outside the PIH catchment areas of central rural Haiti. Over the following years the organisation became recognised as a national referral centre for mental health care. Whilst the organisation responded to the emergency, it did so with

20 Available at: www.who.int/sdg/targets/en/. 21 Raviola, G., Eustache, E., Oswald, C., & Belkin, G. (2012), Mental health response in the aftermath of the 2010 Haiti earthquake: a case study for long-term solutions, Harvard Review of Psychiatry, Jan–Feb, 20(1): 68–77. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3335115/.

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attention to laying the groundwork for a longer-term community-based mental health system, with knowledge of the lack of resources at two national psychiatric facilities, and in response to the request of the MSPP.

A long-term community-based mental health initiative In 2011 the Pan-American Health Organization (PAHO) carried out an assessment of the Haitian mental health system using the WHO-Assessment Instrument for Mental Health Systems (WHO-AIMS).22 This revealed that despite the many initiatives of leading Haitian psychiatrists from the 1940s to 1960s to establish a mental health sector within the MSPP, the country lacked mental health legislation, a national mental health policy, a mental health strategic plan, and any reliable data on the prevalence of mental health problems. Mental health services were provided almost exclusively by the public sector and limited to two psychiatric hospitals: the 120-bed Défilée de Beudet Hospital, located outside Port-au-Prince, and the 60-bed Mars and Kline University Hospital in the capital city. Services for people living with disabilities were non-existent. The limited government resources available for mental health service delivery have continued to be centralised almost entirely within these two facilities, both of them already dilapidated prior to the earthquake. In 2001, 18% of patients in these facilities had been hospitalised for ten years or more, and neither facility had a human rights monitoring system. Besides Mars and Kline and Beudet Hospitals, some NGOs and religious organisations have run several mental health programmes, particularly in rural areas of the country. Other limitations of the system had included a significant scarcity of specialised human resources. In 2011 Haiti had only 27 psychiatrists, most of whom were practising in the private sector in the capital. Although only estimates, nationally there were around 194 psychologists (at either undergraduate or graduate level), 82 social workers, 14 general practitioners trained in provision of mental health care, three psychiatric nurses, and only one neurologist. Overwhelmingly, health providers were insufficiently trained to provide mental health care and had no treatment protocols or guidelines from which to work. The cost of treatment was also identified as a barrier to access and care, with no social security insurance system in Haiti, and the cost of antipsychotic and antidepressant medications prohibitive, given the national income average of US$2 per day. The WHO-AIMS evaluation made several recommendations orientated towards communitybased mental health system reform, including decentralisation of mental health services from general hospitals to primary health centres, and the training of non-specialist health providers. However, in 2016, an external consultation by a consultant psychiatrist from PAHO confirmed that five years after the WHO-AIMS publication, the mental health system in most of Haiti remained almost unchanged, with mental health still underfunded by the government and public mental health services for most of the country still provided by the two psychiatric institutions.23 Less than 10% of the national budget is allocated to health, and only 1.5% of the total health budget is allocated to mental health. Specialised human resources continue to be scarce, with only ten psychiatrists and three psychiatric nurses currently working in the public sector. The annual budget of the Mars and Kline Hospital is currently approximately US$30,000. Physicians

22 World Health Organization (2011), Le système de santé mentale en Haïti: rapport d’évaluation du système de Santé mentale en Haïti a l’aide de l’instrument d’évaluation conçu par L’Organisation Mondiale de la Santé (OMS) (Ministère de la Santé Publique et de la Population, Organisation Mondiale de la Santé, Organisation Panamericaine de la Santé). 23 Echeverri, C. (2016), Assessment of the Mental Health System in Haiti: Needs and Perspectives (Pan-American Health Organization and Zanmi Lasante/Partners In Health), 13–15 June.

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and psychologists do not receive training in bio-psychosocial approaches to evaluation, diagnosis and treatment. No national treatment protocols exist, and general practitioners frequently refer patients to the psychiatric hospitals rather than manage them independently.24 From 2010–11, a planning model was articulated by PIH/ZL with the intention of presenting a clear strategy based on current knowledge of what was possible, and with an eye toward coordinating approaches, building consensus and the political will to bring change.25 Broad mental health needs were pursued, with an acknowledgement that the limited resources would necessitate a certain focus on a limited number of conditions within a comprehensive approach to care. For this reason, the prioritised conditions were chosen following a combination of evidence and expert opinion: qualitative assessment during the year following the earthquake, local and international experts’ views, an understanding of the burden of illness with regard to common mental disorders such as depression, in addition to knowledge of the severity of severe psychotic disorders and the potential risks of leaving them unaddressed. The government’s mental health representatives were engaged in the process, provided recommendations and participated in learning over the course of the development of the system of care. To a significant degree, Haiti has historically been dictated to by foreign powers (whether under slavery and colonialism until revolutionary independence from France in 1804, or thereafter). As a dependent peripheral state with outsiders seeking to influence the Haitian economy, the need for international actors to be cognisant of historical precedent was considered essential.26 Over the course of the development of a community-based model of care, multiple meetings were held to update the Ministry of Health on developments related to the pilot project. An understanding of the local context was considered critical for the adaptation of approaches from external sources. Thus, the project was led by a local team of implementers at ZL who, working in collaboration with a cross-site team from PIH, made decisions about appropriateness and suitability of clinical and administrative approaches to programme development. A qualitative assessment to evaluate local perspectives and priorities with regard to mental health was carried out which indicated that local community members, traditional healers, and medical providers agreed that depression care was a priority. Accordingly, the ZL/PIH mental health team initially developed a care pathway for depression care. In alignment with the WHO’s mhGAP Intervention Guide,27 ZL/PIH created an adapted curriculum for depression as an initial condition through which to articulate a system of care, tailored to each provider-type along with care protocols, clinical support tools, and curricular materials for depression. Several years after the earthquake in 2012, a locally valid screening tool for depression using local concepts of illness that could be used by CHWs in assessing depression was developed—the Zanmi Lasante Depression Screening Inventory (ZLDSI).28 This locally validated stepped care model for depression was included in a collaborative depression care pathway and developed as a template for a new formal community-based system of care.

24 WHO (2011), op. cit., nt.22. 25 Belkin, G., Unützer, J., Kessler, R., et al. (2011), Scaling up for the ‘bottom billion’: 5 x 5 implementation of community mental health care in low-income regions, Psychiatr Serv., 62(12): 1494–1502. Available at: doi.org/10.1176/appi.ps.000012011. 26 P. Farmer (2006), The Uses of Haiti (Monroe: Common Courage Press), pp.65–74. 27 WHO (2016), WHO Mental Health Gap Action Programme (mhGAP). Available at: www.who.int/ mental_health/mhgap/en/. 28 Rasmussen, A., Eustache, E., Raviola, G., et al. (2015), Development and validation of a Haitian Creole screening instrument for depression, Transcultural Psychiatry, Feb (epub 30 July 2014), 52(1): 33–57. Available at: doi.org/10.1177/1363461514543546.

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Medication Hospital/clinic Rescreen with ZLDSI, perform Initial Mental Health Evaluation (psychologist/SW)

Hospital/Clinic Case identification (nurse)

Above 18

Acute (between 28 and 39)

Physician

Less acute (between 18 and 27) Psychologist/SW IPT

Screen with ZLDSI Between 13 and 17

Community Case identification (CHW)

Community Follow-up and IPT (CHW)

Figure 16.1 The depression care pathway developed in Haiti by Zanmi Lasante and Partners In Health29

Based on the ZLDSI score, CHWs now refer moderate and severe cases of mental illness to Haitian psychologists embedded within the primary care system, who in turn refer more acute and severe patients to physicians for medication prescription. Psychologists and social workers manage most of the cases with psychotherapy (including a version of interpersonal therapy (IPT) adapted to the Haitian context), psychoeducation, behavioural activation, and relaxation techniques adapted by local providers. As patients improve, they return to the community where CHWs continue care using a simplified version of IPT adapted to the Haitian context. Nurses also identify depression cases within the clinic or hospital, and refer them to psychologists and social workers. IPT was chosen because of its effectiveness in treating depression and post-traumatic stressrelated pathology in high- and low-income settings, as well as its emphasis on the social and interpersonal approach, which was perceived by the team of local nationals as critical in the Haitian collective society. Qualitative interviews with local community members, health care providers, and community leaders prior to implementation and adaptation of the intervention reinforced the decision to start with a focus on depression. Its further adaptation for the Haitian context followed an iterative process that resulted from the collaboration between two sources of expertise: the Haitian team’s local, clinical, and cultural expertise and the U.S.-based trainer’s IPT expertise. The two parties guided each other in identifying areas in the IPT strategies that needed modification: incorporation of local practices and rituals; addition of strategies that were popular in Haiti (such as various types of relaxation that our local colleagues had always used successfully); and use of religion as a major spiritual and social resource.30

29 Adapted from Raviola, G., Eustache, E., Oswald, C., & Belkin, G. (2012), Mental health response in the aftermath of the 2010 Haiti earthquake: a case study for long-term solutions, Harvard Review of Psychiatry, Jan–Feb, 20(1): 68–77. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3335115/. 30 Verdeli, H., Therosme, T., Eustache, E., et al. (2016), Community norms and human rights: supervising Haitian colleagues on interpersonal psychotherapy (IPT) with a depressed and abused pregnant woman, Journal of Clinical Psychology, 72(8): 847–855.

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Care pathways for the remaining priority disorders were also subsequently developed. Patients began receiving formal mental health services in the several years following the earthquake, and by word of mouth the effectiveness of the services provided was noted and observed in the community. A subsequent qualitative study focusing on perspectives of care recipients has shown the feasibility of this approach and its acceptability to service users.31 Cultural adaptation of all elements of the system was led by the local team, and all clinical care was provided by local providers hired and working within the existing health care delivery system. Particularly important components of the system include a monitoring, evaluation, and quality improvement (MEQ) system, and a clinical supervision system to monitor patient safety. A clinical supervision model was developed through the creation of a local provider expert supervisor group, and an electronic data collection system was developed following pilots with a paper system. Due to the lack of consistent internet or WiFi access, this is a computer-based system that is managed by site psychologists, with data shared with a cross-site coordinator at monthly team meetings. Ongoing use of an evolving electronic medical record system increasingly enables the collection of patient encounter data across all facilities and allows the team to measure and report on many indicators, including the number of patients (including children), patient visits, distribution of disorders, interventions received by patients, and change in patient symptoms over time. For example, currently ZL provides care for more than 3,500 patients. From 2,500 mental health patient visits across 11 facilities in 2013, the numbers increased to 4,500 patient visits in 2015 to more than 8,000 mental health patient visits in 2016. This represents an increase in service demand of 320% from 2013 to 2016. The clinical supervision system has been designed to address Haiti’s lack of expert human resources. Accordingly, a clinical supervisor is assigned for each type of provider (physicians at hospitals and clinics, nurses at hospitals and clinics, psychologists/social workers at hospitals and clinics, and community health workers in the community), and a psychologist supervisor provides one day of supervision at each site on a monthly basis, with telephone supervision sessions also available to discuss challenging cases. There is also a monthly gathering of psychologists with their supervisors for capacity-building, review of any adverse events, additional didactic learning and refresher training, and sharing of computer-based data with the team coordinator. Both CHWs and psychologists who provide IPT are supervised by an American expert over the telephone on a weekly basis. Finally, in terms of psychiatrist support, the programme has developed a fellowship in global mental health delivery, supported by PIH and Harvard Medical School in the US. An early-career US psychiatrist provides supervisory clinical support of the ZL and PIH initiative in Haiti, and supports the ZL mental health supervisors in their work. The opening of a 300-bed tertiary medical centre, Mirebalais University Hospital (HUM) in 2012, jointly run by MSPP, ZL and PIH, provided a central base for the supervision team’s activities. HUM is currently one of the few fully operational university hospitals in the country. For over six years PIH and ZL have worked together to build a community-based model for mental health care service delivery integrated into a primary care system run by ZL and delivered through 11 sites in two areas of Haiti—the Central Plateau and Artibonite—within a catchment area of 1.3 million people. Since 2011 Haitian non-specialists have been recruited, trained, employed and supervised in mental health care delivery, based on current practices in the field of global mental health.

31 Fils-Aimé, R. (2016), Recovery from Psychosis in Rural Haiti: A Qualitative Study of Lived Experience (Master of Medical Sciences in Global Health Delivery thesis; Boston: Department of Global Health and Social Medicine, Harvard University), May.

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Between 2012 and 2015, PIH and ZL developed context-appropriate curricula across four priority disorder areas (depression, psychotic disorders, epilepsy, and child and adolescent mental health) tailored to different providers, as well as cultural and service system-appropriate encounter tools for care delivery. These encounter tools include evaluation of follow-up forms, care delivery checklists for each priority condition, and protocols for psychopharmacologic management, as well as for safe management of agitated patients. The main objective of the programme has been to build the capacities of community health workers and non-specialist health care professionals to provide mental health treatment and care.32 Starting with depression a collaborative, steppedcare, task-sharing model was employed, with clinical, service delivery, systems-building, and quality improvement responsibilities distributed within a multidisciplinary team. Between January 2013 and December 2015, approximately 10,000 people in Haiti received care within the system, with approximately 2,000 diagnosed with depression, 1,500 diagnosed with epilepsy, and 1,000 diagnosed with a psychotic disorder. By 2015, 88 CHWs, 114 mid-level providers (psychologists and social workers), 86 nurses and 37 physicians were trained across the different care pathways, with 72 nurses and 31 physicians trained in pharmacology. Any improvement in the functioning of patients receiving care in the system was measured using the WHODAS 2.0 Brief,33 and improvement in depression symptoms was recorded using the ZLDSI. Throughout 2016, services were ongoing, with efforts sustained to collect outcome data, optimise clinical supervision systems, and improve the overall system of care. Between 2013 and 2016, ZL/PIH recorded almost 19,000 patient visits, and between 2015–16, 2,355 individual patients were served. A qualitative study of patient and family experience of the system of care was also completed. From 2014 to 2016, a significant and robust qualitative research assessment of the programme and its impact on patients and families was undertaken at ZL by a Haitian member of the team with support from PIH and Harvard Medical School. Through focus groups and individual interviews, this research engaged the perspectives of 75 people, comprised of 24 persons with lived experience of psychosis, 22 family caregivers, five CHWs, three religious leaders (houngan and pastors), eight doctors and nurses, eight psychologists and social workers, and five national policy leaders. The research applied a purposeful maximal variation sampling methodology to explore local knowledge, lived experience, and best paths to recovery from psychosis in the rural Haitian context. Through this research, persons with lived experience of psychosis and their families narrated their journeys before entering the ZL programme, and described experiences that were personally, socially and economically devastating. Not surprisingly, family members involved in the care-seeking and caregiving process reported many structural constraints such as inaccessibility of care in the past, poverty and stigma in seeking care and support. They often faced moral quandaries and were forced to make impossible choices whilst desperately trying to take care of their loved ones (for example, having to leave sick family members at the hospitals in Port-au-Prince). Study participants generally asserted the relevance and effectiveness of the mental health services offered at ZL, and also of the importance of taking medication and remaining in care for recovery when living with a severe mental illness. Their experiences in the study suggest a model of recovery is required that encompasses clinical recovery, social and spiritual connections, and the ability to fulfil one’s social role, not unlike similar studies in other contexts. The findings of this study have resulted in recommendations about appropriate rehabilitation programmes and tools, and the need for a national mental health system in Haiti that effectively

32 For more on the use of lay workers in the mental health field, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, and Chapter 8 by Carol Vlassoff. 33 Available at: www.who.int/classifications/icf/WHODAS2.0_12itemsSELF.pdf.

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facilitates recovery.34 It reinforces the notion not only that the direction that the ZL/PIH team has taken in developing formal mental health services is fulfilling a critical need in the communities that are served, but also that greater commitment of resources, training and systems are needed country-wide. With this recovery model in mind, it is recommended that implementers seek to go beyond clinical improvement and to facilitate the learning of essential skills.35 They must also engage the community and accelerate structural changes that will allow persons with lived experience of psychosis in the rural context to fulfil the social roles that they value most. In 2016 the system of care was found by an external consultant working with PAHO to provide quality services that were culturally adapted, acceptable to patients and families receiving care, and effective in reducing the burden of mental disorders in its catchment area in Haiti. Strengths of the programme were identified as including a comprehensive approach, a wide range of services, culturally relevant psychoeducation for the wider community, psychosocial support for those in distress, and appropriate clinical services for the more severely affected mentally ill. The task-sharing model of mental health care, by which responsibilities are distributed amongst different cadres of providers already working in the system of care, was found to have been appropriately adapted and functional in the Haitian context.36 The quality of the local capacitybuilding process was also assessed, and the training tools which had been developed were found to be culturally adapted, evidence-based, and consistent with the WHO mhGAP Intervention Guide. Curricula and training manuals were developed by the team incorporating local language and cultural norms, integrated with evidence-based consensus as endorsed in the WHO mhGAP materials. The supervision model was found by the consultation to be consistent with the WHO mhGAP programme recommendations for effective training of non-specialised professionals.

Mental health care system reform in Haiti Since 2010, progress to improve the suffering of those living with mental disorders at the national level has been limited in Haiti. There have been, however, some positive developments. Following the recommendations of the 2011 WHO-AIMS report, a Mental Health Unit was created within the MSPP. This unit, composed of a three-person team, was tasked with developing a mental health policy and plan, as well as coordinating and supervising different activities in the field. In late 2014, the MSPP Mental Health Unit published the Mental Health Component of the National Health Policy. The new component emphasises the need to integrate mental health in different levels of care, and in particular at the primary care level. The policy recommends decentralisation and integration of services at different levels of care, including community-based care, and de-institutionalisation as priority strategies for national mental health reform. However, despite the articulation of these recommendations and priorities, the policy has not yet been implemented, with a national strategic plan for mental health lacking, and no dedicated funding promised. The organisation has also pursued partnerships directly with Mars and Klein Hospital and the national psychiatry residency programme, as well as with the national schools of medicine and nursing. However, significant challenges have existed—logistical, technological, and human resource-related—in bringing together a large number of stakeholders to assist with this task.

34 Fils-Aimé (2016), op. cit., nt.31. 35 Ibid. 36 For more on the concept of task-shifting models, see Chapter 2 of this book by Lawrence O. Gostin and Laura Davidson, Chapter 5 by Chris Underhill, Victoria K. Ngo, and Tam Nguyen, Chapter 8 by Carol Vlassoff, Chapter 11 by Cornelius Ani and Olayinka Omigbodun, and Chapter 12 by Stephen J. Bartels.

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The government lead for mental health developed a national planning concept, coordinated not by the NGO, but with its support, and within the Ministry of Health itself. This involved an overall public health approach including mental health policy reform with an emphasis on increasing political will for mental health care with colleagues within MSPP. Ongoing advocacy in collaboration with the national lead for mental health led to some progress towards affiliation with key stakeholders, including the government, PAHO, and PIH. However, limited funding, physical distances, political instability, and ongoing significant competing health challenges and disasters such as cholera, in addition to the 2016 hurricane, have hindered the process of advancing mental health decentralisation and integration as a priority for the Haitian Government and MSPP. Young physicians training in psychiatry at the national referral hospital were invited to spend several months also rotating within the ZL and PIH system to learn about community-based mental health care. This included time spent working as a member of the ZL mental health team based at a new major tertiary care academic hospital at Mirebalais, funded by PIH/ZL. This experience served as a model for the articulation of a plan for a potential psychiatric residency training programme that would include the national facilities in the capital, and the ZL and PIH care system. Several major grants were obtained, including from Grand Challenges Canada and the US National Institutes of Health, to support the nascent system of care, as well as to build local research capacity to evaluate the programme. Principal investigators paid by grants were also local service leaders, rather than foreign nationals. All of the service delivery was provided by Haitian nationals. ZL and PIH continue to view themselves as long-term joint partners with MSPP, with the goal of supporting and nurturing MSPP’s commitment to more dedicated community-based mental health services that can facilitate the de-emphasis of the psychiatric hospital model in Haiti.

Implications for global mental health and the SDGs Haiti’s difficult recent history has had severe consequences for the population in terms of mental health. However, it has also provided the government and key stakeholders with an opportunity to improve an ailing, inefficient and outdated mental health system. In the global context, the importance of good mental health is finally being recognised, with the inclusion of ‘wellbeing’ in the UN’s goals under SDG3. Haiti’s health system was already highly compromised prior to the 2010 natural disaster. The international mental health response to the Haiti earthquake exposed significant and complex challenges in terms of coordination, relevance of interventions to context, funding, and political mobilisation for change with regard to inadequate mental health care. The mental health system was ill-equipped to care for the mentally disordered prior to the disaster event, and therefore unprepared to address trauma and distress related to the natural disaster. However, there have been some isolated advances in mental health care in the country, including a number of substantial training and research initiatives, and several service delivery programmes. The ZL and PIH effort cited here reflects one NGO’s health care delivery effort, despite limited resources, to develop a strategic approach to building local knowledge and experience in mental health care delivery. This was accomplished through the gradual mobilisation of political will for commitment to mental health care at government level, seeking to strengthen the health system at large. There remains significant additional work to do in Haiti in the protection of the rights of those living with mental disorders, the development of functional systems of care that can be replicated more broadly nationally, and to foster leadership within the government to commit to national planning and financing for mental health care in the long-term and on an on-going basis. 248

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The processes involved in this effort, however, have informed further commitments by ZL and PIH across the organisation’s ten country sites to integrate mental health and wellness services into the core service delivery mission of the organisation through programmes for primary care, HIV, TB, maternal and child health, and child development. Mental health as a key component of sustainable development has been elevated as a programmatic priority at PIH as a result of the Haiti earthquake effort, including at sites in Rwanda, Peru, Mexico, Malawi, Liberia, Sierra Leone, Lesotho, Russia, and the United States (Navajo Nation, New Mexico, and Rosebud Sioux Indian Reservation, South Dakota). To address the burden of mental illness, a PIH cross-site mental health programme today supports mental health programme development at PIH. PIH’s mental health programme supports development of community-based task-shared mental health services integrated within the primary care systems where PIH works. Country programmes are led by local implementers and leaders focused on the alignment of service delivery, training, and research. Mental health services integrate strong traditional perceptions and beliefs and contemporary bio-psychosocial approaches. Given the common comorbidities between communicable and NCDs, mental health and poverty, PIH’s mental health programme seeks to integrate mental health services into the community-based primary care system at each site, whilst also responding to crises as they occur. PIH implements a task-sharing model, where mental health service delivery tasks are taken on by cadres of general health workers with less mental health training than mental health care specialists such as psychologists or psychiatrists. Depending on the site, physicians, nurses, social workers and CHWs are trained to treat patients with mental disorders, working with psychologists and psychiatrists whenever possible for support and supervision.37 In 2016, greater organisational commitment to raising the standard of mental health care delivery to the populations that PIH serves led to a strategic plan calling for greater primary care integration of mental health as a priority. A PIH Mental Health Service Planning Matrix was articulated to determine long-term staffing needs, budgets, development goals, outcomes and research priorities to support achievement of universal health coverage for mental health conditions, including depression and anxiety, psychotic illness, and epilepsy. Particular attention will be paid to the integration of mental health care with HIV, TB, NCDs, cancer, and maternal and child health programmes.

Conclusion In the global context, the importance of good mental health is finally being recognised, with the inclusion of ‘well-being’ in the UN’s goals under SDG3. Mental health has been identified by the UN as a cross-cutting issue, with its inclusion in the SDGs holding the potential to increase the likelihood of achieving global priorities for development such as poverty reduction, economic development, improved health (and not only physical health), and ensuring protection for the most vulnerable.38 Clearly, there also must be increased advocacy on the need to include mental wellbeing and disability in all aspects of disaster response and disaster risk reduction. Disasters can provide governments and key stakeholders with opportunities to improve ailing, inefficient, and outdated mental health systems. The promotion of knowledge-sharing with

37 Hanlon, C., Alem, A., Medhin, G., et al. (2016), Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial, Trials [online], 11 Feb: 17. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4750210/. 38 Eaton, J., Kakuma, R., Wright, A., & Minas, H. (2014), A position statement on mental health in the post-2015 development agenda, International Journal of Mental Health, 8(28).

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respect to good practices and lessons learned in relation to mental wellbeing in disaster risk reduction cannot be over-emphasised.39 The achievements by ZL and PIH and their continuing commitments in Haiti, as well as other examples of ‘building back better’, serve as a hopeful indication that progress may spring from adversity. The valuable lessons learned in Haiti since 2010 can be adapted and applied to other LMICs struggling with the aftermath of natural and humanitarian disasters. The empowerment of communities should be encouraged. Expert recommendations on actualising the recently developed Sendai Framework with regard to disasters and mental health should be considered. For example, there is likely to be a need for the mapping of human and institutional resources for mental wellbeing, and to strengthen existing resources to ensure quality and evidence-based implementation. Also necessary will be the inclusion of mental wellbeing in data collection to assist with disaster risk reduction. There is emerging knowledge regarding the science of scaling up services in global health in general (and mental health in particular), and tools now exist to help programme implementers and policymakers take steps to articulate comprehensive, community-based mental health services via a task-sharing model. When integrated with other services (primary care and specialty clinics), evaluated by rigorous policy and implementation research, and with appropriate cultural adaptations, examples such as the Haitian implementation model have the potential to strengthen health systems and advance efforts to meet the targets of SDG3 in low-resource settings.

39 Tsutsumi et al. (2015), op. cit., nt.8.

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17 PARADIGM SHIFT Treatment alternatives to psychiatric drugs, with particular reference to low- and middle-income countries1 Peter Lehmann*

Introduction Psychiatric drugs (also known as psychotropic medications) are prescribed by psychiatrists and general practitioners to almost everyone with a psychiatric diagnosis. The effects of such drugs are associated with significantly reduced quality of life and life expectancy. Drug lists—such as the British National Formulary, the Latin American Vademecum, the US-American Physicians’ Desk Reference, the German Rote Liste, the French Vidal, and the African Dictionnaire Therapeutique—cite more or less identical risks and adverse effects for all doses of psychiatric drugs, including antidepressants, mood stabilisers, psychostimulants, and tranquilisers. The United Nations’ Sustainable Development Goal 3 (SDG3) of the 2030 Agenda for Sustainable Development2 requires states to improve citizens’ wellbeing. However, the perpetuation of discrimination against psychiatric patients and persons in severe emotional distress through the compulsory administration of psychotropic drugs will inhibit attemps to meet it. Accordingly, this chapter will suggest alternatives to psycho-pharmacological psychiatry, and will argue that education about the risks of psychiatric drugs and problems associated with withdrawal, as well as physical health monitoring, can reduce mortality in psychiatric patients, and enhance wellbeing. Supporting the self-help efforts of people in severe emotional distress and collaborating with dedicated family members, community members, and professionals in the development of humanistically oriented support systems should be strategies of first choice for all countries in their approaches to SDG3, including lower- and middle-income countries (LMICs). Such strategies will safeguard psychiatric patients’ civil rights simultaneously.

* Peter Lehmann survived psychiatric treatment in the 1970s and is a freelance activist in the field of humanistic anti-psychiatry, an author in the field of pyschosocial sciences, and an independent publisher based in Berlin, Germany. 1 Translation of the German citations into English by Peter Lehmann. Thanks go to Peter Stastny, Darby Penney, Tricia Owsley, Ann Marshall, and Laura Davidson for support in translation. 2 United Nations (2016), Sustainable Development Goals, Goal 3: Ensure healthy lives and promote wellbeing for all at all ages. Available at: www.un.org/sustainabledevelopment/health/.

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Life expectancy and life quality in psychiatric patients Following the adoption of the SDGs in 2015, countries all over the world have been asked to mobilise efforts to ensure healthy lives and promote wellbeing for all people at all ages, in accordance with SDG3. SDG target 3.4 requires states, ‘[by] 2030, [to] reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being’. It is a pity that psychiatric problems are not specifically mentioned, as many studies in recent years have shown that psychiatric patients’ life expectancy is reduced by, on average, two to three decades, compared to the general population. Since the 1980s, that mortality rate has continued to grow.3

Reduced life expectancy The reduced life expectancy of persons with serious psychiatric diagnoses (such as schizophrenia, bipolar disorder, major depression, and personality disorder) is a vital issue to address. In particular, people diagnosed with (and treated) for schizophrenia in Europe die on average 22 years earlier than the general population, and in the USA, on average, 30 years earlier. SDG3 applies to ‘all at all ages’, and naturally that includes psychiatric patients in all countries, and people of all income levels. Some psychiatrists and major pharmaceutical companies deny that the effects of psychotropic drugs are a significant factor in reduced life expectancy.4 They point to patients’ often precarious economic situations and the health effects associated with poor diet, lack of physical exercise, use of street drugs, alcohol and increased smoking habits. Yet the unwanted effects of potentially toxic psychiatric drugs are amongst the main reasons for patients’ reduced life expectancy, and further, the effects of psychiatric drugs may exacerbate already poor health conditions. Medical researchers have reached different conclusions with regard to the high mortality rate of psychiatric patients. Some studies identify the vulnerability of patients as a factor, and some research has focused on the negative effects of neuroleptics, antidepressants and mood stabilisers on pre-existing cardiovascular disease, combined with inadequate medical attention and access to it. In 2006, the Chair of the Medical Directors Council of the American National Association of State Mental Health Program, Joe Parks, warned: It has been known for several years that persons with serious mental illness die younger than the general population. However, recent evidence reveals that the rate of serious morbidity (illness) and mortality (death) in this population has accelerated.

3 See, e.g., Saha, S., Chant, D., & McGrath, J. (2007), A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time?, Archives of General Psychiatry, 64: 1123–1131. 4 For example, in its newsletter, Choices in Recovery, Janssen Pharmaceuticals, Inc. commented in 2012 upon the increased mortality rate in psychiatric patients, acknowledging that [r]esearch has shown that the life expectancy for people living with a serious mental health condition is, on average, 25 years shorter than the general population. Heart disease, diabetes, respiratory diseases, and infectious diseases (such as HIV/AIDS) are the most common causes of death among this population. (Janssen Pharmaceuticals, Inc. (2012), The importance of total wellness, Choices in Recovery—Support and Information for Schizophrenia, Schizoaffective, and Bipolar Disorder [online], 9(2): 12) However, perhaps understandably, the company failed to accept a connection with the drugs it produces and sells.

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In fact, persons with serious mental illness (SMI) are now dying 25 years earlier than the general population.5 He and his colleagues further identified modern neuroleptics’ toxic effects: However, with time and experience the second generation antipsychotic medications have become more highly associated with weight gain, diabetes, dislipidemia [fat metabolism disorder], insulin resistance and the metabolic syndrome . . . and the superiority of clinical response (except for clozapine) has been questioned. Other psychotropic medications that are associated with weight gain may also be of concern.6

Adverse effects and withdrawal problems associated with psychiatric drugs The Danish physician Peter Gøtzsche, leader of the Nordic Cochrane Center at Rigshospitalet in Copenhagen, Denmark, considers psychiatric drugs to be a leading cause of death from heart disease and cancer.7 He (and others) identified an extensive list of risks accompanying the administration of psychiatric drugs, including the following: cardiovascular disease (especially in elderly people, children and adolescents), cardiac arrhythmia, Takotsubo cardiomyopathy (often caused by physical restraint), syncope, strokes, allergic reactions (such as anaphylactic shock, Lyellsyndrome, DRESS-syndrome or Quincke’s disease), glaucoma, hormonal changes combined with sexual disorders, neoplasm in the mammary glands (which can develop into cancer), hyponatremia, serotonin-syndrome, diabetes, obesity, thromboembolisms, liver fibrosis, icterus, ileus, renal failure, high blood pressure and vascular disorders (e.g, priapism), metabolic syndrome, malignant neuroleptic syndrome, malignant hyperthermia, agranulocytosis, asphyxia, tardive dyskinesia, foetal malformations and life-threatening withdrawal symptoms in newborns whose mothers received neuroleptics and antidepressants during pregnancy. Many psychiatric drugs cause unwanted effects in the central and autonomic nervous system, the muscular system, and the psyche (mind). Common problems include somnolence, sedation, apathy, irritability, delirium, fear, pain, restlessness, and sleep and dream disorders.8 Additionally, psychoses may become more pronounced and may be accompanied by the reduction of grey matter volume and changes in the frontal lobe of the brain,9 which further contribute to the deterioration of cognitive skills, concentration, executive functions, verbal learning, memory and

5 Parks, J. (2006), ‘Foreword’, in J. Parks, D. Svendsen, P. Singer, & M. E. Foti (eds), Morbidity and Mortality in People with Serious Mental Illness (1st edn) [online] (Alexandria: National Association of State Mental Health Program Directors, Medical Directors Council) p.4. Available at: www.nasmhpd.org/sites/ default/files/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf. 6 Parks et al. (2006), ibid., p.6. 7 See P. C. Gøtzsche (2015), Deadly Psychiatry and Organised Denial (Copenhagen: People’s Press). 8 See P. Lehmann, V. Aderhold, M. Rufer, & J. Zehentbauer (2017), Neue Antidepressiva, atypische Neuroleptika—Risiken, Placebo-Effekte, Niedrigdosierung und Alternativen. Mit einem Exkurs zur Wiederkehr des Elektroschocks (1st edn) (Berlin and Shrewsbury: Peter Lehmann Publishing). 9 See Bonelli, R. M., Hofmann, P., Aschoff, A., et al. (2005), The influence of psychotropic drugs on cerebral cell death: female neurovulnerability to antipsychotics, International Clinical Psychopharmacology, 20: 145–149; Andreasen, N. C., Nopoulos, P., Magnotta, V., et al. (2011), Progressive brain change in schizophrenia: a prospective longitudinal study of first-episode schizophrenia, Biological Psychiatry, 70: 672–679; Aderhold, V., Weinmann, S., Hägele, C., & Heinz, A. (2015), Frontale Hirnvolumenminderung durch Antipsychotika?, Nervenarzt, 86: 302–323. Available at: www.springermedizin.de/ frontale-hirnvolumenminderung-durch-antipsychotika/8065000.

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problem-solving abilities. In addition, antidepressants can have paradoxical suicidal effects, and antipsychotics (neuroleptics), intrinsic suicidal effects.10 Clearly, there remains an urgent need for involvement of psychiatric patients’ organisations in all aspects of psychiatric drug issues— especially licensing processes and monitoring. Patients in countries with poor infrastructure face additional difficulties. Poorly developed primary care community-based service infrastructure for psychiatric patients deter recovery and in some cases, increase mortality.11 Access to emergency departments in a timely manner, especially in rural areas, can be very challenging, even when a condition is recognised as an emergency. This is particularly the case in relation to life-threatening adverse effects of psychiatric drugs, such as heart attack, dystonic attack (asphyxia), neuroleptic malignant syndrome, febrile hyperthermia, agranulocytosis, deep vein thrombosis, pneumonia, anaphylactic shock, and states of raptus (a sudden state of excitation) or delirium. Those effects can lead quickly to death; emergency treatment often cannot stop the deadly processes which have begun. Further, it should not be overlooked that all kinds of psychiatric drugs can produce physical dependence, or at least strong withdrawal syndromes. Monitoring, including admission into intensive care units, may be medically necessary to help patients cope with withdrawal. Withdrawal may even cause death through severe brain cramping and cardiac arrest. The symptoms can include heart and circulatory problems, such as racing heartbeat, dizziness and physical collapse. This has been explained in an animal study by Helma Sommer and Jochen Quandt at the Psychiatric Clinic in Bernburg in former GDR. Their observations were based on metabolic changes induced by chlorpromazine, the neuroleptic prototype, that caused a circulatory collapse after withdrawal. For six months, Sommer and Quandt had administered neuroleptics to 20 rabbits. The four animals that had received the highest dosage (16.7 mg/kg) died after a brief fit of cramping, and the psychiatrists reported: At a dosage of 13.3 mg/kg of chlorpromazine, abrupt withdrawal led to a sudden death within 14 days, probably due to irreversibly blocked metabolic processes that stopped functioning (similar observations in human beings have been published in which death followed a brief stage of cramping).12 The Swiss pharmaceutical company Janssen-Cilag has also warned of withdrawal problems for newborns, when their mothers have received antipsychotic medication during pregnancy. In 2016, its product information stated as follows: In the neonates of mothers who took antipsychotics (including haloperidol) during the third trimester of pregnancy, there is risk of extrapyramidal symptoms and/or withdrawal symptoms. These symptoms in newborns may include agitation, abnormally

10 For more information, see Lehmann, P. (2012), About the intrinsic suicidal effects of neuroleptics: towards breaking the taboo and fighting therapeutical recklessness, International Journal of Psychotherapy, 16: 30–49. Available at: www.peter-lehmann-publishing.com/articles/lehmann/pdf/neurolepticssuicide.pdf. 11 See, e.g., Makgoba, M. W. (2017), The Report into the ‘Circumstances Surrounding the Deaths of Mentally Ill Patients: Gauteng Province’—No Guns: 94+ Silent Deaths and Still Counting (Pretoria: Office of Health Standards Compliance), p.1. Available at: www.sahrc.org.za/home/21/files/Esidimeni%20full%20report. pdf. 12 Sommer, H. & Quandt, J. (1970), Langzeitbehandlung mit Chlorpromazin im Tierexperiment, Fortschritte der Neurologie-Psychiatrie und ihrer Grenzgebiete, 38: 466–491, 487.

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increased or decreased muscle tone, tremors, sleepiness, difficulty breathing or feeding problems. These complications may vary in their severity. In some cases, the symptoms were self-limiting, in other cases, the newborns required monitoring in the intensive care unit or a longer hospitalisation.13 Numerous other research has shown a clear link between psychiatric drugs (especially antipsychotics) and reduced life expectancy.14 Some researchers with links to the pharmaceutical industry, however, have tended to deny such links.15 Patients who fail to withdraw slowly enough to minimise risks may suffer from unpleasant and/or life-threatening withdrawal problems that can contribute to a relapse into severe emotional distress and/or result in their return to the doctor’s surgery or a psychiatric ward. This

13 Janssen-Cilag, A. G. (2016), ‘Haldol (Product information)’, in Arzneimittel-Kompendium Online (Basel: Documed AG). Available at: compendium.ch/mpro/mnr/3404/html/de?start=1#7450. 14 See, e.g., Newman, S. C. & Bland, R. C. (1991), Mortality in a cohort of patients with schizophrenia: a record linkage study, Canadian Journal of Psychiatry, 36: 239–245; Ösby, U., Correia, N., Brandt, L., et al. (2000), Mortality and Causes of Death in Schizophrenia in Stockholm County, Sweden, Schizophrenia Research, 45: 21–28; Colton, C. W. U. & Manderscheid, R. W. (2006), Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states, Preventing Chronic Disease, 3(2): 1–14; Manderscheid, R. W. (2006), The quiet tragedy of premature death among mental health consumers, National Council News, Sept, pp.1 and 10. See also Manderscheid, R. W. (2009), Premature death among state mental health agency consumers: assessing progress in addressing a quiet tragedy, International Journal of Public Health, 54(1): 7–8; Aderhold, V. (2010), Neuroleptika zwischen Nutzen und Schaden: Minimale Anwendung von Neuroleptika— ein Update. Available at: www.dgsp-ev.de/fileadmin/user_files/dgsp/pdfs/Texte_Anmeldecoupons/ Aderhold_Antipsychotika_Update.pdf. See in addition Weinmann, S., Read, J., & Aderhold, V. (2009), Influence of antipsychotics on mortality in schizophrenia: systematic review, Schizophrenia Research, 113: 1–11; Chang, C. K., Hayes, R. D., Perera, G., et al. (2011), Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London, PLoS One [online], 6: e19590. Available at: journals.plos.org/plosone/arti cle?id=10.1371/journal.pone.0019590. See also Laursen, T. M., Munk-Olsen, T., & Vestergaard, M. (2012), Life expectancy and cardiovascular mortality in persons with schizophrenia, Current Opinion in Psychiatry, 25: 83–88; Tenback, D., Pijl, B., Smeets, H., et al. (2012), All-cause mortality and medication risk factors in schizophrenia: a prospective cohort study. Journal of Clinical Psychopharmacology, 32: 31–35; Ringen, P. A., Engh, J. A., Birkenaes, A. B., et al. (2014), Increased mortality in schizophrenia due to cardiovascular disease—a non-systematic review of epidemiology, possible causes, and interventions, Frontiers in Psychiatry, 5(137); Walker, E. R., McGee, R. E., & Druss, B. G. (2015), Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis, Journal of the American Medical Association, 72: 334–341. 15 See, e.g., Tiihonen et al., who state that ‘[i]n patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted’ (Tiihonen, J., Lonnoqvist, J., Wahlbeck, K., et al. (2009), 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study), The Lancet, 374: 620–627). In a declaration on conflicts of interest two years later, Tiihonen had to state: Dr Tiihonen has served as a consultant to Lundbeck, Organon, Janssen-Cilag, Eli Lilly, AstraZeneca, Hoffmann-La Roche, and Bristol-Myers Squibb and has received fees for giving expert opinions to Bristol-Myers Squibb and GlaxoSmithKline and lecture fees from Janssen-Cilag, Bristol-Myers Squibb, Eli Lilly, Pfizer, Lundbeck, GlaxoSmithKline, and AstraZeneca. (Tiihonen, J., Haukka, J., Taylor, M., et al. (2011), A nationwide cohort study of oral and depot antipsychotics after first hospitalization, American Journal of Psychiatry, 168: 603–609, at 608. Available at: ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2011.10081224)

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can create a spiral effect where the symptoms caused by withdrawal from psychiatric drugs may cause patients to continue taking them indefinitely when they are no longer necessary.16 Interestingly, in LMICs such as India, Nigeria, and Colombia, where until recently there has been a lack of availability of expensive second-generation psychiatric drugs, recovery rates from severe emotional distress are higher, which compares similarly to results in high-income countries, where some research has found that recovery rates are better if psychiatric drugs are not given so readily,17 not prescribed,18 or are under the control of patients themselves.19 Nevertheless, psychiatric patients are at increased risk of death in all countries where psychiatric drugs are administered. It is likely that the negative effects of many psychiatric drugs on the psyche, the central nervous system, the autonomic system and the internal organs may also unintentionally intensify the burden of patients’ severe emotional distress. On the other hand, sometimes drugcaused diseases overlap with the original emotional problems, or suppress them. Klaus Dörner, a prototypical leader of the ‘reform psychiatry’ movement in Germany, has described the common modern treatment aim of reducing emotional distress: We temporarily turn the mentally suffering patient into a person with an organic brain disease; with ECT [electroconvulsive therapy] it happens in a more global way, but for a substantially shorter period of time than with pharmacological therapy.20

Education about risks, alternatives, and withdrawal support It is regrettable that the medical profession learns to prescribe psychotropic drugs, but not how to help patients withdraw from them.21 Patients too often do not receive information about withdrawal risks and are unaware of the strategies to help minimise withdrawal symptoms. When psychiatric drugs cause health problems, withdrawal is the likely result. However, if a patient—for whatever reason—independently decides to withdraw from their psychiatric drugs, psychosocial professionals often judge the patient adversely.22 Strategies to respect the human rights of patients

16 See P. Lehmann (ed.) (2004), Coming off Psychiatric Drugs: Successful Withdrawal from Neuroleptics, Antidepressants, Lithium, Carbamazepine and Tranquilizers (1st edn) (Berlin, Eugene and Shrewsbury: Peter Lehmann Publishing). 17 See Leff, J., Sartorius, N., Jablensky, A., et al. (1992), The international pilot study of schizophrenia: five-year follow-up findings, Psychological Medicine, 22: 131–145. 18 See Jablensky, A., Sartorius, N., Ernberg, G., et al. (1992), Schizophrenia: manifestations, incidence and course in different cultures: a World Health Organization ten-country study, Psychological Medicine Monograph Supplement, 20: 1–97. 19 See, e.g., Dumont, J. & Jones, K. (2007), ‘The Crisis Hostel: finds from a consumer/survivor-defined alternative to psychiatric hospitalisation’, pp.179–187, and Seikkula, J. & Alakare, B. (2007), ‘Open dialogues’, pp.223–239, both in Stastny & Lehmann (eds) (2007), Alternatives Beyond Psychiatry (1st edn) (Berlin, Eugene and Shrewsbury: Peter Lehmann Publishing). 20 K. Dörner & U. Plog (1992), Irren ist menschlich (7th edn) (Bonn: Psychiatrie-Verlag), p.545. 21 Asmus Finzen, former psychiatrist at the University of Basel, confessed publicly: ‘It is the psychiatrist’s role to prescribe drugs. Physicians learn this role well. They do not learn how to help a patient successfully withdraw from drugs’ (Finzen, A. (2015), ‘Wie man Medikamente absetzen, lernen Ärzte nicht’, in Finzen, A., Lehmann, P, Osterfeld, M., et al. (2015), Psychopharmaka absetzen: Warum, wann und wie, Soziale Psychiatrie, 39(2): 16–19. Available at: www.antipsychiatrieverlag.de/artikel/gesundheit/pdf/ absetzen-bremen.pdf. 22 See Lahti, P. (2004), ‘Preface’, in Lehmann (2004), op. cit., nt.16, pp.13–15.

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ought to be introduced in higher-income countries and LMICs alike in order to overcome the problems arising from a lack of support in withdrawal from dependence upon psychotropic medication.23 If such innovations can be embraced, there is the potential to lower the mortality rate for those suffering from serious mental health problems, and to improve their quality of life and enhance their wellbeing in accordance with SDG3. This is a global phenomenon, criticised by the UN Special Rapporteur on health, Dainius Pu¯ras, in his recent 2017 report.24 The dominance of the biomedical model, together with its attempt to reduce psychological problems to metabolic disorder thereby placing them in the purview of medicine, has resulted in additional diagnostic categories that increasingly endanger the diversity of human life. Information on adverse treatment is tardy, leading to delay in policy change, and therefore leads neither to the development of recovery-oriented treatment approaches, nor to alternatives which make compulsory treatment superfluous. According to the Special Rapporteur, a global change of consciousness is necessary: . . . [T]he field of mental health continues to be over-medicalized and the reductionist biomedical model, with support from psychiatry and the pharmaceutical industry, dominates clinical practice, policy, research agendas, medical education and investment in mental health around the world. The majority of mental health investments in low-, middle- and high-income countries disproportionately fund services based on the biomedical model of psychiatry. There is also a bias towards first-line treatment with psychotropic medications, in spite of accumulating evidence that they are not as effective as previously thought, that they produce harmful side effects and, in the case of antidepressants, specifically for mild and moderate depression, the benefit experienced can be attributed to a placebo effect. Despite those risks, psychotropic medications are increasingly being used in high-, middle- and low-income countries across the world. We have been sold a myth that the best solutions for addressing mental health challenges are medications and other biomedical interventions.25

23 Many users and survivors of psychiatry have experienced withdrawal problems. As in Germany, physicians, pharmacologists, therapists, lawyers, carers and naturopathic healers should distribute knowledge about competent support for withdrawal, collaborating to find answers to currently unsolved questions such as: which withdrawal symptoms in psychiatric drugs are most likely to be experienced during the transition from mini doses to zero? Which naturopathic methods relieve withdrawal symptoms and help stabilise people in the vulnerable period immediately after withdrawal? How are dosages with capsules and pellets best reduced? Which kinds of environments, lifestyles, diets and physical activities support successful withdrawal? How do you cope with sleeping problems caused by withdrawal? For more information, see Lehmann, P. (2017), ‘(Einige) offene Fragen Psychiatriebetroffener zum Absetzen von Psychopharmaka’, in Berliner Organisation Psychiatrie-Erfahrener und Psychiatrie-Betroffener (eds), PSYCHEXIT—Auf dem Weg zum Curriculum ‘Kompetente Hilfe beim Absetzen von Antidepressiva und Neuroleptika’ (2nd edn) (Berlin: self-publication), pp.15–24. Available at: www.antipsychiatrieverlag.de/ artikel/gesundheit/pdf/lehmann_absetzen-offene-fragen-2016.pdf. 24 The UN Special Rapporteur on health has co-authored a chapter of this book; see Chapter 15 by Dainius Pu¯ras and Julie Hannah. 25 United Nations (2017), Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’, report A/HRC/35/21 to the Human Rights Council, 35th session 6–23 June 2017 (3 Mar), agenda item 3, pp.5–6. Available at: documents-dds-ny.un.org/ doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement.

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Dealing with reduced quality and life expectancy As a result of the use of psychiatric drugs, some concomitant Western psychiatric approaches to treatment are liable to compound higher mortality rates and decrease wellbeing. These approaches are considered below.

Treatment without informed consent In general, psychiatric patients do not receive complete information about the risks, unwanted effects, and alternatives to the proposed administration of psychiatric drugs. Therefore, the treatment takes place without genuine informed consent. Further, psychiatric patients seldom receive the necessary medical examinations before or after they begin treatment with psychiatric drugs. For example, following a literature evaluation undertaken by the Psychosis Clinic at the University of California to develop a physical health monitoring system for people diagnosed with schizophrenia,26 the research team recommended regular monitoring of body mass index, plasma glucose levels, lipid profiles, and signs of prolactin elevation or sexual dysfunction. They also proposed cardiac monitoring of patients who receive medications associated with QT interval prolongation, monitoring of myocarditis in patients treated with clozapine, checks for extrapyramidal symptoms and tardive dyskinesia, as well as regular visual examinations in patients who receive neuroleptics. Clozapine is the only psychiatric drug on the World Health Organization (WHO) Complementary List ‘for which specialized diagnostic or monitoring facilities, and/or specialist medical care, and/or specialist training are needed’,27 within the WHO Model List of Essential Medicines. Such testing may never take place, particularly in LMICs due to a lack of resources; one more reason to avoid psychiatric drugs in such countries. However, even the best monitoring facilities do not protect patients from unwanted fatal effects. For example, clozapine is an antipsychotic drug usually prescribed to patients diagnosed with schizophrenia who are considered treatment-resistant. The drug has a somewhat higher death rate attributable to agranulocytosis than alternatives. Therefore, leukocyte and differential blood counts must be carried out before the first administration of clozapine, and monitor counts must be carried out every week for 18 weeks. The monitoring must continue at least every two weeks, and, after one year, at least every four weeks. Nevertheless, the onset of agranulocytoses is often sudden and severe; hence, such blood monitoring has ‘only a relative prophylactic value’.28 As Wahlländer has stated, ‘[e]ven the best medical treatment cannot reduce the risk of a fatal process to zero’.29

26 See Marder, S. R., Essock, S. M., Miller, A. L., et al. (2004), Physical health monitoring of patients with schizophrenia, American Journal of Psychiatry, 161: 1334–1349. Available at: https://ajp.psychiatryonline. org/doi/full/10.1176/appi.ajp.161.8.1334. 27 WHO (2015), WHO Model List of Essential Medicines (19th edn), p.3. Available at: www.who.int/ medicines/publications/essentialmedicines/EML_2015_FINAL_amended_NOV2015.pdf?ua=1. 28 H.-J. Kähler (1967), Störwirkungen von Psychopharmaka und Analgetika (Stuttgart: Wissenschaftliche Verlagsgesellschaft), p.127. 29 Wahlländer, B. (1992), ‘Leukopenie und Agranulozytose’, in D. Naber & F. Müller-Spahn (eds) (1992), Clozapin - Pharmakologie und Klinik eines atypischen Neuroleptikums (1st edn) (Stuttgart and New York: Springer), pp.147–153, at p.149.

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Psychiatric drug alternatives

Patients ought to be alerted as a matter of course to the early warning signs of chronic or lethal diseases due to the administration of psychiatric drugs.30 Before patients decide to take such drugs, they should also be informed about the danger of the development of physical dependence, and about low-risk ways to withdraw from them. With the exception of benzodiazepines and illegal substances, institutions helping patients in withdrawal generally do not exist.

Low dose, zero problems? For some patients, there is no effective alternative to psychotropic drugs. So what can be done to reduce the risk of early mortality, and to minimise adverse effects such as brain shrinkage via the decrease of grey and white matter volume in the frontal brain, and the development of various metabolic and organ disorders? Some psychiatrists advocate finding the ‘lowest effective dose’ and the reduction of polypharmacy. Whilst the lowest effective dose should be provided as a matter of course in medicine, many guidelines suggest comparatively high initial doses. Further, psychiatric patients often receive a number of drug combinations, as each drug’s adverse effects are treated with an additional drug. Minimising the number of potentially toxic drugs and reducing the dose of any useful drug ought to be something for which modern psychiatry strives. Focus on favouring the lowest effective dose (even if the effect is the alleviation of emotional suffering and nothing else) would be a more humane approach for most patients. Furthermore, it would lower drug administration costs for hospitals—which is a particular difficulty in LMICs where universal health insurance coverage is unlikely, and health budgets are stretched. The total cost of the medical treatment of acute and chronic diseases arising from drug effects, would also decrease. Clearly, this would assist states in meeting SDG3. However, unwanted effects can occur independently of drug dosage; they also occur in lower therapeutic doses, and after short-term administration, including, on occasion, after only one dose.31 Some of these unwanted effects can be permanent. Neuroleptics, for example, can produce changes in the brain structure and liver mitochondria, even in low doses.32 Somnolence, dysarthria, hyperthermia, and tachycardia were observed after a once-only application of a low dose of the neuroleptic chlorprothixene.33 Depressive mood with suicidality can also occur at low doses.34 Other risks of low-dose neuroleptics are disorders of the pancreatic hormone system

30 See Lehmann, P. (2013), Early warning signs of chronic or lethal diseases due to the administration of neuroleptics, Journal of Critical Psychology, Counselling and Psychotherapy, 13: 23–29. Available at: www. peter-lehmann-publishing.com/articles/lehmann/pdf/warningsigns-jcpcp.pdf. 31 For further information on this topic see, e.g., P. Lehmann (2017), Schöne neue Psychiatrie, Vol.1: Wie Chemie und Strom auf Geist und Psyche wirken (worked-over edn) (Berlin and Shrewsbury: Antipsychiatrieverlag), pp.115–118 and 172–174; Vol.2: Wie Psychopharmaka den Körper verändern (worked-over edn) (Berlin and Shrewsbury: Antipsychiatrieverlag), pp.158–162 and 264–270. 32 See Christensen, E., Møller, J. E., & Faurbye, A. (1970), Neuropathological investigation of 28 brains from patients with dyskinesia, Acta Psychiatrica Scandinavica, 46: 14–23. 33 See Von Brauchitsch, H. & Bukowczyk, A. (1962), Zur Frage der Verwendung des Chlorprothixen (>Taractan