01 GHM 202 - Emergence of Global Mental Health (2019-2020) AC

GHM 202 – Session 1: Emergence of global mental health
Aims
To review the history of global mental health from the ancient world to the present.
Learning objectives
By the end of this session you should be able to:
 Describe the historical origins of the field of global mental health.
 Identify key milestones in the development of the field.
 Critically appraise current priorities in global mental health as a product of history.
Essential readings
 Patel V, Saxena S, Lund C, Thornicroft G,. . . Unützer J (2018). ‘The journey so far’: The
Lancet Commission on global mental health and sustainable development. Lancet, 392, 1553–
4.
 Cohen A, Patel V & Minas H (2014). A brief history of global mental health. In: Patel V, Minas
H, Cohen A & Prince M (eds.) Global mental health: Principles and practice. New York: Oxford
University Press.
 Patel V & Prince M (2010). Global mental health: A new global health field comes of age.
JAMA, 303, 1976-7.
Recommended readings
 Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, . . . Vos T (2013).
Global burden of disease attributable to mental and substance use disorders: Findings from the
global burden of disease study 2010. Lancet, 382, 1575-1586.
 Patel V (2012). Global mental health: From science to action. Harvard Review of Psychiatry,
20, 6-12.
 Becker AE & Kleinman A (2013). Mental health and the global agenda. New England Journal
of Medicine, 369, 66-73.
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Session outline
Aims....................................................................................................................................................1
Learning objectives.............................................................................................................................1
Essential readings..............................................................................................................................1
Recommended readings....................................................................................................................1
Session outline...................................................................................................................................2
Instructions.........................................................................................................................................3
1. Introduction.....................................................................................................................................3
2. What is global mental health?........................................................................................................3
3. A brief history of global mental health............................................................................................4
4. Global mental health in the 21st century.......................................................................................12
5. Summary......................................................................................................................................17
6. Integrating activity.........................................................................................................................18
7. References...................................................................................................................................20
8. Answers to activities.....................................................................................................................25
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Instructions
In this session you should first work through the different screens and spend time on the various
activities and exercises. This should take you about two hours. You will also be required to do any
required reading, as indicated. This should take you roughly an additional two hours.
You should then complete the integrating activity, referring to the readings as necessary. This
should take you about three hours.
Finally, you should spend a further two hours on self-study covering the supplementary reading
and any others from the references section as necessary.
1. Introduction
The field of global mental health only recently emerged as a critical area of study, research, and
practice within the broader global health agenda (Patel & Prince, 2010). However, the cause,
categorisation, and treatment of mental, neurological, and substance use (MNS) conditions around
the globe have been the subjects of written record for millennia. In this session, we will trace the
history of global mental health from the ancient world to the modern day. In the process, we will
define the term ‘global mental health’, provide an overview of treatment and care of persons with
lived experience of MNS conditions from early civilisation to the present, describe some of the
scientific foundations of the field, and report on key recent developments. This is a broad
introduction to the field and a prelude to most of the topics we will be exploring more in-depth in
subsequent sessions—for example, ‘Culture and critiques of mental health’, ‘Resources for mental
health’, ‘Human rights and legislation’, and ‘Setting priorities in research, service development and
policy’.
2. What is global mental health?

To the best of our knowledge, the term global mental health was first used by Eugene Brody
(1982) in the title of his editorial anticipating the 1983 World Congress of the Federation for Mental
Health, where he wrote that the Federation, ‘[as] the only global, multiprofessional, and voluntary
mental health coalition, signified the sensitivity of American psychiatry to issues beyond our
immediate technical concerns’. After this, however, the term was only used as a measure of the
general level of emotional distress in a specific population (Wells & Sherbourne, 1999). The term
reappears in its broader context when David Satcher, former Surgeon General of the United
States, wrote a commentary, ‘Global Mental Health: Its Time Has Come’ (Satcher, 2001), in
anticipation of the publication of the World Health Organisation’s 2001 World Health Report,
Mental Health: New Understanding, New Hope (WHO, 2001b).
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The publication of The Lancet’s first series in global mental health (Horton, 2007) began to bring
the term and the field prominence. Within a few years, Vikram Patel and Martin Prince (2010)
proclaimed global mental health a field that had ‘come of age’ and whose goals were to increase
access to mental health services, improve treatments, and reduce human rights abuses of people
with lived experience of MNS conditions.
Global mental health is very much a field in the making. To understand its present and future, it is
important that we also understand its past. In this session, we will describe many of the key
milestones in the history of global mental health in more detail.
3. A brief history of global mental health1

As described in Section 2, global mental health ‘came of age’ in the 21 st century, but, in fact,
concerns about MNS conditions go back to the ancient world. In this section, we will examine this
history before and after the Enlightenment, during the colonisation of Asia, Africa, Oceania, and
the Americas, in the aftermath of World War II, and into the very early years of the 21 st century,
before discussing more recent milestones.
3.1. Ancient world and pre-Enlightenment

The medical texts of the ancient worlds of Egypt (Nasser, 1987), China, Greece, Rome (Scull,
2015), and India (Bhugra, 1992) contain many discussions and descriptions of madness, its
causes, and its treatments. One can also point to the global diffusion of institutional care for
persons with MNS conditions as evidence that global mental health is not entirely new. Accounts
differ, but it seems that the first hospitals that cared for persons with MNS conditions were
established by Islamic physicians during the 9 th century CE in Baghdad and Egypt (Dols, 1987).
Within a few hundred years, institutional care had been established about 3,000 miles away in the
cities of Marrakech (12th century) and Fez (13th century) (Moussaoui & Glick, 2015). Influenced by
the practices in Morocco, a hospital in Granada, Spain, was established in the 14 th century, and
began to accept mentally ill persons. Subsequently, in the 15 th and 16th centuries, hospitals for
persons with MNS conditions were established in at least five cities in Spain (Mora, 2008). In
1567, Spain established a psychiatric institution in Mexico City. This was the first hospital of its
kind in the Western Hemisphere, the first example of what later became known as colonial
psychiatry, and the first documented instance of the global expansion of institutional care for
persons with MNS conditions.
Contrary to claims that Valencia, Spain, was the site of the first psychiatric hospital in Europe
(López-Ibor, 2008), there is evidence of the establishment of institutional care in Northern Europe
that predates or coincides with the founding of the hospitals in Spain (Mora, 2008; Pierloot, 1975).
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This account of the emergence of global mental health is, admittedly, Eurocentric. This is due to the relative lack of
records and/or scholarship about the history of mental health systems outside of Europe and North America.
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3.2. Enlightenment
As described in Section 2, the key features of global mental health are its concern with services,
treatment, and care for persons with lived experience of MNS conditions, as well as prevention of
human rights abuses against persons with lived experience of MNS conditions. These concerns
surfaced toward the end of the 18th century with the emergence of ‘moral treatment’, which was
developed simultaneously and independently in a number of places, but is most closely associated
with the work of William Tuke in England and Philippe Pinel in France in the late 18 th century
(Scull, 2015). In brief, this approach rejected the notion that individuals with lived experience of
MNS conditions lacked reason, and acted on the presumption that tolerance and confinement in a
well-ordered and pleasant environment could restore a person to rationality and good mental
health (Grob, 1994). According to Andrew Scull (2015), this optimistic perspective—‘that a new,
more humane, and effective form of therapy had been found’—gave rise to the establishment,
throughout Europe and North America, of national systems of asylums for individuals with MNS
conditions that were intended to replace the cruelty and abuse that were true of most treatment
and care of these individuals.
The establishment of such national systems of asylums, and the effectiveness of care provided in
these asylums, became a prominent topic in the medical journals of the 19 th century. This can be
readily seen in the precursors to five of the leading English-language medical and psychiatric
journals—New England Journal of Medicine, The Lancet, The British Journal of Psychiatry, The
British Medical Journal, and The American Journal of Psychiatry – which collectively ‘published
1,354 articles with titles that contained the word “asylum”’ and nearly 30,000 that contained
‘asylum’ somewhere in the article (Cohen & Minas, 2016). Much of the literature focused on the
management of, mortality and disease in, and statistics about asylums in Great Britain, Ireland,
and the United States. Perhaps the high point of this concern took place in 1875 to 1877 when
The Lancet (1877) established a Commission to investigate the conditions and treatments in
asylums in and around London. There were global interests, too. These journals published
occasional accounts of asylums in other countries (eg Egypt, Italy, India, and Cuba), as well as
dozens of accounts about the Colony of Geel, a Flemish village that represented, at least for
some, an alternative to asylums (Parigot, 1863).
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Figure 1. Geel is now a modern city in the Belgian province of Antwerp that maintains a centuries-old model of mental health care.
Activity 1: Critical thinking

The history of global mental health up to World War II can in some ways be viewed as a history
of the globalisation of institutionalised mental health care. But there were outliers. Geel offers a
famous example of community-based mental health care that survived for centuries. Most
accounts of Geel are quite flattering (e.g., Parigot, 1863)—though there are notable exceptions
(for example, Pliny Earle’s (1994 [1851]) reflections on ‘Gheel’ following his visit in 1849).
Listen to 14.30-31.00 of this podcast (http://www.npr.org/programs/invisibilia/483855073/the-
problem-with-the-solution) from the United States’ National Public Radio or read the transcript
from ‘And then one day… In the library’ to ‘And a third of the boarders stay with the same family
for over 45 years’ (http://www.npr.org/2016/07/01/483856025/read-the-transcript).
The radio reporters are surprised to hear that residents of Geel do not seem to mind sharing
their homes and community facilities with a large contingent of people living with MNS
conditions. This may very well be true, but in this module, we want you to practice your critical
thinking skills as much as possible. Can you think of at least three reasons accounts like this
one could be overstating the positive aspects of care at a place like Geel?
For each reason, submit a short (one- to two-sentence) explanation on Moodle. When you're
done, you can check your responses with the model answers provided at the end of the session
notes.
3.3. Colonial psychiatry

Starting in the 19th century and continuing into the early 20 th century—long after Spain founded a
psychiatric hospital in Mexico—the European colonial powers established large psychiatric
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institutions throughout Asia and Africa (Keller, 2001; Mills, 2006; Ng & Chee, 2006; Pols, 2006;
Sadowsky, 1997; Scarfone, 2016; Swartz, 1999; Weiss, 1983). The case of India is illustrative.
The origins of psychiatric institutions in India can be traced to 1787 when an asylum was
established by the British East India Company2 in Calcutta (now Kolkata) (Jain et al, 2017). By the
end of the 19th century, there were 26 asylums in the country. In general, these facilities reflected
the custodial nature of the asylums in England, with at least two key differences: 1) the treatment
and care provided to Indians was inferior to that provided to British and European patients; and 2)
the services in India were significantly inferior to those in England.
Colonial psychiatry is an important topic, but this session can only provide an exceedingly brief
overview of its history.3 In regard to the history of global mental health, the important point to
remember is that asylum systems that largely provided custodial care were established throughout
the colonies. At the end of European rule, asylums and traditional systems of care (which we will
discuss further in the session on ‘Culture and critiques of global mental health’) were virtually the
only mental health resources available. (We will also discuss the present-day legacy of asylum-
based care in the session ‘Resources for mental health’.)
3.4. Beginnings of comparative psychiatry

Interest in MNS conditions in populations outside of Europe 4 dates back at least to the first
decades of the 19th century (e.g., Halliday, 1828), but serious study of this topic can be traced to
1904 when Emil Kraepelin (2000 [1904]), one of the founders of modern psychiatry, travelled to
Java to test the following assumption: ‘If racial characteristics are reflected in a nation's religion
and customs, in its spiritual and artistic achievements, in its political activity and in its historical
development, they must also find expression in the frequency and clinical forms of its mental
disorders’. During his visit to the asylum of Buitenzorg, Kraepelin found Javanese patients who
had dementia praecox (ie schizophrenia) and manic depression (ie bipolar disorder), but
compared to European patients, found their symptoms to be ‘less florid, less distinctively marked’.
Regrettably, Kraepelin invoked ‘racial characteristics’ to explain these differences, eg that ‘the
relative absence of delusions among the Javanese might be related to the lower stage of
intellectual development attained’.
In the following decades, other European researchers followed Kraepelin’s lead and explored
MNS conditions in, for example, Melanesia (Rivers, 1988 [1922]) and Papua New Guinea
(Seligman, 1929). Some researcher went so far as to generalise about the presentation of MNS
conditions in so-called ‘traditional’ societies, in general (Devereux, 1939).
2
After 1858, when the administration of India was transferred to the British Crown, the asylums also came under the
responsibility of the British Crown (Jain et al, 2017).
3
Students wishing to explore this area can start with the following references: (Bèguè, 1996; Edington, 2013; Ernst,
2010; Goddard, 1992; Jackson, 1999; Prince, 1996; Sadowsky, 1997; Scarfone, 2016; Schmidt, 1967; Swartz, 1999).
Please note, however, that these works represent only a small fraction of what is available on colonial psychiatry.
4
As noted before, this account of comparative psychiatry is Eurocentric. We do not mean to imply, however, that
European ‘interests’ are the ‘true interests’ of the field, nor do we mean to imply that people in other parts of the world
were not themselves interested in the mental illnesses that were experienced in their own populations.
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Kraepelin’s (2000 [1904]) observations not only established the field of comparative psychiatry, but
also established a principle that is still widely accepted in global mental health: although
sociocultural factors may shape the presentation of distress (‘based on the comparison between
the phenomena of disease which I found there and those with which I was familiar at home, the
overall similarity far outweighed the [differences]’), it is also true that MNS conditions ‘represent
universal forms of human suffering which have been described in every society from times
immemorial’ (Patel, 2014). We will discuss this principle—and relevant critiques—at length in the
upcoming session on ‘Culture and critiques of global mental health’.
3.5. Post-World War II

Deinstitutionalisation, the process by which a mental health system makes the transition from
institutional to community-based care, began in many high-income countries soon after the end of
World War II. This rejection of institutional care, which had been the dominant form of treatment
and care for more than a thousand years, came about for several reasons:
 ‘Increased belief in the efficacy of care that took place in the community;
 A growing awareness of abusive conditions in many psychiatric hospitals and that the
effects of long-term institutionalisation were at least as harmful as chronic mental disorder
itself;
 The expense of caring for patients in large institutions;
 The discovery in 1954 of chlorpromazine, the first effective anti-psychotic medication, which
offered people with chronic MNS conditions the prospect of living in the community rather
than in institutions;
 An increasing appreciation of the civil and human rights of persons with mental disorders’
(Cohen et al, 2014).
Deinstitutionalisation led to a sharp decrease in the number of psychiatric inpatient beds available
in Western Europe, North America, and some countries in South America (Cohen et al, 2014).
However, community-based alternatives were often insufficiently resourced to support patients
discharged from institutions and, at times, individuals in need of care landed in institutions of other
kinds, eg prisons and nursing homes (Fakhoury & Priebe, 2007). Even considering the difficulties
of deinstitutionalisation, the field has reached general agreement that care in the community and
in the least restrictive environment possible is the way forward (WHO, 2001b).
The period after World War II also ushered in three other important developments that had
consequences for global mental health.
First, the horrors of World War II, and the crimes against humanity, in particular, prompted great
concern for the protection of human rights. This concern was reflected in the creation of the
Universal Declaration of Human Rights (UN General Assembly, 1948), as well as many
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subsequent treaties and conventions. The relevance of these developments for global mental
health will be discussed in more detail in the ‘Human rights and stigma’ session.
Second, during the post-war period—specifically the 1950s and 1960s—independence
movements in Africa, Asia, and the Caribbean ended European colonialism. However, the
influence of colonial psychiatry persisted in a legacy of custodial psychiatric institutions that
remained largely unchanged even as deinstitutionalisation and the development of community
mental health services began to take place in Western Europe, North America and, somewhat
later, in Australia.
Third, the United Nations established the World Health Organisation (WHO) in 1948, which, in
turn, established a Mental Health Division and convened an Expert Committee on Mental Health.
Over the course of the next several decades, this Expert Committee on Mental Health issued
technical reports on topics such as mental hospitals, substance abuse, and the epidemiology of
mental disorders (WHO, 1953, 1960, 1967). Under the direction of Tsung-Yi Lin (1953), who had
already conducted rigorous epidemiological research on the incidence of mental disorders in
Taiwan, the WHO prepared a series of studies to examine whether it was possible to consistently
diagnose mental disorders in diverse population groups (Lin, 1967). One product of these efforts
was the landmark International Pilot Study of Schizophrenia which demonstrated that it was
possible to develop a research instrument that could be used to diagnosis schizophrenia reliably
and with a high degree of validity in different populations (WHO, 1973).
At about the same time, there was a growing interest in both the epidemiology of mental disorders
in low- and middle-income countries (LMICs, frequently referred to as ‘developing countries’) and
the services available in those countries. The British Journal of Psychiatry published a series of
papers that described the state of mental disorders and their treatment in Asia, Africa, and South
America (German, 1972; Leon, 1972; Neki, 1973). In a fourth paper, Morris Carstairs (1973)
presented an overview of the situation in LMICs and delineated a number of issues in those
countries that would, 35 years later, become central to the field of global mental health: the large
burden of disease attributable to mental disorders, stigma, the lack of human resources to provide
treatment and care for those in need, and the necessity of task-sharing (also called ‘task-shifting’):
One thing is clear: in the developing countries there is no place for 'demarcation disputes'
about who should do what. Even such medical prerogatives as the dispensing of drugs and
injections…may have to be delegated to nurses and other auxiliaries who have been
instructed in these tasks and have first practised them under supervision (Carstairs, 1973).
The recommendations of the Expert Committee on Mental Health resulted in the WHO initiating
the Collaborative Study on Strategies for Extending Mental Health Care, conducted in seven
LMICs. The study’s overall goals were to determine the feasibility of implementing the
recommendations of the Committee (Beigel, 1983; Harding et al, 1983a; Harding et al, 1983b;
Murthy & Wig, 1983; Sartorius & Harding, 1983). One of the most important and long-lasting
effects of the study was to demonstrate that it was possible to train primary care personnel in the
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recognition, treatment, and management of MNS conditions. Perhaps even more importantly, the
integration of mental health services into primary care—through training of primary care personnel
and task-sharing—became the strategy that guides global mental health efforts into the present
day.
Box 1. What happened to the asylum?
Historians of architecture offer fascinating insights into the rise and fall of the asylum, based on
changes to the built environment. This review of the photobook Abandoned Asylums in
ArchDaily explains the relationship between some of the key architectural details, such as sash
windows and porticos, and broader trends in 19 th century thinking about mental health.
https://www.archdaily.com/806559/these-images-of-abandoned-insane-asylums-show-
architecture-that-was-designed-to-heal
In the wake of deinstitutionalisation, many asylums were destroyed or abandoned. Others were
repurposed. If you look closely, you might be surprised to learn that a grand old office building,
museum or block of luxury flats near you was once an asylum.
http://mentalfloss.com/article/72095/7-second-lives-converted-mental-hospitals
3.6. Beginnings of comparative psychiatry

One might think that the accumulation of evidence about the epidemiology of MNS conditions in
LMICs, as well as the development of strategies to address the challenges posed by the lack of
human resources, would have made the treatment of mental illnesses a priority for international
health efforts in the decades following World War II. Yet, this evidence had relatively little impact,
and policymakers continued to rely on mortality statistics to define public health priorities.
As we will discuss further in subsequent sessions, the introduction of disability-adjusted life-years
(DALYs) to measure morbidity and mortality represented a watershed moment for the field of
global mental health. As opposed to mortality statistics, DALYs factor both years lived with
disability as well as years of life lost to calculate the number of years of healthy life lost. The 1993
World Development Report (World Bank, 1993) cited global burden of disease estimates from
1990, indicating that ‘neuropsychiatric disease’ accounted for 6.8% of the global disease burden.
An additional 1.3% of the global disease burden was attributed to self-inflicted injuries (Desjarlais
et al, 1995). For comparison, ‘STDs and HIV’ accounted for 3.8% of the global disease burden in
the same year (at which time an estimated 8-10 million people worldwide were living with HIV)
(Chin, 1990; World Bank, 1993).
The 1993 World Development Report inspired the 1995 publication of World Mental Health:
Problems and Priorities in Low-Income Countries (Desjarlais et al, 1995), written by academics at
Harvard Medical School, including Arthur Kleinman, a medical anthropologist whose work will also
be discussed in the session, ‘Culture and critiques of global mental health’. Launched by the UN
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Secretary General, the book brought attention to how the findings of the global burden of disease
studies demonstrated that MNS conditions impose a significant burden on populations in low- and
high-income countries alike. It was this work, along with the 2001 World Health Report, Mental
Health: New Understanding, New Hope (WHO, 2001b), that marked the beginning of global
mental health as a field (Satcher, 2001).
Activity 2: Check your understanding

Graham Thornicroft’s editorial ‘Premature death among people with mental illness’ challenges
the misconception that MNS conditions do not deserve the same attention as ‘killer’ diseases.
Read his editorial (http://www.bmj.com/content/346/bmj.f2969.long) and then answer the
following questions.

1. According to Thornicroft, what is the main reason why premature mortality is higher
among people with mental illnesses than among the general population?
a. There is an increased risk of suicide among people with mental illness.
b. People with mental illness often have poorer physical health outcomes.
c. Both of the above.
d. Neither of the above.
2. Why do people with mental illness often have poorer physical health outcomes than the
general population?
a. People with mental illness are disproportionately exposed to socioeconomic and
clinical risk factors.
b. People with mental illness generally do not receive the same standard of physical
healthcare.
3. Why might premature mortality among people with mental illness be underestimated
globally?
a. There has not been much research on the topic in LMICs.
b. There are no internationally agreed standards on how to measure the physical
health or mortality outcomes of people with mental illness.
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4. Global mental health in the 21st century

It is difficult to predict how the history of global mental health in the 21 st century will be written.
Events that seem insignificant now could revolutionise the field in a few years’ time. Equally, what
we presently see as important milestones could fade into obscurity.
At the risk of oversimplifying the messy process of global policymaking, it is perhaps most useful
for you, as students of global health policy, to carve this history-in-the-making into three
overlapping phases of activity: 1. compiling the evidence necessary for action; 2. using this
evidence to set an agenda for action; and finally, 3. securing commitment to the agenda. For ease
of understanding, we have mapped these phases onto a roughly chronological timeline in this
section; however, please keep in mind that this is a mere outline to help newcomers to the field
make sense of recent events in global mental health. Those who have lived through and
participated in these events would tell you a much more nuanced, iterative and complex story of
global mental health in the 21st century.
Box 2. Evidence for action on mental health in China
Epidemiological research has played an important role in the emergence of global mental health
as a field, quantifying the burden of MNS conditions in LMICs and highlighting issues of
inadequate and inequitable access to services. The researchers involved are often quite aware
of—and even motivated by—the relevance of their findings to mental health policy and practice.
In his 2009 podcast for the Lancet, Professor Michael Phillips discusses the implications of his
survey findings to the Healthy China 2020 agenda and the WHO’s global mental health Gap
Action Programme, as well as the ways in which nuances in research methodology in LMICs
can drastically impact estimates of the global burden of MNS conditions.
Click this link to find the associated article: https://doi.org/10.1016/S0140-6736(09)60660-7. To
access the podcast, scroll to the bottom of the article, and you will see a link to ‘Related audio’,
which is the June 12, 2009, edition of the Lancet podcast.
4.1. Collecting the evidence

In the years immediately following the publication of the 2001 World Health Report, the WHO
focused on building the evidence base—including evidence-based tools and guidance—to inform
mental health planning and policymaking.
The WHO’s Mental Health Atlas project, started in 2001, continues to ‘collect and compile
essential information about mental health care resources available at national, regional and global
level’ (WHO, 2001a, 2015b). Linked to Mental Health Atlas, the WHO’s Assessment Instrument for
Mental Health Systems (WHO-AIMS), launched in 2003, regularly collects data on ‘all
organisations and resources focused on mental health’ (WHO, 2005). Findings from Mental Health
Atlas and WHO-AIMS reports are often cited to highlight the gross disparities between needs and
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resources (for example, the global shortage of human resources for mental health, which we will
discuss in the session ‘Resources for mental health’). You will likely find yourself turning to these
two resources as you prepare your two assessments for this module.
While both Mental Health Atlas and WHO-AIMS present regular digests of essential data on
mental health, the Mental Health Policy and Service Guidance Package, released in 2003, offers
technical guidance to support policy and planning (WHO). It includes 13 different modules,
covering a wide range of topics, eg mental health information systems, financing, advocacy, and
quality improvement.
Activity 3: WHO MiNDbank

In 2014, WHO launched MiNDbank, an online platform collating policy-relevant material on
mental health from around the world: http://www.mindbank.info/
You will want to refer to MiNDbank when preparing your two assessments for this module. To
get comfortable with the platform, try selecting a country from the Country Resources tab. Does
it have a WHO-AIMS report? What other resources are listed?
When you are finished examining the resources for your country on MiNDbank, refer to the
section on “Mental Health Systems Governance” of the 2017 WHO Atlas:
http://apps.who.int/iris/bitstream/handle/10665/272735/9789241514019-eng.pdf?ua=1
In your country’s region, what percentage have a stand-alone mental health policy or plan? A
stand-alone mental health law? Take a moment to reflect: How does your country appear to be
performing, in terms of mental health systems governance, in comparison to the rest of the
region?
Write a brief paragraph (4-5 sentences) recording your reflections on Moodle. You may wish to
revisit your answers before starting your assessment. It is important to understand the current
state of governance of the mental health system in your country of choice before preparing a
policy report.
4.2. Setting the agenda

It is important to note that while many cite either the 1995 World Mental Health publication or the
2001 World Health Report as the moment that defined global mental health as a field, the term
was not widely recognised until The Lancet series on global mental health was first published in
2007 (Horton, 2007). The series featured six articles focusing on the global burden of mental
disorders, current resources and services for mental health, barriers to adequate service provision,
evidence on treatment and prevention of mental disorders, and a call to ‘scale up the coverage of
services for mental disorders in all countries, but especially in LMICs’ (Lancet Global Mental
Health Group, 2007).
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The call to action in this series – which mirrored several recommendations made previously, eg
the 2001 World Health Report – highlighted five key goals to achieve adequate scale-up of
services for mental disorders:
 Identify and scale up priority packages of service interventions;
 Increase development assistance for mental health;
 Increase budget allocations for mental health;
 Strengthen data collection and monitoring systems;
 Increase funding for global mental health research.
Figure 2. Preparing for a mhGAP training in Sierra Leone. Photograph courtesy of Carmen Valle, CBM International.
This series brought international attention to global mental health, elevated the status of the field,
and sparked further action. For example, the WHO’s Mental Health Gap Action Programme
(mhGAP) (WHO, 2008) was launched in 2008. mhGAP aims to increase service coverage for
MNS conditions, as well as stakeholders’ commitment of resources for mental health. The
programme identified priority conditions (using criteria such as disease burden, vulnerability to
human rights violations, and economic costs), compiled evidence-based prevention and
management strategies for each of these priority conditions into ‘intervention packages’ that can
be adapted to a variety of settings, and provided context-specific guidance on the process of
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scaling up mental health services. The first version of the mhGAP Intervention Guide (mhGAP-IG),
designed to assist non-specialist healthcare providers in the delivery of these ‘intervention
packages’, was released two years later and updated in 2016 (WHO, 2016). A special version of
the mhGAP-IG for use in humanitarian settings was released in 2015 (WHO, 2015a).
The year 2008 also saw the launch of the Movement for Global Mental Health (MGMH), which
brought together a ‘coalition of individuals and institutions committed to collective actions that aim
to close the treatment gap for people living with mental disorders worldwide’ (Patel et al, 2011).
MGMH provided a forum for advocacy that had previously been limited to largely academic circles.
Representatives of MGMH helped to ensure that human rights and empowerment were made
central themes in the 2011 update to The Lancet’s original series on global mental health. Since
2013, MGMH has been led by ‘people with lived experience’ of MNS conditions (also ‘experts by
experience’, ‘service users’ or ‘users and survivors of psychiatry’) (Patel et al, In Press).
Academics and research funders do continue to play a significant role in advocacy. The Grand
Challenges in Global Mental Health Initiative led by the National Institute of Mental Health (NIMH)
and the Global Alliance for Chronic Disease in partnership with the Wellcome Trust, the
McLaughlin-Rotman Centre for Global Health, and the London School of Hygiene and Tropical
Medicine, was launched in 2010 (NIMH, n.d.-b). In 2011, the landmark paper ‘Grand Challenges in
Global Mental Health’, published in Nature, set out a prioritised research agenda generated
through Delphi methods (Collins et al, 2011). This research agenda could shape the way that
evidence is generated in this field for years to come.
Already, the Grand Challenges Initiative has had an impact on how global mental health projects
are funded. Also in 2011, NIMH financed its first Collaborative Hubs for International Research on
Mental Health (NIMH, n.d.-a). These are regional consortia based in LMICs, which share a focus
on task-sharing and scaling up mental health interventions. In the same year, Grand Challenges
Canada announced that $20 million in Canadian taxpayer money would be dedicated to funding
‘bold ideas with big impact’ in global mental health (Grand Challenges Canada, n.d.). Subsequent
funding rounds have focused on helping projects with a strong proof of concept to transition to
scale. These initiatives—and others from around the world—more than doubled the amount of
overseas development assistance dedicated to mental health between the years 2007 and 2013
(Gilbert et al, 2015; Patel et al, In press).
In 2018, The Lancet Commission for global mental health reconvened to assess and reframe
progress in global mental health within the context of the Sustainable Development Goals.
4.3. Securing commitment

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) went into force
in 2008, the same year that mhGAP and the Movement for Global Mental Health were launched
(UN High Commissioner for Human Rights, 2017), a reminder of the non-linear path that global
policymaking inevitably takes. The CRPD is an international treaty that protects the human rights
15
of all persons with disabilities, and includes a number of protections that are highly relevant to
persons with psychosocial or intellectual disabilities. As of 2017, the CRPD has been either ratified
or acceded by 174 member states, and the Optional Protocol has been ratified or acceded by 92
member states. There are ongoing efforts not only to secure a universal commitment to both the
CRPD and its Optional Protocol (https://www.un.org/development/desa/disabilities/convention-on-
the-rights-of-persons-with-disabilities.html), but also to ensure that it is properly actioned,
monitored and enforced. For example, the WHO QualityRights Project and Toolkit
(http://www.who.int/mental_health/policy/quality_rights/en/) was launched in 2012, originally
focused on assessment of CRPD compliance in mental health and social care facilities. New
QualityRights materials that go far beyond the purview of monitoring are currently being piloted.
Figure 3. A Quality Rights Training in Samoa. Photograph courtesy of Carmen Valle, CBM International.
We will discuss the CRPD and QualityRights in the ‘Human rights and stigma’ session. However, it
is worth noting here that, although the two terms are frequently used interchangeably, ‘mental
illness’ and ‘psychosocial disability’ are not one and the same. The CRPD describes people with
disabilities as ‘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’ (UN General Assembly, 2006). The term ‘psychosocial disability’
16
therefore does not refer to a particular diagnosis or health condition, but instead recognises that
many of the challenges that people with MNS conditions face exist as a result of the way in which
societies are organised and how people living with these conditions are treated.
In recent years, the more health-specific aims of global mental health have also moved up the
international development agenda. Although not legally binding, the 2013-2020 Mental Health
Action Plan (MHAP) adopted by the 66th Assembly of the WHO set an important precedent (WHO,
2013). MHAP outlines four key objectives, each of which is assigned corresponding targets and
indicators:
 Strengthen effective leadership and governance for mental health;
 Provide comprehensive, integrated, and responsive mental health and social care services
in community-based settings;
 Implement strategies for promotion and prevention in mental health;
 Strengthen information systems, evidence, and research for mental health.
Agreed by all WHO member states, MHAP showed that there was indeed a growing international
consensus that mental health matters, and that it was possible for policymakers to agree on a way
forward. This precedent was crucial because mental health had been notably absent from the
Millennium Development Goals (Wagstaff & Claeson, 2004), which defined global development
priorities for more than 10 years. When the Sustainable Development Goals
(http://www.un.org/sustainabledevelopment/) were released in 2016, many were relieved to see
the words ‘mental health’ and ‘substance abuse’ included in targets under Goal 3, ‘Good health
and well-being’. Disability was also mentioned—including psychosocial disability—and has a
strong presence in the SDGs, especially in Goals 4, 8, 10, 11 and 17.
#FundaMentalSDG, an international, multi-sectoral campaign that advocated for the inclusion of
mental health in the SDGs (https://www.fundamentalsdg.org), launched a campaign to ensure that
appropriate mental health indicators were also assigned to SDG targets, abiding by the adage that
‘what gets measured gets done’. These efforts have not been quite so successful, raising
concerns that countries may not be held accountable for their commitment to mental health as part
of the SDGs.
5. Summary
Concerns and ideas about MNS conditions and its treatment have been circulating around the
globe for millennia, but institutionalised care was only established beginning in the 9 th century in
the Islamic world of the Middle East and North Africa. During the late 18 th century, moral treatment
was developed in England and France and in the first decades of the 19 th century, state-supported
systems of asylum were established in Europe and North America, which cemented institutional
care as the modus operandi. This system of care was then established in countries colonised by
European powers. Along with the expansion of institutional care came new perspectives on
17
cultural influences on MNS conditions and, in turn, this gave rise to the discipline of comparative or
transcultural psychiatry at the beginning of the 20 th century.
Soon after the end of World War II, countries in North America and Europe began the process of
deinstitutionalisation, shifting toward community-based services. At about the same time, many
colonies gained independence from European powers; however, independence for these nations
occurred before the European shift away from institutional care took place. This is one reason
mental health services remain largely institutional in many LMICs today. However, even in most of
North America and Europe, deinstitutionalisation has neither been completed nor been coupled
with sufficient scale-up of community-based services.
Thus, the ‘treatment gap’ that is often referred to in global mental health—ie the proportion of
people living with MNS conditions who do not receive treatment (Kohn et al, 2004)—is, in many
ways, a product of history. So, too, are the means by which global mental health has sought to
address this gap, primarily through the adoption of task-sharing approaches that shift the main loci
of care from institutions to communities. Even the ways in which we seek to explain cultural
differences in global mental health are rooted in the deeply troubling history of colonisation, as we
will discuss further in the session ‘Culture critiques of global mental health’. It is crucial to keep the
history of the field in mind as you progress through this module and shape your own critical
perspectives.
As students of the field, perhaps the most important takeaway from the history of global mental
health is the significant role that both research and expert opinion play in shaping global health
agendas. The field of global mental health was born from a change in metrics—the creation of
DALYs, which combined mortality with morbidity data. While we often assume that research is
objective, the decisions made about how and what to measure are just as political as they are
technical. Similarly, the decisions made about whose unique expertise distinguishes them as
‘experts’ can have profound consequences, launching new priorities and either reifying or
obscuring existing ones. By understanding how those decisions have shaped the field of global
mental health in the past, we can better inform the decisions that will shape its future.
6. Integrating activity
Integrating activity: Critical thinking
In this session, we start to address the fundamental question, ‘What is global mental health?’ by
first explaining the origins of the field. But in order to answer this question, there is another,
much broader question with which we must also grapple in this module: ‘What is mental
health?’.
In this exercise, we ask you to choose two of the terms listed below. These terms are
sometimes used interchangeably as either synonyms or antonyms of one another. Think
18
carefully about the connotation of each term. What makes it unique?

After you have had a chance to reflect, navigate to the word clouds for each of these terms on
AnswerGarden, via Moodle. For each word cloud, enter three words that you think help to
capture the unique connotation of the term (six words total).
 Mental health
 Mental health condition
 Mental health problem
 Mental illness
 Mental disability
 Mental disorder
 Mental well-being
After making your contribution, take some time to look at the two word clouds. Do any words
stand out to you? Do you agree with the words your classmates and tutors have contributed, or
do any words appear to be out of place? Do any of these words challenge you to think about
your terms in new ways?
Write a brief, two-paragraph reflection comparing and contrasting the two terms. In the first
paragraph, discuss how the terms are similar and how they are different. In the second
paragraph, discuss the implications of these differences for global mental health. If the field
were to focus entirely on addressing ‘mental well-being’, for example, how would this differ from
a focus on ‘mental disorders’? Upload your two-paragraph reflection to Moodle. Feel free to
also read and comment on your classmates' reflections.
19
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24
8. Answers to activities
8.1. Activity 2
Can you think of at least three reasons accounts like this one could be overstating the positive
aspects of care at a place like Geel?
For each reason, write a short (one- to two-sentence) explanation.
1. Social desirability bias: when confronted with challenging questions, a resident of Geel
is likely to say what he or she thinks the investigator wants to hear.
2. Selection bias: the investigators are speaking primarily to people involved with this
unique system of care at Geel. People who are unhappy with this system are less likely
to stay in Geel and are therefore not available for interview.
3. Conflict of interest: this unique system of care is a source of income for residents of
Geel, who might not want to share the more negative aspects and risk their livelihood.
4. Subjectivity: residents of Geel might genuinely believe that this is a good system of
care, regardless of whether or not this can be demonstrated objectively.
8.2. Activity 3
1. According to Thornicroft, what is the main reason why premature mortality is higher among
people with mental illnesses than among the general population?
a. There is an increased risk of suicide among people with mental illness.
b. People with mental illness often have poorer physical health outcomes.
2. Why do people with mental illness often have poorer physical health outcomes than the
general population?
a. People with mental illness are disproportionately exposed to socioeconomic and clinical
risk factors.
b. People with mental illness generally do not receive the same standard of physical health
care.
3. Why might premature mortality among people with mental illness be underestimated
globally?
a. There has not been much research on the topic in LMICs.
b. There are no internationally agreed standards on how to measure the physical health or
mortality outcomes of people with mental illness.
25

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GHM 202 – Session 1: Emergence of global mental health

2. What is global mental health?

3. A brief history of global mental health1

3.1. Ancient world and pre-Enlightenment

Activity 1: Critical thinking

3.3. Colonial psychiatry

3.4. Beginnings of comparative psychiatry

3.5. Post-World War II

3.6. Beginnings of comparative psychiatry

Activity 2: Check your understanding

4. Global mental health in the 21st century

4.1. Collecting the evidence

Activity 3: WHO MiNDbank

4.2. Setting the agenda

4.3. Securing commitment

carefully about the connotation of each term. What makes it unique?

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