Global Mental Health: Anthropological Perspectives

Global health has been defined as an area for study, research, and practice that places a priority on achieving health and improving equity in health for all people worldwide; that emphasizes transnational issues, determinants, and solutions; that involves many disciplines (within and beyond the health sciences); and that promotes collaboration (1). Global mental health naturally follows the same path, except that the emphasis is placed upon mental health and behavioral problems, particularly those that significantly affect cost and disability worldwide. The use of the term “global mental health” is quite recent, apparently used first by former U.S. Surgeon General David Satcher in the early 2000s in a commentary published in the Journal of the American Medical Association (2). However, the term would not become “fashionable” and universally used until 2010 or so. Today, there are several textbooks written on the topic of global mental health, and even the American Journal of Psychiatry includes a section called “Perspectives in Global Mental Health” that highlights global mental health issues worldwide.

Historically, an important perspective in global mental health has been the anthropological one. This approach, which originally focused on the description of exotic syndromes from distant lands, advanced important theories concerning the “emic” (from phonemics, meaning local) and “etic” (from phonetics, meaning universal) perspectives on mental disorders. In today’s globalized world, however, with the massive waves of migration and giant communication networks, these syndromes have less clear boundaries, so they can be seen in many countries, even highly developed ones. The “etic” or universal approach has gained impetus with studies sponsored by the World Health Organization showing that major psychiatric disorders can be reliably identified in most countries and cultures and that psychiatric classifications such as DSM-5 and particularly ICD-10 appear to have universal acceptance and appeal. The fact that the “emic” perspective may be losing ground does not alter the obvious impact that cultural background has on the presentation, treatment preferences, and treatment response of mental disorders across the globe.

The book reviewed herein provides an updated view of the promises and intricacies of this approach. The passionate focus of some investigators from high-income countries (such as the United States) on combating stigma and on building, improving, or integrating mental health care services in low- and middle-income countries abroad often ignores the fact that in our own country, the availability and integration of mental health and primary care services are still quite deficient. Therefore, it is not surprising that leading global figures such as Paul Farmer, the founder of Partners in Health, have also focused on deprived areas of our own country.

By presenting a number of chapters that focus on the United States, this book is a refreshingly new addition to the literature in this area. Modern anthropologists have indeed tackled domestic issues in the United States, but these have been restricted to minority groups or other specific topics such as those described in the excellent book by Tanya Luhrmann on the education of U.S. psychiatrists (3).

A few decades ago, Arthur Kleinman, one of the leading researchers in this area, outlined four key questions in efforts to illustrate the contribution of anthropology to psychiatry (4):

This book touches upon questions 1 and 2, and possibly 4, but there is little if any material addressing question 3, including translation and linguistic competency.

This book is a collection of brief pieces written mainly by psychological, medical, and cultural anthropologists, and practically all of them are U.S. and Canadian academicians. The only exceptions appear to be Reverend Jalla, from Liberia, and Professor Vikram Patel from India and the United Kingdom, a leading figure in the global mental health movement who is also the senior author of a major global mental health textbook and who wrote the foreword for this book.

While one understands the practical motives for these choices, they make the book less global, as everything is seen through the lens of the “outsider” (except for the pieces focusing on U.S. domestic issues), thus evoking at times the emic/etic dichotomy of yesteryear.

The senior editors provide a general framework, including an introduction and the two leading chapters, as well as an introduction to each of the three main sections of the book: “Social and Structural Origins,” “Treatment Approaches,” and “Access, Task Sharing, and Alternative Models.” At the end, they also provide a roadmap for anthropology and global mental health. In the opinion of this reviewer, these contributions by the book editors are the most valuable component of the book.

The various chapters included under each of the three major sections represent colorful vignettes from many exotic and distant lands but also from our own U.S. territory, thus forming a unique quilt spanning global and local issues. These include pieces from countries such as Mozambique (care providers), Ethiopia (unemployment, task shifting), Belize (sexual violence), Bolivia (water security), Colombia (addiction), Nicaragua (families in distress), the Dominican Republic (Haitian immigrants), Haiti (treating distress), India (conservation refugees), Romania (psychiatric hospitals), Iraq (refugees), and Liberia (anthropology and the experience gap). Individual chapters on U.S. issues focus on Mexican immigrants (depression and diabetes), U.S. veterans and women in the military (combat and posttraumatic stress disorder), urban dwellers (peer treatment for psychotic disorders), and educational issues (teaching global health to psychiatry residents). While a systematic anthropological model is not clearly followed in each instance, many of the chapters provide rich cultural descriptions and useful information for practicing clinicians.

In the early 1930s, the American anthropologist Edward Sapir—who interestingly devoted significant attention to psychiatry—referred, rather critically, to the cross-cultural inquiries of early anthropologists with statements such as this: “Perhaps it is not too much to expect that a number of gifted psychiatrists may take up the serious study of exotic and primitive cultures, not in the spirit of meretricious voyaging in behalf of Greenwich Village, nor to collect an anthology of psychoanalytic fairy tales, but in order to learn to understand, more fully than we can out of the resources of our own cultures, the development of ideas and symbols and their relevance for the problem of personality” (5). In that context, this book appears as a welcome addition to the global mental health literature and reinforces the maxim “think globally, act locally.”