Global Aspects of Chronic, Severe Mental Disorders: Realities and Opportunities for Education and Research

Four major mental health conditions (major depression, substance use disorders, bipolar disorders, and schizophrenia) have been included for almost two decades among the top 10 most disabling and costly medical disorders in the world (5). Effective biological treatments (antidepressants, antipsychotics, and mood stabilizers) and psychotherapeutic interventions such as interpersonal psychotherapy and cognitive-behavioral therapy have been shown to be universally effective and applicable, taking advantage of manualized packages and practical approaches that can be readily implemented almost everywhere, even if there is a shortage of specialized mental health professionals, as demonstrated by several studies (6–8)

Notwithstanding their high prevalence, their impact on cost and disability, and the availability of effective interventions, the recognition and treatment of mental disorders remains one of the most neglected areas in health care worldwide. This neglect may be related to stigma, as well as to diagnostic issues that may result in ambiguous definitions affecting the proper characterization of those in need of services. The lack of adequate services is most pressing in the case of low-income countries. The World Health Organization (WHO) (9) Mental Health Atlas illustrates the fact that many low- and middle-income countries lack basic mental health services and that there is a significant gap worldwide between the burden caused by mental disorders and the resources available to prevent and treat them (Table 1). According to the above WHO report, four of five people with serious mental disorders living in developing countries do not get the mental health services that they need (9). Thus, one of the main goals of the global mental health movement is to improve mental health care services for people living with mental illness and psychosocial disabilities worldwide. The global burden of disease (GBD) resulting from chronic severe mental illness has been well documented (10). According to a recent report, mental and substance use disorders are the leading cause of years lived with disability worldwide. The global burden of mental disorders alone accounted for the highest proportion of disability-adjusted life-years (DALYs) at 56.7%, whereas depressive disorders accounted for 40% of DALYs and schizophrenia and bipolar disorder accounted for 7% each. Most concerning is the fact that the burden of mental and substance use disorders continues to increase (Box 1); for example, it went up almost 40% between 1990 and 2010. A consortium that included significant input from the National Institute of Mental Health (NIMH) described these global challenges in a leading article in Nature (11).

According to WHO, mental, neurologic, and substance use disorders are common in all regions of the world, affecting every community and age group across all income countries. Although 14% of the GBD is attributed to these disorders, most of the people affected (up to 75%) who live in low-income countries do not have access to the treatment they need. In efforts to address these problems, WHO created the Mental Health Gap Action Program (12).

The discrimination against people with mental disorders is widespread. This stigma causes communities and decision makers in the health field to view those affected with little regard, and there is a reluctance to invest time and resources for mental health care. Even health care workers acknowledge negative perceptions regarding those with mental disorders. Globally, there is a scarcity of resources, including professionals such as psychiatrists, psychologists, nurses, and social workers, for those with mental disorders (Figure 1). The balance between community and hospital-based services is one of the best indicators of comprehensive mental health care (13). However, this is usually only achieved in high-income countries, whereas individuals in lower-income countries are far away from the target. Many clinical services in poor countries cannot even provide the most basic antidepressant drugs (13).

To decrease stigma, educating family members of patients about chronic, severe, mental disorders is essential. These education programs can be added to social skill–building strategies for the patients using special modules. It is important to apply interventions that raise the self-esteem of those suffering from chronic, severe mental disorders simultaneously with interventions that can effectively reduce the severity of the disorder (14). The Open the Doors program was created in 1996 by the World Psychiatric Association (WPA), with the goal of reducing the stigma associated with schizophrenia. In 2005, the WPA created a Section on Stigma and Mental Health to reduce the stigma of mental disabilities in general (15). Since then, many organizations have agreed that stigma within mental health is a major public and global challenge. The continuation of this program is necessary for the reduction of stigma globally. Open the Doors has taken action by creating antistigma interventions for schools, mass media, mental health professionals, and family and friends of people with schizophrenia, as well as many other groups of people (15). The program also hopes to change the public’s negative perceptions and enhance knowledge about mental illnesses to more effectively curtail stigma. Although this program was initially created to reduce the stigma of people with schizophrenia, it is now being applied to reducing stigma for people with any kind of mental disability. As awareness of existing stigmas grows around the world, people may be better able to understand the difficulties that patients with mental illness face and the discrimination that they experience as a consequence of their mental illness.

Historically, an important perspective in global mental health has been the anthropological one. This approach originally focused on the description of “exotic syndromes from distant lands” and 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 WHO showing that major psychiatric disorders can be reliably identified in most countries and cultures and that psychiatric classifications such as DSM-5 and ICD-10 appear to have universal acceptance and appeal. The fact that the emic perspective may be losing ground does not alter the obvious effect that cultural background has on the presentation, treatment preferences, and treatment response of patients with mental disorders across the globe. A recent book, Global Mental Health: Anthropological Perspectives (4), provides an updated view of the promises and intricacies of this approach in efforts to dispel perceptions such as the one suggesting that the traditional emic approach may be “patronizing” because many of the leading emic investigators come from westernized countries. Indeed, the passionate focus of some investigators from high-income countries (e.g., the United States) on combating stigma and building up, improving, or integrating mental health services in low-income/middle-income countries abroad often ignores the fact that in our own country, the availability and integration of mental health and primary care services is still quite deficient. It is therefore not surprising that leading global figures such as Paul Farmer, the founder of Partners in Health (PIH), are also focusing on deprived areas in our own country. Farmer, who first implemented successful programs in Haiti’s central plateau region and several other programs around the world, has also developed several initiatives to address health problems in impoverished and neglected areas of the United States (the PIH/Community Outreach and Patient Empowerment program in the Navajo nation of the southwestern United States and the PIH/Prevention and Access to Care and Treatment program in Boston).

Global health research has been expanding in recent times, stimulated by the relevance of globalization to today’s world and the availability of research funds from the National Institutes of Health (NIH) and other agencies. In August 2009, after his inauguration as NIH director, Dr. Francis S. Collins, former director of the Human Genome Project, listed global health as one of five key areas on which he would focus during his tenure as NIH director. Collins stated that global health research “should be an ongoing conversation with other countries, but not one in which the great United States tells the world what the answers are without listening to their experiences.” Collins also stated that “the ability of NIH to play a major role in the United States’ soft power abroad, seems like an opportunity we should not pass up, a chance to be more of a doctor to the world rather than a soldier to the world, by helping control both infectious and non-communicable diseases.” Unfortunately, several years later, this notable NIH global initiative would stall, owing to political and budgetary issues.

However, nongovernmental initiatives have flourished, thanks to philanthropic organizations such as the Bill and Melinda Gates Foundation and to other initiatives, such as the Global Health Investment Fund, to which corporations such as J.P. Morgan and pharmaceutical companies such as Pfizer and Merck actively contribute funds. Another major recent impetus on global investments followed the creation of the Lancet Commission and the Global Health 2035 investment framework (16). This pivotal new development for global health investments launched in 2012, and it articulated an ambitious initiative called “Global Health 2035.” The commission includes an independent group of 25 leading economists and global health experts, led by Lawrence H. Summers, president emeritus of Harvard University. Major goals of this initiative are to reach sustainable development goals for health, to stimulate donor investment in global health, and to encourage domestic health investments in low- and middle-income countries toward universal health coverage.

Most of the support from the large foundations primarily targets infectious diseases and other medical entities for which quick interventions may yield rapid results. There are also interesting initiatives that may indirectly affect mental health, such as the Gates Foundation/BRAC (formerly Bangladesh Rural Advancement Committee) project (17), a collaboration of the Gates Foundation with a large university system in Bangladesh that has created an innovation fund for “mobile money challenges.” This initiative uses “mobile” or “digital” money as an alternative to banks, thus giving access to 70% of the Bengali people who can use this resource for shelter, nutrition, and education, primarily for children.

Unfortunately, noncommunicable disorders, notably mental health problems, continue to lag behind infectious and parasitic diseases in terms of the attention they receive from potential sponsors.

In our view, a key aim of the field of global mental health is to advance education on mental health issues across the globe by disseminating information about mental disorders, their effect on disability, and the availability of effective treatments and interventions that may improve their prognosis and outcomes. A priority in addition to the above is to redouble efforts to reduce the stigma related to these disorders, particularly the more chronic and severe ones (e.g., schizophrenia). Given the shortage of specialized professionals, there is an acute need for practical and cost-effective models for training mental health workers (e.g., task shifting) in efforts to develop cost-effective interventions to meet mental health needs in all areas. Interestingly, NIH Director Francis Collins, when announcing his strategic planning inclusive of global health a few years back, confided to reporters his experience of volunteering at a hospital in Nigeria earlier in his career, calling it one of the things that had the greatest influence on his approach to health research. These impressions closely resemble those of medical students returning from global health rotations abroad—experiences that have a deep and long-lasting impact on their careers.

Mental health is an integral part of health. The European Union ministers had it right when they added the phrase “there is no health without mental health” and placed it at the top of the United Nation’s list of development goals for the new millennium. Mental illness and its complications (e.g., suicide) constitute a universal crisis and this is now the largest cause of disability worldwide, over and above the disability induced by chronic medical diseases such as cardiovascular illness, diabetes, or hypertension. This global emergency can be improved only through the systematic adoption and implementation of comprehensive approaches to recognize and manage mental illness, develop effective mental health policies, protect human rights, and reduce stigma. Global mental health education is a critical piece of this effort. On a positive note, global mental health research projects and collaborations should continue producing important scientific findings and, more importantly, contributing to training of new investigators and incentivizing future researchers in the field.

The authors are with the Office of Global Health, Rutgers–Robert Wood Johnson Medical School, New Brunswick, NJ, where Dr. Escobar is associate dean and professor of Psychiatry and Family Medicine and Dr. Debbarma is a postdoctoral fellow.

The authors report no competing interests.