mental health.pptx

Global Mental Health
A brief history
Alex Cohen
London School of Hygiene & Tropical Medicine

The term
 1982: First use of the term:
 Are We for Mental Health as Well as Against Mental Illness? The
Significance for Psychiatry of a Global Mental Health Coalition
(Brody 1982)
• Prior to 2001:
– GMH used to denote overall level of stress in an individual
 2001:
 Global Mental Health: Its Time Has Come (Satcher)
 2007:
 The Lancet series
 2010:
 A New Global Health Field Comes of Age (Patel & Prince)
 2014:
 Why Mental Health Matters to Global Health (Patel)

Why Mental Health Matters
to Global Health
 Burden
 300 to 400 million people affected by psychosis,
intellectual disability, dementia, drug and alcohol
dependence, or severe depression
 Great majority in low-income countries
 Excess mortality
 Life expectancies ≈20 years shorter
 Worldwide, suicide a leading cause of death among
young adults
 Disability

Mental Health Matters…
 Lack of treatment
 In high income countries, up to 50% go without treatment
 As high as 90% in low-income countries
 Abuse
 Often in the very institutions that are responsible for care.
 Lack of global evidence
 Lack of resources

Is Global the New Part?
Concerns about mental disorders have been circulating
the globe for thousands of years

Egyptian texts – 16th century BCE
“He huddled up in his clothes and lay, not knowing
where he was. His wife inserted her hand under his
clothes and said ‘no fever in your chest, it is the
sadness of the heart.’
Now death is to me like health to the sick, like the
smell of a lotus, like the wish of a man to see his
house after years of captivity.”

China
• 12th to 4th centuries BCE: texts describing mental
illness
• Discussions of the legal status and responsibility of
persons who were mentally ill
• Yellow Emperor’s Classic of Internal Medicine
– circa 1000 BCE
– An imbalance of the life forces (Yin and Yang) may
result in insanity

India
 Caraka Samhita (circa 600 BCE)
 A seminal work in Ayurvedic medicine
 Two categories of insanity
 Imbalances in three humours
 wind, bile and phlegm
 Possession by good or evil spirits
 Treatments included:
 Medication (e.g., herbs)
 Physical therapies (e.g., massage & Yoga)
 Magico-religious methods (e.g., talismans & prayer)
 ‘Shock therapy’ (e.g., life-threatening acts) also employed
in difficult cases

Ancient Greece
• From the 5th Century BCE to the 5th Century CE,
Greek (and Roman) physicians generally agreed that
the brain was the organ in which mental functions
were based
• “Men ought to know that our pleasures, joys,
laughter and jests arise from the brain alone, as do
also pains, sorrows, sadnesses and tears.”
– On the Sacred Disease, 400 BCE

Ancient Greece, continued.
 Believed that humoural imbalances accounted for
disease, in general, and mental illnesses, in particular
 Blood, phlegm, and black and yellow bile
 Could be disturbed by internal or external forces
• Diet
• Exercise
• Climate
• Religious pollution

Parallels
 We do not know the extent to which the scholars
and physicians of ancient China, India, and Greece
communicated, but it is striking that their
explanatory models were similarly based on the idea
that imbalances in life forces were the causes of
disease:
 Yin and Yang of traditional Chinese medicine
 Humoural theories of disease in Ayurvedic medicine
 Hippocratic traditions of ancient Greece.

Parallels, continued
 Similar explanatory models gave rise to the
development of similar, physiologically-based
treatments:
 Traditional Chinese medicine
 Herbal potions and acupuncture
 Ayurveda
 Massage and Yoga
 Hippocratic tradition
 Massage, baths, balanced diet, and exercise

The Rise of Institutional Care
 From the time of the oldest written accounts of mental
disorders (ca. 20th Century BCE) to the establishment of the
first general hospitals by Islamic physicians in the 8th Century
CE, care of persons with mental disorders was the
responsibility of families
 ‘Institutional’ care only took place when families brought ill
members to temples, churches, or other places of religious or
spiritual importance
– In ancient Greece, people worshipped at the ‘grave sites
of…mythological and mythohistorical figures’ in the belief that this
would cure illnesses
• St Dymphna
• Islamic dargahs
• Hindu temples
• Christian religious healers

 Accounts from as early as the 3rd Century CE of the
confinement of mentally ill people in Syrian Catholic Churches
 But true institutional (i.e., hospital) care appeared somewhat
later in the Islamic world of the Middle East and North Africa
 The special provision for the insane [was] a remarkable aspect
of the medieval Islamic medical tradition. (Dols 1987)
 In contrast to the Christian custom of exorcism, Islamic
physicians followed Greek medical teachings and focused on
the physical causes of mental disorders and emphasized
physiological treatments
The Rise of Institutional Care, continued

 Disagreement about when and where the first institutional
care for persons with mental disorders was established
 By some accounts, the first asylums were established in the
8th Century in Fez and Bagdad
 Other accounts claim that the earliest institutional care took
place in Cairo in 872 CE
 By the 13th Century, institutional care could be found from
Damascus to Fez
 Not clear whether treatment took place in institutions
devoted exclusively to the care of persons with mental
disorders, in divisions within general hospitals, or both

 Nevertheless, even with the establishment of
hospitals, care remained the responsibility of families
and took place at home
 Hospital care was intended for poor families that
could not afford maintaining an ill person at home

 General agreement that the Islamic hospitals were
distinguished by ‘relaxed atmospheres’
 Fountains and gardens
 Treatments that included baths, bloodletting, leeches,
cupping, and a variety of drugs
 Psychosocial interventions were also employed
• Dancing, singing, theater
 Careful attention to diet

 16th Century account of a facility in Constantinople describes
patients being beaten, chained, and displayed for ‘public
amusement’
 The harsh conditions of the asylum should not be
misconstrued…The chains and irons…were simply necessary
devices to prevent harm to the insane or to others-- (Dols
1987)
 Whether such practices were forms of abuse or benign
protection remains an open question

A Rake’s Progress – Hogarth
Sir John Soane’s Museum
Lincoln’s Inn Fields, London

 Institutional practices entered Europe with the Moorish
invasion of Spain in the 8th Century
 Establishment of institutional care first recorded in the 14th
Century in Granada
 Similar Catholic institutions were founded beginning in the
15th Century

Parallel Developments
 1100: Metz, France
 1111: Milan, Italy
 1191: Ghent, Belgium
 1305: Uppsala, Sweden
 1326: Elbing, Germany
 1377: Charing Cross,
London
 1400: Bethlem, London
Stone House at Charing Cross
contained, ‘distraught and
lunatike people…but it was said,
that sometime a King of England,
not liking such a kind of people to
remaine so neere his Palace,
caused them to be removed…to
Bethlem without Bishops
gate…and to that Hospitall the
said house of Charing Crosse
doth yet remaine.’

 The extent to which the model for these hospitals was
based on a tradition of Christian charity or was a product
of Islamic practices in Spain – or some combination of
both – remains to be determined
 Central and South America:
 Aztecs, Incas, Mayas
 Little information
 Evidence of trephination, use of hallucinogens
 Sub-Saharan Africa:
 No written records
 Ethnographic evidence of biological and psychosocial
interventions
Parallel Developments, continued

Going Global
• 1567: psychiatric hospital established in
Mexico
– First institution of its kind in the Western
Hemisphere
– First instance of colonial psychiatry
– First global expansion of institutional mental
health care

Europe
 Institutional care in England can be traced to the 14th
Century (and earlier).
 Private institutions first developed in the 18th Century
 Expansion of public asylums in England began in 1808 with
the County Asylums Act
 1838: France established a state-run system of
asylums
 Between 1830 and 1850 religious orders in Belgium
opened 18 asylums

Bethlem Hospital / Imperial War Museum

West Riding Pauper Lunatic Asylum
One of a great number of establishments erected in various counties
throughout England, for the reception and treatment of those
unfortunate people who, drinking a two-fold portion of the cup of
affliction, are suffering under both abject poverty and mental alienation.
– Pliny Earle 1839

Europe, continued
Salpétrière, Paris

 Institutions were not founded in Scandinavia
until the 18th Century
 A ‘madhouse’ was established in Sweden and a
Norwegian royal ordinance decreed that hospitals
must set aside beds for the purpose of treating
mentally ill persons
Europe, continued

North America
• 1773: First asylum opened in Virginia
• Followed in the first half of the 19th Century with the
establishment initially of private and then later, state-
run psychiatric hospitals throughout the United
States
• In Canada, a hospital in Quebec may have started
admitting mentally ill persons in 1714, but the
establishment of psychiatric asylums in most
provinces only took place after 1840

State Lunatic Hospital at Northampton

Looking for an Alternative
Flemish Village of Geel

Geel
Saint Dymphna
 Martyred in 600 AD
 Veneration began as early as 8th
Century
 11th or 12th Century: shrine
famous for miraculous cures of
various health conditions
 Canonized in mid-13th Century
 Guest house built for pilgrims:
1286 AD
 About same time as Bethlem
Hospital

• Church of St. Dymphna: 1349
• Sick room built: 1480
• End of 15th Century: patients boarded out with
families close to Church
• 17th Century: boarding system expanded to other
districts of Geel
• 1797: France closes Church temporarily
– boarding out system becomes secular
– 200 boarders in 1800
Geel, continued

• 1803:
 Brussels transfers its patients
 Antwerp and other communities do the same
 Cities and central government appoint inspectors
to monitor care
 But attempts to address abuses are repeatedly
blocked by the town government
Geel, continued

 Remoteness:
 …considered beyond the pale of civilization, and but little
known even by residents of adjacent provinces
 No trains until the 1830's
 Equivalent of a leper colony?
 1850-52: ‘Foster care’ in Geel comes under the
regulation of the central government of Belgium
 Jules Parigot appointed as first medical
superintendent of Rijkskolonie (State Colony) of Geel
 He becomes one of the most passionate and vocal
advocates of l'air libre, the free air system of care
Geel, continued

The Great Debate
 1850s & 1860: Debate on merits of Geel
 Prompted by concerns about increasing need for services
and concerns about increasing costs
 Those who saw abuses
 Those who saw an alternative
 Future of the asylum decided in 1860s & 70s
 France, Great Britain, United States
 Cottage System loses
 Possibility of community care did not re-emerge, for all
practical purposes, until the 1950s.
 Continued expansion of large asylums

Colonial Psychiatry
 With Colonialism came the spread of Western psychiatry
and the establishment of mental asylums across much of
the globe
 For example, beginning toward the end of the 18th
Century and continuing until the early 20th Century,
British authorities established asylums in India,
Singapore, South Africa, and Nigeria
 Colonial psychiatry meant that the essential feature of
the mental health systems of Europe – the large,
custodial asylum – became the dominant feature of the
mental health systems in the colonies

Mental Hospital, Angoda, Sri Lanka

 The end of colonialism, in the late 1950’s and early 1960’s,
took place at the same time that community-based mental
health systems were being developed in Western Europe and
North America.
 This alternative did not have an opportunity to become
established in the former colonies.
 Thus, the legacy of mental asylums continues to dominate
many mental health systems in low-income countries.
 Exception: development of community psychiatry beginning in
the late 1940’s in Madras, India
Colonial Psychiatry

Deinstitutionalization
 The paramount place of institutional care for persons with
mental disorders, a practice that had begun more than a
1,000 years before, effectively came to an end, at least in
many of the industrialized nations of the West, in the 1950’s.
 Impetus came about as the result of several factors:
 Increased belief in the efficacy of community care
 Attention to civil and human rights of people with mental disorders
 Abuses in many psychiatric facilities
 Growing awareness of the negative effects of long-term
institutionalization
 Expense of institutional care
 Discovery (1954) of chlorpromazine, the first effective anti-psychotic
medication
 Effects of deinstitutionalization and varying consequences according
to diagnosis

 Deinstitutionalization has resulted in a steep decline
in the number of psychiatric inpatient beds and the
closing or downsizing of psychiatric facilities in many
Western industrialized countries, as well as several
countries of South America.
 In contrast, the number of hospital beds has
continued to increase in Japan and South Korea.
 Institutional care remains dominant in many LMICs.
Deinstitutionalization, continued

Mixed results
 Patients discharged without planning or sufficient
resources to live in the community.
 Transinstitutionalization
 Forensic hospitals
 Prisons
 Adults homes
 Homelessness
 The neglect and abuses that characterized
institutional care of the past have been replaced by
neglect and abuse in the community

Community-based
Mental Health Services
 As effective, if not more so, than hospital-based
services
 Though not necessarily less expensive
 In keeping with principle of least restrictive care
 Least effect on personal freedom, status and privileges
in the community
 Citizenship

Foundations of Global Mental Health
 Comparative psychiatry
 Emil Kraepelin’s visit to
Java in 1904
 Is psychopathology:
 the product of universal
biological / psychological
processes?
 Or ultimately shaped by
culture? Buitenzorg Hospital, Java

International Pilot Study of Schizophrenia
(IPSS)
 9 countries
 Late 1960s
 Possible to a conduct a valid and reliable cross-
cultural studies of schizophrenia
 Suggested that the prognosis for schizophrenia was
better in ‘developed’ vs. ‘developing’ settings

Determinants of Outcome of
Severe Mental Disorders (DOSMD)
• 10 countries
• Follow-up to IPSS
• Late 1970s
• More rigorous
• Supported ‘better prognosis’ hypothesis

Cornell-Aro
Mental Health Research Project
 Canada / Nigeria
 Early 1960s
 “The Yoruba group seem to have more symptoms but
fewer cases of clearly evident psychiatric disorder.
Whereas in the Stirling County Study the prevalence of
psychiatric disorder…was considerably greater among
women than men, in the Yoruba sample prevalence is
greater among the men.”1
-------------------------
1. Leighton AH. 1963. Psychiatric Disorder among the Yoruba: A Report. Ithaca, NY: Cornell
University Press.

The Yoruba group also show a higher prevalence than in
Stirling County of psychiatric symptoms based primarily on
organic disorder. This is compatible with the greater amount
of severe endemic disease and malnutrition.
By and large…the similarity in the two samples is much more
impressive than the differences. In view of the contrast
between the cultures and life situations, this is truly
remarkable.
Cornell-Aro
Mental Health Research Project

Interest in Primary Care
 Pre-dates Alma Ata Conference
 Carstairs 1973
 WHO Expert Committee 1974
 In the developing countries, trained mental health
professionals are very scarce indeed. Clearly, if basic
mental health care is to be brought within reach of the
mass of the population, this will have to be done by non-
specialized health workers…working in collaboration with,
and supported by, more specialized personnel.

Collaborative Study on Strategies for Extending
Mental Health Care
 1975
 WHO project
 Development of cross-culturally valid psychiatric surveys
 Training primary care health workers in the recognition
and management of mental disorders
 Establishment of mental health programs in primary care
settings
 Evaluation of each activity

World Development Report 1993
 Global Burden of Disease Study
 DALYs
 Measure of burden that accounts for mortality and
morbidity
 Large burden of neuropsychiatric disorders

World Mental Health:
Problems & Priorities in Low-Income Countries
 1995
 Dept. of Social Medicine, Harvard Medical School
 Highlighted the burden of mental disorders and the
mental health crisis in low-income countries

 Nations for Mental Health (WHO)
 WFMH advisor to The World Bank
 World Mental Health Survey Consortium
 IOM (US) report on neuropsychiatric disorders in
developing countries
 World Health Report 2001
Other resources

WHO
Mental Health Programme
 Focus on services rather than research
 Policy & Service Guidance Package
 ATLAS
 AIMS
 MiNDbank
 QualityRights Project
 Guidelines for psychosocial support during
humanitarian crises
 mhGAP

Funding begins
 UK Department for International Development
 Mental Health and Poverty Project (2005)
 Wellcome Trust
 Projects in low-income countries
 MANAS trial in Goa, India

The Lancet GMH series
(2007)
 No health without mental health
 Resources for mental health: Scarcity, inequity, and
inefficiency
 Treatment and prevention of mental disorders
 Mental health systems
 Barriers to improvement of mental health services
 Call to Action

Mental Health Gap Action Programme
(mhGAP)
 Best available evidence about priority conditions
 Depression
 Psychotic disorders
 Suicide
 Epilepsy
 Dementia
 Disorders due to use of alcohol and illicit drugs
 Mental disorders in children

mhGAP Intervention Guide
 Guidelines for identification, treatment and
management in general health care settings
 Non-specialized settings because of the lack of
mental health professionals in LMICs

Grand Challenges in GMH
 Led by US National Institute of Mental Health &
Global Alliance for Chronic Disease
 In partnership with:
 Wellcome Trust
 McLaughlin‐Rotman Centre for Global Health
 London School of Hygiene and Tropical Medicine

Top 5 Challenges
 Integrate screening and core packages of services into
routine primary health care
 Reduce cost and improve the supply of effective
medications
 Provide effective and affordable community-based care
and rehabilitation
 Improve access to evidence-based care for children in
LMICs
 Strengthen mental health training for all health-care
personnel

Grand Challenges Canada
• Integrated Innovations in Global Mental Health
– Driven by top 5 Grand Challenges
• Bold Ideas with Big Impact
• Committing up to $10 CAD
• Funded the Mental Health Innovation Network

DFiD
 PRogramme for Improving MEntal Health Care
 Goal: generate research evidence on
implementation and scaling up of treatment
programmes for priority mental disorders in
primary and maternal health care contexts in low
resource settings
 Consortium of research institutions and Ministries
of Health in Ethiopia, India, Nepal, South Africa &
Uganda
 Partners in the UK and WHO

Challenges in the next 10 years
• Lack of resources (human, financial, and technical)
has consequences for nearly every aspect of global
mental health1
• Need for research that examines questions of
aetiology, treatment, and sociocultural variations2
• Human rights abuses3
----------------
1. See, Saxena S, et al. 2007. Resources for mental health scarcity, inequity, and
inefficiency. Lancet 370(9590):878-889.
2. See, Minas H. 2009. Mentally ill patients dying in social shelters in Indonesia.
Lancet 374(9690):592-593.
3. See, Irmansyah I, et al. 2009. Human rights with persons of with mental illness
in Indonesia: More than legislation is needed. Int J Ment Health Sys 3(1):14.

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