The Lancet Commission on Global Mental Health and Sustainable Development

I.    Background

II.   The Need to Reframe Mental Health Patel

III.  Taking a dimensional approach

Vikram Patel, recipient of the GA's Presidential Citation for Lifetime Achievement Award, sharing highlights of the Lancet Commission's landmark report in his keynote address at our Coming Together for Action 2018 conference in Denver.  

 

Background

On World Mental Health Day (October 10, 2018), the Lancet Commission on Global Mental Health and Sustainable Development outlined a blueprint for reducing the global burden of mental health problems.  The Commission's report builds on more than a decade of work, beginning with the original Lancet series in 2007, aimed at making mental health a global priority. 

The report relies on scientific evidence to raise awareness of critical issues in mental health globally and to urge investment in reframing the global mental health agenda to emphasize prevention and early intervention, closing the treatment gap, improving quality of care, and addressing the wide range of conditions that affect mental health and well-being.  

Sustainable Development Goals

Central to the Commission's report is a call to reframe mental health in the context of the Sustainable Development Goals (SDGs).  The 17 SDGs provide an opportunity for broadening the global mental health agenda to include entire populations.  Virtually all of the SDGs related to mental health, however Goal #3 -- Good Health and Well-Being -- is specifically applicable to mental health and to the Commission's call to reframe the agenda.  Implementing a population approach to mental health will require a coordinated, multisectorial approach. 

The Foundational Pillars 

The Commission grounded its agenda in 4 basic principles:

  1. Mental health is a global good and relevant to sustainable development in all countries
  2. Mental health problems exist along a continuum from mild, time-limited distress to chronic, progressive, and severely disabling conditions
  3. Each individual's mental health is a product of social and environmental conditions, especially in the early years, interacting with genetic, neurodevelopmental, and psychological processes and affecting biological pathways in the brain
  4. Mental health is a fundamental human right for everyone.  A rights-based approach is necessary to protect the rights of people with mental disorders and those at risk of developing disorders, and to stimulate an environment that promotes mental health for all.   

The Need to Reframe Mental Health

The perception of mental health by the general public matters.  When mental health is associated with chronic and severely disabling conditions, it shapes the types of services available and whether people seek treatment.   The Commission argues that mental health must be reframed to address some of the common barriers to seeking treatment and receiving appropriate care for mental health conditions.    

What are the barriers?  

  • Stigma
Stigma of mental health problems can cause people to avoid seeking help when they need it.  Stigma can damage self-esteem.  It can also lead to discrimination and social exclusion at school, in the workplace and in the community.  As a result, individuals with milder disorders may not seek treatment until their disorder becomes worse.  The failure to access care may also widen disparities in mental health. 

  • Treatment Gap 

As it currently exists in high income countries, the mental health system is plagued by a number of structural barriers, the result of which is a significant treatment gap.  Where services do exist, quality is often poor or not responsive to the needs of individuals with mental health problems.  In low- and middle-income countries (LMICs), services are even more scarce.  

  • Access to care
Several factors may have the effect of limiting access to care.  In many communities, access to care is exacerbated by a shortage of practitioners and appropriate, and sometimes nonexistent, services.  Social factors, including attitudes about mental health and psychiatric treatment, may determine whether a person seeks help for a mental health problem.  The lack of integration of mental health and physical health services can also be a barrier to seeking help. 

  • Prevention and Early Intervention

Although the majority of people who experience mental health problems do not have serious mental health disorders, the mental health system historically has prioritized acute care over prevention and early intervention.  The relationship of social factors, like poverty, income inequality, climate and environment threats, rapid urbanization, conflict and displacement, pandemics and growing economic and political uncertainties, to mental health provides opportunities for the implementation of broad strategies that benefit the entire population, as well as strategies targeted to individuals with high risk.   Prevention and early intervention is especially important in working with children and youth.  

In offering a "fresh perspective on global mental health and sustainable development," the Commission proposes three key principles to guide the reframing of mental health: Video   

  • An approach to understanding and responding to mental health problems that looks at mental health along a continuum, from health promotion to recovery. 
  • Convergence of the findings of the social and biological determinants of mental health problems.
  • Recognition that mental health is a fundamental human right, in particular for those who have already developed mental health problems and those at risk of developing problems. 
Watch the video, It's Time to Act on Mental Health, to learn more about the need for a new mindset....
 

 

Taking a dimensional approach to mental health  

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.  - World Health Organization

Dimensions of Mental Health

Source:  Vikram Patel presentation at the Global Alliance's Coming Together for Action Conference, 2018.  

Mental health is a global public good, which occurs along a continuum from well-being to more serious disorders and recovery. As the Lancet Commission argues, the dimensional approach to mental health balances treatment, rehabilitation, care, and recovery with the promotion of mental health and the prevention of mental disorder.   When mental health is reframed as an asset along a continuum, it is possible to see how promoting mental health and preventing mental disorders can reduce the prevalence of serious mental disorders at the population level over time. 

Staging Approach for Mental Disorders

The use of a dimensional approach to mental health raises the issue of describing and classifying mental health disorders.  The Lancet Commission does not advocate getting rid of classification systems (e.g., International Classification of Disease (ICD), Diagnostic and Statistical Manual of Mental Disorders (DSM)) because diagnoses are useful in clinical settings.  However, in the context of a continuum that recognizes diversity in experience between people and for the same person over time, giving an individual a diagnosis can unnecessarily label the individual and diminish his or her agency.  Diagnoses oversimplify and undervalue the complexities of personal circumstances.   Still, diagnoses are important for clinicians and researchers.  

According to the Commission, one way of identifying when a person might be considered to have a disorder or diagnosis is to assess functional impairment.  Functional impairment is a measure of whether individuals can fill their desired social roles in their community.  In the context of diverse cultural and socioeconomic settings, assessing functional impairment is important so it will remain a priority for global mental health research.  However, it cannot be the only criterion used for  detecting disorders and for intervening if the goal is to intervene early before substantial disability sets in.  Often, a person's functioning declines gradually over time so opportunities to intervene early also narrow.  However, it often is possible to identify the need for care long before a diagnosis can be made.  Providing appropriate support and engagement, and paying attention to the individual while promoting self-care can be useful.  

The Lancet Commission offers a compromise between the dimensional and diagnostic approaches -- the staging model.  The model recognizes that opportunities for intervention exist along the continuum.  It also implies that appropriate interventions are not only directed to the individual in the form of treatment and care, but also directed at the population level with a goal of strengthening environments to promote mental health and to reduce risk factors.

The Commission notes that the staging model is particularly relevant for the developmental phase of adolescence and youth.  It's during this period that onset occurs for most mental and substance use disorders, so it's particularly important to intervene early and appropriately.     

The model is also relevant in primary care settings.  Physicians in primary care settings are more likely to see individuals with less severe and more mixed symptoms.  Primary care physicians also can identify risk factors that may help in identifying individuals at high risk for developing severe conditions.   

The Social Determinants of Mental Health 

Reframing mental health as an asset also enables us to develop strategies for addressing social and environmental factors at a population level that may be harmful to positive mental health and well-being.  The Ottawa Charter on Health Promotion identifies the fundamental conditions and resources for health: 

  • peace;
  • shelter;
  • education;
  • food;
  • income;
  • a stable eco-system;
  • sustainable resources; and
  • social justice and equity. 

Mental health is essential to overall health.  It is well-established that an individual's health is shaped by his or her social environment.  Understanding this broadens the responsibility for mental health beyond the providers trained to provide medical or psychiatric treatment.  Treatment is one of the possible responses to mental disorder, however the resources that can be generated at the community and individual levels are equally as important in providing sustained support.  A population approach to mental health focuses attention on the range of social and economic factors that influence mental health.  A particularly effective way of addressing the social determinants is to invest in the mental health and well-being of children.