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

The Institute of Medicine (1) defines global health as “those health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.” Global mental health naturally follows the same path, except that the emphasis is placed on 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. In the early 2000s, then–U.S. Surgeon General David Satcher (2) used this term “officially” for the first time in a commentary published in the Journal of the American Medical Association. However, the term would not become “fashionable” and universally used until approximately 2010 (3). Today, there are several full textbooks written on the topic of global mental health (3, 4), and leading psychiatric journals devote space to the topic. For example, “Perspectives in Global Mental Health” in the American Journal of Psychiatry and the “Global Mental Health Reforms” column in Psychiatric Services each discuss worldwide mental health issues.

Global Burden of Mental Disorders

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).

Stigma of Chronic, Severe Mental Disorders

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.

Anthropology and Global Mental Health

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).

Research Investments in Global Health

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.

Research in Global Mental Health

NIMH

In the mental health arena, the global focus of NIMH from the 1980s to the 2000s was related almost exclusively to HIV research. The last decade has seen several new initiatives focused on services and “task-shifting” strategies. Most importantly, these initiatives have stimulated the formation of several “collaborative hubs” for international mental health research, with centers and investigators currently located in Africa, Asia, and Latin America. A more recent NIMH initiative (RFA-MH-16-350) aims to foster research partnerships for scaling mental health research in low- and middle-income countries. These efforts seek to integrate mental health into the global health platform for low- and middle-income countries and to make resources more readily available for patients with mental disorders (18). In terms of services and because of the imbalance of the distribution of physicians across the globe, NIMH (18) is looking to place “an emphasis of equity in access to, quality of, and outcomes of mental health care worldwide.” NIMH staff members have also put together a “top five” list of the most crucial challenges to overcome for mental health disorders. The goals of addressing these challenges are to increase opportunities for the topic to be researched effectively and to reduce the burden of disease, inequalities in health and health care, and the length of time before results can be observed (18). These efforts aim to integrate screening and core packages of services into routine primary health care, as well as to reduce costs and improve the supply of effective medications. Improving children’s access to evidence-based care would improve mental health globally. NIMH also wants to focus on providing effective and affordable rehabilitation services because they are scarce in many regions; to reduce stigma inside health centers, NIMH wants to strengthen the mental health component in the training of all health care personnel (18).

Fogarty International Center

The international arm of NIH, the Fogarty International Center, has also had a number of recent initiatives that directly or indirectly support global research on mental disorders. These initiatives include “Brain Disorders in the Developing World: Research Across the Lifespan,” “Mobile Health Technology Outcomes in Low and Middle Income Countries,” and a good number of training grants for investigators to focus on HIV and other diseases, including brain disorders. Therefore, although the overall NIH investment in global health remains relatively small, it has stimulated needed international collaborations in this important area. Fortunately, despite administrative and bureaucratic hurdles, several international collaborations in mainstream psychiatric research have been funded through NIH R01 grants. Some pertinent examples of projects funded with these mechanisms are presented below.

The above research initiatives from NIMH and the Fogarty International Center have provided the impetus to examine and improve the service component of mental disorders in many areas of the world. This increased globalization has increased awareness of the various facets of mental health that can be incorporated into a new global approach to tackle this huge problem. Emphasis has been placed, understandably, on public health issues such as the high prevalence of mental disorders documented by epidemiologic surveys, the gap in services, and the lack of mental health professionals to properly address worldwide mental health service needs. This has opened new collaborative research and educational opportunities that may benefit both developing and developed countries. A key perspective in these endeavors is improving the recognition of mental disorders and enhancing access to services in efforts to achieve equity for people around the globe.

Examples of Global Mental Health Research Contributing to Mainstream Scientific Psychiatry

Another important (and relatively neglected) area for global collaborations is that of scientific research that will help to build a research tradition in other countries at the same time that it advances mainstream, scientific research in the field of major mental disorders. Here, the focus on certain world areas helps to increase understanding of the unique cultural imprints of psychopathology and the importance of specific environmental and biological (genetic) factors. The study of special populations allows the systematic study of major disorders such as bipolar disorder and schizophrenia, using state-of-the-art strategies (genetics, imaging, and measurable markers). Indeed, international studies on special populations (geographical isolates, genetic isolates, and others) are contributing important knowledge to mainstream psychiatry. Below we provide some examples related to Alzheimer’s disease, bipolar disorder, and schizophrenia.

Special Populations

Unique geographic, cultural, linguistic, and genetic factors that affect certain populations (population isolates, ethnic isolates, or genetic isolates) present unique challenges, but they also offer excellent opportunities to advance scientific knowledge in the mental health field. In addition, negative environmental contingencies affecting immigrant and displaced populations are all factors that play an important role in today’s globalized world and may influence the presentation, recognition, and management of mental disorders.

Alzheimer’s Disease

A key ongoing study on Alzheimer’s disease is taking place in Colombia. This study focuses on a special genetic isolate called the “paisa” population, residing in a mountainous area near Medellin, Colombia. This population isolate is characterized by large extended family systems with little mobility and high levels of inbreeding (first-cousin marriages). The study is led by Dr. Francisco Lopera, a Colombian neurologist, and it now includes a collaboration between Colombian and U.S. investigators as part of an international consortium including NIH, the Alzheimer’s Foundation, and the pharmaceutical industry. This study focuses on a large family system in which there is a mutation in the E280A Presenilin-1 gene, which increases beta amyloid (AB42) deposition and severe brain pathology and produces early-onset Alzheimer’s disease. A $100 million “prevention trial” is currently underway targeting younger members of this 5,000-member extended family who do not have symptoms of Alzheimer’s disease but do have the genetic variation. This project has been funded by NIH, the National Plan to Address Alzheimer’s Disease, Banner Health, and Genentech (Roche) (19–21).

Schizophrenia

The article by Balda et al. in this issue of Focus reports on the study of a special population in the Andes mountains of northern Argentina. The focus of the study is on an indigenous, Quechua-speaking rural population that has been isolated by geography and has had little, if any, access to mental health services. This group of investigators, led by Dr. Gabriel de Erausquin, previously documented the efficacy of targeted education of health agents (high school education or lower) working in primary care teams in reducing the duration of untreated psychosis in a rural population (22). In that study, the investigators attempted to reduce the duration of untreated psychosis (DUP) in rural Argentina in an effort to improve patient outcomes and increase the effectiveness of psychotropic medications. In the earlier study, Padilla et al. (22) mentioned past research showing that DUP was associated with neurotoxic effects, reduced cortical thickness, and cognitive impairment, all conditions resulting in poor patient outcomes. As part of their study, this team of investigators implemented annual training programs of local health agents for illness recognition and interventions. An international instrument, the Structured Clinical Assessment in Neuropsychiatry, was used to estimate the DUP. Each training session was 3 hours and provided printed material, basic knowledge about risk factors, and practical instructions on risk management and referral for specialty care. The primary outcome of the training was the number of appropriate referrals to the mental health system. The study results showed that sustained training of health agents and the implementation of an effective system to refer patients to specialty care led to a significant reduction in DUP in new patients detected in a rural environment (22).

Bipolar Disorders

The senior author (JIE) was also a member of a research team that performed an extensive global mental health clinical genetic investigation of bipolar disorder of extended pedigrees in Costa Rica and Colombia (23). This research aimed to identify loci contributing to the risk for bipolar I disorder and to provide genetic analysis of bipolar disorder. Results of the phenotypic and genetic variation analyses yielded significant correlations among the traits, many of which share a common underlying genetic architecture. In another recent study targeting the same population (24), researchers investigated brain-behavior associations of patients with bipolar disorder with heavy genetic loading for the illness. The results based on brain neuroimaging analyses showed an association between bipolar disorder and global brain volume reduction and thinning of the brain cortex. Analysis of the behavioral phenotypes identified a distinct subtype of bipolar symptoms and markers that may have predictive value (24).

Global Mental Health Education

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.

Conclusions

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.