12 The global dimensions of mental health Flashcards
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Overview Summary
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Welcome to the session on global dimensions of mental health. This session explores mental health globally, examining its significance as a critical global health and development component. We will analyse mental health’s social and economic determinants across different cultural contexts, evaluate global mental health systems and approaches, and critically examine international policies and human rights frameworks. The session will also explore the main actors and initiatives shaping global mental health. Finally, we will assess current challenges and opportunities in global mental health and consider future research, policy, and practice directions.
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Aims
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The session aims to provide an overview of mental health as a global issue, including its conceptualisation, determinants, global burden, policy frameworks, key actors, and future challenges and initiatives. It also aims to develop critical thinking skills in analysing global mental health issues and their interconnections with broader global health and development agendas.
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Learning outcomes
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By the end of this session, you should be able to: Evaluate the global burden of mental health disorders and their impact on global health and development agendas; Analyse the social, economic, and cultural determinants of mental health from a global perspective; Assess the roles and contributions of key global actors and initiatives in shaping the field of global mental health; and Critically discuss current global initiatives and policy challenges for mental health.
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Key terms Cultural contexts in mental health
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Recognition and integration of diverse cultural beliefs, practices, and values in understanding, diagnosing, and treating mental health across populations (Kirmayer & Ryder, 2016).
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Key terms Digital mental health
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Use of digital technologies to deliver mental health services, support, and interventions (Hollis et al., 2015).
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Key terms Global burden of mental disorders
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Impact of mental disorders on mortality, morbidity, disability, and economic costs worldwide, often measured in Disability-Adjusted Life Years (DALYs) (Vos et al., 2020, Whiteford et al., 2013).
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Key terms Global mental health
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Study, research and practice that prioritises improving mental health and achieving equity globally (Patel & Prince, 2010).
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Key terms Global mental health policy
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International and national policies aimed at improving mental health outcomes and reducing disparities globally (Patel et al., 2011).
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Key terms Human rights in mental health
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Application of human rights principles to mental health care, emphasizing dignity, autonomy, and non-discrimination (UN, 2020).
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Key terms Mental health systems
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Network of services, policies, and resources for prevention, treatment, and management of mental health conditions (Thornicroft & Tansella, 2013).
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Key terms Social determinants of mental health
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Social, economic, and physical environments influencing mental health outcomes across the lifespan (Allen et al., 2021).
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Key terms Sustainable Development Goals (SDGs)
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UN’s 17 global goals, including mental health targets (United Nations, 2015).
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Key terms Treatment gap
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Difference between need for mental health care and actual service utilisation due to barriers like stigma and limited access (Kohn et al., 2018).
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- Introduction to Global Mental Health
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Mental health is increasingly recognised as a critical global health issue, affecting millions worldwide regardless of socioeconomic status or geographic location. This issue also has far-reaching impacts on individuals, communities, and economies worldwide. According to the World Health Organisation (WHO), approximately 1 in 8 people globally were living with a mental disorder in 2019. Mental, neurological and substance disorders account substantially for the global burden of disease, with depression alone affecting over 264 million people globally (Vos, T., GBD 2019 Diseases and Injuries Collaborators, 2020). Also, these disorders have significant economic implications, stemming from reduced productivity, increased healthcare costs, and lost economic output. The World Economic Forum estimates that mental health conditions could cost the global economy up to $16 trillion between 2010 and 2030 if not adequately addressed (Bloom, D.E, et al. 2011). Furthermore, there is a clear link between mental health and other global health priorities. Mental health conditions often co-occur with and can exacerbate non-communicable diseases like cardiovascular disease and diabetes among other health issues (Prince, M. 2007). Conversely, individuals with chronic physical health conditions are at higher risk of developing mental health problems (Ngo, V. et al., 2013).
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- Introduction to Global Mental Health
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Global mental health has emerged as a critical area within the broader field of global health, emphasising the importance of mental wellbeing for all people worldwide (Patel, V. et al., 2011). This field recognises that mental health is fundamental to overall health, social cohesion, and sustainable development (Patel et al., 2018). Recognising mental health as a global priority has been a long and complex pathway, marked by evolving understanding, challenges in healthcare provision, and the need for a truly global perspective. Current challenges include the treatment gap, where a large proportion of individuals with mental health conditions do not receive adequate care, particularly in low- and middle-income countries (LMICs) (Patel et al., 2018). The WHO reports that between 76% and 85% of people with mental disorders in these countries receive no treatment for their condition (WHO 2021). While neuropsychiatric care options have expanded, improvements have not reached most people living with mental conditions, especially those in middle and low-income countries (Patel V., et al., 2018). Social risk factors, including gender, ethnicity, and socioeconomic status, interact with environmental factors such as neighbourhood, occupation, violence, and rapid social change (Allen J., et al., 2014). Rapid social transformation and cultural dislocation, as experienced by indigenous peoples and those in transitional economies, are often associated with high rates of substance abuse, self-harm, and suicide (Kirmayer L., et al., 2014). Lastly, global events such as the COVID-19 pandemic have further emphasised the interconnectedness of mental health across nations. The pandemic has led to increased rates of anxiety and depression worldwide (Santomauro D., et al., 2021). Future challenges in the field will involve addressing the impact of global crises, such as climate change and pandemics, on mental health, as well as leveraging digital technologies to improve access to mental health services.
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1.1 Defining Mental Health in a Global Context
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The WHO defines mental health as “a state of well-being in which an individual realises 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” (WHO, 2018). This definition emphasises that mental health is more than just the absence of mental disorders or disabilities, and in a global context, recognising that conceptions of mental health and wellbeing can vary across cultures and societies (Kirmayer & Ryder, 2016). What might be considered a symptom of mental illness in one culture could be viewed as a normal variation or even a valued trait in another (e.g., hearing the voices of deceased relatives might be pathologised in Western cultures but considered a spiritual gift in some indigenous societies). Global mental health acknowledges these cultural variations while recognising universal mental health aspects.
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1.1 Defining Mental Health in a Global Context
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Diagnosing mental illness has changed as our understanding of its causes has deepened. Initially, the “dimensional approach” to diagnosis used a collection of symptoms. This was followed by the broader “disorder approach” which included symptoms, their duration and the resulting impact on daily function (Norquist & Magruder). Disorders are classified as mild, moderate and severe. The disorder approach is set out in the Diagnostic and Statistical Manual of Mental Disorders, now in its 5th edition (see table 1). These are standard guideline criteria which are widely accepted in clinical settings.
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1.2 The Global Burden of Mental Disorders
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Mental disorders contribute significantly to the global burden of disease. According to the Global Burden of Disease Study 2019, mental disorders accounted for 4.9% of all disability-adjusted life years (DALYs) globally, with depression and anxiety disorders being the most prevalent (Vos et al., 2020).
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1.2 The Global Burden of Mental Disorders
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Key statistics highlight the magnitude of the problem: By 2019, over 280 million people were affected by depression, 301 million by anxiety disorders 24 million by schizophrenia, 40 million by bipolar disorder, and 283 million by substance use disorders worldwide (Vos et al., 2020, WHO, 2022).
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1.2 The Global Burden of Mental Disorders
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The impact of mental disorders extends beyond just health, affecting educational attainment, economic productivity, social relationships, and physical health (Patel et al., 2018). Mental disorders can reduce life expectancy by 10-20 years in severe cases (Liu et al., 2017).
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1.2 The Global Burden of Mental Disorders
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However, the burden is not evenly distributed globally. Low- and middle-income countries (LMICs) bear a disproportionate share of the burden due to limited mental health resources, socioeconomic challenges, and the impacts of humanitarian crises (Kakuma et al., 2011; Lund et al., 2010; Charlson et al., 2019).
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1.2 The Global Burden of Mental Disorders
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Compounding the global burden is the significant treatment gap. In LMICs, between 76% and 85% of people with mental disorders receive no treatment, while even in high-income countries, 35-50% of those with severe mental disorders go untreated (Demyttenaere et al., 2004; WHO, 2021). Barriers to accessing care include shortages of mental health professionals, financial constraints, stigma, and lack of awareness about mental health issues (Thornicroft et al., 2016; Kakuma et al., 2011; Patel et al., 2018).
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- The social and economic determinants of Global Mental Health
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The global burden of mental health disorders is significant and unevenly distributed. As already discussed, this burden varies widely across different populations and regions, highlighting the substantial impact of social and economic factors on mental health outcomes.
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2.1 Socioeconomic Factors and Mental Health
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Socioeconomic factors play a crucial role in shaping mental health outcomes globally. These factors, including income, education, employment, and housing, significantly influence individual and community wellbeing. Research consistently demonstrates a strong association between socioeconomic status and mental health (Lund et al., 2018).
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2.1 Socioeconomic Factors and Mental Health
Poverty is a particularly key determinant of mental health. A systematic review by Lund et al. (2018) highlights a negative cycle where poverty exacerbates the risk of mental illness, and in turn, mental illness increases the likelihood of remaining in or falling into poverty. This cycle is especially pronounced in LMICs, where economic instability compounds existing vulnerabilities in mental health care.
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2.1 Socioeconomic Factors and Mental Health
Education serves as both a risk and protective factor for mental health. Lower levels of educational attainment are linked to higher rates of mental disorders, while higher education can act as a protective factor. A longitudinal study in Chile found that higher education levels were associated with lower rates of common mental disorders, even when controlling for other socioeconomic variables (Araya et al., 2018).
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2.1 Socioeconomic Factors and Mental Health
Employment status and job security are significant predictors of mental health outcomes. Unemployment and precarious work environments are closely associated with an increased risk of mental health problems. A meta-analysis by Modini et al. (2016) found that unemployment is linked to a two-fold increase in the likelihood of common mental disorders.
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2.1 Socioeconomic Factors and Mental Health
Housing insecurity, particularly homelessness, contributes to mental health challenges. Research by Aldridge et al. (2018) demonstrates that individuals experiencing homelessness are at greater risk of developing mental disorders. Interventions like Housing First programs have shown promise in improving mental health outcomes among homeless populations with severe mental illness (Aubry et al., 2015).
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2.1 Socioeconomic Factors and Mental Health
Gender inequality compounds mental health disparities. Women, particularly in societies where they face disproportionate levels of gender-based violence, economic dependency, and caregiving responsibilities, experience higher rates of common mental disorders (Seedat et al., 2009).
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2.1 Socioeconomic Factors and Mental Health
Early life experiences, particularly adverse childhood experiences (ACEs), play a critical role in long-term mental health. A meta-analysis by Hughes et al. (2017) found that individuals with four or more ACEs were at considerably higher risk for depression, anxiety, and substance use disorders later in life.
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2.1 Socioeconomic Factors and Mental Health
The influence of these socioeconomic factors on mental health is especially pronounced in LMICs, where mental health care resources are severely constrained. Although LMICs account for 84% of the global population, they possess less than 20% of the world's mental health resources (Patel et al., 2018).
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2.2 Cultural Contexts and Mental Health
Cultural contexts significantly shape the understanding, experience, and management of mental health and illness across different societies, with profound implications for global mental health research, policy, and practice. Variations in cultural concepts of distress highlight unique ways in which psychological issues are expressed; for instance, "ataque de nervios" in Latin American cultures and "khyal cap" in Cambodian culture exemplify culturally specific manifestations of anxiety-like symptoms (Kirmayer & Ryder, 2016). Stigma and discrimination associated with mental illness also differ across cultures, impacting help-seeking behaviours and treatment outcomes. A cross-cultural study by Pescosolido et al. (2013) revealed significant variations in the acceptance of individuals with mental illness among 16 countries, demonstrating that some cultures are more supportive than others. Additionally, many cultures employ traditional healing practices for mental distress, and integrating these with modern mental health care can enhance the acceptability and effectiveness of interventions (Nortje et al., 2016). The influence of family and community is also pivotal; in collectivist societies, interventions that incorporate family members and community leaders tend to yield better outcomes than individual-focused approaches (Kirmayer & Ryder, 2016). Moreover, religious, and spiritual beliefs can profoundly affect how mental health issues are perceived and addressed; a classic meta-analysis by Bonelli and Koenig (2013) reported that religious involvement correlates with improved mental health outcomes across various psychiatric conditions. Cultural explanatory models of illness further influence treatment-seeking behaviours. The language used to describe mental health experiences also varies, impacting symptom reporting and understanding. For instance, in many Asian cultures, somatic expressions of distress are more prevalent than psychological ones, which can affect diagnosis and treatment approaches (Ryder et al., 2008). Finally, the effectiveness of evidence-based mental health interventions often hinges on cultural adaptation; a systematic review by Chowdhary et al. (2014) found that culturally adapted psychological interventions were significantly more effective than non-adapted ones in LMICs.
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2.3 International Inequities in Mental Health Access and Outcomes
Global mental health is characterised by stark inequities in access to care and health outcomes, reflecting broader patterns of global health disparities both within and between countries. A significant treatment gap exists in LMICs, where up to 90% of individuals with mental disorders do not receive necessary treatment, in contrast to 50-70% in high-income countries (HICs) (Thornicroft et al., 2017). This gap is especially pronounced for severe mental disorders; for example, research in rural Ethiopia revealed that only 1.6% of individuals with schizophrenia had received treatment in the previous year (Fekadu et al., 2019). Despite mental disorders accounting for 14% of the global burden of disease, they receive less than 1% of global health funding, with LMICs often allocating similarly meagre resources to mental health, typically less than 1% of their national health budgets (Vigo et al., 2019; WHO, 2021). The workforce shortage of mental health professionals exacerbates this issue, with only 6.6 psychiatrists per 100,000 population in HICs, compared to fewer than 0.1 per 100,000 in low-income countries (WHO, 2021). Furthermore, even when services are available, the quality can be substandard, particularly in resource-poor settings, leading to issues such as human rights violations, over-reliance on psychotropic medications, and insufficient evidence-based psychosocial interventions (Patel et al., 2018). Certain population groups face disproportionately high barriers to accessing care; for instance, refugees often report elevated rates of mental disorders alongside significant obstacles to treatment (Blackmore et al., 2020). Urban-rural disparities further compound the challenge, as mental health resources are typically concentrated in urban areas, leaving rural populations underserved (Thornicroft et al., 2017). The digital divide presents additional complications, as inequalities in internet access and digital literacy can exacerbate disparities in mental health care (Hollis et al. 2015). Addressing these complex inequalities necessitates concerted global action that includes increased funding for mental health, strengthening health systems, and implementing evidence-based interventions while tackling the social determinants of mental health. Strategies such as task-sharing, integrating mental health into primary care, and leveraging digital interventions can enhance accessibility (Patel et al., 2018). Additionally, emphasising mental health as a human right can drive policy change and improve resource allocation (United Nations, 2021). Initiatives such as the Lancet Commission on Global Mental Health aim to raise awareness and promote policy reform, and adapting evidence-based interventions to local cultural contexts can further improve their acceptability and effectiveness (Patel et al., 2018; Chowdhary et al., 2014).
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3. Human rights and Global Mental Health Policy
Mental health governance involves the complex interplay of actors, policies, and systems at various levels to ensure the promotion, protection, and care of mental health. At the national level, governments typically lead policy development and implementation through their health ministries. Regional bodies, such as the European Union or the African Union, often provide frameworks and coordination for cross-border initiatives. Internationally, organisations like the World Health Organization (WHO) and the UN play key roles in setting global standards and promoting best practices. Non-governmental organisations (NGOs), academic institutions, and civil society groups also contribute to shaping these policies and advocating for the rights of individuals with mental conditions.
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3. Human rights and Global Mental Health Policy
The recognition of mental health as an integral aspect of overall health has led to the development of various international human rights instruments that protect and promote the rights of individuals with mental conditions.
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3. Human rights and Global Mental Health Policy
The foundation of international human rights protection related to mental health is the International Bill of Human Rights, which consists of: 1) The Universal Declaration of Human Rights (1948), 2) The International Covenant on Economic, Social and Cultural Rights (1966) and 3) The International Covenant on Civil and Political Rights (1966) and its two optional protocols.
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Box 1 Key articles relevant to mental health
Universal Declaration of Human Rights: Article 1 (All human beings are born free and equal in dignity and rights) Article 25 (right to a standard of living adequate for health and well-being). International covenant on economic, social and cultural rights: Article 12 (right to the highest attainable standard of physical and mental health). International Covenant on civil and political rights: Article 7 (no one shall be subjected to torture or cruel, inhuman or degrading treatment), Article 9 (right to liberty and security of person)
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3. Human rights and Global Mental Health Policy
The Convention on the Rights of Persons with Disabilities and its Optional Protocol was adopted on 13 December 2006. This aimed to codify the change from viewing those with disabilities as ‘objects’ of charity, treatment, and social protection towards ‘subjects’ with rights, capable of claiming those rights making decisions and contributing to society through free and informed consent. The CRPD marked a paradigm shift in approaching disability rights, including mental health conditions. Key principles include the respect for inherent dignity and individual autonomy, non-discrimination, full and effective participation and inclusion in society, equality of opportunity and Accessibility. Article 12 of the CRPD, which affirms that persons with disabilities have the right to equal recognition before the law, has significant implications for mental health law and policy, particularly regarding legal capacity and supported decision-making.
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3. Human rights and Global Mental Health Policy
Additional influential, though non-binding, statements, resolutions, and principles have helped to shape the discourse around mental health rights and have influenced national and international policies. These include the MI Principles or the UN Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (1991), The Caracas Declaration (1990), The WHO Mental Health Action Plan 2013-2030 (updated in 2021) and the QualityRights Initiative (WHO, launched in 2012).
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3. Human rights and Global Mental Health Policy
International human rights law broadly obliges governments to: 1. respect the rights of those with mental disorders (thus, no arbitrary confinement); 2. protect those with mental disorders from individual abuses; and 3. fulfil various obligations in promoting the rights of those with mental disorders (such as access to education and services).
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3. Human rights and Global Mental Health Policy
All UN member States have signed up for at least one human rights convention. This legal framework is important for mental health for two reasons 1) it is the only source of law that allows international monitoring of mental health policies and practices within countries 2) it provides fundamental protections that do not rely on national governments’ beneficence. This is particularly important for countries without democratic systems since it provides what can be the only safeguard against political and social abuses of those with mental disorders. Despite this international legal framework, there are no enforcement mechanisms to ensure that decisions made under these frameworks are carried out. This legal loophole means people with mental illness and disabilities continue to be vulnerable.
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3. Human rights and Global Mental Health Policy
The lack of robust enforcement mechanisms presents several challenges, such as uneven implementation across countries, difficulty holding states accountable for violations, limited recourse for individuals whose rights have been violated, and the persistence of discriminatory practices and policies.
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3. Human rights and Global Mental Health Policy
International human rights instruments relating to mental health and disability are non-binding resolutions rather than obligatory conventions. However, mental health legislation is not simply subject to the domestic discretion of governments. National governments are obliged, under binding international human rights law, to ensure that their policies and practices conform to international human rights law, including the protection of people with mental disorders. Again, these laws are not enforceable.
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3. Human rights and Global Mental Health Policy
In addition to the International Bill of Rights, there are several key international and regional instruments that protect people with mental disorders. These include the legally-binding UN Convention on the Rights of the Child, which contains human rights provisions specifically relevant to children and adolescents, particularly Articles 23, 25, 27, and 32; and the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1984). For example, Article 16 makes signatory states responsible for preventing acts of cruel, inhuman or degrading treatment, irrespective of a lack of financial or human resources.
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3. Human rights and Global Mental Health Policy
Additionally, regional human rights systems have developed their own frameworks, which often provide additional protections and mechanisms for enforcement. For example, the European Convention on Human Rights (1950), the American Convention on Human Rights (1969), and the African Charter on Human and Peoples' Rights (1981).
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3. Human rights and Global Mental Health Policy
Mental health law, regulations and declarations provide a legal framework for developing and implementing of mental health policy. They establish a system of enforceable rights that protect those with mental disorders from discrimination and other human rights violations by government or private entities and guarantee fair and equal treatment (WHO Resource Book on Mental Health).
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3. Human rights and Global Mental Health Policy
Treaty monitoring bodies at international and regional levels have the role of overseeing and monitoring compliance by states that have ratified international human rights treaties. Governments that ratify a treaty agree to report regularly on the steps they have taken to implement that treaty at the domestic level through changes in legislation, policy and practice. Treaty monitoring bodies consider the reports, taking into account any information submitted by NGOs and other competent bodies, and publish their recommendations and suggestions in “concluding observations”, which may include a determination that a government has not met its obligations under the treaty.
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3. Human rights and Global Mental Health Policy
The international and regional supervisory and reporting process thus provides an opportunity to educate civil society about a specialised area of rights. This process can also pressure governments to uphold convention-based rights. The treaty bodies of the European and Inter-American human rights system have also established individual complaints mechanisms, which provide the opportunity for individual victims of human rights violations to have their cases heard and to seek reparations from their governments.
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3.1 International Human Rights Legislation Related to Mental Health
The global landscape of mental health is increasingly shaped by a strong foundation of legal instruments and frameworks that aim to protect the rights of individuals with mental health conditions. These frameworks have emerged over the past several decades, signalling a growing commitment by countries and regions to address the systemic inequities and vulnerabilities faced by those living with mental disorders.
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3.1 International Human Rights Legislation Related to Mental Health
At the regional level, notable examples include the African Charter on Human and Peoples' Rights (1981) and the establishment of the African Court on Human and People's Rights (2004) in Africa. In Europe, the European Convention for the Protection of Human Rights and Fundamental Freedoms (1950) and its associated European Court of Human Rights have been instrumental in upholding the rights of those with mental health issues. Supplementary European frameworks such as the Convention on Human Rights and Biomedicine (1996) and Recommendation (2004)10 on the Protection of the Human Rights and Dignity of Persons with Mental Disorder have further strengthened legal protections.
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3.1 International Human Rights Legislation Related to Mental Health
The Americas have also developed key human rights instruments, including the American Declaration of the Rights and Duties of Man (1948) and the American Convention on Human Rights (1978), which enshrine civil, political, economic, social and cultural rights. The Inter-American Convention on the Elimination of all Forms of Discrimination against Persons with Disabilities (1999) is an important regional agreement that specifically addresses the needs of those with mental and physical disabilities.
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3.1 International Human Rights Legislation Related to Mental Health
While the existence of these legal frameworks is an important milestone, their application and enforcement remain uneven across different contexts. Critiques often highlight the presence of legal loopholes and insufficient implementation, which can undermine the full realization of rights for vulnerable populations. However, the very existence of these instruments signals growing global recognition that mental health is a fundamental human right that requires robust legal safeguards.
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3.1 International Human Rights Legislation Related to Mental Health
Moving forward, greater attention should be paid to how these regional frameworks are being interpreted and applied within specific national and local contexts. A deeper analysis of their impact, strengths, and limitations would help identify opportunities to strengthen legal protections and ensure equitable access to mental health services and supports. Ultimately, the true measure of success will be the degree to which these human rights mechanisms translate into tangible improvements in the lives of those living with mental health conditions around the world.
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3.1.1 The 10 basic principles of mental health care law
WHO’s Ten Basic Principles (1996), provide further interpretation of the MI Principles to assist countries in developing their mental health laws. These are: 1. Promotion of Mental Health and Prevention of Mental Disorders; 2. Access to Basic Mental Health Care; 3. Mental Health Assessments in Accordance with Internationally Accepted Principles; 4. Provision of the Least Restrictive Type of Mental Health Care; 5. Self-Determination; 6. Right to be Assisted in the Exercise of Self-Determination; 7. Availability of Review Procedure; 8. Automatic Periodical Review Mechanism; 9. Qualified Decision-Maker; and 10. Respect of the Rule of Law.
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3.1.1 The 10 basic principles of mental health care law
In addition to the major regional human rights instruments, a collection of influential global frameworks and standards have further advanced the protection of rights for individuals with mental health conditions. The Siracusa Principles of 1984 outlined criteria for justifiable restrictions on individual rights, while the UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities in 1993 promoted prevention, rehabilitation and equal opportunity. The Declaration of Caracas in 1990 called for a significant shift towards community-based, integrated mental health services, and the Salamanca Statement of 1994 affirmed the right to inclusive education for children with mental disabilities.
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3.1.1 The 10 basic principles of mental health care law
The Declaration of Madrid, adopted by the World Psychiatric Association in 1996, provided guidelines for ethical professional practice in psychiatry. Additionally, the WHO has issued several influential frameworks, including the Mental Health Care Law: Ten Basic Principles in 1996 and the Mental Health Action Plan 2013-2030 (updated in 2021), which set global standards and policy directives. The WHO's QualityRights Initiative, launched in 2012, aimed to improve quality of care and promote human rights for those with mental health conditions.
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3.1.1 The 10 basic principles of mental health care law
These diverse global frameworks demonstrate the growing international consensus that mental health is a fundamental human right that requires robust legal protections and policy support. However, the adoption and implementation of these standards has been uneven across countries, with higher-income regions more likely to have dedicated mental health legislation compared to lower-resource settings. Moving forward, greater attention is needed to ensure these global standards are effectively translated into national policies and practices that uphold the dignity and rights of all persons living with mental health conditions.
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3.2 Alignment of Mental Health with the SDGs
Launched in 2000, the United Nation’s Millennium Development Goals (MDGs) aimed to improve health for all, particularly those in extreme poverty. Eight goals with indicators and timeframes set out a blueprint for action. However, mental health and other non-communicable diseases were not addressed in the MDGs. Given the burden of non-communicable diseases to health, their oversight was met with criticism. The UN SDGs, launched in 2015, explicitly include mental health, addressing a significant oversight in the previous MDGs. Specifically: Target 3.4 requests that by 2030 countries: “reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being” and Target 3.5 – “Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.”
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3.2 Alignment of Mental Health with the SDGs
To meet these goals, indicators have been created to guide interventions. These targets necessitate serious commitments of time, money, and resources at all governance levels - global, regional, national, and local - to achieve lasting improvements in mental health care and support. Supporting people dealing with MNS disorders must be a priority.
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3.3 Monitoring the implementation of mental health agreements
Despite the existence of these comprehensive human rights frameworks, mental health has historically been under-resourced from policy level to service availability. This would lead to discrimination, stigma and abuse.
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3.3 Monitoring the implementation of mental health agreements
Drew and colleagues (2011), revealed pervasive human rights violations of those with mental and psychosocial disorders linked with discrimination and stigma, particularly in low and middle-income countries. These violations spanned civil, social, cultural, economic, and political rights – particularly employment discrimination and rights to exercise legal capacity. In relation to healthcare, the two major issues were lack of access to mental healthcare and abuse by health workers. To strengthen the implementation of the UN Convention on the Rights of Persons with Disabilities, several strategies have been recommended: e.g., changing negative false beliefs about mental health, providing community-based services, empowering people with mental disorders, reforming law and policy and establishing governance mechanisms.
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3.3 Monitoring the implementation of mental health agreements
The WHO established the Comprehensive Mental Health Action Plan in 2013 to establish global targets for mental health improvement. Following this plan, an updated plan was created for 2013-2020. Key objectives include: 1) Strengthening effective leadership and governance for mental health. 2) Providing comprehensive, integrated, and responsive mental health and social care services in community-based settings, 3) Implementing strategies for the promotion and prevention of mental health and 4) Strengthening information systems, evidence, and research for mental health.
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3.3 Monitoring the implementation of mental health agreements
One key target is to urge states to have an explicit mental health policy and plan. A national mental health plan brings the issue of mental health to the forefront on a policy and service level. National recognition makes states accountable for improving the organization, quality, and access to these services.
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Activity 1
Conduct some research on mental health issues in your country. List the most common disorders and include data on which services are available, and how many psychiatrists and psychologists exist in your country. In addition, research what mental health legislation currently exists. A good place to start is the Mental Health Atlas of the WHO. Please share your findings in the discussion board.
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4. Global Actors and Initiatives in Mental Health
The field of global mental health has experienced significant growth and evolution over the past few decades. This expansion has been driven by a growing recognition of the global burden of mental disorders, the human rights implications of neglecting mental health, and the potential economic benefits of addressing mental health issues. Key institutional actors that helped place mental health on the global agenda include the WHO, UN agencies, international academic collaborations and research initiatives. These are discussed in more detail below.
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The WHO plays a central role in global mental health, providing leadership, setting norms and standards, and supporting member states in developing and implementing mental health policies and programs.
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The WHO’s Department of Mental Health and Substance Abuse coordinates the Comprehensive Mental Health Action Plan. Initially covering 2013-2020 and extended to 2030, this plan provides a framework for action on mental health globally. Its four primary objectives are: 1) Strengthening effective leadership and governance for mental health; 2) Providing comprehensive, integrated, and responsive mental health and social care services in community-based settings; 3) Implementing strategies for the promotion and prevention of mental health and 4) Strengthening information systems, evidence, and research for mental health.
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The plan also sets specific targets for each objective, such as increasing service coverage for severe mental disorders by 50% and reducing the rate of suicide by one-third by 2030 (WHO, 2021).
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4.1 Key International Organisations and their roles 4.1.1 The WHO
WHO’s Mental Health Gap Action Programme (mhGAP) was launched in 2008 and aims to scale up services for mental, neurological and substance use disorders, particularly in LMICs.
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The program provides evidence-based guidelines and tools for non-specialist health settings. Key components include: -The mhGAP Intervention Guide: A clinical guide for non-specialist health-care providers -Training materials and a mobile app to support implementation and -Operations manual to help in the planning and implementation of mhGAP. mhGAP has been implemented in over 100 countries and has significantly contributed to integrating mental health into primary care settings (WHO, 2022).
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The WHO Mental Health Atlas, published periodically, monitors progress towards the targets set in the Comprehensive Mental Health Action Plan. It provides valuable data on the existence and implementation of national mental health policies and plans, mental health legislation, resources allocated to mental health services, and the availability and accessibility of mental health care.
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4.1 Key International Organisations and their roles 4.1.1 The WHO
This periodic publication provides a comprehensive overview of mental health systems worldwide. The 2020 edition highlighted persistent mental health system development challenges, including inadequate financing and workforce shortages in many countries (WHO, 2021).
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The WHO Quality Rights Initiative, launched in 2012, aims to improve the quality of care in mental health and social services and to promote the rights of people with mental health conditions. It includes training and guidance materials, assessment tools for mental health facilities and support for countries in reforming mental health laws and policies.
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4.1 Key International Organisations and their roles 4.1.1 The WHO
The initiative has been implemented in numerous countries and has contributed to significant improvements in the quality of mental health services and the protection of human rights (WHO, 2023).
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4.1 Key International Organisations and their roles 4.1.2 UN Agencies
Other UN agencies have increasingly incorporated mental health into their mandates, recognising its cross-cutting nature and importance in various domains.
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4.1 Key International Organisations and their roles 4.1.2 UN Agencies
The United Nations Children's Fund (UNICEF) has expanded its focus on child and adolescent mental health, particularly in humanitarian settings. Its work has been crucial in highlighting the importance of early intervention and prevention in mental health. Some of UNICEF’s key initiatives include (UNICEF, 2021): 1) The State of the World's Children 2021 report, which focused entirely on child and adolescent mental health; 2) The development of a global framework for mental health and psychosocial support in schools and 3) Integration of mental health interventions in early childhood development programs.
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4.1 Key International Organisations and their roles 4.1.2 UN Agencies
The United Nations High Commissioner for Refugees, the UN Refugee Agency (UNHCR) addresses mental health and psychosocial support (MHPSS) for refugees and displaced populations (UNHCR, 2023). Its work includes developing MHPSS guidelines for refugee settings, training staff and partners in MHPSS, and integrating MHPSS in emergency response planning.
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4.1 Key International Organisations and their roles 4.1.2 UN Agencies
The United Nations Development Programme (UNDP) has increasingly recognised mental health as a development issue. It has incorporated mental health considerations into its work on the SDGs, poverty reduction strategies and crisis prevention and recovery, underscoring the importance of mental health in broader development contexts (UNDP, 2022).
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4.2 International Academic Collaborations and Research Initiatives
A large number of international membership organisations work in global mental health. Some examples include:
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4.2 International Academic Collaborations and Research Initiatives
The Centre for Global Mental Health (CGMH) was launched in 2009 as a collaboration between LSHTM and King’s Health Partners (including the Institute of Psychiatry and three of London’s NHS Foundation Trusts).
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4.2 International Academic Collaborations and Research Initiatives
In 2012, the LSHTM and the KCL Institute of Psychiatry launched an MSc in Global Mental Health, which aims to “provide people with the knowledge and skills to initiate, develop and oversee mental health policies and programmes in low-resource settings, and conduct or critically evaluate research on Global Mental Health.”
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4.2 International Academic Collaborations and Research Initiatives
CGMH continues to be a leader in research and capacity building. Its work includes conducting implementation research in LMICs, developing and evaluating interventions for various mental health conditions and training the next generation of global mental health researchers.
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4.2 International Academic Collaborations and Research Initiatives
The World Federation for Mental Health was founded in 1948 to advance, among all peoples and nations, the prevention of mental and emotional disorders, proper treatment and care of those with such disorders, and promotion of mental health. The Federation is the only worldwide grassroots advocacy and public education organisation in the mental health field. Organisational and individual members in over 100 countries include mental health workers of various disciplines, mental health service users and interested individuals.
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4.2 International Academic Collaborations and Research Initiatives
The Lancet Commission on Global Mental Health and Sustainable Development. The Lancet journal, through its Global Health Series, has worked to influence policy agendas on topics of global health importance since 2007. Building on the previous Lancet series, the Lancet Commission on Global Mental Health and Sustainable Development, published in 2018, reframed global mental health within the sustainable development agenda. Their key contributions include 1) emphasising a dimensional approach to mental health, 2) highlighting the importance of early intervention, 3) proposing a staged model of care, and 4) emphasising the role of social and environmental determinants of mental health. The commission's work has influenced policy and research agendas globally (Patel et al., 2018).
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4.2 International Academic Collaborations and Research Initiatives
To address mental health research, the Grand Challenges in Global Mental Health was launched in 2011 to identify priorities for mental health research. While the original project has concluded, its impact shapes research agendas, numerous research efforts and funding decisions in the field (Collins et al., 2011). Some of the priorities identified included: integrating screening and core packages of services into routine primary health care, reducing the cost and improving the supply of effective medications and providing effective and affordable community-based care and rehabilitation.
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4.2 International Academic Collaborations and Research Initiatives
The Mental Health Innovation Network (MHIN) is a global community of mental health innovators, researchers, practitioners, policy-makers, and donors, that has been instrumental in disseminating research findings and promoting best practices in global mental health. Its aims are a) share knowledge and resources, b) promote innovation in global mental health and c) foster collaboration between different stakeholders.
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5. Challenges and Opportunities in Global Mental Health
As mental health is firmly embedded in the global health agenda, the challenges are to create, implement, evaluate policies arising from its inclusion. Much of the challenge is focused on areas of greatest need. For instance, much effort is focused on supporting health systems in resource-constrained countries to implement mental health interventions.
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5.1 Mental Health in Humanitarian Crises and Conflict Zones
Humanitarian crises, such as armed conflicts, disasters, and forced displacement, significantly impact mental health and wellbeing. The psychological repercussions of these events can be profound and enduring, yet delivering mental health care in these challenging environments is fraught with difficulties. Populations affected by humanitarian crises experience high rates of mental disorders. A meta-analysis reported that 22.1% of individuals in conflict-affected areas suffer from conditions like depression, anxiety, and post-traumatic stress disorder (Charlson et al., 2019). Refugees and internally displaced persons often face mental health challenges at rates approximately double those of non-refugee populations (WHO, 2022).
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5.1 Mental Health in Humanitarian Crises and Conflict Zones
Providing mental health care in these settings is complicated by multiple factors. Disruptions to health systems frequently undermine existing mental health services, while ongoing security concerns hinder both access to care and the safety of health workers (Inter-Agency Standing Committee, 2008). Resource constraints further exacerbate the situation, with significant shortages of trained mental health professionals. Additionally, cultural and linguistic barriers can impede the delivery of appropriate care, particularly in cross-border crises. Competing priorities often force mental health to take a backseat to more immediate needs, such as food, shelter, and physical health care. Nonetheless, several innovative approaches offer promise for addressing these challenges. Psychological First Aid (PFA), endorsed by the WHO, provides crucial immediate support (WHO, 2011), while scalable psychological interventions, like Problem Management Plus (PM+), effectively engage non-specialists in delivering care (Rahman et al., 2016). Integrating mental health and psychosocial support across all sectors of humanitarian response is promoted by the Inter-Agency Standing Committee (IASC) guidelines (IASC, 2007).
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5.2 Impact of Global Pandemics on Mental Health
The COVID-19 pandemic has spotlighted the profound mental health impacts of global health crises, revealing that the psychological consequences can be as severe and lasting as the physical threats. Research indicates a significant increase in mental health issues during the pandemic, with a meta-analysis showing a 28% rise in global depression and a 26% rise in anxiety in 2020 (COVID-19 Mental Disorders Collaborators, 2021).
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5.2 Impact of Global Pandemics on Mental Health
The pandemic also presented valuable lessons and opportunities for enhancing global mental health responses. Future pandemic preparedness plans must integrate mental health considerations explicitly (Holmes et al., 2020). Also, the pandemic fostered unprecedented global collaboration in mental health research and practice, which could serve as a foundation for future initiatives (Holmes et al., 2020).
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5.3 Digital Technologies and Global Mental Health
Digital technologies offer significant opportunities to tackle challenges in global mental health by enhancing access to care and addressing resource constraints. Various digital interventions include telepsychiatry for real-time consultations, mobile health (mHealth) apps for education and self-help, internet-based programs based on cognitive-behavioural therapy, virtual reality (VR) for exposure therapy, and artificial intelligence (AI) for diagnosis and treatment. These technologies can improve access for remote populations, reduce costs, scale to larger audiences, offer personalised care, and enable real-time symptom monitoring (Naslund et al., 2019; Patel et al., 2018).
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5.3 Digital Technologies and Global Mental Health
Despite their potential, these interventions face challenges such as the digital divide, which may exacerbate health inequities, and concerns over privacy and data security (Torous et al., 2019). The rapid proliferation of mental health apps raises questions about quality and cultural appropriateness (Naslund et al., 2019), while integrating these solutions with existing services poses additional difficulties. Future directions include developing hybrid models that combine digital and face-to-face care, fostering global collaborations for context-specific adaptations (Naslund et al., 2019), establishing ethical guidelines for AI, advancing implementation science to scale interventions, and ensuring user-centered design by involving individuals with lived experiences (Torous et al., 2019).
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Integrating activity
In this activity you will analyse various stakeholders' roles, interests, and potential impacts in implementing a global mental health initiative. Please follow the below steps for your analysis before posting your results in the discussion board: 1. Scenario: Imagine you are part of a team tasked with implementing a new global initiative to integrate mental health services into primary care in LMICs. 2. Actor Identification: Review the list of actors provided in the left column of the table (as shown in Image 1). 3. Actor Analysis: For each stakeholder, consider: a) Their level of influence (high, medium, low) b) Their potential interest in the initiative (supportive, neutral, opposed) c) Reasons for their stance d) Potential strategies to engage them 4. Complete a Table: Create a table with 5 columns and fill it with your analysis. Use the following format: [Stakeholder Name] | [Influence Level] | [Interest Level] | [Reasons] | [Engagement Strategies] 5. Reflection: After completing the table, answer the following questions: a) Which stakeholders are most critical for the success of this initiative? b) What are the main challenges you foresee in engaging these stakeholders? c) How might cultural or regional differences affect stakeholder engagement in different parts of the world? 6. Peer Discussion: Share your completed table and reflections on the discussion board. Respond to at least one other post, comparing your analysis and offering constructive feedback. 7. Final Thoughts: Based on the discussion, write a brief paragraph (150-200 words) on how you would prioritize stakeholder engagement for this global mental health initiative. Once you have completed the activity you can check your answer with the feedback below.
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Summary
In this session, we discussed how global mental health has made significant strides, with increased recognition of its importance in overall health, policy, and development. However, substantial challenges remain, particularly in addressing the treatment gap, tackling inequities, and responding to the mental health impacts of global crises. Moving forward, continued research, policy, and international collaboration will be crucial in addressing the complex, multifaceted nature of global mental health challenges and ensuring equitable access to mental health care worldwide.
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Summary
Introduction to Global Mental Health. Mental health is a critical global health issue affecting millions worldwide. The global burden of mental disorders is significant, with substantial economic implications, and there is a clear link between mental health and other international health priorities.
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The social and economic determinants of Global Mental Health. Socioeconomic factors play a crucial role in shaping mental health outcomes globally. Cultural contexts significantly influence mental health's understanding, experience, and management. Inequalities in access and outcomes persist, particularly in LMICs.
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Human rights and Global Mental Health Policy. International human rights instruments protect and promote the rights of individuals with mental conditions. The UN Convention on the Rights of Persons with Disabilities marked a shift in disability rights. Mental health is included in the UN SDGs.
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Global Actors and Initiatives in Mental Health. The WHO plays a central role. Other UN agencies, academic collaborations, and research initiatives contribute significantly to the field. Global research networks and initiatives shape research agendas and funding decisions.
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Challenges and Opportunities in Global Mental Health. The global treatment gap remains a significant challenge, with many lacking access to care. Mental health in crises and conflicts presents unique challenges. The COVID-19 pandemic has highlighted the profound impact of global health crises on mental health. Digital technologies offer promising opportunities.
