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Global mental health (GMH) is a relatively new but rapidly growing and highly influential field that has emerged from an awareness that there is “no health without mental health” (Prince et al., 2007) and that there is a need for mental health care that can be scaled up in communities across the globe (Chisholm et al., 2016).

GMH has relied on a number of pre-existing fields of study. First, multi-national epidemiological studies have shown that mental health conditions are prevalent across the globe but are often underdiagnosed and undertreated (World Health Organization, 2017). The treatment gap between the number of people in need of mental health services and those that receive them is widest in low- and middle-income countries, exceeding 90% in sub-Saharan Africa (Kohn, Saxena, Levav, & Saraceno, 2004). Second, community psychiatry has highlighted social integration as a key outcome for mental health services (Baumgartner & Susser, 2013) and studies in psychiatric anthropology, including work with refugees, have emphasised that interventions need to include an appreciation of the relevant socio-cultural context (de Jong, Komproe, & van Ommeren, 2003).

In the last decade, there has been increasing acknowledgment that mental health should be addressed on a global scale. The Lancet series on GMH first published in 2007 and updated in 2011 provided a benchmark of evidence and a renewed call to action to scale-up mental health services worldwide. This call emphasised evidence-based, cost-effective and culturally appropriate interventions to address the mental health treatment gap (Lancet Global Mental Health Group, 2007, 2011). A second landmark publication which galvanised the field of GMH was the WHO’s flagship programme on mental health launched in 2008, mhGAP, which produced an intervention guide for scaling-up interventions by non-specialist providers (World Health Organization, 2010). These guidelines comprehensively addressed a range of care components including psychological and pharmacological, though its authors recognised that the challenge of translating evidence-based solutions to diverse context remain.

It is clear that substantial progress has been made in developing an evidence base for innovative treatments which have been shown to work. For example, “best practice” and “good practice” interventions for prevention and promotion of mental health conditions have recently been identified at the population and community‑levels (Petersen et al., 2016, p. 256), including success from anti-stigma campaigns and awareness raising programmes (Thornicroft et al., 2016). Meta-analyses have been conducted to establish packages of care for LMIC using diagnostic criteria for schizophrenia (Mari, Razzouk, Thara, Eaton, &

Thornicroft, 2009) and depression (Patel & Thornicroft, 2009). Studies have shown success in scaling up services amid resource-poor health systems (Chisholm et al., 2016). Furthermore, the GMH movement has made strides to bolster recognition of the true global disease burden of mental health conditions (Vigo et al., 2016) and renewed the national and international efforts to galvanise governments and United Nations (UN) Member States to take action in reforming mental health systems.

Despite these improvements, there is as yet little evidence of how to implement these in real-life settings beyond those already identified in recent studies. The questions that

remain are far broader than that of scaling-up transportable technologies: they involve issues of cultural contexts, health systems challenges, and interfaces between seemingly

incompatible sets of demands and needs of societies, such as competing health priorities and limited resources (Braathen, Vergunst, Mji, Mannan, & Swartz, 2013).

A key contributor to the treatment gap is the meagre investment in public mental health. Data from WHO’s Mental Health Atlas 2014 survey (2015a) suggest that most LMICs spend less than US$2 per person annually on the treatment and prevention of mental health conditions compared with an average of more than $50 in HIC. As a result, the large

treatment gap affects not just the health and wellbeing of people with mental health conditions and their families, but also has inevitable consequences for communities and governments as a result of diminished productivity at work, a reduction in labour participation, and increased health and other welfare expenditures (Chisholm et al., 2016).

Findings from studies (Trautmann, Rehm, & Wittchen, 2016) have also shown the enormous economic challenge mental health conditions pose to communities and society at large. For example, depression, which is the most common mental health condition among adults, is known for its economic impact. Relative to other diseases common in working-age adults, depression has an earlier age of onset (often twenties) and higher chronicity.

Depression impacts economic gains through its association with work and decreased productivity (30% decline with mild depression) (Woo et al., 2011). An estimated US$ 2.5– 8.5 trillion worldwide in lost output was attributed to mental, neurological and substance use disorders (Bloom et al., 2011). This sum is expected to double by 2030 which is why the promotion of mental health and wellbeing have been explicitly included in the United Nations’ Sustainable Development Goals (SDGs) (United Nations, 2015).

There is widespread critique that psychiatry, and the GMH movement in particular, construct distress as symptomatic of “neuropsychiatric disorders” rather than as responses to the socio-cultural, political and economic conditions of chronic poverty, conflict, and

entrenched social inequality (Mills, 2014). This view - reducing complex matters of living, behaving and thinking to disorder - is strongly contested by groups of service users and survivors of psychiatry, or those who identify as psychosocially disabled, and by academics and professionals in the field of cross-cultural psychiatry (Fernando, 2014). This is where cross-cultural psychiatry, described in section 2.2.2, may be at odds with the GMH movement.

A 2011 article in Nature entitled “Grand Challenges in Global Mental Health” identified mental health priorities for research in the next 10 years, sparking controversy and debate about the appropriate methods for establishing priorities, research themes, and

interventions in GMH (Collins et al., 2011). The article described and promoted the approach of the GMH movement, which led to a contentious meeting in Montreal where many

academics in transcultural psychiatry expressed serious misgivings (Bemme & D’souza, 2014). In the meeting, discussion about the nature and vision of the GMH agenda oscillated between two antagonistic poles. One side described it as a bottom-up, public health

movement driven by local knowledge and priorities, with the aim of providing access to mental health care for everyone. In the other, GMH was seen as a top-down, imperial agenda exporting Western illness categories and treatments that would ultimately replace diverse cultural traditions for interpreting mental health. Subsequent comments critical of the

movement appeared (Campbell & Burgess, 2012; Das & Rao, 2012), and a letter in Openmind referred to the fact that Nature had refused to publish an editorial critical of the ideas

presented in the article by Collins et al. (2011), thereby raising the possible political nature of the GMH movement.

Arguably, the push for a “global norm for mental health” (Shukla et al., 2012, p. 292), and a “standard approach for all countries and health sectors” (Patel, Collins, et al., 2011, p. 1442), not only ignores local realities, but also works to discredit and replace local

frameworks for responding to distress. Ethan Watters’ book Crazy Like Us: The Globalization of the American Psyche (2011) describes the loss of cultural diversity in understanding and responding to distress worldwide as one that leaves everyone the poorer, not just people in LMICs. For example, local knowledge of distress is traditionally embedded in religion or spirituality which is unique to that culture.

Das and Rao (2012) critique the individualist focus of the Western diagnostic system, taking the individual as its unit of analysis, which serves as a fundamental basis for the GMH movement’s approach to scientific evidence. They argue it distracts attention away from the social context, failing to address adequately the social determinants of health. Likewise, with a focus on WHO policies, such as mhGAP (2008), White and Sashidharan (2014) argue that the over-reliance on the scale up of medical resources and prominence of diagnoses within such policies diverts attention from the social and cultural determinants of distress. White and Sashidharan argued that GMH also strengthens hospital-based care to the detriment of

community support.