1. Introduction to Global Mental Health
Lauren Ng, PhD
MGH Global Psychiatry Division
Carmel Salhi, ScD
Labs of Cognitive Neuroscience, Boston Children’s Hospital

2. Very Broad Overview of Global Mental Health
Background
State of mental health care globally
Recent policy proposal
Socioeconomic status, stress and mental health
BREAK
Issues in cross-cultural mental health
Global mental health research
Cross-cultural care and adaptation
Case-study: Comorbid mental health & refugee resettlement

3. Mental Health Physical, mental and social well-being
Mental illness = medical conditions that impair thinking, feeling, mood, ability to relate to others and daily functioning
Mental health and physical health directly impact each other (bidirectional)
In most of the world mental health is ignored or neglected

4. Prevalence High Prevalence Young people impacted
World Mental Health Survey (2011) estimated lifetime prevalence of any mental health disorder from 47% in USA to 12% in Nigeria
Assumes valid cross-cultural comparison
Young people impacted
10%-25% of people 12-24
~ 1 in 4 families has at least one member with a mental disorder
~ 1 in 4 patients seeking care for a physical health problem has a diagnosable mental disorder
No group is immune
Risk is higher for vulnerable populations (ex: poor, victims of violence, indigenous populations, etc.)
(Collins et al., 2011; Bloom et al., 2011; (Patel, Flisher, Hetrick, & McGorry, 2007) )

5. Suicide WHO just released the first report on suicide around the world
Preventing Suicide: A Global Imperative
Every 40 seconds someone dies by suicide
Globally, suicide is the 2nd leading cause of death for people between 15-29
Many more people who attempt suicide than complete
Probably extremely underreported, and many countries have no vital records registration

6. Suicide Rates per 100,000 (2012); Age-standardized
<5
5 – 9.9
10 – 14.9
No data
>15
N/A
All over the world, but variation
(WHO, 2014)

7. Disability Adjusted Life Years (DALYs) and Mental Health
DALYs = Years lost to disability or early death
Mental, neurological, and substance-use disorders constitute 13% of the global burden of disease
Dramatic negative impact on productivity and quality of life.
Depression is the 3rd leading contributor to the global disease burden
Mental health conditions are the leading non-communicable disease (NCD) cause of DALYs worldwide
Account for 37% of healthy life years lost from NCDs
(Collins, et al., 2011; WHO, 2005; Bloom et al., 2011)

8. DALYs lost to NCDs
Together, mental health and cardiovascular disease account for almost 70% of lost output to NCDs
(Bloom et al., 2011)

9. % Neuropsychiatric DALYs Globally
All Neuropsychiatric Disorders
DALYs (millions)
% mental health DALYs
All neuropsychiatric disorders
199
Depression 65 33
Alcohol use disorders 24 12
Schizophrenia 17 8
Bipolar disorder 14 7
Alzheimer and other dementias 11 6
Epilepsy 4
Drug use disorders
Top 4 disorders account for over 60% of the mental health DALYs in the world

10. Burden of Mental Disorders in Low- and Middle-Income countries (LMICs)
~82% of the world’s populations lives in LMICs
All Neuropsychiatric Disorders
% of DALYs
Depression 85
Alcohol use disorders 82
Schizophrenia 90
Bipolar disorder
Alzheimer and other dementias 61
Epilepsy 92
Drug use disorders 77
(Collins et al., 2007)

11. Mental Health Care
Mental disorders can be managed with psychosocial intervention and/or medication
Only a small minority of patients receives even the most basic treatment.
In HICs 44% - 70% of patients with mental illnesses do not receive treatment
In LMICs, the treatment gap is closer to 90%
(Collins et al., 2011; WHO, 2003)

12. Mental Health Funding
Mental health is very underfunding throughout the world
High income countries (HICs) devote ~7% of the health budget to mental health
The majority of LMICs devote less than 1% of the health budget to mental health
Great majority of the mental health budget goes to inpatient neuropsychiatric hospitals rather than primary or community care
(WHO, 2003)

13. Disparities in Mental Health Service Availability
% ANY Presence
Low
High
Community Care 52 97
Any mental health care in primary care 76
Severe mental illness care in primary care 55 87
Median # psychiatric beds per 10,000
< 1 8
(WHO, 2005)

14. Disparities in Mental Health Human Resources
Per 100,000
Low / Low Mid
High-Mid
High
Psychiatrists
< 1 3 11
Psychiatric Nurses 5 33
Neurologists 1
Neurosurgeons
Psychologists 2 14
Mental Health Social Workers 16
More mental health professionals at HMS than in many
(if not most) low-income countries
(WHO, 2005)

15. Cost of Mental Health Care
When care is available, cost is often out of pocket, even when families have insurance
Mental disorders are often not covered at the same level as other disorders
This creates significant economic difficulties for patients and families

16. Policy to address disparities: WHO Mental Health Action Plan 2013-2020
To strengthen effective leadership and governance for mental health
80% of countries will have developed or updated their policies/plans for mental health
50% of countries will have developed or updated their laws for mental health
To provide comprehensive, integrated and responsive mental health and social care services in community-based settings
Service coverage for severe mental disorders will have increased by 20%

17. Policy to address disparities: WHO Mental Health Action Plan 2013-2020
To implement strategies for promotion and prevention in mental health
80% of countries will have at least two functioning national, multisectoral promotion and prevention programmes in mental health
The rate of suicide in countries will be reduced by 10%
To strengthen information systems, evidence and research for mental health
80% of countries will be routinely collecting and reporting at least a core set of mental health indicators every two years through their national health and social information systems

18. Socioeconomic Status and Mental Illness
Apart from causing suffering, mental illness is closely associated with:
Socioeconomic status, notably poverty and gender disadvantage
Poor physical health, including having HIV/ AIDS and poor maternal and child health
Mental disorders impoverish people because of both increased costs of health care and lost employment opportunities

19. Mental Illness and Poverty
Mental illness is associated with low income and poverty
Unemployment is a critical link
Poverty and unemployment increase with severity of the disorder
Both unemployment and mental illness come at a social and economic cost

20. Poverty & Mental Illness: A Vicious Cycle
80% of the global burden of disease due to mental health disorders is found in LAMIC
Mental disorders are associated with unemployment rates between 70-90%
Depression is 1.5 to 2 times more prevalent among low-income groups of a population
Poverty
Unemployment
Low Income
Less Education
Mental Disorders

21. Social Cost of Mental Illness
Mental illness sufferers often face stigma, constituting an immense barrier to treatment and access to services
Family members are often the primary caregivers of people with mental disorders and can be their supports as well as barriers
However, the extent of the burden of mental disorders on family members is difficult to assess and quantify and often ignored
Those suffering from mental illnesses are also victims of human rights violations and discrimination
This may occur both inside and outside psychiatric institutions

22. Recovering from Mental Illness

23. Stressors Types of stressors Acute stress Chronic stress
War and ongoing political conflict
Overcrowding and environmental exposures
Community-level adversity
Acute stress
Sudden, typically short-lived or defined end, threatening event (e.g., robbery, giving a speech)
Chronic stress
Ongoing, continuously demanding (e.g., discrimination by law enforcement, economic blockade, sanctions)
Learned helplessness after repeated

24. Complex layers of loss
Stressors often happen at the community-level and are multi-faceted
Systems of cooperation and mutual dependence: broken social networks
Interpersonal relationships
Anxious attachment to caregivers
Solidarity with family/kin
Disrupted social identities
Environmental effects
Neuro-developmental effects
Trans-generational transmission of trauma

25. Complex PTSD: A New Diagnosis?
Simple PTSD
Single Trauma
Complex PTSD exposure
Multiple Trauma
Traumatised Under age of 14 / 26
Developmental stage important
Complex PTSD symptoms
loss of sense of safety, trust, & coherent sense of self
pervasive insecurity
often disorganized-type attachment
But complex PTSD has not been generally accepted
Not enough evidence for a new diagnosis (Resick et al., 2012)
Serves to highlight general shortcomings of PTSD
Experienced, witnessed an event involving actual or threatened death/ serious injury, or threat to physical integrity of self/ others
Intrusion Symptoms
Persistent Avoidance
Alterations in Cognitions and Mood
Hyperarousal and Reactivity Symptoms
Erroneous self- or other-blame
Negative mood states
Reckless and maladaptive behavior

26. Break

27. Issues in Cross-Cultural Mental Health
Culture includes:
Belief systems
Value orientations
Religious practices
Medical practices
Organization of society
Structure of families
Legal systems
Economic resources
Culture can affect:
Which behaviors are considered to be illness
Theories of etiology (causation)
Ideas of appropriate treatment and healers
How people seek help and receive care

28. Intersection of Mental Health and Culture
Across cultures, similar types of mental illnesses (e.g., schizophrenia), with similar symptoms (e.g., cognitive defects, asocial behaviors) are often observed
Interpretation of symptoms may differ markedly
Meaning of symptoms
Source of symptoms
Duration of symptoms
Curability
Certain aspects of psychiatric illness are socially constructed
Homosexuality as a disease in DSM-I, DSM-II and DSM-III
Medicalization of grief
Psychotic delusions, hallucinations can incorporate cultural elements which differ between societies

29. Mental Health Research Gap
Almost all data on mental health (particularly interventions) comes from high-income countries
10–90% divide in research
Presentation, attribution, classification, prevalence, and prognosis of mental disorders varies greatly between cultures.
Cross-cultural work is under-represented in the mainstream psychiatric literature
Of 183 published studies on the mental health of refugees, four fifths relied exclusively on measures of psychopathology developed with Western populations.
(Kieling et al., 2011; Summerfield, 2008)

30. Factors Affecting Research Quality
Design of studies may not account for marginalized groups
Mental illness among non-respondents tends to be higher in marginalized communities
Not capturing idiomatic expressions or local forms of distress limits representativeness outside of norm
Masculine depression
The value of protective sociodemographic characteristics varies between cultures
Family structure
Coping strategies and their meaning are important to understand
Religiosity

31. Useful Interpretive Frames
Etic model
Similar instruments used in each culture
Assumes no bias
Differences between groups mean construct differences in each culture
For example, give identical tests in each culture, differences in test scores indicate differences between the cultures on the construct
Emic model
Use different instruments for each culture, see if they measure same thing
Measures a wider range of behaviors that are perhaps more appropriate for each culture
Harder to identify bias
Measurement equivalence uncertain

32. Models of Cross-Cultural Care
How might these lessons be carried over to mental health care?
Cultural competence: The level of a provider’s knowledge, attitude, and skills about cultural values
Cross-cultural efficacy: Providers learn how their own culture and behaviors can impact others of different cultures
Cultural humility: Provider engages in regular self-evaluation and self-critique
The models share the ultimate goal of preparing providers to manage sociocultural issues that emerge
For example, in preparing to work with translators and interpreters
Cultural competence has lacked a set of guiding principles with clear operationalization
Cultural competence: The level of a provider’s knowledge, attitude, and skills about cultural values and health-related beliefs, disease incidence and prevalence, and treatment efficacy for diverse cultural groups.
Cross-cultural efficacy: Providers learn how their own culture and behaviors can impact others of different cultures, and understand how patients’ culturally-based behaviors may impact the provider.
Cultural humility: Provider engages in regular self-evaluation and self-critique. Goal is to developed power-balanced relationships with patients of different cultures.
The models share the ultimate goal of preparing providers to manage sociocultural issues that emerge
Cultural skills training programs often utilize elements of all 3 models
Each model requires attention to knowledge, attitudes, and skills.
The umbrella term ‘cross-cultural competence’ will be used to encompass these models

33. Cross-Cultural Intervention Development
Can psychiatric approaches developed in HICs be effective in lower resource contexts with potentially differing cultural norms and expectations?
Must be aware of the role of poverty, political, social and economic instability, and lack of rights on mental health
Increasingly, the literature is pointing to the potential of mental health interventions to improve clinical and economic outcomes in low- and middle-income countries

34. Problems with Relying on Western Approaches in Cross-Cultural Intervention Development
Cultural validity: How closely western concepts match local concepts; Western/outside concepts may not apply locally
Unknown local concepts: Are there important local issues/concepts unknown to us? How to include questions we don’t know we should be asking?
Translation problems: Who translates? Translation and back translation methods are inadequate, can result in semantic equivalence but real-world insignificance (i.e. lighting fires)
RISK: Interventions are not appropriate or effective and evaluations don’t accurately measure impact
RISK: Misidentify individuals as having a mental disorder rather than a culturally and contextually “normal” reaction
(Betancourt, 2013)

35. A Model for Designing and Evaluating Mental Health Services in Diverse Cultural Settings
Qualitative data informs assessment
and intervention
Apply lessons learned to new settings and intervention adaptations
Use qualitative data to select, adapt, and create
mental health measures and interventions; conduct
validity study
Implement culturally relevant
intervention;
evaluate with rigorous design
Identify important
mental health constructs relevant to the context
(qualitative inquiry)
(Betancourt, 2013)

36. Improving access to psychological treatments: Lessons from developing countries
Patel, Chowdhary, Rahman & Verdeli (2011)
Describes the development and evaluation of psychological treatments for depression in 3 resource poor countries (India, Pakistan, & Uganda)
Systematically adapted treatments developed in high income countries to contextual factors
Interventions were delivered by lay or community health workers
All demonstrated significant recovery rates when compared to usual care

37. India
2,796 Adults over 17 y.o. attending primary care who screened positive for depression
Cluster randomized controlled trial at health centers
Intervention
Psychoeducation
Interpersonal therapy (IPT)
Antidepressants
Specialist Referral
Compared to “enhanced” usual care – providing treatment guidelines on depression screening and antidepressants to primary care doctors
24% reduction in depression and anxiety disorder over 12 months

38. India adaptations Delivery agent
Women
College graduates in any field
Recruited from the local community
Supervised by clinicians certified in IPT
Explained depression as a stress related illness rather than using the term “Depression” or other psychiatric label
Sessions were more structured and presented with simplified scripts in the local language
Discussion of religious practices as coping methods
Delivery in individual rather than group settings due to confidentiality concerns

39. Pakistan
903 married women aged in the 3rd trimester of pregnancy who screened positive for depression
Cluster randomized controlled trial in 40 councils (geographic areas)
Intervention
Cognitive Behavioral Therapy (CBT) delivered in the home
16 sessions from the last month of pregnancy to 10 months post-partum
Compared to “enhanced” usual care with similar numbers of sessions
78% reduction in depression at 6 months, 77% reduction at 12 months

40. Pakistan adaptations Delivery agent
Women
Lady health workers who are part of the primary health care system
Mostly high school completers
Supervised by mental health specialists
Focus on mother and infant health rather than maternal depression
Use of “stressed” or “burdened” rather than psychiatric labels
Involvement of significant family members
Sessions structured to the perinatal period (ex: mother’s personal health, mother-infant relationship)
Culturally appropriate illustrations and homework activities

41. Uganda
248 adults 18 and older who self-identified or were identified by others as having depression or who screened positive for depression
Cluster randomized controlled trial in 30 villages
Intervention
IPT delivered in 2 individual and 16 weekly group sessions
Compared to information provided about other available services (e.g., local healers and NGOs)
80% reduction in depression at termination, 74% reduction in depression at 6 month follow-up

42. Uganda adaptations Delivery agent Single-sex groups
Males and females matched to sex of single-sex group
Mostly high school completers, some in college
Supervised my psychologists with experience in group therapy
Single-sex groups
Simplified language
“grief” renamed “death of loved ones”
“role transitions” became “life changes”
Local idioms of distress to discuss depression
Clarification that distress was not “madness”
Interpersonal deficits section was removed since communal activities are necessary and social isolation is rare

43. Scaling Up Mental Health Services
Key conditions must be met to delivery psychological treatment with lay workers
Lay workers from the local community
Well-designed participatory training
The treatment modified to address the skill set of the workers and the contextual issues and barriers
Supervision provided by people with more extensive mental health experience and skills and there a risk management system in place
Stigma associated with mental illness is addressed
Mental health is integrated into routine health care or existing community delivery systems
(Patel, Chowdhary, Rahman & Verdeli, 2011)

44. Case study: Comorbid Mental Health conditions & Refugee resettlement

45. Outline Background on PTSD and family
Overview Iraqi refugee resettlement in US and Worcester
Findings on Iraqi resettlement, family life, and well-being
Implications for policy and intervention

46. What does PTSD look like?
No one, clear clinical picture
Trauma stereotypes don’t reflect variation in reality
There are some “hallmarks”
Nightmares
Poor sleep
Anger
Numbness or sadness
Avoidance of groups

47. Anger and PTSD
Hyperarousal symptoms are the most related to anger and aggression
Depression are risk factors for aggression
Triggers can include:
Loss of sleep
Caffeine and other stimulants
Physical pain

48. Political Conflict and Parenting
Most literature on war exposure and parenting comes from veterans
Focus has been on fathers returning from combat duty
Mental illness in a spouse can cause increased hardship to the entire family unit
Difficulties in the post-war context may be compounded by parenting, particularly for mothers
PTSD may be associated with symptoms of hostility, grief, guilt and anxiety which can disrupt the family environment
Children whose parents have PTSD are at higher risk for symptoms of mental illness, including PTSD

49. Number of Iraqis Resettled In Worcester

50. Proportion of All Arrivals in Central Mass

51. Research Participants
12 Iraqi Families*
6 Muslim Families
6 Mandaean Families
6 Fathers
6 Mothers
*One Christian family was also interviewed

52. Parent Psychological Distress
Father: Frankly, I do not subscribe to the Arabic channels, nor am I following anything on the Internet. I personally am very sensitive. So I try as much as possible to stay away from the news. Because this is certainly a tragedy. Certainly, one is affected by this. No matter what, it remains your country, and this is the closest thing to your heart. In general, for sure, problems will arise, people lose their temper. If it's not myself, it's my family in Iraq; when I see my relatives losing their temper, I excuse them. Their families are in danger, one of their relatives has been injured, or killed. For sure the situation is hard because the situation is not stable in Iraq for sure.

53. Child Psychological Distress
Mother: [My son] was telling the story at school. He was little then and he remembers going to the market with his father, how he got into the car, he remembers the Americans getting into their car, he remembers how their car blew up. When my son came he was pale with fright, so when somebody this young goes through that - every time we mention Iraq he yells "we don't want to go back to Iraq! Don't bring up Iraq! I saw death!" This is what my son says.

54. Raising Children
Father: Over there he is surrounded by his uncles, his grandfather, he would not be able to get away with doing these things. I would be supported by all the family members. They would help me in bringing up my son. Here I'm alone. I am working against the current…If I tell them something, he has a response contrary to mine. He tells me "you shouldn't yell at me". I would tell him it's not a matter of me wanting to yell at you, sometimes you frustrate me and make me lose my temper. He tells me "even if you lose your temper you can't yell at me."

55. Discussion
Higher previous living standards, proximity to traumatic events, and faster resettlement process for Iraqi refugees may complicate adjustment to new communities
Parents continue to suffer from their past war experiences and the continued violence in Iraq, which may put other family members at risk
The challenges facing Iraqi families during resettlement may reinforce a cycle of socioeconomic decline and mental illness

56. Implications
Approaches to working with Iraqi refugees differs from that of other refugees
Shortened resettlement period may affect trauma prevalence and presentation
Alienation and isolation of resettled Iraqi families can exacerbate problems of trauma and anger
Can complicate relationships with aid agencies
Reducing the barriers to employment closer to parents' education and training gained overseas could improve well-being of entire family
May also help mitigate feelings of loss and re-experiencing trauma
Strategies for obtaining information relevant to services (e.g. mental health screening) can leverage cultural values and family dynamics

57. Thank you

58. References
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