Challenges and priorities for global mental health in the Sustainable Development Goals (SDG) era

Author: 
Academy of Medical Sciences
Publication date: 
28 June 2018

Published in 2011, the Grand Challenges in Global Mental Health initiative provided a framework to guide the research needed to improve treatment and prevention of mental health disorders and expand access to mental health services. At the Academy’s workshop on global mental health participants reflected on progress since 2011, focusing on specific life-course stages, and identified priorities for research in treatment and prevention, as well as enduring challenges and emerging opportunities.

Guiding principles for global mental health research

The integration of mental health into global health and development agendas: Participants agreed that, since 2011, the global profile of mental health has increased significantly. Mental health is both explicitly and implicitly referred to in the SDGs and, more importantly, the interdependence of mental health and other SDGs is widely recognised. Expanding access to appropriate mental health services to everyone regardless of socio-economic status is also integral to the global momentum towards UHC. The close association between mental health and these global agendas could provide additional impetus and present new research opportunities to reduce the burden of mental health disorders.

A life-course perspective: Participants also noted that the life-course perspective is a key developmental framework for addressing mental health questions. Life stages such as motherhood, early childhood, adolescence, adulthood and older adulthood present unique challenges, influencing the nature of mental health disorders experienced and the support and care required. The life-course perspective also highlights how mental health disorders may have their roots in the early stages of life, and the important implications for prevention.

Current status of global mental health research for treatment and prevention

Significant progress has been made in the development and evaluation of psychosocial interventions for mental health disorders and in models of multidisciplinary teams suitable for LMICs. Importantly, the recognition that mental health disorders are universal aspects of the human condition has provided a rationale for the repurposing of effective, theoretically informed treatments across diverse contexts. Nevertheless, access to mental healthcare globally remains low. A multitude of social determinants affect mental health, spanning multiple domains, which impacts on strategies for prevention and promotion. Research has begun to unpick complex pathways of causation, examining which distal and proximal factors affect mental health, as well as the reciprocal relationship between mental health and economic wellbeing. These efforts will underpin the development of effective, affordable, and implementable interventions.

Priority areas for global mental health research

Treatment and care: Participants concluded that an extensive body of evidence now exists on the effectiveness of treatments for mental health disorders and, to some extent, their delivery by non-specialised providers. Key research challenges include the design and evaluation of evidence-based treatments tailored to local health systems and socio-cultural contexts, and the design and assessment of strategies for use at a population level. Participants outlined a ‘core plus custom’ model. As the understanding of mental health disorders improves, and new interventions are evaluated, the range of core options available for adaptation to local circumstances could be expanded. These core options, such as validated treatments and models of care, could be customised to local needs, constraints and facilitators. Within the context of UHC, participants also identified a need for research on strengthening health systems, incorporating mental healthcare and the development of sustainable models of funding. It was suggested that research could assess how medical professionals, community health workers, informal healthcare providers (such as traditional healers and peers) and existing social infrastructure (including religious institutions, cooperatives, schools or self-help groups) could play a role in expanding access to services. Participants also identified research priorities at key life stages. These included how best to engage partners and other family members in maternal mental health interventions; how to design adolescent-specific interventions; and how to provide care for vulnerable older people with multiple health conditions.

Prevention and promotion: It was agreed that the evidence base is not as well established for promotion and prevention, providing less scope for applied intervention studies. It was recognised that a deeper understanding of chains of causation, and how proximal determinants such as those that precipitate diseases mediate the effects of distal determinants that represent an underlying vulnerability for a particular condition, was required. This would help identify appropriate points of intervention and provide a basis for the evaluation of interventions. Promotion was also seen to raise an evaluation challenge. Good mental health is not simply the absence of a mental health disorder, yet there is no agreed metric for the ‘positive’ aspects of mental health. The need for mental health promotion to evaluating positive mental health outcomes was recognised as a significant challenge. When looking at mental health from a life-course perspective, it was felt that research on interventions early in the life course for prevention and promotion was vital. A better understanding of the factors contributing to mental health resilience could help identify ways to build protective mental health reserves. It was suggested that research could examine issues such as the role of parents and schools in promoting good mental health, how to improve links between education and health sectors, and how to reach vulnerable young people outside the education system.

The issue of how best to protect the mental health of vulnerable older people, many of whom are at risk of poverty, social isolation, discrimination and elder abuse, was also seen as an important challenge. Innovative models of community or financial support were seen as possible solutions for further investigation.

Challenges and opportunities

Understanding cultural context: Participants recognised that conceptualisations of, and responses to, mental health disorders are strongly influenced by factors such as early life experiences and socio-cultural context. Service providers typically rely on standard methods of diagnosis and categorisation of mental health disorders, yet these may not be consistent with individuals’ belief systems, and patients may reject diagnostic labels. Research on these contextual factors could inform the design of appropriate diagnostic and assessment tools, support efforts to increase the demand for mental health services, improve understanding of the mechanisms involved in the aetiology of mental health disorders or responses to interventions, and influence the design of intervention strategies.

The impact of digital technologies: New digital technologies were seen to be a double-edged sword. Their positive impact being the opportunities they offer in capturing mental health-related data directly from individuals, and delivering individualised self-help and training of providers. Conversely, concerns were raised about the potential mental health impact of the growing global use of social media and other digital technologies, as well as privacy and data security issues. This field is new and further research would bring insight into the advantages and disadvantages of these issues.

Intersectoral approaches: It was suggested that intersectoral approaches should be central to the development and evaluation of integrated mental health services, spanning social care and community support. Research across sectors is also important for understanding the impact of distal determinants and pathways of causation. Participants also noted that sectors such as education or the workplace could contribute to the development and evaluation of interventions to promote mental wellbeing.