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Essentials of GlobalMental Health

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Essentials of GlobalMental Health

Edited by

Samuel O. OkpakuExecutive Director of the Center for Health, Culture, and Society, Nashville, Tennessee, USA




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Library of Congress Cataloging-in-Publication DataEssentials of global mental health / [edited by] Samuel O. Okpaku.

p. ; cm.Includes bibliographical references.ISBN 978-1-107-02232-4 (Hardback)I. Okpaku, Samuel O., editor of compilation.[DNLM: 1. Mental Health. 2. Developing Countries.3. Mental Disorders. 4. Mental Health Services.5. World Health. WM 101]RA790.55362.19689–dc232013026598

ISBN 978-1-10702232-4 Hardback

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Every effort has been made in preparing this book to provideaccurate and up-to-date information which is in accord withaccepted standards and practice at the time of publication. Althoughcase histories are drawn from actual cases, every effort has been madeto disguise the identities of the individuals involved. Nevertheless, theauthors, editors and publishers can make no warranties that theinformation contained herein is totally free from error, not leastbecause clinical standards are constantly changing through researchand regulation. The authors, editors and publishers thereforedisclaim all liability for direct or consequential damages resultingfrom the use of material contained in this book. Readers are stronglyadvised to pay careful attention to information provided by themanufacturer of any drugs or equipment that they plan to use.




To my departed parents, sisters, uncles and aunts, who always hadconfidence in me and supported my dreams




Contents

List of contributors xPreface xvAcknowledgments xixIntroduction xx

Section 1 – History and background ofglobal mental health

1 History of global mental health 1Samuel O. Okpaku and Sanchita Biswas

2 Burden of illness 11Jordi Alonso, Somnath Chatterji, Yanling He,and Ronald C. Kessler

3 Trends, gaps, and disparities in mentalhealth 27Robert Kohn

4 Global health and mental health asdiplomacy 39Samuel O. Okpaku

5 Global mental health and the UnitedNations 52Takashi Izutsu and Atsuro Tsutsumi

Section 2 – Advocacy and reductionof stigma

6 The voice of the user/survivor 63Moosa Salie

7 Internalized stigma 72Edwin Cameron

8 Definition and process of stigma 78Heather Stuart

9 Stigmatization and exclusion 85Ramachandran Padmavati

10 Grassroots movements in mental health 93Chris Underhill, Sarah Kippen Wood, JordanPfau, and Shoba Raja

11 The rise of consumerism and localadvocacy 103Dinesh Bhugra, Norman Sartorius, and DianaRose

12 Programs to reduce stigma in epilepsyand HIV/AIDS 110Rita Thom

Section 3 – Systems of development13 The challenges of human resources

in low- and middle-incomecountries 117David M. Ndetei and Patrick Gatonga

14 Integration of mental health services intoprimary care settings 126Shoba Raja, Sarah Kippen Wood, and Jordan Pfau

15 Collaboration between traditional andWestern practitioners 135Victoria N. Mutiso, Patrick Gatonga, DavidM. Ndetei, Teddy Gafna, Anne W. Mbwayo,and Lincoln I. Khasakhala

16 Setting up integrated mental healthsystems 144Manuela Silva and José Miguel Caldas deAlmeida

17 Integrated mental health systems: the Cubanexperience 152Ester Shapiro and Isabel Louro Bernal

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Section 4 – Systems of development forspecial populations

18 Poverty and perinatal morbidity as risk factorsfor mental illness 163Feijun Luo, Xiangming Fang, Lijing Ouyang, andDeborah M. Stone

19 Maternal mental health care: refining thecomponents in a South African setting 173Sally Field, Emily Baron, Ingrid Meintjes, Thandivan Heyningen, and Simone Honikman

20 Screening for developmental disabilities inepidemiologic studies in low- andmiddle-income countries 187Maureen S. Durkin and Matthew J. Maenner

21 Children’s services 195Margarita Alegría, Anne Valentine, Sheri Lapatin,Natasja Koitzsch Jensen, Sofia Halperin-Goldstein, and Anna Lessios

22 Child abuse as a global mental healthproblem 204Felipe Picon, Andrea Fiorillo, and Dinesh Bhugra

23 Child soldiers 213Ruwan M. Jayatunge and Daya Somasundaram

24 Mental health and intellectual disability:implications for global mental health 222Marco Bertelli and M. Thomas Kishore

25 Adolescent alcohol and substance abuse 231Julia W. Felton, Zachary W. Adams, LauraMacPherson, and Carla Kmett Danielson

Section 5 – Gender and equality26 Women’s mental health 243

Samuel O. Okpaku, Thara Rangaswamy, andHema Tharoor

27 Violence against women 251Erminia Colucci and Reima Pryor

28 Women and global mental health:vulnerability and empowerment 264Janis H. Jenkins and Mary-Jo DelVecchio Good

29 Trafficking in persons 282Atsuro Tsutsumi and Takashi Izutsu

Section 6 – Human resources andcapacity building

30 Capacity building 289Rachel Jenkins, Florence Baingana, DavidMcDaid, and Rifat Atun

31 Child mental health services inLiberia: human resourcesimplications 297Janice L. Cooper and Rodney D. Presley

32 Mental health and illness outcomes incivilian populations exposed to armedconflict and war 307Duncan Pedersen and Hanna Kienzler

33 Implications of disasters for global mentalhealth 316Sabrina Hermosilla and Sandro Galea

34 International response to natural andmanmade disasters 326Inka Weissbecker and Lynne Jones

35 Global health governance, international law,and mental health 336Lance Gable

36 The role of non-governmentalorganizations 346Robert van Voren and Rob Keukens

37 Mental health, mass communication,and media 356Marten W. de Vries

Section 7 – Depression, suicide, andviolence

38 Suicide and depression 367Diego De Leo and Lay San Too

39 Violence as a public healthproblem 374Claire van der Westhuizen, Katherine Sorsdahl,Gail Wyatt, and Dan J. Stein

40 The war on drugs in the USA,Mexico, and Central America: PlanColombia and the Mérida Initiative 384Samuel O. Okpaku and Jayanthi Karunaratne

Contents

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Section 8 – Research and monitoring theprogress of countries

41 Medical education and global mentalhealth 391Clare Pain and Atalay Alem

42 Research priorities for mental health inlow- and middle-income countries 399Samuel O. Okpaku and Grace A. Herbert

43 Research infrastructure 407Athula Sumathipala

44 Monitoring the progress of countries 416Jorge Rodríguez and Víctor Aparicio

Epilogue 425Index 428

Contents

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Contributors

Zachary W. Adams, PhDNational Crime Victims Research & TreatmentCenter, Department of Psychiatry & BehavioralSciences, Medical University of South Carolina,SC, USA

Margarita Alegría, PhDProfessor, Department of Psychiatry, HarvardMedical School; Director, Center for MulticulturalMental Health Research, Cambridge Health Alliance,Somerville, MA, USA

Atalay Alem, MDProfessor of Psychiatry, Department of Psychiatry,School of Medicine, College of Health Sciences, AddisAbaba University, Ethiopia

Jordi Alonso, MD, PhDEpidemiology and Public Health Program, IMIM(Institut Hospital del Mar d’InvestigacionsMèdiques); Pompeu Fabra University (UPF); CIBERen Epidemiología y Salud Pública (CIBERESP),Barcelona, Spain

Victor Aparicio, MD, PhDDirector of Management, Mental Health Clinic,Asturias Central University Hospital (HospitalUniversitario Central de Asturias),Oviedo, Spain

Rifat Atun, MBBS, MBAProfessor of International Health Management,Imperial College, London, UK

Florence Baingana, MBChB, MMed (Psych), MSc(HPPF)Makerere University School of Public Health,Uganda; Personal Social Services Research Unit,London School of Economics and Political Sciences,London, UK

Emily Baron, BSc, MScPerinatal Mental Health Project, Alan J Flisher Centrefor Public Mental Health, Department of Psychiatryand Mental Health, University of Cape Town, CapeTown, South Africa

Marco Bertelli, MDScientific Director, CREA (Research and ClinicalCentre), San Sebastiano Foundation, Florence, Italy

Dinesh Bhugra, PhD, FRCPsychProfessor of Mental Health and Cultural Diversity,Institute of Psychiatry, King’s College London,London, UK

Sanchita Biswas, MA, MPhilVice-Principal, AL Noor Public School, Aligarh, India

José Miguel Caldas de Almeida, MD, PhDNOVA Medical School & CEDOC (Chronic DiseasesResearch Center), NOVA University of Lisbon,Portugal

Edwin Cameron, BA, LLBJustice of the Constitutional Court of South Africa,Johannesburg, South Africa

Somnath Chatterji, MDGlobal Burden Disease Unit, World HealthOrganization, Geneva, Switzerland

Erminia Colucci, PhDCentre for International Mental Health, School ofPopulation Health, the University of Melbourne,Melbourne, Vic., Australia

Janice L. Cooper, PhDDepartment of Health Policy and Management,Emory University, Atlanta, GA, USA; College ofScience and Technology, University of Liberia,Monrovia, Liberia

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Carla Kmett Danielson, PhDAssociate Professor of Psychiatry, National CrimeVictims Research & Treatment Center, MedicalUniversity of South Carolina, Charleston, SC, USA

Diego De Leo, MD, PhDProfessor of Psychiatry; Director, Australian Institutefor Suicide Research and Prevention, GriffithUniversity, Mt Gravatt, Qld., Australia

Mary-Jo DelVecchio Good, PhDProfessor of Social Medicine, Department of GlobalHealth and Social Medicine, Harvard Medical School,Harvard University, Boston, MA, USA

Marten W. de Vries, MD, PhDProfessor of Social Psychiatry and Public MentalHealth (emeritus), Maastricht University,The Netherlands

Maureen S. Durkin, PhD, DrPHWaisman Center, University of Wisconsin-Madison,Madison, WI, USA

Xiangming Fang, PhDProfessor of Applied Economics, Director,International Center for Applied Economicsand Policy, China Agricultural University, Beijing,China

Julia W. Felton, MDAssistant Clinical Professor, Department ofPsychology, University of Maryland, College Park,MD, USA

Sally Field, BA, MAPerinatal Mental Health Project, Alan J Flisher Centrefor Public Mental Health, Department of Psychiatryand Mental Health, University of Cape Town, CapeTown, South Africa

Andrea Fiorillo, MD, PhDDepartment of Psychiatry, University of NaplesSUN, Italy

Lance Gable, JD, MPHWayne State University Law School, Detroit, MI,USA

Teddy Gafna, BAProject Officer with Africa Mental Health Foundation

Sandro Galea, MD, DrPHGelman Professor and Chair, Department ofEpidemiology, Mailman School of Public Health,Columbia University, New York, NY, USA

Patrick Gatonga, MD, MBADepartment of Public Health, University of Nairobi,Kenya

Sofia Halperin-GoldsteinMacalester College, St. Paul, MN, USA

Yanling He, MDDepartment of Psychiatric Epidemiology,Shanghai Mental Health Center, Shanghai,China

Grace A. Herbert, BACenter for Health, Culture, and Society, Nashville,TN, USA

Sabrina Hermosilla, MIA, MPH, MSDepartment of Epidemiology, Mailman School ofPublic Health, Columbia University, New York,NY, USA

Simone Honikman, MD, MPhilPerinatal Mental Health Project, Alan J Flisher Centrefor Public Mental Health, Department of Psychiatryand Mental Health, University of Cape Town, CapeTown, South Africa

Takashi Izutsu, PhDDepartment of Forensic Psychiatry, National Instituteof Mental Health, National Center of Neurology andPsychiatry, Chiba, Japan

Ruwan M. Jayatunge, MDFormer Medical Officer of Mental Health, Ministry ofHealth, Sri Lanka

Janis H. Jenkins, PhDProfessor of Anthropology, Adjunct Professor ofPsychiatry, University of California at San Diego,CA, USA

Rachel Jenkins, MB BChir, MDProfessor of Epidemiology and International MentalHealth Policy, Institute of Psychiatry, King’s CollegeLondon, London, UK

Contributors

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Lynne Jones OBE, MBChB, PhDHonorary Consultant, South London and MaudsleyNHS Trust; Honorary Senior Clinical Fellow,Department of Psychiatry, Cambridge University, UK

Jayanthi Karunaratne, BA, PGDJCenter for Health, Culture, and Society, Nashville,TN, USA

Ronald C. Kessler, PhDDepartment of Health Care Policy, HarvardMedical School, Harvard University, Boston,Massachusetts, USA

Rob KeukensDepartment of Community Mental Health Nursing,HAN University of Applied Sciences, Nijmegen,The Netherlands

Lincoln I. Khasakhala, MBChBSenior Lecturer, Daystar University, Nairobi;Honorary Lecturer, Department of Psychiatry,University of Nairobi, Kenya

Hanna Kienzler, PhDDepartment of Social Science, Health & Medicine,King’s College London, London, UK

Sarah Kippen Wood, MPHInternational Research Manager, BasicNeeds,Bangalore, India

M. Thomas Kishore, PhDReader in Health Psychology, University ofHyderabad, India

Robert Kohn, MD, MPhilProfessor, Psychiatry and Human Behavior, TheWarren Alpert Medical School of Brown University,The Miriam Hospital, Providence, RI, USA

Natasja Koitzsch Jensen, MPHDanish Research Centre for Migration, Ethnicity andHealth, University of Copenhagen, Copenhagen,Denmark

Sheri Lapatin, MIAAssociate Director, Center for Mulitcultural MentalHealth Research, Somerville, MA, USA

Anna Lessios, BACenter for Mulitcultural Mental Health Research,Somerville, MA, USA

Isabel Louro Bernal, PhDNational School of Public Health (Escuela Nacionalde Salud Publica, ENSAP), University of MedicalSciences, Havana, Cuba

Feijun Luo, PhDNational Center on Birth Defects and DevelopmentalDisabilities, Centers for Disease Control andPrevention, Atlanta, GA, USA

Laura MacPherson, PhDAssociate Professor, Department of Psychology,University of Maryland, College Park, MD, USA

Matthew J. Maenner, PhDWaisman Center, University of Wisconsin-Madison,Madison, WI, USA

Anne W. Mbwayo, PhDWIMA Africa and United States InternationalUniversity – Africa, Nairobi, Kenya

David McDaid, MScResearch Fellow in Health Policy and HealthEconomics, London School of Economics andPolitical Science, London, UK

Ingrid Meintjes, MSocScPerinatal Mental Health Project, Alan J Flisher Centrefor Public Mental Health, Department of Psychiatryand Mental Health, University of Cape Town, CapeTown, South Africa

Victoria N. Mutiso, PhDClinical Psychologist and Research Director, AfricaMental Health Foundation, Nairobi, Kenya

David M. Ndetei, MDProfessor of Psychiatry, University ofNairobi; Director,Africa Mental Health Foundation, Nairobi, Kenya

Samuel O. Okpaku, MD, PhDExecutive Director of the Center for Health, Culture,and Society, Nashville, TN, USA

Lijing Ouyang, PhDNational Center on Birth Defects and DevelopmentalDisabilities, Centers for Disease Control andPrevention, Atlanta, GA, USA

Ramachandran Padmavati, MD, DPMSchizophrenia Research Foundation, Tamilnadu,India

Contributors

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Clare Pain, MD, MSc, FRCPCAssociate Professor, Department of Psychiatry,University of Toronto; Director, Psychological TraumaProgram, Mount Sinai Hospital, Toronto, Canada

Duncan Pedersen, PhDAssociate Scientific Director, Douglas Mental HealthUniversity Institute, McGill University, Montreal,Canada

Jordan PfauBasicNeeds, Bangalore, India

Felipe Picon, MD, MScChild and Adolescent Psychiatrist, Porto Alegre, Brazil

Rodney D. Presley, MSWProject Director and Operational Manager, JohnF. Kennedy Memorial Medical Center/Grant MentalHealth Hospital, Monrovia, Liberia

Reima Pryor, BBSciDirector, Research and Evaluation, Drummond StreetServices, Carlton, Melbourne, Vic., Australia

Shoba Raja, MADirector, Policy and Practice, BasicNeeds, Bangalore,India

Thara Rangaswamy, MD, PhDDirector, Schizophrenia Research Foundation,Chennai, India

Jorge Rodriguez, MD, PhDSenior Advisor, Mental Health, Pan American HealthOrganization, Washington, DC, USA

Diana Rose, PhDReader in User-Led Research, Institute of Psychiatry,King’s College London, London, UK

Moosa Salie, BSc, BEdFormer Chair and Co-Chair, World Network ofUsers and Survivors of Psychiatry

Norman Sartorius, MD, PhDPresident, Association for the Improvement of MentalHealth Programmes (AMH), Geneva, Switzerland

Ester Shapiro, PhDPsychology Department, Gaston Institute for LatinoCommunity Development and Public Policy,University of Massachusetts, Boston, MA, USA

Manuela Silva, MD, MScHospital de Santa Maria and Faculty of Medicine,University of Lisbon, Lisbon, Portugal

Daya Somasundaram, MDClinical Associate Professor, Discipline of Psychiatry,University of Adelaide; Consultant Psychiatrist,Glenside Mental Health Services, SA, Australia

Katherine Sorsdahl, PhDDepartment of Psychiatry and Mental Health,University of Cape Town, Cape Town, South Africa

Dan J. Stein, MD, PhDDepartment of Psychiatry and Mental Health,University of Cape Town, Cape Town, South Africa

Deborah M. Stone, ScD, MSW, MPHNational Center for Injury Prevention and Control,Centers for Disease Control and Prevention, Atlanta,GA, USA

Heather Stuart, MA, PhDProfessor and Bell Canada Mental Health and Anti-Stigma Research Chair, Department of CommunityHealth Epidemiology, Queen’s University, Kingston,ON, Canada

Athula Sumathipala, MBBS, DFM, MD, PhDSenior Lecturer, Institute of Psychiatry, King'sCollege London, London, UK; Director, Institute forResearch and Development, Battaramulla, Sri Lanka

Hema Tharoor, DPM, DNB, MNAMSConsultant Psychiatrist, Schizophrenia ResearchFoundation (SCARF), Chennai, India

Rita Thom, PhDDepartment of Psychiatry, University of theWitwatersrand, Johannesburg, South Africa

Lay San TooAustralian Institute for Suicide Research andPrevention, Griffith University, Mt Gravatt, Qld.,Australia

Atsuro Tsutsumi, PhDUnited Nations University International Institute forGlobal Health (UNU-IIGH), Kuala Lumpur, Malaysia

Chris Underhill, MBEFounder Director, BasicNeeds, Leamington Spa,Warwickshire, UK

Contributors

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Anne Valentine, MPHCenter for Multicultural Mental Health Research,Somerville, MA, USA

Claire van der Westhuizen, MBChBDepartment of Psychiatry and Mental Health, GrooteSchuur Hospital, Cape Town, South Africa

Thandi van Heyningen, MA, MA ClinPsychPerinatal Mental Health Project, AlanJ Flisher Centre for Public Mental Health,Department of Psychiatry and Mental Health,University of Cape Town, Cape Town,South Africa

Robert van Voren, PhDChief Executive, Global Initiative on Psychiatry;Professor of Political Science, Vytautas MagnusUniversity, Kaunas, Lithuania; Professor of PoliticalScience, Ilia Chavchavadze State University, Tbilisi,Georgia

Inka Weissbecker, PhD MPHGlobal Mental Health and Psychosocial Advisor,International Medical Corps

Gail Wyatt, PhDProfessor of Psychology, University of California, LosAngeles, CA, USA

Contributors

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Preface

Modern globalization refers to a one-world systemthat has been triggered by a telecommunicationrevolution, quicker air travel, and mass migration. Itimplies the presence of some dominant factors whichare influential in the field of economics, politics,culture, ideology, and public health. In their article“Global health law: a definition and grand chal-lenges,” Gostin and Taylor define globalization thus:

Globalization can be broadly understood as a processcharacterized by changes in a range of social spheresincluding economic, political, technological, cultural andenvironmental. These processes of global change arerestructuring human societies, ushering in new patternsof health and disease and reshaping the broaddeterminants of health. Indeed, the globalization oftrade, travel, communication, migration, informationand lifestyles has obscured the traditional distinctionbetween national and global health. Increasingly humanactivities have profound health consequences for peoplein all parts of the world, and no country can insulateitself from the effects. Members of the world’scommunity are interdependent and reliant on oneanother for health security.

(Gostin & Taylor 2008)

No matter the derivation and background, globaliza-tion cannot be divorced from issues of internationaltrade, commerce, communication, and politics. Hence,global health cannot be seen in isolation from suchconsiderations, or divorced from such a contextualframework.

The world is a smaller place, and the individualand community relationships in this shrunken placehave been significantly affected by radio, television,cell phones, and the internet. These technologicalinnovations bring world events to living rooms andoffices worldwide. Evidence the 2010 rescue of 33miners in Chile who were trapped underground for64 days. The international collaboration whichbrought about their rescue along with the worldwideattention paid to the dramatic events is just one

example of our new-found interconnectivity. Stateborders and barriers are shifting. We are witnessingthe rise of transnational corporations, and globaliza-tion studies are mushrooming in many universities.There are calls for universities to shift their traditionalroles and pay greater attention to global issues,community development, and research. Non-governmental organizations (NGOs) such as the GatesFoundation and the Wellcome Trust are playing asignificant role in the eradication of poverty and dis-ease. In this respect, discourse on human rights andthe eradication of poverty has taken a global perspec-tive. Needless to say, the word global has replacedinternational. This world view signifies new dynamicapproaches and attitudes which have relevance forglobal health and global mental health. The WorldHealth Organization (WHO) has a slogan, “There isno health without mental health” (Prince et al. 2007).I would go further, and suggest that if we perceivehuman activities as a hierarchical pyramid, the apex ofthe pyramid is mental health, followed by physicalhealth, and then other human priorities. An individ-ual’s will, motivation, self-esteem, and perceptions aredependent on his or her psychological state and well-being. These then influence physical health, relation-ships to family and caregivers, workplace functioning,creativity, and productivity. In other words, one’smental health is paramount. From a clinical point ofview, depression often affects the natural history andoutcome of many physical illnesses.

So what is meant by global health and globalmental health? In the preamble to its constitution,the WHO defined health as “a state of completephysical, mental and social well-being and not merelythe absence of disease or infirmity” (WHO 1946), andin 2001 the WHO stated that:

Mental health is as important as physical health to theoverall well-being of individuals, societies and countries.Yet only a small minority of the 450 million peoplesuffering from mental or behavioural disorders are

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receiving treatment . . . like many physical illnesses,mental and behavioural disorders are the result of acomplex interaction between biological, physiologicaland social factors. While there is still much to belearned, we already have the knowledge and power toreduce the burden of mental and behavioural disordersworldwide.

(World Health Organization 2001)

The Global Initiative in Psychiatry group conceptual-ized the WHO message thus:

Mental health problems are the result of the complex –and still not fully understood – interaction ofbiological factors such as heredity and birth trauma,physiological factors such as lack of care and love,and social factors such as social exclusion. By contrast,intellectual disability is most commonly present atbirth. Both nevertheless place affected individuals andtheir immediate care-givers in an extremely vulnerableposition in terms of their basic human rights, socialintegration and access to educational and economicopportunities.

(Global Initiative on Psychiatry 2008)

From my perspective, the mere substitution of theterm global mental health for international mentalhealth will be no more than window dressing ifthere are no innovative strategies for a clarion callfor greater attention to the core values of autonomy,equality, empowerment, advocacy, and respect fordiversity and human rights. Therefore, globalmental health should be seen as a new approach tothe ideals of mental health services and researchworldwide. It is a movement with both a humani-tarian and a philosophical basis. Our experiencesfrom unwanted consequences of the communitymental health movement and the increase of men-tally ill individuals in prisons, or the rise of home-lessness, should alert us to the need for carefularticulation, planning, and execution of the move-ment for global mental health.

Similarly, there is some strenuous criticism ofthe term global mental health. The globalization trendhas not gained universal acceptance. We can recallthe confrontations which heralded the InternationalMonetary Fund meetings in Seattle and Toronto, andthe more recent Occupy Wall Street movement. Thereare fears of neo-colonialism or neo-liberalism andcapitalism, with the potential for the rich to get richerand the poor to get poorer.

New Partnership for Africa’s Development(NEPAD), an African Union strategic framework for

pan-African socioeconomic development, whileaddressing the challenges of globalization says,

In the absence of fair and just global rules, globalisationhas increased the ability of the strong to advance theirinterests to the detriment of the weak, especially in theareas of trade, finance and technology. It has limitedspace for developing countries to control their owndevelopment, as the system makes no provision forcompensating the weak. The conditions of thosemarginalized in this process have worsened in realterms. A fissure between inclusion and exclusion hasemerged within and among nations.

(NEPAD 2001)

In the same context of challenges of globalization theex-World Bank President Wolfensohn stated, “Wecannot turn back globalisation. Our challenge is tomake globalisation an instrument of opportunity andinclusion – not of fear and insecurity. Globalisationmust work for all” (Wolfensohn 2001).

The marketplace and capitalism are not perfect.These criticisms should not be dismissed but shouldbe fully confronted. For example, it is true that globalactivities have now become a way to justify careerpaths, and to increase research funding and salaries.All this, however, should pale against the moral basisand humanitarian ideals of international cooperation.It is not difficult to make a moral case for globalmental health. We are all in this together. There iswidespread suffering in many developed and develop-ing countries. In many countries manpower andinfrastructure are very limited. There are countrieswith fewer than 10 psychiatrists. Therefore, globalmental health underscores our interconnectivity andinterconnectedness. Witness the enthusiasm of youngprofessionals and students who participate inexchange programs, the dedication of aid workers,and the contribution of NGOs.

Nevertheless, there is a cautionary note fromD. Summerfield, who argues that Western definitionsand solutions cannot be routinely applied to problemsin developing countries. He also challenges the claimthat, for example, every year up to 30% of the globalpopulation will develop some form of mental disorder(Summerfield 2008). His point of view has to be fullyaddressed. This implies the need for attention todiversity, cultural relevance, and local conditions.There is an urgent need for capacity building andsustainability, as funding tends to occur in cycles.Trust between donors and recipient entities hasbecome a sine qua non.

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Furthermore, there is always a need to explore themutual benefits of international collaboration. Nonation can produce enough mental health profession-als to meet her needs. Poverty, which is a major causeof illness and depression, is worldwide, even in theUnited States, as shown by the latest study conductedby the Urban Institute (Nichols 2012). There areslums in New York City, London, Mumbai, Rio deJaneiro, and Lagos. Human suffering is ubiquitous.Knowledge from the low-income and middle-incomecountries can also contribute to mental health servicesand research in high-income countries. There is anadvantage to a more plural knowledge base in mentalhealth against a background of diversity. Researchfindings and service delivery systems in low- andmiddle-income countries can provide alternativemodels of service delivery in the developed countries.

In 1986, I participated in an international confer-ence in Kenya where some African psychiatristslamented the lack of opportunities for research intheir home countries. From my vantage point as aUnited States resident I was able to observe thenumerous opportunities in African countries toaddress some fundamental issues in mental health.One good example is the application of traditionalapproaches to post-conflict reconciliation in Rwanda,the Congo, and their extensions to European andAmerican liturgy. Another example is the relativesuccess of integration of mental health services intoprimary care in developing countries.

There are many competitive definitions of globalhealth. However, I choose to use the definition byKoplan and colleagues, who defined global health as:

an area of study, research and practice that places ahigh priority on improving health and achieving equalityin health for all people worldwide. Global healthemphasizes transnational health issues, determinants,and solutions; involves many disciplines within andbeyond the health sciences and promotesinterdisciplinary collaboration; and is a synthesis ofpopulation-based prevention with individual-levelclinical care.

(Koplan et al. 2009)

Generally, in definitions of global health there are nospecific references made to mental health and ill-nesses. Usually, references are made to such majorpublic health burdens as HIV/AIDS, tuberculosis,maternal and infant mortality. Even the MillenniumFund does not make any specific reference to mentalhealth and illness. This is in spite of the relationship

between behavior and lifestyle and their role inthe causation of diseases. In fact, mental illness con-tributes directly to about 14% of the burden of dis-ease, and indirectly much more so (Prince et al. 2007).This contribution of mental illness to the burden ofdiseases was underscored by the World DevelopmentReport (World Bank 1993) and the influential GlobalBurden of Disease report (Murray & Lopez 1996).These reports and the concerns they generated led toadditional high-level reports. They mobilized furtherinterest and a call to policy makers to act on thisproblem. These reports with their recommendationsincluded those from the World Federation for MentalHealth, the Institute of Medicine, and the WHO(World Federation for Mental Health 2009). Essen-tially these reports emphasized the need to pay atten-tion to the well-being of those afflicted by mentaldisorders. More specifically, they made recommenda-tions to expand and improve the current systems ofmental health delivery, provide cost-effective inter-ventions, and provide care in the primary care settingof each country.

Other recommendations included:

� the establishment of linkages with other systems� strengthening the workforce to provide effective

care� enhancing the human resources� creating medical centers for research and linking

these with institutions in high-income countries� establishing national health policies, legislation

and programs� encouraging families, communities and users to

be involved� engaging in reduction of stigma and

discrimination

The above provides a background to the founding of aglobal mental health movement. Again, for clarity,I have chosen to adopt Dr. Vikram Patel and hiscolleagues’ definition of global mental health as

the area of study, research and practice that places apriority on improving mental health and achievingequity in mental health for all people worldwide.

(Patel & Prince 2010)

A major objective of this volume is to define thedomain of global mental health and draw the bound-aries of the field. The underlying philosophy of thisinternational vision is to make cost-effective, evidence-based treatment services available to those potentially

Preface

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ill individuals worldwide, but more especially to indi-viduals in low- and middle-income countries.

The Movement for Global Mental Health hasidentified five priorities. These are global advocacy,systems of development, research programs, capacitybuilding, and monitoring progress of countries.

These areas are addressed in the pages that follow,as are the barriers and challenges that stand in the wayof achieving these complex tasks. The volume also

showcases some best practices that have worldwideapplications, and it contains discussions about ethicalpractices in service delivery and research, includingthe role of donor countries and NGOs. This volume istherefore targeted at students and trainers in relevantmental health and related disciplines, professionals ofthese fields, administrators, policy makers, and librar-ies. It should be a useful foundation book for individ-uals interested in global mental health.

ReferencesGlobal Initiative on Psychiatry (2008)

Prioritizing mental healthImproving psychosocial and mentalhealth care in transitional anddeveloping countries. http://www.gip-global.org/images/24/209.pdf(accessed June 2013).

Gostin LO, Taylor AL (2008) Globalhealth law: a definition and grandchallenges. Public Health Ethics 1:53–63. doi: 10.1093/phe/phn005.

Koplan JP, Bond TC, Merson MH,et al. (2009) Towards a commondefinition of global health. Lancet373: 1993–5.

Murray CJL, Lopez AD (1996) TheGlobal Burden of Disease: aComprehensive Assessment ofMortality andDisability fromDiseases,Injuries, and Risk Factors in 1990 andProjected to 2020. Cambridge, MA:Harvard University Press.

NEPAD (2001) The New Partnershipfor Africa’s Development (NEPAD).

Abuja, Nigeria. http://www.un.org/africa/osaa/reports/nepadEngversion.pdf (accessed July 2013).

Nichols A (2012) Poverty in the UnitedStates. Washington, DC: UrbanInstitute. http://www.urban.org/publications/412653.html (accessedJuly 2013).

Patel V, Prince M (2010) Global mentalhealth: a new global health fieldcomes of age. JAMA 303: 1976–7.doi: 10.1001/jama.2010.616.

Prince M, Patel V, Saxena S, et al.(2007) No health without mentalhealth. Lancet 370: 859–77.

Summerfield D (2008) Howscientifically valid is the knowledgebase of global mental health? BMJ336: 992–4.

Wolfensohn JD (2001) The challengesof globalization: the role of theWorld Bank. Public DiscussionForum, Berlin, Germany, April 2,2001. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/

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World Bank (1993) WorldDevelopment Report 1993: Investingin Health. Oxford: OxfordUniversity Press.

World Federation for Mental Health(2009) Mental health in primarycare: enhancing treatment andpromoting mental health. WorldMental Health Day.

World Health Organization (1946)Constitution of the World HealthOrganization. New York, NY:International HealthConference.

World Health Organization (2001)The World Health Report 2001.Mental Health: New Understanding,New Hope. Geneva: WHO. http://www.who.int/whr/2001/en/whr01_en.pdf (accessed July 2013).

Preface

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Acknowledgments

There is some inscrutability about the impulses thatdrive an individual to edit a volume. Nevertheless,upon reflection I seem to have been driven by severalinfluences.

One influence is the unique experience of mycareer. My interest in culture and society, which mademe choose psychiatry over neurosurgery or immun-ology, seems to have persisted. That interest very oftenpropels me to express an African opinion on issues.

Second influence – as an African who has neverhad the privilege to work in Africa, I have a diasporicneed, indeed an Adlerian need, to contribute some-thing, no matter how small, to scaling up mentalhealth services in Africa and elsewhere in the develop-ing world.

Third influence – as an African, I am forced toempathize with the suffering of the poor and mentallyill in low- and middle-income countries. All thatstigmatization of the mentally ill is universal, and ittakes on a greater depth in developing countries.Witness the mentally ill and their treatment in Kenyaand India, as depicted by CNN in a TV series in 2010.

Lastly, any volume that discusses global themesand issues of necessity has to be highly selective.Otherwise it will require a large canvas and the exer-cise will be chaotic.

In summary, then, my interest in this area derivesfrom my background as a citizen of Nigeria and theUSA. This places me in a unique position to empa-thize with local, national, and international mentalhealth issues. My goal, therefore, was to select whatI consider the most relevant issues in global healthand recruit experts in these fields to contribute to thevolume. Furthermore, the editor generally is a band-master and has to rely very much on the contributors.So I would like to express my intense gratitude to allthe contributors to the volume.

I am also deeply indebted to the reviewers whowere kind enough to review chapters in their areasand make useful suggestions. For undertaking thistask I thank Judith Bass, Fred Kigozi, Birthe LoaKnizek, William Lawson, James A. Mercey, SagganeMusisi, Temisan Okpaku, Uma Rao, Maria Tomasic,and Helen Ullrich.

Another group to whom I wish to extend mygratitude consists of people who when I was formu-lating my ideas gave me helpful suggestions and com-ments. These individuals included Lawrence Gostin,Jaswant Guzder, Helen Herrman, Laurence Kirmayer,Peter Martin, Donna Stewart, and Mitchell Weiss.

Also I want to express my thanks and gratitude tomy full-time or temporary staff as I preoccupied theirminds with my own obsessions about global mentalhealth. These people helped at all stages of preparingthe manuscript. They included Chris Hack, Mary Hare,Kristen Jackson, Mary Ozanne, and Carol Watson.

My special thanks go to the staff of CambridgeUniversity Press under Richard Marley. It was a delightto work with them, especially with Jane Seakins, whosehelp and encouragement was extraordinary.

I am greatly indebted to five individuals whocontributed immensely to the volume – my youngestson Temisan Okpaku, who was always a soundingboard and gave me valuable editorial assistance; TonyDreher, who provided technical assistance during themiddle phase of editing; and Sanchita Biswas, GraceHerbert, and Jayanthi Karunaratne, who workedmany hours to make the volume possible.

Lastly, there are those unnamed individuals whocontributed in some way to clarify my thoughts butwhose names elude me. To them I say thanks. IfI have omitted any other names, it is not by design –the omission can be attributed to the vagaries of timeand memory.

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Introduction

This volume was conceived in an attempt to givesome voice to mental health, as the movement forglobal health and global health diplomacy mush-rooms. In spite of the ubiquity of mental illnessand the demand for relief, mental illness continuesto be ignored in policy and practice. This is despitethe evidence that there are possibilities for the pro-motion of mental health and the prevention ofmental illness. The practice of these disciplinesdoes not require expensive instruments and tech-nology, but rather the training and availability ofskilled personnel and adequate public healthinformation.

The volume is divided into eight sections.

Section 1: History and background of globalmental healthIn this section, the terms globalization and globalmental health are defined. The origin of modernglobal health diplomacy is traced. The role of theUnited Nations and its specialized agencies are men-tioned. A typology of sponsorships of global healthinitiatives is undertaken. The worldwide burden ofmental illness and the gaps between needs and ser-vices are addressed.

Section 2: Advocacy and reduction of stigmaStigma leads to discrimination, and to the exclusionof individuals with mental illness and their families.This section has two chapters written by service users/survivors. Their perspectives serve to underscore themagnitude of the plague of stigma and demonstrateattempts to deal with it. Their chapters are buttressedby a number of chapters written by mental healthprofessionals, analyzing the issues surrounding stig-matization and exclusion, and describing some initia-tives in the area of advocacy on behalf of individualswith mental illness.

Section 3: Systems of developmentThis section addresses salient features of integratingmental health into the general health systems. Thechallenges of human resources in low- and middle-income countries is addressed, as is the need torecognize and encourage collaboration between trad-itional and Western practitioners.

Section 4: Systems of development for specialpopulationsIndividuals with special needs tend to be overlooked.These groups include children, individuals with intel-lectual disability, and adolescents with substanceabuse problems. This section addresses the specialneeds of these groups. The problems of child soldiersand child abuse are discussed. Poverty is a majorfactor in both adult and child mental health illness.The role of poverty as a social determinant and pre-cursor of mental illness is mentioned. The task ofdeveloping interventions in a low-resource context isaddressed.

Section 5: Gender and equalityThe place and role of women in society have beenemphasized by various UN declarations and nationalpolicies. Women, by their empowerment, their civicrights, and their influence, contribute immensely to acommunity’s development. Their potentials in educa-tion and economic empowerment cannot be over-stated. The reduction of violence toward women andgirls is addressed.

Section 6: Human resources and capacitybuildingThe delivery of efficient mental health services relieson well-trained personnel, education, and communi-cation. The issues of delivery of service becomemore critical in special contexts, such as in conflictareas and disaster zones – manmade or natural. This

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section addresses these issues. Additionally, because ofthe plethora of stakeholders and the need for effi-ciency, transparency, and accountability in the deliveryof services, the issue of good governance is discussed.

Section 7: Depression, suicide, and violenceThere are indications that there is a rise in theprevalence of depression worldwide. An associatedphenomenon is the risk of suicide. The twin phenom-ena of depression and suicide are given a place in viewof the increasing recognition of the disability andother consequences of depression. The same consid-eration applies to violence as a public problem. Itappears that the world is witnessing greater violence,with reports of terrorism, mass murders, and guntrafficking. The war on drugs in the USA and CentralAmerica has failed. This section deals with the impli-cations of increasing depression, public violence, andfailed wars on drugs.

Section 8: Research and monitoring theprogress of countriesThis section addresses the issues of scaling up themental health services, entailing education, research,and monitoring the progress made in different coun-tries. The challenge of limited infrastructure, humancapacity, and material resources is great in developingcountries. Research, education, and monitoring pro-gress can contribute to improving service delivery byevaluative studies and their implication for relevantlocal best practices.

It is anticipated that this volume will provide afoundational reading for scholars, students, practi-tioners, and policy makers in understanding thepotentials and challenges of global mental health.Readers are encouraged to reflect on the relevance ofthese chapters to their practice or research settings,and on how they can further contribute to the globalalleviation of suffering due to mental health.

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