Offline: WHO's hits and misses for mental health

Abstract

There are few truly watershed moments in medicine and global health. But the publication this month of WHO's World Mental Health Report is one such milestone. It is the agency's first major global foray into mental health for over two decades. Led by Dévora Kestel, who directs the Department of Mental Health and Substance Use in Geneva, WHO aims, in her words, for nothing less than “a transformation” in mental health. 20 years ago, mental health was completely ignored by development experts. There was no mention of mental health in the MDGs. But WHO's 2001 World Health Report on mental health, together with the launch of the Movement for Global Mental Health in 2007 (after publication of The Lancet's first global mental health series), created a foundation for more informed advocacy. Today, mental health is a core component of programmes to address the growing burden of non-communicable diseases. Improving mental health is a monitored objective of the SDGs. WHO's latest report seeks to sum up the state of mental health worldwide, to make the case for deeper change, and to encourage policy makers to reinvigorate mental health systems.The most important part of the report is not the summary of research evidence. It is the glimpses of progress being made in countries. WHO accepts that no country can meet every aspiration to create a perfect mental health system. But every country can do something to make meaningful progress. In Chile in 2005, the government launched a universal health coverage package that included services for depression, bipolar disorder, alcohol and drug dependence, schizophrenia, and dementia. Mental health has been fully integrated into all levels of general health care. In Pakistan, the Pursukoon Zindagi (Peaceful Life) programme has improved access to mental health services for the poorest communities. Lay counsellors offer community based psychological treatments and referrals. By 2019, over 100 000 people had been screened for anxiety and depression. In Sri Lanka, the 1980 Control of Pesticides Act was a response to the finding that pesticide poisoning accounted for more than two-thirds of all suicides. By 2016, the annual suicide rate had fallen by more than 70%, with thousands of lives saved every year. These stories of success are truly inspirational.View Large Image Copyright © 2022 David Lefranc/Kipa/Sygma via Getty ImagesBut there is a huge gap in WHO's report. And it is a gap that potentially represents a fatal flaw in the agency's thinking. In one word, it is accountability. First, trying to provoke change by sharing examples of successful country mental health programmes is good. But it will amount to little, and certainly will not produce “transformation”, without a robust and independent mechanism to monitor and review progress in building mental health systems in countries. There is nothing in WHO's report about implementing a means for independent accountability of country governments. Second, there is an accountability gap concerning the structural determinants of mental health. WHO provides a compelling review of the importance of poverty, financial insecurity, income inequality, and social exclusion in shaping mental health. The value of education, safe and secure housing, measures to protect against discrimination, gender equality, and mental health care in prisons are all underlined. The effects of economic crises, public health and humanitarian emergencies (including COVID-19), migration and forced displacement, and the climate crisis are all acknowledged. But nowhere does WHO remind specific countries of their responsibilities to safeguard mental health by addressing these structural determinants. Hong Kong is praised for using sports to promote life skills for young people. But what of the effects of the government's brutal erasure of political freedoms across all sectors of society? Turkey is commended for scaling up care to Syrian refugees. But nowhere is the government held accountable for the atmosphere of fear created by the arbitrary arrest of opposition politicians and journalists, or for its homophobic rhetoric, or for its crackdown on civil society organisations. And Lebanon is cited for its guided self-help programme for depression. But WHO fails to point to the corruption of the country's political process, which is edging Lebanon towards becoming a failed state. WHO's World Mental Health Report deserves wide reading and recognition. But until the agency takes independent accountability of those with the power to influence mental health seriously, the promised transformation will die on an altar of empty eloquence.View Large Image Copyright © 2022 David Lefranc/Kipa/Sygma via Getty Images There are few truly watershed moments in medicine and global health. But the publication this month of WHO's World Mental Health Report is one such milestone. It is the agency's first major global foray into mental health for over two decades. Led by Dévora Kestel, who directs the Department of Mental Health and Substance Use in Geneva, WHO aims, in her words, for nothing less than “a transformation” in mental health. 20 years ago, mental health was completely ignored by development experts. There was no mention of mental health in the MDGs. But WHO's 2001 World Health Report on mental health, together with the launch of the Movement for Global Mental Health in 2007 (after publication of The Lancet's first global mental health series), created a foundation for more informed advocacy. Today, mental health is a core component of programmes to address the growing burden of non-communicable diseases. Improving mental health is a monitored objective of the SDGs. WHO's latest report seeks to sum up the state of mental health worldwide, to make the case for deeper change, and to encourage policy makers to reinvigorate mental health systems. The most important part of the report is not the summary of research evidence. It is the glimpses of progress being made in countries. WHO accepts that no country can meet every aspiration to create a perfect mental health system. But every country can do something to make meaningful progress. In Chile in 2005, the government launched a universal health coverage package that included services for depression, bipolar disorder, alcohol and drug dependence, schizophrenia, and dementia. Mental health has been fully integrated into all levels of general health care. In Pakistan, the Pursukoon Zindagi (Peaceful Life) programme has improved access to mental health services for the poorest communities. Lay counsellors offer community based psychological treatments and referrals. By 2019, over 100 000 people had been screened for anxiety and depression. In Sri Lanka, the 1980 Control of Pesticides Act was a response to the finding that pesticide poisoning accounted for more than two-thirds of all suicides. By 2016, the annual suicide rate had fallen by more than 70%, with thousands of lives saved every year. These stories of success are truly inspirational. But there is a huge gap in WHO's report. And it is a gap that potentially represents a fatal flaw in the agency's thinking. In one word, it is accountability. First, trying to provoke change by sharing examples of successful country mental health programmes is good. But it will amount to little, and certainly will not produce “transformation”, without a robust and independent mechanism to monitor and review progress in building mental health systems in countries. There is nothing in WHO's report about implementing a means for independent accountability of country governments. Second, there is an accountability gap concerning the structural determinants of mental health. WHO provides a compelling review of the importance of poverty, financial insecurity, income inequality, and social exclusion in shaping mental health. The value of education, safe and secure housing, measures to protect against discrimination, gender equality, and mental health care in prisons are all underlined. The effects of economic crises, public health and humanitarian emergencies (including COVID-19), migration and forced displacement, and the climate crisis are all acknowledged. But nowhere does WHO remind specific countries of their responsibilities to safeguard mental health by addressing these structural determinants. Hong Kong is praised for using sports to promote life skills for young people. But what of the effects of the government's brutal erasure of political freedoms across all sectors of society? Turkey is commended for scaling up care to Syrian refugees. But nowhere is the government held accountable for the atmosphere of fear created by the arbitrary arrest of opposition politicians and journalists, or for its homophobic rhetoric, or for its crackdown on civil society organisations. And Lebanon is cited for its guided self-help programme for depression. But WHO fails to point to the corruption of the country's political process, which is edging Lebanon towards becoming a failed state. WHO's World Mental Health Report deserves wide reading and recognition. But until the agency takes independent accountability of those with the power to influence mental health seriously, the promised transformation will die on an altar of empty eloquence.