Public mental health: the need for a broader view of the issues.

Abstract

K. Wahlbeck's paper (1) provides a good overview of the field of public mental health. Right from the first paragraphs, the paper makes it explicit that public mental health deals with mental health promotion, prevention of mental disorders and of suicide, integrated and comprehensive mental health service, and the fight against stigma and human right abuses. These issues are of importance to every country or community, irrespective of their level of economic or social development. There may of course be a need for contextualizing the specific solutions to the various challenges that the issues pose, but developing those solutions should nevertheless be on the public health agenda of every country, from the low- to the high-income categories. The relevance of these issues to every country, irrespective of their developmental stage, is an important point to stress. Even though psychiatry constantly grapples with the challenge of finding the most valid ways to categorize and classify mental health problems, any notion that seeks to deny, either explicitly or implicitly, that human beings share some common biological features irrespective of their race is an absurd one. Those features make them vulnerable to develop health, including mental health, problems irrespective of where they live. It is of course also true that those health problems are influenced by where and how they live and may respond differently to various interventions, some of which may also be shaped and informed by where people live. So, while it can be said that “diagnoses” are social constructs, shaped by current understanding and consensus and reflecting the imperfect nature of the process of classifying them (2), the disorders that they seek to characterize are not. Mental disorders have consequences everywhere and, while there can be debates about the labels we ascribe to them, practicing clinicians know that the syndromes they deal with have effects on the lives of those experiencing them. A review of public mental health is in a sense a review of global mental health, and to deny the importance of one is to deny the relevance of the other. In this regard, and in addition to the points articulated in Wahlbeck's paper, the emphasis must be placed on bridging the gap in treatment for mental disorders. Global mental health is essentially the mobilization of resources to meet the challenges of population health needs and strive for equity in doing so. Given the large unmet need for mental health service in low- and middle-income countries, it is understandable that global mental health will often be seen as having a major focus on those countries. However, treatment gap for mental disorders exists everywhere across the world (3). Also, the gap is driven by essentially the same issues across the world: inadequate resources, inequity, and lack of parity with physical health. Inequity exists between countries in their ability to provide adequate mental health service for their populations, but it also exists within countries, including high-income countries. Stigma is an overarching issue and often dictates what resources are made available to provide mental health service. Addressing the challenge posed by poor policy attention to mental health service and the negative attitude to persons with mental disorders by the public requires a good understanding of the principles of public health. Unfortunately, a lack of that understanding by mental health professionals has been a major barrier to developing effective mental health service (4). Responding to the treatment gap for mental disorders is a public health imperative for which public and political support is crucial. Concerted advocacy efforts are required. The skills necessary for mounting such efforts, however, are unfortunately uncommon among mental health professionals. A broad perspective of public mental health will emphasize what is known about the burden of mental disorders, and the social determinants that underlie the burden, but will also focus on the issues that engender inequity between communities in their access to adequate mental health care, lack of parity between mental and physical conditions, and the overarching barriers that stigma and policy neglect constitute. Efforts at building leadership and advocacy skills among mental health practitioners and stakeholders and at improving access to care through appropriate capacity building for non-specialists must be of central concern to public mental health (5).