Recognising the right to be different

Abstract

Everyone is different but, to paraphrase George Orwell, some are more different than others. While physical differences are more noticeable, emotional, cognitive, and behavioural differences can be more profound—they make us who we are. Society has gradually become more accepting of physical diversity: we now see actors and television presenters with physical disabilities and the 2022 Commonwealth Games were the first major international event to integrate para sports fully. Is similar progress being made with respect to mental conditions? This year's World Mental Health Day aims to “Make mental health and wellbeing for all a global priority”. Action is certainly needed as globally crisis seems to follow crisis: short-term effects of events, such as war and floods, are known to be traumatising. Long-term effects can be equally debilitating for mental health, as shown by studies on the COVID-19 pandemic, as can the consequences, such as economic recession. A welcome initiative this year has been the inclusion of mental health as part of the 2023–28 strategy for the Global Fund to Fight HIV, Tuberculosis, and Malaria. Ways in which mental health care could be coordinated with management of these diseases were discussed by Victoria Haldane and colleagues using HIV and substance misuse services as an example. They described a conceptual framework of determinants and models of integrated care for HIV and substance use disorder defined by the point at which the user entered services: HIV care site, substance use care site, and other sites. Crucially, the framework incorporates consideration of human rights, and the extent to which care is designed, implemented, and evaluated with meaningful participation of people with HIV and substance use disorders. A major barrier to accessing care for both these groups is stigmatisation. Ending stigma and discrimination in mental health is the goal of the most recent Lancet Commission. The report was co-produced by people with and without lived experience of mental health conditions: the clear message throughout is that people with lived experience are the key agents for change. However, they need support to lead or co-lead interventions. The Commission found that the most effective ways to reduce stigmatisation are interventions based on the principle of social contact, appropriately adapted to local contexts and cultures. This supports the finding by Haldane and colleagues that peer navigators who share the same lived experience facilitate access to care for people living with HIV and substance use disorders. Anti-stigma programmes are most effective when people with lived experience are involved as co-producers in all aspects of development, and when target groups are consulted on programme content and delivery. Crucially, programmes have to be sustained long term—decades of stigma and discrimination cannot be overturned in weeks or even months. An important player in the campaign to end stigma is the media. WHO has produced guidelines for the reporting of suicide, which are adopted, if not strictly followed, in many countries. More general guidelines on the portrayal of people with mental illness in the media and on including recovery-oriented content exist at the national level: is it time for global leadership on this? Who would monitor the output? How could such guidelines be applied to social media? Should educational organisations be involved, teaching children from their earliest years that mental illness exists and should be understood and accommodated rather than seen as something that should be banished? Which brings us back to World Mental Health Day's aim of mental health and wellbeing for all. Is this achievable or even desirable? We recognise grief as a natural part of bereavement: is the corollary that sadness is a natural part of life? So-called nerves or butterflies before a challenging situation reflect a rise in adrenaline that prepares the body for flight or fight and can aid physically but can become debilitating and impair even simple social engagement. The aim of reducing the effect of mental illness generally is certainly laudable, but society must also accept that not all individuals with mental disorders can achieve mental health and that wellbeing should encompass living with mental illness. Recognising and accepting difference is the core of ending stigma and discrimination.