Global Mental Health Initiatives and COVID-19

This is the third part of a IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.

Part III – Global Mental Health Initiatives and COVID-19

Mental health issues pose a significant public health burden and in the context of COVID-19 this burden is growing substantially. In low- and middle-income countries, 76%-85% of people with mental disorders do not receive needed treatment. Many countries do not have the infrastructure, resources and/or political support to adequately ensure that all persons have access to high quality mental health services. Therefore, there is a large gap between the need for mental health treatment and available services.

One important indicator of a country’s capacity to address the growing mental health burden is the availability of adequately trained personnel to provide treatment and care. In 2010, the World Health Organization (WHO) released the results of a study that found that low- and middle-income countries in the African Region and the South-East Asian Region reported fewer mental health professionals than the Americas or the European Region. According to the 2017 Mental Health Atlas country profiles, this trend still exists. For example, India reported 1.93 total mental health workers per 100,000 population, Rwanda reported 2.01, and China reported 8.75, whereas Germany reported 144.87, France reported 173.63, Finland reported 250.55 and the United States reported 271.28. In order to meet the increasing demand for mental health care globally adequately trained mental health care providers are critically needed.

One initiative aiming to reduce the burden of mental health issues globally is the Mental Health Gap Action Programme (mhGAP) which was launched in 2008. This program uses evidence-based tools, training, and interventions to expand mental health service provision in resource-poor, low-income countries around the world. The original 2010 mhGAP Implementation Guide has been used in over 100 countries and translated into more than 20 languages. The program directs its training towards health-care providers who do not have specialized training in mental health. For instance, in 2017, to address the mental health needs of persons affected by conflict in Borno State, in northeastern Nigeria, the Federal Neuro-Psychiatric hospital and governmental authorities launched the mhGAP program. This program trained primary care workers to identify and provide care for persons with mental disorders. The story of Aisha, a girl directly impacted by this conflict who received mental health treatment through mhGAP can be found here.

In the World Health Organization’s (WHO) most recent global targets and goals (Sustainable Development Goals (SDGs)), mental health was explicitly included as a part of SDG Target 3.4. In December 2019 WHO held a meeting to accelerate progress on SDG Target 3.4 on Noncommunicable Disease and Mental Health in Oman. The goal of this meeting was to have countries come together to share success stories and challenges in order to develop innovative ideas on how to scale up national interventions to reach SDG target 3.4 by 2030. There were sessions titled: “Mental health and psychosocial support in emergencies” and “Story-telling and mass media for mental health.” Video of panels held during the meeting can be viewed here

As part of their QualityRights Initiative, WHO has developed training and guidance modules that are meant to empower all stakeholders to promote mental health recovery and human rights in mental health facilities, improve service delivery, and change mindsets around mental health. The modules are designed to be used in low, middle, and high-income countries. Updated modules were introduced in November 2019. QualityRights has been introduced into 31 countries, with Ghana being the first to introduce the program country-wide in early 2019. A total of 22 member states of the European Region formally agreed to carry out mental health related activities during 2018-2019, and a majority stated they would use WHO QualityRights toolkit and guidance materials. 

Another WHO initiative, WHO MiNDbank, is a free online platform that contains a wide variety of international and country-specific resources covering behavioral health. MiNDbank is a part of WHO’s QualityRights campaign and aims to facilitate dialogue, advocacy and research surrounding human rights violations against people experiencing mental health challenges and disabilities. 

Current Initiatives Focused on COVID-19

Global Initiatives

New global initiatives are being implemented to address the mental health burden of the COVID-19 pandemic. Many initiatives are focused on disseminating educational resources out to the public. In direct response to the COVID-19 pandemic, WHO released a list of mental health and psychosocial considerations for different groups, such as people in isolation, carers of children, and healthcare workers. To support research efforts on behavioral insights related to COVID-19, the WHO Regional Office for Europe developed a survey tool for European Member States to use. 

On March 17, 2020, the Inter-Agency Standing Committee (IASC), a humanitarian coordination forum created by the United Nations, published an interim briefing note titled, “Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak.” Like WHO’s list of considerations, this briefing note summarizes important mental health and psychosocial support considerations in relation to the COVID-19 outbreak. The document includes 14 recommended activities and six interventions that can be globally implemented as part of the COVID-19 mental health response. The briefing note is available in over 15 different languages. 

Initiatives in the United States 

The United States is implementing several initiatives that aim to address the mental health burden of the COVID-19 pandemic. Information about some of these initiatives is provided below:

Centers for Disease Control and Prevention (CDC)

  • The CDC webpage – Stress and Coping. This page provides general and population specific recommendations.

National Alliance on Mental Illness (NAMI)

Substance Abuse and Mental Health Services Administration (SAMHSA)

  • A web page dedicated to COVID-19, with SAMHSA resources and information, guidance for opioid treatment programs, and additional federal guidance 
  • A list of SAMHSA COVID-19 funded grants organized by state

Mental Health America

  • Information and resources on mental health and COVID-19. Includes tips for social distancing, quarantine, and isolation, resources for financial support, tools and information on anxiety, links to webinars and workshops, and information for parents, older adults, domestic violence survivors, and more. 

American Psychiatric Association (APA)

Harvard University

National Child Traumatic Stress Network (NCTSN)

ThriveNYC

About the Authors:

Screen Shot 2020-03-31 at 7.52.50 PMElena Schatell MPH (c) MMS (c)

Elena Schatell is a current student at Arcadia University enrolled in the Dual Master of Public Health/Master of Medical Science in Physician Assistant Program. She aims to promote public health in underserved communities as a future physician assistant. Her current public health interests include access to mental health services, stigma surrounding mental illness, and the relationship between faith and mental health. She has interned at the National Alliance for Mental Illness (NAMI) national office in Arlington, Virginia, working closely with the Advocacy and Public Policy team on conducting research on service barriers and state mental health policy. During her time at NAMI, she also authored articles for the Advocate magazine and blog.

McClintock.PictureDr. Heather F. McClintock PhD MSPH MSW

Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life Study and Integrating Management for Depression and Type 2 Diabetes Mellitus Study.

An Overview of Global Mental Health

By: Dr. Heather F. McClintock PhD MSPH MSW, Elena Schatell MPH (c) MMS (c), and Hannah Stewart

This is the first part of a IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.

Part I: An Overview of Global Mental Health 

According to the World Health Organization (WHO) mental health is more than the absence of mental disorders. It is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” The Global Burden of Disease Study has reported that for nearly three decades more than 14% of Years Lived with Disability (YLDs) were due to mental health concerns, such as depressive disorders and substance abuse. Over one in three people will experience a mental health problem in their lifetime. Depression, the most prevalent psychiatric diagnosis, affects an estimated 264 million people globally. Bipolar disorder and schizophrenia affect 45 million and 22 million people worldwide, respectively. One out of five of the world’s children and adolescents have a mental disorder, and about half of mental health concerns begin before the age of 14. The burden of mental health concerns has serious human repercussions. Every year, approximately 800,000 people die by suicide, this is nearly 1 person every 40 seconds.  

The burden of mental disorders varies significantly by country. In order to track this variation, WHO created a Mental Health Atlas. The Atlas contains profiles for nearly all member states presenting information on each country’s burden of mental health concerns, system governance, resources, and service availability and uptake. The Atlas also contains many other important indicators of mental illness including suicide mortality rates and the number of treated cases of severe mental disorders.       

According to the most recent 2017 Atlas, the United States reported that 4,128.45 disability adjusted life years (DALYs) per 100,000 people were lost due to mental health concerns. This is higher than some of the USA’s high-income counterparts: Denmark (3,819.99 DALYs per 100,000), France, (3,700.67 DALY’s per 100,000), Australia (2,972.99 DALY’s per 100,000), and Japan (2,240.63 DALY’s per 100,000). And while reported rates of mental health concerns tend to be higher in high-income countries, more than 80% of people living with mental health concerns live in low- and middle income countries (LMIC’s). In these settings, access to culturally appropriate and effective mental health services remains low with treatment rates often as low as 35-50%. The outlook isn’t improving. By 2030, major depression alone is projected to be the largest contributor to global disease burden

Determinants of mental health concerns include biological, psychological, social, economic, environmental, and cultural factors. Biologically, genetic factors increase risk for the onset of mental disorders. Psychologically, personality factors are associated with poor mental health. Contextual factors such as violence, unsafe neighborhoods, war, unemployment, minimal social cohesion, discrimination, and human rights violations all increase the likelihood of mental disorders. Humanitarian crises, due to their widespread impact globally, have been a recent focus for the assessment and evaluation of mental health issues. In conflict settings the prevalence of depression and anxiety is more than double. Roughly one in five people who have experienced conflict or war in the past 10 years will have depression, anxiety, post-traumatic stress disorder, bipolar disorder, or schizophrenia. 

In comparison with the general population, persons with psychiatric diagnoses die 10 to 20 years younger than those without such disorders, a prognosis worse than heavy smoking. The morbidity and mortality of mental health concerns translate into devastating global economic costs. We lose about $1 trillion U.S. dollars globally per year in productivity due to depression and anxiety. It is projected that the burden of poor mental health will cost the global economy $16.3 trillion between 2011 and 2030, more than chronic heart disease. The economic costs of mental disorders go beyond the direct healthcare costs and extend to hidden indirect economic costs such as loss of productivity according to the 2011 World Economic Forum report.

But the true cost of the burden of mental health concerns comes at the price of human  suffering. Living with mental health concerns not only affects the human psyche, it has social and human rights consequences. Unmanaged and untreated mental illness not only impacts the individual lives of those affected; it impacts family, friends, their social and work-related environments, and society as a whole. Individuals experiencing mental illness are often maltreated and marginalized on a global level. They are subjected to human rights violations, including denial of employment, denial of education, malnutrition, negligence, and physical abuse. It’s critical that the world radically change the way we deliver mental health services to create new systems that are rights-oriented, user-centered, and achieve true parity. 

References (in order of appearance)
  1. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response
  2. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. DOI:https://doi.org/10.1016/S0140-6736(18)32279-7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6227754/
  3. https://www.ncbi.nlm.nih.gov/pubmed/24648481
  4. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext
  5. https://www.who.int/health-topics/suicide#tab=tab_1
  6. https://www.who.int/news-room/fact-sheets/detail/mental-disorders
  7. Wang et al., (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet.
  8. https://www.ncbi.nlm.nih.gov/pubmed/17826169
  9. https://www.who.int/mental_health/evidence/atlas/profiles-2017/en/
  10. https://www.who.int/news-room/fact-sheets/detail/mental-disorders
  11. https://www.who.int/news-room/fact-sheets/detail/mental-health-in-emergencies
  12. https://www.who.int/news-room/facts-in-pictures/detail/mental-health
  13. https://journals.sagepub.com/doi/full/10.1177/2158244014526209
  14. Bloom DE, Cafiero ET, Jané-Llopis E, et al. The global economic burden of non-communicable diseases. Geneva, 2011. https://apps.who.int/medicinedocs/documents/s18806en/s18806en.pdf
  15. https://journals.sagepub.com/doi/full/10.1177/2158244014526209

About the Authors:

Dr. Heather F. McClintock PhD MSPH MSW

McClintock.PictureDr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life Study and Integrating Management for Depression and Type 2 Diabetes Mellitus Study.

Elena Schatell MPH (c) MMS (c)

Screen Shot 2020-03-31 at 7.52.50 PMElena Schatell is a current student at Arcadia University enrolled in the Dual Master of Public Health/Master of Medical Science in Physician Assistant Program. She aims to promote public health in underserved communities as a future physician assistant. Her current public health interests include access to mental health services, stigma surrounding mental illness, and the relationship between faith and mental health. She has interned at the National Alliance for Mental Illness (NAMI) national office in Arlington, Virginia, working closely with the Advocacy and Public Policy team on conducting research on service barriers and state mental health policy. During her time at NAMI, she also authored articles for the Advocate magazine and blog.

Hannah Stewart

Screen Shot 2020-03-31 at 7.53.02 PMHannah Stewart is a global mental health researcher and advocate that uses the power of research methodology to elevate mental health as a human rights issue. She earned her Bachelor of Science in Psychology from Baylor University and her Master of Public Health in Global Health Leadership at the University of Southern California. Her research interests include the psychological impact of traumatic experience, culturally appropriate psychosocial interventions, and the intersection of mental health and climate change. She is currently a research scholar at the Global Environmental Health Lab where she focuses on building research capacity at universities in Myanmar. Hannah is also one of two delegates from the United States to the Executive Committee of the Global Mental Health Peer Network, a lived-experience organization that advocates for individuals living with mental health concerns by engaging diverse stakeholders in mental health.

 

“Tejas means friend” and other lies we tell ourselves.

If you hear me speak more than a few sentences, you’ll hear the unmistakable accent. And as soon as I can find a natural way to fit it into the conversation, I’ll tell you flat out: I’m from Texas.

As a Texan, I was required to take one year of Texas history in the seventh grade, a statewide tradition since 1946. In Texas history, you’ll undoubtedly learn a few facts that every one of us 29-million Texans has engraved in our hearts.

1.     You don’t pick bluebonnets. They’re a sacred part of our state’s landscape.

2.     Texas was a sovereign nation once: the Republic of Texas. 

3.     California may have more people, but we’re bigger in size.

4.     “Tejas means friend”.

I’ve always found the root of the state’s name to be fascinating, because it has evolved with the land itself and represents the story of Texas. The word traces back to the Caddo word for “friend”, taysha. That word would be misspelled and mispronounced to be Tejas and eventually, Texas. For those of us whose hearts are deeply intertwined with the “Lone Star State”, the root of the word feels right. It embodies our roots, who we were, and the Southern hospitality on which we grew up. The origin of Texas’ name does NOT embody who we are today.

Texas has become the frontline of continued inhumane policy experimentation by the Trump administration. To deter undocumented entry to the United States and tamp down the number of asylum claims made at ports of entry, Trump and his nominated officials began separating children from their caregivers. 2,654 children were taken from their parents, guardians, and chaperones during the peak of this policy’s enforcement, and most of those children were detained in Texas.

The science around this matter is still developing, but one thing is certainly clear: this is bad news for the cognitive development and mental health outcomes of these children. In fact, the picture is becoming clearer that family separation policies produce rates of toxic stress and trauma that are as detrimental to the child psyche at the violence as the violence and insecurity they are fleeing. Researchers, and even the United Nations, cite evidence that separating children from their caregivers creates the type of emotional disturbance and dysregulation seen in survivors of torture.

We aren’t talking about acute emotional disturbance that will recede after reunification. The child’s brain has evolved to be incredibly respondent to its environment. Continued exposures to “fight, flight, or freeze” (especially in the absence of a trusted attachment figure) train the brain to bypass emotional inhibition and complex, rational thought to depend on more primitive survival mechanisms. This means permanent alteration of the brain, shrinking the prefrontal cortex and hippocampus (the parts of the brain that largely control decision making, working memory, and personality expression).  Their brains, and often their relationships with the parents, may never recover. 

“Here we have taken away what science has said is the most potent protector of children in the face of any adversity—the stability of the parent-child relationship”

– Jack Shonkoff

It’s not just theoretical damage happening in research studies void of a human face. Children inside these Texas detention centers have reported high rates of insomnia, decreased ability to concentrate, diminished literacy (even in their native languages), severe mood swings, and feeling constant states of panic and fear. And when they leave, their medical records (including any psychiatric care they’ve needed or received) are often incomplete. Many of these children will receive asylum in the United States, and we will have to face the mental health epidemic we created with a mental health system that is underfunded and culturally inadequate.

Sweeping separation of families and detainment of children was theoretically stopped, but the Human Rights Watch has found that nearly 200 children have been subject to the continuation of this policy since last year. There is no law on the books in the US that requires the separation of families at the border. This was a policy decision that can be rescinded as quickly as it was haphazardly implemented.

These children have often experienced trauma before they ever arrive at our border. They have left the familiarity and comfort of home. They are often physically vulnerable at the end of their migration journey. And they are welcomed with something that, for most of them, is even more traumatic: facing the hostility of a foreign country all alone.

This isn’t exclusively a Texan issue. ICE detention centers now exist in all 50 states. And it isn’t uniquely American, as 100 other countries have policies that allow children to be detained as part of standing immigration policy. But Texas has become ground zero for what the inhumane treatment of children looks like. Texas is no longer a land of Southern hospitality. It certainly isn’t embodying the state motto of “friendship”. And no one should be angrier about what’s happening in our home state than Texans ourselves. 

This article was written in memory of the children who needlessly died in Texas as a result of inhumane immigration policy. These faces represent the failure of all of us.

From top left to bottom right:

Mariee Juarez, aged 2, died after leaving a detention center in Dilley, TX

Carlos Hernandez Va’squez, age 16, died in US custody in Brownsville, TX

Jakelin Caal Maquin, age 7, died in US custody in El Paso, TX

Juan de Leo’n Gutie’rrez, age 16, died in US custody in Brownsville, TX