Challenges of creating synergy between global mental health and cultural psychiatry

Abstract

This article addresses four major challenges for efforts to create synergy between the global mental health movement and cultural psychiatry. First, although they appear to share domains of mutual interest, the worlds of global mental health and cultural psychiatry have distinct lineages. Expanding their horizons by learning from adjacent disciplines would be mutually beneficial. A second challenge concerns the conceptualization of a new classification system for mental health problems. Adopting a classification system that integrates new insights from socio-neurobiology and from a networks perspective could bring cultural psychiatry and global mental health closer and change the way each field addresses the mental health gap, which constitutes the third challenge. I summarize attempts to achieve comprehensive mental health coverage around the globe and question whether the strategies employed to achieve these goals have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). In LMIC, the dominant strategy needs to be complemented by mobilization of other community resources including local practitioners. A fourth challenge is the lack of mathematical models to guide action and research and solve major preoccupations such as access to care or multi-level analyses in complex ecological or health systems.

Keywords

collaboration cultural psychiatry global mental health LMIC synergy

Introduction

This paper identifies four major challenges in efforts to create synergy between the global mental health movement and cultural psychiatry and proposes some strategies and initiatives to address these issues. Some initiatives suggested can be implemented in the short term and the specific challenge solved within a few years; other challenges are more theoretical and may require decades to resolve.

The first challenge is that the worlds of global mental health and cultural psychiatry have distinct pedigrees. Yet, like the scholars engaged in these fields, they share domains of mutual interest. Thus, expanding their horizons by learning from adjacent disciplines could be mutually beneficial. Global mental health is a domain of global health, derived from public health and international health, which, in turn, evolved from hygiene and tropical medicine. Public health in the modern sense emerged in the mid-19th century in several countries. In line with global health, global mental health can be defined as an area for study, research, and practice that prioritizes improving mental health and achieving equity in mental health worldwide. Historically, global mental health is closely related to medical science and sociopolitical theory, world psychiatry, public health and health systems research. Global mental health emphasizes transnational health issues, determinants, and solutions. It involves several disciplines, promotes interdisciplinary collaboration, and integrates population-based prevention with individual-level clinical care (Koplan et al., 2009). Moreover, global mental health is relatively action-oriented and interested in group phenomena, populations, and beneficiaries, which it generally explores through quantitative methods such as population and clinical epidemiology, reviews and meta-analyses.

Cultural psychiatry can be traced to explorers’ early observations of foreign peoples, and became an organized field within the larger discipline of psychiatry through the establishment of the Division of Social and Transcultural Psychiatry at McGill University in 1955. Cultural psychiatry has been driven by the following major concerns: questions about the universality or relativity of psychopathology; the cross-cultural applicability of psychopharmacological, psychotherapeutic, and psychosocial interventions, both by biomedical and indigenous practitioners; service provision and emerging practice models for providing culturally responsive care across cultures and culturally diverse settings; and the analysis of psychiatric theory and practice, including how they reproduce gender, class, and other social differences of the dominant society (Kirmayer, 2007). Cultural psychiatry is related to academic psychiatry and cultural and medical anthropology. It tends to focus on localized phenomena and formulating critiques of the broader field of psychiatry or, more recently, the global mental health movement. This article will provide several examples of how, despite their distinct lineages, global mental health and cultural psychiatry can learn much from one another as well as from adjacent disciplines including social sciences, social psychology, health systems research, cultural psychology, mathematics, neurobiology, and cultural neuroscience (Chiao, 2009; Kirmayer, 2009).

The second challenge that this paper addresses concerns the need for a new classification system for mental health problems. The development of psychiatric classification systems has been a source of great contention within general psychiatry. Kendell (1989) summarized the overall aims of psychiatric classification as an effort to categorize, explain, predict, and treat observed phenomena. Discussions continue as to whether the DSM and ICD have achieved this aim and whether these systems meet external validity criteria (Kupfer & Regier, 2011). Kendell and Jablensky (2003) have argued that a psychiatric diagnostic system can only be valid on two conditions: (i) there are zones of rarity between normality and adjacent syndromes, and (ii) the definitions are based on fundamental characteristics of disorders, for example, physiological, genetic, or other biological data. Based on these considerations, Hyman (2007) and Kupfer, Regier, and Kuhl (2008) outlined three options for the DSM-5 Task Force: (1) a dimensional system with dimensional criteria for each disorder; (2) identification of clinically significant symptom clusters built on hypotheses about underlying neuronal circuits (as exemplified in the trend towards Research Domain Criteria (RDoC) (Insel et al., 2010); and (3) rearranging over 300 existing diagnoses into spectrum disorders (e.g., for obsessive behavior, affective disorders, schizophrenia, or a stress-induced and fear circuitry spectrum), based on knowledge about symptom clustering, genetics, and shared pathophysiological traits (Andrews, Charney, Sirovatka, & Regier, 2009; Hyman, 2007; Kupfer et al., 2008). There was much debate about the proposed dimensional classification of personality disorders (Bernstein et al., 2007; Hyman, 2007; Livesley, 2012; McCrae & Terracciano, 2005; Shedler et al., 2010). In the end, however, neither dimensional diagnoses nor spectrum disorders found their way into the DSM-5. Interestingly, neurobiologists and anthropologists expressed similar critiques of the DSM-IV and urged the Cultural Issues Subcommittee to propose an introductory chapter for the DSM-5 (Lewis-Fernández, 2009). This led to revisions to the text and the development of the Cultural Formulation Interview (Lewis-Fernández et al., 2014). I will argue that if psychiatry and psychology were able to reach agreement on integrating insights from neurobiology and employ a networks perspective to develop a revised diagnostic system, this would create new synergy between cultural psychiatry and global mental health. Such a classification system could help to improve the fate of individuals suffering from psychological problems across the globe.

The third challenge arises from the discordant approaches to improving mental health globally. The global mental health movement is unrealistic about the potential effectiveness of the strategies it advocates to solve the mental health gap; for example, task sharing or task shifting to primary care workers in low- and middle-income countries (LMIC). In some respects, the global mental health strategy resembles the movements for integrative or complementary and alternative medicine (CAM), with an emphasis on consultative care (clinicians working closely with the patient’s primary care physician), comprehensive care (an expert clinician managing a specific medical condition), and primary care throughout the patient’s life span (Horrigan, 2012). The global mental health strategy also closely resembles the WHO’s initiative in the 1980s to integrate mental health into primary care. Reviewing the attempts to achieve comprehensive mental health coverage around the globe, however, raises the question of whether the strategies employed have been successful, both in high- (HIC) and low- and middle-income countries (LMIC). I will argue that the dominant strategy needs to be complemented by the mobilization of other community resources including local practitioners and healers, which represents a basic research domain of cultural psychiatry and medical anthropology.

A fourth challenge is the lack of adequate models to guide mental health action and research through multi-level analyses in complex ecological or health systems. Global health and public mental health are both influenced by human ecology or systems approaches as described by scholars such as Von Bertalanffy (1969) or Bronfenbrenner (1979). But in the domains of mental health and psychiatry, we have not succeeded in quantifying how multiple ecological system levels interact with each other.

Addressing the pedigrees of global mental health and cultural psychiatry

The first challenge concerns the distinct origins and lineage of the disciplines of cultural psychiatry and global mental health. We have noted that cultural psychiatry is closely related to anthropology and tends to focus on localized phenomena, whereas global mental health is more action-oriented, relying primarily on quantitative methods such as epidemiology. The following are some examples of domains in which the disciplines may synergize with one another:

Epidemiology can be informed by cultural psychiatry in refining its methodology and instrumentation to provide valid data and interpret the local significance of findings. For a culturally-informed epidemiology, adaptation of instruments is required to provide conceptual equivalence and construct validity—addressing what Kleinman (1987) referred to as the category fallacy—in order to generate valid and reliable figures. Cultural epidemiology, inspired by social science, uses combinations of qualitative and quantitative research to assess needs, generate hypotheses, design contextually relevant instruments and interventions, derive local relevance from its findings, and explain outliers (De Jong & Van Ommeren, 2002). An example demonstrating the importance of collaboration between the two fields is the apparently increased prevalence of schizophrenia among immigrants in Europe, which research suggests may be explained both by the cross-cultural assessments resulting in false positive diagnoses of schizophrenia, as well as migration acting as a risk factor for schizophrenia (Cantor-Graae & Pedersen, 2013; Zandi, 2014).

Another relevant interdisciplinary collaborative domain is the interpretation of concepts such as distress, dysfunction, disability, impairment, or quality of life when applying the WHO Disability Assessment Schedule (WHODASII) or the WHO International Classification of Functioning, Disability and Health (WHO ICF) across cultures or among youth (De Jong & Van Ommeren, 2002; Jordans, Komproe, Tol, & de Jong, 2009; Tol, Komproe, Jordans, Susanty, & de Jong, 2011; Tol, Reis, Susanty, de Jong, 2010; Von Korff et al., 2008). For example, population attributable risk proportion (PARP), and disability-adjusted life years (DALYs) are measures of illness burden in global health. The global health movement and health economists use DALYs as a metric allowing for direct comparisons between interventions.¹ DALYs are often mentioned to illustrate the importance of the burden of the mental, neurological, or substance misuse (MNS) disorders that constitute 13% of the global burden of disease, surpassing both cardiovascular disease and cancer (Collins et al., 2011; Patel et al., 2007; WHO, 2006). However, DALYs—and the same applies to PARP—are often used as if they were definitive indicators of health or mental health status, whereas they should be considered only as rough measures of various conditions. One of the methodological questions associated with these measures is how to weigh the degree to which a person suffers from a particular disability or disorder, taking age, gender, and social context into account. Minor differences in parameter choices may change the number of DALYs associated with a condition by a few percent or by as much as a factor of two (Glassman & Chalkidou, 2012). Moreover, like other forms of “hard evidence” focused on individual outcomes, the DALY does not address the disability’s impact on a household or community, or the interplay with socioeconomic factors or often-occurring comorbidities of physical and mental conditions. The anthropological approach embraced by cultural psychiatry may help researchers assess the interpersonal, cultural, and temporal variation of the disability metric by engaging the perspective of those who suffer from a condition.

Global mental health might benefit from closer attention to the writing in critical social sciences like that of Nichter (2008) or Hahn and Inhorn (2009). It also might find inspiration in successful health system changes in countries such as Ethiopia, Ghana, or Rwanda (Chabot, 2011). Similarly, cultural psychiatry might learn much from the methodological advances of cultural neuroscience and cultural psychology in research domains such as personality, quality of life, or intelligence testing. In other words, there are several domains where global mental health and cultural psychiatry share mutual interests and where expanding their horizons through increased dialogue would be mutually beneficial.

Benefits of a renewed diagnostic system

In general, it appears that mental health professionals are moving away from DSM categories as the “gold standard” of psychiatry. Two global surveys (Evans et al., 2013; Reed et al., 2013) have shown that both psychiatrists and psychologists prefer more flexible and conceptual diagnostic guidelines rather than strict criteria, with fewer categories, allowing for clinical judgment and cultural variation. This approach is more characteristic of the WHO’s ICD than of the DSM. Both groups of mental health professionals agreed that clinical utility, concepts of functional impairment, severity, and dimensional classification are all essential for a diagnostic classification system. A renewed diagnostic system may represent both a challenge and an opportunity. In particular, a dimensional classification system may create new synergy between cultural psychiatry and global mental health for several reasons, as outlined below.

A dimensional system would facilitate assessment of the severity of complaints. It would permit monitoring treatment in public mental health programs over time while allowing variations in culturally determined illness behavior and response bias, which are both classical preoccupations of cultural psychiatry and medical anthropology. In other words, a dimensional system would recognize the relativity of the distinction between syndromes (and sub-syndromal symptom categories) and idioms of distress (IODs), and allow us to identify symptom domains (such as depression, anxiety, cognitive, or motivational limitations) across diagnostic categories or spectrum disorders. This has implications for the development of integrated multilevel care systems, which involves the determination of when, for example, mild and moderate depressive or anxious states become conditions that need the attention of a mental health professional.² Addressing this question requires cooperation among health professionals and community resources. Using a dimensional diagnostic system would allow public mental health planners to decide which threshold of complaint severity best corresponds with each tier of a local health care system. Cultural psychiatrists may then play a role in helping to identify the salience of the symptom domains, disorders, or spectrum disorders in particular local ecologies, and helping to sort out which cultural concepts of distress or idioms of distress (IODs) would be best managed by other practitioners such as lay people or healers (see further on).

Related to the previous issue, a dimensional system would help mental health professionals to conceptualize the development of mental illness as a gradual transition from normalcy to perceived deviancy in a specific socio-cultural context, rather than relying on predetermined cut-points that raise questions of validity and create skewed prevalence rates in cross-cultural studies. One may wonder, for example, about the utility of existing epidemiological categories if the prevalence rates of psychiatric disorders after human rights violations vary from 0–99% for PTSD and from 3–85% for depression (Steel et al., 2009). If research addressed the need for flexible and conceptual diagnostic guidelines this would facilitate the incorporation of local population norms regarding normal versus deviant behavior in a given sociocultural or historical context.

A variety of higher order constructs that have been proposed based on factor structures underlying various phenotypes of psychopathology may result in transdiagnostic spectrums, for example, for affective disorders, obsessive behavior, stress-induced disorders, and psychotic spectrum disorders (cf. Barlow, 1988; Dutta et al. 2007; Helzer et al., 2007; Krueger, 1999; Van Os, Kenis, & Rutten, 2010). Such an approach might end discussions on the distinction between, for example, the two groups of depression and anxiety disorders that share genetic traits, show high levels of comorbidity, can be measured with the same research instruments, and which are treated with the same SSRIs (Baldessarini, 2000; Gadermann, Alonso, Vilagut, Zaslavsky, & Kessler, 2012; Horwitz & Wakefield, 2007; Kessler et al., 1994). The overlap in depressive and anxiety symptoms is often pronounced in cross-cultural contexts and thus poses difficulties when LMIC primary care workers are involved in task shifting or task sharing (Patel, 2001). An example is when the Intervention Guide (WHO, 2010) of the Mental Health Gap Action Program (mhGAP) obliges primary care workers to construct an affective spectrum as distinct disorders with distinct flow charts. A simpler and culturally more valid spectrum with clearer zones of rarity would help to reduce false positive and false negative diagnoses and broaden the range of possible care providers involved in diminishing the mental health gap. Reducing the large number of construed diagnoses in favor of a limited number of spectra would also pave the way for simplified transdiagnostic modular treatments of behavioral and cognitive therapies. These modular treatments may replace the large number of treatment protocols and enable the ethical use of more sophisticated forms of psychotherapy such as cognitive behavioral therapy (CBT) by general health workers and paraprofessionals in LMIC. Modular treatments improve diagnostic utility by linking a population and primary care perspective to a tertiary care perspective in a stepped-care or public mental health model.

Incorporating new insights from cultural and social neuroscientific or neuro-anthropological research into a renewed diagnostic system might also help resolve major tensions between global mental health and cultural psychiatry. If the hypothesis that “brain molds culture like culture molds the brain” proves to be true (Chiao, 2009), it is likely that we will discover local biologies that undermine the desirability and feasibility of a global universal classification system. Or, on the contrary, social neuroscience research may reveal a limited number of (spectrum) disorders that fulfill the aforementioned second validity criterion of Kendell and Jablensky (2003). Yet, these “universal” disorders may show sufficient modulation or variation around the globe to justify distinct classification systems.

Beyond a purely dimensional classification, another serious short-term candidate to replace the current diagnostic system is a clinical staging model using a network approach that describes the symptoms of psychopathology as dynamic networks or circuits, impacting each other and crossing diagnostic boundaries. This model involves both a spectrum and a dimensional approach. It argues that mental distress and the need for care are present long before any clear clinical diagnosis (McGorry & Van Os, 2013; Schmittmann et al., 2011; Wigman et al. 2013). The clinical staging model acknowledges the possibility of intervening before reaching a clinical diagnosis. It is attractive for cultural psychiatry because IODs, Cultural Syndromes, Cultural Concepts of Distress or specific patterns of somatization easily fit or overlap with the symptoms of the early clinical stage of the model.

The most intriguing aspect of these alternative diagnostic approaches for global mental health and cultural psychiatry is that they allow for the use of quantitative techniques to generate a totally new phenomenology that reinvents psychiatry. The longitudinal perspective on the development or resolution of complaints, symptoms, and syndromes opens the door to new methods of personal (idiographic), ecological, and digital self-quantification. For example, an application installed on a mobile phone allows monitoring of psychological experiences (e.g., mood), behaviors (eating, intake of substances), environment (stress, company), and activities (work, study) over time. These innovative approaches promise a breakthrough in the perennial universalism–relativism debate because they allow us to generate locally and ecologically meaningful categories of psychopathology without the complex preparatory qualitative research of collecting vernacular indigenous symptoms and comparing them with internationally recognized psychiatric nosologies such as DSM or ICD. The self-quantification approach uses highly complex methodologies and statistics (cf. Wigman et al., 2013). Wardenaar and de Jonge (2013) propose Multimode Principal Component Analysis and (Mixture)-Graphical Modeling as promising techniques to solve the basic and enduring problem that classifications are heterogeneous clinical descriptions rather than valid diagnoses.

A long-term candidate for a new diagnostic system is the aforementioned NIMH Research Domain Criteria (RDoC) project that aims to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system (Adam, 2013). There is no reason to assume that the various new systems being developed could not be integrated in the long term. On the contrary, these new trends open a wide interdisciplinary research domain involving psychology, cultural psychiatry, and the global mental health movement to examine cultural variations of cognitive systems, arousal patterns, emotions, and psychopathology. Thus, the collaborative effort to develop a new diagnostic classification system may represent the ultimate step to transcend the perennial universalism–relativism, nature–nurture, or genotype–phenotype debates.

Collaboration to address the mental health gap

The third and medium-term challenge is expanding collaboration to mitigate the treatment gap. The global mental health movement seems quite confident about solving the mental health gap through solutions such as task shifting to primary care workers. This paper argues that this strategy needs to be complemented by the mobilization of other community resources including local practitioners and healers, a typical research domain of cultural psychiatry and medical anthropology.

Global needs and efforts in mental health

The WHO World Mental Health Survey Consortium recently published comprehensive figures on the global burden of mental illness and on efforts to provide services worldwide (Alonso, Chatterji, & Yanling, 2013). Table 1 summarizes the data from this survey of 121,000 respondents in 24 countries.

Table 1.

Comparison of burden of mental disease, mental health budget, and treatment delivery by country income level.^a

Income level^b	Burden of mental disease (as % of total burden of disease)	Mental health budget (as % of total health budget)	Residential care budget (as % of total mental health budget)	Percentage of patients with disorders who receive care		Percentage of patients who receive follow-up community care
Income level^b	Burden of mental disease (as % of total burden of disease)	Mental health budget (as % of total health budget)		Physical disorders	Psychiatric disorders	Percentage of patients who receive follow-up community care
LIC	7.9	0.5	73	48	6	7
LMIC	9.5	1.9	n/a	n/a	n/a	29
HMIC	14.6	2.4	74	59	14	39
HIC	21.4	5.1	54	65	24	45

^aData from Alonso et al. (2013); “n/a” indicates data not available.

^bLIC: Low-income countries, LMIC: Lower-middle-income countries, HMIC: Higher-middle-income countries, HIC: High-income countries; classification based on criteria of World Bank (2014).

The table shows that worldwide there is a large discrepancy between the burden of mental illness, mental health expenditure as part of the national health budget, and coverage of mental disorders in terms of treatment or aftercare. Based on previous and less comprehensive figures, several calls were launched to increase access to mental health services globally—a process currently referred to as “scaling up.” Scaling up implicates an increase in coverage and in the range of services available. In addition, it is recommended that these services be evidence-based, shown to be effective in a similar context, and sustainable through policy formulation, implementation, and the strengthening of health systems (Eaton et al., 2011).

The WHO’s core approach to improving mental health globally is the aforementioned Mental Health Gap Action Program or mhGAP. The program aims to reinforce stakeholder commitment and the allocation of financial and human resources for the care of people with MNS disorders, and to achieve increased coverage, especially in LMIC, for example, by involving specialists in primary care (i.e., task sharing). In addition, it envisages deinstitutionalizing psychiatric care and integrating services provided by the community, hospitals, and chronic care providers, including lay people and health workers. Major barriers to scaling up include: (1) the absence of financial resources and government commitment; (2) over-centralization; (3) lack of integration of mental health care into primary and chronic care settings; (4) a scarcity of trained mental health personnel; (5) limited public health expertise among mental health leaders hindering collaboration with other sectors (such as education) and disciplines (Collins et al., 2011); (6) considerably lower care consumption by patients with a mental disorder compared to those with a physical disorder, even in the presence of a higher level of disability; and (7) stigma and discrimination (Alonso et al., 2013).

From theory to practice

WHO’s mhGAP policy aims to address a selection of neuropsychiatric diseases within a public health framework by integrating mental health treatment into primary care. Although this may appear to be a sensible strategy in terms of reducing prevalence rates, alleviating severity, or improving cost-effectiveness, it is unclear whether people with an MNS problem in LIMCs are best served by emphasizing a health care approach. Examining policies, service providers, and service beneficiaries may clarify some arguments against this approach.

First, on a policy level, LMIC government officials often regard psychiatry as a medical specialization requiring a psychiatric hospital where a psychiatrist or a psychiatric nurse provides curative services. As Table 1 shows, psychiatric facilities absorb 50–75% of these governments’ financial resources, thus leaving limited or no funds for other mental health services and demonstrating a lack of intention to deinstitutionalize or decentralize services. The inward-looking psychiatric hospital easily becomes a barrier to a horizontal public health approach—regarded as standard practice since the Alma Ata Declaration in 1978. As a result, less than one third of the patients receive follow-up care, as shown in Table 1. The imbalance of care between the hospital and the community results in these governments’ underperformance in addressing social determinants of mental health, as seen, for example, in their failure to collaborate with other sectors such as education, social affairs, livelihood building, poverty alleviation, or rural development. Since most funding for mental health care in LMIC is earmarked for the psychiatric hospital, governments are unable to pay a decent salary to those psychiatrists providing some community services, and these psychiatrists thus need to supplement their salaries from private practice. Unfortunately, participating in a public mental health program with training and supervision in underserved areas is hard to combine with private practice. The same may apply to academics juggling multiple career pressures and income streams to survive.

In considering these challenges, it may be instructive to recall a similar strategy proposed by the WHO in the 1980s which aimed to “integrate mental health into primary care”. Despite the success of that initiative, the strategy was not widely adopted by other countries, nor was it sustainable in most of the countries involved in Asia, Africa, and Latin America for reasons that are still relevant today (De Jong, 1996; Sartorius & Harding, 1983; Srinivasa Murthy & Wig, 1983). Even today few LMIC meet the basic health systems conditions to address mental health needs in terms of clear policies, laws, expertise at central and peripheral government levels, funding, human resources, and drug supply. If local government or district health authorities show interest in basic mental health care, their willingness is seldom translated into sustainable action. And even when a local program in a country or a region has shown cost-effectiveness, it is not likely to be disseminated. While most experts agree that collaboration between local health and local government is best practice, a Cochrane review showed that interagency collaboration does not lead to health improvement (Hayes et al., 2011). Moreover, local governments or non-governmental organizations (NGOs) often state that they do not understand where or how to start to address their population’s psychological and psychiatric problems. In a number of countries where we were invited to (co)develop mental health programs, the lack of government interest, expertise, or funding in mental health resulted in NGOs filling the gap (as we did in Uganda, Burundi, Algeria, Mozambique, Namibia, Afghanistan, Cambodia, among Tibetans in India, Nepal, and northern Sri Lanka) (De Jong, 2002; Green et al., 2003). The WHO’s new initiative “Building back better”, which aims to improve the lives of people through mental health reform after emergencies (WHO, 2013), thrives on the NGOs’ willingness to step in where governments tend to fail, as most countries involved in this WHO initiative illustrate. But, NGOs carry an inherent risk of causing a health worker brain drain that may weaken instead of strengthen the public sector and thus perpetuate the problem of underserving a population. Sometimes the collaboration between government and NGO sectors results in highly appreciated training programs for the local government and district staff, but quite regularly it evokes professional envy. The divide between NGOs and the government—representing human rights or humanitarianism and civil service worlds, respectively—may result in reticence to cooperate or to integrate NGO services into the local government. Although such integration would obviously be the hoped-for outcome of the WHO’s “Building back better” initiative, a recent review confirmed that in humanitarian emergencies, most interventions take place and are funded outside the national public health system (Tol et al., 2011).

Second, the emphasis on residential care is further compounded by complexities among service providers, such as the aforementioned lack of trained professionals in LMIC to drive the integration of mental health into primary care.

This shortage of human resources becomes even more precarious in areas exposed to political violence and natural disasters. Humanitarian emergencies and wars may result in high mortality rates among service providers or an exodus of health workers (De Jong, 2011). In recent years, it appears that natural disasters and armed conflict tend to occur in a geographic belt stretching from Southeast Asia over the Middle East, the African Great Lakes area and West Africa to the Caribbean and Central America (De Jong, 2010). The WHO Atlas (2011) shows that the lowest concentration of mental health resources occurs in the same geographic areas. Other service provider factors that maintain the treatment gap are the preference of the few existing mental health workers to focus on cure instead of investing in public health or prevention (for example, via e-mental health), the limited applicability or the lack of adaptation of evidence-based knowledge from high-income settings in resource-restrained settings, and the lack of awareness of the treatability of mental disorders among both the population and local health workers in LMIC.

Third, with regard to the beneficiaries of services, the treatment gap is compounded by the aforementioned local variations in the expression of psychopathology that may fit poorly with the DSM or ICD criteria. In addition, urban professionals may meet distrust among rural or poverty-stricken populations; they may have difficulty relating to patients who express their plight in a culture-specific discourse, display specific illness behavior, or use alternative explanatory models.

Global nature of the treatment gap

From the perspective of global mental health, one may wonder if HIC fare better than LMIC in managing the treatment gap. Let us consider Western Europe, often assumed to have cleared the aforementioned major barriers and closed the mental health gap due to: (1) government commitment in terms of financial resources and elaborate policies; (2) decentralization by integrating mental health care into primary and chronic care; (3) a sufficient number of trained mental health personnel; (4) public health expertise at the government level; and (5) a social safety net, with almost universal health care insurance, and generous welfare arrangements as compared to the USA or LMIC, for example.

A recent comprehensive survey of all European Union member countries found that 38.2% met the criteria for a psychiatric disorder, but less than one third actually received treatment (Wittchen et al., 2011). 14 percent of the European population seeks help annually for a psychological problem from their general practitioner (11%), a psychotherapist (2%), or a psychiatrist (1%) (European Opinion Research Group, 2010). The results also show that more resources do not always result in a greater use of services for people with mental disorders. Other factors, such as the nature of professional support available, referral practices, financing (e.g., requirements for out-of-pocket expenditures), and sociocultural factors also play a key role in access to care.

As Table 1 shows, more than half of governments’ health budgets in HIC are directed to residential care. In several countries there is a serious problem with the over-prescription of antidepressants, currently being tackled with moderate results by implementing collaborative care and a web-based decision aid in primary care (Seekles, van Straten, Beekman, van Marwijk, & Cuijpers, 2011). Moreover, in countries such as the USA, Australia, or the Netherlands, almost half of the people with a mood or anxiety disorder use CAM therapy (Bystritsky et al., 2012; Hoenders, Appelo, & Milders, 2006; Thomson, Jones, Evans, & Leslie, 2012). An additional problem is that mental health providers are not able to adjust to some of the major transitional forces at play in today’s world: demographic, epidemiological, urban, energy, economic, nutritional, bio-ecological, cultural, and democratic (Lang & Rayner, 2012).

In short, even this bird’s eye view suggests that both HIC and LMIC struggle with strategies to manage the burden of emotional and behavioral problems. The availability of resources in HIC do not resolve the mental health gap, as illustrated by the examples of over-medicalization or over-funding of the residential setting. It is also noteworthy that political violence and ill health share a range of risk factors such as inequality, lack of democracy, and group marginalization. This overlap in predictors poses an additional challenge for key actors in the domains of health, mental health, and human rights (Collins et al., 2011; Daar et al., 2007; De Jong, 2010; Wiist et al., 2014).

Despite these persistent challenges, global and public mental health might take a step forward by seeking to align more closely with cultural psychiatry and anthropology. For example, in light of the rich and longstanding anthropological literature on traditional healing, it is striking how little methodologically sound outcome research has been done on the efficacy of traditional healers. It is surprising how often accusations of financial or other forms of abuse are made about healers, and not about similar (and verified) behavior among health professionals. And another conundrum: why is there so much resistance to traditional healers among intellectuals in LMIC, while in HIC, “evidence-informed” intellectuals are among the preferred CAM users?

This poor understanding of the role of traditional healers in global mental health persists despite the fact that they are often described as the “ideal” primary care workers. In LMIC, traditional healers are ubiquitous (about 1:200–650 inhabitants is a healer), geographically, culturally, and financially accessible, share the world view and meaning-making systems of local populations, use a wide variety of psychological interventions that they share with clinical psychology, and are experts in a systemic approach to managing social stressors (De Jong, 2001; Frank & Frank, 1991). For example, we did a study comparing patients of traditional healers (n = 350 patients) with those of counselors (n = 250) and a control group (n = 200) in Burundi in which the healers appeared to be more effective in managing psychosocial problems than the counselors, who in turn facilitated a better outcome than seen in the control group (De Jong et al., in preparation).

As we saw earlier, cultural psychiatry has also produced a rich and growing literature on IODs and cultural syndromes that were included as “Cultural Concepts of Distress” in the DSM-5 (De Jong & Reis, 2010; Hinton & Lewis-Fernandez, 2011; Kohrt et al., 2014; Nichter, 2010; Van Duijl, Kleijn, & de Jong, 2012). The global mental health movement may seek inspiration in this literature and gain impetus by showing more interest in culturally salient phenomena. Cultural concepts can fit within a public mental health paradigm and help to accommodate the traditional healing complex in the basic tier of the health pyramid. Cultural concepts of distress are the prototypical realm of healers, healing churches, and ritual leaders. With mutual training and supervision, healers can join the public health system as practitioners to whom other caregivers can refer patients with the aforementioned sub-threshold diagnoses, cultural syndromes, and IODs.

All too often, public health systems adopt a position of superiority. One may even argue that the “mental health gap” only exists due to the exclusion of local, complementary, and alternative healers. Based on the shared values, norms, and cultural schemata within a given local socio-cultural context, it is likely that non-specific therapy-variable factors account for healers’ therapeutic success, just as they do in psychotherapy. Several studies showed that these non-specific factors account for about 30% of the variance in therapeutic outcomes across psychotherapy (Asay & Lambert, 1999; Cooper, 2008). A recent study illustrated that non-specific therapy factors are equally important in LMIC as elsewhere (Jordans et al., 2012). The fact that lay people often do as well as professionals (Boer, Wiersma, Russo, & Bosch, 2009), that new psychotherapies are no more effective than older ones—despite their “evidence-based” status—and that therapists’ success is primarily related to the quality of their alliance with patients, are sometimes hard to accept (Baldwin, Wampold, & Imel, 2007; Budd & Hughes, 2009; De Jong, 2011; Driessen et al., 2010).

The marginalization of traditional healers is sometimes justified by the assumption that modern psychopharmacology provides more effective treatment. However, as we saw earlier in this paper, we should also be modest in relying on psychopharmacology as the primary response to serious mental illness. Recent meta-analyses of drug treatments demonstrate that drug–placebo differences are minimal for depression, and that the effectiveness of first- and second-generation antipsychotic drugs is “disappointingly limited” (Fournier et al., 2010; Lepping, Sambhi, Whittington, Lane, & Poole, 2011; NICE, 2009).

An additional expression of the assumed superiority of health system professionals is that they tend to expect that local healers will refer their patients to the formal health system. Health professionals might opt for a more modest position and refer patients to healers for conditions for which healers are a preferred source of treatment over mental health professionals, who have a poor track record with disturbances such as IODs, dissociation, mass sociogenic illness, or psychogenic convulsions (cf. De Jong, 2011; Brand, Classen, & Lanins, 2009; Van Duijl, Kleijn, & de Jong, 2014). Healers can also serve as allies in the maintenance treatment of psychotic disorders (De Jong & Komproe, 2006).

No one doubts the complexity of the issues around collaboration, cooptation, and quality control of traditional healing, or the urgent need for outcome data from healers and rituals. It is also unknown whether healers feel legitimated or disempowered when they are involved in a local health system, or whether urbanization has been accompanied by an increase or decrease of complementary, alternative, and traditional health care consumption. There remains an astounding discrepancy between insights from the anthropological literature on the potential of traditional healers to help alleviate the treatment gap and the daily reality of understaffed programs in LIMC in which healers and trained lay people might play a role.

The lack of mathematical models

A fourth obstacle and challenge is that we need mathematical models of complex systems to advance our field. Though global and public mental health are guided by human ecology or systems approaches (Bronfenbrenner, 1979; Von Bertalanffy, 1969), we have not succeeded in quantifying how multiple ecological system levels interact with one another. Levins (1974) suggested that “the most difficult general problem of contemporary science is how to deal with complex systems as wholes” (p. 123). Our inability in this domain is in contrast to other disciplines such as evolutionary biology, game theory, or economics, which use complex mathematical models that can be tested in computer simulations (Nowak & Highfield, 2011; Nowak & Sigmund, 2005). These models have illustrated how biological systems, and especially human societies, are organized around altruistic, cooperative interactions that promote unselfish behavior.³ The evolution of cooperation by indirect reciprocity leads to reputation building, morality judgments, and complex social interactions with ever-increasing cognitive demands. Adopting an approach driven by mathematical models may help us to develop testable models related to cooperation and to solve some of our major preoccupations such as equity, access to care, life course research, complex health systems, or stigma. Multilevel linear models (Diez-Roux, 2000) and the causal modeling proposed by Galea, Ahern, and Karpati (2006) may improve our understanding of the dynamic relationships among various population groups and guide public mental health prediction.

Our need for mathematical models is also manifest in day-to-day domains. Apart from the WHO-CHOICE initiative (Chisholm, 2005), policy makers or planners hardly use models to calculate the capacity of their mental health system on a national, regional, or district level. Calculating capacity requires taking public mental health criteria into account, such as prevalence and incidence, locally perceived needs, severity of disorders (in terms of e.g., disability, physical and psychiatric comorbidity, days out of role, stigma), treatability (by healers, e-Health, lay workers, primary care staff, mental health professionals), expertise and knowledge of practitioners, ethical applicability (e.g., in the use of psychotherapy or pharmacotherapy), or cost-effectiveness (De Jong, 2002, 2011). A mathematical modelling approach would enable policy makers to distribute their limited resources in proportion to demographics, socio-economics, national or social insurance, number of hospital beds, duration of hospitalization, incidence, suicide rates, or stigma. Such a public health model can be combined with network theory considering the mental health system as a hub among sectors. For example, the economic sector (for income generation among the poor), the social sector (as a safety net), the educational sector (for children and youth), the legal sector and women’s organizations (for human rights violations and family violence), consumers (e.g., self-help groups), insurance and other companies.⁴ Some mathematical models might be implemented in the short term; others will require much more research.

Conclusion

This paper has described several challenges that need to be addressed to create more synergy between the domains of global mental health and cultural psychiatry. Each of the challenges can be translated into a number of research questions. The first challenge directly concerns the collaboration between global mental health and cultural psychiatry. I gave several examples of domains (epidemiology, disability, critical social science) in which both disciplines may synergize each other. A second challenge within psychiatry is the need for a new classification system; this will have far reaching consequences for both global mental health and cultural psychiatry. There may be advantages to a clinical staging model with a dimensional approach for improving service delivery. Spectrum disorders and modular treatments may lead to more effective use of psychotherapy in primary care.

The third major challenge is that we know quite well what to do to scale up services and to close the treatment gap. In our experience, many decisions that have far-reaching consequences for patients are not made on rational or scientific grounds. Donors, the World Bank, or other UN agencies, often make decisions that are contrary to their principles. All too often, practitioners and governments seem to be driven by the status quo or by private rather than public interest. Many in LMIC know what to do, but often lack the will or the institutions to act. On the other hand, HIC may impress as having well-developed health care systems, but in fact they are often poor role models for resource-constrained countries. Therefore, we have suggested that a fourth challenge is to further develop public mental health or stepped-care models to address inequalities with the help of mathematical modelling to guide health system policy and planning on both local and global scales.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Notes

Biography

Joop T.V.M. de Jong MD, PhD, is staff member of the Amsterdam Institute for Social Science Research of the University of Amsterdam, Emeritus Professor of Cultural Psychiatry and Global Mental Health at the VU University, and Adjunct Professor of Psychiatry at Boston University. He founded TPO, a large relief organization in mental health and psychosocial care of (post) conflict and post-disaster populations in over 20 countries in Africa, Asia, and Europe. Joop de Jong worked part-time with immigrants and refugees in the Netherlands. He publishes in the field of cultural psychiatry, public and global mental health, epidemiology, psychotraumatology, and medical anthropology.

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