Monday, December 22, 2014

Two Views on Global Mental Health - Evidence-Based vs. Cultural Sensitivity

The two articles cited below were referenced in one of the weekly "best of" lists that I read, sorry that I can't remember which one. But these two articles offer very different takes on the topic of mental health as a global health concern.

In 2010, a team of scholars from the Harvard School of Public Health and the World Economic Forum issued a report on the current and future global economic burden of disease.
In 2010, the report’s authors found, noncommunicable diseases caused 63 percent of all deaths around the world, and 80 percent of those fatalities occurred in countries that the World Bank characterizes as low income or middle income. Noncommunicable diseases are partly rooted in lifestyle and diet, and their emergence as a major risk, especially in the developing world, represents the dark side of the economic advances that have also spurred increased longevity, urbanization, and population growth. The scale of the problem is only going to grow: between 2010 and 2030, the report estimated, chronic noncommunicable diseases will reduce global GDP by $46.7 trillion.
One surprise was that the report predicted that the largest source of future financial costs would be mental disorders, which the report suggested would account for at least a third of the global economic burden of "noncommunicable diseases" by 2030.
Taken together, the direct economic effects of mental illness (such as spending on care) and the indirect effects (such as lost productivity) already cost the global economy around $2.5 trillion a year. By 2030, the team projected, that amount will increase to around $6 trillion, in constant dollars—more than heart disease and more than cancer, diabetes, and respiratory diseases combined. 

The above quotes are taken from a very recent article in the Jan/Feb 2015 issue of Foreign Affairs, "Darkness Invisible: The Hidden Global Costs of Mental Illness." The article is written by Thomas R. Insel (Director of the National Institutes of Mental Health), Pamela Y. Collins (Director, Office for Research on Disparities & Global Mental Health National Institute of Mental Health), and Steven E. Hyman (Director of the Stanley Center for Psychiatric Research and a core member at the Broad Institute of MIT and Harvard).

All three of these authors have skin in the game, so to speak - their jobs are based on the existence of mental disorders on a wide scale that must be treated. That makes me suspect of their opinions. 

Still, their article is worth a read.  

In the post that referenced that article, the author also mentioned an alternative view presented by and at a collaborative website called Somatosphere, "Global Mental Health and its Discontents." Their article was spurred by a then-recent series of articles and conferences on the topic of Global Mental Health.
Recently, an article in Nature entitled “Grand Challenges in Global Mental Health” (2011) identified mental health priorities for research in the next 10 years, sparking controversy and debate about the appropriate methods for establishing priorities, research themes, and interventions in GMH. This year’s annual Advanced Study Institute (ASI) and Conference, hosted by McGill’s Division of Social & Transcultural Psychiatry (July 5-7 2012) in Montreal, Canada, sought to address these concerns and focused on ways to generate critique of the GMH movement to ensure that its goals and methods are responsive to diverse cultural contexts.
Here is the rest of the introductory paragraph from their article:
The ASI workshop and conference entitled “Global Mental Health: Bridging the Perspectives of Cultural Psychiatry and Public Health.”, was chaired by Laurence Kirmayer and Duncan Pedersen, and was animated with intense discussions about various themes related to the GMH endeavour. The three-day ASI series sought to address ongoing controversies and tensions between a public health approach to mental health (grounded in current evidence-based practices largely produced by high-income countries and exported and adapted to local situations) and a culturally-based approach (which emphasizes local priorities and community-based resources and solutions). The first two days took the form of a workshop bringing together experts in cultural psychiatry, public health and medical anthropology for a consideration of ways to bridge various perspectives on GMH.
The authors present their coverage of the conference discussion "in the form of a debate, giving voice to those in attendance." It's definitely worth the time to read.

Broader Topic

This topic points out one of the many issues with the standard position taken on tackling mental health issues, locally or globally - the opposition between one-size-fits-all, "evidence-based" models approach and an individually and culturally sensitive approach that may not fit the "evidence-based" standards of the NIMH.

Living and working in Tucson has provided me with an opportunity to see this conflict in my daily work. A large percentage of our clients are Hispanic, many of whom are Catholic, but others hold beliefs tied to their indigenous heritage (pre-Spanish influence). Even within our Anglo clients there are wide differences in cultural beliefs, religious beliefs, and socioeconomic status, all of which affects their understanding of themselves and of their place in the world.

The treatments favored by the authors of the first article are very often psychopharmacological, i.e., medications, many (if not most) of which create more problems than they solve. For example, antipsychotic drugs used to treat schizophrenia (the costliest of the mental health issues faced in any nation) actually perpetuate the problems they are meant to treat.
During the mid 1990s, MRI studies found that antipsychotics can cause basal ganglion structures and the thalamus to swell, and the frontal lobes to shrink. Then, in 1998, Raquel Gur at the University of Pennsylvania reported that the swelling of the basal ganglia and thalamus was "associated with greater severity of both negative and positive symptoms." In other words, this research showed that the drugs cause morphological changes in the brain that are associated with a worsening of the very symptoms the drugs are supposed to treat. (Robert Whitaker, Psychology Today, May 18, 2010)
The effects of long-term pharmacological interventions are often cited to explain the apparent disparity between outcomes for psychosis between developing nations (better outcomes) and developed nations (poorer outcomes). The research cited by Whitaker supports that belief.

In a longitudinal study of schizophrenia outcomes by Harrow, Jobe, and Faull (2012), it was found that "SZ patients not on antipsychotics for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery; they also had more favorable risk and protective factors. SZ patients off antipsychotics for prolonged periods did not relapse more frequently."

In his Psychology Today article, Whitake cited another study, in Lapland, Finland, which treated first-time psychosis with a very conservative degree of pharmacological interventions- and the results are striking.
Since 1992, the medical community in the western Lapland region of northern Finland has been using antipsychotics in a selective, cautious manner. At the end of five years, only about one-third of their first-episode psychotic patients have been exposed to antipsychotics, and only about 20% are regularly maintained on the drugs. This is a "continual use" rate similar to the rate for schizophrenia patients from developing countries in the second WHO study, and here are the long-term outcomes for western Lapland's first-episode psychotic patients: Eighty-six percent are working or back in school at the end of five years, and only fourteen percent are on long-term disability. These outcomes are far better than the norm in Western Europe and the rest of the developed world.
Because Finland is a developed nation, this research supports the belief that the deciding factor in why people in developing nations have better outcomes in psychosis is not necessarily due to cultural factors (such as wider family support or better social support), but may largely be due to the pharmacological interventions that are the primary line of treatment in developed nations.

In fact, Parmanand Kulhara (2009), whose research suggests that the difference in outcomes between developed and developing nations is real, notes in his review that “culture should not be used as a synonym for unexplained variance” (Asian Journal of Psychiatry, 2(2); 55-62) - further, "exact factors and the mechanisms subsumed under “culture” that influence outcome and course are still hidden; thus, the “black box” still remains unopened."

It is unlikely that treatment methods in the U.S. are going to change any time soon - pharmacological interventions are considered the primary method, and the only beneficial treatment, for schizophrenia and psychosis.

If you develop symptoms and are lucky enough to find a therapist who understands that psychosis is "a natural though very risky and haphazard process initiated by their psyche in an attempt to cope and/or heal from a way of being in the world that was simply no longer sustainable for them" (Full Recovery from Schizophrenia?,

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