The Lancet Commission on Global Mental Health and Sustainable DevelopmentI. Background Vikram Patel, recipient of the GA's Presidential Citation for Lifetime Achievement Award, sharing highlights of the Lancet Commission's landmark report in his keynote address at our Coming Together for Action 2018 conference in Denver. BackgroundOn World Mental Health Day (October 10, 2018), the Lancet Commission on Global Mental Health and Sustainable Development outlined a blueprint for reducing the global burden of mental health problems. The Commission's report builds on more than a decade of work, beginning with the original Lancet series in 2007, aimed at making mental health a global priority. The report relies on scientific evidence to raise awareness of critical issues in mental health globally and to urge investment in reframing the global mental health agenda to emphasize prevention and early intervention, closing the treatment gap, improving quality of care, and addressing the wide range of conditions that affect mental health and well-being. Sustainable Development GoalsCentral to the Commission's report is a call to reframe mental health in the context of the Sustainable Development Goals (SDGs). The seventeen SDGs provide an opportunity for broadening the global mental health agenda to include entire populations. Virtually all of the SDGs relate to mental health; however Goal #3 – Good Health and Well-Being – is specifically applicable to mental health and to the Commission's call to reframe the agenda. Implementing a population approach to mental health will require a coordinated, multi-sectorial approach. The Foundational PillarsThe Commission grounded its agenda in four basic principles:
The need to reframe mental healthThe perception of mental health by the general public matters. When mental health is associated with chronic and severely disabling conditions, it shapes the types of services available and whether or not people seek treatment. The Commission argues that mental health must be reframed to address some of the common barriers to seeking treatment and receiving appropriate care for mental health conditions. What are the barriers?
In offering a "fresh perspective on global mental health and sustainable development," the Commission proposes three key principles to guide the reframing of mental health:
Watch the video, It's Time to Act on Mental Health, to learn more about the need for a new mindset. Taking a dimensional approach to mental health Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community. -World Health Organization Source: Vikram Patel presentation at the Global Alliance's Coming Together for Action Conference, 2018. Mental health is a global public good, which occurs along a continuum from well-being to more serious disorders and recovery. As the Lancet Commission argues, the dimensional approach to mental health balances treatment, rehabilitation, care, and recovery with the promotion of mental health and the prevention of mental disorder. When mental health is reframed as an asset along a continuum, it is possible to see how promoting mental health and preventing mental disorders can reduce the prevalence of serious mental health disorders at the population level over time. Staging approach for mental disordersThe use of a dimensional approach to mental health raises the issue of describing and classifying mental health disorders. The Lancet Commission does not advocate for getting rid of classification systems (e.g., International Classification of Disease (ICD), Diagnostic and Statistical Manual of Mental Disorders (DSM)) because diagnoses are useful in clinical settings. However, in the context of a continuum that recognizes diversity in experience between people, and for the same person, over time, giving an individual a diagnosis can unnecessarily label the individual and diminish his or her agency. Diagnoses oversimplify and undervalue the complexities of personal circumstances. Still, diagnoses are important for clinicians and researchers. According to the Commission, one way of identifying when a person might be considered to have a disorder or diagnosis is to assess functional impairment. Functional impairment is a measure of whether individuals can fill their desired social roles in their community. In the context of diverse cultural and socioeconomic settings, assessing functional impairment is important, so it will remain a priority for global mental health research. However, it cannot be the only criterion used for detecting disorders and for intervening if the goal is to intervene early before substantial disability sets in. Often, a person's functioning declines gradually over time, so opportunities to intervene early also narrow. However, it is often possible to identify the need for care long before a diagnosis can be made. Providing appropriate support and engagement, and paying attention to the individual while promoting self-care, can be useful. The Lancet Commission offers a compromise between the dimensional and diagnostic approaches – the staging model. The model recognizes that opportunities for intervention exist along the continuum. It also implies that appropriate interventions are not only directed to the individual in the form of treatment and care, but also directed at the population level with a goal of strengthening environments to promote mental health and to reduce risk factors. The Commission notes that the staging model is particularly relevant for the developmental phase of adolescence and youth. It's during this period that onset occurs for most mental and substance use disorders, so it's particularly important to intervene early and appropriately. The model is also relevant in primary care settings. Physicians in primary care settings are more likely to see individuals with less severe and more mixed symptoms. Primary care physicians can also identify risk factors that may help in identifying individuals at high risk for developing severe conditions. The Social Determinants of Mental HealthReframing mental health as an asset also enables us to develop strategies for addressing social and environmental factors at a population level that may be harmful to positive mental health and well-being. The Ottawa Charter on Health Promotion identifies the fundamental conditions and resources for health:
Mental health is essential to overall health. It is well-established that an individual's health is shaped by his or her social environment. Understanding this broadens the responsibility for mental health beyond the providers trained to provide medical or psychiatric treatment. Treatment is one of the possible responses to mental disorder, however the resources that can be generated at the community and individual levels are equally as important in providing sustained support. A population approach to mental health focuses attention on the range of social and economic factors that influence mental health. A particularly effective way of addressing the social determinants is to invest in the mental health and well-being of children. |