Establishing a Framework for Global Mental Health Diplomacy

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Policy Brief by Manaswini Kar, Keerthana Manikandan, and Jonathan Klonowski

With at least one-eighth of the entire global population living with mental illness, the world stands at risk of a mental health pandemic. In addition to being a disability, mental illness increases the risk of physical ailments such as heart attack, diabetes, and stroke. Unfortunately, our understanding of mental illness lags behind our understanding of other illnesses. This is additionally exacerbated by the additional burden of an attached stigma. Thus, concerted efforts on the global stage can play a pivotal role in preventing this crisis. This starts with expanding international research efforts to accelerate therapeutic development while also leading a united effort to increase mental health resource uptake by combating stigma.

The World Health Organization (WHO) estimates that at least 12.5% of people suffer from mental illness, making it the leading cause of years lived with disability across the globe. Psychiatric disorders can manifest as specific mental or behavioral patterns affecting individuals’ personal, professional, and social functioning. Several studies (GBD 2019 Mental Disorders Collaborators, 2022; Patel, 2007) have found that mental health issues are a major concern not just for high-income nations, but also for low and middle-income countries (LAMICs). These illnesses reduce quality of life and impede everyday activities in addition to increasing the risk of suicide, self-harm, and other diseases such as stroke, heart attack, and diabetes. Yet, studies have found devastatingly high numbers of mental health patients in low- and middle-income countries lack access to treatment (Sweetland et al, 2014, Petersen et al, 2014,). With the global rise of mental health needs post-COVID-19, it is high time to add the impetus to expand collaborative international efforts into combating a potential global mental health pandemic. To this end, building diplomatic ties focusing on the mental health needs of the global community can play a crucial role in promoting international research efforts, generating invaluable data for the diagnosis and treatment of several elusive psychiatric conditions. Additionally, investing in the mental and social welfare of other nations, can promote political stability and global stability by 1) ensuring sustained export markets and 2) decreasing the likelihood of radical governments or terrorist activities. These efforts would provide additional indirect benefits for the United States, including communicating US values and building soft power through relationship building. Overall, a healthier global population translates to a motivated workforce, which is crucial to building capital in an economically-interdependent world.

There are three major challenges to advancing global mental health that such concerted global efforts can address:

1. Inability of existing research systems to produce an effective understanding of mental health: In recent decades, the world has made strides in understanding the systems that contribute to psychiatric disorders, with studies having made remarkable discoveries about the societal, biological, and genetic foundations of illnesses such as depression (Deng et al, 2020; Nettis & Pariante, 2020; Nemeroff, 2020; Torres-Berrío et al, 2022) and schizophrenia (Feng et al, 2020; McCutcheon et al, 2020; Dennison et al, 2020). Despite this, our knowledge has lagged in comparison to ailments of other organ systems, with pharmaceutical therapeutics still being employed by trial-and-error instead of targeted treatments. These shortcomings can be explained by the fact that there is a fundamental misalignment between the scale of global challenges and the structures of science funding. Research is most often conducted in isolation by individual countries and output has been historically restricted within European ancestries in the global north (Peterson et al, 2019), with support for global multilateral scientific cooperation being insufficient and fragmented. For example, the Institutes such as the National Institutes of Health’s Fogarty International Center has limited funding for international researchers, and the amount of funding for US-based researchers to conduct research internationally is scant. Further, most of the  knowledge generated by current systems is narrowly-focused, fragmented and compartmentalized. These issues are all magnified in mental health research where the complexity of the brain, the limited usefulness of model organisms, and additional factors such as personal microbiome and society make a uniquely complex problem.
2. Scarcity of medications and professionals in LAMICs: LAMICs are some of the worst hit by mental disorders; unfortunately, most of these countries have the largest differential in the availability of mental health resources, including common psychiatric drugs (Rathod et al, 2017; Saxsena et al, 2007) According to WHO, nearly 20% of countries lack at least one common antidepressant, antipsychotic, or antiepileptic drug in their primary care facilities (McDaid et al, 2013). The access to mental health care professionals in developing countries also paints a similarly discouraging picture, with a median availability of approximately half a  psychiatrist and four psychiatric nurses per million people in low-income countries (Fricchione et al, 2012). Moreover, offering mental health resources as aid alone will not suffice in addressing the issue, as these offers may be haphazardly accepted or outright rejected owing to the stigma of mental illness (Mehta et al, 2015). Only after making substantial gains in combating the stigma of mental health worldwide can the challenge of effectively disseminating mental health resources begin.
3. Insufficient global policy development and implementation: Another major hindrance to global mental health is the lack of impetus on the international front. Although WHO devised a comprehensive mental health plan that sets clear goals for its member states, its implementation is lacking. One-third of all countries still have no mental healthcare policy or plan, and nearly 40% of the countries with such policies have not updated them since 1990 (Saxsena et al, 2007). As a further issue, 22% of countries have no relevant legislation or human rights to protect people with mental disorders (Saxsena et al, 2007). Major societal factors, such as stigma, religion, ethnicity, and caste, neuter the actualized policy impacts of a top-down approach often employed by the UN.

Where can mental health diplomacy step in?

The lack of expressed urgency to address the issue of mental health can be traced back to a poor understanding of the biological basis of mental health and the stigma surrounding mental health. Whether it be accepting that a country’s population stands to benefit from serving those suffering from mental illness through medical aid, policy reforms, or funding research facilities to study mental health disorders, addressing the stigma around mental health and building a comprehensive database would go a long way to bringing improvement. To set up a global alliance for mental health, we propose three solutions:

1. Establish a mission-oriented international multidisciplinary research hub for the treatment of mental illnesses. While factors like insufficient research designs and differing definitions of diseases across countries (Henriksen et al, 2017) contribute to our poor understanding of psychiatric disorders, the historic lack of diversity in populations studied forms a significant roadblock towards uncovering the complete picture of mental illnesses. The authors of a schizophrenia study, containing data from a cohort as expansive as 35,500 subjects, acknowledged that a study with higher genetic variance would ultimately lead to better clinically relevant results  (Donovan, 2015), which is just a mere illustration of many such cases. Such diverse studies necessitate cross-national research abroad, often relying on personal connections with local scientists, governments, organizations, and communities. Establishing research hubs and consortiums can formalize these partnerships, creating structured channels for the creation and expansion of research. A research consortium is a mechanism by which many independent researchers and organizations come together to conduct research under a standard governance model to address a common set of goals. The UN should be leveraged to lead a  global initiative to form an international consortium with equal representation from each continent. In such a consortium, member countries should equitably contribute towards training and maintaining research staff, data collection, analysis, storage, and translating findings into clinical settings. The consortium would prioritize large-scale epidemiological studies collecting behavioral, sociocultural, behavioral, physiological, genetic, and epigenetic data to understand the complex interactions of all these factors that lead to mental disorders. Data compiled by regional hubs responsible for several local research institutes could then be distilled by a global hub and disseminated to the wider public. Organizational precedents at the global level have been successfully set by UN organizations such as UNEP, UNDP, and WHO. Further, institutes like SSPsyGene Consortium, Neuroimmunology of Mood Disorders and Alzheimer’s Consortium, and Psychiatric Genomic Consortium have set the scientific precedents and technical requirements for expanding these endeavors to encompass a larger number of disorders over more diverse populations across the globe.

Further, ensuring equitable representation from LAMICS across research subjects, researchers, and stakeholders would ensure that a diverse set of genetic backgrounds, perspectives, and needs are brought to the table (Goode and  Landefeld, 2018). This can potentially lead to greater research yield, international buy-in and potentially groundbreaking new paradigms on mental illnesses.

2. Facilitate knowledge exchange between researchers and stakeholders by leveraging government and embassy-led initiatives. While research can improve our basic understanding of mental illnesses, a significant impediment to the effective utilization of such knowledge is the prevailing stigma around mental health which is even more prominent in developing countries (Lauber and Rossler, 2006; Mascayabi et al, 2015). Countries should leverage their diplomatic institutions to initiate efforts to destigmatize mental health and promote mental health research. For example, embassy-sponsored mental health conferences could invite scientists and local leaders, including community, spiritual, or faith leaders, to discuss the science of mental health and share stories of overcoming mental health struggles through communal, medical, or psychological intervention. In this “model” approach, trusted and highly regarded community and public figures would serve to inspire others and talk about mental health. Region-specific resources must be distributed at such events, with community leaders being invaluable vessels in disseminating knowledge within their respective groups.

3. Reallocate medical aid specifically for mental health needs. In October, 2020, WHO reported that mental health currently receives less than 1% of the global aids meant for health.  The US is one of the largest global aid donors with an annual budget of $61 billion for economic and military assistance to foreign countries. Institutions in US such as the Centers for Disease Control and Prevention, National Institutes of Health, and others have played tremendous roles in developing drugs and vaccines for infectious and communicable diseases, training medical personnel and researchers,  as well as deploying their own medical staff and scientists across different parts of the world including Africa, Latin America and East Asia. A part of these existing facilities can be easily repurposed for mental health needs. Funds and personnel can be allocated to train mental health-care professionals and researchers, in addition to building the necessary infrastructure e.g. psychiatric facilities and research institutes in LAMICS. Moreover, a proportion of the current aid can also be redirected towards procuring psychiatric drugs to increase their accessibility at primary healthcare institutions in these countries.

Even after a country prioritizes mental health as a key issue and accepts aid, creating an impact is not a foregone conclusion. Given that institutional systems and trusted effectors are different in each country, the distribution of aid can look very different depending on the nation.  For instance, the UN employs the Humanitarian Cluster System in disaster situations to coordinate a response involving organizations at the global, national, and local levels. Extending this principle to global mental health, bringing in different governmental agencies, researchers, practicing mental health professionals and non-governmental organizations to work with international institutions must be key pillars to formulating a response. In this way, international organizations can utilize region-specific knowledge to leverage local systems to facilitate the distribution of mental health aid like psychiatric drugs and psychotherapeutic services.

In a nutshell, the world currently stands at the precipice of a global mental health pandemic. Mental disorders affect about 13% of the world population, with huge individual and societal implications. Therefore, there is an urgent need to create an international collaborative effort to combat them. Through this article we explored possible solutions ranging from establishing a truly global research consortium dedicated to mental disorders to leveraging diplomatic relationships across countries to facilitate the spread of knowledge, societal awareness, and resources. We firmly believe that such concerted multifaceted efforts at a global scale can help tackle the complexities of mental health in a timely manner.

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Written by Manaswini Kar, Keerthana Manikandan, and Jonathan Klonowski

Edited by Kayla Lim and Honoreé Brewton

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