Introduction

Global mental health is an emerging science and the scientists and clinicians engaged in this work are aggressively working to bring this neglected issue to the forefront. Their actions are motivated by the knowledge that the extent of poor mental health is widespread with catastrophic public health impact, and that significant challenges to well-being exist for individuals, families and communities particularly those living in poorly resourced environments. More than 450 million people globally suffer from mental health challenges with 1 in 4 individuals affected by a mental illness (WHO, 2010a); however, two thirds of those in need of mental health treatment never receive it (WHO, 2001a). Mental illness constitutes roughly 13 percent of the global burden of disease, outpacing cardiovascular disease and cancer (WHO, 2001a) with depression expected to be the second highest cause of disease burden in middle-income countries by 2030 (WHO, 2010a). Suicide is ranked as the third leading cause of death in 15- to 44-year-olds and the second cause of death in 10- to 24-year-olds (WHO, 2014), a statistic that translates into 800,000 to one million deaths annually.

Globally, more than 40 percent of countries have no mental health policy (WHO, 2001a) and additionally, one-third of countries allocate less than 1 percent of their health budgets to mental health. There are fewer available mental health beds to address existing needs, with ranges of 5–50 beds per 100,000 population depending on low-, middle-, or high-income country status (WHO, 2014). Globally, nurses are the most prevalent health care professionals and constitute the largest group working in mental health (Morris, Lora, McBain, & Saxena, 2011). However, we argue that nurses are not being fully utilized as resources in mental health promotion and prevention efforts across all countries.

The assertion made in 2005 that, “there can be no health without mental health,” (WHO, 2005, p. 11) endorsed and supported by the World Health Organization (WHO), appears to have been a timely catalyst for an increased focus on obtaining prevalence data on mental, neurological and substance use disorders globally, and for bringing about widespread discussion of mental health and prevention of mental ill health. However, variability exists across countries at multiple levels when looking at drivers known to promote or impede mental health or well-being. At the macro system level, areas that are the responsibility of governments include ensuring healthy economic conditions, developing and enforcing humanistic policies, valuing comprehensive well-being of its citizenry and promoting knowledge by making education accessible for all. These factors provide a basic underlying framework for health, including mental health. Building on these, safeguarding human rights as a fundamental underpinning of well-being, early case finding, ensuring availability of treatment resources (human, materials and services), stigma elimination, supportive cultural attitudes, consumer awareness, mental health literacy and mental health promotion strategies are critical ingredients to further support mental health. The process of global mental health awareness and promotion, research, and developing evidence-based treatment strategies to fit specific resource-able and culturally distinct contexts is developmentally in its infancy across different global communities. New models of treatment must be developed, including intentional integration of mental health care in primary care, task sharing through the use of traditional healers and non-specialist workers in low resourced environments, and expanded use of technology to begin to meet the vast mental health needs that exist and that cannot be managed with the existing number of trained mental health care providers who primarily reside in cities or more populated regions within countries. Without healthy human contributors to societal development, the specific community, state, region or country remains at a disadvantage, fails to flourish and lags behind comparable entities across multiple measures of overall health, including mental health.

Non-communicable disease burden, of which mental health is a component, increased from 36 percent to 49 percent in low- and middle-income countries from 1990–2010. During the same time frame, non-communicable disease burden in high-income countries saw only a 4 percent increase (Charlson et al., 2015). Cause specific deaths (one underlying cause) resulted in 775,000 deaths attributable to Alzheimer’s and other dementias, alcohol abuse and epilepsy. Excess deaths (due to multiple factors) accounted for over 8 million deaths and were associated with alcohol use disorder, schizophrenia, Alzheimer’s and other dementias and opioid misuse. Other mental disorders such as bipolar, major depression, autism, and intellectual disability resulted in 4.5 million deaths (Charlson et al., 2015).

This chapter will provide the framework for understanding the emergent field of global mental health as will be described throughout this text, define common terminology, discuss incidence and prevalence of major neuropsychiatric disorders, describe characteristics of low-, middle-, and high-income countries, illustrate consequences of unmet mental health needs and identify individuals and organizations leading the global mental health movement.

The purpose of this textbook is to provide a nursing perspective on the global mental health crisis, describe prevention, mental health promotion and evidence-based treatments, and present several in country exemplars with individuals and groups experiencing mental and behavioral health challenges. Nurses, as the largest health care profession globally can make significant contributions to improving mental health across all income communities and the profession can play a more significant role in the movement for global mental health and the evolution of global mental health science.

Low-, middle-, and high-income countries

On an annual basis the World Bank determines Gross National Income status of World Bank members and other countries with populations greater than 30,000. The three factors examined are country income level, region of the world in which the country is situated and country lending status.

Low-income countries are defined as countries with citizen incomes of $1035 or less annually. Examples of countries in this category include the Central African Republic, Democratic Republic of the Congo, Cambodia, Afghanistan, Ethiopia, Haiti, and Uganda.

Middle-income countries are countries in which citizens on average earn between $1036 and $12,615. Examples of countries in this category are Angola, Brazil, China, Columbia, Costa Rica, Cuba, Turkey, and the Dominican Republic.

High-income countries are countries in which citizens on average earn greater than $12,616 annually. Countries in this category include the United States, Canada, England, Australia, France, Germany, Belgium, and Argentina (World Bank, n.d.).

Mental health and mental illness

Mental health has been defined as, “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” (WHO, 2001b, p. 1). While mental health is achievable in individuals across the lifespan, it is increasingly clear that overall psychological wellness or mental well-being is dependent on factors frequently outside the control of the individual. These external factors termed social determinants of health (SDH) include environmental conditions that exist where people are born, live, work, and play; socio-economic status such as poverty; access to education and subsequent health literacy; race and gender; early childhood experiences associated with social advantages or disadvantages; availability of and access to resources including health care services; lack of or ineffective policies, and individuals and communities who have been disempowered (Braverman et al., 2011; Friel & Marmot, 2011). In addition, biological risk for mental illness exists, rendering some more vulnerable as most psychiatric disorders have a genetic basis and frequently originate in childhood or adolescence. Recently there has been a push to replace the term mental health simply with well-being due to the stigma associated with the terminologies of mental health and mental illness. Both terms, mental health and well-being will be used in this textbook.

Mental illness, at times referred to as mental ill health, is a brain disease manifested when the individual experiences alteration in thinking, mood or behavior often accompanied by distress and/or impairment in functioning, disability or mortality (WHO, 2013). Addressing and ameliorating individual vulnerabilities across multiple areas must become the focus of effective interventions to avoid or mitigate mental ill health. The burdens associated with mental disorders include poor health literacy, poor quality of life, inability to achieve one’s potential, isolation, and potential for shorter life expectancy. There are an estimated 450 million people worldwide living with a mental illness and of that number, approximately 50–85 percent who are in need of mental health services do not receive them (Demyttnaere et al., 2004). In low-income countries less than 1 percent of health spending is allocated to mental health. In middle-income countries approximately 2.5 percent is spent on mental health, and in high-income countries, 5 percent of health care dollars are earmarked for mental health services (WHO, 2011).

Along with the sparse allocation of financial resources dedicated to mental health promotion and treatment, many countries are either missing written policies or plans, or have outdated documentation outlining a vision for ensuring the mental health of its citizenry. In addition, accurate data collection on prevalence, monitoring of services and research on treatment effectiveness are missing, primarily in low- and middle-income countries. Variability across countries in the area of data collection methodology impacts the quality, accuracy and completeness of what truly exists and what is known. Without these data, it is difficult to make a compelling case for reallocation of funds even if they were available (WHO, 2013). Global mental health scientists are aggressively striving to rectify this situation.

Global Burden of Disease (GBD) represents epidemiological data reflecting risk factors, mortality, morbidity, health and injuries associated with disease burden. GBD incorporates prevalence and disability to arrive at an estimate of years lived with disability (YLDs). In addition it collects data on number of years that are lost to premature mortality (YLLs). The sum of both of these factors yields to disability-adjusted life years (DALYs). The 2010 GBD survey indicated that mental, neurological, and substance use disorders were the leading cause of YLDs, accounting for more than 10 percent of the global burden of disease (Whiteford et al., 2013; Whiteford, Ferrari, Degenhardt, & Feigin, 2015). These chronic and non-communicable diseases more significantly impact low- and middle-income countries. Table 1.1 illustrates the WHO GBD for neuropsychiatric disorders and Table 1.2 provides a comparison between WHO and the Institute for Health Metrics and Evaluation (IHME) across neurologic, mental, behavioral, self-harm, and inter personal violence dimensions.

General information on calculating the burden of disease for mental ill health (unrelated to the WHO Mental Health Atlas 2011)

There are two global health authorities that calculate the global burden of disease (GBD) for mental ill health, the Institute for Health Metrics and Evaluation (IHME) and the World Health Organization (WHO). The IHME and the WHO calculate the GBD for mental ill health by classifying conditions according to type, and both organizations classify conditions differently. The GBD can be reported according to Disability Adjusted-Life Years (DALYs) where one DALY equates to one lost year of “healthy” life.

The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences.

(World Health Organization, n.d.)

Overview of mental health challenges

Mental, neurological/neurodevelopmental and substance use disorders all present challenges to individuals, families, and communities, impacting global burden of disease, economies, and overall health across multiple environments. Low- and middle-income countries are particularly challenged to adequately assess prevalence, develop and implement evidence-based treatments, have adequate human and treatment resources, and to provide long-term supports to maintain mental health. Each of these categories is briefly described below and will be explored in greater length throughout this book.

An upper middle-class country exemplar

China, with a population of 1.3 billion people, reportedly has over 100 million people with mental health challenges (Tse, Ran, Huang, & Zhu, 2013), but accurate data is difficult to obtain. With this volume of individuals and families in need of treatment, the current 4 percent of health budget allocated for mental health along with the lack of inpatient resources created a crisis, which resulted in critical changes. The health budget targeting mental health has recently been doubled, resulting in mental health surveillance and work plans to target surveillance data, and additionally, the first National Mental Health Law has been passed. The law supports voluntary treatment, prevention and rehabilitation, expands the role of non-governmental organizations (NGOs) in providing services, promotes scientific research and international collaboration, puts in place social services to support individuals and families in need and provides resources to finance services (Phillips et al., 2013; Zhou & Xiao, 2015).

Ultimately, unmet mental health needs have serious consequences. Table 1.4 provides a brief list of these effects on individuals. These consequences will be discussed throughout this textbook, reiterating the urgency for an intentional and comprehensive approach to eliminating challenges associated with achieving mental health and well-being.

Global mental health advocates

Numerous organizations have begun to include concepts associated with advancing mental health in their mission, have developed goals to achieve improvement in psychological well-being of individuals, and have identified strategies to improve conditions that contribute to overall community well-being. These organizations include the United Nations (UN), the World Health Organization (WHO), regional WHO offices (in the Americas, Africa, Eastern Mediterranean, Europe, South-East Asia, and Western Pacific), the National Institute of Mental Health (NIMH), Non-Governmental Organizations (NGOs), the World Bank, Human Rights organizations, religious institutions and the London School of Hygiene and Tropical Diseases. While these steps are crucial and laudable, the overwhelming needs and low resource status of some countries makes this work daunting.

The Millennium Development Goals (MDGs) developed by the UN in 2000 identified goals that were complementary to the social determinants of health but did not specifically identify or include mental health or psychological well-being as a goal. Work on achieving the MDGs spanned the period 2000 to 2015. The UN is now in the process of replacing MDGs with Sustainable Development Goals (SDGs). The goals of the original MDGs were to: 1) eradicate extreme poverty and hunger; 2) achieve universal primary education; 3) promote gender equality and empower women; 4) reduce child mortality; 5) improve maternal health; 6) combat HIV/AIDS, Malaria and other diseases; 7) ensure environment sustainability, and 8) develop global partnerships for development (UN-WHO Policy Analysis, 2010). More recently the Movement for Global Mental Health asked the UN to include three components in the new SDG’s that relate to social determinants of health. These include:

1. Promote protection of human rights and prevent discrimination against people with mental illness and psychosocial disability.
2. Bridge the massive mental health treatment gap and improve access to health and social care.
3. Integrate attention to mental health into development initiatives.

(Eaton, Kakuma, Wright, & Minas, 2014)

The SDGs will be constructed with broad input from ministers of health, health care professionals, consumers and advocacy groups from around the world and are expected to be aligned with identified goals of participating low-, middle-, and high-income countries. The broad guiding principles driving goal development for this next round of global health goals include human rights, treatment gaps, equality, and sustainability.

As the mental health crisis continues and expands into all age groups and across borders, it is important to identify seminal works, movements, and organizations that are intentionally working to improve mental health for all. The focus has been on acquiring accurate prevalence data, developing community-involved interventions, training lay individuals from the community and culture to deliver interventions and support those with mental and behavioral challenges, working to decrease stigma, and providing research-informed education to promote mental health literacy in both professional and lay communities. The following is a partial resource list illustrative of this work.

Seminal documents, organizations and advocacy groups in the field of mental health promotion

1. mhGAP: The Mental Health Gap Action Programme of the World Health Organization works to promote government and stakeholder action to scale up services and interventions to provide care for those challenged by mental, neurological, and substance use disorders. mhGAP developed the Mental Health GAP Evidence-Based Treatment Intervention Guidelines for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings (WHO, 2010b) and the mhGAP Humanitarian Intervention Guide (WHO, 2015).
2. WHO: The World Health Organization was established in 1948 by the United Nations and identified as the leading authority worldwide to direct and coordinate the health of all nations within the United Nations. The mission of WHO “in the area of mental health is to reduce the burden of mental disorders and to promote the mental health of the population worldwide” (WHO, 2011). To accomplish its mission, the WHO promotes leadership, research, health standards, importance of using evidence to inform actions and treatments, disease surveillance and response, technical support, education, and monitoring of health conditions. It provides a significant body of work on its website on a variety of health and mental health related topics. WHO has been at the forefront in responsiveness to both communicable and non-communicable diseases, health systems, health promotion and preparedness.
3. Mental Health Atlas: The Mental Health Atlas series is a publication of the WHO that was started in 2001. Subsequent versions of the document were in 2005, 2011 and most recently, 2014. The goal of the Atlas series is to “collect, compile and disseminate relevant information on mental health resources available within countries” (WHO, 2011). This evidence-based document chronicles global trends in the field to support advocacy and action to support an increase in resources, direct research activities, and ultimately catalyze a positive change in conditions.
4. The Lancet Series: The Lancet Mental Health Series of 2007 and 2011 was a groundbreaking set of scholarly papers that brought together researchers and scientists from around the world who engaged in methodical and comprehensive descriptions of initial and updated mental health conditions in low-, middle-, and high-income countries. The authors of many of the papers continue to conduct research and disseminate updated data on a variety of mental health issues. The series can be accessed at: www.thelancet.com/series/global-mental-health and www.thelancet.com/series/global-mental-health-2011.
5. Human Rights Advocacy: Human Rights Advocacy groups work to advocate for victims of human rights violations. Globally most countries have ratified international treaties endorsing human rights and humanitarian laws.
6. Movement for Global Mental Health: The Movement for Global Mental Health (MGMH) is a network of individuals and organizations, whose goal is to improve services for people with mental and psychosocial disabilities worldwide. MGMH prioritizes their work in low- and middle-income countries with a focus on scientific evidence and human rights protection. Additional information can be obtained at www.globalmentalhealth.org.
7. Grand Challenges Canada: The Grand Challenges Canada was established in 2010 to support Bold Ideas and Big Impact global research. The research must identify a barrier that if removed would help solve a significant problem in a developing country. Global mental health is one of the portfolios funded. Additional information can be obtained at www.grandchallenges.ca/grand-challenges/global-mental-health.
8. National Institute of Mental Health (NIMH) (USA): NIMH strives to promote understanding and treatment of mental illnesses by engaging in and advancing basic and clinical research aimed at prevention, recovery and cure. NIMH is the largest organization in the world that endeavors to comprehend brain science and human experiences that contribute to behaviors. The 2016 NIMH operating budget is $31.3 billion dollars. Additional information can be obtained at www.nimh.nih.gov.
9. Substance Abuse and Mental Health Services Administration (SAMHSA) (USA): SAMHSA was established in 1992 to advance behavioral health and decrease the impact of substance abuse and mental illness in communities within the United States. The 2016 budget of 3.7 billion dollars will target goals of building strong communities, strengthen crisis systems, increase the behavioral health workforce, develop strategies to combat prescription drug and opioid abuse and support behavioral health needs in tribal communities. Additional data can be obtained at www.samhsa.gov.
10. Pan American Health Organization (PAHO): Founded in 1902, PAHO is an international public health agency and Regional Office for the Americas of the World Health Organization that provides technical support and fosters partnerships in countries in the Americas, Canada and the Caribbean. Their Non-Communicable Diseases and Mental Health branch focuses on prevention and control of non-communicable diseases, identifying and mitigating risk factors for mental, neurological, and substance abuse disorders that are culture specific. It raises public awareness, supports capacity building, and promotes policies, programs and services to enhance mental health. Additional information about PAHO can be obtained at www.paho.org.
11. Center for Global Mental Health (www.centreforglobalmentalhealth.org) at the London School of Hygiene and Tropical Medicine (www.lshtm.ac.uk): A renowned center that focuses on public and global health research, scholarship and education with a goal of translating knowledge to practice and policy.
12. WHO MiND: Mental Health IN Development: This is a WHO Quality Rights online tool of national and international resources used to end discrimination and violations against those with mental and behavioral disabilities. Additional information can be obtained at ww.who.int/mental_health/policy/contact/en/.
13. WHO AIMS: This is an assessment tool to determine the overall quality of mental health systems. The tool focuses on six domains containing 156 items. Additional information about AIMS can be found at www.who.int/mental_health/WHO-AIMS/en.
14. WHO comprehensive mental health action plan (2013–2020) as shown in Table 1.5.

Conclusion

For the past 15 years there has been an intentional and dynamic focus on bringing an accurate picture of global mental health needs to the forefront and to the attention of those in positions to make necessary changes in the plight of those affected by mental ill health. These efforts are in response to a real crisis wherein only one out of four individuals globally is receiving treatment for their mental health needs. Stigma, poor knowledge of the etiology of mental, neurologic and substance use disorders, and an exclusive and long-standing focus on physical illnesses and communicable diseases have placed contributions to mental ill health at the bottom of the list of health-related priorities. However, it is increasingly clear that overall health or well-being is intertwined with both one’s physical and mental health. Unfortunately, significant disparities exist across low-, middle-, and high-income countries in the areas of mental health literacy, treatment resources (human, facilities, and medications), accuracy of prevalence data, access, stigma, and engagement in research, to inform culturally congruent mental health treatment inter ventions.

At the forefront of the global mental health movement are the World Health Organization, researchers from the UK, Australia, the United States and Canada, non-governmental organizations and the World Bank, among others. Concerted efforts have been under way to disseminate information in multiple venues in order to call attention to the crisis surrounding a significant increase in global mental ill health and the companion threats to individual well-being.

Globally, as stated earlier, nurses are recognized as constituting the largest number of health care providers in all countries, and represent an untapped resource in the movement to impact positive changes in mental health. In addition to supporting and showcasing the aforementioned trailblazers in the global mental health movement, this textbook will acquaint the reader with data, primarily from mental health nurses, about successful strategies engaged in with this population; endorse evidence-based interventions for use in low-, middle-, and high-income environments, and offer new ways of thinking and intervening with individuals challenged by their emotional and mental health vulnerabilities. Many of the mental health nurse scientists who contributed to this textbook support a strong focus on prevention, mental health promotion, mental health literacy, integration of mental health into primary care, and working aggressively with communities to decrease stigma, while providing culturally sensitive mental health care with individuals and groups within diverse communities. This textbook is a unique contribution to the nursing literature in that it offers nurses and other health care providers real-life and relevant experiences from the field about mental health across different countries, shares the voices of nurses working in different environments as they strive to promote mental health, and presents innovative strategies to assist with navigation of policy, practice, research, and advocacy roles. This textbook can serve as a tool kit when working with consumers, other mental health professionals, and those outside of the health care field who are engaged in developing a greater understanding of mental health, mental ill health, and the process of mental health promotion.