Week 2: Defining Global Mental Health Social and Cultural Determinants of

Health

Readings:

1. Collins, P. Y., Patel, V., Joestl, S. S., March, D., Insel, T. R., & Dar, A. S.
(2011). Grand
challenges in global mental health. Nature, 475(7354), 27–30.
https://dx.doi.org/10.1038%2F475027a
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3173804/

Notes:
 Limited understanding of the brain and its molecular and cellular mechanisms
 Effective treatments are not available.
e.g. anti-Parkinsonian treatments are excluded in primary care
 Unequal distribution of human resources, between and within countries,
 4 differences of mental health: Global scope, Delphi method, covers full range of
MNS disorders, build a wide-ranging community of research funders.
 Grand challenge: a specific barrier that, if removed, would help to solve an
important health problem. If successfully implemented, the intervention(s) it
could lead to would have a high likelihood of feasibility for scaling up and
impact.
 Challenges:
a) Life-course approach - risk factors and disorders affecting kids and elderly,
build mental capital – people’s contribution to society and well-being
b) Suffering caused by BOTH patient and the community - health-system-wide
changes, social exclusion and discrimination
c) All treatment interventions need evidence base - provide program planners
d) Environmental exposures and MNS disorders – wars, poverty, natural
disasters
Thoughts:
I think the grand challenge of mental health can result from two factors: limited
evidence-based research, and unequal distribution among countries. Unlike common
physical diseases, one’s mental health disorders can be caused by different factors,
even though the person has similar symptoms to others. It’s always hard to track the
causes of a mental health disorder. Sometimes one disease also has a complication
with it, and thus, lots of research are required to come up with an effective treatment.
But as Collins demonstrated in the article, some treatments, like anti-Parkinsonian
treatments, are not required in primary care. This kind of reflects the ignorance of the
government and countries, or maybe the nation focused more on other challenges that
are more urgent. For example, people suffering from wars may care more about their
housing, careers, physical health, etc. They don’t have more energy to pay attention to
their mental health, which is less visible than other challenges.
2. Kirmayer, L. J., & Pedersen, D. (2014). Toward a new architecture for global
mental health. Transcultural Psychiatry, 51(6), 759–776.
https://doi.org/10.1177/1363461514557202
https://journals.sagepub.com/doi/pdf/10.1177/1363461514557202

Notes:

 Cultural critique of global mental health raised issues:

a) Most framed by professionals in wealthy countries and focused on local areas
b) Rough estimates of major neuropsychiatric disorders - stable features, course,
and outcome
c) Assumes that standard treatments can be applied across cultures with
minimal adaptation
d) Emphasize professional interventions but marginalize indigenous forms
 Koplan - a comparative framework for public health, international health, and
global health domains: geographical reach, cooperation level, focus on
individuals and/or populations, health equity, and disciplines range.
 4 moves that GMH made:
a) Document the enormous disparities of mental health in low- and middle-
income countries
b) Mental health problems should be given a high priority in development
goals and the allocation of resources at all levels of government and
economic institutions
c) Frame the disparity in terms of a treatment gap; relative lack of adequate
mental health services
d) Respond to the treatment gap
 Critics of the GMH movement:
a) Estimates in low and middle-income countries/regions are based on limited
data
b) Social inequalities, poverty and unemployment, structural violence, war and
conflict on local/global scales are important determinants but are missed
c) Privileges mental health professionals but ignores or downplays
community-based and grassroots approaches
d) NOT culturally appropriate, feasible, or effective in other contexts;
predetermine the types of intervention (medication/simple, standardized
behavioral interventions > complex psychosocial interventions)
 Culture contributes to social determinants:
a) Produces categories of identity and social practices that disadvantage
specific groups
b) Aggravate or mitigate particular forms of adversity (e.g., provide
relationships, spiritual practices, or notions of meaningful activity that
change the meanings of poverty and social exclusion)
c) Mediate effectiveness of interventions at population/individual levels
d) Shapes the definitions, values, and priorities of well-being
 CSDH focus on the contextual, supraindividual factors:
a) The extraordinarily unequal social distribution of disease-related morbidity and
mortality
b) Social causation of disease and disability
 Mental disorders depend not solely on access to services, medication, skills, and
the availability of professional care, but also on the reactions, care, and support
provided by family members and the immediate social network of community
resources
 The concentration and accumulation of resources by an elite few will reinforcing
further social inequalities, increasing insecurity and instability, increasing
conflicts and violence, and more suffering, disease, and death.
 EBP (Evidence-based practice)
a) Improve the quality, effectiveness of mental health practice by grounding
clinical care in interventions for which we have good empirical evidence of
effectiveness.
b) Commits a set of methods for generating evidence; base clinical practice on
scientific research and rational decision-making; and use science to guide
health policy and services, and arbitrate conflicts and legal disputes
c) Evidence is not produced on a level-playing field – samples are
unrepresentative of real-life populations, exaggerate positive effects and
undisclosed negative results.
Thoughts:
 (pg. 12) Hence, efforts at mental health literacy must be rethought. Rather than a
one-way transmission of knowledge from scientific experts to an ill-informed
public, education is better conceived of as a symmetrical and bidirectional
exchange of knowledge, values, and perspectives.
 Totally agree with this. It’s difficult to explain what I learned to those who don’t
study psychology. The most question I met with is “Oh, you learn mental health,
can you guess what I am thinking right now?” or even “It sounds dangerous, you
can hypnotize (hip ne tize) me?” So it’s really hard to explain to those who don’t
have a similar psychological education background, because they don’t
understand the terminology. And I think maybe during the conversation with the
public, the professionals can also listen to the perspectives of the public. Because
what they assumed is important may not be consistent with what the public really
cares about.

3. Kleinman, A. (2009). Global mental health: a failure of humanity. The

Lancet, 374(9690), 603-604. https://doi.org/10.1016/S0140-6736(09)61510-5
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61510-
5/fulltext

 Individuals with mental disorders are treated cruelty; patients in east and
southeast Asian towns and villages chained to their beds
 Moral issues and stigmatization of mental health illness
4. Marmot, M., Friel, S., Bell, R., Houweling, T. A. J., & Taylor, S. (2008).
Closing the gap in a generation: health equity through action on the social
determinants of health. The Lancet, 372, 9650, 1661-1669.
https://doi.org/10.1016/S0140-6736(08)61690-6
http://www.sciencedirect.com/science/article/pii/S0140673608616906

 Life chances differ greatly depending on where people are born and raised.
 Imbalance health inequity: if systematic differences in health for different
groups of people are avoidable by reasonable action, then their existence is
unfair.
 The poor health of poor people, the social gradient in health within countries, and
the substantial health inequities between countries are caused by the unequal
distribution of power, income, goods, and services.
 This unequal distribution of health-damaging experiences is NOT in any sense a
natural phenomenon, but is the result of a combination of poor social policies
and programmes, unfair economic arrangements, and bad politics.
 3 principles - the Commission on Social Determinants of Health’s
overarching recommendations: improve daily living conditions (重点关注女童
和男童的早期儿童发展和教育，改善生活和工作条件，制定支持所有人的
社会保护政策), Tackle the inequitable distribution of power, money, and
resources (eg. 男女不平等), Measure and understand the problem and assess the
results of action (train public understanding of social determinants of health ,
stronger focus on social determinants in public health research).
 Upgrade of urban slums should be a priority, control of the number of alcohol
outlets…
 Promote gender inequality:
a) legislation can promote equity and make discrimination on the basis of sex
illegal
b) gender equity units ensure that men and women benefit equitably
c) national accounts can include the economic contribution of housework, care
work, and voluntary work
d) finance policies and programmes can close gaps in education and skills and
support economic participation by women.
e) investment in sexual and reproductive health services and programmes
leading to universal coverage and rights should be increased.

Thoughts:

 menstrual shame
 whether to sell menstrual products on train; before I click the tag of it, I was like
“is that really something that worth discussing? Selling menstrual products is
totally a general phenomenon.”
5. Patel, V. (2014). Why mental health matters to global health. Transcultural
Psychiatry, 51(6), 777–789. https://doi.org/10.1177/1363461514524473
https://journals-sagepub-com.myaccess.library.utoronto.ca/doi/10.1177/13634
61514524473

 Although international health was built in “developed world” , global health

emphasizes what all countries learn from each other to address the health of
everyone in our planet
 Enormous burden affected by mental health disorders, lack of care, incorporation
of “eastern” strategy into “western” strategy reflects the lack of creativity in
developing countries,
 SUNDAR:
a) Simplify the messages we use to convey mental health issues (NOT use
psychiatric labels that are easy to be misunderstood)
b) UNpacking interventions into components which are easier to deliver
c) Deliver care as close as possible to people’s homes
d) recruit and train Available manpower from the local communities
e) Reallocate the skills of specialized manpower to supervise and support these
community health agents.
 Critique:
a) psychiatric diagnostic categories lack validity

A person is sick only if one can demonstrate a biomarker for their sickness?
(eg.在 Koch 发现导致结核病的杆菌之前，不能将结核病视为一种疾病?)

b) a minimal role for individual health care

The dichotomy of social determinants and biological mechanisms is an

inherently naive and flawed view of human healt. (eg.告诉一个手臂被暴力
丈夫打破的妇女，她应该和政治领导人解决性别不平等，而不是治疗她
的伤口！)

In reality, virtually all health conditions are influenced by social determinants

but are ultimately mediated through biological pathways.

c) this discipline is a front for the interests of the pharmaceutical industry

发达国家滥用药物，但其他大多数国家甚至没机会接受诊断

d) applying knowledge generated in developed contexts to developing ones is

tantamount to “medical imperialism.”
 Global mental health is rooted within the discipline of global health, not
psychiatry, and espouses its values of multidisciplinary approaches to
understanding and addressing mental health inequalities.

The full range of tools which are transferred between cultures undergo
systematic adaptation to ensure they are contextually appropriate

 The critiques of global mental health fail to recognize how deeply the social
sciences and cultural psychiatry have influenced its principles and methods.
 5 challenges: integrating the screening and packages of services in routine
primary health care; reducing the cost and improving the supply of effective
medications; improving children’s access to evidence-based care; providing
effective and affordable community-based care and rehabilitation; and
strengthening the mental health education of all health care personnel.

6. Rose-Clarke, K., Gurung, D., Brooke-Sumner, C., et al. (2020). Rethinking

research on the social determinants of global mental health. Lancet
Psychiatry, 7(8):659-662. https://doi.org/10.1016/S2215- 0366(20)30134-6
https://pubmed.ncbi.nlm.nih.gov/32711698/

 Limited research on how gender roles affect mental health

 Need for more evidence-based interventions early in the life course.
 Economic group: deeper understanding of how social security and unemployment
policies influence mental health
 Environmental group: better elucidate mechanisms linking climate change and
mental health, including the role of genetics and epigenetics, and explore the
relevance of mental health guidelines in the context of both acute and chronic
adversity.
 Neighbourhood group: the importance of community mobilisation in changing
the social environment and the need for research to understand how urban
regeneration initiatives could benefit mental health.
 Suggestions:
a) Academics need to stop thinking solely in terms of proximal individual
determinants and give serious attention to determinants at meso levels and
macro levels of the socioecological model.
b) Longitudinal qualitative and quantitative studies are essential to understand
causality and the lived experience of exposure to multiple interacting
determinants.
c) Social determinants are evolving. The growing reality of climate change is
likely to have major mental health consequences, especially for vulnerable
groups, and solastalgia.

Videos:
1. Fast Facts on Health Inequities: https://www.youtube.com/watch?
v=NwnhWJUsUnY&feature=youtu.be

 Health inequities: systematic differences in health outcomes; arise from the social
conditions in which ppl are born, grow, live, work and age.
 Some facts:

a) Material morality is a key indicator of health inequity.

b) Tuberculosis 结核病 is a disease of poverty.
c) Health disparities are huge in cities.

 Health equity considerations need to be integrated into government and

community decision-making, institutions, laws, polices, and programmers.
 Monitoring health inequalities with better data systems while protecting human
dignity.
 Investing in education, training and research on society, equity and health.

2. Social Determinants of Health: An Introduction

https://www.youtube.com/watch?v=8PH4JYfF4Ns

 What is it?
a) Lifespan being influenced by income, education, occupation, etc.
b) Who they are/What they do
c) Shaped by money, power, and resources
 How does it affect health?
 Framework:
A. WHO-Commission:
a) Structural determinants
• Socioeconomic and political context: governance, policies, and values
(unequal distribution of material and monetary resources)
• Socioeconomic position: education, occupation, income, gender, race,
social class (exposure, vulnerability, and outcome… number)
b) Intermediary determinants
• Material circumstances (housing), psychosocial factors (relationships,
support), behaviors biological factors.
*Social cohesion and social capital