ARTICLE

The globalisation
of mental illness
Ross White asks whether recent developments are a problem or progress
The burden (mortality and
disability) caused by mental
disorders across the globe is on
the rise. Psychiatric services for
treating mental health difficulties
are well established in high-income
countries such as the US and UK;
and the World Health Organization
has supported the setting up of
similar services in low- and
middle-income countries (LMIC).
But is the globalising of psychiatric
systems of diagnosis and treatment
the most appropriate line of action?
This article critically reflects on
biomedical explanations of mental
health difficulties; highlights
concerns about the dearth of
research into mental health
difficulties in LMIC; discusses the
lack of emphasis that psychiatry
places on cultural factors; and
raises the possibility that
globalising notions of psychiatric
illness may cause more harm
than good.

question
resources

Suman, F. (2010). Mental health, race and

culture (3rd edn). Basingstoke:
Palgrave Macmillan.
http://transculturalpsychiatry.gla.ac.uk

references

Is the scaling-up of psychiatric services

in low- and middle-income countries
serving to undermine indigenous
sources of support for mental distress?

Alem, A., Kebede, D., Fekadu, A. et al.

(2009). Clinical course and outcome
of schizophrenia in a predominantly
treatment-nave cohort in rural
Ethiopia. Schizophrenia Bulletin, 35,
646654.
Ballenger, J.C., Davidson, J.R.T.,
Lecrubier, T. et al. (2001) Consensus
statement on transcultural issues in
depression and anxiety from the
International Consensus Group on

182

here are huge inequalities in the

availability of resources to support
mental health needs across the globe;
it is estimated that greater than 90 per
cent of global mental health resources are
located in high-income countries (WHO,
2005). This is all the more alarming when
we consider that around 80 per cent of
the worlds population live in low- and
middle-income countries (LMIC: Saxena
et al., 2006). In countries in Africa, Latin
America, and south/south-east Asia under
2 per cent (and often less than 1 per cent)
of expenditure on health tends to go to
services for psychiatric conditions
(compared to over 10 per cent in the
USA) (Kleinman, 2009). And there is
a gathering mental health storm: it is
projected that by 2030, depression will
be the second biggest cause of disease
burden across the globe (Mathers &
Loncar, 2006), second only to HIV/AIDS.
When four out of five people in LMIC
who need services for mental, neurological
and/or substance-use disorders do not
receive them (WHO, 2008), we have
a clear treatment gap the difference
between the levels of mental health
services required by LMIC populations and
what is actually available on the ground.
Prominent clinicians and academics, as
well as international organisations such
as the World Health Organization (WHO,
2008, 2010), have called for the scalingup of services for mental health in LMIC.
Scaling-up involves increasing the number
of people receiving services; increasing the
range of services offered; ensuring these
services are evidence-based, using models
of service delivery that have been found to

Depression and Anxiety. Journal of

Clinical Psychiatry, 62, 4755.
Cohen, A., Patel, V., Thara, R. et al.
(2008). Questioning an axiom: Better
prognosis for schizophrenia in the
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Crozier, I. (2011). Making up koro:
Multiplicity, psychiatry, culture, and
penis-shrinking anxieties. Journal of
the History of Medicine and Allied

be effective in a similar contexts; and

sustaining these services through effective
policy, implementation and financing
(Eaton et al., 2011). Yet in light of the
limited resources available to support
mental health, it is pertinent to ask
whether it makes sense to try to export
systems of service delivery that have been
developed in high-income countries to
LMIC. Will this venture be sustainable in
the longer term? More importantly, will
these systems actually deliver added value
for the increase in budgetary expenditure
that will be required?

The seductive allure of

biological psychiatry
In high-income countries mental
health services tend to gravitate around
psychiatry; the branch of medicine that is
concerned with the study and treatment
of mental illness, emotional disturbance,
and abnormal behaviour. Biological
psychiatry is an approach to psychiatry
that aims to understand mental illness
in terms of the biological function of the
nervous system.
The rise of biological psychiatry
promised great things. Biological
explanations of mental illness permeated
the public consciousness, and the hunt
was on to discover the magical compounds
that could redress the chemical imbalances
that were purported to cause mental
illness. Various different medications have
been developed and the marketed. In the
past 40 years the sales of psychotropic
medications have increased dramatically.
Yet despite the exponential rise in sales
of these medications, the evidence for
biological causes for mental illnesses such
as depression and schizophrenia remain
fairly weak (Nestler et al., 2002; Stahl,
2000). The continued absence of definitive
evidence to support biological processes
that are causal in mental illness has led to
the suggestion that biological psychiatry is
a practice in search of a science (Wyatt &
Midkiff, 2006). Despite these concerns,
biological psychiatry continues to exert a
strong influence on the delivery of mental

Sciences, 67, 3670.

Eaton, J., McCay, L., Semrau, M. et al.
(2011). Scale up of services for
mental health in low-income and
middle-income countries. Lancet.
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Glenmullen, J. (2002). Prozac backlash:
Overcoming the dangers of Prozac,
Zoloft, Paxil and other antidepressants
with safe, effective alternatives. New
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Hall, G.C. (2001). Psychotherapy research

with ethnic minorities: Empirical,
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Psychology, 69, 502510.
Harvey, P.D. & Bellack, A.S. (2009).
Toward a terminology for functional
recovery in schizophrenia: Is
functional remission a viable
concept? Schizophrenia Bulletin, 35,
300306.

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march 2013

mental illness and culture

health services in high-income countries

such as the UK and America.
The seductive allure of the rationale
underlying biological psychiatry is plain
to see. If mental illnesses were to have
universal biological causes, then standard
treatments could be readily applied across
the world irrespective of local differences
and associated cultural differences. If
evidence-based practices lead to positive
outcomes in high-income countries, then
similar positive outcomes will be observed
in LMIC. Right?
This is where the picture gets a bit
more complicated. Before we can answer
this question we need to be clear on what
we mean by: (1) evidence-based practices
and (2) positive outcomes. What is
considered to be evidence-based practice
can serve powerful economic and political
interests (Kirmayer & Minas, 2000). In
2007, US citizens alone spent 25 billion
on antidepressants and antipsychotics
(Whitaker, 2010). All this in spite of the
fact that claims about drug effectiveness
are at times overstated, and that
pharmaceutical companies have been
found to employ questionable research
methodologies (Glenmullen, 2002;
Valenstein, 1998; Whitaker, 2010).
Professor David Healy (Psychiatrist,
University of Cardiff) has stated that a
large number of clinical trials done are not

reported if the results dont suit the

companies sponsoring (the) study
(tinyurl.com/dxlh55w). The evidencebase is heavily skewed towards research
conducted in high-income countries.
Since producing hard evidence depends
on the costly standards of psychiatric
epidemiology and randomised clinical
trials, it can be difficult for clinicians or
researchers in LMIC to contribute to the
accumulation of knowledge (Kirmayer,
2006). The lack of mental health related
research being conducted in LMIC
countries is evident in the finding that
over 90 per cent of papers published in a
three-year period in six leading psychiatric
journals came from Euro-American
countries (Patel & Sumathipala, 2001).
An inductive, bottom-up approach to
research emphasising the importance of
local conceptualisations of mental health
difficulties and focusing on local priorities
in different LMIC is required.
Even if the research capacity in LMIC
can be increased, difficulties remain. The
issue of what constitutes positive
outcomes in relation to mental illness has
plagued clinical practice and research for
many years. There is currently no accepted
consensus on what constitutes positive
outcome for individuals with mental
illness. Traditionally, psychiatry has been
concerned with eradicating symptoms of
mental illness. However, it is
important to appreciate that clinical
symptoms do not improve in
parallel with social or functional
aspects of service users
presentation (Liberman et al.,
2002). Functional outcome relates
to variables such as cognitive
impairment, residential
independence, vocational
outcomes, and/or social functions
(Harvey & Bellack, 2009). In this
sense, using symptomatic remission
as an indicator of recovery can
yield better rates of good outcome
than using indicators of functional
recovery (Robinson et al., 2005).
More than 90 per cent of global mental health
Another important
resources are located in high-income countries
consideration relating to outcome

Hopper, K., Harrison, G., Janka, A. &

Sartorius, N. (Eds.) (2007). Recovery
from schizophrenia: An international
perspective. Oxford: Oxford University
Press.
Kitanaka J. (2011). Depression in Japan:
Psychiatric cures for a society in
distress. Princeton, NJ: Princeton
University Press.
Kirmayer, L.J. (2006). Beyond the new
cross-cultural psychiatry: Cultural

biology, discursive psychology and

the ironies of globalization.
Transcultural Psychiatry, 43, 126144.
Kirmayer, L.J. & Minas, I.H. (2000). The
future of cultural psychiatry: An
international perspective. Canadian
Journal of Psychiatry, 45, 438446.
Kleinman, A.M. (1977). Depression,
somatization and the new crosscultural psychiatry. Social Science
and Medicine, 11, 310.

read discuss contribute at www.thepsychologist.org.uk

in mental illness relates to the extent to

which particular outcomes are culturally
sensitive and inclusive (Vaillant, 2012).
Marked disparities have been highlighted
between ethnic minority groups and white
people in outcome, service usage and
service satisfaction (Sashidharan, 2001).
The lack of culturally inclusive
understandings of positive outcome in
mental illness is compounded by the
underrepresentation of black and minority
ethnic groups in mental health related
research. This has led to some concluding
that there is a lack of adequate evidence
supporting the use of evidenced-based
psychological therapies with individuals
from black and minority ethnic
populations (Hall, 2001). Considering
these issues, it seems that the jury is in no
position to deliver a verdict on whether
evidence-based practices for mental illness
developed in high-income countries
deliver positive outcomes in LMIC.

Diagnosis and culture

Despite the question marks that remain
about the causes of mental illness, the
veracity of the evidence base, what
constitutes good outcome, and how
inclusive mental health services are to
cultural diversity within the population,
the psychiatry-heavy perspective has
a powerful say in how mental health
difficulties are understood in LMIC.
Dissenting voices have questioned the
wisdom of this approach. One particular
source of dissention relates to the process
of psychiatric diagnosis. The international
classification systems for diagnosing
mental illnesses (such as depression and
schizophrenia) have been criticised for
making unwarranted assumptions that
these diagnostic categories have the same
meaning when carried over to a new
cultural context (Kleinman, 1977, 1987).
This issue has potentially been obscured
by the fact that the panels that finalise
these diagnostic categories have been
criticised for being unrepresentative of the
global population. Of the 47 psychiatrists
who contributed to the initial draft of the

Kleinman, A.M. (1987). Anthropology and

psychiatry: The role of culture in
cross-cultural research on illness.
British Journal of Psychiatry, 151,
447454.
Kleinman A. (2000). Social and cultural
anthropology: Salience for psychiatry.
In M.G. Gelder, J.J. Lopez-Ibor &
N.C. Andreasen (Eds). New Oxford
textbook of psychiatry. Oxford: Oxford
University Press.

Kleinman A. (2009). Global mental

health: A failure of humanity. Lancet,
374, 603604.
Liberman, R.P., Kopelowicz, A., Ventura,
J. & Gutkind, D. (2002). Operational
criteria and factors related to
recovery from Schizophrenia.
International Review of Psychiatry, 14,
256272.
Lopez, S.R. & Guernaccia, P.J. (2000).
Cultural psychopathology:

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mental illness and culture

most recent World Health Organization

diagnostic system (ICD-10: WHO, 1992),
only two were from Africa, and none of
the 14 field trial centres were located in
sub-Saharan Africa. Inevitably this led to
the omission of conditions that had been
described for many years in Africa (Patel
& Winston, 1994), such as brain fag
syndrome. (This was initially a term used
almost exclusively in West Africa,
generally manifesting as vague somatic
symptoms, depression and difficulty
concentrating, often in male students.)
ICD-10 does at least acknowledge
that there are exceptions to the apparent
universality of psychiatric diagnoses by
including what are called culture-specific
disorders. One such example is koro; a form
of genital retraction anxiety which presents
in parts of Asia. Prior to ICD-10 symptom
presentations such as koro tended to be
subsumed into existing diagnoses such as
delusional disorder (Crozier, 2011). But
the inclusion of culture-specific disorders
only serves to perpetuate a skewed view
of the impact of culture on mental health;
cultural explanations seem to be reserved
for non-Western patients/populations that
show koro(-like) syndromes, and not for
diagnoses that are more prevalent in highincome countries (e.g. anorexia nervosa).
Indeed it has been suggested that many
psychiatric conditions described in these
diagnostic manuals (such as anorexia
nervosa, chronic fatigue syndrome) might
actually be largely culture-bound to EuroAmerican populations (Kleinman, 2000;
Lopez & Guernaccia, 2000). Because
people living in Western countries tend
to see the world through a cultural lens
that has been tinted by psychiatric
conceptualisations of mental illness,
they are blind to how specific to Western
countries these conceptualisations
actually are.

Transcultural psychiatry
Culture has been defined as a set of
institutional settings, formal and informal
practices, explicit and tacit rules, ways of
making sense and presenting ones

Uncovering the social world of

mental illness. Annual Review of
Psychology, 51, 571598.
Mathers, C.D. & Loncar, D. (2006).
Projections of global mortality and
burden of disease from 2002 to 2030.
PLoS Med, 3, e442.
Nestler, E.J., Barrot, M., DiLeone, R.J. et
al (2002). Neurobiology of
depression. Neuron, 34, 1325.
Patel, V. & Prince, M. (2010) Global

184

experience in forms that will

influence others (Kirmayer,
2006, p.133). Interest in the
potential interplay between
culture and mental illness first
arose in colonial times as
psychiatrists and anthropologists
surveyed the phenomenology
and prevalence of mental
illnesses in newly colonised
parts of the world. This led to
the development of a new
discipline called transcultural
psychiatry, a branch of
Western narratives about mental illness continue
psychiatry that is concerned with
to dominate over local understanding
the cultural and ethnic context of
mental illness.
In its early incarnation, transcultural
best to meet the mental health needs of
psychiatry was blighted by the racist
people across the globe.
attitudes that prevailed at that time about
The need for interdisciplinary working
the notion of naive native minds.
in promoting improved understanding
However, over time this began to change
about the interplay between culture and
as people began to understand that
mental illness has been demonstrated by
psychiatry was itself a cultural construct.
a growing body of evidence indicating that
In 1977 Arthur Kleinman proposed a new
exporting Western conceptualisations of
cross-cultural psychiatry that promised a
mental health difficulties into LMIC can
revitalised tradition that gave due respect
have a detrimental impact on local
to cultural difference and did not export
populations. Ethan Watters book Crazy
psychiatric theories that were themselves
Like Us cites examples from different parts
culture-bound. Transcultural (or crossof the world (including China, Japan,
cultural) psychiatry is now understood
Peru, Sri Lanka and Tanzania) where the
to be concerned with the ways in which
introduction of psychiatric
a medical symptom, diagnosis or practice
conceptualisations of mental illness has
reflects social, cultural and moral concerns
potentially changed how distress is
(Kirmayer, 2006).
manifested, or introduced barriers to
Tensions exist in transcultural
recovery (e.g. the emergence of expressed
psychiatry. Clinicians, who are motivated
emotion in the families of individuals with
to produce good outcomes for service
psychosis in Tanzania). Watters (2010)
users, may work from the premise that
cites the work of Gaithri Fernando who
there is cross-cultural portability of
has written extensively about the aftermath
psychiatric or psychological theory and
of the tsunami that struck Sri Lanka in
practice. Although well intended, this
2006. Fernando claims that Western
approach can be met with disapproval
conceptualisations of trauma and the
from social scientists who are focused
diagnostic criteria for post-traumatic stress
on advancing medical anthropology as
disorder (PTSD) were not appropriate for
a scholarly discipline. However, it is
a Sri Lankan context. Fernando found that
becoming clear that in this era of rapid
Sri Lankan people were much more likely
globalisation, mental health practitioners,
to report physical symptoms following
social scientists and anthropologists need
distressing events. This was attributed to
to come together and engage in
the observation that the notion of a
constructive dialogue aimed at developing
mindbody disconnect is less pronounced
cross-cultural understanding about how
in Sri Lanka. Sri Lankans were also more

mental health A new global health

field comes of age. JAMA, 303,
19761977.
Patel, V. & Sumathipala, A. (2001)
International representation in
psychiatric literature: Survey of six
leading journals. British Journal of
Psychiatry, 178, 406409.
Patel, V. & Winston M. (1994). The
universality of mental disorder
revisited: Assumptions, artifacts and

new directions. British Journal of

Psychiatry, 165, 437440.
Robinson, D.G., Woerner, M.G., Delman,
H.M. & Kane, J.M. (2005).
Pharmacological treatments for firstepisode schizophrenia. Schizophrenia
Bulletin, 31, 705722.
Sashidharan, S.P. (2001). Institutional
racism in British psychiatry.
Psychiatric Bulletin, 25, 244247.
Saxena, S., Paraje, G., Sharan, P. et al.

(2006). The 10/90 divide in mental

health research: Trends over a 10year period. British Journal of
Psychiatry, 188, 8182.
Stahl, S.M. (2000). Four key
neurotransmitter systems. In S.M.
Stahl (Ed.) Psychopharmacology of
antipsychotics (pp.313). London:
Martin Dunitz.
Summerfield, D. (2008). How scientifically
valid is the knowledge base of global

vol 26 no 3

march 2013

mental illness and culture

likely to see the negative consequences of

the tsunami in terms of the impact it had
on social relationships. Because Sri Lankan
people tended not to report problematic
reactions relating to internal emotional
states (e.g. fear or anxiety), the rates of
PTSD following the tsunami were
considerably lower than had been
anticipated. Fernando concluded that
Western techniques for conceptualising,
assessing and treating the distress that
people were experiencing were inadequate.
Watters also explores the way in which
understanding about depression has
changed in Japan over the last 20 years.
This sobering tale allows Watters to
explore how the interplay between cultural
factors and notions of mental illness can be
manipulated for financial gain. In the
1960s Hubert Tellenbach had introduced
the notion of a personality type called
Typus melancholicus. This idea heavily
influenced psychiatric thinking in Japan.
Typus melancholicus had substantial
congruence with a respected personality
type in Japan; those who were serious,
diligent and thoughtful and expressed
great concern for the welfare of others
prone to feeling overwhelming sadness
when cultural upheaval disordered their
lives and threatened the welfare of others
(Watters, 2010; p.228). Although at the
end of the 20th century there had been a
psychiatric term in the Japanese language
for depression (utsuby), this tended to
relate to a rare and very debilitating
condition. Prior to 2000 there had been no
real market for prescribing antidepressant
medications in Japan. However, shifting
public perception about Typus
melancholicus closer toward the Western
conceptualisation of depression would
have huge implications for antidepressant
prescribing in Japan. Watters (2010)
claims that GlaxoSmithKlines enthusiasm
to build a market for its new
antidepressant medication in Japan
dovetailed conveniently with a
GlaxoSmithKline sponsored international
consensus group of experts on cultural
psychiatry discussing cross-cultural
variations in depression (Ballenger et al.,

mental health? British Medical

Journal, 336, 992994.
Timimi, S. (2010). The McDonaldization of
childhood: Childrens mental health
in neo-liberal market cultures.
Transcultural Psychiatry, 47, 686706.
Vaillant, G.E. (2012). Positive mental
health: Is there a cross-cultural
definition? World Psychiatry, 11,
9399.
Valenstein, E.S. (1998). Blaming the brain:

2001) concluding that depression was

vastly underestimated in Japan. Depression
is now conceptualised in Japan as affecting
individuals (particularly men) who are too
hard-working and have over-internalised
the Japanese ethic of productivity and
corporate loyalty. In the last few years, the
market for antidepressants in Japan has
grown exponentially. An important
consequence of this aggressive
pharmaceuticalisation, is that
psychological and social treatments for
depression are being ditched (Kitanaka,
2011).

Globalisation of mental health

There is a growing willingness to explore
ways of addressing inequalities in the
provision made for mental illness across
the globe, but translating this willingness
into effective action is fraught with
potential danger. We must guard against
assumptions that indigenous concepts of
mental health difficulties in LMIC and
strategies used in these contexts to deal
with it are based on ignorance
(Summerfield, 2008). Despite the
apparent sophistication of laws, policies,
services and treatments for mental illness
in high-income countries, outcomes for
individuals with mental health problems
may not actually be any better than in
LMIC. Research has failed to conclusively
show that outcome for complex mental
illnesses (such as psychosis) in highincome countries are superior to
outcomes in LMIC (where populations
may not had access to medication-based
treatments) (Alem et al., 2009; Cohen et
al., 2008; Hopper et al., 2007). The lack
of academic and political engagement
with alternative non-Western perspectives
means that Western narratives about
mental illness continue to dominate over
local understanding (Timimi, 2010), yet
we in high-income countries have much
to learn about mental health provision;
particularly in relation to promoting
inclusion of black and ethnic minority
members of the population.
To conclude, I would like to come

The truth about drugs and mental

health. New York: Free Press.
Watters, E. (2010). Crazy like us: The
globalization of the American psyche.
New York: Free Press.
Whitaker, R. (2010). Anatomy of an
epidemic. New York: Crown.
World Health Organization (1992).
International statistical classification of
diseases and related health problems
(ICD-10). Geneva: WHO.

read discuss contribute at www.thepsychologist.org.uk

back to the title. Rather than the

globalisation of mental illness, perhaps
what we should be aiming for is the
globalisation of mental health. This is an
immensely more inclusive aspiration. By
promoting global mental health there is
the potential for clinicians, academics,
service users and policy makers from
across the world to work together with a
shared purpose. By exchanging knowledge,
LMIC can benefit from hard lessons
learned in high-income countries, and
high-income countries can look afresh
at how mental health difficulties are
understood and treated. It will be
important for clinicians and academics
working in high-income countries to
critically reflect on their own practice
and question the accepted wisdom about
mental health provision.
To assist with this knowledge
exchange, a new MSc Global Mental
Health programme has been launched at
the University of Glasgow. Global mental
health has been defined as the area of
study, research and practice that places a
priority on improving mental health and
achieving equity in mental health for all
people worldwide (Patel & Prince, 2010).
The programme seeks to develop leaders
in mental health who can design,
implement and evaluate sustainable
services, policies and treatments to
promote mental health in culturally
appropriate ways across the globe. Global
mental health is an emergent area of study.
Momentum is building. Although the
challenges are both numerous and
complex, the prize is a worthy one. The
cost of not acting can be counted in the
ever-increasing number of people whose
lives are being affected by mental health
problems across the globe.

World Health Organization (2005). Mental

health atlas 2005. Geneva: WHO.
World Health Organization. (2008). Mental
health Gap Action Programme
(mhGAP): Scaling up care for mental,
neurological and substance abuse
disorders. Geneva: WHO.
World Health Organization (2010). mhGAP
intervention guide for mental,
neurological and substance use
disorders in non-specialized health

Ross White
is in the Institute of Health
and Wellbeing at the
University of Glasgow
[email protected]

settings: Mental health Gap Action

Programme (mhGAP). Geneva: WHO.
Wyatt, W.J. & Midkiff, D.M. (2006).
Biological psychiatry: A practice in
search of a science. Behaviour and
Social Issues, 15, 132151.

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