Healing heads and mending minds: Challenges of mental health

Last month Athens hosted the Global Mental Health Summit, a rare international forum highlighting psychological wellbeing. In the United States a boisterous market in mental health medicines, active advocacy, and growing mental health parity in health insurance ensures that our heads receive plenty of scrutiny, but elsewhere the prognosis appears different.

A recent WHO study concluded that worldwide most mental illness remains untreated , and national prevalence estimates vary so greatly that researchers suspect an epidemic of under-diagnoses. China's mental illness rate is estimated at 4 percent. But that seems low considering their world-leading suicide rate is suggestive of below-average mental health. The U.S.'s mental illness rate of 26 percent may represent over-diagnoses due in part to unreasonable social expectations and pressure from anti-depressant marketers.

Mental health is important. In addition to diminishing quality of life and the ability to be productive members of our community, there are strong links between conditions such as depression and physical ailments such as heart disease. Obviously we need to strengthen the capacity to diagnose and treat mental illness with efficient health systems, sufficiently trained clinicians, and a robust pharmaceutical supply chain. But there are special challenges. We need to refine the definition of diagnoses, and treatment outcomes, and develop cost-effective, culturally specific alternatives to current practices. Simply spreading current treatments around the globe could potentially threaten the effectiveness and affordability of care, for a number of reasons.

The absence of hard clinical measures (a blood test, for example) leaves a high degree of diagnostic discretion to the judgment of clinicians, where it's malleable by provider expectation, belief or lack of experience, pharmaceutical marketing, and a patient's behavior or ability to pay for treatment. Once diagnosed, treatment outcomes are ill-defined. When are you "cured"? Medicines are often expensive, and prone to side effects. Counseling is just as effective as drugs in some cases, but can continue indefinitely, or as long as a therapist receives payment. This isn't just greed, practically speaking couldn't we always improve our mental health? Conditions lacking objective diagnostic criteria are especially prone to "disease mongering," or labeling an everyday experience as a disease. Menstruation-related mood swings, for example, were rebranded into Premenstrual Dysphoric Disorder, conveniently treatable with a pre-approved pharmaceutical.

The role of culture is fascinating. Evidence suggests that facing grave consequences and high responsibility with low levels of control in life is a recipe for poor mental health. Conversely, having more control, or milder consequences, improves health. Expectations play a role. Denmark has been rated the happiest nation on earth, certainly a marker for sound mental health. Why are Danes so gleeful? In addition to relatively abundant social safety nets and standard of living, they have relatively low, and therefore easily fulfilled, expectations of life. Other expectations seem plain odd: South Korea's government has mandated that all Koreans walk on the right, not left, on sidewalks and stairways, claiming it will reduce "mental strain" by 16 to 18 percent. That particular treatment strategy wasn't mentioned in Athens.