Burgess, RA

Collins, PY

Pathare, S

English

UCL Discovery

  World Mental Health Day - Social Justice, Not Just Access to Care Authors: 1. Soumitra Pathare* Centre for Mental Health Law & Policy, Indian Law Society, Pune 411004, India Email: spathare@cmhlp.org  2. Rochelle  A. Burgess UCL Centre for Global Non-Communicable Diseases UCL Institute for Global Health  30 Guilford Street, London  WC1N 1EH United Kingdom Email: r.burgess@ucl.ac.uk  3. Pamela Y. Collins  Department of Psychiatry and Behavioral Sciences/ Department of Global Health University of Washington Hans Rosling Center for Population Health, Box 351620, 3980 15th Ave NE, Seattle, WA 98195 USA Email: PYC1@uw.edu  *for correspondence  World Mental Health Day, which began in 1992, is focused on ‘Mental Health in an Unequal World’ in 2021, including issues of poverty and disparities due to race, ethnicity, sexual orientation and gender identity. The theme also highlights a need to address stigma and discrimination and human rights violations in the mental health sector and the lack of quality mental health services across the world.   Research studies from across the world in the past two decades have highlighted the bi-directional link between poverty and mental health. Notably fewer studies rigorously examine the impact of poverty alleviation on mental health outcomes compared to studies of mental health interventions on economic outcomes.1 Mental health researchers and research funders have primarily focused on the economic benefits of expanding access to mental health care, but there is scant research using an equity perspective to evaluate the impact of economic and other social interventions to improve mental health. Consistently, many mental health researchers have concluded the need to expand mental health services and reduce the ‘treatment gap  ’for mental health.1 The World Health Organization follows this line with its emphasis for this year’s WMHD highlighting the need to expand quality mental health services across countries.  Access to quality services is sorely needed universally. But access to care is not enough. The Covid pandemic has underscored the significant role of socio- political economy on mental health.2 Social disparities are not just correlated with poor mental health but have a significant negative impact on the already socially marginalized. Thus, under the wrong set of social circumstances, everyone is vulnerable to mental health problems.  But mental health is possible for all. We need a shift in current paradigms, which are insufficient in thinking about the connections and intersections between different domains of social life that make good mental health impossible. This requires a recalibration of our understanding of the importance of ‘social determinants of mental health’ within the current state of the field, which acknowledges their existence, but does little to change them or advocate for the establishment of environments that enable good mental health. This is critical, as addressing social determinants could have more impact on mental health than health sector interventions.3 For example, in a large study from Brazil covering nearly half the population over 12 years, recipients of conditional cash transfers had a 61 per cent   reduction in suicide rate as compared to controls.4 The impact of conditional cash transfers (a social care intervention) in reducing suicides is far larger than any mental health intervention for suicide prevention until now. Similar results were seen with conditional cash transfer programs in Indonesia with an 18 per cent reduction in suicides.5 In the Universal Basic Income RCT from Stockton California, one year after receiving cash transfers the effect sizes on mental health, as measured by SF-36 ranged from 0.25 to 0.37, not particularly different from that with conventional mental health treatment.7 Similar findings on mental health of recipients of cash transfers have been reported from a systematic review of cash transfer programs from Sub-Saharan Africa.8  Similarly Housing First programs, which do not require homeless participants with mental illness to be ‘housing ready ’with treatment before getting their first home but provide housing with intensive and flexible mental health support have shown significant mental health outcomes. Studies in Europe and North America have shown Housing First not only results in improved mental health and functioning, but significant reductions in hospitalization for mental health problems.9,10 The commonality between these spaces? Such interventions make it possible for people to live lives of meaning. They create environments for good mental health; marked by opportunities to flourish, achieve social and community actualisation, and remove barriers to accessing care when needed. We enable good mental health, by changing people’s daily lived realities. Mental health in an unequal world will not be addressed solely by focusing on expanding access to mental health treatments, but by reducing inequalities. ‘Scaling up‘ ’quality mental health services’ is crucial but  in the current social context is only a partial solution to problems that require more systemic intervention to the body politic. Panel 1 highlights a few policy areas that could be the start of widespread movements to build mental health enabling societies. We call on mental health   researchers and academics to advocate more forcefully with policy makers, funders and the international community for long term action that shifts policy debates, and shorter-term action to develop social interventions to reduce social inequalities. In this way we can fundamentally address the social origins of mental health problems in our communities.   Conflict of Interest Statement: We declare no competing interests  PANEL:  From Social Determinants to Mental Health Enabling Environments: A Call to Action We suggest 5 critical areas of policy action which will have significant impact on mental health enabling environments  1. Safer societies for women, children, and people facing gender-based violence and exclusion: living with various forms of Interpersonal violence has been associated with increased risk of mental health problems and suicide and poorer outcomes for those with mental health problems. People from LGBTQI communities face marked violence and exclusion which has significant impacts on their mental health possibilities.  2. Rejecting hostile immigration environments: Mental health needs of people who exist at the margins of society due to citizenship status, policies that deny personhood to those who seek refuge from war, conflict, persecution, and other forms of exclusion. Current polices make it impossible for good mental health to be maintained, locking people in states of precarity, which increased risk for mental health crises and long-term conditions.   Commented [PJ(1]: Ensure statement matches what is declared on ICMJE forms  Commented [SP2R1]: yes   3. Decent livelihoods and fair wages: Unemployment has been associated with poor mental health outcomes and those with mental health problems also have high rates of unemployment. Efforts to establish fair wage campaigns across the world should be unified, supported and strengthened.  4. Safe early childhood experiences: Childhood abuse is associated with depression and other common mental disorders in adulthood.  5. Protection from and rejection of racialized and minority exclusion: Globally, forms of racism, xenophobia, and caste-based exclusion impact directly and indirectly on the capacities for people to achieve good mental health – across levels of society, systems, and services. Promotion of movements to end these.  References 1. Lund C, De Silva M, Plagerson S, Cooper S et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet 2011; 378: 1502–14. doi: https://doi.org/10.1016/S0140-6736(11)60754-X 2. Burgess, R. COVID-19 mental health responses neglect social realities. Nature 2020. doi: https://doi.org/10.1038/d41586-020-01313-9 3. Lund C, Brooke-Sumner C, Baingana F et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5:357–69. doi: 10.1016/S2215-0366(18)30060-9 4. Machado, Daiane and Williamson, Elizabeth and Pescarini, Julia and Rodrigues, Laura and Alves, Flavia J. O. and Araújo, Luis and Ichihara, Maria Yury Travassos and Araya, Ricardo and Patel, Vikram and Barreto, Mauricio L., The Impact of a National Cash Transfer Programme on Reducing Suicide: A Study Using the 100 Million Brazilian Cohort. SSRN 2021; published online Jan 14. doi: http://dx.doi.org/10.2139/ssrn.3766234 (preprint). 5. Christian, C., Hensel, L., Roth, C. Income Shocks and Suicides: Causal Evidence From Indonesia. Review of Economics and Statistics 2019; 101: 905–20. doi: https://doi.org/10.1162/rest_a_00777 6. Annie Lowrey. Stockton’s Basic-Income Experiment Pays Off. The Atlantic 2021. Available at: https://www.theatlantic.com/ideas/archive/2021/03/stocktons-basic-income-experiment-pays-off/618174/ [Accessed 27 Sep 2021] 7. West S, Baker AC, Samra S, Coltrera E. Preliminary analysis: SEED’s first year. Stockton Economic Empowerment Demonstration 2021. Report downloaded from https://static1.squarespace.com/static/6039d612b17d055cac14070f/t/6050294a1212aa40fdaf773a/1615866187890/SEED_Preliminary+Analysis-SEEDs+First+Year_Final+Report_Individual+Pages+.pdf. [Accessed 27 Sep 2021]   8. Owusu-Addo E, Renzaho AMN, Smith BJ. The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: a systematic review. Health Policy Plan 2018; 33:675–96. doi: https://doi.org/10.1093/heapol/czy020 9. Prestidge Jo. Housing First: helping people experiencing poor mental health to find stability.  Centre for Mental Health. Available at: https://www.centreformentalhealth.org.uk/blogs/housing-first-helping-people-experiencing-poor-mental-health-find-stability. [Accessed 27 Sep 2021] 10. Aubry T, Nelson G, Tsemberis S. Housing First for People With Severe Mental Illness Who Are Homeless: A Review of the Research and Findings From the At Home-Chez soi Demonstration Project. Can J Psychiatry. 2015;60(11):467-474. doi10.117/070674371506001102 

World Mental Health Day: prioritise social justice, not only access to care

https://discovery.ucl.ac.uk/id/eprint/10136632/3/Burgess_World%20Mental%20Health%20Day-%20prioritise%20social%20justice%2C%20not%20only%20access%20to%20care_AAM.pdf

World Mental Health Day: prioritise social justice, not only access to care

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