Creating a mentally friendly environment

 “I was hearing strange voices so to stay in the community, close to people, I felt they were endangering my life. I felt they might kill me. So I just locked myself away for security…. Only when I heard the voice of my wife I would open the door and she would give me the meals that I was reluctant to take…. I felt very depressed and frightened. And at times I felt nobody loved me. That’s why I wanted to stay isolated.” – Mr Thom, Malawi

CBM has been working with people with mental health conditions, such as Mr Thom, for over 15 years. Their experiences of isolation and fear are too often shared by the estimated 13% of people across the world with a mental health condition. This includes anxiety, depression, schizophrenia, phobias, eating disorders and post-traumatic stress disorder.

Poor mental health has been attributed to both genetic and biological factors affecting the brain, but social factors are thought to play a far greater influence. Difficult interpersonal relationships, low economic status, urbanisation, higher levels of neighbourhood crime and natural disasters can all have a negative impact; and factors such as sex, age and race are associated with differing risks to mental health. In addition, it is understood and described differently around the world, whether originating in the mind, heart or nerves, or from an external or even supernatural force.

Arguably there is a circular relationship between poverty and mental health – poverty is a risk factor for poor mental health and poor mental health can be a driver of poverty – and inequality is known to have an impact on mental illness in higher income countries, although further research is needed to assess the relationship in low income settings. This emphasises the importance of including mental health in all aid, development and poverty reduction approaches.

Humanitarian crises such as war or environmental disaster pose a risk to mental health because of experiences such as bereavement, family separation or losing your home. Existing disorders may also be exacerbated if support structures or drug supplies break down, and the humanitarian response can itself negatively impact mental health, for example if information and resources are scarce or there is the threat of exploitation and abuse in displacement camps.

As a pan-disability organisations, we recognise the importance of addressing co-morbid conditions – co-existing impairments or health conditions – which can have a significant impact on mental health. For example, it is estimated that up to 50% of those with tuberculosis experience depression, possibly due to the impact of chronic infection, the side effects of medication or other risk factors that TB and depression share. People with disfiguring diseases such as lymphatic filariasis are also at greater risk of depression, often due to lowered self-esteem resulting from the physical symptoms of swelling and disfiguration.

Mental health conditions can result in significant social exclusion, whether due to stigmatisation and discrimination from others or due to self-isolation, as in the case of Mr Thom. This is increasingly recognised as psychosocial disability, whereby the social response to a mental health impairment is disabling, in a similar way to physical impairments and disability, which requires more than an exclusively medical response. CBM has been at the forefront of the burgeoning interest in the field of mental health and psychosocial support (MHPSS).

Recognising the importance of locally based and community owned responses, CBM’s newly launched Mental Health Strategy integrates our mental health expertise into our Community Based Inclusive Development work in Africa, Asia and Latin America. We work with partners to deliver community forums, which provide for culturally sensitive engagement in local communities to introduce rights-based approaches and new services; and run peer support groups which play a therapeutic role and provide opportunity for economic empowerment.

We are also working to address structural issues, from anti-stigma campaigns and awareness-raising to working closely with service providers to strengthen systems and seek reform of mental health services and integration into other sectors. This highlights the importance of creating societies that are inherently mental health ‘friendly’ and the role that governments have to play in this, alongside providing services that support a population’s mental health needs.

The UK Government has placed itself as an aspiring leader in global mental health, and the inclusion of mental health in DfID’s Disability Inclusive Development Strategy signifies this commitment. Crucially, DfID recognises the importance of preventing conditions that give rise to poor mental health – and it is here that we believe the UK government can lever its influence across the world.

Richard Bentall talks about ‘fostering psycho-civilised societies’, which requires reducing the structural and external risks to mental health. Through all of its aid and development, international economic and foreign policy decision making, the UK government has an opportunity to assess the impact these decisions might have on the mental health of relevant populations. For instance, what would the likely impact of investing in a country’s infrastructure or, conversely, supporting air strikes or implementing economic embargos, be on that target/recipient country? Alongside this, the UK could mainstream mental health throughout its own advocacy work, directly with other countries or through bodies such as the UN, looking for unlikely bedfellows and unusual opportunities to raise the issue.

Of course, DfID is on its own journey in building expertise and capacity in global mental health – and CBM hopes to see this shared and encouraged within other government departments over time. CBM has produced a new policy paper exploring these issues, with a number of recommendations to the UK Government that we believe will help create a global mentally friendly environment. Read our policy paper here (pdf, 727KB).

Image: Mr Thom at his church in Blantyre, Malawi. © CBM/Eshuchi