I spent much of January in Zambia, one pleasant
task being to establish a new research capacity building project on mental
health, funded by the British Academy. The aim was to recruit 40 colleagues to
work on four strands – HIV, maternal health, prison health and workplace health
– all in relation to mental health. We got off to a flying start!
Mental health has always been championed by
African colleagues, for example at WHO symposia, arguing for its higher
priority. They haven’t always been successful. All over the world, mental health
services are described as the ‘Cinderella services’ – under-resourced,
stigmatized, neglected, whilst the conditions that create good mental health
and good social health are less researched, understood and planned for than
physical health. The drift into a wellbeing paradigm could be expected to focus
more firmly on mental salutogenesis and certainly health promotion is concerned
with how we create the kind of society which brings about mental health justice as well as merely health justice.
It can take a high profile incident to
bring emotional vulnerability to the fore, but too often the news fades and
nothing changes. One example is Robin Williams’ suicide last year – a hugely
successful actor yet prone to some of the demons that seem to beset some very
creative people. (He’s been described as
‘the genius who fizzed with divine madness’). His death did spark a national
debate about mental health and suicide; suicide is the biggest killer of men
between 20 and 49 in the UK, overtaking road accidents, cancer and coronary
heart disease. It’s the second biggest
killer of people aged 15-29 globally, and rates also increase among those over
50. According to the WHO, (Preventing
Suicide: A Global Imperative 2014), every 40 seconds someone somewhere in
the world kills themselves. This is bound to be an underestimate.
Of all suicides in the UK in 2012, 76% were
men. A condition that affects one gender
more than another suggests that ‘something is going on’ regarding masculinity
or femininity, and it’s easy, though perhaps simplistic, to relate suicide to
men’s seemingly lesser ability to ask for help, to be transparent and to talk
about their feelings. One man who did open up was the MP John Woodcock, who in
2013 talked about his depression. He also noted that mental health trusts are
making cuts of 20% higher than other hospitals, and that mental health organizations
have warned that the cuts are threatening people’s lives. The charity Calm –
Campaign Against Living Miserably – has called for men to challenge archaic
male stereotypes and instead to define themselves on their own terms.
There’s a clear link between mental health
and social health, if depression can be said to be related to loneliness. The
charity Relate issued a research
report last year which said that 19% of people (total sample size n=5778 people) questioned said they had never or rarely felt loved in the previous two
weeks. One in ten people said that didn’t have a close friend, which, if
extrapolated to the whole UK population, would be 4.7 million people. Friendship is surely one of the great joys of
life, essential to our wellbeing. Creating and keeping friendships is a skill,
and surely one that needs to be nurtured as part of a salutogenic environment.
It’s difficult to know how far to pathologise
mental illnesses such as depression, but certainly, Robin Williams’ suicide led
the Royal College of Psychiatrists to argue that only about a third of cases of
depression are treated in the UK. The parity between mental and physical health
services seems to be widening; Prof. Simon Wessley, the President of the RCP
said it would be unheard of if say, 70% of cancer patients were not only
receiving no treatment, but if their condition was not even recognized. The last
time statistics were collected centrally on child mental health, in 2004, they showed
that 1.3 million children had a recognizable mental health problem. Signs are
that this has worsened over the interval of time. In 2014 Public Health England
reported a 41% increase in children self-harming and a 33% rise in their
suicidal thoughts.
Survey after survey shows this kind of
emotional vulnerability – and studies
also highlight the inadequacy of services to help those in need. These services
are often provided by the NGO sector which tried to fill in the gaps.
As a health promoter, whilst understanding
the need for downstream services to pick up the emotional pieces, I’m more
interested in how societies create the conditions for good mental and emotional
health. Of course, there’s been a great deal of policy work both to identify
and measure the factors that lead to wellbeing, following the example of
Bhutan, which has been measuring it since the early 1970s. Bhutan has
challenged the idea that increasing wealth does not equate to increasing
happiness. Certainly aspects such as social connections are high up on the OECD’s
Better Life initiative, and this confirms the points made above about the
importance of friendship, loneliness and suicide prevention – see:
However, this doesn’t mean that material
factors are not significant - jobs,
earnings, income and wealth are essential elements of mental wellbeing. In
2012, one in five households in the UK reported difficulty or great difficulty
in making ends meet. Economic downturns often create greater mental health
problems and ironically, this is also when mental health services are cut due
to austerity measures. The UK government’s new mental health strategy published
in April 2014, No Health without Mental
Health, will rely upon better ways of calculating the psychological harm done
by, for example, being made unemployed or not being able to live on your
household budget. Money isn’t everything and we need to resist financial
determinism, but on the other hand, it’s hard to be happy when you’re worried
all the time about making ends meet and about basic survival. In the same week
as Robin Williams’ high profile suicide, a coroner recorded the suicide of Stephanie
Bottrill, aged 53, who had suffered from depression but killed herself
reportedly over extra worries about finding money to pay the ‘bedroom
tax’. She left a suicide note blaming
the government. In another study, by the Children’s Society, a third of
children said that their families had been affected by the economic crisis, and
these children were more likely to have low wellbeing.
I’ve only dipped into the issues here, but
we can see that there is a lot of work happening in the Global North on mental
health and how to create it. There is less happening in the Global South.
Colleagues in Zambia have already made the
connections between mental health and poverty. See:
Mayeya, J., Chazulwa, R, Mayeya, P., Mbewe,
E., Magolo, L., Kasisi, F. & Bowa, A.C. (2004) Zambia mental health country
profile. International Review of
Psychiatry, 16(1-2):63-72
There is a need to too, to understand
social constructions of mental health and mental distress, and to continue some
of the work started for example by Magna Aidoo and Trudy Harpham:
Aidoo, M. and Harpham, T. (2001) The explanatory models of mental
health amongst low-income women and health care practitioners in Lusaka,
Zambia. Health Policy and Planning 07/2001;
16(2):206-13. DOI: 10.1093/heapol/16.2.206
Peter
Chipimo is another researcher and practitioner in this area, and he joined the
first part of our recent workshop in Lusaka. See:
Chipimo, P.J and Fylkesnes,
K (2009)Mental
distress in the general population in Zambia: Impact of HIV and social factors BMC Public Health.; 9: 298. Published online 2009 Aug 18.
doi: 10.1186/1471-2458-9-298
Our new Zambian project will enable
research on mental health in the country and also provide opportunities for
colleagues to hone their research skills and to do research in teams.
Importantly, it will bring an African perspective to the global debate and
policy agenda about how to tackle mental distress, and how to create the
conditions under which people’s mental and emotional health can be nurtured.
