Challenging Times, Changing Focus, and Social Psychiatry

In the recently concluded World Health Summit (October 16–18, 2022), Berlin, Germany with the theme of “Taking Global Health to a New Level,” Dr. Tedros Adhanom Ghebreyesus, Director-General of World Health Organization (WHO) in his inaugural address identified three important global goals. They were (i) a new global agreement, (ii) new global architecture, and (iii) a new global approach. Specifically, he called for: “Taking global health to the next level means a new global approach that prioritises promoting health and preventing disease, rather than only treating the sick. By and large, the world's health systems do not deliver health care. They deliver sick care. Many countries spend huge sums treating diseases that could be prevented for a fraction of the cost. That's why I am calling on all countries to make a paradigm shift towards promoting health and preventing disease, recognizing that health starts not in hospitals and clinics, but in homes, streets, schools, workplaces. Making this shift requires a reorientation and rebalancing of health systems towards primary health care, as the foundation of universal health coverage and health security. It also requires changes in how governments approach health, and fund it. Health can no longer be just the business of the health ministry or the health sector, but of the whole of government, and the whole of society. Health must be a primary consideration in urban planning, tax policy, transport, education policy, commerce, trade, finance, infrastructure and so on. That means health can no longer be a junior portfolio in government, as it is in many countries, but must be elevated, because we need healthy and secure populations.”[¹]

These observations have special relevance to social psychiatry.

The last 3 years of the COVID-19 pandemic have been, for Social psychiatry, the worst of times and in another way, the best of times. This editorial, addresses five aspects of this subject, namely, (i) the increased mental health morbidity and awareness of mental health needs in the community in the COVID-19 era, (ii) recognition of social determinants of the mental health impact and interventions, (ii) the Lancet Commission on depression, (iv) the World Mental Health Report (WMHR) 2022, (v) the Lancet Commission on stigma and discrimination, and (vi) Paro Declaration on Mental Health. Let us examine them in further detail.

During the last 75 years, from the time of the end of the Second World War, there has not been a worldwide event that has affected humanity like COVID-19. The last 3 years of the pandemic have brought focus to the importance of human behavior and social factors. The recent Lancet Commission Report observes:[²] ”Human behaviour is central to transmission of the disease and suppression of the pandemic. Behavioural science provides evidence about the effectiveness of interventions and policies across contexts and the processes required to bring about change; for example, evidence-based optimal behaviours for pandemic control include getting vaccinated and tested, isolating when infectious, wearing face masks, and physical distancing. At a minimum, behavioural change requires appropriate motivation, capability, and opportunity; the absence of any one of these will undermine public health efforts.”

The Commission proposes five pillars that are essential in fighting emerging infectious diseases: prevention, containment, health services, equity, and global innovation and diffusion. To achieve these pillars the commission argues that governments, regulators, and institutions must be reoriented toward society as a whole, rather than the interests of individuals (emphasis added) – a concept the Commissioners call prosociality. Without this shift, the world is vulnerable and unable to effectively tackle any global threat.

During the pandemic, an increased prevalence of anxiety and depression ranging from 30% to 40% has been reported in a number of countries.[³⁴] There are the reports of increased suicides in some countries and decreased suicides in some other countries. Burnout among health-care providers has been reported in high numbers.[⁵⁶] General populations in the countries that are economically well and those living in economically poor countries have reported a “mental health crisis” too.

Interestingly, the COVID-19 pandemic has provided a natural setting to bring out the vulnerabilities and strengths of the community with respect to mental health. Studies have reported that the mental health of poor, minority groups, people who were living alone, elderly persons, and those without access to health care were worse affected. There are also reports of the positive value of prior exercise practices, mindfulness, availability of social contacts, and assured health care as having a protective function.[⁷⁸⁹¹⁰] Another dimension that has come to the forefront is the value of support in terms of sick leave, income support, food support, etc., in minimizing the impact. One report which is a clear example of a comprehensive approach that achieved meaningful results is the economic support provided through the COVID-19 pandemic relief programs in the United States (such as the Economic Impact Payment and expanded Child Tax Credits). These programs achieved what decades of targeted, bureaucratic efforts have failed to do – they reduced childhood poverty, which could in turn benefit an entire generation. In 2020, 3.2 million children in the United States (8 million overall) were elevated above the poverty level.[¹¹] The authors conclude: “Policies and legislation are needed that foster equitable environments, devoid of the societal ills of income inequality, poverty, and racism, if we want to achieve maximal health for all”, which is the essence of social psychiatry.

Global launch of the Lancet-World Psychiatric Association Commission: time for United action on depression, on February 16, 2022, reflects the same importance of the pandemic as follows: “Our task has never felt more urgent. The potentiation by the COVID-19 pandemic of adverse societal factors such as deep-rooted structural inequalities and personal impacts such as social isolation, bereavement, sickness, uncertainty, impoverishment, and poor access to health care has had negative impacts on the mental health of millions of people. It has generated a so-called perfect storm that requires responses at multiple levels. The consequences of the pandemic thus emphasise the need to make the prevention, recognition, and treatment of depression an immediate global priority, which we address through a number of key messages and recommendations.”[¹²]

The recommendations call for action at four levels: (i) the community and people living with depression, (ii) health-care practitioners, (iii) researchers and research funders, and (iv) decision-makers and policy-makers.

The WMHR 2022, titled “Transforming Mental Health for All,” released on June 17, 2022, is a major milestone in the development of mental health in the world.

“Mental health is critically important to everyone, everywhere. All over the world, mental health needs are high but responses are insufficient and inadequate. This “WMHR (2022)-Transforming Mental Health for All” is designed to inspire and inform better mental health for all. Drawing on the latest evidence available, showcasing examples of good practice from around the world, and voicing people's lived experiences, it highlights why and where change is most needed and how it can best be achieved. It calls on all stakeholders to work together to deepen the value and commitment given to mental health, reshape the environments that influence mental health, and strengthen the systems that care for mental health.”[¹³]

There are seven important reasons to consider this Report as pathbreaking. First, this is a Report from the WHO, where the Ministries of Health of all countries of the world, contribute to policy development and is the lead organization for health in the world. Second, this Report is coming 21 years after the last report of October 2001.[¹⁴] Third, unlike the 2001 Report which was a World Health Report with a special focus on mental health, this report is a stand-alone full report on mental health (this Report is twice the size of the 2001 Report). Fourth, the last two decades have seen major advances in the understanding of mental disorders and mental health, especially about the plasticity of the brain and social determinants of health. Fifth, the COVID-19 pandemic has sensitized the general population, politicians, planners, and the population to the importance of mental health as part of life. Sixth, the report presents mental health in an engaging and easy-to-read nontechnical language suitable for reading by professionals and nonprofessionals (more than 70 case studies [innovations, country reports, personal narratives, graphics, etc.] are a special feature of the report). Finally, the Report is a treat from the design point of view with excellent graphics and photographs. All in all, the report is a significant contribution to the understanding and action for the mental health of the world.

This WMHR, 2022, is designed to inspire and inform the indisputable and urgent transformation required to ensure better mental health for all. While promoting a multisectoral approach, this report is specially written for decision-makers in the health sector. This includes ministries of health and other partners in the health sector who are generally tasked with developing mental health policies and delivering mental health systems and services. The report is organized against three overarching themes, namely, (i) principles and drivers of public mental health, (ii) the care for transformation, and (iii) mental health reform in eight chapters, introduction, principles, and drivers in public mental health, world mental health today, benefits of change, foundations for change, promotion and prevention for change, restructuring and scaling up care for impact, and conclusion. The WMHR provides guidance for the reorganization of mental health care and a greater role for persons living with mental disorders and greater utilization of community resources.

The Lancet Commission on stigma and discrimination, released on October 11, 2022[¹⁵] breaks new ground with an extensive review of the world literature and presents eight key recommendations for action by international organizations, governments, employers, the health care and social care sectors, the media, people with lived experiences, local communities, and civil society, each with a specific target and indicators that may be used to develop a framework for accountability and track progress toward ending mental health-related stigma and discrimination. A striking aspect of the report is the recognition of “social contact” as the most important intervention to break the stigma and discrimination. The report presents a clarion call by the following statement: “mental health is part of being human—let's act now to stop stigma and to start inclusion.”

The shifting focus from services to “people” is reflected in September 2022, the WHO South-East Asia Regional Office PARO Declaration on Mental Health.[¹⁶]

As reviewed in the earlier sections, the last few years have squarely brought to focus the importance of the individual, families, communities, and social factors as the key drivers of human health in general and mental health in particular. This recognition and awareness is an opportunity for change. COVID-19 has presented an important opportunity to understand social psychiatry in a wide range of ways.[⁸⁹¹⁰] This opportunity is expressed very well by two recent books:

“The pandemic has, in this sense given us an opportunity to make a decisive break from the ethos that has governed our work and caused burnout over the past 50 years. It is a chance to remake work and reimagine its place in our lives. If we do not take this opportunity, we will slip back into patterns that created the burnout culture in the first place.[¹⁷]

Similarly, Taylor notes[¹⁸] “the pandemic changed everything about our lives: How we worked, socialised, travelled. Dealing with so many changes at once was a mental challenge for us all. The pandemic has also taught us the importance of developing resilience– the ability to manage the stressors, large and small, in our lives. Resilience may be one positive legacy of a very tough couple of years.”

Now, it is for professionals with an interest in social psychiatry to take up the current challenges and opportunities and make a difference.[⁸⁹¹⁰]