Opinion: In the time of COVID-19, we need to invest in a different mental health system

When Michael Wheeler walked into a health facility in Birmingham, England seeking psychological support, he was turned away because of understaffing. Michael went home and continued to suffer — in the next few hours, he took his own life. Across the globe, in Johannesburg, South Africa, Deborah Phehla was moved from a psychiatric facility to a community-based organization offering “sheltered housing” that didn’t have sufficient funding to provide for her basic needs. As a result, Deborah died of starvation, with horrific stories emerging of her eating plastic bags and scraps of paper out of sheer desperation. These entirely preventable tragedies illustrate the lack of resources for addressing the needs of people with lived experience of mental health challenges and underscore the reality of a global problem in need of urgent attention. Indeed, according to the World Health Organization, while global per capita spending on general health averaged $141 per person, the median spending on mental health averaged just $2.50 per person. What we need ... are models of mental health that incorporate peer support and supported decision-making, alongside systemic interventions such as income generation. --— Even in high-income countries, where many policymakers have committed to support mental health through legislation or policy, spending amounts up to 5% of their total health budgets. In foreign aid for health, too, less than 1% of assistance for health is dedicated to mental health. The theme of this year’s World Mental Health Day is “Move for mental health: Let’s invest,” and helps underscore the dire need to seriously invest in mental health, especially at a time of increased emotional distress because of COVID-19, the economic fallout, and the impact of social isolation and bereavement. We need to ask not only how much is being spent, but also ask where funds are being invested. Mainstream mental health systems can often cause more harm than good, separating people from their communities and forcibly — often indefinitely — confining them into institutions. For the most part, these systems are predicated on an “illness” or “deficit” model of mental health that views distress as a disease of the brain rather than the product of factors including one’s financial, social, or family circumstances. These models, developed in Europe and North America, are exported wholesale to the rest of the world with little attention paid to context, local knowledge systems, or cultural norms. Take, for example, the fact that large portions of mental health budgets in low- and middle- income countries are funded by overseas government donors, who emphasize Western clinical traditions in their funding. As a result, traditional practices are often ignored or labeled as “primitive,” despite the vast majority of people seeking support from traditional healers before visiting a clinic in places such as Zimbabwe and Ghana. Invariably, this deficit model relies heavily on medication as the solution. While many people may benefit from such interventions, they simply don’t address the numerous barriers to well-being such as disconnection from one’s community, economic insecurity, or the harmful impact of structural discrimination, like racism. What we need instead are models of mental health that incorporate peer support and supported decision-making, alongside systemic interventions such as income generation, social inclusion through housing, education, and efforts to foster community cohesion. These interventions have shown to have positive effects on mental health. This focus on well-being does not preclude direct psychiatric interventions; it merely highlights that, in most cases, a pill isn’t effective on its own. Yet despite the value of holistic, culturally, and contextually relevant supports, what little research there is on the subject suggests that the vast majority of mental health funding goes to institution-based “care.” These community-based interventions that we know work are dramatically lagging, as demonstrated in stark terms by Deborah’s fate. We have the opportunity to promote mental health through an investment that will reverse centuries of systemic neglect and under prioritization, and this is an extremely necessary course of action. Efforts to increase funding for mental health are worth celebrating, but they must be accompanied by efforts to promote holistic supports that engage with the various determinants of mental health, and that recognize that well-being is more than merely a function of brain chemistry or individual pathology. Advocacy to challenge this dominant narrative can go a long way to shifting the over-reliance on deficit models of mental health, and this must of course centralize the voice of people with lived experience of mental health challenges themselves. Similarly, documentation of and investment in models of support that are rooted in local knowledge and are thus contextually relevant will also be necessary rather than simply investing in problematic or irrelevant approaches that may very well do more harm than good. Of course, shifting to a model of mental health that recognizes the various ways in which our circumstances interact with our well-being should also be a core aspiration. This requires systemic change to address marginalization and inequality through efforts aimed at delivering social justice and the elimination of discrimination. It also requires investment in building stronger and more supportive communities through the social inclusion interventions highlighted above, and it requires an explicit recognition in laws, policies, and practices of the right to dignity and autonomy of all people, including those with lived experience of mental health challenges alongside the needed increases in investment. What happened to Michael Wheeler, Deborah Phehla, and so many others is horrifying; allowing it to happen again would be nothing short of a tragedy.