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BMJ 2008;336:992-994 (3 May),=20 doi:10.1136/bmj.39513.441030.AD
Analysis
How scientifically valid is the knowledge base of global mental = health?
Derek Summerfield, honorary senior=20 lecturer
1 Institute of Psychiatry, King=92s College, London SE5 = 8AF
derek.summerfield{at}slam.nhs.uk
Mental health is a construct that cannot be seen = as=20 independent of culture, society and situation. Derek = Summerfield=20 argues that Western definitions and solutions cannot be = routinely=20 applied to people in developing countries
Global mental health now has its own academic units, literature, =
study, and training courses and the World Health Organization =
is a major articulator of this work. Last September, a series =
on global mental health in the Lancet asserted that mental=20
disorders now represent a substantial "though largely hidden" =
proportion of the world=92s overall disease burden, that =
every=20
year up to 30% of the global population would develop some =
form=20
of disorder, and that there was strong evidence for scaling =
up=20
mental health services worldwide.
Psychiatric research and practice rest on empiricist convention=20
rather than on timeless discovery. The principal =
classification=20
systems, the International Classification of Diseases =
(ICD)=20
and the Diagnostic and Statistical Manual of Mental =
Disorders=20
(DSM), are shaped by contemporary notions about what =
constitutes=20
a real disorder, what counts as scientific evidence, and how=20
research should be conducted. They are Western cultural =
documents=20
par excellence. The diagnostic categories within these classifications are =
essentially=20
conceptual devices emerging from committee decisions. The =
authors=20
of both of these classifications are careful to point out =
that=20
"there is no assumption that each category of mental disorder =
is a completely discrete entity with absolute boundaries =
dividing=20
it from other mental disorders or from no disorder." Claims for the universality of a particular psychiatric category =
would be compelling if a straightforward biological cause had =
been established. But this is the case for only a few =
categories=20
in the Western psychiatric canon. Official psychiatric =
categories=20
evolve, disappear, or appear, reflecting Western social and=20
cultural trends as much as medical thinking. For example, =
DSM-III,=20
published in 1980, expunged homosexuality as a classified =
mental=20
illness and installed post-traumatic stress disorder for the=20
first time. It would be extraordinary if these classification =
systems made sense across the great diversity of societies =
and=20
situations worldwide.
The psychiatric literature contains large numbers of studies =
of=20
non-Western subjects, and publications on refugees and populations=20
affected by disaster rose exponentially during the 1990s. The relevance of much of this published literature is therefore=20
questionable because it fails the fundamental test of =
scientific=20
validity. Validity is a concept meant to assess "the nature =
of=20
reality" for the people being studied. Methods for research =
into the=20
mind cannot rely on the merely technical and quantifiable, =
since "the=20
nature of reality" is bound up with local forms of knowledge =
and=20
philosophy. To ignore the test that follows =96 whose =
reality, whose=20
knowledge, whose philosophy =96 is to risk pseudodiagnoses =
and=20
interventions that are an unwanted distraction in the hard =
pressed=20
lives of non-Western subjects.
It is telling that published studies of non-Western populations=20
often refer to participants=92 "limited knowledge of mental=20
disorders," their lack of "mental health literacy," or the =
need=20
to "teach" health workers and the people they serve about =
mental=20
health. Here Western psychological discourse is setting out =
to=20
instruct, regulate, and modernise, presenting as definitive =
the=20
contemporary Western way of being a person. It is unclear why =
this=20
should be good for mental health in Africa or Asia. This is =
medical=20
imperialism, similar to the marginalisation of indigenous =
knowledge=20
systems in the colonial era, and is generally to the =
disadvantage of=20
local populations.
Many ethnomedical systems have categories that range across =
the=20
physical, supernatural, and moral realms and do not conceive =
of=20
illness as situated in body or mind alone. Since the 1970s many ethnographic studies have shown that the=20
presentation, attribution, classification, prevalence, and =
prognosis=20
of mental disorders varies greatly between cultures. Journals =
such as Social Science and Medicine, Transcultural =
Psychiatry,=20
Anthropology and Medicine, and Culture, Medicine and=20
Psychiatry are replete with this work. However, it is=20
under-represented in the mainstream psychiatric literature, =
which=20
tends to overemphasise cross-cultural similarities and =
minimise the=20
differences.
WHO has stated that "depression" is a worldwide epidemic that=20
within a decade will be second only to cardiovascular disease =
in terms of global disease burden. But it is a basic error of =
validity to assume that because Western mental phenomena can =
be=20
identified in non-Western settings, they mean the same as =
they do in=20
the Western world. Some central and southern African =
societies=20
recognise a local condition - often translated as "thinking =
too much"=20
=96 which has some physiological overlap with Western =
depression, but=20
the understandings, attributions, and remedies applied to it =
are very=20
different.
As discussed above, the DSM or ICD definition of depression =
is=20
merely a descriptive syndrome, highly heterogeneous and socially=20
shaped, albeit subsuming a small subset of severely =
dysfunctional=20
people who do fit the model of depression as a disease. This=20
term simply cannot be used (as WHO uses it) to denote a =
universally=20
valid mental disorder that is amenable to a standard mental=20
health toolkit. A meta-analysis of 56 published studies of refugees=92 mental =
health=20
totalling 67 294 participants found the strongest moderating =
factor=20
to be social conditions after displacement. Lastly, WHO is backing the global application of technologies =
like=20
checklists to estimate population prevalences of depression =
and the=20
therapeutic value of antidepressants or counselling when the =
strength=20
of their evidence base even in Western societies remains=20
controversial.
Social scientists agree that wellbeing and personal resilience =
are=20
linked to social connectedness and the sense of a coherent =
world.=20
Throughout the non-Western world, structural poverty and =
injustice,=20
violent conflict, debt repayments, shifting weather patterns, =
environmental degradation, and inadequate budgets for health, =
education, and social welfare provide a barely viable social =
context=20
for millions of people. Around 85% of Kenya=92s population =
growth in=20
the 1990s was absorbed into the slums of Nairobi and Mombasa, =
reflecting a rapid withering of traditionally self sufficient =
ways of=20
life.
Until these fundamental queries about the knowledge base are=20
answered, claims about the current state of global mental =
health=20
seem risible. There needs to be agreement that Western =
psychiatry=20
is but one among many ethnopsychiatries. New research ideally =
needs to engage with participants in a way that carries no =
preformed=20
notions about what is "mental" or "health" in their world: =
local=20
concepts must be the starting point for the creation of valid =
instruments for screening or diagnosis.
The so called common mental disorders, such as post-traumatic=20
stress disorder and depression, have strongly featured in the =
research literature to date, but there are reasons to query =
how=20
much the impetus for this has come from those on the ground, =
as=20
opposed to interested parties from outside. WHO=92s prevalence =
figures=20
lack credibility and would seriously mislead health planners =
and=20
providers.
Research into more severe mental disorders is on firmer ground.=20
These disorders are much more likely to have a =
neuropsychiatric=20
component and to stretch local social and healthcare =
resources.=20
Based on a survey of 2739 households, Patel and colleagues =
estimated=20
standardised prevalence ratios of psychosis (2.79), learning=20
difficulties (1.48), and seizures (2.00) (seizures are =
commonly=20
seen as a mental disorder in much of Africa) in rural and =
urban=20
Mozambique. An emphasis on qualitative work would promote more grass roots=20
ownership of the terms of reference of mental health and =
enable=20
a robust and relevant knowledge base to emerge. The apparent=20
failure of the =A31.1 trillion spent on development aid =
in Africa=20
over the past 50 years to change anything is partly because =
donors=20
lacked knowledge of the situations on the ground in poor =
countries=20
and because of over-reliance on expensive consultants from =
donor=20
countries.
Competing interests: None =
declared.
Provenance and peer review: Not =
commissioned;=20
externally peer reviewed.
Read all Rapid=20
ResponsesClassification and diagnosis
Validity in mental health research
Cultural variability of mental disorder
Depression as an example
Mental health in a broken social world
Valid assessment
Summary=20
points
=
Contributors and sources: DS has studied, =
lectured,=20
and published widely on health and human rights in Africa, =
Central=20
America, and the Middle East, particularly in war affected=20
populations and on asylum seekers in the UK. He is also a =
teaching=20
associate at Refugee Studies Centre, University of =
Oxford.=20
References
(Accepted 26 January 2008)
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