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Home > Comment > BMJ
2008;336(7651):992 (3 May), doi:10.1136/bmj.39513.441030.AD

BMJ  2008;336:992-994 (3 May),
doi:10.1136/bmj.39513.441030.AD

Analysis

How scientifically valid is the knowledge base of global mental health?

Derek Summerfield, honorary senior
lecturer

1 Institute of Psychiatry, King’s College, London SE5 8AF

derek.summerfield{at}slam.nhs.uk

Mental health is a construct that cannot be seen as
independent of culture, society and situation. Derek Summerfield
argues that Western definitions and solutions cannot be routinely
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
disorders now represent a substantial "though largely hidden"
proportion of the world’s overall disease burden, that every
year up to 30% of the global population would develop some form
of disorder, and that there was strong evidence for scaling up
mental health services worldwide.1 2 In this
article I examine the evidence for these claims and challenge the
assumption that Western frameworks can generate a universally valid
knowledge base.

Classification and diagnosis

Psychiatric research and practice rest on empiricist convention
rather than on timeless discovery. The principal classification
systems, the International Classification of Diseases (ICD)
and the Diagnostic and Statistical Manual of Mental Disorders
(DSM), are shaped by contemporary notions about what constitutes
a real disorder, what counts as scientific evidence, and how
research should be conducted. They are Western cultural documents
par excellence.3

The diagnostic categories within these classifications are essentially
conceptual devices emerging from committee decisions. The authors
of both of these classifications are careful to point out that
"there is no assumption that each category of mental disorder
is a completely discrete entity with absolute boundaries dividing
it from other mental disorders or from no disorder."4
Despite this, in everyday practice these categories have been
effectively accepted as if they were unequivocal diseases like, say,
tuberculosis.

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
in the Western psychiatric canon. Official psychiatric categories
evolve, disappear, or appear, reflecting Western social and
cultural trends as much as medical thinking. For example, DSM-III,
published in 1980, expunged homosexuality as a classified mental
illness and installed post-traumatic stress disorder for the
first time. It would be extraordinary if these classification
systems made sense across the great diversity of societies and
situations worldwide.

Validity in mental health research

The psychiatric literature contains large numbers of studies of
non-Western subjects, and publications on refugees and populations
affected by disaster rose exponentially during the 1990s.5
However, in a review of 183 published studies on the mental health
of refugees, four fifths of the studies relied exclusively on
measures of psychopathology developed with Western
populations.6
Although a few researchers have sought to garner culture specific
information, they too have retained Western psychiatric categories as
their basic template.7 8

The relevance of much of this published literature is therefore
questionable because it fails the fundamental test of scientific
validity. Validity is a concept meant to assess "the nature of
reality" for the people being studied. Methods for research into the
mind cannot rely on the merely technical and quantifiable, since "the
nature of reality" is bound up with local forms of knowledge and
philosophy. To ignore the test that follows – whose reality, whose
knowledge, whose philosophy – is to risk pseudodiagnoses and
interventions that are an unwanted distraction in the hard pressed
lives of non-Western subjects.

It is telling that published studies of non-Western populations
often refer to participants’ "limited knowledge of mental
disorders," their lack of "mental health literacy," or the need
to "teach" health workers and the people they serve about mental
health. Here Western psychological discourse is setting out to
instruct, regulate, and modernise, presenting as definitive the
contemporary Western way of being a person. It is unclear why this
should be good for mental health in Africa or Asia. This is medical
imperialism, similar to the marginalisation of indigenous knowledge
systems in the colonial era, and is generally to the disadvantage of
local populations.9 10

Cultural variability of mental disorder

Many ethnomedical systems have categories that range across the
physical, supernatural, and moral realms and do not conceive of
illness as situated in body or mind alone.11
Distress is commonly understood and expressed in terms of disruptions
to the social and moral order. As Kleinman and Good put it,
"Cultural worlds may differ so dramatically that translation of
emotional terms means more than finding semantic equivalents.
Describing how it feels to be aggrieved or melancholic in another
society leads directly into an analysis of a radically different
way of being a person."12

Since the 1970s many ethnographic studies have shown that the
presentation, attribution, classification, prevalence, and prognosis
of mental disorders varies greatly between cultures. Journals
such as Social Science and Medicine, Transcultural Psychiatry,
Anthropology and Medicine, and Culture, Medicine and
Psychiatry are replete with this work. However, it is
under-represented in the mainstream psychiatric literature, which
tends to overemphasise cross-cultural similarities and minimise the
differences.13

Depression as an example

WHO has stated that "depression" is a worldwide epidemic that
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
identified in non-Western settings, they mean the same as they do in
the Western world. Some central and southern African societies
recognise a local condition - often translated as "thinking too much"
– which has some physiological overlap with Western depression, but
the understandings, attributions, and remedies applied to it are very
different.

As discussed above, the DSM or ICD definition of depression is
merely a descriptive syndrome, highly heterogeneous and socially
shaped, albeit subsuming a small subset of severely dysfunctional
people who do fit the model of depression as a disease. This
term simply cannot be used (as WHO uses it) to denote a universally
valid mental disorder that is amenable to a standard mental
health toolkit.14

A meta-analysis of 56 published studies of refugees’ mental health
totalling 67 294 participants found the strongest moderating factor
to be social conditions after displacement.15
Resolution of the conflict that had displaced them also had positive
effects. This suggests that the mental phenomena being identified
as satisfying criteria for a mental disorder (typically
depression or post-traumatic stress disorder) were mostly incidental
and a normal reaction to their circumstances.15 My
research and clinical experience in war affected rural Zimbabwe, with
rural peasants and wounded former soldiers in Nicaragua, and
with HIV positive African women and other asylum seekers in the
United Kingdom indicated that a diagnosis such as depression,
although commonly made, had little power to explain their
problems.16
17

Lastly, WHO is backing the global application of technologies like
checklists to estimate population prevalences of depression and the
therapeutic value of antidepressants or counselling when the strength
of their evidence base even in Western societies remains
controversial.18

Mental health in a broken social world

Social scientists agree that wellbeing and personal resilience are
linked to social connectedness and the sense of a coherent world.
Throughout the non-Western world, structural poverty and injustice,
violent conflict, debt repayments, shifting weather patterns,
environmental degradation, and inadequate budgets for health,
education, and social welfare provide a barely viable social context
for millions of people. Around 85% of Kenya’s population growth in
the 1990s was absorbed into the slums of Nairobi and Mombasa,
reflecting a rapid withering of traditionally self sufficient ways of
life.19
Average life expectancy is falling in many countries, and one third
of the world’s children are undernourished. Can psychiatric
approaches honed in relatively well resourced and stable societies
distinguish mental disorder from normal responses to a social world
that is no longer coherent or functional? The danger of the
medicalisation of everyday life is that it deflects attention from
what millions of people worldwide might cite as the basis of their
distress - for example, poverty and lack of rights.

Valid assessment

Until these fundamental queries about the knowledge base are
answered, claims about the current state of global mental health
seem risible. There needs to be agreement that Western psychiatry
is but one among many ethnopsychiatries. New research ideally
needs to engage with participants in a way that carries no preformed
notions about what is "mental" or "health" in their world: local
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
stress disorder and depression, have strongly featured in the
research literature to date, but there are reasons to query how
much the impetus for this has come from those on the ground, as
opposed to interested parties from outside. WHO’s prevalence figures
lack credibility and would seriously mislead health planners and
providers.

Research into more severe mental disorders is on firmer ground.
These disorders are much more likely to have a neuropsychiatric
component and to stretch local social and healthcare resources.
Based on a survey of 2739 households, Patel and colleagues estimated
standardised prevalence ratios of psychosis (2.79), learning
difficulties (1.48), and seizures (2.00) (seizures are commonly
seen as a mental disorder in much of Africa) in rural and urban
Mozambique.20
Psychosis would not of course be a homogeneous category, since it
would subsume various organic cerebral states that merited attention
in their own right – not least AIDS encephalopathy or dementia.

An emphasis on qualitative work would promote more grass roots
ownership of the terms of reference of mental health and enable
a robust and relevant knowledge base to emerge. The apparent
failure of the £1.1 trillion spent on development aid in Africa
over the past 50 years to change anything is partly because donors
lacked knowledge of the situations on the ground in poor countries
and because of over-reliance on expensive consultants from donor
countries.21 Local
voices were weakly represented. This poses an ethical challenge for
global mental health: non-Western people can give properly informed
consent only if the terms in which they are being represented,
which here means candidature for psychiatric caseness, are not
alien or irrelevant to their interpretations of the world.

Summary
points

Psychiatric categories are descriptive syndromes
not diseases

Western categories are not universally valid

Qualitative research into mental health is needed
in non-Western settings

Perceived mental health problems may be a normal
reaction to harsh living conditions

Contributors and sources: DS has studied, lectured,
and published widely on health and human rights in Africa, Central
America, and the Middle East, particularly in war affected
populations and on asylum seekers in the UK. He is also a teaching
associate at Refugee Studies Centre, University of Oxford.

Competing interests: None declared.

Provenance and peer review: Not commissioned;
externally peer reviewed.

References

Horton R. Launching a new movement for mental health.
Lancet 2007;370:806.[CrossRef][Web
of Science][Medline]

Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips
MR, et al. No health without mental health. Lancet 2007:370:859-77.

Mezzich J, Kirmayer L, Kleinman A, Fabrega H Jr, Parron
DL, Good B, et al. The place of culture in DSM IV. J Nerv Ment Dis
1999;187:457-64.[CrossRef][Web
of Science][Medline]

Kendell R, Jablensky A. Distinguishing between the
validity and utility of psychiatric diagnoses. Am J Psychiatry
2003;160:4-12.[Abstract/Free Full Text]

Ingleby D. Editor’s introduction. In: Forced migration
and mental health. Rethinking the care of refugees and displaced persons. New
York: Springer, 2005:1-27.

Hollifield M, Warner T, Lian N, Krakow B, Jenkins JH,
Kesler J, et al. Measuring trauma and health status in refugees: A critical
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Mollica R, Caspi-Yavin Y, Bollini P, Truong T, Tor S,
Lavelle J. The Havard trauma questionnaire: validating a cross-cultural
instrument for measuring torture, trauma, and post-traumatic stress disorder
in Indochinese refugees. J Nerv Ment Dis 1992;180:111-6.[Web
of Science][Medline]

Bolton P, Wilk C, Ndogoni L. Assessment of depression
prevalence in rural Uganda using symptom and function criteria. Soc
Psychiatry Psychiatr Epidemiol 2004;39:442-47.[Web
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Said E. Culture and imperialism. London: Chatto and
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Summerfield D. A critique of seven assumptions behind
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Kirmayer L. Cultural variations in the response to
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Kleinman A, Good B, eds. Culture and depression:
studies in the anthropology and cross-cultural psychiatry of affect and
disorder. Los Angeles: University of California Press, 1985.

Kleinman A. Do psychiatric disorders differ in
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eds. The culture and psychology reader. New York: New York University Press,
1995:631-51.

Summerfield D. Depression: epidemic or pseudoepidemic?
J R Soc Med 2006;99:161-2.[Free Full Text]

Porter M, Haslam N. Predisplacement and
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internally displaced persons. JAMA 2005;294:602-12.[Abstract/Free Full Text]

Hume F, Summerfield D. After the war in Nicaragua: a
psychosocial study of war wounded ex-combatants. Medicine and War
1994;10:4-25.[Medline]

Summerfield D. War, exile, moral knowledge, and the
limits of psychiatric understanding. A clinical case study of a Bosnian
refugee in London. Int J Soc Psychiatry 2003;49:264-8.[Abstract/Free Full Text]

Moncrieff J. The anti-depressant debate. Br J
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Davis M. Planet of slums. London: Verso, 2006.

Patel V, Simbine A, Soares I, Weiss HA, Wheeler E.
Prevalence of severe mental and neurological disorders in Mozambique: a
population-based survey. Lancet 2007;370:1055-60.[CrossRef][Web
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Ncayiyana D. Combating poverty: the charade of
development aid. BMJ 2007;335:1272-3.[Free Full Text]

(Accepted 26 January 2008)

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