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[Comment] Offline: A perilous birthday party for mental health

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Birthday parties are joyous celebrations to mark important milestones in time. But, as Harold Pinter knew, the birthday party can also be a moment for menacing reflection. When several hundred people crowded into a cold hall at King's College London, last week, they were there to cheer a decade in the life of the university's Centre for Global Mental Health. Festivities quickly turned into an analysis of the state of global mental health. The conclusions were disturbing.

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It's essential to say that the global mental health community does have consequential successes to honour. A decade ago, mental health was languishing on the margins of global health. Mental disorders had been ignored in the Millennium Development Goals. The non-communicable disease (NCD) advocacy community actively shut out mental health. Research displayed fragmented quality. Practitioners and campaigners were poorly organised. And stigma was widely prevalent. But seeds of change were germinating. In the landmark 1993 World Development Report, Investing in Health, an innocuous-looking Appendix B launched the Global Burden of Disease (GBD). Within that first tentative iteration were the ingredients for a revolution. A category labelled “Neuropsychiatric conditions” included depressive disorders, bipolar affective disorders, psychoses, alcohol and drug dependence, and post-traumatic stress disorder. Calculation of disability-adjusted life-years (DALYs) indicated that for men, for example, around 7% of global DALYs could be attributed to neuropsychiatric conditions. That meant, to the total surprise of most, that mental ill-health was responsible for more disability than tuberculosis, malaria, cancer, ischaemic heart disease, and stroke. Today, mental health has at last received the legitimacy it deserves. Promoting mental health and wellbeing is written into SDG 3.4. Mental health appeared in this year's Political Declaration on Universal Health Coverage (paragraph 27). WHO included mental health in its revised approach to NCD advocacy—5 × 5, in place of 4 × 4: five diseases that embraced mental health (and a fifth risk factor, air pollution). The GBD continued to reveal the growing importance of mental ill-health (depressive disorders rose from fourth to third in global rankings of disability between 1990 and 2018). And the knowledge base for global mental health is expanding. (The Lancet has sought to play a small part with global mental health series in 2007 and 2011, and a Commission on Global Mental Health and Sustainable Development in 2018.) Mental health has surely secured its position as a subject foundational to global health.

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In truth, the position of global mental health is still precarious. There are five reasons to be anxious. First, just what is the ask for mental health as part of Universal Health Coverage? What and how many health workers? What quality services and where? What essential medicines? How much money? Second, the mental health community has failed to devise any credible means to hold political leaders accountable for their promises and commitments. Why? Perhaps fear of upsetting international institutions (such as WHO) or powerful individual governments (such as the US). Third, the civil society landscape in mental health is still atrociously weak by comparison with the AIDS movement and advocacy for women's and children's health. Fourth, the mental health community has a limited vision of its sphere of concern. The broader political, economic, social, and environmental determinants of mental health—poverty, violence, conflict, humanitarian emergencies, inequality, gender inequity—are too often seen as separate to the enterprise of extending mental health services. And finally, the emphasis on mental health has excluded what SDG 3.4 also asks for—an equal concern with mental wellbeing, which must include ideas about fulfilling a person's potential, life satisfaction, and even life's meaning. The great successes of global mental health during the past decade owe much to the extraordinary solidarity and purpose of the mental health community. Now is not the moment to be complacent. And yet there were signs of premature self-satisfaction last week. The anger and fury that one needs to transform global health into a movement with mental health as a core principle were absent. If global mental health is to consolidate and accelerate its progress, mental health professionals and civil society need not only to rediscover their solidarity but also their raging soul.

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