George Alleyne
Director Emeritus, PAHO

I write this in New York on the eve of the United Nations’ High-level meeting on noncommunicable diseases (NCDs) with the very pleasant knowledge that mental health disorders have been given prominence in the Political Declaration. The Commission’s report is a clear and cogent statement of the importance of mental health disorders and is not merely a plaintive cry for recognition. The data on the nature of the problem of mental health disorders, the historical sequence of growing attention, the scientific basis of attention and the three principles for a re-framing of the issue made this report an excellent backdrop to the UN Political Declaration. There is an ambitious effort to frame the discourse not only in terms of the diminution of the gap with respect to attention to and treatment of those with mental health disorders, but also to address the gap between the haves and the have-nots with respect to services for mental health. Of course, there should be no dichotomy as both approaches are essential and both represent the inequities that must be addressed, notwithstanding the interesting assertion that in terms of attention to mental health disorders, all countries are underdeveloped.

 

Given the scarcity of resources of all kinds, I warmed to the idea of employing non-traditional workers and amplification of the use of technology. This took me back to an innovation in the Americas to involve hair-dressers, in the recognition and early detection of mental health problems in clients who could be referred for appropriate therapy. I was particularly taken with the proposal to mobilize the voices of those living with mental health problems. This finds echo in my assertion that the billions of persons with NCDs and mental health disorders in the world outnumber the others by far, but to date the NCD community has not been successful in appreciating the power of numbers in stimulating societal action.

 

I confess to a little ambivalence with respect to the treatment of mental health in the SDGs which the Commission lauds as a great advance. The recognition of the problem is positive, but the way it is it is posited can be improved. I trust that the Commission’s work will enhance the possibility of introducing some useful metric in the area like that given for NCDs. I agree with the rejection of the binary approach to classification which is but another example of the fact that many health personnel are still arrested at the level of binary thought, but I would caution against making the tent so large that it is difficult to know who is in and who is out.

 

I appreciate the nuanced view about placing the expressed wishes and needs of people affected by mental health disorders at the heart of mental health care as indeed there are times when there is diminished agency in some persons so affected. This touches on the well-articulated rights focus in which of course there is a balance between autonomy of decision making and the need to be aware of the requirements of those with impaired capacity to make informed decisions. In terms of responsibilities, I would have appreciated the acknowledgement that there are many important mental health issues surrounding death and the goals of medicine are not limited to the physical aspects of ensuring death with dignity. The Commission does the field a great service by addressing the approach to labelling mental health disorder and it was attractive to note the clear description of the level of functionality as significant for initiation of treatment and its obvious limitations.

 

In the elaboration of the social determinants of mental health, the social and cultural domain clearly includes social capital which is indeed mentioned. It might have been useful to have a wider exploration of the much-undervalued influence of that capital in the discussion of the factors that make for a productive society. To the extent that social capital, like human and physical capital contribute to wealth, to that extent that it will impact on the mental health of the individuals and the population. In this vein, it might also be appropriate to indicate that mental health as well as physical health must be considered as a significant input into human capital. The Commission is abundantly clear about amplifying the availability of evidenced-based care which must be balanced with the danger of medicalizing such care and ignoring the fact that much of care for “disease” was traditionally given in the domestic arena.

 

The Commission has done the field a great service, not only by exploring the many critical aspects of research and service for mental health disorders, but to my mind the most important and novel aspect is the reframing of the issue and of the three principles enunciated, the one related to the human rights aspect resonated with me most strongly. I look forward to this Report having a significant impact on mental health research, funding and the provision of care to those who need it.