Cultural factors in global mental health disparities between developed and developing nations

Global Mental Health

One striking characteristic about the state of global mental health today -- aside from the fact that "four out of the ten diseases with the highest burden are psychiatric" -- is that in the developing world there is greater likelihood of quicker remission than in the developed, Industrial world (Kastrup, Ramos, 2007, p. 42). Schizophrenia, for instance, weighs more heavily and persistently in first-world countries than it does in the third-world. While some researchers attribute this lop-sided relationship to the belief that the developing world has a lower rater of reporting and treatment (thus skewing the statistics) (Gilbert, Patel, Farmer, Lu, 2015), others assert that the higher rate in the Industrialized world is due to a host of reasons related to modernization, such as a disconnect with nature, a greater dependence upon chemical treatment, a detachment from traditions and Old World values, and a fragmentation of culture (Gilbert, 2014). Whatever the reasons, the rate of incidence of mental disease around the world is increasing. This paper will discuss the state of global mental health today and evaluate some of the problems and theories associated with it.

Scope of the Problem

According to researchers, "13% of the global burden of disease" is caused by mental health disorders -- more than cancer and more than heart disease (Collins, Patel, Joestl et al., 2011). The range in mental health disease goes from schizophrenia to dementia to drug and alcohol abuse/dependency. It is estimated that as a result of some form of mental disease, 1.5 million people will be committing suicide every year by 2020 and nearly 30 million people will be suicidal (Bertolote, Flieschmann, 2002). These numbers highlight a serious, epidemic-like problem in the world's mental health. What has happened to make people's minds so troubled -- more troubled than their bodies? In the ancient civilizations of China, Greece, India and Rome, philosophers and doctors speculated that there was some connection between the physical and the mental or spiritual. Plato, for instance, argued that if one wishes to cure the body, he must start by curing the mind/soul (Kyziridis, 2005). The approaches to mental cures differed from one ancient civilization to the next, some emphasizing prayer and spiritual relief, others emphasizing the application of music and rest, others focusing on healing through cleansing of the blood. What each typically had in common, however, was a sense that the disorder in the mind arose from affliction that could be alleviated through the use of some form of cultural means -- whether religious, social or communal.

In the Industrialized world, a decisive break occurred between the Old World culture and the modern culture, with tensions fostered as individuals who clung to traditional values were seemingly pulled in two directions at once (Weaver, 1984). On the one hand, individuals raised with a sense of traditional culture (whether American, European or Asian) would have to contend, generally, at some point in their lives with the pressing demands of modern culture -- the need to assimilate, for instance, accept modern values, keep pace with the modern world through the use of new and increasingly rapid technology. The flood of credit upon the developed world in the mid-20th century, especially in the U.S., following WW2 essentially gave birth to the middle class, lifting millions of people out of the poverty that their families had known prior to the war and rewarding those who served in the military with considerable pensions and kickbacks as consumers. The world of high finance had been born decades earlier and incentives to loan and enjoy the apparent, new "prosperity" -- fruits of victory in Europe -- produced a high feeling of euphoric proportions as a whole new generation settled into the "good life," thanks to substantial dispensations from the government.

By the 1970s, the good life had turned to shambles. Revolutions were mounting everywhere -- not just in the U.S. Wars and coups were waged throughout Asia and Africa and Central and South America. Political strife met economical and social disorder. Even in the spiritual or religious realm, major changes were afoot among the most visible religious leaders in the world under the guidance of the Roman Catholic Pontiff, who had "updated" Church doctrine in the 1960s at the Second Vatican Council, exacerbating the disconnect between traditional values and modern ones. All of this impacted the state of global mental health: depression, drug and alcohol abuse, and schizophrenia soared. Suddenly, the fruits of modernization were manifest in a "split mind" syndrome, as everywhere people attempted outwardly to adapt to modern principles and ways of life and yet inwardly fell apart at the seams. What had kept them together? And what could make them whole once more?

Epidemiology and Causation

When the World Health Organization (WHO) focused on schizophrenia in the 1960s (at about the same time the Cold War was raging, the Roman Church was re-orienting itself along modern lines, and the global economy was shifting under the weight of Bretton Woods), it compared the development/course of the disease and rate of incidence among 10 nations. WHO showed that cases presented similarly though the wider the delineation used the greater the differences became. What was significant was that 63% of persons diagnosed with schizophrenia had improved, with the disease going into remission in only two years' time, in the non-developed world -- as opposed to only 37% of cases seeing remission in the developed world (Kastrup, Ramos, 2007). This curious finding highlighted a considerable factor differentiating the modernized world from the as-of-yet unmodernized world: the societal framework of the "past" was more conducive to mental healing than was the framework of the present (in Industrialized societies). According to Kastrup and Ramos (2007) the "more favorable prognosis" in places like Singapore and Japan is "explained by the tendency to maintain an attachment to elements of their respective traditional cultural patterns more than their technological development" (p. 42). In other words, a dependency upon modern/technological culture facilitates mental disorder, whereas a cultivation of traditional "patterns" produces mind-body harmony -- as far as scholarly schizophrenia studies indicate on the global mental health stage.

But what of other mental health diseases? Major depression is the fourth most widespread "contributor to the global burden of disease" and by 2000 accounted for 4.4% of the total amount of "years lost due to early death" and/or disability (Ustun, Ayuso-Mateos, Chatterji, 2004, p. 386). In Europe alone it was estimate that more than 20 million persons suffered from depression -- numbers that would be of epidemic proportions were they linked to something like HIV, which received major worldwide news coverage for years. Yet, depression which directly impacts so many lives is hardly covered by mainstream media. This startling observation may raise questions about the relationship between global mental health and cultural influences as guided by popular press -- or it could merely be that mental health epidemics are not newsworthy in the Brave New World of today, where so many of the world's leaders appear to operate on a level of insanity that beggars belief (Escobar, 2014).

More alarming still is the finding that depression is relative to income: in poorer countries there are significantly fewer recorded incidences of depression than there are in high-income countries. For example, in Africa depression accounts for little more than 1% of the burden of disease, while in wealthy first-world countries it accounts for nearly 9% of the total burden of disease (Kastrup, Ramos, 2007). What tremendous difference "prosperity" makes!

The question must be asked: what is it about developed, high-income nations that causes almost a tenth of its burden of disease to stem from depression? Why are the "middle-class" nations of the world more susceptible to depression than the impoverished nations? A practical consideration could be that in poorer countries there simply is not as much focus on material possessions, luxury, relaxation, enjoyment, expenditure, consumerism and status as there is in places like America, where the American Dream is based on the desire to accumulate wealth. In poorer countries, life consists of simpler ambitions -- work, providing food and shelter for oneself and one's family, and social interaction within one's local community. The kind of village life in Africa, where depression rates are low, can be compared to suburban life in, say, Cincinnati, where neighbors do not know one another beyond sight recognition, where there is little to no sociality, where the Digital Age has moved most social connectivity to the realm of the Internet, and where isolation is a mode of life (Brandtzaeg, 2012). It is no wonder, if one compares the culture of the latter to the culture of the former, that the Industrialized world is more depressed than the third world: it has essentially become much more anti-social than the so-called "developing" world, which still has a sense of natural, face-to-face social interaction and engagement. If man is a social animal by nature, the fact of his divorcing himself from society and isolating himself in his luxurious quarter-of-a-million-dollar home, loaned to him courtesy of the banks (for which both he and partner must work 40+ hour work-weeks to afford), while shutting out the external world (community) in preference for a virtual world (Facebook) where he/she can exercise a voyeur-like existence without risk of coming into personal, face-to-face contact with another individual and having to engage in real-life socialization -- all of this suggests that the American Dream is actually more of a nightmare in terms of mental health: it de-natures man and cuts him off from one of his most basic, human needs, which is society. Maslow's hierarchy of needs attempted to illustrate these basics in pyramid form, with society (family, respect, etc.) coming after shelter and food (physical needs), though one can certainly argue the extent to which the need for shelter and food must be met (a hut vs. a McMansion, for example) before the need for society becomes greater and more significant (Maslow, 1943).

Nonetheless, the theory that materialistic pursuits are enough to make modern man whole is challenged by the finding that modern man in the developed world is nearly ten times more likely to be depressed than non-modern man in the undeveloped world. It is as though the expectation of self-fulfillment has created a devastating void in the psyche/soul/mind of modern man (Percy, 2011).

The statistics continue to alarm as it is noted by researchers that in modern Europe there are more than 41 million individuals who suffer from anxiety (Kastrup, Ramos, 2007), particularly (as is the case in China) women (with a rate of incidence nearly ten times higher in the Orient than that of their male counterparts). Could the fact that the Cultural Revolution essentially stripped the woman of her right to procreate play a part in this anxiety? Surely there must be some link between culture and symptom. In Europe, where procreation is still legal, the social pressure to avoid procreating is evident in the form of lower birth rates and birth control being viewed as conducive to security, peace, and happiness (with anxiety, apparently, being a side effect). Likewise in the U.S., anxiety is higher among African-Americans than it is among Anglo-Saxon-Americans. Could the fact that African-Americans are considerably more likely (about 4x) to be arrested and imprisoned under federal law than Anglo-Saxon-Americans? The startling statistic 80% of all federal prisoners are African-American might make a minority population anxious. Is there some relation between the socio-cultural makeup of society and its mental health? Percy (2011) believed so.

What of mental disorders that are spawned by trauma, such as military sexual trauma (MST) or post-traumatic stress disorder (PTSD)? With more and more war waged in the Middle East since 9/11, the fruits of war are being seen in the rising rates of suicides, MST and PTSD (Johnson, 2012). The correlation between the war on terror, the modernizing of the military, and the disparity between military and civilian culture (which can lead to shock when it comes time for transition) may factor into this particular aspect of mental health disease.

It may also account for the reliance upon alcohol and drugs as coping mechanisms, although such dependency is not limited to military servicemen. It is recorded that more than 75 million individuals around the world suffer from alcohol dependency and is a factor in "1.5% of all deaths" (Kastrup, Ramos, 2007, p. 43)

Suicide, however, raises the most questions regarding the impact of societal connectivity: as Kastrup and Ramos (2007) indicate, "the occurrence of suicide is closely related to family structures, religion, psychosocial stress, and substance abuse" (p. 43). In short, there is considerable evidence that culture plays a direct part in whether one chooses to live or die. Culture is here defined as that which nurtures the development and growth of a society, which consists of individuals who are shaped and impacted by the beliefs and behaviors associated with their surroundings. Thus, a socio-cultural formation is a major factor in suicide and is incorporated into suicide prevention programs.

It may be considered essential, therefore, to assess the extent to which the globalized culture of the modern world plays a part in the rising epidemic that is global mental disease. In what ways has modern culture contributed to mental disorder? That culture has been globalized should not be surprising in the context of the Digital Age, which has virtually eliminated any concept of time or space: there is instant access to news feeds, communication, video, audio, with travel possible now more than ever before. There is a flow between traditionally disparate cultures and communities in the 21st century that has never before taken place. It has resulted in a homogenization of cultures, a modernization in which peoples in all places adopt the same beliefs, attitudes, behaviors and viewpoints concerning life, morality, religion, politics, economics and society. The adoption of this viewpoint is massively fueled by the prevalence of mainstream media, which propagates the viewpoint across networks owned and controlled by various overlapping boards of directorates that are in turn associated with military corporations, political offices, business entities and the entertainment industry. In brief, the allocation of information to a media cartel that controls and dispenses information to the masses has never been greater. The question is: what impact does this dispensary have on the mental health of its audience? How does it shape their beliefs about the world and about themselves? If socio-cultural influences impact mental health, in some way the mass media must have a role in forming those socio-cultural influences. To what end are they organized? What is the principle that guides that formation? These questions and their answers might help researchers to better understand the relationship between media, culture and mental health awareness.