Possibilities for the future of global mental health: a scenario planning approach

As a starting point to the current exercise, and for the specific purpose of guiding discussions in the Scenario Planning workshop, we interviewed experts in the field of global mental health to explore potential current instabilities and drivers that could affect the future of global mental health. The findings of the interviews were not intended to reflect representative views but to inform and stimulate the subsequent workshop. We therefore conducted interviews with a range of purposively selected experts, who had either personal experience of practical or research activities in global mental health or an explicit interest in the related concepts. Participants were sampled using the following criteria: working in different world regions and countries including HICs and LMICs, and representing different types of backgrounds and expertise. The experts were identified through existing professional networks, web searches of the literature on global mental health and on-line networks (e.g. Mental Health Innovation Network). Every expert who declined or accepted invitation to be interviewed was asked for further experts who had published peer-reviewed papers related to global mental health or had been involved in global mental health projects. The interviews were conducted either at the Unit for Social and Community Psychiatry, London or via Skype, and followed a semi-structured interview schedule, designed to be open-ended to allow participants to guide the direction of the interview. Topics included current challenges in global mental health, what changes there may be in the world in 30 years, and how this might influence or challenge the direction of global mental health in the future. All interviews were audio-recorded, transcribed, and analysed using thematic content analysis, and key themes were identified.

The key themes from the interviews were presented and informed the scenario planning at a two-day workshop in London. The participants for the workshop were purposively selected to represent different continents, different age groups, a range of backgrounds, and different levels of seniority and expertise. All of them were personally contacted and invited. None of the attendees of the workshop had previously participated in the interviews.

The first day of the workshop was held in an art gallery, the second one in the premises of a research unit. During the whole workshop, free thinking and the shaping of ideas in a group process were encouraged without any requirement for wide consensus on the emerging ideas and scenarios. This was stimulated and supported through arts-based experiential activities. These included: participants visited an exhibition of installations showing clashes of nature with modern civilisation (‘Theatre of the Natural World’) and shared their experiences in pairs; they reflected on their impressions and drafted first ideas in individual drawings; and the themes were then discussed and developed using visual material, including a concept mapping exercise. The preliminary resulting scenarios were then shaped in smaller group work. Each smaller group of participants with an interest in a given scenario developed that specific scenario further. The groups were asked to give the scenario a name and outline a specific example, key actors, drivers and enablers, potential risks and milestones. They were also encouraged to consider possible, preferable and plausible aspects.

The discussion of the emerging scenarios enabled the wider group to specify them and explore alternative scenarios, rather than striving for or assessing consensus.

Following the workshop, the scenarios were further refined, involving repeated discussions in the wider research group of the first author. In these discussions, the core content of the scenarios was not altered anymore, but details were specified focusing on the coherence and explanation of each scenario.

In this scenario, there will be a worldwide consensus about the minimal standards of acceptable professional care for patients with mental disorders. These standards will specify what type of treatment should be provided to all patients in mental health care across the world. The standards will define the regulations and conditions for all built institutions, such as hospitals and sheltered living arrangements, and the precise entitlements of different patient groups to in- and outpatient treatments, social care, and other professional support. This will include standards for involuntary treatment and be driven by a strong human rights movement, partly in response to human rights abuses of patients, particularly those with severe mental illnesses (SMI). The standards will outlaw all forms of mechanical restraint, including chains or shackling of patients, and possibly limit other coercive measures. They will be promoted by a strong patient and carer movement and be agreed on, supported by and disseminated through agencies such as the United Nations, Council of Europe and the World Health Organisation. National and regional mental health legislation will be in line with these standards and guarantee their implementation. A new international organisation or network of organisations will be set up to monitor and report regularly on the implementation of these standards at local levels. The results of the monitoring will be publicly available and the recommendations of the overseeing organisation for local changes will be legally binding. This will lead to a rising proportion of health care funding dedicated to mental health care and facilitate the accessibility of mental health services for all groups in need.

Funding for mental health related research will be coordinated on a global level, potentially through a centralised global research institute. Since most of mental health research will remain publicly funded, this co-ordination will apply to the majority of funds. Supported through better information systems recording all completed and on-going research in the world, the co-ordinating centre will endeavour to avoid duplication of work. There will be no competition between nations as the centre acts in the overall interest of progress in research. There may still be competition between research groups across the world, but the centre will ensure that a limited number of groups work on the same issue at the same time and that very different ideas are pursued with sufficient funding, even if they are not mainstream or fashionable at that time. The main aim of the centre will not be to regulate fairness in the competition between research institutions, but to maximise the impact of research for improving mental health care. This co-ordination will consider or even emphasise specific and unusual local contexts and the situation of people with very rare disorders, but it will do this with a global perspective of priorities and research potentials.

Whilst most current research aims to generate evidence that is generalisable and applies to different populations and places, the emphasis in this scenario will be on understanding and utilising differences to improve practice. Mental health care and research will be focused on embracing diversity rather than striving for similarity and universality, with diversity defined as both the differences between and within countries and regions. It will be accepted that different understandings and treatments of mental distress with equal validity exist across the world, and such differences are the focus of research and inform practice. Anthropologists and qualitative researchers will have a strong role in this. Universal diagnostic tools, such as the DSM and ICD, will be replaced with locally specific instruments and systems, if such normative approaches of instruments are seen as appropriate in the given context at all. International consensus conferences and debates within psychiatry will be replaced by mutually respectful exchanges between those working in this new field. A global repository of research findings, service descriptions and evaluations, and of patient and clinician experiences will be created. All information will be freely accessible to all and further promote mutual learning and understanding of differences. When similarities are observed between certain contexts, this will not be disregarded, but instead offer an opportunity to identify common ground and scope for sharing experiences and learning from one another. Where similar prevalence rates and concepts of a mental health problem are identified, individuals from each context will share effective interventions for this. Overall, this will help to promote multi-directional learning and flexible partnerships across the world to inform the practice of mental health care.

There will be a wide consensus that mental health has strong social determinants. These determinants will become more pronounced and relevant through greater social and economic inequalities in societies across the world. There will be an increased focus on and understanding of such factors, their complex global interconnectedness and their local impact on the mental health of different groups in the population. The production of goods and many services will be easily and rapidly moved to different places, noticeably in socio-economically deprived areas. This will affect all societies around the world, possibly accelerated through developments in information technology. This will quickly and repeatedly change the social conditions in regions across the world and lead to constant migration of large parts of the population. Efforts to improve the mental health of populations will primarily deal with such social factors which can be tackled only on a global level. This will be through poverty alleviation strategies or attempts to reduce rising rates of social isolation in large cities. Generally, there will be a higher prioritisation of mental health issues on a global scale and potentially reduced discrimination against those with mental health problems. This will be because mental disorders are viewed through a wider social lens, rather than regarded as individual and abnormal characteristics.

Rapid advances in technology will facilitate the delivery of mental health care remotely or virtually through the internet. Assessments and therapies will be delivered from anywhere in the world and, regardless of where people live; all will have access to the same technology-assisted interventions. Some of these interventions will remain steered by professionals and others will be fully delivered through artificial intelligence. In the latter case, mental health support will be available at any time, at any place and potentially at very low costs. The support provided to individuals will remain personalised, but the overall system and type of support will be globally homogenised. One diagnostic tool will likely be used by everyone where algorithms produce a recommended treatment for the individual, potentially self-administered on a smart phone. In response, medication will be delivered remotely through 3D printing and drone delivery. Overall, the majority of mental health care will be truly globalised with the entire global population using the same software programmes to address their mental health problems. There will still be a place for the local provision of mental health care through professionals, e.g. in emergency situations, inpatient care and outreach activities. Yet, this will be substantially diminished and may – over time and at least in part – also be replaced by robots with artificial intelligence.

In this scenario, the mental health of populations will become a major currency in the global political discourse and the target for related political actions. Indices of mental health will be regularly measured around the world. The indices will influence or even dominate debates about problems and responses both in general throughout society and specifically among politicians. On a global level, they will be used to assess and compare the success of nations and wider regions. They will have a particular role in the international understanding and dealing with crisis situations. Natural and man-made emergencies will be understood in terms of their impact on the mental health of the affected populations. Different types of difficult contexts such as food and water shortages, armed conflicts with forced displacements, and mass unemployment will all be termed as public mental health crises, and subsequently require actions to improve the mental health of the population. This will apply within nations, but be more important on a global scale, since most major crises will directly or indirectly affect several wider regions and be responded to on a global level. Thus, in sessions of the General Assembly of the United Nations, speakers will argue about suggestions to address mental health crises and to improve the mental health of regions and worldwide. In this scenario, the term mental health problem will have a very wide and relatively consistent global meaning, encompassing most forms of misery, as well as unhappiness and dissatisfaction with life.

The main features of each scenario, consequences for research, health care and governance, the key drivers and potential concerns and implications are summarised in Table 2.