Depression and Global Mental Health in the Global South: A Critical Analysis of Policy and Discourse

Abstract

Over the past two decades, depression has become a prominent global public health concern, especially in low- and middle-income countries (LMICs). The World Health Organization (WHO) and the Movement for Global Mental Health have developed international guidelines to improve mental health services globally, prioritizing LMICs. These efforts hold promise for advancing care and treatment for depression and other mental, neurological, and substance abuse disorders in LMICs. The intervention guides, such as the WHO's mhGAP-Intervention Guides, are evidence-based tools and guidelines to help detect, diagnose, and manage the most common mental disorders. Using the Global South as an empirical site, this article draws on Foucauldian critical discourse and document analysis methods to explore how these international intervention guides operate as part of knowledge-power processes that inscribe and materialize in the world in some forms rather than others. It is proposed that these international guidelines shape the global discourse about depression through their (re)production of biopolitical assumptions and impacts, governmentality, and “conditions of possibility.” The article uses empirical data to show nuance, complexity, and multi-dimensionality where binary thinking sometimes dominates, and to make links across arguments for and against global mental health. The article concludes by identifying several resistive discourses and suggesting reconceptualizing the treatment gap for common mental disorders.

Keywords

depression global mental health biopolitics governmentality condition of possibility Global South

1 billion people globally are estimated to be living with a mental disorder, 81% of whom live in low-income and middle-income countries. Among this one billion, 5% of adults have depression, making it a leading cause of disability, and a major contributor to the overall global burden of disease.

— The Lancet Commission Editorial,^1, ^{p. 885}

How we frame and define a mental health problem influences how we respond to it. Depression has been framed as a severe global public health crisis.^1,2 Mental health is predicted to become the greatest international disease burden in 2030 and a primary cause of avoidable suffering and premature mortality.^1–3 Estimates of the global burden of depression in terms of disability, quality of life, and economic impact have also been used to argue for scaling up the detection and treatment of depression as a public health and development priority in low- and middle-income countries (LMICs³).

The Movement for Global Mental Health and the World Health Organization (WHO) have prepared a series of standardized international intervention guidelines and health packages to address depression in LMICs. This information could improve care and treatment for depressive illness along with other mental, neurological, and substance abuse problems⁴ to close the treatment gap. Treatment gap refers to the percentage of people who meet the diagnostic criteria for a specific disorder but do not receive treatment.⁴ This has been a fundamental tenet of global mental health (GMH), which was built on two major assumptions: 1) mental disorders are extremely common; 2) mental health services are scarce worldwide, but the gap is particularly wide in LMICs.^3,4

The proposed enormous level of unmet need for care has led to calls to scale up mental health services globally as a central priority in the field of global mental health^3,5 specifically to address mental health issues in LMICs. The Lancet GMH series of 2007 and 2011^4–6 have argued that the field's central mission is to scale up evidence-based care to close the treatment gap for mental disorders, the most common of which are common mental disorders (i.e., depression, anxiety, and somatoform disorders). These arguments are echoed in key WHO publications that put closing the treatment gap and expanding access to mental services at the forefront of its international mental health policy and the development of a series of Mental Health Gap Action Programs.^7–10 As we write, the program is being implemented in over 100 countries.^11,12 The intervention guides, such as the WHO's mhGAP-Intervention Guide (mhGAP-IG) 2.0 (2016), are evidence-based tools and guidelines to help detect, diagnose, and manage the most common mental disorders.^9,10 Practical concerns like how the programs can be used to advantage in culturally different settings and populations remain.

The ubiquity of treatment gap statistics as a framework for assessing unmet needs largely demonstrates the pervasiveness of this paradigm in global mental health about depression. For example, the most recent global gap report in treatment coverage data for major depression in 84 countries suggest only eight percent of adults in LMICs who meet diagnostic criteria for depression use services for these symptoms.¹³ Similar figures appear in almost every global mental health research article, policy document and advocacy initiative about the depression treatment gap.^1,2,9,10,14 It is unclear whether this reflects a limited supply of mental health services or a lack of demand for medical intervention for these experiences.

There has been much critique of the evidence used to establish and describe the mental health treatment gap. This includes critiques that raise concerns about the dangers of exporting a Western model of disorder and treatment, ignoring cultural variation in understanding, responding to social suffering, and leading to medicalizing distress.^15–20 Scholars in the field of critical psychiatry have issued a call for a comprehensive reevaluation of efforts to expand mental health diagnoses and treatment in LMICs. These initiatives have been formulated and implemented under the assumption that Western biomedical categories and treatment methods can be universally effective on a global scale.^15–18 Several scholars have also questioned the validity of standard depression diagnostic instruments, the reliability of global prevalence estimates, and the applicability of GMH's international programs in LMICs.^16–20

Critics stressed that GMH ignores significant local variation in conceptualizations of mental distress and depression and diverts attention away from the social and economic determinants of illness.^18,21,22 Because of this, there has been a widespread call to tailor interventions to local cultures, local health care systems, and specific populations.^21–25 Another line of critique relates to the de-contextualization of suffering. Mills¹⁵ argues that translating situated accounts of suffering into context-free psychiatric diagnoses involves abstracting symptoms from their personal and social context and framing problems as brain-based disorders rather than a sign of disruption in a person's “lifeworld,” that is, those experiences, activities, and social networks that make human life meaningful.²⁶ This article inserts itself within and expands upon the calls to reconceptualize the treatment gap for common mental disorders like depression via document and discourse analysis.

In response to the critics, the Lancet Commission¹⁴ replaced treatment gap with “care gap”,^14, ^{p. 122} referring to the unmet mental health, physical health, and social care needs of people with mental illness, including depression. However, it can be argued that maintaining the notion of a care gap still misses a more fundamental point in the understanding of depression across LMICs: why do so few people in these settings access mental health treatment for depression? Moreover, how does the assertion of a mhGAP influence how we conceptualize solutions to the lack of service uptake? And how do we know there are so many people in LMICs who have been suffering from depression, creating the demand for more programs of depression awareness for professionals and the public or laypersons alike?

In this article, we critically examine the construction of global mental health policy and practice in LMICs that is heavily influenced by mental health treatment and care gap discourses. It is our argument that the continual framing of mental health problems in individual terms continues to obscure the role of wider determinants of mental health and encourages the provision of clinical interventions rather than public health approaches.²¹ Our critical interrogation takes its cue from Foucault. Using Foucault, we propose that, historically, specific GMH assemblages make existing assertions about the mhGAP possible, while shaping the global discourse about depression through their (re)production of biopolitical assumptions and impacts, governmentality, and conditions of possibility.^27,28 It is our assertion that mhGAP works as part of “the knowledge-power processes that inscribe and materialize in the world in some forms rather than others”,²⁹ ^{p. 7} and allows for certain understandings of mental health to be more accessible than others.

Our analysis begins by analyzing the conditions of possibility and context within which the mhGAP-IG is developed and circulated. We then consider often-overlooked contributors to the depression treatment gap discourse: 1) low demand for services because of non-medical interpretations of depression and related experiences, 2) implications for how we respond to the needs of people who are thought to be depressed. Ultimately, this exploration aims to uncover the ways in which current dominant discourses about depression in GMH and the mhGAP work to produce and limit possibilities of concern and care for mental health in LMICs, by defining only certain forms of personhood and suffering as legible.

Methodology

Discourse Analysis

Our analysis is based on biopolitical discursive analysis.^27,28 In its broader sense, discourse refers to all written, spoken, and other forms of communication.²⁷ Foucault described discourses as “practices that systematically form the objects of which they speak.” Discourse analysis is the systematic study of discourse and its role in constructing social reality,²⁷^{, p. 49}. As Maes stated, a useful approach to exploring insider critique within GMH is to engage in “studying up”,³⁰^{, p. 55}, that is, using critical ethnographic methods of researching. Hence, this current analysis is part of a broader research study that examines global mental health, biopolitics, and depression in the Ethiopian context through an ethnographic method of inquiry. The category of data for this analysis includes selected WHO publicly available international guidelines, policy documents, and the dominant discourses in GMH about depression.

Three main international guidelines implemented in LMICs to address depression were critically analyzed. Definitions, management procedures, and biopolitical discourses^27,28 were analyzed to understand the context and process of global mental health scale-up programs about depression. However, the focus of the analysis is to examine how mhGAP-IGs serve as “inscription devices”,³¹^{, p. 63} in the wider quantification of mental health and depression, diverting attention away from their material processes of production and forming “the domains they appear to represent”,³²^{, p. 198}. Therefore in this analysis, the mhGAP-IG is viewed as a culturally constituted object, aiming to highlight its conditions of production as well as its “social uses and consequences as a social phenomenon”,³³^{, p. 72}.

We selected these three guidelines due to their widespread implementation and extensive use as the primary conceptual framework, guidelines, and clinical tools for addressing depression within the GMH space. Notably, the mhGAP-IG 2.0 (2016) serves as the central guideline currently being implemented in more than 100 countries. It provides a comprehensive resource for the identification, treatment, training, and education related to depression at the primary health care level. Additionally, it has emerged as the primary clinical tool in the context of scaling up mental health services.

We also utilized the Global North and Global South country classifications to contextualize power dynamics, acknowledge historical legacies, economic disparities, and power imbalances in global health policymaking and planning in the Global South.

Analyzing Documents: Discourses and Technologies of Rule

The mental health gap guidelines are multiple—practiced and done (talked about and used) differently in different contexts^10,34 and these disparities are analytically important. The three main documents that are the focus for this analysis illustrate several dominant discourses that are ideological in character. The first document is the WHO's mhGAP-IG.⁸ The mhGAP-IG is part of a larger portfolio of products including training materials and implementation and operations manuals.^8,34 The mhGAP-IG has become the principal clinical tool being used as part of the scaling up strategy of the mhGAP program in LMICs, serving as “the standard approach for all countries and health sectors; irrational and inappropriate interventions should be discouraged and weeded out”,⁶^{, p. 1,442}. The second document is The Lancet Commission on Global Mental Health and Sustainable Development (hereafter the Lancet Commission¹⁴). The third policy document is the WHO's Depression Strategy.³⁵ These three documents deserve a careful analytic reading because they establish a foundation for key components of the GMH approach to address depression as a public health crisis worldwide, including in the Global South, along with the dominant global treatment gap discourses. While all three documents are analyzed here, particular attention is paid to the mhGAP-IG. The WHO describes the mhGAP-IG as “an evidence-based technical tool aimed at supporting non-specialised healthcare providers to redistribute clinical tasks previously reserved for mental health specialists”,³⁶^{, p. 75}.

The mhGAP-IG is examined in greater detail in this analysis given its global significance, evident in the fact that the mhGAP-IG was used in more than 100 countries and translated into more than 20 languages.^11,12 The global significance of the mhGAP-IG makes it especially important to question or explore the conditions of production of its tools and guidelines, their underlying theories and assumptions about mental health, (i.e., depression) and how the kinds of knowledge that these guidelines create have implications for the governance and experience of mental health in the Global South. Findings are, therefore, interpreted and discussed considering the historical, political, and cultural context, therapeutic, and the personal and social implications of how depression is understood.

Findings: Emerged Themes and Analysis

The analysis of the selected documents reveals a set of global dominant discourses that are based on implicit problematic assumptions that underlie current global mental health practice and depression research. This analysis proposes that the dominant narrative discourse of GMH displays six major themes that are ideological in nature: 1) The Architecture of Depression: The Coming into Being of an Illness Like No Other; 2) “The Reach Paradigm:” Universalization and the Transfer of Subjectivities; 3) Evidence-Based Treatment, Standardization, and Audit; 4) Individualization, Responsibilization and Self-Management; 5) Routine Depression Screening in GMH: Psychiatric Risk Profiling of Human Suffering; and 6) Dancing with Complexity: The Supply and Demand Dilemma for Addressing the Depression Treatment Gap. These themes serve as powerful currents to perpetuate the dominant norms and restrict the scope of our thoughts, strategies, research, and actions. We closely examined the ideological underpinnings of these themes below.

The Architecture of Depression: The Coming into Being of an Illness Like No Other

The mhGAP-IG and its associated “packages of care”³⁷ are tools designed for non-specialists to detect, diagnose, manage, and educate the public about common mental disorders in LMICs. The dominant discourse in GMH is that in LMICs, the treatment gaps for depression alone ranges from 82–98 percent¹³ and hence there is a need for more clinical service to close the gap. The WHO's mhGAP (mhGAP-IG) 2.0¹⁰ defines itself as a key component in closing this gap. It is presented as “evidence-based tools” and guidelines to help detect, diagnose, and manage the most common mental, neurological, and substance use disorders,¹⁰^{, p. 2}. Specifically, the documents are developed to aid “non-specialist audiences,” i.e., doctors, nurses, and other health workers who do not have mental health specialties, health planners, and managers.¹⁰

The international guidelines, such as mhGAP-IG, have not only been used as clinical tools, but they have also been used as training courses and research tools in LMICs.^10,11 As a result, as advocated by Patel and his collogues, WHO's mhGAP-IGs have become “the standard approach for all countries and health sectors”,⁶^{, p. 1,442}. Over the last two decades, not only was the construct of depression viewed as universal and objectively measured, but so was the guidelines and drug-based strategies that became universalized, institutionalized, and legitimized on a massive scale: international guidelines for all—“to make mental health for all a reality”,⁶^{, p. 90}. Because of such dominant discourses, the guidelines are increasingly serving as the ultimate source of knowledge and evidence-based reasoning for research agendas, funding, interventions, and scientific curiosities—what Foucault refers to as a “regime of truth”.^38,39

“Truth,” Foucault tells us, “is to be understood as a system of ordered procedures for the production, regulation, distribution, and operation of statements”,³⁹^{, p. 56}. This constructed “truth” about depression, for example, has been achieved through different apparatuses and statements that have been circulated in publications, international organizations, and lobbying efforts. Because of this circulated “truth,” depression has been framed as an “epidemic,” which has been established as a major threat to the planet, prompting every government in LMICs to take action by making anti-depressants more widely available.^40,41 This is the truth and power of biopolitics. In most LMICs, it is crucial to acknowledge that depression is often not perceived solely as a medical issue or a straightforward illness. Instead, it tends to be situated and comprehended within the broader sociocultural context of these societies. Various cultural norms, social functioning patterns, and the unique cultural contexts in LMICs significantly influence how depression is perceived and managed.^42–46

Over 30 years of cross-cultural mental health research has shown that what constitutes a symptom of psychological distress or disturbance worthy of concern and clinical health-seeking varies across and even within cultural settings.^25,46 Moreover, people in the Global South routinely interpret their psychological and emotional states as reactions to social and economic problems, not as health conditions that can be addressed by medical services.^47–49 Therefore, the GMH's continual promotion of depression as an illness like no other in LMICs can serve as an apparatus for the (re)production of subjectivities.^27,28

The mhGAP-IG disregards ongoing debate about the cross-cultural validity of psychiatric diagnoses. It suggests a primary reliance on psychotropic medication⁵⁰ obscures structural determinants of distress and ignores grassroots approaches to healing.²¹ It also constructs mental health as primarily a technical problem of service delivery—a problem treatable with care packages.⁵⁰ This discourse, whether intentionally or not, individualizes, pathologizes, and decontextualizes distress. It also emphasizes personal responsibility.^18,27,32 In the process, such ways of thinking prevent alternative frameworks or broader solutions from emerging, and it creates conceptual voids that reproduce inequity and oppression, resulting in “epistemic injustice”⁵¹ when it comes to speaking about and coping with depression in the LMIC context.

“The Reach Paradigm:” Universalization and the Transfer of Subjectivities

The dominant notion that the central challenge of public mental health is to ensure that mental health expertise reaches more people has been dubbed the “reach paradigm”,⁵²^{, p. 67}. This notion circulated in the GMH discourse has justified prioritization of more clinical services being developed and scaled up in LMICs to address mental health needs.⁵³ The issue here is not with expansion in service provision per se, but in the expansion of services fashioned on assumptions about the biomedical and individual nature of depression that become reinforced when new clinical services are based on the mhGAP. The guidelines’ explicit global framing as a global standard⁶ and role as a foundation for scaling up mental health services for depression^8,9 make them a significant focal point for research into the types of knowledge, techniques, and practices that construct and perform mental disorders, as if they can be universally addressed by a clinical solution. As such, investigating the biopolitical rationality of the mhGAP guidelines provides insight into the processes through which universality is negotiated, enacted, and contested, and into the “conceptual shifts and ruptures in the way universality is claimed” within GMH,⁵⁴^{, p. 856}.

Universality in GMH is “ambiguous and precarious” and is “contingently and collectively produced”,⁵⁵^{, p. 277} as the result of the historically situated, distributed work of a multitude of actors.^23,24 One of the important historical conditions of possibility for the mhGAP guidelines is the rise of evidence-based medicine (EBM^24,54). The emphasis on GMH interventions for depression being evidence-based has been central to constructing mental health as global.^4,11 EBM is itself an empirical object that has gained global currency; it brings more certainty to clinical decision-making, made possible through linkages between the historically separate areas of epidemiology and medical research to offer a more systematized, scientific approach to the practice of medicine.⁵⁴ However, where evidence that meets the criteria for EBM in GMH is lacking; depression being leveled as medical crisis in LMICs, ^23,24,56,57 the lack of evidence discursively became a moral imperative.⁵⁸

The WHO's strong emphasis on evidence-based guidelines (i.e., mhGAP) raises important questions about what constitutes evidence in GMH.¹⁹ Historically, systems of standardization are a “significant site of political and ethical work”,⁵⁹^{, p. 147} because every standard “valorizes some point of view and silences another”,⁵⁹^{, p. 156}, making them part of “the knowledge-power processes that inscribe and materialize” the world in particular ways,²⁹^{, p. 7}. According to Lakoff,⁶⁰^{, p. 68} such standardization through the reduction of complexity, specificity, and locality makes an asset transferable across different contexts—achieving “diagnostic liquidity.” Guidelines production is therefore one of the central practices through which “the apparently universal validity of biomedical knowledge is materially and discursively forged via the standardization of practise across multiple domains”,⁶⁰^{, p. 66–67} resulting in the transfer of subjectivities.

In this regard, evidence has shown that the wholesale export of psychiatric conceptions of mental illness from high income countries to LMICs changed how distress manifests and it introduced barriers to recovery (e.g., expressed emotions in families of individuals with psychosis in Tanzania, Peru, and Sri Lanka;.^61,62 By the same token, the WHO's mhGAP involves material and institutional discursive practices that aim to contingently produce “universality” in mental health and the understanding of depression. That is to say that these guidelines are not neutral, value-free documents, nor are they merely passive descriptions. They are authoritative documents that can do more than describe the territory of depression.

As Bowker and Star,⁵⁹^{, p. 1} note, these documents do not merely “sort things out,” they also link things together. The argument is that the assumptions that are rooted in the GMH packages of care and WHO strategic guidelines have a unique way of defining what constitutes a mental health problem and what counts as relevant knowledge for intervention that is not applicable in the different context of LMICs.²² Consequently, guidelines and diagnosis manuals have a potential to create a different kind of self and personhood through “looping effects” at the clinical as well as at the population level in LMICs,⁶³^{, p. 100}. A “looping effect” refers to the tendency for social categories to reshape human experience in a manner that conforms to the category.⁶³ As Jarvis and Kirmayer state, looping effects can occur at many levels, including within the body, between the body and interpersonal interactions, and between individual cognition and the social environment.⁶⁴ It has been shown that at the social level, diagnostic constructs become figurative as they move out of professional practice into the metaphorical world of popular culture and individual experience.^63,64

Thus, a diagnostic category like depression can become part of a popular idiom (“being depressed”), which becomes a way to talk about everyday life challenges.²⁶There is a wealth of evidence that the clinical use of the category of depression has enabled people to reinterpret suffering in ways that change their experience and expectations for treatment and that influence clinical diagnostic practice in a self-confirming loop.^62,65 Such epistemic problems of looping effects should be seriously considered in relation to the aspirations of GMH in addressing depression in LMICs.

Evidence-Based Treatment, Standardization, and Audit

Depression is a disorder that can be reliably diagnosed and treated in primary care. For common mental disorders such as depression being managed in primary care settings, the key interventions are treated with antidepressant drugs and psychotherapy. Treating depression in primary care is feasible, affordable, and cost-effective.

— The World Health Organization,³⁵^{, p. 7}

While each of the documents suggest that individuals, as well as their families, communities, and workplaces, should be encouraged to take on responsibility for addressing depression, the mhGAP guideline reflects a particular interest in governing professional practice with a view to shaping clinicians’ treatment decisions in desired (cost-minimizing) directions. This interest is reflected in two discursive strategies visible in that document: (1) arguments that only treatment approaches that are “evidence-based” should be encouraged; and (2) support for measures to standardize and audit treatment choices and practice to ensure that they conform to evidence-based insights. Both discursive strategies work to constrain the discretion that practitioners otherwise might proposed based on their expert and contextual knowledge, training, and experience; in so doing, they exemplify biopolitical technologies of rule that enable “governing at a distance”.²⁷

The notion that we should support clinical practices that are backed by the available evidence is, on the face of it, difficult to contest. The discourse of evidence-based serves as an effective way to impose closure on the lively debates that exist about the risks and benefits of various treatments that are available for depression.^9,10 With evidence-based recommendations for the treatment of depression teleologically justified, calls for standardization are likewise justified. However, as the extensive literature points out, there are several levels on which such arguments can be challenged.

For starters, there has been substantial concern expressed about the conventional “hierarchy of evidence” within which data collected through randomized clinical trials is understood to constitute the “gold standard”.^19,24,66 Critics contend that this conceptualization of evidence creates a bias favoring research that focuses on individual-level variables and treatment approaches. In so doing, it fails to adequately consider the qualitative research findings that identify a variety of socioeconomic and political influences on health and that indicate the need for interventions designed to address these contextual features of people's lives.^19,21,24

The mhGAP program's conception of the treatment gap relies largely on burden of disease metrics and very frequently references them,^{5–7,40,41,67} as does global mental health literature,⁶⁸^{, p. 1}. This shows Global Burden of Disease calculations as an important rhetorical resource within global mental health.⁴ The fact is, as scholars have noted, our global data on causes and prevalence of depression in specific settings around the world are far less robust than acknowledged in the promotion of GMH as morally necessary.^56,57 But numbers are usually political, and they are mobilized in the service of moral objectives. As Starr stated, while “the characterization of people is myriad and subtly varied, statistical systems reduce complexity, incorporating this myriad into a single domain, and very often generating a single number that will appear in headlines, in speeches, and the reports”,⁶⁹^{, p. 40}.

According to worldwide projections from the WHO, by 2030 the amount of disability and life lost from depression will surpass that from war, accidents, cancer, stroke, and heart disease.^67,70 Such statements serve as a moral imperative to make depression universal and globally visible and in demand of attention. Paradoxically, in this move aimed at increasing recognition and action, the range of realities and contributors to depression are erased. Despite the many contestable features of claims that clinical treatments for depression should be supported because they are evidence-based, this is a concept that is used in the mhGAP guidelines as if both its meaning and its implications are self-evident. This is not to suggest that such efforts inevitably or absolutely constrain clinical decision-making, rendering it consistent with the goals of those who seek to govern. It is nevertheless important to note how the discourse of “evidence-based” can serve as a strategic resource in efforts to undermine the credibility of a range of interventions beyond the “clinical gaze”.⁷¹

In other words, this poses an ethical risk in the context of LMICs because these documents are intended to serve as a primary guide for training psychiatric personnel, developing diagnostic and screening tools, and educating the public.^8,9,67 In practice, this also means providing explanations that do not fit well with local understandings or that undermine interpretive systems that are associated with coping strategies, healing practices, social support, and integration.^18,21,24,72

Individualization, Responsibilization and Self-Management

In framing the problem needing to be addressed, documents such as the mhGAP guidelines direct our attention to the individual with depression rather than to the broader sociopolitical environment—including current public policy choices—that might be understood as contributing to the high rates of depression among members of the public. The Lancet Commission does identify features of the social and policy environment that could be significant in shaping individuals’ emotional well-being.¹⁴ The Commission notes, for example, that unjust social structures (among other factors) contribute to mental health problems.¹⁴ In its report, the Lancet Commission reframes mental health through the lens of sustainable development and advocates for a dimension-based model mapped along the spectrum of distress–disorder–disability.

Most recently, the New Lancet Commission² also called for a united action to address depression. In this piece, the Commission calls for a public health perspective on depression that addresses its social structural determinants and the severity, breadth, and durability of its consequences, but the commission emphasizes the importance of detecting and diagnosing depression early, which depends on good access to health care. While the Lancet Commission does allude to “public health approaches” as one component of a supportive environment for mental health,¹⁴ it does not expand on this proposal in any detail. Instead, a conceptualization of mental health as a problem within individuals who can be made more or less effectively aware of risks and options for managing what is ultimately a biologically-based condition is repeated. For example, a focus on the individual is visible in the way the Lancet Commission² takes up the question of why the burden of disease generated by depression persists.

The document notes that promotion and prevention services in communities, schools, and workplaces have been studied and advertised, yet the incidence and prevalence of mental disorders continue to increase.^1,2 As such, the explanatory focus is on knowledge and information gaps that leave individuals unable to identify the presence of depression and/or likely to make ineffective or inappropriate choices regarding treatment.^1,2,9,10,14 All documents thus construct those who are ill or at risk of becoming ill as subjects who, through their social and health care environments, may be more or less enabled to recognize and manage their suffering, while leaving earlier assumptions about the individual biomedical source of that suffering intact. There is a departure from the earlier framing of those in need of global mental health resources as “passive recipients of treatment.” But what stands in its stead is an equally limiting construction of subjects in and of global mental health as, to borrow from Foucauldian scholar Nicolas Rose, “enterprising selves who are incited to live as if making a project of themselves; they are to work on their emotional world”,³²^{, p. 157}.

In summary, even in its most recent iterations, GMH discourse drives toward a methodological individualism that focuses on individual-level biological causes, attributes, or risk factors that lend themselves as “targets of intervention” for depression. This point of view is associated with the search for behavioral or technological interventions that are unrelated to specific contexts. What emerges is a single story of change, perpetuating universalizing values, beliefs, culture, and practices associated with depression which may or may not connect to actual conditions in which people live and which may be key contributors to their depression.

Routine Depression Screening in GMH: Psychiatric Risk Profiling of Human Suffering?

Based on experience and the recent recommendations of the US Preventive Services Task Force, we propose the implementation of screening for depression in routine care…for all adult attenders. The use of brief, self-report questionnaires, such as the Patient Health Questionnaire (PHQ-9), takes a few minutes to complete, can be used to generate a diagnostic outcome, and shows sensitivity to treatment response. Routine screening for depression in adult primary care attendees is a vital milestone in the journey towards reducing the very large treatment gaps.

— Reynolds and Patel,⁷³^{, p. 316}

In light of the economic burden of depression, there has recently been a push for the need for routine depression screening.^73,74 In the United States, despite a lack of evidence to support routine depression screening,^75,76 it has been recommended by the U.S. Prevention Services Task Force (USPSTF) for everyone over 13, including, for the first time, during pregnancy and the post-partum period.⁷⁷

It is worth noting that the United Kingdom and Canada, looking at the same evidence as the United States, made the explicit recommendation against screening due to concerns about overdiagnosis, overtreatment, and exposing people to the risks of treatment, particularly antidepressants and second-generation antipsychotics without enough evidence of benefit.⁷⁸ While universal depression screening remains controversial in the United States and elsewhere, advocates or leaders of the global mental health framework ardently advocate for its implementation in LMICs. Reynolds and Patel,⁷³ for example, lament in a World Psychiatry article that efforts to train primary care practitioners in Colombia, India, Sudan, and the Philippines to detect mental disorders have failed to increase diagnosis rates. They argue that instituting the practice of screening all primary care attendees in these settings with variations of the Patient Health Questionnaire (PHQ-9, a nine-item screening tool developed by Pfizer) would be “a critical milestone in the journey towards reducing the very large treatment gaps globally and scaling up the robust evidence on cost-effective interventions”,⁷³^{, p. 316}.

The argument for increased use of depression screening tools at an international level is typically framed in terms of the social and economic “burden” of depression, but it raises critical concerns about the ethnocentric quality of instruments that are frequently glossed over.¹⁵ In such a way, the token of depression has become the “enoncé”,⁷⁹^{, p. 91} for GMH practices that map, measure, and calculate human suffering. Once established, this “enoncé” never stops counting or mapping people and their concerns about suffering. It becomes authentic and has the power to make a new category of people or subjects, which Hacking calls “making up of people”,⁷⁹^{, p. 99}, psychiatric subjects. For Hacking, “making up” is the bringing into being of specific ways of being a person that may not have been possible before. Here, we want to underline that it does not mean that people who experience distress do not exist in LMICs. Instead, such people may not have recognized their distress as illness or depression and so never sought psychological or psychiatric help.^43,45–47

In the GMH space, treating depression, or more specifically, detecting depression in LMICs, has become a source of contention. On the one hand, studies in LMICs indicate that the number of people affected by depressive illness in primary care settings is increasing⁸⁰ and that there is a significant treatment gap: approximately 90 percent of people who are thought to be seeking depression care did not receive any.^1,2,12 Other studies show low rates of detection of depression.^80–82 Although the construction of a “treatment gap paradigm” with its rhetorical sense of urgency is a key condition of possibility²⁷ and a central narrative trope for the development of the mhGAP to address the depression treatment gap in LMICs, these contradictory findings raise several questions: is there a gap in access to treatment, or is there a gap between global diagnostic tools and local definitions of depression? As such, the supply and demand dilemma logic under the notion of a treatment gap has been a long-standing problem to adress deperssion in the GMH space.

Dancing with Complexity: The Supply and Demand Dilemma for Addressing the Depression Treatment Gap in LMICs

In the GMH discourse, the treatment gap is often assumed to indicate a shortage of mental health services in LMICs, and most people who are suffering from depression do not get the treatment they deserve.¹³ The treatment gap has also been justified to focus on increasing more access to mental health services, particularly in settings where resources are most scarce. In other words, there is a problem of supply, supported by evidence of resource deficits for mental health care.⁵³ This deficit was also the driving force behind the development of international guidelines and circulated to LMICs to bridge the gap. However, evidence suggests an alternative interpretation of rationality's demand-supply logic in the case of depression and other common mental disorders. The World Mental Health Surveys, which were conducted in 24 countries with 63,678 participants, revealed that the most frequently reported reason for not seeking treatment for mental health problems was a lack of perceived need for treatment.^47,83 This finding supports the assumption that many people who fall into the treatment gap do not want treatment for their depression or anxiety symptoms.^47,48

More studies have also shown that “closing the treatment gap” for depression and other common mental disorders in GMH research and practice has become more of a demand issue than a supply issue. For example, a report from the Programme for Improving Mental Healthcare (PRIME), an eight-year initiative to increase the supply of mental health services in five LMICs (Ethiopia, Uganda, India, Nepal, and South Africa), confirmed that increasing the supply of mental health services does not close the treatment gap for depression in the absence of demand.⁴⁷

In the GMH discourse and literature, limited attention has been focused on explaining the main reasons behind the lack of demand for mental health services for depression. Scholars in the GMH field assert that limited demand for mental health services in LMICs can be attributed to factors like stigma and access barriers, including travel costs.⁵ Importantly, individuals may forgo seeking or disengage from mental health services, believing that their well-being results primarily from social and economic adversities rather than being treatable medical conditions.⁴⁷ For instance, depression may be attributed to poverty, family conflicts, job instability, or lack of employment, with an emphasis on addressing these socioeconomic challenges for improved mental well-being.^18,21,68,84 This disconnection suggests the significance of addressing psychosocial factors alongside psychiatric interventions for depression.

This argument is consistent with the primary notion of the treatment gap and echoed in the recent Lancet–World Psychiatric Association Commission piece, “Time for United Action on Depression”.² Stigma and barriers to access care are well documented realities that play a role in limited demand for mental health services, but these factors do not negate the importance of exploring how standardized definitions and treatments of depression fit with local understandings. Several recent qualitative studies, for example, have shown that across multiple low-resource settings in the Global South, people fail to seek mental health services and disengage from services because people interpret their psychological and emotional states as reactions to social and economic problems, not as health conditions that can be addressed by medical services.^45,47,48 These studies add to the growing body of evidence that de-contextualized approaches to mental health treatment make little sense for people experiencing psychological distress because of ongoing adversity.^47,68,84 In other words, in addition to a health sector response, we also require a societal response to the causes of common mental disorders like depression that lie beyond the health sector.

In line with this perspective, we wholeheartedly agree with Summerfield, who illustrates how a simple gift of a cow acted as an effective “antidepressant and painkiller” for a farmer in Cambodia experiencing distress due to income insecurity, another intervention that does not conform to the conventional paradigm,¹⁶ ^{par. 8}. This idea raises questions about whether the concept of a treatment gap should consistently be interpreted as indicating a substantial unmet need for mental health services, as is often emphasized in GMH initiatives,⁶⁸ or as a reflection of low demand for biomedical solutions to issues that individuals perceive as rooted in social and economic challenges.^47,68,72 Furthermore, the idea that decontextualized approaches to mental health treatment and care might make a little sense to people whose psychological distress is linked to ongoing adversity such as conflict and extreme poverty.^{15,16,18,47,72} To address depression and other common mental disorders, reconceptualizing the treatment gap is crucial in the Global South where the many forms of adversity people face can and should be addressed directly and externally to a clinical space.

Discussion

Health policy making in global health is a complex and multifaceted process that is influenced by a multitude of factors, ranging from scientific evidence and economic considerations to political ideologies and social values.^15–19 In the context of the Global South, where many nations face unique challenges in providing adequate health care for their populations, power relations play a crucial role in shaping health policies. These power relations, often driven by historical legacies, economic disparities, and geopolitical dynamics, exert a profound impact on the formulation, implementation, and outcomes of health policies in these regions.^15,20 The domain of GMH introduces an additional layer of complexity to this discourse.

In the GMH arena, power dynamics manifest in various ways. First, there exists a significant disparity in knowledge and resources between high-income countries, where much mental health research is conducted, and LMICs, where the burden of mental health conditions is often projected to be the highest.^1–3 However, there has also been a dearth of research in LMICs^{15–19,23,24} where interventions chosen for scaling up tend to align with research methodologies favored by evidence-based medicine, which often favor pharmacological and manualized psychological therapies. Yet these methodologies often fail to empower local actors to challenge the motives and values embedded in global mental health projects or to leverage their own community competencies and solutions of psychosocial care and support.^15,21

Second, the role of international organizations and global mental health initiatives such as the WHO's Mental Health Action Plan (2013–2020)—and now extended to 2030¹⁴—in shaping mental health policies in the Global South is significant. These organizations possess substantial influence in setting the agenda for mental health care, yet their decisions may not always align with the unique needs and contexts of individual countries and diverse contexts.

In fact, the current approach to scale within GMH is deeply influenced by the perceived success of the global HIV/AIDS response, which frames mental health as a global problem with a universal solution.¹⁵ This perspective raises important questions about what, exactly, is being scaled and what politics of scale are at play.^15,19,24 GMH often mirrors Western psychiatric models, emphasizing symptom-based management and evidence-based interventions, raising questions about its universal applicability. GMH has attempted to address these critiques through a “staging model of mental disorders”,¹⁴ but it still predominantly focuses on symptom-based management and fails to appropriately challenge GMH's reliance on psychiatric diagnosis and classification as “indispensable for clinical practice”,¹⁴^{, p. 33}. This narrow view shapes how solutions are identified and developed, emphasizing the scaling up of evidence-based interventions, despite debates about the applicability and validity of evidence-based medicine to mental health treatment globally. In this context, GMH's approach to scaling up reinforces the notion that the global and local are distinct hierarchical units, with the global taking precedence over the local.

Moreover, GMH's approach is deeply rooted in neoliberal values, prioritizing economic productivity over holistic well-being—where mental health services are evaluated primarily based on their economic efficiency and ability to restore individuals to economic productivity, especially in the context of depression.³ The overemphasis on economic considerations can detract from the holistic understanding of mental health, which encompasses broader social and structural determinants beyond symptom reduction and economic productivity. Therefore, instead of solely focusing on how to treat individuals, the focus should shift toward how systems can support people in living meaningful and socially inclusive lives. This reframing invites a broader reconceptualization of mental health care, one that recognizes the complex interplay of social and structural determinants. To achieve this shift, it is crucial to reevaluate the values promoted by scaling up strategies, acknowledging the power disparities that determine what is considered “global” or “local,” and what interventions are scaled and largely promoted.

Conclusion

A key condition of possibility and a central narrative trope for the development of mhGAP and its products is the construction of a treatment gap. GMH assumes that depression treatment gaps in LMICs are enormous. In the discourse of GMH, the term treatment gap is usually interpreted as an indication that mental health services are not available in LMICs, and people who suffer from mental illnesses such as depression are not getting the care they need. As such, largely addressing depression in health care settings has been given a priority. Yet, through our critical discourse and document analysis, we have been able to identify a set of key themes that challenges the current practice of depression in GMH in resource-limited settings.

This analysis demonstrated that there are several persistent dominant ideological norms which have a profound influence (consciously and subconsciously) on GMH's programmatic strategies and scope for addressing depression. The prime example of this kind is the GMH leaders’ extreme solutions or recommendations, including routine depression screening⁷³ at the primary health care level, to detect depression more to close the gap while two decades of research evidence still shows a low rate of detecting depression.^80–82 The mhGAP guidelines represent a key example of a techno-scientific object that contributes to the universality of mental health.^11,15,61 However, the universality achieved through the implementation of the mhGAP guidelines is always partial and contingent.^85–88 Moreover, it is pertinent to note that international guidelines are embedded and circulated within the broader GMH assemblage (crafted using rhetorical global metrics [burden], funding, EBM, etc.).

While the mhGAP has served as an apparatus for a moral imperative for action based on a quantified understanding of the scale of the “problem,”—depression as a global crisis—it has been effective over the past two decades for the global visibility of depression. In this sense, the mhGAP-IG appeared as a solution, a way for governments and clinicians in the Global South to reduce the quantified burden of psychiatric illness (i.e., depression). In fact, the mhGAP-IG has since come to be used in the production of metrics, such as for economic modeling (highlighting the economic burden of depression) and to make a case for the “return on investment” of interventions,³^{, p. 415}.

In this analysis, we highlighted how international guidelines like mhGAP operate as part of “the knowledge-power processes that inscribe and materialize”,²⁹^{, p. 7}, i.e., comprehend mental health differently (as an illness, as universal, and as measurable) than in other contexts. It is therefore possible to see that the mhGAP-IG functions as a global “inscription device” that reinforces and reifies specific theories and practices.^20,31 As a result, the “ethno-specific narrative field”,²⁹^{, p. 4} of mhGAP-IG is portrayed as universal, while the guidelines function as a means of connecting and circulating different ideals of distress in a manner already defined by Euro-American standards.^15,88 In doing so, the current dominant paradigm in GMH perpetuates a problematic assumption that human emotions and behaviors can be understood independently of context and that the “symptoms” identified are equally pathological wherever they are encountered.¹⁸

The continual framing of mental health problems and depression in individual terms obscures the role of wider social determinants and encourages the provision of medical interventions rather than public health approaches.²¹ More research has also raised the concern that universal criteria fail to reflect locally meaningful constructs given variation in experiences and idioms of distress between settings.^42,43 From the start, the GMH movement evaded the now decades-old question of whether the diagnostics and treatments of Western-rooted defining of depression are applicable in other cultural contexts. Global interventions have, accordingly, become a matter of scaling up, before and without calling for an investigation into the appropriateness of using standardized diagnostic categories as the basis for measuring need and providing expanded access to care.

Therefore, it is critical to consider the epistemological underpinning assumptions within the mhGAP-imaginary. To move forward with this process effectively, we recommend that we must take the critique of mhGAP-IG seriously, both in terms of its own paradigm and from other epistemological perspectives. Particularly relevant are the multiple perspectives and critiques from “user/survivor/mad” to situated, localized, and indigenous epistemologies.⁸⁹ We suggest that a radical shift in thinking about programmatic strategies in GMH is possible only when we critically examine the set of norms and assumptions that shape the very foundation of what we produce as knowledge and the programmatic actions that are developed from such knowledge. By inverting dominant discourses, we may also be able to develop alternative approaches and theoretical frameworks. These approaches may help us reorient ourselves fundamentally in a less conventional and more innovative way.

We want to stress that our aim in this analysis is not to dismiss the aspirations of GMH, but to suggest that there are fundamental problems with the continual framing of mental health under the notion of treatment gap that seeks to introduce global standard packages of care without a full understanding of local contexts. We stressed that addressing depression in non-clinical settings is just as significant as addressing it in health care settings. Since the health care response has been the dominant discourse in GMH to address depression in LMICs, the notion of treatment gap has limited the various interventions aimed at adressing the root causes directly. Importantly, the treatment gap with its clinical focus solution, sidelined the broader socio-cultural and economical adversaries people face every day which are significant contributors to depression.

While this analysis contributes to the GMH literature about depression research and practice, it does have certain limitations. The analysis, for instance, did not examine in detail how the mhGAP guidelines are applied in practice within a variety of contexts; it did not examine the wider epistemic infrastructure within which the guidelines operate; and, crucially, it failed to consider the impact its diagnoses and recommendations may have on the lives and subjectivities of those affected. Despite these limitations, however, this article argues that the universality of mental disorders is contingent and partial, and the different strategies employed in GMH to address depression can be seen as “contingent universals”^85,87 upon which its main thesis is based. Most importantly, although the GMH agenda has placed significant emphasis on expanding services to reach all those who meet diagnostic criteria for common mental disorders, many of them do not consider themselves to need or want such treatment. As a result, we argue, our goal in terms of increasing access to services must be not only “the human right to care is met but also that people have the ability to improve their lives in ways they consider meaningful” (,⁴⁷ p. 555).

In summary, providing interventions that address people's mental health needs is central to global mental health, but treatment, per se, does not necessarily meet these needs. We must therefore expand the notion of what constitutes a mental health intervention. The goal of global mental health is not disputable. Increasing access to care and strengthening mental health care in LMICs are important and timely endeavors. However, it is important to recognize that achieving lasting success in reducing mental distress around the world will not come from more psychiatric interventions. Instead, a genuine progress in reducing mental ill-health in the LMICs necessitates comprehensive, large scale socio-economic and political reforms targeting the root social determinants of distress. For GMH to truly advance in adressing depression in the Global South, it must move beyond the treatment gap paradigm.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gojjam Limenih

Author Biographies

Gojjam Limenih, a PhD candidate, holds an MSc and an MA. She is a critical global public health and mental health researcher and academic who has been working as a lecturer and senior researcher in the School of Social Work and Health Sciences at the University of Gondar, Ethiopia. Currently, Gojjam is a lecturer of mental health at the School of Health Studies at Western University and a Global Mental Health Research Fellow, Department of Psychiatry, Western University, Canada. She is also a Research Associate of the Mental Health Nursing Research Alliance (MHNRA) Lab at the Lawson Health Research Institute, St. Joseph Healthcare, London. Her research interests include mental health systems, mental health illness and care, and global health research ethics. Her expertise includes global mental health interventions, policies, and practices; mental health care in resource-limited settings; depression; gender and mental health; and cross-cultural psychiatric research and psychiatric research ethics.

Arlene MacDougall, MD, MSc, FRCPC, is a Psychiatrist and an associate professor (clinician researcher) and Director of Research for the Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University. Dr MacDougall is a Canadian mental health researcher and leader in global mental health. She is the founder and CEO of The Global MINDS Collective, a nonprofit organization headquartered in Canada () aiming to bring underheard voices into transformative action to improve mental well-being.

Elysee Nouvet holds a PhD is an associate professor at the School of Health Studies at Western University. She is a medical anthropologist and global health researcher with expertise in global health care and research in low- and middle-income countries. Her research program is centered on cultural particularities of suffering and strategies to support improved global health equity, and she is an expert in qualitative global health research.

Marnie Wedlake holds a PhD and is an assistant professor of psychotherapy and a critical psychiatrist at the University of Western Ontario. She has done intensive work in the areas of mental health and wellness, mental health, and social justice.

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