It is now possible to live in a rural area of India, board a bus, be diagnosed with a depression, or schizophrenia, or another ‘mental disorder’ by a psychiatrist hundreds of miles away via skype, and collect any prescribed medication before you return home. Follow ups can be delivered by community health workers who are trained and supervised by mental health professionals via video conferencing. This kind of tele-psychiatry and mobile mental health service can cover populations of hundreds of thousands (for example, see SCARF Telepsychiatry programme in Pudukkottai (STEP) in India).
This week is mental health week, a good time to reflect on the ways that mental health has, over the past few years, transformed from being seen as an invisible problem within international development to being framed as ‘one of the most pressing development issues of our time’, and is now included on the UN Sustainable Development Goals (SDGs). Digital technology (e-health and m-health) plays a key part in making mental health count within global health, from the production and circulation of data, to increasing access to treatment globally. Digital online and mobile applications (including, smartphone applications to enable users and clinicians to track a condition; automated analysis of facial expression to aid diagnosis; and mobile tele-psychiatry) are framed as having the potential to ‘transform mental healthcare by connecting patients, services and health data in new ways’, and by enhancing clinical management through access to real-time data.
Many argue that the use of data-driven decision-making and digital technology enhanced treatment is promising in low and middle-income countries, where due to fewer resources there is a need for innovation. The WHO’s Mental Health Action Plan 2013-2020 emphasises the need for more data collection (Objective 4) and the importance of technology for ‘the promotion of self-care, for instance, though the use of electronic and mobile health technologies’ (Objective 2, No. 48, p. 14). The UK Government’s ‘No Health without Mental Health’ strategy recommends increased use of information and communication technology (ICT) to improve care and access to services. The SDGs emphasise development of new and enabling ICTs (1.4) to bridge the digital divide and develop knowledge societies (15). Thus, quantification and digitalisation of mental health sit squarely at the heart of international development and global health.
Some claim that new technologies within mental health replace “subjective clinical judgements” with “more objectivity and reliability”. Improvement is certainly needed given widespread critique of psychiatric diagnostic practises, the validity of the diagnoses themselves and of treatments. Yet it is also important to trace what assumptions about mental health are being written into technology. The design of technology invariably reflects assumptions made by software programmers, which are currently still more often than not based in the global North. Furthermore, devices that implement psychiatric diagnostic criteria from the global North may not always be easily transferable across different cultures. We argue that in order to trace the different stages of digital technology’s development and use it is important to conceptualize data and technology as culturally constituted objects based on interactions between people. This can reveal how technological interventions in the field of mental health enable new relations between people, but also how the engagement with a digital device can reimagine diagnosis and clinical management.
Because the digital revolution in mental health has the potential to significantly reshape practices of diagnosis, epidemiology and service delivery it also raises pressing questions about how digital technologies shape how people understand their own mental health. It makes us question the normalisation of mental health protocols at the global level, despite lack of a global consensus on how best to understand ‘mental disorder’. Making mental health count through digital technology has wide-ranging implications. On the plus side it can lead to empowerment through access to information and real-time data and a diffusion of expertise. But it could also further promote purely pharmaceutical responses to mental distress. Protocols may further entrench Eurocentric models of illness to understand distress. Thus, we argue that it is important to understand how mental health data and digital technologies are produced, used, reworked, locally appropriated, or resisted, and how they mediate new social relations and new ways of being in an increasingly quantified and algorithmic world.
Those of us working on the Collaborative Network in Critical Approaches to Global Mental Health, funded through Sheffield Institute for International Development (SIID) are developing a plan of research around these topics, and would love to hear from you if you also work on these areas (please contact China Mills and Eva Hilberg). Please watch this space for upcoming events, publications, workshops, and future blogs.
For recent publications on discussion of the inclusion of mental health within the SDGs; issues around scaling up mental health services within low and middle-income countries; and for local alternatives to global mental health, see:
Mills, C. (2016). Mental Health and the Global Mindset of Development. In Grugel, J. and Hammett, D. (Eds). The Palgrave Handbook of International Development.
Mills, C. and White, R. (2016). Efforts to Scale-up Mental Health Services in Low and Middle Income Countries (LMIC). In White, R., Read, U., Jain, S. and Orr, D. (Eds.) The Palgrave Handbook of Global Mental Health: Socio-cultural Perspectives. Palgrave.
Mills, C. and Davar, B. (2016). A local critique of Global Mental Health. In Grech, S. and Soldatic, K. (eds.) Disability and the Global South: The Critical Handbook. Springer.