How Do Other Countries Deal With Mental Health?

Mental health is essential to everyone's well-being. However, attitudes around it and mental health stigma varies from country to country. While there can be common themes and beliefs between these places, a country’s specific mental health views will be affected by its unique practices, attitudes, and challenges. In addition, they will have their own distinct, culturally-specific strategies to address these. This article will explore what mental health care looks like in various countries across the globe.

General Country-Specific Mental Health Cultural Practices

Globally, mental health disorders have been found to be the second leading cause of disease burden in terms of “years lived with disability.” Additionally, the treatment gap for those living with mental illness is especially vast in low- and middle-income countries.

As stated above, different cultures have different practices that influence their approach to mental health care. “Some of these practices may be beneficial, while others may be harmful or ineffective,” says Dr. Ketan Parmar, a forensic psychiatrist based in India. As a means to give a general overview, Dr. Parmar lists the following examples:

1. In some Asian cultures, such as China, Japan, or Korea, there is a concept of “face,” which refers to one’s reputation, dignity, or honor. People may avoid seeking help for mental health problems or disclosing their condition to others, as they may fear losing face or bringing shame to their family or community.
2. In some African cultures, such as Nigeria, Ghana, or Kenya, there is a belief in witchcraft, which refers to the use of supernatural powers to cause harm or misfortune. People with mental health disorders may be accused of being witches or possessed by evil spirits and may face violence or ostracism from their family or community.
3. In some Latin American cultures, such as Mexico, Brazil, or Argentina, there is a value of “familism,” which refers to the importance of family loyalty, solidarity, and support. Family members are expected to prioritize family interests over individual preferences. People with mental health conditions may seek emotional and practical help from their family members first.
4. In some Indigenous cultures, such as Native American, Aboriginal Australian, or Maori, there is a holistic view of health, which includes physical, mental, emotional, and spiritual aspects. People with mental health conditions may seek help from traditional healers, who may use rituals, ceremonies, or herbal medicines to restore balance and harmony.

India

India is estimated to have a treatment gap of 95%, with only 1 in 20 individuals receiving treatment. Research into this gap in treatment suggests multiple factors in play, such as stigma, poor mental health awareness, discrimination, a lack of trained professionals, poor help-seeking, and low availability (and thus accessibility) to these services across the country.

That being said, India was one of the first low- and middle-income countries to develop a National Mental Health Programme (NMHP) as a means to address the mental health needs of the population. This NMHP was launched in 1982 as a means to tackle the critical need for mental health care infrastructure, and it was re-strategized in 2003 to include the “upgradation” of psychiatric wings of medical colleges/general hospitals and the modernization of state mental hospitals. Since this time, significant progress has been made, though challenges to its efficacy still remain.

While this can benefit some individuals, people facing mental health concerns may not be able to seek treatment until their situation escalates due to the varying levels of understanding and support within families. Faith healers and religious leaders are also preferred sources of support for mental health concerns in India. “Ignorance and myths around mental health concerns, which attribute them to ‘bad karma or curse or possession by evil spirits,’ often lead people to reach out to their faith healers or religious leaders for support with this,” she says. This is particularly common in rural areas and tier II cities.

That said, mental health practitioners are sensitized about the importance of faith healers and spiritual and religious beliefs. So rather than stop people from seeking these services, they’ll encourage individuals to utilize them in tandem with the treatment pathways prescribed by their mental health practitioner.

As for other cultural practices that contribute to protecting mental health in India, Joshi mentions:

• Mind-body practices: This includes practices like yoga and meditation. 
• Ayurveda: A traditional Indian system of medicine that emphasizes a holistic approach to general health and mental health through herbal treatments, dietary modifications, and lifestyle practices aimed at restoring balance and promoting mental and physical well-being.
• Joint family support: This refers to the practice of several generations living together in one home. This system can offer emotional support, a sense of belonging, and a safety net for individuals, contributing to their mental well-being.
  

China

Research has found that many Chinese still harbor a negative attitude towards receiving mental health treatment. Many people are not familiar with the causes, treatments, and prevention of mental illness. This varies based on age, education level, social support, and income, and more efforts are needed to improve understanding and openness to mental health care. Providing more mental health education, training of mental health professionals, and popularizing the use of mental health services is important and could contribute to the reduction of public stigma and increase in people seeking and receiving mental health services and support.

Following the elimination of China’s community-based mental health system, specialist mental health services were the predominant way to access mental health care. As a result, mental health care can be primarily received from psychiatric hospitals or from the psychiatric department of general hospitals — bypassing the primary and secondary health care levels. That being said, considerable changes have been made to China’s mental health service system in recent years.

Nevertheless, while there has been an improvement, there is a significant lack of nonpsychiatric mental health professionals such as psychotherapists — there are only 5,000 for a population of over 1.4 billion— as well as the inequitable distribution of these professionals.

Therefore, research has found that two potential problems to the development of high-quality psychotherapy are a lack of councils of accreditation for psychotherapy and authorized institutions as well as the lack of insufficient medical experience of psychology graduates, which hinders them from conducting psychotherapies and entering into these hospitals.

Japan

In Japan, mental health treatment is widely available and covered by national health insurance for the most part. Individuals, therefore, are only expected to cover 30% of the total cost, and they are also free to select a medical institution of their choice. That being said, Japan has more psychiatric care beds, and it also lags behind other countries in terms of deinstitutionalization when compared with other countries. And while the length of stay in psychiatric care beds has fallen from approximately 500 days in 1990 to approximately 266 days in 2018. There is a push (and discussion) on the further reduction of both the number of psychiatric inpatients and the length of hospital stays.

Additionally, while research has indicated that social and cultural stigma surrounding mental health in Japanese culture is a barrier to accessing these services, further research has found just how prevalent these beliefs are. One study, in particular, found that a low perceived need for mental health care was the primary and most common reason for individuals not seeking care — with 63.9% of individuals reporting this. In addition, 68.8% of individuals reported delaying access to care due to wishing to handle the problem on their own. And 54.2% dropped out of care due to a low perception of need.

Thus, it has been discussed that better recognition of mental health issues, increased knowledge around the availability and location of these services, and improved community understanding of the early signs and symptoms of mental health issues, may improve the access of Japanese individuals to these services. Additionally, when it comes to community mental health services, it is thought that improved therapist-patient communication and the general quality of care could also benefit.

South Africa

In South Africa, the pandemic exacerbated previous structural inequalities, such as access to quality healthcare, poverty, and unemployment. Historically, major challenges facing the health system towards the end of Apartheid saw the severe unequal allocation of resources, and while the South African government sought to address these through legislative change, the implementation of such policy did not bridge the gap.

Thus, due, in part, to the lack of a sustainable funding model, research indicated that mental health accounted for around 5% of South Africa’s total public health budget. Additionally, 86% of the overall expenditure was found to be from inpatient care.

When it came to treating mental illnesses, data presented by the South African College of Applied Psychology estimated that only 27% of South Africans reporting severe mental illness ever receive treatment. This is of concern as South Africa’s history is characterized by various ongoing intergenerational and social traumas — such as Apartheid, the AIDS pandemic, and gender-based violence (GBV)—which, when compounded with the pandemic, could lead to more serious mental illness presentations such as mood disorders, post-traumatic stress disorder (PTSD), GAD, and phobias.

Particularly if it instead included alternative strategies recommended by other disciplines — for example, psychologists, mental health professionals, and behavioral scientists working in collaboration.

Colombia

Much like in South Africa, an understanding and appreciation of the population-wide exposure to violence in the country's history is vital. This is because the historical ramifications of 60 years of armed conflict, high rates of homicide, gang activity, gender-based violence, and intra-family violence is important context for understanding the impact on mental health in the country.

As a result, there is a significant proportion of the population affected by trauma. Alcohol misuse and illicit drug use also contribute to a burden on these services. Also, around 15% of the Colombian population has been displaced by the conflict and, as a result, have additional needs that are hard to address in the communities that they live in — which further increases the risk of poor mental health and a lack of access to support.

In addition, the Rudesindo Soto Mental Hospital in Cúcuta is the only hospital that provides mental health care and specialized psychiatry in the Department of Norte de Santander. With private sector services being limited and not easily accessible, this is an issue as the hospital cannot cover the needs of the region alone. Other severe barriers to access to care have also been highlighted; these include economic, geographical, and cultural difficulties and their impact on the health system and its members.

Spain

Spain has a publicly funded health system that allows its people access to health services through reliance on the public sector — healthcare is funded through state, provincial, and municipal taxation. This public funding accounts for 71%, and the remaining 29% is privately funded through “voluntary” payments.

In this country, a community model of care is utilized for those with mental health problems. The aim is to provide comprehensive care by focusing on prevention while following principles of autonomy, accessibility continuity, and equity. As a result, community healthcare providers work in tandem with primary care teams in an interdisciplinary manner. In more recent years, more improvements to this model have been made, such as population-based improvements, person-centered care, user experience, and the further development of assessment models. Thus, people with mental illnesses generally perceive good responsiveness from their primary care, mainly as it concerns confidentiality, communication, and dignity.

In agreement with this, an alternate study found that poor mental health increased in 2021 by 55.92% compared to the previous years of study (2005–2016 scoring 15–17.72%). Thus, this work highlighted the urgent need to reallocate resources to mental health services to increase access, even when the healthcare system is overloaded.

Costa Rica

Costa Rica is often ranked highly on healthcare quality metrics, as well as happiness, too. In addition, the country’s unofficial slogan, pura vida, which directly translates to “pure life,” highlights the typical kind of lifestyle and ethos of the people - valuing happiness, optimism, and living life to the fullest. Thus, the dominant values in this society involve caring for others and maintaining a good quality of life.

The healthcare system in this country is called the Caja Costarricense de Seguro Social (CCSS), and it is funded by payroll taxes. As a result, nearly the entire population of Costa Rica has access to healthcare services free of charge within it. Because of this, Costa Rica is ranked as one of the top three in Latin America by a number of institutions, and it is often praised for the quality of this system.

That being said, while it is frequently commended, there are some barriers to care. For instance, the prevalence of mental illness in the country is not well-researched or documented. Additionally, as there are no specific mental healthcare programs, this type of care is accessed through primary care only. Therefore, not only is there a need for the improvement of mental health care in the country, but also more current research on the mental health and mental healthcare landscape overall.

Mexico

Access to mental healthcare in Mexico is an issue, leading to a significant treatment gap. There are a few reasons for this; however, overall, the lack of infrastructure has led to mental health services being delivered through an underresourced, underfunded, and uncoordinated network of institutional providers, which is isolated from the larger health care system. As a result, 87.4% of those with mild mental disorders, 77.9% of those with moderate disorders, and 76.2% of those with severe ones (such as bipolar disorder or schizophrenia) do not receive treatment.

Additionally, while there is a lack of trained mental health professionals in these services, there is also a lack of financial resources for transportation to their nearest health center to contend with.

When it comes to the role of stigma within Mexico’s general attitudes to mental health, Psychologist David German Gonzalez Flores states, “Presently, there is great acceptance towards psychotherapeutic and mental health practices due to the evolution of consciousness and seeing thoughts and emotions as important parts of life.” “However, it is undeniable that in some areas of the country, these services are still considered taboo since the belief that psychotherapy is a service only for people with severe mental health illness is still present,” he adds.

That being said, the geographical location of the individual will have an impact. He says, “in places where people are more open-minded, it has been observed that asking for help is something done as a daily, necessary, and important thing that supports people in their self-discovery and continuous improvement.” In contrast, “in other communities, there is still a fear of mental health services in some people who desire to start services due to feeling ashamed and feeling they do not meet the criteria of what this service is assumed to be for.”

As for the other strategies people may use, in Mexico, there is a range of non-traditional strategies that are practiced too. Gonzalez Flores states that these include esoteric and metaphysical practices where individuals use crystals, angel therapy, card reading, Bach flowers, and more. However, with these, he advocates for caution. After all, many of these practices are considered pseudosciences within evidence-based psychology.

He says, “[these practices], rather than helping, can harm or increase psychological discomfort that the subject presents.” That being said, if these practices are to be done, he highlights the importance of getting a professional who has all their credentials in order, who is trained and experienced with dealing with the concerns of the individual.

Other Ways People From These Countries Seek Mental Health Care

The Use of Online Platforms

There has been a rise in the usage of online platforms — such as apps, websites, or social media — when it comes to managing mental health. As a result, the use of online platforms has become a non-traditional strategy of its own. According to Dr. Parmar, these platforms are popular as they provide people with a sense of connection, belonging, or support from others who understand their situation. “These platforms may also offer people access to information, resources, or tools to manage their mental health problems or to seek help from professionals or peers,” he says.

In Joshi’s experience, while working for Wysa, she states that there has been a rise in interest from Indian employers and organizations to bring their digital services to their employees — especially during and after the pandemic. “The government has also set up various 24/7 helplines to offer free psychosocial support for crisis and stress management in various languages,” she says. “Despite a lot of reservations earlier, people have slowly warmed up to the idea of receiving mental health services online,” she adds.

Seeking Mental Health Care From Practitioners Located Abroad

Even though she is a psychotherapist working in the United States, Avigail Lev, PsyD, founder & director at Bay Area CBT Center, has had clients reach out to her looking for assistance from many countries, including India, Mexico, and Spain.

As a result, she can attest to the struggles individuals from these countries face when it comes to accessing mental health resources. “Clients reaching out from abroad seem to be struggling with finding a therapist who specializes in evidence-based treatments and cognitive behavioral therapy (CBT),” she says. This is likely because of the limited availability of specialized modalities like CBT as well as challenges to access due to limited availability.

Of the people who do reach out, she says, “they specifically express a desire for CBT or acceptance and commitment therapy (ACT) over psychodynamic therapy.” Thus, it tends to be for a therapy modality they can’t access in their country. “It’s seeming that the people who reach out to me can afford the fees, so they do have the financial resources to afford therapy,” she adds.

However, even within seeking help from abroad, there are still prevalent issues. For example, country-dependent licensing restrictions and language barriers, which hinder in-depth therapeutic engagement.

In Closing

Even though mental health is a global issue affecting every single person in the world, individuals will need culturally sensitive and attuned treatment that is curated to their unique context.

As Dr. Parmar states, “there is no one-size-fits-all solution for mental health care… Therefore, it is important to respect and understand the diversity and complexity of mental health across regions and cultures and to promote culturally sensitive and appropriate mental health services and interventions for everyone.”