Countries with vast resources and those with very few have at least one major challenge in common: the need to meet escalating demand for mental-health care and improve brain health at a population level. Globally, the unmet need for high-quality and equitable preventive and treatment resources has led to a high level of disease burden from mental, substance use, and neurological disorders. A steady stream of global crises (armed conflicts, natural disasters, and the COVID-19 pandemic) have left more people than ever feeling stressed, anxious, and emotionally vulnerable.
Shekhar Saxena, MD, has dedicated his professional life to improving brain health around the world. He worked for more than 20 years at the World Health Organization (WHO), serving as the director of the Department of Mental Health and Substance Use for eight of those years. He is currently Professor of the Practice of Global Mental Health at the Harvard T.H. Chan School of Public Health. He advises policy makers, researchers, and practitioners around the world on how to advance better systems for the prevention and management of mental-health, developmental, neurological, and substance use issues.
Saxena recently sat down for a conversation with Kana Enomoto, director of brain health at the McKinsey Health Institute, and shared his definition of health, reasons why mental health is a borderless issue, actions that could improve mental-health outcomes, and the importance of taking innovative approaches. The following is an edited version of their conversation.
Kana Enomoto: Shekhar, thank you so much for joining the Conversations on Health series. It is inspiring to see what you have accomplished in mental health and beyond over the course of your career. Given your experience as a global leader in health policy, why is adopting a broader, more holistic definition of health important, and how are physical, social, and spiritual health connected with mental health?
Shekhar Saxena: I worked for many years for WHO, which defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”1 This definition encompasses the interconnectedness of health—a concept that goes back to ancient cultures. It’s important that we go back to this holistic and integrated concept of health rather than take each component separately. The inclusion of spiritual wellbeing is also quite important because it integrates well within the concept of health and well-being.
I also feel that modern medicine has been focused on the causation of disease and finding solutions. This has been extremely useful and saved millions of lives, but there is also an unintended consequence: losing sight of the whole person. We need to go back to the interconnectedness of the various aspects of health and well-being without losing the details of each of them.
Kana Enomoto: As we work to embrace a whole-person approach to health, help us understand why mental health is a global issue and what we can all learn from one another.
Shekhar Saxena: During my time at WHO, I had the opportunity to interact with professionals in more than 100 countries. I learned that when it comes to mental health, all countries are developing countries, including economically developed countries like the United States. Each country is making attempts to improve mental health for its citizens; the starting point is different, but the direction and the destination are the same.
In parts of the world that are resource poor, there is an urgent need to innovate so that they can serve more people and provide quality care because a business-as-usual attitude is not working. But the flow of knowledge, data, ideas, and innovations should be multidirectional. Mental health has no country boundaries. We all need to learn from the experience that is accumulating throughout the world.
Kana Enomoto: When we think about mental health as a borderless, global issue, who are the critical stakeholders?
Shekhar Saxena: The primary stakeholder for mental health, and for brain health, is us as individuals because it is something we each need to cherish, protect, and preserve. But health systems, governments, the nonprofit sector, business leaders, and, of course, mental-health professionals are all important stakeholders. Unfortunately, they have a tendency to think about their role not in partnership with others but in isolation, and that is a waste of resources and energy. People with lived experience with mental-health issues are important stakeholders, but we often forget them. They have expertise based on experience and can contribute a lot to planning services that meet their interests and needs. We need to include them in our conversation at all stages.
Kana Enomoto: Do you see different winning strategies for engaging people with lived experience across cultures?
Shekhar Saxena: Some groups in high-income countries have focused too much on the right to refuse treatment, while many other groups in low-resource countries and cultures are still looking for better care, or at least some care. I see that as an integrated agenda. People should have the resources to seek help as they need. And, of course, they need the right to decide what they access and what they don’t.
We can expand care by making every healthcare worker a mental-health worker. This means training all healthcare professionals in the essentials of brain health so they can diagnose and treat mental-health issues, at least to some degree.Shekhar Saxena
Kana Enomoto: Are there a few critical actions that you think would drastically improve mental-health outcomes on a global scale?
Shekhar Saxena: We can expand care by making every healthcare worker a mental-health worker. This means training all healthcare professionals in the essentials of brain health so they can diagnose and treat mental-health issues, at least to some degree. We know that most healthcare providers have very rudimentary knowledge, or sometimes no knowledge at all, of brain health and behavioral health, and, as a consequence, these conditions are not diagnosed early and not treated. I don’t mean all healthcare workers will become psychiatrists, but they can contribute a lot to improved mental-health outcomes.
In fact, this will help improve not only mental-health care but all healthcare because those providers will provide better overall care. Countries can adopt policies that involve increasing focus on brain health in preservice training as well as in-service training, ensuring that all healthcare providers have at least the basic capacity to provide this care. This will be entirely in line with a holistic definition of health and the principles of universal healthcare.
Kana Enomoto: Do you see other innovations that could help overcome workforce shortages and help meet the growing demand for mental-health services?
Shekhar Saxena: We know there are not enough mental-health professionals to provide the care we need globally, especially in the majority of low- and middle-income countries. The ways we have gone about expanding care aren’t working, so we really need to think out of the box for solutions for high-resource and low-resource settings. Studies have shown that trained teachers and even laypersons can provide mental-health support and basic psychological interventions. There is a lot of experimentation happening around the world. Middle-aged women in Africa were trained to provide care to their peers. Educators have been trained to detect mental-health issues in schools and colleges. Another approach is to use more digital channels, which helped tremendously during the COVID-19 pandemic, to provide telehealth services for mental health.
Kana Enomoto: How is the global mental-health community responding to the trauma associated with COVID-19, global conflicts, climate change, and other crises?
Shekhar Saxena: Mental health has always been important, so it’s not that it has suddenly become more important. Rather, it’s that awareness and evidence on effectiveness have increased substantially. Obviously, some people are much more affected than others by all these global crises. But needs across the board are also increasing, and the capacity to serve has either remained the same or gone down. The gap between what is needed and what is available has enlarged. It’s timely that we are talking more and doing more about mental health in our countries and communities as we prepare to face even more crises in the future.
I would also like to refer to the impact of all of this on young people. We thought, as the pandemic began, that older people’s mental health would be most affected. And that has been proved completely wrong. It is the young adults—who are finishing their education, joining a job, or looking forward to establishing a family—that have been most affected. This is going to affect them throughout their lives, so we need to be very careful about providing the kind of ongoing support these young people need within the community and the healthcare system. These are urgent priorities.
It’s timely that we are talking more and doing more about mental health in our countries and communities as we prepare to face even more crises in the future.Shekhar Saxena
Kana Enomoto: How do you see us addressing the needs of today’s young adults—Generation Z—that might be different from older generations such as millennials, Gen Xers, and baby boomers?
Shekhar Saxena: We must ask them what they need, of course, but there are a few other things to remember. First, we need to provide the whole spectrum of care, with much more emphasis on prevention, protection, and promotion of mental health rather than on treatment. Second, this generation is already much more open to talking about their mental health than people at my age, for example, and we need to give them guidance for self-care and for helping others. These are nonclinical interventions that are going to be much more useful for them than the standard clinical ones. And third, we need to provide these kinds of interventions where people are because they’re not likely to visit a clinic. We need to look at how to support mental health at school and in the workplace in an environment that does not stigmatize. Resources for mental-health care of youth are going to have an excellent return on investment.