Bolstering global mental health by prioritizing prevention

Pamela Collins’ journey to global mental health started on a bus in Haiti in 1987.

Working for the first time in a predominantly Black country, the young medical student sometimes took public transportation and enjoyed blending into the majority. “What really struck me that summer was how important social context is for health,” says Collins, MD, MPH, Bloomberg Centennial Professor and chair of mental health.

“Our daily experiences, how we move through the world, as members of the majority or minority groups—all of those have ramifications for our health outcomes and certainly our mental health status.”

She left Haiti with a commitment to pursue global mental health—and would later lead research into HIV and mental health, stigma and discrimination, and urban adolescent mental health.

Collins, who became chair in July 2023, shares her insights in this Q&A on the challenges of accessing mental health care, preventing mental disorders, and priorities for her department.

Why don’t more people get the mental health care they need?

Access is an issue everywhere. This is a story where the issues are global, where the challenges are truly global. There are tremendous differences in resources between countries, but surprisingly similar challenges: Only a minority of people receive minimally adequate care once they are recognized as having depression, anxiety, or substance use disorder. That is something that we really must fix.

Also, in many parts of the world, the history of mental health services has been tainted by negative experiences with colonialism and its sequelae. The services that evolved are often not services that people typically feel comfortable accessing, compounded with the fact that those services are extremely underfunded.

I think many people have a lot of reservations about specialist mental health services in most parts of the world, this country included. And given a history of human rights abuses and misuse of these services as well as discrimination and poor-quality care, that’s understandable.

So even if access were universally available, people would still be leery about getting care?

If you know that you’re getting access to poor quality, overly restrictive mental health services, most people don’t want that. In the United States, overly restrictive care often means jails and prisons, right? A large percentage of people in jails and prisons live with mental health conditions.

The National Alliance on Mental Illness points out, for example, that the Cook County jail in Chicago is one of the largest mental health care providers in the country. And the pathway to jail can sometimes be linked to a lack of services in the community. The goal is to create and deliver quality, community-based care that will meet most needs.

How do you approach improving global mental health?

That’s a complex question because there are biological, social, and environmental factors that add to vulnerability to poor mental health. We can start with felt need: How do we prevent and reduce the risk for mental illnesses? And, when they occur, how do we provide care and reduce disability? Those are the key questions for global mental health.

What can the U.S. learn about mental health care from other countries?

There’s no country in the world that has enough mental health care providers for the population. One of the exciting things about the last 15 years or so has been the chance to see how people are innovating in places around the world that have very different levels of resources, very different kinds of health systems.

When I was leading the work on global mental health at [the National Institute of Mental Health], some of our early initiatives were focused on whether nonspecialists can deliver mental health care that is evidence-based and culturally congruent in a variety of settings. Community health workers and peers—for example, if you are a woman suffering with perinatal depression—can be equipped to deliver mental health services.

What can we be doing now to prevent mental disorders?

In 2022, researchers conducted a rigorous global meta-analysis to identify important risk factors for mental disorders that, if addressed, could reduce population-level mental illnesses. They found that childhood adversity topped the list. If you could reduce childhood adversity—which was a broad bucket of issues from war crimes to neglect and child abuse—you could potentially reduce the global incidence of schizophrenia spectrum disorders by around 38%.

That’s just one example, but it means we should really be thinking about the causes of childhood adversity. About 50% of mental disorders begin in the teenage years. We need to intervene then and earlier! One of the responsibilities of public health is to continually ask what we can do at a population level to keep children and youth safer and reduce their exposure to adverse events that are likely to affect both their physical and mental health.

Your recent Nature analysis focused on creating mental health-friendly urban areas. Why?

As humans, we survive adversity, but it still leaves a scar. That paper is looking aspirationally at the things a city could do to prevent the scarring. What are the resources that people need in a city to foster strength and to support their development? We want to ensure the trajectory of youth is not curtailed by the fear of violence, by harassment, by injustice, by discrimination, by the kinds of things that interfere with people’s ability to develop freely as human beings.

These require complex actions, but we can take simpler steps. We can create nonjudgmental spaces for young people, where can you actually, authentically be yourself.

What’s your main priority for the department?

Our priority is to respond to the current public mental health crisis and to anticipate population-level mental health needs of the next decade. I met with a group of young people on the West Coast recently, and they were saying, “We can’t get attention without a crisis. How do we get help before we get to crisis?”

Some of our work helps to respond to these crises by designing interventions, testing them, and studying their implementation. But how do we avert the crisis? This gets us back to the theme of prevention, which continues to be a priority for our department.