Social Determinants and Clinical Realities

Mental health: a crucial component of the new global reality.


There is little doubt that, nowadays, globalization is among the most prominent topics of discussions and studies in practically all types of academic and professional disciplines. Many factors have contributed to this development but, particularly in the last 5 or 6 decades, technological advances in communication and transportation, as well as migrations of all kinds across the world, are considered its main sources.1 Thus, globalization exhibits a rather ambiguous image of glorious machine-based achievements and profoundly uncertain—and at times, chaotic—human experiences. Health, then, becomes a reality to handle in the global context, and its care rests with the demands, expectations, and hopes of billions of people. Sequential reasoning leads next to mental health as a crucial component of the new “global reality,” one that had already acquired a growing presence, long before the arrival of the COVID-19 pandemic.

Global mental health (GMH) is now an important field for every psychiatrist, because of the various challenges that humanity confronts as expressions of nature itself, social coexistence, survival, climate distortions, and war or peace.2 Every human experience tests mental health resources and engenders possibilities of success as well as risks of failure. Such threats may result in clinical consequences, symptoms, syndromes, or disorders that require management interventions, as simple or sophisticated as their degree of severity or as the setting where they occur. Yet, solid knowledge, diagnostic processes, treatment resources, and ethical norms are—or should be—the same all over.

At the international level, several organizations have responded to this challenge, calling for implementation of public health and mental health measures, universal health coverage, promotion of mental health, prevention and treatment of specific conditions, etc. GMH principles imply that every physician—and psychiatrists more than any other—who are facing clinical encounters with patients from different socioeconomic, geographic, ethnic or cultural backgrounds in today’s “global village”3 must be familiar with the global social determinants of health,4 the substantial features of an integrated (bio-psycho-socio-cultural-spiritual) care approach, and the funding and equipment gaps that reflect the fact that the world has simply not responded to the evidence. In fact, a prominent world mental health figure has affirmed that “all countries are ‘developing’ when it comes to mental health,” and that we must go “beyond addressing the treatment gap to also reduce the prevention, care and quality gaps to reduce the global burden of mental health problems.”5

In This Special Report

This Special Report attempts to cover just a few areas of the current GMH scenario, giving examples of many existing problems. In the context of the migratory phenomena, a part of what the author of one of the articles calls the Enormity problem, the refugee crisis shows a dramatic transcontinental impact with impressive levels of posttraumatic stress disorder resulting from a variety of incidents. Maslow’s Hierarchy of Needs and the H-5 Model offer wise options of social and clinical interventions.

In the same context, another article that analyzes the GMH consequences of the COVID-19 pandemic. Distinctions between high- and low-income countries are related to public health infrastructural problems in the latter, more than to the social rebelliousness against vaccination that has emerged in the former. Furthermore, the variety of mental and emotional symptoms and syndromes seen in people who have survived COVID-19 infection are the subject of ongoing debates: Are they primarily related to the virus (ie, brain and central nervous system inflammatory processes) or to the surrounding circumstances of quarantine, social isolation, UCI-related stressors, domestic violence, sleep problems, etc?

Women’s health and mental health issues in the global context are another relevant issue. Thus, we present an article that explains levels of clinical fragility as reflected in prevalence figures of several conditions, and exploring the challenges women face as frontline workers. Observations about vaccine response, pharmacokinetic differences, and gender-sensitive perspectives in clinical trials open doors of productive and clinically meaningful research.

Finally, another article discusses the powerful challenges that GMH faces now and in the future, along with cogent foundations to approach proposed solutions.

Concluding Thoughts

Mental health is an essential component of universal health coverage, and therefore it is relevant to people in all countries, particularly those who are vulnerable.5 The commitment of individual health and mental health professionals to improve the current situation across the world is as important as the responsibilities of governments and public health authorities to improve the impact of social determinants, implement evidence-based interventions, increase mental health investments, and support multifaceted research initiatives.6

Two final points must be made. The first is to emphasize the importance of cultural psychiatry principles in training programs and practice settings of specialists; these components of mental health education assist not only in a better understanding of the suffering of different cultural groups brought to us by the avatars of globalization, but also help erase the prejudices of a pervasive Otherness and its discriminatory, stigmatizing arms.7 The second issue is the need to pursue systematic research topics in GMH aimed at the delineation of bioepigenetic and clinical differences among patients with similar diagnoses and diverse backgrounds.8 These research initiatives must extend to international collaboration in laboratories, clinical settings, and public health offices in search of comprehensive global policies of mental health care.9

Dr Alarcón is Distinguished Emeritus Professor of Psychiatry at Mayo Clinic School of Medicine in Rochester, Minnesota; Honorio Delgado Chair at the Universidad Peruana Cayetano Heredia in Lima, Perú; and an editorial board member of Psychiatric TimesTM.


1. Lechner FJ. Globalization: The Making of World Society. Wiley-Blackwell; 2009.

2. Alegría M, Álvarez K, DiMarzio K. Immigration and mental health. Curr Epidemiol Rep. 2017;4(2):145-155.

3. Rathod S, Pinninti N, Irfan M, et al. Mental health service provision in low- and-middle-income countries. Health Serv Insights. 2017;10:1178632917694350.

4. Social determinants of health. World Health Organization. Accessed November 11, 2021.

5. Saxena S. What next in Global Mental Health? Carter Center Mental Health Task Force Meeting. Atlanta, GA, June 12, 2019.

6. Cabezas C. Productos estratégicos en salud: una necesidad para afrontar adecuada y oportunamente las pandemias y epidemias. Rev Peru Med Exp Salud Publica. 2021;38(3):377-380.

7. Bhugra D, Bhui K, eds. Textbook of Cultural Psychiatry. Cambridge University Press; 2007.

8. Amarasekera S, Ugo V, Flórez V, Patalay P. Research task shifting and youth as drivers of a more global mental health science. Lancet Psychiatry. Published online October 25, 202l.

9. DaSilva ATC, Hanlon C, Susser E, et al. Enhancing mental health research capacity: emerging voices from the National Institute of Mental Health (NIMH) global hubs. Int J Ment Health Syst. 2019;13(1):21. ❒