Covid-19 and mental health: The importance of cultural contexts

The current mental health crisis has been declared one of the worst and most far-reaching global public health crises, with staggering inequalities between the global South and the global North in the accessibility and quality of treatments. The outbreak and rapid global spread of Covid-19 have further complicated the situation and instigated a large number of projects and initiatives which aim to alleviate the adverse psychological consequences of the pandemic.

The pandemic’s dramatic effects on the mental health of different population groups are currently receiving increasing attention among psychiatric researchers and clinicians, policymakers and the broader public [1]. A large number of studies and surveys are being published to document this, while many more are in preparation or awaiting peer review [2]. But it seems that some of the most important conclusions of anthropologists, cross-cultural psychiatrists and local mental health activists about the complex relationship between socio-cultural contexts and mental health are not being heeded in this latest research initiative. In most of the Covid-19-related discussions, researchers assume the universality of such mental health consequences around the world – after all, the pandemic-related circumstances and social measures appear to be strikingly similar in most socio-cultural contexts, and in the current climate of global mental health, the same research instruments, diagnoses and questionnaires are often used across the globe. The leading international health organisations such as the WHO and World Psychiatric Association have issued universal guidance for preserving mental health in times of Covid-19 and simply translated it into different languages. However, a recent Lancet editorial has noted that the outbreak of Covid-19 reinforced an important recognition that ‘expertise comes from individuals and communities in specific social, cultural, and economic environments, rather than the world being a blank slate on which supposedly value-neutral, technocratic solutions can be imposed ’[3]. We need to explore critically the emerging literature and debates about global mental health effects of the Covid-19 pandemic and related social isolation and economic downturn and examine how cultural and social difference is constructed and worked into this very topical mental health research.

In the context of the history of transcultural psychiatry, which has shed light on the complex relationship between culture, society and mental illness, such assumptions about the global universality of psychological problems and emotional worlds can be problematic and should be questioned [4]. The universalization of psychiatric concepts and instruments without taking into account complex socio-cultural contexts can lead to the marginalization of both patients and experts from developing countries, may reinforce Eurocentric tendencies and power structures in mental health, and often results in ineffective policies [5]. For those reasons, we should attempt a nuanced historical and anthropological analysis of the intricate web of interrelationships between socio-cultural environment and mental health, which should enhance the cultural sensitivity of the current global mental health thinking, and draw attention to important historical precedents which ought to inform present-day decision-making.

The first task for researchers is to explore the emerging Covid-19 mental health literature (psychiatric, psychological and anthropological) and patients' narratives in different cultural contexts in order to look beyond the discourses of universality, and to see how different societies have experienced the pandemic/lockdown psychologically, what is highlighted and diagnosed (or self-diagnosed) as the core problem in different socio-cultural settings, and how mental health strategies for dealing with Covid-related psychological difficulties could be culturally and socially tailored. This would be particularly important as some of the external general circumstances do indeed appear to be quite uniquely universal, and an exploration of any cultural differences in psychological responses or discourses might point to some crucial aspects of the relationship between culture and concepts of mental illness.

Currently, some of the Covid-19 mental health research from different national contexts is rapidly becoming available in several partial databases, but only if it is published in English-language journals. However, a much more comprehensive range of the emerging mental health literature needs to be made available, both in English and in other languages, and the source base of such mental health research should be significantly extended beyond psychiatric literature to include anthropological and psychosocial research as well as published mental health narratives of Covid-19 survivors and other ‘lay persons’ who are experiencing the pandemic and its consequences.

Moreover, in addition to analysing a much broader variety of mental health literature, researchers ought to engage with the universalist discourse about mental health and explore critically the methodology used in the existing psy studies as well as the assumed universality of their diagnostic concepts. What questionnaires and surveys are being developed and delivered? How are they translated into different languages and is there consideration for possible socio-cultural differences included in these translations? Are there any culture-specific surveys and instruments at all?

The DECOLMAD project looks forward to collaborating with this new research at UCPH, as it is very well positioned to offer a vital historical perspective on cross-cultural debates regarding the psychological consequences of Covid-19. DECOLMAD explores the emergence and historical development of the discipline of transcultural psychiatry and examines the historical background of the global mental health movement. The current global discussion about mental health in the context of Covid-19 relies heavily on these earlier debates about the assumed universality of psychiatry, and it would benefit crucially from a critical historical perspective. The universalist concepts and research methodologies, whose intricate origins this project explores, are still often used without much reflection on their fraught historical background and potentially problematic assumptions about the nature of transcultural knowledge production. As Lancet warned, ‘It is a concern that “global mental health” contains assumptions about knowledge and expertise that are inimical to the very populations it purportedly sets out to help. Without sufficient forethought, global mental health may become a globalised iteration of psychiatry’s potential to reinforce existing power structures and hierarchies [7]. Moreover, we explore a particular psychiatric study – International Pilot Study of Schizophrenia, IPSS (1966-1972) – the first truly global psychiatric research programme, which faced a very similar set of methodological and conceptual dilemmas [8]. The current Covid-19 discussion resembles IPSS developments to a surprising extent. Most significantly, IPSS researchers thought very carefully about how to define the cultural differences in their standardized research instruments, and how to translate concepts and therapies in radically different social settings. Still, they subsequently faced criticism for focusing on a narrowly defined set of homogeneous symptoms, and for excluding those cases of schizophrenia or psychosis, which were most clearly shaped by local cultural patterns [9]. Moreover, IPSS discourses of cross-cultural research collaboration were critiqued for reinforcing the existing power hierarchies and preserving the ideas of ‘first world’ superiority [10]. Such historical comparisons, and an awareness of relevant past challenges and methodological shortcomings, can usefully inform the current discussion on Covid-19 and mental health. In the following years, DECOLMAD will, therefore, engage with these new debates, drawing important parallels and emphasising the historical precedents and intellectual complexities which can refine current assumptions about the relationship between culture and psychological illness.