UC Berkeley

Mental health is an integral part of health and well-being. Mental health enables people to realize their potential, cope with the stressors of everyday life, and make contributions to society. Mental, neurological and substance use (MNS) disorders constitute 13% of the global burden of disease. And yet, across all countries, public investment in preventing and treating this cluster of disorders is disproportionately low relative to this disease burden. Health systems have not adequately or sufficiently responded to the burden of MNS disorders: the gap between the need and supply of treatment ranges from 76% to 85% in low- and middle-income countries, and from 35% to 50% in high-income countries. Mounting evidence underlines the inequitable distribution, poor quality, and inefficient use of scarce resources to address mental health needs. Globally, annual spending on mental health is less than US $2 per person in high-income countries and less than US $0.25 per person in low-income countries, with 67% of these financial resources allocated to stand-alone mental hospitals. Flagrant abuse of human rights and discrimination against people with mental disorders and psychosocial disabilities have been found in such psychiatric institutions. The redirecting of mental health budgets toward community-based services, including the integration of mental health into general health care settings, is needed. To address this state of affairs, this dissertation takes a fresh look at the actions taken to formulate a comprehensive, coordinated response from health and social sectors. It is founded at the nexus of new institutional, world culture, and diffusion of innovation theories.

This dissertation employs a mixed methods approach, combining statistical and survey analyses. A mental health policy is an official statement of a government that defines its vision, values, principles, and objectives to improve the mental health of a population. It also outlines the areas of actions, strategies, timeframes, budgets, targets and indicators used to realize the vision and achieve the objectives of the policy. In the first study, I examine the coercive and emulative isomorphic effects on the diffusion of mental health policy across geopolitical borders. Using discrete-time data for 193 countries covering the period from 1950 to 2011, I conduct an event history analysis to examine the influence of WHO accession, foreign aid, and peer influence on mental health policy adoption. The results confirm that the act of adopting mental health policy is partly owed to membership in the World Health Organization, as well as influence of neighbors in the same World Bank and World Health Organization regions.

National mental health policy adoption is trumpeted as a milestone for mental health reform. Is mental health policy limited to a rhetorical plane or taken up for pragmatic reasons? The effectiveness of this "upstream" factor could be realized based on examining "downstream" models of deinstitutionalized programming. While mental health policy adoption is treated as an outcome of interest in the first study, it is treated as a predictor in the second study. More specifically, I test the phase of policy adoption as a determinant of psychiatric bed rate changes using panel data for the same 193 countries between 2001 and 2011. The analysis finds that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals.

Deinstitutionalization is a much more complex and sophisticated process than reducing dehospitalization, or the reduction of psychiatric beds. It is also about improving the quality of care provided by inpatient facilities while increasing access to care through the development of mental health services in other medical and community settings. However, progress towards mental health reform is often stalled because it is an essentially contested issue in professional and advocacy circles and a highly politicized one among governments. For these reasons, the third study gathers contemporary perspectives on deinstitutionalization from 78 mental health experts. The survey administered assesses their knowledge, attitude, and practices of expanding community-based mental health services and/or downsizing institution-based care. The respondents also attested to the enabling, reinforcing, and constraining factors prevalent in the 42 countries they collectively represent. The qualitative evidence is complementary to the quantitative evidence in that it portrays the contemporary mental health system as being controlled by a nucleus of inpatient care. It further suggests that innovations are made in linking specialty services with primary and social services to support people with mental, neurological, and substance use disorders and their families as they (re)integrate into their communities.

Mental health care has branched out in new directions at the turn of the 21st century. Time and again when governments are in the throes of strengthening their mental health systems, a closer look into the setup of infrastructure, essential medicines, human resources, and civil society involvement becomes necessary. This dissertation demonstrates that deinstitutionalization is a result of mental health policies imposed from the top down by the government. The experience with deinstitutionalizing mental health care also involves grassroots mobilization of social change by citizens, clients, families, and other advocates. In parallel with service reorganization, advances have been made in training lay personnel to offer services to people with MNS disorders. Research and development have made treatment more cost-effective and accessible. Cutting across temporal and geographic borders, tradition and modernity, this dissertation probes into the permeability of mental health policy and unpacks the complexity of deinstitutionalization.