Mental health, and the human rights and lived experiences of people living with the stigma of mental ill health, are an increasingly important priority in global health.
Liverpool School of Tropical Medicine has strong recent history in this area, with a speciality in co-producing research directly with people who have experienced mental ill-health. The REDRESS programme, which focused on addressing stigma for people with skin NTDs in Liberia, was awarded International Collaboration of the Year at the latest THE Awards.
A decision was made by LSTM to make strategic investment in this area of work, and late last year, appointed its first Professor of Global Mental Health, Julian Eaton, an experienced public health psychiatrist and leader in international development.
Professor Eaton has joined LSTM to link across the multiple research projects with a mental health focus, and ultimately to expand them, aligning mental health to the disease areas where LSTM is traditionally strong and establishing global mental health research in its own right.
And he is clear – whether it’s the co-morbidities of mental ill-health and maternal and child health, for the victims of tropical snakebite living with life-long physical disabilities or the social stigma often experienced by people with TB, or any of the severe mental health conditions experienced by people across the globe – global mental health is a vital area of study which has grown in prominence in recent decades.
He said: “People have been engaged in transcultural psychiatry for a very long time, but previously there was no sense of what we meant by a cohesive field, so we needed to define our primary aims and research questions that are common across people studying this area in different countries.
“It was in the early 2000s in a series of papers in The Lancet that some really foundational things took place, just asking the questions like, how common are these problems in different countries? How similar are these conditions in different countries? What proportion of people are accessing services?
“Those kinds of questions have now been brought together in a much clearer framework…and there are stronger research centres growing in different places.”
Professor Eaton is a psychiatric doctor by background, who has come to research relatively late in his career. For 15 years, he lived in Nigeria and Togo and worked as Mental Health Director for the NGO CBM Global. Here he promoted greater access to health care services, social inclusion, and realisation of rights for people with mental illnesses and psychosocial disabilities, focused mainly on poor and marginalised communities.
“This was about how to make sure mental health is available in primary care, which is almost non-existent in many countries. It tends to be only available in big psychiatric hospitals in capital cities, which just means you end up with five or 10% of coverage. That means that 95% of people are missing out on services that they need, evidence-based interventions that just are not available.
“Service access has been a big part of my research to date and I'm looking forward to working with health systems researchers in Liverpool to integrate mental health into that.”
In recent years based at the London School of Hygiene and Tropical Medicine, Professor Eaton has published on issues relating to public mental health in low- and middle-income countries, and led a body of research on integrating mental health and wellbeing considerations into care for people with Neglected Tropical Diseases, resulting in key WHO guidance. This work brought him together regularly with researchers at LSTM, and led to his collaboration with Dr Laura Dean and her team.
“One area that's really strong at LSTM is the ethos of working with people affected as a central principle and research methodology.
“This was an important journey for me, going from a fairly standard medical approach to psychiatry to thinking much more about people-centred approaches that go well beyond what healthcare can provide. Thinking about people’s place in society, and their status and experience of stigma. Those approaches are definitely going to be something that will feature in the way we do things.”
To Professor Eaton, this notion of co-production is critical to research in mental health. “The foundational principle of this is “nothing about us without us”. So how can someone who has no concept of the experience of the person with the condition they're studying possibly be asking the right questions, thoughtful to the nuances of what kind of research they should be doing.
“That's true for all kinds of different conditions and disabilities, but mental health accentuates that by a thousand, because it is probably, of all disabilities, the most stigmatised and excluded group. For example, there is no other group in British society apart from prisoners who are allowed to be locked up.
“And that's reflected in the language we use about people with mental health conditions, which is extremely derogatory in many places. This is a group of people with incredibly low status, and therefore no-one's ever asked them before what they think about how research should be done, or what the important priorities are for research, or how it feels to take an anti-psychotic - it's horrible, by the way.
“People with mental health conditions might also not be used to standing up and talking confidently to doctors and saying, actually, I disagree with you. We have to work really hard to make sure they’re meaningfully participating in our efforts."
Professor Eaton will be continuing his own research focusing on access to services for people in LMICs with severe mental illness, especially psychosis, both in health and making sure that community resources can support them and their families to enable access to employment and education. Following practical experience in responding to outbreaks including Ebola, Zika virus and COVID-19, he will also continue to lead the Mental Health and Psychosocial Support team at the UK Public Health Rapid Support Team at LSHTM.
This new role is also something of a homecoming for him, having undertaken part of his medical training at the old Fazackerley Hospital in Liverpool. And in recent years, he’s seen the quality work at LSTM close-up.
He said: “I have worked collaboratively with a number of people at LSTM and really enjoyed that. Partly that’s about the research excellence that I saw, but also the way that research was done, particularly with the attention to people who lived experience being an important part of that."