【This article deals with mental health.Please pay attention to your own physical and mental condition as you read.】

With the spread of the novel coronavirus around the world, we have faced anxiety about an invisible disease we might catch at any time, lockdowns, economic contraction including bankruptcies and unemployment, and environmental changes such as no longer being able to easily see family and friends. These circumstances have drawn attention to mental health for their impact on people’s minds. However, issues related to mental health have, of course, always existed in every society. In fact, in2017, an estimated 790 million people, that is, about101worldwide were living with mental health problems. Even if the body is healthy, anyone can, for any number of reasons, find their mental health impaired. Here, we consider the reality and importance of mental health.

A stuffed animal looking outside (Photo: Snugg LePup / Flickr [CC BY-NC 2.0])

What is mental health?

What is mental health in the first place? The term originates from the English “Mental Health,” which has become established as a loanword in Japanese meaning “health of the mind.” Looking more closely, the World Health Organization (WHO) defines it as a state of health in which an individual realizes their abilities, can cope with the normal stresses of life, can work productively, and is able to contribute to their community. Such a state is considered “essential for overall health,” and “shaped by socioeconomic, biological, and environmental factors.” There are many reasons a person’s mental health can be impaired: psychological well-being can be affected by environmental factors around them,leading in some cases to disability as a result. In addition, where people are neurodivergent from birth, such as with developmental disorders (※1), a society that makes life hard for them can place further strain on their mental health. The forms of disability arising from surrounding environments are diverse; depression, bipolar disorder, schizophrenia and other psychotic disorders, and dementia (※2) are among the most common. Also, dependence on drugs or alcohol can arise from the same causes as mental health problems, and such dependence itself can be either a cause or a consequence of poor mental health.

How many people experience these kinds of mental health problems?2017data indicate that9.3%of men and11.3%of women worldwide had some form of mental health condition that year. However, this figure may be an underestimate. There are many casesthat go unreported because mental health lacks the attention and response it deserves, and many caseswhere the person or those around them do not recognize the illness depending on symptom severity. As a result, there is a current shortfall in the necessary care for people with mental health conditions. Such care can include counseling or therapy provided by counselors or primary care physicians, and pharmacological treatment by physicians. In some cases, treatments such as music therapy and animal-assisted therapy are also used. Which treatment approach to adopt should be decided based on scientific evidence and the patient’s own wishes. In addition, gaining understanding and support from family, friends, and the workplace also plays an important role in mental health care. Separately from these forms of care, when environmental factors are the root cause of poor mental health, the underlying problems must be addressed.

Therapy dog (Photo: Shawn / Flickr [CC BY-NC 2.0])

In particular, low-income countries have limited budgets for health in the first place, leaving very little for mental health. As a result, there are often not enough medical facilities, healthcare workers, counselors, and others to provide adequate care and support for mental health. When medical support for mental health is lacking, families of patients who are already stretched just to make a living have no capacity to provide care. Under such circumstances, there are cases where patients are confined at home or chained, leading to serious situations that may amount to human rights violations. Access to necessary care when mental health deteriorates thus varies by country and region depending on economic conditions and more.

Worldwide, knowledge about mental health remains insufficient, and prejudice against mental illness is widespread. Because people hide their mental health problems, not only do they suffer and feel isolated without receiving appropriate care, but the reality also fails to be reflected in the data.

As child survival improves globally and life expectancy rises overall, the budget necessary for mental health care is expected to increase further in the future,potentially costing the world $16 trillion by 2030.

Mental health is essential to human survival, and no one1is unaffected. In what follows, we focus especially on people who are more susceptible to impacts on mental health or for whom care is harder to reach, examining several perspectives. We look at mental health in relation to armed conflict, poverty, gender, and minority populations, in that order.

Armed conflict and mental health

Armed conflict involves violence and extreme fear and has a major impact on mental health. Conflicts cause immense damage to many people around the world, and10% of the world’s population live without guarantees of personal safety.

The threats posed by conflict are not limited to the body: in conflict areas,20%of people are said to have mental health conditions. Experiences such as being subjected to or witnessing violence, grief after losing loved ones, the stress of living surrounded by armed soldiers, and, particularly common among women, trauma from sexual violenceare identified as causes of mental health problems.

Refugees walking among collapsed buildings, Syria (Photo: Chaoyue PAN 超越潘 / Flickr [CC BY-NC-ND 2.0])

People also face many difficulties during displacement as they flee conflict to other areas. In2020, the number of refugees and internally displaced people forced to move due to armed conflict, violence, and human rights violations reached82.4 million. They are exposed to life-threatening situations not only during conflicts but also during movement—violence, dangerous journeys, detention, and more. Even after escaping conflict, refugees and displaced people face a host of stressors: living in unfamiliar places or crowded camps, lack of guaranteed access to food, water, and other essentials, and anxiety about the future. In fact, there are refugees forced into camp life for decades, as in Palestine and Afghanistan, while in places like Libya people continue to suffer inhumane treatment in detention. After migration, problems may persist, including inadequate access to social security, poverty, family separation, and poor labor conditions.

These stressors and traumas affect people’s mental health in many ways, potentially leading to mental disorders such as depression, post-traumatic stress disorder (PTSD) (※3), and sleep disorders, among others,which can develop.

In emergencies such as conflicts, with limited resources and funding for humanitarian aid, material safety is prioritized and opportunities to receive adequate mental health treatment are restricted. There is also the challenge that people who were already receiving treatment may be unable to continue accessing care when forced to leave their homes.

As ways to improve these situations, NGOs, support organizations, and international agencies are exploring mental health care for people affected by conflict and refugees/displaced people. Initiatives include training counselors and healthcare workers in skills to listen to the experiences of people affected by conflict, and implementing group work and counseling as education to improve mental health literacy within local communities, as part of broader efforts.

However, while measures often focus on trauma as the cause of poor mental health arising from conflict, without addressing the root problems that create that trauma, a true resolution of mental health issues will remain out of reach. In other words, we need to pay attention to political violence, social disadvantage, inequality, and discrimination, and incorporate improvements to living and working conditions into strategies to strengthen mental health care.

As we have seen, conflict is a major cause of poor mental health, yet in societies experiencing or affected by conflict, care tends to be deprioritized.

Internally displaced people cooking in the rain, Somalia (Photo: Frank Keillor / Flickr [CC BY-NC 2.0])

Poverty and mental health

Next, let us consider the relationship between poverty and mental health. Today, more than half of the world’s people live in poverty. According to 2014 data, the share of people living below the “ethical poverty line” (US$7.4 per day), which indicates whether the minimums for food, clothing, and shelter are guaranteed, was approximately57%of the world’s population.

People living in poverty experience many hardships and life-threatening risks due to lack of money. In addition to stressors such as daily uncertainty about wages and securing food, and being unable to provide children with sufficient education, they often face anxieties about future work and health and feelings of social exclusion.

When such conditions continue, there is a higher tendency for mental health problems such as mood disorders and personality disorders (※4) to develop, and in some cases these lead to suicide and drug or alcohol abuse. The impact of poverty on children is also significant: children from low-income families are3times more likely to experience mental health problems compared to those from high-income families, according to data.

In short, poverty and mental health are strongly correlated. Continued poverty harms mental health, and unless financial worries are alleviated, it is difficult to break out of this cycle. Moreover, when one’s physical and mental health are not intact, motivation to live independently is sapped, making escape from poverty even harder.

To break the negative cycle between poverty and mental health, eradicating poverty would be a key starting point. However, in a world where poverty is widespread, that itself is difficult. The structures that produce poverty are immense and can no longer be solved by individual effort alone. While changing the environment of poverty is difficult, it is necessary to expand programs that provide mental health care to low-income populations. There are also programs that combine mental health improvements with financial assistance.

Low-income countries also face far more challenges than high-income countries. Because the majority of the population in low-income countries lives in poverty, barriers to providing mental health care will remain unless poverty reduction is achieved at the societal level. For example, in regions lacking sufficient general hospitals and healthcare workers, facilities and personnel dedicated to mental health care are even scarcer.

Impoverished area in South Africa (Photo: Niko Knigge / Flickr [CC BY 2.0])

While various measures are being considered for mental health issues seen in poverty, it is not necessarily the case that governments are proactive in investing in mental health and poverty alleviation programs. Low-income country governments may simply lack funds, and even in high-income countries, investment in mental health care—whose effects are less immediately visible—tends to be deprioritized. As a result, the relationship between poverty and mental health is often insufficiently reflected in policy.

Gender and mental health

Viewed through a gender lens, it is known that the presentation of mental health problems differs by sex. By condition, the incidence of unipolar depression (※5) is three times higher in women than in men; substance and alcohol dependence is twice as high in men as in women; and antisocial personality disorder (※6) is three times more common in men than in women. Meanwhile, there is said to be no gender difference in the incidence of schizophrenia or bipolar disorder.

Focusing on stressors that affect mental health and their causes, women are generally considered to face more social stressors than men. These include violence, socioeconomic disadvantage, low-wage labor, lower and subordinate social status, and the expectation that caring for others—such as family members—is “women’s work.” Due to these factors, women tend to experience higher rates of symptoms such as depression and anxiety than men. There is also the reality that when housework is included, women “work” longer hours than men, suggesting a heavier mental burden on women.

Stress related to reproductive health (sexual and reproductive health)—including pregnancy and childbirth—is also unique to women. Major physical changes due to hormonal shifts, childbirth, anxiety about subsequent child-rearing, and impacts on work can all be sources of stress. In fact,20%of women experience anxiety or mood disturbances during pregnancy.

Although the social stressors women experience are diverse, we should also note that their extent varies by country, region, and society. For example, customs that restrict women’s behavior as in countries like Saudi Arabia where there have been large gender gaps in school enrollment, or in regions like Latin America where abortion is prohibited, can change women’s mental health status depending on local differences.

Sexual minorities (※7) are also affected by various stressors that impact mental health. Because people in sexual minority groups may feel daily that their sexual orientation or gender identity (※8) differs from those around them, that difference itself can be a source of stress. In addition, they are exposed to a range of prejudice and discrimination—from microaggressions to hate crimes (※9)—and sometimes to psychological and physical violence. These factors can lead to depression, anxiety, and substance dependence. Furthermore, people who are gay or lesbian are reported to be more than three timesas likely as heterosexual people to attempt suicide.

Empowerment message for sexual minorities, Germany (Photo: 7C0 / Flickr [CC BY 2.0])

Rights for sexual minorities differ by country and region. For example, some countries and regions recognize same-sex marriage, while in others, such as Uganda, it is treated as a crime, and in countries such as Sudan and Iran, homosexuality can be punishable by death.

Gender-responsive mental health care is still far from sufficient. For women, where programs do exist, many existing health programs focus on “pregnant women and mothers” rather than “women” per se as individuals. Discussions about women’s health are often limited to contexts such as child health, reproductive health, and family planning, and the actual needs of women are not fully reflected. One reason is the insufficient representation of women in decision-making1. In light of this, in recent years there has been a growing call to redefine “women’s health” and to integrate a gender perspective into mental health policy as a necessity. Incorporating the perspectives of sexual minorities is likewise necessary. Policies such as hate crime laws, anti-discrimination measures, and bans or legalization of same-sex marriage may influence the mental health of sexual minorities, suggesting the need to review legal systems and the broader social structure.

Minority populations and mental health

Across the world there are people who live as “racial”/ethnic minorities within their societies, and people who leave their homelands to live in foreign countries. Because these people are minorities within their communities, they are often marginalized and subjected to discrimination. Let us look at how the situations surrounding minorities affect mental health.

First, let us focus on “racial”/ethnic minorities. “Racial”/ethnic minorities refers to people classified as minorities in a given society due to differences in identity or lifestyle such as race, skin color, language, religion, culture, and food. These groups are often exposed to social stressors such as discrimination and socioeconomic inequality to a greater degree. Discrimination they face includes microaggressions, verbal abuse, and physical violence; socioeconomic inequalities include poverty and homelessness, poor education and employment environments, and weak connections to welfare services. Exposure to these circumstances can lead to depression and other mental disorders. For example, in the United States, people who identify as “African American” have higher rates of schizophrenia and depression than those who identify as “white.”

There are also various problems when seeking care. Barriers include differences in understanding of mental health problems, lack of awareness of available support, language barriers, financial barriers, and low trust in services. In the United States, which of these factors present the greatest barriers varies by racial/ethnic group to some extent, but financial barriers are a primary factor across groups. Blocked by these barriers, minorities are more likely than majorities to be unable to access care, or, if they do, to receive only lower-quality care on average.

Skills training for migrants, Indonesia (Photo: ILO Asia-Pacific / Flickr [CC BY-NC-ND 2.0])

Next, consider the situation of migrants, whose numbers are increasing year by year. The number of international migrants has increased over the past50years, reaching about2020280 million as of. However, as a share of the total, they account for only3.6%of the world’s population, and, with the exception of the Persian Gulf states, migrants are minorities within individual countries.

Migrants experience different stressors at every stage—from before migration to after arrival. Before migration, there may be stress from harsh living conditions such as poverty and unemployment. Even if one moves abroad seeking a better life, after migration there is a risk of falling into poverty due to factors such as higher hurdles to obtaining stable employment—because conditions are worse compared to citizens of the receiving country—and insufficient welfare for migrants. During settlement, people must continue to face cultural and language differences, discrimination, friction with the host society, and anxiety about the future while living far from loved ones and their homelands. It is also known that children left behind by parents who migrate abroad for work are more prone to mental health problems.

All of these are risk factors that affect mental health and can lead to depression, anxiety, andPTSD, among others,with potential to develop. Measures include strengthening employment and welfare services, language support, and family reunification. It is also important to build systems that invite clinicians and counselors to listen to patients’ migration experiences, thereby laying the groundwork for recognizing barriers to prevention and treatment.

Paying attention to mental health

Just as physical health changes, mental health is continually affected by changing environments. Yet across all of the groups above, prejudice, lack of care, and resultant data shortfalls around mental health stand out.

Mental health may appear to be an individual issue, but it is deeply intertwined with society at large. Therefore, in addition to care at the individual and household levels, we need community-level efforts to include individuals’ voices and medical and welfare institutions to deliver services. Furthermore, policies at national and local government levels, and responses at every level including international organizations, are required. For example,WHO, over the five years from2019to2023, set a goal to provide quality, accessible mental health care to 100 million people in12priority countries, and is promoting collaboration across public and private sectors.

Protest calling attention to the importance of mental health, Ireland (Photo: Sinn Féin / Flickr [CC BY 2.0])

During the recent COVID-19 pandemic, new problems have arisen in addition to infection-related stress; economic disparities within and between countries have widened, and there are significant differences in budgets allocated to mental health. Infection control has also created situations in which in-person care cannot be fully provided, increasing the need for services that are more accessible to those who need care than ever before.

Thinking about mental health can deepen understanding of those who need care and may also be of great help if you notice changes in your own mental state.1It is a topic that each of us should approach with a sense of personal stake.

※1　Developmental disorders are conditions in which differences in cognition and behavior arise during childhood due to characteristics of brain function.

※2　Depression is a type of mood disorder. In addition to psychological symptoms such as low mood, physical symptoms such as insomnia, loss of appetite, and fatigue appear, causing major impairment in daily life.
　　Bipolar disorder is a type of mood disorder (depression). It is a condition in which elevated and depressed moods alternate, with repeated manic and depressive episodes.
　　Schizophrenia is a condition in which various brain functions fail to coordinate, leading to symptoms such as hallucinations and delusions.
　　Dementia is a condition in which cognitive function declines due to brain disorders and other causes, impairing daily life.

※3　Post-traumatic stress disorder (PTSD) is a condition in which, after experiencing an overwhelming event that becomes traumatic, one involuntarily relives the experience like a flashback and feels heightened anxiety and tension.

※4　Mood disorders is a general term for illnesses in which mood causes impairment in daily life. In this article, depression, bipolar disorder, and unipolar depression are included.
　　Personality disorders are conditions in which reactions and behaviors that differ from the majority cause distress to the person or difficulties for those around them. Also called “personality disorders,” of which antisocial personality disorder is one subtype.

※5　Unipolar depression is a type of mood disorder (depression). It is a condition in which an extremely low mood or apathy persists. There is no manic state; only depressive states are observed.

※6　Antisocial personality disorder is a type of personality disorder. It is characterized by breaking social norms, deceiving others, or violating others’ rights without guilt.

※7　Sexual minorities refers to people whose sexual orientation or gender identity differs from the sexual majority and includes people such as those in theLGBTIQ community. Respectively: lesbian (women who feel romantic and/or sexual attraction to women), gay (people who are homosexual; particularly men who feel romantic and/or sexual attraction to men), bisexual (people who feel romantic and/or sexual attraction to people of the opposite sex, the same sex, or other genders), transgender (among sexual minorities, people whose gender identity and body do not align), intersex (people whose physical sex does not align with the generally defined categories of male/female, or is between them), and queer (a collective term for sexual minorities including homosexual people).

※8　Gender identity refers to how one recognizes one’s own gender. It is also called one’s “internal” gender.

※9　Microaggressions are acts that, while not overt discrimination, unintentionally hurt others through statements or behaviors based on stereotypes and prejudice. A hate crime is a criminal act motivated by hatred or prejudice against individuals or groups with specific attributes such as race, skin color, sexual orientation, gender, or religion.

Writer: Madoka Konishi

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