Growing up as a black African, mental health is something that was largely misunderstood in my community. This was a result of misinformation, or lack of mental health information- due to the shortage of mental health research. As such, I have witnessed many people struggle with mental health problems and not receive the care that they need.
I have been struggling with an eating disorder for the past few years. I am afraid to eat and afraid I will gain weight. The fear is unjustified as I was never overweight. I have weighed the same since I was 12 years old, and I am currently nearing my 25th birthday. Yet, when I see my reflection, I see somebody who is much larger than reality.
I told my therapist that I thought I was fat. She said it was 'body dysmorphia'.
She explained this as a mental health condition where a person is apprehensive about their appearance and suggested I visit a nutritionist. She also told me that this condition was associated with other anxiety disorders and eating disorders. I did not understand what she was saying as I was in denial; I had a problem, to begin with. I wanted a solution without having to address my issues.
Upon visiting my nutritionist, he conducted an in-body scan and told me my body weight was dangerously low.
I disagreed with him.
I felt he was speaking about a different person than the person I saw in the mirror. I felt like the elephant in the room- both literally and figuratively. He then made the simple but revolutionary suggestion to keep a food diary to track what I was eating.
This was a clever way for my nutritionist and me to be on the same page. By recording all my meals, drinks, and snacks, I was able to see what I was eating versus what I was supposed to be eating. Keeping a meal diary was a powerful and non-invasive way for my nutritionist to walk in my shoes for a specific time and understand my eating (and thinking) habits.
No other methodology would have allowed my nutritionist to capture so much contextual and behavioural information on my eating patterns other than a daily detailed food diary.
However, by using a paper and pen, I often forgot (or intentionally did not enter my food entries) as I felt guilty reading what I had eaten or that I had eaten at all.
I also did not have the visual flexibility to express myself through using photos, videos, voice recordings, and screen recordings. The usage of multiple media sources would have allowed my nutritionist to observe my behaviour in real-time and gain a holistic view of my physical and emotional needs.
I confessed to my therapist my deliberate dishonesty in completing the physical food diary and why I had been reluctant to participate in the exercise. My therapist then suggested to my nutritionist and me to transition to a mobile diary study.
Whilst I used a physical diary (paper and pen), a mobile diary study app would have helped my nutritionist and me reach a common ground (and to be on the same page) sooner rather than later.
As a millennial, I wanted to feel like journaling was as easy as Tweeting or posting a picture on Instagram. But at the same time, I wanted to know that the information I provided in a digital diary would be as safe and private as it would have been as my handwritten diary locked in my bedroom cabinet.
Further, a digital food diary study platform with push notifications would have served as a constant reminder to log in my food entries as I constantly check my phone. It would have also made the task of writing a food diary less momentous by transforming my journaling into micro-journaling by allowing me to enter one bite at a time rather than the whole day's worth of meals at once.
Mainly, the digital food diary could help collect the evidence that I was not the elephant in the room, but rather that the elephant in the room was my denied eating disorder.
The elephant in the room
Mental health, as defined by the World Health Organisation (WHO), is a state of mental well-being where people cope well with the many stresses of life, can realize their own potential, can function productively and fruitfully, and are able to contribute to their communities.
This means it is more than just the absence of a mental illness. It relates to the core of what makes us human: the way we interact, connect, learn, work and experience suffering and happiness. Good mental health enables us to perform in key roles within our families, communities, and effectively contribute to the economy.
Over the years there has been an increasing interest and acknowledgement of the importance of mental health in the development agenda. This acknowledgement came with the realisation that mental health is a serious development issue that should be given the same recognition as other health issues.
Good mental health is slowly being acknowledged as a crucial component to drive sustainable development and economic growth.
Mental and neurological disorders are said to be responsible for 13% of the global burden of disease¹, with depression being the leading cause of disability. Moreover, it is reported that suicide is the second leading cause of death among people between the ages of 15 to 29 years. Despite this, mental health remains an under-researched area in public health particularly in the low-and-middle income countries.
The pandemic exposed the many inequalities that exist in society. In many cases, it exacerbated the living conditions of those who were already struggling in the pre-covid world. It brought various negative impacts on mental health and created new barriers for those who had pre-existing mental health conditions.
The covid-19 pandemic has increased the risk factors that are generally associated with poor mental health. These include financial insecurity, unemployment, heightened fear and anxiety, and bereavement amongst many. More so removing the existing protective factors of social connection, introducing a routine change, and a change to life as we know it. This has led to a significant and unprecedented worsening of population mental health². For many countries, especially low-income countries, the pandemic worsened and even halted mental health care services as the focus became covid-19.
Prior to the pandemic, mental healthcare services were already over-stretched especially in low-income countries, where they were spending less than 2 percent of the national health budget on mental health.
The pandemic is placing an increasing demand for adequate mental health services to be available for all to help people deal and process with what is happening in the world around us.
Research has shown that the pandemic has led to a drastic increase in substance and drug abuse as a way of coping during this period. This also came with a drastic increase in anxiety and depression from March 2020 onwards³.
Research is an important part of our world. Through research we can make sense of the world around us. Research also affords the opportunity to dissect the challenges that we are faced with, helping us frame solutions.
The same applies with mental health research. Over the years, mental health research has aided in conceptualising mental health. Research on mental health has been found to be disproportionate to the burden of mental disorders. This is even worse for research relating to the prevention of mental illness⁴.
Here are four reasons why mental health research matters:
Research helps keep track of how far we have come while also mapping out what still needs to be done. Through mental health research we can see the progression of mental health treatment over time. We are able to build on what was previously successful.This helps us find new and better treatments for a wider range of mental health problems.
Mental health research identifies the various determinants of mental health (social, biological, economic factors) and how these determinants each link to one another. Understanding these linkages helps policy makers understand the synergies and develop effective policies. Not only is this helpful in policy development, but it also creates more awareness and education about mental health, making it easier to talk about it. This helps break the stigma about mental disorders - allowing people suffering from mental disorders to speak out and seek help.
There is not enough research around mental health issues, especially in low and middle-income countries. Yet, these are the countries that tend to be affected the most due to various socioeconomic variables.
Such research will give contextual understanding of the societal needs to inform decision making of policy and program planners. The mental health needs of populations differ based on various factors. These could be based on political climate, health factors, economic status, and so on. Therefore, we cannot implement an umbrella approach when addressing mental health. Research helps us know the needs of the area being studied to craft viable interventions that will be best suitable for that population.
Research in mental health can be used as a tool to evaluate the effectiveness of policies, strategies and programmes targeted at mental health. This helps us identify the benefits of such policies and programmes, and areas of improvement to ensure optimum effectiveness.
These are but a few reasons why mental health research matters. Nonetheless, mental health research is underfunded and under-prioritised by governments. Unfortunately, we are missing opportunities to achieve breakthroughs seen in other areas of healthcare such as cancer, malaria, and HIV/AIDS, that could transform people’s lives and enhance wellbeing.
Mental health prioritisation is something that needs to start from policy level. Here are some policy recommendations:
It is important for government and governing bodies to prioritise mental health as a crucial component of health.
This prioritisation starts with adequate investment in mental health and healthcare. In low- and middle- income countries between 76% and 85% of people with mental health conditions receive no treatment for their condition, despite the evidence that effective interventions can be delivered in any resource context.
Many of the low-and-middle income countries are struggling to meet the mental health needs of their population due to lack of resources. Investing in mental health and healthcare includes adequate budget allocation for mental healthcare needs such as human resources, and treatment tools and equipment.
When HIV/AIDS first hit the world, it seemed as though it was ushering the end of humanity. It has taken close to four decades of conjoined global efforts to fight HIV/AIDS. After years of research there have been different models of managing the virus across the globe to successfully reduce the mortality rate.
Before, having HIV/AIDS was seen as a death sentence, but now people can healthily live with HIV/AIDS due to the development of various treatments. This is because of the investment in research towards HIV/AIDS. The same can apply to mental health. With increased funding for research towards mental health research, people living with mental illnesses would be able to get help.
The mental health needs of people vary depending on several factors. This means that the mental health needs of people in Eswatini differ from those of people in Norway, for example.
Similarly, mental health needs of someone in a rural area may differ to those of a person in an urban area. Therefore, it is important for each country to develop mental health research priority areas specific to the population needs. Having research priority areas will help to ensure that the allocated funds are used for what matters, meeting the urgent and direct needs of the population. It will also prevent the misuse of research funds.
An individual’s mental health is influenced by several cross-cutting issues such as poverty, gender, socioeconomic status, research capacity and government policies, and many more.
Gender and socioeconomic status also influence the access of individuals to health care and the quality of the treatment received. Unemployment for example, has been identified as a determinant of mental ill-health especially amongst the youth. These cross-cutting issues can be best addressed by mainstreaming them as key variables in all strategies. Socioeconomic and gender sensitivity can only be achieved with a coherent set of policies to build capacity among researchers and involve civil society organizations in the determination of research priorities and in the design and conduct of individual studies.
Coming from a low-income country, I have seen the disparities that exist when it comes to accessing mental health care. I have also seen many people suffer due to lack of knowledge on mental health problems.
I believe that there is a huge opportunity for mental health to benefit from the research community. This could lead to many lives being saved and the quality of life for others being improved as more knowledge about mental health problems, treatment, and preventative measures is acquired.
Mental health is everybody’s business - an issue of shared responsibility.
As we live in an ever-changing society, the need to prioritise mental health research is more evident. However, this prioritisation ought to begin at policy level so that there is a trickle down effect.
The recommendations above are some of the ways that policy makers can consider in making mental health research matter. In the words of Kurt Lewin, there’s no research without action, and no action without research.
West African Lead, ALMA Youth Advisory Council/Zero Malaria Champion
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Dear Digital Diary,
I realized that there is an unquestionable comfort in being misunderstood. For to be understood, one must peel off all the emotional layers and be exposed.
This requires both vulnerability and strength. I guess by using a physical diary (a paper and a pen), I never felt like what I was saying was analyzed or judged. But I also never thought I was understood.
Paper does not talk back.Using a daily digital diary has required emotional strength. It has required the need to trust and the need to provide information to be helped and understood.
Using a daily diary has needed less time and effort than a physical diary as I am prompted to interact through mobile notifications. I also no longer relay information from memory, but rather the medical or personal insights I enter are real-time behaviours and experiences.
The interaction is more organic. I also must confess this technology has allowed me to see patterns in my behaviour that I would have otherwise never noticed. I trust that the data I enter is safe as it is password protected. I also trust that I am safe because my doctor and nutritionist can view my records in real-time.
Also, with the data entered being more objective and diverse through pictures and voice recordings, my treatment plan has been better suited to my needs.
No more elephants in this room