Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
A Theoretical, Historical, and Socio-Economic
Case for Saving Lives through Strategic
Improvement of Mental Health Systems around
the World
David P. Cecil1, Kasparas Žiaučyna2
1Samford University, Birmingham, Alabama, USA
2Children and Adult Family Welfare Center, Klaipeda, Lithuania
Address for correspondence:
David P. Cecil, PhD, LICSW, Samford University, Birmingham, Alabama, USA.
Email:
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Cecil, 2023
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v6i1.145
Submitted for publication: 18
August 2022
Revised: 04 November 2022
Accepted for publication:
29 December 2022
2
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Introduction
The World Health Organization’s (WHO, 2020)
best practice approach, adopted by most
European countries, includes robust inpatient,
intensive outpatient, and outpatient services that
address all levels of need. Though it may seem
obvious, it must be stated that these
recommendations necessitate adequate
resourcing that create a sustainable relationship
with quality communications between patients
(clients) and mental health practitioners. How
societies and governments view this resourcing,
as investment or as poorly utilized limited funding,
largely dictates mental health outcomes. This
paper argues for a substantiated positive
investments attitude that leads to a win-win for
those suffering from mental problems and the
broader societies in which they live.
Mental illnesses, including psychological and
emotional struggles, occur across a wide and
complex spectrum, and for a treatment system to
be effective it has to precisely reflect that
complexity. Especially with advances in neuro-
science (Shapiro, 2012; van der Kolk, 2014) we
have increasingly effective treatments for every
area of defined mental health condition. In the
Mental Health Action Plan 2013-2020 (which has
been extended to 2030), the World Health
Organization (WHO, 2013) states,
“Health systems have not yet adequately
responded to the burden of mental disorders; as a
consequence, the gap between the need for
treatment and its provision is large all over the
world. Between 76% and 85% of people with
severe mental disorders receive no treatment for
their disorder in low-income and middle-income
countries; the corresponding range for high-
income countries is also high: between 35% and
50%. A further compounding problem is the poor
quality of care for those receiving treatment.”
An optimized mental health system requires
particular characteristics for both practitioners and
clients. First, in terms of capacity, practitioners
need access to affordable and high-quality
education and training followed by clear career
options with user-friendly and adequately
remunerating pay. The World Health Organization
(2020) emphasizes prioritizing mental well-being,
eradicating stigma, discrimination, and social
exclusion, providing effective and comprehensive
care with choice for those in need. The obvious
impediment is funding, which includes both
societal and governmental willingness and
financial capacity. In any case, nothing changes
until such funding is committed.
Purpose
This paper examines mental health systems in
three countries, which vary across a spectrum of
mental health systems and outcomes, in order to
provide historical, theoretical, and socio-economic
analyses for problems and the critical need for
change. Important contrasts can be drawn
between the largely private and profit-oriented
United States, more robust and universal systems
of Western Europe (e.g., Germany), and countries
with limited resources and still in early
developmental phases, such as in Eastern Europe
(e.g., Lithuania). Population and GDP per capita
estimates provide context for the size and relative
prosperity of people in each country (The
Organization for Economic Cooperation and
Development [2022]). The World Health
Organization’s (WHO, 2020) Mental Health Action
Plan 2013-2020 (extended to 2030) recommends
a guiding framework for best practices. The
systems, historical and theoretical analyses work
together to make a case for vital, complete, and
sustainable change, especially emphasizing
theories of functionalism, social-dynamics, and
the socio-economic asset development
perspective (Dolgoff & Feldstein, 2007).
Methodology
This critical analysis includes historical
research, systems examination, and theory-based
analysis. Critical analysis was selected because
of how it guides a logical deconstruction that
makes way for criticisms and recommendations
for progress in mental health care (Browne &
Keeley, 2012). For this study, 86 scholarly
sources were examined and 54 were included in
the article. There were 19 for Germany, 21 for
Lithuania, and 27 for the United States. The
remaining sources for this article provided
comparisons and important context, such as
World Health Organization (2020) accounts of
best practice recommendations. Key search terms
include each country’s name with mental health,
mental health treatment, national mental health
evaluation, mental health problems, mental health
administration, mental health system history,
mental health practice approaches, and
international mental health recommendations.
The authors also scanned the literature for
comparisons of any of these countries’ mental
health systems to others. The order of
examination for each country was current mental
health conditions (e.g., suicide rates), type of
system and administration (health care and
mental health care), investment in context of
overall economy, specifics of types and depth of
mental health treatment, and outcomes evaluation
This critical analysis deconstructs systems,
especially focusing on historical context and
specific systems evolutions. Theory is used to
evaluate the relevance of these historical and
systems development findings and provides
frameworks through which to guide important
questions for continued advocacy and research.
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Results
Multinational Comparison
Table 1: Comparison of Countries’ Mental Health Systems (History, Systems Investment, General
Treatment Approaches)
Country
Population
(GDP per
Capita)
Historical
Development
Systems
Investment
General Treatment
Approaches
Germany
83.1 million
(58,386
USD)
Public funded
through the two
major churches;
cost-regulated
private insurance
market
4% GDP
(cost saving
measures)
• Medication
• Inpatient psychiatric
• Comprehensive
psychotherapy
Lithuania
2.8 million
(42,551
USD))
Public funded,
government
administered
.125% GDP
• Emphasize medication
• Limited Psychotherapy
United
States
331.9 million
(69,558
USD)
Private for-
profit with
selective
government non-
profit (disabled,
elderly, veterans)
3.5% GDP
(no cost saving
measures in
private market)
• Emphasize medication
• Inpatient psychiatric
• Comprehensive
psychotherapy
Note.
• Population and GDP per Capita (The Organization for Economic Cooperation and Development
[OECD] [2022])
• Citations for all other information are in the text of the article.
• Systems Investment Column
o Estimates do not reflect indirect costs of untreated mental health problems.
o Estimates do not reflect cost saving measures which, for example, do exist for Germany but do
not for the United States (i.e., Germany getting more for their investment).
Germany
WHO (2011b) reports that Germany
(population 83.1 million; GDP per Capita 58,386
USD [OECD, 2022]) has a quite robust mental
health care delivery system, considering it a top
public health priority, including authorizations at
the level of primary care. Perhaps their largest
impediment to mental health care is stigma, which
reduces mental health help-seeking (Kessler,
Agines, & Bowen, 2014).
History of Mental Health System- Germany
The timing of medical advancement and post-
World War II reconstruction led to many western
European countries reforming their health care
systems. It took a couple of decades post-World
War II for this change to occur; during the 1950s
and 1960s there was widespread shame and
neglect and thus care was “restricted to large, old-
fashioned institutions in remote areas” (Salize,
Rossler, & Becker, 2007). Germany experienced
a deinstitutionalization of chronic and severely
mentally ill people in the 1970s, leading to an
increased need for community mental health.
Later, the reorganization of East and West
Germany “required dramatic changes in the
structure and quality of the mental health system
of the former German Democratic Republic
(GDR)” (Salize, Rossler, & Becker, 2007). A big
and expensive effort, but federal law from the
1970s set very high standards for access to high
quality and affordable services. Also, in the 1970s
Germany’s system of subsidiarity was born
(Göçmen, 2013). Subsidiarity stipulates decisions
about services should be made as close to those
in need as possible, so the German government
sends funding through the two major churches
(Diakonisches Werk der Evangelischen Kirche in
Deutschland [Diakonie] and Deutscher Caritas
Verband [Caritas]) in Germany to provide all
health and human services.
Systems Investment- Germany
Germany is among the nations with highest
GDP dedicated to health care (11.43%) (WHO,
2021) and mental health (~4%) and has been
growing consistently in recent years (Schwarz, et
al., 2020). The German system has Statutory
Health Insurance (SHI) known in German as
Krankenkasse. The government requires that all
German citizens (and actually many non-German
citizens) have market access to any insurance
provider they choose at what the government sets
as a reasonable rate. More recently, Germany
shifted to a Global Treatment Budget approach.
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Schwarz, et al. (2020) state that this change,
popular among practitioners and patients, shifts
from a daily performance-based approach to a
“lump-sum GTB”, shifting from in- to outpatient
settings. Savings can then be reinvested along
the full spectrum of care. While there are strong
federal policies there still is a struggle to
systematize mental health services across 16
German states. In particular, differences can be
found between actual number of psychiatric beds
(Salize, Rössler, & Becker, 2007).
General Treatment Approaches- Germany
Germany’s treatment approaches span a wide
spectrum of services deeply steeped in expert
tradition and backed by a robust economy and
heavy regulations that ensure there is accessibility
and outreach. Germany designates three theory-
based psychotherapeutic approaches: Behavioral,
Depth, and (Psycho) Analytic (PubMed Health,
2016). Concepts frequently enunciated within the
German mental health care system are social
education, mental health consulting, assessment,
and case management, in addition to those
providing deep, intensive psychoanalytic
approaches. Germany produced and hosted some
of the world’s most influential psychoanalysts,
including Karen Horney, Erich Fromm, Erik
Erikson, and Gustav Kafka. German was also the
language of Sigmund Freud and thus the early
field of psychoanalysis (Ermann, 2010). They also
track utilization through what they call a Point of
Contact system (National Library of Medicine,
2016). This requires health care professionals
throughout the system to intentionally perform
exploratory examination along with
psychoeducation to ensure people understand the
availability of mental health services.
Lithuania
Lithuania (population 2.8 million; GDP per
Capita 42,551 USD [OECD, 2022]) has a triad of
problems related to mental health care, including
troubling behavioral trends (i.e., addiction,
suicide), under-resourced mental health care
delivery system (WHO, 2011c), and profound
culture-based avoidance to mental health care.
Perceptions of soviet era institutionalization
magnifies stigma toward mental illness (Pūras,
2019). In spite of these challenges, there remains
a growing push for increased funding and
investment in WHO oriented best practices
(Skvernelis & Veryga, 2017).
History of Mental Health System- Lithuania
Lithuania struggles with some of the highest
rates of suicide and alcoholism, all while
attempting to revise their health care systems,
since 1991, after 100+ years of occupation (Puras
et al., 2004). Mental health clinics started in 1996
and grew to ~115 clinics by 2016 (Skvernelis &
Veryga, 2017). In 2007 the Lithuanian parliament
voted to adopt the European mental health
principles recommended by the World Health
Organization (WHO) (Muntianas, 2007). They
hoped to ensure human rights of patients and to
integrate modern services to address mental
health needs through a biopsychosocial method.
Systems Investment- Lithuania
Records on financing of the Lithuanian mental
health system can be hard to find, but financing
for the overall health care system increased from
45.7 to 57.5 million Euros (~$56 to $70 million
USD) between 2012-2016 (Skvernelis & Veryga,
2017). The amount of mental health clinics and
professionals have increased, but there are still
deficits, particularly in child and adolescent
psychiatry). There is a lack of diversified and
prioritized financing in Lithuanian mental health
care, which obscures and limits innovative
services that could benefit the system in the long
run (Šumskienė, 2017; Šumskienė & Petružytė,
2017). Ironically, the current financing approach
most resembles the soviet model, denying
innovation and advancement. Becoming a
European Union (EU) member in 2004 did not
bring essential systemic changes (Pūras et al.,
2013). Certain institutions have stable financing
and no competition. Experts further argue that
inadequate financing hurts non-governmental
organizations, which seek alternative approaches,
a wider range of specialized interventions,
innovative service models, and current mental
health care system reform (Pūras et al., 2013).
General Treatment Approaches- Lithuania
Lithuania has both inpatient and outpatient
psychiatric services that utilize a blend of
counseling, psychopharmacology, and social
supports (often referred to as case management
or psychosocial support) (Dembinskas, 2003).
Lithuanians may more commonly be able to
access mental health care that reflects a
psychosocial paradigm (Šumskienė & Petružytė,
2017). These services focus on sustaining
independent living for those struggling with mental
health issues (Šukys, 2012). While this is likely
done with sensitivity and compassion for the
mental health struggle the person is experiencing,
the level of funding indicates that this
psychosocial approach does not necessarily
include deep and effective psychotherapeutic
treatment (Šumskienė & Petružytė, 2017). There
are discussions in the ministry of health to make
psychotherapy a part of the system, but for now
psychotherapy is primarily attainable only through
private practices (LPS, 2021). There is a
government supported emotional mental hotline
and a complex services packet.
Addiction and suicide continue to plague
Lithuania as rates are among the highest in the
world. Funding and prevention programs have
been inadequate thus far (Skruibis & Žemaitienė,
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2015; Šumskienė & Petružytė, 2017). There have
been proactive efforts on both of these issues.
Strategic planning includes capacity building in
areas of recruitment, education, training,
professional development, and prevention
programs, all of which would increase the quality
and availability of mental health services.
United States of America
The mental health care system in the United
States (population 83.1 million; GDP per Capita
58,386 USD [OECD, 2022]) is in a state of
emergency, especially considering both mental
health and addiction problems. The National
Alliance on Mental Illness (NAMI) is “the nation’s
[United States] largest grassroots mental health
organization dedicated to building better lives for
the millions of Americans affected by mental
illness… started as a small group of families…
blossomed into the nation’s leading voice on
mental health. (NAMI, 2022)” NAMI gives the
United States a grade of D, stating “Mental health
care in America is in crisis. Even states that have
worked hard to build life-saving, recovery-oriented
systems of care stand to see their progress wiped
out. (2009)” Advances in health care along with
the AMA’s lock on a private entrepreneurial model
for medicine making the U.S. health care system
exorbitantly expensive, far beyond most
American’s ability to sustain. As a strength in the
United States, medical training and expertise are
world class (Garson & Engelhard, 2008), but
millions are shunned (50 million prior to the
Patient Protection and Affordable Care Act of
2010 [PPACA] and 31.6 million now [National
Center for Health Statistics, 2022]). The United
States is also the only industrialized country that
bankrupts citizens for catastrophic medical debt;
two-thirds of people who file for bankruptcy in the
United States cite medical issues as the primary
cause (Konish, 2019).
History of Mental Health System- United
States
The United States mental health system is a
study in contradiction and ambivalence, mostly an
extension of the profit-driven medical system with
also an underfunded and inconsistent
government-based system (i.e., Medicaid,
Medicare, and Veterans Administration) primarily
for the poor, disabled, elderly, and veterans. The
profit driven private health care system, created
by the American Medical Association (AMA) and
amplified through an evolution of private health
insurance and pharmaceutical industries,
necessarily creates scarcity while passing along
high and ever-escalating costs to clients and
patients.
The AMA began in 1845 with a stated purpose,
“Scientific advancement, standards for medical
education, launching a program of medical ethics,
improved public health” (AMA, 2021). But the
AMA evolved as a wealthy and powerful lobbying
group and its most prominent impact is that it
ensured the field of medicine would remain a
private, entrepreneurial, and for-profit system
(Rosenthal, 2018). Hospitals, clinics, and health
insurance companies followed the for-profit
model.
Health insurance companies started as
nonprofits in the 1890s to stabilize doctor and
hospital revenue over the course of a year to
avoid sharp financial peaks and valleys.
Rosenthal (2018) states,
“They intended it to help the sick. And in the
beginning, it did. A hundred years ago medical
treatments were basic, cheap, and not terribly
effective. Often run by religious charities, hospitals
were places where people mostly went to die.
‘Care,’ such as it was, was delivered at
dispensaries by doctors or quacks for minimal
fees.”
Eventually insurance companies followed the
AMA’s for-profit approach and between the 1920s
and the 1960s, progressively engaged in
discriminatory practices, in particular denying
coverage to those with pre-existing conditions.
There is evidence that the early health insurance
companies (e.g., Blue Cross) held out as
exclusively nonprofits but could not compete with
newer for-profit insurance companies (e.g., Aetna
and Cigna), and caved to economic pressures to
gain access to the stock market (Rosenthal,
2018).
The government-based programs of Medicare,
Medicaid, and military-affiliated health care (e.g.,
Veterans Administration [VA]) developed between
the 1940s and 1960s to protect vulnerable
populations and to take care of veterans
(Tikkanen, Osborn, Mossialos, Djordjevic, &
Wharton, 2020). These resources, though often
inadequate, are critical for those meeting eligibility
requirements (e.g., poverty, disability, old age,
and veteran status).
President Obama’s Patient Protection and
Affordable Care Act of 2010 (PPACA) was the
most significant health care legislation since the
1960s. It has its strengths, but it was actually
implemented without a core component, the
Public Option, which would have been a
government-based nonprofit health insurance plan
that any American could purchase. The
Congressional Budget Office (CBO), the strictly
nonpartisan budget analyst for the U.S. Congress,
estimated 6 million Americans would have opted
for the public option in the roll-out of PPACA
(CBO, 2009). That number likely would have
grown exponentially by now since it has been
shown that overall satisfaction is significantly
higher for Americans with government-based
health insurance (e.g., Medicare) than in the
private market (McCarthy, 2012). It also could
have generated market pressures for the private
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insurance system to lower prices while improving
coverage.
Systems Investment- United States
The National Institute of Mental Health (NIMH,
2011) cites a cost of $57.8 billion in 2006, 163
billion in 2011, and $238 billion in 2020. US GDP
leads the world in percentage of investment in
health care and is ever-growing at 17.7% in 2019
(Centers for Medicaid and Medicare Services
[CMMS], 2019). But estimates on mental health,
which also include certain aspects of indirect
costs, put mental health GDP at 3.5%. Estimates
on cost rise dramatically when including indirect
costs of untreated mental health problems, which
include those who could work but will remain on
disability, those turning to addictions as coping
mechanisms and ending up with catastrophic
treatment costs or in the criminal justice system
(Insel, 2008). “It goes without saying that the
excess costs of untreated or poorly treated mental
illness in the disability system, in prison, and on
the streets are part of the mental health care
crisis. We are spending too much on mental
illness in all the wrong places. And the
consequences for consumers are worse than the
costs for taxpayers” (Hogan, 2002).
General Treatment Approaches- United
States
Most mental disorders are treated solely with
medication, even though more than 50% call for
psychotherapy (Arean, Renn, & Ratzliff, 2020).
Most mental health practitioners in the U.S.
espouse a general cognitive-behavioral therapy
approach, but for many of them that mostly means
they simply talk with their clients about general
thought and emotional disturbances. There is a
significant population of practitioners with deep
and high-quality proficiencies in specialized areas,
including Psychodynamic, Motivational
Interviewing, Attachment Theory, and, more
recently, the neurobiological approaches, such as
Eye Movement Desensitization and Reprocessing
(EMDR) (Shapiro, 2012). For the percentage able
to gain access to psychotherapy, it is very difficult
to discern which practitioners will provide the best
and most specialized services.
Community Mental Health
The vision behind Kennedy’s Community
Mental Health Act of 1963 was to
deinstitutionalize chronic and severely mentally ill
people into a wide-reaching network of
community-based outpatient centers. The agenda
was broad and administration across presidential
terms (e.g., from Carter to Reagan) varied and
ultimately weakened outcomes (Drake & Latimer,
2012). The two biggest problems with community
mental health are the lower prevalence of
experienced and competent practitioners (owing
mostly to low pay) and hyper-focus on case
management (basic resources for independent
living) and psychopharmacology, in lieu of
psychotherapeutic treatment. In truth, there are
most excellent services provided through
community mental health; here and there pockets
of particularly good treatment teams arise. But this
is a widely varying and unpredictable
phenomenon. For those with Medicaid, they can
expect their care to be mostly in the areas of
psychopharmacology (e.g., anti-depressants) and
case management. They may also receive
individual and/or group therapy, but availability
and quality also vary widely.
Private Health Insurance (Uninsured/Private
Fee)
Most Americans have private health insurance
that covers a percentage of mental health care
costs. A typical copay to cover a $125 outpatient
psychotherapy fee is between $30 and $60.
Insurance plans are not required to cover mental
health, and many do not. A person seeking
weekly psychotherapy for a year could pay as
much as $3000 for copays on top of expensive
health insurance premiums. Increasingly,
psychiatrists and psychotherapists opt out of
insurance altogether, citing issues with low
reimbursement and a disorganized, unreliable,
and cumbersome billing system. 34% of people
with private insurance seeking mental health care
had difficulty finding a practitioner accepting their
insurance (NAMI, 2016). And with increasing
demand, mental health providers can charge
higher rates and find plenty of financially able
people to pay out of pocket. Yalom (2009) states:
“So I worry about psychotherapy—about how it
may be deformed by economic pressures and
impoverished by radically abbreviated training
programs. Nonetheless, I am confident that, in the
future, a cohort of therapists coming from a variety
of educational disciplines (psychology,
counseling, social work, pastoral counseling,
clinical philosophy) will continue to pursue
rigorous postgraduate training and, even in the
crush of HMO reality, will find patients desiring
extensive growth and change willing to make an
open-ended commitment to therapy.”
This epitomizes a mental health systems
status quo in the United States that includes no
plan for affordable access to quality services to all
in need.
Discussion and Theoretical
Examination
History and theory are powerful teachers for
understanding the present and making plans for
the future. Lives and human well-being are at
stake, so for our purposes we assume that we
need to go no further in making the case that
mental health systems improvements are vital,
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even if in varying degrees between nations. Social
dynamics (or sociodynamic theory) proposes that
all systems are in a state of dynamic change
through positive and negative feedback (Durlauf &
Young, 2001). From this, we could deduce that
when an argument for change does not appear to
be winning in the public domain, enough feedback
(frequency and intensity) eventually causes
change to occur. This can explain how dramatic
change often does seem to suddenly occur after
decades of debate that seemed to go nowhere.
Although aspects of certain systems may appear
quite fixed, policy history shows that change can
happen dramatically when there are motivated
electorates and government officials (e.g.,
Advance Child Tax Credit and Economic Impact
Payments in the United States [USA.gov, 2022]).
The Past
The reality is that in various ways most nations
have not adequately responded to mental health
needs of their societies, whether by underfunding
(and thus de-prioritizing), ill-informed strategies,
inadequate expertise, or stigma causing
reluctance to seek professional help. WHO
(2020) states, “Mental health is one of the most
neglected areas of public health.” They further
estimate an inadequate average of 2% of health
budgets going toward mental health globally. And
then where services are available, there tend to
remain major impediments to help-seeking for
those most in need. The weight and
consequences of untreated mental illness on the
health care, mental health care, and criminal
justice systems, and most importantly on families
and communities, are incalculable. Dedicating
appropriate resources and expertise would
equally bring about inestimable societal benefits.
A central tenet of conflict theory states that
money interests win out at the expense of
vulnerable populations (Marx, 1848; Turner,
1975). But conflict theory is not necessarily about
how the rich and powerful victimize the
vulnerable, per se; it is an indication of what
naturally happens as humans look out for
themselves and close others, rather than ways to
mitigate the negative outcomes that might occur
when marginalized groups suffer. The Socio-
Economic Asset Developmental perspective
(Dolgoff & Feldstein, 2008) illuminates just such a
mitigating approach. Robust longitudinal
economic data demonstrate the financial wisdom
of resolving social and health problems as early
and thoroughly as possible (Centers for Disease
Control [2022]). This reinforces the age-old
wisdom, “an ounce of prevention is worth a pound
of cure”. There is a win-win phenomenon when
we avoid the cost of crisis care and also have
many more people productively functioning at all
levels of society.
The Present
A fundamental principle of governmental policy
is that sweeping legislation is difficult, expensive,
and always yields unintended consequences
(Dolgoff & Feldstein, 2007). There is no way for a
country with millions in population to adopt
sweeping legislation that immediately and
universally works effectively for all. Change along
with changing needs assures that there will
always be complications that include some people
struggling and suffering in the interim. It should be
an axiom of every nation that aspires to principles
of freedom and liberty to stay ever vigilant and
committed to addressing and resolving these
struggles and suffering as fast as humanly
possible. But how does change really happen?
And why can it be so slow in coming?
The human capacity to adapt to dysfunction is
immensely influential. In short, people adopt an “it
is what it is” attitude, believing there would be no
way to change large, problematic systems.
Regardless of how we find ourselves in failing
systems, we understand through a theory such as
structural functionalism (Durkheim & Halls, 1894)
that we can expect that there will always be
resistance to change from the status quo, even
when that change is clearly superior. Structural
functionalism reveals how complex mental health
systems have shifted, adapted, and evolved to
become a sustainable general strategy aimed at
alleviating mental health problems. Since the
environment in which this system exists is a
human construction, it does not necessarily follow
laws of nature (Durkheim & Halls, 1894). Thus, if
there was anything faulty about the overall
system, for example an unbalanced ratio that
prefers profit to human health, then subsystems
seeking to adapt within this system, might
necessarily only function as an extension of these
imbalances. In that case you will have sometimes
quite altruistic and developed resources (e.g.,
grant funded faith-based clinics in inner-cities) that
would cease to exist if the system, as a whole,
was rectified. This can lead to those with a heart
for the vulnerable unwittingly arguing for
strategies that prevent the greater-good for those
they serve.
The Future
Since the global mental health community has
ever-increasing clarity about maximally beneficial
mental health systems (WHO, 2020), and it has
been shown that investment in mental health
systems is beneficial to both those in need and
the broader society, there is no reasonable
excuse for delay. According to Dolgoff and
Feldstein (2007), “The socio-economic asset
development perspective evolved through
attempts to harmonize social welfare with efforts
directed at economic development that focuses on
ways in which social welfare can contribute
efficiently and effectively to economic
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development through social investment.” Getting
away from a liberal vs conservative struggle, there
is political-theoretical middle ground. The socio-
economic asset development perspective asserts
a win-win scenario that it benefits society, both in
social and economic terms, to ensure people have
mental health needs affordably and effectively
met. It is less expensive to prevent or catch
problems early, and it is better to have people
socially and occupationally functioning, as this is
an economic and tax-base generator. Thus, it is a
fiscally wise thing to aggressively treat all health
conditions, mental and physical, that prevent
people from thriving
Limitations and Strengths of the
Study
Limitations of the Study
Limitations of this study include a small sample
size of countries analyzed, a strong preference by
the authors to see mental health systems
improved (i.e., potential bias), and assumptions
that such analysis and comparisons generate
substantive guiding insights. There are no globally
enforceable guiding regulations for mental health
systems and numerous societal, economic, and
cultural factors, beyond the scope of this article,
also go into if and how a mental health system is
developed and utilized. In an effort to promote
progress, the authors also acknowledge that
these theoretical interpretations could be affected
by bias. The authors also acknowledge that many
of the important socio-economic variables
involved in mental health care systems are
beyond the scope of this study.
Strengths of the Study
The strengths of this study include an
elaborate analytic approach (history, systems, and
theory-based analysis), unifying information about
the global struggle toward effective mental health
services, and substantial contribution to salient
advocacy declarations. This article is a concise
blend of examination and analysis that efficiently
enhances advocate messaging and future
research foci. Additionally, this format of analysis
provides a framework for examining and
comparing additional countries’ mental health
systems
Conclusions
This article compares and contrasts these
countries’ systems while also making the case for
the inevitability of change. Nations vary in terms of
stress, levels of mental struggles, mental health
infrastructure, prevalence of stigma, and funding
willingness and capacity, but there is still an
international standard to evaluate each system
against. The authors hope this article serves to
educate and bring clarity to people so they can, in
turn, do their part to advocate for change in their
home countries. Change is inevitable, but it
serves all when it comes with strategic and
resourced planning. Most countries can estimate
numbers and types of mental struggles and
develop local quotas for practitioners and
resources. And this yields a multifaceted return on
investment (i.e., socio-economic asset
development [Dolgoff & Feldstein, 2008]). To
continue this work, the authors recommend
qualitative studies focusing in varying countries on
front-line mental health providers, health care
administrators, and economists familiar with
funding and strategies in areas of health and
mental health care. It is equally important that
recommendations keep pace with constantly
evolving data on best practices across the mental
health continuum.
Conflict of interest
The authors declare that they have no conflicts
of interest.
Acknowledgements
We wish to acknowledge Dr. Rachel Hagues
(Samford University) and Dr. Jean Roberson
(Samford University) for proofreading and critical
examination that sharpened prominent article
points
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26
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
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psychotherapy in Germany: where can I find
help? PubMed Health: National Institutes of
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https://www.ncbi.nlm.nih.gov/books/NBK2795
13
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srities deinstitucionalizacija ir su ja susiję
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psichikos-sveikatos-srities-
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lietuvoje/
Pūras, D., Germanavicius, A., Povilaitis, R.,
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Pūras, D., Šumskienė, E., Veniūtė, M., Šumskas,
G., Juodkaitė, D., Murauskienė, L., Mataitytė-
Diržienė, J., Šliužaitė, D. (2013). Iššūkiai
įgyvendinant Lietuvos psichikos sveikatos
politiką. Vilnius: Vilniaus universiteto leidykla.
ISBN: 9786094592799
Puschner, B., Cosh, S., & Becker, T. (2016).
Patient-rated outcome assessment with the
German version of the Outcome
Questionnaire 45 in people with severe
mental illness. European Journal of
Psychological Assessment, 32 (4), 273-282.
Rogers, E. M. (1983). Diffusion of innovations (4th
ed). The Free Press: New York.
Rosenthal, E. (2018). An American sickness: how
health care became big business and how
you can take it back. Penguin Books: New
York.
Salize, H. J., & Rössler, W., & Becker, T. (2007).
Mental health care in Germany: current state
and trends. European Archives of Psychiatry
and Clinical Neurosciences, 257 (2), 92-103.
Schwarz, J., Galbursera, L., Bechdolf, A., Birker,
T., Deister, A., Duve, A., … von Peter, S.
(2020). Changes in German mental health
care by implementing a Global Treatment
Budget- A mixed-method process evaluation
study. Frontiers in Psychiatry, 11(426).
https://doi.org/10.3389/fpsyt.2020.00426
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from EMDR therapy. Rodale Inc: New York.
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psichikos sveikatos strategijos ir savižudybių
prevencijos alternatyvus priemonių planas
2016-2018 m. p. 39-45. Psichikos Sveikatos
Perspektyvos.
Skvernelis, S. & Veryga, A. (August 2nd, 2017).
Nutarimas dėl psichikos sveikatos strategijos
įgyvendinimo 2007-2016 metų ataskaitos
pateikimo lietuvos respublikos seimui.
Government of the Republic of Lithuania. Nr.
639. Vilnius
Šukys, R. (August 21st, 2012). Dėl
psichosocialinės reabilitacijos paslaugų
psichikos sutrikimų turintiems asmenims
teikimo tvarkos aprašas. Nr. - 788. Vilnius
Šumskienė, E., Petružytė, D. (2017). Psichikos
sveikatos ir gerovės paradigmų kaita
Lietuvoje. Vilnius: Vilniaus universitetas
Tikkanen, R., Osborn, R., Mossialos, E.,
Djordjevic, A., & Wharton, G. A. (2020).
International health care system profiles:
United States. The Commonwealth Fund.
https://www.commonwealthfund.org/internati
onal-health-policy-center/countries/united-
states
Turner, J. H. (1975). Marx and Simmel revisited:
reassessing the foundations of conflict
theory. Social Forces, 53:4 (618-627)
USA.gov. (2022). Advance child tax credit and
economic impact payments- stimulus checks.
https://www.usa.gov/covid-stimulus-checks
Van der Kolk, B. (2014). The body keeps the
score: brain, mind, and body in the healing of
trauma. Penguin Publishing Group: New
York.
World Health Organization. (2011a). Mental health
atlas: United States of America. Department
of Mental Health and Substance Abuse.
https://www.who.int/mental_health/evidence/
atlas/profiles/usa_mh_profile.pdf?ua=1
27
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
World Health Organization. (2011b). Mental health
atlas: Germany. Department of Mental Health
and Substance Abuse.
https://www.who.int/mental_health/evidence/
atlas/profiles/deu_mh_profile.pdf?ua
World Health Organization. (2011c). Mental health
atlas: Lithuania. Department of Mental Health
and Substance Abuse.
https://www.who.int/mental_health/evidence/
atlas/profiles/ltu_mh_profile.pdf?ua=1
World Health Organization. (2013). Mental health
action plan: 2013-2020.
https://www.who.int/publications/i/item/97892
41506021
World Health Organization. (2020). World Mental
Health Day: An opportunity to kick-start a
massive scale-up in investment in mental
health. News Release.
https://www.who.int/news/item/27-08-2020-
world-mental-health-day-an-opportunity-to-
kick-start-a-massive-scale-up-in-investment-
in-mental-health
World Health Organization. (2021). Current health
expenditure (% of GDP). The World Bank.
https://data.worldbank.org/indicator/SH.XPD.
CHEX.GD.ZS
Yalom, I. (2009). The gift of therapy: an open
letter to a new generation of therapists and
their patients. HarperCollins
-
28