Wars have enormous negative mental health consequences for the civilians involved. This is particularly true for the recent Israel-Hamas war in Gaza. We present an analysis of the current humanitarian situation in Gaza, its dire mental health impact, and highlight the critical silence of medical and mental health professional organizations on this public health disaster.

Abstract Awareness of the threats of climate change is engendering distress in increasingly documented ways, with young people particularly affected. Experiences such as climate distress and eco-anxiety have implications for the health and wellbeing of societies, economies, and for climate action, including mental health, agency to address the crisis, and future planning. While multi-country studies suggest that eco-anxiety and related experiences of distress may vary with context, the hypothesis that exposure to climate-related impacts increases eco-anxiety and associated psychological impacts is underexplored in youth at the individual level. Here we show that in a large sample of US youth (aged 16–24, n = 2834), self-reported direct experience of climate-related events significantly increased eco-anxiety, climate distress and the impact of climate change on future planning, but also psychological adaptation, meaning-focused coping and climate agency. As the climate crisis accelerates and exposure to climate-related hazards increases, these findings have important implications for the mental health of populations, life choices that have socioeconomic impact, and climate behaviours of the growing group of young people experiencing these threats.

Despite massive unmet needs, U.S. mental health care systems and policy continue to aim too low. Laments about brittle foundations-including inadequate funding, fragmentation, stigma, lack of parity, ineffectiveness, unavailability, overmedicalization, and coercion-all share the same source. The mental health system is not working because it has been chasing the wrong goal: to treat illness, rather than to enable people to do nurturing things together. A focus on community nurturing and caring changes everything. It yields better treatment approaches while also engaging with the mutually reinforcing and desperately needed work of social cohesion, emotional well-being, participatory action, and communal learning and connection. In fact, the nurtured emotional health of individuals is fundamental to humane and resilient societies and to democracy itself. And in the face of environmental collapse and the related unraveling of core institutions, the stakes have never been higher. This essay makes the case for a paradigm shift in care and explores a recent effort to implement it at scale: ThriveNYC. The successes and especially the failures of ThriveNYC point to the possibilities and challenges of this essential mission.

The climate and ecological crisis will constitute the defining public health challenge of the twenty-first century, posing an unprecedented global threat to all determinants of health, and to healthcare delivery systems. We believe that mental health professionals have a crucial role to play in responding to this crisis. Whilst responding to the mental health consequences of the climate crisis will remain a key role for us as mental health professionals, we argue that our remit goes beyond this, and should include advancing public understanding of the climate crisis, highlighting its impact on physical and mental wellbeing, and advocating for systemic changes to limit its impending harms. This paper is an urgent call to action for all mental health professionals to take up a role in the context of the climate and ecological crisis. This paper will describe the relationship between mental health and climate change, and frame it within wider systemic and conceptual frameworks. It will demonstrate that as mental health professionals we are well placed to act as leaders of change-arguing that we have a duty to do so-and suggest actions that can be implemented depending on interests, skill sets and opportunities.

The aim of this paper is to share our experiences of engaging with the climate crisis as citizens and mental health professionals (MHPs). We hope the outputs will usefully validate the experiences of fellow MHPs and support them to reflect on their role in this crisis. We came together as eight MHPs, participating in group discussions and one-one interviews with the first author to reflect on our experiences. The collaboratively generated themes reflect how engagement with the crisis has: (i) disrupted our personal and professional experiences; (ii) helped us adapt and grow; and (iii) enabled us to live, work and act in more accordance with our values. A key reflection was that these experiences are not linear and we continue to wrestle with our responses to the climate crisis. Discussions also elicited visions of how mental health paradigms could be better adapted to meeting the escalating public health need that this crisis is generating. We conclude by advocating for MHPs to process and respond to the climate crisis and recognize that their skills can make a vital contribution to this global challenge.

Leadership for the Social Climate Our ability to implement the necessary responses to adapt to or mitigate climate and ecologic change, endure its consequences, and turn ambitious policy into resul...

Between 2010 and 2019 the international health care organization Partners In Health (PIH) and its sister organization Zanmi Lasante (ZL) mounted a long-term response to the 2010 Haiti earthquake, focused on mental health. Over that time, implementing a Theory of Change developed in 2012, the organization successfully developed a comprehensive, sustained community mental health system in Haiti's Central Plateau and Artibonite departments, directly serving a catchment area of 1.5 million people through multiple diagnosis-specific care pathways. The resulting ZL mental health system delivered 28 184 patient visits and served 6305 discrete patients at ZL facilities between January 2016 and September 2019. The experience of developing a system of mental health services in Haiti that currently provides ongoing care to thousands of people serves as a case study in major challenges involved in global mental health delivery. The essential components of the effort to develop and sustain this community mental health system are summarized.

Immediate and short-term attention has been directed to the negative mental health effects of COVID-19 in many countries.1Czeisler MÉ Lane RI Petrosky E et al.Mental health, substance use and suicidal ideation during the COVID19 pandemic—United States, June 24–30, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1049-1057Crossref PubMed Scopus (0) Google Scholar However, such attention needs to be put to more ambitious use. Now is the opportunity to make securing the emotional and mental wellbeing of humanity a common expectation of global governance. We call attention to this opportunity as part of the International City and Urban Regional Collaborative (I-CIRCLE), a consortium of mental health system leaders and managers that came together through shared involvement in the International Initiative for Mental Health Leadership. I-CIRCLE is a growing network for sharing lessons learned, to integrate mental health capacity within the work of building vibrant, just, and humane communities. Socioemotional health is key to the state of communal life and wellbeing. COVID-19 has underscored and magnified this connection, which will become increasingly pivotal as the state of planetary and civic health are severely tested by climate change and ecological destruction, of which COVID-19 is an early but not unique symptom of things to come.2Di Marco M Baker ML Daszak P et al.Opinion: sustainable development must account for pandemic risk.Proc Natl Acad Sci USA. 2020; 117: 3888-3892Crossref PubMed Scopus (202) Google Scholar Facing that future depends on facing up to the unfinished business of adequately addressing the mental health needs and emotional capacity of communities. Unless there is bold change, remediable social factors (poverty, food insecurity, unstable housing, childhoods of diminished education and nurture), racial and economic oppression, and mental health systems with too few resources and too narrow a mission, will continue to undermine the emotional health and ties that bind humanity and which are foundations for collective action to solve pressing problems. We therefore urge the global mental health community and efforts to galvanize worldwide consensus for pandemic response and recovery, such as The Lancet COVID-19 Commission, to commit to making wellbeing-centered policymaking a pillar of the future.3Biglan A Johansson M Van Ryzin M Embry D Scaling up and scaling out: consilience and the evolution of more nurturant societies.Clin Psychol Rev. 2020; 81101893Crossref PubMed Scopus (14) Google Scholar This commitment should drive future international cooperation and incorporate the following perspectives and purposes. The negative mental health effects of COVID-19 are and will remain massive, far reaching, and long term.4WHOMental health and psychosocial considerations during the COVID-19 outbreak.https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdfDate: Mar 18, 2020Date accessed: October 12, 2020Google Scholar These effects include the cumulative toll of diagnosable illness fueled by wide exposure to loss, stress, and trauma, but also reflect much more. Planetary-sized ecological ruptures like this pandemic amplify structural disadvantage and a cascade of compounding risks and multiple vulnerabilities that all result in deep social and emotional damage.5United Nations Development ProgrammeBeyond income, beyond averages, beyond today: inequalities in human development in the 21st century. Human Development Report 2019.http://hdr.undp.org/sites/default/files/hdr2019.pdfDate: 2019Date accessed: November 22, 2020Google Scholar These effects therefore not only add to clinical burdens, but also take apart social cohesion, collective efficacy, and overall health and longevity. They are a collective trauma. They reflect a degree of loss, grief, polarisation, and damaged ways of life and suffering that require far more access to services to help individuals. But they also sap the collective will, civic morale, and prosocial soul of whole communities. Such a fragile and depleted social climate disables the civic muscle needed to navigate the urgent and relentless realities of the ongoing global ecological crisis, of which COVID-19 is an opening act.6Belkin G Leadership for the social climate.N Engl J Med. 2020; 382: 1975-1977Crossref PubMed Scopus (4) Google Scholar The implications of all this should open wide the narrow box into which mental health has been put by policy makers and the health system. An individual disease-centric paradigm has frozen action and limited understanding of the breadth of social life that fuels and relies on mental health. This needs to end. Now is the time for an overdue transformation of the purposes of mental health systems and policy to ones that put the reciprocal connections between mental health, the global climate and ecological emergency, and social determinants of racial and economic oppression and inequity, at the centre. Two things need to change to do this: first, mental health care itself, as it is currently constituted; and second, the absence in this transformation of active and coordinated participation and leadership from a vast array of stakeholders outside of the mental health field. Changing how mental health care works is important; specialised providers of mental health care can be at the forefront of this change through adopting the following. First, mental health and community wellbeing should be participatory, coalition-driven, hyperlocal work that permeates and engages all policies and the whole of society, and sees non-clinicians and non-specialists as experts in local needs and co-owners of healing practices. Second, the growing field of task-sharing (which refers to the adoption of skills and tools by non-specialists, lay people, and peers to do much of the work of care, prevention, and promotion) needs to be scaled up and mainstreamed.7Singla D et al.Psychological treatments for the world: lessons from low- and middle-income countries.Annu Rev Clin Psychol. 2017; 13: 149-181Crossref PubMed Scopus (382) Google Scholar In this way, specialist clinicians can be capacity-building partners and backup care providers for an array of other front-line workers. This framework, rather than the prevailing illness-driven specialist office-based model, should be the starting point for building systems and policy that finally acknowledge that most of the mental and emotional suffering on the planet is driven by social conditions and choices that are under our control to change. Third, these commitments should challenge old habits including: over medicalisation, specialist and illness focus, hierarchical knowledge and practice, and little attention or actionable capacity to deliver on promotion and prevention of, and resilience and attention to, social determinants. Finally, the new normal should also include: pervasive incorporation of an equity lens in all of our research, teaching, and care practices; necessary investments in cultural change, learning, and leadership to drive these changes; and a shift in resources to communities that have historically been discriminated against and historically colonised and impoverished nations. The prize is the wellbeing of all people. The mental health field faces an overdue reckoning that it can no longer dodge. The field has the chance to bring and reshape what it knows and does to be relevant to the task of maintaining humane and equitable steward communities. These actions should be integral to any serious effort at safeguarding population mental health and be part of the long-term COVID-19 response, meeting the UN Sustainable Development Goals, and facing up to our imperiled ecological future. This reimagining of how mental health fits within wider society is urgently needed and will require changes to what makes up the mental health system. Other stakeholders, users, community members, and sectors can lead and co-create this widened scope and purpose for mental health systems. Expanded ownership will only add value to, rather than detract from, the system's traditional focus on specialist care of illness. At the same time mental health professionals should be familiar with, and advocate for, broader social policies crucial to future population mental health, including pursuit of equity,8Black Thrive PartnershipBlack Thrive aims and outcomes.https://www.blackthrive.org.uk/black-thrive-outcomes/Date: 2020Date accessed: November 22, 2020Google Scholar income security,9Government of CanadaCanada Emergency Response Benefit (CERB): closed.https://www.canada.ca/en/services/benefits/ei/cerb-application.htmlDate: Jan 22, 2021Date accessed: November 15, 2020Google Scholar and budgeting that prioritises wellbeing.10Government of New ZealandThe wellbeing budget.https://www.treasury.govt.nz/sites/default/files/2019-05/b19-wellbeing-budget.pdfDate: May 30, 2019Date accessed: November 15, 2020Google Scholar It is possible to take charge of how emotional and mental wellbeing is mutually interdependent with its social, economic, and environmental drivers. Our urgent task and challenge is to step up and deliver the contributions that the mental health field can make in securing, with others, a sustainable, symbiotic path for the human future. In conclusion, although the COVID-19 pandemic has previewed deep obstacles for the global future, it has also shown the possibilities for people to come together in collective mobilisation, mutual aid, and solidarity, and the tangible linking together of mental health, illness, and suffering with the aims and paths of broader social progress and justice. There is much to build on. Let us begin. The signatories to this statement (listed in the appendix pp 1-2) urge this change to mental health and wellbeing's priority of place in the work of governments and communities. The global COVID-19 pandemic and ongoing ecological crises make this imperative. We urge others to join this work. We declare no competing interests. Download .pdf (.21 MB) Help with pdf files Supplementary appendix

Promoting population mental health and meeting the burdens of mental illness is a priority public health challenge of the 21st century. But too little attention has been placed on how to design and sustain the scope of strategies and commitments that credibly live up to the full breadth of that challenge. ThriveNYC is an effort by New York City to fill that gap, through a public health approach backed by investment in resources and leadership. ThriveNYC can by example help mobilize a larger community of investigators and policymakers to consider how to meet this challenge, to get to consensus on key elements for effective action and implementation, to reimagine who and what the mental health "system" includes, and, in doing so, to strengthen the social contract that underlies well-being.

Exciting changes have the potential to reshape the tools used to treat mental illness, promote mental health, and bring this country's too-long fragmented and specialist-centered mental health system closer to delivering on the goals of improving population health, expanding access, and engaging with structural and social determinants. Innovative practices such as task sharing, cross-sector integration, and participatory methods are ready to be mainstreamed into psychiatric professional identity and practice. Local governments have started to adopt these new strategies, perhaps the most prominent recent example being ThriveNYC, a comprehensive attempt to drive mental health improvement. By enabling and partnering with other practitioners in these ways, psychiatrists can reach more people in more places, giving psychiatry an opportunity to evolve and flourish. As psychiatrists, we and our leadership should seize that opportunity and help lead this progress.

Background: In sub-Saharan Africa, mental and substance-related disorders account for 19% of all years lived with disability, yet the intersection between poverty and mental distress is poorly understood since most psychiatric research is conducted in high-income countries. Aims: To examine the prevalence of and associations between food insecurity, mental distress and suicidal ideation in three rural village clusters in sub-Saharan Africa. Method: Cross-sectional multivariate analysis of sociodemographic variables associated with mental distress and suicidal ideation in three countries. The sample included 1,142 individuals from three rural village clusters in Nigeria (n = 380), Uganda (n = 380) and Ghana (n = 382). Food insecurity was measured based on the number of months in the previous year that the respondent's family reported being 'unable to eat two square meals per day'. Mental distress was assessed using the Kessler non-specific psychological distress scale (K6) and suicidal ideation was measured using an item from PRIME-MD. Other sociodemographic variables included gender, age, literacy and occupation. Results: The prevalence of individuals with moderate or severe mental distress in Nigeria, Uganda and Ghana were higher than previously reported in the literature: 35.5%, 30.8% and 30.4%, respectively, and suicidal ideation rates were 29.7%, 21.3% and 10.9%. No differences were observed in mental distress between men and women in any of the sites. Being a farmer (vs student or other) was protective for mental distress in two sites (Uganda and Ghana) but no other social indicators, such as age, gender, literacy and food insecurity, were significantly associated with mental distress. Risk for suicidal ideation differed across sites: it was associated with food insecurity in Nigeria, female gender in Uganda, and older age in Uganda. Conclusions: Mental distress and suicidal ideation were highly prevalent in three settings of extreme poverty across all groups, in ways that were not always consistent with the global literature. These findings suggest that more research is needed in to better understand the social etiology of mental distress in sub-Saharan Africa.

Global mental health has rapidly attracted increasing attention by health policy makers and researchers during the last 10 years. The groundwork for this shift was laid in data beingmade available on the prevalence (Demyttenaere et al. 2004) and burden (Lopez et al. 2006) of mental disorders and also on the resources allocated to mental health within countries (WHO, 2001, 2005, 2011, 2015). Publication of a series of review papers on specific areas within global mental health (Lancet Series on Global Mental Health, 2007, 2011) and on Grand Challenges in Global Mental Health (Collins et al. 2011) focused attention on what was known and also on what were the gaps in knowledge. On the side of policy makers, mental health has been discussed at ministerial level in the Commonwealth, the AsiaPacific Economic Commission, and in the World Health Assembly consisting of 194 ministers of health. The latter discussion led to the adoption of Comprehensive Mental Health Action Plan 2013–2020 (WHO, 2013), first time in the history of World Health Organization. The Mental Health Action Plan of WHO captures this global engagement, and is clearly focused on action. It has four objectives: to improve leadership and governance, health and social care, promotion and prevention, and information and research. It also identifies key cross-cutting principles encompassing universal health coverage, human rights, evidence based practice, life-course approach, multi-sectoral approach and empowerment of persons with mental disorders and psychosocial disabilities. The Action Plan is based on the vision of ‘a world in which mental health is valued, promoted and protected, mental disorders are prevented and persons affected by these disorders are able to exercise the full range of human rights and to access high-quality, culturallyappropriate health and social care in a timely way to promote recovery, all in order to attain the highest possible level of health and participate fully in society and at work free from stigmatization and discrimination’ The Plan calls for specific actions to be taken by member states, WHO secretariat and international and national partners. As the action plan is getting implemented, world leaders have also made an even larger commitment to mental health by including it in the United Nations Sustainable Development Goals 2015–2030. This places mental health within the global development agenda. Do we have all the knowledge that we need to implement the Plan or the mental health and wellbeing component of UN Sustainable Development Goals? The clear answer is no. Existing knowledge has been critical in setting the high-level agendas for action, but there remain knowledge gaps that need to be filled. Nonetheless, having these global goals and shared aims is an important start to advance and align growing research activity in mental health services design and implementation, especially in lowand middleincome countries (LMICs). Efforts by researchers and innovators supported by funders like the Grand Challenges Canada (GCC website), National Institute * Address for correspondence: G. Belkin, Global Mental Health. (Email: gary.belkin@nyumc.org)

BACKGROUND:Depression is under-diagnosed and under-treated in most areas of the US. New York City is currently looking to close gaps in identifying and treating depression through the adoption of a screening and collaborative care model deployed throughout the city.METHODS:We examine the cost-effectiveness of universal two-stage screening with the 2- and 9-item Patient Health Questionnaires (PHQ-2 and PHQ-9) in New York City followed by collaborative care for those who screen positive. We conducted microsimulations on hypothetical adult participants between ages 20 and 70.RESULTS:The incremental cost-effectiveness of the interventions over the average lifespan of a 20-year-old adult in NYC is approximately $1,726/QALY gained (95% plausible interval: cost-saving, $10,594/QALY gained).CONCLUSIONS:Two-stage screening coupled with collaborative care for depression in the clinical setting appears to be significantly less expensive than most clinical preventive interventions, such as HIV screening in high-risk patients. However, effectiveness is dependent on the city's ability to manage scale up of collaborative care models.

We are a group of researchers and clinicians with collective experience in child survival, nutrition, cognitive and social development, and treatment of common mental conditions. We join together to welcome an expanded definition of child development to guide global approaches to child health and overall social development. We call for resolve to integrate maternal and child mental health with child health, nutrition, and development services and policies, and see this as fundamental to the health and sustainable development of societies. We suggest specific steps toward achieving this objective, with associated global organizational and resource commitments. In particular, we call for a Global Planning Summit to establish a much needed Global Alliance for Child Development and Mental Health in all Policies.

Developing mental health care capacity in postearthquake Haiti is hampered by the lack of assessments that include culturally bound idioms Haitians use when discussing emotional distress. The current paper describes a novel emic-etic approach to developing a depression screening for Partners in Health/Zanmi Lasante. In Study 1 Haitian key informants were asked to classify symptoms and describe categories within a pool of symptoms of common mental disorders. Study 2 tested the symptom set that best approximated depression in a sample of depressed and not depressed Haitians in order to select items for the screening tool. The resulting 13-item instrument produced scores with high internal reliability that were sensitive to culturally informed diagnoses, and interpretations with construct and concurrent validity (vis-à-vis functional impairment). Discussion focuses on the appropriate use of this tool and integrating emic perspectives into developing psychological assessments globally. The screening tool is provided as an Appendix.

Global Mental Health (GMH) appears as a new Open Access journal, just as ‘Global Mental Health’ emerges as a new field. It is necessary, and timely: current international survey data suggest that mental illness is a key driver of population wellbeing, with evidence suggesting that mental healthcare might be a more cost-effective investment than physical healthcare for improving that outcome (Helliwell et al. 2013). The huge and growing morbidity burden attributable to common mental conditions (Murray et al. 2012; Vos et al. 2012), and their multiplier effect on the morbidity and mortality of other medical conditions (Prince et al. 2007), have prompted governments in lowand middle-income countries (LMICs) to increasingly and more aggressively pursue scalable solutions to close mental health treatment gaps (Ssebunnya et al. 2012; http://www.guardian.co.uk/global-development/2011/ aug/29/ghana-new-mental-health-bill). Mental health has increasingly become a part of the global health scientific agenda (Becker & Kleinman 2013). Among the signs of this are multiple special series on global mental health in The Lancet, a global Delphi exercise identifying research priority ‘Grand Challenges’ for global mental health reported in Nature (Horton 2007; Collins et al. 2011), a Grand Challenges Canada funding initiative to support those priorities (http://www.grandchallenges.ca/grand-challenges/gc4non-communicable-diseases/mentalhealth/), a series of annual meetings to promote and cultivate global mental health research strategies and research capacity sponsored by the US National Institute of Mental Health, and endorsement of a Global Mental Health Action Plan by the World Health Assembly (WHO 2013). In addition, early work on Sustainable Development Goals (SDGs), expected to replace the Millennium Development Goals in 2015 as the set of global benchmarks driving much of the world’s development investments, appears likely to include specific mental health targets and metrics for population wellbeing and happiness (Leadership Council of the Sustainable Development Solutions Network). So it is especially timely to be launching a scientific and research journal specific to Global Mental Health. But such a launch carries a responsibility we intend to take seriously: to be a resource for helping establish just what this new ‘field’ is, and how successful it can be. Making the compelling case for mental health is no longer enough; we need clear and globally aligning metrics and targets, delivery designs, shared technical tools and language to do mental health, packaged in ways that are readily understandable to mainstream public health and social policy, planning, and healthcare delivery. We can mobilize the scientific field of global mental health to accelerate an ambitious scale of global investment, action, and organization for mental healthcare, in the same way the globalized fields of HIV care and maternal and child health (MCH) transformed the availability of effective and scaled care for those conditions. To do this, the field needs to evolve so that it is not a niche field, but includes a broad array of expertise, including those of economists, organizational design and systems analysts, primary care providers and managers, quality improvement specialists, social media engineers, educators, users and advocates, and others beyond the usual ‘mental health’ disciplines itself. This range of expertise will especially play a key role in developing the cross-sector strategies needed to * Address for correspondence: Gary S Belkin, New York University School of Medicine. (Email: Gary.Belkin@nyumc.org)

BACKGROUND:Despite being one of the leading causes of disability worldwide, fewer than 10% of depressed individuals in low-resource settings have access to treatment. Mounting evidence suggests that nonspecialist workers are capable of providing counseling and case management at the community level. They often use brief psychiatric screening instruments as clinical tools to identify cases and monitor symptoms over time. In order for such tools to be used in diverse settings, they must demonstrate adequate reliability and validity in addition to cross-cultural relevance. To be used to guide routine care they also need to be flexibly adapted and sensitive to change. The goal of this paper is to assess the cross-cultural validity of brief psychiatric screening instruments in sub-Saharan Africa, identify best practices, and discuss implications for clinical management and scale-up of mental health treatment in resource-poor settings. METHOD:Systematic review of studies assessing the validity of screening instruments for depression, anxiety, and mental distress in sub-Saharan Africa using Medline and PsycINFO. RESULTS:Sixty-five studies from 16 countries assessing the validity of brief screening instruments for depression, anxiety, and/or mental distress. CONCLUSIONS:Despite evidence of underlying universality in the experience of depression and anxiety in sub-Saharan Africa, differences in the salience, manifestation, and expression of symptoms suggest the need for the local adaptation of instruments. Rapid ethnographic assessment has emerged as a promising, low-cost, and efficient strategy for doing so.

In the last article of a five-part series providing a global perspective on integrating mental health, Vikram Patel and colleagues discuss the competencies, operational innovation, and packages of care needed, and argue that integration will complement primary care system strengthening. Please see later in the article for the Editors' Summary

The predominant historical narrative of bioethics describes how ethical expertise rescued medicine from growing dilemmas, and that these dilemmas were presumably best understood as ethical problems...