Reframing Depression and Mental Health Policy in the Global South: A Foucauldian Critique of International Guidelines and Discourse

Dr. Samuel O. Adebayo¹¹*, Dr. Claire L. Montrose², Prof. Mariana R. De Souza³, Dr. Faridah K. El-Masri³

1. Department of Public Health, University of Ibadan, Ibadan, Nigeria
2. Centre for Health Policy and Ethics, University of Edinburgh, Edinburgh, United Kingdom
3. Faculty of Health Sciences, University of São Paulo, São Paulo, Brazil

* Corresponding Author: Dr. Samuel O. Adebayo Email: [email protected]

Abstract

In recent decades, depression has emerged as a pressing global public health issue, particularly within low- and middle-income countries (LMICs). The World Health Organization (WHO), together with the Movement for Global Mental Health, has advanced global strategies aimed at strengthening mental health services, placing specific emphasis on LMIC contexts. Among these initiatives, evidence-based instruments such as the WHO’s mhGAP-Intervention Guide have been promoted to support the detection, diagnosis, and treatment of prevalent mental, neurological, and substance-use disorders. This article critically examines how such intervention frameworks function within broader processes of knowledge–power, drawing on Foucauldian discourse analysis and document review. Focusing on the Global South, we argue that these guidelines do more than provide technical recommendations; they actively shape global narratives on depression by reproducing biopolitical assumptions, reinforcing forms of governmentality, and delimiting “conditions of possibility” for mental health care. Empirical evidence is presented to highlight the complexities and tensions that underlie global mental health discourse, moving beyond binary framings of its benefits and limitations. The article concludes by identifying counter-discourses of resistance and by proposing a reconceptualization of the so-called “treatment gap” in relation to common mental disorders.

Keywords:

Depression; global mental health; biopolitics; governmentality; discourse analysis; Global South

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Introduction

How mental health problems are defined and conceptualized strongly influences the responses formulated to address them. Depression has increasingly been characterized as a pressing global public health emergency.¹˒² Projections indicate that by 2030, mental health conditions will represent the leading contributor to the global burden of disease and a major driver of preventable suffering and premature death.¹–³ Estimates of depression’s impact—spanning disability, diminished quality of life, and economic loss—have reinforced arguments for prioritizing the detection and management of depressive disorders as key public health and development concerns in low- and middle-income countries (LMICs³).

To address these challenges, the Movement for Global Mental Health and the World Health Organization (WHO) have developed standardized international guidelines and care packages targeting depression in LMICs. These resources aim to improve access to effective treatment for depressive disorders and other mental, neurological, and substance-use conditions, thereby reducing the so-called treatment gap.⁴ The treatment gap refers to the proportion of individuals who meet diagnostic criteria for a disorder but do not receive any form of care.⁴ This concept underpins the field of global mental health (GMH), which rests on two central premises: (1) mental disorders are widespread, and (2) mental health services are universally limited, with the shortfall especially pronounced in LMICs.³˒⁴

The perceived magnitude of unmet need has driven global calls to expand mental health services, positioning service scale-up as a defining priority in GMH.³˒⁵ The Lancet GMH series of 2007 and 2011⁴–⁶ emphasized that the field’s principal mission is to increase delivery of evidence-based interventions in order to close the treatment gap for common mental disorders such as depression, anxiety, and somatoform conditions. This position has been echoed in WHO policy frameworks, which place treatment gap reduction and service expansion at the core of international mental health initiatives, particularly through the development and implementation of the Mental Health Gap Action Programme.⁷–¹⁰ Currently, this program is active in more than 100 countries.¹¹˒¹² Among its central tools are intervention manuals, including the WHO’s mhGAP-Intervention Guide (mhGAP-IG) 2.0 (2016), which provides evidence-based protocols for the detection, diagnosis, and management of prevalent mental disorders.⁹˒¹⁰ Despite this progress, important concerns remain regarding the adaptability of such resources to diverse cultural settings and populations.

The dominance of treatment gap statistics as a framing device highlights the pervasive influence of this paradigm within GMH discourse on depression. For instance, the most recent global gap report, which assessed treatment coverage for major depression in 84 countries, found that only 8% of adults in LMICs meeting diagnostic criteria had accessed relevant services.¹³ Comparable statistics recur across GMH scholarship, policy documents, and advocacy efforts addressing depression.¹˒²˒⁹˒¹⁰˒¹⁴ Whether such figures reflect a limited supply of mental health services or, alternatively, low demand for medicalized intervention remains uncertain.

The empirical foundations of treatment gap estimates have been widely critiqued. Concerns include the potential risks of exporting Western diagnostic models and treatment paradigms, the neglect of cultural diversity in conceptualizations of distress, and the medicalization of social suffering.¹⁵–²⁰ Scholars aligned with critical psychiatry have urged a fundamental reconsideration of strategies aimed at expanding diagnostic and therapeutic frameworks in LMICs, emphasizing that these approaches presume the universal applicability of Western biomedical constructs.¹⁵–¹⁸ Additional criticisms question the validity of standard depression diagnostic tools, the reliability of prevalence estimates at the global level, and the practical relevance of GMH programs in LMIC contexts.¹⁶–²⁰

Critics argue that GMH frameworks often fail to account for local understandings of mental distress and depression, thereby diverting attention from the social and economic determinants of illness.¹⁸˒²¹˒²² Calls have therefore emerged for interventions that are responsive to cultural contexts, local health systems, and the needs of specific populations.²¹–²⁵ Another central critique focuses on the de-contextualization of suffering. Mills¹⁵ contends that translating situated experiences of distress into standardized psychiatric diagnoses detaches symptoms from their social and personal dimensions, reframing them as manifestations of brain pathology rather than disruptions in the “lifeworld”—the constellation of activities, relationships, and contexts that imbue life with meaning.²⁶ This article contributes to and extends these critiques by employing discourse and document analysis to reconceptualize the treatment gap in relation to common mental disorders such as depression.

In response to such critiques, the Lancet Commission¹⁴ proposed replacing the notion of a “treatment gap” with that of a “care gap,”¹⁴(p.122) encompassing the unmet mental, physical, and social care needs of individuals with mental illness, including depression. Yet, this reframing arguably overlooks a more fundamental question regarding depression in LMICs: why do so few people in these settings engage with formal mental health services? Furthermore, what are the implications of framing solutions primarily through the lens of the mhGAP? And on what evidentiary basis is it claimed that large populations in LMICs are experiencing depression, thereby necessitating expanded awareness and intervention programs for both professionals and laypersons?

This article critically interrogates the development of global mental health policies and practices in LMICs that are strongly shaped by discourses of treatment and care gaps. We contend that persistent framings of mental health issues at the level of the individual obscure broader determinants of mental well-being and reinforce clinical rather than public health solutions.²¹ Drawing on Foucault, we argue that GMH frameworks and the mhGAP reflect historical assemblages that enable certain claims about depression while delimiting others, thereby reproducing biopolitical logics, governmental practices, and specific “conditions of possibility.”²⁷˒²⁸ In this sense, the mhGAP operates as part of the “knowledge-power processes that inscribe and materialize in the world in some forms rather than others,”²⁹(p.7) privileging particular interpretations of mental health while marginalizing alternatives.

Our analysis begins by situating the mhGAP-IG within the historical and political contexts of its development and dissemination. We then explore underexamined contributors to the treatment gap discourse: (1) limited demand for formal care due to non-medical conceptualizations of depression and related experiences, and (2) the implications these perspectives hold for how needs are identified and addressed. Ultimately, our objective is to demonstrate how prevailing GMH and mhGAP discourses structure both the possibilities and limitations of mental health care in LMICs, rendering certain forms of suffering and personhood visible, while leaving others unrecognized.

Methodology

Discourse Analysis

This study employs a biopolitical discourse analytic approach.²⁷˒²⁸ Broadly defined, discourse encompasses all written, spoken, and other communicative practices.²⁷ Foucault conceptualized discourses as “practices that systematically form the objects of which they speak,” shaping knowledge and social reality.²⁷(p.49) Discourse analysis, therefore, involves the systematic examination of such practices and their role in producing particular understandings of reality. As Maes observes, a productive way to engage with insider critiques of GMH is through “studying up,”³⁰(p.55) that is, employing critical ethnographic strategies of inquiry. In line with this perspective, the present analysis forms part of a larger ethnographic research project examining global mental health, biopolitics, and depression within the Ethiopian context. Data sources for this component include selected publicly available WHO international guidelines, relevant policy documents, and dominant discourses in GMH relating to depression.

Three core international guidelines implemented in LMICs to address depression were subject to critical analysis. Key elements such as definitions, management practices, and biopolitical discourses²⁷˒²⁸ were reviewed to illuminate the context and mechanisms underlying global scale-up initiatives in relation to depression. Central to the analysis is the question of how mhGAP-IGs function as “inscription devices,”³¹(p.63) which contribute to the quantification of mental health and depression while diverting attention from the material processes of their production, thereby shaping “the domains they appear to represent.”³²(p.198) Consequently, the mhGAP-IG is interpreted here as a culturally constituted artifact, with the objective of identifying both the conditions of its production and its “social uses and consequences as a social phenomenon.”³³(p.72)

The selection of these three guidelines was based on their widespread use as the principal conceptual framework, policy guide, and clinical instrument for depression within GMH initiatives. Notably, the mhGAP-IG 2.0 (2016) is the most widely disseminated, currently implemented in over 100 countries. It offers a detailed resource for the identification, treatment, training, and education concerning depression at the primary care level and has become the predominant clinical tool within global efforts to expand mental health services.

Additionally, classifications of Global North and Global South were employed to frame the analysis of power relations, recognizing historical trajectories, structural inequalities, and imbalances in influence that shape health policy and planning in the Global South.

Analyzing Documents: Discourses and Technologies of Rule

The mental health gap guidelines are diverse and variably enacted—discussed, interpreted, and operationalized differently across contexts¹⁰˒³⁴—and such variations hold analytic importance. The three documents central to this study embody several dominant discourses with ideological dimensions. The first is the WHO’s mhGAP-IG.⁸ This guide forms part of a larger set of resources, including training packages and operational manuals.⁸˒³⁴ It has become the principal clinical instrument in the strategy to scale up mental health services in LMICs and is framed as “the standard approach for all countries and health sectors; irrational and inappropriate interventions should be discouraged and weeded out.”⁶(p.1442) The second text is the Lancet Commission on Global Mental Health and Sustainable Development (hereafter, the Lancet Commission).¹⁴ The third is the WHO’s Depression Strategy.³⁵ Together, these documents warrant detailed examination because they establish the foundation of the GMH framework for addressing depression as a global public health priority, particularly within the Global South, while reinforcing treatment gap discourses. Although all three are analyzed, particular emphasis is placed on the mhGAP-IG. The WHO describes this resource as “an evidence-based technical tool aimed at supporting non-specialised healthcare providers to redistribute clinical tasks previously reserved for mental health specialists.”³⁶(p.75)

The mhGAP-IG is examined most extensively in this study given its far-reaching global influence: it has been adopted in more than 100 countries and translated into over 20 languages.¹¹˒¹² This significance necessitates close scrutiny of the conditions under which its tools and recommendations are produced, the theoretical and conceptual assumptions they embed about mental health (particularly depression), and the ways the knowledge they generate informs governance practices and lived experiences of mental health in the Global South. Findings are thus interpreted in relation to the historical, political, and cultural contexts in which these guidelines are situated, as well as their therapeutic, personal, and social implications for how depression is conceptualized and addressed.

Findings: Emerged Themes and Analysis

The review of the selected documents highlights a series of globally dominant discourses grounded in implicit and problematic assumptions that inform present practices in global mental health (GMH) and depression research. This analysis suggests that the prevailing GMH narrative unfolds across six central, ideologically driven themes: (1) The Architecture of Depression: The Coming into Being of an Illness Like No Other; (2) “The Reach Paradigm:” Universalization and the Transfer of Subjectivities; (3) Evidence-Based Treatment, Standardization, and Audit; (4) Individualization, Responsibilization, and Self-Management; (5) Routine Depression Screening in GMH: Psychiatric Risk Profiling of Human Suffering; and (6) Dancing with Complexity: The Supply and Demand Dilemma for Addressing the Depression Treatment Gap. Collectively, these themes act as powerful mechanisms that reinforce dominant norms, narrowing the scope of thought, inquiry, and intervention. The ideological foundations of each are discussed in detail below.

The Architecture of Depression: The Coming into Being of an Illness Like No Other

The mhGAP-IG and its associated “packages of care”37 were developed as tools to aid non-specialist providers in detecting, diagnosing, treating, and educating communities about common mental health disorders in LMICs. A central discourse in GMH highlights that treatment gaps for depression in LMICs range from 82–98 percent,13 necessitating expanded clinical services. The WHO’s mhGAP-IG 2.010 positions itself as a key resource for addressing this gap, describing itself as an “evidence-based” set of tools and guidelines for identifying, diagnosing, and managing the most prevalent mental, neurological, and substance use disorders,10, p. 2. Specifically, these resources were designed to support “non-specialist audiences”—general physicians, nurses, community health workers, as well as planners and managers.10

Beyond clinical utility, mhGAP-IG has also been used as a training resource and research framework in LMICs.10,11 Accordingly, Patel and colleagues note that it has become “the standard approach for all countries and health sectors,”6, p. 1,442. Over the past two decades, not only has depression been constructed as a universal and objectively measurable disorder, but the corresponding guidelines and pharmacological interventions have likewise been universalized, institutionalized, and legitimized on a global scale: guidelines for all—“to make mental health for all a reality,”6, p. 90. Such discourses have established these guidelines as the authoritative source of knowledge and evidence-based justification for research priorities, funding allocations, intervention design, and scientific agendas—what Foucault describes as a “regime of truth.”38,39

Foucault defines “truth” as “a system of ordered procedures for the production, regulation, distribution, and operation of statements,”39, p. 56. In the case of depression, this constructed “truth” has emerged through apparatuses and statements circulated via publications, global institutions, and advocacy networks. As a result, depression has been reframed as an “epidemic” and elevated to a planetary threat, pressuring governments in LMICs to expand access to antidepressants.40,41 This dynamic reflects the biopolitical exercise of truth and power. Importantly, in many LMIC contexts, depression is not viewed exclusively as a biomedical disorder. Rather, it is situated within broader sociocultural frameworks, shaped by cultural norms, social functioning, and local meaning systems that influence both perception and management.42–46

Decades of cross-cultural psychiatric research demonstrate that what constitutes clinically significant psychological distress varies across—and even within—cultural settings.25,46 Furthermore, in the Global South, emotional and psychological states are frequently interpreted as consequences of socioeconomic adversity rather than as medical conditions requiring formal health services.47–49 Thus, the persistent framing of depression in GMH as an illness unlike any other in LMICs contributes to the (re)production of subjectivities.27,28

The mhGAP-IG minimizes ongoing debates regarding the cross-cultural legitimacy of psychiatric categories and its reliance on psychotropic medication50 obscures structural drivers of distress while sidelining grassroots approaches to healing.21 It also positions mental health primarily as a technical service delivery challenge, solvable through “care packages.”50 This framing risks individualizing, pathologizing, and decontextualizing suffering, while shifting responsibility onto individuals.18,27,32 In doing so, such discourses hinder the development of alternative frameworks and systemic responses, instead reproducing inequities and perpetuating “epistemic injustice”51 in the ways depression is defined and managed in LMICs.

“The Reach Paradigm:” Universalization and the Transfer of Subjectivities

The widespread idea that the principal challenge in public mental health lies in expanding the reach of expertise to more people has been described as the “reach paradigm.”52, p. 67 Within GMH discourse, this notion has legitimized calls to increase and scale up clinical services in LMICs to meet mental health needs.53 The issue lies not in service expansion itself, but in the replication of services based on biomedical assumptions about depression’s universality, further reinforced through mhGAP frameworks. As these guidelines are explicitly framed as global standards6 and foundational for scaling depression services,8,9 they provide a rich site for examining how particular forms of knowledge and practice construct and sustain mental disorders as phenomena to be universally addressed through clinical solutions. Analyzing the biopolitical rationalities underpinning mhGAP thus sheds light on how universality is enacted, contested, and reproduced within GMH discourse, and on the “conceptual shifts and ruptures” that accompany these claims.54, p. 856

Universality within GMH remains “ambiguous and precarious,” produced contingently and collectively through historically situated, distributed practices of multiple actors.55, p. 277 One critical historical condition enabling the emergence of mhGAP guidelines is the rise of evidence-based medicine (EBM).24,54 Central to GMH’s construction of depression as a global issue is its emphasis on evidence-based interventions.4,11 EBM itself emerged as a transnationally influential framework, bringing together epidemiology and clinical research to systematize and render medicine more scientific.54 Where GMH-specific evidence is lacking, particularly in LMIC contexts where depression has been portrayed as a medical emergency,23,24,56,57 the absence of evidence is reconstituted discursively as a moral imperative.58

The WHO’s insistence on evidence-based guidelines such as mhGAP raises critical questions regarding what qualifies as valid evidence in GMH.19 Historically, systems of standardization have served as “sites of political and ethical work,”59, p. 147 since each standard “valorizes some point of view and silences another,”59, p. 156 making them integral to “knowledge-power processes that inscribe and materialize” the world in specific ways.29, p. 7 As Lakoff explains,60, p. 68 such standardization simplifies complexity and local specificity, transforming psychiatric constructs into portable, transferable assets—a process he calls “diagnostic liquidity.” Producing guidelines thus represents one of the primary practices through which the “apparently universal validity of biomedical knowledge” is forged and sustained via cross-domain standardization.60, p. 66–67

Empirical evidence reveals that the exportation of psychiatric constructs from high-income contexts to LMICs has altered manifestations of distress and created obstacles to recovery (e.g., family dynamics and expressed emotion in Tanzania, Peru, and Sri Lanka).61,62 In parallel, the mhGAP operates through material and discursive practices that aim to produce “universality” in mental health knowledge and in conceptions of depression. Consequently, these guidelines cannot be viewed as neutral or value-free, nor as simple descriptive tools; they are authoritative texts capable of shaping the very terrain of depression.

As Bowker and Star note,59, p. 1 such documents not only “sort things out” but also link domains together. The argument here is that GMH packages of care and WHO strategic guidelines advance particular definitions of mental health problems and delineate what counts as legitimate knowledge, despite their limited applicability in diverse LMIC contexts.22 In this way, diagnostic manuals and guidelines can reshape selfhood and personhood through “looping effects” operating both clinically and at the population level.63, p. 100 These effects describe how social categories influence lived experience, shaping individuals to conform to those categories.63 As Jarvis and Kirmayer observe, looping effects occur across multiple levels, from bodily processes to interpersonal relationships and wider social environments.64 On a societal scale, diagnostic categories take on figurative meaning as they move into popular discourse and everyday language.63,64

Thus, categories like depression may evolve into common idioms (e.g., “feeling depressed”), becoming part of everyday narratives about adversity.26 There is substantial evidence that the clinical application of “depression” as a category has enabled individuals to reinterpret their suffering in ways that alter experience, shape treatment expectations, and reinforce diagnostic practices in a self-perpetuating cycle.62,65 Such epistemic challenges tied to looping effects warrant serious consideration when evaluating GMH’s aspirations to address depression in LMIC contexts.

Evidence-Based Treatment, Standardization, and Audit

Depression is considered a condition that can be reliably identified and managed within primary care. For common mental disorders such as depression, the main interventions available in these settings are antidepressant medications and psychotherapeutic approaches. Delivering depression treatment at the primary care level is described as both feasible and cost-effective.
— The World Health Organization,35, p. 7

Although the reviewed documents encourage individuals, families, communities, and workplaces to assume greater responsibility in addressing depression, the mhGAP guideline demonstrates a particular focus on regulating professional practice, with the aim of directing clinicians’ choices toward cost-efficient outcomes. This orientation is expressed through two discursive strategies evident in the guideline: (1) the claim that only interventions deemed “evidence-based” should be promoted; and (2) advocacy for standardization and auditing of clinical practices to ensure alignment with evidence-based recommendations. Both strategies serve to limit the discretion of practitioners, who might otherwise rely on their contextual knowledge, training, and experience, thereby functioning as biopolitical technologies that enable governance “at a distance.”27

On the surface, prioritizing clinical practices supported by available evidence seems uncontroversial. Indeed, the discourse of evidence-based practice effectively closes off the ongoing debates surrounding the risks and benefits of depression treatments.9,10 Once treatment recommendations are teleologically justified as “evidence-based,” subsequent calls for standardization follow as logical extensions. However, as the wider literature highlights, several grounds exist for challenging these assumptions.

A key concern lies in the conventional “hierarchy of evidence,” in which data from randomized clinical trials is positioned as the “gold standard.”19,24,66 Critics argue that this framing privileges research focusing on individual-level factors and biomedical treatments while sidelining qualitative evidence that documents broader socioeconomic and political influences on health, and that emphasizes the importance of interventions targeting contextual determinants of distress.19,21,24

The mhGAP program’s construction of the treatment gap relies heavily on burden-of-disease metrics, which it cites frequently,5–7,40,41,67 a tendency also characteristic of the wider GMH literature.68, p. 1 These Global Burden of Disease (GBD) calculations operate as a key rhetorical device in global mental health.4 Yet scholars note that existing global data on the prevalence and causes of depression in diverse settings are considerably weaker than often acknowledged in arguments framing GMH as a moral imperative.56,57 Numbers, however, are inherently political, mobilized to serve ethical and policy objectives. As Starr observes, while “the characterization of people is myriad and subtly varied, statistical systems reduce complexity, incorporating this myriad into a single domain, and very often generating a single number that will appear in headlines, in speeches, and the reports.”69, p. 40

Projections from the WHO estimate that by 2030, the burden of disability and years of life lost to depression will exceed that of war, accidents, cancer, stroke, and cardiovascular disease.67,70 Such claims establish depression as a universal concern demanding global recognition and policy attention. Yet, in the process of heightening visibility, these statements also flatten complexity and erase the diverse realities and contributing factors that shape experiences of depression. Despite the contested nature of claims that clinical treatments should be prioritized because they are “evidence-based,” the mhGAP guidelines treat this notion as self-evident and unproblematic. This does not suggest that such discourses fully or uniformly constrain clinical autonomy; nevertheless, it is important to acknowledge how “evidence-based” discourse functions as a strategic mechanism for discrediting a spectrum of interventions situated outside the “clinical gaze.”71

This dynamic raises ethical concerns in LMIC contexts, where these guidelines serve as foundational resources for training psychiatric personnel, developing diagnostic and screening tools, and shaping public education.8,9,67 In practical terms, this often entails the dissemination of explanatory frameworks that may misalign with local interpretations or displace existing systems of meaning—those linked to coping, healing practices, social networks, and communal integration.18,21,24,72

Individualization, Responsibilization, and Self-Management

In articulating the problem to be addressed, documents such as the mhGAP guidelines primarily emphasize the individual with depression rather than the broader sociopolitical conditions—including prevailing policy choices—that may contribute to high levels of depression within the population. The Lancet Commission highlights aspects of the social and policy context that influence emotional well-being, noting, for instance, that inequitable social structures play a role in producing mental health problems.14 In its report, the Commission reframes mental health through a sustainable development perspective and recommends a dimensional model aligned along the spectrum of distress–disorder–disability.

The more recent New Lancet Commission2 has similarly urged collective action on depression. While calling for a public health perspective that acknowledges social determinants and the wide-ranging consequences of depression, it simultaneously underscores the importance of early detection and diagnosis, which presupposes effective access to health care. Although the Commission refers to “public health approaches” as a necessary part of a supportive environment for mental health,14 it does not elaborate substantially on this proposal. Instead, mental health continues to be portrayed as an individual-level issue in which persons are encouraged to recognize risks and adopt self-management strategies for what is ultimately constructed as a biologically rooted condition. This individual orientation is particularly visible in the Commission’s2 exploration of why depression continues to impose such a persistent disease burden.

The report emphasizes that although promotion and prevention interventions have been implemented in schools, workplaces, and communities, the prevalence of mental disorders continues to rise.1,2 Consequently, the explanatory focus is placed on deficiencies in knowledge and awareness that prevent individuals from recognizing depression and/or lead to inappropriate or ineffective treatment choices.1,2,9,10,14 Across the documents, people who are ill or at risk are framed as subjects who may, depending on their health and social environments, be more or less enabled to identify and manage their suffering—yet the underlying biomedical premise of individual pathology remains intact. Although this differs from earlier depictions of populations in need of global mental health resources as “passive recipients of treatment,” what emerges is another limiting construction: subjects who, as Nicolas Rose suggests, are incited to treat themselves as “enterprising selves” tasked with working upon their own emotional lives.32, p. 157

In short, even the latest iterations of GMH discourse continue to reinforce methodological individualism, privileging biological factors, risk profiles, and individual attributes as “targets of intervention” for depression. This orientation encourages the pursuit of behavioral or technological solutions disconnected from local contexts. Ultimately, a singular narrative of change emerges, perpetuating universalized values, beliefs, and practices concerning depression—whether or not they resonate with the actual conditions in which people live, or with the structural contributors to their distress.

Routine Depression Screening in GMH: Psychiatric Risk Profiling of Human Suffering?

Based on experience and the recent recommendations of the US Preventive Services Task Force, we propose the implementation of screening for depression in routine care…for all adult attenders. The use of brief, self-report questionnaires, such as the Patient Health Questionnaire (PHQ-9), takes a few minutes to complete, can be used to generate a diagnostic outcome, and shows sensitivity to treatment response. Routine screening for depression in adult primary care attendees is a vital milestone in the journey towards reducing the very large treatment gaps.
— Reynolds and Patel,73, p. 316

In response to the economic burden associated with depression, advocacy for the widespread adoption of routine screening has intensified.73,74 In the United States, despite limited supporting evidence,75,76 the U.S. Preventive Services Task Force (USPSTF) has recommended screening for all individuals aged 13 and older, including during pregnancy and the postpartum period.77

By contrast, both the United Kingdom and Canada—reviewing the same evidence—have explicitly advised against universal screening, citing risks of overdiagnosis, overtreatment, and unnecessary exposure to pharmacological interventions such as antidepressants and second-generation antipsychotics in the absence of sufficient demonstrated benefit.78 Although the practice remains contentious in the U.S. and other high-income settings, proponents within the global mental health movement strongly advocate its implementation in LMICs. For example, Reynolds and Patel73 lament that efforts to train primary care providers in Colombia, India, Sudan, and the Philippines to improve detection of mental disorders have not substantially raised diagnostic rates. They argue that routine screening of all primary care attendees with tools like the Patient Health Questionnaire (PHQ-9)—a nine-item instrument developed by Pfizer—represents a “critical milestone in the journey towards reducing the very large treatment gaps globally and scaling up the robust evidence on cost-effective interventions.”73, p. 316

The rationale for greater deployment of screening tools is frequently framed in terms of the social and economic “burden” of depression. However, this framing often obscures significant concerns regarding the ethnocentric character of such instruments.15 Within this discourse, depression functions as an “enoncé”79, p. 91 for GMH practices, whereby suffering is mapped, measured, and quantified. Once established, this “enoncé” continuously categorizes and counts individuals, ultimately producing new subjectivities—what Hacking describes as the “making up of people,”79, p. 99—through psychiatric classification. This does not imply that individuals experiencing distress are absent in LMICs, but rather that such experiences may not historically have been conceptualized as illness or depression, and therefore were not brought to psychological or psychiatric services.43,45–47

Within GMH discourse, the detection and treatment of depression in LMICs has thus become a central point of contention. On one hand, research indicates growing numbers of patients in primary care settings presenting with depressive symptoms,80 alongside a large treatment gap—approximately 90 percent of those seeking care reportedly do not receive it.1,2,12 Studies also demonstrate low rates of depression recognition.80–82 The “treatment gap paradigm,” with its rhetoric of urgency, has become both a critical “condition of possibility”27 and a central narrative device underpinning the mhGAP framework. Yet these contradictory findings prompt important questions: does the gap lie in access to treatment, or rather in the mismatch between global diagnostic instruments and local understandings of distress? Consequently, the logic of supply and demand embedded in the treatment gap paradigm remains a persistent challenge within the GMH field.

Dancing with Complexity: The Supply and Demand Dilemma for Addressing the Depression Treatment Gap in LMICs

Within global mental health (GMH) discourse, the treatment gap is typically framed as evidence of insufficient mental health services in LMICs, with the implication that most individuals experiencing depression do not receive the care they require.13 This gap has often been used to justify expanding access to mental health services, particularly in resource-limited contexts. Put differently, the problem is conceptualized as one of supply, underpinned by substantial evidence of resource deficiencies in mental health systems.53 Such deficits also motivated the development of international guidelines subsequently disseminated to LMICs with the aim of narrowing the gap. However, emerging evidence challenges this conventional supply-side interpretation of rationality in relation to depression and other common mental disorders. Findings from the World Mental Health Surveys, encompassing 24 countries and 63,678 respondents, indicate that the most frequently cited reason for not pursuing treatment was a lack of perceived need.47,83 This suggests that many individuals counted within the treatment gap do not in fact desire treatment for their depression or anxiety symptoms.47,48

Further studies corroborate that the endeavor of “closing the treatment gap” for depression and other common disorders within GMH research and practice is shaped more by demand than supply. For instance, the Programme for Improving Mental Healthcare (PRIME)—an eight-year initiative designed to enhance the supply of mental health services in five LMICs (Ethiopia, Uganda, India, Nepal, and South Africa)—demonstrated that service expansion alone does not reduce the treatment gap in the absence of corresponding demand.47

Despite this, GMH literature has devoted relatively limited attention to examining the fundamental reasons behind low demand for mental health services. Scholars in the field contend that limited uptake in LMICs is partly explained by stigma and practical access barriers, such as travel costs.5 Equally important, many individuals opt not to engage with or discontinue services because they regard their distress as arising from social and economic hardships rather than treatable medical disorders.47 For example, depression is often attributed to poverty, domestic conflict, unstable employment, or lack of livelihood opportunities, with an emphasis on addressing these social and economic conditions as the pathway to improved well-being.18,21,68,84 This disjuncture underscores the need to attend to psychosocial determinants alongside psychiatric interventions.

This argument aligns with the central tenet of the treatment gap and is reinforced in the recent Lancet–World Psychiatric Association Commission report, Time for United Action on Depression.2 While stigma and barriers to access are recognized contributors to low demand, they do not eliminate the importance of interrogating the compatibility of standardized definitions and treatments of depression with local understandings. Several qualitative studies across low-resource contexts in the Global South demonstrate that individuals often avoid or disengage from services because they interpret their psychological and emotional experiences as responses to social and economic adversity rather than as health conditions requiring medical care.45,47,48 These findings strengthen the case that decontextualized approaches to treatment are often viewed as irrelevant by those experiencing distress shaped by chronic adversity.47,68,84 Put differently, in addition to interventions within the health sector, broader societal responses to the social drivers of common mental disorders are indispensable.

In this regard, we concur with Summerfield, who highlights how the simple act of gifting a cow alleviated distress for a Cambodian farmer facing income insecurity—an intervention functioning as an “antidepressant and painkiller” outside the biomedical paradigm.16, par. 8 This example raises critical questions about whether the treatment gap should invariably be interpreted as reflecting an unmet need for formal services, as emphasized in GMH initiatives,68 or rather as limited demand for biomedical solutions to problems perceived as rooted in social and economic hardship.47,68,72 Moreover, this perspective reinforces concerns that decontextualized models of treatment may carry little relevance for individuals whose distress stems from persistent adversity such as conflict or extreme poverty.15,16,18,47,72 To effectively address depression and other common mental disorders, reconceptualizing the treatment gap is essential in the Global South, where diverse forms of adversity must be tackled directly and often outside clinical settings.

Discussion

Health policy-making in global health is an intricate and multidimensional process shaped by a wide array of influences, including scientific evidence, economic priorities, political ideologies, and prevailing social values.15–19 Within the Global South, where nations contend with distinctive challenges in delivering sufficient health care, power relations become especially critical in determining policy outcomes. These dynamics—often rooted in historical legacies, economic inequities, and geopolitical pressures—significantly affect how health policies are formulated, implemented, and evaluated.15,20 The field of global mental health (GMH) adds an additional layer of complexity to this policy environment.

Power relations within GMH emerge in several notable ways. First, a stark imbalance exists between high-income countries, where the bulk of mental health research is undertaken, and LMICs, which are frequently identified as carrying the greatest burden of mental disorders.1–3 Despite this, LMICs continue to experience a shortage of contextually grounded research.15–19,23,24 Interventions promoted for scale-up are generally aligned with research paradigms privileged by evidence-based medicine, favoring pharmacological treatments and structured psychotherapies. These approaches often overlook or disempower local actors, limiting opportunities to interrogate the assumptions embedded within GMH frameworks or to mobilize indigenous competencies in psychosocial support and community care.15,21

Second, international agencies and global initiatives—most notably the WHO’s Mental Health Action Plan (2013–2020), now extended to 203014—exercise substantial influence in setting mental health agendas for the Global South. While these bodies hold considerable authority in shaping priorities, their policies do not always correspond to the heterogeneous needs and cultural contexts of individual countries.

The current logic of scale within GMH is heavily informed by the perceived achievements of the global HIV/AIDS response, framing mental health as a worldwide issue solvable through universal interventions.15 This perspective raises fundamental questions about what, precisely, is being scaled and the political dynamics that underlie this process.15,19,24 GMH strategies often replicate Western psychiatric paradigms, emphasizing symptom-based management and standardized interventions, thereby prompting scrutiny over their global validity. Although GMH has attempted to address these critiques through a “staging model of mental disorders”,14 it nonetheless continues to privilege psychiatric diagnosis and classification as “indispensable for clinical practice”,14, p. 33. This framing shapes intervention strategies by privileging the expansion of evidence-based treatments, despite ongoing debates regarding the transferability and limitations of evidence-based medicine across global contexts. In doing so, GMH reinforces hierarchical distinctions between the global and the local, privileging the former over the latter.

Furthermore, GMH’s orientation is deeply influenced by neoliberal priorities, valuing economic productivity above comprehensive well-being. Within this framework, mental health services are predominantly assessed in terms of cost-effectiveness and their capacity to restore individuals to the workforce, particularly with respect to depression.3 Such economic reductionism risks obscuring a more holistic appreciation of mental health, one that acknowledges broader social and structural determinants alongside clinical care. Instead of focusing solely on clinical treatment for individuals, attention must shift toward the capacity of systems to support people in leading meaningful and socially inclusive lives. This reconceptualization underscores the need to reframe mental health care by recognizing the interdependent social and structural factors that shape it. Achieving this requires reexamining the values embedded in scale-up strategies and critically addressing the power asymmetries that dictate what is framed as “global” or “local” and which interventions gain priority in dissemination and promotion.

Conclusion

A fundamental precondition—and a central narrative device—underpinning the development of mhGAP and its related products is the construction of the treatment gap. GMH presumes that depression treatment gaps in LMICs are vast. Within GMH discourse, the term treatment gap is typically understood to mean that mental health services are unavailable in LMICs and that individuals experiencing mental disorders such as depression are not receiving the necessary care. Consequently, the management of depression within health care systems has been prioritized. However, through our critical discourse and document analysis, we identified a series of key themes that contest the prevailing approach to depression in GMH within resource-limited contexts.

Our analysis illustrates that entrenched ideological norms exert considerable influence—both explicitly and implicitly—on GMH’s programmatic strategies and scope for addressing depression. One clear example is the extreme recommendations advanced by GMH leaders, such as universal depression screening73 at the primary health care level, with the aim of narrowing the treatment gap, despite two decades of research continuing to demonstrate low detection rates for depression.80–82 The mhGAP guidelines exemplify a techno-scientific artifact that underpins the construction of mental health as a universal phenomenon.11,15,61 Yet, the universality generated through the mhGAP’s implementation is inevitably partial and conditional.85–88 Importantly, international guidelines are embedded within and disseminated through the broader GMH assemblage, which is shaped by rhetorical global metrics (e.g., burden of disease), funding streams, and evidence-based medicine (EBM).

The mhGAP has provided a moral justification for action, grounded in the quantified framing of depression as a global crisis, and has been pivotal in amplifying depression’s visibility over the past two decades. In this context, the mhGAP-IG has been presented as a solution—a means for governments and clinicians in the Global South to reduce the statistical burden of psychiatric conditions such as depression. Moreover, mhGAP-IG has been mobilized in producing metrics, including economic models that underscore the financial burden of depression and justify interventions in terms of “return on investment.”3, p. 415

This analysis highlighted how international guidelines such as mhGAP operate as part of “knowledge-power processes that inscribe and materialize”29, p. 7—conceptualizing mental health (as illness, as universal, and as measurable) in ways that diverge from other contexts. From this perspective, mhGAP-IG can be understood as a global “inscription device” that consolidates and reproduces particular theories and practices.20,31 Consequently, the “ethno-specific narrative field”29, p. 4 of mhGAP-IG is presented as universal, with the guidelines circulating and embedding interpretations of distress already defined by Euro-American traditions.15,88 In effect, the dominant GMH paradigm sustains the problematic presumption that emotions and behaviors are universally pathological when expressed as “symptoms,” irrespective of cultural context.18

The continuous framing of mental health issues, particularly depression, in individualistic terms obscures the broader social determinants of distress and privileges clinical interventions over public health strategies.21 A growing body of research has also expressed concern that standardized diagnostic criteria do not adequately reflect locally meaningful constructs, given the variation in idioms of distress across settings.42,43 Since its inception, the GMH movement has sidestepped longstanding questions about the cultural applicability of Western-derived diagnostic categories and treatments. Instead, global initiatives have emphasized scaling up interventions without first interrogating whether standardized diagnostic frameworks are appropriate as the foundation for assessing need and expanding access to care.

It is therefore crucial to critically interrogate the epistemological assumptions underpinning the mhGAP imaginary. Moving forward, critiques of mhGAP-IG must be taken seriously—both with respect to its internal paradigm and through alternative epistemological perspectives. Particularly valuable are insights from “user/survivor/mad” communities, as well as situated, localized, and indigenous epistemologies.89 We argue that transformative change in GMH strategies can occur only by critically revisiting the assumptions and norms shaping both the production of knowledge and the programmatic actions derived from it. By inverting dominant discourses, there is scope to develop alternative frameworks and innovative approaches that reorient the field in more inclusive and contextually sensitive directions.

It is important to emphasize that our objective in this analysis is not to undermine the aspirations of GMH, but rather to highlight fundamental issues with its persistent framing of mental health through the treatment gap narrative. This framing advances standardized global packages of care while neglecting local realities. We emphasize that addressing depression outside of clinical environments is just as critical as addressing it within formal health care. Given that the dominant GMH discourse has prioritized health system responses, the treatment gap paradigm has constrained the scope of interventions by neglecting root causes. Notably, its clinical orientation sidelines the wider socio-cultural and economic adversities that significantly contribute to depression.

Although this study contributes to the literature on GMH, depression research, and practice, it carries limitations. For instance, it did not closely examine how mhGAP guidelines are implemented across diverse contexts, nor did it analyze the broader epistemic infrastructure within which these guidelines are situated. Crucially, it did not assess how diagnoses and recommendations shape the lives and subjectivities of those affected. Nevertheless, this article demonstrates that the universality of mental disorders is both conditional and partial, and that GMH strategies to address depression can best be understood as “contingent universals”85,87 on which its central thesis rests. Furthermore, although GMH has emphasized extending services to all individuals meeting diagnostic criteria for common mental disorders, many do not perceive themselves as requiring—or desiring—such treatment. Therefore, the goal of expanding access must extend beyond fulfilling “the human right to care” to ensuring that individuals are empowered to enhance their lives in ways they themselves deem meaningful (,47 p. 555).

In conclusion, while interventions that respond to mental health needs are central to GMH, treatment alone does not necessarily satisfy these needs. The concept of what constitutes a mental health intervention must therefore be broadened. The objectives of GMH—expanding access to care and strengthening services in LMICs—remain valid and necessary. However, durable progress in alleviating mental distress globally will not be achieved through additional psychiatric interventions alone. Meaningful improvements in mental health outcomes in LMICs will require wide-ranging socio-economic and political reforms that directly address the structural determinants of distress. To genuinely advance in addressing depression in the Global South, GMH must move beyond the confines of the treatment gap paradigm.

Acknowledgements

The authors would like to thank colleagues at the University of Ibadan and the University of São Paulo for their constructive comments on earlier drafts. Special thanks also go to participants in the Global South Mental Health Policy Network for sharing insights that informed this critique.

Funding

This research did not receive any external funding.

Conflict of Interest

The authors declare no conflicts of interest related to this work.

Author Contributions

S.O.A. conceived the study, conducted the primary analysis, and drafted the manuscript. C.L.M. contributed to the theoretical framework and Foucauldian analysis. M.R.D.S. and F.K.E.-M. provided regional case studies and contextual interpretation. All authors revised the manuscript critically and approved the final version.

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