Setting the scene
It is increasingly recognised that norms are part and parcel of everyday life. They influence and guide attitudes and behaviours and they are produced and reproduced both formally and informally through a range of mechanisms and institutions, including social interactions. Many of these norms are gendered and discriminatory, often affecting girls and women more than boys and men. Hence, largely as girls enter puberty, they are often forced into early marriage, expected to bear male offspring, anticipated to drop-out of school and encouraged not to, or prevented from, seeing or talking to other males. The effects of these gendered norms are far-reaching and touch on most domains of a person’s life, including on their mental health and psychosocial well-being and can result in girls and women facing isolation, depression, anxiety, fear and sometimes even contemplate or carry out suicide.
Before exploring these issues further, it is important to provide a brief background on the prevalence of mental health problems as well as their causes, as is conceptualised in the broader literature. Mental health problems affect more than one in four persons with disorders like depression affecting more than 350 million people globally (WHO, 2015a). Additionally, suicide, linked strongly in high income countries with depression, claims the lives of over 800,000 people annually across the globe (WHO, 2015b) and between 1990 and 2010, the burden of mental and substance use disorders increased by 37.6% globally (Whiteford et al., 2013). Mental ill-health and psychosocial problems often start during adolescence with common mental disorders (CMD), comprising anxiety and depression, being the most prevalent psychiatric illnesses among adolescents and young people worldwide (WHO, 2001a). Other studies show that suicide rates (often a result of un-diagnosed and untreated mental ill-health and psychosocial distress) among young people are increasing, with young people now the highest-risk group for suicide in around 30% of all countries; moreover, in China, India and the South-East Asia region, suicide is the leading cause of death among those aged 15 to 19 (Patel et al. 2007; WHO 2014; WHO 2016; Samuels et al, 2016).
A body of literature across various disciplines, though largely from psychology, explores the causes of mental ill-health and psychosocial distress showing that it is multifactorial and includes biological, psychological and social and environmental factors (see e.g. Chesney et al, 2015; WHO 2001; WHO and Calouste Gulbenkian Foundation, 2014). It is the latter group of causes i.e. the social factors and environmental, to which this piece contributes. In so doing, it focuses on mental ill-health and psychosocial distress at the milder end of the mental health disorder spectrum, also referred to as common mental disorders (CMDs), and largely to what have been defined internationally as internalising/emotional problems such as anxiety, depression, loneliness, sadness and somatic complaints, all of which can have a range of negative outcomes, including suicide. This piece also focuses largely on the Global South, though, critically such issues are just as pertinent to the Global North including in the UK where there has been considerable recent media attention on mental ill-health, largely again focused on CMDs and as a consequence of social and environmental factors (see, for example, this recent article in the Guardian which notes that being lonely can be as bad for ones health as having a long-term illness).
According to WHO, mental disorders are defined as “a combination of abnormal thoughts, perceptions, emotions, behaviour and relationships with others,” whereas biologically based disorders can include depression, bipolar affective disorder, schizophrenia and other psychoses, dementia, intellectual disabilities and developmental disorders including autism (WHO, fact sheet 2015a).
In addition to biologically based disorders, mental health can also be affected by psychosocial factors that cause distress. According to the Capetown Principles, “‘psychological effects' are defined as those experiences that affect emotions, behaviour, thoughts, memory and learning ability and the perception and understanding of a given situation” (Capetown Principles, UNICEF 1997). These include social effects on well-being as a result of various factors such as poverty, war, migration, famine and climate change.
In May and June, 2015, media outlets around the world reported a devastating new finding that shocked the public and public health researchers alike. The Telegraph, Guardian, and National Public Radio all published articles highlighting the fact that suicide had surpassed maternal mortality as the leading cause of death among girls aged 15–19 years globally.