In the wake of US President Joe Biden dropping out of the 2024 presidential race, the internet has come alive with news stories, social media posts and humor generated by this monumental decision. But one meme has stood out, featuring the presumptive Democratic candidate, Vice-President Kamala Harris. She recounts one of her mother’s favorite turns of phrase to describe young people’s tendency to neglect the influence of previous generations, “You think you just fell out of a coconut tree? You exist in the context of all in which you live and what came before you.”

Although Harris was referring to family and economic opportunities, it is an apropos sentiment to apply to health, as well as mental health. Social and cultural forces have long been hypothesized to shape concepts of self, expressions of self and self-regulation. Although ‘country’ identification can be conflated with a predominant culture artificially circumscribed by borders, it confers at least some level of connectedness to a certain set of customs, beliefs and norms. Not surprisingly, the idea that one’s country or cultural contact can shape an individual has been part of scholarly discourse for centuries among theologians, philosophers and anthropologists. At a fundamental level, understanding the human condition and mental health requires the discussion of culture.

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The nuanced ways in which a country or culture may interact with an individual’s biology alongside institutional and structural factors warrant prominence in theoretical models of mental health and risk of developing mental health disorders. Contemporary frameworks that incorporate social determinants of mental health include cultural components and can highlight the potential additive effects of culture in shaping an individual’s experience. The extent to which someone is likely to engage in help-seeking behavior for a mental health condition can be predicated on cultural or community norms. For example, as a group, Asian Americans are less likely to utilize mental health services. The experience of stigma around mental health issues is often magnified in eastern cultures, where an individual’s behaviors and health can reflect on their familial lineage. By contrast, there are culturally salient factors, such as one’s proficiency in English language or feminine gender, that can serve to lessen stigma and promote contact with mental health providers.

Although there can be major barriers to accessing mental health care prompted by cultural influences, access itself is subject to community and country-level constraints, including funding for compensating providers, training for specialized care for certain groups, and coverage for medication and treatment. Culturally competent or responsive care, which is designed to involve stakeholders and representation from community members, integrates components of mental health care that may be outside of more medicalized treatment and can include religion, spirituality or the arts, and relies on active dismantling of impediments to receiving treatment, such as increasing access to telemedicine or group therapy. Improving the quality and accessibility of mental health care also incorporates a broad view of culture and cultural needs in the sense that individual mental health is woven together with intersectional identity and community — for example, being a woman, identifying as LGBT+, or immigration status. The complexity of identity and culture make one-size-fits-all mental health approaches obsolete and inadequate.

The August 2024 issue of Nature Mental Health includes several pieces that highlight some of the ways in which country setting or culture can influence mental health. In their Perspective, Toffol et al. discuss recent country-level developments in the programs for one of the most vulnerable groups, children of parents with a mental illness (COPMI). The authors discuss some of the key lessons learned from intervention programs aimed at COPMI, including European projects in Germany, Denmark and Austria. The authors outline specific barriers and problems, and propose facilitators and recommendations to identify affected children as early as possible, and provide culturally responsive and interconnected mental health care for people who have often been underserved.

Australia’s Emerging Minds program is another national strategy that trains professionals to identify, assess and support COPMI with a cultural lens. In addition to specific programming for children, the project oversees training and resources for practitioners, families and researchers that specifically focus on children’s mental health. People of Aboriginal and Torres Strait Islander heritage in Australia have long experienced racial discrimination associated with negative physical and mental health consequences. Emerging Minds incorporates training pathways that encompass unique cultural experiences, drawing on spiritual and cultural concepts and tenets, the interaction with social, legal and political frameworks in Australia, and considers the intergenerational trauma that affects families and communities.

In an Article, Agarwal et al. report an association between stock market fluctuations and mental and physical health effects, providing another vantage point to appreciate the potential influence of culture and country context. Tracking daily market returns alongside visits to emergency rooms at three of the largest hospitals in Beijing over a four-year period (2009–2012), stock market declines were linked to significant increases in emergency room visits for stress-related issues, including cardiovascular disease, mental health concerns and alcohol abuse. Notably, older adults and men were the groups most affected by these fluctuations.

Although these data are considered ‘historical’ (which can probably apply to most data collected before the onset of the COVID-19 pandemic), they provide unique insights into the Chinese cultural context and the potential mental health effects of economic volatility in a developing country. Much of the previous work in this area was conducted in high-income countries, where a greater proportion of individuals sampled were seasoned investors. By contrast, investors in the time frame assessed in Beijing were more likely to be novices who were interacting with a less sophisticated and less stable market, underscoring the immediacy of stress-related responses. These findings suggest that economic shock and volatility can be considered substantial public health concerns, even more so for resource-limited individuals in developing countries

Health systems data from different regions or countries can also reflect ‘natural experiments’, such as emergency room visits prompted by disasters or crises. With so much scrutiny in recent years on overdose deaths, rising stimulant prescriptions and mental health diagnoses, hospital admissions data can often provide insights into current versus previous timepoints in an epidemiological landscape. In their Article, Xing et al. look at hospital admissions in the USA over more than a decade, using weighted National Inpatient Survey data from 2008 to 2020. The authors report a 10.5-fold increase in mental health disorder-related hospital admissions with concurrent methamphetamine use. Hospital admissions related to mental health disorders increased only modestly during this period (1.4-fold), but these data point to the enormous burden on US hospital systems presented by the increased methamphetamine use — a phenomenon that differentially affects North America.

These are just a few examples of research where culture or country setting may enhance the interpretation of the results or provide additional background, and it is vital that more work is done specifically in cultural mental health research, and also to better understand the specific structures and institutions within country and regional mental health care systems. Nature Mental Health takes a keen interest in work that describes and documents mental health care systems internationally. By presenting and discussing for whom and how mental health care is organized and delivered, and by disseminating shortcomings and achievements, we move closer to better treatment, improved access, training and outcomes. The contexts and what came before us do not have to limit mental health care, but instead can inform and determine where we go next.