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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: World Psychiatric Association
- Sprache: Englisch
Written by many of the world's leading practitioners in the delivery of mental health care, this book clearly presents the results of scientific research about care and treatment for people with mental illness in community settings. The book presents clear accounts of what is known, extensively referenced, with critical appraisals of the strength of the evidence and the robustness of the conclusions that can be drawn. Improving Mental Health Care adds to our knowledge of the challenge and the solutions and stands to make a significant contribution to global mental health.
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Veröffentlichungsjahr: 2013
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Contents
Contributors
SECTION 1 The global challenge
CHAPTER 1 The nature and scale of the global mental health challenge
Introduction
The nature of the challenge
The scale of the challenge
From evidence to practice
Conclusions
References
CHAPTER 2 Scaling up mental health care in resource-poor settings
Introduction
Assessment of needs, resources and constraints
Scaling up care
mhGAP framework for scaling up care
Political commitment
Development of a policy and legislative infrastructure
Development and delivery of the intervention package
Strengthening human resources
Mobilisation of financial resources
Monitoring and evaluation
Building partnerships
Conclusion
References
CHAPTER 3 The swings and roundabouts of community mental health: The UK fairground
Brief history of community psychiatry before 1950
Phase 1: Outpatient care
Phase 2: Extending into primary care
Phase 3: The community mental health team
Phase 4: Assertive outreach treatment
Phase 5: Crisis resolution and home treatment teams
A synthesis
References
CHAPTER 4 Mental health services and recovery
What is recovery?
The dominance of personal recovery
How recovery can be supported by mental health services
The evidence for personal recovery
The REFOCUS intervention
Future developments
References
SECTION 2 Meeting the global challenge
CHAPTER 5 Implementing evidence-based treatments in routine mental health services: Strategies, obstacles, new developments to better target care provided
Introduction
Discrepancies between research evidence and clinical practice: The efficacy–effectiveness and the evidence–practice gaps
Translating research evidence into clinical practice: The case of early intervention in psychosis
Challenges and obstacles of implementing evidence-based treatment in early psychosis
Implementing evidence-based early interventions in routine settings: The GET UP programme
Increasing knowledge on the interplay between biological, environmental and clinical factors to better target implementation of treatments
Conclusion
References
CHAPTER 6 The need for new models of care for people with severe mental illness in low- and middle-income countries
Introduction
Development of community-based care in LAMICs
The context of Latin America
The experience of Chile
Implications for global mental health
Acknowledgement
References
CHAPTER 7 The role of primary care in low- and middle-income countries
Introduction
Setting up mental illness services in primary care
Evidence-based interventions in low- and middle-income countries: The Mental Health GAP
Different forms of collaboration between psychiatric and primary care services
Evidence of effectiveness and cost-effectiveness of collaboration between the two services
Other studies of interventions in primary care in LAMICs for common mental disorders
Things that can, and do, go wrong
A centrally mandated and funded national plan, but poor local acceptance
Failures at local level
Poor supervision of the trained staff
Local managers assign low priority to mental health work
The availability and quality of psychotropic drugs
Community services for severe mental disorders in low-income countries
Using traditional healers to supplement PHC services
What are the positive arguments for mental health services based in primary care?
References
CHAPTER 8 Meeting the challenge of physical comorbidity and unhealthy lifestyles
Introduction
An exploratory intervention project
Background: From the early studies to a widespread interest in physical comorbidity of mental patients
Physical diseases in comorbidity
Risk factors
Lifestyles
Interventions
The health promotion study in South Verona (PHYSICO I)
Conclusions
References
CHAPTER 9 Complex interventions in mental health services research: Potential, limitations and challenges
Introduction
Process evaluation: What is its importance?
Five examples of complex intervention trials and understanding processes
Discussion
Conclusion
Acknowledgement
References
CHAPTER 10 The feasibility of applying the clinical staging paradigm to the care of people with mental disorders
Clinical staging: A new paradigm for intervention in mental health
Principles underlying the application of the clinical staging model to mental disorders
New perspectives in mental health prevention
The duration of untreated mental illness and its consequences
The critical period in mental illness
Objectives of early intervention
Operational criteria for the early stages of mental disorders
Stage 0: ‘At-risk asymptomatic’
Stage 1: The prodrome
Stage 2: The first episode of a full-threshold disorder
Stages 3 and 4: Incomplete recovery, relapse and treatment resistance after the first episode
Strategies of mental health care in the clinical staging model
Repercussions of the application of clinical stage paradigm
References
CHAPTER 11 Work, mental health and depression
Introduction
Work and mental health
Changes in the workplace
Socio-political context
Different mental disorders and work
Work and depression
Work and bipolar disorder
Mental health, mental health care and work: Own studies
Conclusions and discussion
Acknowledgements
References
CHAPTER 12 Training mental health providers in better communication with their patients
Introduction
Key concepts
Implications for training
Implications for assessment and evaluation
Conclusions
References
CHAPTER 13 Making an economic case for better mental health services
Introduction: The relevance of economics
Efficiency and equity
Economic evaluation
Links to policy and practice
Conclusions
References
SECTION 3 New research methods
CHAPTER 14 Incorporating local information and prior expert knowledge to evidence-informed mental health system research
Introduction
Evidence-based care in health system research
‘Consilience’ approach to health service research
Incorporating observational/local information to the evidence base
Incorporating prior expert knowledge to data analysis
The evidence-based cooperative analysis approach
Conclusion
References
CHAPTER 15 Innovative epidemiological methods
Introduction
Analyses of costs in mental health
Social conditions and mental health
Mental health services utilisation and socio-economic status
Accessibility to mental health services
Determinants of different pathways of care
Mortality studies in mental health
Conclusions
Note
References
CHAPTER 16 Routine outcome monitoring: A tool to improve the quality of mental health care?
Introduction
The Australian and Dutch national ROM models
Outline of the Groningen online ROM application (RoQua)
ROM implementation
ROM outcomes for clinicians
ROM and health-care consumers
Conclusion
References
CHAPTER 17 Psychiatric case registers: Their use in the era of global mental health
Introduction
Definition
Types of use
Strengths and limitations
Ethics
The future for psychiatric register research
Final remarks
References
CHAPTER 18 Can brain imaging address psychosocial functioning and outcome in schizophrenia?
Introduction
Acknowledgements
References
CHAPTER 19 Statistics and the evaluation of the effects of randomised health-care interventions
Introduction
What do we mean by a treatment effect?
Treatment-effect heterogeneity
Average treatment effects
Estimating average treatment effects from a perfect randomised trial
Estimating average treatment effects from observational data
Estimating efficacy in a broken RCT: Complier-average causal effects
Instrumental variable regression
Equivalence and non-inferiority
Further discussion and conclusions
References
CHAPTER 20 Service user involvement in mental health research
Introduction
History of user-led research
Developing new methods: The case of outcome measures
International developments
Concepts
Challenges to user-led research
Conclusion
References
SECTION 4 Delivering better care in the community
CHAPTER 21 Psychotropic drug epidemiology and systematic reviews of randomised clinical trials: The roads travelled, the roads ahead
The roads travelled
The roads ahead
References
CHAPTER 22 Services for people with severe mental disorders in high-income countries: From efficacy to effectiveness
Introduction
Community psychiatric services: Fit for purpose? Which purpose?
Beyond the generic community mental health team
Crisis resolution
Problems in identifying cost-effectiveness
Social and psychological interventions in psychosis
Treatment innovations and the attributes of psychosis
Insomnia and psychosis
Recent epidemiological findings
Appraisals and reasoning processes
Negative symptoms
Towards personalised treatment
Combining interventions
Conclusions
References
CHAPTER 23 The management of mental disorders in the primary care setting
Introduction
Organisation of primary care services
The prevalence of mental health disorders in primary care
Psychotropic drug treatment
Conclusions
References
CHAPTER 24 Some wobbly planks in the platform of mental health care
Introduction
Estimating mental health needs
Providing community care
Task shifting
Mental health care can be provided at a low cost
Coda
Note
References
CHAPTER 25 Treatment gaps and knowledge gaps in mental health: Schizophrenia as a global challenge
Introduction: Schizophrenia in the global burden of disease
Origins and metamorphoses of the concept of schizophrenia
Uses and abuses of the concept of schizophrenia
Schizophrenia today: Advances in neuroscience and genetics
Variations in the prevalence and incidence of schizophrenia
Variations in the course and outcome of schizophrenia
The burden of comorbidity and mortality
Social and economic costs of schizophrenia
Conclusions and future directions
References
Index
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Library of Congress Cataloging-in-Publication Data
Improving mental health care : the global challenge / edited by Graham Thornicroft, Mirella Ruggeri, David Goldberg.p. ; cm.Includes bibliographical references and index.
ISBN 978-1-118-33797-4 (hardback : alk. paper) – ISBN 978-1-118-33798-1 (obook online product) – ISBN 978-1-118-33799-8 (eMobi) – ISBN 978-1-118-33800-1 (ePub) – ISBN 978-1-118-33801-8 (ePDF)I. Thornicroft, Graham. II. Ruggeri, Mirella. III. Goldberg, David P.[DNLM: 1. Mental Health Services. 2. Community Mental Health Services. 3. Delivery of Health Care. 4. Mental Disorders–therapy. 5. Socioeconomic Factors. 6. World Health. WM 30.1] RA790.5362.2′2–dc23
2013003251
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Maggiorina Valbusa, Untitled, Acrylic on canvas, 2009, Verona, ItalyCover design by Sarah Dickenson
Dedication
This book is appearing at the time Michele Tansella is due to retire. His colleagues both in Italy and elsewhere have marked the occasion by considering the enormous contribution he has made to mental health services in community settings. He has made the services in South Verona known to mental health professionals across the world and has been immensely influential in influencing the development of community care internationally.
The volume that has resulted has aimed to provide clear guidance on how mental health services can be provided in both high- and low-income countries, bearing in mind both the manpower and resource available in each. It is still sadly the case that most beds for patients with mental disorders are situated in mental hospitals in low-income countries: this book describes the way in which services can progress beyond this, so that community-based services can be developed. The book describes these developments and emphasises the important part that primary care services must provide in all countries, regardless of their income, in providing mental health services that are truly comprehensive.
New services need new research methods and new planning decisions. These topics are fully covered and there are also two chapters (Chapters 3 and 24) on the good and bad points in community services that have developed in high-income countries. New services need to take account of conditions that exist in any particular country, but wherever they are developed services need to be readily accessible and provided in environments which are non-institutional.
Michele Tansella arrived in Verona from the Istituto Mario Negri in Milano in 1969, then soon left to spend six months at the Institute of Psychiatry in London. At that time, he had little to learn about community mental health services at the Maudsley Hospital but a great deal to learn about epidemiology and the systematic collection and analysis of data. He also widened his circle of professional colleagues and has brought many of the authors of the present chapters to visit the Verona service and publish comparative studies. During an earlier visit to the Institute, he met his wife Christa, who has assisted him at every stage in building up a united and happy Department, publishing many joint papers [1, 2]. Michele returned to Verona in early 1970 and collaborated with the team charged with the responsibility of setting up new mental health services in South Verona.
Michele quickly made his mark, insisting from the start on the meticulous collection of data about every aspect of the developing service [3]. In those early years, he advocated the changes introduced to Italian psychiatry by Law 180 which eventually prevented new admissions to mental hospitals, in favour of services offered in less formal community settings [4, 5]. The first formal description of the South Verona service in a high-impact journal was published in 1985 [6], followed by the first description of the all-important case register [7] dealing with the epidemiology of schizophrenia in a community setting. Since that time, he has published many informative accounts of the local services [8].
Over the next few years Michele trained many future Italian academic psychiatrists, building up a formidable team of psychiatric researchers. Since these early years, he has published 286 papers in international peer-reviewed journals, as well as numerous books and chapters. A most important development was his book with Graham Thornicroft called The Mental Health Matrix, which sets out a detailed plan for providing mental health services to a community. The book was translated into four languages [9] and more recently brought up to date [10] in Better Mental Health Care (now translated into eight languages).
Since 1992, Michele has edited Epidemiologia e Psichiatria Sociale (now retitled Epidemiology and Psychiatric Sciences), which has been important in providing Italian psychiatrists with a forum for exchanging views and data. The journal has continuously increased its international reputation; in 2011, it was ranked 22nd of the 117 Journals quoted by the Journal Citation Reports within the category ‘Psychiatry’. Since 1997, Michele has edited Social Psychiatry and Psychiatric Epidemiology and is a member of the board of several international journals. Between 2006 and September 2012, he served two consecutive terms as Dean of the University of Verona’s medical school.
Under Michele’s leadership, Verona was designated by the World Health Organization as “Collaborating Centre for Research and Training in Mental Health” on February 1987, confirmed in 2001, 2005, 2009 and still active. By 2005, his team of 23 tenured staff had produced 2000 citations in high-impact journals, and this figure climbed to 12 400 in 2011. In that year, there were 58 papers published by the team, including high-impact journals such as Lancet, BMJ, American Journal of Psychiatry and Biological Psychiatry.
These bare facts give little impression of the man. Michele is warm, witty and excellent company. He is fiercely proud of what has been achieved in South Verona and has been a major influence on the development of services for people with mental illness across the world.
References
[1] Zimmermann-Tansella C, Tansella M, Lader M. (1976) The effects of chlordesmethyldiazepam on behavioral performance and subjective judgment in normal subjects. Journal of Clinical Pharmacology10: 481–488.
[2] Zimmermann-Tansella C, Tansella M, Lader M. (1979) Psychological performance in anxious patients treated with diazepam. Progress in Neuro-Psychopharmacology3 (4): 361–368.
[3] Tansella M. (1974) An institution-based register in a psychiatric university clinic. Psychiatria Clinica7 (2): 84–88.
[4] Tansella M. (1985) Misunderstanding the Italian Experience. British Journal of Psychiatry147: 450–452.
[5] Tansella M. (1986) Community psychiatry without mental hospitals – the Italian Experience – a review. Journal of the Royal Society of Medicine79: 664–669.
[6] Siciliani O, Bellantuono C, Williams P et al. (1985) Self-reported use of psychotropic drugs and alcohol abuse in South-Verona. Psychological Medicine15 (4): 821–826.
[7] Tansella M. (ed.) (1991) Community-Based Psychiatry. Long-Term Patterns of Care in South-Verona. Psychological Medicine Monograph Supplement 19. Cambridge: Cambridge University Press, pp. 1–54.
[8] Tansella M, Amaddeo F, Burti L et al. (2006) Evaluating a community-based mental health service focusing on severe mental illness. The Verona experience. Acta Psychiatrica Scandinavica429 (Suppl.): 90–94.
[9] Thornicroft G, Tansella M. (1999) The Mental Health Matrix. A Manual to Improve Services. Cambridge: Cambridge University Press, pp. 1–291.
[10] Thornicroft G, Tansella M. (2009) Better Mental Health Care. Cambridge: Cambridge University Press, pp. 1–184.
Contributors
Ruben AlvaradoFaculty of Medicine, Salvador Allende School of Public Health, University of Chile, Santiago, ChileFrancesco AmaddeoDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyMatteo BalestrieriDepartment of Experimental and Clinical Medical Sciences, University of Udine, Udine, ItalyCorrado BarbuiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyPaul BebbingtonMental Health Sciences Unit, Faculty of Brain Sciences, UCL, London, UKThomas BeckerDepartment of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, GermanyMarcella BellaniDepartment of Public Health and Community Medicine, Section of Psychiatry and Section of Clinical Psychology, Inter-University Center for Behavioural Neurosciences (ICBN), University of Verona, Verona, ItalyLoretta BertiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyVictoria BirdHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UKDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyChiara BonettoDepartment of Public Health and Community Medicine,Section of Psychiatry,University of Verona,Verona,ItalyElena BonfioliDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyPaolo BrambillaDepartment of Experimental & Clinical Medical Sciences (DISM), Inter-University Center for Behavioural Neurosciences (ICBN), University of Udine, Udine, ItalyDepartment of Psychiatry and Behavioral Sciences, University of Texas Medical School at Houston,USALorenzo BurtiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyAndrea CiprianiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyBenedicto Crespo-FacorroDepartment of Psychiatry, Psychiatric Research Unit of Cantabria, University Hospital “Marqués de Valdecilla”, IFIMAV, CIBERSAM, Santander, Cantabria, SpainDoriana CristofaloDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyKatia De SantiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyLidia Del PiccoloDepartment of Public Health and Community Medicine, Section of Clinical Psychology, University of Verona, Verona, ItalyGiuseppe DeleddaDepartment of Public Health and Community Medicine, Section of Clinical Psychology, University of Verona, Verona,ItalyValeria DonisiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyGraham DunnInstitute of Population Health, Centre for Biostatistics, University of Manchester, Manchester, UKNicola DusiDepartment of Public Health and Community Medicine, Section of Psychiatry and Section of Clinical Psychology, Inter-University Center for Behavioural Neurosciences (ICBN), University of Verona, Verona, ItalyIrene FioriniDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyDavid FowlerDivision of Health Policy and Practice, School of Medicine, University of East Anglia, Norwich, UKCarlos Garcia-AlonsoDepartment of Management and Quantitative Methods, Loyola University Andalusia, Cordoba, SpainKarina GibertKnowledge Engineering and Machine Learning Group, Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona, SpainNadja van GinnekenNutrition and Public Health Intervention Research Department, London School of Hygiene and Tropical Medicine, London, UKSangath, Goa, IndiaDavid GoldbergHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UKClaudia GossDepartment of Public Health and Community Medicine, Section of Clinical Psychology,University of Verona, Verona, ItalyJustin GransteinWeill Cornell Medical College, Cornell University, New York, NY, USALaura GrigolettiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyHiske HeesDepartment of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The NetherlandsAssen JablenskySchool of Psychiatry and Clinical Neurosciences, The University of Western Australia, AustraliaMartin KnappPersonal Social Services Research Unit, London School of Economics and Political Science, London, UKCentre for the Economics of Mental and Physical Health, Institute of Psychiatry, King’s College London, London, UKMaarten KoeterDepartment of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The NetherlandsLian van der KriekeUniversity Center for Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The NetherlandsElizabeth KuipersDepartment of Psychology, Institute of Psychiatry, King’s College London, London, UKAntonio LasalviaDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyClair Le BoutillierHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UKMary LeamyHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UKMariangela MazziDepartment of Public Health and Community Medicine, Section of Clinical Psychology,University of Verona, Verona, ItalyAlberto MinolettiFaculty of Medicine, Salvador Allende School of Public Health, University of Chile, Santiago, ChilePovl Munk-JørgensenDepartment of Organic Psychiatric Disorders and Emergency Ward, Aarhus University Hospital,Risskov, DenmarkMichela NosèDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyNiels OkkelsOrganic Psychiatric Disorder Research Unit, Aarhus University Hospital, Risskov, DenmarkBernd PuschnerDepartment of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, GermanyMichela RimondiniDepartment of Public Health and Community Medicine, Section of Clinical Psychology,University of Verona, Verona, ItalyGraciela RojasDepartment of Psychiatry, Clinical Hospital, University of Chile, Santiago, ChileDiana RoseService User Research Enterprise (SURE), Health Services and Population Research, Institute of Psychiatry, King’s College London, London, UKAlberto RossiDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyMirella RuggeriDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyLuis Salvador-CarullaCentre for Disability Research and Policy, Faculty of Health Sciences, University of Sydney, AustraliaSpanish Research Network on Mental Health Prevention and Promotion (Spanish IAPP Network)Benedetto SaracenoUniversity Nova of Lisbon, WHO Collaborating Center, University of Geneva, Geneva, SwitzerlandNorman SartoriusAssociation for the Improvement of Mental Health Programmes, Geneva, SwitzerlandShekhar SaxenaDepartment of Mental Health and Substance Abuse, World Health Organization, Geneva, SwitzerlandAart ScheneDepartment of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The NetherlandsMike SladeHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UKEzra SusserDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USADepartment of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, New York, NY, USADepartment of Psychiatry, University of Göttingen, Göttingen, GermanySjoerd SytemaUniversity Center for Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The NetherlandsGraham ThornicroftHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UKSarah TosatoDepartment of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, ItalyPeter TyrerDepartment of Medicine, Centre for Mental Health, Imperial College, London, UKElie ValenciaFaculty of Medicine, Salvador Allende School of Public Health, University of Chile, Santiago, ChileDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USAJosé Luis Vázquez-BarqueroDepartment of Psychiatry, Psychiatric Research Unit of Cantabria, University Hospital “Marqués de Valdecilla”, IFIMAV, CIBERSAM, Santander, SpainJavier Vázquez-BourgonDepartment of Psychiatry, Psychiatric Research Unit of Cantabria, University Hospital “Marqués de Valdecilla”, IFIMAV, CIBERSAM, Santander, SpainGabe de VriesDepartment of Occupational Therapy, Arkin, Amsterdam, The NetherlandsChrista ZimmermannDepartment of Public Health and Community Medicine, Section of Clinical Psychology,University of Verona, Verona, Italy
SECTION 1
The global challenge
CHAPTER 1
The nature and scale of the global mental health challenge
Mirella Ruggeri1, Graham Thornicroft2 and David Goldberg2
1 Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, Italy2 Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK
Introduction
In the last 20 years, there has been an unprecedented surge of research aimed at identifying improvements in psychiatric treatments and mental health care. This builds upon the earlier foundation of psychiatric epidemiology, which considers the occurrence and distribution of mental disorders across time and place. Yet, increasingly this work has evolved from describing these realities to going even further to understand which interventions deliver real advances in care. However, until relatively recently almost all such studies took place in high-income (HI) countries, even though most of the world’s population live in low- and middle-income countries (LAMICs).
The nature of the challenge
The definition of ‘Global mental health’ appeared for the first time in an Editorial by Eugene Brody published in 1982 on the American Journal of Psychiatry [1]. However, the roots of this discipline can be found much earlier, in the field of cross-cultural epidemiology of severe mental disorders. Originally, these studies had the aim of determining the relevance of a biomedical perspective and, later on, to compare psychopathology in different contexts, as a basis for classification and clinical decision-making. This research effort found that mental disorders affect people in all cultures and societies. Since then, a growing body of cross-national research has shown that neuropsychiatric disorders constitute 13% of the world health burden, and demonstrated their substantial impact on disability, on direct and indirect societal costs [2] and the strong association of mental disorders with both societal disadvantage and physical health problems [3].
A clear-cut discrepancy in both the resources and treatments availability for mental health between HI countries and LAMICs emerged, with resource allocation for mental health disproportionately low in the latter. This resource–needs gap [4, 5] goes in parallel with a mental health treatment gap: of all adults affected by mental illnesses, the proportion who are treated is around 30.5% in the United States and 27% across Europe, while more than 90% of individuals with serious mental illness in less-developed countries do not receive treatment for those problems [6, 7]. This stands as disconcerting evidence of a major failure in global health delivery [8–10].
To propose a framework to address the treatment gap, Thornicroft and Tansella have extended their balanced care model (BCM), originally aimed at mental health service planning based on a pragmatic balance of hospital and community care [11], to refer also to a balance between all of the service components that are present in any system, whether this is in a low-, medium- or high-resource setting, and identified three sequential steps relevant to different resource settings [12].
According to this model, in low-resource settings, the crucial resource allocation decisions will be how to balance any investment in primary and community care sites against expenditure in psychiatric hospitals. Following the World Health Report 2001 recommendations [13], in these countries, an optimal balance between resources and response to population needs can be given by promoting mental health service delivery within the primary care system. Different forms of collaboration between psychiatric and primary care setting should be pursued, stemming from the less to the most expensive and elaborate ones. In rural areas in many low-income countries, the nearest mental health service may be very far away, and it is necessary for the primary care service to take the lead in providing basic mental health care. In places where it is practicable to refer some patients to the mental health service, then some form of stepped care should be adopted (see Chapter 7). The provision of mental health training to primary care staff is therefore of the greatest importance. Several studies have shown that these kind of mental health services based in primary care are less stigmatising, more accessible, efficacious and cost-effective [10, 14–17].
In medium-resource settings, the BCM approach proposes that services are provided in all of the five main categories of care: outpatient clinics, community mental health teams, acute inpatient services, community residential care and work/occupation.
In high-resource settings, these complex choices apply to an even greater extent, as there are even more specialized mental health teams and agencies present, resulting in a greater number of possibilities for resource investment to achieve a more balanced mix of services, as long as there is a strong emphasis upon primary health care, and attention is paid to the training needs of primary care staff. In these countries, primary care should be the priority setting especially for patients with a combination of anxious, depressive and somatic symptoms, while major disorders could benefit from more specialised and dedicated interventions [18].
A research gap between HI countries and LAMICs has also clearly been identified, showing that 94% of research takes place in countries that cover 10% of the population. This treatment deficit cannot be resolved by extending presently available services alone. The adaptation of treatments will thus be an essential accomplishment, as well as the development of service-delivery models with greater local relevance and the provision of a robust empirical base supporting their local effectiveness and feasibility [19, 20]. Innovative approaches to mental health services are thus required, including interventions that encompass both clinical and social domains of action. Finally, in-country research and training are necessary, and clinical infrastructure and capacity must be built [21].
The landmark series of papers on global mental health published in the Lancet between 2007 and 2012 [8, 22–31] has been influential in contributing to a social movement for global mental health, and the number and quality of studies to evaluate mental health treatment and care in the developing world is now steadily improving.
As a further contribute, this book brings together many of the world’s leading practitioners and researchers active in the fields related to improving mental health care. The primary aim of the book is to present clear information arising from scientific research for a concerned readership about care and treatment for people with mental illness in community settings in relation to the global challenge to improving mental health care. The book consists of 24 chapters, with experts in each chapter area invited to give structured accounts of knowledge in that field, extensively referenced, to include critical appraisals of the strength of the evidence and the robustness of the conclusions that can be drawn.
Under the overall umbrella of the global challenge to improving mental health care and to understanding how to provide more and better mental health care worldwide, up-to-date knowledge in the following fields is included in these chapters: clinical trials, epidemiology, global mental health, health economics, health services research, implementation science, needs assessment, physical and mental co-morbidities, practitioner–patient communication, primary health care, outcome measures, pharmaco-epidemiology, public understanding of science, the recovery paradigm, spatial analyses, stigma and discrimination, and workplace aspects of mental health.
The scale of the challenge
If the why of the global mental health challenge has become self-evident in the last two decades, the what needs to be done and the how this approach should be scaled up are issues that deserve greater conceptual framing and operational implementation [32–34].
Using the Delphi method, the Grand Challenges in Global Mental Health Initiative Study – funded by the US National Institute of Mental Health, supported by the Global Alliance for Chronic Diseases – has identified priorities for research in the next ten years that will make an impact on the lives of people living with mental, neurological and substance abuse (MNS) disorders [35]. A ‘grand challenge’ was defined as ‘a specific barrier that, if removed, would help to solve an important health problem. If successfully implemented, the intervention(s) it could lead to would have a high likelihood of feasibility for scaling up and impact’. Twenty-five grand challenges were identified, which capture several broad themes, which can be summarised under four main issues.
First, the results emphasise the need for research that uses a life-course approach; this approach acknowledges that many disorders manifest in early life, thus efforts to build mental capital could mitigate the risk of disorders.
Second, the challenges recognise that the suffering caused by MNS disorders extends beyond the patient to family members and communities, thus, health-system-wide changes are crucial, together with attention to social exclusion and discrimination.
Third, the challenges underline the fact that all care and treatment interventions – psychosocial or pharmacological, simple or complex – should have an evidence base to provide programme planners, clinicians and policy-makers with effective care packages.
Fourth, the panel’s responses underscore important relationships between environmental exposures and MNS disorders: extreme poverty, war and natural disasters affect large areas of the world, and we still do not fully understand the mechanisms by which mental disorders might be averted or precipitated in those settings.
It is thus clear that more investment in research into the nature and treatment of mental disorders is needed, and that this research must be carried out in both HI countries and LAMICs. The mental health Gap Action Programme (mhGAP) promoted by the WHO with the mandate of producing evidence-based guidelines for managing MNS disorders identified eight groups of ‘priority conditions’ due to their major global public health impact: depression; schizophrenia and other psychotic disorders (including bipolar disorder); suicide prevention; epilepsy; dementia; disorders due to use of alcohol and illicit drugs; and mental disorders in children [36, 37]. The first product of this programme, launched in 2010, is a 100-page manual – the World Health Organization mhGAP intervention guide for mental, neurological and substance use disorders in non-specialised health settings: mental health – Gap Action Programme (mhGAP-IG) [38] – which contains case findings and treatment guidelines, whose main focus was what can be done in routine mental health care by non-specialist health workers. This manual is based on the assumption that task sharing – that is, a rational distribution of tasks among health professionals teams – might be a powerful answer to the scarcity of human personnel resources which is a barrier to the delivery of efficacious treatments in the LAMICs, but is also an emerging challenge in the HI countries in times of economical crisis [39, 40].
Evidence shows that lay people or community health workers can be trained to deliver psychological and psychosocial interventions for people with depressive and anxiety disorders, schizophrenia and dementia [17]. In a ‘collaborative’ model of care, a mental health specialist’s task should be to train these people appropriately and provide continuing supervision, quality assurance, and support. In the new world of global mental health, where an increasing proportion of mental health care is shared with non-specialist health workers, psychiatrists and other mental health practitioners will need to be proficient in skills for training and supervising non-specialist health workers, be engaged in monitoring and evaluation for quality assurance of mental health-care programmes and acquire the management skills essential for leading teams of health workers [21].
But the challenge to scaling up mental health treatments should also deal with the violation of human rights and pervasive stigma against those who are suffering from mental disorders, for which mental health staff should serve as advocate [41–43] and catalysts for the entire community, and fight the often rather weak commitment of politicians, administrators and the other community stakeholders in the understanding of the benefits that could take place worldwide if a global mental health approach is pursued [44].
And, finally, a major barrier relates to the imperfections in our current state of knowledge about the nature of mental disorders and the armamentarium of effective treatments. What is needed is a more finely tuned understanding of the interplay between biological, psychological, relational and environmental factors [45], and also of those political, economic and cultural barriers that have for so long impeded global mental health care and that have caused a serious disadvantage to people suffering from mental illness worldwide.
From evidence to practice
Few initiatives in the health field have received the level of attention being given to ‘evidence-based practice’. Growing concerns in recent years for underutilization of evidence-based practice in health-care systems have been raised. Most of the problems derive from the barriers that prevent a continuous flow from efficacy to effectiveness.
Efficacy refers to the use of experimental standards for establishing causal relationships between interventions and positive outcomes. Effectiveness relates to outcomes that can be achieved in real-world practice in representative cohorts of patients, and a broader set of implementation issues involving patient’s representativeness, professional consensus, generalisability, feasibility and costs.
Bridging the gap between efficacy and effectiveness implies first of all a concrete intention to test the advantages and the disadvantages of an intervention’s implementation in the frame of the routine care. There is the need for investing resources in the development and use of implementation strategies and methods that are grounded in research and elaborated through accumulated experience and sensitisation on its beneficial effects as well as to develop ongoing, long-term partnerships with researchers.
The action of health service researchers should be firmly grounded in the promotion of studies that can increase knowledge about this process and offer practical guidance for both policy-makers and service providers. In particular, core intervention components of evidence-based practices should be clearly identified, field-based approaches should be used to assess the effectiveness of implementation procedures that have been put into practice, proper outcome measures to monitor these practices should be developed and operationalisation of these processes should be clarified [46].
There is also a need for studying organizational as well as broader socio-political factors that influence and sustain innovation implementation [47–49]. To this extent, an increase in the awareness that the models used in comparatively better resourced settings have little chance of addressing the huge treatment gaps in LAMICs is needed. It is also necessary to promote actions that increase awareness that investing resources to improving service delivery is essential but in itself not sufficient: a continuing commitment to implementation of evidence-based practice is vital for long-term patient benefit.
Various factors shape the process and outcomes of innovation implementation: the ‘multi-level’ complexities involving not only financial resources and the effectiveness of interventions but also training process and fidelity, staff clinical skills and motivation, organisations and systems characteristics, organisational climate, managerial support, long-term managerial determination and high-level policy support [50].
‘Routine practice’ is the culmination of such successful implementation and service consolidation. Progression through each stage is usually not rigidly linear. Indeed, there are cyclical phases of progress with setbacks involved; these dynamics represent the most vulnerable ‘points of impact’ for many of these change factors.
Innovations that pass these stages successfully tend to become standard ‘practice’ and should bring improvements to patient care. If this is accomplished, it is important that ongoing monitoring of effectiveness indicators be established and that continued attention be given to organisational functioning and continuing assessments of the costs of care.
To increase the probability that this process can penetrate in mental health service research and care, long-term investment in training and capacity development is necessary. Capacity building, in turn, requires leadership, resources and sustained commitments, if global expertise and experience are to respond effectively to local priorities and needs.
The implementation of innovative care must face problems that are different whether this task is undertaken in HI countries or in LAMICs; however, the experience developed in these two contexts can occur to allow transferrable learning with the potential to generate research questions that are more attuned to some crucial, yet unanswered, questions posed by the global mental health challenge [51–53].
Conclusions
We have clustered the chapters in this volume into the three unified sections of the book: those that deal with the specificity of mental health care in the LAMICs, those more focused on the effectiveness of interventions at the level of primary care and/or specialised services, and those which propose innovative methodologies to fully capture the complexities of mental health research. The contributions of the authors are influenced by the book’s commitment to producing evidence that can be useful to pursuing the goals mentioned in this chapter, converting them into practice, and in so doing assessing how best to achieve such translation. Lively examples of the complex interactions of policy-makers, service user and carer advocacy, research findings and service provider practices are provided. The underlying thrust of the contributions can be stated plainly: to understanding how to provide more and better mental health care worldwide.
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CHAPTER 2
Scaling up mental health care in resource-poor settings
Shekhar Saxena1, Benedetto Saraceno2 and Justin Granstein3
1 Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland2 University Nova of Lisbon, WHO Collaborating Center, University of Geneva, Geneva, Switzerland3 Weill Cornell Medical College, Cornell University, New York, NY, USA
Introduction
Mental health is paramount to personal well-being, building relationships and making contributions to society. Mental, neurological and substance use (MNS) disorders are major contributors to premature mortality and morbidity. The stigma, discrimination and human rights violations directed towards people with these disorders compound the difficulties in accessing care, increase socioeconomic vulnerability and hinder efforts to rise out of poverty. Nearly 14% of the global burden of disease is attributable to MNS disorders; likewise, almost 30% of the total non-communicable disease (NCD) burden is due to these disorders. Nearly 75% of all disability-adjusted life years (DALYs) lost due to neuropsychiatric disorders are in low- and lower-middle-income countries. The total number of DALYs lost in low-income countries alone due to neuropsychiatric disorders is 2.3 times that seen in high-income countries.
Regarding long-term disability specifically, 31% of the years lived with disability are attributable to neuropsychiatric disorders. Unipolar depressive disorders account for one-third of those attributed to neuropsychiatric disorders [1]. The World Health Organization (WHO) has, from its inception, recognised the need for action to reduce the burden of MNS disorders worldwide, and for enhancing the capacity of member states to respond to this rising challenge. In 2001, the issue of mental health was highlighted to the general public, national and international institutions and organisations, the public health community and other stakeholders. Through the World Health Day, World Health Assembly and World Health Report 2001 (Mental Health: New Understanding, New Hope), WHO and its member states pledged their full and unrestricted commitment to this vital public health issue.
Table 2.1 Burden of mental disorders and budget for mental health.
Burden of mental disorder
a
(%)
Proportion of budget for mental health
b
(%)
Low-income countries
7.88
0.53
Lower-middle-income countries
14.50
1.90
Upper-middle-income countries
19.56
2.38
High-income countries
21.37
5.10
All countries
11.48
2.82
a Proportion of disability-adjusted life years (DALYs), defined as the sum of the years of life lost due to premature mortality in the population and the years lost due to disability for incident cases of mental disorders [1].b Median values for proportion of total health budget allocated to mental health [3].
The last decade has seen an increasing awareness of the large gap between the prevalence of MNS disorders and the availability of treatment for them. A consensus has emerged that improved access to mental health care for people with these disorders, especially in the poorer parts of the world, is the highest priority for global health. This exciting development follows an unprecedented era of increasing efforts to address global health inequalities, largely as part of the UN’s Millennium Development Goals (MDGs) initiative. HIV/AIDS, tuberculosis, malaria and maternal and child health (specifically addressed in the MDGs) have seen a huge increase in targeted resources: development assistance for health grew from $5.6 billion in 1990 to $21.8 billion in 2007, and there has been a similar escalation in activity related to other priorities in education and social development [2]. The investment of the global health community has been traditionally directed to infectious diseases; only recently have NCDs and MNS disorders received some attention. The likely culprit behind such a lack of attention is the fact that NCDs and MNS disorders have long been considered diseases of affluence because they reflect ill-health resulting from improved living standards. Today, however, it is well known that countries with economies in transition and many middle-income countries face a double burden as the increasing prevalence of NCDs and MNS disorders coexists with infectious diseases.
However, the resources provided to tackle the huge burden of MNS disorders remain grossly insufficient. Almost one-third of countries still do not have a specific budget for mental health [3]. Of the countries that do have a designated mental health budget, 21% spend less than 1% of their total health budgets on mental health. Table 2.1 [1, 3] compares the burden of mental disorders with the budget assigned to mental health; it shows that countries allocate disproportionately small percentages of their budgets to mental health compared to the distribution of their disease burdens.
The scarcity of committed resources is even more serious for human resources; Figure 2.1 presents the distribution of human resources for mental health across different income categories. This scarcity is exacerbated by inefficiency and inequitable distribution of resources. For example, many middle-income countries that have made substantial investments in large mental hospitals are reluctant to replace them with community-based and inpatient facilities in general hospitals, despite evidence that mental hospitals provide inadequate care and that community-based services are more effective.
Figure 2.1 Total number of human resources (per 100 000 population) working in the mental health sector by World Bank income group (Reproduced from Mental Health Atlas 2011 ([3], p. 55)).
WHO has described scaling up as ‘deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and programme development on a lasting basis’ [4]. Developing these key themes further, in this chapter we take scaling up to mean ‘deliberate efforts to increase the availability, coverage and sustainability of effective health care interventions to confer benefit on people needing treatment and care for MNS disorders’.
Progress in scaling up services can be best measured by comparing change in effective coverage, for example, the proportion of the population having a mental disorder that is receiving appropriate treatment. This concept combines response to need with the quality of interventions delivered. Information relating to scaling up mental health services, however, is not widely published in the governmental or scientific literatures, and research from low- and middle-income countries (LAMICs) is particularly poorly represented. There are, therefore, little available baseline prevalence data in LAMICs, and even if standardised prevalence rates were used, service impact data are not available to estimate coverage at any particular point in time, let alone for changes over a period of time.
Recognising the alarming extent of these issues, the Lancet Series on Global Mental Health in 2007 sounded a call for action to scale up mental health care in the world. WHO responded and launched its mental health Gap Action Programme (mhGAP) the following year. This chapter provides an introduction to mental health system assessment and WHO’s efforts to scale up mental health care.
Assessment of needs, resources and constraints
WHO Atlas study reports that in 2005, more than 24% of countries did not have any system for collecting and reporting mental health information. Many other countries have reporting systems but they often are of limited scope and quality. This lack of good information is an important impediment to the development of mental health policies, plans and services [3].
To combat these basic and strategic weaknesses, WHO developed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS). This tool enables countries to perform a comprehensive, information-based assessment of their mental health system, as well as the services and support offered to people with mental disorders that are provided outside the psychiatric services sector (e.g. mental health in primary care, links with other key sectors) [5]. Moreover, WHO-AIMS allows countries to monitor progress in implementing policy reforms, the provision of community services and the involvement of consumers, families and other stakeholders in mental health promotion, prevention, maintenance and rehabilitation.
The ten recommendations of the World Health Report 2001 served as the foundation for the instrument, as they still represent WHO’s vision for mental health [6].
The World Health Report 2001 recommendations are:
In order to operationalise the recommendations, many indicators were generated and grouped together into domains and facets. Experts and other respondents from resource-poor countries were consulted to ensure clarity, content validity and feasibility of the generated items. Based on this feedback, a pilot version of the instrument was released and tested in 12 LAMICs. Following further consultations with other international experts, the final version was released for use in country assessments in February 2005, consisting of the following six domains [4]:
These 6 domains address the 10 recommendations of the World Health Report 2001 through 28 facets comprising 155 items. The instrument consists largely of input and process indicators, given that in many LAMICs outcome data are extremely difficult to collect. WHO-AIMS assessments are carried out by a local team headed by an in-country ‘focal point’ which in most cases is identified and approved by that country’s ministry of health. Technical support for the project is provided by WHO staff at the country, regional and headquarters levels.
To date, WHO-AIMS assessments have been conducted in over 80 LAMICs. An analysis of the first 42 countries to complete an assessment indicated that 62% of the countries used the information gathered through WHO-AIMS to either develop or revise a mental health policy or plan, 55% used the assessment for some other planning purpose, 74% of countries presented the results of the assessment in a national workshop attended by key stakeholders, 24% published the results of the assessment in a scientific journal and 29% of countries used WHO-AIMS to improve their mental health information system [7]. Notably, while the data provide baseline information that can be used to develop plans to strengthen or scale up services, the process of data collection itself brings together key stakeholders within the countries, placing them in a stronger position to collaborate and press ahead with needed reforms.
Synthesising the information gathered through WHO-AIMS enables countries to better gauge the major challenges they face in providing care for their citizens with mental disorders. This deeper understanding of the type and depth of constraints that affect a country’s health system at different levels – be it community care, service delivery, health policy or environment – allows countries to take stock of available resources, prioritise needs and strengthen mental health care.
