Global Mental Health a new global health discipline comes of age
Vikram Patel London School of Hygiene & Tropical Medicine, UK Sangath, India Public Health Foundation of India
1 ALAN FLISHER (1957-2010) 2 Global Health
. “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al, Lancet 2009)
3 Global vs International
. Concerned with health disparities within and between countries . Interest in global determinants such as climate change and migration . Emphasis on prevention and individual clinical care . Priority setting by burden of disease
4 Global Mental Health
. The application of these principles to the specific domain of mental ill-health . Concerned with any ‘priority’ disorder affecting the brain (“MNS” disorders) . Primary focus is reducing mental health inequalities within and between countries . Most striking inequity are disparities in provision of care and respect for human rights of people living with mental disorders between rich and poor countries 5 Outline
. Scientific foundations
. Major initiatives and opportunities
. Role of psychiatry
6 Scientific foundations of GMH
1. Cross-cultural research
2. Burden of disease
3. Intervention and health services
4. Discrimination and human rights
7 Cross-cultural research
8 Cross-cultural research
. Rich history of multi-disciplinary research, rooted in medical anthropology, clinical mental health sciences and epidemiology, on the cultural construction, social narratives, prevalence and risk factors for mental disorders, with especially rapid growth since the 1960s
9 Key findings
. Major categories of mental disorders can be identified in all cultures, and share similar ‘core’ psychopathological features . Research methodologies can be both internationally comparable and contextually and culturally appropriate . Social disadvantage is strongly correlated with mental disorder; there is a vicious cycle of disadvantage and mental disorder 10 11 12 13 Burden of disease
14 Burden of disorders by region (GBD 2006)
Neuropsychiatric DALYs as % of total: by WHO region
15 Burden of disorders by income (GBD 2006)
Neuropsychiatric DALYs as % of total: by income group
16 Which disorders?
Rank Category Total
1 Unipolar depressive disorders 4.30
2 Alcohol use disorders 1.56
3 Schizophrenia 1.10
4 Bipolar affec ve disorder 0.95
5 Alzheimer’s and other demen as 0.73
6 Drug use disorders 0.55
7 Epilepsy 0.52
8 Migraine 0.51
9 Panic disorders 0.46
10 Obsessive-compulsive disorder 0.34 17 In childhood
Rank Category Total 1 Mental retarda on, lead caused 9,482,313 2 Unipolar depressive disorders 5,671,709 3 Other Neuropsychiatric Disorders 4,020,808 4 Migraine 3,365,036 5 Epilepsy 2,776,991 6 Schizophrenia 1,630,579 7 Alcohol use disorders 722,934 8 Bipolar affec ve disorder 722,375
9 Demen as 688,516 10 Obsessive-compulsive disorder 632,438 18 19 Dementia and mortality
20 Schizophrenia and mortality
21 The close relationship of mental disorders with physical health
22 Intervention and health services research
23 The evidence base for treatments in LMIC . DCP2 reviewed evidence and modelled cost-effectiveness.
(Hyman et al; Chandra et al; Durkin et al; Rehm et al; Hall et al, 2006) . Lancet Series on Global Mental Health; review #3 systematically reviews evidence for treatment and prevention of mental disorders
(Patel et al, Lancet, 2007) 24 The treatment gap is over 50% in all countries
Reaches an astonishing 90% in some low income countries
25 26 Resources for Mental Health
Policy and legislative infrastructure MH services Community resources Human resources Funding
Availability Scarcity
Distribution Inequity
Utilization Inefficiency Specialist human resources Task-shifting to close HR gaps
. the strategy of rational redistribution of tasks among health workforce teams, . specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health.
29 30 What about mental health?
We know what works, but how do we deliver these treatments in low resource settings?
31 Lay health workers delivering group Interpersonal therapy for depression in rural Uganda (Bolton et al, JAMA 2005, 2007)
32 Community health worker delivered group interventions for depression in primary care in Chile (Araya et al, Lancet 2003, 2007)
33 Lady health visitors using CBT to treat postnatal depression in rural Pakistan (Rahman et al, Lancet 2008)
34 Community mental health workers delivering care for schizophrenia in rural India (Chatterjee et al, Br J Psych 2003, 2009)
35 Community health workers supporting caregivers of persons affected by dementia (Dias et al, PLoS One, 2008)
36 37 Integrating packages of care
38 Human rights
39 Discrimination and human rights
40 Time Cover Story: November 2003
41 42 43 44 45 46 47 48 #6: The Call for Action
. To scale up the coverage of services for mental disorders in all countries, but especially in low and middle income countries. . Based on two principles: . an evidence-based package of services for core mental disorders and . strengthening the protection of the human rights of persons with mental disorders and their families. 49 Implementing the call to action
50 Critical actions
. Getting mental health on the global health and development agenda
. Building capacity and evidence
. Building global networks to ‘change minds and hearts’
51 . Providing effective mental health services in primary care settings would help to reduce the stigma associated with mental disorders and could prevent unnecessary hospitalization and human rights violations of people with mental health problems. … . Such a strategy makes good economic sense….it is also a pro-poor strategy. … . Let us this year resolve to reduce the public health burden and the individual suffering of people with mental health problems worldwide.
. Ban Ki-Moon, October 2009
52 New global programs
53 New resources-2010
. EC call for research targeting risk factors for mental disorders (up to 1 million euros for each successful program) . DFID call for consortia to research mental health in primary care (7.5 million pounds) . Wellcome Trust strategy for 2010-20; mental disorders in 2 of the 5 priority themes
54 The roles of psychiatry?
. Building capacity
. Supporting community and primary care intervention programs
. Implementing priority mental health research
. Advocacy to raise mental health literacy
55 Capacity Building
. In lay health workers, to deliver specific front-line mental health care tasks such as brief psychological treatments and monitoring medication use . In other health professional groups, to integrate mental health in health programs, e.g. HIV/AIDS, maternal and child health . In mental health professionals, to increase public health skills to scale up services
56 Building capacity
57 New academic initiatives
The Centre for Global Mental Health
www.centreforglobalmentalhealth.org 58 Supporting community and primary mental health care programs
. Numerous community and primary care programs now being implemented around the developing world
. Led by public health services and NGOs
59 Community Mental Health
60 Role of mental health professionals
. Diagnostic and referral services in outreach camps
. Training, support and supervision of community teams
. Training of partner organizations (e.g. NGOs, health services)
. Documentation and evaluation of programs 61 Implementing priority research
62 Focus
63 What research is needed?
. to develop and evaluate interventions for people with mental disorders to be delivered by non-mental health professionals, . What is the relationship between specialists and non-specialists in a mental health care team? . to evaluate how health systems can scale up feasible and effective interventions across all routine care settings,
64 Manas Program
To evaluate the clinical and cost-effectiveness of a collaborative stepped care intervention for depression and anxiety in primary care in Goa, India
Largest trial on mental disorders in a developing country with over 2700 participants
65 66 Beyond implementation research in global mental health . More than 90% of evidence is derived purely from research on 10% of the global population
. What are the key research questions in global mental health which can: . Improve our understanding of the aetiology of MNS disorders . Increase the choice of effective treatments for MNS disorders
67 68 The mission of global mental health research
. Local solutions, global lessons
. Advancing systems, advancing science
69 70 Grand Challenges in Global Mental Health
71 Advocacy
. To stand alongside people affected by mental disorders and combat the stigma of mental disorders . To stop the continuing human rights violations of people with mental disorders within mental hospitals, in the prisons, and in communities
72 Advocacy
. …..how can we all make a difference?
73 Imagine a health condition which..
. Is associated with great suffering . Is associated with profound levels of stigma and human rights abuse . Has cost-effective treatments but resources for treatment are scarce . Vast majority of those affected cannot access these treatments
74 Imagine….
Step by step, everyone with this health condition will get treatment within 10 to 15 years
Is this a dream?
75 76 The arguments
Evidence of effective treatments
Reduce cost of treatment and make it more accessible by task-shifting
Human rights
77 Ten years on
Massive global, regional and national commitment and resources to provide comprehensive continuum of care for millions of PLHIV in countries across the developing world
78 Movement for Global Mental Health
79 Goals
To establish a movement of individuals and institutions, bringing professionals and people affected by mental disorders together on a common platform, to carry out actions to scale up services for people with mental disorders and promote their human rights
80 81 82 Activities
. Global Mental Health Summit
. Capacity building atlas
. Advocacy (with the WFMH)
. Lancet series on GMH 2011
83 Join the Movement on www.globalmentalhealth.org 2nd Global Mental Health Summit, October 2011, Cape Town
84 Redefining our roles…
. From primarily clinicians
. To being both clinicians and public health practitioners
85 Ultimately an opportunity
To close the treatment gap and gain the immense satisfaction of knowing that our skills can now benefit countless more people, beyond those who can access our clinics
86 Global mental health: a new discipline comes of age . Change in public health needs three core elements: a knowledge base, strategies to implement what we know and the political will to carry these out. . In recent years, the Lancet Series, PLoS Medicine series and mhGAP have synthesized the knowledge and some of the strategies. . The Movement for GMH and the Grand Challenges in GMH build on this evidence . Now we need the full support of all stakeholders, especially policy makers and mental health professionals to make this dream come true 87 The Return Home Program
Play
88 Patel, V. The future of psychiatry in low and middle income countries. Psychological Medicine, 2010
Patel, V. & Prince, M. Global Mental Health: a new global health field comes of age. JAMA 2010
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