EDITORIAL Mental health and life on a small island David Skuse University of London Institute of Desert Island Discs has been a popular radio pro- British Territories, the provision of legislation Child Health, London, UK; email: [email protected] gramme in the UK since 1942. Guests are asked for the management of mental health problems to choose the discs they would most want to is subject (at least for now) to the European doi:10.1192/bji.2018.3 save, in order to make life on a desert island bear- Convention of Human Rights. Updating the for- able after shipwreck. The potential impact of mer Mental Health Ordinance for the islands, © The Author 2018. This is an Open Access article, distributed loneliness on the unfortunate celebrity’s mental which was not compliant, brought about new under the terms of the Creative health is rarely discussed. Yet the inhabitants of opportunities and demands for training local Commons Attribution- NonCommercial-NoDerivatives small islands do suffer mental health problems, staff. Karen Rimicans and Dr Tim McInerny pro- licence (http://creativecommons. and our theme this month is a discussion of the vide a fascinating insight into the challenges faced org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, ways in which services to assist them are being by such a remote community. distribution, and reproduction in delivered. Yutaro Setoya and Dévora Kestel dis- Finally, we consider the provision of psychi- any medium, provided the ori- ginal work is unaltered and is cuss how the World Health Organization is offer- atric services to the Shetland Isles, which lie well properly cited. The written per- ing support to several small island states in the north of Scotland and not too far from Norway. mission of Cambridge University fi Press must be obtained for com- Paci c and the Caribbean through the Mental Martin Scholtz and Almarie Harmse give us a mercial re-use or in order to cre- Health Gap Action Programme. Training has glimpse into the history of these islands, which ate a derivative work. been delivered to a few Caribbean islands over are warmed by the Gulf Stream and whose popu- the internet as a pilot project, and the strategy lation is rapidly recovering from its lowest point has caught on with such enthusiasm that it is over the past 50 years. The economy of the islands going to be rolled out to many more small island has been improving owing to initiatives in the oil states soon. and the seafood industries, and with this growth Far from the sunny Caribbean are the has come a demand for more medical and mental Falkland Islands (or Malvinas). These islands are health services. Dependency on mainland facil- geographically remote and have a small popula- ities for major mental health support poses a tion of mainly British descent. There are frequent range of logistical problems, and so novel crisis visitors from ships sailing to the Cape or and home treatment protocols have been intro- Antarctica, as well as many fishing vessels, with duced, which seem highly effective in reducing fishermen bringing their own problems to the admissions. The small island experience has attention of the medical services available there. been a positive one for the authors of this contri- Remarkably, because the Falkland Islands are bution to our theme this month. THEMATIC WHO Mental Health Gap Action PAPER Programme implementation in the Small Island Development States: experience from the Pacific and English-speaking Caribbean countries Yutaro Setoya1 and Dévora Kestel2 1Technical Officer Mental Health, Division of Pacific Technical Owing to the relatively small population sizes To overcome these limitations, the World Support, Western Pacific Region, and remoteness of the Small Island Health Organization (WHO) Mental Health WHO, Nuku’alofa, Tonga; email [email protected] Development States (SIDS), their mental Gap Action Programme (mhGAP), which aims 2Unit Chief, Mental Health and health systems face many common to decrease the treatment gap by training Substance Use, Pan American difficulties. These include having few mental non-specialists, was implemented in more Health Organization (PAHO/ WHO), Washington, DC, USA health specialists per country, limited access than 20 Pacific and English-speaking to mental health services and low awareness. Caribbean countries. Many lessons were learnt BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 27 Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 12:09:03, subject to the Cambridge Core terms of use. Conflicts of interest. None. from the experience. Mental health specialist • Strong informal support, which compliments support is crucial, and online training and the weak formal social support in areas such doi:10.1192/bji.2017.16 supervision could be a solution. mhGAP as social security, housing services and disabil- training proved to be effective to improve © The Authors 2018. This is an ity pensions. open access article distributed knowledge and attitude, but close monitoring • Availability of functioning basic health services under the terms of the Creative and supervision are needed to change clinical via general hospitals, primary healthcare Commons Attribution- NonCommercial-NoDerivs 3.0 practice. Awareness raising and mental health clinics and, in some countries, dispensaries. IGO License which permits distri- service capacity building need to occur Most of the countries have a tax-based health bution and reproduction in any medium, for non-commercial simultaneously. To realise sustainable system, similar to the British system. The gov- uses provided the original work is development goals, countries need to invest ernment pays medical fees, including the cost properly cited. In any reproduc- tion of this article there should more in mental health, especially in human of medicines, and provides services as part of not be any suggestion that PAHO resources; mhGAP will be one effective a public system. or this article endorse any specific solution. organization, services or products. Because of these limitations and strengths, the The use of the PAHO logo is not permitted. This notice should be World Health Organization (WHO) Mental preserved along with the article's Health Gap Action Programme (mhGAP) original URL. (WHO, 2008), which aims to decrease the treat- Background ment gap by training non-specialists, is the obvi- Although many of the Small Island Development ous strategy for SIDS. mhGAP is a programme States (SIDS) are renowned as holiday destina- developed by WHO, which aims to increase men- tions, they are not unscathed by the same mental tal health service coverage and to reduce the gap health issues which affect other countries. Owing between needs and supply. The programme was to the relatively small population sizes of SIDS – launched in 2008, and its clinical protocol to ranging from countries as small as Niue (popula- assess and manage priority mental disorders and tion about 1200) to Jamaica with nearly 3 million conditions, the mhGAP Intervention Guide people – and their remoteness, their mental (mhGAP-IG), was developed in 2010 (WHO, health systems face many common difficulties, 2010). A second version was revised and released including the following. in 2016 (WHO, 2016). mhGAP-IG targets non- • Few mental health specialists owing to popula- specialist health workers, mainly doctors and tion size, high turnover and brain drain. Some nurses who do not specialise in mental health. of the countries have a population below 10 000, Since then, more than 90 countries across the which makes it difficult to afford psychiatrists or world have implemented mhGAP, including mental health specialists. more than 20 SIDS. • Here, we will describe examples of mhGAP Limited access to mental health services in fi countries with small, scattered islands. In implementation in the Paci c and the Caribbean some countries, mental health services are regions, then discuss lessons learned and the only available on the main island, which may way forward. take days or even weeks to reach from remote mhGAP implementation islands with infrequent transfers by boat. fi • Low mental health awareness, which leads to Example from the Paci c stigma and discrimination. Confidentiality is Implementation of mhGAP in the Pacific island difficult to maintain, owing to the small popu- countries started with an in-country planning lation and closeness of community members; workshop to which key mental health stake- everybody knows everybody else. holders were invited. During the workshop, stake- • Non-communicable diseases are a serious con- holders discussed various topics related to cern, leading to an increase in mental health mhGAP implementation, such as who to train, issues. who the trainer will be, who the supervisor will • High alcohol use owing to limited leisure activ- be, establishing support and a supervision system, ities, or to attract tourism. Gender-based vio- ensuring drug availability at the target facilities, lence is common and usually associated with and monitoring and evaluation of the whole pro- alcohol misuse. cess. Adaptations of mhGAP implementation to • Vulnerability to climate change, especially the local context, such as which conditions and related to the increase in natural disasters. medications to train in as a priority, and what Most recently, Fiji has been struck by Cyclone the consultation and referral pathways will be, Winston, and Hurricane Matthew has hit sev- were also discussed. Cultural adaptation was usu- eral Caribbean countries and provoked serious ally addressed through the training. Depending damage in Haiti. Mental health and psycho- on the priority of the country and number of social support are needed for those affected. training days, the sessions usually focused on the modules for depression, psychosis, alcohol, However, there are also the following suicide, and other significant emotional or medic- strengths. ally unexplained complaints. • Strong cultural bonding because of the relatively For larger countries, a ‘training of the trainers’ small population. Strong community solidarity (ToT) model was applied, in which mental health and a strong sense of supporting each other.