EDITORIAL Mental health and life on a small David Skuse

University of London Institute of Discs has been a popular radio pro- British , 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 Rights. Updating the for- able after shipwreck. The potential impact of mer Mental Health Ordinance for the , © 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 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 and not too far from Norway. mission of Cambridge fi Press must be obtained for com- Paci c and the 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 . The 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 (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 crisis visitors from sailing to the Cape or and home treatment protocols have been intro- , 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 Yutaro Setoya1 and Dévora Kestel2

1Technical Officer Mental Health, Division of Pacific Technical Owing to the relatively small sizes To overcome these limitations, the World Support, Western Pacific , and remoteness of the Small Island Health Organization (WHO) Mental Health WHO, Nuku’alofa, ; 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 , 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 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 (popula- assess and manage priority mental disorders and tion about 1200) to 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 , 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 . 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 . 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, 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. specialists were to become mhGAP trainers. The

28 BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 12:09:03, subject to the Cambridge Core terms of use. 900 Niue 800 700 600 500 CNMI 400 300 FSM 200 Fiji 100 Tonga 0 Jan-14 May-14 Sep-14 Jan-15 May-15 Sep-15 Jan-16 May-16 Sep-16

CNMI: Commonwealth of Northern Marian Islands, FSM: Federated States of Fig. 1 Number of mhGAP trainees in the Pacific island countries.

mhGAP training programme developed by WHO is . A team of key partners, led by PAHO, designed to be interactive, using discussions, case revised and adapted mhGAP to be delivered studies, roleplays and videos. The first mhGAP online, with the support of three tutors and a training in each country was completed by a com- technical coordinator. Six countries were selected, bination of international and local facilitators, and and Ministries of Health from those countries and then rolled out by local facilitators, depending on territories were invited to identify participants for the country’s capacity and needs. the training. Over the course of 5 months, 28 gen- Three mhGAP ToTs were conducted in the eral practitioners and nurses from six Caribbean Pacific: two in Fiji with participants from Kiribati, countries and territories were able to complete Tonga and Vanuatu, and one in Guam with parti- the training at their own rhythm and pace. cipants from the Marshall Islands, Federated States Despite initial doubts or concerns regarding of Micronesia, Palau and Northern Mariana. So the use of the virtual modality to train clinical far, 14 countries have initiated mhGAP and trained concepts, evidence revealed a positive acquisition more than 900 doctors and nurses (Fig. 1). Pre- and of the knowledge through participant feedback post-training tests showed remarkable improve- and a post-training survey. Participants achieved ment in knowledge, and the trainees showed confi- the learning objectives by interacting with each dence in assessing and managing people with other and with tutors over a long period of time. mental disorders after completing the training. The length and modality of the course allowed Learning from the Caribbean experience participants to continue their clinical practice and (below), an online version of the training is to share their real-life patients’ challenging situa- planned for 2017, mainly targeting busy medical tions with their peers and tutors. doctors. Based on the positive feedback, a second round was proposed in 2015, this time with an open call. Example from the Caribbean From the 158 postulants, we selected 42 partici- The limited presence of specialised professionals pants from 13 Caribbean countries. A third round in several Caribbean countries, particularly in the for Spanish-speaking participants took place in smaller ones, makes even more clear the need to 2016; another one for the Caribbean in 2017. strengthen primary health care capacities to pro- vide care for people with mental health condi- Lessons learned and the way forward tions. The small number of health professionals From implementation of mhGAP in more than 20 made it challenging to carry out training in each SIDS, many lessons have been learned regarding island, and to request all the general practitioners the way forward. We will discuss a few of the most and nurses to attend a few days of training. In important ones. 2013 the Pan American Health Organization Mental health specialist support is crucial. (PAHO) proposed a web-based modality for train- Each mhGAP trainee will be trained to assess ing professionals in English-speaking Caribbean and manage common mental disorders, but will countries. The training was implemented need a mental health specialist who can support, through PAHO Virtual Campus, a tool for tech- supervise, continue to train and be a reference nical cooperation developed to promote and for the more difficult cases. Online training and facilitate networked learning in the region of the supervision could be one solution to this problem.

BJPSYCH INTERNATIONAL VOLUME 15 NUMBER 2 MAY 2018 29 Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 12:09:03, subject to the Cambridge Core terms of use. mhGAP training has been proved to be effec- developing States’. To realise these targets by tive to improve the trainees’ knowledge and atti- 2030, countries need to invest more in mental tudes towards people with mental disorders, but health, especially in human resources. Mental close monitoring and supervision is needed to health services do not require expensive equip- change their clinical practice. ment, but they do need more trained human It is crucial to raise awareness on mental health resources. mhGAP is one effective solution, but and also on the availability of mental health services there is also need to increase human resources to increase help-seeking behaviour. Awareness rais- at all levels – specialists, non-specialists and com- ing and mental health service capacity building munity/village health workers. need to go hand in hand. Weak health information systems make moni- References fi toring and evaluation dif cult. There is a need (2016) Sustainable Development Goals. UN. Available to integrate and strengthen health information at https://sustainabledevelopment.un.org/sdgs (accessed 1 November systems, and to report on a core set of mental 2016). health indicators. World Health Organization (2008) mhGAP: Mental Health Gap Mental health has been included in Action Programme: Scaling up Care for Mental, Neurological, and Sustainable Development Goals (United Nations Substance Use Disorders. WHO. Available at http://www.who.int/ 2016); for example, target 3.4 states: ‘By 2030, mental_health/evidence/mhGAP/en/ (accessed 1 November 2016). reduce by one third premature mortality from World Health Organization (2010) mhGAP Intervention Guide for non-communicable diseases through prevention Mental, Neurological and Substance Use Disorders in Non-Specialized and treatment and promote mental health and Health Settings. WHO. Available at http://www.who.int/ ’ mental_health/publications/mhGAP_intervention_guide/en/ well-being . Target 3.c recommends an increase (accessed 1 November 2016). in the health workforce in SIDS: ‘Substantially increase health financing and the recruitment, World Health Organization (2016) mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized development, training and retention of the health Health Settings – Version 2.0. WHO. Available at http://www.who.int/ workforce in developing countries, especially in mental_health/mhgap/mhGAP_intervention_guide_02/en/ (accessed least developed countries and small island 1 November 2016).

THEMATIC 52 degrees south: mental health services PAPER in the Falkland Islands Karen Rimicans1 and Tim McInerny2

1RMN, Specialist Practitioner in The Falkland Islands are situated approxi- Community Mental Health This article discusses the factors that have mately 8000 miles from the UK and 400 miles Nursing, Nurse Teacher, and shaped the development of the new mental Senior Community Psychiatric from . The islands are geographic- health legislation within the Falkland Islands. Nurse, Falkland Islands ally remote with limited access by sea and air. 2 The process of implementing new legislation Visiting Psychiatrist, Falkland There are 700 islands, of which 50 are sparsely Islands; South London and within this remote island community is Maudsley National Health Service populated, spread across an of 12 000 square discussed, including the aspirations underlying Foundation Trust, Bethlem Royal miles. The Falkland Islands have 2931 residents, Hospital, Beckenham, UK; email the new legislation, the management of [email protected] composed of islanders mainly of British descent psychiatric emergencies and the needs of the who immigrated in the 1800s, and expatriates fl clinical team. Con icts of interest. None. from the UK, St Helena, , , the doi:10.1192/bji.2017.15 and other countries. Of the residents, 62% have lived in the islands for more than 10 © The Authors 2018. This is an The management of mental health needs in the years. The majority of people live in , the Open Access article, distributed fl under the terms of the Creative British Overseas Territories is in uenced by capital of the islands, while the remainder live in Commons Attribution- many factors, including economic capacity to , the local term for the countryside outside NonCommercial-NoDerivatives licence (http://creativecommons. invest in services, organisational structure and Stanley (Falkland Islands Government, 2015). org/licenses/by-nc-nd/4.0/), which resources, perceptions of mental health need Transient visitors to the islands include sea- permits non-commercial re-use, fi distribution, and reproduction in and the accessibility of mental health resources farers and shermen who work on the inter- any medium, provided the ori- within neighbouring countries or the UK. national commercial fishing ships within Falkland ginal work is unaltered and is fi properly cited. The written per- The Falkland Islands are self-governed and Islands waters. The shing industry has a unique mission of Cambridge University self-funded with the exception of defence. Public working environment and holds the unenviable Press must be obtained for com- mercial re-use or in order to cre- administration, including health and , rank of highest occupational mortality rate, with ate a derivative work. operate in parallel to English systems with local fishermen being considered 52.4 times more likely adaptations in place. to have a fatal accident at work relative to other

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