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Series China–India Mental Health Alliance the Magnitude of And Series China–India Mental Health Alliance The magnitude of and health system responses to the mental health treatment gap in adults in India and China Vikram Patel, Shuiyuan Xiao, Hanhui Chen, Fahmy Hanna, A T Jotheeswaran, Dan Luo, Rachana Parikh, Eesha Sharma, Shamaila Usmani, Yu Yu, Benjamin G Druss, Shekhar Saxena This Series paper describes the first systematic effort to review the unmet mental health needs of adults in China and Published Online India. The evidence shows that contact coverage for the most common mental and substance use disorders is very low. May 18, 2016 Effective coverage is even lower, even for severe disorders such as psychotic disorders and epilepsy. There are vast http://dx.doi.org/10.1016/ S0140-6736(16)00160-4 variations across the regions of both countries, with the highest treatment gaps in rural regions because of inequities This paper forms part of the in the distribution of mental health resources, and variable implementation of mental health policies across states and China–India Mental Health provinces. Human and financial resources for mental health are grossly inadequate with less than 1% of the national Alliance Series. Other papers in health-care budget allocated to mental health in either country. Although China and India have both shown renewed the series are available at commitment through national programmes for community-oriented mental health care, progress in achieving http://www.thelancet.com/ series/china-india-mental-health coverage is far more substantial in China. Improvement of coverage will need to address both supply-side barriers and London School of Hygiene & demand-side barriers related to stigma and varying explanatory models of mental disorders. Sharing tasks with Tropical Medicine, London, UK community-based workers in a collaborative stepped-care framework is an approach that is ripe to be scaled up, in (Prof V Patel PhD, particular through integration within national priority health programmes. India and China need to invest in increasing S Usmani MPH); Centre for the demand for services through active engagement with the community, to strengthen service user leadership and ensure Control of Chronic Conditions, Guragon, India (Prof V Patel); that the content and delivery of mental health programmes are culturally and contextually appropriate. Centre for Chronic Conditions and Injuries, Public Health Introduction and effective coverage to further measure the extent to Foundation of India, In recognition of the large gap between the need for which the service has effectively improved the health of New Delhi, India (Prof V Patel, R Parikh MPH); Department of 4 treatment of mental disorders and the provision of that people who used it. Social Medicine and Health treatment, WHO’s Mental Health Action Plan calls for an Management, Xiangya School increase in service coverage for severe mental disorders Contact coverage of Public Health, Central South by at least 20% by the year 2020.1 The reduction of the Five population-based studies from India and 14 from University, China (Prof S Xiao MD, D Luo PhD, treatment gap in India and China, the two most populous China contributed findings on contact coverage (table 1). Y Yu MPH); Shanghai Mental countries in the world, is crucially important for The available evidence is weak, particularly in India, where Health Center, Shanghai achievement of this goal. Systematic assessment of the there are no reliable studies to suggest contact with mental Jiaotong University School of scale of and health system response to the treatment gap health-care providers for any of the priority disorders. In Medicine, Shanghai, China (H Chen MD); Department of could not only help these two countries to improve their both India and China, contact coverage rates vary greatly Mental Health and Substance mental health system performance, but also shed light on across disorders and studies, but are particularly low for Abuse (F Hanna MD, how other countries might achieve their mental health goals. In this Series paper we address four issues: estimation of the magnitude of the treatment gap; Search strategy and selection criteria description of the response of the mental health-care We carried out a systematic review using the steps recommended in the PRISMA systems; identification of the barriers to addressing the statement. for papers published in English or Chinese between Jan 1, 2005, and Dec 31, treatment gap; and identification of innovations with 2014. We searched MEDLINE, Embase, PsycINFO, PubMed, the Cochrane Library, and the potential to overcome these barriers. We undertook a Web of Science; we also searched country-specific databases including IndMED, the only systematic review of the indexed literature and a non- database of Indian medical journals, many of which are not indexed on any other systematic review of so-called grey literature on these four international database, and SinoMed, the most comprehensive electronic database of issues for depression, psychosis, bipolar disorder, medical journals published in mainland China, covering publications since 1978. The epilepsy, dementia, and alcohol and drug use disorders, search strategy sought to identify original studies related to contact and effective all deemed priority adult mental disorders by the WHO coverage, health systems response, barriers and innovations using a piloted search 2 Mental Health Gap Action Programme. We have focused strategy developed by the authors (appendix). Publications without any original data on biomedical (modern) medicine, as traditional health- (eg, correspondence and editorials), related to Chinese and Indian immigrants (from care systems, which are popular in both countries, are mainland China and India) and with small sample sizes (eg, case studies) or insufficient 3 addressed in a dedicated paper in this Series. data (eg, conference abstracts) were excluded. Relevant studies were identified by title and abstract screening by two independent reviewers (ES, HC, DL, RP, SU, and YY in teams The magnitude of the treatment gap of two) with a specific requirement of mutual consensus over articles excluded. A more We used two indicators to estimate the magnitude of the detailed search strategy is included in the appendix. treatment gap: contact coverage to measure service use, www.thelancet.com Published online May 18, 2016 http://dx.doi.org/10.1016/S0140-6736(16)00160-4 1 Series S Saxena MD), Department of common mental disorders and substance use disorders. schizophrenia, dementia, and epilepsy. In China, Ageing and Life Course Most people who seek medical care do so in the general contact coverage for dementia approaches 90% in rural (A T Jotheeswaran PhD), medical sector.21,22 In China, contact coverage for common areas, and 98% in urban areas.20 Contact coverage for World Health Organization, Geneva, Switzerland; mental disorders ranges from a low of 2·7% in Beijing and schizophrenia and other psychotic disorders is 77% in Department of Psychiatry, 3·1% in Shanghai according to the 2004 World Mental urban areas and 70% in rural areas. Contact coverage King George Medical Health Survey8 to just over 10% in a more recent for epilepsy is 65% in all areas in Yueyang19 and 95% in University, Lucknow, Uttar 5 23 Pradesh, India (E Sharma MD); investigation of four provinces of China. In India, the urban Beijing. In India, the contact coverage for 10,11 and Mental Health School of contact coverage for depression is 12% in the six states that schizophrenia is much lower, at 40–50%, which is Public Health: Health Policy & participated in the World Mental Health Survey.11 An consistent with the WHO estimation of service contact Management, Emory unpublished, population-based epidemiological study of people with severe mental disorders in low-income University, Atlanta, GA, USA 1 (Prof B Druss MD) done by the Government of India between 2002 and 2005 and middle-income countries. Contact coverage for reported a 12-month coverage rate of only 5% for epilepsy could range from a low of 6% in a tribal Correspondence to: 17 18 Prof Shuiyuan Xiao, Department prescriptive medical treatment for common mental population to 92% in an urban population. Studies of Social Medicine and Health disorders and substance use disorders (unpublished). from both countries show that contact coverage differs Management, School of Public Contact coverage rates increase with severity of significantly between rural and urban samples and Health, Central South University 11,17,18 Mental Health Center, Xiangya mental disorder in both countries and are highest for between high and low socioeconomic groups. Hospital, China [email protected] India China See Online for appendix Patients having contact with Patients having Patients having contact with Patients having contact any health-care providers (%) contact with mental any health-care providers with mental health-care health-care (%) providers (%) providers (%) Any disorder Prescriptive medical treatment NA Lifetime, 8·3–15·55–7 Lifetime, 4·95–6·77 in past 1 year, 5·1 Any disorder with any severity NA NA 1 year, 2·78–3·49 1 year, 0·69 Any disorder* with mild severity NA NA 1 year, 1·79–2·08 1 year, 1·79 Any disorder* with moderate severity NA NA 1 year, 11·98–19·89 1 year, 4·69 Psychotic disorders NA NA Lifetime, 24·0;7 72·45 Lifetime, 15·47–60·45 1 year, 10·67 1 year, 4·87 Schizophrenia Current, 40·010–49·811 NA Lifetime, 71·512 Lifetime, 63·612 1 year, 92·813 Bipolar disorder NA NA Lifetime, 23·17 Lifetime, 16·97 1 year, 6·27 1 year,
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