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]
RA790.5
362.2′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, Italy
Cover design by Sarah Dickenson
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.
[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 Pharmacology 10: 481–488.
[2] Zimmermann-Tansella C, Tansella M, Lader M. (1979) Psychological performance in anxious patients treated with diazepam. Progress in Neuro-Psychopharmacology 3 (4): 361–368.
[3] Tansella M. (1974) An institution-based register in a psychiatric university clinic. Psychiatria Clinica 7 (2): 84–88.
[4] Tansella M. (1985) Misunderstanding the Italian Experience. British Journal of Psychiatry 147: 450–452.
[5] Tansella M. (1986) Community psychiatry without mental hospitals – the Italian Experience – a review. Journal of the Royal Society of Medicine 79: 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 Medicine 15 (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 Scandinavica 429 (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.
Ruben Alvarado
Faculty of Medicine,
Salvador Allende School of Public Health,
University of Chile,
Santiago,
Chile
Francesco Amaddeo
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Matteo Balestrieri
Department of Experimental and Clinical Medical Sciences,
University of Udine,
Udine,
Italy
Corrado Barbui
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Paul Bebbington
Mental Health Sciences Unit,
Faculty of Brain Sciences,
UCL,
London,
UK
Thomas Becker
Department of Psychiatry II,
Ulm University,
Bezirkskrankenhaus Günzburg,
Germany
Marcella Bellani
Department 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,
Italy
Loretta Berti
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Victoria Bird
Health Service and Population Research Department,
Institute of Psychiatry,
King’s College London,
London,
UK
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Chiara Bonetto
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Elena Bonfioli
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Paolo Brambilla
Department of Experimental & Clinical Medical Sciences (DISM),
Inter-University Center for Behavioural Neurosciences (ICBN),
University of Udine,
Udine,
Italy
Department of Psychiatry and Behavioral Sciences,
University of Texas Medical School at Houston,
USA
Lorenzo Burti
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Andrea Cipriani
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Benedicto Crespo-Facorro
Department of Psychiatry,
Psychiatric Research Unit of Cantabria,
University Hospital “Marqués de Valdecilla”,
IFIMAV,
CIBERSAM,
Santander,
Cantabria,
Spain
Doriana Cristofalo
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Katia De Santi
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Lidia Del Piccolo
Department of Public Health and Community Medicine,
Section of Clinical Psychology,
University of Verona,
Verona,
Italy
Giuseppe Deledda
Department of Public Health and Community Medicine,
Section of Clinical Psychology,
University of Verona,
Verona,
Italy
Valeria Donisi
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Graham Dunn
Institute of Population Health,
Centre for Biostatistics,
University of Manchester,
Manchester,
UK
Nicola Dusi
Department 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,
Italy
Irene Fiorini
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
David Fowler
Division of Health Policy and Practice,
School of Medicine,
University of East Anglia,
Norwich,
UK
Carlos Garcia-Alonso
Department of Management and Quantitative Methods,
Loyola University Andalusia,
Cordoba,
Spain
Karina Gibert
Knowledge Engineering and Machine Learning Group,
Department of Statistics and Operations Research,
Universitat Politècnica de Catalunya,
Barcelona,
Spain
Nadja van Ginneken
Nutrition and Public Health Intervention Research Department,
London School of Hygiene and Tropical Medicine,
London,
UK
Sangath,
Goa,
India
David Goldberg
Health Service and Population Research Department,
Institute of Psychiatry,
King’s College London,
London,
UK
Claudia Goss
Department of Public Health and Community Medicine,
Section of Clinical Psychology,
University of Verona,
Verona,
Italy
Justin Granstein
Weill Cornell Medical College,
Cornell University,
New York,
NY,
USA
Laura Grigoletti
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Hiske Hees
Department of Psychiatry,
Academic Medical Center,
University of Amsterdam,
Amsterdam,
The Netherlands
Assen Jablensky
School of Psychiatry and Clinical Neurosciences,
The University of Western Australia,
Australia
Martin Knapp
Personal Social Services Research Unit,
London School of Economics and Political Science,
London,
UK
Centre for the Economics of Mental and Physical Health,
Institute of Psychiatry,
King’s College London,
London,
UK
Maarten Koeter
Department of Psychiatry,
Academic Medical Center,
University of Amsterdam,
Amsterdam,
The Netherlands
Lian van der Krieke
University Center for Psychiatry,
University Medical Center Groningen,
University of Groningen,
Groningen,
The Netherlands
Elizabeth Kuipers
Department of Psychology,
Institute of Psychiatry,
King’s College London,
London,
UK
Antonio Lasalvia
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Clair Le Boutillier
Health Service and Population Research Department,
Institute of Psychiatry,
King’s College London,
London,
UK
Mary Leamy
Health Service and Population Research Department,
Institute of Psychiatry,
King’s College London,
London,
UK
Mariangela Mazzi
Department of Public Health and Community Medicine,
Section of Clinical Psychology,
University of Verona,
Verona,
Italy
Alberto Minoletti
Faculty of Medicine,
Salvador Allende School of Public Health,
University of Chile,
Santiago,
Chile
Povl Munk-Jørgensen
Department of Organic Psychiatric Disorders and Emergency Ward,
Aarhus University Hospital,
Risskov,
Denmark
Michela Nosè
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Niels Okkels
Organic Psychiatric Disorder Research Unit,
Aarhus University Hospital,
Risskov,
Denmark
Bernd Puschner
Department of Psychiatry II,
Ulm University,
Bezirkskrankenhaus Günzburg,
Germany
Michela Rimondini
Department of Public Health and Community Medicine,
Section of Clinical Psychology,
University of Verona,
Verona,
Italy
Graciela Rojas
Department of Psychiatry,
Clinical Hospital,
University of Chile,
Santiago,
Chile
Diana Rose
Service User Research Enterprise (SURE),
Health Services and Population Research,
Institute of Psychiatry,
King’s College London,
London,
UK
Alberto Rossi
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Mirella Ruggeri
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Luis Salvador-Carulla
Centre for Disability Research and Policy,
Faculty of Health Sciences,
University of Sydney,
Australia
Spanish Research Network on Mental Health Prevention and Promotion (Spanish IAPP Network)
Benedetto Saraceno
University Nova of Lisbon,
WHO Collaborating Center,
University of Geneva,
Geneva,
Switzerland
Norman Sartorius
Association for the Improvement of Mental Health Programmes,
Geneva,
Switzerland
Shekhar Saxena
Department of Mental Health and Substance Abuse,
World Health Organization,
Geneva,
Switzerland
Aart Schene
Department of Psychiatry,
Academic Medical Center,
University of Amsterdam,
Amsterdam,
The Netherlands
Mike Slade
Health Service and Population Research Department,
Institute of Psychiatry,
King’s College London,
London,
UK
Ezra Susser
Department of Epidemiology,
Mailman School of Public Health,
Columbia University,
New York,
NY,
USA
Department of Psychiatry,
College of Physicians and Surgeons,
Columbia University and New York State Psychiatric Institute,
New York,
NY,
USA
Department of Psychiatry,
University of Göttingen,
Göttingen,
Germany
Sjoerd Sytema
University Center for Psychiatry,
University Medical Center Groningen,
University of Groningen,
Groningen,
The Netherlands
Graham Thornicroft
Health Service and Population Research Department,
Institute of Psychiatry,
King’s College London,
London,
UK
Sarah Tosato
Department of Public Health and Community Medicine,
Section of Psychiatry,
University of Verona,
Verona,
Italy
Peter Tyrer
Department of Medicine,
Centre for Mental Health,
Imperial College,
London,
UK
Elie Valencia
Faculty of Medicine,
Salvador Allende School of Public Health,
University of Chile,
Santiago,
Chile
Department of Epidemiology,
Mailman School of Public Health,
Columbia University,
New York,
NY,
USA
José Luis Vázquez-Barquero
Department of Psychiatry,
Psychiatric Research Unit of Cantabria,
University Hospital “Marqués de Valdecilla”,
IFIMAV,
CIBERSAM,
Santander,
Spain
Javier Vázquez-Bourgon
Department of Psychiatry,
Psychiatric Research Unit of Cantabria,
University Hospital “Marqués de Valdecilla”,
IFIMAV,
CIBERSAM,
Santander,
Spain
Gabe de Vries
Department of Occupational Therapy,
Arkin,
Amsterdam,
The Netherlands
Christa Zimmermann
Department of Public Health and Community Medicine,
Section of Clinical Psychology,
University of Verona,
Verona,
Italy
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 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.
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.
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].
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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