Improving Mental Health Care

The Global Challenge

Graham Thornicroft, Mirella Ruggeri, David Goldberg, Graham Thornicroft, Mirella Ruggeri, David Goldberg

• Editorial: Wiley-Blackwell
• Año: 2013
• ISBN:
  9781118338001
• Edición: 1
• Categoría: Medicina
• Categoría: Psiquiatría y salud mental

Written by many of the world's leading practitioners in the delivery of mental health care, this book clearly presents the results of scientific research about care and treatment for people with mental illness in community settings. The book presents clear accounts of what is known, extensively referenced, with critical appraisals of the strength of the evidence and the robustness of the conclusions that can be drawn. Improving Mental Health Care adds to our knowledge of the challenge and the solutions and stands to make a significant contribution to global mental health.

SECTION 1

The global challenge

CHAPTER 1

The nature and scale of the global mental health challenge

Mirella Ruggeri¹, Graham Thornicroft² and David Goldberg²

¹ Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Verona, Italy
² Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK

Introduction

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 nature of the challenge

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.

The scale of the challenge

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...

Índice

• Cover
• Title page
• Copyright page
• Dedication
• Contributors
• SECTION 1: The global challenge
• SECTION 2: Meeting the global challenge
• SECTION 3: New research methods
• SECTION 4: Delivering better care in the community
• Index