Introducing the movement for global mental health.
Subject: Mental health
Mental illness
Author: Prince, Martin
Pub Date: 11/01/2008
Publication: Name: Indian Journal of Medical Research Publisher: Indian Council of Medical Research Audience: Academic Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2008 Indian Council of Medical Research ISSN: 0971-5916
Issue: Date: Nov, 2008 Source Volume: 128 Source Issue: 5
Accession Number: 221850591
Full Text: A year ago, the Lancet published a series of five articles on Global Mental Health, with a focus on low and middle income countries (LAMIC) (http://www.theLancet.com/online/focus/mental_health). The articles comprised systematic reviews and secondary analyses, the aim being to draw together the best available evidence to inform action. The target was the global health community, raising awareness of the problems and highlighting potential solutions.

The series drew attention to (i) the burden of mental disorder, accounting for 14 per cent of the global burden of disease, 84 per cent of which is in low and middle income countries. Mental disorders affect disproportionately the poor, the disadvantaged and vulnerable, (ii) the inequity in the allocation of healthcare resources. In all regions, the slice of the overall health budget spent on mental health is one third or less what would be expected given their burden, (iii) the scarcity of human resources in low and middle income countries. Across most of Africa, south and south east Asia there is fewer than one psychiatrist per million population, (iv) the inefficient spending on large institutions, usually located in major cities and inaccessible to many of those who could benefit from care, (v) the evidence that low-cost treatments (drugs, psychological treatments, community-based rehabilitation) are feasible, affordable and cost-effective for many mental disorders in developing countries--these could be delivered by community health workers with adequate training and supervision, (vi) the enormous treatment gap, between those that might benefit from interventions, and those that receive them--as high as 90 per cent for serious mental illnesses in LAMIC, (vii) the inextricable links between mental health and other health and social concerns including communicable, non communicable diseases, accidents and injuries--this is why there can be 'no health without mental health', and why greater integration of mental healthcare with general healthcare is a key priority, (viii) the discrimination, and stigma experienced by many with mental disorders and their families--reducing the demand for effective treatments, and undermining the potential for networking, lobbying and advocacy, and (ix) the neglect of the human rights of people with mental disorders--there is far too much unnecessary and unmonitored detention, restraint, neglect and exclusion from the rights to good quality healthcare, and full and active social and civil participation.

Solutions to these problems are at hand, and these form the basis of the Call for Action (1) issued by Lancet Global Mental Health Group for: (i) The immediate scaling up of the coverage of services for mental disorders especially in low and middle income countries, based on an evidence-based package of affordable and accessible community-based services for core mental disorders. (ii) A new commitment to the protection of the human rights of persons with mental disorders and their families. (iii) New funding for mental health, both as health assistance from international donors and lending agencies to low and middle income countries, and in budget allocations from governments (a minimum increase in investment within 10 years of USS 2 per head in low-income countries and USS 3-4 in middle-income countries).

Today, World Mental Health Day 2008, sees the launch of a new Movement for Global Mental Health (www.globalmentalhealth.org). In the words of the Call for Action l: "This Series has provided the evidence for advocacy. Now we need political will and solidarity to translate this evidence into action. The time to act is now."

The Movement for Global Mental Health was initiated following discussions with an expanded advisory group of 56 global mental health stakeholders, representing all regions and a wide variety of constituencies, including users and consumers, healthcare providers, policymakers, researchers and advocacy groups. The Movement will be global in scope, but the focus is on low and middle income countries where the treatment gaps are the largest. The Movement is not an organization; it has no constitution, no formal leadership and no budgets. Anybody, and any organization can join the Movement; all that is required is to support a common set of principles and objectives, namely the 'Call for Action' (1) Change will be incremental, not revolutionary, but will require new and sustained commitment, new investment and fundamental changes in the way in which mental healthcare is delivered. The users of mental health services and their families, mental health professionals, technical experts, academics and policymakers need to show solidarity and work collaboratively to find solutions. All of these stakeholders need to work with opinion formers in public health to ensure the inclusion of mental health on the public health policy agenda, and the effective integration of mental health prevention and care into every level of general healthcare. Hence, the Movement for Global Mental Health. Advocacy is the key to success--the advisory group has proposed an agenda with a more detailed focus on the steps that might need to be taken to scale up services, protect human rights, and ensure adequate funding for mental health.

For most low and middle income countries, particularly those with the most limited resources, scaling up services for mental health in the community will require two important reforms. First, existing services need to be decentralized. Treatment in the community should replace institutional care. Community care is local, more accessible and affordable, consistent with the preferences of service users, and less stigmatizing. Recovery and rehabilitation would be facilitated. Aside from its intrinsic disadvantages, institutional care too often affronts the dignity and violates the basic human rights of its recipients. The second fundamental reform, given the scarcity of specialists, involves task-shifting. Assessment, diagnosis, and routine management of most mental health conditions could, in principle, be carried out by non-specialists working in primary care. There is already promising evidence supporting the feasibility of this approach for the treatment of severe depression by primary health care workers using cognitive behavioural therapy in Chile (2) and Pakistan (3) and for group interpersonal therapy for Ugandan villagers by community volunteers (4). Task-shifting would mean that mental health professionals working within a decentralized community-based system would deploy their expertise in different ways. More of their time would be spent training and supervising colleagues working in general healthcare, and less in direct patient care. Some increase in specialist staffing levels would be necessary to ensure that the lines of supervision were not too attenuated. New, small-scale short-stay inpatient treatment units would need to be provided to improve the quality of care for those who require it. A constant supply of essential medicines for the treatment of mental disorders in primary health care would need to be assured.

More than any other action, strengthening the human rights of people with mental disorders requires solidarity between all stakeholders. Most governments have now ratified the Universal Declaration of Human Rights and the recent Convention on the Rights of Persons with Disabilities, and are thus obliged under international law to guarantee all citizens, without discrimination, all the rights enshrined within them. This includes, inter alia, the right to liberty and security, the right not to be subjected to arbitrary detention, the right to social security, the right to work, the right to an adequate standard of living, the right to have access to healthcare, the right to full and active participation in society, and a variety of civil rights (to marry, to own and dispose of property, to participate in government, and to vote). Violations of the basic rights of those with mental disorders are particularly common in countries without democracy where the rights of all citizens are severely circumscribed. However, this is a global problem requiring urgent attention in all countries, including mature pluralist democracies with accountable governments, strong institutions and respect for the rule of law. In India, for example, a study of the status of the mental hospitals commissioned by the National Human Rights Commission (5) revealed gross inadequacies in all aspects of care, clinical services and rehabilitation. As the authors pointed out, "the subhuman living conditions in some of them were a stark violation of human rights and a painful eye-opener to many" (6). Governments can be called to account, through the Office of the High Commissioner on Human Rights. However, grass roots activism through self-advocacy of users and carers is perhaps the strongest guarantee of sustained progress. Mental health professionals and advocacy organizations have an important part to play by building the capacity of users and carers to participate in decisions affecting them and to demand their rights. We all need to work in a spirit of solidarity to promote the inclusion of people with mental disorders as equal citizens in society and in the work force, and to challenge discrimination wherever and whenever it occurs.

In the fourth article in the Lancet Series (7), Jacob and colleagues have outlined the considerable progress made in India since the 1999 report of the National Human Rights Commission and the notorious Erwadi fire in 2001. The Commission now monitors quality of care in mental hospitals. The implementation of the Mental Health Act is being tightened. The National Mental Health Programme was restructured in 2003 with a comprehensive district level approach, prioritizing access to care. Some degree of task-shifting is contemplated, to scale up coverage to districts with no specialist psychiatric input through the creation of programme officer posts that can be held by medical officers with six months additional specialist training.

The national mental health budget has increased seven-fold with further sharp increases in investment envisaged. Much has been achieved, and all of this undoubtedly constitutes grounds for optimism. The review concludes:

"The new plans and programme include a revitalised national programme; rejuvenated district mental health programme; increased accessibility to essential psychotropic medication; and provision for public education, relevant research and for increasing mental health resources. The plans have resulted in increased budgetary allocation of resources and improved monitoring of psychiatric institutions.... Nevertheless, the implementation of proposed plans will need to be assessed to see whether the new programmes are satisfactorily put into practice across the country."

I would ask you to signify your support for the 'Call for Action' by joining the Movement for Global Mental Health today. The more of us that join, the more impetus there is for the global advocacy campaign. There is also an important monitoring function. The Movement's members are encouraged to provide information on innovative packages and programmes of care, to report research initiatives that will provide further evidence of the effectiveness of these approaches, to share information on opportunities for training and capacity building, and to communicate both good news and bad regarding the promotion and protection of human rights of those with mental disorders. Forms can be submitted on the Movement's website, and the information generated can be accessed via a search engine. We hope that this will evolve over time into a participatory and interactive medium, with materials, resources, news and views, all intended to increase the volume and range of the Movement's activities. The Movement will host a Global Mental Health Summit in September 2009 in Athens to take stock of progress. Anybody can get involved; indeed everybody needs to get involved if we are to effect real and lasting change.

Finally, as a fellow professional, I would request colleagues in India to support and embrace the processes of deinstitutionalization and decentralization of services. Likewise, task-shifting will not work without our active engagement. The fifth review in the Lancet Seriess observed that, in some countries, mental health professionals, for understandable reasons, had been prominent among the barriers to progress in these areas. In the past, as mental health professionals, we have concentrated, quite properly, on the quality of the care that we provide. Now we need to attend also to the quantity of that care--our individual and collective professional contribution to increasing the coverage of mental health services and reducing the treatment gap. This cannot occur if we work in isolation from our colleagues in general healthcare and maintain that only we have the necessary skills to assess, diagnose and treat those that need our help.

While the advisory group will help to co-ordinate the campaign, promote the growth of the network and its interactivity, and facilitate the priority actions, the strength of the Movement for Global Mental Health will be the energy and creativity of its membership. It is through our co-ordinated actions that we will achieve our goals. In just 10 years, grass roots activism, international commitment, and the Global Fund have transformed the lives of people living with HIV. Can we do the same?

This editorial is published on the occasion of World Mental Health Day--October 10, 2008.

References

(1.) Chisholm D, Flisher A J, Lund C, Patel V, Saxena S, Thoruicrofi G, et al. Scale up services for mental disorders: a call for action. Lancet 2007; 370 : 1241-52.

(2.) Araya R, Rojas G, Fritsch R, Gaete J, Rojas M, Simon G, et al. Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial. Lancet 2003; 361 : 995-1000.

(3.) Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008; 372 : 902-9.

(4.) Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P, et al. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA 2003; 289 : 3117-24.

(5.) National Human Rights Commission. Quality assurance in mental health--A Project of the National Human Rights Commission. New Delhi: National Institute of Mental Health and Neuro Sciences; 1999.

(6.) Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in India. BrdPsychiatry 2004; 184 : 366-73.

(7.) Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, et al. Mental health systems in countries: where are we now? Lancet2007; 370 : 1061-77.

(8.) Saraceno B, Van OM, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007; 3 70 : 1164-74.

Martin Prince

Institute of Psychiatry

King's College London

Institute of Psychiatry

P060 De Crespigny Park

London, SE5 8AF

United Kingdom

m.prince@iop.kcl.ac.uk
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