Julian Eaton

Scale up of services for mental health in low-income and middle-income countries

Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. One response to this issue has been the call to scale up mental health services. We assess progress in scaling up such services worldwide using a systematic review of literature and a survey of key national stakeholders in mental health. The large number of programmes identified suggested that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organised services. However, there was a lack of well documented examples of services that had been taken to scale that could guide how to replicate successful scaling up in other settings. Recommendations are made on the basis of available evidence for how to take forward the process of scaling up services globally.

Structure of the key toxin in gas gangrene

Clostridium perfringens α-toxin is the key virulence determinant in gas gangrene and has also been implicated in the pathogenesis of sudden death syndrome in young animals. The toxin is a 370-residue, zinc metalloenzyme that has phospholipase C activity, and can bind to membranes in the presence of calcium. The crystal structure of the enzyme reveals a two-domain protein. The N-terminal domain shows an anticipated structural similarity to Bacillus cereus phosphatidylcholine-specific phospholipase C (PC-PLC). The C-terminal domain shows a strong structural analogy to eukaryotic calcium-binding C2 domains. We believe this is the first example of such a domain in prokaryotes. This type of domain has been found to act as a phospholipid and/or calcium-binding domain in intracellular second messenger proteins and, interestingly, these pathways are perturbed in cells treated with α-toxin. Finally, a possible mechanism for α-toxin attack on membrane-packed phospholipid is described, which rationalizes its toxicity when compared to other, non-haemolytic, but homologous phospholipases C.

Packages of Care for Schizophrenia in Low- and Middle- Income Countries

In the third in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Jair Mari and colleagues discuss the treatment of schizophrenia.

Three models of community mental health services In low-income countries

ObjectiveTo compare and contrast three models of community mental health services in low-income settings.Data Sources/Study SettingPrimary and secondary data collected before, during, and after site visits to mental health programs in Nigeria, the Philippines, and India.Study DesignQualitative case study methodology.Data CollectionData were collected through interviews and observations during site visits to the programs, as well as from reviews of documentary evidence.Principal FindingsA set of narrative topics and program indicators were used to compare and contrast three community mental health programs in low-income countries. This allowed us to identify a diversity of service delivery models, common challenges, and the strengths and weaknesses of each program. More definitive evaluations will require the establishment of data collection methods and information systems that provide data about the clinical and social outcomes of clients, as well as their use of services.ConclusionsCommunity mental health programs in low-income countries face a number of challenges. Using a case study methodology developed for this purpose, it is possible to compare programs and begin to assess the effectiveness of diverse service delivery models.

Psychosocial effects of an Ebola outbreak at individual, community and international levels

Abstract The 2013–2016 Ebola outbreak in Guinea, Liberia and Sierra Leone was the worst in history with over 28 000 cases and 11 000 deaths. Here we examine the psychosocial consequences of the epidemic. Ebola is a traumatic illness both in terms of symptom severity and mortality rates. Those affected are likely to experience psychological effects due to the traumatic course of the infection, fear of death and experience of witnessing others dying. Survivors can also experience psychosocial consequences due to feelings of shame or guilt (e.g. from transmitting infection to others) and stigmatization or blame from their communities. At the community level, a cyclical pattern of fear occurs, with a loss of trust in health services and stigma, resulting in disruptions of community interactions and community break down. Health systems in affected countries were severely disrupted and overstretched by the outbreak and their capacities were significantly reduced as almost 900 health-care workers were infected with Ebola and more than 500 died. The outbreak resulted in an increased need for health services, reduced quality of life and economic productivity and social system break down. It is essential that the global response to the outbreak considers both acute and long-term psychosocial needs of individuals and communities. Response efforts should involve communities to address psychosocial need, to rebuild health systems and trust and to limit stigma. The severity of this epidemic and its long-lasting repercussions should spur investment in and development of health systems.

The Mental Health Leadership and Advocacy Program (mhLAP): a pioneering response to the neglect of mental health in Anglophone West Africa

Developing countries in Africa and other regions share a similar profile of insufficient human resources for mental health, poor funding, a high unmet need for services and a low official prioritisation of mental health. This situation is worsened by misconceptions about the causes of mental disorders, stigma and discrimination that frequently result in harmful practices against persons with mental illness. Previous explorations of the required response to these challenges have identified the need for strong leadership and consistent advocacy as potential drivers of the desired change. The Mental Health Leadership and Advocacy Program (mhLAP) is a project that aims to provide and enhance the acquisition of skills in mental health leadership, service development, advocacy and policy planning and to build partnerships for action. Launched in 2010 to serve the Anglophone countries of The Gambia, Ghana, Liberia, Nigeria, Sierra Leone, this paper describes the components of the program, the experience gained since its initiation, and the achievements made during the three years of its implementation. These achievements include: 1) the annual training in mental health leadership and advocacy which has graduated 96 participants from 9 different African countries and 2) the establishment of a broad coalition of service user groups, non-governmental organizations, media practitioners and mental health professionals in each participating country to implement concerted mental health advocacy efforts that are focused on country-specific priorities

Development of a Community-Based Rehabilitation Intervention for People with Schizophrenia in Ethiopia

Background Community-based rehabilitation (CBR) is a multi-sectoral strategy to improve the functioning and quality of life of people with disabilities. The RISE (Rehabilitation Intervention for people with Schizophrenia in Ethiopia) trial will evaluate the effectiveness of CBR for people with schizophrenia in Ethiopia. Nevertheless, the components of CBR that are both feasible and likely to prove effective in low and middle-income countries such as Ethiopia are unclear. Methods In this study intervention development work was undertaken to design a CBR intervention that is acceptable and feasible in the local context. The development work consisted of five phases. 1: Identify potential components of CBR for schizophrenia, 2: Situational analysis, 3: Determine feasibility of CBR (Theory of Change workshops with experts and local stakeholders), 4: Determine acceptability of CBR (16 in-depth interviews and five focus group discussions with people with schizophrenia, caregivers, health workers and community leaders) and 5: Synthesise results to finalise intervention. A Theory of Change map was constructed showing the causal pathway for how we expect CBR to achieve its impact. Results People with schizophrenia in rural Ethiopia experience family conflict, difficulty participating in work and community life, and stigma. Stakeholders perceived CBR to be acceptable and useful to address these problems. The focus of CBR will be on the individual developing the skills and confidence to perform their previous or desired roles and activities. To ensure feasibility, non-health professionals will be trained to deliver CBR and provide supervision, rather than mental health specialists. Novel components of CBR for schizophrenia included family intervention and dealing with distressing symptoms. Microfinance was excluded due to concerns about stress and exploitation. Community mobilisation was viewed as essential to ensure the effectiveness and sustainability of CBR. Conclusion Extensive formative research using a variety of methods has enabled the design of a culturally appropriate CBR intervention for people with schizophrenia that is acceptable and feasible.

The importance of global mental health for the Sustainable Development Goals

Currently the United Nations are negotiating the next generation of global development goals: the new Sustainable Development Goals (SDG) for the Post 2015 agenda. The previous 10 Millennium Development Goals (MDGs) (United Nations Millennium Declaration, 2000) have helped to accelerate development in many lowand middleincome countries (LAMICs) (United Nations, 2013). While ‘‘[t]here have been visible improvements in all health areas’’, as United Nations Secretary General Ban Ki-Moon stated in the introduction to the MDG report 2013 (United Nations, 2013), mental health, although highly relevant to the MDGs, was wholly excluded from these goals. For the new SDGs, the international community now needs to recognise the evidence showing the growing burden of disease and the extensive social and economic global consequences of mental disorders and psychosocial disabilities (World Economic Forum, 2011). Mental health has for too long been a low priority in development. In the future Post-2015 agenda, mental health needs to be clearly included, with a specific mental health target and two indicators.

Declaration on mental health in Africa: moving to implementation

Urgent action is needed to address mental health issues globally. In Africa, where mental health disorders account for a huge burden of disease and disability, and where in general less than 1% of the already small health budgets are spent on these disorders, the need for action is acute and urgent. Members of the World Health Organization, including African countries, have adopted a Comprehensive Mental Health Action Plan. Africa now has an historic opportunity to improve the mental health and wellbeing of its citizens, beginning with provision of basic mental health services and development of national mental health strategic plans (roadmaps). There is need to integrate mental health into primary health care and address stigma and violations of human rights. We advocate for inclusion of mental health into the post-2015 Sustainable Development Goals, and for the convening of a special UN General Assembly High Level Meeting on Mental Health within three years.Urgent action is needed to address mental health issues globally. In Africa, where mental health disorders account for a huge burden of disease and disability, and where in general less than 1% of the already small health budgets are spent on these disorders, the need for action is acute and urgent. Members of the World Health Organization, including African countries, have adopted a Comprehensive Mental Health Action Plan. Africa now has an historic opportunity to improve the mental health and wellbeing of its citizens, beginning with provision of basic mental health services and development of national mental health strategic plans (roadmaps). There is need to integrate mental health into primary health care and address stigma and violations of human rights. We advocate for inclusion of mental health into the post-2015 Sustainable Development Goals, and for the convening of a special UN General Assembly High Level Meeting on Mental Health within three years.

Crystallization and preliminary X-ray diffraction studies of α-toxin from two different strains (NCTC8237 and CER89L43) of Clostridium perfringens

The alpha-toxin of Clostridium perfringens is the major virulence determinant for gas gangrene in man. The gene encoding the alpha-toxin has been cloned into E. coli from two strains of the bacterium (NCTC8237 and CER89L43) and subsequently purified to homogeneity. The two strains of alpha-toxin differ by five amino acids, resulting in the toxin from NCTC8237 being sensitive to chymotrypsin digestion while that from CER89L43 is resistant. The alpha-toxin from each of these strains has been crystallized in two different forms by the hanging-drop vapour-diffusion method at 293 K. CER89L43 form I crystals belong to space group R32 and have two molecules in the crystallographic asymmetric unit and a unit cell with a = b = 151.4, c = 195.5 A, alpha = beta = 90, gamma = 120 degrees. The crystals diffracted to dmin = 1.90 A. The characteristics of the NCTC8237 form I crystals have already been reported. The form II crystals from both strains belong to space group C2221 with one molecule in the crystallographic asymmetric unit and, for strain CER89L43, have cell dimensions a = 61.05, b = 177.50, c = 79.05 A, alpha = beta = gamma = 90 degrees, while for strain NCTC8237 the cell dimensions are a = 60.50, b = 175.70, c = 80.20 A, alpha = beta = gamma = 90 degrees. The crystals diffracted to maximum resolutions of 1.85 and 2.1 A for the CER89L43 and the NCTC8237 strains, respectively.