Kavitha Kolappa

A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come

Vikram Patel and other global mental health leaders call for a special session of the UN General Assembly to discuss and debate action needed on mental, neurological, and substance use disorders, which have been left off the international NCDs agenda.

Overcoming Obstacles To Enable Access To Medicines For Noncommunicable Diseases In Poor Countries

The modern access-to-medicines movement grew largely out of the civil-society reaction to the HIV/AIDS pandemic three decades ago. While the movement was successful with regard to HIV/AIDS medications, the increasingly urgent challenge to address access to medicines for noncommunicable diseases has lagged behind-and, in some cases, has been forgotten. In this article we first ask what causes the access gap with respect to lifesaving essential noncommunicable disease medicines and then what can be done to close the gap. Using the example of the push for access to antiretrovirals for HIV/AIDS patients for comparison, we highlight the problems of inadequate global financing and procurement for noncommunicable disease medications, intellectual property barriers and concerns raised by the pharmaceutical industry, and challenges to building stronger civil-society organizations and a patient and humanitarian response from the bottom up to demand treatment. We provide targeted policy recommendations, specific to the public sector, the private sector, and civil society, with the goal of improving access to noncommunicable disease medications globally.

Responding to the evidence for the management of severe malaria

Humanity owes a great debt to quinine. Cinchona alkaloids have been used to treat malaria for hundreds of years after the arrival of cinchona bark in Europe in the 17th century, where it was mixed with rose leaves, lemon juice and wine to treat the malarious patients of Essex (Butler et al. 2010). While quinine has been largely replaced by more effective and better-tolerated drugs in the treatment of uncomplicated malaria, it remains the standard treatment for severe malaria in many countries. In Africa, where over 90% of the estimated 781 000 malaria-related deaths in 2009 occurred, quinine is first-line therapy for severe malaria in almost all countries (WHO 2010). Recent evidence shows that it is time to replace quinine for severe malaria as well. A large randomized trial conducted in Asia in 2005 found that parenteral artesunate reduced overall mortality by 39% compared with quinine (Dondorp et al. 2005). As a result, in 2006 WHO recommended artesunate as the treatment of choice for adults, but considered there was insufficient evidence to extend this recommendation to children in Africa. That evidence came in late 2010, from the largest ever study of severe malaria (5425 children across Africa), which found that artesunate reduced mortality by 22.5% compared with quinine (Dondorp et al. 2010). Importantly, there was no evidence in this or previous studies of an increase in neurological sequelae in survivors. These results were confirmed by a recent Cochrane meta-analysis that found an overall mortality reduction of 39% among adults and 24% among children compared to quinine (Sinclair et al. 2011), an identical finding to the meta-analysis accompanying the African trial (Dondorp et al. 2010). So what now? WHO has just changed its guidelines to put artesunate as the treatment of choice for severe malaria everywhere (WHO 2011), and these recommendations need to be disseminated to all relevant malaria actors to support national guideline change where needed. To date, only one African country (Nigeria) has revised its guidelines to include artesunate for severe malaria, and only as an alternative treatment (WHO 2010). Given the long history of quinine use, the dissemination of national guidelines will need to be accompanied by training to help shift health provider habits and personal convictions. All this needs to be properly supported, both by international donors and through technical advice from WHO’s regional offices. The challenge in translating evidence into practice should never be underestimated, particularly when it comes to malaria treatment, as recent history shows. In 2000, WHO recommended a policy shift in the management of uncomplicated malaria from chloroquine to artemisinin-based combination therapies (ACTs) because of high levels of chloroquine resistance. Yet, despite substantial evidence supporting the superior efficacy of ACTs, international donors and ministries of health in malaria-endemic countries continued to support chloroquine use for several years, mainly because chloroquine was a much cheaper drug (Attaran et al. 2004). Similarly, the higher unit price of artesunate is likely to be a barrier. Cost effectiveness studies, however, show that when mortality and associated costs such as reduced side-effect management and hospitalization are considered, artesunate is cost effective (Lubell et al. 2009, 2011). Furthermore, the cost of artesunate may fall as demand increases. Nevertheless, for policy and practice to change in the short-term, additional international funding support is needed. Another important potential concern is the limited availability of quality-assured sources of artesunate. Currently, only one source of injectable artesunate has been pre-qualified by WHO, and malaria control programmes may be reluctant to make the switch as long as consistency in supply is uncertain. In addition, quinine production represents an important economic activity in a number of malaria-endemic countries; in Burundi, for example, quinine is one of the few drugs manufactured in-country, making it more popular and more easily accessible than imported antimalarial drugs (Amuasi et al. 2011). However, artemisinin, the raw material for artesunate, is increasingly being produced in Africa, including in Kenya, Tanzania and Uganda (http://www.artepal.org), and as demand grows, supply should logically follow. Finally, it can be anticipated that calls for local evidence may be made by national governments out of concern that studies performed in other contexts may not apply to their setting. MSF faced similar challenges when trying to move from chloroquine to ACT (Guthmann et al. 2008). While this may initially appear reasonable, the evidence to date is broadly generalizable and the latest Cochrane review concludes that further research to assess the efficacy of artesunate versus quinine is unnecessary (Sinclair et al. 2011). Patients should only be subjected to experimental trials if there is real uncertainty about which drug is better (CIOMS 2002), and while operational research may help guide implementation, it would clearly be unethical to delay implementation and subject patients to further drug effectiveness studies. Global funding for malaria control is already insufficient (Snow et al. 2010), and in the current economic climate, donors may be reluctant to support a switch to a more expensive treatment. However, replacing quinine with artesunate is a clear cut intervention that has the potential to save nearly 200 000 lives each year and the total annual cost of providing artesunate for treating all cases of severe malaria worldwide would likely be less than

A two-phase approach for the identification of refugees with priority need for mental health care in Lebanon: a validation study

US 50 million (MSF 2011). For African countries to make the switch, strong international support will be required to provide additional funds to support drug procurement and training costs and send a clear message to manufacturers that quality sources of artesunate are needed.

Access to psychotropic medicines in low-resource settings

BackgroundTime and resource efficient mental disorder screening mechanisms are not available to identify the growing number of refugees and other forcibly displaced persons in priority need for mental health care. The aim of this study was to identify efficient screening instruments and mechanisms for the detection of moderate and severe mental disorders in a refugee setting.MethodsLay interviewers applied a screening algorithm to detect individuals with severe distress or mental disorders in randomly selected households in a Palestinian refugee camp in Beirut, Lebanon. The method included household informant and individual level interviews using a Vignettes of Local Terms and Concepts for mental disorders (VOLTAC), individual and household informant portions of the field-test version of the WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS) and the WHO Self Reporting Questionnaire (SRQ-20). A subset of participants were then reappraised utilizing the Mini International Neuropsychiatric Interview (MINI), WHO Disability Assessment Schedule II, and the Global Assessment of Functioning. The study constitutes a secondary analysis of interview data from 283 randomly selected households (n = 748 adult residents) who participated in a mental health disorders prevalence study in 2010.ResultsThe 5-item household informant portion of WASSS was the most efficient instrument among those tested. It detected adults with severe mental disorders with 95% sensitivity and 71% specificity (Area Under Curve (AUC) = 0.85) and adults with moderate or severe mental disorder with 85.1% sensitivity and 74.8% specificity (AUC = 0.82). The complete screening algorithm demonstrated 100% sensitivity and 58% specificity.ConclusionsOur results suggest that a two phase, screen-confirm approach is likely a useful strategy to detect incapacitating mental disorders in humanitarian contexts where mental health specialists are scarce, and that in the context of a multi-step screen confirm mechanism, the household informant portion of field-test version of the WASSS may be an efficient screening tool to identify adults in greatest need for mental health care in humanitarian settings.

Mapping actions to improve access to medicines for mental disorders in low and middle income countries.

www.thelancet.com/psychiatry Vol 3 October 2016 913 symptoms (relative risk [RR] 1·53, 95% CI 1·13–2·08). It is also notable that Jacola and colleagues found that the siblings of cancer survivors exhibited more frequent internalising problems, per parent ratings, than normative expectations, suggesting that psychological supports for the entire family are warranted. The work of Jacola and colleagues adds to the fi ndings of other single-institution, cross-sectional studies that used performance-based assessment measures to characterise the trajectory of neurocognitive changes in survivors. Additional longitudinal studies are needed. This body of research is crucially important to provide families with realistic expectations of survivorship and to determine when interventions might be most eff ectively applied across the lifespan.

One good hand

AIMS In recent years a number of intergovernmental initiatives have been activated in order to enhance the capacity of countries to improve access to essential medicines, particularly for mental disorders. In May 2013 the 66th World Health Assembly adopted the World Health Organization (WHO) Comprehensive Mental Health Action Plan 2013-2020, which builds upon the work of WHOs Mental Health Gap Action Programme. Within this programme, evidence-based guidelines for mental disorders were developed, including recommendations on appropriate use of medicines. Subsequently, the 67th World Health Assembly adopted a resolution on access to essential medicines, which urged Member States to improve national policies for the selection of essential medicines and to promote their availability, affordability and appropriate use. METHODS Following the precedent set by these important initiatives, this article presents eleven actions for improving access and appropriate use of psychotropic medicines. RESULTS A 4 × 4 framework mapping actions as a function of the four components of access - selection, availability, affordability and appropriate use - and across four different health care levels, three of which belong to the supply side and one to the demand side, was developed. The actions are: developing a medicine selection process; promoting information and education activities for staff and end-users; developing a medicine regulation process; implementing a reliable supply system; implementing a reliable quality-control system; developing a community-based system of mental health care and promoting help-seeking behaviours; developing international agreements on medicine affordability; developing pricing policies and a sustainable financing system; developing or adopting evidence-based guidelines; monitoring the use of psychotropic medicines; promoting training initiatives for staff and end-users on critical appraisal of scientific evidence and appropriate use of psychotropic medicines. CONCLUSIONS Activating these actions offers an unique opportunity to address the broader issue of increasing access to treatments and care for mental disorders, as current lack of attention to mental disorders is a central barrier across all domains of the 4 × 4 access framework.

Reversing hard won victories in the name of human rights: a critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons with Disabilities

If you had been a few feet away, you would have never guessed she was nearly 50 years old. She looked more like a child, her tiny silhouette hiding beneath the bleached-white hospital sheets. A brightly colored cloth wrapped her hair, further concealing her years. Only temporal wasting and paper-like tightening of the caramel-colored skin over her cheekbones betrayed her age and illness. I met Ms. Lana as I would come to call her, while on-call as a medical student. As a third-year medical student, you are always hoping to get the ‘‘perfect patient’’ . . . the one who gives you a clear, concise history, the one whomakes you look good in front of your team, and the one who does not mind you rudely waking them for morning rounds. At first Ms. Lana seemed anything but the ‘‘perfect patient.’’ When I entered her room for the admission interview, she could not have seemed less interested. She did not open her eyes throughout the encounter; she mumbled faint responses laced with irritation to only a sporadic selection of my questions. Most of what I knew aboutMs. Lana that first day I gleaned from her extensive hospital records. She had been admitted to our health system 12 times over the previous 5 years, the past 10 admissions being for recurrent abdominal pain and nausea secondary to diabetic gastroparesis. She had had 13 abdominal/ pelvic CT scanswith contrast and four ultrasounds of the abdomen. All imaging tests had been negative except imaging years ago that had shown gall stone pancreatitis and cholecystectomy. Multiple X-rays of her abdomen, an upper gastrointestinal series, a small bowel follow-through, an upper endoscopy and a colonoscopy – all had been unrevealing. Two gastric emptying studies showed mild gastroparesis, Ms. Lana had been non-adherent with the promotility agent that had been repeatedly prescribed, and had over the course of several hospitalizations become dependent on oxycodone, whichwould exacerbate hermotility issues. Her illness was further complicated by HIV, hepatitis C, depression, alcohol abuse, and intermittent cocaine use. Our attending had actually taken care of Ms. Lana twice before. Her abdominal pain and nausea would be controlled at each admission, and after discharge she would not take her pro-motility agents or follow through with HIV and substance use care. At first, Patient Education and Counseling 98 (2015) 1164–1166