Maya Semrau

WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.

Stigma and discrimination related to mental illness in low- and middle-income countries

AIMS This paper aims to provide an overview of evidence from low- and middle-income countries (LAMICs) worldwide to address: the nature of stigma and discrimination, relevant context-specific factors, global patterns of these phenomena and their measurement and quantitative and qualitative evidence of interventions intended to reduce their occurrence and impact. The background to this study is that the large majority of studies concerned with identifying effective interventions to reduce stigma and discrimination originate in high-income countries (HICs). This paper therefore presents such evidence from, and relevant to, LAMICs. METHODS Conceptual overview of the relevant peer-reviewed and grey literature on stigma and discrimination related to mental illness in LAMICs are available in English, Spanish, French and Russian. RESULTS Few intervention studies were identified related to stigma re-education in LAMICs. None of these addressed behaviour change/discrimination, and there were no long-term follow-up studies. There is therefore insufficient evidence at present to know which overall types of intervention may be effective and feasible and in LAMICs, how best to target key groups such as healthcare staff, and how far they may need to be locally customised to be acceptable for large-scale use in these settings. In particular, forms of social contacts, which have been shown to be the most effective intervention to reduce stigma among adults in HICs, have not yet been assessed sufficiently to know whether these methods are also effective in LAMICs. CONCLUSION Generating information about effective interventions to reduce stigma and discrimination in LAMICs is now an important mental health priority worldwide.

Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: systematic review

BackgroundThe involvement of mental health service users and their caregivers in health system policy and planning, service monitoring and research can contribute to mental health system strengthening, but as yet there have been very few efforts to do so in low- and middle-income countries (LMICs).MethodsThis systematic review examined the evidence and experience of service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation. Both the peer-reviewed and the grey literature were included in the review, which were identified through database searches (MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, SciELO, Google Scholar and Cochrane), as well as hand-searching of reference lists and the internet, and a snowballing process of contacting experts active in the area. This review included any kind of study design that described or evaluated service user, family or caregiver (though not community) involvement in LMICs (including service users with intellectual disabilities, dementia, or child and adolescent mental health problems) and that were relevant to mental health system strengthening across five categories. Data were extracted and summarised as a narrative review.ResultsTwenty papers matched the inclusion criteria. Overall, the review found that although there were examples of service user and caregiver involvement in mental health system strengthening in numerous countries, there was a lack of high-quality research and a weak evidence base for the work that was being conducted across countries. However, there was some emerging research on the development of policies and strategies, including advocacy work, and to a lesser extent the development of services, service monitoring and evaluation, with most service user involvement having taken place within advocacy and service delivery. Research was scarce within the other health system strengthening areas.ConclusionsFurther research on service user and caregiver involvement in mental health system strengthening in LMICs is recommended, in particular research that includes more rigorous evaluation. A series of specific recommendations are provided based on the review.

Indicators for routine monitoring of effective mental healthcare coverage in low- and middle-income settings: a Delphi study

High-quality information to measure the need for, and the uptake, cost, quality and impact of care is essential in the pursuit of scaling up mental health care in low- and middle-income countries (LMIC). The aim of this study was to identify indicators for the measurement of effective coverage of mental health treatment. We conducted a two-round Delphi study (n = 93 experts from primarily LMIC countries Ethiopia, India, Nepal, Nigeria, South Africa and Uganda), in order to generate and prioritize a set of indicators. First, 52 unique indicators were generated (based on a total of 876 responses from participants). Second, the selected indicators were then scored for significance, relevance and feasibility. Mean priority scores were calculated per indicator (score range, 1-5). All 52 indicators had a weighted mean score that ranged from 3.20 for the lowest ranked to 4.27 for the highest ranked. The 15 highest ranked indicators cover the different domains of measuring effective mental health treatment coverage. This set of indicators is highly stable between the different groups of experts, as well as between the different participating countries. This study provides data on how mental health service and financial coverage can be assessed in LMIC. This is an important element in the move to scale-up mental health care.

Information systems for mental health in six low and middle income countries: cross country situation analysis

BackgroundResearch on information systems for mental health in low and middle income countries (LMICs) is scarce. As a result, there is a lack of reliable information on mental health service needs, treatment coverage and the quality of services provided.MethodsWith the aim of informing the development and implementation of a mental health information sub-system that includes reliable and measurable indicators on mental health within the Health Management Information Systems (HMIS), a cross-country situation analysis of HMIS was conducted in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda), participating in the ‘Emerging mental health systems in low and middle income countries’ (Emerald) research programme. A situation analysis tool was developed to obtain and chart information from documents in the public domain. In circumstances when information was inadequate, key government officials were contacted to verify the data collected. In this paper we compare the baseline policy context, human resources situation as well as the processes and mechanisms of collecting, verifying, reporting and disseminating mental health related HMIS data.ResultsThe findings suggest that countries face substantial policy, human resource and health governance challenges for mental health HMIS, many of which are common across sites. In particular, the specific policies and plans for the governance and implementation of mental health data collection, reporting and dissemination are absent. Across sites there is inadequate infrastructure, few HMIS experts, and inadequate technical support and supervision to junior staff, particularly in the area of mental health. Nonetheless there are also strengths in existing HMIS where a few mental health morbidity, mortality, and system level indicators are collected and reported.ConclusionsOur study indicates the need for greater technical and resources input to strengthen routine HMIS and develop standardized HMIS indicators for mental health, focusing in particular on indicators of coverage and quality to facilitate the implementation of the WHO mental health action plan 2013–2020.

Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study

Aims. The aims of this paper are to: (i) explore the experiences of involvement of mental health service users, their caregivers, mental health centre heads and policy makers in mental health system strengthening in three low- and middle-income countries (LMICs) (Ethiopia, Nepal and Nigeria); (ii) analyse the potential benefits and barriers of such involvement; and (iii) identify strategies required to achieve greater service user and caregiver participation. Methods. A cross-country qualitative study was conducted, interviewing 83 stakeholders of mental health services. Results. Our analysis showed that service user and caregiver involvement in the health system strengthening process was an alien concept for most participants. They reported very limited access to direct participation. Stigma and poverty were described as the main barriers for involvement. Several strategies were identified by participants to overcome existing hurdles to facilitate service user and caregiver involvement in the mental health system strengthening process, such as support to access treatment, mental health promotion and empowerment of service users. This study suggests that capacity building for service users, and strengthening of user groups would equip them to contribute meaningfully to policy development from informed perspectives. Conclusion. Involvement of service users and their caregivers in mental health decision-making is still in its infancy in LMICs. Effective strategies are required to overcome existing barriers, for example making funding more widely available for Ph.D. studies in participatory research with service users and caregivers to develop, implement and evaluate approaches to involvement that are locally and culturally acceptable in LMICs.

“We Are Not Really Marketing Mental Health”: Mental Health Advocacy in Zimbabwe

Introduction Few people with mental disorders in low and middle-income countries (LMICs) receive treatment, in part because mental disorders are highly stigmatized and do not enjoy priority and resources commensurate with their burden on society. Advocacy has been proposed as a means of building political will and community support for mental health and reducing stigma, but few studies have explored the practice and promise of advocacy in LMICs. Methods We conducted 30 semi-structured interviews with leaders in health and mental health in Zimbabwe to explore key stakeholder perceptions on the challenges and opportunities of the country’s mental health system. We coded the transcripts using the constant comparative method, informed by principles of grounded theory. Few interview questions directly concerned advocacy, yet in our analysis, advocacy emerged as a prominent, cross-cutting theme across participants and interview questions. Results Two thirds of the respondents discussed advocacy, often in depth, returning to the concept throughout the interview and emphasizing their belief in advocacy’s importance. Participants described six distinct components of advocacy: the advocates, to whom they advocate (“targets”), what they advocate for (“asks”), how advocates reach their targets (“access”), how they make their asks (“arguments”), and the results of their advocacy (“outcomes”). Discussion Despite their perception that mental health is widely misunderstood and under-appreciated in Zimbabwe, respondents expressed optimism that strategically speaking out can reduce stigma and increase access to care. Key issues included navigating hierarchies, empowering service users to advocate, and integrating mental health with other health initiatives. Understanding stakeholder perceptions sets the stage for targeted development of mental health advocacy in Zimbabwe and other LMICs.

Building the capacity of policy-makers and planners to strengthen mental health systems in low- and middle-income countries: a systematic review

BackgroundLittle is known about the interventions required to build the capacity of mental health policy-makers and planners in low- and middle-income countries (LMICs). We conducted a systematic review with the primary aim of identifying and synthesizing the evidence base for building the capacity of policy-makers and planners to strengthen mental health systems in LMICs.MethodsWe searched MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, ScieELO, Google Scholar and Cochrane databases for studies reporting evidence, experience or evaluation of capacity-building of policy-makers, service planners or managers in mental health system strengthening in LMICs. Reports in English, Spanish, Portuguese, French or German were included. Additional papers were identified by hand-searching references and contacting experts and key informants. Database searches yielded 2922 abstracts and 28 additional papers were identified. Following screening, 409 full papers were reviewed, of which 14 fulfilled inclusion criteria for the review. Data were extracted from all included papers and synthesized into a narrative review.ResultsOnly a small number of mental health system-related capacity-building interventions for policy-makers and planners in LMICs were described. Most models of capacity-building combined brief training with longer term mentorship, dialogue and/or the establishment of networks of support. However, rigorous research and evaluation methods were largely absent, with studies being of low quality, limiting the potential to separate mental health system strengthening outcomes from the effects of associated contextual factors.ConclusionsThis review demonstrates the need for partnership approaches to building the capacity of mental health policy-makers and planners in LMICs, assessed rigorously against pre-specified conceptual frameworks and hypotheses, utilising longitudinal evaluation and mixed quantitative and qualitative approaches.

Reliability and validity of the Spanish version of the IDEAL Schedule for assessing care needs in dementia: Cross-sectional, multicenter study

The IDEAL Schedule was developed for staging “care needs” in patients with dementia. We here aim to validate the Spanish version, further test its psychometric properties and explore a latent construct for “care needs”.

Mental health capacity building in low and middle income countries: The Emerald Programme

This is a time of unprecedented interest in the field of global mental health. Since the WHO World Mental Health Report of 2001 (World Health Organization, 2001) there has been an accelerating tempo of evidence and initiatives. These show an appreciation of the scale of the mental health gap across all of the world (Wang et al. 2007; Thornicroft et al. 2017), and demonstrate the strengthening evidence base of effective interventions to treat people with mental illnesses in low and middle income countries (LMICs) (Patel & Thornicroft, 2009; Patel et al. 2016; Petersen et al. 2016; World Health Organisation., 2016). In terms of the inter-related elements necessary to strengthen health systems (including primary care, community care and specialist care) in providing treatment to people with mental illness, one aspect that has been relatively neglected is the need to provide actionable and sustained training to staff (Thornicroft et al. 2012). This edition of Epidemiology and Psychiatric Sciences includes three papers that address this issue. The Editorial by Semrau et al. outlines capacitybuilding approaches and outputs to support mental health system strengthening for three target groups (i) mental health service users and caregivers, (ii) service planners and policy-makers, and (iii) mental health researchers) in six LMICs in Sub-Saharan Africa and in Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). The second paper by Hanlon et al. focuses on the methods, which can be used to evaluate the impact of such capacity-building in these three target groups. Third, the paper by Lempp et al. reports on a crosscountry qualitative study of in-depth interviews with service users and caregivers to assess their involvement in mental health system strengthening. This is important because service user involvement in any aspect of mental health care planning, provision or evaluation is still in its infancy in many LMICs (Thornicroft & Tansella, 2005), although in several countries this is now gaining pace (Samudre et al. 2016; Abayneh et al. 2017; Gurung et al. 2017). These papers arise from the EU-funded Emerald (Emerging mental health systems in lowand middle-income countries) programme, which is investigating mental health system strengthening in these six countries (see www.emerald-project.eu) (Semrau et al. 2015) alongside financial equity (Chisholm et al. 2017), integrated care (Petersen et al. 2017) and establishing mental health system indicators (Jordans et al. 2016; Upadhaya et al. 2016). An important part of the legacy of Emerald is the development of 27 Masters-level teaching modules, and three short courses on mental health system strengthening (for service users and caregivers; policymakers and planners; and mental health researchers), in addition to having provided support for preand post-doctoral research staff, These teaching packages will be made available under a Creative Commons open access license in the near future via the Emerald website at King’s College London. The capacitybuilding approaches taken by Emerald may serve as a model to be adapted for other LMICs for future initiatives designed to support knowledge, attitude and skill enhancement for everyone concerned with mental health system strengthening in LMICs.