Nadja van Ginneken

Human resources for mental health care: current situation and strategies for action

A challenge faced by many countries is to provide adequate human resources for delivery of essential mental health interventions. The overwhelming worldwide shortage of human resources for mental health, particularly in low-income and middle-income countries, is well established. Here, we review the current state of human resources for mental health, needs, and strategies for action. At present, human resources for mental health in countries of low and middle income show a serious shortfall that is likely to grow unless effective steps are taken. Evidence suggests that mental health care can be delivered effectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, affected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden. We also discuss scale-up costs, human resources management, and leadership for mental health, particularly within the context of low-income and middle-income countries.

Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review

BackgroundIt has been suggested that lay community health workers (LHWs) could play a role in primary and secondary prevention of Mental, Neurological and Substance use (MNS) disorders in low resourced settings. We conducted a systematic review of the literature with the aim of assessing the existing evidence base for the roles and effectiveness of LHWs in primary and secondary prevention of MNS disorders in low and middle income countries (LMICs).MethodsInternet searches of relevant electronic databases for articles published in English were done in August 2011 and repeated in June 2013. Abstracts and full text articles were screened according to predefined criteria. Authors were asked for additional information where necessary.ResultsA total of 15 studies, 11 of which were randomised, met our inclusion criteria. Studies were heterogeneous with respect to interventions, outcomes and LHWs’ roles. Reduction in symptoms of depression and improved child mental development were the common outcomes assessed. Primary prevention and secondary prevention strategies were carried out in 11 studies and 4 studies respectively .There was evidence of effectiveness of interventions however, most studies (n = 13) involved small sample sizes and all were judged to have an unclear or high risk of bias.ConclusionsLHWs have the potential to provide psychosocial and psychological interventions as part of primary and secondary prevention of MNS disorders in LMICs, but there is currently insufficient robust evidence of effectiveness of LHW led preventive strategies in this setting. More studies need to be carried out in a wider range of settings in LMICs that control for risk of bias as far as possible, and that also collect indicators relating to the fidelity and cost of interventions.

Non-specialist health worker interventions for mental health care in low- and middle- income countries

This is the protocol for a review and there is no abstract. The objectives are as follows: OVERALL OBJECTIVE In order to assess the impact of delivery by non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs) on the effectiveness of mental healthcare interventions in low- and middle- income countries (LMICs), we will specifically analyse the effectiveness of NSHWs and OPHRS in delivering acute mental health interventions; as well as the effectiveness of NSHWs and OPHRs in delivering long term follow-up and rehabilitation for people with mental disorders; and the effect of the detection of mental disorders by NSHWs and OPHRs on patient and health delivery outcomes. For each of these objectives we will examine the current evidence for the impact of delivery by NSHWs and OPHRs on the resource use and costs associated with mental healthcare provision in LMICs.

The development of mental health services within primary care in India: learning from oral history

BackgroundIn India very few of those who need mental health care receive it, despite efforts of the 1982 National Mental Health Programme and its district-level component the District Mental Health Programme (DMHP) to improve mental health care coverage.AimsTo explore and unpack the political, cultural and other historical reasons for the DMHP’s failures and successes since 1947 (post-independence era), which may highlight issues for today’s current primary mental health care policy and programme.MethodsOral history interviews and documentary sourcing were conducted in 2010–11 with policy makers, programme managers and observers who had been active in the creation of the NMHP and DMHP.ResultsThe results suggest that the widely held perception that the DMHP has failed is not entirely justified, insofar that major hurdles to the implementation of the plan have impacted on mental health coverage in primary care, rather than faults with the plan itself. These hurdles have been political neglect, inadequate leadership at central, state and district levels, inaccessible funding and improperly implemented delivery of services (including poor training, motivation and retention of staff) at district and community levels.ConclusionAt this important juncture as the 12th Five Year Plan is in preparation, this historical paper suggests that though the model may be improved, the most important changes would be to encourage central and state governments to implement better technical support, access to funds and to rethink the programme leadership at national, state and district levels.

Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes

Background Given the scarcity of specialist mental healthcare in India, diverse community mental healthcare models have evolved. This study explores and compares Indian models of mental healthcare delivered by primary-level workers (PHW), and health workers’ roles within these. We aim to describe current service delivery to identify feasible and acceptable models with potential for scaling up. Methods Seventy two programmes (governmental and non-governmental) across 12 states were visited. 246 PHWs, coordinators, leaders, specialists and other staff were interviewed to understand the programme structure, the model of mental health delivery and health workers’ roles. Data were analysed using framework analysis. Results Programmes were categorised using an existing framework of collaborative and non-collaborative models of primary mental healthcare. A new model was identified: the specialist community model, whereby PHWs are trained within specialist programmes to provide community support and treatment for those with severe mental disorders. Most collaborative and specialist community models used lay health workers rather than doctors. Both these models used care managers. PHWs and care managers received support often through multiple specialist and non-specialist organisations from voluntary and government sectors. Many projects still use a simple yet ineffective model of training without supervision (training and identification/referral models). Discussion and conclusion Indian models differ significantly to those in high-income countries—there are less professional PHWs used across all models. There is also intensive specialist involvement particularly in the community outreach and collaborative care models. Excessive reliance on specialists inhibits their scalability, though they may be useful in targeted interventions for severe mental disorders. We propose a revised framework of models based on our findings. The current priorities are to evaluate the comparative effectiveness, cost-effectiveness and scalability of these models in resource-limited settings both in India and in other low- and middle- income countries.

The three official language versions of the Declaration of Helsinki: what’s lost in translation?

Background: The Declaration of Helsinki, the World Medical Association’s (WMA’s) statement of ethical guidelines regarding medical research, is published in the three official languages of the WMA: English, French and Spanish. Methods: A detailed comparison of the three official language versions was carried out to determine ways in which they differed and ways in which the wording of the three versions might illuminate the interpretation of the document. Results: There were many minor linguistic differences between the three versions. However, in paragraphs 1, 6, 29, 30 and in the note of clarification to paragraph 29, there were differences that could be considered potentially significant in their ethical relevance. Interpretation: Given the global status of the Declaration of Helsinki and the fact that it is translated from its official versions into many other languages for application to the ethical conduct of research, the differences identified are of concern. It would be best if such differences could be eliminated but, at the very least, a commentary to explain any differences that are unavoidable on the basis of language or culture should accompany the Declaration of Helsinki. This evidence further strengthens the case for international surveillance of medical research ethics as has been proposed by the WMA.

Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes

Background In order to provide effective primary care for refugees and to develop interventions tailored to them, we must know their needs. Little is known of the health needs and experiences of recently arrived refugees and other migrants throughout their journey through Europe. We aimed to gain insight into their health needs, barriers in access and wishes regarding primary health care. Methods In the spring of 2016, we conducted a qualitative, comparative case study in seven EU countries in a centre of first arrival, two transit centres, two intermediate-stay centres and two longer-stay centres using a Participatory Learning and Action research methodology. A total of 98 refugees and 25 healthcare workers participated in 43 sessions. Transcripts and sessions reports were coded and thematically analyzed by local researchers using the same format at all sites; data were synthesized and further analyzed by two other researchers independently. Results The main health problems of the participants related to war and to their harsh journey like common infections and psychological distress. They encountered important barriers in accessing healthcare: time pressure, linguistic and cultural differences and lack of continuity of care. They wish for compassionate, culturally sensitive healthcare workers and for more information on procedures and health promotion. Conclusion Health of refugees on the move in Europe is jeopardized by their bad living circumstances and barriers in access to healthcare. To address their needs, healthcare workers have to be trained in providing integrated, compassionate and cultural competent healthcare.

Psychiatry in India: Historical Roots, Development as a Discipline and Contemporary Context

The authors provide an overview of the development of psychiatric services in India. They track the early developments in ancient and medieval periods, and after Western medicine made its appearance. Lunatic Asylums were established in India by the East India Company, and extended to various parts of the country, under British rule. The spread of medical education and services was quite slow, and there were very few psychiatrists, and a small number of beds by mid-twentieth century. Publicly funded universal health care, planned on similar lines as the NHS at the eve of Independence, did not develop sufficiently in subsequent decades. Economic and social disruption, and low priority to spending on health care thwarted efforts at extending the services. The development of pharmacological treatments in the 1950s raised the possibility of general hospital-based psychiatric services, at least of severe mental illness. Importantly, efforts to understand the psychosocial causes and correlates of both common and severe mental disorders were slow to develop. There was unease expressed with ‘Western’ models of psychopathology and intervention, and there were attempts at incorporating indigenous ideas and philosophical traditions. These remained sporadic, however, and did not give rise to any pan-Indian approach to understanding psychiatric illness or its cure. Although epidemiologic rates for psychiatric disorders are lower than in high-income countries, the rates in India are higher compared to other average Asian prevalence rates. However, there have been few concerted efforts at understanding these differences and the local psychosocial factors producing psychiatric illness. Further, inadequate human resources to deal with the existing problems and serious operational problems with the National Mental Health Programme are ground realities. The growing number of private for-profit and not-for-profit mental health facilities is welcome as some have innovative mental health care reach-out strategies. However, they also remain a cause for concern due to their poor regulation and sometimes human rights violations. The new mental health policy hopefully provides a framework for better partnership, quantity and quality of care. With the re-emerging interest in global mental health and ‘universal’ treatment guidelines, it is an appropriate time for serious reflection on the way forward and to examine the relevance of local and sociocultural contexts in understanding and treating psychiatric illnesses.