Niall Boyce

A renewed agenda for global mental health.

4 years ago, The Lancet published a Series of articles highlighting the global health crisis due to an astonishingly large treatment gap: up to nine of ten people with a mental health problem do not receive even basic care in some countries. The Series showed that this gap was not due to insufficient evidence about the effect of mental health problems or their effective treatment, but to a range of barriers operating at all levels of the health system, from global policies through to local health-care provision. The Series ended with a call to action to scale up services for people with mental health problems, especially in low-income and middle-income countries where the gaps are the largest, and where some of the most serious human rights abuses against affected people are perpetrated.1 4 years on, we take stock of what progress has been made. The themes of this new Series were selected by the members of the Movement for Global Mental Health, a coalition of 95 institutions and over 1700 individuals from more than 100 countries, representing professionals and civil society, and working together to advocate for the necessary conditions for a better life for people affected by mental health problems. In this respect, the Series represents a unique example of agenda setting for scientific publications by a social movement. The Movement chose themes about tracking progress in achievement of the goals of the call to action, and filling in gaps in the knowledge synthesised in the first Series. There is cause for us to celebrate the emergence of global and national responses to mental health care. Several global initiatives have been launched in the past 4 years, notably: WHOs mhGAP intervention guidelines, which provide the symbolic bednets for priority mental, neurological, and substance misuse disorders for use by non-specialists in routine healthcare settings;2 the Grand Challenges in Global Mental Health that support a new generation of research;3 and the Movement for Global Mental Health itself.4 At national and local levels, we see concrete examples of countries making bold steps to develop mental health policies and plans to step up care;5 an impressive growth in the evidence base for treatments and delivery systems (eg, for children’s mental health6 and in humanitarian settings7); new programmes for building capacity;5 and an increasing presence of diverse stakeholder communities, particularly from low-income and middle-income countries, in leadership roles. In this context, we are delighted that 40% of the 52 authors in the Series are based in low-income and middle-income countries and another 15% are based in UN or international development agencies. In view of the need to involve diverse stakeholder communities, we are also pleased to note that more than a third of authors are drawn from outside academia, including representatives of user groups in low-income and middle-income countries. Exciting new evidence points to the effectiveness of task sharing with non-specialist and lay health workers to address the massive shortage of specialists.8 Scaling up such innovations will require a substantial redefinition of the role of specialist personnel which, in turn, will need the strong buy-in of the professional bodies that lead these specialists.5 In this context, we welcome the engagement of the World Psychiatric Association leaders with the challenges posed by the shortage of specialists.9 However, there is still a long way to go, with many challenges to face. First and foremost, the issue of the human rights of people with mental health problems should be placed at the foreground of global health— the abuse of even basic entitlements, such as freedom and the denial of the right to care,10 constitute a global emergency on a par with the worst human rights scandals in the history of global health, one which has rightly been called a “failure of humanity”.11 People with mental health problems, particularly serious mental disorders and disabilities, who bear a disproportionate burden of human rights abuses, should be empowered to ensure a life of dignity. Second, health systems need increased resources to scale up care. Budgetary allocations for mental health care are still grotesquely out of proportion to the burden posed by mental health problems, resulting in slow progress in scaling up of care.5 Furthermore, there is a need to ensure that the increasing resources for developing mental health services account for the unique needs of people who are particularly vulnerable, notably children and those affected by serious mental disorders and disabilities. The mental health needs of children and adolescents, a demographic group comprising more than a third of the global population, have been neglected, even though addressing their needs might alleviate suffering, improve educational attainment in childhood, and potentially reduce the burden of mental disorders in adulthood.6 Third, much is still to be learned about how to deliver effective treatments in the real world. The mhGAP guidelines should become the standard approach for all countries and health sectors; irrational and inappropriate interventions should be discouraged and weeded out. Use of scarce resources for ineffective treatments and inefficient models of care is unacceptable. Delivery of effective treatments depends crucially on the development of human resources, especially among the frontline health workforce, often using innovative solutions.8 Furthermore, a review of research into interventions that can break the vicious cycle of poverty and mental health problems has shown evidence that effective mental health interventions can lead to a reduction in poverty.12 We need to ensure that all development assistance for global health specifically tracks mental health-related funding and assesses the effect of development activities on mental health problems in the population.12 Fourth, natural disasters and conflicts provide not only a high need but also a unique opportunity to scale up care to the affected population.7 This new Series on global mental health reaffirms our conviction that the provision of appropriate mental health services is intrinsic to the development of prosperous, humane societies worldwide.

Pilots of the future: Suicide prevention and the Internet

Niall Boyce reports on increasing efforts to understand the path that people with suicidal thoughts browse online, and to work out when and how to intervene. Samaritans founder Chad Varah was that most British of things: an old-fashioned gentleman with a pronounced enthusiasm for the modern world. Besides his work in suicide prevention, he promoted progressive attitudes towards sex education in Picture Post, and was the astronautical consultant to Dan Dare, the “Pilot of the Future” whose exploits thrilled the readers of the Eagle. So it is fair to say he would have approved of the latest innovation by Samaritans: a box with the organisations helpline number (08457 90 90 90) that appears at the top of the page in response to searches for terms relating to suicide on Google UK. It has been there since November 2010: a small change, but a significant one. This is not by any means the organisations first foray into cyberspace—that came as far back as 1992 with the piloting of the jo@samaritans.org email address—but it represents an important advance in the way Samaritans engages with the public, and an indication that it is keen to address the challenges posed by a future spent more and more online. Language: en

The UK's fix for fixated threats

Niall Boyce reports on the UKs Fixated Threat Assessment Centre—a joint health and policing initiative—which begins work when a public figure receives a threatening communication.

The Wakley Prize, 2012: “This is my truth, now tell me yours”

What have you read that has changed your mind? It’s likely that the list will include observational studies, randomised controlled trials, and systematic reviews and meta-analyses. But that won’t be all. Your point of view will also have been formed by your peers, teachers, and things you have read beyond the core science of medicine—these infl uences enrich your life. In recent years, the personal perspective has become all-important in a rapid-fi re world of live blogging, viral video campaigns, and Twitter storms that blow themselves out within hours. In the midst of this online explosion of opinion, is there still a role for the essay, that form of personal refl ection essentially unchanged since it was pioneered by Michel de Montaigne in the 16th century? Recent experience would suggest so: in a year that has seen heated debate in the UK about National Health Service (NHS) reform, some of the most memorable contributions came from extended, contemplative personal accounts of patients and practitioners whose lives had been changed by the creation of the NHS. The importance of the individual perspective is something NHS founder Aneurin Bevan would have recognised: “This is my truth,” he is quoted as saying, “now tell me yours.” If you are working, studying, or researching in health care or biomedical science anywhere in the world, The Lancet wants to know your truth. If you’d like to tell us, we will consider your essay for the 2012 Wakley Prize. Essays of no more than 2000 words on any topic relating to health should be submitted via the journal’s electronic submission system by Oct 15, 2012, with “Wakley Prize” selected as the publication type. Entries will be anonymised, and judged by The Lancet’s editors. The winner will receive £2000, and the essay will be published in the fi nal issue of the year, will feature in The Lancet podcast, and, very possibly, do that most diffi cult of things: change someone else’s mind.

The Wakley Prize 2012: Good night, and good luck

The submissions for the Wakley Prize this year provided a rich and varied range of stories: some funny, some sad, and all deeply felt. This year’s winning essay, by anaesthetist James Nielsen, combines all three qualities. Nielsen writes with humour and compassion about “medical parenthood”: his experience of caring for his daughter, Kate, who has cerebral palsy. He shows an impressive degree of courage in his ability to deal with “5 am ruminations”: “Will she be independent? Will she be happy? What happens when we’re gone?” Nielsen also describes his anxiety about Kate being “overmedicalised”: a worry that is put to rest in a way that is both charming and surprising. Nielsen’s description of the support off ered by healthcare workers, teachers, his family, and Kate herself is touching, and a reminder of the privilege there is in being able to support others. It brings to mind a scene in Charles Dickens’ A Christmas Carol, in which the isolated Ebenezer Scrooge gazes out of his window to see “phantoms, wandering hither and thither in restless haste”: looking more closely, he realises that “The misery with them all was, clearly, that they sought to interfere, for good, in human matters, and had lost the power for ever.” “Once again, we have been lucky”, Nielsen concludes. Good fortune can take many forms: Nielsen lists “geographical luck”, “medical luck”, and “fi nancial luck”. Being able to help other people is also a form of luck: one shared by Nielsen, his family, those who assist in his daughter’s care, and, I dare say, the readers of The Lancet. While we can, let’s use our fortune wisely.

The Lancet Technology: June 2011

www.thelancet.com Vol 377 June 11, 2011 1995 Back to the future We begin the fi rst Lancet Technology column with a brief look backwards. As followers of the @TheLancetTech Twitter feed will be aware, over 100 years ago The Lancet published a New Inventions column, featuring reviews of such kit as the Diamond Jubilee Portable Telephone—a batteryoperated device from 1897 that might conceivably fi t into a large handbag. Although New Inventions was eventually dropped, The Lancet continued to cover technology. In 1993, an item of corre spondence described the transmission of fetal ultrasound images between London and San Francisco via “the international computer network, Internet”. Last year, The Lancet published the results of the WelTel Kenya1 trial, using text messaging to monitor the health of HIV patients. The Lancet Technology takes up the challenge of covering the latest, most exciting developments in technology for health. Please feel free to tweet or email me if you have anything of interest. At the moment, I’m particularly keen on global health, social networking, surgery, and gaming technology for health.

2017 Wakley Prize Essay

www.thelancet.com Vol 390 December 23/30, 2017 2751 We would like to thank the many readers who entered the 2017 Wakley Prize Essay. The winning essay published in this issue was selected by Lancet editors and is “You Don’t Know Me” by Kate Rowland, an Assistant Professor at the Department of Family Medicine at Rush University, Chicago, IL, USA. Kate is board certified in family medicine and is a Fellow of the American Academy of Family Physicians. She’s worked as a family physician for 10 years and her professional interests include understanding how doctors make decisions during patient care and learning about how new medical evidence is taken up in practice. Her essay describes an encounter with a dying patient that has had a lasting influence on the way she practises medicine. Seeking to understand patients is at the heart of clinical practice. Patients and doctors have perceptions of themselves but the way we imagine ourselves is sometimes very different from how others perceive us. Kate told The Lancet that “During my training in family medicine, I cared for a patient with terminal brain cancer over the course of several hospital visits. ‘You don’t know who I am’ he said on his last stay. I did know him, I thought, as well as any doctor could know a patient. This patient wanted to be seen as he knew himself: strong, important, well. I wanted to be seen as I knew myself: capable, managing, learning. In truth, neither of us were those things. My patient did not have a chance to return to his image of himself. I remind myself, with the help of a memento from the patient, that I can still try to know my patients and take better care of them.” Kate says that the idea for the essay began when “I took a new job, and when I cleaned out my lab coat before leaving my former hospital, I decided to finally put a bent, soft business card to rest. I had carried it with me for 10 years before I decided I could remember what I learned from the patient who gave it to me without the tactile reminder.” We hope you enjoy reading the 2017 Wakley Prize Essay.

Time out of joint

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Seen and not seen

King Lear, poet W H Auden declared, is an unstageable drama: “the one play of Shakespeare that, in the storm scene, really requires the movies”. Yet the art of staging does not simply concern the challenge of presenting things described but not seen; it also involves detecting the spaces between the words, locating concepts, events, and even characters that the text merely hints at. In a recent production of Macbeth at London’s Globe Theatre, director Iqbal Khan put the Macbeths’ child on stage, with a limited degree of eff ectiveness. Gregory Doran’s new King Lear, at Stratford-upon-Avon’s Royal Shakespeare Theatre, does something similar to more substantial eff ect. The “wretches”—the homeless beggars whose plight Lear finally acknowledges once he has been banished to roam across the stormy heath—are on stage right from the beginning. Pitiful fi gures shrouded in blankets, they are shooed off to make way for the arrival of the court, but hover on the periphery of the action, a mute reminder of the failure of Lear’s governance. Clad in a thick fur robe and carried on in a glass case for his fi rst scene, Antony Sher’s Lear resembles a stuff ed bear—in appearance, of course, rather than in performance. As would be expected from one of the leading Shakespearean actors of his generation, Sher’s performance is rich, lively, complex, and utterly gripping. Flitting between aff ected frailty, priestly gravitas, and ferocious wrath, he nevertheless maintains a fi rm hold of the character. Medical speculation as to Lear’s diagnosis (is it dementia and, if so, which subtype?) is simply irrelevant here. Sher appears to conceive of Lear primarily as a performer; he has never been without a crowd, and it is the loss of this audience— the court, his retinue, the country itself—that provokes and defines his crisis. Even his previously feared abilities to curse are mocked by his daughter Regan: like an actor forgetting his lines, Sher’s Lear stumbles, blusters, his speech fragmenting as he labours his way through incoherent threats “I will do such things—/What they are, yet I know not; but they shall be/The terrors of the earth.” It’s a brave approach, one that requires an actor to confront what must be their worst professional fears, fears that Sher faces unfl inchingly.

Thanks to our peer reviewers in 2015

At the end of our fi rst complete year, the editoria l team at The Lancet Psychiatry would like to take this opportunity to thank our peer reviewers. While each paper clearly represents a huge amount of work by the authors, the published work also refl ects the dedication and expertise of our peer reviewers, who so generously give up their time to ensure that each Article, Review, or Personal View reaches the highest standards and is of interest and relevance to our readers. The names of the experts who reviewed papers for us in 2015 are published on our website; those who reviewed fi ve papers or more are marked with an asterisk. We look forward to continuing our work in 2016, to develop The Lancet Psychiatry as a leading journal, with a clear focus on excellence in research and clinical care.