Pamela Y. Collins

Grand challenges in global mental health

A consortium of researchers, advocates and clinicians announces here research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment.

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.

Grand Challenges in Global Mental Health: Integration in Research, Policy, and Practice

In the first article of a five-part series providing a global perspective on integrating mental health, Pamela Collins and colleagues set the scene for why mental health care should be combined with priority programs on maternal and child health, non-communicable diseases, and HIV, and how this might be done.

The Movement for Global Mental Health

The Movement for Global Mental Health is a coalition of individuals and institutions committed to collective actions that aim to close the treatment gap for people living with mental disorders worldwide, based on two fundamental principles: evidence on effective treatments and the human rights of people with mental disorders.

Ourselves, our bodies, our realities: an HIV prevention intervention for women with severe mental illness.

This paper describes a 10-session behavioral intervention introducing female-initiated methods of human immunodeficiency virus (HIV) prevention to reduce vulnerability to HIV infection for women with severe mental illness. In a pilot test of the intervention, 35 women were randomly placed in the experimental intervention group or an HIV education control. Subjective norms, intentions to use, perceived efficacy, and attitudes toward the male condom, female condom, and a microbicide were assessed at baseline, postintervention, and 6-week follow-up. The participants in the treatment group reported a significantly more positive attitude toward the use of female condoms (t = −2.12, P <.05) at 6-week follow-up. Providing women with severe mental illness with choices o f protective methods and the knowledge and skills to ensure proper use are among the many crucial ingredients in prevention of acquired immunodeficiency syndrome.

Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review.

OBJECTIVE People with serious mental illness (SMI) die at least 11 years earlier than the general U.S. population, on average, due largely to cardiovascular disease (CVD). Disparities in CVD morbidity and mortality also occur among some U.S. racial and ethnic minorities. The combined effect of race/ethnicity and SMI on CVD-related risk factors, however, remains unclear. To address this gap, we conducted a critical literature review of studies assessing the prevalence of CVD risk factors (overweight/obesity, diabetes mellitus, metabolic syndrome, hypercholesterolemia, hypertension, cigarette smoking, and physical inactivity) among U.S. racial/ethnic groups with schizophrenia-spectrum and bipolar disorders. METHODS AND RESULTS We searched MEDLINE and PsycINFO for articles published between 1986 and 2013. The search ultimately yielded 40 articles. There was great variation in sampling, methodology, and study populations. Results were mixed, though there was some evidence for increased risk for obesity and diabetes mellitus among African Americans, and to a lesser degree for Hispanics, compared to non-Hispanic Whites. Sex emerged as an important possible effect modifier of risk, as women had higher CVD risk among all racial/ethnic subgroups where stratified analyses were reported. CONCLUSIONS Compared to general population estimates, there was some evidence for an additive risk for CVD risk factors among racial/ethnic minorities with SMI. Future studies should include longitudinal assessment, stratification by sex, subgroup analyses to clarify the mechanisms leading to potentially elevated risk, and the evaluation of culturally appropriate interventions to eliminate the extra burden of disease in this population.

HIV prevalence among men and women admitted to a South African public psychiatric hospital.

Abstract In settings with low seroprevalence, people with severe mental illness have a higher prevalence of HIV infection compared to the general population. In the high-prevalence countries of southern Africa, where the pandemic taxes resources for HIV prevention, care, and treatment, the needs of people with mental illness can be easily overlooked if they are not identified as vulnerable to infection. Yet, few African studies have investigated HIV seroprevalence in psychiatric settings. We systematically examined the HIV seroprevalence among psychiatric patients admitted to a public psychiatric institution in KwaZulu Natal province, South Africa, between 27 July and 14 November 2003. We conducted anonymous testing among 151 patients who were psychiatrically stable and able to give informed consent. Forty patients (26.5%) were HIV-positive; women were more likely to be infected than men (OR 2.74; 95% CI=1.25–6.04; P=0.012). Our findings demonstrate that in the midst of a generalized AIDS epidemic, people with mental illness are also vulnerable and must be included in prevention and treatment efforts. These results underscore the importance of integrated mental health and HIV care in institutional and outpatient mental health settings and affirm the need for detailed HIV risk assessment as a routine part of psychiatric care. Correspondingly, HIV care and treatment programs should be made available to people with psychiatric symptoms.

Relationship of Stigma to HIV Risk Among Women with Mental Illness

Urban women with severe mental illness (SMI) are vulnerable to stigma and discrimination related to mental illness and other stigmatized labels. Stigma experiences may increase their risk for negative health outcomes, such as HIV infection. This study tests the relationship between perceived stigma and HIV risk behaviors among women with SMI. The authors interviewed 92 women attending community mental health programs using the Stigma of Psychiatric Illness and Sexuality Among Women Questionnaire. There were significant relationships between personal experiences of mental illness and substance use accompanying sexual intercourse; perceived ethnic stigma and having a riskier partner type; and experiences of discrimination and having a casual or sex-exchange partner. Higher scores on relationship stigma were associated with a greater number of sexual risk behaviors. The findings underscore the importance of exploring how stigma attached to mental illness intersects with other stigmatized labels to produce unique configurations of HIV risk. HIV risk reduction interventions and prevention research should integrate attention to stigmatized identities in the lives of women with SMI.

The core competencies for mental, neurological, and substance use disorder care in sub-Saharan Africa

The 2010 Global Burden of Disease Study points to a changing landscape in which non-communicable diseases, such as mental, neurological, and substance use (MNS) disorders, account for an increasing proportion of premature mortality and disability globally. Despite evidence of the need for care, a remarkable deficit of providers for MNS disorder service delivery persists in sub-Saharan Africa. This critical workforce can be developed from a range of non-specialist and specialist health workers who have access to evidence-based interventions, whose roles, and the associated tasks, are articulated and clearly delineated, and who are equipped to master and maintain the competencies associated with providing MNS disorder care. In 2012, the Neuroscience Forum of the Institute of Medicine convened a meeting of key stakeholders in Kampala, Uganda, to discuss a set of candidate core competencies for the delivery of mental health and neurological care, focusing specifically on depression, psychosis, epilepsy, and alcohol use disorders. This article discusses the candidate core competencies for non-specialist health workers and the complexities of implementing core competencies in low- and middle-income country settings. Sub-Saharan Africa, however, has the potential to implement novel training initiatives through university networks and through structured processes that engage ministries of health. Finally, we outline challenges associated with implementing competencies in order to sustain a workforce capable of delivering quality services for people with MNS disorders.The 2010 Global Burden of Disease Study points to a changing landscape in which non-communicable diseases, such as mental, neurological, and substance use (MNS) disorders, account for an increasing proportion of premature mortality and disability globally. Despite evidence of the need for care, a remarkable deficit of providers for MNS disorder service delivery persists in sub-Saharan Africa. This critical workforce can be developed from a range of non-specialist and specialist health workers who have access to evidence-based interventions, whose roles, and the associated tasks, are articulated and clearly delineated, and who are equipped to master and maintain the competencies associated with providing MNS disorder care. In 2012, the Neuroscience Forum of the Institute of Medicine convened a meeting of key stakeholders in Kampala, Uganda, to discuss a set of candidate core competencies for the delivery of mental health and neurological care, focusing specifically on depression, psychosis, epilepsy, and alcohol use disorders. This article discusses the candidate core competencies for non-specialist health workers and the complexities of implementing core competencies in low- and middle-income country settings. Sub-Saharan Africa, however, has the potential to implement novel training initiatives through university networks and through structured processes that engage ministries of health. Finally, we outline challenges associated with implementing competencies in order to sustain a workforce capable of delivering quality services for people with MNS disorders.

Psychosocial and biological aspects of acute brief psychoses in three developing country sites

This study explored biological as well as psychosocial contributions to the incidence of acute brief psychoses in three developing country sites. The samples were taken from the five year follow-up data of the Internatinal Pilot Study of Schizophrenia sites in Ibadan, Nigeria and Agra, India, and from the Determinants of Outcome of Severe Mental Disorders rural Chandigarh site. Baseline narratives of the cases and controls were reviewed and rated for presence or absence of three exposures: fever, departure from or return to parental village (women), and job distress (men). Results showed an association between fever and acute brief psychosis in all three sites. There was an association between acute brief psychosis and departure from or return to the parental village among women in all sites, and among men, an association between job distress and acute brief psychosis was noted in Ibadan and Agra. These findings suggest that psychosocial and biological factors such as these three exposures merit further research to clarify their roles in the etiology of acute brief psychoses.