Four years ago the London-based medical journal, The Lancet, published a special series on global mental health, highlighting the gap in provision between rich countries and the rest of the world. Even in developed countries it is estimated that only one in three people with mental health problems receives the treatment they need; in low- and middle-income countries it may as low as one in 50.
Since the initial report, a new coalition has been formed, the Movement for Global Mental Health, to press for the scaling-up of treatment.
In a keynote paper for the new Lancet report, a Nigeria-based psychiatrist, Julian Eaton, with colleagues from India, Uganda, the UK and the World Health Organization, note “some improvement in awareness of mental health issues among leaders in the past three years”.
Yet, they say, “about 40 percent of respondents, from 26 countries, identified continuing poor awareness and low priority or poor commitment by political leaders as major barriers to the development of mental health services”.
One informant from Liberia told them, “There appears to be a disconnect in government, regarding expressed interest and support for mental health services… and resource availability and policy implementation.”
Another frustration is a disregard for the evidence of what works – that devolved services and “deinstitutionalization” provide the best outcomes; large psychiatric hospitals continue to dominate care in many low- and middle-income countries.
Uganda gets a favourable mention for more than doubling its regional mental health units, increasing by 75 percent the number of psychiatric nurses at district level. By 2010, an annual performance report found that 80 percent of all health sub-districts had at least one anti-psychotic, one anti-epileptic and one anti-depressant drug available.
“In many of the countries represented in the survey,” says the paper, “the mere decentralization of any mental health expertise to district level (rather than only the very largest cities) would have an enormous effect on access to care.” A very high proportion of needs, they say, can be met with simple packages of care delivered in non-hospital settings by non-specialists.
A key message is that non-mental-health specialists will have to be used to widen access to care. Eaton and his colleagues say that “in most low-income and middle-income countries, the ratio of people who need mental healthcare to the number of qualified psychiatrists is so disproportionate that there is no prospect of the psychiatrists being able to deliver the care that is needed in the foreseeable future”.
A second paper, on the Human Resources for Mental Health Care, explores this issue in more detail. Ritsuko Kakuma of Melbourne’s Centre for International Mental Health and her colleagues look at task-shifting and task-sharing as necessary solutions.
In Sri Lanka, which has only 25 working psychiatrists for a population of 20 million people (142 Sri Lankan-trained psychiatrists were working abroad) the 2004 tsunami prompted the recruitment of a new category of community mental health workers offering community support and “psychological first aid” to the afflicted. A survey found 128 community support officers case-managing more than 1,500 people with mental disorders.
Looking at how more use can be made of the manpower available, Kakuma and her colleagues say: “Primary care doctors with mental health training have been involved in identification, diagnosis, treatment and referral of complex cases. Trained nurses, social workers and lay workers can take on follow-up and educational and promotional roles. Lay workers have provided support for care-givers, befriended affected individuals, ensured adherence to treatment and helped to detect mental health problems.”
By contrast, India has spent extra money on training more psychiatrists and increasing the numbers of positions in psychiatric specialties. This may benefit cases of psychosis and major psychiatric illness, which are likely to get referred to specialist hospitals, but will do little for depression, anxiety or dementia. If every psychiatrist in India worked full-time, they would still treat fewer than 10 percent of people with mental health needs.
Protecting the vulnerable
The Lancet series includes articles on mental health provision for children and young people, a group even more poorly served than the rest of the population in developing countries, and on the need to combat the violation of the human rights of people with mental and psycho-social disabilities.
A paper by Wietse Tol of Yale University and his colleagues on Mental Health Interventions in Humanitarian Settings found these were, most commonly, counselling for individuals or families distressed or traumatized by violent events, community support for vulnerable individuals, and the provision of child-friendly spaces, and were run and funded outside national mental health and protection systems.
There were few attempts to find out how cost-effective the programmes had been, and the fact that they were usually outside normal national mental-health provision raised questions about the sustainability of such interventions.
The Lancet, in its editorial accompanying the series, welcomed the initiatives in global mental health in the past four years, but, “there is still a long way to go and many challenges to face”.