Learning from global mental health
Over the past decade, global mental health has emerged as an important area of
discourse and research as well as a powerful impetus for mental health service
development in low- and middle-income countries (LMIC). Unfortunately, there is
a misconception that global mental health is about improving care in just the
poorest countries, whereas we believe that global mental health should be about
making mental healthcare better everywhere, including high-income countries:
global mental health necessitates a truly global focus.
It is argued that wealthy countries, whether they have market-driven or
state-planned systems, have created expensive and inefficient mental healthcare
services, and decisions about mental healthcare do not sufficiently involve
those who use services and their families.
Although mental healthcare systems vary a great deal in richer counties
in most resource-rich countries they remain inaccessible and insensitive
with suggestion of ‘widespread evidence of poor quality care’ in
England, for example.
There is also concern that mental health interventions often fail to
make a significant difference to people's lives, especially in relation to
their recovery or social inclusion.
This amounts to a ‘recovery gap’ between what services are prioritising
in terms of outcomes, compared with what actually matters to service users and
their families. This may be particularly pronounced for marginalised groups
such as minority communities in these countries. Further investment in mental
health services in high-income countries is unlikely to bring about
proportional, qualitative improvements in patient outcome or satisfaction. For
this to happen, more fundamental changes in the way mental health services are
organised and delivered are necessary. Closer attention will need to be paid to
bridging the ‘recovery gap’ as an integral part of transforming mental
healthcare in high-income countries.
We believe that the emerging health capabilities and care methodologies of
global mental health, developed and implemented successfully in LMIC, have a
role to play here. These may help us address some of the challenges that mental
health services currently face in high-income countries and help improve
outcomes. This will mean a process of ‘reverse transfer’ or ‘counter-flow’ of
knowledge and practice from low- and middle-income to high-income countries,
based on the experience of mhGAP and related programmes.
Here we consider two specific innovations that have the potential to improve
the processes and outcome of mental healthcare systems in high-income
countries. These are (a) task-sharing or task-shifting, and (b) a community
development model that focuses on livelihood and social inclusion when
designing and delivering mental healthcare.
Task-sharing (or task-shifting) is defined as delegating tasks to existing or
new cadres of workers with either less training or narrowly tailored training.
Many healthcare interventions in LMIC are delivered by community workers who
are newly recruited and trained for a specific purpose. In mental health,
task-sharing helps to achieve a rational redistribution of resources, from
specialist mental health professionals, including psychiatrists, psychologists
and psychiatric nurses, to non-specialist health workers in primary care and
community settings. In many LMIC, effective and accessible mental healthcare
cannot be provided through a system that relies on mental health professionals
as they are a scarce and expensive resource. Instead, mental health
interventions are delivered by new cadres of community workers, recruited from
‘available human resources from the local communities’.
Task-sharing has been successfully employed in delivering complex
interventions for several mental health conditions in LMIC. Trials have shown
that lay people or community health workers can be trained to deliver effective
psychological and psychosocial interventions for people with depressive and
anxiety disorders, schizophrenia and dementia in a diverse range of LMIC, and
task-sharing has been recognised as a key innovation for delivering
psychosocial interventions at the World Innovation Summit in Health.
A Cochrane review that summarises the relevant research indicates that
task-sharing in mental healthcare in LMIC can improve clinical outcomes for
depressive disorders, post-traumatic stress disorder, alcohol use disorders and dementia.
If task-sharing is effective in LMIC, is there any reason to think that this
approach would not be equally effective in richer countries? Already in
high-income countries, there are models of care that replicate the conventional
roles of specialists (psychiatrists and psychiatric nurses) by generalists
(primary care) or non-professional, lay workers and peer support. Implementing
task-sharing as an integral part of service delivery in mental healthcare in
high-income countries offers several advantages. It has the potential to scale
down the top heavy, inefficient and seemingly overbureaucratic mental health
systems in these countries and will allow the re-allocation of resources to
underinvested areas, such as addressing social determinants of mental ill
health and services that could enhance well-being, primary prevention, early
detection, recovery and psychosocial rehabilitation. Furthermore, we believe
that task-sharing, through fostering personalised and humanistic care, has the
potential to improve the quality of relationships between patients (especially
those with long-term needs and disabilities), their families and service
providers. A programme of task-sharing, delivering routine and complex mental
healthcare interventions based on the experience from LMIC, would also tackle
the potential shortage in the health and social care workforce. One of the
biggest challenges for today's professional workforce is that it was trained
and developed to work within a model centred around single episodes of
treatment in hospital, whereas those placing the greatest demand on services
are likely to be those who need integrated, long-term health and social care.
This is highly relevant when providing sustained, humanistic and
person-centred care and support for people with complex and long-term mental
health problems in the community.
To be successful in high-income country settings, task-sharing requires a
health systems approach that includes ongoing training and professional
development, supportive supervision, clear referral pathways to specialist care
and a clear role for the non-specialist within the health system.
Factors such as remuneration and training, are also important. The
necessary infrastructure for developing task-sharing is clearly available in
most high-income countries. For example, training and supervision of new cadres
of staff should be possible within well-developed mental health teams. Care
methodologies, such as a case management and care programme approach will
underpin task-sharing and ensure integrated care. As Patel points out,
mental health is too important to be left to mental health professionals
alone and all communities are richly endowed with people who are capable of
caring for those with mental health problems.
Development approach in mental healthcare
A major fault line in the way mental healthcare is organised in many
high-income countries is the separation of healthcare (services largely
confined to detection and treatment of mental disorders) from social care
(addressing the social determinants of poor health and the environmental
context). This leads to an imbalance emerging between the priority given to a
biomedical approach and the relative lack of resources for addressing the
broader social determinants of mental ill health. Mental healthcare tends to be
dominated by the views of healthcare professionals and focuses on specific
disorders or conditions. As a result, priorities in mental healthcare remain
narrowly defined with disproportionate investment in a biomedical approach.
An important innovation in global mental health is the ‘bottom up’ or
grass-roots approach to developing and designing mental health services. This
approach serves to increase the uptake of services, while also improving social
outcomes for service users and at the community level.
Such changes are unlikely to be achieved if mental health services
remain remote from the local communities. A professionally driven or ‘top down’
approach to developing services is unlikely to address the social and material
determinants of mental ill health and its outcome. This requires the adoption
of a development model for planning, commissioning and delivering care.
The experience of mainly non-governmental organisations (NGOs) working in
resource-poor settings shows the importance of adopting a development model
when planning and implementing mental healthcare. The development approach
involves mobilising, training and sensitising relevant mental health and
development stakeholders in any given community. Although appropriate medical
interventions are delivered through community mental health programmes, there
is an equal emphasis on helping people with mental health problems to gain or
regain the ability to work, to earn and to contribute to their family and community.
For example, the work of Basic Needs has reached over
half a million people with mental health problems, their carers and family
members in some of the poorest parts of the world.
This approach has resulted in a significant increase in those accessing
treatment and, at the same time, appears to improve mental health, productive
employment or income generation, quality of life and overall functioning among
people with severe mental illness.
The relative poverty and high levels of social and material difficulties in
many urban areas in high-income countries have an adverse impact on mental well-being.
In these communities the level of distrust and disengagement from mental
health systems tends to be high. These are significant barriers to developing
effective mental health systems and initiatives to enhance community resilience
and well-being. Based on the experience in LMIC a development approach has the
potential to improve community engagement and enhance the involvement of
service users and their families in the design and delivery of mental
healthcare. The development approach places an equal emphasis on enhancing
livelihoods as in ensuring care and treatment and has the potential to improve
health system capacity and social inclusion in high-income countries.
Innovations, such as task-sharing, are still at an early stage of development
in LMIC. Although task-sharing has been found to be effective in diverse
settings, it has not been scaled-up significantly in any country, nor been
tested in any high-income countries, is restricted at present to a few mental
health conditions and has not been evaluated for procedures such as diagnosis.
The long-term sustainability of innovations such as task-sharing and
community development is as yet unknown. There is a need to explore the
potential effectiveness (and cost-effectiveness) of these innovations in
high-income countries before they are implemented. We acknowledge that care
systems cannot be simply copied from low- and middle-income to high-income
countries any more than in the opposite direction. The very different
political, cultural and economic contexts in these settings will have a bearing
on the adaptability and success of such programmes. This means that differences
in community organisation, culture and social contexts will need to be taken
into consideration when transferring models of care from one setting to
another. However, we believe that there is a strong case for adapting, testing
and potentially implementing mental health innovations that have been proved to
be effective and acceptable in resource-poor countries, in resource-rich
countries. Given the seemingly perpetual crisis in relation to current services
in high-income countries, there is a need to re-imagine and reshape mental
healthcare in these countries. Learning from global mental health will be an
important step in this direction.
It has been argued previously
that wealthy countries can learn from prevention and management of
mental health problems in low-income countries and this may help to address the
remoteness of psychiatry and its allied professions from the communities they
serve in many Western countries.
Furthermore, this process of ‘reverse transfer’ may also prompt a move
towards replacing the current dominance of psychiatric diagnostic
categories/labels in favour of distress models that are more familiar and less
stigmatising to those who use mental health services and their families.
Delivery of care through collaborative models of care, as has been proposed in
many LMIC settings, is also likely to ensure that the patient/family is at the
centre and involve a partnership between the community-based worker and medical
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