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Mental health service delivery needs radical reimagination in the United States where unmet needs for care remain large and most metrics on the burden of mental health problems have worsened, despite significant numbers of mental health professionals, spending on service provision and research. The COVID-19 pandemic has exacerbated the need for mental health care. One path to a radical reimagination is “Community Initiated Care (CIC)” which equips and empowers communities to address by providing brief psychosocial interventions by people in community settings. We co-developed a theory of change (ToC) for CIC with 24 stakeholders including representatives from community-based, advocacy, philanthropic and faith-based organizations to understand how CIC could be developed and adapted for specific contexts. We present a ToC which describes ways in which the CIC initiative can promote and strengthen mental health in communities in the United States with respect to community organization and leadership; community care and inclusion and normalizing mental health. We propose 10 strategies as part of CIC and propose a way forward for implementation and evaluation. This CIC model is a local, tailored approach which can expand the role of community members to strengthen our response to mental health needs in the United States.

Objective:

Tobacco consumption among low- and middle-income countries where food insecurity remains a challenge poses several concerns. This review examines the available global evidence linking smokeless tobacco (SLT) use with public health nutrition and its implications.

Design:

Systematic review of articles extracted from PubMed and Scopus from January 2000 to December 2020.

Setting:

Included studies that demonstrated the relationship between SLT and nutrition-related factors, that is, BMI, malnutrition, anaemia, poor birth outcomes and metabolic disorders. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines have been followed to conduct the systematic evidence review.

Participants:

A total of thirty-four studies were finally used in the systematic review, which included cross-sectional (thirty-one) and cohort (three).

Results:

SLT use has a huge impact on body weight, alteration in taste, poor oral health, and consumption of fruits and vegetables leading to malnutrition. Maternal use of SLT not only leads to anaemia but also hampers birth outcomes. Increased risk of metabolic syndrome and gallstone disease among SLT users are also well documented in the studies.

Conclusion:

The review highlights the linkages between SLT usage and poor nutritional outcomes. Tobacco control efforts should be convergent with public health nutrition to achieve overall health benefits. Attention is also required to explore suitable mechanisms for SLT cessation combined with enhancing food and nutrition security at the community level in sync with investments in public health nutrition intervention.

Background

Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services.

Aims

To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3.

Method

Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach.

Results

A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62–0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60–0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46–0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates.

Conclusions

Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

Summary

Over the past four decades the World Health Organization (WHO) has produced a number of assessment instruments intended for national and cross-cultural psychiatric research. WHO instruments have been tested and used in many collaborative studies, involving more than 100 centres in different parts of the world. This chapter reviews the main WHO instruments for the assessment of:

• psychopathology
• disability and burden
• quality of life
• health services and systems
• environment and risks to mental health.

Instruments for qualitative research are also examined, before the principles used in the development of WHO instruments, their translation and their use across cultures and settings are discussed.

The WHO occupies a unique position in the field of healthcare and represents a neutral platform that can be used to bring about international collaboration in research. It has a mandate to promote and conduct research in the field of health and standardise diagnostic procedures and instruments (WHO, 2005). Over the years the WHO has gained experience in the management of international collaborative research projects and has produced reliable methods for their conduct in different cultures and settings (Sartorius, 1989). The development of cross-culturally applicable and reliable methods for the assessment of problems related to mental health has been one of the major activities in the WHO Mental Health Programme. Many of these methods have been described in scientific publications, released for general use and applied in various research projects worldwide (Sartorius, 1993). This chapter outlines the basic characteristics of the main instruments produced and used in the studies coordinated by the WHO Mental Health Programme. The specific characteristics of the instruments described – their format, area of assessment, main users, training requirements and available translations – are summarised in Tables 17.1–17.5. More details about these and other WHO instruments can be found in the catalogue of assessment instruments used in the studies coordinated by the WHO Mental Health Programme (Janca & Chandrashekar, 1993), available from the WHO on request.

Instruments for the assessment of psychopathology

Alcohol Use Disorders Identification Test

The Alcohol Use Disorders Identification Test (AUDIT; Babor et al, 1989) is a brief structured interview aimed at identifying people whose alcohol consumption has become harmful to their health. It consists of ten questions: three on the amount and frequency of drinking, three on drinking behaviour and four on problems or adverse psychological reactions related to alcohol.

Aims – This paper attempts to examine the current state of mental health services in Central and Eastern Europe. Methods – Selected review of available literature has been done with emphasis on information complied by World Health Organization (WHO). Results – The magnitude and burden of mental disorders is high in Europe, the mental health services are inadequate in most Central and Eastern European countries and human rights situation is unsatisfactory. However, there are some positive recent developments worth noting. These include increased attention to human rights, cooperation and collaboration at subregional level and emergence of family and consumer associations. Conclusions – A concerted and systematic attempt needs to be made to respond to the challenge of providing adequate and human rights-based mental health services in Central and Eastern European countries. The framework developed by WHO can assist the countries in their initiatives aimed at improving mental health systems.

Declaration of Interest: none

Summary

India is a low-income country that is characterised by huge diversity within and between its 35 states and union territories. For example, the infant mortality rate (per 1000 live births) ranges from a low of 16.3 in Kerala to a high of 86.7 in Uttar Pradesh, over a fivefold difference (International Institute for Population Sciences & ORC Macro, 2001). This considerable variation is evident in virtually every aspect of human development in India, and any summary figures are likely to be unrepresentative of most parts of the country. Within the scope of this short article, this important limitation of averages must be recognised at the outset.

The latest population figures for India show that the population has now crossed the 1 billion mark and is continuing to grow, although at a gradually slower pace than before. The substantial epidemiological evidence base in relation to mental disorders shows that severe and common mental disorders are at least as common as in the developed world. The social and economic risk factors for mental disorders are on the rise in many parts of the country and there has been a reduction in the already pitiful level of spending by the Government on health and social welfare (5.2% of gross domestic product). There is evidence that a substantial proportion of healthcare in India is delivered in the private sector; some estimates put this at above 75% of all health consultations.

Mental health resources

There are an estimated 4000 psychiatrists in India, which represents a ratio of approximately one psychiatrist for 250 000 people (WHO, 2001). However, as mentioned earlier, this rate varies hugely between urban and rural areas, and between more developed and less developed states. Thus, in some states the ratio falls to one psychiatrist for more than one million people. The majority of psychiatrists work in urban areas, and in the private sector. The number of other mental health professionals, such as psychologists or psychiatric nurses, is even lower: there is one nurse for every 10 psychiatrists and one psychologist for every 20. There are an estimated 25 000 psychiatric beds in the country, or one bed for every 40 000 people. About 80% of these beds are situated in mental hospitals, where the quality of care has been found to violate even basic human rights (National Human Rights Commission, 1999).

Aims — To describe the mental health system in Albania. Methods — Data were gathered in 2003 and in 2004 using a new WHO instrument, World Health Organization Assessment Instrument for Mental health Systems (WHO-AIMS), designed for collecting essential information on the mental health system of low and middle income countries. It consists of 6 domains, 28 facets and 156 items. Results — The information collected through WHO AIMS covered the key aspects of mental health system in Albania: the mental health policy and the legislative framework, the network of mental health services and the characteristics of the users, the role of the primary health care, the human resources, the public education and the links with other governmental sectors, monitoring and research. Conclusions — The data collection through WHO AIMS represented a needed step for a better in-depth knowledge of the system and for implementing actions to strengthen the system. Examples of planned actions were the improvement of the mental health component in primary care, a clear shift of resources from mental hospitals to community facilities, an increase of the outpatient care and an expansion of the mental health information system.

Declaration of Interest: none.

Summary

Background

No systematic attempt has been made to calculate the costs of scaling up mental health services in low-and middle-income countries.

Aims

To estimate the expenditures needed to scale up the delivery of an essential mental healthcare package over a 10-year period (2006–2015).

Method

A core package was defined, comprising pharmacological and/or psychosocial treatment of schizophrenia, bipolar disorder, depression and hazardous alcohol use. Current service levels in 12 selected low-and middle-income countries were established using the WHO–AIMS assessment tool. Target-level resource needs were derived from published need assessments and economic evaluations.

Results

The cost per capita of providing the core package attarget coverage levels (in US dollars) ranged from $1.85 to $2.60 per year in low-income countries and $3.20 to $6.25 per year in lower-middle-income countries, an additional annual investment of $0.18–0.55 per capita.

Conclusions

Although significant new resources need to be invested, the absolute amount is not large when considered at the population level and against other health investment strategies.

Summary

INTRODUCTION

The Global Burden of Disease data for the year 2002 shows that depression is the fourth leading cause of disability in women worldwide and accounts for 5.66% of disability-adjusted life years (DALYs) in women, whereas it is the seventh leading cause of disability in men and accounts for 3.45% of DALYs (World Health Organization [WHO], 2003a). It is projected that by 2020 depression will become the second leading cause of disability in women (Murray & Lopez, 1996). Traditionally, mental health programs have paid little attention to the special or unique needs, of women. But, the heavy burden placed by depression on the mental health of women; the association of depression with different phases of women's life cycle and other gender-specific determinants; and gender differences in clinical presentation, course, response to treatment, service needs, and response of care givers makes a gender-sensitive approach in service development and management of depression an imperative. This chapter includes information from WHO's Project Atlas regarding the availability of treatment services in the world and provides suggestions regarding methods by which the gap between need for and receipt of effective services for depressed women can be reduced. It also reviews the types and efficacy of physical and psychosocial treatment of depression in women and whether such treatments vary by gender. Suggestions from a life cycle perspective on the clinical management of depression in women and issues regarding prevention, disability, and rehabilitation are highlighted.

A search (precision value 94%, recall value 93%) of the ISI Web of Science database (1992–2001) revealed that mental health publications accounted for 3–4% of the health literature. A 10/90 divide in internationally accessible mental health literature was evident and remained undiminished through 10 years as low- and middle-income countries (n= 152) contributed only 6%, high-income countries (n=54) 94%, and 14 leading high-income countries (with more than 1% contribution for majority of years under consideration) contributed 90% of internationally accessible mental health research. Steps should be taken to improve the research infrastructure and capacity to conduct and disseminate mental health research in general, and on a priority basis in low- and middle-income countries.

Background

Bipolar disorder has been ranked seventh among the worldwide causes of non-fatal disease burden.

Aims

To estimate the cost-effectiveness of interventions for reducing the global burden of bipolar disorder.

Method

Hospital-and community-based delivery of two generic mood stabilisers (lithium and valproic acid), alone and in combination with psychosocial treatment, were modelled for 14 global sub-regions. A population model was employed to estimate the impact of different strategies, relative to no intervention. Total costs (in international dollars (I$)) and effectiveness (disability-adjusted life years (DALYs) averted) were combined to form cost-effectiveness ratios.

Results

Baseline results showed lithium to be no more costly yet more effective than valproic acid, assuming an anti-suicidal effect for lithium but not for valproic acid. Community-based treatment with lithium and psychosocial care was most cost-effective (cost per DALY averted: I$2165–6475 in developing sub-regions; I$5487–21123 in developed sub-regions).

Conclusions

Community-based interventions for bipolar disorder were estimated to be more efficient than hospital-based services, each DALY averted costing between one and three times average gross national income.

Financing is a critical factor in the realisation of a viable mental health system. It is the mechanism by which plans and policies are translated into action through the allocation of resources. Financing is essential for operations and the delivery of services, for the development and deployment of a trained workforce, and for the required infrastructure and technology (Chernichovsky & Chinitz, 1995; World Health Organization, 2003). Financing mechanisms can also be used to facilitate change and introduce innovations in systems (World Health Organization, 2003).

Background

International evidence on the cost and effects of interventions for reducing the global burden of depression remain scarce.

Aims

To estimate the population-level cost-effectiveness of evidence-based depression interventions and their contribution towards reducing current burden.

Method

Primary-care-based depression interventions were modelled at the level of whole populations in 14 epidemiological subregions of the world. Total population-level costs (in international dollars or I) and effectiveness (disability adjusted life years (DALYs) averted) were combined to form average and incremental cost-effectiveness ratios.

Results

Evaluated interventions have the potential to reduce the current burden of depression by 10–30%. Pharmacotherapy with older antidepressant drugs, with or without proactive collaborative care, are currently more cost-effective strategies than those using newer antidepressants, particularly in lower-income subregions.

Conclusions

Even in resource-poor regions, each DALYaverted by efficient depression treatments in primary care costs less than 1 year of average per capita income, making such interventions a cost-effective use of health resources. However, current levels of burden can only be reduced significantly if there is a substantial increase in treatment coverage.

Country profiles provide summary information on mental health policy, services, training and research in the country, along with key references for more details. The aim is to give a bird's eye view of the situation within about 1500 words. It is hoped that this will not only increase the reader's awareness of distant and often forgotten countries, but also provide an opportunity for learning from others’ experiences. The profiles can also open possibilities for further dialogue and even collaboration.

How many members of the College know about the state of psychiatry in Nigeria or Egypt? Perhaps just a few. How many would be interested in knowing more? Perhaps many. The country profiles section of International Psychiatry attempts to narrow this information-and-awareness gap.

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A theory of change for community-initiated mental health care in the United States

Smokeless tobacco use and public health nutrition: a global systematic review

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence

17 - Psychiatric assessment instruments developed by the World Health Organization

Summary

Mental health services in Central and Eastern Europe: current state and continuing concerns

India

Summary

Mental health system and services in Albania

Use of clinical and service indicators to decrease the treatment gap for mental disorders: a global perspective

17 - Psychiatric assessment instruments developed by the World Health Organization

Summary

Cost of scaling up mental healthcare in low-and middle-income countries

17 - Services and Treatment for Depression

Summary

The 10/90 divide in mental health research: Trends over a 10-year period

Cost-effectiveness of clinical interventions for reducing the global burden of bipolar disorder

Introduction

Financing of mental health services: an international perspective

Reducing the global burden of depression: Population-level analysis of intervention cost-effectiveness in 14 world regions

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Psychiatry in India

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