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The Chester M. Pierce, MD Division of Global Psychiatry
The Role of Research in Mental Health Policy
David Henderson, M.D.Director
Leading Causes of Years Lived with Disability
1 Unipolar depressive disorders 10.9%2 Hearing loss, adult onset 4.63 Refractory errors 4.64 Alcohol use disorders 3.75 Cataracts 3.06 Schizophrenia 2.77 Osteoarthritis 2.68 Bipolar affective disorder 2.49 Iron-deficiency anemia 2.210 Birth asphyxia and birth trauma 2.2
Gender Differences in Mental Health Problems Worldwide
Percentage of DALYs* Lost
Burden vs. Budget
(WHO World Mental Health Consortium, JAMA, June 2nd 2004)
Gap in treatment:Serious cases receiving no treatment during the last 12 months
0
10
20
30
40
50
60
70
80
90
Developed countries Developing countries
Lower range Upper range Lower range Upper range
35%
50%
76%
85%
ScarcityHuman Resources
(N=157 to 183 countries)
Figure 2: Human resources for mental health in each income group of countries per 100 000 population
Number of psychiatrists per 100,000 population
Comparing Resources
Psychiatric Beds and Professionals Mozambique Nigeria Rwandai Sierra Leoneii
Uganda
Total psychiatric beds per 10,000 population 0.23 0.4 0.2 0.47 0.44
Psychiatric beds in mental hospitals per 10,000 population 0.2 0.3 0.2 0.32 0.22
Psychiatric beds in general hospitals per 10,000 population 0.04 0.04 0 0.11 0.22
Psychiatric beds in other settings per 10,000 population 0.01 0.01 0 0.03 0.009
Number of psychiatrists per 100,000 population 0.04 0.09 0.03 0.02 1.6
Number of neurosurgeons per 100,000 population 0.01 0.009 0.02 0 0.009
Number of psychiatric nurses per 100,000 population 0.01 4 0.8 0.04 2
Number of neurologists per 100,000 population 0.01 0.02 0 0.02 0.1
Number of psychologists per 100000 population 0.05 0.02 0.3 0 2
Number of social workers per 100,000 population 0.01 0.02 0 0.06 2
i There are 200 other mental health personnel ii There are 200 psychiatric assistants
Mental Health systems in low and middle-income countries
Context and Governance Poorly developed and disconnected system elements
Output and outcomes
Governments, educators, researchersLow capacity in policy development and implementation (services, training, research)MH is a low priority – weak drive for MH system developmentPopulationLow ‘mental health literacy’Low demand for mental
Weak investment. Shortage of everything – skilled workers, facilities, drugs, etc.Undeveloped information systems to support planningGeographic maldistribution of available workforceDisciplinary imbalance: doctor and nurse dominatedHospital-centeredPoorly organized and marginalized consumers, carers
Narrow population coverageVery wide gap between best and worst MH servicesLow access (geographic, economic, linguistic, cultural)Stigma, discrimination, social exclusionMental health training is unattractive for most disciplinesInadequate protection of rightsLack of locally relevant evidence for policy and practice
WHY IS MENTAL HEALTH NOT A PRIORITY?
We have not made the case in the language of policymakers or the general public, either in terms of cost-effectiveness or in terms of outcomes.
We do not have consensus on “model” interventions, especially for low-resource contexts.
We have not demonstrated that we can take successful programs and go to scale
We have not built consumer and family voice to garner political and public support
Mental Health Policy
• Mental heath policy and human protection laws are important
• Strategic plan and coordination are even more important.
• Research agenda should be designed to answer important questions and feeds back into policy and strategic plan
• As data becomes available, policy and strategic plan should be updated.
FACTORS AFFECTING INTERVENTION IMPLEMENTATION
System leadershipOrganizational culture/consensusIT capacity/outcomes measurementPolicies/proceduresIntegration with performance/quality
improvementHuman resource capacity/trainingFunding methods
Leadership Training
There is no sustained development without effective leadership
Leadership perspectives and skills are best taught alongside teaching on mental health system development / capacity building
Effective leadership is learned by doing, with continuing support and mentoring
Collaborative programs of activity (in policy development, service design and implementation, research – particularly mental health system research, education and training, and consumer, carer and civil society engagement) are the most effective way to develop effective leadership skills
Leadership training without sustained and productive engagement is probably of doubtful value
MOHs
• Should also be responsible for the coordination of all mental health activities by local and international non-governmental organizations (NGOs), UN agencies, and international donors.
• MOHs can also develop and monitor a simple, scientifically valid and reliable national mental health data system capable of informing national public health policy. – This requires that the MOH, as the lead agency in mental
health , has a national mental health action plan that can be fully supported and financed by the national government through mental health policy and legislation.
Key Needs in Global Mental Health Research
• Demonstration projects tied to rigorous external evaluation and funding for generalization of programs if outcomes are positive
• Network of global mental health policy research centers in the developed and developing worlds
• Networking Centers, Researchers, and Trainees
Culture, Context and Western Imports• Concern about imposing western approaches to
psychiatry on diverse cultures – undermining indigenous healing
• Risk of bringing in the “worst”: old and riskier drugs, institutionalization, stigma
• At same time, neglect of MI is major practical/HR issue in p-c environment (Lancet 2000)
• Principle: High level of critical awareness in melding essentials of western psychiatry with local traditions and customs
• Dilemma: Is this “marriage” always feasible. Unintended dangers (stigma, adverse effects, disruption of traditional care systems).
Approaches• Global Mental Health Research Collaborations• Global Mental Health Research Centers• Research Training Programs• Population studies
Collaborative Interdisciplinary Basic Applied Surveillance Local policy agendas Intervention studies Evaluation
POTENTIAL GLOBAL MENTAL HEALTH RESEARCH AREAS
Intervention models Implementation strategies
• Uptake• Going to scale• Sustainability• Financing/economics
Advocacy• Evidence bas• Optimal strategies
Recovery outcomes• What works? What does not?
INTERVENTION MODELS
Intervention models limited by over reliance on RCT as criteria.
We need explicit ways of building acceptable knowledge using different methodologies.
Research is limited to specific contexts or outcomesTransferability and relevance of models across
nations and cultures needs examinationEngagement of consumer and family voice in
developing models and assessing outcomes has been uneven
ADVOCACY ISSUES
Effective models for mental health advocacyBuilding the evidence base for advocacy
interventionsOptimizing consumer and family member
involvementDeveloping mutually beneficial partnerships
RECOVERY OUTCOMES
Measuring recovery Individual recovery process System support for recovery
Relationship of recovery trajectory to treatment outcomes
Role of consumer and family member
• Community Research and Socio-Cultural Research– Poverty and Labor Conditions– Stigma– Substance Abuse– Gender– Infectious Disease– Political Violence and Refugee Populations
• Epidemiology and Ethnography• Mental Health Services Research
REASONS FOR OPTIMISM
Mental health is becoming part of the rhetoric of global health and development
Effective innovation is occurring at the local level in many countries
There are a few successful national-level programs related to prevention and promotion
There are opportunities on the horizon such as the UN Assembly on non-communicable diseases in 2011
The global mental health movement is becoming an engine for change
Mental Health Policy
• Mental heath policy and human protection laws are important
• Strategic plan and coordination are even more important.
• Research agenda should be designed to answer important questions and feeds back into policy and strategic plan
• As data becomes available, policy and strategic plan should be updated.
Thank You!
“You must be the change you want to see in the world.”
Mahatma Gandhi