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Minding the Baby in the Bathwater: setting a research agenda for global mental health
Pamela Y. Collins, MD, MPH National Institute of Mental Health
February 27, 2015
National Institutes of Health (NIH) & National Institute of Mental Health (NIMH)
• NIH is a part of the US Department of Health and Human
Services and is the nation’s medical research agency
• Leading supporter of medical research in the world
• NIMH is one of the 27 institutes & centers that make up the National Institutes of Health (NIH)
Mission: To transform the understanding and treatment
of mental illnesses through basic and clinical research, paving the way for prevention,
recovery, and cure.
NIMH
4
NIMH Offices and Divisions
• Office on AIDS
• Office of Autism Research Coordination
• Office of Constituency Relations and Public
Liaison
• Office of Genomics Research Coordination
• Office for Research on Disparities and Global
Mental Health
• Office of Resource Management
• Office of Rural Mental Health Research
• Office of Science Policy, Planning, and
Communications
• Office of Technology Development and
Coordination
• Division of Intramural Research
Programs
• Division of Neuroscience and Basic
Behavioral Science
• Division of Translational Research
Division of Services and Intervention
Research
• Division of AIDS Research
• Division of Extramural Activities
Office of the Director NIMH Divisions
ORDGMH & ORMHR
Admin
Workforce Diversity
Equity & Disparities
Global Mental Health
Women’s Mental Health
Rural Mental Health REPORTING
& ANALYSIS RESEARCH
CAPACITY BUILDING
OUTREACH & COLLABORATION
6
Guided by NIMH Strategic Plan • Strategic Objective 1: Define the Mechanisms of
Complex Behaviors
• Strategic Objective 2: Chart Mental Illness Trajectories to Determine When, Where, and How to Intervene
• Strategic Objective 3: Strive for Prevention and Cures
• Strategic Objective 4: Strengthen the Public Health Impact of NIMH-supported Research
7
http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml
Adapting to a Changing Ecosystem
• Increasing Public Health Burden • BRAIN Initiative • Changing Mental Health Care
Landscape • Technology • Comparative Effectiveness • New Sources of Research Support
and Collaboration • Citizen-centered Science
NIMH Strategic Plan Adaptation to Change and Cross-cutting Themes
http://www.nimh.nih.gov/about/strategic-planning-reports/introduction.shtml#intro-sub1
Cross-cutting Research Themes
• Transforming Diagnostics
• Accelerating Therapeutics
• Role of the Environment
• Digital Enterprise
• Preemptive Medicine
• Global Mental Health
• Mental Health Disparities
• Partnerships
• Investing in the Future
Outreach & Collaboration: HHS
Resolution- WHO Executive Board
Resolution – World Health Assembly
Comments on draft document
Regional consultation process
ACTION PLAN! 9
Understanding the systems in which we operate
Health financing
Health workforce
Mental health
services
Global mental health operates within the global health system
Set an agenda
Allocate resources
Research and develop new ideas
Implement & deliver services
Monitor, evaluate, learn
Moon et al. PLoS Med 2010
GLOBAL GAME CHANGERS
“HIV prevention and treatment scale-up during the first decade of the 21st century qualifies as a game changer that has irreversibly changed
perceptions of and approaches to global health.”
De Cock et al, 2011
Radical innovations that fundamentally change how something is done, thought about, or
approached.
RESEARCH & INNOVATION….and more • Rapid development and scale up of
innovations – Rapid HIV tests – Early infant diagnostic tests
• Willingness to change when new evidence appears – Incorporate new activities into
longstanding programs – Quick and coordinated changing
of antiretroviral drug regimens • Targeted funding, “unorthodox” partnerships (CBOs, gov, civil society, professional societies) De Cock et al 2011
What determines whether a problem achieves prominence on the agenda ? • Transnational influences
– Norm promotion – Resource provision
• Domestic advocacy
– Policy community cohesion – Political entrepreneurship – Credible indicators – Focusing events – Clear policy alternatives
• National political environment
– Political transitions – Competing health priorities
Shiffman AJPH 2007
A few key factors
• The policy community and its portrayal of the issue – How credible and how salient are the messages?
• Problem and solution claims
– What can be done?
• What institutions can this community build? – Critical to keeping the issue on the agenda
See Shiffman, WHO Bull 2009
“The rise, persistence and decline of a global health issue may best be
explained by the way in which its policy community – the network of
individuals and organizations concerned with the problem – comes to understand and portray the issue and establishes institutions that can
sustain this portrayal.” Shiffman 2009
Global mental health stakeholders
• People with mental illness • Families affected by mental illness • Researchers/academics • Mental health professionals • Professional associations • Advocacy organizations • Funders • Policymakers
Disabling Disorders of Youth
Vos et al, 2012
Percentage of years lived with a disability in 2010 by cause and age.
Male individuals Female individuals
Mortality and the Global Burden of Mental Disorders
• People with mental disorders have a mortality rate that is 2.2 times higher than the general population
• All cause mortality was elevated for psychoses, mood disorders, and anxiety
• All cause mortality for psychoses > anxiety, depression, and bipolar d/o
• Median of 10 years of potential life lost from all causes
• 8 million deaths a year are attributable to mental disorders Walker et al. JAMA Psychiatry, 2015
Millennium Development Goals and mental health: a salient frame
GOAL 5: REDUCE MATERNAL MORTALITY
Miranda & Patel, 2004
GOAL 4: REDUCE CHILD MORTALITY
GOAL 6: Combat HIV/AIDS, Malaria, and other Diseases
Problem claims: Costly disorders
“The global cost of mental health conditions in 2010 was estimated at US$ 2.5 trillion, with the cost projected to surge to US$ 6.0 trillion by 2030 .”
“Currently, high-income countries shoulder about 65% of the burden, which is
not expected to change over the next 20 years.”
World Economic Forum, 2011
Problem claims: Poor mental health financing
Globally, spending on mental health is less than $2 per person, per year and less than $0.25 in low income countries Mental health expenditures per capita are more than 200 times greater in high income countries compared with low income countries
WHO Atlas, 2011
Finding solutions around the globe: Task shifting/sharing for mental health
• Good examples in many low- and middle-income countries – India – MANAS trial (Patel et al., 2010) – Pakistan – Lady Health Workers ( Rahman et al, 2008) – Uganda – Group IPT for depression (Bolton et al, 2003) – Chile – Treating depression in primary care (Araya et al, 2003)
Institutions for Global Mental Health
• Movement for Global Mental Health • Global Mental Health Journal • World Federation for Mental Health • World Psychiatric Association • -Considerable variability in the “norms and
strategies” adopted by our institutions
Is Global Mental Health (GMH) on the Agenda?
• Institutions – GMH institutions are insufficient
• Ideas – Difficult to develop and promote a common construct – Lack a widely accepted framework for classification,
course, treatment of disorders – No distinction between internal and external debates
Tomlinson & Lund 2012
Is Global Mental Health on the Agenda?
• Context – Can we take advantage of key opportunities to
influence decision makers?
• Framing our problem – Do we have credible indicators? – How can we better demonstrate salience?
Tomlinson & Lund, 2012
What is the role of research?
--Creating transnational norms --Credible solutions for national health systems --Building the evidence for salience
NIMH-GACD Collaboration
• NIMH joined the Global Alliance for Chronic Disease in November 2009
• The Alliance is a community of the world’s largest health research funding agencies organized to collaborate in the battle against chronic non-communicable diseases
• Mental health is on the agenda • NIMH is leading the Grand Challenges in Global Mental
Health initiative
• Global Scope • Use of the Delphi process • Covers the full range of mental, neurological,
and substance use disorders • Aims to build a community of global mental
health research funders
What’s new in the Grand Challenges?
Goodman, 1987
• Establish leadership structures • Nomination of Delphi Panel • 3 Delphi Rounds • Leadership meeting • Preparation and publishing of report
Overview of Procedures
• Three discrete leadership bodies are responsible for the stewardship of the initiative • Executive Committee • Scientific Advisory Board • Administrative Board
GCGMH Leadership
Grand Challenge Goals
• Goal A: Identify root causes, risk, and protective factors
• Goal B: Advance prevention and implementation of early interventions
• Goal C: Improve treatments and expand access to care
• Goal D: Raise awareness of the global burden
• Goal E: Build human resource capacity
• Goal F: Transform health system and policy responses
Addressing the Gaps
Questions – What research is needed
to reduce the treatment gap?
– Which stakeholders
need to interact to produce service-relevant research? Scale up?
Participants
NGOs providing Services
Mental Health Policymakers
Implementation researchers
COLLABORTIVE HUBS FOR INTERNATIONAL RESEARCH ON MENTAL HEALTH (U19)
-Research component on task-shifting -Research capacity-building for the region -True collaborative partnerships with end-users
AFFIRM hub South Africa*, Ethiopia, Ghana, Malawi, Uganda, Zimbabwe
SHARE hub India*, Pakistan, Afghanistan, Bangladesh, Nepal, Sri Lanka
LATIN-MH hub Brazil*, Peru, Colombia, Ecuador Guatemala
Pam-D hub Nigeria*, South Africa, Kenya, Ghana, Liberia,
Collaborative Hubs for International Research on Mental Health
RedeAmericas hub Chile*, Brazil, Argentina, Colombia, USA
RedeAmericas • Improving the health of people
with psychosis
• Research mentoring for young investigators
• Critical Time Intervention – Task-Shifting
• Peer mentors assist people new to treatment with links to health care and community resources
www.nimh.nih.gov
South Asian Hub for Advocacy, Research & Education (SHARE) on Mental Health
• Mental health of mothers with depression
• Research capacity-building
• Thinking Healthy Program – Peer Delivery
• Delivery by peers – lay people with no formal health training background
www.nimh.nih.gov
Africa Focus on Intervention Research for Mental Health (AFFIRM)
• Maternal depression in South Africa
• Community care for schizophrenia in Ethiopia
• Short courses, Master’s program
• Task-shifting to community health workers/primary health workers
http://www.nimh.nih.gov/about/organization/od/globalhubs/africa-focus-on-intervention- research-for-mental-health-affirm.shtml; http://www.affirm.uct.ac.za/
Partnership for Mental Health Development in sub-Saharan Africa (PAM-D)
• Expanding service for people with psychosis
• Research capacity-building through targeted training and mentoring
• Exploring complementary and alternative providers
http://www.nimh.nih.gov/about/organization/od/globalhubs/ partnership-for-mental-health- development-in-sub-saharan-africa-pam-d.shtml
Latin America Treatment and Innovation Network in Mental Health (LATIN-MH)
• Research capacity-building
• Managing co-morbid depression and hypertension or diabetes
• Low-intensity psycho-educational intervention delivered via smartphones
http://www.nimh.nih.gov/about/organization/gmh/globalhubs/ latin-america-treatment-amp-innovation-network-in-mental-health-latin-mh.shtml
Mental health and HIV
• Increasing attention to integrated care
• Transnational norms
• Little evidence base on how to integrate care outside of high-income countries
Integrating mental health: a Grand Challenge
• Healthy Options: Group psychotherapy for HIV+ depressed perinatal women – Tanzania
• Integrated care for co-morbid diabetes and depression in India
• The depression hypertension COACH study – China
• Integrating depression care for acute coronary syndrome patients in low resource hospitals
in China • COBALT: Co-morbid Affective disorders,
HIV/AIDS and Long-term Health – South Africa
• Improving mental health through integration with primary care in rural Karnataka - India
PLoS Medicine series 2013