Development in mental health services - a world view

The limited resources in developing countries, combined with the inappropriate legacy of the colonial era, has meant that a large proportion of their population has been deprived of even basic mental health services. In this chapter we first review the major causes of mental disorder in the developing world, and then the social and environmental factors associated with these disorders. The strategy initiated by the World Health Organization (WHO) of mental health services based in primary care has been the major theme in the development of new services, with National Mental Health plans describing how the specialized mental health services should be best organized in each country. Having reviewed services in a variety of countries, we describe the four phases of the development of community mental health services in Pakistan, as this is a country which the authors know best and has an advanced service.We finish by describing the problems which are likely to arise as progressively more people drift into the megacities of the future.     

Establishing mental health policy and services in Vanuatu

With a population of 245,000 spread mostly over six groups of islands and a total land area of 12,189 km², Vanuatu is one of the larger Pacific Island countries. Compared to other Pacific Island countries of similar or larger size, mental health has received little attention from government until very recently. While systematic studies are lacking, the limited available data suggest that mental disorders and suicide are increasing. The first ever National Mental Health Policy and Strategic Plan were launched in October 2009. Key areas include formalization of the National Mental Health Committee established in 2007, financing, mental health legislation, service organization, human resources, essential medicines, information systems, quality, advocacy, and monitoring and evaluation. In 2010, mental health was inserted for the first time into the new Ministry of Health organizational structure. The Ministry of Health mandate is to work with partners to achieve sustainable progress in reducing all key risk factors to improve the wellbeing of everybody with mental illness. The country has commenced a program of mental health training for workers at primary and secondary health facilities and community awareness, with support from the World Health Organization Pacific Island Mental Health Network (PIMHnet) and others. A foundation for modern mental health services has been laid.     

European comparisons between mental health services

When developing accessible, affordable and effective mental health systems, exchange of data between countries is an important moving force towards better mental health care. Unfortunately, health information systems in most countries are weak in the field of mental health, and comparability of data is low. Special international data collection exercises, such as the World Health Organization (WHO) Atlas Project and the WHO Baseline Project have provided valuable insights in the state of mental health systems in countries, but such single-standing data collections are not sustainable solutions. Improvements in routine data collection are urgently needed. The European Commission has initiated major improvements to ensure harmonized and comprehensive health data collection, by introducing the European Community Health Indicators set and the European Health Interview Survey. However, both of these initiatives lack strength in the field of mental health. The neglect of the need for relevant and valid comparable data on mental health systems is in conflict with the importance of mental health for European countries and the objectives of the 'Europe 2020' strategy. The need for valid and comparable mental health services data is today addressed only by single initiatives, such as the Organisation for Economic Co-operation and Development work to establish quality indicators for mental health care. Real leadership in developing harmonized mental health data across Europe is lacking. A European Mental Health Observatory is urgently needed to lead development and implementation of monitoring of mental health and mental health service provision in Europe.     

The relationship between elderly suicide rates and mental health funding, service provision and national policy: a cross-national study

BACKGROUND: Elderly suicide rates may be influenced by mental health funding, service provision and national policy. METHODS: A cross-national study examining the relationship between elderly suicide rates and (i) the presence of national policy on mental health, (ii) funding for mental health, and (iii) measures of mental health service provision was undertaken by utilizing data from the World Health Organization website. RESULTS: The main findings are: (i) there is no relationship between suicide rates in both sexes in both elderly age-bands and different measures of mental health policy, except they were increased in countries with a substance abuse policy; and (ii) suicide rates in both sexes in both elderly age-bands were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists, psychiatric nurses, and the availability of training in mental health for primary care professionals. CONCLUSIONS: Cross-national ecological studies using national-level aggregate data are not helpful in establishing a causal relationship (and the direction of this relationship) between elderly suicide rates and mental health funding, service provision and national policies. The impact of introducing national policies on mental health, increasing funding for mental health services and increasing mental health service provision on elderly suicide rates requires further examination in longitudinal within-country studies.     

Developing child mental health services in resource-poor countries

Despite significant gains in tackling the major causes of child mortality and evidence of an urgent need for child mental health services, resource-poor countries continue to lag behind in child and adolescent mental health service development. This paper analyses possible barriers to the development of child mental health services in resource-poor countries and attempts to proffer solutions. Obstacles identified are the magnitude of child mental health problems that remain invisible to policy makers, an absence of child mental policies to guide the process of service development, and overburdened child mental health professionals. The belief systems about mental illness also prompt help seeking in alternative health systems, thereby reducing the evidence for the burden associated with health seeking. Solutions that may support child mental health service development are the provision of adequate advocacy tools to reveal the burden, poverty alleviation, health awareness programmes, enforcing legislation, training centred within the region, and partnerships with professionals in developed countries. These solutions require simultaneous approaches to encourage service development and utilization. Reductions in child mortality in resource-poor countries will be even more dramatic in the years to come and preparations need to be made to take care of the mental health needs of the children who will survive.     

Developing a culturally appropriate mental health care service for Samoa

Mental Health Care Services are part of the National Health Services for Samoa. Their function is to provide mental health care services to the population of Samoa, which numbers 180,000 people. However, like many other countries in the Pacific region, mental health is considered a low priority. The mental health budget allocation barely covers the operation of mental health care services. More broadly, there is a lack of political awareness about mental health care services and mental health rarely becomes an issue of deliberation in the political arena. This article outlines the recent development of mental health care services in Samoa, including the Mental Health Policy 2006 and Mental Health Act 2007. It tells the story of the successful integration of aiga (family) as an active partner in the provision of care, and the development of the Aiga model utilizing Samoan cultural values to promote culturally appropriate family‐focused community mental health care for Samoa. Mental Health Care Services today encompass both clinical and family‐focused community mental health care services. The work is largely nurse‐led. Much has been achieved over the past 25 years. Increased recognition by government and increased resourcing are necessary to meet the future health care needs of the Samoan people.     

The Australian experience of deinstitutionalization: interaction of Australian culture with the development and reform of its mental health services

OBJECTIVE: To describe the Australian experience of deinstitutionalization of the Australian National Mental Health Strategy in the context of the history of mental health services in Australia, and of Australian culture. METHOD: The development of Australian Mental Health Services is described with reference to developments in both psychiatric intervention research and Australian culture. The effects and achievements of national mental health reforms are described and critically examined. RESULTS: The relationship in Australia between the development of mental health services and the development of Australian society includes the stories of colonization, gold rush, suppression of indigenous peoples' rights, incarceration of mentally ill people, and incompatible state service systems. Mental health services required reform to provide consistent services and support for full citizenship and rights for such individuals who are still on the margins of society. Recent national developments in service models and service system research have been driven by the Australian National Mental Health Strategy. The translation of national policy into state/territory mental health service systems has led to a 'natural' experiment between states. Differing funding and implementation strategies between states have developed services with particular strengths and limitations. CONCLUSION: The effects of competition for limited resources between core mental health service delivery and the shift to a population-based public health approach (to prevention of mental illness and promotion of mental health), leaves our services vulnerable to doing neither particularly well. The recent loss of momentum of these reforms, due to failure of governments to continue to drive and fund them adequately, is causing the erosion of their considerable achievements.     

WHO's Assessment Instrument for Mental Health Systems: collecting essential information for policy and service delivery

Information about mental health systems is essential for mental health planning to reduce the burden of neuropsychiatric disorders. Unfortunately, many low- and middle-income countries lack systematic information on their mental health systems. The objectives, scope, structure, and contents of mental health assessment and monitoring instruments commonly used in high-income countries may not be appropriate for use in middle- and low-income countries. The World Health Organization (WHO) has recently developed the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), a comprehensive assessment tool for mental health systems designed for middle- and low-income countries. WHO-AIMS was developed through an iterative process that included input from in-country and international experts on the clarity, content, validity, and feasibility of the instrument, as well as a pilot trial. The resulting instrument, WHO-AIMS 2.2, consists of six domains: policy and legislative framework, mental health services, mental health in primary care, human resources, public information and links with other sectors, and monitoring and research. These domains address the ten recommendations of the World Health Report 2001 through 28 facets and 155 items. All six domains need to be assessed to form a basic, yet broad, picture of a mental health system, with a focus on health sector activities. WHO-AIMS provides essential information for mental health policy and service delivery. Countries will be able to develop information-based mental health policy and plans with clear baseline information and targets. Moreover, they will be able to monitor progress in implementing reform policies, providing community services, and involving consumers, families, and other stakeholders in mental health promotion, prevention, care and rehabilitation. This article provides an overview of the rationale, development process, and potential uses and benefits of WHO-AIMS.     

Pakistan mental health country profile

The Republic of Pakistan is a South East Asian country with a population of over 140.7 million. Its population is fast growing and the majority (70%) live in rural areas with a feudal or tribal value system. The economy is dependent on agriculture and 35% of the population live below the poverty line. Islam is the main religion and ‘mental illnesses’ are stigmatized and widely perceived to have supernatural causes. The traditional healers along with psychiatric services are the main mental health service providers. The number of trained mental health professionals is small as compared to the population demands and specialist services are virtually non-existent. Lack of data on prevalence of various mental illnesses and monitory constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the ‘Community Mental Health Programme’ and ‘Schools Mental Health Programme’ have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a ‘National Mental Health Policy’ and ‘Mental Health Act’ in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery and safeguarding the rights of mentally ill people. A favourable political will and the help of international institutions like the World Health Organization are required to achieve these aims.     

Pakistan mental health country profile

The Republic of Pakistan is a South East Asian country with a population of over 140.7 million. Its population is fast growing and the majority (70%) live in rural areas with a feudal or tribal value system. The economy is dependent on agriculture and 35% of the population live below the poverty line. Islam is the main religion and 'mental illnesses' are stigmatized and widely perceived to have supernatural causes. The traditional healers along with psychiatric services are the main mental health service providers. The number of trained mental health professionals is small as compared to the population demands and specialist services are virtually non-existent. Lack of data on prevalence of various mental illnesses and monitory constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the 'Community Mental Health Programme' and 'Schools Mental Health Programme' have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a 'National Mental Health Policy' and 'Mental Health Act' in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery and safeguarding the rights of mentally ill people. A favourable political will and the help of international institutions like the World Health Organization are required to achieve these aims.     

Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care?

OBJECTIVE: To report recent findings regarding differences in the provision, cost and outcomes of mental health care in Europe, and to examine to what extent these studies can provide a basis for improvement of mental health services and use of findings across countries. METHOD: Findings from a number of studies describing mental health care in different European countries and comparing provision of care across countries are reported. RESULTS: The development of systems of mental health care in western Europe is characterized by a common trend towards deinstitutionalization, less in-patient treatment and improvement of community services. Variability between national mental healthcare systems is still substantial. At the individual patient level the variability of psychiatric service systems results in different patterns of service use and service costs. However, these differences are not reflected in outcome differences in a coherent way. CONCLUSION: It is conceivable that the principal targets of mental healthcare reform can be achieved along several pathways taking into account economic, political and sociocultural variation between countries. Differences between mental healthcare systems appear to affect service provision and costs. However, the impact of such differences on patient outcomes may be less marked. The empirical evidence is limited and further studies are required.     

Mental Health Policy and Plans : Promoting an Optimal Mix of Services in Developing Countries

The World Health Report 2001 makes a compelling case for addressing the mental health needs of populations around the world. The key messages of the report are that mental disorders account for a significant burden of disease in all societies; effective interventions are available but are not accessible to the majority of the people who need them; and a comprehensive mental health policy is an important tool in increasing the accessibility of effective services. When properly formulated and implemented, a mental health policy can have a positive impact on the mental health of the population. Service organization forms one of the most important areas of a mental health policy and plan. In order to deliver a high standard of mental health treatment and care it is necessary to adopt an integrated system of service delivery that comprehensively addresses the full range of psychosocial needs of people with mental disorders. The World Health Organization Mental Health Policy and Service Development project commenced in 2000 and covers four main areas: the development of normative technical documents on mental health policy and service development; provision of training forums for policy makers and mental health professionals; direct country assistance; and the development of a faculty of consultants.     

Income differences in persons seeking outpatient treatment for mental disorders: a comparison of the United States with Ontario and The Netherlands

BACKGROUND: Variations in the relationships among income, use of mental health services, and sector of care are examined by comparing data from 3 countries that differ in the organization and financing of mental health services. METHODS: Data come from the 1990-1992 National Comorbidity Survey (n = 5,384), the 1990-1991 Mental Health Supplement to the Ontario Health Survey (n = 6,321), and the 1996 Netherlands Mental Health Survey and Incidence Study (n = 6031). Analysis of the association between income and use of mental health services was carried out for the population that was between ages 18 and 54 years. Differential use of mental health treatment was examined in 3 sectors: the general medical sector, the specialty sector, and the human services sector. RESULTS: No significant association between income and probability of any mental health treatment was observed for persons with psychiatric disorders in any of the 3 countries. However, there were significant differences among countries in the association between income and sector of mental health care treatment. In the United States, income is positively related to treatment being received in the specialty sector and negatively related to treatment being received in the human services sector. In the Netherlands, patients in the middle-income bracket are less likely to receive specialty care, while those in the high-income bracket are less likely to be seen in the human service sector. Income is unrelated to the sector of care for patients in Ontario. CONCLUSIONS: Future research should examine whether differential access to the specialty sector for low-income people in the United States is associated with worse mental health outcomes.     

Pathway for inpatients with depressive episode in Flemish psychiatric hospitals: a qualitative study

Background

While the mental health situation for most people in low and middle-income countries is unsatisfactory, there is a renewed commitment to focus attention on the mental health of populations and on the scaling up of mental health services that have the capacity to respond to mental health service needs. There is general agreement that scaling up activities must be evidence-based and that the effectiveness of such activities must be evaluated. If these requirements are to be realised it will be essential to strengthen capacity in countries to conduct rigorous monitoring and evaluation of system development projects and to demonstrate sustained benefit to populations.

The Observatory

The International Observatory on Mental Health Systems (IOMHS) will build capacity to measure and to track mental health system performance in participating countries at national and sub-national (provincial and district) levels. The work of IOMHS will depend on the establishment of robust partnerships among the key stakeholder groups. The Observatory will build the capability of partner organisations and networks to provide evidence-based advice to policy makers, service planners and implementers, and will monitor the progress of mental health service scaling up activities.

Summary

The International Observatory on Mental Health Systems will be a mental health research and development network that will monitor and evaluate mental health system performance in low and middle-income countries.     

"The family is the clinic, the community is the hospital": community mental health in Timor-Leste

OBJECTIVE: This paper describes the history and recent development of mental health services in Timor-Leste, a small developing country recovering from conflict. Challenges to effective service delivery are discussed as well as plans for future development. CONCLUSIONS: Timor-Leste's mental health service began just over a decade ago. Unlike many other low and middle income countries where hospital-based services predominate, the mental health model in Timor-Leste is entirely community based. However, challenges to effective mental health care delivery are similar to most developing countries and include a lack of sufficient financial resources, human resources, and mental health infrastructure. Addressing these issues successfully requires political will, a greater prioritization of mental health services, close coordination between stakeholders, as well as developments in the area of education, training and infrastructure. Greater understanding and education about the links between mental and physical health would benefit the overall health of the population, and integration of these respective policies may prove a successful method of more equitably redistributing finances and resources.     

Farm-Link

The Farm-Link Program is funded by the Australian Government through the Department of Health and Ageing under the National Suicide Prevention Strategy and is coordinated by the University of Newcastle's Centre for Rural and Remote Mental Health in collaboration with New South Wales (NSW) Health's Rural Area Mental Health Services and the NSW Farmers' Association. It was operational across NSW from July 2007 to December 2009 and is funded to continue in the New England region until June 2011. A major aim of the program was to improve access to and responsiveness of mental health services to the needs of people who live and work on farms. Frontline agricultural workers, who have a lot of contact with farmers and their families, received Mental Health First Aid training provided by Farm-Link staff. Across NSW, 220 participants received this training during 2008, and an additional 133 participants received training in the New England region throughout 2009-10. This training is still being delivered by Farm-Link in the New England region. Farmers' mental health networks were developed and expanded to engage both agricultural and mental health agencies, so that pathways to mental health care could be defined, described, and utilized. These networks were developed in selected sites across three rural area health services. By establishing the conditions for successful cross-agency networks to flourish in rural NSW, Farm-Link developed a credible reputation in target communities. An external evaluation, including comparative service network analysis, indicated that Farm-Link successfully identified and established mental health service development interventions in target communities. The evaluation identified a requirement for substantial change within a short-time frame as an inhibiting factor in Farm-Link 2007-09. Farm-Link's ongoing work indicates further time and continuity of service in rural communities has a positive impact on the depth of knowledge built and project aims being delivered. In addition, although documentation of referrals for farmers to various mental health service providers and general practitioners has occurred, more adequate systems need to be developed for the future.     

Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective

Purpose of Review

Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research.

Recent Findings

Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services.

Summary

Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.

     

Implementing the World Health Report 2001 recommendations for integrating mental health into primary health care: a situation analysis of three African countries: Ghana, South Africa and Uganda

Integrating mental health into primary health care is widely promoted for a host of reasons, chief among which is providing a more comprehensive health care service. However, only a few countries have adequate mental health resources to undertake the integration of mental health into primary health care in a uniform manner, with wide variations among countries. This paper examines the extent to which two low-income countries (Ghana and Uganda) and one middle-income country (South Africa) are managing the integration of mental health into primary health care using the recommendations of the WHO World Health Report, 2001. Primary and secondary data sources from a situational analysis of mental health services in the three countries were analysed. The findings indicate that significant challenges remain in integrating mental health care into primary health care. Poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons advanced. Aside from better human resource planning for mental health, integration may be advanced by the development of packages of care which adopt a task-shifting approach suited to a country's needs.     

Better mental health services for young people: responsibility, partnerships and projects

OBJECTIVE: This paper argues that adolescent psychiatry is best linked with child psychiatry and opposes separate youth mental health programmes for 12-25-year-olds. It reports on the current status of services and considers how adult mental health services (AMHS) can improve services for young adults (18-25-year-olds). METHOD: Factors in development, psychopathology, prevention, training and service systems are reviewed to suggest that current child and adolescent mental health service systems (CAMHS) are appropriate for 0-17-year-olds. Improvements in CAMHS are described from a Victorian perspective, including the model of specialist clinical programmes or teams for specific patient populations. Mechanisms are outlined for AMHS to better assist young adults from 18 to 25 years of age. RESULTS: The model of clinical projects or clinical programme teams, developed in partnership with primary health and others, is a suitable vehicle to help AMHS to improve clinical services to their young adult populations. These may be funded from a variety of sources, including re-engineering existing service resources. CONCLUSIONS: Such developments complement the work of specialist research units and build local competencies. More programme development and evaluation is needed, which will require the support of the College and State and Commonwealth Mental Health Branches.     

Outreach services to clients with severe mental illness in the Okayama Prefectural Mental Health and Welfare Center

The community mental health system in Japan is being adversely affected by diminishing public mental health services, including those provided by public healthcare centers and the mental health divisions of municipal governments. It seems reasonable to expect that this will lead to the inadequate detection, assessment, and treatment of the population with mental health problems, and thus to the flooding of psychiatric hospitals with excessive numbers of severely mentally ill patients. In this article, the author suggests the utility of a 'network-based outreach team' as a possible remedy for the current situation. The Okayama Prefectural Mental Health & Welfare Center is running a network-based outreach team on a trial basis to work with individuals with serious mental illness who are disengaged from mental health services. The team is composed of members from the Mental Health & Welfare Center, public mental health services, and human service agencies. The main aims of this team are two-fold: to enhance support for clients with severe mental illness who are overwhelmed with multiple complex problems, through collaborative intervention within the framework of a network-based outreach team; and to develop the qualities and skills of public mental health service and human agency personnel in order that they better assist people with severe mental illness, by providing joint training with mental health specialists of the Mental Health & Welfare Center in community settings. The author suggests that the team structure of the network-based outreach team will benefit public mental health services by reintegrating currently fragmented services into coordinated ones.