Action on global mental health

Last Friday, I attended the launch of the Centre for Global Mental Health (CGMH), a high profile event held at the London School of Hygiene and Tropical Medicine.

I was there because PLoS Medicine recently kicked off a series on “packages of care” for six mental health problems in low and middle income countries, starting with depression.  We timed our kick off with the CGMH launch.  Both of the Guest Editors of the series, Vikram Patel and Graham Thornicroft, are involved with the new center (Vikram is one of two people leading it).

One of the many highlights of the launch was a barnstorming keynote address from Dr Benedetto Saraceno, Director of the WHO’s Department of Mental Health and Substance Dependence.

Dr Saraceno was remarkably frank about how little had been done so far to provide mental health interventions in low and middle income settings.

He acknowledged that there’s been lots of research to describe the burden of disease and to highlight the “treatment gap,” yet this work hasn’t yet translated into action.

Research to describe the global burden, for example, started with the 1995 World Health Report and spanned a twelve year period, he said, culminating in the 1997 Lancet series on global mental health (which is free to access). “We’ve been excellent in describing the burden for twelve years,” said Dr Saraceno.  “We’ve been excellent in describing the gaps.”  Those gaps, he said, include gaps in human rights:

“Systematic violation of human rights occurs in developed and developing countries and is substantially ignored by many psychiatrists.”

So why, he asked, has nothing happened despite twelve years of reports?

He said there were four barriers to action:

• Political will and funding.  There’s a widespread and incorrect belief that mental health care is cost-ineffective.  There’s the problem of inconsistent and unclear advocacy on the part of different groups of mental health advocates (in contrast to HIV activism, where advocates have had a single clear message).  People with mental health disorders aren’t organized into powerful lobby.
• Mental health resources are centralized in large institutions in and near big cities, and extra funding is needed to shift to community based resources.
• There’s difficulty integrating mental health care into primary health care services.  Primary health care workers are already overburdened, and there’s a lack of supervision and support after they receive training. Many primary health care centers don’t even have a continuous supply of medications.
• Mental health leaders often lack public health skills and experience (“Great clinicians aren’t necessarily great reformers,” he said; on the other hand, professional public health training doesn’t include mental health)

In going forward, said Dr Saraceno, “we should stop blaming donors and ministers.”

“We should stop talking about the burden and gap and start talking about solutions.  We have them. They are cost effective.”

The WHO has launched a solutions-focused project, chaired by Graham Thornicroft, called the mental health Gap Action Programme, or mhGAP.  As with the PloS Medicine series, which was intended as being complementary to mhGAP, the WHO program focuses on packages of care for major disorders.  Dr Saraceno explained that the mhGAP model has 7 phases:

1. Assess needs and resources
2. Enhance political commitment
3. Facilitate policy development
4. Mobilize financial resources
5. Strengthen human resources
6. Deliver the intervention packages
7. Establish a plan for monitoring and evaluation (M&E) of the packages.

“Adapting, adopting, delivering, and M&E of the packages will be crucial,” he said.  The WHO will be partnering with CGMH in this effort, especially for M&E, and it also wants to partner with the UN health agencies, development agencies like the World Bank, NGOs, health professionals, service users, and caregivers.

From 1995 to 2007, he said, there was “a big effort, small results.”  But with the launch of CGMH, the mhGAP project, and the Movement for Global Mental Health, he hopes that from 2010 to 2014 we’ll see “big efforts and big results.”