Countdown Global Mental Health 2030

Transforming mental health systems globally: principles and policy recommendations

A burgeoning mental health crisis is emerging globally, regardless of each country's human resources or spending. We argue that effectively responding to this crisis is impeded by the dominant framing of mental ill health through the prism of diagnostic categories, leading to an excessive reliance on interventions that are delivered by specialists; a scarcity of widespread promotive, preventive, and recovery-oriented strategies; and failure to leverage diverse resources within communities. Drawing upon a series of syntheses, we identify five principles to transform current practices; namely, address harmful social environments across the life course, particularly in the early years; ensure that care is not contingent on a categorical diagnosis but aligned with the staging model of mental illness; empower diverse front-line providers to deliver psychosocial interventions; embrace a rights-based approach that seeks to provide alternatives to violence and coercion in care; and centre people with lived experience in all aspects of care. We recommend four policy actions which can transform these principles into reality: a whole of society approach to prevention and care; a redesign of the architecture of care delivery to provide a seamless continuum of care, tailored to the severity of the mental health condition; investing more in what works to enhance the impact and value of the investments; and ensuring accountability through monitoring and acting upon a set of mental health indicators. All these actions are achievable, relying-for the most part-on resources already available to every community and country. What they do require is the acceptance that business as usual will fail and the solutions to transforming mental health-care systems are already present within existing resources.

PROTOCOL: Treatment for depressive disorder among adults: An evidence and gap map of systematic reviews

This is the protocol for a Campbell evidence and gap map. The objective of the map is to map available systematic reviews on the effectiveness of treatments for depressive disorders among adults. Specifically, this EGM includes studies on the effectiveness of treatments across a range of outcome domains.

A population-based study of macronutrient intake according to mental health status with a focus on pure and comorbid anxiety and eating disorders

PURPOSE

Eating disorders (ED) and anxiety impact food choices. In addition, comorbid anxiety seems to increase ED symptoms and severity. However, the association between such comorbidity and dietary intake is unknown. This population-based, cross-sectional study aimed to assess macronutrient intake according to mental health status (i.e., no disorder, pure and comorbid anxiety and ED).

METHODS

The study included N = 24,771 participants (74% female, mean age = 53.2 ± 13.7 years) in the NutriNet-Santé cohort, who completed once the trait subscale of the State-Trait Anxiety Inventory (STAI-T; high anxiety: ≥ 40 points) between 2013 and 2016 and the SCOFF questionnaire screening for ED in 2014. The Expali algorithm was applied to categorize ED (no ED; restrictive: RS; bulimic: BL; hyperphagic: HP; other ED). Participants were divided into ten groups by crossing their anxiety status (two groups: low or high) and their ED status (five groups). Macronutrient intakes were evaluated from ≥ 3 24-h dietary records. Analyses of covariance (ANCOVA) and Dunnett-Hsu tests (reference = no disorder) were performed.

RESULTS

Significant differences in macronutrient intake were seen between the pure and comorbid forms, especially for RS and HP. Compared to the "no disorder" group, a significantly higher percentage of energy from carbohydrates, higher intakes of total carbohydrates, simple sugars, and plant-based protein, lower intakes of total fat, saturated and monounsaturated fatty acids, and cholesterol were observed in the comorbid anxiety + RS group, but not in the pure RS group. In contrast, significantly lower intakes of added sugar and plant-based protein, and a higher intake of cholesterol were observed in the pure HP group, but not in the comorbid anxiety + HP group. For BL and other ED, similar results were observed between the pure and comorbid forms.

CONCLUSION

This large epidemiological study provided some support for differences in macronutrient intake between individuals with pure or comorbid anxiety and ED. Differences in intake were largely dependent on ED type. Future prospective studies and studies using clinically defined anxiety and ED are needed to elucidate causality as well as potential effect modification of the observed associations.

Dietary macronutrient intake according to sex and trait anxiety level among non-diabetic adults: a cross-sectional study

Background

Studies suggest that anxiety is correlated with eating behavior, however, little is known about the association between anxiety status as predictor of dietary macronutrient intake. The aim of the present study was to investigate the sex-stratified cross-sectional associations of trait anxiety with intake of various macronutrients in a large population-based sample of non-diabetic adults.

Methods

N = 20,231 participants (mean age = 53.7 ± 13.6 years) of the NutriNet-Santé web-cohort, who had completed the trait anxiety subscale of the Spielberger State-Trait Anxiety Inventory (T-STAI; 2013–2016) were included in the analyses. Dietary intake was calculated from at least 3 self-administered 24-h dietary records. The associations of interest were assessed by multiple linear regression stratified by sex, owing to significant interaction tests.

Results

In total, 74.3% (n = 15,033) of the sample were females who had a significantly higher mean T-STAI score than did males (39.0 versus 34.8; p < 0.01). Among females, the fully-adjusted analyses showed significant positive associations of T-STAI with total carbohydrate intake (β = 0.04; p < 0.04), complex carbohydrate intake (β = 0.05; p < 0.02), and percentage energy from carbohydrates (β = 0.01; p < 0.03), as well as a significant inverse association of T-STAI with percentage energy from fat (β = -0.01; p < 0.05). As regards males, the only significant finding was an inverse association between T-STAI and percent of the mean daily energy from protein (fully-adjusted model: β = -0.01; p = 0.05).

Conclusion

This cross-sectional study found modest sex-specific associations between anxiety status and macronutrient intake among French non-diabetic adults. Prospective studies are needed to further elucidate the observed associations.

Motivation and methods of external organisations investing in mental health in low-income and middle-income countries: a qualitative study

Mental disorders (including substance use disorders, dementia, and self-harm) account for a substantial burden of disease and economic costs in low-income and middle-income countries (LMICs), yet they attract little funding. External resources are urgently needed but evidence on investments is scarce. This Health Policy paper uses 35 elite interviews and documentary analyses to examine how and why external organisations have invested in mental health in LMICs over the past three decades, and how this investment has changed over time. Four levels are examined: organisations, source countries, recipient countries, and global landscape. Organisations have invested in numerous internal and external activities. Among the various factors shaping organisational decisions, actors (ie, individuals and organisations concerned with mental health) were the most salient at all four levels. To increase external organisation investments in mental health in LMICs, organisational leadership and understanding are crucial, along with increased political support in source and recipient countries, and a stronger governance structure at the global level.

Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic

Background

The COVID pandemic has been devastating for not only its direct impact on lives, physical health, socio-economic status of individuals, but also for its impact on mental health. Some individuals are affected psychologically more severely and will need additional care. However, the current health system is so fragmented and focused on caring for those infected that management of mental illness has been neglected. An integrated approach is needed to strengthen the health system, service providers and research to not only manage the current mental health problems related to COVID but develop robust strategies to overcome more long-term impact of the pandemic. A series of recommendations are outlined in this paper to help policy makers, service providers and other stakeholders, and research and research funders to strengthen existing mental health systems, develop new ones, and at the same time advance research to mitigate the mental health impact of COVID19. The recommendations refer to low, middle and high resource settings as capabilities vary greatly between countries and within countries.

Discussion

The recommendations for policy makers are focused on strengthening leadership and governance, finance mechanisms, and developing programme and policies that especially include the most vulnerable populations. Service provision should focus on accessible and equitable evidence-based community care models commensurate with the existing mental health capacity to deliver care, train existing primary care staff to cater to increased mental health needs, implement prevention and promotion programmes tailored to local needs, and support civil societies and employers to address the increased burden of mental illness. Researchers and research funders should focus on research to develop robust information systems that can be enhanced further by linking with other data sources to run predictive models using artificial intelligence, understand neurobiological mechanisms and community-based interventions to address the pandemic driven mental health problems in an integrated manner and use innovative digital solutions.

Conclusion

Urgent action is needed to strengthen mental health system in all settings. The recommendations outlined can be used as a guide to develop these further or identify new ones in relation to local needs.

Reframing implementation science to address inequities in healthcare delivery

BACKGROUND

Research has generated valuable knowledge in identifying, understanding, and intervening to address inequities in the delivery of healthcare, yet these inequities persist. The best available interventions, programs and policies designed to address inequities in healthcare are not being adopted in routine practice settings. Implementation science can help address this gap by studying the factors, processes, and strategies at multiple levels of a system of care that influence the uptake, use, and the sustainability of these programs for vulnerable populations. We propose that an equity lens can help integrate the fields of implementation science and research that focuses on inequities in healthcare delivery.

MAIN TEXT

Using Proctor et al.' (12) framework as a case study, we reframed five elements of implementation science to study inequities in healthcare. These elements include: 1) focus on reach from the very beginning; 2) design and select interventions for vulnerable populations and low-resource communities with implementation in mind; 3) implement what works and develop implementation strategies that can help reduce inequities in care; 4) develop the science of adaptations; and 5) use an equity lens for implementation outcomes.

CONCLUSIONS

The goal of this paper is to continue the dialogue on how to critically infuse an equity approach in implementation studies to proactively address healthcare inequities in historically underserved populations. Our examples provide ways to operationalize how we can blend implementation science and healthcare inequities research.

Philanthropy for global mental health 2000-2015

BACKGROUND

Mental disorders are the leading cause of years lived with disability worldwide. While over three-quarters of people with mental disorders live in low- and middle-income countries (LMICs) and effective low-cost interventions are available, resource commitments are extremely limited. This paper seeks to understand the role of philanthropy in this area and to inform discussions about how to increase investments.

METHODS

Novel analyses of a dataset on development assistance for health were conducted to study philanthropic development assistance for mental health (DAMH) in 156 countries between 2000 and 2015.

RESULTS

Philanthropic contributions more than doubled over 16 years, accounting for one-third (US$364.1 million) of total DAMH 2000-2015. However, across health conditions, mental disorders received the lowest amount of philanthropic development assistance for health (0.5%). Thirty-seven of 156 LMICs received no philanthropic DAMH between 2000 and 2015 and just three LMICs (Antigua and Barbuda, Grenada, Saint Vincent and the Grenadines) received more than US$1 philanthropic DAMH per capita over the entire period. Eighty-one percent of philanthropic DAMH was disbursed to unspecified locations.

CONCLUSIONS

Philanthropic donors are potentially playing a critical role in DAMH, and the paper identifies challenges and opportunities for increasing their impact in sustainable financing for mental health.

Mental health: in the spotlight but a long way to go

We need to radically reframe our conversations about mental health to address the massive global prevention, care and quality gaps to reduce the global burden of mental health problems. This commentary looks at mental health over the past decade and what more we need to do to tackle this priority global health issue.

Sustainable development for global mental health: a typology and systematic evidence mapping of external actors in low-income and middle-income countries

INTRODUCTION

Mental disorders account for a substantial burden of disease and costs in low-income and middle-income countries (LMICs), but attract few resources. With LMIC governments often under economic pressure, an understanding of the external funding landscape is urgently needed. This study develops a new typology of external actors in global health adapted for the sustainable development goals (SDGs) era and uses it to systematically map available evidence on external actors in global mental health.

METHODS

The new typology was developed in line with conceptualisation in the literature and the SDGs to include 11 types of external actors for health in LMICs. Five databases (EconLit, Embase, Global Health, MEDLINE, PsycINFO) were searched for manuscripts published in peer-reviewed journals in English, French, Italian, Portuguese or Spanish between 1 January 2000 and 31 July 2018 and reporting information on external actors for mental disorders in LMICs. Records were screened by abstract, then full-text against inclusion criteria. Data were extracted and synthesised using narrative analysis.

RESULTS

79 studies were included in the final review. Five were quantitative studies analysing the resource flow of development assistance for mental health globally over the last two decades. The remainder were qualitative studies providing a description of external actors: the majority of them were published in the last decade, focused on Africa, and on public sector (bilateral and multilateral governmental organisations) and third sector organisations (non-governmental organisations). Evidence was particularly scarce for for-profit organisations and individual households.

CONCLUSION

This study reveals opportunities for unlocking additional funding for global mental health in the SDG-era from an ecosystem of external actors, and highlights the need to coordinate efforts and to use sustainable, ethical approaches to disbursements. Further research is needed to understand all external actors and the allocation of their contributions in different settings.

Rethinking global mental health and its priorities

Global mental health (GMH) seems to enjoy increasing visibility in the global health and development discourse. However, this visibility implies also the urgency of addressing few questions about new priority setting in the domains of policy, care delivery, service organisation and research. Even before trying to answer these questions, rethinking more deeply the notion and implications of GMH seems to be a useful collective exercise. Some unanswered questions should be at the core of this exercise: Is GMH really global or rather Western? Is GMH concerned enough with local context? Is GMH too unbalanced towards a biomedical model? What are the consequences of the predominant emphasis given by GMH on common mental disorders and primary care level on people with severe mental disabilities? GMH is not global but rather it is hegemonised by western institutions. It would be useful to have an independent and very inclusive think tank which should promote a global debate on these issues and offer an unbiased support to WHO.

'Global mental health': systematic review of the term and its implicit priorities

BACKGROUND

The term 'global mental health' came to the fore in 2007, when the Lancet published a series by that name.

AIMS

To review all peer-reviewed articles using the term 'global mental health' and determine the implicit priorities of scientific literature that self-identifies with this term.

METHOD

We conducted a systematic review to quantify all peer-reviewed articles using the English term 'global mental health' in their text published between 1 January 2007 and 31 December 2016, including by geographic regions and by mental health conditions.

RESULTS

A total of 467 articles met criteria. Use of the term 'global mental health' increased from 12 articles in 2007 to 114 articles in 2016. For the 111 empirical studies (23.8% of articles), the majority (78.4%) took place in low- and middle-income countries (LMICs), with the most in Sub-Saharan Africa (28.4%) and South Asia (25.5%) and none from Central Asia. The most commonly studied mental health conditions were depression (29.7%), psychoses (12.6%) and conditions specifically related to stress (12.6%), with fewer studies on epilepsy (2.7%), self-harm and suicide (1.8%) and dementia (0.9%). The majority of studies lacked contextual information, including specific region(s) within countries where studies took place (20.7% missing), specific language(s) in which studies were conducted (36.9% missing), and details on ethnic identities such as ethnicity, caste and/or tribe (79.6% missing) and on socioeconomic status (85.4% missing).

CONCLUSIONS

Research identifying itself as 'global mental health' has focused predominantly on depression in LMICs and lacked contextual and sociodemographic data that limit interpretation and application of findings.

DECLARATION OF INTEREST

None.