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.

Evaluation of a Culturally Adapted Online Basic Psychosocial Skills Training Program for International Frontline Workers in Under-Resourced Contexts During the COVID-19 Pandemic

OBJECTIVE

Frontline workers report negative mental health impacts of being exposed to the risk of COVID-19, and of supporting people struggling with the effects of the virus. Uptake of psychological first-aid resources is inconsistent, and they may not meet the needs of frontline workers in under-resourced contexts. This study evaluates a culturally adapted basic psychosocial skills (BPS) training program that aimed to meet the needs of frontline workers in under-resourced settings.

METHODS

A cross-sectional survey administered to frontline workers who completed the program between 2020 and 2022, investigated their perceived confidence, satisfaction, and skill development, as well as their views on relevance to context and accessibility of the program.

RESULTS

Out of the 1000 people who had undertaken the BPS program, 118 (11.8%) completed the survey. Participants reported high levels of satisfaction and improved confidence in, and knowledge of, psychosocial skills. Participants reported that the BPS program was culturally and contextually relevant, and some requested expansion of the program, including more interactivity, opportunities for anonymous participation, and adaption to other cultural contexts, including translation into languages other than English.

CONCLUSION

Findings indicate a need for free, online, and culturally adapted psychosocial skills training program that is designed with key stakeholders to ensure relevance to social and cultural contexts.

The Pasifika Veilomani Project: a pilot online training programme for healthcare workers in managing gender-based violence and family violence and sharing experiences

OBJECTIVE

Pacific Island Countries (PICs) record high rates of gender-based violence (GBV). COVID-19 has significantly increased the number of GBV cases globally. This research aims to understand educational pathways for PICs' healthcare workers (HCWs) to strengthen GBV clinical practices in the Pasifika Veilomani (sharing the love) project.

METHOD

A literature review, content experts' discussion and review of stakeholder governance documents were used to inform the design of the telehealth training. HCWs were invited to share experiences, further exploring the capacity of online learning to meet clinical practice needs.

RESULTS

Global health guidance was adapted by Pacific experts to deliver a 12-week multidisciplinary course. One hundred and thirty-six participants from nine PICs registered and participated in the telehealth sessions. Despite internet and technical difficulties, participants' responses were positive. Results indicated the online training improved their confidence, helped them to reflect on practice and that more training would be valued.

CONCLUSIONS

The Pasifika Veilomani Project engaged HCW and clinical leaders to inform current practices, education, and public health approaches on GBV as a public health priority. This project demonstrates the potential for engaging and supporting HCW remotely across challenging geographic, service and cultural domains in the context of COVID-19 social and service demands.

Piloting online training in the Pacific-Ophelia project for child and adolescent mental health

INTRODUCTION

In June 2020, St Vincent's Mental Health, Fiji National University, and the Royal Australian and New Zealand College of Psychiatrists, Faculty of Child and Adolescent Psychiatry collaborated to deliver online, specialized child and adolescent mental health (CAMH) training to Pacific-based healthcare workers. This accompanying research aimed to understand the telehealth model and structures that would sustain an engaged community of practice and support the development of professional networks across the Pacific.

METHOD

Quantitative and qualitative feedback was analyzed to understand participation and self-rated measures of skills, knowledge, and confidence in providing health care for children and young people, as well as experiences of training, including access, engagement, and applicability of the initiative to the Pacific Islands health care organizations.

RESULTS

Ophelia Training was able to meet the stated learning objectives. The data from all stakeholders identifies the value of a telehealth initiative incorporating training, technical assistance, knowledge networks, and professional coaching as a capacity building approach.

CONCLUSION

This program offers an integration of research and practice. This regional approach to understanding telehealth capacity for Pacific Island mental health services is valuable for informing decision-making with respect to clinical care, management, workforce training and policy. It also provided an opportunity to improve health inequalities, by improving access to CAMH training via telehealth.

Information processing by community health nurses using mobile health (mHealth) tools for early identification of suicide and depression risks in Fiji Islands

Objectives

High rates of depression and suicide and a lack of trained psychiatrists have emerged as significant concerns in the low-income and middle-income countries (LMICs) such as the Pacific Island Countries (PICs). Readily available smartphones were leveraged with community health nurses (CHNs) in task-sharing for early identification of suicide and depression risks in Fiji Islands, the largest of PICs. This investigation examines how CHNs can efficiently and effectively process patient information about depression and suicide risk for making diagnostic and management decisions without compromising safety. The research is driven by the theoretical framework of text comprehension (knowledge representation and interpretation) and decision-making.

Methods

Mobile health (mHealth) Application for Suicide Risk and Depression Assessment (ASRaDA) was designed to include culturally useful clinical guidelines for these disorders. A representative sample of 48 CHNs was recruited and presented with two clinical cases (depression and suicide) in a simulated setting under three conditions: No support, paper-based and mobile-based culturally valid guideline support. Data were collected as the nurses read through the scenarios, ‘thinking aloud’, before summarising, diagnoses and follow-up recommendations. Transcribed audiotapes were analysed using formal qualitative discourse analysis methods for diagnostic accuracy, comprehension of clinical problems and reasoning patterns.

Results

Using guidelines on ASRaDA, the CHNs took less time to process patient information with more accurate diagnostic and therapeutic decisions for depression and suicide risk than with paper-based or no guideline conditions. A change in reasoning pattern for nurses’ information processing was observed with decision support.

Discussion

Although these results are shown in a mental health setting in Fiji, there are reasons to believe they are generalisable beyond mental health and other lower-to-middle income countries.

Conclusions

Culturally appropriate clinical guidelines on mHealth supports efficient information processing for quick and accurate decisions and a positive shift in reasoning behaviour by the nurses. However, translating complex qualitative patient information into quantitative scores could generate conceptual errors. These results are valid in simulated conditions.

Art-making in mental health - a Fijian pilot study

OBJECTIVE

A pilot art-making and mental health recovery project addressed consumer and carer mental health and well-being in Suva, Fiji.

METHOD

Using feedback surveys, the project evaluated initial training, and a 12-month art programme for consumers, carers and staff across several mental health services.

RESULTS

First person and stakeholder group reports from the project reflected broad-scale approval for the novel modality and its potential for continued application in keeping with local cultural values. A broad stakeholder base was involved in planning and participation, aligned with the values of inclusive recovery-oriented mental health service approaches.

CONCLUSIONS

These results suggest that the programme can add value to mental health care being provided for people with a mental illness in Fiji.

Impact of a mobile-based (mHealth) tool to support community health nurses in early identification of depression and suicide risk in Pacific Island Countries

OBJECTIVE

To convert screening tools for depression and suicide risk into algorithmic decision support on smartphones for use by community health nurses (CHNs), and to evaluate the efficiency, effectiveness, and usability of the mHealth tool in providing mental health (MH) care.

METHOD

Two scenarios of depression and suicide risk were developed and presented to 48 nurses using paper-based and mobile-based guidelines under laboratory (nonclinical) conditions. Participants read through the case scenarios to provide summaries, diagnoses, and management recommendations. Audiotapes were transcribed and analyzed for accuracy in scoring guidelines, therapy decisions, and time for tasks completion. The validated System Usability Scale (SUS) was used to measure mobile app usability.

RESULTS

Using mHealth-based guidelines, nurses took significantly less time to complete their tasks, and generated no errors of addition, as compared to paper-based guidelines. Although coding errors were noted when using the mHealth app, it did not influence treatment recommendations. The system usability scores for both guidelines were over 84%.

CONCLUSIONS

Usable mHealth technology can support task-sharing for CHNs in Fiji, for the efficient and accurate screening of patients for depression and suicide risks in a nonclinical setting. Studies on clinical implementation of the mHealth tool are needed and planned.

Development and usability of a mobile tool for identification of depression and suicide risk in Fiji

BACKGROUND

In Fiji and other South Pacific island countries, depression and suicide are of great concern. There is a pressing need to rapidly identify those at risk and provide treatment as soon as possible.

OBJECTIVE

Design, develop and test a mobile health tool that enables CHNs to easily and rapidly identify individuals at risk for suicide and depression and provide guidelines for their treatment.

METHODS

Using Android Studio, a native app called ASRaDA was developed that encoded two validated scales: Center for Epidemiological Studies-Depression (CES-D), and Suicide Behavior Questionnaire-Revised (SBQ-R). The usability of the app was measured using the System Usability Scale by community health nurses in Fiji.

RESULTS

Out of a maximim possible of 100 on SUS, ASRaDA was scored at 86.79.

CONCLUSION

Mobile tools with high usability can be designed to aid community health nurses in Fiji and Pacific island counties rapidly identify those at risk for depression and suicide.

Child and Adolescent Psychiatry International Relations (CAPIR): building bridges for psychiatry workforce capacity with Pacific Island nations

OBJECTIVE

To describe the span of work of child and adolescent psychiatrists in Australia and New Zealand in recent years aimed at collaborative efforts to build mental health capacity in the Pacific Island nations of Fiji, Samoa, Cook Islands, Tonga, Kiribati, Vanuatu, Solomon Islands and Papua New Guinea.

METHOD

Steps taken to coordinate resourcing, networking, delivery of appropriate initiatives, establishing and maintaining key relationships with partners are described.

RESULTS

Engagement with Pacific nations mental health professionals, ministries of health, NGOs, universities, multilateral agencies and professional and international organisations has expanded and strengthened since 2013.

CONCLUSIONS

Planned and staged implementation of initiatives can harness RANZCP (and its faculties and interest groups) goodwill to effectively contribute to psychiatry and mental health capacity building in partnerships with Pacific Island nations to address mental health needs over the life-span.

Addressing the specialist workforce CAMH skill-gap: providing and evaluating iCAMH training in Fiji and Papua New Guinea

OBJECTIVE

Child and adolescent mental health problems are common and result in significant morbidity. Whereas in high-income countries there is an established workforce, in lower income countries, such as the Pacific nations, the workforce has little capacity despite a potentially higher population risk of mental disorder. We report on a workforce development effort, a child and adolescent mental health training package.

METHOD

We describe the implementation and evaluation of the International Child and Adolescent Mental Health certificate training in two Pacific nations.

RESULTS

Clinicians rated the training positively. Some participants reported concern with teaching materials. Attitudes to child and adolescent mental health were more favourable following the course. A change in knowledge or skill could not be determined.

CONCLUSIONS

The training seems of value to Pacific clinicians and the framework provides for case-based learning across settings. The training would benefit from the addition of a valid assessment of participant skill and knowledge. The sociocultural and contextual factors are considerations for the content and delivery. Contextually appropriate resources and teaching strategies are important.

Implementation of the mental health Gap Action Programme (mhGAP) within the Fijian Healthcare System: a mixed-methods evaluation

Background

To facilitate decentralisation and scale-up of mental health services, Fiji’s Ministry of Health and Medical Services committed to implementing the World Health Organization’s mental health Gap Action Programme (mhGAP). mhGAP training has been prolific; however, it remains unclear, beyond this, how successfully Fiji’s national mental health program has been implemented. We aim to evaluate Fiji’s mental health program to inform Fiji’s national mental health program and to develop an evidence-base for best practice.

Methods

The study design was guided by the National Implementation Research Network and adhered to the Consolidated Framework for Implementation Research. CFIR constructs were selected to reflect the objectives of this study and were adapted where contextually necessary. A mixed-methods design utilised a series of instruments designed to collect data from healthworkers who had undertaken mhGAP training, senior management staff, health facilities and administrative data.

Results

A total of 66 participants were included in this study. Positive findings include that mhGAP was considered valuable and easy to use, and that health workers who deliver mental health services had a reasonable level of knowledge and willingness to change. Identified weaknesses and opportunities for implementation and system strengthening included the need for improved planning and leadership.

Conclusion

This evaluation has unpacked the various implementation processes associated with mhGAP and has simultaneously identified targets for change within the broader mental health system. Notably, the creation of an enabling context is crucial. If Fiji acts upon the findings of this evaluation, it has the opportunity to not only develop effective mental health services in Fiji but to be a role model for other countries in how to successfully implement mhGAP.

Establishment and characterization of a new cell line from koi brain (Cyprinus carpio L.)

A novel permanently growing brain cell line from koi (Cyprinus carpio L.) (KB cell line) was established, and its suitability for detection of koi herpesvirus (KHV) was demonstrated in this study. The KB cell line was optimally maintained at 27°C in Leibovitz's L-15 medium supplemented with 10% foetal bovine serum (FBS). It was subcultured more than 100 times, and chromosome analysis revealed that 51.54% of KB cells at passage 80 maintained the abnormal diploid chromosome number 2n = 96 while the modal chromosome number was 2n = 100. The cell line was cryopreserved in liquid nitrogen at -196°C and was recovered from storage after 1 year with good cell viability and vitality. The results of virus isolation demonstrated that KB cells were susceptible to KHV, which was shown by the presence of an obvious cytopathic effect and abundant virus particles. The viral titres of KHV in KB reached 10^5.73 TCID₅₀ /0.1 ml within 7 days. Immunofluorescence and Western blot assays confirmed that KB replicated KHV. The newly established KB cell line will serve as a useful tool to elucidate KHV disease (KHVD) pathogenesis.

Fiji's Mental Health Decree 2010

Fiji’s Mental Treatment Act 1940 had become outdated, in part because it concentrated on treatment within a psychiatric hospital. The Mental Health Decree 2010 covers not only in-patient treatment but also the promotion of mental health, the prevention of mental illness, and the community-based and rehabilitative aspects of mental healthcare, as well as human rights issues.