The Chester M. Pierce, MD Division of Global Psychiatry

The Role of Research in Mental Health Policy

David Henderson, M.D.Director

Leading Causes of Years Lived with Disability

1 Unipolar depressive disorders 10.9%2 Hearing loss, adult onset 4.63 Refractory errors 4.64 Alcohol use disorders 3.75 Cataracts 3.06 Schizophrenia 2.77 Osteoarthritis 2.68 Bipolar affective disorder 2.49 Iron-deficiency anemia 2.210 Birth asphyxia and birth trauma 2.2

Gender Differences in Mental Health Problems Worldwide

Percentage of DALYs* Lost

Burden vs. Budget

(WHO World Mental Health Consortium, JAMA, June 2nd 2004)

Gap in treatment:Serious cases receiving no treatment during the last 12 months

0

10

20

30

40

50

60

70

80

90

Developed countries Developing countries

Lower range Upper range Lower range Upper range

35%

50%

76%

85%

ScarcityHuman Resources

(N=157 to 183 countries)

Figure 2: Human resources for mental health in each income group of countries per 100 000 population

Number of psychiatrists per 100,000 population

Comparing Resources

Psychiatric Beds and Professionals Mozambique Nigeria Rwandai Sierra Leoneii

Uganda

Total psychiatric beds per 10,000 population 0.23 0.4 0.2 0.47 0.44

Psychiatric beds in mental hospitals per 10,000 population 0.2 0.3 0.2 0.32 0.22

Psychiatric beds in general hospitals per 10,000 population 0.04 0.04 0 0.11 0.22

Psychiatric beds in other settings per 10,000 population 0.01 0.01 0 0.03 0.009

Number of psychiatrists per 100,000 population 0.04 0.09 0.03 0.02 1.6

Number of neurosurgeons per 100,000 population 0.01 0.009 0.02 0 0.009

Number of psychiatric nurses per 100,000 population 0.01 4 0.8 0.04 2

Number of neurologists per 100,000 population 0.01 0.02 0 0.02 0.1

Number of psychologists per 100000 population 0.05 0.02 0.3 0 2

Number of social workers per 100,000 population 0.01 0.02 0 0.06 2

i There are 200 other mental health personnel ii There are 200 psychiatric assistants

Mental Health systems in low and middle-income countries

Context and Governance Poorly developed and disconnected system elements

Output and outcomes

Governments, educators, researchersLow capacity in policy development and implementation (services, training, research)MH is a low priority – weak drive for MH system developmentPopulationLow ‘mental health literacy’Low demand for mental

Weak investment. Shortage of everything – skilled workers, facilities, drugs, etc.Undeveloped information systems to support planningGeographic maldistribution of available workforceDisciplinary imbalance: doctor and nurse dominatedHospital-centeredPoorly organized and marginalized consumers, carers

Narrow population coverageVery wide gap between best and worst MH servicesLow access (geographic, economic, linguistic, cultural)Stigma, discrimination, social exclusionMental health training is unattractive for most disciplinesInadequate protection of rightsLack of locally relevant evidence for policy and practice

WHY IS MENTAL HEALTH NOT A PRIORITY?

We have not made the case in the language of policymakers or the general public, either in terms of cost-effectiveness or in terms of outcomes.

We do not have consensus on “model” interventions, especially for low-resource contexts.

We have not demonstrated that we can take successful programs and go to scale

We have not built consumer and family voice to garner political and public support

Mental Health Policy

• Mental heath policy and human protection laws are important

• Strategic plan and coordination are even more important.

• Research agenda should be designed to answer important questions and feeds back into policy and strategic plan

• As data becomes available, policy and strategic plan should be updated.

FACTORS AFFECTING INTERVENTION IMPLEMENTATION

System leadershipOrganizational culture/consensusIT capacity/outcomes measurementPolicies/proceduresIntegration with performance/quality

improvementHuman resource capacity/trainingFunding methods

Leadership Training

There is no sustained development without effective leadership

Leadership perspectives and skills are best taught alongside teaching on mental health system development / capacity building

Effective leadership is learned by doing, with continuing support and mentoring

Collaborative programs of activity (in policy development, service design and implementation, research – particularly mental health system research, education and training, and consumer, carer and civil society engagement) are the most effective way to develop effective leadership skills

Leadership training without sustained and productive engagement is probably of doubtful value

MOHs

• Should also be responsible for the coordination of all mental health activities by local and international non-governmental organizations (NGOs), UN agencies, and international donors.

• MOHs can also develop and monitor a simple, scientifically valid and reliable national mental health data system capable of informing national public health policy. – This requires that the MOH, as the lead agency in mental

health , has a national mental health action plan that can be fully supported and financed by the national government through mental health policy and legislation.

Key Needs in Global Mental Health Research

• Demonstration projects tied to rigorous external evaluation and funding for generalization of programs if outcomes are positive

• Network of global mental health policy research centers in the developed and developing worlds

• Networking Centers, Researchers, and Trainees

Culture, Context and Western Imports• Concern about imposing western approaches to

psychiatry on diverse cultures – undermining indigenous healing

• Risk of bringing in the “worst”: old and riskier drugs, institutionalization, stigma

• At same time, neglect of MI is major practical/HR issue in p-c environment (Lancet 2000)

• Principle: High level of critical awareness in melding essentials of western psychiatry with local traditions and customs

• Dilemma: Is this “marriage” always feasible. Unintended dangers (stigma, adverse effects, disruption of traditional care systems).

Approaches• Global Mental Health Research Collaborations• Global Mental Health Research Centers• Research Training Programs• Population studies

Collaborative Interdisciplinary Basic Applied Surveillance Local policy agendas Intervention studies Evaluation

POTENTIAL GLOBAL MENTAL HEALTH RESEARCH AREAS

Intervention models Implementation strategies

• Uptake• Going to scale• Sustainability• Financing/economics

Advocacy• Evidence bas• Optimal strategies

Recovery outcomes• What works? What does not?

INTERVENTION MODELS

Intervention models limited by over reliance on RCT as criteria.

We need explicit ways of building acceptable knowledge using different methodologies.

Research is limited to specific contexts or outcomesTransferability and relevance of models across

nations and cultures needs examinationEngagement of consumer and family voice in

developing models and assessing outcomes has been uneven

ADVOCACY ISSUES

Effective models for mental health advocacyBuilding the evidence base for advocacy

interventionsOptimizing consumer and family member

involvementDeveloping mutually beneficial partnerships

RECOVERY OUTCOMES

Measuring recovery Individual recovery process System support for recovery

Relationship of recovery trajectory to treatment outcomes

Role of consumer and family member

• Community Research and Socio-Cultural Research– Poverty and Labor Conditions– Stigma– Substance Abuse– Gender– Infectious Disease– Political Violence and Refugee Populations

• Epidemiology and Ethnography• Mental Health Services Research

REASONS FOR OPTIMISM

Mental health is becoming part of the rhetoric of global health and development

Effective innovation is occurring at the local level in many countries

There are a few successful national-level programs related to prevention and promotion

There are opportunities on the horizon such as the UN Assembly on non-communicable diseases in 2011

The global mental health movement is becoming an engine for change

Mental Health Policy

• Mental heath policy and human protection laws are important

• Strategic plan and coordination are even more important.

• Research agenda should be designed to answer important questions and feeds back into policy and strategic plan

• As data becomes available, policy and strategic plan should be updated.

Thank You!

“You must be the change you want to see in the world.”

Mahatma Gandhi