Situational analysis: preliminary regional review of the Mental Health Atlas 2014.

The WHO comprehensive Mental Health Action Plan 2013-2020 established goals and objectives that Member States have agreed to meet by 2020. To update the Atlas of Mental Health 2011, specific indicators from the Mental Health Action Plan and additional indicators on service coverage were incorporated into the questionnaire for the Atlas 2014. The data will help facilitate improvement in information gathering and focus efforts towards implementation of the Mental Health Action Plan. The questionnaire was completed by the national mental health focal point of each country. This preliminary review seeks to consolidate data from the initial response to the Atlas 2014 questionnaire by Member States in the Eastern Mediterranean Region. Data for this review were analysed for the whole Region, by health systems groupings and by individual countries. Where possible, data are compared with the Mental Health Atlas 2011 to give a longitudinal perspective.

Mental health surveillance and information systems.

Routine information systems for mental health in many Eastern Mediterranean Region countries are rudimentary or absent, making it difficult to understand the needs of local populations and to plan accordingly. Key components for mental health surveillance and information systems are: national commitment and leadership to ensure that relevant high quality information is collected and reported; a minimum data set of key mental health indicators; intersectoral collaboration with appropriate data sharing; routine data collection supplemented with periodic surveys; quality control and confidentiality; and technology and skills to support data collection, sharing and dissemination. Priority strategic interventions include: (1) periodically assessing and reporting the mental health resources and capacities available using standardized methodologies; (2) routine collection of information and reporting on service availability, coverage and continuity, for priority mental disorders disaggregated by age, sex and diagnosis; and (3) mandatory recording and reporting of suicides at the national level (using relevant ICD codes).

Mental health research: developing priorities and promoting its utilization to inform policies and services.

Investment in research on the prevention and treatment of mental health disorders is disproportionately low in the WHO Eastern Mediterranean Region (EMR) relative to the disease burden. Scaling-up mental health research in the EMR could generate enormous returns in terms of reducing disability, improving outcomes and preventing premature death, through early diagnosis, better management and community-based rehabilitation. EMR countries must therefore work to identify research priorities, mobilize resources, develop human and infrastructure capacities and institutionalize use of research findings to guide development of policies and service delivery models. Several key strategic interventions for EMR Member States are recommended: adopt a prioritized national mental health research agenda; systematically map national and international research funding to identify and secure resources to support the implementation of the agenda; strengthen national capacity to undertake prioritized research; periodically map research output in mental health; and foster dialogue between researchers and policy-makers/programme managers.

Reorganization of mental health services: from institutional to community-based models of care.

Mental health services in the Eastern Mediterranean Region are predominantly centralized and institutionalized, relying on scarce specialist manpower. This creates a major treatment gap for patients with common and disabling mental disorders and places an unnecessary burden on the individual, their family and society. Six steps for reorganization of mental health services in the Region can be outlined: (1) integrate delivery of interventions for priority mental disorders into primary health care and existing priority programmes; (2) systematically strengthen the capacity of non-specialized health personnel for providing mental health care; (3) scale up community-based services (community outreach teams for defined catchment, supported residential facilities, supported employment and family support); (4) establish mental health services in general hospitals for outpatient and acute inpatient care; (5) progressively reduce the number of long-stay beds in mental hospitals through restricting new admissions; and (6) provide transitional/bridge funding over a period of time to scale up community-based services and downsize mental institutions in parallel.

Sex differences in the prevalence and detection of depressive and anxiety disorders in general health care settings: report from the World Health Organization Collaborative Study on Psychological Problems in General Health Care.

BACKGROUND: Understanding the relevance of biological and social factors to sex differences in the prevalence and detection of depressive and anxiety disorders has been impaired by the lack of standardized research methods across cultures. METHOD: Prevalence rates of depressive and anxiety disorders were assessed using a 2-stage design from 26,969 patients attending for primary care in 15 centers from 4 continents. Logistic regression analysis was used to examine sex differences in prevalence and detection across centers. RESULTS: Odds ratios for women compared with men of current depression (1.60; 95% confidence interval [CI], 1.37-1.86) and agoraphobia or panic (1.63; 95% CI, 1.18-2.20) were consistent across centers. The odds ratio for generalized anxiety varied among centers: 3 groups of centers were identified with odds ratios of 0.46 (95% CI, 0.27-0.78), 1.34 (95% CI, 1.08-1.66), and 3.09 (95% CI, 1.60-5.89). There was no sex difference in the detection of depressive and anxiety disorders by physicians across centers. CONCLUSIONS: The absence of a sex-by-center effect for current depression and agoraphobia or panic disorder is consistent with biological and psychosocial factors, either interacting or working alone, that have a similar final effect across cultures. It does not support the idea that sex differences in prevalence are caused by local psychosocial factors that vary from country to country. The variation in the odds ratio for generalized anxiety disorder offers some support to the idea that there are local differences between the centers contributing to the sex difference in rates. Patients' sex does not appear to affect the likelihood of current depression and anxiety being detected by primary care physicians.

Is the lifetime risk of depression actually increasing?

Data from an international study of psychological problems in primary care were examined for evidence of increasing depression risk. At 15 sites, patients aged 15-65 (n = 26,421) were screened with the GHQ-12 and a stratified random sample (n = 5603) selected for psychiatric assessment (Composite International Diagnostic Interview). Initial analyses agreed with earlier cross-sectional studies, finding higher depression risk and earlier onset in recent birth cohorts. Additional analyses suggested that methods effects may explain these findings. First, apparent prevalence increases were nonspecific with similar trends seen across all study sites and for all disorders examined. Second, reporting patterns suggested significant under-counting of past depressive episodes. Respondents of all ages typically reported first onset of depression during the last 5 years. Reported lifetime prevalence was only 2.02 times current prevalence. These findings suggest that depression risk is not rapidly increasing and that true lifetime prevalence is much higher than estimated by cross-sectional surveys.

Gender differences in the prevalence of depression: a survey in primary care.

Epidemiological surveys demonstrate that unipolar depression is more common in females than in males. Gender-specific cultural and social factors may contribute to the female preponderance. This study explores this possibility in a cross-cultural sample of general-practice patients systematically recruited in the WHO study "Psychological Problems in Primary Care" conducted in 14 countries with identical sampling and assessment strategies. Although absolute prevalence rates are broadly varying between centers proposing that the gender ratio is nearly constant with 1:2. The cultural context does not contribute substantially to the female preponderance. This study lends some support to previous observations that the magnitude of female preponderance is associated with the number of symptoms associated with depression requested for caseness and inversely related to the degree of social impairment. Matching social role variables (marital status, children, occupational status) between females and males reduces the female excess by about 50% across all centers. Therefore, we conclude that social factors are inducing part of the preponderance of females among depressed cases.

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis.

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.

Implications of the World Health Organization study of mental illness in general health care for training primary care staff.

A substantial international study of mental disorders seen in primary care settings has shown that there are marked differences in prevalence between centres. Detection of mental disorders is better in centres using a 'personal' style of clinical service, and where there has been close collaboration between psychiatrists and general practitioners. However, even in the better centres, substantial numbers of mental disorders are missed and treatment often appears to be given regardless of diagnosis. It is argued that changes need to be made to the way in which both undergraduates and vocational trainees are taught about mental disorders, so that teaching emphasizes the psychological syndromes that general practitioners are likely to meet in their everyday work. Training packages need to be developed for primary care staff in the detection and management of mental disorders.

Effects of a community mental health service on the practice and attitudes of general practitioners.

Recent years have seen closer links developing between general practitioners and mental health specialists. A study was undertaken in Manchester to determine the effects of a new community mental health service on the practice and attitudes of general practitioners. Ten doctors had access to the community based psychiatric team over a three year period while another 10 doctors continued to use hospital services. Those with access to the team were significantly more satisfied with the specialist support services, and were more likely to give high priority to community psychiatric nurses and psychiatric social workers working as part of a primary health care team than those without access to the service. Those with access were more willing than those without access to share with psychiatrists the care of patients with chronic neurotic disorders. The community mental health team was considered particularly helpful in reducing the burden posed by patients with neurotic and psychosocial problems, but this resulted in the general practitioners doing less counselling themselves. The study did not find that the new service had an effect on the general practitioners' ability to detect or manage psychiatric illness.

Detection of disabilities by schoolchildren: a pilot study in rural Pakistan.

An important consideration in planning services for disabled children is to establish the need, including the size of the potential beneficiary group. However, surveys are expensive and time consuming (especially surveys of disability, which has a low prevalence within the population), and can raise expectations of service for patients who are often very unsure about how to cope with their disabled child. The World Health Organization (WHO) has produced a series of survey tools which have been used to identify disabled children in settings where a service is planned. Zaman et al, produced the '10 Question Screen', a simple screening tool for use by community health staff to identify disabilities among children in the community. Both the WHO survey tools and the 10 Question Screen rely on trained primary health care (PHC) or community-based rehabilitation (CBR) staff. The small study reported here shows that schoolchildren are effective identifiers of disabled children within their home communities and may be a useful resource when there are no trained CBR or PHC workers to conduct surveys. Furthermore, the children's ability to identify within the five major disability groups was relatively robust when compared with medical diagnosis.

Mental health: the missing link in primary care? Health for All by the Year 2000 revisited.

The effects on the uptake of services offered in primary health care of a demonstration community mental health project in Pakistan were assessed. A subdistrict with the project was compared with a matched area without the project over 7 years. Routinely collected information on service use was used, including the detection and treatment of mental disorders. Compared with the comparison subdistrict, the index subdistrict showed an increase in use of primary care by men, reduction in pregnancy rate, increased use of antenatal care, reduced maternal mortality, increased immunization coverage, and increased detection and treatment of mental disorders.

Pathways to psychiatric care in South Manchester.

Of 250 patients newly referred to the mental illness services of South Manchester, almost two-thirds were referred directly by their GPs; a further third were referred by hospital doctors. Non-medical sources of referral accounted for only 2% of new cases. Patients with somatic problems had the longest interval between seeking care and referral to the psychiatric services. Being employed was associated with a longer delay before seeking care; among women, those living with their husbands or children had longer total intervals between the onset of the problem and arrival at the psychiatric services.

Quality of life in liaison psychiatry. A comparison of patient and clinician assessment.

BACKGROUND: This exploratory study investigates the performance of the Health Measurement Questionnaire (HMQ), as compared with the Psychiatric Assessment Schedule (PAS) and the Nottingham Health Profile (NHP), and compares self- and observer-completed measures. METHOD: A total of 138 medical patients scoring over the screening threshold for probable psychiatric illness completed the HMQ, NHP and PAS, and were rated by a psychiatrist on Rosser disability and distress. RESULTS: HMQ disability correlated well with NHP and PAS physical health items, while HMQ distress correlated well with the NHP emotional reactions and PAS Index of Definition. There was significant correlation between self-report and psychiatrist ratings, the latter being more sensitive to distress. CONCLUSION: The HMQ is a useful measure of generic health status in liaison psychiatry settings.

Affective and neurotic disorders in community-based services: a comparative study in south Verona and south Manchester.

The service utilization by patients with affective and neurotic disorders in two defined populations of south Verona in Italy and south Manchester in England was compared. The composition and function of the two community-based psychiatric services, and the sociodemographic characteristics of the two centers are described and related to epidemiologically based data on service use in the community, outpatient clinic, day hospital and inpatient care. The results suggest that close liaison with primary care in south Manchester results in more referrals, and therefore higher treated incidence and prevalence rates. The close integration between hospital and community staff in south Verona is associated with greater permeability of the filter between inpatient and community care, indicated by higher admission rates for patients known to the service, and shorter length of inpatient stay (only for affective disorders) in south Verona compared with south Manchester.

Somatic symptoms of distress: an international primary care study.

The objective of this study was to examine cross-national differences in somatic symptoms associated with psychological distress. Data from the World Health Organization (WHO) collaborative study of psychological problems in general health care (5438 patients at 15 sites) were used to examine somatic symptoms associated with psychological distress. At each site, a stratified random sample of consecutive primary care patients completed the 28-item General Health Questionnaire (GHQ) and the Composite International Diagnostic Interview (CIDI). At all sites, the number of current CIDI somatic symptoms (whether medically explained or not) was strongly associated with current psychological distress (measured by selected GHQ-28 items). Pearson correlation of somatic symptom count with psychological distress score was .42 for all sites and ranged from .20 to .58 (p < .0001 at all sites). Across all sites, anxiety and depressive symptoms showed roughly the same association with somatic symptom counts, and specific somatic symptoms or symptom clusters did not show differential association with anxiety or depression. Although somatic symptoms did cluster into meaningful groups (gastrointestinal, neurological/conversion, autonomic, and musculoskeletal), these symptom groups did not show differential association with psychological distress. Examination of individual somatic symptoms and symptom clusters across sites did not reveal clear patterns of association according to geography or level of economic development. These data show a strong association between somatic symptoms and psychological distress, which did not vary across disparate cultures and levels of economic development. Cultural factors, however, may influence the meaning attached to symptoms or the likelihood of presentation for health care.