Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare.

Background & objectives: Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation. Methods: Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training. Results: Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State. Interpretation & conclusions: The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Whose responsibility? Part 2 of 2: views of patients, families, and clinicians about responsibilities for addressing the needs of persons with mental health problems in Chennai, India and Montreal, Canada.

BACKGROUND: Individuals with mental health problems have many insufficiently met support needs. Across sociocultural contexts, various parties (e.g., governments, families, persons with mental health problems) assume responsibility for meeting these needs. However, key stakeholders' opinions of the relative responsibilities of these parties for meeting support needs remain largely unexplored. This is a critical knowledge gap, as these perceptions may influence policy and caregiving decisions. METHODS: Patients with first-episode psychosis (n = 250), their family members (n = 228), and clinicians (n = 50) at two early intervention services in Chennai, India and Montreal, Canada were asked how much responsibility they thought the government versus persons with mental health problems; the government versus families; and families versus persons with mental health problems should bear for meeting seven support needs of persons with mental health problems (e.g., housing; help covering costs of substance use treatment; etc.). Two-way analyses of variance were conducted to examine differences in ratings of responsibility between sites (Chennai, Montreal); raters (patients, families, clinicians); and support needs. RESULTS: Across sites and raters, governments were held most responsible for meeting each support need and all needs together. Montreal raters assigned more responsibility to the government than did Chennai raters. Compared to those in Montreal, Chennai raters assigned more responsibility to families versus persons with mental health problems, except for the costs of substance use treatment. Family raters across sites assigned more responsibility to governments than did patient raters, and more responsibility to families versus persons with mental health problems than did patient and clinician raters. At both sites, governments were assigned less responsibility for addressing housing- and school/work reintegration-related needs compared to other needs. In Chennai, the government was seen as most responsible for stigma reduction and least for covering substance use services. CONCLUSIONS: All stakeholders thought that governments should have substantial responsibility for meeting the needs of individuals with mental health problems, reinforcing calls for greater government investment in mental healthcare across contexts. The greater perceived responsibility of the government in Montreal and of families in Chennai may both reflect and influence differences in cultural norms and healthcare systems in India and Canada.

Whose responsibility? Part 1 of 2: A scale to assess how stakeholders apportion responsibilities for addressing the needs of persons with mental health problems.

BACKGROUND: Individuals with mental health problems have multiple, often inadequately met needs. Responsibility for meeting these needs frequently falls to patients, their families/caregivers, and governments. Little is known about stakeholders' views of who should be responsible for these needs and there are no measures to assess this construct. This study's objectives were to present the newly designed Whose Responsibility Scale (WRS), which assesses how stakeholders apportion responsibility to persons with mental health problems, their families, and the government for addressing various needs of persons with mental health problems, and to report its psychometric properties. METHODS: The 22-item WRS asks respondents to assign relative responsibility to the government versus persons with mental health problems, government versus families, and families versus persons with mental health problems for seven support needs. The items were modelled on a World Values Survey item comparing the government's and people's responsibility for ensuring that everyone is provided for. We administered English, Tamil, and French versions to 57 patients, 60 family members, and 27 clinicians at two early psychosis programs in Chennai, India, and Montreal, Canada, evaluating test-retest reliability, internal consistency, and ease of use. Internal consistency estimates were also calculated for confirmatory purposes with the larger samples from the main comparative study. RESULTS: Test-retest reliability (intra-class correlation coefficients) generally ranged from excellent to fair across stakeholders (patients, families, and clinicians), settings (Montreal and Chennai), and languages (English, French, and Tamil). In the standardization and larger confirmatory samples, internal consistency estimates (Cronbach's alphas) ranged from acceptable to excellent. The WRS scored average on ease of comprehension and completion. Scores were spread across the 1-10 range, suggesting that the scale captured variations in views on how responsibility for meeting needs should be distributed. On select items, scores at one end of the scale were never endorsed, but these reflected expected views about specific needs (e.g., Chennai patients never endorsed patients as being substantially more responsible for housing needs than families). CONCLUSIONS: The WRS is a promising measure for use across geo-cultural contexts to inform mental health policies, and to foster dialogue and accountability among stakeholders about roles and responsibilities. It can help researchers study stakeholders' views about responsibilities, and how these shape and are shaped by sociocultural contexts and mental healthcare systems.

The management of adult psychiatric emergencies in low-income and middle-income countries: a systematic review.

The aim of this Review is to identify effective interventions and treatment guidelines to manage common types of psychiatric emergencies in non-specialist settings in low-income and middle-income countries. Mental health specialist services in low-income and middle-income countries are scarce. We did a systematic review of interventions for psychiatric emergencies and a literature search for low-income and middle-income-specific treatment guidelines for psychiatric emergencies. A dearth of high-quality guidelines and contextualised primary evidence for management of psychiatric emergencies in low-income and middle-income countries exists. Filling these gaps in present guidelines needs to be an urgent research priority in view of the adverse health and social consequences of such presentations and the present drive to scale up mental health care.

Course and outcome of schizophrenia.

This paper does not provide an exhaustive review of all outcome studies in the developing world. It raises some issues that relate to research on course and outcome such as gender differences, changes over time, untreated states, homelessness and mortality. An overview of the debate over the nature of better outcome in developing countries is also provided. Areas critical for future research have also been discussed.