The WHO Mental Health Gap Action Programme for mental, neurological, and substance use conditions: the new and updated guideline recommendations.

The WHO Mental Health Gap Action Programme (mhGAP) guideline update reflects 15 years of investment in reducing the treatment gap and scaling up care for people with mental, neurological, and substance use (MNS) conditions. It was produced by a guideline development group and steering group, with support from topic experts, using quantitative and qualitative evidence and a systematic review of use of mhGAP. 90 recommendations from the 2015 guideline update were validated and endorsed for use in their current format. These are joined by 30 revised recommendations and 18 new recommendations, including a new module on anxiety. Psychological interventions are emphasised as treatments and digitally delivered interventions feature across many modules, as well as updated recommendations for psychotropic medicines. Research gaps identified include the need for evidence from low-resource settings and on the views of people with lived experience of MNS conditions. The revised recommendations ensure that mhGAP continues to offer high-quality, timely, transparent, and evidence-based guidance to support non-specialist health workers in low-income and middle-income countries in providing care to individuals with MNS conditions.

Baseline situational analysis in Bangladesh, Jordan, Paraguay, the Philippines, Ukraine, and Zimbabwe for the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health.

INTRODUCTION: Mental, neurological and substance use conditions lead to tremendous suffering, yet globally access to effective care is limited. In line with the 13th General Programme of Work (GPW 13), in 2019 the World Health Organization (WHO) launched the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health to advance mental health policies, advocacy, and human rights and to scale up access to quality and affordable care for people living with mental health conditions. Six countries were selected as 'early-adopter' countries for the WHO Special Initiative for Mental Health in the initial phase. Our objective was to rapidly and comprehensively assess the strength of mental health systems in each country with the goal of informing national priority-setting at the outset of the Initiative. METHODS: We used a modified version of the Program for Improving Mental Health Care (PRIME) situational analysis tool. We used a participatory process to document national demographic and population health characteristics; environmental, sociopolitical, and health-related threats; the status of mental health policies and plans; the prevalence of mental disorders and treatment coverage; and the availability of resources for mental health. RESULTS: Each country had distinct needs, though several common themes emerged. Most were dealing with crises with serious implications for population mental health. None had sufficient mental health services to meet their needs. All aimed to decentralize and deinstitutionalize mental health services, to integrate mental health care into primary health care, and to devote more financial and human resources to mental health systems. All cited insufficient and inequitably distributed specialist human resources for mental health as a major impediment. CONCLUSIONS: This rapid assessment facilitated priority-setting for mental health system strengthening by national stakeholders. Next steps include convening design workshops in each country and initiating monitoring and evaluation procedures.

Disease burden and government spending on mental, neurological, and substance use disorders, and self-harm: cross-sectional, ecological study of health system response in the Americas.

BACKGROUND: Disorders affecting mental health are highly prevalent, can be disabling, and are associated with substantial premature mortality. Yet national health system responses are frequently under-resourced, inefficient, and ineffective, leading to an imbalance between disease burden and health expenditures. We estimated the disease burden in the Americas caused by disorders affecting mental health. This measure was adjusted to include mental, neurological, and behavioural disorders that are frequently not included in estimates of mental health burden. We propose a framework for assessing the imbalance between disease burden and health expenditures. METHODS: In this cross-sectional, ecological study, we extracted disaggregated disease burden data from the Global Health Data Exchange to produce country-level estimates for the proportion of total disease burden attributable to mental disorders, neurological disorders, substance use disorders, and self-harm (MNSS) in the Americas. We collated data from the WHO Assessment Instrument for Mental Health Systems and the WHO Mental Health Atlas on country-level mental health spending as a proportion of total government health expenditures, and of psychiatric hospital spending as a proportion of mental health expenditures. We used a metric capturing the imbalance between disease burden and mental health expenditures, and modelled the association between this imbalance and real (ie, adjusted for purchasing power parity) gross domestic product (GDP). FINDINGS: Data were collected from July 1, 2016, to March 1, 2017. MNSS comprised 19% of total disability-adjusted life-years in the Americas in 2015. Median spending on mental health was 2·4% (IQR 1·3-4·1) of government health spending, and median allocation to psychiatric hospitals was 80% (52-92). This spending represented an imbalance in the ratio between disease burden and efficiently allocated spending, ranging from 3:1 in Canada and the USA to 435:1 in Haiti, with a median of 32:1 (12-170). Mental health expenditure as a proportion of government health spending was positively associated with real GDP (ß=0·68 [95% CI 0·24-1·13], p=0·0036), while the proportion allocated to psychiatric hospitals (ß=-0·5 [-0·79 to -0·22], p=0·0012) and the imbalance in efficiently allocated spending (ß=-1·38 [-1·97 to -0·78], p=0·0001) were both inversely associated with real GDP. All estimated coefficients were significantly different from zero at the 0·005 level. INTERPRETATION: A striking imbalance exists between government spending on mental health and the related disease burden in the Americas, which disproportionately affects low-income countries and is likely to result in undertreatment, increased avoidable disability and mortality, decreased national economic output, and increased household-level health spending. FUNDING: Weatherhead Center for International Affairs, Harvard University.

WHO Mental Health Gap Action Programme implementation in the Small Island Development States: experience from the Pacific and English-speaking Caribbean countries.

Owing to the relatively small population sizes and remoteness of the Small Island Development States (SIDS), their mental health systems face many common difficulties. These include having few mental health specialists per country, limited access to mental health services and low awareness. To overcome these limitations, the World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP), which aims to decrease the treatment gap by training non-specialists, was implemented in more than 20 Pacific and English-speaking Caribbean countries. Many lessons were learnt from the experience. Mental health specialist support is crucial, and online training and supervision could be a solution. mhGAP training proved to be effective to improve knowledge and attitude, but close monitoring and supervision are needed to change clinical practice. Awareness raising and mental health service capacity building need to occur simultaneously. To realise sustainable development goals, countries need to invest more in mental health, especially in human resources; mhGAP will be one effective solution.

[Epidemiology of suicide among adolescents and young adults in EcuadorEpidemiologia do suicídio em adolescentes e jovens no Equador]. / Epidemiología del suicidio en adolescentes y jóvenes en Ecuador.

OBJECTIVE: To collect information - and provide it to decision-makers in health programs in general and mental health programs in particular - on epidemiological patterns in suicide deaths among young adults and adolescents in Ecuador. METHODS: A cross-sectional ecological study was conducted using data obtained from records of deaths by suicide among young adults and adolescents in Ecuador from 2001 to 2014. For analysis, results were disaggregated by geographic region, sex, age, ethnic group and suicide method. Rates of death by suicide (per 100,000 population) and relative risks (RR) for suicide were estimated by sex and region. RESULTS: Between 2001 and 2014, 4,855 suicides were recorded among adolescents and young adults. The highest estimated risk was found among males aged 15 to 24 years and adolescents living in the Amazon region, followed by those living in the Andean region. Mestizos were the ethnic group with the greatest number of suicides, although 40% of young people who commit suicide in the Amazon region are indigenous. The most frequent method was by hanging, followed by pesticide poisoning. CONCLUSIONS: Suicide among adolescents and young adults is an important public health problem in Ecuador. Since various psychological, social, and cultural influences come into play, there is wide variation among regions, age groups, and ethnic groups. Restricting access to pesticides and other chemical products, implementing universal prevention programs and programs in education centers in the areas with the highest rates, and targeting vulnerable populations for specific interventions could help reduce the suicide rate among young people in Ecuador.

OBJETIVO: Coletar e prover informação aos responsáveis pela tomada de decisão nos programas de saúde, em geral, e de saúde mental, em particular, quanto às características epidemiológicas do suicídio em jovens e adolescentes equatorianos. MÉTODOS: Um estudo ecológico transversal foi realizado com dados dos registros de mortalidade por suicídio em adolescentes e jovens do Equador entre 2001 e 2014. A análise foi desagregada por região de origem, sexo, idade, grupo étnico e método usado para o suicídio. Foram estimados os índices de mortalidade por suicídio (por 100.000 habitantes) e o risco relativo (RR) de suicídio por sexo e região. RESULTADOS: No período entre 2001 e 2014, foram registrados 4.855 suicídios em adolescentes e jovens. Maior risco de suicídio foi estimado em indivíduos do sexo masculino com idade de 15 a 24 anos e adolescentes residentes na Amazônia e região de La Sierra. O grupo étnico com maior número de casos de suicídio foi o dos mestiços, embora 40% dos casos de suicídio em jovens na Amazônia ocorreram em indígenas. Os métodos mais usados foram enforcamento e, em segundo lugar, envenenamento por pesticidas. CONCLUSÕES: O suicídio de adolescentes e jovens é um importante problema de saúde pública no Equador. Como se trata de um fenômeno determinado por uma conjunção de fatores psicológicos, sociais e culturais, observa-se uma grande variação segundo região, faixa etária e grupo étnico. Restrição ao acesso a pesticidas e a outros produtos químicos, programas de prevenção universais e em centros educacionais em áreas com as taxas mais elevadas e intervenções específicas voltadas aos grupos vulneráveis podem contribuir para reduzir os casos de suicídio entre jovens no Equador.

[The burden of mental disorders, neurological, substance use and suicide: Report on mental health priorities in Argentina]. / Carga de los trastornos mentales, neurológicos, por consumo de sustancias y suicidio y prioridades de salud mental en Argentina.

The objective of this study is to provide an estimate of the burden of disease related to mental health in Argentina, in order to provide elements for the rational prioritization of resource allocation and the development of services. Based on the estimations made by the Study of the Global Burden of Disease (1) we add an analysis of the load product of: a) self-injuries and suicide; b) common neurological disorders with severe psychological and behavioral manifestations; c) somatic consequences of alcohol use disorder; and iv) an estimate of the disorder by somatic symptoms with prominent pain. The burden of disease caused by mental, neurological, substance use and suicide disorders (MNSS) is approximately one fifth of the years of life adjusted for disability (DALYs) and more than a third of the years lived with disability (ADLs) total, resulting in the most disabling subgroup of all non-communicable diseases (NCDs), and far exceeding the combined group of infectious and maternal-child diseases, and the group of non-self-inflicted accidents and injuries. The analysis of DALYs by age and sex allows a hierarchy of the disorders that should guide the development of services for MNSS disorders, their integration in primary care, and the allocation of resources. The first level of care is the only one with a relatively homogeneous presence throughout the country, being the only one capable of effectively increasing coverage and reducing inequality. The strengthening of the first level of care can be achieved through training in mental health of non-specialized personnel and the use of computer and communication technology resources to counteract regional inequities in coverage. Such strategic vision will allow to diminish: the excessive expenses in specialized resources, which by definition are more expensive and intervene only when the pathology exceeded a certain threshold; and the indirect costs caused by the loss of labor productivity. Fundamentally, it will allow increasing coverage and reversing regional and socioeconomic inequality in the quality of mental health care in a country rich in professional resources.

Epidemiología del suicidio en adolescentes y jóvenes en Ecuador / Epidemiology of suicide among adolescents and young adults in Ecuador / Epidemiologia do suicídio em adolescentes e jovens no Equador

RESUMEN Objetivo Recabar y ofrecer información a quienes toman decisiones en los programas de salud en general, y de salud mental en particular, sobre las características epidemiológicas del suicidio de jóvenes y adolescentes ecuatorianos. Método Se realizó un estudio ecológico transversal con datos de los registros de mortalidad por suicidio de los jóvenes y adolescentes de Ecuador de 2001 a 2014. El análisis se desagregó por región natural, sexo, edad, grupo étnico y por el método usado para cometer el suicidio. Se estimaron tasas de mortalidad por suicidio (por 100 000 habitantes) y los riesgos relativos (RR) de suicidio por sexo y regiones. Resultados Entre 2001 y 2014 se registraron 4 855 suicidios en adolescentes y jóvenes. El riesgo más alto se estimó en los varones de 15 a 24 años y en los adolescentes residentes en la Amazonía, seguidos por los de la Sierra. La etnia con más casos de suicidio fueron los mestizos, aunque 40% de los jóvenes que se suicidan en la Amazonía son indígenas. El método más frecuente fue el ahorcamiento seguido por el envenenamiento con pesticidas. Conclusiones El suicidio de adolescentes y jóvenes es un problema de salud pública importante en Ecuador. Como en él influyen diversos factores psicológicos, sociales y culturales, se observan grandes variaciones según la región, los grupos de edad y las etnias. La restricción del acceso a pesticidas y a otros productos químicos, los programas de prevención universales y en centros educativos en las áreas con las tasas más altas, y las intervenciones específicas dirigidas a grupos vulnerables podrían ayudar a reducir los suicidios de jóvenes en Ecuador.

ABSTRACT Objective To collect information - and provide it to decision-makers in health programs in general and mental health programs in particular - on epidemiological patterns in suicide deaths among young adults and adolescents in Ecuador. Methods A cross-sectional ecological study was conducted using data obtained from records of deaths by suicide among young adults and adolescents in Ecuador from 2001 to 2014. For analysis, results were disaggregated by geographic region, sex, age, ethnic group and suicide method. Rates of death by suicide (per 100,000 population) and relative risks (RR) for suicide were estimated by sex and region. Results Between 2001 and 2014, 4,855 suicides were recorded among adolescents and young adults. The highest estimated risk was found among males aged 15 to 24 years and adolescents living in the Amazon region, followed by those living in the Andean region. Mestizos were the ethnic group with the greatest number of suicides, although 40% of young people who commit suicide in the Amazon region are indigenous. The most frequent method was by hanging, followed by pesticide poisoning. Conclusions Suicide among adolescents and young adults is an important public health problem in Ecuador. Since various psychological, social, and cultural influences come into play, there is wide variation among regions, age groups, and ethnic groups. Restricting access to pesticides and other chemical products, implementing universal prevention programs and programs in education centers in the areas with the highest rates, and targeting vulnerable populations for specific interventions could help reduce the suicide rate among young people in Ecuador.

RESUMO Objetivo Coletar e prover informação aos responsáveis pela tomada de decisão nos programas de saúde, em geral, e de saúde mental, em particular, quanto às características epidemiológicas do suicídio em jovens e adolescentes equatorianos. Métodos Um estudo ecológico transversal foi realizado com dados dos registros de mortalidade por suicídio em adolescentes e jovens do Equador entre 2001 e 2014. A análise foi desagregada por região de origem, sexo, idade, grupo étnico e método usado para o suicídio. Foram estimados os índices de mortalidade por suicídio (por 100.000 habitantes) e o risco relativo (RR) de suicídio por sexo e região. Resultados No período entre 2001 e 2014, foram registrados 4.855 suicídios em adolescentes e jovens. Maior risco de suicídio foi estimado em indivíduos do sexo masculino com idade de 15 a 24 anos e adolescentes residentes na Amazônia e região de La Sierra. O grupo étnico com maior número de casos de suicídio foi o dos mestiços, embora 40% dos casos de suicídio em jovens na Amazônia ocorreram em indígenas. Os métodos mais usados foram enforcamento e, em segundo lugar, envenenamento por pesticidas. Conclusões O suicídio de adolescentes e jovens é um importante problema de saúde pública no Equador. Como se trata de um fenômeno determinado por uma conjunção de fatores psicológicos, sociais e culturais, observa-se uma grande variação segundo região, faixa etária e grupo étnico. Restrição ao acesso a pesticidas e a outros produtos químicos, programas de prevenção universais e em centros educacionais em áreas com as taxas mais elevadas e intervenções específicas voltadas aos grupos vulneráveis podem contribuir para reduzir os casos de suicídio entre jovens no Equador.