District mental healthcare plans for five low- and middle-income countries: commonalities, variations and evidence gaps.

BACKGROUND: Little is known about the service and system interventions required for successful integration of mental healthcare into primary care across diverse low- and middle-income countries (LMIC). AIMS: To examine the commonalities, variations and evidence gaps in district-level mental healthcare plans (MHCPs) developed in Ethiopia, India, Nepal, Uganda and South Africa for the PRogramme for Improving Mental health carE (PRIME). METHOD: A comparative analysis of MHCP components and human resource requirements. RESULTS: A core set of MHCP goals was seen across all countries. The MHCPs components to achieve those goals varied, with most similarity in countries within the same resource bracket (low income v. middle income). Human resources for advanced psychosocial interventions were only available in the existing health service in the best-resourced PRIME country. CONCLUSIONS: Application of a standardised methodological approach to MHCP across five LMIC allowed identification of core and site-specific interventions needed for implementation.

Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: systematic review.

BACKGROUND: The involvement of mental health service users and their caregivers in health system policy and planning, service monitoring and research can contribute to mental health system strengthening, but as yet there have been very few efforts to do so in low- and middle-income countries (LMICs). METHODS: This systematic review examined the evidence and experience of service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation. Both the peer-reviewed and the grey literature were included in the review, which were identified through database searches (MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, SciELO, Google Scholar and Cochrane), as well as hand-searching of reference lists and the internet, and a snowballing process of contacting experts active in the area. This review included any kind of study design that described or evaluated service user, family or caregiver (though not community) involvement in LMICs (including service users with intellectual disabilities, dementia, or child and adolescent mental health problems) and that were relevant to mental health system strengthening across five categories. Data were extracted and summarised as a narrative review. RESULTS: Twenty papers matched the inclusion criteria. Overall, the review found that although there were examples of service user and caregiver involvement in mental health system strengthening in numerous countries, there was a lack of high-quality research and a weak evidence base for the work that was being conducted across countries. However, there was some emerging research on the development of policies and strategies, including advocacy work, and to a lesser extent the development of services, service monitoring and evaluation, with most service user involvement having taken place within advocacy and service delivery. Research was scarce within the other health system strengthening areas. CONCLUSIONS: Further research on service user and caregiver involvement in mental health system strengthening in LMICs is recommended, in particular research that includes more rigorous evaluation. A series of specific recommendations are provided based on the review.

Partnerships in a Global Mental Health Research Programme-the Example of PRIME.

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.

Success indicators for integrating mental health interventions with community-based rehabilitation projects.

Community interventions for people with physical disabilities and for people with mental illness have evolved following similar trajectories, although at different periods of time. This study develops and tests indicators for successful integration of community-based rehabilitation (CBR)-mental health and development (MHD) services. An in-depth study was conducted of two organizations in Sri Lanka and India that successfully integrated CBR and MHD services as well as two organizations in Nepal and Bangladesh, which were planning integration. Interviews and focus groups were used to gather nonconfidential information. The study suggests many benefits of integration and several indicators of readiness: willingness to work with mentally ill people, a basic understanding of the mental health concept and mental illness problems, a match of context and strategy between current CBR activities and proposed MHD activities, stability of basic resources and infrastructure in the organization. A second set of indicators determined the long-term viability of an integrated CBR-MHD approach: ability to strategize and plan a mental health programme, ability to network with stakeholders effectively, ability to make use of resources efficiently. A major finding of the study was the need for training in the practical aspects of integration of mental health interventions with CBR. Tool sets are available that can be used by donors and by local organizations for assessing needs and readiness as well as developing viable strategies for the integration of community-based mental health interventions into existing CBR work.

A Multiple Case Study of Mental Health Interventions in Middle Income Countries: Considering the Science of Delivery.

In the debate in global mental health about the most effective models for developing and scaling interventions, there have been calls for the development of a more robust literature regarding the "non-specific", science of delivery aspects of interventions that are locally, contextually, and culturally relevant. This study describes a rigorous, exploratory, qualitative examination of the key, non-specific intervention strategies of a diverse group of five internationally-recognized organizations addressing mental illness in middle income countries (MICs). A triangulated approach to inquiry was used with semi-structured interviews conducted with service recipients, service providers and leaders, and key community partners (N = 159). The interview focus was upon processes of implementation and operation. A grounded theory-informed analysis revealed cross cutting themes of: a holistic conceptualization of mental health problems, an intensive application of principles of leverage and creating the social, cultural, and policy "space" within which interventions could be applied and resourced. These findings aligned with key aspects of systems dynamic theory suggesting that it might be a helpful framework in future studies of mental health service implementation in MICs.

A rapid appraisal of access to and utilisation of psychotropic medicines in Bihar, India.

BACKGROUND: A major aspect of providing mental healthcare is access to and use of psychotropic medications. Bihar is a state in northeast India with limited mental healthcare provision; consequently access to and utilisation of psychotropic medications are likely to be limited. However, to date there has been no research assessing the situation. This study therefore aims to analyse the psychotropic medications management cycle (selection, procurement, distribution and use), and identify the barriers to access and utilisation, and their underlying causes. METHOD: A rapid appraisal method was used in which primary and secondary data sources were collected and analysed. Semi-structured interviews were conducted with twenty-two stakeholders and twenty-one service users from the government, non-governmental organisation (NGO) and private sectors. The qualitative data collected was analysed using a comparative thematic approach. The research was supported by the NGOs BasicNeeds and Nav Bharat Jagriti Kendra. RESULTS: Availability, distance and cost were the main barriers to access and utilisation. At the medical college hospital level a lack of supply appears to be due to a discrepancy between orders made by the hospital and medications supplied by the manufacturers. At the primary health centre and district hospital level the main barrier is a cycle between lack of demand for treatments for mental illness by doctors and patients. CONCLUSION: Further investigation and monitoring is necessary to ensure the availability of psychotropic medications at the medical college hospital level. In addition, implementation of the District Mental Health Programme is likely to address the access and utilisation barriers due to its potential to break the current cycle of lack of demand.

Outcomes of the mental health and development model in rural Kenya: a 2-year prospective cohort intervention study.

BACKGROUND: The aim of this study was to evaluate outcomes for participants in BasicNeeds' Mental Health and Development programme in rural Kenya. METHODS: All new entrants to the programme in the Meru South and Nyeri North districts were enrolled in the study over a 3-month period (n = 203). Assessments of mental health, functioning, economic status and quality of life were conducted at baseline and at 1-year and 2-year follow up, using a single group cohort design. RESULTS: Over the 2 years there were significant improvements in scores on the General Health Questionnaire (21.5 [95% CI: 20.2-22.8] to 6 [95% CI: 4.8-7.2] p < 0.01), Global Assessment of Functioning scale (78 [95% CI: 75.5-80.3] to 94 [95% CI: 90.7-97.3] p < 0.01), summed WHO Quality of Life-Brief scale (39.5 [95% CI: 38.6-40.4] to 57.2 [95% CI: 56.2-58.3] p < 0.01) and the proportion who were engaged in either income generation or productive work (45.3-64.0%, p < 0.01). CONCLUSIONS: The mental health and development model shows improvements in mental health, functioning, income generation and quality of life among people living with severe mental illness in rural Kenya. The findings demonstrate the feasibility and benefits of integrating mental health and poverty alleviation components in mental health care in Africa.

Knowledge and attitudes of doctors regarding the provision of mental health care in Doddaballapur Taluk, Bangalore Rural district, Karnataka.

BACKGROUND: Specialist mental health care is out of reach for most Indians. The World Health Organisation has called for the integration of mental health into primary health care as a key strategy in closing the treatment gap. However, few studies in India have examined medical practitioners' mental health-related knowledge and attitudes. This study examined these facets of service provision amongst doctors providing primary health care in a rural area of Karnataka is Southern India. METHODS: A mental health knowledge and attitudes questionnaire was self- administered by participants. The questionnaire consisted of four sections; 1) basic demographics and practice information, 2) training in mental health, 3) knowledge of mental health, and self-perceived competence in providing mental health care, and 4) attitudes towards mental health. Data was analysed quantitatively, primarily using descriptive statistics. RESULTS: This study recruited 46 participants. The majority of participants (69.6%) felt competent in providing mental health services to their patients. However, there was a substantial level of endorsement for several statements that reflected negative attitudes. Almost one third of participants (28.0%) had not received any training in providing mental health care. Whilst three-quarters of participants correctly identified depression (76.1%) and psychosis (76.1%) in a vignette, fewer were able to name three common signs and symptoms of depression (50.0%) and psychosis (28.3%). CONCLUSIONS: Integrating mental health into primary health care requires evidence-based up-skilling programs. Doctors in this study desired such training and would benefit from it, with a focus on both depth of knowledge and uncovering stigmatising attitudes towards people with mental health problems.

Sitting with others: mental health self-help groups in northern Ghana.

BACKGROUND: Over the past four decades, there has been increasing interest in Self-Help Groups, by mental health services users and caregivers, alike. Research in high-income countries suggests that participation in SHGs is associated with decreased use of inpatient facilities, improved social functioning among service users, and decreased caregiver burden. The formation of SHGs has become an important component of mental health programmes operated by non-governmental organisations (NGOs) in low-income countries. However, there has been relatively little research examining the benefits of SHGs in this context. METHODS: Qualitative research with 18 SHGs, five local non-governmental organisations, community mental health nurses, administrators in Ghana Health Services, and discussions with BasicNeeds staff. RESULTS: SHGs have the potential to serve as key components of community mental health programmes in low-resource settings. The strongest evidence concerns how SHGs provide a range of supports, e.g., social, financial, and practical, to service users and caregivers. The groups also appear to foster greater acceptance of service users by their families and by communities at large. Membership in SHGs appears to be associated with more consistent treatment and better outcomes for those who are ill. DISCUSSION: This study highlights the need for longitudinal qualitative and quantitative evaluations of the effect of SHGs on clinical, social and economic outcomes of service users and their carers. CONCLUSIONS: The organisation of SHGs appears to be associated with positive outcomes for service users and caregivers. However, there is a need to better understand how SHGs operate and the challenges they face.

A mental health training program for community health workers in India: impact on knowledge and attitudes.

BACKGROUND: Unmet needs for mental health treatment in low income countries are pervasive. If mental health is to be effectively integrated into primary health care in low income countries like India then grass-roots workers need to acquire relevant knowledge and skills to be able to recognise, refer and support people experiencing mental disorders in their own communities. This study aims to provide a mental health training intervention to community health workers in Bangalore Rural District, Karnataka, India, and to evaluate the impact of this training on mental health literacy. METHODS: A pre-test post-test study design was undertaken with assessment of mental health literacy at three time points; baseline, completion of the training, and three month follow-up. Mental health literacy was assessed using the interviewer-administered Mental Health Literacy Survey. The training intervention was a four day course based on a facilitator's manual developed specifically for community health workers in India. RESULTS: 70 community health workers from Doddaballapur, Bangalore Rural District were recuited for the study. The training course improved participants' ability to recognize a mental disorder in a vignette, and reduced participants' faith in unhelpful and potentially harmful pharmacological interventions. There was evidence of a minor reduction in stigmatizing attitudes, and it was unclear if the training resulted in a change in participants' faith in recovery following treatment. CONCLUSION: The findings from this study indicate that the training course demonstrated potential to be an effective way to improve some aspects of mental health literacy, and highlights strategies for strengthening the training course.

Partnerships for better mental health worldwide: WPA recommendations on best practices in working with service users and family carers.

WPA President M. Maj established the Task Force on Best Practice in Working with Service Users and Carers in 2008, chaired by H. Herrman. The Task Force had the remit to create recommendations for the international mental health community on how to develop successful partnership working. The work began with a review of literature on service user and carer involvement and partnership. This set out a range of considerations for good practice, including choice of appropriate terminology, clarifying the partnership process and identifying and reducing barriers to partnership working. Based on the literature review and on the shared knowledge in the Task Force, a set of ten recommendations for good practice was developed. These recommendations were the basis for a worldwide consultation of stakeholders with expertise as service users, families and carers, and the WPA Board and Council. The results showed a strong consensus across the international mental health community on the ten recommendations, with the strongest agreement coming from service users and carers. This general consensus gives a basis for Task Force plans to seek support for activities to promote shared work worldwide to identify best practice examples and create a resource to assist others to begin successful collaboration.

Mapping mental health finances in Ghana, Uganda, Sri Lanka, India and Lao PDR.

BACKGROUND: Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services. METHODS: A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions. RESULTS: National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels. CONCLUSIONS: Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.

Barriers in the mind: promoting an economic case for mental health in low- and middle-income countries.

In recent years, policy makers in high-income countries have placed an increasing emphasis on the value of maintaining good mental health, recognizing the contribution that this makes to quality of life, whilst ever more mindful of the socio-economic consequences of poor mental health. The picture in many other parts of the world is much less encouraging; policy attention and resources are still directed largely at communicable diseases. We reflect on some of the challenges faced in these countries and outline the role that economic evidence could play in strengthening the policy case for investment in mental health. Clearly this should include assessment of the economic impact of strategies implemented outside, as well as within the health sector. The ways in which mental health services are delivered is also of critical importance. Non-governmental organizations (NGOs) have long been shown to be key stakeholders in the funding, coordination and delivery of these services in high-income countries. Their role in low- and middle-income countries, where infrastructure and policy focus on mental health are more limited, can be even more vital in overcoming some of the barriers to the development of mental health policy and practice.