Elsevier

The Lancet

Volume 370, Issue 9594, 6–12 October 2007, Pages 1241-1252
The Lancet

Series
Scale up services for mental disorders: a call for action

https://doi.org/10.1016/S0140-6736(07)61242-2Get rights and content

Summary

We call for the global health community, governments, donors, multilateral agencies, and other mental health stakeholders, such as professional bodies and consumer groups, to scale up the coverage of services for mental disorders in all countries, but especially in low-income and middle-income countries. We argue that a basic, evidence-based package of services for core mental disorders should be scaled up, and that protection of the human rights of people with mental disorders and their families should be strengthened. Three questions are critical to the scaling-up process. What resources are needed? How can progress towards these goals be monitored? What should be the priorities for mental health research? To address these questions, we first estimated that the amount needed to provide services on the necessary scale would be US$2 per person per year in low-income countries and $3–4 in lower middle-income countries, which is modest compared with the requirements for scaling-up of services for other major contributors to the global burden of disease. Second, we identified a series of core and secondary indicators to track the progress that countries make toward achievement of mental health goals; many of these indicators are already routinely monitored in many countries. Third, we did a priority-setting exercise to identify gaps in the evidence base in global mental health for four categories of mental disorders. We show that funding should be given to research that develops and assesses interventions that can be delivered by people who are not mental health professionals, and that assesses how health systems can scale up such interventions across all routine-care settings. We discuss strategies to overcome the five main barriers to scaling-up of services for mental disorders; one major strategy will be sustained advocacy by diverse stakeholders, especially to target multilateral agencies, donors, and governments. This Series has provided the evidence for advocacy. Now we need political will and solidarity, above all from the global health community, to translate this evidence into action. The time to act is now.

Introduction

We believe that scaling-up of services for people with mental disorders is the most important priority for global mental health. Every year up to 30% of the population worldwide has some form of mental disorder, and at least two-thirds of those people receive no treatment, even in countries with the most resources.1 In the USA, for example, 31% of people are affected by mental disorder every year, but 67% of them are not treated.2 In Europe, mental disorder affects 27% of people every year, 74% of whom receive no treatment.3 The proportions of people with mental disorder who are treated in low-income and middle-income countries are even lower than in the USA and UK; for example, a global survey reported that only 11·1% of severe cases of mental disorder in China had received any treatment in the previous 12 months. This survey also reported that, in low-income and middle-income countries, only a minority of treated people (as low as 10·4% in Nigeria) received adequate treatment.4 Therefore, we argue that the overall volume of services provided to treat people with mental disorders needs to be substantially increased in every country—but especially so in low-income and middle-income countries—so that the available care is proportionate to the magnitude of need.1 We refer to this process as scaling-up. We call on governments, multilateral agencies, and donors (most of whom frequently ignore mental health), public-health organisations, mental health professionals, and consumer groups that represent mental health stakeholders to act now to make this happen.

This Lancet Series on Global Mental Health has presented evidence that mental health is an essential and inseparable component of health. The burden of mental disorders goes well beyond their effect on mental health. Mental disorders are risk factors for, or consequences of, many other health problems; they contribute to mortality (most notably through suicide); and they directly affect progress toward achievement of many of the Millennium Development Goals (MDGs).5, 6 Mental disorders in all world regions are associated with poverty, marginalisation, and social disadvantage. Despite the body of evidence that attests to the importance of mental disorders, health systems around the world face enormous challenges in delivery of mental health care and protection of the human rights of people with severe disorders. Such challenges include scarce financial and human resources, iniquitous distributions (between and within countries), and inefficient allocation.7 The neglect of mental health cannot be accounted for by scarcity of evidence for effective interventions for mental disorders. Indeed, evidence from low-income and middle-income countries is now good, especially for pharmacological and psychological interventions for depressive and anxiety disorders, and for schizophrenia.8 Furthermore, these interventions have been shown to be affordable in low-income and middle-income countries,9 and are just as cost effective as, for example, antiretroviral treatment for HIV/AIDS.8 Although mental health services have been scaled up to country or regional level in a few places, attainment of core mental health indicators varies widely between and within countries, and most countries have no mechanisms to monitor progress.10 Mental health system reform faces barriers in low-income and middle-income countries, but we have discussed possible solutions, such as collaboration between advocates for people with mental disorders, and strengthening of their advocacy with consistent and consensual calls for action.11

Many possible avenues for action have been identified: for example, the World Health Report in 2001 outlined ten specific strategies for reform.12 Our call for action has been guided by these strategies, by the evidence presented in this Series, and by discussions initiated by the Lancet Global Mental Health Group at a meeting in London (September 1–2, 2006). We were committed to ensuring that the call should be specific and practicable. Although we acknowledge that strengthening of general health services (eg, interventions which improve perinatal care) would help prevent and reduce suffering associated with mental disorder, we have reached the conclusion that action to scale up services for people who already suffer from mental disorders is most urgently needed. This scaling-up should consist of a basic, evidence-based package of services for core mental disorders. Three questions are critical to the implementation of our call for action. What resources are needed for the scaling-up process? How can progress towards these goals be monitored? What should be the priorities for mental health research? We address these questions and discuss strategies for achieving the goal to scale up services.

Section snippets

What resources are needed?

The coverage of evidence-based services for people with mental illnesses is extremely low in most low-income and middle-income countries.1, 4 We calculated the resource needs and costs associated with the scaling-up of a core package of mental health interventions in low-income and middle-income countries; the methods and data sources for this costing exercise are reported elsewhere.13 We aimed to allow comparisons between countries and between estimates for scaling up mental health services

What indicators should be used to monitor progress?

Following the dictum that what cannot be measured is difficult to improve, reliable and valid indicators need to be used to monitor progress on mental health. The Health Care Quality Indicators Project of the Organisation for Economic and Community Development (OECD) has proposed three criteria with which to judge health-related indicators: importance for health, scientific soundness, and availability of data.21 Some countries now routinely use such indicators for specific conditions, typically

What are the priorities for mental health research?

Research has a critical role to play in response to the public-health challenge of mental disorders. The development of evidence-based health policies and practice in low-income and middle-income countries, and the maturation of clinical medicine and public health, are stunted by the fact that only 10% of the world's medical research addresses the health needs of the 90% of the global population who live in low-income and middle-income countries.34, 35, 36 The adverse effect of this gap is

Call for action

The coverage of services for people with mental disorders in most low-income and middle-income countries is grossly deficient.1, 4, 7, 10 Most attempts to enhance coverage have been inadequately planned and resourced. Many training, pilot, and demonstration programmes have been conducted in small geographic areas, but generally without any plans for sustainability or scaling-up. As a group of concerned scientists, public-health professionals, and mental health advocates, we call for action to

Conclusion

We intend that this Series should provide ammunition for advocacy by stakeholders in global mental health. They must press for the reforms that are urgently needed if people with mental disorders in low-income and middle-income countries are to receive the basic care that is effective, affordable and, above all, morally justified. We know how mental disorders affect the development potential of individuals and communities; we have identified simple and effective treatments for mental disorders;

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