Rethinking mental health services

The World Health Organization (WHO) acknowledges mental health as an important component of total health. Yet, currently there is a major treatment gap for people with mental, neurological and substance-use disorders (MNS), especially in low- and middle-income countries (LMICs), due to lack of mental health professionals and widespread stigma surrounding these issues. As the populations of

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LMICs transition epidemiologically and demographically, the burden of MNS (including major depression, anxiety, substance-use disorders, and Alzheimer's disease) makes up an increasing proportion of global disability-adjusted life years (DALYs). It is estimated that the burden of MNS accounts for 14% of global DALYs, and is likely to further increase due to predicted conflict and violence, the reduced burden of communicable diseases, and the aging of the global population.

Evidence supports the potential to use non-specialist health workers (NSHWs) and other professionals with health roles (OPHRs), such as doctors, nurses, social workers, and teachers without specialized training in MNS disorders, to close the mental health gap through integrated primary and community health care interventions. In order to harness the potential capacity of NSHWs and OPHRs, significant research is needed to understand which aspects of treatment interventions these cadres can effectively handle while ensuring proper case management, and to understand how they can best work hand in hand with initiatives aimed at strengthening primary health care overall without siloing MNS.

In a recent Cochrane Review available through the PHC Evidence portal, van Ginneken et al reviewed 38 studies of non-specialist health

workers and teachers delivering MNS interventions in LMICs to begin to address these research gaps. Most of the studies in this review showed some potential for NSHWs/OPHRs to expand detection, treatment and rehabilitation of mental illnesses, and many studies found that NSHW/OPHR-led interventions had some positive impact on patient outcomes. In particular, the review concludes that the use of NSHWs may increase the number of adults who recover from depression and anxiety, reduce symptoms of perinatal depression, reduce symptoms of adults with PTSD, improve symptoms of dementia patients and improve the mental well-being of carers of people with dementia, and decrease the amount of alcohol consumed by people with alcohol-use disorders. These findings illustrate significant pieces of the PHCPI framework that are key to population health management and effective service coverage of NCDs and mental health, and could potentially impact how we think about the primary health system workforce. They are also critical to the people-centered care model of treating a patient as a whole person with multiple needs, emphasized by the WHO Global Strategy on People-centered and Integrated Health Services.

Scale-up of mental health services in LMICs will require significant policy attention and resource infusion, which must be based on evidence from high-quality studies with rigorous design. This issue is gaining attention within the global development agenda, and the WHO and World Bank held an event in April 2016 to advocate for immediate investments in mental health, and emphasize the substantial expected health, social, and economic returns on investment. It is estimated that a global investment of US$147 billion to scale up treatment coverage of depression and anxiety will result in 43 million healthy life-years added, which is valued at $310 billion. In addition, scale-up of effective mental health services could result in economic productivity gains valued at nearly $400 billion.

We need more and better information about how to structure and implement effective interventions in a context-sensitive way. However, the Cochrane Review found that the quality of available studies was too low to draw firm conclusions about which NSHW-led interventions are most effective, and the lack of comparable studies, especially cost-analysis studies, is holding back potential progress in organization and management of mental health services. Despite the lack of firm conclusions, the van Ginneken review is helpful in specifying directions and methodologies for the further research needed, including: defining and quantifying potential benefits of task-shifting; assessing any potential adverse effects of NSHW/OPHR-led interventions; cost-effectiveness and sustainability assessments; and more clearly articulating and defining the appropriate roles and responsibilities of different cadres of NSHWs and OPHRs in order to facilitate cross-study comparison and better understand variations in intervention effects.

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Resources

van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, Chandrashekar S, Patel V. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD009149. DOI: 10.1002/14651858.CD009149.pub2.

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Hannah Ratcliffe is a Research Analyst at Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T. H Chan School of Public Health.

Elisabeth Tadiri is a Primary Health Care Intern at Ariadne Labs, , a joint center between Brigham and Women’s Hospital and the Harvard T. H Chan School of Public Health.