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Towards a more nuanced global mental health

  • Ross G. White (a1) and S. P. Sashidharan (a2)
Summary

The World Health Organization has made concerted efforts to scale up mental health services in low- and middle-income countries through the Mental Health Gap Action Programme (mhGAP) initiative. However, an overreliance on scaling up services based on those used in high-income countries may risk causing more harm than good.

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Corresponding author
Dr Ross White, Mental Health and Well-being, 1st Floor Admin Building, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK. Email: ross.white@glasgow.ac.uk
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Declaration of interest

None.

Footnotes
References
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1 World Health Organization. Mental Health Gap Action Programme (mhGAP): Scaling Up Care for Mental, Neurological, and Substance Use Disorders. WHO, 2008.
2 World Health Organization. mhGAP Intervention Guide: For Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings. WHO, 2010.
3 World Health Organization. Comprehensive Mental Health Action Plan 2013–2020. WHO, 2013.
4 Summerfield, D. How scientifically valid is the knowledge base of global mental health? BMJ 2008; 336: 992–4.
5 Patel, V, Abas, M, Broadhead, J, Todd, C, Reeler, AP. Depression in developing countries: lessons from Zimbabwe. BMJ 2001; 322: 482–4.
6 Nestler, EJ, Barrot, M, DiLeone, RJ, Eisch, AJ, Gold, SJ, Monteggia, LM. Neurobiology of depression. Neuron 2002; 34: 1325.
7 Wyatt, WJ, Midkiff, DM. Biological psychiatry: a practice in search of a science. Behav Soc Issues 2006; 15: 132–51.
8 Angermeyer, MC, Holzinger, A, Carta, MG, Schomerus, G. Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. Br J Psychiatry 2011; 199: 367–72.
9 Weinmann, S, Read, J, Aderhold, V. Influence of antipsychotics on mortality in schizophrenia: systematic review. Schizophr Res 2009; 113: 111.
10 Wunderink, L, Sytema, S, Nienhuis, FJ, Wiersma, D. Clinical recovery in first-episode psychosis. Schizophr Bull 2009; 35: 362–9.
11 Whitaker, R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Crown, 2010.
12 Timimi, S. The McDonaldization of childhood: children's mental health in neo-liberal market cultures. Transcult Psychiatry 2010; 47: 686706.
13 Watters, E. Crazy Like Us: The Globalization of the American Psyche. Simon and Schuster, 2010.
14 Saxena, S, Thornicroft, G, Knapp, M, Whiteford, H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370: 878–89.
15 Hopper, K, Harrison, G, Janka, A, Sartorius, N (eds). Recovery from Schizophrenia: An International Perspective. Oxford University Press, 2007.
16 Williams, CC. Re-reading the IPSS research record. Soc Sci Med 2003; 56: 501–15.
17 Halliburton, M. Finding a fit: psychiatric pluralism in south India and its implications for WHO studies of mental disorder. Transcult Psychiatry 2004; 41: 8098.
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Towards a more nuanced global mental health

  • Ross G. White (a1) and S. P. Sashidharan (a2)
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Towards a more nuanced Global Mental Health

Ross G. White, Senior Lecturer
26 November 2014

The authors thank Dr Ranil Abeyasinghe for the correspondence. It seems that the Wunderink et al. paper has been incorrectly referenced in the published version of the paper. The correct reference is: Wunderink, L., Nienhuis, F. J., Sytema, S., Slooff, C. J., Knegtering, R., & Wiersma, D. (2007). Guided discontinuation versus maintenance treatment inremitted first-episode psychosis: relapse rates and functional outcome. Journal of Clinical Psychiatry, 68, 654-661.

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Conflict of interest: None declared

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Re:A nuanced perspective?

Ranil Abeyasinghe, Consultant Psychiatrist
11 November 2014

I read with great interest, the article "Towards a more nuanced global mental health" by White and Sashidharan. As others have rightly pointed out the authors have used WHO publications in a selective manner when they discuss so called "better prognosis in LMIC countries". However,a much more major error in their paper has been overlooked by the reviewers. The authors quote the study by Wunderlink et al in the paper, clinical recovery in first episode psychosis published Schizophr Bull 2009, 35, 362-9. Whilte and Sashidharan quote this paper to support their conclusion: "Research indicates that reducing or discontinuing the doses of antipsychotic medication in the early stages of remission from first-episode psychosis is actually associated with superior recovery compared with maintenance treatment with antipsychotics". I read and re-read the said article by Wunderlink et al. This is the final conclusion oftheir research paper: " DUP (duration of untreated psychosis) and base level social functioning were the only factors that independently predicted recovery after 2 years of follow up. No recovery occurred in patients with DUP of 6 months or longer. DUP has been shown to predict various parameters of outcome in many other studies. Though not as strong as DUP, social role functioning before treatment is also an index of better recovery chances."

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What Liason Psychiatry can learn from mhGAP

sayed A Hussain, Consultant Psychiatrist
19 August 2014

AbstractLiaison Psychiatry occupies bridges between specialties, locations of careand workplace cultures. The RAID-model seeks comprehensive integration of psychiatry into the general hospital by exerting influence through day to day immersion in its activities rather than solely relying on formal referral to psychiatry. The original RAID team in Birmingham published results suggesting that in terms of economic savings this influence was more effective than direct contact with patients. An understanding of the boundaries that RAID-type Liaison Psychiatry has to straddle is essential its operation and evolution. As such it is required to be sensitive to theexisting culture within the general hospital which is likely to not include a willingness to embrace the mental health needs of patients who arrive in a setting which has a predominant orientation towards physical health.The journey of the RAID teams that are being established across the UK hasparallels with the mhGAP projects being set up in LAMIC countries. The MHGAP programme has been developed by the WHO with the aim of scaling up care for people with neurological and psychiatric problems in settings farremoved from access to secondary care psychiatry and where the prevailing culture may not be oriented towards an illness model of profound mental distress. We think that comparison between RAID and MHGAP provides an opportunity for mutual learning. The Integration AgendaThere is a recognition that to become sustainable the NHS must change dramatically and integration has been proposed as one means to achieve a healthcare system with a centre of gravity within the community. In this model primary care is the key driver for development and secondary care is drawn upon but does not provide the overarching paradigm for care. Unfortunately, integration has been hard to define and encompasses a rangeof related but incongruent themes: omnicompetent clinicians working acrossspecialty boundaries, joint working of medical and social care, specific care pathways that bring together a diverse group of practitioners and organisational mergers. In LAMIC, integration is not a philosophical stance of uncertain manifestations but a stark reality because the paucityof healthcare resource mandates brief non-specialist intervention with the aim of recruiting personal, family and community resources.ContextThe Liaison Team (LT) at Royal Derby Hospital (RDH) was formed in Summer 2013 from the merger and expansion of 3 pre-existing mental health services specialising in deliberate self-harm, alcohol issues and confusion respectively. Our aim was to recognise these specialist . We opened our doors to any mental health presentation that non-psychiatric staff felt they needed help with but the ambition was not to assess all patients for clinicians who want to focus on other areas of care rather toencourage a mental health orientation in the service delivered by all non-psychiatric staff within the hospital. Similarly, MHGAP recognises that mental health has to be "owned" by a wider health community in which secondary care access is extremely limited. As with RAID, formal training sessions for non-specialists , modelling car and discussions around case studies are important elements within MHGAP training. Group work for non-specialists is used within MHGAP training sessions and remains an area we have insufficiently explored within RAID-delivered training.

Specialism v GenericismRAID has been challenging for some of our most experienced specialists whose exposure to areas outside their specialism may not have been very recent. Skills in assessment have been acquired by the completion of a simple training passport and joint assessments. An intense programme of induction lectures was less effective and, as happens in MHGAP training, we should have focussed more on patient-based learning and case discussions. It is the "what to do next" following assessment, that has proved most difficult because recent knowledge of specialist systems and is vital. In this regard, joint working has proved invaluable and is likely to continue to do so because of the steady stream of complex cases requiring the collation of information from diverse sources, liaison with several agencies (Social services, police, 3rd sector). The similarities with the experience of MHGAP projects are salient- once an assessment guideline is established, case discussions and ongoing supervision of generic practitioners by clincians with specialist knowledge has been found to be the most effective means of embedding learning.Referral versus LiaisonThe volume of psychiatric problems within the general hospital means that within the current resources, a referral-reliant system would become unsustainable unless a true culture of liaison work is nurtured. The efficacy of a liaison was suggested by the association between "RAID-influence" and reduced length of stay and readmission within the original Birmingham RAID model. Again, this experience is paralleled within MHGAP,which aims to educate and empower clinicians at close proximity to the patient within the community whilst specialist supervision is very much at"arm's length".Medical v Biopsychosocial care Medical care is rightly prioritised within the general hospital but the mental welfare of patients can be relegated by the dominating medical paradigm at the expense of holistic care. What is required is more than compassion (which is difficult to operationalise in practice) but care derived from collaborative judgements involving patients , families and carers about needs, safety, choice, equity and mental capacity within a broad-based framework. An NHS Liaison Team could usefully look towards MHGAP for this framework. MHGAP is not rigid but offers a structure for assessment and care planning that allows for patient-specific and culturaladjustments - important when considering the diversity of professional (not just patient) sub-cultures prevalent within a general hospital.The diagnostic disputes surrounding dementia and delirium exemplify this tension. Delirium is a risk factor for dementia and dementia predisposes to delirium. A medical model of care leads to the assumption that deliriumis caused by acute physical illness whilst dementia is medically untreatable and therefore merits social intervention exclusively. In reality, delirium that is not resolved by medical intervention segues intodementia whilst patients with dementia are exquisitely vulnerable to delirious decompensation even in the face of seemingly minor disruption such as a change of ward. The tension between a narrative-based approach a diagnostically-led one are highlighted by the prevalence of undiagnosed dementia in vulnerable patients undergoing repeated admissions to hospital. "The elephant in the room" often turns out to be the capacity of the patient to engage with care in the community including attendance for formal memory assessment within secondary care. The need for streamlining the diagnosis of dementiais vital if the revolving door is to be halted for these patients. Liaisonconsultation can achieve opportune diagnosis but moving memory services closer towards the patient within a primary care might have bolstered carein a more timely fashion. It is concerning that a secondary care memory clinic model misses many vulnerable elderly patients. MHGAP recognises that building capacity in secondary care may be a distant pipedream and therefore endogenous solutions need to be generated using the power of well-informed non-specialist clinicians who

are in receipt of adequate supervision. In RAID, we have found that much skill in cognitive and functional assessment exists within OT services but a culture of synthesising the evidence into a diagnosis does not exist. MHGAP provides a model of empowerment of non-specialist clinicians to, at least, make an attempt at a diagnosis when the circumstances indicate the relevance of this approach.

The FutureWe have abandoned the title RAID because of its military connotations suggesting that our raison d'etre is to fight a battle against the incursion of mental health issues into the general hospital. However, theskills we are using represent "soft" rather than "hard" power. Listening, Learning, Linking, Lobbying and Landscaping the hospital into somewhere where those with mental health issues gain rather than lose ground, is what we do and it should feel more like nurturance than conflict. Such is the prevalence of mental disorder and psychosocial disturbance within the general hospital that the only way psychiatry can effect meaningful and sustainable improvement in outcomes is by systemic change, entering the DNA of the institution and recruiting all practitioners into a sharedendeavour of maintaining focus on the mental wellbeing of patients even intimes of medical crisis. The aims of MHGAP are parallel but contextually very different. The fragmented state of modern NHS psychiatric care in which numerous interfaces have to be negotiated by the patient and his/her advocates, is a gap-laden system through which patients can all too easily slip. The West must reflect on its own gaps incare, many of which have been generated by increasing specialist and silo-dictated care rather than the paucity of resource in LAMICs. At heart, both RAID and MHGAP are seeking a change of encultured attitudes to mentalhealth care and our convergence of aims stands to be a powerful mutual resource for future collaboration.Summary and recommendations, As mentioned in the article their seem to quite similarity in the nature of intervention and training needed in liason and mhgap intervention in developing countries.the techniques used for delivering mhgap can be used in liason psychiatry and the evidence based inetrvention can be applied inboth?settings.an?example is the evidence based recommendation for dementiain LMIAC countiries . similar recommendations are there for other mental and neurological conditions.it is not just the funding that is the stumbling block for service delivery and risk of falling through the net but the system and approach and the complexity of the liason between different service providers.The simpler and easier the evidence based intervention available the easier it will be to deliver it in non specialist settings of both primary care or in the liason sector of general hospital. and easier to evaluate An example is the evidence based recommendations of dementia which although recommended for mhgap in low income settings can be effectively used in primary care settings of developed countries as well in general hospital settings for assessment and early management of patients admitted as delerium with undelying dementia.

The simplicity and real-world wisdom of the MHGAP dementia guideline is a refreshing antidote to the lengthy NICE guidance that we should adhere to in England. If all care staff? at the RDH were aware of the themes in the MHGAP guideline that would be a great start. Modern NHS documents tend to over-inclusiveness rather than emphasising a few key points eg. the importance of informant history when ascertaining a dementia syndrome.The PLOS article is particularly interesting in its comments about the lack of research into how guidelines can be implemented to maximise impacton clinical performance and patient outcome. We really struggle with this one in the NHS - targets and financial incentives can be set eg. the dementia CQUIN which incentivises dementia case-finding in hospitals - butcan easily lead to gaming of the system. The dementia CQUIn rewards for the number of people screened regardless of the quality of the screen leading to high false-positive rates.The other research challenges eg. how we simplify interventions so that non-governmental agencies can implement and how can we engage communities are also very relevant to the UK. Dementia Friends uses a simple awarenessraising tool to develop dementia-awareness in lay-people in the UK. What is happening to evaluate the effectiveness of this approach? -I am not sure and I suspect evaluation may be limited. Again the parallels with MHGAP are salient.?.There is an optimism about psychiatry having ?a key role in interpreting distress and promoting the narrative dimension. Indeed, with its emphasis on viewing the patient's predicament in a socio-biographic context, psychiatry should be in a good position to provide culturally-sensitive care. Why does it so often fail? The seduction of psychiatry by Big Pharmain the 1980 and 1990 was a chastening experience and current research focussing on brain scan correlates is far removed from the care paradigm.

I think an appropriate metaphor is that MHGAP ?provides the skelton but the specific culture in which it is employed must put the flesh on thebones.

A report on mhGAP Training submitted by Royal college of psychiatry to Kashmir Government highlighted the feedback by more than 100 trainees from diverse professionals including doctors, nurses,social workers,psychologists, NGOs, teachers regarding mhGAP training in Kashmir .The feedback clearly mentioned that the trainees could effectively use itin day to day practice and no where did any one comment that it focussed just on medication which non prescribing trainees could not do which reiteriated the biopsychosocial model of mhGAP.A feedback at follow up training by Royal College of Psychiatry in Kashmir on mhGAP this month again showed that the trainees felt more comfortable in using the biopsychosocial model in their practice over the last year than just the biological model which they were used to before the mhGAP training last year.This was one of the main component of discussion of an article on mhGAP recently published in BJP which felt that mhGAP focussed on only the medical component of treatment. To combine the knowledge and skills from west with LAMIC we think "Cultural colonisation" and "slavish importation" must be avoided but we should not withhold the advances made in the West. LAMICs should be able to learn from our mistakes eg. undue faith in second generation antipsychotics and sloppy use of antidepressants. Again the parallels withLiaison in its RAID form are striking: introducing a streamlined, responsive psychiatry that seeks to divert from secondary care and empowernon-specialist care but can take more assertive action if the need arises.

A MOU which was signed between Royal College of Psychiatry and Kashmir Government might help to work together to find a balanced and practical approach to address the problem.

AUTHORS

Dr Simon Thacker Lead Consultant Psychiatrist Liaison Team Royal Derby Hospital Clinical Director Centre for Dementia Ashbourne Centre Kingsway Derby

Dr Sayed Aqeel HussainConsultant PsychiatristInstitute of Mental Health andINeuro Sciences SrinagarKashmir IndiaProject Lead for mhGAP in Indiain collaboration with Royal Collegeof Psychiatry with Support from WHOand Research Collaborater for PRIME inIndia

Conflict of Interest:None declared

Conflict of Interest:None declared
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Towards a more nuanced global mental health

Peter P hughes, Consultant Psychiatrist
11 July 2014

We read this editorial but are not sure we can identify the mhGAP that is described. Both respondents have experienced mhGAP projects throughout Africa and the Middle East. mhGAP is being used effectively in over 50 low and middle-income countries currently.

mhGAP has strengths and weaknesses but we cannot agree with the proposed weaknesses of cultural imperialism and medical model. Key to its mandate is an explicit cultural adaptation process for each place where itis implemented and an emphasis on psychosocial interventions.

There are two types of mhGAP-facilitated training. In the base training the emphasis is on case identification. The second type of training is standard training where medication is discussed as part of a broad bio psychosocial approach. Principles are emphasised of psychoeducation, problem solving, attention to well being in that session and to follow-up.

There is a suggestion that medication is used for distress and this is absolutely not in mhGAP. There is a stress module, which actively dissuades people from prescribing but to focus on psychosocial interventions.

The mhGAP focuses on the WHO essential medicine list so the issue of pharmaceutical companies is mute as they don't promote the essential medicine list. Long-term use of medication does bring up issues of EPSE, tardive dyskinesia but not generally metabolic side effects. mhGAP recommends medications that are affordable and available.

The mhGAP model is able to help deliver mental health that is culturally appropriate at a community level and thus overcomes stigma.

One of the overarching chapters in mhGAP is the section "general principles of care". This covers the principles of good, culturally sensitive, communication, assessment, treatment, mobilising local supports, attention to well-being and importantly human rights. I would suggest that attention to this core chapter of the guide would cover the concerns of the author if training is followed up by robust supervision emphasising these principles.

There is a criticism that the mhGAP mimics high-income country approaches. I would argue the opposite and in fact the high-income countries can use principles of LMIC mhGAP work in the west. We can learn much, especially of the psychosocial interventions -the importance of psychoeducation, problem solving, mobilising community supports, physical health, cultural, and spiritual understanding.

An issue that is valid is the lack of service users in development ofmhGAP.

The role of traditional healers is open in mhGAP. The mhGAP model allows intersectoral collaboration including traditional healers. They area vital part of the psychosocial milieu in LMIC.

The mhGAP is not a substitute for ways of coping or help seeking thatpeople already find beneficial. The aim of mhGAP is to give options of care that would not have been there otherwise.

In summary mhGAP IG is an imperfect document and has limitations. Theauthors have brought up some very stimulating ideas that could be incorporated into the next edition.

The Volunteering and International psychiatry Special Interest Group has occasional UK orientations that UK health professionals are welcome toattend

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Conflict of interest: Dr. Hughes has done occasional mhGAP training for WHO. Dr. Inka Weissbecker Global Mental Health and Psychosocial Advisor International Medical Corps

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A nuanced perspective?

Alex Cohen, Senior Lecturer
10 July 2014

16 June 2014

To the Editor:

In their commentary, Towards a more nuanced global mental health,(1) White and Sashidharan point to the putatively good outcomes in schizophrenia in low- and middle-income countries (LMIC), "where populations may not have access to medication-based treatments." This evidence is offered as a caution against scaling up biomedical interventions in LMIC. White and Sashidaran then go on to make a plea for, "a more balanced exchange of knowledge...between high-income countries and LMIC." However, in only citing evidence from the WHO studiesof schizophrenia, while neglecting a wealth of evidence from studies in LMIC, they do not heed their own advice for a greater exchange of knowledge. In fact, research conducted by investigators in India, Ethiopia, and China suggests that the provision of biomedical treatment does, in fact, improve outcomes in persons with schizophrenia.(2) Furthermore, by only citing the WHO studies - while ignoring all the evidence from LMIC - White and Sashidharan do not, despite the title of their commentary, offer a nuanced perspective on this question. When considering the evidence from the long-term research on schizophrenia outcomes in LMIC, there is no doubt that the picture is one of heterogeneity and complexity.(2) Thus, by only citing the WHO studies, White and Sashidaran fail to acknowledge the work of a large number of psychiatric researchers from LMIC.

It is difficult, if not impossible, to defend the statement, "better outcomes for complex mental health difficulties...may be a consequence of the multiplicity of treatment/healing options available in LMIC compared with high-income countries." First, I would hazard to guess that there areas many, if not more, options for treatment/healing in London, New York, Paris, and Sydney than there are in New Delhi, Beijing, Lagos, and Rio de Janeiro. For example, in much of Indonesia the options for care are so limited or non-existent that families often resort to pasung, the practiceof chaining, shackling, or confining psychotic individuals, in an attempt to protect those individuals from harming themselves or others.(3) Second, having a multiplicity of options does not necessarily result in better outcomes. It can also lead to a continuous sampling of ineffective cures offered by charlatans.

I do not mean these comments to be taken as a tacit endorsement of the indiscriminate use of psychotropic medication. Antidepressants and antipsychotics are less effective than desired and both are associated with troubling side-effects. Rather, these comments are offered in the hope that White and Sashidaran, as well as others, will be prompted to provide a truly nuanced perspective on what is needed to improve the livesof individuals who experience severe mental illness, wherever they reside.

Alex Cohen, PhDSenior LecturerLondon School of Hygiene & Tropical Medicine

References

1. White RG, Sashidharan SP. Towards a more nuanced global mental health. Br J Psychiatry. 2014; 204(6): 415-7.2. Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008;34(2): 229-44.3. Puteh I, Marthoenis M, Minas H. Aceh Free Pasung: Releasing the mentally ill from physical restraint. Int J Ment Health Syst. 2011; 5(1): 10.

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