Challenge: while mental health is a cross-cutting issue, standalone programs are common

Large bodies of evidence support the bidirectional negative relationships between mental health problems and physical health issues including infectious diseases, sexual and reproductive health (inclusive of perinatal health), nutrition, non-communicable diseases and early childhood development, as well as education, violence and poverty (Doherty and Gaughran, Reference Doherty and Gaughran2014). Poor mental health has been linked to worse physical health outcomes both directly and indirectly by means of reduced uptake of prevention and treatment services (WHO, 2009; Doherty et al., Reference Doherty, Kelly, McDonald, O’Dywer, Keane and Cooney2013; Doherty and Gaughran, Reference Doherty and Gaughran2014; Belkin et al., Reference Belkin, Wissow, Lund, Aber, Bhutta, Black, Kieling, McGregor, Rahman, Servili, Walker and Yoshikawa2017; Remien et al., Reference Remien, Stirratt, Nguyen, Robbins, Pala and Mellins2019; Collins et al., Reference Collins, Velloza, Concepcion, Oseso, Chwastiak, Kemp, Simoni and Wagenaar2021; Sparling et al., Reference Sparling, Cheng, Deeney, Santoso, Pfeiffer, Emerson, Amadi, Mitu, Corvalan, Verdeli, Araya and Kadiyala2021; Ronaldson et al., Reference Ronaldson, Santana, Carlisle, Atmore, Chilman, Heslin, Markham, Dregan, Das-Munshi, Lampejo, Hotopf and Bakolis2024; Sisodia et al., Reference Sisodia, Hammond, Leonardi-Bee, Hanlon and Asher2025). People living with mental health conditions die on average 15 years earlier than the general population (Chan et al., Reference Chan, Correll, Wong, Chu, Fung, Wong, Lei and Chang2023), and yet MHPSS programs are often separate from physical health programs if they exist at all. Separation increases cost and reduces access, which is further exacerbated by the stigma surrounding mental health care. Standalone programs – programs that are operated independently of existing health and social systems –are less likely to be sustained or scaled up than those integrated into existing health and social systems. Meanwhile, programs addressing physical health, education and social problems, are less likely to achieve their objectives without addressing the contributing mental health issues.

Recommendation: support integration into physical health and other programs

Integrating MHPSS into physical health and other service programs can greatly improve uptake of mental health services through easing access and ensuring privacy. Integration is cost-effective and promotes MHPSS sustainability as part of existing services (Cubillos et al., Reference Cubillos, Bartels, Torrey, Naslund, Uribe-Restrepo, Gaviola, Diaz, John, Williams, Cepeda, Gomez-Restrepo and Marsch2021). There is strong evidence that addressing mental health issues as part of these programs contributes to achieving their program goals, including programs for Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) and Communicable and Non-communicable Diseases (NCDs) (Kaaya et al., Reference Kaaya, Eustache, Lapidos-Salaiz, Musisi, Psaros and Wissow2013; Kulisewa et al., Reference Kulisewa, Stockton, Hosseinipour, Gaynes, Mphonda, Udedi and Pence2019; Musayon-Oblitas et al., Reference Musayon-Oblitas, Carcamo and Gimbel2019; Stein et al., Reference Stein, Benjet, Gureje, Lund, Scott, Poznyak and van Ommeren2019; Tachibana et al., Reference Tachibana, Koizumi, Akanuma, Tarui, Ishii, Hoshina, Suzuki, Asano, Sekino and Ito2019; Tol et al., Reference Tol, Greene, Lasater, Le Roch, Bizouerne, Purgato, Tomlinson and Barbui2020; Safren et al., Reference Safren, O’Cleirigh, Andersen, Magidson, Lee, Bainter, Musinguzi, Simoni, Kagee and Joska2021). For example, integrating mental health care into tuberculosis care improves both mental health outcomes and tuberculosis treatment adherence (Sweetland et al., Reference Sweetland, Galea, Shin, Driver, Dlodlo, Karpati and Wainberg2019). Such integration should also support individuals with severe mental illnesses such as bipolar disorder or schizophrenia, who are at heightened risk of neglect, abuse or exclusion from essential services, particularly when mental health services are siloed from broader physical and social services systems. Integration with social services simultaneously addresses social factors and mental health, enhancing the impact of both, for example, early childhood development and violence (Kohrt et al., Reference Kohrt, Griffith and Patel2018; McGorry et al., Reference McGorry, Mei, Chanen, Hodges, Alvarez-Jimenez and Killackey2022). Poverty alleviation from cash transfer also is enhanced by addressing depression, grief, anxiety, etc. (given the bi-directional causal relationship between poverty and mental health), otherwise running the risk of worsening inequity by leaving behind those with these issues (Ridley et al., Reference Ridley, Rao, Schilbach and Patel2020). The impact of cognitive behavioral therapy – a common treatment for depression – can be enhanced by economic support among poorer populations (Blattman et al. Reference Blattman, Jamison and Sheridan2017). While the recommendation to integrate mental health with physical health and social services is not new, particularly in humanitarian settings (IASC, 2007), it needs to be implemented more systematically in practice. We advocate for such a comprehensive approach in settings facing longstanding emergencies as well as developmental contexts.

Integrating mental and physical health care should be done through a collaborative care model which helps identify physical conditions with psychological or behavioral symptoms and vice versa, reducing the risk of diagnostic overshadowing (Firth et al., Reference Firth, Siddiqi, Koyanagi, Siskind, Rosenbaum, Galletly, Allan, Caneo, Carney, Carvalho, Chatterton, Correll, Curtis, Gaughran, Heald, Hoare, Jackson, Kisely, Lovell, Maj, McGorry, Mihalopoulos, Myles, O’Donoghue, Pillinger, Sarris, Schuch, Shiers, Smith, Solmi, Suetani, Taylor, Teasdale, Thornicroft, Torous, Usherwood, Vancampfort, Veronese, Ward, Yung, Killackey and Stubbs2019; Ee et al., Reference Ee, Lake, Firth, Hargraves, de Manincor, Meade, Marx and Sarris2020). Integration means a comprehensive care system of inter-connected and complementary interventions to address the full spectrum of need, encompassing both psychosocial support and mental health treatment. The former includes prevention efforts such as changes to the environment to reduce stress (by engaging employers,Footnote ³ social services, local governments and private groups), as well as integrating mental health education and stress management as part of adult education and school curricula. The latter – treatments for mental health conditions – includes community-based care linked to consultation and referral to professional mental health providers and temporary hospitalization where necessary. Addressing mental health problems through integration at the primary care level decreases need for referral to expensive and often inaccessible professional mental health services including psychiatric hospitals. Principles derived from implementation science can guide enhanced integration. For example, in Nepal, Rimal et al. (Reference Rimal, Choudhury, Agrawal, Basnet, Bohara, Citrin, Dhungana, Gauchan, Gupta, Gupta, Halliday, Kadayat, Mahar, Maru, Nguyen, Poudel, Raut, Rawal, Sapkota, Schwarz, Schwarz, Shrestha, Swar, Thapa, Thapa, White and Acharya2021), used the capability, opportunity, motivation and behavior (COM-B) framework to improve primary care providers’ treatment skills, motivation, access to counselors and psychiatrists, and a reliable medication supply. The program has been scaled up to serve over 10,000 beneficiaries in Nepal and is a model that the WHO is using to field test mental health integration in Ghana and Dominican Republic. Some authors on this article and colleagues have outlined the comprehensive, collaborative and community-based care or “C4” framework for the integration of stand-alone mental health programs with health and social community-based services. It delineates the types of workers involved, treating comorbidities as a norm and explicitly addressing referral and collaborative pathways (Bolton et al., Reference Bolton, West, Whitney, Jordans, Bass, Thornicroft, Murray, Snider, Eaton, Collins, Ventevogel, Smith, Stein, Petersen, Silove, Ugo, Mahoney, El Chammay, Contreras, Eustache, Koyiet, Wondimu, Upadhaya and Raviola2023).

Community-level treatment providers should be trained in multi-problem, modular methods as well as transdiagnostic approaches to address comorbidities (Lovero et al., Reference Lovero, Basaraba, Khan, Suleman, Mabunda, Feliciano, Dos Santos, Fumo, Mandlate, Greene, Fiks Salem, Mootz, Mocumbi, Duarte, Gouveia, Oquendo, Wall and Wainberg2021). Addressing common mental health conditions such as depression, anxiety and trauma together produces greater impacts on each of these conditions than treating them separately. Such an approach is also more scalable, broadly relevant to community needs (Wainberg et al., Reference Wainberg, Scorza, Shultz, Helpman, Mootz, Johnson, Neria, Bradford, Oquendo and Arbuckle2017; Kane et al., Reference Kane, Vinikoor, Haroz, Al-Yasiri, Bogdanov, Mayeya, Simenda and Murray2018) and aligns better with current “real-world” clinical practice (i.e., how clinicians treat clients). Mozambique, which faces a critical shortage of health resources, has adopted some of these innovations. For example, the country has formalized task-sharing within its national health platform to meet multiple population mental health needs (Dos Santos et al., Reference Dos Santos, Wainberg, Caldas-de-Almeida, Saraceno and Mari Jde2016), which has led to the sustainable scale-up of comprehensive mental health and substance use care that has been integrated within their community primary care clinics system with existing human resources (Wainberg et al., Reference Wainberg, Gouveia, Stockton, Feliciano, Suleman, Mootz, Mello, Fiks Salem, Greene, Bezuidenhout, Ngwepe, Lovero, Fortunato Dos Santos, Schriger, Mandell, Mulumba, Neves Anube, Mabunda, Mandlate, Cournos, Alves-Bradford, Nicholson, Kann, Fumo, Duarte, de Jesus Mari, Mello, Mocumbi, Oquendo and Weissman2021).

Digital technology has become a promising tool in integrated health care, particularly mental health care addressing depression and anxiety in low- and middle-income countries (LMICs). It offers a cost-effective solution that enhances non-specialist providers’ capacity, supports task-sharing of evidence-based practices (EBPs) and makes mental health care more accessible. Mobile-delivered brief EBPs improve treatment rigor and fidelity, providing comparable outcomes to traditional methods while reducing costs (Naslund et al., Reference Naslund, Aschbrenner, Araya, Marsch, Unützer, Patel and Bartels2017). Digital psychosocial interventions and training for non-specialist workers in LMICs show moderate effect sizes – comparable to those in high-income countries – for conditions like depression and substance misuse (Fu et al., Reference Fu, Burger, Arjadi and Bockting2020). While effectiveness against treatment as usual varied due to differing standards of care, digital interventions showed strong effects compared to no treatment, highlighting their potential in settings with limited mental health services. Some examples of effective digital interventions are as follows: Inuka, a chat-based application based on the Friendship Bench problem-solving therapy intervention (Dambi et al., Reference Dambi, Norman, Doukani, Potgieter, Turner, Musesengwa, Verhey and Chibanda2022), and Step-by-Step, a digital tool based on behavioral activation to treat depression (Cuijpers et al., Reference Cuijpers, Heim, Abi Ramia, Burchert, Carswell, Cornelisz, Knaevelsrud, Noun, van Klaveren, Van’t Hof, Zoghbi, van Ommeren and El Chammay2022). Additionally, digital platforms enable record-keeping and remote monitoring of patient progress. Given these benefits, integration of digital mental health interventions, particularly in LMICs, is recommended to strengthen mental health care provision and increase access to care. The Red Cross Red Crescent (RCRC) Movement MHPSS Hub (2024a); b; c), for example, has published resources to guide the development of human centered digital MHPSS solutions that can be utilized in relevant settings. Large-scale implementation trials are needed to assess the long-term effectiveness and sustainability of these interventions in diverse contexts (Wainberg et al., Reference Wainberg, Gouveia, Stockton, Feliciano, Suleman, Mootz, Mello, Fiks Salem, Greene, Bezuidenhout, Ngwepe, Lovero, Fortunato Dos Santos, Schriger, Mandell, Mulumba, Neves Anube, Mabunda, Mandlate, Cournos, Alves-Bradford, Nicholson, Kann, Fumo, Duarte, de Jesus Mari, Mello, Mocumbi, Oquendo and Weissman2021).

Each community needs to be part of such a system of MHPSS integrated into their existing and commonly accessed health and social services (WHO, 2025a). Each point of integration is also an assessment and triage point through which clients can access whatever combination of services they need. Each model recognizes the need to meet people where they are in terms of needs and resources and provide a mechanism to “step up” care for those with greater needs and/or comorbidities. In Liberia, for example, a Universal Health Coverage pilot is implementing cross-sectoral engagement and sustainable change for integration of mental health with NCD care through collaborations with persons affected, formal and informal healthcare sectors and multidisciplinary technical advisory boards (Godwin-Akpan et al., Reference Godwin-Akpan, McCollum, Kollie, Berrian, Seekey-Tate, Smith, Zaizay, Chowdhury, Kollie, Rogers, Parker, Zawolo, Wickenden, Dean and Theobald2025).

Successful integration necessitates addressing workforce challenges. Most local MHPSS programs, including programs integrated into other programming, rely on task sharing – the sharing of treatment and psychosocial programming skills with non-professional workers. This emulates the primary health care model of training non-professional health workers in specific skills most in need. At the local level, existing workers can incorporate psychosocial skills to their roles so long as they have the training, supervision and dedicated time and space to do so, while full treatment with counseling therapies requires dedicated workers (see, section on program quality below). The right combination of existing workers who take on psychosocial support activities alongside their other responsibilities plus staff specifically hired to provide mental health treatment will depend on local programs and capacity (Bolton et al., Reference Bolton, West, Whitney, Jordans, Bass, Thornicroft, Murray, Snider, Eaton, Collins, Ventevogel, Smith, Stein, Petersen, Silove, Ugo, Mahoney, El Chammay, Contreras, Eustache, Koyiet, Wondimu, Upadhaya and Raviola2023). Integration also requires linking the health information systems so that clients are tracked across both MHPSS and other health care. Making this work and truly integrating mental health as a cross-cutting issue across services requires support from not just the ministry of health but also from other ministries related to women’s issues, child protection and finance.

Challenge: programs often address only a few issues rather than the range of mental health and psychosocial problems of those most in need

While there has been extensive research and development of interventions to address common mental health disorders such as depression, anxiety, posttraumatic stress, as well as generalized distress, other important mental health issues have received insufficient program attention:

• ○ Stigma and discrimination against persons with mental health conditions

• ○ Treatment of severe mental health conditions, such as bipolar disorder and schizophrenia.

• ○ Safety against self-harm or suicide

• ○ Youth and child mental health conditions and neurodevelopmental conditions

• ○ Substance misuse and abuse

• ○ Intimate partner violence (IPV) and gender-based violence (GBV) prevention by addressing the mental health of both victims and perpetrators.

• ○ Variations in mental health issues by gender and sexuality

Programs do not often address stigma and discrimination, yet these are universal and affect all levels of society. They are major barriers to individual, collective and societal action toward addressing mental health, affecting prioritization, resources, quality of programs, service delivery and service seeking. They are based on widespread misconceptions and fear: that mental health conditions is a personal failing or an inherited weakness, that persons with mental health conditions cannot hold responsible positions or healthy relationships, that treatment is expensive, long term and relatively ineffective. Multiple reviews of demand-side research link lack of help seeking to stigma and poor understanding and awareness of effective services (van den Broek et al., Reference van den Broek, Gandhi, Sureshkumar, Prina, Bhatia, Patel, Singla, Velleman, Weiss, Garg, Sequeira, Pusdekar, Jordans and Nadkarni2023; Dumke et al., Reference Dumke, Wilker, Hecker and Neuner2024). Stigma and discrimination produce marginalized, hidden populations of individuals with mental health conditions who are reluctant to seek care and unable or unwilling to advocate for their own needs and interests.

While treatment of severe mental health conditions is often the sole focus of existing routine mental health services in many countries, there have not been efforts to make improvements or link them to community-level services. MHPSS programs led by external, academic or international NGOs instead tend to provide, per our definition, psychosocial support only in that they focus on reaching large numbers of relatively accessible people with interventions focused on prevention of single conditions (e.g., perinatal depression). Issues perceived as more difficult or expensive – treatment of mental health conditions, safety, programs for substance abuse and programs intended to reach youth and marginalized groups – are less often programmed. Where programs do offer treatment, it frequently targets a small number of conditions (such as depression or trauma) despite comorbidity being more common (Martel et al., Reference Martel, Pan, Hoffmann, Gadelha, do Rosario, Mari, Manfro, Miguel, Paus, Bressan, Rohde and Salum2017; McGrath et al., Reference McGrath, Lim, Plana-Ripoll, Holtz, Agerbo, Momen, Mortensen, Pedersen, Abdulmalik, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Bromet, Bruffaerts, Bunting, de Almeida, de Girolamo, De Vries, Florescu, Gureje, Haro, Harris, Hu, Karam, Kawakami, Kiejna, Kovess-Masfety, Lee, Mneimneh, Navarro-Mateu, Orozco, Posada-Villa, Roest, Saha, Scott, Stagnaro, Stein, Torres, Viana, Ziv, Kessler and de Jonge2020; Giusto et al., Reference Giusto, Ayuku and Puffer2022) particularly in conflict-affected areas (Charlson et al., Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena2019). For example, Mental Health Gap Action Program (mhGAP; WHO, 2016) uses algorithms suited to diagnose and treat mental health conditions in isolation. Its algorithmic and medication-based approach is difficult to apply to the treatment of comorbidity. Therefore, non-specialists with only a brief mhGAP training are not equipped to manage comorbidities, unless they also reliably receive ongoing supervision from specialists such as psychiatrists or are trained in transdiagnostic psychotherapies.

Programs do not consider the influences of gender and sexuality on mental health. Mental health conditions tend to be more frequent among women, partly due to domestic and gender-based violence and lower status in many societies (Kiely et al., Reference Kiely, Brady and Byles2019). Men have higher suicide risk and higher rates of substance use but are less likely to seek care due to social expectations that they be resilient, due to the pressure to earn income as the main supporters of their families, and potentially other factors that are under-explored. Currently, the most frequent approach to addressing gender and sexuality in mental health is to limit programming to a single gender, usually women. Similarly, schizophrenia, bipolar disorder, substance-abuse, post-traumatic stress disorder, etc., also place a significant disability burden on a subset of the population, yet community- and primary-care-based mental health programs tend to overlook these illnesses.

While social determinants are an impact factor in mental health, they are not identified as targets for MHPSS programs. The very limited funds for MHPSS programming require a focus solely on the provision of MHPSS services rather than on determinants like poverty and education. With poverty being a subject of a much larger existing programming, recent evidence suggests that poverty-reduction interventions combined with psychological interventions frequently drive significant mental health gains, as compared to psychological components alone (Tanski et al., Reference Tanski, Wei, Singh, Pabon, Bahure, Jordans, Lund, Roy, Singh, Thapa, Tol and Evans-Lacko2025). Integrating MHPSS with those that address social determinants can also expand the reach of mental health services toward universal access (WHO, 2025a).

Recommendation: programs need to address these issues as part of comprehensive care – both in terms of addressing all major mental health problems and barriers and reaching all those in need

Stigma and discrimination need to be addressed in MHPSS programming at all levels: patients, their families, communities, healthcare workers, counselors, leadership and policy makers. This includes mental health literacy programs for the general population to correct misperceptions and provide accurate information on mental health care services (WHO, 2025a). Enabling people to be more open about their situation, especially those experiencing severe mental illnesses, is also essential as there is ample evidence that social contact with people with lived experience is effective at reducing stigma (Thornicroft et al., Reference Thornicroft, Sunkel, Alikhon Aliev, Baker, Brohan, El Chammay, Davies, Demissie, Duncan, Fekadu, Gronholm, Guerrero, Gurung, Habtamu, Hanlon, Heim, Henderson, Hijazi, Hoffman, Hosny, Huang, Kline, Kohrt, Lempp, Li, London, Ma, Mak, Makhmud, Maulik, Milenova, Morales Cano, Ouali, Parry, Rangaswamy, Rusch, Sabri, Sartorius, Schulze, Stuart, Taylor Salisbury, Vera San Juan, Votruba and Winkler2022). This requires addressing systemic stigma and discrimination, which is best done empowering individuals with lived experience to engage in creating safe social environments, co-developing and implementing needs assessments, programs and research and in the design of service provision (WHO, 2025a). Increasing their visibility, leadership and engagement in implementation, in turn, requires addressing structural discrimination by governments, employers and other institutions, to repeal discriminatory laws and policies. These should be replaced with protections for the rights of individuals with mental health conditions, drawing on existing human rights frameworks (UNGA, 2006) and instruments that promote equitable treatment through focus on recovery and rehabilitation into the wider society.Footnote ⁴ These are necessary to engage political stakeholders and garner community support while encouraging and assisting people with mental health conditions to use services.

Programs should include gender and sexuality considerations in staff training (e.g., sensitization on gender equity, trauma-informed approaches and GBV prevention), monitoring and evaluation (e.g., disaggregating indicators by gender) and intervention design (e.g., gender-specific strategies for expanding access).

Challenge: mental health programming priorities and practices in LMIC continue to be dominated by the global north, with insufficient local involvement and adaptation

The global mental health field has been described as one of north to south power imbalances and colonialist practices (Rivera-Segarra et al., Reference Rivera-Segarra, Mascayano, Alnasser, van der Ven, Martinez-Ales, Durand-Arias, Moro, Karam, Hernandez-Torres, Alarcon, Ramos-Pibernus, Alvarado and Susser2022). Despite progress toward equity, imbalances remain (Abimbola and Pai, Reference Abimbola and Pai2020). Western, well-resourced institutions (e.g., NGOs outside of the local or national context) have dominated global mental health with less input from the Global South, including local policy makers, providers, patients and other community voices. This has resulted in widespread adoption of Western concepts and methods of screening, diagnosis, and treatment (Moleiro, Reference Moleiro2018). While cross-cultural research has supported the widespread applicability of these approaches, it also emphasizes the need for local adaptation, yet they are often not well adapted and only partially reflect local mental health issues. For example, in societies where collectivist values, spiritual beliefs and traditional healing methods can also play a central role in mental well-being (Bass et al., Reference Bass, Bolton and Murray2007).

Most mental health assessment by external actors relies on Western instruments, which, in turn, are based on symptom diagnostic criteria drawn from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). One argument for using these instruments without adaptation is the need for standardization of assessment across populations. But using the same instrument across populations can result in a lack of comparability. For example, if some aspects of depression manifest differently in different populations using the same instrument may result in not measuring depression correctly in any of them. This can go deeper: western assessments prioritize symptoms as measures of need and impact, with less attention to broader challenges. This includes the impact of mental health problems on key activities of daily living, particularly those that are necessary to support self and family, which are often higher priority locally. Externally developed instruments are often poorly adapted and not well validated locally. For example, the Patient Health Questionnaire (PHQ-9) is widely used but often without local adaptation and validation in the populations surveyed.

The same considerations relate to treatment, which also cannot be just the importation of Western approaches. Most successful treatment approaches have undergone significant adaptation of their materials to be acceptable, implementable and sustainable. Such local adaptation is not the norm for most programming.

Recommendation 1: emphasize locally driven design and implementation with North–South cooperation and capacity-building

This should be done under the rubric of mutual capacity building, defined as an equal bidirectional exchange of ideas between LMICs, Small Island Developing States (SIDS) and high-income countries (HICs) to promote shared learning toward increasing local system appropriateness and capacities (Wainberg et al., Reference Wainberg, McKinnon, Mattos, Pinto, Mann, de Oliveira, de Oliveira, Remien, Elkington, Cournos and Project2007; Binagwaho et al., Reference Binagwaho, Nutt, Mutabazi, Karema, Nsanzimana, Gasana, Drobac, Rich, Uwaliraye, Nyemazi, Murphy, Wagner, Makaka, Ruton, Mody, Zurovcik, Niconchuk, Mugeni, Ngabo, Ngirabega Jde, Asiimwe and Farmer2013; Jack et al., Reference Jack, Myers, Regenauer and Magidson2020; Giusto et al., Reference Giusto, Jack, Magidson, Ayuku, Johnson, Lovero, Hankerson, Sweetland, Myers, Fortunato Dos Santos, Puffer and Wainberg2024; Jack et al., Reference Jack, Giusto, Rose, Mwamuka, Brown, Bere, Verhey, Wainberg, Myers, Kohrt, Wingood, DiClemente and Magidson2024). This requires fostering truly mutual and equitable partnerships in which all partners reflect on each aspect of programming from the definition of concepts and goals to implementation and choice and measurement of indicators and interventions (Wainberg et al., Reference Wainberg, McKinnon, Mattos, Pinto, Mann, de Oliveira, de Oliveira, Remien, Elkington, Cournos and Project2007; Bemme et al., Reference Bemme, Roberts, Ae-Ngibise, Gumbonzvanda, Joag, Kagee, Machisa, van der Westhuizen, van Rensburg, Willan, Wuerth, Aoun, Jain, Lund, Mathias, Read, Taylor Salisbury and Burgess2024). It includes adopting evidence-based interventions and guidelines from the Global South in the Global North in ways that move beyond “reverse innovation” (Ngaruiya et al., Reference Ngaruiya, Sobowale and Annamalai2021) and require the same process of local adaptation as North to South. For example, a program developed in the Global South to improve depression would not just be adopted by a community in the United States, but undergo appropriate adaptation and testing to ensure cultural relevance (Giusto et al., Reference Giusto, Jack, Magidson, Ayuku, Johnson, Lovero, Hankerson, Sweetland, Myers, Fortunato Dos Santos, Puffer and Wainberg2024) as well as effectiveness. Mutual capacity building encourages communication and partnership across sites to build capacity to improve mental health in both settings. This shift increases input from local policy makers, providers, patients/individuals with lived experiences and community voices.Footnote ⁵

Mutual capacity building is a formal process that requires more than initial ad hoc interviews with local stakeholders to inform program design. Community-based participatory research (CBPR) methods provide structured and in-depth approaches to collaborative decision-making, centering the voice of communities in program design and implementation (Wainberg et al., Reference Wainberg, McKinnon, Mattos, Pinto, Mann, de Oliveira, de Oliveira, Remien, Elkington, Cournos and Project2007; Wallerstein, Reference Wallerstein2021; Payan et al., Reference Payan, Zawadzki and Song2022). CBPR is part of the broader Community-Engaged Research (CEnR) approach which emphasizes ongoing engagement of the community as experts, shared decision-making and emphasizes shared values, goals, communication processes and power. It incorporates specific strategies for community engagement such as creation of meaningful advisory boards with community representation, as well as principles that center reflection, clear communication, honesty and mutual respect (Chou and Frazier, Reference Chou and Frazier2020; Goodman et al., Reference Goodman, Papastavrou Brooks, Price and Barley2020). Implementing organizations should routinely embed this type of structured approach to collaboration for program implementation. Funders, who play a critical role in sustaining mental health programming, could use this approach to determine priorities and funding cycles.

A participatory approach of local adaptation is necessary even with existing globally recognized approaches. For example, the Nepali version of the mhGAP Intervention Guide includes additional modules for anxiety disorders and conversion disorders to meet local needs (Luitel et al., Reference Luitel, Breuer, Adhikari, Kohrt, Lund, Komproe and Jordans2020). Interpersonal Psychotherapy has proved effective in various cultures, but only after local adaptation by providers (Verdeli et al., Reference Verdeli, Clougherty, Bolton, Speelman, Lincoln, Bass, Neugebauer and Weissman2003). We acknowledge that such adaptations could be challenging amidst a lack of time, resources and clear guidance. However, participatory adaptation is necessary and feasible where there is already a deep understanding of traditional practices. In our rapidly evolving world, traditional practices and beliefs have often been eroded, particularly among the young. So, in each new setting, there is a need to conduct pre-assessments before program design, understanding the perspectives of all groups to be affected.

Recommendation 2: recovery should be the primary objective of treatment services and, therefore, a major part of impact assessment. Instruments that assess recovery and symptoms need local adaptation and testing prior to use

Recovery should be the main outcome of mental health care services (WHO, 2025a). Recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential” (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014). This places a focus on activities required for a satisfying and meaningful life. While standard functioning assessment instruments exist and can be a resource, like the WHO Disability Assessment Schedule (WHO-DAS 2.0), they require local culturally appropriate adaptation to be relevant and sensitive to important local activities. Western functioning instruments still rely on individual productivity impairment whereas a broader global view of functioning includes social wellness and collective capabilities (Bolton et al., Reference Bolton, Wilk and Ndogoni2004; Hartman et al., Reference Hartman, Noyola, Murillo, Rodríguez Cuevas and Cardemil2023). Knowing what activities and symptoms are important locally requires knowledge of the local community which requires meaningful collaboration with community members using approaches such as CBPR, as previously described. Symptoms should continue to be assessed, with the inclusion of those known to be relevant and distressing locally.

Screening instruments and other measurements need to be locally adapted. Rather than thwarting cross-cultural comparison, this enhances it. For example, only if an instrument truly assesses the local manifestation of depression can the results be compared with assessments of depression in other populations. This requires a prior understanding of mental health and how it manifests in each population, which in turn requires prior qualitative investigation, which is still infrequently done.

Screening instruments and other measurement tools also require local validity and reliability testing to determine how well each item, and each instrument as a whole, is performing. Poor performance, particularly by individual items, is common even with instruments that have undergone local adaptation. Instrument adaptation and testing need to be a standard part of program development unless proven instruments already exist for the same population. An example is the Cognitive Processing Therapy (CPT) Functionality Tool to assess and monitor the impact of CPT on individuals recovering from trauma (Elhra, Reference Elhra2014).

Challenge: program quality is not well supported

Program quality is often poor due to inadequate training and supervision, a lack of monitoring and impact evaluation and inadequate integration of workers and services into existing health and social systems. Interventions too often have little or no scientific evidence of effectiveness relevant to the populations being served, yet are often transplanted from one global region (often Western) to another with little adaptation or local impact assessment.

While guidelines and manuals for some evidence-based low-intensity psychological interventions are accessible online, operational challenges such as inadequate training, lack of cultural adaptation and limited supervision affect the quality of their frequent “off the shelf” use. The alternative approach – direct training – tends to have more thorough processes for training, supervision and fidelity, but otherwise is affected by the same issues. Direct training also faces challenges with a lack of trainers and their time and can involve high costs when trainers are based in HICs.

Insufficient resources, particularly workers and worker time, are a significant challenge. MHPSS services in LMICs often exist solely as “add-ons” to the duties of existing and already busy staff without additional paid time or resources. Lower intensity psychosocial or brief psychological interventions (e.g., brief behavioral activation delivered over 2–4 sessions or single session interventions) are important first-line services that can be delivered as add-ons by community health workers (CHWs) or other community-based workers, but only if these workers have clear and substantial time carve-outs to provide these services. Full psychotherapeutic services of 8–12 sessions (e.g., cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT)) are more time-consuming and require different skill sets from those of most existing program staff, including CHWs and physical health providers. They cannot be added to existing job descriptions, instead requiring dedicated psychotherapeutic workers working full-time.

Monitoring and evaluation are critical to maintaining the quality of key program elements: assessment and triage, supervision, fidelity, effectiveness and provider and client satisfaction. While task-sharing has been shown in trials to be an effective method of providing MHPSS services (Lange, Reference Lange2021), quality of services is not sustainable without systems of continuous mentorship, supervision and support. Supervision is of prime importance, since assessing and maintaining quality is a vital function of good supervision, particularly for services provided through task-sharing. Supervision also provides the necessary ongoing training.

Recommendation: expand focus on training, supervision and monitoring and evaluation, providing the necessary time and resources

A primary consideration for program quality is ensuring that workers receive training, provide services, participate in supervision and support monitoring and evaluation through dedicated funding, time and resources, as described above.

Most task-sharing training is an add-on and ad hoc for existing workers only. Including mental health training in pre-service training (e.g., part of curricula at academic/training institutions as recommended by WHO’s guide on pre-service education (WHO, 2025b)) or part of existing in-service training to expand existing skills or add new ones is less expensive than postgraduate or post hoc training and can improve professional standards and quality of care. Professional schools are more capable of assessing, improving and confirming the competencies of counselors compared to ad hoc sessions at the workplace. Integration into professional training helps inculcate mental health as an important and routine aspect of the role of existing workers.

In-service training can include short courses, but the most essential components to building competency are supervised practice followed by ongoing supervision to refine skills, support workers’ own mental health and sustain motivation (Wainberg et al., Reference Wainberg, Gouveia, Stockton, Feliciano, Suleman, Mootz, Mello, Fiks Salem, Greene, Bezuidenhout, Ngwepe, Lovero, Fortunato Dos Santos, Schriger, Mandell, Mulumba, Neves Anube, Mabunda, Mandlate, Cournos, Alves-Bradford, Nicholson, Kann, Fumo, Duarte, de Jesus Mari, Mello, Mocumbi, Oquendo and Weissman2021). For mental health specialists in LMICs, they need to master the skills needed to work within task-shared interventions: a) working in teams, b) collaborative clinical decision-making, c) supporting the quality of team members’ work, d) overseeing a large panel of patients to ensure people are not falling through the cracks; e) providing supervision for non-specialists to deliver mental health care rather than directly delivering care (Acharya et al., Reference Acharya, Ekstrand, Rimal, Ali, Swar, Srinivasan, Mohan, Unutzer and Chwastiak2017; Jackson et al., Reference Jackson, Dangal, Dangal, Gupta, Jirel, Khadka, Rimal and Acharya2022). The case conference is an effective supervision method where trained primary healthcare workers gather, led by a psychiatrist or other professional involved in training these workers. Workers present patients and receive feedback from other health workers and the trainer. This approach has been reported as helpful for both healthcare workers and patients (WHO, 2018a).

Workforce development and maintenance require respectful integration of mental health workers as part of the health and social services systems. Each worker needs a title and pay appropriate to their training and work. This should be a program prerequisite, particularly for task-sharing approaches. Otherwise, when organizations hire, train and support lay workers, but without official integration into existing systems, their roles disappear when funding dries up.

Each intervention should include fidelity measures that can be used to train, assess and retrain workers to ensure that their services are high quality. Existing evidence-based treatments (e.g., CBT, IPT, narrative exposure therapy (NET)) tend to have fidelity monitoring incorporated in their supervision and certification processes. For interventions that do not, the Ensuring Quality in Psychological Support (EQUIP) model is a WHO and UNICEF project that aims to enhance the skills of support providers while ensuring training and service delivery are consistent and high-quality. EQUIP consists of a platform with free competency assessment tools and e-learning courses to support governments, training institutions and non-governmental organizations, both in humanitarian and development settings, to train and supervise the workforce to deliver effective psychological support to adults and children (Kohrt et al., Reference Kohrt, Schafer, Willhoite, Van’t Hof, Pedersen, Watts, Ottman, Carswell and van Ommeren2020; Kohrt et al., Reference Kohrt, Pedersen, Schafer, Carswell, Rupp, Jordans, West, Akellot, Collins, Contreras, Galea, Gebrekristos, Mathai, Metz, Morina, Mwenge, Steen, Willhoite, van Ommeren, Underhill and Consortium2025).

Challenge: interventions are selected without reference to the best available evidence

MHPSS programs frequently include interventions that are not adequately evidence-basedFootnote ⁶ for the populations and problems in question, or even similar populations. While evidence is lacking for most interventions in most populations, it is critical that we make the best use of the best available evidence. WHO’s mhGAP (WHO, 2016) recommends evidence-based therapies treatments such as the Thinking Healthy Program (WHO, 2015), Interpersonal Psychotherapy (WHO and Columbia University, 2016) and psychosocial interventions developed by WHO such as Self-Help Plus (WHO, 2021b) and Problem Management Plus (WHO, 2018b). Yet, program decisions are often made at a high and external level by professional administrators and/or by external mental health experts, often from a HIC and with the lack of the local input described previously. External technical experts often base their selection of interventions on that which they are familiar without reference to existing studies and prior programming among relevant populations.

Recommendation: promote the adoption of evidence-based interventions by reference to continuously updated databases of interventions

Decisions on the content of programs should be based on consultation of up-to-date global databases of evidence-based interventions that include what counterfactual studies have been done, among which populations, and for which problems. Criteria for relevance of evidence, from highest to lowest, could be: (1) Studies conducted among the population in question for the same issues to be addressed; (2) Studies conducted among similar populations for the same issues; (3) Studies not conducted among the same or similar populations but among multiple diverse populations; (4) Studies conducted among a single population different from the population in question (Groves et al., Reference Groves, Fawaz and Olenik2021). Existing updatable databases that have much of this information include those created by the Mental Health Innovation Network and Metapsy.

While intervention choice should be based on scientific impact, there are still places in the world for which no relevant scientific evidence exists for any specific intervention. In these situations, collaboration with local providers, patients and community voices (via a CBPR approach) to gain insights into what is accessible, appropriate and acceptable is an appropriate basis for selection. The mhGAP Community Toolkit could also serve as a resource for program managers to identify local mental health needs and tailor services to address these needs. However, implementation should include impact assessment, preferably a counterfactual study, to confirm effectiveness.

Challenge: lack of guidelines for development contexts

While many countries have developed their own mental health systems and guidelines, many have not. For those without local guidelines, major international organizations, including the United Nations International Children’s Emergency Fund (UNICEF), WHO and the UNHCR, have taken a lead in establishing guidelines for MHPSS programs. Primary among these are the development of the Inter Agency Standing Committee (IASC) Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), World Health Assembly’s (WHA) Resolution WHA77.3 on “strengthening mental health and psychosocial support before, during and after armed conflicts, natural and human-caused disasters and health and other emergencies” (WHO, 2024a). Development programs are often based on these guidelines, which, while providing excellent guidance for humanitarian contexts, were not designed to support long-term system development. While they do emphasize coordination with development platforms, as well as “building up” the MHPSS system and referral mechanisms, their humanitarian focus means they lack detailed guidelines on establishing sustainable, locally integrated mental health systems.

WHO has taken a leading role in mental health service implementation in development with the mhGAP program (WHO, 2008). Treatment under mhGAP is focused on diagnosis of single mental health conditions by primary care providers and treatment by medications, which WHO acknowledges are overall less effective than counseling therapies for common mental health conditions, particularly trauma. In 2024, WHO added a manual for integrating counseling/psychological interventions to fill this gap (WHO, 2024c). However, the manual refers to the integration of one or a few interventions for a limited number of specific conditions, rather than a system of care meeting the various and usually comorbid mental health problems of individuals and populations. The manual is also brief and necessarily nonspecific, functioning more as a “what to do” rather than a “how to” for integrating a system of mental health care that meets all the major needs of people at all ages. WHO has also produced resources and toolkits for implementing mental health services in primary care (WHO, 2023a) which provides valuable tools and serves as a reference, but a focused guidance document for program development has not been produced.

Recommendation: develop comprehensive guidelines for mental health for the development sector

We need specific implementation guidelines for integrating a comprehensive mental health system into development programming. This system needs to incorporate community-based prevention, promotion and treatment linked to professional care as needed. The guidelines need to provide clear, actionable direction rather than just a broad list of issues to consider, drawing on existing resources from WHO but going further to provide concrete guidance for implementation. Guidelines for development and humanitarian response should reflect the transition from relief to development, rather than operating without consideration of the other. This can ensure that emergencies and disasters make use of opportunities provided by short-term expansion of attention and resources for permanent improvements in mental health services and policy. For example, in Lebanon, the Ministry of Public Health capitalized on enhanced global interest and funds following the Syrian influx to reform mental health policy and systems and build long-term services for all persons (host population and the displaced) who reside in Lebanon.Footnote ⁷ Post-earthquake recovery and rebuilding in Haiti provided a similar opportunity. Both of these cases have been described, alongside a proposed list of competencies for humanitarian mental health responses (Raviola et al., Reference Raviola, El Chammay, Houde, Singer and Smith2023), but the resulting comprehensive guidelines have not yet been produced.