Global Mental Health a new global health discipline comes of age

1. Global Mental Healtha new global health discipline comes of age Vikram Patel London School of Hygiene & Tropical Medicine, UK Sangath, India Public Health Foundation of India Department of Global Health & Social Medicine, Harvard Medical School

2. Global Health • “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al, Lancet 2009)

3. Global vs International • Concerned with health disparities within and between countries • Interest in global determinants such as climate change and migration • Priority setting by burden of disease

4. “international is what we can do for you…global is what we can do together” Srinath Reddy

5. Global Mental Health • The application of these principles to the specific domain of mental ill-health • Concerned with any ‘priority’ disorder affecting the brain (“MNS” disorders) • Primary focus on disparities in provision of care and respect for human rights of people living with mental disorders between rich and poor countries

6. Scientific foundations of GMH • Cross-cultural mental health research • Burden of disease estimates • Intervention and health services • Discrimination and human rights

7. Cross-cultural research

8. Cross-cultural research • Rich history of multi-disciplinary research, rooted in medical anthropology, clinical mental health sciences and epidemiology, on the cultural construction, social narratives, prevalence and risk factors for mental disorders, with especially rapid growth since the 1960s

9. Key findings • Major categories of mental disorders can be identified in all cultures, and share similar ‘core’ psychopathological features • Research methodologies can be both internationally comparable and contextually and culturally appropriate • Social disadvantage is strongly correlated with mental disorder; there is a vicious cycle of disadvantage and mental disorder

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13. Burden of disease

14. MNS disorders are common • Prevalence varies with setting and disorder • 10% of adults overal • Up to 30% of Primary Care Attenders • Between 0.5 and 2% of all adults suffer from a chronic, severe MNS disorder • About 1 in 10 children suffer from a childhood MNS disorder

16. GBD 2013 GBD 2013 estimated DALYs for 306 diseases and injuries, across 188 countries The burden of MNS disorders increased by 41% between 1990 and 2010. MNS disorders now account for one in every ten years of lost health globally

17. Mental disorders strike in youth Most MNS disorders, possibly more than 75% of the burden in the population, have their onset during youth, the most productive years of life (Kessler et al 2005)

19. Mental disorders kill • Cause-specific deaths versus excess deaths • Cause-specific deaths are constrained by ICD coding which obscures the contribution of other underlying causes of death • Excess deaths are derived from natural history models (all-cause mortality) • Estimates of excess deaths include but are not limited to cause-specific deaths (i.e. deaths from causal and non-causal origins).

20. Total Cause-specific and Excess Deaths for All MNS Disorders 13,559,271

21. Leading cause of death in young people

22. People with mental disorders die younger

23. The close relationship of mental disorders with physical health

24. Intervention and health services research

25. Synthesizing evidence on what works

26. Treatments Specific treatments for specific disorders Psychological treatments Drug treatments Social interventions targeting relevant social determinants Clinical algorithms

27. Integrating treatments into “disorder” packages

28. Key aspects of ‘disorder’ packages • Prevention and promotion: weak evidence for most disorders with some exceptions • Detection and diagnosis: • for common conditions, screening/training; • for rarer conditions, pro-active community case-finding and diagnostic interview • Treatment and care: • combined pharmacological-psychosocial • use of off-patent medications • Continuing health and social care

29. Platforms of care

30. 55 chapter authors from 14 countries

31. Most people, up to 90% of those with mental health problems in some settings (LMIC), do not receive these interventions

32. Barriers to scaling up LANCET PAPER

33. The GMH solutionUse ordinary people! Lay health workers delivering group Interpersonal therapy for depression in rural Uganda (Bolton et al, JAMA 2003) Lay counsellors led collaborative care for depression and anxiety disorders in primary care (Patel et al, Lancet 2010, Br J Psych 2011) Lady health visitors using CBT to treat postnatal depression in rural Pakistan(Rahman et al, Lancet 2008)

35. Human rights

36. Discrimination and human rights

37. Time Cover Story: November 2003

45. #6: The Call for Action • To scale up the coverage of services for mental disorders in all countries, but especially in low and middle income countries. • Based on two principles: • an evidence-based package of services for core mental disorders and • strengthening the protection of the human rights of persons with mental disorders and their families.

46. Impact on policy and practice

47. Providing effective mental health services in primary care settings would help to reduce the stigma associated with mental disorders and could prevent unnecessary hospitalization and human rights violations of people with mental health problems. … • Such strategy makes good economic sense….it is also a pro-poor strategy. … • Let us this year resolve to reduce the public health burden and the individual suffering of people with mental health problems worldwide. Ban Ki-Moon, October 2009

48. The future? • Act early in the life course and the course of an emerging mental health problem to prevent mental disorders • Scale up evidence based interventions for mental disorders through innovative approaches, such as task-sharing and use of digital technologies. • Support and empower persons with mental disorders to become effective advocates and engage with mental health care

49. JAMA, May 2010