Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries

Charlotte Hanlon, Nagendra P Luitel, Tasneem Kathree, Vaibhav Murhar, Sanjay Shrivasta, Girmay Medhin, Joshua Ssebunnya, Abebaw Fekadu, Rahul Shidhaye, Inge Petersen, Mark Jordans, Fred Kigozi, Graham Thornicroft, Vikram Patel, Mark Tomlinson, Crick Lund, Erica Breuer, Mary De Silva, Martin Prince, Charlotte Hanlon, Nagendra P Luitel, Tasneem Kathree, Vaibhav Murhar, Sanjay Shrivasta, Girmay Medhin, Joshua Ssebunnya, Abebaw Fekadu, Rahul Shidhaye, Inge Petersen, Mark Jordans, Fred Kigozi, Graham Thornicroft, Vikram Patel, Mark Tomlinson, Crick Lund, Erica Breuer, Mary De Silva, Martin Prince

Abstract

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care.

Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts.

Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care.

Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Requirements for integrating mental health…
Figure 1. Requirements for integrating mental health into primary health care –.

References

    1. Kohn R, Saxena S, Levav I, Saraceno B (2004) The treatment gap in mental health care. Bulletin of the World Health Organisation 82: 858–866.
    1. Wang PS, Angermeyer M, Borges G, Bruffaerts R, Chiu WT, et al. (2007) Delay and failure in treatment seeking after first onset of mental health disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry 6: 177–185.
    1. Alem A, Kebede D, Fekadu A, Shibre T, Fekadu D, et al. (2009) Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia. Schizophrenia Bulletin 35: 646–654.
    1. Kebede D, Alem A, Shibre T, Negash A, Deyassa N, et al. (2005) Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia. Schizophrenia Research 78: 171–185.
    1. Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M (2009) Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 373: 408–415.
    1. Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, et al. (2010) Poverty and common mental disorders in low and middle income countries: A systematic review. Social Science and Medicine 71: 517–528.
    1. Teferra S, Shibre T, Fekadu A, Medhin G, Wakwoya A, et al. (2011) Five-year mortality in a cohort of people with schizophrenia in Ethiopia. BMC Psychiatry 11: 165.
    1. World Health Organization (2008) Mental Health Gap Action Programme (mhGAP): Scaling up care for mental, neurological, and substance use disorders. Geneva: WHO.
    1. Barbui C, Dua T, van Ommeren M, Yasamy MT, Fleischmann A, et al. (2010) Challenges in Developing Evidence-Based Recommendations Using the GRADE Approach: The Case of Mental, Neurological, and Substance Use Disorders. PLoS Med 7: e1000322.
    1. Dua T, Barbui C, Clark N, Fleischmann A, Poznyak V, et al. (2011) Evidence-Based Guidelines for Mental, Neurological, and Substance Use Disorders in Low- and Middle-Income Countries: Summary of WHO Recommendations. PLoS Med 8: e1001122.
    1. World Health Organization (2010) Mental Health Gap Action Programme Implementation Guide (mhGAP-IG) for mental, neurological and substance use disorders in non-specialized health settings. Geneva: WHO.
    1. Cohen A (2001) The effectiveness of mental health services in primary care: the view from the developing world. Geneva: World Health Organization.
    1. Thornicroft G (2012) Evidence-based mental health care and implementation science in low- and middle-income countries. Epidemiology and Psychiatric Sciences 21: 241–244.
    1. Hanlon C, Wondimagegn D, Alem A (2010) Lessons learned in developing community mental health care in Africa. World Psychiatry 9: 185–189.
    1. Thornicroft G, Alem A, Antunes Dos Santos R, Barley E, Drake RE, et al. (2010) WPA guidelines on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry 9: 67–77.
    1. Petersen I, Lund C, Stein DJ (2011) Optimizing mental health services in low-income and middle-income countries. Current Opinion in Psychiatry 24: 318–323.
    1. World Health Organization and Wonca (2008) Integrating mental health into primary care. A global perspective. Geneva: World Health Organization and World Organization of Family Doctors.
    1. Lund C, Tomlinson T, De Silva M, Fekadu A, Shidhaye R, et al. (2012) PRIME: A programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Med 9: e1001359.
    1. Cohen A, Eaton J, Radtke B, George C, Manuel BV, et al. (2011) Three models of community mental health services in low-income countries. International Journal of Mental Health Systems 5: 3.
    1. Bhana A, Petersen I, Baillie KL, Flisher AJ (2010) the MHAPP Research Programme Consortium (2010) Implementing the World Health Report 2001 recommendations for integrating mental health into primary health care: a situation analysis of three African countries: Ghana, South Africa and Uganda. International Review of Psychiatry 22: 599–610.
    1. World Health Organization (2005) World Health Organization Assessment Instrument for Mental Health Systems. Geneva: WHO.
    1. Thornicroft G, Tansella M (2013) The balanced care model for global mental health. Psychological Medicine 43: 849–863.
    1. World Health Organization (2011) Mental Health Atlas. Geneva: WHO.
    1. Alem A, Kebede D, Kullgren G (1999) The epidemiology of problem drinking in Butajira, Ethiopia. Acta Psychiatrica Scandinavica, Supplementum 397: 77–83.
    1. Kebede D, Alem A, Shibre T, Negash A, Deyassa N, et al. (2004) The sociodemographic correlates of schizophrenia in Butajira, rural Ethiopia. Schizophrenia Research 69: 133–141.
    1. Kebede D, Alem A, Shibre T, Negash A, Deyassa N, et al. (2005) Socio-demographic correlates of bipolar disorder in Butajira, rural Ethiopia. East African Medical Journal 82: 34–39.
    1. Awas M, Kebede D, Alem A (1999) Major mental disorders in Butajira, southern Ethiopia. Acta Psychiatrica Scandinavica, Supplement 99: 56–64.
    1. Luitel NP, Jordans M, Sapkota RP, Tol WA, Kohrt BA, et al. (2013) Conflict and Conflict and mental health - Cross sectional epidemiological study in Nepal. Social Psychiatry & Psychiatric Epidemiology 48: 183–193.
    1. Herman SS, Stein DJ, Seedat S, Heeringa SG, Moomal H, et al. (2009) The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. South African Medical Journal 99: 339–344.
    1. Jorm AF (2000) Mental health literacy. Public knowledge and beliefs about mental disorders. British Journal of Psychiatry 177: 396–401.
    1. Alem A, Jacobsson L, Araya M, Kebede D, Kullgren G (1999) How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia. Acta Psychiatrica Scandinavica, Supplementum 397: 40–47.
    1. Shibre T, Alem A, Tekle-Haimanot R, Medhin G, Jacobsson L (2006) Perception of stigma in people with epilepsy and their relatives in Butajira, Ethiopia. Ethiopian Journal of Health Development 20: 170–176.
    1. Shibre T, Negash A, Kullgren G, Kebede D, Alem A, et al. (2001) Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Social Psychiatry & Psychiatric Epidemiology 36: 299–303.
    1. BasicNeeds (2009) Community mental health practice. Seven essential features for scaling up in low- and middle-income countries. Bangalore: BasicNeeds.
    1. World Health Organization (2001) The World Health Report 2001. Mental health: new understanding, new hope. Geneva: WHO.
    1. Bruckner TA, Scheffler RM, Shen G, Yoon J, Chisholm D, et al. (2011) The mental health workforce gap in low- and middle-income countries: a needs-based approach. Bulletin of the World Health Organisation 89: 184–194.
    1. Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, et al. (2013) Grand Challenges: Integrating Mental Health Services into Priority Health Care Platforms. PLoS Med 10: e1001448.
    1. Rahman A, Malik A, Sikander S, Roberts C, Creed F (2008) Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 372: 902–909.
    1. Patel V, Weiss H, Chowdhary N, Smita N, Sulochana P, et al. (2010) Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet 376: 2086–2095.
    1. Jordans MJD, Komproe IH, Tol WA, Kohrt B, Luitel N, et al. (2010) Evaluation of a classroom-based psychosocial intervention in conflict-affected Nepal: A cluster randomized controlled trial. Journal of Child Psychology and Psychiatry 51: 818–826.
    1. CBM (2012) CBM programmes in Ethiopia available at .
    1. Prince M, Patel V, Saxena S, Maj M, Maselko J, et al. (2007) Global mental health 1: no health without mental health. The Lancet 370: 859–877.
    1. Kaaya S, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, et al. (2013) Grand Challenges: Improving HIV Treatment Outcomes by Integrating Interventions for Co-Morbid Mental Illness. PLoS Med 10: e1001447.
    1. Ngo VK, Rubinstein A, Ganju V, Kanellis P, Loza N, et al. (2013) Integrating Mental Health Care into the Non-Communicable Disease Agenda. PLoS Med 10: e1001443 doi:
    1. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH (2004) Improving the quality of health care for chronic conditions. Qual Saf Health Care 13: 299–305.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe