|Year : 2017 | Volume
| Issue : 2 | Page : 79-85
Preventive psychiatry in clinical practice
Mamta Sood, Vijay Krishnan
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||30-Jun-2017|
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
In the last two and a half decades, there have been series of global burden of disease studies which have highlighted significant disability attributable to mental and behavioral disorders with a huge treatment gap. Integration of the preventive strategies in the clinical practice has the potential to reduce the disability due to mental illnesses. The patients come to the clinic with an intention to get treated and investigated for the symptoms they have. At this point, they may also be amenable to the advice related to prevention. Therefore, the clinical encounter can be seen as an opportunity to implement preventive strategies. Preventive efforts in clinical practice must be guided by knowledge about the epidemiological data related to specific mental illnesses and about the evidence-based preventive strategies available for specific mental illnesses. These should be directed toward all those persons (patients, caregivers accompanying and at home, teachers, employers, etc.) who are present and also toward those who are not present during the clinical encounter and must be age, gender, and culture sensitive. Sociodemographic characteristics of a person seeking relief from a problem in the clinical encounter help in directing the preventive efforts. The preventive efforts are also driven by the fact that the patient has the first episode or established or treatment refractory mental illness and the short or long duration of illness. For prevention-minded clinical practice, it helps to have a template so that the assessments and interventions relevant for prevention can be carried out as per that scheme; it also helps in orienting the practicing mental health professionals. While making various assessments, making a list of the likely issues to be addressed by preventive efforts during clinical encounter ( first and subsequent) is also helpful.
Keywords: Clinical practice, mental health, prevention, preventive psychiatry
|How to cite this article:|
Sood M, Krishnan V. Preventive psychiatry in clinical practice. Indian J Soc Psychiatry 2017;33:79-85
| Introduction|| |
Preventive psychiatry is a public health approach to mental health. The Institute of Medicine (IOM) brought principles of public health, primary, secondary, and tertiary prevention, in the practice of medicine and initially focus was on acute and infectious diseases having a known etiology. Later, chronic noncommunicable diseases were also brought under its ambit; many of these are chronic and related to complex genetic and lifestyle factors. However, preventive efforts in psychiatry lagged behind the happenings in medicine. One of the important reasons was that for most of the mental illnesses, etiology was not established making it difficult to apply principles of prevention. Although preventive psychiatry had its beginnings in the mental hygiene movement, the main impetus for its growth came from Institute of Medicine (IOM) report that it was possible to conceptualize prevention for mental health even in the absence of clear etiology. Subsequently, the World Health Organization adopted this as a framework for prevention of mental disorders and promotion. A few journals exclusively devoted to mental health prevention and promotion have also been published.,, In the last few decades, research publications have increased in the field of preventive psychiatry. It has also been emphasized in medical curriculum. Currently, several psychiatric associations have independent sections on preventive psychiatry. There has been a paradigm shift from emphasis on treatment of mental illnesses to their prevention that also includes treatment as one of its components.
In the last two and a half decades, there have been series of global burden of disease studies which have highlighted significant disability (13% of disability-adjusted life years) attributable to mental and behavioral disorders with treatment gap of about 60%–80%. The literature suggests that IOM framework-based, evidence-based, and disorder-specific preventive strategies exist for mental disorders. Integration of these preventive strategies in the clinical practice has the potential to reduce the disability due to mental illnesses. The patients come to the clinic with an intention to get treated and investigated for the symptoms they have. During routine clinical encounter between mental health professional and person with mental illness, the immediate and explicit focus is on the relief of symptoms and prevention of relapse. There is an implicit expectation of improved functioning and quality of life. At this point, they may also be amenable to the advice related to prevention. Therefore, the clinical encounter can be seen as an opportunity to implement preventive strategies. However, in actual practice of medicine, there has been separation of community-based preventive medicine and hospital-based clinical medicine. The dichotomy between two practices exists as the former deals with unrecognized illness or disability and is oriented towards improving outcomes at a community level and the latter deals with the effective diagnosis and intervention for subjects who recognize that they have a problem, and is oriented towards improving individual outcomes. This dichotomy is seen even in the medical curriculum and the trend has continued in the practice of psychiatry as well. However, recently, it is being suggested that this is a false dichotomy and clinical medicine practitioners are uniquely placed to provide preventive services.
In this article, we discuss the importance of preventive approaches and how to integrate these for the routine and everyday clinical encounter between a user of mental health treatment facility and the mental health professional providing treatment. We will restrict ourselves to the role that mental health professionals play while performing their clinical responsibilities, and not discuss the role of mental health professionals as advocates, teachers, researchers, or policymakers in furthering a preventative agenda.
| Preventive Psychiatry and Clinical Practice|| |
Preventive psychiatry has two major goals: prevention of mental illnesses and promotion of mental health. These two goals, although similar, are different in their focus. Preventive approaches aim to directly decrease morbidity and dysfunction, and disrupt the chain of events that leads to the final outcome of mental illness. It differs from clinical practice. The outcome of a clinical intervention may be directly observed as the resolution of the index illness whereas favorable outcome for preventive intervention is that the index event does not occur at all and these gains are evident only after a long gap. Furthermore, the outcome of a preventive intervention must be assessed at an aggregate level, by comparison with a population in which the event has been allowed to occur without intervention. Cost considerations are as important as effectiveness, while devising a preventive strategy. Preventive strategies that are targeted at the earliest phase of the illness are attractive when these do not incur as much cost as treatment services; therefore, are amenable to being scaled up significantly. Thus, they are often recommended as priorities for low-resource services. However, strategies for early intervention are also physically challenged by a problem of power as in the earliest phases of the illness, it is usually difficult to distinguish those who are at risk for adverse outcomes (illness or disability) and thus a larger number would need to be assessed to identify the subgroup that is suitable for intervention.
In many ways, the routine clinical tasks of a mental health professional have a preventive orientation. The adequate diagnosis, formulation, and treatment of those with mental illness improves individual outcomes, but also has a long-term effect on morbidity in the community by shortening the time spent in illness. This is an essential aspect of secondary prevention that can be achieved by merely providing basic services to all. Preventive practices may overlap, but do not automatically coincide with the routine clinical practice of mental health professionals. The approaches to preventive psychiatry may involve some modification in the orientation of practitioners. There may be an expansion in the services provided to include preventive measures. This may also encompass broader changes in the guiding principles behind some of these actions, or even the orientation of the physician toward patients. Thus, preventive services may overlap, but may not automatically coincide with the routine clinical practice of mental health professionals.,
It is important to consider following points for the integration of preventive psychiatry in clinical practice:
- The primary prevention is aimed at the individuals without recognized illness, to decrease the incidence of disease by reduction of risk factors (malleable and nonmalleable; causal and proxy) and enhancement of protective factors at macro (society and the culture) as well as micro levels (individuals, small groups, or social networks). The strategies for secondary prevention are aimed at individuals with a diagnosable illness, intending to reduce the rate of complications due to an established disease and the tertiary prevention is aimed at reducing the disability. Primary prevention interventions are further considered to be universal, selective, and indicated. The universal interventions can be applied to the entire population without any attempt to select candidates on the basis of risk. Selective interventions are for the candidates selected on the basis of their membership in a group with high risk for a condition. The indicated prevention strategies are applicable for persons at an individually elevated risk due to the presence of symptoms that are directly due to the illness, though in a subclinical or unrecognized form. The risk and the protective factors in psychiatry include individual, family related, and social and environmental determinants of mental health. Promotive aspects in preventive psychiatry aim to increase the prevalence of personality traits and psychological strategies that are associated with improved mental health. These include interventions aimed at enhancing characteristics such as self-esteem, competence, and a sense of personal well-being. These interventions have a direct in uence on quality of life in the short term, but they are also aimed to prevent mental illness morbidity by protecting against the in uences of other concurrent risk factors., Prevention in mental health is practiced at primary, secondary, and tertiary prevention. Mental health promotion is related concept. Preventive efforts in clinical practice can be guided by following points:
- For practicing prevention in clinics, it is important to know epidemiological data about a mental illness in terms of its prevalence rates, distribution across various sociodemographic variables, burden, risk and protective factors affecting onset, progression and course, biopsychosocial impact on the persons with mental illness, their families and society 
- Preventive efforts in clinical practice have to be informed by the knowledge about what are the evidence-based biological and psychosocial preventive interventions available for specific mental illnesses
- The preventive efforts may be directed toward all the persons during the clinical encounter like patients with mental illness, their caregivers who are present and also those who are not present, school teachers in case of children, employers, etc., This is especially true in the cultures, like India where family caregivers play an important role in the identification, treatment, and management of mental illnesses 
- It is important to be age and gender sensitive while practicing prevention in clinics
- The preventive efforts should be culture-informed
- The sociodemographic characteristics, of a person seeking relief from a problem in the clinical encounter, are also helpful in deciding about focus of preventive efforts. This helps in deciding what kind of problems the patient and his/her caregiver are going to face. For example, in a young unmarried girl with mania, due to increased libido, increased libido, lack of social inhibition and impaired judgment, there may be impulsive sexual behavior and subsequent pregnancy that may result in social embarrassment. On the other hand, in a married young girl with mania, the use of mood stabilizers may be difficult because of risk of unplanned pregnancy and chances of teratogenicity with their use and risk of postpartum onset episode without their use. In a young girl who has had mania, is on prophylactic medications and she is planning to get married, there may be high chances of relapse because of medication nonadherence and lack of sleep due to sociocultural reasons, for example, in North India, most of the marriage ceremonies are conducted during the night time and in her new family taking medications may not be liked or permitted
Therefore, outcome expectations will differ according to the sociodemographic characteristics of the patients. The needs and problems vary as per age, sex, occupation, marital status, financial status, type of family and residence
- The preventive efforts will need to be modified according to whether the patient has first episode or established or treatment refractory mental illness, or they have presented with illness of short or long duration. These factors affect the presentation of illness, needs of the patients and caregivers, and expected outcome and will need to be addressed in different ways
- During a routine clinical encounter, limited time is available, especially in high patient volume settings; most of it is devoted to making diagnosis and treatment. Having good communication skills help in effective utilization of the limited available time. It may help practicing clinicians to acquire and improve their communication skills so that preventive strategies can be embedded in the time available for routine clinical encounter [Box 1].
| Integration of Preventive Psychiatry in Clinical Practice|| |
In clinical practice, preventive strategies can be planned on the lines of primary, secondary, and tertiary prevention.
Primary prevention strategies may be aimed at increasing directly or indirectly the levels of ongoing support that the patient receives from formal and informal caregiving networks. Although the absence of clear etiological information makes planning primary prevention difficult, except in the case of nutritional or infectious causes of mental morbidity like Iodine deficiency causing intellectual disability, syphilis-causing neuropsychiatric syndromes. However, it is possible to practice some of the strategies for primary prevention. The patients can be encouraged to modify their lifestyles with an emphasis on having an adequate sleep, balanced diet, and moderate physical exercise. They can also be educated about harmful effects of smoking and other psychoactive substance use. In young adults, especially married young females of reproductive age group, discussing contraception will help in the prevention of unplanned pregnancy. Psychoeducational interventions can help the caregivers by imparting knowledge about their relative's illness, their concerns faced during the caregiving, strengthening problem solving, and preventing stress and burden. Most family caregivers experience stress in their caregiving role and may experience anxiety and depressive symptoms, especially if their relative has chronic mental illness. Therefore, they should be screened for the presence of subsyndromal or syndromal psychiatric disorders and if present, these should be managed. The children of patients with severe mental illnesses may be particularly vulnerable, therefore, need special attention to their needs. The patients and their caregivers face stigma and discrimination. They can be informed about and encouraged to form self-help and support groups.
Secondary and tertiary preventive techniques are essentially those that are used in the clinical care of patients. The objective of these interventions is to identify the presence of a mental illness preferably at an early stage, and thereafter to curtail the duration of the episode and then ensure a symptom-free remission period in which functioning is optimized. However, a preventive outlook is possible even in this context. It is important to ensure a certain standard of care in which frequent predictors of relapse or high risk of complication are identified early and managed. For example, treatment resistance in depression has been linked , to the contribution of factors such as comorbidity and stress, which may be ascertained merely by routine screening for their presence. The same is true for other psychiatric illnesses as well.
In most of the patients with mental illness, there is a disruption in socio-occupational functioning. Therefore, it is important to emphasize the importance of resuming functioning early in the treatment. Most of the times, approach to resuming socio-occupational role varies from one extreme of no expectation of resumption by the self and family caregivers to another extreme of over expectation and critical attitude toward patient not being able to fulfill his/her socio-occupational role. As the patient improves gradually, the functioning should also be restarted in graded fashion. It is important to acquire and maintain age, gender, and culturally appropriate vocational skills and occupation. Similarly, the patients and their family caregivers should continue to engage in recreation and socialization as this helps in reducing the stress as well as stigma.
For the prevention of complications due to treatment, though protocols exist for the routine investigation and management of potential adverse effects due to the use of psychotropic medications such as clozapine, lithium, and antipsychotic medications,,, repeated surveys have shown that the rate of adherence to such guidance is poor. Increased awareness and routine screening have been reported to be helpful in the area of suicide prevention. Studies have shown that suicide completers are frequently in touch with medical practitioners in the period immediately before the suicidal act. Although this rate may show significant variation between countries with changes in access to healthcare, they do highlight the need for routine identification and intervention for suicide in the mentally ill population.
For the identification of undiagnosed comorbidity, a number of strategies have been thought of. The use of self-report measures for screening of depression, anxiety and substance use, or of broader outcomes such as quality of life or functioning., These are usually used in the waiting area of clinics, and their utility has been limited by patients' willingness to complete them, and by doctors' willingness to use this data in their decision-making. Their utility may be further hampered among those with lower educational levels. Mobile and internet based technologies have been used to screen for screening psychiatric symptoms, improving medication adherence, and early recognition of relapse.
The most common preventive task for a mental health professional in clinical practice is the prevention of relapse. Although this may seem to be a routine part of treatment services and therefore not warranting a specialized preventive approach, certain findings counter this notion, for example, one-third of patients with psychosis discontinue their medication within the first year, leading to a 5-fold elevation in relapse risk. Relapse is often related to factors that can be modified, but may not be directly related to the illness, and thus might be missed, for example, associated medical, psychiatric and substance use comorbidity, and continuing psychosocial adversity. The effective management of these conditions requires that they receive sufficient attention in the clinical settings. Therapeutic drug monitoring may help maintain adequate levels of drugs such as clozapine, lithium, valproate, carbamazepine and may thus help in preventing or minimizing relapse. Monitoring for metabolic syndrome can also be implemented routinely.
For prevention-minded clinical practice, it helps to have a template so that the assessments and interventions relevant for prevention can be carried out as per that scheme; it also helps in orienting the practicing mental health professionals. Listing of the likely issues to be addressed by preventive efforts is also helpful.
This can be illustrated with the help of an example of obesity in the patients with schizophrenia [Box 2]:
- What is the problem that can occur (nature of the problem)?
- Obesity (nature of the problem) occurs in patients with schizophrenia on antipsychotics
- What are the chances of developing the problem (prevalence)?
- 7%–15% of them develop obesity
- How to reduce chances of developing the problem (reducing incidence– primary prevention)?
- Chances of developing obesity can be reduced by reducing the risk factors and enhancing protective factors:- What increases the chance of having the problem (risk factors)?
There are increased chances of developing weight gain with second-generation antipsychotics, sedentary lifestyle, and unhealthy food eating habits. Social isolation, negative stigma, and deficits in cognitive skills hinder development of close relationships and deficits in executive functions; this result in limited opportunities for physical fitness and learning of new skills
- What decreases the chance of having the problem (protective factors)?
Protective factors are healthy diet, physical activity, and participation, high potency antipsychotics and absence of substance use.
- What are the early signs for identification of the problem (early detection– secondary prevention)?
- Regular monitoring of weight, waist circumference, and body mass index is important
- What to do once the problem has occurred (early intervention– secondary prevention)?
- Psychoeducation of the patients with schizophrenia and their family caregivers about increased chances of weight gain is important. Dietary advice is important like the restriction of high carbohydrates, high fat and low fiber food and limiting total calorie intake in males to 1500–1800 kcal/day in males and 1200–1500 kcal/day in females. Increased physical activity is also important, initially to be started at low level of 30 min 2–3 times/week and maintaining at 200–300 min/week
- How to minimize the impact of the problem (prevention of complications/further deterioration-tertiary prevention)?
- Monitoring of blood pressure, fasting sugar, lipid profile, and electrocardiography should be regularly checked to monitor for the risk of diabetes mellitus, hypertension, and cardiovascular events
- If the problem persists despite treatment, how to modify biopsychosocial factors so that there is an improvement in quality of life and functioning (tertiary prevention)?
- In case of development of these diseases, modification of biopsychosocial factors entails institution of regular medications for these diseases with focus on improving adherence, regular physical exercise, treating substance use, and dietary advice. This may help to reduce complications and disability arising out of diabetes mellitus or a cardiovascular event and thus may contribute to improved functioning and quality of life.
| Challenges to Integration of Preventive Psychiatry in Clinical Practice|| |
There are many challenges to integration of preventive psychiatry in clinical practice.
- At a health system level, the shortage of trained mental health professionals and lack of mental health training in general physicians leads to delayed, inadequate and often inappropriate treatment of those with mental illness.,, This means that negligible resources are available for preventive efforts
- The scientific basis for prevention in psychiatry remains limited. In the first place, our better understanding of the working of the human brain has not yet translated directly into better health technology for patient diagnosis or treatment. Most importantly, much of primary prevention is focused on risk factor reduction, and therefore, rely on a causal model for mental illness. However, as etiological hypotheses for mental illness have not been substantiated, prevention becomes more difficult
- The lack of evidence for preventive psychiatry is also due to the fact that psychiatry still lags behind other branches in medicine in terms of research output. Even within this field, publications on preventive interventions form only one small fraction, and very few interventions have shown effectiveness when scaled up
- As with other domains in which both risk factors and interventions have small cumulative effects, studies of sufficient power are often not feasible, further weakening the evidence base. The relative importance of various risk factors may vary from setting to setting, and thus community-level interventions may need to be adapted in each instance
- Technological aids have a role in prevention as they are less dependent on human expertise, and thus easier to deploy on a mass scale. However, mental illness diagnosis and treatment are still largely dependent on the clinical encounter and thus require human expertise
- Due to the stigma associated with mental illness, patients and caregivers resist referral to mental health services, and practitioners do not broach discussions of mental health. Mental health promotion and preventive interventions rely on components that are educational, sociological, and are thus most effective when coordinated through experts in multiple disciplines.
Clinicians are uniquely well positioned to contribute to mental disorder prevention in the area of research. Mental disorders are conceptualized to be multi-factorial in origin, and preventive services are best directed at risk factors that are common and important. These patterns are similar but not identical across different societies. Thus, locally generated data on risk factors and the relationship between them would be invaluable. Currently, much of the data on risk factors for mental health are generated in the west. With the rise of the “global mental health” movement, there have been repeated calls for the prioritization of research topics that are of relevance to the developing countries.,,, However, there are few structured programs of preventive research, where there is integrated understanding of the risk factors and the appropriate intervention that could be used to target them.
| Conclusion|| |
It is possible to incorporate preventive strategies in clinical practice as many of the routine clinical tasks of a mental health professional during clinical encounter have a preventive orientation. For prevention-minded clinical practice in the framework of primary, secondary, and tertiary prevention, it is important to formulate the preventive strategies on the findings from the extant literature. However, for effective integration, it is important to have locally relevant preventive strategies incorporating sociocultural, gender, and lifespan perspective. Clinicians can also contribute to the research in mental health prevention by generating locally relevant sociocultural data as they are uniquely placed at the intersection of health system and society.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Muñoz RF, Mrazek PJ, Haggerty RJ. Institute of medicine report on prevention of mental disorders. Summary and commentary. Am Psychol 1996;51:1116-22.
Institute of Medicine (US) Committee on Prevention of Mental Disorders; Mrazek PJ, Haggerty RJ, editors. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academies Press (US); 1994.
World Health Organization. Prevention and Promotion in Mental Health. Geneva: World Health Organization; 2002.
World Psychiatric Association. WPA core curriculum in psychiatry for medical students. New York: World Psychiatric Association, World Federation for Medical Education; 1998. Available from: http://www.wpanet.org/sectorial/edu5-1.html
. [Last accessed on 2017 Apr 17].
World Health Organization. Prevention of Mental Disorders: Effective Interventions and Policy Options – Summary Report. Geneva: World Health Organization; 2004.
Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry 2016;3:171-8.
Mrazek PJ, Ritchie GF. Becoming a preventionist. Psychiatr Ann 2007;37:365-60.
Coie JD, Watt NF, West SG, Hawkins JD, Asarnow JR, Markman HJ, et al.
The science of prevention. A conceptual framework and some directions for a national research program. Am Psychol 1993;48:1013-22.
Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008;358:661-3.
Cohen A, Eaton J, Radtke B, George C, Manuel BV, De Silva M, et al.
Three models of community mental health services in low-income countries. Int J Ment Health Syst 2011;5:3.
Killackey E, Yung AR. Effectiveness of early intervention in psychosis. Curr Opin Psychiatry 2007;20:121-5.
Compton MT, editor. Clinical Manual of Prevention in Mental Health. Washington, DC: American Psychiatric Publishing, Inc.; 2009.
Chadda RK. Caring for the family caregivers of persons with mental illness. Indian J Psychiatry 2014;56:221-7.
] [Full text]
Fava M. Diagnosis and definition of treatment-resistant depression. Biol Psychiatry 2003;53:649-59.
Berlim MT, Turecki G. Definition, assessment, and staging of treatment-resistant refractory major depression: A review of current concepts and methods. Can J Psychiatry 2007;52:46-54.
Practice guideline for the treatment of patients with schizophrenia. American Psychiatric Association. Steering Committee on Practice Guidelines American Psychiatric Association, 2010.
Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines in Psychiatry. 12th
ed. Chichester, West Sussex, Hoboken, NJ: John Wiley & Sons Inc.; 2015.
Shrivastava A, Shah N. Prescribing practices of clozapine in India: Results of a opinion survey of psychiatrists. Indian J Psychiatry 2009;51:225-6.
] [Full text]
Greenhalgh J. The applications of PROs in clinical practice: What are they, do they work, and why? Qual Life Res 2009;18:115-23.
Holloway F. Outcome measurement in mental health – Welcome to the revolution. Br J Psychiatry 2002;181:1-2.
Wolpert M, Curtis-Tyler K, Edbrooke-Childs J. A qualitative exploration of patient and clinician views on patient reported outcome measures in child Mental Health and Diabetes Services. Adm Policy Ment Health 2016;43:309-15.
Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al.
Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007;370:991-1005.
Razzouk D, Sharan P, Gallo C, Gureje O, Lamberte EE, de Jesus Mari J, et al.
Scarcity and inequity of mental health research resources in low-and-middle income countries: A global survey. Health Policy 2010;94:211-20.
Lora A, Hanna F, Chisholm D. Mental health service availability and delivery at the global level: An analysis by countries' income level from WHO's Mental Health Atlas 2014. Epidemiology and Psychiatric Sciences 2017;1-12.
Linden DE, Fallgatter AJ. Neuroimaging in psychiatry: From bench to bedside. Front Hum Neurosci 2009;3:49.
Saxena S, Paraje G, Sharan P, Karam G, Sadana R. The 10/90 divide in mental health research: Trends over a 10-year period. Br J Psychiatry 2006;188:81-2.
Sharan P, Gallo C, Gureje O, Lamberte E, Mari JJ, Mazzotti G, et al.
Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean. Br J Psychiatry 2009;195:354-63.
Khandelwal S, Avodé G, Baingana F, Conde B, Cruz M, Deva P, et al.
Mental and neurological health research priorities setting in developing countries. Soc Psychiatry Psychiatr Epidemiol 2010;45:487-95.
Collins PY, Saxena S. Action on mental health needs global cooperation. Nature 2016;532:25-7.
Patel V, Boyce N, Collins PY, Saxena S, Horton R. A renewed agenda for global mental health. Lancet 2011;378:1441-2.