|
 
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| DEBATE ON GLOBAL MENTAL HEALTH MOVEMENT - AGAINST |
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| Year : 2016 | Volume
: 32
| Issue : 3 | Page : 261-266 |
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Global mental health movement has not helped in reducing global burden of psychiatric disorders
BS Chavan1, Jitender Aneja2
1 Professor and HeadDepartment of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh, India
2 Assistant Professor, Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh, India
| Date of Web Publication | 3-Nov-2016 |
Correspondence Address:
Dr. B S Chavan
Professor and Head Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-9962.193203
How to cite this article:
Chavan B S, Aneja J. Global mental health movement has not helped in reducing global burden of psychiatric disorders. Indian J Soc Psychiatry 2016;32:261-6 |
How to cite this URL:
Chavan B S, Aneja J. Global mental health movement has not helped in reducing global burden of psychiatric disorders. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 May 16];32:261-6. Available from: https://www.indjsp.org/text.asp?2016/32/3/261/193203 |
| Introduction | |  |
It is pertinent to define global health because without the agreed definition, it will be difficult to monitor the impact of intervention. Koplan and colleagues attempted to distinguish between global health, international health, and public health despite admitting that there is widespread overlap among the three terms.[1] The ‘Global Health’ is defined as an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide. The ‘International Health’ focuses on the health issues, especially infectious diseases, and maternal and child health in low-income countries. The ‘Public Health’ focusses on the health of the population of a specific country or community. However, elsewhere, the international health is also used as a synonym for global health.[2],[3] In the same line came the concept of ‘No Health without Mental Health’, an initiative of “The Lancet” that was later on appreciated and adapted by WHO.
Global mental health (GMH) is defined as the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide. In other words, it is an international perspective on various aspects of mental health that includes epidemiology of mental disorders, available treatment options, mental health education, financial aspects, mental health delivery systems, protection of human rights, and available human resources for providing mental health. The overall aim of GMH is to strengthen mental health globally by providing information about the mental health situations and identifying mental health care needs to develop cost-effective interventions.
What is Global Mental Health Movement?
The concept of GMH evolved in 2007, after a series of landmark articles in The Lancet and later on in PLoS Medicine, Epidemiology and Psychiatric Sciences that focused on the status of mental health in low and middle-income (LAMI) countries and highlighted the gap between the burden of mental health problems and mental health services available. Two years later in August 2009, a Global Mental Health Summit was held in Athens, which sought to promote awareness of mental health, tackle stigma, deal with barriers in promoting mental health, advocate and prompt governments to frame plans and policies with interdepartmental co-ordination. The movement is significant as it got a push from the World Health Organization (WHO, 2010, 2013). Presently, the movement is not limited to academic institutes only but aims at curbing mental health problems at grass root level. WHO and the proponents of this movement have been reaching out to various stakeholders of mental health in the form of deliberations, research and publications, website (http://www.globalmentalhealth.org), committees and organizations, and conduction of training. In a short span of less than 10 years, the movement has grown to a membership of around 200 institutions and 10,000 individuals, many of whom are actively involved. The members of the GMH movement include individuals and families affected by mental health problems, health care providers, activists, decision makers, and researchers.
How do we measure Global Burden of Psychiatric Disorders?
The global burden of any disease (GBD) can be estimated in the form of several direct and indirect indicators like incidence and prevalence of the disease, years of life lived with disability (DALY), years of life lost to disability (YLL), and mortality rate attributed to that disease. Another indicator of burden due to a specific disease may be due to its ranking in the list of top 10 or say 20 diseases contributing to GBD. Similarly, in context of psychiatric conditions, the global burden of diseases can be estimated by assessing the incidence and prevalence of mental illnesses, YLL, DALYs, and mortality attributed to these disorders.[6] According to Wahlbeck et al., life expectancy decreases by about 20 years in people with mental illnesses.[7] Suicide, one of the major cause of mortality globally, also provides fair estimate of life expectancy in mental disorders.
Burden of Mental and Substance Use Disorders
The mental and substance use disorders have a large impact on individuals, families, and communities. It is estimated that one in four families has at least one member currently suffering from a mental or behavioral disorder (WHO, 2001).[8] These families, in addition to shoulder the responsibility of providing physical and emotional support, bear the negative impact of stigma and discrimination. The burden on families ranges from economic difficulties, the stress of coping with disturbed behavior, the disruption of household routine, and the restriction of social activities. The expenses for the treatment of mental illness are often borne by the family because mental disorders are not covered under insurance in most of the countries. Despite being important, the human aspects of the burden of mental disorders are difficult to assess and quantify.
One way to account for the chronicity of disorders and the disability caused by them is the GBD. In the original estimates developed for 1990, the mental and neurological disorders accounted for 10.5% of the total DALYs, lost due to all diseases and injuries. The estimate for 2000 is 12.3% for DALYs due to mental and neurological disorders. Three neuropsychiatric conditions rank in the top twenty leading causes of DALYs for all ages, and six in the age group 15-44. From an analysis of trends, it is evident that this burden will increase rapidly in the future. Projections indicate that it will increase to 15% in the year 2020.[9] The increase in the DALYs due to depressive disorders, which are at present ranked 2nd in the top 20 disorders, and expected to surpass the cardiovascular disorders by 2020, are one of the major drivers of Global Burden due to mental disorders. The authors of the GBD 2010 studies expected further increase in the GBD due to Mental and Behavioral disorders especially in LAMI countries. On the same line, the GBD 2013 Mortality and Causes of Death Collaborators[10] assessed the mortality pattern of all causes and reported a decline of deaths due to schizophrenia by one third over the period 1990-2013. However, there has been a rise of deaths due to dementias and substance use disorders. Also, there was a significant rise in deaths due to self harm both amongst the high income countries and the low and middle- income countries with rates being higher in the former. The authors pointed to important gaps in the data available from India.
Is there reduction in GBD due to psychiatric disorders after launch of GMH movement?
A lot of progress has been made since 2007 after the Global Mental Health movement commenced. The GMH movement with the support of the WHO and some of the major funding agencies has got partners from the field of research, academicians, educationists, mental health professionals and NGOs, and they all have been working together to achieve its goals. A year later, the WHO came up with the mental health Gap Action Programme (mhGAP) and later on brought intervention guides and manuals to help reduce the gap. In 2012, the World Health Assembly (at Geneva) for the first time passed resolution and asked member states to address mental disorders and frame policies and guidelines for this purpose. In the last 9 years, many WHO member states (including India) have framed national mental health policies, and the GMH taskforce along with WHO had developed intervention packages for various mental health problems with the aim of reducing the global burden of mental diseases.
To see the impact of global mental health movement, unlike the objective outcome parameters of physical health like infant mortality rate, maternal death rate, reported incidents of HIV and AIDS, deaths due to roadside accidents etc, there are no clear-cut quantifiable and measurable indicators of burden due to mental disorders. However, the following parameters are likely to provide indirect evidence of impact of global mental health movement.
Global Burden of Diseases: First published in 1996, GBD is a comprehensive set of estimates of mortality and morbidity of commonly occurring diseases and injuries including neuropsychiatric disorders. Since then WHO is regularly developing GBD estimates.[11],[12] Although GBD is a useful tool to assess the impact of various diseases, the projection from GBD are based on estimated data and make many assumptions regarding measurement of disability. GBD estimates have many limitations including:
- Disability may be caused by more than one factor, and thus it will be over simplification to attribute it to one disease.
- The variation in society’s views of health and disease is ignored while calculating GBD.
- Cultural differences while assessing the severity of disability is not recognized.
- The study findings will have limitation in allocation of resources, as impact of disease will vary according to the context where a person lives.
- Lastly, risk factors like poverty, malnutrition, sanitation and hygiene, and poor water supply, which are the root cause of diseases and disability, are region specific.
The overall findings of the GBD study raise several alarms. It is projected that the GBD will remain unchanged until 2020, and it has been primarily attributed to rapid population growth in the developing counties. However, without the population control, health intervention variable is unlikely to reduce disease burden. The burden of the disease is expected to remain constant despite increase in life expectancy and population size. There is an assumption that healthier life years are to be lived in future than today and this again ignores future uncertainty.In 2010, depressive disorders accounted for 40·5% of DALYs caused by mental and substance use disorders, with anxiety disorders accounting for 14·6%, illicit drug use disorders for 10·9%, alcohol use disorders for 9·6%, schizophrenia for 7·4%, bipolar disorder for 7·0%, pervasive developmental disorders for 4·2%, childhood behavioral disorders for 3·4%, and eating disorders for 1·2%. The burden of mental and substance use disorders increased by 37·6% between 1990 and 2010.[13]
Suicide: is among the top 10 most common causes of death worldwide, and it was estimated to account for 1.8% of total global burden of disease in 1998 and is expected to rise to 2.4% by 2020. There is no published data on the pattern of suicide globally. However, the data is available from the GBD Study 2013 as well as studies conducted across the world. A recent Dutch study on the trends of suicide behavior from 1983 to 2013 reported an increase in male suicide attempts since 2009.[14] Similarly, the trends of suicide and non-fatal self-harm attempts have shown increase in England and Belgium over the last decade.[15],[16] The mortality data from the Center for Disease Control (US) from 1999 to 2013 shows gradual increase in total deaths caused due to suicide from 10.5 per lakh per annum in 1999 to 11.8 in 2008 and 13.0 in 2013.[17] The rate of suicide in India has also shown rising trend from 10.9 in 2009 to 11.4 in 2011. Infact, the rates of suicide from India were significantly higher (23.6 per lakh for men and 17.5 per lakh for women) in a recently published study in The Lancet.[18] In contrast to rest of the world, the studies from China have shown a decline in suicide rate in the last decade, and the trend of suicide has remained stable in Australia over a period.[19],[20] The overall rate of suicide has increased in most of the countries of the world.
Trends of Stigma globally: Stigma against people with mental illness is a global problem, and it is not only a significant source of burden but also a major contributor to treatment gap. Many programmes and interventions have been launched at national and international levels to tackle the problem. The specific interventions initiated in different countries including England, Germany, Australia, and LAMI countries showed improvement in attitude towards person with mental illness.[21] Surprisingly, the national program in England named ‘Time to Change’ did not find any change in knowledge about mental illness,[22] and a study from Germany found that people did not accept biological basis of depression and alcohol and attributed these disorders to environmental factors.[23] Another study from Australia found increase in beliefs about danger and unpredictability of patients with schizophrenia.[24] Thus, despite better understanding of mental disorders, the knowledge has not percolated uniformly among the masses, and there are many misconceptions about the mental illness and persons suffering from these disorders.
Estimation of coverage of ‘Treatment Gap’: The huge treatment gap has been a major concern in most of the countries, more so in LAMI countries. In fact, reduction of treatment gap by removing barriers in seeking mental health services is one of the major agenda of the GMH movement. The findings from various studies carried out in different countries show better coverage. The programmes started in Australia showed reduction in treatment gap for mental, neurological, and substance (MNS) use disorders.[25] The studies from Chile, Denmark, China, and Italy also showed improved coverage of services for different MNS.[26] On the other hand, the recent series in The Lancet on China- India Mental Health Alliance shows that the contact coverage and effective coverage for most common mental and substance use disorders is still very low.[27] In addition, there is an inequitable distribution of mental health resources with high treatment gaps in rural regions. The availability of nationally representative data for mental health problems is partly available from China. Recently, India conducted National Mental Health Survey in 12 states where estimation of treatment gap was one of the objective. The findings will be available in next 2-3 months. Both India and China have committed to renew efforts to reduce the treatment gap, but China has taken far more substantial actions than India. China has also invested more from health budget towards the cause and has undertaken community level programmes etc.
Cost effectiveness of programs for reducing treatment gap: The cost of treatment is one of the major deterrents in seeking treatment, more so in LAMI countries and efforts are being made to develop cost-effective intervention models. South Africa has initiated various projects to reduce direct and indirect cost of treatment of MNS disorders, and these interventions included incorporation of mental health care with primary care without use of specialized workers, integrated treatment of co-morbid disorders like HIV and alcohol use disorders, utilization of traditional medicines, tailor made intervention packages, and preventive programs. The outcome of these interventions showed improved treatment coverage.[28] The measures like reduction of accessibility to firearms in Australia and ban of pesticide in India have been very cost-effective in reducing suicide.[29] The WHO CHOICE (Cost effectiveness and strategic planning), an international project showed that intervention measures like use of generic medicines and older molecules combined with community-based psychosocial care proved to be very cost-effective.[30] Similarly, the cost-effective interventions for depression, epilepsy, and alcohol use disorders in the form of use of older antidepressants, management in primary care, use of older anticonvulsants in primary care, and random breath testing for motor vehicle drivers were able to produce one extra year of healthy life in Nigeria.[31]
Critics of GBD as an indicator of burden: In the absence of any other valid and objective criteria to measure burden of mental disorders, GBD is the only parameter, which has a consensus among the scientists and clinicians. Yet GBD has many critics, and many scientists and researchers have shown their reservations about the GBD as an indicator of burden of mental, neurological, and substance use disorders. These include:
Method of calculation of GBD: The method of calculation of burden due to mental and neurological disorders has certain limitations.[32] The authors state that GBD study has ignored the overlap with neurological disorders. The study separates suicide from injuries/deaths due to deliberate self-harm, excluding personality disorders and medically unexplained symptoms, The study does not take into consideration the contribution of mortality due to associated physical causes in the mentally ill patients. The authors recommend revision of the GBD study estimates of YLDs and DALYs to 32.4% and 13% respectively, which brings the global burden of diseases due to mental and behavioral diseases at par with cardiovascular disorders.
Is Global Mental Health Actually Global?: One of the major controversies surrounding the GMH is the deficiencies in the major classification systems used in psychiatry [that is, International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM)]. The criticism of the foundation of mental disorder categories, lack of ample scientific evidence, and the influence of extraneous factors (viz. culture, society etc.) have negatively affected this branch of medicine. Additionally, over the years, evolution of new categories, some deletions, and modifications of mental disorder categories imply that these lacked strong research evidence. On one hand, some of the mental disorders have been removed from these nosological systems (like homosexuality), while there have been some additions also (e.g. post-traumatic stress disorder). The removal of homosexuality and addition of Post Traumatic Stress Disorders (PTSD) are on the influence of the West and Europe. Thus, the categories of mental disorders are not clear and constant when compared to diseases like infections where there are some definitive biological underpinnings.[33]
Impact on the quality of care of persons with mental illness: The overall aim of GMH movement is to implement the Call For Action published in the 2007 Lancet series on global mental health. The objective is to improve the availability, accessibility, and quality of services for people with mental disorders worldwide– especially in LAMI countries by scaling up services based on scientific evidence and human rights. Although the movement has gradually grown to a stage where members are able to share ideas, initiate activities, and seek resources, yet it is to be seen whether these theoretical concepts have reached to a stage to influence clinical care of persons suffering from mental health problems. Unless the intervention is simple, cost-effective, culturally fair and backed by the government with resource allocation, it will be premature to expect reduction in burden. In addition, in the absence of any constitution and obligation on the part of members, the movement is unlikely to have enough force to bring about a perceptible change.
Lack of funding: The movement has proposed five priority actions- covering global advocacy, systems of development including specific care packages, research promotion, capacity building, and monitoring of progress of countries in scaling up mental-health care. The biggest hurdle of the GMH movement is lack of funding for supporting research and capacity building. Although, mental disorders account for 14% of disease burden worldwide, they receive less than one percent (0.5%) of health budget in low-income countries (WHO Atlas More Details, 2011)[34], and out of this negligible budget, approximately, three-fourth (73%) is spent on mental hospitals. Very little money is left for community care and rehabilitation. Thus, the need is not only to increase the budget allocation for mental health but also to spend more on community care where more people with mental illness reside.
Westernization of mental disorders and mental health care: The critics of the movement strongly feel that in the process of teaching the rest of the world to think like west, there has been an attempt in exporting not only the Western “symptom repertoire” but also trying to change the treatments and the expression of mental illness in other cultures. Dr. Sing Lee,[35] a psychiatrist and researcher at the Chinese University of Hong Kong feels that a handful of mental-health disorders, such as depression, post-traumatic stress disorder, and anorexia are spreading across cultures with the speed of contagious diseases. Lee feels that mental-health professionals in the West and in the United States, in particular, create official categories of mental diseases and promote them in a diagnostic manual that has become the worldwide standard. Since the American researchers and institutions run most of the premier scholarly journals and host top conferences in the fields of psychology and psychiatry, western drug companies pump out large amount for research and marketing medications for mental illnesses. The western categories of mental illness have gained dominance, and the micro-cultures that shape the illness and experiences of the individual patients are being discarded. The diagnostic systems (ICD and DSM) are conceived and designed by the Euro-American framework, and there is a lot of pressure on the mental health professionals from rest of the world to fit everything into this framework.
Lack of clarity in the approach: In GMH movement, there is a lack of clarity about the approach to achieve the set goals and there are two different views. One school of thought describe it as a ‘bottom-up’approach, which is driven by local knowledge and priorities. And the other group describe it as ‘top-down’ approach exporting Western illness categories and treatments that would ultimately replace diverse cultural environments for interpreting mental health. Vikram Patel,[36] a major proponent of the GMH, strongly argues that the movement be spearheaded by “what can we do collaboratively?” rather than “what can we [the West] do for you?”. He further argues that GMH movement should be driven by local knowledge.
Questioning the hidden burden of mental illness: An alternative perspective on the GMH movement was voiced by Derek Summerfield[33],[37] and Suman Fernando,[38] who suggested that GMH is becoming a predominantly Western scientific endeavour driven by psychiatry and the pharmaceutical industry. Both questioned the existence of a ‘hidden burden of mental illness’, which only becomes conceivable when Western psychiatric categories and measures are assumed universal. The critics felt that assigning diagnostic label to culturally acceptable phenomenon is likely to lead to cultural instability and demand for additional resources. Both the researchers further stated that in the absence of robust evidence of efficacy for many psychiatric treatments in the west, there is no use of scaling up these disorders in the South for the same. Similarly, Fernando (2012)[39] argued that the movement does not include the voices of the service users and the poor.
Outcome criteria: Another problem in GMH is lack of standard intervention package for many psychiatry disorders.[40] All the interventions being practiced across the globe, particularly psychosocial interventions are not supported by RCTs, and thus it may be difficult to standardize, randomize, and blind them. According to Kirmayer (2012)[40], the challenge of integrating evidence-based medicine and cultural psychiatry raises the question of methodological, epistemological, and political pluralism. Kirmayer (2012)[40] also advocates that the need to recognize diversity in outcome and symptom reduction should not be the only criteria for outcome. He says that the most important parameter should be that the person is able to pursue his personal, familial, and community goals in a culturally relevant manner. Certain types of symptoms and behavior should not get psychiatric label unless such symptoms and behavior are culturally inappropriate or there is a personal distress.
Using mental illness to bypass legal system: The GMH movement has also been criticized on the ground that mental illness might be used as a political instrument to create legitimacy and avenues for the refugees to get access to care which otherwise would have been denied to certain persons. There is a possibility that many people use mental health strategically to circumvent legal system. In the absence of standardized diagnostic criteria, it will be difficult to segregate genuine and feigned persons. Mental health practitioners are aware of persons using diagnostic label like PTSD with a clear aim to enter into a safe country.[41]
Narrow concept of mental illness: The role of social determinants of mental health is relatively ignored in the GMH movement, and all illnesses are presumed to have identical underlying biological basis. Kirmayer and Pedersen stated that war and trauma, and ongoing forms of regional violence are extreme contributors to mental health, which cannot be ignored.[41] The author acknowledges the deficit in the GMH and argues that a balanced global health research agenda for the future in GMH should focus on not only the global burden of illness as outlined in theLancet(2007) series but also on the social, political, environmental, and economic determinants of illnesses. He expressed his concern that issues of global equity and social justice were missing from the discussion.
| Conclusion | | |
After extensive study and review of published data, the authors are of the opinion that the GMH movement is still in the infancy stage and has not gained enough momentum and force to change the clinical care of persons with mental illness. In fact, the GBD due to MNS has increased over years and is expected to rise further. The major hurdles being faced by the GMH movement include insufficient budget, lack of constitution to implement the proposed agenda, non-availability of cost-effective and culture specific intervention package, limited human resources, and stigma associated with mental illness. In addition, whatever change has occurred in the field cannot be attributed to the GMH movement.
| Acknowledgement | | |
Nil
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK. Consortium of Universities for Global Health Executive Board. The Lancet 2009;373:1993-5.  |
| 2. | Merson MH, Black RE, Mills AJ. International public health: diseases, programs, systems, and policies. 2nd ed. Sudbury, MA: Jones and Bartlett; 2006. |
| 3. | Kickbush I. The need for a European strategy on global health. Scandinavian Journal of Public Health 2006;34:561-5. |
| 4. | The world health report. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. |
| 5. | |
| 6. | Patel V. Why mental health matters to global health. Transcultural Psychiatry 2014;51:777-89. [ PUBMED] |
| 7. | Wahlbeck K, Westman J, Nordentoft M, Gissler M, Laursen TM. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. The British Journal of Psychiatry 2011;199:453-8. [ PUBMED] |
| 8. | The world health report 2001- mental health: new understanding, new home. Geneva: World Health Organization: 2001. |
| 9. | Murray CJ, Lopez AD. The incremental effect of age-weighting on YLLs, YLDs, and DALYs: a response. Bulletin of the World Health Organization 1996;74:445-6. [ PUBMED] |
| 10. | GBD 2013 Mortality and Causes of Death Collaborators Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2015;385:117-71. |
| 11. | Mathers CD, Shibuya K, Boschi-Pinto C, Lopez AD, Murray CJ. Global and regional estimates of cancer mortality and incidence by site: I. Application of regional cancer survival model to estimate cancer mortality distribution by site. BMC Cancer 2002;2:36. [ PUBMED] |
| 12. | The world health report 2002-reducing risks, promoting healthy life. Geneva: World Health Organization: 2002. |
| 13. | Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet 2013;382:1575-86. |
| 14. | De Beurs DP, Hooiveld M, Kerkhof AJFM, Korevaar JC, Donker GA. Trends in suicidal behavior in Dutch general practice 1983-2013: a retrospective observational study. BMJ Open 2016;6:e010868-doi:10.1136/ bmjopen-2015-010868. |
| 15. | Genlayov G, Kapur N, Turnbull P, Clemens C, Waters K, Ness J. et al.Epidemiology and trends in non-fatal self-harm in three centres in England, 2000–2012: findings from the Multicentre Study of Self-harm in England. BMJ Open 2016;6:e010538-doi:10.1136/bmjopen-2015-010538. |
| 16. | Boffin N, Moreels S, Casteren VV. Trends from the surveillance of suicidal behavior by the Belgian Network of Sentinel General Practices over two decades: a retrospective observational study. BMJ Open 2015;5:e008584-doi:10.1136/bmjopen-2015-008584. |
| 17. | Xu J, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final Data for 2013. National Vital Statistic Report 2016;64:1-119. |
| 18. | Patel V, Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Gururaj G. Suicide mortality in India: a nationally representative survey. The Lancet 2012;379:2343-51. |
| 19. | Zhang J, Sun L, Liu Y Zhang J. The change in suicide rates between 2002 and 2011 in China. Suicide and Life-threatening Behavior 2014;44:560-8. |
| 20. | Wang CW, Chan CL, Yip PS. Suicide rates in China from 2002 to 2011: an update. Social Psychiatry and Psychiatric Epidemiology 2014;49:929-41. [ PUBMED] |
| 21. | Mascayano F, Armijo JE, Yang LH. Addressing stigma relating to mental illness in low and middle-income countries. Frontiers in Psychiatry 2015;6:1-4. |
| 22. | Lacko SE, Henderson C, Thornicroft G. Public knowledge, attitudes and behavior regarding people with mental illness in England 2009-2012. The British Journal of Psychiatry 2013;55:s51-7. |
| 23. | Angermeyer MC, Matschinger H, Schomerus G. Attitudes towards psychiatric treatment and people with mental illness: changes over two decades. British Journal of Psychiatry 2013;203:146-51. [ PUBMED] |
| 24. | Reavley NJ, Jorm AF. Stigmatising attitudes towards people with mental disorders: changes in Australia over 8 years. Psychiatry Research 2012;197:302-6. [ PUBMED] |
| 25. | Pirkis J, Ftanou M, Williamson M, Machlin A, Spittal MJ, Bassilios B. Australia’s Better Access initiative: an evaluation. The Australian and New Zealand Journal of Psychiatry 2011;45:726-39. |
| 26. | De Silva MJ, Lee L, Fuhr DC, Rathod S, Chisholm D, Schellenberg J. Estimating the coverage of mental health programmes: a systematic review. International Journal of Epidemiology 2014;43:341-53. |
| 27. | Patel V, Xiao S, Chen H, Hanna F, Jotheeswaran AT, Luo D. The magnitude of and health system responses to the mental health treatment gap in adults in India and China. China- India Mental Health Alliance Series The Lancet 2016. http://dx.doi.org/10.1016/S0140-6736(16)00160-4. |
| 28. | Jack H, Wagner RG, Petersen I, Thom R, Newton CR, Stein A. Closing the mental health treatment gap in South Africa: a review of costs and cost-effectiveness. Global Health Action. 2014;7:23431- http://dx.doi.org/10.3402/gha.v7.23431. |
| 29. | |
| 30. | Chisholm D. Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organization. World Psychiatry 2005;4: 37-44. [ PUBMED] |
| 31. | Gureje D, Chisholm D, Kola L, Lasebiken V, Saxena S. Cost-effectiveness of an essential mental health intervention package in Nigeria. World Psychiatry 2007;6:42-8. |
| 32. | Vigo D, Thornicroft G, Rifat A. Estimating the true global burden of mental illness. Lancet Psychiatry 2016;3:171-8. |
| 33. | Summerfield D. How scientifically valid is the knowledge base of global mental health. British Medical Journal 2008;336:992-4. [ PUBMED] |
| 34. | |
| 35. | |
| 36. | Patel V, Prince M. Global mental health: A new global health field comes of age. JAMA 2010;303:1976-7. [ PUBMED] |
| 37. | Summerfield D. ICD and DSM are contemporary cultural documents. BMJ 2002;324:914. [ PUBMED] |
| 38. | Fernando S. A global mental health program or markets for ‘Big Pharma’. Open Mind 2011;168:22. |
| 39. | Fernando GA. The roads less traveled: mapping some pathways on the global mental health research roadmap. Transcultural Psychiatry 2012;49:396-17. [ PUBMED] |
| 40. | Kirmayer LJ. Cultural competence and evidence-based practice in mental health: Epistemic communities and the politics of pluralism. Social Science and Medicine 2012;75:249-56. [ PUBMED] |
| 41. | Kirmayer LJ, Pedersen D. Toward a new architecture for global mental health. Transcultural Psychiatry 2014;51:759-76. [ PUBMED] |
|
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