|Year : 2016 | Volume
| Issue : 3 | Page : 289-295
Role of international collaboration in developing mental health services
R Srinivasa Murthy
Professor of Psychiatry (Retd) Mental Health Advisor, Sri Shankara Cancer Hospital and Research Centre, Shankar Mutt, Bengaluru, India
|Date of Web Publication||3-Nov-2016|
Prof. R Srinivasa Murthy
Professor of Psychiatry (Retd), Mental Health Advisor, Sri Shankara Cancer Hospital and Research Centre, Shankar Mutt, Bengaluru
Source of Support: None, Conflict of Interest: None
Development of mental health care for the total population is a challenge in all countries. Common challenges are accessibility, acceptability, affordability and stigma. There has been a progress in shifting the location of mental health services from jails, to asylums, to psychiatric hospitals, to general hospitals to community care facilities over the last three hundred years. Developing mental health services presents both universal and local challenges. There are advantages in collaboration across countries. Past efforts have taken advantage of collaboration to develop innovative approaches to care, tools for measuring impact of services, training methodology and evaluation of impact of interventions. Collaboration allows for bringing together wide ranging experiences and expertise, increase the size of the populations and understand the differences that influence development of mental health care. World Health Organization has pioneered collaborative projects in the past. The development of mhGAP Guidelines for non-specialists in recent times illustrates the value of collaboration. World Psychiatric Association promoted fighting stigma by bringing together over 20 countries. Grand Challenges Canada initiative is another example in this field. India has contributed to development of mental health services by focusing the importance of family in mental health care, integration of mental health with general health care, demonstrating the effectiveness of community care, revitalizing the traditional practices like yoga/meditation and presenting a different approach to psychotherapy. International collaboration for developing mental health services presents a win-win situation for all the partners and should be utilized to a greater extent.
Keywords: Collaboration, Services, Stigma, World Health Organization, Grand Challenges Canada
|How to cite this article:|
Murthy R S. Role of international collaboration in developing mental health services. Indian J Soc Psychiatry 2016;32:289-95
| Introduction|| |
The development of mental health services is a challenge in all countries. A recent review article, referred to mental health situation in the world, is as follows: “when it comes to mental health, all countries are developing countries.” Even in wealthy countries, 40-60% of people with severe mental disorders do not receive the care they need. It is this universal challenge of organizing mental health services that calls for an active international collaboration. Following the WHO initiative in 1975, there have been a number of international collaborative efforts to address development of mental health services. The important ones are from the Harvard University in 1995, Surgeon General of USA in 1999, WHO, Geneva, 2001, and Institute of Medicine(IOM) in 2001.
This article addresses this subject by:
- Historical development of mental health services review
- Past international collaboration in mental health services, especially in low and middle income countries(LAMIC)
- Current collaborations for mental health services
- Indian contribution to international mental health services
- Lessons learnt.
Historical development of mental health services
The development of mental health care all over the world is best described as a developing story.
Over the last few centuries different approaches have been used to address the needs of persons diagnosed with mental disorders. The World Health Report 2001, described the changes over the last two centuries as follows:
“Over the past half century, the model for mental health care has changed from the institutionalization of individuals suffering from mental disorders to a community care approach. This change is based both on respect for the human rights of individuals with mental disorders, and on the use of updated interventions and techniques. The care of people with mental and behavioural disorders has always reflected prevailing social values related to the social perception of mental illness. Through the ages, people with mental and behavioural disorders have been treated in different ways During the second half of the 20th century, a shift in the mental health care paradigm took place, largely owing to three independent factors, namely (i) psychopharmacology made significant progress, with the discovery of new classes of drugs, particularly neuroleptics and antidepressants, as well as the development of new forms of psychosocial interventions; (ii) the human rights movement became a truly international phenomenon under the sponsorship of the newly created United Nations, and democracy advanced on a global basis, albeit at different speeds in different places and (iii) social and mental components were firmly incorporated in the definition of health of the newly established WHO in 1948.These technical and sociopolitical events contributed to a change in emphasis: from care in large custodial institutions to more open and flexible care in the communityDe-institutionalization has not been an unqualified success, and community care still faces some operational problems. For example, in some countries, many people with severe mental disorders are shifted to prisons or end up becoming homeless. In most developing countries, there is no psychiatric care for the majority of the population; the only services available are in mental hospitalsFurthermore, most developing countries do not have adequate training programmes at national level to train psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers, and occupational therapists”.
The universal challenges for the development of mental health services [Table 1], calls for international collaboration.
International collaborations for mental health services
The organisation of mental health services in low- and middle-income countries (LAMIC) is nearly four decades old (2, 7, 8). The beginnings of organized mental health care in LAMIC can be traced to the important Sixteenth World Health Organization (WHO) Expert Committee meeting held at Addis Ababa, Ethiopia, in 1974 titled ‘Organization of mental health care in developing countries’. This meeting is important as it not only reviewed the mental health situation in developing countries, but also outlined a road map for development of services. These guidelines have largely influenced the developments of the last four decades. The important recommendations of this meeting were:
‘Basic mental health care should be integrated with general health services and be provided by non-specialized health workers, at all levels; countries should, in the first instance carry out one or more pilot programs to test the practicability of including basic mental health care in an already established programme of health care in a defined rural or urban population; training programs, including simple manuals of instructions for training of health workers should be devised and evaluated.’
WHO seven country international collaboration for mental health care
A follow up of this important meeting and the publication of the Expert Committee report by the W.H.O. was the international collaborative study titled, “Strategies for Extending Mental Health Care”.,, This study (1975-1981) was located in 7 countries- Brazil, Colombia, Egypt, India, Philippines, Senegal, and Sudan. This was a collaborative effort to put to test the recommendations the Sixteenth World Health Organization (WHO) Expert Committee in LAMIC countries. The approach was to carry out a series of baseline studies and then introduce mental health interventions, followed by repeat baseline studies. The baseline studies included survey of the knowledge and practices of health personnel, key informant interviews and screening of the general clinic attenders for the prevalence of mental disorders, and the recognition by the health personnel. The interventions were different in different countries, depending on the existing health personnel and the health care system. For example, nurses were the main care providers in Colombia, while in most other countries the basic health workers and doctors were the care providers. The priorities chosen were also different across the centers. The mental health educational activities were also appropriate to the priorities chosen and the health system. Annual meetings were organized in sequence in the different field practice areas of the project.,,
In this project, collaboration occurred at many levels.
- In the development of the research protocol.
- In the development of the tools for research [one very important tool coming out of this study and widely used is the Self-reporting Questionnaire (SRQ)]. SRQ has become one of the basic screening tool used in more than two dozen countries.
- There was an active exchange of community care experiences across centers to help in developing centre specific interventions. For example, Colombia had demonstrated the value of community nurses in the delivery of mental health care. The Chandigarh centre had experience with use of ‘vignettes’ for community attitude studies. This was adapted as Key Informant Interview for the study.
- The annual meetings acted as a catalyst for inclusion of mental health care in the general health services, in each of the countries. For example, in India the development of the National Mental health Programme (NMHP) in 1982 was largely based on the results if the project, along with a similar community care programme from the Bangalore center (described later).
- The large number of publications brought international attention to the need for mental health care in developing countries as well as the feasibility of integrating mental health care as part of general health care.
The following is a brief description of the Chandigarh centre work in this project. The Chandigarh efforts were initiated in 1975. This effort was the outcome of the observation of the limited utilisation of psychiatric services from the hospital. The field practice area, was the Raipur Rani Block of Ambala district of Haryana State, about 50 kms from Chandigarh. The results of this project, completed in 1981, demonstrated the feasibility to integrate mental health with general health services by choosing priorities and developing proper training programs for the health personnel.,
Two decades after the above seven country collaboration, there was collaboration between India and Pakistan to understand in greater depth the cost of integration of mental health care with general health care. Both the country experts and the UK team, which coordinated the collaboration, worked to develop the research design and the tools for evaluation besides stimulating country level initiatives.
The benefits of collaborative efforts across countries to develop mental health services has been an important aspect of international efforts to develop mental health services.
Programme for Improving Mental Health Care(PRIME)
PRIME is a consortium of research institutions and ministries of health. The project is funded by the UK Government. PRIME aims to scale up mental health services in Ethiopia, India, Nepal, South Africa, and Uganda. The priorities selected are: depression, psychosis, and alcohol use disorders. The project teams have developed locally relevant mental health careplans (MHCP) informed by the community advisory boards, that include district mental health administrators, service users, traditional healers, and police. Collaborative efforts have been important to develop local adaptations. For example, adaptations at the different centers have included development of new assessment tools in Nepal, district managers in South Africa, mental health case managers in India. MHCP has seven packages for enabling and service delivery. The lessons from the piloting of packages were:
- Mental health delivery can be strengthened only with strong facilitation by an external resource.
- An additional human resource of a case manager is essential.
- Enabling packages need to be installed as a foundation prior to the implementation of service delivery packages.
- The MHCP should include medically unexplained somatic presentations.
The experience from five countries has shown that interventions at the levels of health care organization, health facility, and community is essential for sustainable delivery of quality mental health care integrated into primary care.
Basic Needs initiatives
The other important international collaborative effort is by Basic Needs. Basic Needs is a global health charity established in 2000 in Britain, with the aim of facilitating access to employment and mental health care. This work is going on in Africa and Asia in countries like China, Ghana, India, Nepal, Tanzania, and Vietnam. A very important development of this project, is the recent initiative to translate the model to a deprived, inner-city environment in the USA.
One other ongoing initiative of international collaboration is the many projects funded by the Grand Challenges Canada.
WHO Collaborative efforts
Another international collaboration for mental health services, is the WHO initiative to develop educational materials and implement mental health services in non-specialist settings (Mental Health Gap Action Programme, or mhGAP).This has been a major international collaborative effort. mhGap Guidelines have been adapted by over three dozen countries with the local adaptations. A very elaborate system of monitoring and evaluation has been developed and disseminated to assist countries with limited professional resources to develop similar materials locally. WHO Global Clinical Practice Network is an online platform in which thousands of clinicians from around the world contribute to and benefit from mental health research. About 12000 clinicians from 39 countries have participated in field trials.,
WHO Project on psychiatric disorders in general health care
This was an international collaborative project to understand the nature of mental disorders in primary health care and develop interventions to address the same in 14 countries. The outcome of this collaboration was the development of tools for research and educational materials for non-specialist personnel.
Open the doors collaborative project to fight stigma
This initiative of World Psychiatric association is probably the widest collaborative effort involving over twenty countries. The result was not only a world-wide programme to fight stigma, but also the development of interventional materials.
India China Collaboration
China and India, which together contain 37% of the world’s population, are both undergoing rapid social change. Because mental disorders account for a high proportion of morbidity, detailed knowledge of the mental health status of the populations in these two countries, and the evidence-base regarding the treatment of those disorders are of importance to the whole world. The China-India Mental Health Alliance comprises experts from both countries and elsewhere. The initial collaboration is in looking at the burden of mental disorders, unmet treatment needs and role of traditional medicine in the two countries.,, In terms of burden of mental disorders, India has similarities with other developing countries (around 50% of DALYs attributable to non-communicable disease), whereas China more closely resembled developed countries (around 80% of DALYs attributable to non-communicable disease). The overall population growth in India explains a greater proportion of the increase in mental, neurological, and substance use disorder burden from 1990 to 2013 (44%) than in China (20%). This burden is estimated to increase by 10% in China and 23% in India between 2013 and 2025. The contact coverage for the most common mental and substance use disorders is very low in both the countries. Effective coverage is even lower, even for severe disorders such as psychotic disorders and epilepsy. There are vast variations across the regions of both countries, with the highest treatment gaps in rural regions because of inequities in the distribution of mental health resources, and variable implementation of mental health policies across states and provinces. Human and financial resources for mental health are grossly inadequate with less than 1% of the national health-care budget located to mental health in either country. The progress in achieving coverage is far more substantial in China. India and China need to invest in increasing demand for services through active engagement with the community, to strengthen service user leadership, and ensure that the content and delivery of mental health programmes are culturally and contextually appropriate. The comparison of the types of traditional, complementary, and alternative medicine in India and China and their effectiveness suggest practitioners of traditional, complementary, and alternative medicine. The mental health professionals need to forge collaborative relationships to provide more accessible, affordable, and acceptable mental health care in India and China. In both countries, a substantial proportion of individuals with mental illness use traditional, complementary, and alternative medicine, either exclusively or with biomedicine, for reasons ranging from faith and cultural congruence to accessibility, cost, and belief that these approaches are safe. The group has identified areas for collaboration to develop mental health services.
India-Pakistan Autism intervention
Autism spectrum disorder affects more than 5 million children in South Asia. Recently, a collaborative effort to understand the feasibility and acceptability of the parent-mediated intervention for autism spectrum disorder (PASS) in India and Pakistan, was evaluated. A single-blind randomized trial of the comparison of 12 sessions of PASS plus treatment as alone delivered by non-specialist health workers, was delivered at two centres, in Goa, India, and Rawalpindi, Pakistan. The Children aged 2-9 years with autism spectrum disorder were randomly assigned (1:1) by use of probabilistic minimisation, age (<6 years or ≥6 years), and functional impairment. 81% of participants completed the intervention. The primary outcome showed a treatment effect in favor of PASS in parental synchrony and initiation of communication by the child with the parent, but the time in mutual shared attention was reduced. The collaborative study demonstrated the feasibility of adapting and task-shifting, an intervention used in a high-income context, to LAMIC situation.
India’s contribution to development of mental health services
There have been a number of contributions to the development of mental health services from India. The important initiatives developed locally/nationally, which have had global impact are: integration of family in routine mental health care, indigenous methods of psychotherapy, yoga and meditation, and integration of mental health in general health care.
The indian psychiatry has been a pioneer in recognizing the importance of family in mental health care. This can be one of the important contributions of Indian psychiatry to global psychiatry. At a point of time when the family of a person with mental disorder was considered ‘toxic’ in the western countries, Indian psychiatrists’ recognized them as partners in mental health care. There are two aspects that have received attention, namely, the special nature of functioning of the family, and the role of the family in mental health care. The first formal recognition of the importance of the family as part of organized mental health care can be traced to the work of Prof. Vidya Sagar in the early period of post-independent India. The next major experiment was initiated at the Mental Health Centre, C.M.C., Vellore from 1957. A very important contribution to the involvement of the family in the community care of persons with mental disorders was by Dr. Shaila Pai and Dr. Kapur, who demonstrated the feasibility and effectiveness of family based mental health care.
Psychotherapy, as a treatment for common mental disorders, occupies an important place in the Indian psychiatry, and this is one subject where a large number of psychiatrists have contributed with different ways to present a different approach to the practice of psychotherapy. This differing conceptualization is illustrated by the following observation:
“In the West (UK, USA) the goal of maturity is an independent existence. There, unacceptable and unrecognized dependency longings become the focus of psychopathology, and psychotherapy attempts to resolve these dependency needs in a manner, which satisfies the requirements of a culture that idealizes individual independence. In an Indian environment, the ideal of maturity is, satisfying the continuous dependency striving in a manner that satisfies the requirements of a culture that idealizes individual submergence in complex interdependence. In the use of the word 'dependency' relationship, we can already discern the language distortion and interpretation distortion, I spoke of. A Western value judgement is unwittingly thrust on the people. There is no real equivalent word conveying the same value judgement. One speaks of 'Bandha'; 'Sambandha'; 'Bandhvya' bond, bondship, kinship etc.,but not of dependency. It would be hazardous to import this word dependency into the Indian psychotherapeutic scene. The integration of personality functions is the Western aim. But some degree of dissociation and ideally a detachment of the higher from the lower functions is the ideal. One can speak of 'My body is suffering. I can only watch - or I do not mind. My eyes weep but I am helpless'. The witness function of the Ego,-emphasized by the Hindu thought, is an important step in psychotherapy. One is encouraged to be first a nonparticipant 'witness' of one's own reactions, before corrections can occur. Ours is a complex civilization. The mere cataloguing of the numerous characteristics of our people from trait questionnaires drawn up in the west will give a very contradictory and distorted picture. The Kiplingisque importunate, docile, dependent, untrustworthy Indian, and the firm, gender, but stern and unflinching Gandhain, Indians are two facets of the same coin."
The other important concept from India is the use of ‘Guru-Chela’ paradigm in therapeutic situations. Similar is the use of cultural, religious and spiritual concepts for mental health care.
One of the Indian contribution to wellbeing, in general and mental health in particular, which is practiced worldwide, is yoga and meditation. The initial research reports suggest use of yoga and meditation for a wide range of mental disorders. This was followed by comparison of standard treatment with yoga in psychoneuroses, anxiety, drug addiction, and psychogenic headache. The more recent studies have examined the effectiveness in dysthymia, depression, schizophrenia, and drug and alcohol dependence. There is wider use of yoga and meditation all over the world to address mental health issues. The increased interest in eastern therapies, and the availability of measures to study the effects should result in more sophisticated studies of effectiveness of the different therapies in different mental disorders and promotion of mental health.
India has been a pioneer in community based mental health programmes, through integration of mental health care with general health care. The initial efforts to integrate mental health with general health services, was initiated at two centres, namely Bangalore and Chandigarh. The Chandigarh centre work was part of WHO project, described in the earlier section. The programme of community psychiatry at NIMHANS, Bangalore was launched in 1976. The aim of the rural project was to develop suitable training programs for the doctors and the multipurpose workers from the various primary health centres in the state of Karnataka, so that after their training PHC personnel could provide basic mental health care (detection and management of epilepsy and psychosis). Following the efforts of understanding the needs and methods of care in the community, pilot experiment to integrate mental health with primary health care in one PHC with a population of 100 000 (1980-86) was implemented.This was a model programme covering a district with a population of 2 million, which has come to a milestone in this field, for India and other countries. A visible outcome of the efforts of India mental health professionals is the formulation of the National Mental Health Programme (NMHP) in 1982. NMHP provided both the direction for the organization of services and the models for reaching there. From the initial studies of 1970’s, today it covers over 125 districts (over 100 million population) in the country.,
It is significant to recognize that the community mental health care through integration of mental health with general health services have directly influenced the development of mental health services in Afghanistan, Bangladesh, Bhutan, Islamic Republic of Iran, Nepal, Pakistan, Palestine, Sri Lanka, Sudan, and Yemen. Such collaboration has occurred through professional visits, use of the training and public educational materials, and evaluation tools. In addition, professionals have provided support in the form of consultancy support, training opportunities, and research.,,,,,,,
The review has shown that International collaboration for delivery of mental health services is an ongoing effort on and it has value. Collins and Saxena have identified the following six steps for future work in this field [Table 2].
Looking at the developments of the last four decades, the following lessons can be drawn for future international collaboration in delivery of mental health services. The following section addresses the questions of relevance of collaboration, the feasibility of collaboration, and the benefits of collaboration.
- Recognizing the universal nature of the challenges of developing mental health services, for effective availability of mental health services in the world, there is need for increasing global commitment. Such advocacy can best be achieved by collaboration across countries.
- The mental health services are sensitive to cultural, societal, political, personal contexts, and values. Collaboration helps to be both sensitive to the differences as well as build on the learning of different communities.
- The experiences of one or more countries can help speed up innovative approaches to provide mental health care in other countries.
- The global initiatives have to be ‘locally’ adapted for effectiveness in implementation. Collaboration helps in avoiding ‘rediscovering the wheel’ as well as taking the learning forward from the experience of other countries.
- The continuous professional communication and establishment of networks is a good way of sharing of experiences.
- The collaborative projects of two or more countries create a momentum,which is not possible when efforts are carried out in isolation.
- Research tools and educational materials can be developed by collaborative efforts faster and better than when these efforts are only in single centres.,,
- The evaluation of interventions and impact is an important part of the development of mental health services. Collaboration provides opportunity to increase size of sample, and the comparisons across wider range of variables.
- The international agencies like WHO, Grand challenges of Canada, SAARC network, Africa group initiatives, European network, South American Network are valuable avenues for collaborative programs.
- The evidence has shown funding support from donors (eg,Grand challenges Canada) can kick start not only innovative programmes, but can also bring about changes in the programmes and mental health policies in different countries.
| Conclusions|| |
The development of mental health services is a continuous process. The barriers to develop mental health services are universal. As the knowledge about mental health and mental disorders increases, and the societal values towards the disadvantaged person changes, there will be newer and newer approaches to care. In these efforts, international collaboration is important as it allows for building of a momentum for change, offers opportunities for learning from mutual experiences, and advancing international understanding of mental health. Past efforts provide hope for future international collaborative efforts.
| Acknowledgement|| |
My sincere thanks to Prof. D. Basu, Chandigarh, for his critical comments onthe initial draft of the paper.
Financial support and sponsorship
Conflicts of interest
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[Table 1], [Table 2]