Global Mental Health

Needs for and Barriers to Correctional Mental Health Services: Inmate Perceptions

The last two decades have witnessed a growing acknowledgment of the importance of research on mental health in the global health context. The 1995 edited volume, World Mental Health [1], the 1996 publication of the Global Burden of Disease Study [2], and the 2001 World Health Report [3] powerfully utilized mental health data or underscored the role of research in achieving gains in mental health around the world. By 2007, the World Health Organization and the Global Forum for Health Research released their report on research capacity for mental health, demonstrating the dearth of mental health research from low- and middle-income countries, in particular, as well as the need to bridge the gap between research, practice, and policy [4]. That same year, the Lancet special issue on global mental health galvanized the global mental health community, outlining concrete actions to advance the field [5]. The series Call to Action underscored the importance of research as a means to expand the global evidence base and to make the case for mental health care delivery reform, especially in low-and middle-income countries (LMICs) [5]. At the time, however, medical students and residents from high-, middle-, and low-income countries, alike, would have noted a dearth of funding to support research training focused on global mental health themes. Despite this, by 2009, new global health programs at universities were rapidly appearing in the USA and providing more opportunities for training in global health [6], but few had well-developed mental health components—either research or clinically focused. At the National Institute of Mental Health (NIMH), a reevaluation of the institute’s role in global health research was also underway. By mid-2009, NIMH began reorganizing the Office for Special Populations and the Office of Global Mental Health to create the Office for Research on Disparities and Global Mental Health (ORDGMH) in 2010. Consistent with the NIMH mission, the new office underscored (1) the critical need to mount an inclusive global effort to expand research—and the capacity to conduct research—on preventing and treating mental illness, (2) the centrality of eliminating disparities as part and parcel of this effort, and (3) the value of recognizing that local contexts around the globe share commonalities that can provide insights into equitably reducing the suffering associated with mental illness. An explicit goal of ORDGMH was to create a research career path in global mental health for US investigators, while also supporting research capacity building in low- and middle-income countries as a route to building high-quality collaborative research. To achieve this goal, ORDGMH expanded collaborations with the Fogarty International Center (FIC)—the NIH center tasked with supporting and facilitating global health research and research training—and, where indicated, developed new targeted initiatives for research capacity development in mental health. In this article, we briefly describe NIMH activities in support of global mental health research training and future directions for research training in global mental health.

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

16 - Ethical issues in global mental health

Global mental health and HIV care: gaps and research priorities.

County-Level Estimates of Need for Mental Health Professionals in the United States

Perceived Effectiveness of Medications Among Mental Health Service Users With and Without Alcohol Dependence

ObjectiveThis paper examines the scope of practice of global health, drawing on the practical experience of a global health initiative of the Government of Canada – the Teasdale-Corti Global Health Research Partnership Program. A number of challenges in the practical application of theoretical definitions and understandings of global health are addressed. These challenges are grouped under five areas that form essential characteristics of global health: equity and egalitarian North–South partnerships, interdisciplinary scope, focus on upstream determinants of health, global conceptualization, and global health as an area of both research and practice.DesignInformation in this paper is based on the results of an external evaluation of the program, which involved analysis of project proposals and technical reports, surveys with grantees and interviews with grantees and program designers, as well as case studies of three projects and a review of relevant literature.ResultsThe philosophy and recent definitions of global health represent a significant and important departure from the international health paradigm. However, the practical applicability of this maturing area of research and practice still faces significant systemic and structural impediments that, if not acknowledged and addressed, will continue to undermine the development of global health as an effective means to addressing health inequities globally and to better understanding, and acting upon, upstream determinants of health toward health for all.ConclusionsWhile it strives to redress global inequities, global health continues to be a construct that is promoted, studied, and dictated mostly by Northern institutions and scholars. Until practical mechanisms are put in place for truly egalitarian partnerships between North and South for both the study and practice of global health, the emerging philosophy of global health cannot be effectively put into practice.

This article charts the historical development of the discipline of global mental health, whose goal is to improve access to mental health care and reduce inequalities in mental health outcomes between and within nations. The article begins with an overview of the contribution of four scientific foundations toward the discipline's core agenda: to scale up services for people with mental disorders and to promote their human rights. Next, the article highlights four recent, key events that are indicative of the actions shaping the discipline: the Mental Health Gap Action Programme to synthesize evidence on what treatments are effective for a range of mental disorders; the evidence on task shifting to nonspecialist health workers to deliver these treatments; the Movement for Global Mental Health's efforts to build a common platform for professionals and civil society to advocate for their shared goal; and the Grand Challenges in Global Mental Health, which has identified the research priorities that, within the next decade, can lead to substantial improvements in the lives of people living with mental disorders. The article ends by examining the major challenges for the field, and the opportunities for addressing them in the future. (harv rev psychiatry 2012;20:6–12.)

Introduction Although mental health problems are common in the workplace, discrimination against mental health is still prominent. Characteristics of one’s own occupation can influence aspects of stigma and attitudes to mental health problems in the workplace context, but there are limited studies examining differences in them between occupational groups. Objectives We investigated occupational differences in mental health stigma, and attitudes to both mental and physical health in the workplace. Methods Data from the British Social Attitudes 2015 survey were used. Logistic regression models were conducted to investigate associations between occupational categories and stigma as measured by desire for social distance, as well as attitudes towards mental and physical health in the workplace. Occupational categories were based on the National Statistics Socio-economic Classification. Measures for attitudes to mental and physical health in the workplace include whether paid work is good for mental and physical health, how soon one should return to work following depression, whether work can help speed recovery from depression, whether one’s medical history should affect their promotion, including depression, schizophrenia and diabetes. Desire for social distance from people with depression and schizophrenia was measures using unlabelled vignettes. Results We found occupational differences in attitudes towards mental and physical health in the workplace, but not in levels of stigma. People in lower supervisory and technical (group 4), semi-routine and routine (group 5) occupations were more likely to have negative attitudes towards mental and physical health in the workplace compared to managerial and professional occupations (group 1). Both occupation groups were less likely than group 1 to believe that paid work is good for mental health (group 4: odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.24-0.61; group 5: OR = 0.34, 95% CI = 0.24-0.49). They were also less likely to believe that people with depression should return to work when they can do some or most of the job (group 4: OR = 0.67, 95% CI = 0.48-0.94; group 5: OR = 0.52, 95% CI = 0.41-0.66). People in group 5 were less likely to believe that paid work is good for physical health (OR = 0.69, 95% CI = 0.53 to 0.89) and that having schizophrenia should not affect promotion at work (OR = 0.78, 95% CI = 0.62-0.97) than group 1. Conclusions Our study reinforced the importance of job characteristics on attitudes to mental health in the workplace. First, employers need to invest more in improving their employees’ well-being. Second, governments should provide more support and resources for small companies to help them develop mental health policies and practices. Third, modifications need to be made to improve job control for employees and to ensure enough reasonable adjustments can be made. Disclosure of Interest G. Cheung: None Declared, A. Ronaldson: None Declared, C. Henderson Consultant of: C.H. has received consulting fees from Lundbeck and educational speaker fees from Janssen.

This chapter describes mental health in Peru within the historical legacy of colonialism and the enduring ethno-racial inequalities to which that history gave rise. Explanatory models and cultural concepts of distress found in Andean communities are discussed, as an important example of the indigenous approaches to mental health that remain influential for many communities within Peru. Peru's first mental health law was passed in 1950 and provided for national planning for mental health at the level of the Ministry of Health. The trauma and suffering unleashed by the conflict between Shining Path and the state in the 1980–1990s led to an unprecedented acknowledgement of mental health as a focus of reconstruction efforts. Psychologists specialising in Clinical and Health Psychology also commonly work in mental health; the minimum training required is the 10-semester psychology degree. Peru's diverse cultural traditions offer a varied range of idioms and explanations for the experiences that biomedicine classifies as 'mental health issues'.

“The implementation gap prevents our nation from reaping the benefit of billions of US tax dollars spent on research and, more important, prolongs the suffering of millions of Americans who live with mental disorders.”—President's New Freedom Commission on Mental Health 2003. Despite the development of effective treatments, depression is still ranked as one of the top ten causes of disability worldwide according to the World Health Organization. It often takes years if not decades to translate evidence-based depression treatments into nonacademic, community-based practices. This research-to-practice gap can lead to millions of dollars of funded research being wasted when the treatments themselves never reach the populations in need [1]. Without a clear strategy to foster implementation and acceptance at the community provider level, a “voltage drop” is experienced when an evidence-based depression treatment developed in tightly-controlled academic settings is then introduced into real-world settings [2]. Moreover, current clinical trials populations are still highly selective (<5% of the diagnosed population) despite the movement towards “community-based research.” There is a paucity of effective strategies or implementation approaches for getting effective treatments for depression and other mental disorders off the academic shelf and into the hands of those who need them. Subsequently, there is a need for further cross-disciplinary research on effective processes to facilitate the uptake of evidence-based treatments in real-world practices. Implementation science is an emerging field poised to address the organizational, provider, and patient-level barriers to the adoption of new treatments for depression as well as for other conditions. The National institute of Mental Health defines implementation as the “use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings [3].” This current issue explores novel approaches based on implementation science for enhancing the uptake of depression treatments. The articles address a range of concepts, both at a higher level on tools for and theories of effective implementation and at the practical level of lessons learned on the ground. This series of articles also focuses on implementing evidence-based programs to improve depression outcomes particularly for underserved populations including lower income patients, adolescents, and women with postpartum depression. Four articles describe the application of implementation theory and measures to inform changes in mental health practice in general and for depression treatment in particular. J. K. Benzer et al. describe barriers and facilitators to coordinated mental health care in primary care settings. Key findings were used to refine an implementation theory for coordinated depression care included the importance of organizational factors such as resources, provider training and workflow designs, and an understanding and appreciation of mental health and primary care practice boundaries. Two additional articles describe complementary approaches for engaging providers in the implementation of new mental health treatments. E. Aisenberg et al. describe a process for building a community-academic partnership to implement telephone cognitive-behavioral therapy for rural Latinos. The article points to how such partnerships can facilitate the adaptation of evidence-based practices in community settings by garnering frontline participant feedback on which elements need to be changed to implement a more scalable and culturally appropriate program. Similarly, D. E. Goodrich et al., using the Enhanced Replicating Effective Programs implementation framework, describe the implementation of an outreach program for Veterans with mental disorders, and what lessons were learned in regards to activating and empowering providers to “lead from the middle” and work within their systems to facilitate patient access. In addition, the paper by A. J. Lewis et al. describes how qualitative data can be applied to develop fidelity and implementation measures to assess update of a family-focused depression intervention. Providers are key stakeholders in the implementation process, yet few studies have focused on the development of effective implementation strategies to facilitate provider training in and sustainability of using evidence-based depression treatments. Three of the papers in this special issue address the challenges in training clinicians in new mental health treatments, and whether training leads to long-term adoption and use of these practices, in particular, problem-solving therapy (PST). J. A. Cartreine et al. describe a web-based training program to further disseminate PST training to novice clinicians and whether long-term coaching by more experienced providers to further boost training effectiveness might be needed. In the paper by R. M. Crabb et al., clinicians undergoing training in PST were followed over to assess the long-term impact of the training on adoption and spread. S. W. Stirman et al. identified key reasons for variation in cognitive behavioral therapy training outcomes across community-based practices and the importance of garnering feedback from frontline providers prior to implementing training initiatives. Additional studies in this issue involved the implementation of depression treatments, notably in real-world populations. J. A. Waxmonsky et al. found that implementing a depression chronic care management programs in a public sector health plan led to significantly reduced depression severity over a 12-month period with a modest increase in health care costs. R. R. Dopp et al. present results of a novel program for adolescents with depression, demonstrating an alternative way to address mood symptoms that in turn also address other major chronic conditions such as obesity. Finally, B. P. Yawn et al. present a systematic review of postpartum depression treatment programs in which the most effective components included formal psychiatric evaluation, colocation of mental health care, and tracking of long-term outcomes. Ultimately, implementation science can inform the adoption and adaptation of effective depression treatments, primarily through a better understanding of the importance of building partnerships with end-users such as health care organizations and frontline providers, understanding barriers to adoption of effective treatments at these levels, and developing interventions that use organizational strategies such as collaborative care or systematic training programs to facilitate adoption. Moreover, there will be additional opportunities for researchers and practitioners to apply the lessons learned from this emerging field to develop more effective and practical depression treatments from the beginning, as well as the use of provider and health care organization-level strategies to ensure their adoption and sustainability in the real world. To this end, new skills will need to be acquired, including the measurement of factors facilitating or impeding treatment uptake, especially at the provider and system level using both qualitative and quantitative methods, application of nonrandomized controlled study designs that take into account variations in provider and organizational differences, as well as the inclusion of real-world patient populations that to date are not well-represented in depression clinical trials. Moreover, by placing greater emphasis on partnerships, frontline provider input, and practical treatment strategies, mental health implementation researchers will be poised to lead the development of the next generation of effective depression treatments. Amy M. Kilbourne Mark Williams Mark S. Bauer Patricia Arean

There is a dearth of research that aims to understand graduate students’ lived experience of global health practice. Difficulties, distress, and trauma occur before and after these students’ placement abroad, and they often increase when returning home. Moreover, few articles address the increased vulnerabilities faced by women, such as sexual violence and gender-based discrimination. We conducted a phenomenological study to understand the lived experience of Canadian and US women graduate students participating in global public health practice. Eight participants participated in 21 in-depth interviews, while 17 participants created 35 lived experience descriptions through a guided writing exercise. Our findings reveal participants’ underlying discomfort with privilege while conducting fieldwork abroad, as well as depressive feelings once they return home. According to participants, while their global health fieldwork challenged previous ways of thinking and being, limited spaces and avenues for openly sharing these processes contributed to mental health challenges. Participants reported that these interviews were their first opportunity to fully share their global health experiences. Based on our analysis of these shared experiences, we argue that academic institutions participating in global health should provide appropriate and accessible resources, adequate financial compensation, safe spaces for authentic conversations, and time for processing experiences throughout the research cycle and especially in the months and years following fieldwork.

There is growing concern within the global mental health arena that interventions currently being executed to scale up mental health services in Africa will be ineffective unless simultaneous steps are taken to address people's help-seeking behaviour. Drawing upon two conceptual tools arising from science and technology studies (STS), those of a "classification system" and "the black box," this paper looks critically at discursive constructions of help-seeking in Africa within mental health research over the last decade. Research in this area can be divided into two dominant traditions: the knowledge-belief-practice survey and indigenous-knowledge-system approaches. Although the content and value-codes between these approaches differ, structurally they are very similar. Both are mediated by the same kind of system of classification, which demarcates the world into homogenous entities and binary oppositions. This system of ordering is one of the most stubborn and powerful forms of classification buried in the "black box" of the modernist/colonial knowledge archive and is fraught with many questionable Eurocentric epistemological assumptions. I consider whether there might be other ways of understanding help-seeking for mental illness in Africa and discuss two studies that illustrate such alternative approaches. In conclusion, I discuss some of the challenges this alternative kind of research faces in gaining more influence within contemporary global mental health discourse and practice.

10.1176/appi.ps.59.1.105