Going to Scale with Mental Health Innovations in Low- and Middle-Income Countries

Presenter

Beverly Pringle, Ph.D.
Office for Research on Disparities & Global Mental Health

Goal

This initiative aims to (a) support research on scaling up delivery of science-based mental health interventions in low- and middle-income countries (LMICs); and (b) enhance regional capacity to conduct mental health research. Support will be provided for teams composed of research institutions, representatives of governmental and non-governmental organizations, providers, and mental health advocates to conduct state-of-the-science mental health services implementation research. Studies will evaluate the feasibility and effectiveness of strategies for large-scale, sustainable delivery of science-based mental health interventions with demonstrated effectiveness. NIMH anticipates that the initiative will identify useful implementation models for expanding access to and engagement in high quality care in low-resource settings globally, and provide tools for testing implementation mechanisms in evolving provider organizations and healthcare systems. Awards will also support activities to enhance regional capacity for conducting research that can improve implementation quality, policy impact, sustainable delivery of evidence-based mental health care, and care outcomes.

Rationale

The Grand Challenges in Global Mental Health initiative identified expanding access to effective mental health care as a major challenge,¹ and the World Health Organization (WHO) and others have called for intensified efforts to close the mental health treatment gap.² The mental health treatment gap refers to the proportion of persons who need, but do not receive care. This gap exists globally, but collateral issues in LMICs make closing it there especially challenging. More than 80% of the world population lives in LMICs and the burden of disease associated with mental disorders is these countries is rising. Moreover, the gap between treatment need and the allocation of human, scientific, and fiscal resources for mental health in LMICs is huge. The median number of psychiatrists per 100,000 people is 0.05 in low-income countries, compared to 8.6 in high-income countries.³ The need for rigorous mental health research is tremendous, and research activity in this area is disproportionately lower than for other areas of health.⁴ At the same time, financing for mental health is insufficient: on average, there is a 200-fold difference between investments in low-income and high-income countries.⁵ These situational factors require innovative solutions for scaling up evidence-based care in LMICs.

Recent policy shifts and growing evidence of the efficacy, cost-effectiveness, and successful delivery of a range of pharmacological and psychosocial treatments for mental disorders in LMICs have set the stage for new investments aimed at reducing the mental health treatment gap in these countries.⁶ Over the past 10 years, NIMH and other funders have supported research focused on mental health services in LMICs. These studies are extending our understanding of the elements that contribute to successful mental health care systems in LMICs and will inform subsequent efforts to scale up services. A decade ago, a randomized controlled trial of group interpersonal psychotherapy for depression showed significant reductions in depression and dysfunction among adults in rural Ugandan villages.⁷ More recently, the Programme for Improving Mental Health Care (PRIME) found that task-sharing mental health services (i.e., delivery of mental health services by non-professionals under the supervision of specialists) is acceptable and feasible under certain conditions in countries in Africa and Asia.⁸ Other research initiatives will produce results in the coming months and years, including the NIMH-funded Collaborative Hubs for International Research on Mental Health, the European Commission’s EMERALD Project (Emerging Mental Health Systems in LMICs), and Grand Challenges Canada’s Global Mental Health program. The WHO and, increasingly, LMICs are promoting policies to expand mental health care. The WHO’s comprehensive mental health action plan 2013-2020 calls for member states to increase service coverage for serious mental disorders by 20% by the year 2020. Taken together, these research and policy initiatives make now the time to invest in research on scaling up mental health care in LMICs.

Initiative

This initiative aims to stimulate and support implementation research to scale up existing and emerging mental health innovations in LMICs. NIMH is interested in approaches for identifying, understanding, and overcoming barriers to the adoption, integration, scale-up, and sustainability of evidence-based interventions. Research that builds on and expands the knowledge generated by NIMH-supported and other research efforts with potential for scale up in LMICs will be encouraged.

The breadth of projects could include, but would not be limited to, testing strategies or models for scaling up:

• Delivery of mental health care in community-based settings to expand, and achieve equity in, access to care;
• Use of core competencies in training and certifying mental health care providers;
• Training and supervision for mental health care delivered by non-specialists;
• Integration of screening and core packages of services into routine primary health care;
• Integration of mental health care with care for other chronic medical conditions;
• Implementation of effective, equitable, and efficient mental health policies and guidelines;
• Interventions that reduce the cost and improve the supply of effective medications; and,
• Use of mobile and IT technologies to increase access to evidence-based mental health care.

Expected Outcomes

Expected outcomes include new knowledge for scaling-up delivery of evidence-based care for mental illnesses, new knowledge about mechanisms of successful scale-up in low-resource settings, enhanced regional research capacity in LMICs, and expanded regional collaborations for continued research on practice quality and variation, policy impact, and sustainable delivery of evidence-based mental health care.

References

¹ Collins PY, Insel TR, Chockalingam A, Daar A, Maddox YT. Grand Challenges in Global Mental Health: integration in research, policy, and practice. PLoS Med 2013; 10: e1001448.

² World Health Organization, Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders. WHO, Geneva, Switzerland, 2008.

³ World Health Organization, Mental Health Atlas. WHO, Geneva, Switzerland, 2011.

⁴ Global Forum for Health Research and World Health Organization. Research Capacity for mental health in low- and middle-income countries: results of a mapping project. GFHR & WHO, 2007.

⁵ World Health Organization, Mental Health Atlas. WHO, Geneva, Switzerland, 2011.

⁶ Patel V, Araya R, Chatterjee S, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007;370:991–1005.

⁷ Bolton P, Bass J, Neugebauer R, et al. Group interpersonal psychotherapy for depression in rural Uganda: A randomized controlled trial. JAMA 2003; 289:3117–3124.

⁸ Mendenhall E, De Silva MJ, Hanlon C, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social Science and Medicine 2014; 118:33-42.

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