Access to mental health services: informing efforts to close the mental health treatment gap

Addressing the mental health treatment gap: The Global Burden of Disease studies carried out in the late 1990s established for the first time that mental, neurological and substance-use (MNS) conditions were among the most significant of all disease categories in terms of global Disability Adjusted Life Years (DALYs), with depression, dementia, schizophrenia and alcohol use disorders among the top ten contributors to total global burden of disease. In 2016, the total proportion of global DALYs attributed to MNS conditions was 9.4% at a global level, and 4.3% in low-income countries. Despite the high level of disability associated with mental ill health, around 35-50% of people with mental conditions in high income countries, and 76%-85% in low and middle income countries do not access mental health care. If the expected standard of care is defined as ‘minimally adequate’, then the treatment gap is even higher. A survey of 21 countries found that only 41% of people who attended services received adequate treatment for depression. The first paper submitted with this analytical commentary (‘Interventions to increase use of services; mental health awareness in Nigeria’) addresses one of the postulated reasons for low service use – lack of awareness about existence of services, and lay explanatory models of illness not lending themselves to help - seeking through health services. A campaign consisting of media appearances and targeted engagement with community groups in South Eastern Nigeria, led to a substantial increase in primary health care-based mental health service use. Subsequent work in stigma has emphasised contact interventions (direct or virtual engagement with people living with the stigmatised condition) as a key active ingredient, and there has been important evolution of measures to more accurately explore knowledge, attitudes and discrimination (referring specifically to the behavioural consequences of stigma), which we are now employing in subsequent iterations of this work. Scaling up services: Addressing stigma is an example of one intervention component that contributes to closing the treatment gap, and the second paper submitted (‘Scale up of services for mental health in low-income and middle-income countries’) focuses on the question of measuring the extent to which implementation at scale has been achieved. This paper, part of the 2011 Lancet Series on Global Mental Health, found that despite an impressive number of rigorous studies that showed positive improvements in symptom and functioning outcomes, few governments have invested in applying this evidence at scale. These studies have led to an increasingly well-defined model for mental health service reform. However, there are important differences between how an intervention works as a pilot or in a trial, and when replication is attempted at scale. The barriers to scaling up mental health care essentially remain those that were identified in a key early paper by Saraceno et al in the first Lancet Global Mental Health series. One significant challenge we highlighted was weak health information systems in mental health and poor epidemiological data, so that coverage could not be accurately calculated. Use of other information such as policy reform and investment in national services or Official Development Assistance for mental health, reinforced the conclusion that little concrete progress had been made towards closing the treatment gap. Accountability to service users: In the Lancet Commission on Global Mental Health and Sustainable Development in 2018, I led the section on a ‘dimensional approach to mental health’, where we discussed reframing perspectives around mental health and illness, diagnosis, disability and the role of service users in their own recovery. To understand whether service users have influence in mental health service reform, we assessment objectively their participation in global accountability mechanisms (my third submission: Accountability for the rights of people with psychosocial disabilities: an assessment of country reports for the convention on the rights of persons with disabilities’). In the reports, we found outdated approaches, inappropriate language, and low levels of participation described, particularly in low income countries. However, despite this, there is a significant move towards participation of service users and rights-based approaches as a basis for new international normative guidance development, and we describe the essential role of co-production in global mental health research moving forward. Applying lessons learnt in different contexts and population groups: As in other low- and middle-income countries, while there has been progress on pilots evaluating decentralised services using task-sharing and collaborative stepped care, driving policy change with evidence, and gaining financial investment for scaling up in Nigeria has proved more challenging. The fourth submission (‘A structured approach to integrating mental health services into primary care: development of the Mental Health Scale Up Nigeria intervention (mhSUN)’) outlines the development of an intervention and a plan for scaling up mental health services in Nigeria. The process was participatory, using Theory of Change methodology to ensure broad stakeholder participation in model development, while drawing onglobal guidance and research findings. Key methodological considerations in this work included a focus on process alongside outcome evaluation (on the basis that positive clinical and social outcomes are well documented, but the proof of application in Nigeria was of primary interest to policy makers). Future contribution to the field: This learning around integration of mental health into primary care and community settings can be usefully applied to other target groups or sectors. One example of how this has been done is the field of neglected tropical diseases (NTDs). With a team at University of Jos in Nigeria, a number of studies were carried out to ascertain comorbidity and test an intervention for mental health integration in primary health care (PHC) to improve access for people with NTDs. I describe how research can contribute to building a case for application of these ideas in this new sector, resulting to date in a scoping review, a WHO Guide on Mental Health and NTDs and a forthcoming WHO Essential Care Package. I conclude that in this way, we can increase coverage (and reduce the treatment gap) by not only mental health service strengthening, but also mainstreaming mental health care into other sectors, using the lessons we have learnt in global mental health. More work is needed in health services research to understand how such normative guidance translates to adoption, embedding and sustaining change as we move to a new phase of scaling interventions and integrated services.