Department of Psychiatry

GMH – Articles of Interest

Mental Health and Developing Countries

In 2007, The Lancet published a series of 6 articles on Global Mental Health that documented the current evidence for global mental health, with a focus on low-income and middle-income countries, and issued a call for action. This article provides a narrative account of the background to the series, its development and the key messages of these articles. This is the first in the Lancet series of six articles on global mental health, with a focus on mental disorders in low-income and middle-income countries.
The second in the Lancet series of six articles on global mental health. This article in the series focuses on structural inequities in the provision of mental health services. Current scarcity of mental health resources from both a financial and political perspective are discussed in conjunction with analysis about inefficiency in the usage of existing resources.
The third in the Lancet series of six articles on global mental health. This article in the series focuses on whether interventions to treat and prevent mental disorders are sufficiently effective and affordable to support a substantial scaling-up of such services in low-income and middle-income countries. The review was restricted to evidence gathered on the four mental disorders that pose the greatest burden in adults and children: depression, schizophrenia, alcohol-use disorders, and developmental disabilities.
The fourth in the Lancet series of six articles on global mental health. This article focused on the level of mental health capacity currently found in low and middle income countries. They present country-specific data on the existing mental health systems and highlight recent trends in these nations. Special focus is placed on indicators like development, economics, and health resources with the article’s overarching goal being to provide decision-makers and programme planners with a baseline, and a realistic view of the challenges and opportunities in the development of mental health systems.
The fifth in the Lancet series of six articles on global mental health. This article focused on the numerous structural barriers to improving mental health services in low and middle-income countries. These included factors like stigma, political infeasibility, financial donations and availability of psychiatric residents and support staff.
The sixth in the Lancet series of six articles on global mental health. This article focused on a personal call to action from the authors asking the global health community, governments, donors, multilateral agencies, and other mental health stakeholders, such as professional bodies and consumer groups, to scale up the coverage of services for mental disorders in all countries. They reinforce that the concentration should be on low-income and middle-income countries where the incidence of these illnesses is highest. They also argue that a basic, evidence-based package of services for core mental disorders should and could be scaled up, and that protection of the human rights of people with mental disorders and their families should be strengthened.
This article represent an overview of the recommendations in the Lancet 2007 series. The article concludes that mental disorders are so inextricably linked with other health concerns that there can be no health without mental health; mental disorders disproportionately affect the poor, and those who are disadvantaged and vulnerable; mental disorders are, even in the poorest countries of the world, a leading cause of disability and loss of economic productivity; low-cost treatments are feasible, affordable and effective for many mental disorders and these treatments can be delivered by community or general health workers; and the treatment gap approaches 90% even for the most severe disorders.
One year after the Lancet series was published, the authors take stock of the effect it had, focusing on implementation of the call for action. Using an objective barometer to see if stakeholders have shown increased commitment to global mental health in recent years, the study found some evidence of the Lancet series effects. Some examples of positive change cited include the development of the WHO mhGAP program to address issues pertaining to global mental health as well as the creation of a national Taskforce on Community Mental Health System Development in Vietnam and Indonesia.
A consortium of researchers, advocates and clinicians announces research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment. They identify the top five challenges in global health and argue that they should serve as a starting point for immediate research and prioritization of policies via WHO and NIMH action.
Chaired by Dr. Peter Singer, the Canadian Academy of Health Sciences (CAHS) provides scientific advice for a healthy Canada. In this article, they assess Canada’s role in expanding global health access and suggest a few strategic opportunities worth pursuing. They found that Canadians and Canadian institutions and organizations are making a real difference in identifying and addressing critical global health challenges. Unlike other high-income countries (HICs) though, Canada does not have a national multi-sectoral strategy to address the increasingly complex issue of global health.
The objective of this study was to describe the characteristics and capacities of mental health systems in low- and middle-income countries. Using the World Health Organization Assessment Instrument for Mental Health Systems, the mental health service in 42 countries was analyzed and the authors report that mental hospitals consume 80% of mental health budgets and that outpatient care and community contact post-release is limited. They also discovered that there was less than one community contact per inpatient day.
With an objective of estimating the shortage of mental health professionals in low and middle-income countries, this research paper used data from the World Health Organization’s Assessment Instrument for Mental Health Systemss (WHO-AIMS) to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. The paper concluded that all low-income countries and 59% of middle-income countries in the sample have far fewer professionals than needed to deliver a core set of mental health interventions.
With an objective of mapping mental health research capacity and resources in low and middle-income countries for the years 1993–2003, this research paper sought out mental health researchers from 114 lower and middle income countries identified through their publications and from local grey literature. A questionnaire was developed and sent to authors to elicit information about researchers’ background, available resources and details of up to three recent projects. With 912 researchers from 52 countries completing the questionnaire, it was discovered that most mental health researchers and publications were concentrated in 10% of the countries and thus, that mental health research capacity is scarce and unequally distributed in the nations of the world.
Less than 10% of research funds are spent on the diseases that account for 90% of the global disease burden. This case study of north–south, south–south collaborations in Sri Lanka is a classic example of the issues faced by mental health researchers in low and middle-income countries. In this paper, Sri Lanka is presented to show an example of a successful private research institution based in a developing country as a product of south–south and north–south collaboration in mental health research. The paper also makes recommendations to international funding agencies, academics, and other bodies on addressing ways to sustain such initiatives in order to reduce scarcity and inequity in mental health research in developing countries.
In the context of the WHO Mental Health GAP program, this paper makes a few proposals for responsible global mental health governance. These include ensuring mental health services in low and middle-income countries are informed by a relevant evidence base to prevent harm and maximize effectiveness, to prioritize international mental health agendas, and to institutionalize the general orientation of mental health research to deal with problems of organizational structure, research prioritization and insufficient involvement of local stakeholders.
In order to monitor global representation in the psychiatric literature, this paper compared publication rates in the ten psychiatric journals with the highest impact factors in 1998 and 2008 by world regions. In both 1998 and 2008, North America, Northern Europe, Western Europe and Oceania produced the majority of psychiatric research papers published in these journals, despite representing only a small fraction of the world’s population. The paper suggests that much of the world’s population continues to be underrepresented in highly influential psychiatric journals and that this must change.

Disaster Psychiatry

This paper discusses the vital role of disaster psychiatry in the evolving structures for preparedness and response in the fields of disaster management. The authors address the role of science and experience in addressing the tragedies of mass catastrophe, the need for systems and the challenges of integrating mental health contributions into the practical requirements for survival, aid, emergency management, and ultimately, recovery. The human face of disaster and the understanding of human strengths and resilience alongside the protection of, and care for, those suffering profound trauma and grief, are central issues.
A disaster is the consequence of an extraordinary event that destroys goods, kills people and produces massive psychological harm. Disasters shake the life of a community and raise questions about safety, social organization and the meaning of life. During early interventions after a disaster, psychiatrists often have to work out of their usual clinical premises, in contact with unfamiliar professionals (i.e. rescue personnel) and with individuals who should not be considered as ‘cases’, and therefore without keeping regular clinical records. In the latter stages of disaster response, they have to confront many factors which tend to cause chronic clinical consequences for survivors who developed a psychiatric condition. Conceptualizing the practice of psychiatry within a bio-psycho-social model can help psychiatrists to understand what disasters are, how some negative aspects of them could be prevented, and how their consequences, both clinical as well as social, can be reduced.
Maintenance of a daily routine, which includes scheduled medications, access to a health care provider, and a stable environment, forms an anchor point in the lives of people diagnosed with mental illness. When a disaster, either man made or natural, interferes with this, patients often experience an acute exacerbation of their illness. Efforts to mitigate the ensuing disruption require a contingency plan ensuring access to medications, health information, and caregiver stability. Recent world events, such as the Asian Tsunami in 2004 and Hurricane Katrina in 2005, indicate that minimal research exists regarding the magnitude of the effects of disasters on those with mental illness. A review of the literature indicates that the impact on survivors’ mental well-being is directly related to the level of exposure to a disaster. Mental health professionals must include crisis management, planning, and communication in pre- and post-disaster interventions with people who have mental illnesses.
Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. This study aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care. The study found the migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. The study then proposed a few specific policy suggestions for addressing these challenges.
The immigrant experience can have profound impacts on health and well-being, even among those who immigrate voluntarily. The healthcare system is usually the first point of contact for immigrants and refugees in need of care and it is an ideal locus to address both physical and mental health needs or to implement illness prevention strategies. This paper reviewed existing data on immigrant/refugee health outcomes and made recommendations for the comprehensive management of these patients. These include consideration of country of origin and immigration history, consideration of risk factors for poorer outcomes (forced immigration, low income, language proficiency), screening and vaccination against standard medical illnesses, and assessment and treatment of mental disorders and chronic medical conditions.

Education in Global Mental Health

This study assessed the educational value of an international psychiatry elective using a cross section of psychiatric residents. In 2010, a 10-item semi-structured questionnaire was administered to Mount Sinai psychiatric residents who have participated in the Global Health Residency Track of the Mount Sinai School of Medicine. Participants found much value in the exposure that was given to sicker, treatment-naive patients in resource scarce conditions and in the cross-cultural communications skills required for the work. Some participants even felt that the elective was a place to consolidate skills already learned during residency and resulted in increased professional confidence.