1. Global Mental Health a new global health discipline comes of age
Vikram Patel
London School of Hygiene & Tropical Medicine, UK
Sangath, India
Public Health Foundation of India
Department of Global Health & Social Medicine, Harvard Medical School

2. Global Health
“an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide”
(Koplan et al, Lancet 2009)

3. Global vs International
Concerned with health disparities within and between countries
Interest in global determinants such as climate change and migration
Priority setting by burden of disease

4. “international is what we can do for you…global is what we can do together”
Srinath Reddy

5. Global Mental Health
The application of these principles to the specific domain of mental ill-health
Concerned with any ‘priority’ disorder affecting the brain (“MNS” disorders)
Primary focus on disparities in provision of care and respect for human rights of people living with mental disorders between rich and poor countries

6. Scientific foundations of GMH
Cross-cultural mental health research
Burden of disease estimates
Intervention and health services
Discrimination and human rights

7. Cross-cultural research

8. Cross-cultural research
Rich history of multi-disciplinary research, rooted in medical anthropology, clinical mental health sciences and epidemiology, on the cultural construction, social narratives, prevalence and risk factors for mental disorders, with especially rapid growth since the 1960s

9. Key findings
Major categories of mental disorders can be identified in all cultures, and share similar ‘core’ psychopathological features
Research methodologies can be both internationally comparable and contextually and culturally appropriate
Social disadvantage is strongly correlated with mental disorder; there is a vicious cycle of disadvantage and mental disorder

10. Click Link to book for more information

11. Click link to book for more information

13. Burden of disease

14. MNS disorders are common
Prevalence varies with setting and disorder
10% of adults overal
Up to 30% of Primary Care Attenders
Between 0.5 and 2% of all adults suffer from a chronic, severe MNS disorder
About 1 in 10 children suffer from a childhood MNS disorder

16. GBD 2013
GBD 2013 estimated DALYs for 306 diseases and injuries, across 188 countries
The burden of MNS disorders increased by 41% between 1990 and MNS disorders now account for one in every ten years of lost health globally
Note. This figure is based on GBD 2013 estimates for 1990 and The points to make here are:
that high level findings have not changed
We are seeing an increase in absolute burden due to demographic shifts in the population.

17. Mental disorders strike in youth
Most MNS disorders, possibly more than 75% of the burden in the population, have their onset during youth, the most productive years of life
(Kessler et al 2005)

19. Mental disorders kill Cause-specific deaths versus excess deaths
Cause-specific deaths are constrained by ICD coding which obscures the contribution of other underlying causes of death
Excess deaths are derived from natural history models (all-cause mortality)
Estimates of excess deaths include but are not limited to cause-specific deaths (i.e. deaths from causal and non-causal origins).
The relatively small YLL burden attributable to MNSD may incorrectly lead to the interpretation that premature death in people with MNS disorders is inconsequential. Evidence shows that people with MNS disorders experience a significant reduction in life expectancy, with risk of mortality increasing with disorder severity.
Mortality is quantified using two different, yet complementary, methods employed as part of the GBD analyses. First, cause-specific mortality draws upon vital registration systems and verbal autopsy studies that identify deaths attributed to a single underlying cause using the ICD death coding system. Second, GBD creates natural history models of disease, drawing on a range of epidemiological inputs, which ultimately provide epidemiological estimates for parameters including excess mortality—that is, the all-cause mortality rate in a population with the disorder above the all-cause mortality rates observed in a population without the disorder. By definition, the estimates of excess deaths include but are not limited to cause-specific deaths.
Cause-specific mortality estimated via the ICD obscures the contribution of other underlying causes of death (for example, suicide as a direct result of depressive disorder) and likely underestimates the true number of deaths attributable to a particular disease. However, the estimation of excess mortality using natural history models often includes deaths from both causal and non-causal origins and likely overestimates the true number of deaths attributable to a particular disorder. The challenge is to parse out causal contributions to mortality (beyond those already identified as cause-specific) from the effects of confounders.

20. Total Cause-specific and Excess Deaths for All MNS Disorders
13,559,271

21. Leading cause of death in young people

22. People with mental disorders die younger

23. The close relationship of mental disorders with physical health

24. Intervention and health services research

25. Synthesizing evidence on what works

26. Treatments Specific treatments for specific disorders
Psychological treatments
Drug treatments
Social interventions targeting relevant social determinants
Clinical algorithms

27. Integrating treatments into “disorder” packages

28. Key aspects of ‘disorder’ packages
Prevention and promotion: weak evidence for most disorders with some exceptions
Detection and diagnosis:
for common conditions, screening/training;
for rarer conditions, pro-active community case-finding and diagnostic interview
Treatment and care:
combined pharmacological-psychosocial
use of off-patent medications
Continuing health and social care

29. Platforms of care

30. 55 chapter authors from 14 countries

31. Most people, up to 90% of those with mental health problems in some settings (LMIC), do not receive these interventions

32. Barriers to scaling up
LANCET PAPER

33. The GMH solution Use ordinary people!
Lay health workers delivering group Interpersonal therapy for depression in rural Uganda (Bolton et al, JAMA 2003)
Lady health visitors using CBT to treat postnatal depression in rural Pakistan (Rahman et al, Lancet 2008)
Lay counsellors led collaborative care for depression and anxiety disorders in primary care (Patel et al, Lancet 2010, Br J Psych 2011)

35. Human rights

36. Discrimination and human rights

37. Time Cover Story: November 2003

45. #6: The Call for Action
To scale up the coverage of services for mental disorders in all countries, but especially in low and middle income countries.
Based on two principles:
an evidence-based package of services for core mental disorders and
strengthening the protection of the human rights of persons with mental disorders and their families.

46. Impact on policy and practice

47. Providing effective mental health services in primary care settings would help to reduce the stigma associated with mental disorders and could prevent unnecessary hospitalization and human rights violations of people with mental health problems. …
Such strategy makes good economic sense….it is also a pro-poor strategy. …
Let us this year resolve to reduce the public health burden and the individual suffering of people with mental health problems worldwide.
Ban Ki-Moon, October 2009

48. The future?
Act early in the life course and the course of an emerging mental health problem to prevent mental disorders
Scale up evidence based interventions for mental disorders through innovative approaches, such as task-sharing and use of digital technologies.
Support and empower persons with mental disorders to become effective advocates and engage with mental health care

49. JAMA, May 2010