Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author

r 2008; all rights reserved. Advance Access publication 29 March 2008

Health Policy and Planning 2008;23:218220 doi:10.1093/heapol/czn008

10 best resources on . . . mental health

Vikram Patel

Accepted

4 March 2008

At the outset, I must acknowledge the position I take on the topic of mental health, following the example set by Davidson Gwatkin in an earlier article in this series (Gwatkin 2007). My selection of the 10 best resources in mental health is unabashedly influenced by two perspectives which have heavily influenced my work: these are the perspectives of public health interventions (as opposed to clinical interventions) and the international or global perspective which, as a number of my chosen resources emphasize, arises from a massive inequity in the distribution of mental health resources in the world. A reader seeking the 10 best resources on the clinical management of mental disorders may not find this list of resources very helpful; although most of them do contain information on evidence-based treatments, only a couple are devoted to actual mental health care interventions for individuals with disorders (Resources 6 and 8). Mental health is a poor cousin of other health concerns in the global health arena. Despite important reports on the scale of suffering and lack of response dating back to 1995 (Desjarlais et al. 1995, see below), virtually none of the major global health initiatives launched in the past decade have even mentioned mental health. This neglect may hopefully be at least partly addressed by the publication of the Lancet Series on Global Mental Health, a series of six review articles (including one call for action) which were published in September 2007. These six articles focus on mental disorders, and (i) review the interrelationship between mental disorders and other health conditions, making the case that there is no health without mental health (Prince et al.); (ii) document the scarcity of mental health resources globally, but also the inequity and inefficiency in their allocation (Saxena et al.); (iii) review the evidence base for effective treatments and prevention of mental disorders in low-middle income countries (Patel et al.); (iv) document the state of mental health systems in all countries of the world, based on United Nations and World Health Organization (WHO) databases and individual country reports (Jacob et al.); and (v) describe the barriers to scaling up evidence-based care for mental disorders at the national and global levels (Saraceno et al.). The final article is a call for action to scale up services for mental disorders, and provides information on three critical elements for scaling up, viz. the cost of scaling up, indicators to monitor scaling up and the research needed to inform scaling up (Lancet Global Mental Health Group).
Professor of International Mental Health, NPHIRU, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. E-mail: Vikram.Patel@lshtm.ac.uk

The Lancet Series represents the latest significant step in building of the evidence base on mental health with the aim of stimulating action by global health policy makers, a process whose first major milestone was the remarkable, and in my view classic, World Mental Health report led by authors from the Department of Social Medicine of Harvard Medical School (Desjarlais et al.) and published in 1995. This report was the first to systematically address the wider social and public health issues which are intimately connected with mental health and mental disorders. Its approach was refreshing; instead of chapters on specific disorders as many resources prior to this report were wont to adopt, we had chapters on risk factors for poor mental health like dislocation and violence, and a life course perspective with chapters on children and youth, women and the elderly. The report was, at least in part, spurred by the remarkable and unexpected findings of the first Global Burden of Disease report which found mental disorders were leading causes of disabilityadjusted life years (DALYs), even in low-middle income countries (Murray and Lopez 1996). Its framework of the model of overlapping clusters of health problems (which include both mental and physical disorders), exacerbating conditions such as unemployment and poverty, and social pathologies such as violence, remains a relevant theoretical basis for understanding the social origins of mental disorders and offering promising opportunities for possible interventions. Six years after this report, and no doubt spurred by its messages, two leading policy organizations released reports emphasizing the burden, unmet need for care and policy imperatives for global mental health. The WHOs World Health Report 2001 titled Mental health: new understanding, new hope is a comprehensive, policy-oriented review on global mental health and was a landmark publication in a year which saw a number of WHO initiatives focusing on this neglected subject. The report provides a superb text for both general public health and specialist mental health audiences, on the burden, causes, treatment and service provision issues related to mental disorders, and rounds off with 10 specific recommendations on addressing unmet need for care. In the same year, the US Institute of Medicine released its report on Neurological, psychiatric and developmental disorders: meeting the challenge in the developing world. This report took a much broader perspective of nervous system disorders or brain disorders, essentially health conditions arising due to structural or functional disturbances in brain function, thereby including conditions such as stroke, epilepsy and dementia alongside mental disorders. This term has since become more popular, for example the Fogarty International Centre of the National

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Institutes of Health uses a similar framework for supporting research in developing countries. Apart from a common origin in the brain, there are many health system issues shared by these disorders, which makes this an original and refreshing contribution to the field. The approach of the book tends to balance a public health and clinical perspective, with most chapters organized around specific biomedical disorder categories (for example, schizophrenia). Two recent publications which describe effective interventions for mental disorders, most of which are delivered by nonspecialist health workers, are important resources. The Disease Control Priorities Project aims to generate information about what works, specifically the cost-effectiveness of interventions in a variety of settings. It is hoped that such information will guide the design of health programs and the allocation of resources with the ultimate goal of reducing the morbidity and mortality. The second edition of Disease Control Priorities in Developing Countries, published in 2006, has five chapters related to nervous system or brain disorders (mental disorders, neurological disorders, developmental disabilities, alcohol abuse and opiate abuse). These five chapters can be accessed online as a collated volume published by the WHO and the Project Disease control priorities related to mental, neurological, developmental and substance abuse disorders. Together, they constitute the most comprehensive documentation of the cost-effective treatments for mental disorders and are the basis for the economic modelling for scaling up carried out by the author from the Lancet series call-for-action group mentioned earlier (Chisholm et al. 2007). The second important publication on interventions is related to mental health problems associated with humanitarian emergencies, such as disasters or conflict, arguably the only area of global health where mental disorders have been addressed to any significant extent. The Inter-Agency Standing Committee (IASC) Taskforce on Mental Health and Psychosocial Support, which was formed in June 2005, released its final report, The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, in 2007. Although there has been much global action to intervene in emergencies, there has been equally considerable controversy and disagreement about appropriate mental health interventions in these contexts (Summerfield 1999). The use of the two terms in the title is an indicator of one of the fracture points in mental health responses to emergencies; thus, whereas many aid agencies outside the health sector have historically preferred to avoid a biomedical approach and use terms such as supporting psychosocial well-being, programmes led by the health sector agencies tend to speak of mental health and mental disorder, and consider the role of both medical and psychosocial interventions. This report represents an important step as it is the product of a multi-sectoral, inter-agency collaboration which clearly identifies useful practices, as well as potentially harmful practices, and provides a broad framework for mental health promotionfor example, the critical role of safety, shelter and nutritionand the detection and treatment of mental disorders in these contexts. Despite the substantial burden of mental disorders and the availability of effective treatments, the treatment gap for mental disorders is large in all countries, but significantly so in lowmiddle income countries. One reason for this is the considerable

scarcity and inequity in distribution of mental health resources in countries of the world. The Atlas project released it first report in 2001, and I recommend its revision published in 2005the Mental Health Atlas. These reports, built on data from multiple sources, provide a systematic picture of mental health resources including policies and budget/financing, human resources, beds, availability of psychotropic drugs and community resources. These data are presented both at the level of individual countries and aggregated according to various dimensions (income group, WHO geographical region). The publication of these two reports using similar methodologies allows for comparison between and within countries, over time, of mental health resources; handily, these data can also be accessed, tabulated or displayed in interactive maps through the Atlas website. This great lack of mental health resourcesin particular, specialist human resources such as psychiatrists and psychologistsin most countries of the world (and their inequitable distribution within countries) means that all the major reports mentioned above have indicated that most mental health care must take place in routine general health care settings by nonspecialist health workers. This is both a recognition of the implications of scarce resources, as well as the reality that most persons with mental disorders prefer to receive help near their homes from their usual health care provider. In 2003, I wrote Where There Is No Psychiatrist in an effort to provide a clinical resource for the non-specialist health worker. The title of the book hints to the source of my inspirationthe classic guide for community health workers written many decades earlier by David Werner (1992). The approach I took was a clinical problem-solving based one; thus, instead of the approach taken by most clinical manuals which use a disorder category approach, I chose to structure the chapters according to common clinical presentations. The book distributed through Teaching Aids at Low Cost to developing countries (TALC) and has been translated into several languages in developing countries. Clinical care can only be delivered effectively if there is strong support from policy makers and an enabling framework for mental health policy development and planning. WHO has produced a guidance package, the Mental Health Policy and Service Guidance Package, related to the development of mental health policies, plans and service delivery models. This package comprises 12 related publications, which together aim to assist policy makers to: develop policies and strategies for addressing the mental health needs of their populations, use existing resources more efficiently and equitably, provide effective services to those in need and assist the reintegration of persons with mental disorders in their communities. The package covers a range of themes, some of which have never been covered in the pragmatic, clear and systematic manner which is the hallmark of this package, such as quality improvement, information systems, workplace policies, human resources and budgeting. I reserve my final choice of my 10 best resources for the issue of stigma and discrimination against people with mental disorders. Mental disorders are the most stigmatized health conditions historically and currently, and stigma has contributed significantly to the tardy response of the global health community to mental disorders. Much has been written in recent years on this subject; readers may be interested to refer

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to some key recent papers on this topic (Link et al. 1999; Jamison 2006). However, my choice for the best resource on this subject is the 2006 book Shunned, by Graham Thornicroft. This superb book is a labour of love arising out of the authors compassion for people with serious mental disorders. The author combines photographs, narratives of experiences of people with mental disorders, and analysis of the causes and strategies to combat stigma and discrimination in a remarkably frank and insightful book. Essential reading for anyone who wonders why, despite the evidence presented in the previous recommended resources, there is still such little response to the unacceptably large unmet need for care for people with mental disorders.

Resources
1. Lancet Series on Global Mental Health, 2007: (i) Prince M, Patel V, Saxena S et al. No health without mental health a slogan with substance. The Lancet 370: 85977. (ii) Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. The Lancet 370: 87889. (iii) Patel V, Araya R, Chatterjee S et al. Treatment and prevention of mental disorders in lowincome and middle-income countries. The Lancet 370: 991 1005. (iv) Jacob KS, Sharan P, Mirza I et al. Mental health systems in countries: where are we now? The Lancet 370: 106177. (v) Saraceno B, van Ommeren M, Batniji R et al. Barriers to improvement of mental health services in lowincome and middle-income countries. The Lancet 370: 116474. (vi) Lancet Global Mental Health Group. Scaling up services for mental disorders-a call for action. The Lancet 370: 124152 http://www.thelancet.com/online/focus/ mental_health. 2. Desjarlais R, Eisenberg L, Good B, Kleinman A. 1995. World Mental Health: Problems and priorities in low-income countries. Oxford: Oxford University Press. 3. World Health Organization. 2001. The World Health Report 2001: Mental health: new understanding, new hope. Geneva: WHO. 4. Institute of Medicine. 2001. Neurological, psychiatric and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press. 5. World Health Organization and Disease Control Priorities Project. 2006. Disease control priorities related to mental,

neurological, developmental and substance abuse disorders. Geneva: WHO and DCPP. Online at: http://whqlibdoc.who.int/publications/2006/924156332X_eng.pdf. Publication reproducing five chapters from Jamison D, Breman J, Measham A et al. (eds). 2006 Disease control priorities in developing countries (2nd edition). Washington, DC: Oxford University Press and the World Bank. 6. Inter-Agency Standing Committee (IASC). 2007. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: IASC. Online at: http://www.humanitarianinfo.org/iasc/content/products/docs/Guidelines %20IASC%20Mental%20Health%20Psychosocial.pdf. 7. WHO. 2005. Mental health atlas 2005. Online at: http://www.who.int/globalatlas/default.asp. Geneva: World Health Organization. 8. Patel V. 2003. Where there is no psychiatrist. London: Gaskell. 9. World Health Organization. Mental Health Policy and Service Guidance Package. Online at: http://www.who.int/ mental_health/policy/services/en/index.html. 10. Thornicroft G. 2006. Shunned. Oxford: Oxford University Press.

References
Chisholm D, Lund C, Saxena S. 2007. Cost of scaling up mental healthcare in low- and middle-income countries. British Journal of Psychiatry 191: 52835. Gwatkin DR. 2007. 10 best resources on . . . health equity. Health Policy and Planning 22: 34851. Jamison KR. 2006. The many stigmas of mental illness. The Lancet 367: 5334. Institute of Medicine. 2001. Neurological, psychiatric and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press. Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89: 132833. Murray C, Lopez A. 1996. The global burden of disease. Boston, MA: Harvard School of Public Health, WHO and World Bank. Summerfield D. 1999. A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine 48: 144962. Werner D. 1992. Where there is no doctor. Berkeley, CA: Hesperian Foundation.