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Current Opinion in Psychiatry:
doi: 10.1097/YCO.0000000000000068
Edited by Dieter Naber and Harold Pincus

Innovative strategies for closing the mental health treatment gap globally

Rebello, Tahilia J.a; Marques, Andreab; Gureje, Oyec; Pike, Kathleen M.a

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Author Information

aGlobal Mental Health Program, Columbia University, New York, New York, USA

bDepartment of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil

cInstitute of Neuroscience, University College Hospital Ibadan, Ibadan, Nigeria

Correspondence to Kathleen M. Pike, PhD, Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA. E-mail:

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Purpose of review: In the field of global mental health, an enormous gap between what we know and what we do exists in the delivery of clinical care. Creative and effective strategies that surmount the barriers to provision of mental healthcare are essential to improve the lives of millions affected by mental illness. This article provides a review of three classes of innovative strategies currently being developed and implemented to diminish the mental health treatment gap globally.

Recent findings: This review provides recent evidence related to the feasibility of implementation and efficacy for the following three classes of innovation that show promise for building clinical capacity and expanding mental health coverage: integration of mental health services into primary care; expansion of human capacity through task sharing and training of nonspecialists; and innovative use of technological platforms to enhance access, cut costs, and reduce stigma.

Summary: The strategies outlined in this review hold great potential for enhancing mental health treatment services, and address some of the major barriers globally to accessing mental healthcare, such as scarcity of resources (infrastructure, capacity, and funding) and stigma. Despite much evidence supporting the efficacy of these models, thorough studies that test their feasibility, acceptability, utility, and effectiveness in various contexts, including low-income and middle-income countries, are required. Moreover, these innovations require social support and political will in order to be successfully implemented and scaled-up such that they have a meaningful impact on the burden of disease associated with mental illness worldwide.

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Psychiatric disorders are highly prevalent, frequent causes of disability and represent an elevated burden to society [1]. Between 1990 and 2010, mental and behavioral disorders accounted for nearly one-quarter of all ‘years lost because of disability’ or YLDs [2]. During the same period, disability-adjusted life-years (DALYs) attributable to mental, neurological, and substance use disorders (MNSDs) rose by 38% worldwide, and now represent 7.4% of the world's total burden of health problems [1,3]. This rising burden imposes significant challenges on healthcare systems, on the individuals who rely on these systems, and on mental healthcare providers worldwide.

Worldwide, access to proper mental health treatment is disturbingly low, particularly in low and middle-income countries (LMICs) [4]. Treatment rates for MNSDs are suboptimal, ranging from 35 to 50% [4–6]. In addition, there is a substantial deficit of human resources for mental health, predominantly in LMICs [7].

Innovative strategies involving healthcare systems, mental health professionals, and consumers are needed to close the mental healthcare treatment gap and make the best use of available resources. There are several approaches that hold promise for diminishing the mental health treatment gap [8,9]. In this article, we discuss three strategies that have the potential to substantially reduce the disease burden of mental illness: the integration of mental healthcare into primary care services, which can play an important role in reducing stigma in addition to addressing the lack of established mental health systems; task shifting and task sharing, which can substantially reduce the cost and the number of healthcare providers otherwise needed to close mental health service gaps at the primary healthcare level; and the incorporation of technological innovations into existing mental healthcare service delivery models to expand the reach of services, cut costs, and reduce stigma.

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Integrating mental health into the primary care setting is a powerful model with the potential to increase treatment capacity in places lacking specialist mental health providers. In low-resource contexts, the vast majority of mental healthcare is obtained in nonspecialist settings. Thus, there is widespread recognition that decreasing the mental health service gap in LMICs requires integration of mental health services into the preexisting primary health system [10▪▪,11–13]. This model is supported by the greater likelihood that, even in remote and resource-limited regions, there is a greater likelihood of finding preestablished primary health infrastructure. Moreover, given their integrative nature and location, primary care services are strategically positioned to provide the necessarily integrated care that can address both physical and mental needs. In addition, the central location of primary care centers within the community facilitates both access to and development of culturally sensitive and regionally nuanced skills in health delivery, which counteracts the barriers related to costs (e.g., transportation) and to the stigma associated with specialized mental health treatment centers. In this way, the integrative model has the potential to enhance quality of care and help-seeking behavior, thereby diminishing the treatment gap for mental illness.

Identifying the integrative model as an effective and viable way of closing the treatment gap globally, the WHO and the World Federation of Family Doctors (WONCA) jointly issued a comprehensive report which describes the rationale and measures needed for successful integration [13]. This report highlights the fact that harmonization of mental and primary healthcare allows more holistic and less fragmented patient care, which is especially important given the high incidence of comorbidity and the complex and bidirectional interactions between mental disorders and physical illness [14–17]. The report also emphasizes the need to customize the local aspects of the integration depending on the existing health structure. Finally, the report highlights the need for primary care physicians to receive adequate training and supervision from specialists so that they are able to develop the skills and confidence to recognize, screen, diagnose, and manage prevalent mental disorders.

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Evidence and considerations for successful integration

Several recent studies have shown the efficacy of the collaborative care model for the treatment of mental and substance abuse disorders [18–20]. For instance, in a recent systematic review, it was shown that the collaborative care model has shown good results in the treatment of depression and anxiety, and in patients with comorbid mental and physical conditions, including cancer and diabetes [14,20–23]. Studies showed that this model was effective even in low-income and minority populations [21,22]. Importantly, the collaborative care model has been shown to have the best cost–benefit ratio for disseminating information, training primary care staff in mental health, facilitating treatment compliance, and impacting patient outcomes [19,24–26].

Although integrative and collaborative care models hold promise for establishing and scaling up mental health services in various settings, they are not without caveats [27]. The model may not be suitable for serving the needs of patients with complex diagnoses requiring treatment and management at specialized centers. Also, in a general primary care setting with constraints on clinicians’ time and resources, some cases of mental disorders may go undetected or be neglected [10▪▪,27]. There is also the risk of placing additional workload on an already overburdened system if adequate resources, supervision, referral processes, and access to follow-up care are not in place. For this model to work, primary care facilities should be able to count on a readily available supply of psychotropic medications and other essential resources such as day hospitals, semi-intensive psychiatric care, and psychiatric beds as well as functional referral procedures and facilities for the management of complex cases [10▪▪,13]. A system thus arranged is likely to offer a range of evidence-based interventions that may be collaboratively delivered or structured to provide a stepped-care model, in which the specific intervention delivered is commensurate with the medical needs of the patient [26,28]. This maximizes the limited resources for mental health available globally.

Successful integration also requires interactions with other realms of public service, such as social welfare, education, and other government sectors. Primary care for mental health must be coordinated with a network of services at different levels of care and complemented by broader health system developments. For instance, most successful initiatives were achieved when mental health was incorporated into health policy and legislative frameworks and supported by senior leadership [8,10▪▪,13]. The integrated strategy of developing a collaborative and multidisciplinary team-based approach to mental healthcare, when scaled-up to the highest level, has the potential to greatly decrease the mental health service gap.

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A dearth of health professionals trained in mental health is the single most significant contributor to the mental health treatment gap in LMICs. Despite evidence for the existence of psychosocial interventions with documented efficacy in various settings, including LMICs, the human resources required to implement such interventions are scarce [19,29,30▪,31,32]. An innovative approach that addresses this deficit is utilizing a diverse cadre of general health professionals and community workers who receive training in mental health. In this ‘task-sharing’ or ‘task-shifting’ model, the responsibility for providing mental health screening, referrals, management, and follow-up is shared between trained nonspecialized health workers and specialists. Task shifting in mental healthcare is congruent with the collaborative care model described in the previous section and may include the training of primary care physicians, nurses, community health officers, paramedics, and even nonhealthcare workers, such as lay community members and peer support workers [30▪,31–34]. The task-sharing paradigm allows the efficient use of nonspecialists, who exist in greater numbers than specialists and are often already embedded in the health system.

It is increasingly evident that individuals with limited or no mental health background are able to effectively provide mental healthcare and support when given basic training and ongoing supervision [31–36]. Additionally, given the resources and infrastructure required to train and retain specialists, task sharing and training of nonspecialists is a particularly attractive model, as it may be both more efficient and more economical (particularly in LMICs) to engage in mass general training for nonspecialists [24,37,38].

As a resource for scaling-up services and building clinical capacity, the WHO launched its Mental Health Gap Action Program (mhGAP) in 2008 [39]. A key component of the program is the mhGAP-Intervention Guide (mhGAP-IG), a tool intended to assist nonspecialists in identifying and offering evidence-based treatment across a spectrum of nine priority mental, neurological, and substance use disorders [40]. In line with the literature on successful task-sharing paradigms, WHO emphasizes the requirement for effective, contexualized, and ongoing high-quality training for nonspecialist end users of the guide.

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Best practices and case studies in task sharing

Recently, Abdulmalik et al.[41▪▪] implemented a demonstration project based on mhGAP to increase the mental health workforce in Nigeria. The implementation consisted of two main phases: the contextualization and adaptation of the mhGAP-IG for the extant Nigerian health system; and expanding the capacity of primary care providers needed to deliver evidence-based interventions for selected mental health conditions, using the mhGAP-IG. Both phases required a high degree of adaptation to the context of the Nigerian health system and to existing capacity. The WHO Assessment Instrument for Mental Health Systems [42] was used to conduct a situational analysis to determine the resources required to implement the program successfully. To ensure delivery of quality training with high fidelity and maximize the utilization of limited specialist resources, a special variant of cascade training was used, wherein a few master trainers trained a selection of facilitators, or second-level trainers, who subsequently trained primary care providers. This program was able to successfully adapt the mhGAP and increase the number of nonspecialized health workers able to deliver evidence-based interventions for selected mental health conditions.

In India, an intervention by trained lay health workers was shown to be effective in decreasing disability and symptoms in patients with schizophrenia [43,44▪]. This Community care for People with Schizophrenia in India (COPSI), a multicenter, randomized controlled trial, compared the efficacy of a community-based intervention for people with schizophrenia and their caregivers with standard facility-based care in India [44▪]. Patients who received a diagnosis of schizophrenia were randomly assigned to receive either community-based care delivered by a lay health worker in combination with facility-based care or facility-based care alone. The main outcome being investigated was a change in the symptoms and disabilities over 12 months, as measured by the Positive and Negative Syndrome Scale (PANSS) and by the Indian Disability Evaluation and Assessment Scale (IDEAS). At 12 months, the PANSS and IDEAS scores of patients in the intervention group were significantly lower than those in the control group. On the basis of their moderate effects on patient outcomes, this group suggested that, in a resource-constrained setting, the community health worker model is best implemented as an initial phase of care for patients with schizophrenia.

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Need for further innovation

Although there is great promise for using trained nonspecialists in the provision of mental healthcare, studies that more definitively show the efficacy, feasibility, and acceptability of these task-sharing programs are warranted. Additionally, although the task-sharing model decreases the sole reliance on specialists for the provision of mental healthcare, it does not remove the requirement for these specialists altogether. Trained psychologists, psychiatrists, and other specialists are still vital in providing initial training and ongoing supervision to trained nonspecialists. Innovative methods to further enhance mental healthcare capacity are thus required to decrease the treatment gap. Some of these novel approaches, involving technological platforms, are described in the following section.

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The utilization of novel technological tools to reduce the mental health treatment gap has recently been emphasized as a key policy initiative by the global agencies, including the WHO's Mental Health Action Plan [45], and at the World Innovation Summit for Health held in Doha, Qatar in December 2013. Technological tools have the potential to enhance access to effective care in a cost-effective manner, reach a more diverse and wider group of users, and reduce stigma [46▪,47–50]. Over the last few years, there has been a tremendous global increase in the ability to access technological innovations and communication devices, including remote and rural regions in LMICs. By 2017, 85% of the world's population will have internet coverage and there will be close to nine billion mobile subscriptions [51]. Technology expands the ability to provide care to disadvantaged patients who are otherwise unable to access it because of their geographical location, prohibitive transportation costs, or incapacitation due to serious physical or mental illness. The costs involved in the usage of technology have been decreasing exponentially and the appropriate use of technological innovations can allow limited, or unevenly distributed (e.g., higher density of specialists in urban centers or in non-LMICs), resources to be used maximally. By allowing anonymity, technology also has the unique potential to contribute to de-stigmatization of mental illness and enhance help-seeking behavior, especially in younger populations [50,52]. Information communication technology also offers relevant and innovative strategies for young people at increased risk of developing mental health difficulties, and allows the widespread dissemination of antistigma campaigns and advocacy material that can result in improved attitudes toward mental health issues among youth, thereby potentially enhancing the help-seeking behavior [50].

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Technological platforms with potential

There is a growing body of work demonstrating the use of technology in various domains of mental healthcare provision, including screening, diagnosis, management, data collection, treatment delivery, and promoting patient adherence. For instance, telepsychiatry (also referred to as ‘TeleMental Health’), through the use of videoconference tools, has been shown to support the integration of mental health into primary care by providing remote specialist support, clinical guidance, and second-opinion consultations resulting in reliable diagnosis and treatment and improved levels of satisfaction and acceptance from a variety of clinical populations [53–57]. For instance, in the USA, the Mental Health Integration Program provides telepsychiatry in more than 150 community health clinics, and more than 10 000 consultations reached 35 000 people in 2011 [56]. A recent, randomized, comparative effectiveness study compared the impact on patient outcomes of a solely practice-based collaborative care model (in which patients received treatment in a general health center from a primary care practitioner and a nurse manager) vs. a telemedicine-based intervention (on-site primary care provider and an off-site nurse care manager and a pharmacist via telephone, and a psychologist or psychiatrist via videoconferencing) [57]. The study found that depressed patients receiving collaborative care in a primary health center using a telemedicine-based model, had greater reductions in symptom severity over time, compared with patients receiving only practice-based care. Another example is the Schizophrenia Research Foundation (SCARF) project in India, which uses telepsychiatry consultations in mobile clinics to provide mental health services to remote areas [58].

Mobile phone text messaging also has the potential to enhance access because of service availability worldwide, low cost, instant communication capability, and low requirement of technological expertise [59,60]. In South Africa, for instance, a preliminary qualitative study reported that a majority of participants supported SMS text messaging as a means of reminding mental health service users to take their medication and attend follow-up appointments [60].

Mobile Health smartphone applications (mHealth apps) have shown promising results in enhancing patient adherence and behavioral change, and have shown acceptance and feasibility by end users [59,60,61▪,62–64]. Recently, there has been a tremendous increase in the number of mobile health apps, some of them related to mental healthcare. Applications for mobile-phone-based assessment can facilitate cost-effective interventions [61▪,65]. A recent systematic review suggests that mobile apps for mental health have the potential to be effective in reducing depression, anxiety, stress, and possibly substance use for individuals experiencing these symptoms [61▪]. Finally, web-based psychotherapy programs that address mental illness of mild-to-moderate severity have also gained popularity in some developed countries and may prove a cost-effective model for LMICs as well. ‘MoodGYM’ in Australia is a free web-based psychological therapy program which has proven effective at treating mild-to-moderate depression and anxiety and in promoting mental well being [66]. Similarly ‘VIARY’ digital technology in Sweden [67] offers a mobile and web application that facilitates the delivery of blended therapy for common mental disorders. Moreover, ‘e-learning’ using online training and education modules or materials enables high-quality, relevant information related to mental health to reach a large number of healthcare workers, patients, or the general population in a rapid and cost-effective manner. Some examples of effective use of e-learning in mental health include the E-Health Project in Afghanistan, which provides direct intervention for young adults through cell phones, raises skill and knowledge levels of healthcare workers in the community and the hospital through e-learning, and provides service delivery through virtual teleconsultations [68]. Additionally, promotion of distance mental health education courses for primary care professionals and other education initiatives for both patients and practitioners has been growing in Brazil, especially in regions with low coverage of mental health professionals. As an example, through the Programa Telessaúde Brasil [69,70], continuous online support and educational activities and second-opinion consulting programs have been implemented in several states of Brazil, and have been widely accepted and qualified as relevant by 95% of participants [70].

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Considerations for effective implementation and scaling-up

Although the use of information technology holds tremendous potential for enhancing the access to mental healthcare, it has its challenges. First, it requires a specialized workforce with the expertise to develop and implement these tools. Thus, a lack of training resources or technological expertise may act as a barrier to the development, dissemination, and implementation of these tools. Although technological innovations bring cost savings in the long term, the initial costs and resources involved in the technological change are substantial and can prove a major barrier to progress in resource-constrained settings. Additionally, the lack of interoperability and uniform systems limits the reach and acceptability of many technological innovations. Patient privacy and data security are also issues that require consideration and policy development in order to protect sensitive or private patient information. Moreover, before any technological innovation is scaled up, additional studies, implementation, and efficacy studies in diverse contexts and global regions are needed to further assess the effectiveness, utility, cost-efficiency, feasibility, and acceptability of technological tools for mental health. Despite these challenges, it is clear that technological innovations hold great potential to help make major strides in reducing the burden of mental illness.

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The mental health treatment gap is substantial and expansive in many parts of the world, with an exacerbated situation in resource-poor settings. However, it has been demonstrated that innovative interventions to reduce this gap exist. We have discussed three effective strategies that can help close the treatment gap by best utilizing the available resources: integration of mental health services into primary care; task sharing and capacity building to generate a new cadre of mental healthcare providers; and the use of innovative technological solutions to enhance access, cut costs, and reduce stigma. The examples cited in the current article serve to illustrate the efficacy of these strategies. However, more research on their feasibility of implementation, utility, acceptability, and effectiveness, especially in LMICs and other resource-limited contexts, is necessary. Moreover, given the complex cause, pathophysiology, and impact of mental illness, it is likely that the most successful strategies to close the treatment gap will require a multidisciplinary, collaborative approach to care involving diverse segments both within and external to the health sector, such as the social and educational sectors. Finally, in order for these strategies to be successfully scaled up such that they have a meaningful impact on the mental health treatment gap, it is imperative that a permissive and supportive social and political environment exists, in which relevant policies and legislation, backed by financial commitment, are in place.

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The authors would like to acknowledge the assistance of Rodrigo Dias, MD, PhD, Hermano Tavares, MD, PhD, Nikhil Gupta, MD, Sang-Hee Min, BA, Patricia Kelly, MA, and Andrea Grant, PsyD, in the research and background preparation of the article.

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Conflicts of interest

There are no conflicts of interest.

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Papers of particular interest, published within the annual period of review, have been highlighted as:

▪ of special interest

▪▪ of outstanding interest

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mental health integration; mental health innovations; task-sharing; telemental health; treatment gap

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


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