From delivery science to discovery science: realising the full potential of global mental health

Accounting for mental health research funding: developing a quantitative baseline of global investments

High-quality data on funding for mental health research are essential to mapping funding levels, identifying gaps in the funding landscape, and tracking the impact of research funding. To date, quantitative analyses of research funding in mental health have been restricted in scope. In this Health Policy paper, we present a comprehensive analysis of grant funding for mental health research as a starting point for discussion among stakeholders globally. We drew on a major international research database and used existing definitions and automated classification tools for mental health research. Our analysis shows a flat and stable trend over the years 2015-19 and highly unequal geographical distribution of funding, and reveals patterns of funding across different conditions and across the research spectrum. Improvements in data availability and quality, in the definitions delineating mental health research from other areas, and in automated classification tools are needed to ensure funders and policy makers can fully rely on the data and generate bespoke analyses as needed. We argue that collaborative reporting of funding for mental health research globally could help to inform and evaluate efforts to increase investments, to improve strategic dialogue, and to achieve the best possible allocation of finite resources.

Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review

BACKGROUND

Mental health conditions are leading causes of disability worldwide. Psychosocial interventions for these conditions might have a key role in their treatment, although applicability of findings to poor-resource settings might be a challenge. We aimed to evaluate the strength and credibility of evidence generated in low-income and middle-income countries (LMICs) on the efficacy of psychosocial interventions for various mental health outcomes.

METHODS

We did an umbrella review of meta-analyses of randomised studies done in LMICs. Literature searches were done in Medline, Embase, PsychINFO, CINAHL, Cochrane Library, and Epistemonikos from Jan 1, 2010, until May 31, 2019. Systematic reviews of randomised studies investigating the efficacy of psychosocial interventions for mental health conditions in LMICs were included. Systematic reviews of promotion, prevention, and protection interventions were excluded, because the focus was on treatment interventions only. Information on first author, year of publication, outcomes, number of included studies, and reported summary meta-analytic estimates was extracted from included meta-analyses. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects, and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was assessed using quantitative umbrella review criteria, and credibility of evidence using the GRADE approach. This study is registered with PROSPERO, number CRD42019135711.

FINDINGS

123 primary studies from ten systematic reviews were included. The evidence on the efficacy of psychosocial interventions in adults with depression in humanitarian settings (standardised mean difference 0·87, 95% CI 0·67-1·07; highly suggestive association, GRADE: moderate) and in adults with common mental disorders (0·49, 0·36-0·62; highly suggestive association, GRADE: moderate) was supported by the most robust evidence. Highly suggestive strength of association was found for psychosocial interventions in adults with schizophrenia for functional outcomes, in adults with depression, and in adults with post-traumatic stress disorder in humanitarian settings. In children in humanitarian settings, and in children with disruptive behaviour, psychosocial interventions were supported by suggestive evidence of efficacy.

INTERPRETATION

A relatively large amount of evidence suggests the benefit of psychosocial interventions on various mental health outcomes in LMICs. However, strength of associations and credibility of evidence were quite variable, depending on the target mental health condition, type of population and setting, and outcome of interest. This varied evidence should be considered in the development of clinical, policy, and implementation programmes in LMICs and should prompt further studies to improve the strength and credibility of the evidence base.

FUNDING

University of Verona.

Four reflections on the new global mental health priorities

The discussion of the achievements and limitations of the strategies prioritised in global mental health that has taken place in recent years contributed to a unified vision for action that addresses the gaps still existing on prevention, treatment, quality of care and human rights protection. This editorial presents four reflections on the impact of this vision on the definition of future priorities, particularly in the areas of policy implementation, services reconfiguration and organisation, human rights and research. It concludes that further debate is needed to redefine the balance between priorities and strategies that can better promote an effective response to the needs of low and middle income countries, and to ensure an efficient coordination of efforts in the future.

Global mental health and schizophrenia

PURPOSE OF REVIEW

The aim was to synthesize recent evidence on schizophrenia illness experience and outcomes and models of care in low and middle-income countries (LMICs).

RECENT FINDINGS

There is a plurality of explanatory models for psychosis and increasing evidence that context influences experiences of stigma. People with schizophrenia in LMICs are vulnerable to food insecurity, violence and physical health problems, in addition to unmet needs for mental healthcare. Family support may help to improve outcomes if present, but caregivers may be overwhelmed by the challenges faced. Despite efforts to increase availability, evidence-based care remains inaccessible to many people with schizophrenia. Non-randomized evaluations in South Africa and Mexico indicate that psychosocial support groups for people with schizophrenia and caregivers may be acceptable and useful. Randomized controlled trials in Pakistan and China show that culturally adapted cognitive-behavioural therapy can reduce symptom severity. There is emerging evidence that alternative medicine, such as Tai Chi, may be beneficial, but to date most studies are of low quality. The challenges of biomedical-traditional provider collaborations have been highlighted. Evaluations of integrated mental healthcare in primary care are underway and promise to provide vital information about how to scale-up quality care.

SUMMARY

Acceptable and effective responses to schizophrenia in LMICs should be cognisant of both cultural context and universal concerns. Efforts to enhance the quality of family support should be central to models of care.