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      Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries


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          Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care.


          A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts.


          The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care.


          The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

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          Most cited references23

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          Poverty and common mental disorders in low and middle income countries: A systematic review.

          In spite of high levels of poverty in low and middle income countries (LMIC), and the high burden posed by common mental disorders (CMD), it is only in the last two decades that research has emerged that empirically addresses the relationship between poverty and CMD in these countries. We conducted a systematic review of the epidemiological literature in LMIC, with the aim of examining this relationship. Of 115 studies that were reviewed, most reported positive associations between a range of poverty indicators and CMD. In community-based studies, 73% and 79% of studies reported positive associations between a variety of poverty measures and CMD, 19% and 15% reported null associations and 8% and 6% reported negative associations, using bivariate and multivariate analyses respectively. However, closer examination of specific poverty dimensions revealed a complex picture, in which there was substantial variation between these dimensions. While variables such as education, food insecurity, housing, social class, socio-economic status and financial stress exhibit a relatively consistent and strong association with CMD, others such as income, employment and particularly consumption are more equivocal. There are several measurement and population factors that may explain variation in the strength of the relationship between poverty and CMD. By presenting a systematic review of the literature, this paper attempts to shift the debate from questions about whether poverty is associated with CMD in LMIC, to questions about which particular dimensions of poverty carry the strongest (or weakest) association. The relatively consistent association between CMD and a variety of poverty dimensions in LMIC serves to strengthen the case for the inclusion of mental health on the agenda of development agencies and in international targets such as the millenium development goals. Copyright 2010 Elsevier Ltd. All rights reserved.
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            Mental health literacy. Public knowledge and beliefs about mental disorders.

            A. JORM (2000)
            Although the benefits of public knowledge of physical diseases are widely accepted, knowledge about mental disorders (mental health literacy) has been comparatively neglected. To introduce the concept of mental health literacy to a wider audience, to bring together diverse research relevant to the topic and to identify gaps in the area. A narrative review within a conceptual framework. Many members of the public cannot recognise specific disorders or different types of psychological distress. They differ from mental health experts in their beliefs about the causes of mental disorders and the most effective treatments. Attitudes which hinder recognition and appropriate help-seeking are common. Much of the mental health information most readily available to the public is misleading. However, there is some evidence that mental health literacy can be improved. If the public's mental health literacy is not improved, this may hinder public acceptance of evidence-based mental health care. Also, many people with common mental disorders may be denied effective self-help and may not receive appropriate support from others in the community.
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              Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative.

              Data are presented on patterns of failure and delay in making initial treatment contact after first onset of a mental disorder in 15 countries in the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Representative face-to-face household surveys were conducted among 76,012 respondents aged 18 and older in Belgium, Colombia, France, Germany, Israel, Italy, Japan, Lebanon, Mexico, the Netherlands, New Zealand, Nigeria, People's Republic of China (Beijing and Shanghai), Spain, and the United States. The WHO Composite International Diagnostic Interview (CIDI) was used to assess lifetime DSM-IV anxiety, mood, and substance use disorders. Ages of onset for individual disorders and ages of first treatment contact for each disorder were used to calculate the extent of failure and delay in initial help seeking. The proportion of lifetime cases making treatment contact in the year of disorder onset ranged from 0.8 to 36.4% for anxiety disorders, from 6.0 to 52.1% for mood disorders, and from 0.9 to 18.6% for substance use disorders. By 50 years, the proportion of lifetime cases making treatment contact ranged from 15.2 to 95.0% for anxiety disorders, from 7.9 to 98.6% for mood disorders, and from 19.8 to 86.1% for substance use disorders. Median delays among cases eventually making contact ranged from 3.0 to 30.0 years for anxiety disorders, from 1.0 to 14.0 years for mood disorders, and from 6.0 to 18.0 years for substance use disorders. Failure and delays in treatment seeking were generally greater in developing countries, older cohorts, men, and cases with earlier ages of onset. These results show that failure and delays in initial help seeking are pervasive problems worldwide. Interventions to ensure prompt initial treatment contacts are needed to reduce the global burdens and hazards of untreated mental disorders.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                18 February 2014
                : 9
                : 2
                : e88437
                [1 ]Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
                [2 ]Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
                [3 ]School of Psychology, University of KwaZulu-Natal, Durban, South Africa
                [4 ]PRIME India team, Sangath Non-Governmental Organisation, Goa, India
                [5 ]Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
                [6 ]Butabika National Mental Hospital, Kampala, Uganda
                [7 ]Centre for Mental Health, Public Health Foundation of India, New Delhi, India
                [8 ]Department of Research and Development, HealthNet Transcultural Psychosocial Organisation, Amsterdam, The Netherlands
                [9 ]Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [10 ]Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
                [11 ]Sangath Non-Governmental Organisation, Goa, India
                [12 ]Centre for Public Mental Health, Department of Psychology, Stellenbosch University and Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
                [13 ]Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
                [14 ]Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [15 ]Centre for Global Mental Health, Institute of Psychiatry, King's College London, London, United Kingdom
                Iranian Institute for Health Sciences Research, ACECR, Iran (Islamic republic of)
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Performed the experiments: NL TK VM SS GM JS AF RS IP MJ FK. Analyzed the data: CH GT VP MT CL EB MD MP. Contributed reagents/materials/analysis tools: CH MDS EB IP MJ AF FK RS. Wrote the paper: CH. Had the idea for a situation analysis tool, which was then developed with input from all the co-authors: CH. Reviewed and commented upon the drafts of the paper: CH NL TK VM SS GM JS AF RS IP MJ FK GT VP MT CL EB MDS MP. Reviewed the final draft and agreed with submission of the paper for publication: CH NL TK VM SS GM JS AF RS IP MJ FK GT VP MT CL EB MDS MP.

                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                : 25 August 2013
                : 12 January 2014
                Page count
                Pages: 12
                This document is an output from the PRIME Research Programme Consortium which has been funded by UK Aid from the UK Government; however the views expressed do not necessarily reflect the UK Government's official policies. All authors have declared that no competing interests exist. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
                Research Article
                Social epidemiology
                Global health
                Mental health
                Non-clinical medicine
                Health care policy
                Health systems strengthening
                Primary care
                Social and behavioral sciences
                Social discrimination



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