Summary Resources for mental health include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. We discuss here the general ...availability of these resources, especially in low-income and middle-income countries. Government spending on mental health in most of the relevant countries is far lower than is needed, based on the proportionate burden of mental disorders and the availability of cost-effective and affordable interventions. The poorest countries spend the lowest percentages of their overall health budgets on mental health. Most care is now institutionally based, and the transition to community care would require additional funds that have not been made available in most countries. Human resources available for mental health care in most low-income and middle-income countries are very limited, and shortages are likely to persist. Not only are resources for mental health scarce, they are also inequitably distributed—between countries, between regions, and within communities. Populations with high rates of socioeconomic deprivation have the highest need for mental health care, but the lowest access to it. Stigma about mental disorders also constrains use of available resources. People with mental illnesses are also vulnerable to abuse of their human rights. Inefficiencies in the use of available resources for mental health care include allocative and technical inefficiencies in financing mechanisms and interventions, and an overconcentration of resources in large institutions. Scarcity of available resources, inequities in their distribution, and inefficiencies in their use pose the three main obstacles to better mental health, especially in low-income and middle-income countries.
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COVID-19 presents significant social, economic, and medical challenges. Because COVID-19 has already begun to precipitate huge increases in mental health problems, clinical psychological science must ...assert a leadership role in guiding a national response to this secondary crisis. In this article, COVID-19 is conceptualized as a unique, compounding, multidimensional stressor that will create a vast need for intervention and necessitate new paradigms for mental health service delivery and training. Urgent challenge areas across developmental periods are discussed, followed by a review of psychological symptoms that likely will increase in prevalence and require innovative solutions in both science and practice. Implications for new research directions, clinical approaches, and policy issues are discussed to highlight the opportunities for clinical psychological science to emerge as an updated, contemporary field capable of addressing the burden of mental illness and distress in the wake of COVID-19 and beyond.
Public Significance Statement
Clinical psychological science must lead a national response to address mental health issues following COVID-19. This article highlights urgent challenges to confront, and timely opportunities to contemporize a field to better address mental health issues now and long after. The article concludes by discussing implications for new research directions, clinical approaches, and policy issues.
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Better But Not Well Frank, Richard G; Glied, Sherry A
2006, 2006-09-08, 20060101
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The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and ...support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough.
In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness—severe and persistent disorders as well as less serious mental health conditions—are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs—such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps—and the development of new treatments that are easier for patients to tolerate and for physicians to manage.
The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The mainstreaming of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.
Major depressive disorder (MDD) is a leading cause of disability worldwide.
To examine the: (a) 12-month prevalence of DSM-IV MDD; (b) proportion aware that they have a problem needing treatment and ...who want care; (c) proportion of the latter receiving treatment; and (d) proportion of such treatment meeting minimal standards.
Representative community household surveys from 21 countries as part of the World Health Organization World Mental Health Surveys.
Of 51 547 respondents, 4.6% met 12-month criteria for DSM-IV MDD and of these 56.7% reported needing treatment. Among those who recognised their need for treatment, most (71.1%) made at least one visit to a service provider. Among those who received treatment, only 41.0% received treatment that met minimal standards. This resulted in only 16.5% of all individuals with 12-month MDD receiving minimally adequate treatment.
Only a minority of participants with MDD received minimally adequate treatment: 1 in 5 people in high-income and 1 in 27 in low-/lower-middle-income countries. Scaling up care for MDD requires fundamental transformations in community education and outreach, supply of treatment and quality of services.
In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of ...mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing.
A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction d = 0.34 in AUD symptoms, 6.4-point reduction d = 0.43 in psychosis symptoms, 7.2-point reduction d = 0.58 in depression symptoms) at 12 months post-treatment.
These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).
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Crisis resolution and home treatment teams respond rapidly to people experiencing mental health crises and offer an alternative to hospital admission. They are an increasingly important component of ...mental health care and are adopted by many health care systems around the world. This practical and pioneering book describes the evidence for the effectiveness of such teams, the principles underpinning them, how to set up and organise them, how patients should be assessed and what types of care the teams should offer. Other topics covered include integration of crisis teams with in-patient, community residential and day care services, the service users' experiences of crisis teams, and responding to diversity in home treatment. This book is essential reading for all policy makers, service managers and mental health workers interested in establishing or operating crisis resolution and home treatment services, as well as for researchers and students seeking to understand this model.
ABSTRACT
BACKGROUND
Foreign‐born children rarely use traditional school mental health services. Comprehensive programs that combine mental health services with academic, economic, and socioemotional ...supports reach more foreign‐born children and improve wellbeing. However, little practical guidance exists regarding how to best combine these diverse services.
METHODS
To identify essential service components and their organization, we interviewed 92 parents, school staff, mental health providers, and community agency staff from 5 school‐linked mental health programs designed specifically to serve immigrant and refugee youth.
RESULTS
Foreign‐born parents did not distinguish between academic, behavioral, and emotional help for their children; these western categorizations of functioning were not meaningful to them. Consequently, programs needed to combine 4 components, organized in a pyramid: family engagement, assistance with basic needs, assistance with adaptation to a new culture, and emotional and behavioral supports. Family engagement was the foundation upon which all other services depended. Assistance with economic and cultural stressors directly promoted emotional wellbeing and helped parents trust clinical mental health interventions.
CONCLUSIONS
Specific strategies to implement the 4 essential components include home visits by program staff, a one‐stop parent center located in the school to help with basic needs, working with cultural brokers, and informed consent procedures that clearly explain recommended care without requiring immigrant and refugee parents to internalize western conceptualizations of psychopathology. Future evaluations should assess the cost and effectiveness of these strategies. These data are essential to advocate payment for these nonclinical services by traditional funding mechanisms.
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This volume, successor to the 1973 volume "Racism and Mental Health," presents a range of perspectives on mental health, prejudice, and discrimination. Contributors are of multiracial, multiethnic, ...and gender-diverse backgrounds. They use their existential experiences to analyze pressing mental health and mental illness issues. Contributions include: (1) "Connections between Racism and Mental Health" (Castellano B. Turner and Bernard M. Kramer); (2) "Sexism and Women's Psychological Status" (Patricia Perri Rieker and M. Kay Jankowski); (3) "The Decline of Public Mental Health in the United States" (Elaine R. Brooks, Maria Zuniga, and Nolan E. Penn); (4) "Racial, Ethnic, and Mental Illness Stereotypes: Cognitive Process and Behavioral Effects" (John Townsend); (5) "Racism and African American Adolescent Development" (James P. Comer); (6) "Transracial Adoptions" (Joyce A. Ladner and Ruby M. Gourdine); (7) "Teenage Motherhood" (Constance Willard Williams); (8) "Inner-City Community Mental Health: The Interplay of Abuse and Race in Chronically Mentally Ill Women" (Elaine (Hilberman) Carmen); (9) "Lives in Jeopardy: Women and Homelessness" (Ellen L. Bassuk); (10) "Turbulence on the College Campus and the Frustration-Aggression Hypothesis" (Charles Vert Willie and Jayminn Sulir Sanford); (11) "Stress Analogs of Racism and Sexism: Terrorism, Torture, and Disaster" (Chester M. Pierce); (12) "Sex and Gender as Critical Variables in Psychotropic Drug Research" (Jean A. Hamilton); (13) "Training for Culturally Appropriate Mental Health Services" (Harriet P. Lefley and Evalina W. Bestman); (14) "Women's Mental Health: Research Agenda for the Twenty-first Century" (Nancy Felipe Russo); and (15) "A Brief History of the Center for Minority Group Mental Health Programs at the National Institute of Mental Health" (Bertram S. Brown and K. Patrick Okura). References follow each chapter. (Contains 27 figures and 10 tables.) (SLD)
Objectives
To describe reasons for unmet need for mental health care among blacks, identify factors associated with causes of unmet need, examine racism as a context of unmet need, and construct ways ...to improve service use.
Data Sources
Data from the 2011‐2015 National Survey on Drug Use and Health were pooled to create an analytic sample of black adults with unmet mental health need (N = 1237). Qualitative data came from focus groups (N = 30) recruited through purposive sampling.
Study Design
Using sequential mixed methods, reasons for unmet need were regressed on sociodemographic, economic, and health characteristics of respondents. Findings were further explored in focus groups.
Principal Findings
Higher education was associated with greater odds of reporting stigma and minimization of symptoms as reasons for unmet need. The fear of discrimination based on race and on mental illness was exacerbated among college‐educated blacks. Racism causes mistrust in mental health service systems. Participants expressed the importance of anti‐racism education and community‐driven practice in reducing unmet need.
Conclusion
Mental health systems should confront racism and engage the historical and contemporary racial contexts within which black people experience mental health problems. Critical self‐reflection at the individual level and racial equity analysis at the organizational level are critical.
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