Summary Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves. Most medical literature in this area of research has ...been descriptive and has focused on attitudes towards people with mental illness rather than on interventions to reduce stigma. In this narrative Review, we summarise what is known globally from published systematic reviews and primary data on effective interventions intended to reduce mental-illness-related stigma or discrimination. The main findings emerging from this narrative overview are that: (1) at the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement; (2) for people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment; (3) for specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains; (4) this is a heterogeneous field of study with few strong study designs with large sample sizes; (5) research from low-income and middle-income countries is conspicuous by its relative absence; (6) caution needs to be exercised in not overgeneralising lessons from one target group to another; (7) there is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress; (8) few studies in any part of the world have focused on either the service user's perspective of stigma and discrimination or on the behaviour domain of behavioural change, either by people with or without mental illness in the complex processes of stigmatisation. We found that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma.
Summary The burden of mental, neurological, and substance use (MNS) disorders increased by 41% between 1990 and 2010 and now accounts for one in every 10 lost years of health globally. This sobering ...statistic does not take into account the substantial excess mortality associated with these disorders or the social and economic consequences of MNS disorders on affected persons, their caregivers, and society. A wide variety of effective interventions, including drugs, psychological treatments, and social interventions, can prevent and treat MNS disorders. At the population-level platform of service delivery, best practices include legislative measures to restrict access to means of self-harm or suicide and to reduce the availability of and demand for alcohol. At the community-level platform, best practices include life-skills training in schools to build social and emotional competencies. At the health-care-level platform, we identify three delivery channels. Two of these delivery channels are especially relevant from a public health perspective: self-management (eg, web-based psychological therapy for depression and anxiety disorders) and primary care and community outreach (eg, non-specialist health worker delivering psychological and pharmacological management of selected disorders). The third delivery channel, hospital care, which includes specialist services for MNS disorders and first-level hospitals providing other types of services (such as general medicine, HIV, or paediatric care), play an important part for a smaller proportion of cases with severe, refractory, or emergency presentations and for the integration of mental health care in other health-care channels, respectively. The costs of providing a significantly scaled up package of specified cost-effective interventions for prioritised MNS disorders in low-income and lower-middle-income countries is estimated at US$3–4 per head of population per year. Since a substantial proportion of MNS disorders run a chronic and disabling course and adversely affect household welfare, intervention costs should largely be met by government through increased resource allocation and financial protection measures (rather than leaving households to pay out-of-pocket). Moreover, a policy of moving towards universal public finance can also be expected to lead to a far more equitable allocation of public health resources across income groups. Despite this evidence, less than 1% of development assistance for health and government spending on health in low-income and middle-income countries is allocated to the care of people with these disorders. Achieving the health gains associated with prioritised interventions will require not just financial resources, but committed and sustained efforts to address a range of other barriers (such as paucity of human resources, weak governance, and stigma). Ultimately, the goal is to massively increase opportunities for people with MNS disorders to access services without the prospect of discrimination or impoverishment and with the hope of attaining optimal health and social outcomes.
Summary Background China and India jointly account for 38% of the world population, so understanding the burden attributed to mental, neurological, and substance use disorders within these two ...countries is essential. As part of the Lancet/Lancet Psychiatry China–India Mental Health Alliance Series, we aim to provide estimates of the burden of mental, neurological, and substance use disorders for China and India from the Global Burden of Disease Study 2013 (GBD 2013). Methods In this systematic analysis for community representative epidemiological studies, we conducted systematic reviews in line with PRISMA guidelines for community representative epidemiological studies. We extracted estimates of prevalence, incidence, remission and duration, and mortality along with associated uncertainty intervals from GBD 2013. Using these data as primary inputs, DisMod-MR 2.0, a Bayesian meta-regression instrument, used a log rate and incidence-prevalence-mortality mathematical model to develop internally consistent epidemiological models. Disability-adjusted life-year (DALY) changes between 1990 and 2013 were decomposed to quantify change attributable to population growth and ageing. We projected DALYs from 2013 to 2025 for mental, neurological, and substance use disorders using United Nations population data. Findings Around a third of global DALYs attributable to mental, neurological, and substance use disorders were found in China and India (66 million DALYs), a number greater than all developed countries combined (50 million DALYs). Disease burden profiles differed; India showed similarities with other developing countries (around 50% of DALYs attributable to non-communicable disease), whereas China more closely resembled developed countries (around 80% of DALYs attributable to non-communicable disease). The overall population growth in India explains a greater proportion of the increase in mental, neurological, and substance use disorder burden from 1990 to 2013 (44%) than in China (20%). The burden of mental, neurological, and substance use disorders is estimated to increase by 10% in China and 23% in India between 2013 and 2025. Interpretation The current and projected burden of mental, neurological, and substance use disorders in China and India warrants the urgent prioritisation of programmes focused on targeted prevention, early identification, and effective treatment. Funding China Medical Board, Bill & Melinda Gates Foundation.
Purpose
VISHRAM is a community-based mental health program to address psycho-social distress and risk factors for suicide in a predominantly rural population in Central India, through targeted ...interventions for the prevention and management of Depression and Alcohol Use Disorders (AUD). The evaluation was designed to assess the impact of program on the contact coverage of evidence-based treatments for depression and AUD through a repeated survey design. This paper describes the baseline prevalence of depression among adults in rural community, association of various demographic and socio-economic factors with depression and estimates contact coverage and costs of care for depression.
Methods
Population-based cross-sectional survey of adults in 30 villages of Amravati district in Vidarbha region of Central India. The outcome of interest was a probable diagnosis of depression which was measured using the Patient Health Questionnaire (PHQ-9). Data were analyzed using simple and multiple logistic regression.
Results
The outcome of current depression (PHQ-9 ≥ 10) was observed in 14.6 % of the sample (95 % CI 12.8–16.4 %). The contact coverage for current depression was only 4.3 % (95 % CI 1.5–7.1 %). Prevalence of depression varied greatly between the two sites of the study; higher age, female gender, lower education, economic status below poverty line and indebtedness were associated with depression; and while a contact coverage with formal health care was very low, a large proportion of affected persons had consulted family members.
Conclusions
Our findings clearly indicate that psycho-social distress in rural communities in Maharashtra is strongly associated with social determinants such as gender, poverty and indebtedness and affects the entire population and not just farmers.
Population-representative prevalence data for mental, neurological, and substance use disorders are essential for evidence-based decision making. As a background to the China-India Mental Health ...Alliance Series, we aim to examine the availability of data and report prevalence for the most common mental, neurological, and substance use disorders in China and India from the Global Burden of Disease study 2013 (GBD 2013).
In this systematic analysis, data sources were identified from GBD 2013 for the prevalence of mental, neurological, and substance use disorders in China and India published up to Dec 31, 2013. We calculated the proportion of the population represented by the data with the adjusted population coverage (APC) method adjusting for age, sex, and population size. We developed prevalence models with DisMod-MR 2.0, a Bayesian meta-regression instrument used to pool population-representative epidemiological data as part of GBD 2013. We report estimates and 95% uncertainly intervals (95% UI) for 15 mental, neurological, and substance use disorders for China and India in 1990 and 2013, and benchmark these against those for other BRICS countries (Brazil, Russia, and South Africa) in 2013.
Few population-representative data were found for the disorders, with an average coverage of 15% of the population of the Chinese mainland and 1% of the population of India. For men in both China and India, major depressive disorder, anxiety disorders, and alcohol dependence were the most common mental, neurological, and substance use disorders. Prevalence of major depressive disorder was 2·2% (95% UI 1·5-2·8) in Chinese men and 3·5% (2·4-4·6) in Indian men; prevalence of anxiety disorders was 2·0% (1·1-3·2) and 1·9% (1·2-2·3), respectively. For women, anxiety disorders, major depressive disorder, and dysthymia were the most common. Prevalence of major depressive disorder was 3·3% (2·3-4·1) in Chinese women and 4·7% (95% UI 3·3-6·2) in Indian women; prevalence of anxiety disorders was 3·3% (1·6-5·3) and 4·1% (3·3-5·0), respectively. Schizophrenia was more prevalent in China (0·5%, 95% UI 0·4-0·5) than in India (0·2%; 0·2-0·2).
More data for mental, neurological, and substance use disorders are needed for India and China but the large population and geographic scale of these countries present challenges to population-representative data collection.
China-India Mental Health Alliance, China Medical Board.
Understanding the epidemiological profiles of mental, neurological, and substance use disorders provides opportunities for the identification of high-risk population subgroups and for the development ...of effective country-specific prevention and intervention strategies. Guided by the Conceptual Framework for Action on the Social Determinants of Health by WHO we reviewed the literature to examine the association between a range of social correlates (eg, sex, age, education, income, urbanicity, marital status, and regional differences) and mental, neurological, and substance use disorders in China and India, the most populous countries in the world. We looked for papers on mental, neurological, and substance use disorders with location identifiers and socioeconomic correlates published between 1990 and 2015 and our search found 65 relevant studies from China and 29 from India. Several association patterns between social correlates and mental, neurological, and substance use disorders were not consistent with those reported in high-income countries, including a high concentration of middle-aged men with alcohol use disorders in China and to a lesser extent in India, and a positive association between being married and depression among women in India. Consistent with previous global reports, low education and poverty were associated with higher occurrence of dementia in both China and India, although there is evidence of an interaction between education and income in the risk for dementia in China. Large variations across regions and ethnic groups were consistently documented in China. These unique correlation patterns for mental, neurological, and substance use disorders identified in China and India emphasise the importance of understanding the local social context when planning targeted strategies to reduce the burden of these disorders. High-quality, up-to-date information about the constantly changing pattern of societal factors correlated with mental, neurological, and substance use disorders is urgently needed to help reduce the large and increasing negative social and economic effects that these conditions are having in China, India, and other low-income and middle-income countries.
Local non-governmental organisations (NGOs) provide mental health and psychosocial services (MHPSS) to over 1 million Rohingya refugees in Bangladesh. To provide insights to inform the development of ...MHPSS services in populations targeted in ethnic cleansing campaigns, we undertook a project that aimed to identify how refugees' understanding of the justice process is linked to their psychosocial wellbeing.
We conducted two focus groups and 13 in-depth qualitative interviews with Rohingya refugees residing in camps in Bangladesh. Refugees were recruited from the MHPSS work area of a local NGO—Friends in Village Development, Bangladesh—where a new intensive care programme for people who have experienced sexual and physical violence in Myanmar is being developed. We used baseline intake data to select participants who were known to be from a Myanmar village that suffered violence and who had a potential need for intensive psychological therapy because of direct exposure to violence. A brief interview guide included questions about refugees' understanding of the general concept of justice, of the justice process as applied to their situation, and of the emotional impact caused by justice being realised or denied. Interviews were recorded, transcribed, and translated. Two coders analysed transcripts for key themes based on a codebook using grounded theory.
Between Nov 1, 2018, and Aug 30, 2019, we interviewed ten male participants and 12 female participants aged between 10 years and 60 years. All had either experienced or witnessed violence when their villages were attacked. Respondents' concepts of justice included: a descriptive account of conflict resolution processes, noted to be culturally variable and often corrupt; and an aspirational account of full restoration of rights within their homeland. Some mentioned retributive punishment, but it was not emphasised. Participants acknowledged distress when thinking about a lack of justice, as well as a possibility of inner peace through achieving justice, but noted that even full restoration of their rights could not completely resolve the effects of the violence. Refugees reported inconsistent access to updates about repatriation, and media outlets, such as international news websites and social media sites, were not routinely accessible.
MHPSS programmes can potentially enhance refugee wellbeing by providing education, access to news updates, and advocacy surrounding the justice process. A further understanding of how concepts of justice may inform MHPSS programming is important to improve refugee care worldwide.
The Institute for Public Health, Washington University in St Louis, MO, USA and Washington University in St Louis Division of Infectious Diseases, School of Medicine, MO, USA.
The aim of this Review is to identify effective interventions and treatment guidelines to manage common types of psychiatric emergencies in non-specialist settings in low-income and middle-income ...countries. Mental health specialist services in low-income and middle-income countries are scarce. We did a systematic review of interventions for psychiatric emergencies and a literature search for low-income and middle-income-specific treatment guidelines for psychiatric emergencies. A dearth of high-quality guidelines and contextualised primary evidence for management of psychiatric emergencies in low-income and middle-income countries exists. Filling these gaps in present guidelines needs to be an urgent research priority in view of the adverse health and social consequences of such presentations and the present drive to scale up mental health care.
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