Lessons learned in developing community mental health care in Africa

This paper summarizes the findings for the African Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. We present an overview of mental health policies, plans and programmes in the African region; a summary of relevant research and studies; a critical appraisal of community mental health service components; a discussion of the key challenges, obstacles and lessons learned, and some recommendations for the development of community mental health services in the African region.     

Steps,challenges and lessons in developing community mental health care

This paper summarises our own accumulated experience from developing community-orientated mental health services in England and Italy over the last 20-30 years. From this we have provisionally concluded that the following issues are central to the development of balanced mental health services: a) services need to reflect the priorities of service users and carers; b) evidence supports the need for both hospital and community services; c) services need to be provided close to home; d) some services need to be mobile rather than static; e) interventions need to address both symptoms and disabilities; and f) treatment has to be specific to individual needs. In this paper we consider ten key challenges that often face those trying to develop community-based mental health services: a) dealing with anxiety and uncertainty; b) compensating for a possible lack of structure in community services; c) learning how to initiate new developments; d) managing opposition to change within the mental health system; e) responding to opposition from neighbours; f) negotiating financial obstacles; g) avoiding system rigidities; h) bridging boundaries and barriers; i) maintaining staff morale; and j) creating locally relevant ser- vices rather than seeking “the right answer” from elsewhere.     

Integration of child mental health services to primary care: challenges and opportunities

In the first decade of this new millennium, health professionals are faced with a rapidly increasing need for child mental health services and changing models of service provision. This gives us a unique opportunity to make provision for services where it has not been available before, or to improve upon the existing services. This paper examines the challenges and opportunities while attempting to integrate child mental health services to primary care.     

Factors predicting drop‐out in community mental health centres

This study aimed to identify treatment, therapist and patient factors associated with dropping out of treatment in four outpatient mental health services. The experimental group comprised all 789 individuals who attended for the first time the mental health services during one year and dropped out of treatment in the same year or during the two following ones. The control group consisted of the same number of individuals, chosen at random from patients who, in the same year, attended for the first time the services and did not subsequently drop out of treatment. The overall drop-out rate was 33.2%. According to logistic regression analysis, the predictive factors of dropping out were: being treated in a particular centre, the involvement of more than one therapist in treatment, having no previous history of psychiatric disorders, being young and being male.     

Exploring core competencies for mental health and addictions work within a Family Health Team setting

Approximately 200 Family Health Teams (FHTs) have been implemented in Ontario to improve access to primary healthcare, including mental health and addiction. The objectives of this project were to examine, through a focus group and qualitative methodology with three FHTs, the profile of patients'' mental health and addiction-related needs and to identify the implications for the development of core competencies in these innovative organisations. A spectrum of needs and service trajectories was identified, as well as the importance of a wide range of clinical skills and knowledge. The results indicate that ‘core’ competencies for mental health work in the context of an FHT go well beyond those required for an embedded mental health ‘programme’ or specialised mental health counsellors, but rather they relate to the core and discipline-specific competencies of members of the entire team. In addition to specific knowledge and skills, competencies include common attitudes and values relating to teamwork, good communication and collaboration. Challenges were noted with regard to working with some community service providers, especially addiction services. Implications for core competencies at the individual and organisational level were identified.     

Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability

Integration of mental health into primary care is essential to meet population needs yet faces many challenges if such projects are to achieve impact and be sustainable in low income countries alongside other competing priorities. This paper describes the rationale and progress of a collaborative project in Kenya to train primary care and community health workers about mental health and integrate mental health into their routine work, Within a health systems strengthening approach. So far 1877 health workers have been trained. The paper describes the multiple challenges faced by the project, and reviews the mechanisms deployed which have strengthened its impact and sustainability to date.     

Designing and scaling up integrated youth mental health care

Mental ill‐health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID‐19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co‐designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad‐spectrum, integrated primary youth mental health care services. They represent a blueprint and beach‐head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, “soft entry” youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill‐health in young people globally demands that this focus be elevated to a top priority in global health.     

WPA guidance on steps,obstacles and mistakes to avoid in the implementation of community mental health care

This paper provides guidance on the steps, obstacles and mistakes to avoidin the implementation of community mental health care. The document is intendedto be of practical use and interest to psychiatrists worldwide regarding thedevelopment of community mental health care for adults with mental illness.The main recommendations are presented in relation to: the need for coordinatedpolicies, plans and programmes, the requirement to scale up services for wholepopulations, the importance of promoting community awareness about mentalillness to increase levels of help-seeking, the need to establish effectivefinancial and budgetary provisions to directly support services provided inthe community. The paper concludes by setting out a series of lessons learnedfrom the accumulated practice of community mental health care to date worldwide,with a particular focus on the social and governmental measures that are requiredat the national level, the key steps to take in the organization of the localmental health system, lessons learned by professionals and practitioners,and how to most effectively harness the experience of users, families, andother advocates.     

Low-intensity workers: lessons learned from supervising primary care mental health workers and dilemmas associated with such roles

The UK government's latest primary care mental health initiative, Improving Access to Psychological Therapies (IAPT), seeks to achieve its aims partly through the extensive use of low-intensity workers (LIWs). As clinical supervisors to teams of primary care mental health workers (PCMHWs) already offering brief, evidence-based interventions in primary care mental health services, we draw on the growing body of literature and our own experience to discuss dilemmas associated with the roles of such workers. These concern clinical governance, training, supervision and integration into existing services. We discuss how IAPT service characteristics may provide solutions to some of these dilemmas. We argue that it is unlikely they will be completely resolved and that IAPT services, in addressing future challenges, could benefit from lessons learned from the PCMHW role.     

Reform of mental health care in Serbia: ten steps plus one

Disastrous events in the country and the region caused a 13.5% increasein the prevalence of mental and behavioral disorders in Serbia in the lastfew years, thus making them the second largest public health problem. Dueto prolonged adversities, the health system has deteriorated and is facingspecific challenges. However, the reform of mental health care has been initiated,with a lot of positive movements such as the preparation of a national policyfor mental health care and a law for protection of mentally ill individuals.The transformation of mental health services has started, with an accent oncommunity care, antistigma campaigns and continuing education. Based on anassessment carried out by the National Committee on Mental Health, serviceprovision, number of professionals working in services, funding arrangements,pathways into care, user/carer involvement and other specific issues are reported.     

The needs of primary care mental health service users: a Q-sort study

Background Within scientific and policy literature, the broader needs and preferences of the service user are usually described as being relatively homogenous for any particular condition. Additionally, despite common adult mental health problems being a huge burden to primary care services, there has been little research into the client's perspective of their needs regarding such difficulties. The aim of this research was thus to uncover the issues and preferences for this sample.Method The attitudes of 28 service users were explored through use of a Q-methodology approach. This procedure involves statistical analysis of the order that participants rank pertinent statements associated with the area of study.Results Five independent factors (clusters of preferences) were identified. These differed over issues associated with: relationships with service providers, access/barriers associated with services, information provision, stigma, choices associated with therapy and the care pathway, medication and complementary approaches, as well as social support.Discussion The study suggests that differing individual needs exist within diagnostic categories which, unless considered, may impede service engagement. Issues associated with the implications for service delivery for these differing clusters of perceived needs and viewpoints are outlined.     

Lessons learned in developing community mental health care in Latin American and Caribbean countries

This paper summarizes the findings for the Latin American and Caribbeancountries of the WPA Task Force on Steps, Obstacles and Mistakes to Avoidin the Implementation of Community Mental Health Care. It presents an overviewof the provision of mental health services in the region; describes key experiencesin Argentina, Belize, Brazil, Chile, Cuba, Jamaica and Mexico; and discussesthe lessons learned in developing community mental health care.     

Priorities for mental health research in Europe: A survey among national stakeholders' associations within the ROAMER project

Within the ROAMER project, funded by the European Commission, a survey was conducted with national associations/organizations of psychiatrists, other mental health professionals, users and/or carers, and psychiatric trainees in the 27 countries of the European Union, aiming to explore their views about priorities for mental health research in Europe. One hundred and eight associations/organizations returned the questionnaire. The five most frequently selected research priorities were early detection and management of mental disorders, quality of mental health services, prevention of mental disorders, rehabilitation and social inclusion, and new medications for mental disorders. All these areas, except the last one, were among the top ten research priorities according to all categories of stakeholders, along with stigma and discrimination. These results seem to support the recent argument that some rebalancing in favor of psychosocial and health service studies may be needed in psychiatric research.     

Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.     

Oral health care for frail elderly people: actual state and opinions of dentists towards a well-organised community approach

Objective: This study was undertaken to provide an analysis of the actual oral heath care for frail elderly people living in different settings and to explore opinions of dentists towards new concepts in developing a community approach. Method: Data were collected from a sample of 101 dentists (15%) in the county of Antwerp using a self‐administered 30‐item questionnaire including questions about age, gender, education, organisational aspects of dental surgery, questions concerning dentists’ own contribution to oral healthcare services for frail elderly people and statements concerning opinions and attitude toward the organisation of oral health care for frail elderly people. At the same time, qualitative data were collected from focus group sessions with all participating dentists. Non‐parametric analysis was used to explore possible relationships between opinion and possible explanatory variables. Results: Half of the dentists offered dental services to residential or nursing homes (mean number of treatments a year: 5.4) and at home (mean number of treatments a year: 2.4). Prosthetic treatments such as relieving denture pressure points, repairing, rebasing and making new dentures were carried out in 77.4% and 76.7% of the cases in residential or nursing homes and at home respectively. Extractions were carried out in 16% and 18.6% of the cases in both living situations respectively. The main reasons for dentists refusing domiciliary oral health care were the absence of dental equipment (63%), lack of time (19%), with 11% convincing the patients to be treated in their dental surgery. Analysis showed different opinions of dentists depending on age, gender and university of education; however, statistically significant differences were only found by age. Conclusion: The older the dentist, the greater the tendency to refuse domiciliary oral healthcare services. The younger dentists were reluctant to cooperate in the provision of oral health care in a structured community approach.     

Reducing the treatment gap for mental disorders: a WPA survey

The treatment gap for people with mental disorders exceeds 50% in all countries of the world, approaching astonishingly high rates of 90% in the least resourced countries. We report the findings of the first systematic survey of leaders of psychiatry in nearly 60 countries on the strategies for reducing the treatment gap. We sought to elicit the views of these representatives on the roles of different human resources and health care settings in delivering care and on the importance of a range of strategies to increase the coverage of evidence-based treatments for priority mental disorders for each demographic stage (childhood, adolescence, adulthood and old age). Our findings clearly indicate three strategies for reducing the treatment gap: increasing the numbers of psychiatrists and other mental health professionals; increasing the involvement of a range of appropriately trained non-specialist providers; and the active involvement of people affected by mental disorders. This is true for both high income and low/middle income countries, though relatively of more importance in the latter. We view this survey as a critically important first step in ascertaining the position of psychiatrists, one of the most influential stakeholder communities in global mental health, in addressing the global challenge of scaling up mental health services to reduce the treatment gap.     

Partnerships for better mental health worldwide: WPA recommendations on best practices in working with service users and family carers

WPA President M. Maj established the Task Force on Best Practice in Working with Service Users and Carers in 2008, chaired by H. Herrman. The Task Force had the remit to create recommendations for the international mental health community on how to develop successful partnership working. The work began with a review of literature on service user and carer involvement and partnership. This set out a range of considerations for good practice, including choice of appropriate terminology, clarifying the partnership process and identifying and reducing barriers to partnership working. Based on the literature review and on the shared knowledge in the Task Force, a set of ten recommendations for good practice was developed. These recommendations were the basis for a worldwide consultation of stakeholders with expertise as service users, families and carers, and the WPA Board and Council. The results showed a strong consensus across the international mental health community on the ten recommendations, with the strongest agreement coming from service users and carers. This general consensus gives a basis for Task Force plans to seek support for activities to promote shared work worldwide to identify best practice examples and create a resource to assist others to begin successful collaboration.