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An evidence based reply to critiques of global mental health | Mary De Silva | 3rd Feb 2015

Mary De Silva

Mary De Silva

on 21 March 2016

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Transcript of An evidence based reply to critiques of global mental health | Mary De Silva | 3rd Feb 2015

Research uptake
Mental Health Care Plans
Nepal Ministry of Health
Ethiopia Ministry of Health
South African Department of Health
University of Addis Ababa
Public Health Foundation of India
Makerere University
University of
Cape Town
supported by
South Africa
Uganda Ministry of Health
Madhya Pradesh Department of Public Health & Family Welfare
To generate evidence on the implementation and scaling up of treatment programmes for priority mental disorders in primary and maternal health care contexts in low resource settings.
Disadvantaged groups:
poor, women, people with mental illness
2. Evidence
1. Partnership
Not “what” but “how”
Adapt & test interventions based on WHO mhGAP IG
Add psychosocial community-based interventions
Identify additional resources needed
3. Implement/evaluate
Priority disorders:
Alcohol Use Disorders
Depressive Disorders
PRIME Theory of Change
Community Survey
Community Survey
Cost outcome
Treatment gap
Intervention intensity
Final 'story' of intervention to inform scale up of MHCP
Theory of Change
PRIME Phase II Evaluation
1. Situational analysis
2. Formative studies:
key stakeholders (Theory of Change workshops)
focus groups and interviews with:
health managers, facility staff, CHWs, community members
4. Economic costing of the packages of care
Development of mental health care plans
Strengthen capacity to:
mental health research in low and middle income countries
Small Grants Initiative
Skills Development Training
Postgraduate training, mentoring doctoral and post-doctoral researchers
Photo: Mental Health & Poverty Project (MHaPP)
Stakeholder analysis

Dissemination & communication:
Local: Community Advisory Board, local media
National: websites, media, conferences
International: social media, WHM day, open-access publications
Research uptake
Translate research into policy through research uptake strategy
Advantage: policy-makers included in consortium
Lack of MoH resources
Continuity of staff in district
Lack of service user involvement
Hawthorn effect
Complexity of evaluation
An evidence based response to critiques of global mental health
Mary De Silva
District level mental health care plans
PRIME consortium

Implementation of mental health care plans
Finalise MHCPs

Finalise evaluation methods
Implement MHCPs

Evaluate MHCPs
Scale up mental health care plan
Adapt and refine MHCP
Scale up to new districts
Evaluate scale up
Complexity of implementation
Complexity of evaluation
Political buy in for scale up
How to evaluate scaled up programmes?
Research question:
Does the MHCP reduce the treatment gap for people with priority disorders?
Facility Detection Survey
Facility detection
Does the MHCP increase correct diagnosis and initiation of evidence based treatment for depression and AUD?
Research question:
Cohort Studies
Pilot RCTs
Research question:
Do people treated by the MCHP and their families have improved clinical, social and economic outcomes?
Case Study
Case Study
Research question:
How well was the
MHCP implemented?
Size of problem
Western models
"Depression is social suffering"
Size of problem is exaggerated
"GMH is a front for Big Pharma"
Argument limited to depression
GMH promotes biopsyhosocial model
Social determinants critical
Biomedical interventions can break poverty and mental illness cycle
Recognition that current system is inadequate
Tests psychological interventions or health systems research
Only 1 GMH trial included drugs as active ingredient (Patel 2003)
All drugs recommended in mhGAP are off patent
NIMH | Research Domain Criteria (RDoC)
GMH research is not funded by Pharma
Burden based on screening & diagnostic tools which are problematic
All burden of disease studies have limitations
Redefining the treatment gap
3 million seek treatment (50%)
1.5 million diagnosed (50% /
900,000 would opt for IAPT (60% /
594,000 receive some therapy (66% /
160,380 recovered (45% /
356,400 adherent to therapy (60% /
Increasing Access to Psychological Therapies Report
Redefining the treatment gap
Burden: 10% global population affected
Gap: up to 90% get no treatment
GMH is evidence based - some of which is generated in West
mhGAP based on huge body of literature, carefully chosen to be relevant to low resource settings
mhGAP are
treatment guidelines
Years of local adaptation by local researchers is the task of GMH
Southern led projects
GMH research
What are major critiques of Global Mental Health?
RISE: Rehabilitation Intervention for Schizophrenia in Ethiopia
What is global mental health?
Applies the core principles of global health (improving health and equity in health for all people worldwide) to mental health.
To reduce the burden of mental disorders using an evidence-based and human rights approach with a focus on low and middle income countries (LMIC) as this is where inequity in mental health treatment and care is the greatest.
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