A policy implementer's perspective
Authors: Rabih El Chammay
Journal: World Psychiatry (2017)

We live in a time when we have a fair knowledge about what works for mental health, how best to deliver it, where best to fit the intervention and who should be doing it. Yet we are still far from achieving what we are committing ourselves to in the World Health Organization's Mental Health Action Plan 2013-20201. When it comes to the framework proposed by Liu et al2 to address the excess mortality in persons with severe mental disorders, it is clear that the authors are tackling all relevant levels with the aim of building up a holistic evidence-based approach to address the issue. Let me list, however, some crucial points. The first point is an operational one, that can be summarized by the following questions: How does this framework link with local health systems at country level? What would be the cost and what is the best order of implementation of the different proposed interventions? Are there any best buys for countries that cannot fully implement? How does the framework rank in terms of priority with respect to other mental health interventions at country and global levels? Should some proposed interventions – especially policy level ones – be a prerequisite for other clinical ones? For example, should we consider launching tobacco cessation programmes for persons with severe mental disorders even if a country does not have policy regulations in line with the Framework Convention on Tobacco Control? These are the kind of over-arching questions that arise when considering the implementation of this framework. The second point focuses more on the content of the framework and more explicitly on the groupings used for severe mental disorders and the integration of mental health into primary care. The inclusion of moderate-to-severe depression within the “severe mental disorders” grouping might be problematic, as the course of that condition, the help-seeking behavior of the person, and the stigma around it are different from those related to schizophrenia. The inclusion of moderate-to-severe depression within the same framework as schizophrenia might be counter-productive for both disorders, as the implications for service design and delivery seem to be – at least in our experience – different, for example at the primary care level. Furthermore, when talking about the integration of mental health into primary care, it might be beneficial to allocate some attention to the way it is being done. Although implementation research is still ongoing, the Mental Health Gap Action Programme (mhGAP) Intervention Guide has been useful in training and supervising the primary care staff. However, to ensure the effective and sustainable integration of mental health within health systems, tools for the implementation and incorporation of the mhGAP within existing health systems are much needed. Such tools would help in the allocation of tasks/roles among different professionals at the primary care level, in the care packages and pathways for different disorders, in the health information system, and in the links of the primary care with specialized services. A lot of attention is also needed for human resources. The tipping point in positive attitude change towards persons with mental disorders for many primary health care staff is often seen after they disclose a personal experience with mental health concerning themselves or a member of their family to an mhGAP supervisor and feel that the supervisor is able to listen and support. Addressing the mental health of the staff is a key action for integrating mental health into primary care and as such deserves closer attention. A further factor to consider in order to enhance the integration of mental health into primary care is the use of innovations in domains such as management and information technology that have the potential to decrease cost and increase efficiency. The third point highlights the importance of the context where persons with severe mental disorders live. Two main examples are prisons and humanitarian crisis. It might be a good idea if the framework delineated by Liu et al could include an item to highlight persons with severe mental disorders living in prisons as a vulnerable group in need of specific interventions. The same applies to persons with severe mental disorders living in humanitarian settings, where they are often either locked in big institutions or very disadvantaged in reaching the needed services, which in both cases will put them at a higher risk for premature death. In summary, details pertaining to the implementation of the framework and to how it links to other mental health priorities are needed. This being said, this framework adds to the available tools and usefully highlights the importance of addressing the excess mortality in persons with severe mental disorders. In low-resource contexts – where mental health systems are under development with competing priorities – mental health disorder management, physical health treatment, screening for medical conditions, and stigma reduction interventions seem to be the components of the framework that would be easier and most important to consider, especially when the health system as a whole is fragmented or facing big challenges. Finally, as mental health professionals and policy makers, we can learn a lot if we look to other disciplines and to emerging research in related fields, such as the newly published report “Insights for impact”3. This can help us increase the coherence of any model we propose with the bigger socio-political and technological world in which we live. Leveraging the knowledge we can gather on management innovations as well as latest evidence in human psychology and in mental health at the workplace, we can develop tailored interventions for health systems management and for the health workforce that would increase the engagement, well-being and efficiency of every health worker and of the system, helping them to achieve their goal of improving the health of the persons served. Rabih El Chammay Head of the National Mental Health Programme, Ministry of Public Health, Lebanon