Integrated care for mental, neurological and substance use disorders in non‐specialized health settings: rising to the challenge
Authors: Tarun Dua, Allie Sharma, Archana Patel, Fahmy Hanna, Neerja Chowdhary, Shekhar Saxena
Journal: World Psychiatry (2017)

Worldwide, mental, neurological and substance use (MNS) disorders are major contributors to the global burden of disease as estimated by disability adjusted life years, and this is rising especially in low- and middle-income countries (LMIC)1. MNS disorders commonly co-occur with other chronic health conditions, both communicable (e.g., HIV/AIDS) as well as non-communicable (e.g., diabetes, cardiovascular disease) and, if untreated, worsen the outcome of these conditions. People with MNS disorders and their families are doubly challenged by stigma that further worsens their quality of life, affects social acceptability, employability and interferes with help seeking. Financial resources for developing and maintaining mental health services in LMIC are very low. The level of public expenditure on mental health is less than US$2 per capita. Furthermore, the number of mental health workers is below 1 per 100,000 in LMIC compared to over 50 in high-income countries2. The scarcity and unequal distribution of services means that 76-85% of people with MNS disorders in LMIC do not receive the care they need. Recognizing the urgent priority to scale up services for MNS disorders, global initiatives have pressed for reforms to ensure that people with these disorders receive care that is effective and affordable, and respects their rights and dignity3, 4. In line with the World Health Organization (WHO)'s leadership in the field of global public health, the Mental Health Gap Action Programme (mhGAP)5 was initiated, with the objectives to scale up services and enhance coverage. Through its objectives, the mhGAP is contributing towards achieving the targets of the Comprehensive Mental Health Action Plan 2013-2020, particularly in providing comprehensive, integrated and responsive mental health and social care services in community-based settings. The underlying principle of mhGAP is to strengthen non-specialist primary health care systems and providers to deliver MNS services, thus facilitating the vital link to integrate mental and physical health6. To support countries to strengthen MNS care by non-specialist health care providers, the mhGAP Intervention Guide (mhGAP-IG) was developed in 2010 using evidence-based guidance and extensive stakeholder consultation. The mhGAP-IG was translated in over 20 languages and has had widespread application by a range of stakeholders in over 90 countries for integrated management of priority MNS disorders. It has been used as a key tool in the phased approach to scale up mental health services and reduce the treatment gap on a regional-national-subnational level, as a capacity building tool for a wide range of health professionals and para-professionals, and for developing and updating undergraduate and postgraduate curricula for health professionals. It has also been used to scale up mental health response in emergency settings7, 8. The WHO has incorporated feedback and recommendations from international experts as well as latest evidence in the field to update the mhGAP-IG and has now released the mhGAP-IG Version 2.09. The key developments include: content update in various sections based on new evidence; design changes for enhanced usability; a streamlined and simplified clinical assessment that includes an algorithm for follow-up; inclusion of two new modules (Essential Care and Practice, and Implementation), and revised modules for Psychoses, Child and Adolescent Mental and Behavioural Disorders, and Disorders due to Substance Use. An interactive electronic version of the mhGAP-IG is currently under development and will have benefits in terms of increased ease of use, added functionality and cost savings. The inclusion of mental health and substance abuse in the Sustainable Development Goals (SDGs) at the 70th Session of the United Nations General Assembly in September 2015 has paved the way for mental health to be integrated into the broader development plans of countries over the next 15 years. There is now fresh impetus for countries to provide sufficient financial and human resources for mental health care; improve access to care for people with mental illness and their families; and integrate mental health care across different sectors such as social, education and employment, and implement community programmes. In order to initiate a collaborative, multisectoral commitment to put the mental health agenda at the centre of global health and development priorities, the World Bank Group and WHO co-hosted the Out of the Shadows: Making Mental Health a Global Priority meeting in April 2016, that emphasized the cross-cutting nature of mental health issues and the need to integrate mental health services into general health systems10. To realize the goal of universal health coverage, it is essential for health care providers and planners to maximize efforts to scale up care for people with MNS disorders, and the mhGAP-IG Version 2.0 will be a valuable tool to facilitate this process. Tarun Dua1, Allie Sharma2, Archana Patel3, Fahmy Hanna1, Neerja Chowdhary1, Shekhar Saxena1 1World Health Organization, Geneva, Switzerland; 2Mental Health Service Corps, New York, NY, USA; 3Boston Children's Hospital, Harvard Medical School, Boston, MA, USA T. Dua, F. Hanna, N. Chowdhary and S. Saxena are staff members of the WHO. The authors alone are responsible for the views expressed in this letter and they do not necessarily represent the decisions, policy or views of the WHO.