1. World Mental Health Day, 2011 1 |1 | Invest in Mental Health Mental Health Gap Action Programme Scaling up care for mental, neurological and substance use disorders World Mental Health Day, 2011 presentation for health providers

2. World Mental Health Day, 2011 2 |2 | Outline The problem The resources The solution (mhGAP) Objectives Strategic directions Framework for action How to find resources and reallocate The tool for intervention: mhGAP-IG How to start and proceed at the country level

3. World Mental Health Day, 2011 3 |3 | Mental disorders are common Lifetime prevalence rates of mental disorders in adults are 12.2- 48.6 worldwide. High burden –13% of the Global Burden of Disease (GBD) measured in Disability Adjusted Life Years (DALYS) is due to mental, neurological and substance use disorders (DALYS = years lost to early death + years lost due to disability)

4. World Mental Health Day, 2011 4 |4 | Large treatment gap A large multi-country survey supported by WHO showed that 35.5–50.3 % of serious cases in developed countries and 76.3 –85.4 % in less-developed countries had received no treatment in the previous year It means that a lmost 4 out of 5 people in need of treatment for serious mental disorders in developing countries do not receive any treatment. In many countries there is absolutely no mental health care. Mental health systems in LAMICs provide care to only a small proportion of all who need care, with a median treated prevalence of 0.67% of the population per year. The corresponding rate for children is even lower - 0.16% (2) Seven out of 10 people with schizophrenia are not receiving treatment in LAMICs. (2) (2) Mental health systems in selected low and middle-income countries: A WHO-AIMS cross national analysis" publication (2009)

5. World Mental Health Day, 2011 5 |5 | Mental disorders and other conditions Mental disorders are closely related to other priority conditions including HIV/AIDS, maternal and child health and noncommunicable diseases Up to 63% of HIV-positive people in LAMICs have also have depression People with co-morbid depression are three times less likely to comply with recommended treatment plans

6. World Mental Health Day, 2011 6 |6 | Poverty & Mental Health: A Vicious Cycle 80% of the global burden of disease due to mental health disorders is found in LAMIC(1) Mental disorders are associated with unemployment rates between 70-90%(1) Depression is 1.5 to 2 times more prevalent among low- income groups of a population(2) 1.World Health Organization (2010). Mental health and development: targeting people with mental health conditions as a vulnerable group. Geneva, World Health Organization. 2.World Health Organization (2003). Investing in Mental Health. Geneva, World Health Organization. Mental Disorders Poverty Unemployment Low Income Less Education

7. World Mental Health Day, 2011 7 |7 | The resources The median per capital spending on mental health in Low and Middle Income countries (LMIC) is 0.30 US $.This is far below the estimated 3-4 US $ needed for a cost effective package for the treatment of common mental disorders (2) 33% have no separate budget for mental health care. (3) The median percentage of the health budget devoted to mental health in LMIC is 2% (2) 35% of the countries do not have the minimum number of essential medications (three) to treat these disorders (1) (1) Mental Health Atlas 2001 and 2005 (2) Mental health systems in selected low and middle-income countries: A WHO-AIMS cross national analysis publication (2009) (3) mhGAP: Mental Health Gap Action Programme: Scaling up care for mental, neurological and substance use disorders

8. World Mental Health Day, 2011 8 |8 | The resources (continued) 40% of countries do not have training facilities for primary health care personnel in mental health (1) The median number of mental health professionals per 100,000 population in LAMICs is only 6 (2) Most of world’s population does not have access to minimum number of psychiatrists and other professionals required for mental health care (1) 68.6% of the beds for mental health care are in separated mental hospitals (1) The move from institutional to community care is slow and uneven, as inpatient care is still the predominant form of care delivered. In LAMICs there is less than one outpatient contact/visit (0.7) per one day spent in inpatient care (2) (1) Mental Health Atlas 2001 and 2005 (2) Mental health systems in selected low and middle-income countries: A WHO-AIMS cross national analysis" publication (2009)

9. World Mental Health Day, 2011 9 |9 | There are cost-effective interventions Current mental health spending in low– and middle-income countries is $ 0.30 per capita oAn investment of US $3-4 per capita can result in 350-700 healthy years of life gained(2) oDepression treatment in primary care is as cost-effective as antiretroviral treatment for HIV/AIDS(1) (1) Saraceno B., van Ommeren M., Batniji R., Cohen A., Gureje O., Mahoney J. Barriers to improvement of mental health services in low- income and middle-income countries. Lancet. 2007;370:1164–1174. (2) World Health Organization (2006). Dollars, Dalys and Decisions: Economic Aspects of the Mental Health System. Geneva, World Health Organization

10. World Mental Health Day, 2011 10 | Summary: Need to reorient our efforts General awareness about mental health has improved. Awareness generates more demand for country specific action. Disease burden or coverage with key interventions has not been improving as expected. There is a real need for studying, mobilizing and reorganizing potential resources to deal with the problem. Shortage of resources can partly be compensated for through integration of the programmes into primary care.

11. World Mental Health Day, 2011 11 | Finding new resources and reallocation Identify new resources for mental health, e.g. increasing tax on alcohol and tobacco may increase resources for health. Reallocate investment from large hospitals to primary health care and community mental health care. Do not forget children and adolescents Foster inter-sectoral collaboration. Adopt and promote mental health policies, laws and services that support comprehensive education, employment, housing and social services for people with mental disorders.

12. World Mental Health Day, 2011 12 | 2001 2005 2007 2008 2009- 2010 Mobilizing a global response: Setting the agenda Helsinki Brasilia 2010 + mhGAP country implementation

13. World Mental Health Day, 2011 13 | Today, with the launch of the Mental Health Gap Action Programme, we have reached a critical juncture. The long-standing failure to take action and make progress against these disorders is no longer acceptable. There are no excuses anymore. Dr Margaret Chan, WHO Director General mhGAP Launch, 9 October 2008 mental health Gap Action Programme (mhGAP)

14. World Mental Health Day, 2011 14 | mhGAP: objectives Reinforce the commitment of governments, international organizations and other stakeholders to increase financial and human resources Accelerate activities to achieve significantly higher coverage with key interventions in the resource-poor countries

15. World Mental Health Day, 2011 15 | mhGAP Vision Effective and humane care for all with mental, neurological and substance use disorders

16. World Mental Health Day, 2011 16 | Main strategic directions Advocating at all levels, adopting a participatory approach,establishing partnerships and intersectoral collaboration Identification of barriers for implementation of scaling up, realistic prioritization of needs and planning accordingly Integration into primary care and strengthening the health systems Considering various entry points based on country's health needs and services (e.g. HIV or maternal health programme) Proactive resource mobilization and appropriate reallocation of resources Constant improvement through monitoring, evaluation and application of lessons learned

17. World Mental Health Day, 2011 17 | Priority conditions, Can be adapted at the country level Depression Psychosis and Bipolar disorder Self harm/ Suicide Epilepsy Dementia Alcohol use and alcohol use disorders Drug use and drug use disorders Child and adolescent mental disorders: - depression - developmental disorders - behavioural disorders

18. World Mental Health Day, 2011 18 | Child and Adolescent Mental Disorders Depression Development al disorders Behavioural disorders

19. World Mental Health Day, 2011 19 | mhGAP Intervention Guide Launched on 7th of October 2010 Based on systemtic review of evidence of effective treatments for priority conditions For use by non-specialized health providers in low resource settings Includes both pharmacological and psychosocial interventions

20. World Mental Health Day, 2011 20 | How to start and proceed at country level (framework for action)? Establish national level stakeholders committee for scaling up services Conduct situation analysis, identify priorities and barrier to scaling up Adapt the intervention guide accordingly Identify a geographic area for demonstration project WHO-AIMS: a useful tool for situation analysis

21. World Mental Health Day, 2011 21 | How to start and proceed at country level ? (framework for action, continued) Plan and Implement the demonstration project Involve health managers and receive the required agreements Identify resources and consider reallocation of resources Provide logistics and essential medicines Develop capacity, manage task shifting and train health providers at different levels Regularly monitor, evaluate the programme, reapply the lessons learned and expand the programme to a larger scale

22. World Mental Health Day, 2011 22 | And Always… Respect the dignity and promote the rights of people with mental disorders.

23. World Mental Health Day, 2011 23 | Thank you