The Global Burden of Disease and Risk Factors1
is a widely used benchmark to assess, and compare, the burden posed by various health conditions in each region of the world. According to this report, mental and neurological disorders (MNDs) account for 9.8% of the total burden of disease in low- and middle-income countries (LAMICs). Self-inflicted injuries account for 1.5% of all deaths in LAMICs, and this is likely to be an underestimate due to reporting biases. There are also considerable regional variation in burden of MNDs; for example, self-inflicted injuries account for over 2% of total deaths in Eastern Europe and Central Asia, making them the fifth leading cause of mortality in these LAMICs. Unipolar depressive disorder is the leading cause of ‘years lived with a disability’; two other mental disorders appear in the leading 10 causes: schizophrenia and alcohol-use disorders. It is in this context, no less than one of the biggest global health crises of our times, that a group of academics produced the landmark Lancet
series on global mental health. The series reviewed the evidence, focusing on mental disorders in LAMICs. The major messages arising from the series are listed in .
The messages of the Lancet series on global mental health.
In spite of this evidence, MNDs in LAMICs are, arguably, the most neglected global health problem on virtually any metric we choose. The ratio of burden to resources available for mental health care in LAMICs is extremely inequitable, perhaps one of the worst among all major health domains.2
Unsurprisingly, the ‘treatment gaps’ for people with MNDs exceed 50% in most countries and approach 90% in some.3,4
Large numbers of people with MND suffer some of the most appalling human rights abuses witnessed in modern times, often perpetrated within the institutions run to care for them.5
Family members, left often without any access to care, are forced to rely on restraints and other degrading practices to manage disturbed behaviours.6
The vast majority of those who suffer from MNDs with no obvious externally apparent symptoms (for example, those with depression or alcohol-use disorders) are simply ignored altogether.
series ended with a call to action to scale up services for people with mental disorders.7
A number of initiatives have been launched in response to this call to action.8
A crucial goal is to describe packages of care for specific mental disorders. The WHO's new Mental Health Gap Action Program (mhGAP) specifically aims to develop packages of care for seven mental, neurological and substance-abuse disorders and for suicide.9
The World Psychiatric Association has launched an initiative to assess psychiatrists’ perspectives on delivery of evidence-based treatments for mental disorders across the continuum of life, with a focus on mechanisms that aim to achieve equity of coverage in low-resource settings. The journal PLoS Medicine
will soon publish a series of articles on packages of care for six MNDs. The Movement for Global Mental Health10
has launched a website from which unpublished packages of care can be disseminated.11
All these initiatives focus on either specific disorders or specific demographic groups. The key challenge remains how these various packages can be integrated across disorder categories and demographic groups and, furthermore, how these can be integrated within existing health-care programmes. In this article, the evidence available so far is utilized to propose such an integrated model. The article will first consider how disorders can be grouped based on shared clinical, epidemiological and health-service considerations. Next, the delivery of the packages of care for each group of disorders will be considered based on a primary-care delivery system serving a defined population or ‘health district’.12
This article is based on the development of a District Mental Health Program (DMHP) proposal developed by the authors, on behalf of the government of a state in India, in response to the National Mental Health Program of India.