As referenced in a previous section on this course, the Global Burden of Disease survey 2010 showed that mental and substance issue disorders accounted for 7.4% of all Disability Adjusted Life Years (DALYs) worldwide, accounting for 0.5% of all Years of Life Lost (YLL) and 22.9% of all Years Lived with Disability (YLD) (Whiteford et al, 2013). However, there is a treatment gap recognised between the burden of disease and the treatment available for mental and neurological disorders worldwide. This is exacerbated in Lower and Middle Income countries. As stated by the World Health Organisation: “Despite the prevalence and burden of MNS (mental, neurological and substance misuse) disorders, a large proportion of people with such problems do not receive treatment and care. A large multicountry survey supported by WHO showed that 35–50% of serious cases in developed countries and 76–85% in less-developed countries had received no treatment in the previous 12 months. A review of the world literature found treatment gaps to be 32% for schizophrenia, 56% for depression, and as much as 78% for alcohol use disorders.”

Even when available, the interventions often are neither evidence-based nor of high quality. WHO launched the Mental Health Gap Action Programme (mhGAP) for low- and middle-income countries with the objective of scaling up care for mental, neurological and substance use disorders. You can read an online version here, or there is an older summary here.

The mhGAP is thus based on the following approach:

  • Identification of priority conditions based on psychiatric morbidity (depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia, disorders due to use of alcohol, disorders due to use of illicit drugs, and mental disorders in children)

  • Engaging political commitment and mobilising multidisciplinary resources for implementation, including financial resources and building partnerships (including government, Non Governmental Organisations, civil society and international agencies)

  • Identification of service providers in local, community and national settings (such as community works, primary care physicians). To ensure the training needs and curricula for them for each given intervention

  • Identification of an intervention package for each priority condition (see page 11 &12 of the document) and adaption to local context based on efficacy, feasibility, cost and acceptability

  • Scaling up programmes that have worked well on a pilot basis to regional or national projects

  • Ensuring a system of evaluation and monitoring of service delivery

Further Reading:

In 2007 Patel et al reviewed the evidence base for effective treatments and prevention of mental disorders in low-middle income countries. Please read the Lancet article: Global Mental Health 3: Treatment and prevention of mental disorders in low-income and middle-income countries. 

This was updated in 2018 in The Lancet Commission on global mental health and sustainable development, which is well worth exploring: "A decade on from the 2007 Lancet Series on global mental health, which sought to transform the way policy makers thought about global health, a Lancet Commission aims to seize the opportunity offered by the Sustainable Development Goals to consider future directions for global mental health. The Commission proposes that the global mental agenda should be expanded from a focus on reducing the treatment gap to improving the mental health of whole populations and reducing the global burden of mental disorders by addressing gaps in prevention and quality of care. The Commission outlines a blueprint for action to promote mental wellbeing, prevent mental health problems, and enable recovery from mental disorders."

Other reviews include the following: Promotion, prevention and protection: interventions at the population- and community-levels for mental, neurological and substance use disorders in low- and middle-income countries. A summary states "Interventions provided at the population- and community-levels have an important role to play in promoting mental health, preventing the onset, and protecting those with MNS disorders....At the population-level, laws and regulations to control alcohol demand and restrict access to lethal means of suicide were considered “best practice”. Child protection laws, improved control of neurocysticercosis and mass awareness campaigns were identified as “good practice”. At the community level, socio-emotional learning programmes in schools and parenting programmes during infancy were identified as “best practice”. The following were all identified as “good practice”: Integrating mental health promotion strategies into workplace occupational health and safety policies; mental health information and awareness programmes as well as detection of MNS disorders in schools; early child enrichment/preschool educational programs and parenting programs for children aged 2–14 years; gender equity and/or economic empowerment programs for vulnerable groups; training of gatekeepers to identify people with MNS disorders in the community; and training non-specialist community members at a neighbourhood level to assist with community-based support and rehabilitation of people with mental disorders."

Mental Health in Developing Countries: Challenges and Opportunities in Introducing Western Mental Health System in Uganda offers a case study and concludes: "Uganda can continue to implement the Western mental health practice model which emanates from a different cultural base, based on the medical model and whose tenets are currently being questioned, or establish a model based on their needs with small baseline in-country surveys that focus on values, beliefs, resiliency, health promotion and recovery. The latter approach will lead to a more efficient mental health system with improved care, better outcomes and overall mental health services to Ugandan individuals and communities."

Mental Health from the World Bank includes the following: "Countries are not prepared to deal with this often “invisible” and often-ignored challenge. Despite its enormous social burden, mental disorders continue to be driven into the shadows by stigma, prejudice, or fear of disclosure because a job may be lost, social standing ruined, or simply because health and social support services are not available or are out of reach for the afflicted and their families...the estimated cost of treatment interventions at the community level for moderate to severe cases of depression, including basic psychosocial treatment for mild cases and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases, is  quite low: the average annual cost during 15 years of scaled-up investment is $.08 per person in low-income countries, $0.34 in lower middle-income countries, $1.12 in upper middle-income countries, and $3.89 in high-income countries.  (Chisholm et al., 2016).  And the economic returns on investment are high: the benefit-to-cost ratios for scaled-up depression treatment across country income groupings were in the range of 2.3 to 2.6, and for anxiety disorders, the ratios were slightly higher, with a range 2.7–3.0 "

Now take a look at the following article which discusses the training needs of local providers and is an example of how an evidence-based approach can be adapted to an LMIC resource setting: Murray, L.K., Dorsey, S., Bolton, P., Jordans, M.J.D., Rahman, A., Bass, J. & Verdeli, H. (2011). Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers. International Journal of Mental Health Systems, 5, 30

This article discusses approaches to scaling up successful pilot interventions: Scale up of services for mental health in low-income and middle-income countries (2011) Eaton, Julian et al. The Lancet, 378.9802: 1592 – 1603.

Optional: if you require detailed information or for interest.....

The mhGAP Intervention Guide (mhGAP-IG) has been developed to facilitate mhGAP-related delivery of evidence-based interventions in non-specialized health-care settings. This gives more detailed information on the clinical assessment, management and delivery of interventions by health care workers within the health care system for each priority condition. The guide book is a summary of both clinical and psychosocial interventions recommended for use in low- and middle-income countries. It summarises evidence-based interventions to identify and manage a number of priority conditions (depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm / suicide and other significant emotional or medically unexplained complaints). The guidance is useful for providing ideas for health promotion or prevention strategies as well as guiding treatment approaches. Should you wish to review the evidence base upon which the mhGAP interventions are based, they can be accessed from here: 

Last modified: Sunday, 4 June 2023, 5:40 AM