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Worldwide perspective

Bridging the global mental health gap

The World Health Organization (WHO) estimates that 450 million people are affected by mental illness worldwide, contributing to 14% of the global burden of disease.

However, this burden is not shared equally. Access to treatment varies drastically between countries, with over 90% of those in low- and middle-income countries (LMICs) with depression not receiving the treatment they need. Trained healthcare workers are incredibly scarce – for example, in Ethiopia there are 110 psychiatrists in a population of 112 million.

King’s research has been central to the continuing global call to address the gap in mental health infrastructure around the world. The multi-level approach King’s has advocated – combining change at national and governmental level with effective grass roots implementation – has helped instigate changes in policy and strategy while providing evidence to implement and scale-up mental health programmes on the ground.

Collectively, this has brought much needed support to empower countries and communities with limited resources to bridge the mental health treatment gap.

Identifying the gaps – and the opportunities

As part of an international collaboration that was co-led by King’s, The London School of Hygiene and Tropical Medicine (LHSTM) and the WHO, researchers highlighted that a scarcity of resources, inequities in their distribution and inefficiencies in their use worldwide were the norm in the first ever Lancet Series on Global Mental Health in 2007.

This evidence-backed call to invest in mental health service provision worldwide was further developed by King’s research which defined the gap between those who need mental health care and those who receive it; identified factors contributing to low rates of mental health treatment (namely stigma, discrimination, poverty and access); and reported the economic benefits of providing mental health care. Taken together, these findings made a compelling case for addressing mental illness in LMICs.

Importantly, King’s research showed that the critical factors for implementing evidence-based service provision in LMICs countries are: (i) strong governance; (ii) financing; (iii) a trained and supported workforce; (iv) mental health information systems; and (v) effective knowledge transfer.

This was coupled with research identifying effective local approaches for integrating mental health care into primary care. Under the Programme for Improving Mental Health Care (PRIME) – a consortium of research institutions and ministries of health in five countries was established to generate high quality evidence on the effective implementation of mental health treatment programmes in primary healthcare contexts and low resource settings – researchers from the University of Cape Town, King’s, LSHTM and WHO worked with partners in Ethiopia, India, Nepal, South Africa and Uganda to develop and evaluate evidence-based interventions. King’s made an important contribution in supporting southern leadership of the PRIME mental health research consortium.

Identifying factors which enable the scaling up of mental health care approaches is critical. The ‘Emerging mental health systems in LMICs’ (EMERALD) consortium, led by King’s, investigated how integrated mental health care approaches, developed and proven to work locally, can be scaled up for use at district level and above.

King’ College London is a part of a highly active and effective worldwide network of collaborators who are dedicated to better global mental health. The work illustrated here shows how we contribute to increasing the provision of evidence-based care, support and treatment to people with lived experience of mental health conditions in low- and middle-income countries. This is a powerful example of how King’s, working with our partners across the globe, can really make a difference towards improving health care worldwide.– Professor Sir Graham Thornicroft, Professor of Community Psychiatry at the Centre for Global Mental Health, King’s College London and Consultant Psychiatrist at South London & Maudsley NHS Foundation Trust

Tackling Stigma

King’s identified that stigma around mental health in LMICs is a major barrier to treatment. King’s research in over 40 countries showed that social contact reduces stigma and enables people with mental illness to better engage with mental health care.

By working closely with communities, King’s researchers identified and co-developed meaningful and effective routes to provide mental health services such as task-sharing and community detection tools. Local communities have been at the heart of the development of mental health interventions in LMICs, and people living with mental illness have been engaged with the planning and delivery of services. This has helped make implementation more effective and has combatted barriers to treatment caused by mental health stigma.

With a focus on the reduction of stigma around mental health, the INDIGO partnership programme has implemented service user involvement in stigma reduction in 42 villages across Andhra Pradesh, India, and showed significant improvements in knowledge, attitude and behaviour. In Ethiopia, the EMERALD program included experts with lived experience of mental illness into training for primary care workers, based on King’s evidence that social contact is the best approach to reduce stigma.

Implementing mental health interventions in limited resource settings

Based on research highlighting the lack of resources for mental health care in LMICs, the ongoing WHO Mental Health Global Action Program (mhGAP) was launched in 2008. The programme is aimed at scaling up services for mental, neurological and substance use disorders, particularly in LMICs where healthcare resources are scarce.

Informed by King’s evidence, the WHO developed an mhGAP Intervention Guide and Operations Manual which supports primary healthcare workers in implementing mental health interventions in limited resource settings. The Intervention Guide is now available online and in a smartphone app. It is used in over 100 countries worldwide and has been produced in Arabic, Chinese, French, Greek, Hindi, Russian and Spanish.

King’s researcher Dr Charlotte Hanlon’s co-authored book, Where There Is No Psychiatrist, informed the development of the mhGAP Community Toolkit. The toolkit has helped programme managers tailor interventions to meet their local mental health needs. It provides practical information and tools for communities to promote mental health, identify and prevent mental illness, and implement effective treatments.

 

King’s College London has worked in equitable partnerships with researchers, Ministries of Health, non-governmental organisations and the World Health Organization to generate vital evidence on mental health care needs in low resource settings. Importantly, we have gone beyond this to develop and evaluate affordable models of mental health care in community and primary care settings. With the right level of political commitment and resources, these models can be scaled up to meet the needs of many vulnerable people around the world.– Professor Crick Lund, Professor of Global Mental Health and Development at the Global Health Institute and Centre for Global Mental Health, King's College London

Working with local communities to integrate mental healthcare

Through collaboration with local communities, King’s research has informed national mental health strategies in countries such as Ethiopia and Nepal. With the development and evaluation of innovative interventions, King’s researchers have trained members of local communities to deliver mental health care on the ground, leading to effective treatment of mental illness in LMICs.

Nepal

Service users were directly involved in the training and supervision of primary healthcare workers in Nepal. King’s researchers successfully worked with local communities to implement an integrated mental healthcare plan in Chitwan district. The success of this local intervention has led to national policy changes throughout Nepal, as well as more local initiatives developed outside of Chitwan. Similar integrated mental health care plans have been adapted and scaled up to 94 facilities across five countries as part of the PRIME consortium.

Ethiopia

Local communities were fundamental to the development of mental health interventions in Ethiopia. Service users shared their stories to teach community members and to train primary care staff in Ethiopia.

King’s researchers worked with Ethiopian colleagues and stakeholders to develop an integrated district level plan which was implemented and scaled-up to the whole of the Gurage Zone in Ethiopia. King’s research findings shaped Ethiopia’s first National Mental Health Strategic Plan. Following King’s-linked projects, more than 250 frontline health workers, 250 community health workers, as well as healthcare managers and pharmacy technicians were trained to support the delivery of mental health care. Now, more than 600 people with severe mental illness and 350 people with epilepsy have received care in rural Ethiopia.

Underpinning all our work has been our partnerships with colleagues and collaborators in low- and middle-income countries. At King’s we are committed to developing equitable partnerships, strengthening capacity of early career researchers in the global south and working closely with people with lived experience of mental health conditions. Together we can do so much more!– Dr Charlotte Hanlon, Reader in Global Mental Health at the Centre for Global Mental Health, King's College London

King’s research continues to make the case for improved global mental health care, providing new and valuable insights into how to make this happen on the ground for a broader range of resources and projects.

Following COVID-19, the prevalence of anxiety and depression increased by 25% globally. This has guided COVID response plans around the world, encouraging an emphasis on mental health and psychosocial support following the pandemic. King’s work is vital for unearthing the impact of the pandemic in LMICs and supporting the implementation of mental health interventions in low-resource settings.

In this story

Charlotte Hanlon

Charlotte Hanlon

Reader in Global Mental Health

Graham Thornicroft

Graham Thornicroft

Professor of Community Psychiatry

Crick Lund

Crick Lund

Professor of Global Mental Health and Development