A position statement on mental health in the post-2015 development agenda.

BACKGROUND: The Millennium Development Goals have guided development co-operation in the 15 years up to 2015, achieving some significant progress in the priorities on which they focused. As the framework for the post-2015 development agenda is negotiated, this article reviews the evidence for the place of mental health in broader development issues that have already been outlined in the run-up to 2015. DISCUSSION: If mental health is going to be recognised as having an essential role in development, there needs to be a consensus on priorities for advocacy. Various key issues emerged from a survey of stakeholders in the Movement for Global Mental Health (MGMH), leading to a Position Statement, which is now available for use by advocates. The priorities that emerged were increasing access to mental health services, and addressing human rights abuse, stigma, and exclusion. SUMMARY: Mental health is a cross-cutting issue, and including it in frameworks for action will increase the likelihood of achieving global priorities for development such as poverty reduction, economic development, improved health, and ensuring the most vulnerable in society are not left behind

Service user and family participation in mental health policy making in Timor-Leste: a qualitative study with multiple stakeholders.

BACKGROUND: Participation in mental health system strengthening by people with mental health problems and their families is a cornerstone of people-centred mental health care, yet there is a dearth of research about participation from low- and middle-income countries (LMICs), particularly from the Asia Pacific region. Hence, this study aimed to assess the current situation, challenges, enabling factors and future actions for service user and family participation in mental health policy making in Timor-Leste. METHODS: In-depth interviews were conducted with 85 adults (≥18 years) who were: (1) mental health service users (n = 20) and their families (n = 10); (2) government decision makers (n = 10); (3) mental health and social service providers (n = 23); (4) civil society (n = 9); and (5) other groups (n = 13). Interview data was analysed using framework analysis. RESULTS: There was limited service user, family and community participation in mental health policy making in Timor-Leste. Perceptions that policy making is a technical exercise and that people with mental health problems lack cognitive capacity, and a lack of supportive mechanisms challenged participation. Enabling factors were a strong focus on human rights within the social sector, and existing mechanisms for advocacy and representation of people with disabilities in social policy making. Participants suggested bolstering civil society representation of people with mental health problems, and increasing mental health awareness and literacy, including government competencies to facilitate service user participation. CONCLUSION: The findings highlight the need for theoretical and practical focus on the role of family within mental health system development in LMICs. Global mental health research and practice should adopt a critical approach to mental health service user and family participation to ensure that the concept and strategies to achieve this are embedded in LMIC knowledge

Acceptability of a role for community health workers in integrated mental health care for perinatal depression: a qualitative study from Surabaya, Indonesia

Abstract Background: Integrated antenatal care in Indonesia has the potential to extend the role of community health workers (CHWs) to include the identification of perinatal depression in the community and referral to primary health care (PHC) centres, which is an example of task-sharing. This study aimed to examine the acceptability of this type of task-sharing in perinatal depression in Surabaya.Methods: Semi-structured interviews were conducted with participants from four PHC stakeholder groups. 62 participants were recruited from PHC centres, villages and integrated health service posts, the district health office, and one hospital. Data were analysed using framework analysis.Results: More than ninety percent of participants accepted or conditionally accepted task-sharing in perinatal depression. Acceptability was influenced by the perceived benefits of task-sharing, the convenience of the service delivery, the existence of cases of perinatal depression perceived by stakeholders, personal characteristics of CHWs, and the scope of their responsibility within existing tasks. Acceptability was limited by stigma of mental health problems, confidentiality, CHWs’ perceived self-capacity, lack of confidence in CHWs’ competencies, and the objectives of task-sharing in depression identification.Conclusion: Results indicate the need to enhance CHWs’ knowledge about perinatal depression and the needs of users, and CHWs’ competencies in identifying depression. Stigma influences potential health service users’ attitudes to mental health services and help-seeking and help-providing behaviours among service providers, and can reduce motivation to use and to provide services.</jats:p

Personal attributes and competencies required by community health workers for a role in integrated mental health care for perinatal depression: voices of primary health care stakeholders from Surabaya, Indonesia.

BACKGROUND: Non-professional community health workers have been widely reported as possibly having a role in mental health. In Indonesia, their role is currently being introduced in the national health system for perinatal depression. Prior publications have shown that it is generally considered feasible and acceptable by key stakeholders for community health workers to identify and refer women experiencing mental health issues during their perinatal phase to primary care. However, characteristics and competencies required for these workers have not yet been identified. METHODS: 62 participants from four groups of stakeholders in primary health care in Surabaya were interviewed, including program managers, health workers, community health workers (CHWs), mental health specialists, and pregnant and postpartum women. Semi-structured questions were used to explore participants' views about characteristics and competencies required by CHWs to identify and refer perinatal depression. RESULTS: Literacy and social skills were seen as basic characteristics required for CHWs to contribute to perinatal identification, together with willingness to volunteer and time availability. Participants identified females in the age range 30-50 years who have experienced pregnancy as being preferable. To ensure competency, training addressing knowledge about maternal life and depression, and communication skills are regarded as prerequisites for the role. CONCLUSIONS: The results are consistent with WHO guidelines for informal workers working with people with mental disorders in non-specialised settings. The results provide a rationale for the criteria to be met when informal workers are to be involved in primary care mental health area and provide information for the development of training in the identification of perinatal depression

Social inclusion and exclusion of people with mental illness in Timor-Leste: a qualitative investigation with multiple stakeholders.

BACKGROUND: Social inclusion is a human right for all people, including people with mental illness. It is also an important part of recovery from mental illness. In Timor-Leste, no research has investigated the social experiences of people with mental illness and their families. To fill this knowledge gap and inform ongoing mental health system strengthening, we investigated the experiences of social inclusion and exclusion of people with mental illness and their families in Timor-Leste. METHODS: Eighty-five participants from the following stakeholder groups across multiple locations in Timor-Leste were interviewed: (1) people with mental illness and their families; (2) mental health and social service providers; (3) government decision makers; (4) civil society members; and (5) other community members. Framework analysis was used to analyse interview transcripts. RESULTS: People with mental illness in Timor-Leste were found to face widespread, multi-faceted sociocultural, economic and political exclusion. People with mental illness were stigmatised as a consequence of beliefs that they were dangerous and lacked capacity, and experienced instances of bullying, physical and sexual violence, and confinement. Several barriers to formal employment, educational, social protection and legal systems were identified. Experiences of social inclusion for people with mental illness were also described at family and community levels. People with mental illness were included through family and community structures that promoted unity and acceptance. They also had opportunities to participate in activities surrounding family life and livelihoods that contributed to intergenerational well-being. Some, but not all, Timorese people with mental illness benefited from disability-inclusive programming and policies, including the disability pension, training programs and peer support. CONCLUSIONS: These findings highlight the need to combat social exclusion of people with mental illness and their families by harnessing local Timorese sociocultural strengths. Such an approach could centre around people with mental illness and their families to: increase population mental health awareness; bolster rights-based and culturally-grounded mental health services; and promote inclusive and accessible services and systems across sectors

Intersectoral collaboration for people-centred mental health care in Timor-Leste: a mixed-methods study using qualitative and social network analysis.

BACKGROUND: Intersectoral collaboration is fundamental to the provision of people-centred mental health care, yet there is a dearth of research about how this strategy operates within mental health systems in low- and middle-income countries. This is problematic given the known attitudinal, structural and resource barriers to intersectoral collaboration in high-income country mental health systems. This study was conducted to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system. METHODS: This study employed a mixed-methods convergent design. Qualitative data elicited from in-depth interviews with 85 key stakeholders and document review were complemented with quantitative social network analysis to assess understandings of, the strength and structure of intersectoral collaboration in the Timorese mental health system. RESULTS: There was consensus among stakeholder groups that intersectoral collaboration for mental health is important in Timor-Leste. Despite resource restrictions discussed by participants, interview data and social network analysis revealed evidence of information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste (network density = 0.55 and 0.30 for information and resource sharing, respectively). Contrary to the assumption that mental health services and system strengthening are led by the Ministry of Health, the mixed-methods data sources identified a split in stewardship for mental health between subnetworks in the health and social sectors (network degree centralisation = 0.28 and 0.47 for information and resource sharing, respectively). CONCLUSIONS: Overall, the findings suggest that there may be opportunities for intersectoral collaborations in mental health systems in LMICs which do not exist in settings with more formalised mental health systems such as HICs. Holistic understandings of health and wellbeing, and a commitment to working together in the face of resource restrictions suggest that intersectoral collaboration can be employed to achieve people-centred mental health care in Timor-Leste

Current needs for the improved management of depressive disorder in community healthcare centres, Shenzhen, China: a view from primary care medical leaders.

BACKGROUND: The prevalence of depressive disorder in Shenzhen is higher than for any other city in China. Despite national health system reform to integrate mental health into primary care, the majority of depression cases continue to go unrecognized and untreated. Qualitative research was conducted with primary care medical leaders to describe the current clinical practice of depressive disorder in community healthcare centres (CHC) in Shenzhen and to explore the participants' perceptions of psychological, organizational and societal barriers and enablers to current practice with a view to identifying current needs for the improved care of depressive disorder in the community. METHODS: Seventeen semi-structured, audio-recorded interviews (approx. 1 h long) were conducted in Melbourne (n = 7) and Shenzhen (n = 10) with a convenience sample of primary care medical leaders who currently work in community healthcare centres (CHC) in Shenzhen and completed any one of the 3-month long, Melbourne-based, "Monash-Shenzhen Primary Healthcare Leaders Programs" conducted between 2015 and 2017. The interview guide was developed using the Theoretical Domain's Framework (TDF) and a directed content analysis (using Nvivo 11 software) was performed using English translations. RESULTS: Despite primary care medical leaders being aware of a mental health treatment gap and the benefits of early depression care for community wellbeing, depressive disorder was not perceived as a treatment priority in CHCs. Instead, hospital specialists were identified as holding primary responsibility for formal diagnosis and treatment initiation with primary care doctors providing early assessment and basic health education. Current needs for improved depression care included: (i) Improved professional development for primary care doctors with better access to diagnostic guidelines and tools, case-sharing and improved connection with mentors to overcome current low levels of treatment confidence. (ii) An improved consulting environment (e.g. allocated mental health resource; longer and private consultations; developed medical referral system; better access to antidepressants) which embraces mental health initiatives (e.g. development of mental health departments in local hospitals; future use of e-mental health; reimbursement for patients; doctors' incentives). (iii) Improved health literacy to overcome substantive mental health stigma in society and specific stigma directed towards the only public psychiatric hospital. CONCLUSIONS: Whilst a multi-faceted approach is needed to improve depression care in community health centres in Shenzhen, this study highlights how appropriate mental health training is central to developing a robust work-force which can act as key agents in national healthcare reform. The cultural adaption of the depression component of the World Health Organisation's mental health gap intervention guide (mhGAP-IG.v2) could provide primary care doctors with a future training tool to develop their assessment skills and treatment confidence