Recruiting doctors from poor countries: the great brain robbery?

An important impediment to achieving health for all in developing countries is the shortage of doctors and nurses. Can the NHS justify schemes to recruit staff from these countries

Reducing the burden of depression in youth: what are the implications of neuroscience and genetics on policies and programs?

Mood disorders are a leading cause of the burden of disease in youth. Three critical lessons emerge from the reviews in this issue that are relevant to our understanding of these common mental disorders: first, that the brain is in a highly dynamic stage of its development during youth; second, that environmental factors interact with genetic factors to influence the probability of risk behaviors and dysphoric states; and third, that shared developmental and genetic factors may account for the bulk of emotional and behavioral outcomes in youth, and that environmental influences may affect the specific expression of the phenotypes associated with these pathways. Although this evidence does not immediately indicate the potential for new interventions, it is consistent with current policy and practice recommendations. Interventions should focus on both improving the early detection and management of depressive disorders as well as preventive strategies that aim to train children and youth to improve cognitive control and manage stress more effectively. Limiting access to harmful risk-taking situations and providing opportunities to engage are less harmful, but equally exciting, alternatives in a pragmatic universal prevention policy option. Key research priorities and paradigms emerge from this evidence, particularly in the context of the grand challenges in global mental health

Universal Health Coverage for Schizophrenia: A Global Mental Health Priority.

The growing momentum towards a global consensus on universal health coverage, alongside an acknowledgment of the urgency and importance of a comprehensive mental health action plan, offers a unique opportunity for a substantial scale-up of evidence-based interventions and packages of care for a range of mental disorders in all countries. There is a robust evidence base testifying to the effectiveness of drug and psychosocial interventions for people with schizophrenia and to the feasibility, acceptability and cost-effectiveness of the delivery of these interventions through a collaborative care model in low resource settings. While there are a number of barriers to scaling up this evidence, for eg, the finances needed to train and deploy community based workers and the lack of agency for people with schizophrenia, the experiences of some upper middle income countries show that sustained political commitment, allocation of transitional financial resources to develop community services, a commitment to an integrated approach with a strong role for community based institutions and providers, and a progressive realization of coverage are the key ingredients for scale up of services for schizophrenia

Talking sensibly about depression.

In an Essay to highlight World Health Day 2017, Vikram Patel proposes a staged model, from wellness to distress to disorder, for classifying depressive symptoms

Global mental health: an interview with Vikram Patel.

In this podcast, we talk to Professor Vikram Patel about the impact of global mental health in the field of medicine, and discuss the initiatives and platforms being developed to promote capacity building, research, policy and advocacy within the established Centre for Global Mental Health. The anticipated challenges, controversies, and future directions for this discipline of global health are highlighted as well.The podcast for this interview is available at: http://www.biomedcentral.com/sites/2999/download/Patel.mp3

Why do British Indian children have an apparent mental health advantage?

BACKGROUND: Previous studies document a mental health advantage in British Indian children, particularly for externalising problems. The causes of this advantage are unknown. METHODS: Subjects were 13,836 White children and 361 Indian children aged 5-16 years from the English subsample of the British Child and Adolescent Mental Health Surveys. The primary mental health outcome was the parent Strengths and Difficulties Questionnaire (SDQ). Mental health was also assessed using the teacher and child SDQs; diagnostic interviews with parents, teachers and children; and multi-informant clinician-rated diagnoses. Multiple child, family, school and area factors were examined as possible mediators or confounders in explaining observed ethnic differences. RESULTS: Indian children had a large advantage for externalising problems and disorders, and little or no difference for internalising problems and disorders. This was observed across all mental health outcomes, including teacher-reported and diagnostic interview measures. Detailed psychometric analyses provided no suggestion of information bias. The Indian advantage for externalising problems was partly mediated by Indian children being more likely to live in two-parent families and less likely to have academic difficulties. Yet after adjusting for these and all other covariates, the unexplained Indian advantage only reduced by about a quarter (from 1.08 to .71 parent SDQ points) and remained highly significant (p < .001). This Indian advantage was largely confined to families of low socio-economic position. CONCLUSION: The Indian mental health advantage is real and is specific to externalising problems. Family type and academic abilities mediate part of the advantage, but most is not explained by major risk factors. Likewise unexplained is the absence in Indian children of a socio-economic gradient in mental health. Further investigation of the Indian advantage may yield insights into novel ways to promote child mental health and child mental health equity in all ethnic groups

Designing Psychological Treatments for Scalability: The PREMIUM Approach.

INTRODUCTION: Lack of access to empirically-supported psychological treatments (EPT) that are contextually appropriate and feasible to deliver by non-specialist health workers (referred to as 'counsellors') are major barrier for the treatment of mental health problems in resource poor countries. To address this barrier, the 'Program for Effective Mental Health Interventions in Under-resourced Health Systems' (PREMIUM) designed a method for the development of EPT for severe depression and harmful drinking. This was implemented over three years in India. This study assessed the relative usefulness and costs of the five 'steps' (Systematic reviews, In-depth interviews, Key informant surveys, Workshops with international experts, and Workshops with local experts) in the first phase of identifying the strategies and theoretical model of the treatment and two 'steps' (Case series with specialists, and Case series and pilot trial with counsellors) in the second phase of enhancing the acceptability and feasibility of its delivery by counsellors in PREMIUM with the aim of arriving at a parsimonious set of steps for future investigators to use for developing scalable EPT. DATA AND METHODS: The study used two sources of data: the usefulness ratings by the investigators and the resource utilization. The usefulness of each of the seven steps was assessed through the ratings by the investigators involved in the development of each of the two EPT, viz. Healthy Activity Program for severe depression and Counselling for Alcohol Problems for harmful drinking. Quantitative responses were elicited to rate the utility (usefulness/influence), followed by open-ended questions for explaining the rankings. The resources used by PREMIUM were computed in terms of time (months) and monetary costs. RESULTS: The theoretical core of the new treatments were consistent with those of EPT derived from global evidence, viz. Behavioural Activation and Motivational Enhancement for severe depression and harmful drinking respectively, indicating the universal applicability of these theories. All the steps of both phases in PREMIUM contributed to the development of the final EPT. However, if there were significant resource constraints, the steps can be limited to workshops with international and local experts in the first phase, and case series with specialists, and case series and pilot trial with counsellors in the second phase. CONCLUSIONS: Integrating global evidence with local knowledge and practices are complementary and feasible goals to contribute to the development of contextually appropriate and feasible EPT in resource poor country settings. The emerging EPT share similar theoretical frameworks to those described in the global evidence. The PREMIUM method has relevance for any setting where populations have poor access to EPT as its explicit goal is to develop scalable treatments