Saxena, Shekhar

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Against the stark reality of the fact that worldwide mostpeople with mental illness are not treated (Thornicroft,2007), the impact of any serious undertaking in the area ofglobal mental health has to be judged against the bench-mark of whether it leads to more people being treated.Treatment gap for mental disorders can be defined as theproportion of individuals who require but do not receivetreatment. Some recent studies have demonstrated thattreatment gap for mental disorders is surprising high. Areview of international literature (Kohn et al., 2004)revealed that one-third of all individuals withSchizophrenia and other non-affective psychoses do notreceive any treatment. Figures for depression, dysthymia,bipolar disorder, panic, obsessive compulsive and anxietydisorders are all around 50%. The World Mental HealthSurvey data show that 35 to 50% of serious cases in devel-oped countries and 76 to 85% in developing countriesreceived no treatment in the previous year (WHO WorldMental Health Consortium, 2004). This commentary exam-ines a few selected issues around the role and limitations ofclinical and service indicators in decreasing the treatmentgap in a global perspective. It also introduces WHO’s indi-cator scheme for assessing mental health systems.ARE INDICATORS NEEDEDIN LOW RESOURCE SETTINGS?The primary reasons for the large treatment gap formental disorders seem to be scarcity, inequity and ineffi-ciency of resources for mental health (Saxena et al.,2007b). The budgetary allocation for mental health fromthe total health budget is usually very small; the medianpercentage for this for all countries is 3.76 and for lowincome countries, 2.26. A large number of countriesspend less than 1% of their health budget on mentalhealth. The availability of human resources is also highlyinadequate. The median numbers of psychiatrists andpsychiatric nurses in low income countries are 0.05 and0.16 per 100,000 population- hardly adequate to provideeven basic mental health care to all who need it. In viewof this severe lack of financial and human resources formental health care, are clinical and service indicatorsneeded for low and middle income countries? If yes, whatshould the indicators look like?If evidence based clinical interventions and services arenecessary for resource rich settings, these are even moreneeded for resource poor settings. When resources arescarce, none should be wasted. Indicators serve theextremely useful function of facilitating evaluation of cur-rent practices, identification of strengths and weaknessesand making possible comparisons across services andtime. However, information collected with indicators alsomakes corrective action possible, not only at services levelbut also at the level of policy and programme. Resourcescan be enhanced, distributed more equitably and utilizedmore efficiently based on service and clinical indicators.For all these reasons, the SIEP-DIRECT’S Project(DIscrepancy between Routine practice and Evidence inpsychiatric Community Treatments on Schizophrenia)(Ruggeri et al., 2008; Semisa et al., 2008; Ruggeri et al.,2008) is a valuable and innovative initiative and providesuseful tools to optimize resource allocation and use.WHICH INDICATORS WOULD BE MOSTUSEFUL IN LOW RESOURCE SETTINGS?Though indicators serve very useful needs globally, itis important to match the level and specificity of indica-Epidemiologia e Psichiatria Sociale, 17, 4, 2008267Address for correspondence: Dr. S. Saxena, Department of MentalHealth and Substance Abuse World Health Organization CH-1211,Geneva (Switzerland).E-mail: saxenas@who.intDeclaration of Interest: None.Use of clinical and service indicators to decrease the treatmentgap for mental disorders: a global perspectiveSHEKHAR SAXENADepartment of Mental Health and Substance Abuse, World Health Organization, Geneva (Switzerland)https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1121189X00000075Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 15:54:11, subject to the Cambridge Core terms of use, available attors to their expected use. High level aggregate serviceindicators are more useful for policy, plans and serviceorganization. More specific fine grained indicators arelikely to be needed for improving the fidelity of deliveryof interventions and for training of clinical care providers.At different stage of service development and resourceavailability, the mix of indicators will vary. In general,service systems that are poorly resourced, tend to benefitmore from aggregate high level service and system levelindicators. However, the current availability of indicatorsseems not to be sensitive to this need (Saxena et al.,2006). Evidence for clinical guidelines and indicatorsfocusing on discrete interventions is accumulating at arapid pace. However, evidence for effectiveness and cost-effectiveness of services is lagging behind. For example,National Schizophrenia Guidelines for UK (NationalInstitute for Mental Health, 2003) concluded that evidencefor service level interventions for schizophrenia is largelyinsufficient to make definite recommendations. This cre-ates the situation in which the confidence with which spe-cific services for mental disorders can be recommended ismuch lower than the confidence for specific interventions.Scientific evidence seems to provide less help precisely inthe area that is the main priority for low resource settings.SHOULD INDICATORS COVER HUMANRIGHTS ASPECTS?Abuse or neglect of basic human rights of people withmental disorders are quite commonly encountered inmental health services (World Health Organization,2005b). Clinical and service indicators need to cover thehuman rights aspects of care along with the interventionsbeing delivered. Human rights guidance needs to be areflection of values rather than of the evidence for effec-tiveness. Unfortunately, currently available clinicalguidelines all but ignore human rights issues. This resultsin an erroneous message to service providers and traineesthat they are accountable for the delivery of scientific evi-dence based interventions to their patients while humanrights and other value based aspects are peripheral to theirresponsibilities. This situation must change and one ofthe ways to bring this about is to integrate human rightsissues in clinical and service guidelines and indicators.WHO-AIMSIn view of the serious and urgent need to have reli-able and accurate information on mental health systemsand services from low and middle income countries,World Health Organization has developed WHO-AIMS(The World Health Organization AssessmentInstrument for Mental Health Systems). This instru-ment is an indicator scheme that systematically assess-es important attributes of mental health systems andservices. Details of the rationale and the process fol-lowed to develop this instrument are described else-where (World Health Organization, 2005a; Saxena etal., 2007a). The instrument contains 155 measures cov-ering six core domains: the policy and legislativeframework for mental health, mental health services,mental health in primary health care, human resources,links with other sectors, and monitoring and research.In terms of the overall structure and focus of the instru-ment, WHO-AIMS contains mainly process and struc-ture measures rather than outcome measures. The pri-mary reason is that the majority of low-income coun-tries still lack the basic mental health infrastructure,such as community-based services, or a functioninginformation system. Thus, collecting data on clinicalinterventions or practices as well as on outcomes wouldbe extremely difficult, if not impossible within reason-able effort. WHO-AIMS includes indicators for notonly overall national/provincial systems but also con-crete service indicators like availability of human,financial and other resources and the throughput andcharacteristics of patients being cared for. A number ofindicators are devoted to human rights considerations(e.g. inspection of human rights in mental health facil-ities, physical restraints and seclusion in mental healthfacilities).WHO-AIMS is currently being used in morethan 60 low and middle income countries and finalreports from more that 40 countries are already avail-able (http://www.who.int/mental_health/evidence/WHO-AIMS/en/index.html). A number of these coun-tries are using the WHO-AIMS data and reports forstrengthening their mental health systems.Since scaling-up of services seems the highest prior-ity for most low and middle income countries (LancetGlobal Mental Health Group, 2007), clinical and ser-vice guidelines need to be developed in a way that theyserve the need for enhancing the coverage with ser-vices rather than to focus exclusively on improving thequality of services. In some cases, these two objectiveswill be mutually incompatible; in resource poor set-tings, a few people can be given excellent care or manymore people can be given basic (but still effective)care. Guidelines and indicators need to be sensitive tothese possibly contradictory needs and strike a goodbalance.S. SaxenaEpidemiologia e Psichiatria Sociale, 17, 4, 2008268https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1121189X00000075Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 15:54:11, subject to the Cambridge Core terms of use, available atREFERENCESKohn R., Saxena D., Levav I. & Saraceno B. (2000). The treatment gapin mental health care. Bulletin of the World Health Organization 8,858-864.Lancet Global Mental Health Group (2007). Scale up services for men-tal disorders: a call for action. Lancet 370, 1241-1252.National Institute for Mental Health (2003). Schizophrenia: FullNational Clinical Guidelines on Core Interventions in Primary andSecondary Care. Gaskell and British Psychological Society:London.Ruggeri M. (2008). Guidelines for treating mental illness: love them,hate them. Can the SIEP-DIRECT’S Project serve in the search for ahappy medium? Epidemiologia e Psichiatria Sociale 17(4), 270-277.Ruggeri M., Lora A. & Semisa D. on behalf of the SIEP-DIRECT’S Group(2008). The SIEP-DIRECT’S Project on the discrepancy between rou-tine practice and evidence. An outline of the main findings and thepractical implications for the future of community based mental healthservices. Epidemiologia e Psichiatria Sociale 17(4), 358-367.Saxena S., van Ommeren M., Lora A. & Saraceno B. (2006).Monitoring of mental health systems and services – comparison offour existing indicator schemes. Social Psychiatry and PsychiatricEpidemiology 41, 488-497.Saxena S., Lora A., van Ommeren M., Barrett T., Morris J. & SaracenoB. (2007a). WHO’s assessment instrument for mental health systems: Collecting essential information for policy and service deliv-ery. Psychiatric Services 58(6), 816-821.Saxena S., Thornicroft G., Knapp M. & Whiteford H. (2007b).Resources for mental health: scarcity, inequity, and inefficiency.Lancet 370, 878-889.Semisa D., Lora A., Morosini P. & Ruggeri M. (2008a). The SIEP-DIRECT’S Project on the discrepancy between routine practice andevidence in the treatment of schizophrenia. The design, the indica-tors, and the methodology of the study (in Italian). Epidemiologia ePsichiatria Sociale 17(4), 278-290.Thornicroft G. (2007). Most people with mental illness are not treated.Lancet 370, 807-808.WHO World Mental Health Consortium (2004). Prevalence, severityand unmet need for treatment of mental disorders in the WorldMental Health Organization World Mental Health Surveys. Journalof the American Medical Association 291, 2581-2590.World Health Organization (2005a). World Health OrganizationAssessment Instrument for Mental Health Systems (WHO-AIMS)Version 2.2. World Health Organization: Geneva. Retrieved August19, 2008, from http://www.who.int/mental_health/evidence/AIMS_WHO_2_2.pdfWorld Health Organization (2005b). Resource Book on Mental Health,Human Rights and Legislation. WHO: Geneva.Epidemiologia e Psichiatria Sociale, 17, 4, 2008269Use of clinical and service indicators to decrease the treatment gap for mental disorders: a global perspectivehttps:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1121189X00000075Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 11 Jul 2017 at 15:54:11, subject to the Cambridge Core terms of use, available at

Use of clinical and service indicators to decrease the treatment gap for mental disorders: a global perspective

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