1. Global Mental Health: A way forward Pamela Y. Collins, MD, MPH Office for Research on Disparities & Global Mental Health NIMH Associate Clinical Professor of Epidemiology & Psychiatry Columbia University

2. National Institutes of Health NIH is a part of the US Department of Health and Human Services and is the nation’s medical research agency Largest source of funding for medical research in the world NIH is made up of 27 institutes and centers, of which the National Institute of Mental Health is one Fogarty International Center is dedicated to facilitating global health research conducted by US and international investigators

3. NIMH Offices and Divisions Office of the Director NIMH Divisions Office on AIDS Office of Autism Research Coordination Office of Constituency Relations and Public Liaison Office for Research on Disparities and Global Mental Health Office of Rural Mental Health Office of Science Policy, Planning, and Communications Division of Intramural Research Programs Division of Neuroscience and Basic Behavioral Science Division of Adult Translational Research and Treatment Development Division of Developmental Translational Research Division of AIDS Research Division of Extramural Activities

4. “Resources for mental health are scarce and inequitably distributed between countries, between regions, and within local communities.” (Saxena et al., 2007)

6. The biological basis of mental disorders “…from the brain, and from the brain only, arise our pleasures, joy, laughter and jests, as well as our sorrows, pains, griefs, and tears.” “…all the most acute, most powerful, and most deadly diseases, and those which are most difficult to be understood by the inexperienced, fall upon the brain.” Hippocrates Adams, 1939, p.360 in Costello, 2010

7. Understanding Etiology of Mental Disorders WHO, 2000, Women’s Mental Health

8. Worldwide Distribution of DALYs Lost Among Young Women, By Age Group, 2002 Ages 5-14 Ages 15-29 Notes: Numbers are rounded. Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 59.1

9. Worldwide Distribution of DALYs Lost Among Young Men, By Age Group, 2002 Ages 5-14 Ages 15-29 Notes: Numbers are rounded. Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 59.1

10. Source: Global Burden of Disease, WHO 2004

11. Identifying Global Mental Health Research Priorities http://grandchallengesgmh.nimh.nih.gov

12. Global Engagement in Mental Health Research Directions: Grand Challenges Responses: Grand Challenges Canada commits up to $20 million to combat stigma and to address Goal C: Improve treatment & Expand access to care

13. A Practical Goal for Services: Integrate mental health into primary care Long-standing goal globally Needs favorable political conditions Benefits from decentralized government Adequate training/supervision of primary care providers Grand Challenges Integrate screening and core packages of services into routine primary health care Strengthen the mental-health component in the training of all health-care personnel

14. Psychiatry NOS:What are we talking about?? Diagnostic systems need improvement Think dimensionally Need valid, simplified diagnoses for use in primary care What are the real disorders? What language can we use? Grand Challenge Develop valid and reliable definitions, models and measurement tools for quantitative assessment at the individual and population levels for use across cultures and settings

15. No Health without Mental Health A human is a single organism, health should not be segmented into “mental” and “physical.” Mental disorders can increase risk, morbidity, and mortality associated with infectious and non-communicable disease Grand Challenge Redesign health systems to integrate MNS disorders with other chronic-disease care

16. The social context of mental health in Context of poverty/economic deprivation Internal displacement due to conflict Power of devastating traumatic experiences Exposure to chronic, daily stressors Grand Challenge Understand the impact of poverty, violence, war, migration and disaster

17. What care do we provide?Where does that care occur? Engage traditional sources of support in the community (religious leaders, teachers, traditional healers) in mental health Our treatment settings contribute to stigma Grand Challenge Provide effective and affordable community-based care and rehabilitation Develop culturally informed methods to eliminate the stigma, discrimination and social exclusion of patients and families across cultural settings

18. Using policy & implementing plans for mental health services Importance of integrating mental health into all levels of health system Translate research to policy Clinical experience informing policymakers Grand Challenge Establish and implement minimum health care standards for MNS disorders around the world

19. Task shifting for mental health Using providers with more abbreviated training to perform the tasks of specialists Good examples in many low- and middle-income countries India – MANAS trial (Patel et al., 2010) Pakistan – Lady Health Workers ( Rahman et al, 2008) Uganda – Group IPT for depression (Bolton et al, 2003) Chile – Treating depression in primary care (Araya et al, 2003)

20. Challenges for research In 1990 5% of the world’s research investment addressed 93% of the world’s population (Commission on Health Research for Development) By 2003 global health research expenditures quadrupled (Global Forum for Research, www.globalhealthforum.org) Critical questions cannot be answered with data from a limited portion of the world’s population Brain drain! Burden of clinical and administrative responsibilities Lack of demand for publication Few opportunities for research capacity-building Poorly accessible research findings

21. Opportunity #4: Encouraging a greater focus on global health

22. Focus on Equity:Reduce the treatment gap in LMICs On the Pulse of Global Mental Health Action: Identifying Strategic Research Opportunities 2-3 March, 2010 Hyatt Regency, Bethesda, MD

23. Scientific Opportunity: Human Heredity & Health in Africa (H3 Africa)

24. Build on global health programs

25. Anticipate global public health needs

26. Build Research Capacity

27. Opportune Time for Global Mental Health Activities Global Funding Opportunities Global Policy Opportunities UK-East Kilbride: HRPC10 Improving Mental Health Services in Low Income Countries DFID is seeking Expressions of Interest (EOIs) from suppliers to lead a consortium of organisations with multi- disciplinary skills in the theme "Improving Mental Health Services in Low Income Countries".

28. New Developments in Global Mental Health Meet criteria for vulnerability Merit targeting by development strategies and plans Different development stakeholders have roles to play in designing & implementing policies and programs for reaching people with mental disorders Development programs should protect the human rights of people with mental disorders and build capacity to participate in public affairs WHO, 2010