Assessing readiness for implementation of psychedelic-assisted mental health therapy, in low- and middle-income countries

Global pandemic perspectives: public health, mental health, and lessons for the future

Will RDoC hasten the decline of America's global leadership role in mental health?

The last two decades have witnessed a growing acknowledgment of the importance of research on mental health in the global health context. The 1995 edited volume, World Mental Health [1], the 1996 publication of the Global Burden of Disease Study [2], and the 2001 World Health Report [3] powerfully utilized mental health data or underscored the role of research in achieving gains in mental health around the world. By 2007, the World Health Organization and the Global Forum for Health Research released their report on research capacity for mental health, demonstrating the dearth of mental health research from low- and middle-income countries, in particular, as well as the need to bridge the gap between research, practice, and policy [4]. That same year, the Lancet special issue on global mental health galvanized the global mental health community, outlining concrete actions to advance the field [5]. The series Call to Action underscored the importance of research as a means to expand the global evidence base and to make the case for mental health care delivery reform, especially in low-and middle-income countries (LMICs) [5]. At the time, however, medical students and residents from high-, middle-, and low-income countries, alike, would have noted a dearth of funding to support research training focused on global mental health themes. Despite this, by 2009, new global health programs at universities were rapidly appearing in the USA and providing more opportunities for training in global health [6], but few had well-developed mental health components—either research or clinically focused. At the National Institute of Mental Health (NIMH), a reevaluation of the institute’s role in global health research was also underway. By mid-2009, NIMH began reorganizing the Office for Special Populations and the Office of Global Mental Health to create the Office for Research on Disparities and Global Mental Health (ORDGMH) in 2010. Consistent with the NIMH mission, the new office underscored (1) the critical need to mount an inclusive global effort to expand research—and the capacity to conduct research—on preventing and treating mental illness, (2) the centrality of eliminating disparities as part and parcel of this effort, and (3) the value of recognizing that local contexts around the globe share commonalities that can provide insights into equitably reducing the suffering associated with mental illness. An explicit goal of ORDGMH was to create a research career path in global mental health for US investigators, while also supporting research capacity building in low- and middle-income countries as a route to building high-quality collaborative research. To achieve this goal, ORDGMH expanded collaborations with the Fogarty International Center (FIC)—the NIH center tasked with supporting and facilitating global health research and research training—and, where indicated, developed new targeted initiatives for research capacity development in mental health. In this article, we briefly describe NIMH activities in support of global mental health research training and future directions for research training in global mental health.

Global mental health: policy, progress, and prospects

SPECIAL ISSUE: Do Biofeedback, Neurofeedback, and Neuromeditation Have a Role in Psychedelic-Assisted Therapies?

Why Adolescent Depression Is a Global Health Priority and What We Should Do About It

Think globally, act locally

In the first article of a five-part series providing a global perspective on integrating mental health, Pamela Collins and colleagues set the scene for why mental health care should be combined with priority programs on maternal and child health, non-communicable diseases, and HIV, and how this might be done.

Meeting the UN Sustainable Development Goals for mental health: why greater prioritization and adequately tracking progress are critical.

The World Health Organization (WHO) is revising the ICD-10 classification of mental and behavioural disorders, under the leadership of the Department of Mental Health and Substance Abuse and within the framework of the overall revision framework as directed by the World Health Assembly. This article describes WHO's perspective and priorities for mental and behavioural disorders classification in ICD-11, based on the recommendations of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The WHO considers that the classification should be developed in consultation with stakeholders, which include WHO member countries, multidisciplinary health professionals, and users of mental health services and their families. Attention to the cultural framework must be a key element in defining future classification concepts. Uses of the ICD that must be considered include clinical applications, research, teaching and training, health statistics, and public health. The Advisory Group has determined that the current revision represents a particular opportunity to improve the classification's clinical utility, particularly in global primary care settings where there is the greatest opportunity to identify people who need mental health treatment. Based on WHO's mission and constitution, the usefulness of the classification in helping WHO member countries, particularly low- and middle-income countries, to reduce the disease burden associated with mental disorders is among the highest priorities for the revision. This article describes the foundation provided by the recommendations of the Advisory Group for the current phase of work.

Psychological therapy to improve HIV care and reduce stigma

SummaryBackgroundMental and substance use disorders are a major public health concern globally, with high rates of disability, morbidity, and mortality associated with these. In low- and middle-income countries, such as Kenya, mental health is often given low priority, and resources for the prevention and treatment of mental and substance use disorders are limited. Adolescence and young adulthood are critical periods for the development of mental and substance use disorders, with many disorders emerging during this time. In Kenya, the burden and risk factors of mental and substance use disorders among adolescents and young adults is not well understood.MethodsThe data used in this study were obtained from the Global Burden of Disease (GBD) Study 2019. We selected the data on the number of mental and substance use disorders among adolescents and young adults in Kenya from the GBD results tool. The data were extracted by mental health (MH) condition, by age group and by sex. We used descriptive statistical methods to summarise and present the data. Specifically, we calculated the disability-adjusted life-years (DALYs) rates, risk factors of mental and substance use disorders by age group and sex.FindingsIn 2019, among 10–24-year-olds in Kenya, mental disorders ranked as the second leading cause of disability, following unintentional injuries, and accounted for 248,936 [95% uncertainty interval 175,033; 341,680] DALYs or 9.4% of 2,656,546 total DALYs. Substance use disorders accounted 15,022 [9948; 20,710] DALYs. Depressive, anxiety, and conduct disorders accounted for the most DALYs of mental disorders accounting for 3.1%, 2.3% and 1.7% of the total DALYs, respectively. The main risk factors for incident DALYs in 10–24-year-olds were bullying and victimization (66.5%). Childhood sexual abuse accounted for 13.7% of the DALYs, lead exposure accounted for 8.5% of the DALYs, intimate partner violence accounted for 11.3% of the DALYs (2%) with all victims being females, and illicit drug use accounted for (52.7%) of DALYs.InterpretationImproved surveillance of mental health and substance use burden at national and county levels is needed. Focus on timely screening and intervention for idiopathic developmental intellectual disability, conduct disorder, and substance use disorder in young boys and depression, anxiety, and eating disorders in young girls and women is critically needed.FundingMK is funded by 10.13039/100000061FIC/10.13039/100000025NIMH K43 TW 010716 and R33MH124149-03. The publication was made possible by funding from the Gates Foundation.

Offline: The fetishisation of “global”

Global priorities of civil society for mental health services: findings from a 53 country survey.

Stroke is the second leading cause of death and the third leading cause of disability-adjusted life-years (DALYs) worldwide.1Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar, 2Murray CJ Vos T Lozano R Naghavi M et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6098) Google Scholar Moreover, the global burden of stroke is increasing. Between 1990 and 2010, the number of stroke-related deaths increased by 26% and DALYs by 19%.1Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar, 2Murray CJ Vos T Lozano R Naghavi M et al.Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2197-2223Summary Full Text Full Text PDF PubMed Scopus (6098) Google Scholar Is this epidemic of stroke global or regional, and what is the explanation? A systematic review3Feigin VL Lawes CM Bennett DA Barker-Collo SL Parag V Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.Lancet Neurol. 2009; 8: 355-369Summary Full Text Full Text PDF PubMed Scopus (1830) Google Scholar of 56 population-based studies of the incidence and early case fatality of stroke, published from 1970 to 2008, showed that, in ten low-income and middle-income countries, the age-adjusted incidence of stroke more than doubled, from 52 per 100 000 person-years in 1970–79 to 117 per 100 000 person years in 2000–08—an increase of 5·6% per year. However, the incidence of stroke in 18 high-income countries almost halved, from 163 to 94 per 100 000 person-years—a decrease of 1% per year.3Feigin VL Lawes CM Bennett DA Barker-Collo SL Parag V Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review.Lancet Neurol. 2009; 8: 355-369Summary Full Text Full Text PDF PubMed Scopus (1830) Google Scholar These data suggest divergent patterns of stroke epidemiology in different socioeconomic regions of the world, but might be subject to selection or sampling bias because of sampling of only ten of the world's low-income and middle-income countries over four decades, and diagnostic or stroke classification bias because of a failure to distinguish major pathological subtypes of stroke (ie, ischaemic vs haemorrhagic), which have different diagnostic criteria, causes, and outcomes. In The Lancet Global Health, Rita Krishnamurthi and colleagues from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and Stroke Expert Group estimate the incidence, mortality, and DALYs of first-ever ischaemic and haemorrhagic stroke (intracerebral and subarachnoid haemorrhage) in all 21 regions of the world in 1990, 2005, and 2010.4Krishnamurthi RV Feigin VL Forouzanfar MH Mensah GA et al.on behalf of the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study)the GBD Stroke Experts GroupGlobal and regional burden of ischaemic and haemorrhagic strokes in 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet Glob Health. 2013; (published online Oct 24.)http://dx.doi.org/10.1016/S2214-109X(13)70089-5Google Scholar The investigators derived the estimates from a systematic review of all relevant studies published between 1990 and 2010. 119 studies were identified in which pathological subtypes of stroke were confirmed by brain imaging or autopsy in at least 70% of cases. Specific analytical techniques were used to calculate regional and country-specific estimates of incidence and mortality rates and DALYs lost, by age group and country income status. Surprisingly, the major finding is that, in 2010, most of the global burden of stroke was due to haemorrhagic, not ischaemic, stroke. Haemorrhagic stroke constituted a third (31·5%) of the 16·9 million incident stroke events (20% in the high-income countries and 37% in the low-income and middle- income countries), which is higher than hitherto appreciated.4Krishnamurthi RV Feigin VL Forouzanfar MH Mensah GA et al.on behalf of the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study)the GBD Stroke Experts GroupGlobal and regional burden of ischaemic and haemorrhagic strokes in 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet Glob Health. 2013; (published online Oct 24.)http://dx.doi.org/10.1016/S2214-109X(13)70089-5Google Scholar However, despite being only half as common as ischaemic stroke, haemorrhagic stroke caused more than half (51·7%) of the 5·9 million stroke-related deaths, and three fifths (61·5%) of the 102·2 million DALYs lost throughout the world. The number of years of life lost were greater with haemorrhagic stroke because it affected people at a younger age (mean 65·1 years [SD 0·11]) than did ischaemic stroke (73·1 years [0·10]) and had a higher case fatality (57% vs 25%). The second major finding is that most of the burden of ischaemic and haemorrhagic stroke is in low-income and middle-income countries, which bear 63% of incident ischaemic strokes and 80% of haemorrhagic strokes, 57% of deaths due to ischaemic stroke and 84% due to haemorrhagic stroke, and 64% of DALYs lost due to ischaemic stroke and 86% due to haemorrhagic stroke. The average age of incident and fatal ischaemic and haemorrhagic strokes was 6 years younger in low-income and middle-income countries than in high-income countries. The third finding is that most of the burden of ischaemic and haemorrhagic stroke is in people younger than 75 years, who bear 62% of incident ischaemic strokes and 78% of haemorrhagic strokes, and 63% of DALYs lost due to ischaemic stroke and 83% due to haemorrhagic stroke. The fourth finding is that, over the past two decades (1990–2010) the absolute number of people with incident ischaemic stroke has increased significantly by 37% and incident haemorrhagic stroke by 47%, the number of deaths due to ischaemic stroke by 21% and haemorrhagic stroke by 20%, and the number of DALYs lost due to ischaemic stroke by 18% and haemorrhagic stroke by 14%. The increase in absolute numbers has arisen despite a reduction in the age-standardised incidence of ischaemic stroke by 13% and haemorrhagic stroke by 19%, a reduction in the mortality rates of ischaemic stroke by 37% and haemorrhagic stroke by 38%, and a reduction in DALYs rates of ischaemic stroke by 34% and haemorrhagic stroke by 39%. The reduction in rates probably shows improved education, prevention, diagnosis, treatment, and rehabilitation of stroke. The increase in absolute numbers, despite a reduction in rates, is presumably because global population growth and increasing life expectancy have increased the denominator by a greater proportion than the increasing number of stroke events has increased the numerator. The fifth finding is that the incidence of haemorrhagic stroke in low-income and middle-income countries is one rate that has increased over the past two decades (22% increase, 95% CI 5–30), particularly in people younger than 75 years (19%, 5–30). Indeed, low-income and middle-income countries had a 40% higher incidence, 77% higher mortality, and 65% higher DALY rates of haemorrhagic stroke than did high-income countries. Krishnamurthi and colleagues' results suggest that key priorities in the quest to reduce the global and regional burden of stroke are prevention of haemorrhagic stroke, particularly in low-income and middle-income countries, and in people younger than 75 years. Most haemorrhagic strokes can be attributed to hypertension and an unhealthy lifestyle (eg, physical inactivity, obesity, unhealthy diet, alcohol excess, and smoking; table).5Lawes CM Vander Hoorn S Rodgers A for the International Society of HypertensionGlobal burden of blood-pressure-related disease, 2001.Lancet. 2008; 371: 1513-1518Summary Full Text Full Text PDF PubMed Scopus (1708) Google Scholar, 6O'Donnell MJ Xavier D Liu L et al.on behalf of the INTERSTROKE investigatorsRisk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.Lancet. 2010; 376: 112-123Summary Full Text Full Text PDF PubMed Scopus (2049) Google ScholarTableRisk factors for haemorrhagic stroke in 663 cases of acute first haemorrhagic stroke (within 5 days of symptom onset) compared with 3000 controls with no history of stroke who were matched with cases for age and sex, assessed in 22 countries between 2007 and 20106O'Donnell MJ Xavier D Liu L et al.on behalf of the INTERSTROKE investigatorsRisk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.Lancet. 2010; 376: 112-123Summary Full Text Full Text PDF PubMed Scopus (2049) Google ScholarPrevalenceOdds ratio (99% CI)Population-attributable riskControlsCasesHistory of hypertension954/2996 (32%)399/662 (60%)3·8 (3·0–4·8)44% (37–52%)Regular physical activity362/2994 (12%)45/662 (7%)0·7 (0·4–1·1)28% (7–67%)Waist-to-hip ratio (T3 vs T1)984/2960 (33%)231/655 (35%)1·4 (1·02–1·9)26% (14–43%)Diet risk score (T3 vs T1)904/2982 (30%)221/658 (34%)1·4 (1·01–2·0)24% (12–43%)Alcohol intake*More than 30 drinks per month or binge drinker. T3=tertile 3. T1=tertile 1.324/2989 (11%)108/660 (16%)2·0 (1·3–3·0)15% (8–24%)Current smokers732/2994 (24%)207/662 (31%)1·4 (1·1–2·0)9% (4–20%)Psychosocial stress440/2987 (15%)124/654 (19%)1·2 (0·9–1·7)3% (1–16%)Data are n/N (%), unless otherwise indicated. Multivariable model adjusted for age, sex and region.* More than 30 drinks per month or binge drinker. T3=tertile 3. T1=tertile 1. Open table in a new tab Data are n/N (%), unless otherwise indicated. Multivariable model adjusted for age, sex and region. Population-based mass strategies to reduce consumption of salt, calories, alcohol, and tobacco by improving education and the environment will complement high-risk strategies of identifying those at risk of haemorrhagic (and ischaemic) stroke, thus empowering these individuals to improve their lifestyle behaviours and, if necessary, lower their mean blood pressure and blood pressure variability with appropriate doses of antihypertensive drugs.7Rose G Strategy of prevention: lessons from cardiovascular disease.Br Med J. 1981; 282: 1847-1851Crossref PubMed Scopus (800) Google Scholar, 8Hankey GJ Nutrition and the risk of stroke.Lancet Neurol. 2012; 11: 66-81Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 9Law MR Morris JK Wald NJ Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.BMJ. 2009; 338: b1665Crossref PubMed Scopus (2008) Google Scholar, 10Webb AJS Fischer U Mehta Z Rothwell PM Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis.Lancet. 2010; 375: 906-915Summary Full Text Full Text PDF PubMed Scopus (563) Google Scholar I declare that I have no conflicts of interest. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the Global Burden of Disease Study 2010Although age-standardised mortality rates for ischaemic and haemorrhagic stroke have decreased in the past two decades, the absolute number of people who have these stroke types annually, and the number with related deaths and DALYs lost, is increasing, with most of the burden in low-income and middle-income countries. Further study is needed in these countries to identify which subgroups of the population are at greatest risk and who could be targeted for preventive efforts. Full-Text PDF Open Access