Grand challenges in global mental health (PDF)

COMMENTNANOTECHNOLOGY Materialsshould not be regulated onsize alone p.31SUMMER BOOKS Reviewersand editors suggestreading for your holiday p.32CONSERVATION Concernabout alien species isscientific and practical p.36EQUALITY Action needed tostop science prizes goingprimarily to men p.37H. TIMMERMANS/GLOBAL INITIATIVE ON PSYCHIATRYImproving treatment for children with mental illness, like this girl in Somalia, is an urgent priority.Grand challenges inglobal mental healthA consortium of researchers, advocates and cliniciansannounces here research priorities for improving thelives of people with mental illness around the world,and calls for urgent action and investment.Schizophrenia, depression, epilepsy,dementia, alcohol dependence andother mental, neurological and substance-use(MNS) disorders constitute 13%of the global burden of disease (Table 1),surpassing both cardiovascular diseaseand cancer 1 . Depression is the third leadingcontributor to the global disease burden,and alcohol and illicit drug use account formore than 5% (ref. 2). Every seven seconds,someone develops dementia 3 , costing theworld up to US$609 billion in 2009 (ref. 4).By 2020, an estimated 1.5 million people willdie each year by suicide, and between 15 and30 million will make the attempt 5 .The absence of cures, and the dearth ofpreventive interventions for MNS disorders,in part reflects a limited understandingof the brain and its molecular and cellularmechanisms. Where there are effective treatments,they are frequently not available tothose in greatest need. In 83% of low-incomecountries, there are no anti-Parkinsoniantreatments in primary care; in 25% thereare no anti-epileptic drugs 6 . Unequal distributionof human resources — between andwithin countries — further weakens access:the World Health Organization’s Europeanregion has 200 times as many psychiatristsas in Africa 7 . Across all countries, investmentin fundamental research into preventing andtreating MNS disorders is disproportionatelylow relative to the disease burden 8 .To address this state of affairs, the GrandChallenges in Global Mental Health initiativehas identified priorities for research inthe next 10 years that will make an impacton the lives of people living with MNSdisorders. The study was funded by theUS National Institute of Mental Health(NIMH) in Bethesda, Maryland, supportedby the Global Alliance for Chronic Diseases(GACD), headquartered in London.Answers to the questions posed will requirea surge in discovery and delivery science. Weuse the term ‘mental health’ as a convenientlabel for MNS disorders. We exclude conditionswith a vascular or infectious aetiology(such as stroke or cerebral malaria), becausethese fell within the scope of the two previousgrand challenges initiatives — in globalhealth and in chronic non-communicablediseases 9 .This initiative differs from previouspriority-setting exercises for mental© 2011 Macmillan Publishers Limited. All rights reserved7 JULY 2011 | VOL 475 | NATURE | 27

COMMENTTABLE 1 | GLOBAL BURDEN OF MENTAL, NEUROLOGICAL AND SUBSTANCE-USE (MNS) DISORDERS*Rank Cause DALYs ‡Worldwide High-income countries † Low- and middle-income countries(millions)CauseDALYs(millions)1 Unipolar depressive disorders 65.5 Unipolar depressive disorders 10.0 Unipolar depressive disorders 55.52 Alcohol-use disorders 23.7 Alzheimer’s and other dementias 4.4 Alcohol-use disorders 19.53 Schizophrenia 16.8 Alcohol-use disorders 4.2 Schizophrenia 15.24 Bipolar affective disorder 14.4 Drug-use disorders 1.9 Bipolar affective disorder 12.95 Alzheimer’s and other dementias 11.2 Schizophrenia 1.6 Epilepsy 7.36 Drug-use disorders 8.4 Bipolar affective disorder 1.5 Alzheimer’s and other dementias 6.87 Epilepsy 7.9 Migraine 1.4 Drug-use disorders 6.58 Migraine 7.8 Panic disorder 0.8 Migraine 6.39 Panic disorder 7.0 Insomnia (primary) 0.8 Panic disorder 6.210 Obsessive–compulsive disorder 5.1 Parkinson’s disease 0.7 Obsessive–compulsive disorder 4.511 Insomnia (primary) 3.6 Obsessive–compulsive disorder 0.6 Post-traumatic stress disorder 3.012 Post-traumatic stress disorder 3.5 Epilepsy 0.5 Insomnia (primary) 2.913 Parkinson’s disease 1.7 Post-traumatic stress disorder 0.5 Multiple sclerosis 1.214 Multiple sclerosis 1.5 Multiple sclerosis 0.3 Parkinson’s disease 1.0CauseDALYs(millions)*Data from ref. 1. Examples of MNS disorders under the purview of the Grand Challenges in Global Mental Health initiative.† World Bank criteria for income (2009 gross national income (GNI) per capita): low income is US$995 equivalent or less; middle income is $996–12,195; high income is $12,196 or more.‡ A disability-adjusted life year (DALY) is a unit for measuring the amount of health lost because of a disease or injury. It is calculated as the present value of the future years of disability-free lifethat are lost as a result of the premature deaths or disability occurring in a particular year.health 10–12 in four ways. First, its scope isglobal. Second, it is the first to employ theDelphi method 13 , a structured techniqueusing controlled feedback to arrive at consensuswithin a dispersed panel of manyparticipants. Third, it covers the full rangeof MNS disorders. Finally, the effort hopes tobuild a wide-ranging community of researchfunders — much as the challenge for noncommunicablediseases led to the creationof the GACD.SETTING PRIORITIESThe prioritization exercise assembled thelargest international Delphi panel so faron the subject. An executive committee ofleaders of key funding agencies providedbroad oversight. A scientific advisory boardcomprising leaders in the relevant scientificdisciplines guided the process. And anadministrative team from the NIMH workedwith the chairs of the committee and advisoryboard to coordinate communicationand data analysis.The advisory board nominated 594researchers, advocates, programme implementersand clinicians; 422, working inmore than 60 countries, agreed to participate.Researchers in genetics and genomics, neuroscience,basic behavioural science and neurodevelopmentmade up just over one-thirdof the panel. Mental-health services researchersconstituted another quarter, and a furtherthird were clinical researchers and epidemiologists(see Supplementary Figs 1–3).In Round 1, panel members were asked torespond to the question “What are the grandchallenges in global mental health?” bylisting up to five areas they considered to betop priorities. As in previous initiatives 14,15 ,a ‘grand challenge’ was defined as “a specificbarrier that, if removed, would help to solvean important health problem. If successfullyimplemented, the intervention(s) it couldlead to would have a high likelihood of feasibilityfor scaling up and impact.” Round 1yielded 1,565 challenges.These were distilled by the administrativeteam and chairs of the executive committeeand advisory board into a shorter list of154 unique challenges from which panellistsselected their top 40 in Round 2 (SupplementaryTable 1). The top 25 challenges from thislist are shown in Table 2. Round 3 asked panelliststo rank each challenge on a four-pointscale for: ability to reduce disease burden;impact on equity; immediacy of impact; andfeasibility (see Supplementary Methods). Toarrive at the final ranked master list of grandchallenges, individual rankings for each challengewere weighted, summed across all fourcriteria, and divided by the total number ofresponses (Supplementary Table 3).THE LISTThe 25 grand challenges in Table 2 run theresearch gamut from preclinical questionsinto the aetiology and treatment of MNSdisorders, to implementation and policyneeds to scale up effective interventions. Allthe challenges emphasize the need for globalcooperation in the conduct of research tocreate shared access to data, expertise andcapacity-building opportunities. Childrenemerge as requiring particular attention forprevention and care. Most mental disordersinvolve developmental processes, so reducingthe duration of untreated illness byfocusing resources on the earliest definableclinical stage of illness could revolutionizetreatment. Similarly, it is imperative that weexplore the role of prenatal exposures anddevelop interventions to reduce the longtermnegative impact of low childhoodsocioeconomic status on cognitive ability.The challenges capture several broadthemes. First, the results underscore the needfor research that uses a life-course approach.This approach acknowledges that many MNSdisorders either begin or manifest in earlylife, and is equally attentive to risk factors anddisorders affecting children and the elderly.Efforts to build mental capital — the cognitiveand emotional resources that influencehow well an individual is able to contributeto society and experience a high quality oflife — could also mitigate the risk of disorderssuch as depression, substance-use disorders,bipolar disorder and dementia 16 .Second, the challenges recognize that thesuffering caused by MNS disorders extendsbeyond the patient to family members andcommunities. Thus, health-system-widechanges are crucial, together with attentionto social exclusion and discrimination. Atthe same time, research into systems interventions,such as integrating care for MNSdisorders into chronic-disease care, couldtransform health services and reduce costs.Third, the challenges underline the factthat all care and treatment interventions —psychosocial or pharmacological, simple orcomplex — should have an evidence base toprovide programme planners, clinicians and28 | NATURE | VOL 475 | 7 JULY 2011© 2011 Macmillan Publishers Limited. All rights reserved

COMMENTTABLE 2 | GRAND CHALLENGES FOR MNS DISORDERSGoal AIdentify root causes,risk and protectivefactorsGoal BAdvance preventionand implementationof early interventionsGoal CImprove treatmentsand expand accessto careGoal DRaise awareness ofthe global burdenGoal EBuild human resourcecapacityGoal FTransform healthsystemand policyresponsesSummary principlesTop 25 challenges*• Identify modifiable social and biological risk factors across the lifecourse• Understand the impact of poverty, violence, war, migration anddisaster• Identify biomarkers• Support community environments that promote physical andmental well-being throughout life• Reduce the duration of untreated illness by developing culturallysensitiveearly interventions across settings• Develop interventions to reduce the long-term negative impact oflow childhood socioeconomic status on cognitive ability and mentalhealth• Develop an evidence-based set of primary preventioninterventions for a range of MNS disorders• Develop locally appropriate strategies to eliminate childhoodabuse and enhance child protection• Integrate screening and core packages of services into routineprimary health care• Reduce the cost and improve the supply of effective medications• Develop effective treatments for use by non-specialists, includinglay health workers with minimal training• Incorporate functional impairment and disability into assessment• Provide effective and affordable community-based care andrehabilitation• Improve children’s access to evidence-based care by trainedhealth providers in low- and middle-income countries• Develop mobile and IT technologies (such as telemedicine) toincrease access to evidence-based care• Develop culturally informed methods to eliminate the stigma,discrimination and social exclusion of patients and families acrosscultural settings• Establish cross-national evidence on the cultural, socioeconomicand services factors underlying disparities in incidence, diagnosis,treatment and outcomes• Develop valid and reliable definitions, models and measurementtools for quantitative assessment at the individual and populationlevels for use across cultures and settings• Establish shared, standardized global data systems for collectingsurveillance data on the prevalence, treatment patterns andavailability of human resources and services• Increase capacity in low- and middle-income countries by creatingregional centers for mental-health research, education, training andpractice that incorporate the views and needs of local people• Develop sustainable models to train and increase the numberof culturally and ethnically diverse lay and specialist providers todeliver evidence-based services• Strengthen the mental-health component in the training of allhealth-care personnel• Establish and implement minimum health-care standards forMNS disorders around the world• Redesign health systems to integrate MNS disorders with otherchronic-disease care, and create parity between mental andphysical illness in investment into research, training, treatment andprevention• Incorporate a mental-health component into international aid anddevelopment programmes• Use a life-course approach tostudy• Use system-wide approaches toaddress sufferingIllustrative research questions• What is the relationship between early fetal and child developmentand the onset of MNS disorders?• What are the phenotypes and endophenotypes of MNS disordersacross cultural settings?• What gene–environment interactions are associated with theincreased risk for mental disorders?• What factors promote resilience and prevent mental disorders inpersons at extreme social disadvantage?• What role does social context play in the persistence of MNSdisorders throughout life?• Which behavioral skills can enhance executive function, resilienceand cognitive flexibility throughout life?• What neuroprotective agents and/or cognitive retrainingparadigms can be used during the period of rapid braindevelopment to reduce vulnerability to disorders in adolescence?• How effective are home- and school-based interventions for childabuse and neglect?• How effective are brief screening tools for the detection of MNSdisorders in routine care settings?• How effective are interventions for serious mental disordersdelivered by lay health workers?• How will increased understanding of neural circuits lead toalternatives to current pharmacological interventions?• How can mobile-phone technology be used to monitor seizurefrequency?• How can video games and other electronic media be used forcognitive remediation across cultural settings?• What psychosocial interventions produce the best outcomes forcommunity-based care for MNS disorders across cultural settings?• What are the components of effective interventions to reducestigma associated with MNS disorders?• What interventions to reduce stigma and discrimination can betargeted to and implemented in health and social service settings indifferent health-system environments?• What is the impact of macroeconomic factors (such asunemployment rates, international trade, national income) on theprevalence of MNS disorders over time?• What is the impact of policy initiatives on the coverage oftreatment for MNS disorders?• What measurement factors contribute to differences in theprevalence of mental disorders across ethnic groups within andbetween countries?• What is the most effective way to train primary health-care workersto deliver evidence-based care with adequate fidelity to guidelines?• What is the comparative effectiveness of care for MNS disordersby different cadres of health-care providers?• What are the views of low-income communities in high- andlow-income countries on the priority research questions for MNSdisorders?• What can we learn from different approaches (and associatedcosts) to integrated delivery of care across health systems?• What are the most effective health-system-wide strategies toreduce consumption of alcohol and illicit drugs?• What is the impact of legislation that ensures parity betweenmental and other illnesses on access to mental-health services?• Use evidence-basedinterventions• Understand environmentalinfluences*The order in which the challenges are presented does not indicate frequency of endorsement or relative importance. Bold type denotes the top five challenges ranked by disease-burdenreduction, impact on equity, immediacy of impact and feasibility.© 2011 Macmillan Publishers Limited. All rights reserved7 JULY 2011 | VOL 475 | NATURE | 29

T. DIRVEN/PANOSWomen in Priluki psychiatric hospital, Ukraine.policy-makers with effective care packages.Finally, the panel’s responses underscoreimportant relationships between environmentalexposures and MNS disorders.Extreme poverty, war and natural disastersaffect large swathes of the world, and westill do not fully understand the mechanismsby which mental disorders mightbe averted or precipitated in those settings.NEXT STEPSThere have been some major advances in ourunderstanding of the aetiology and treatmentof MNS disorders. Future breakthroughs arelikely to depend on discoveries in genomicsand neuroscience, in tandem with explorationof the role of sociocultural and environ mentalcontexts. The top five challenges ranked bydisease-burden reduction, impact on equity,immediacy of impact, and feasibility shouldserve as a starting point for immediateresearch and prioritization of policies (seebold lines in Table 2).Action on all the challenges will requirelong-term investment. Substantial researchprogress can be achieved in the next ten yearsif funding begins immediately. Already, theNIMH’s initiative, Collaborative Hubs forInternational Research in Mental Health,has committed to support research on theuse of non-specialist mental health-careproviders and research training in low- andmiddle-income countries. But a wider set ofstakeholders must also be engaged, particularlyin problems that require integratedresearch and policy interventions.The WHO should disseminate informationon these challenges to its member countries’health ministries and research councils toshape research and action priorities. Giventhe intimate relationship between economicand social development and the needs ofpeople with MNS disorders, the WorldBank, regional development banks, nationaldevelopment agencies, foundations, nongovernmentalorganizations and the globalbusiness community should all participate inaddressing the challenges.Researchers and funders have tremendousresponsibility in this context. Consortia andnetworks, advocacy organizations, universitiesand their partners should organizetheir activities around one or more of thegoals and the attendant grand challenges.The leaderships of the Grand Challenges inGlobal Mental Health, the GACD and theirpartners will meet in October to develop astrategy for regular monitoring of progress.Even incremental progress in addressingthe grand challenges in global mentalhealth could lead to significant economicand quality-of-life benefits — includingreductions in inappropriate use of healthcare and increased productivity for years tocome 17 — that would far outweigh investmentcosts. Although the greatest challenge— the elimination of MNS disorders — maynot be attainable within the next 10 years, theresearch suggested above must be conductedforthwith. ■Pamela Y. Collins Office for Research onDisparities and Global Mental Health,National Institute of Mental Health,Maryland, USA. Vikram Patel, Centre forGlobal Mental Health, London School ofHygiene & Tropical Medicine UK, Sangath,Goa, India. Sarah S. Joestl, Office forResearch on Disparities and Global MentalHealth, National Institute of Mental Health,USA. Dana March, Office for Researchon Disparities and Global Mental Health,National Institute of Mental Health, USA.Thomas R. Insel, National Institute ofMental Health, USA. Abdallah S. Daar,University of Toronto and McLaughlin-Rotman Centre for Global Health, Toronto,Canada, and Chair, Global Alliance forChronic Diseases.On behalf of the Scientific Advisory Boardand the Executive Committee of the GrandChallenges on Global Mental Health.e-mails: pamela.collins@nih.gov;a.daar@utoronto.ca1. World Health Organization The Global Burden ofDisease: 2004 Update (WHO, 2008).2. WHO Atlas on Substance Use (WHO, 2010).3. Ferri, C. P. et al. Lancet 366, 2112–2117 (2005).4. Wimo, A., Winblad, B. & Jönsson, L. Alzheimer’s &Dementia 6, 98–103 (2010).5. Bertolote, J. & Flieschmann, A. Suicidologi 7, 6–8(2002).6. WHO Country Resources for NeurologicalDisorders 2004 (WHO, 2004).7. WHO Mental Health Atlas (WHO, 2005).8. Saxena, S., Thornicroft, G., Knapp, M. &Whiteford, H. Lancet 370, 878–889 (2007).9. Daar, A. S. et al. Nature 450, 494–496 (2007).10. Lancet Mental Health Group Lancet 370,1241–1252 (2007).11. Sharan, P. et al. Br. J. Psychiatry 195, 354–363(2009).12. Tomlinson, M. et al. Bull. WHO 87, 438–446(2009).13. Jones, J. & Hunter, D. Br. Med. J. 311, 376–380(1995).14. Daar, A.S. et al. Nature 450, 494–496 (2007).15. Varmus, H. et al. Science 302, 398–399 (2003).16. Beddington, J. et al. Nature 455, 1057–1060(2008).17. Rupp, A. Br. J. Psychiatry 166, 26–33 (1995).Supplementary Information and a full list ofauthors accompany this article online at www.nature.com/nature and can also be viewed athttp://grandchallengesgmh.nimh.nih.gov.30 | NATURE | VOL 475 | 7 JULY 2011© 2011 Macmillan Publishers Limited. All rights reserved