Grand Challenges: Integrating Mental Health Services into Priority Health Care Platforms

Vikram Patel, Gary S. Belkin, Arun Chockalingam, Janice Cooper, Shekhar Saxena, Jürgen UnützerPLOS x

Published: May 28, 2013

https://doi.org/10.1371/journal.pmed.1001448

Article

Authors

Metrics

Comments

Media Coverage

Introduction

Why Integration

What to Integrate

How to Integrate

Limitations and Potential Risks

Next Steps

Author Contributions

References

Reader Comments (1)

Figures

Figures

Table 1Table 1Table 1

Citation: Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, Unützer J (2013) Grand Challenges:
Integrating Mental Health Services into Priority Health Care Platforms. PLoS Med 10(5): e1001448.
https://doi.org/10.1371/journal.pmed.1001448

Published: May 28, 2013

Copyright: © 2013 Patel et al. This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Funding: VP is supported by a Wellcome Trust Senior Research Fellowship in Clinical Science. GB is
supported by the Sanofi-Aventis Access to Medicine Program. The funders had no role in study design,
data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: VP is a member of the Editorial Board of PLOS Medicine. The authors have
declared that no other competing interests exist.

Abbreviations: CC, Collaborative Care; LMIC, low- and middle-income countries; NCD, non-
communicable diseases

Provenance: Not commissioned; externally peer reviewed.

Summary Points

The rationale for integration of mental health care into other health care platforms includes improving
access to mental health care; providing patient-centered care; avoiding fragmentation of health
services; reducing stigma; optimising both mental health and physical health outcomes; and overall
health system strengthening.

Interventions for common mental disorders and alcohol abuse, the mental disorders contributing to the
greatest global burden of disease, are the most promising for integration.

The process of integration requires assessment of and customization for the specific platform;
identification of tasks and human resources for case finding and delivery of interventions; and
application of the principles of collaborative care, care management, and quality improvement.

The risks of a purely integrated approach to mental health care are that some types of mental disorders
may be neglected, that there might be an overburdening of already weak health systems, and that the
evidence base for scaling up of integrated interventions is patchy.

Integrated care is smart because the operational and functional innovations needed for such integration
into other health care platforms are consistent with efforts to strengthen the capacity of primary care
systems to address multiple health priorities more broadly.

This paper is the fifth in a series of five articles providing a global perspective on integrating mental
health.

This is one article in a five-part series providing a global perspective on integrating mental health.

Introduction
In this final paper in a five-part series highlighting the opportunities for integrating mental health care
into priority global health programs and platforms of health service delivery, we aim to synthesize the
evidence presented in the articles in the series addressing maternal health [1], non-communicable
diseases (NCD) [2], and HIV/AIDS care [3], with the goal of identifying overarching themes across these
platforms [4]. Our focus is on competencies and work packages appropriate for health care settings that
do not historically address mental health issues and that do not usually include mental health specialists.
Primary health care is the quintessential example of such a care delivery platform. In this paper, we
consider the rationale for integration, the extent to which specific mental disorders can be addressed in
other delivery platforms (and, the corollary, which disorders may need a more specialized approach to
care), the process of integration, potential risks and barriers to successful integration and strategies how
these might be addressed, and the promise of this approach for addressing the leading Grand
Challenges in Global Mental Health [5].

Why Integration

Mental health problems, such as depression, anxiety, and alcohol and drug abuse, are among the most
common and disabling health conditions worldwide [6]. They often co-occur with acute and chronic
medical problems and can substantially worsen associated health outcomes [7]. When mental health
problems are not effectively treated, they can impair self-care and adherence to medical and mental
health treatments, and are associated with increased morbidity and mortality, increased health care
costs, and decreased productivity.

Effective treatments exist for most common mental health problems [8], but few patients have access to
such treatments. Adequate access to mental health specialists is a challenge, especially in low- and
middle-income countries (LMICs). For example, the number of psychiatrists serving the entire continent
of Africa with a population of almost a billion is less than that practicing in the US state of Massachusetts
with a population of less than 7 million. But even in developed countries ,such as the US, , primary care
practices are the de facto location of care for most individuals with common mental health problems [9]
and only 2 in 10 adults with common mental health problems receive care from a mental health
specialist in any given year [10]. To reach a reasonable proportion of community-living individuals with
common mental health problems will require leveraging the limited number of mental health specialists
as consultants to help enhance the capacity of primary care and other care delivery settings that do not
provide specialty mental health services to address these common problems.

There are at least two additional advantages to treating common mental health problems in primary
care and other priority health care programs. First, integrated treatment programs in which medical
providers are supported to treat common mental health problems offer a chance to treat ‘the whole
patient’, an approach that is more patient-centered and often more effective than an approach in which
mental health, acute and chronic physical health, reproductive health, and chronic pain problems are
each addressed in a different ‘silo’ without effective communication between providers. Second,
integrated care programs that can address patients' mental health needs in the context of general or
other specialized health care settings are often more attractive to patients and family members who are
concerned about the stigma that is still associated with mental and substance abuse disorders and the
treatment settings that specialize on caring for individuals with severe mental disorders.

Treatment of common mental health problems in primary care can be improved via evidence-based
collaborative care interventions, yielding better access to care, better physical as well as mental health
outcomes, and improved overall cost-effectiveness [11]–[14]. An integrated approach to addressing
mental health in the context of care for HIV, maternal mental health, and NCD is rooted in the
conviction and growing evidence of its efficiency, effectiveness, and cost-savings [15]. Prevention and
early intervention also contribute significantly to reducing the global burden of disease, both mental and
physical. An integrated population-based approach that seeks to prevent conditions affecting mental
health and physical health would share many common strategies; for example, motivating behavior
changes, such as reducing alcohol intake and smoking; promoting physically active lifestyles; and
restricting the sale and distribution of tobacco and alcohol products [16]. Finally, integrating mental
health can accelerate progress and achievement of sustainable development goals by leveraging existing
health platforms designed to care for individuals with HIV/AIDS and other health problems [17].

What to Integrate

As suggested in other articles in this series [1]–[3], the proposal is to integrate care for common mental
health problems into the routine care for people affected by other chronic NCD (such as cancer,
diabetes and cardiovascular disorders), HIV/AIDS, and maternal health care. Collectively, these health
care contexts address the lion's share of the global burden of disease. A common theme that runs
through all of these delivery platforms is that two types of mental health conditions are particularly ripe
for integration given their prevalence and evidence as to the effectiveness of “task-shared” care:
common mental disorders, such as depression and anxiety; and alcohol use disorders. The responses to
these conditions share common core elements, including implications across the lifespan, strong
association with poverty and education, potential for prevention and early intervention, multiple points
for identification and treatment, the need for a collaborative approach to care, and the availability of
pharmacological and psychosocial treatments that can be delivered by non-specialists with adequate
support and have potential for strong stakeholder involvement [18]. Effective integration efforts should
include workforce development and capacity building supported by training guidelines for clinical and
psychosocial management of care; effective tools, such as screeners and validated instruments to track
clinical outcomes; consumer and family support; and policies and payment systems supportive of
integrated practice. They should also include routine and effective use of outcomes monitoring,
evaluation, and research to recognize effective practices [4].

How to Integrate

Assessment and Customization

Because there are wide variations in the capacity and readiness of priority health care programs within
countries, adequate assessment and customization is essential for planning the integration of mental
health care. An example is the Integrated Management of Adult and Adolescent Illnesses (IMAI) used in
providing mental health care to persons with HIV/AIDS
(http://www.who.int/3by5/capacity/fs/en/index.html). Joint assessment by the managers of the priority
health programs and mental health professionals/service planners also enhances ownership and
commitment to achieve the planned outcomes within agreed timelines. The most common reasons for
failure to integrate mental health care into primary or other priority health care programs are lack of
adequate assessment and overly ambitious target setting without the necessary customization of the
detailed activities, and a full and explicit agreement on the targets and activities needed to achieve
them. The following steps may facilitate optimization of the integration.

Assessment of the goals, functions, and resources (human and financial) of the priority program. This
step should include attention to the existing knowledge and skills of health care providers as relates to
their identification and care of common mental health problems; recognition of when to refer;
inclination/motivation to enhance their skills; and the perceived benefits of these skills to advance their
professional and programmatic goals. For example, stakeholders need to agree that mental health
treatment within maternal and child health platforms advances specific Millennium Development Goals
and front line clinicians must see the value of adding these treatments to their current services.

Identifying shared and achievable objectives. This step requires joint assessment of the needs and
feasibility of integration; the identification of exact tasks; and the training, support, and supervision
needed for clinicians to provide these services. Attention must be paid to congruence of the integration
efforts with the overall objectives of the priority programs and the resources needed to ensure initial
success and sustainability. Beginning with limited but clear and specific objectives is recommended. For
example, the initial target for integration of mental health care within HIV programs may be the
identification and management of depression to achieve better adherence with HIV care.

Assigning responsibilities and establishing a monitoring mechanism. Clear and explicit responsibilities
need to be assigned to the health care providers and managers of the priority programs and to the
mental health team at each level. Flowcharts and referral algorithms, such as WHO's mental health Gap
Action Programme (mhGAP)-Intervention guide [8], can be very helpful in this step of planning. . They
also can then be linked to the monitoring mechanism using a limited number of clear, relevant, and
agreed-on goals.

Tasks and Human Resources

The papers in this series have emphasized the importance of preventing, identifying, and reducing the
burdens of co-occurring disorders for population health [1]–[3]. But the key challenge facing scale up of
all health care is the effective deployment of complementary skill sets in order to address a range of
health problems within a shared platform. Such co-competency needs as much attention as co-
morbidity. A substantial obstacle to the integration of mental health care is lack of consensus over how
to standardize and assign mental health care tasks so they can be scaled up within overall delivery.
Consensus treatment packages, such as those in the WHO mhGAP-Intervention Guide, describe what
counts as good and evidence-based care [8]. But these packages need to be adapted and integrated into
existing health care systems. For any health workforce to be effective, and for care packages to be
delivered as intended, treatment guidelines need to be operationalized into coordinated roles and tasks.
The starting point for effective integrated care pathways is to specify skill sets necessary to effectively
deliver integrated care and plan for the development and deployment of these skills in the context of
available human resources. Building blocks for such core skill sets include: (1) screening, engagement,
education of patients and family members, close follow-up, and tracking of adherence and clinical
outcomes; (2) targeted, evidence-based psychological interventions (e.g., motivational interviewing,
behavioral activation, problem-solving or interpersonal therapy); (3) pharmacologic treatment; (4)
population-based outcomes tracking and quality improvement; and (5) specialist supervision and
consultation [19].

Effective treatment programs bundle skills that logically group together in terms of content, needed
training, and operational use. Most of the required functions can be performed by a range of workers,
most of whom are already part of primary care settings, thus allowing some flexibility in planning and
adaptation and marginal additional investments. Experience with task-shifting and/or task sharing, as
highlighted in the case studies in other articles this series [1]–[3] shows that many of the required skills
and tasks of care can be learned and delivered by a range of non-specialist health workers with
appropriate training and supervision. Particular skills, such as case finding, support of treatment
adherence and motivational coaching, follow-up tracking, patient education, and self-management
support, turn out to be quite critical to providing effective care. These “care management tasks” or work
packages can be effectively assigned to non-specialist health workers who are well positioned to bring
them into the community, extending the reach of primary care.

Several recent meta-analyses have concluded that Collaborative Care (CC), the best-evaluated model for
treating common mental disorders such as depression or anxiety in primary care settings, is consistently
more effective than care as usual [13],[20],[21] (Table 1). CC builds on the foundations of effective
collaborative management of other chronic diseases, such as diabetes. Katon and colleagues recently
reported on the effectiveness of a TEAMcare (http://www.teamcarehealth.org/) approach in which
nurses and consulting specialists support primary care providers in successfully managing multiple
chronic diseases including depression, diabetes, and heart disease [22]. This example underscores how
innovation for integrated mental health care can align with and accelerate overall health systems
strengthening. While much of the CC evidence is based on research literature from high-income
countries, such as the United States, Canada, the United Kingdom, and the Netherlands, there is a
growing evidence base testifying to its applicability in primary care in LMIC [23],[24]. The papers in this
series show that the components summarized in Table 1 are also effective and feasible in LMIC [1]–[3].
Several randomized controlled trials show that lay community health workers and nurses can effectively
provide depression management in low-resource settings, including such psychotherapies as
interpersonal psychotherapy [23],[25], cognitive behavioral therapy [26],[27], behavioral activation [28],
and problem-solving therapy [29], as well as medication monitoring and management [23]. The MANAS
trial in Goa, India brought many of these elements together in an effective package [30].
thumbnail Download:

PPTPowerPoint slide

PNGlarger image

TIFForiginal image

Table 1. Key Elements of Collaborative Care for Depression.

https://doi.org/10.1371/journal.pmed.1001448.t001

Standardization

CC is amenable to the kind of standardization needed for scaled integration because it follows the
principles of measurement-based care [31], treatment-to-target, stepped care [32], and other aspects of
the chronic illness care model proposed by Wagner and colleagues [33]. In such programs, each patient's
progress is closely tracked using validated clinical rating scales (e.g., the Patient Health Questionnaire-9
(PHQ-9) for depression [34]), which is analogous to how patients with diabetes are monitored via HbA1c
laboratory tests. Treatment is systematically adjusted — “stepped” up — if patients are not improving as
expected with input from a specialist consultant. Patients who continue to show no response to
treatment, or have an acute crisis, are referred to mental health specialty care; in practice, however,
only a relatively small fraction of patients in CC programs request or require this referral. Such
systematic ‘treatment to target’ can prevent patients from falling through the cracks and overcome the
clinical inertia that is often responsible for ineffective treatments of common mental disorders in
primary care [35].

The systematic implementation of evidence-based CC programs challenges the conventional wisdom

that while physical health skills are objective, mental health skills are highly subjective and so are not
amenable to standardization. A workflow description, or care pathway, aligns and connects these CC
elements, matching roles with the appropriate skill sets and triage decisions, and application of
screening or symptom tracking tools. This approach positions and leverages more specialized clinical
judgment at the right stage of care. The Partners in Health/Zanmi Lasante health system in Haiti, for
example, after listing key skill packages and assigning them across available workers, adapted the CC key
elements into a care pathway for integrating depression care that maps out standard work and triage
points, supported with a locally validated symptom scale [32]. Effective development and
implementation of integrated care pathways and routines, and their successful scale up, require
ongoing, iterative adaptation, hypothesis testing, performance data monitoring, and improvement [19].

Proven quality improvement (QI) methods have been shown to be effective in LMIC for sustained scale
up and adaptation of standardized treatment packages for Millennium Development Goal health priority
areas. There is growing acceptance of and attention to quality improvement as a critical part of health
systems strengthening for health in LMIC. Quality improvement should also be a routine part of mental
health implementation and customization in these settings [36].
Limitations and Potential Risks

A key limitation to the proposal to integrate mental disorders is the relatively uneven evidence base
existing across platforms of care and the almost complete absence of evaluations of scaled-up
integrated care programs outside high-income countries (HIC) needed to guide the process [37]. Other
papers in this series show that while there is a reasonable evidence base, in the form of randomized
controlled trials, on the integration of interventions for depression in maternal health programs in LMIC
[1], the evidence base for HIV/AIDS is weaker [3], and such evidence is completely absent for NCD or for
integrating care for other mental disorders from LMIC [2]. From a global perspective, however, including
the overall evidence base in support of integration, including evidence from high income countries, is
more compelling.

Health care systems vary in their ability to respond to national health care needs. As Samb and
colleagues point out, a robust approach to addressing mental health conditions, HIV, or NCD requires
strong health systems [38]. Many health care systems, and particularly those in fragile post-conflict
settings, lack the core health system elements needed to provide the most basic set of services to
address mental health, chronic conditions, or HIV/AIDS [39]. Problems include poor financing and a fiscal
infrastructure largely dependent on external aid, fragmentation of structures and services, weak
systems for procurement (including inadequate supply of medications and poor or no access to
diagnostic services), inadequate or fledgling governance and leadership [40], and a workforce that is
often overwhelmed and experiencing high turnover. Integration may be the only feasible option to
address mental health problems in the context of a weak health system, and doing so can contribute to
systems strengthening more generally. Meeting mental health needs, as has been argued is this series,
involves precisely the kinds of delivery design innovations needed for overall system strengthening and
development. Such a route has a proven, albeit limited, track record, and getting there will need
alignment of objectives between donors and governments, a “sector wide” approach to health care, and
secured new investments [40].

A final and important concern about the goal of integration is the scope of mental disorders that are
suitable for integrated care. The papers in this series do not address the important burdens of severe
and persistent mental disorders, such as chronic psychoses; childhood mental disorders, such as autism;
or neuropsychiatric disorders, such as epilepsy, dementia, or the neuropsychiatric sequelae of traumatic
brain injuries. These disorders, put together, account for at least half of the overall burden of mental
disorders. The lack of evidence on integrating care for these disorders with routine platforms — for
example, child health care for child mental disorders — is not in itself an indicator that such integration
is not feasible, but instead, that this represents a priority research agenda. Other concerns may involve
the potential diversion of scarce mental health resources from individuals suffering with severe, chronic
psychotic disorders to individuals with less severe common disorders, such as depression and anxiety,
seen in primary care settings.
Next Steps

Integration of care is smart because of the impact of untreated mental disorders on the course, risks,
and outcomes of other health conditions. Integration of care is the only feasible way to provide care for
mental disorders in most LMIC (Box 1). An equally important message it that integrated care is smart
because the operational and functional innovations needed for such integration into other health care
platforms are consistent with efforts to strengthen the capacity of primary care systems to care for
individuals with multiple health problems more broadly. Thinking in this integrated way about systems
strengthening will therefore also position health systems to contribute to solutions that improve
population well-being. This is a broader, multi-sectoral framing of health and social development that
will require operational capabilities to integrate interacting social and clinical determinants of overall
health and functioning.

Box 1. Next Steps

Integrate mental health into routine health care platforms, because this integration is the only feasible
way to address the treatment gaps for mental disorders, in particular for common mental and alcohol
use disorders.

Use proven methods of care management, supervision, support, and evaluation, which provide a robust
starting point and common framework for implementation of integrated mental health care.

Conduct further implementation research to build the evidence base on integration and scaling up of
care for mental disorders in routine health care platforms.

Refine the skills packages for various members of the health workforce.

Explore the integration of a wider set of mental disorders, such as severe and child mental disorders, in
routine health care platforms.

Scaling up of the evidence presented in this series will greatly benefit from further implementation
research. Trials and other types of evaluation studies are needed, for example, to test the applicability in
LMIC of multi-disease CC as demonstrated by Katon in a high-income setting [22]. The evidence base in
the form of trials of integrated interventions may be greatly enhanced as a result of new funding for
such experiments (such as the National Institute of Mental Health Hubs and R01 RFAs and the Grand
Challenges Canada), programs seeking to evaluate scaled up mental health programs in LMIC (such as
the United Kingdom's Department for International Development (DFID) -funded PRIME consortium;
www.prime.uct.ac.za), and new avenues for publication of mental health integration in practice in this
journal [41] amongst others. Key elements in these programs would be further refinement of skills
packages for various members of the health workforce and an exploration of the integration of a wider
set of mental disorders in routine care platforms. Expanding the integration agenda to address child
mental disorders (for example, in school and paediatric care platforms), epilepsy, and the prevention of
mental disorders are important priorities for future action. We urge Health Ministries and researchers
alike to understand that skill package-based planning and CC, as well as the use of proven methods of
supervision, support and evaluation, provide a robust starting point and a shared language and
framework for implementation of integrated mental health care in LMIC.
Author Contributions

Wrote the first draft of the manuscript: VP. Contributed to the writing of the manuscript: AC JC GB JU SS.
ICMJE criteria for authorship read and met: VP GB JC AC SS JU. Agree with manuscript results and
conclusions: VP GB JC AC SS JU.

References

1.Rahman A, Surkan PJ, Cayetano CE, Rwagatare P, Dickson KE (2013) Grand challenges: integrating
maternal mental health into maternal and child health programmes. PLoS Med 10: e1001442 .

View ArticleGoogle Scholar

2.Ngo VK, Rubinstein A, Ganju V, Kanellis P, Loza N, et al. (2013) Grand challenges: integrating mental
health care into the non-communicable disease agenda. PLoS Med 10: e1001443 .

View ArticleGoogle Scholar

3.Kaaya SF, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, et al. (2013) Grand challenges: improving hiv
treatment outcomes by integrating interventions for co-morbid mental illness. PLoS Med 10: e1001447 .

View ArticleGoogle Scholar

4.Collins PY, Insel TR, Chockalingam A, Daar A, Maddox YT (2013) Grand Challenges in Global Mental
Health: integration in research, policy, and practice. PLoS Med 10: e1001448 .

View ArticleGoogle Scholar

5.Collins PY, Patel V, Joestl SS, March D, Insel TR, et al. (2011) Grand challenges in global mental health.
Nature 475: 27–30.

View ArticleGoogle Scholar

6.Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2013) 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 380: 2197–2223.

View ArticleGoogle Scholar

7.Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, et al. (2007) Depression, chronic diseases, and
decrements in health: results from the World Health Surveys. Lancet 370: 851–858.

View ArticleGoogle Scholar

8.World Health Organisation (2010) mhGAP intervention guide for mental, neurological and substance
use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP).
Geneva: WHO.
9.Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, et al. (1993) The de facto US mental and
addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of
disorders and services. Arch Gen Psychiatry 50: 85–94.

View ArticleGoogle Scholar

10.Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, et al. (2005) Twelve-month use of mental health
services in the United States: results from the National Comorbidity Survey Replication. Arch Gen
Psychiatry 62: 629–640.

View ArticleGoogle Scholar

11.Community Preventive Services Task Force (2012) Recommendation from the community preventive
services task force for use of collaborative care for the management of depressive disorders. Am J Prev
Med 42: 521–524.

View ArticleGoogle Scholar

12.Glied S, Herzog K, Frank R (2010) Review: the net benefits of depression management in primary
care. Med Care Res Rev 67: 251–274.

View ArticleGoogle Scholar

13.Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, et al. (2012) Collaborative care to improve the
management of depressive disorders: a community guide systematic review and meta-analysis. Am J
Prev Med 42: 525–538.

View ArticleGoogle Scholar

14.Gilbody S, Bower P, Whitty P (2006) Costs and consequences of enhanced primary care for
depression: systematic review of randomised economic evaluations. Br J Psychiatry 189: 297–308.

View ArticleGoogle Scholar

15.Sweeney S, Dayo Obure C, Maier CB, Greener R, Dehne K, et al. (2011) Costs and efficiency of
integrating HIV/AIDS services with other health services: a systematic review of evidence and
experience. Sex Transm Infect 88: 85–99.

View ArticleGoogle Scholar

16.Miranda JJ, Kinra S, Casas JP, Davey Smith G, Ebrahim S (2008) non-communicable diseases in low-
and middle-income countries: context, determinants and health policy. Trop Med Int Health 13: 1225–
1234.

View ArticleGoogle Scholar

17.Skeen S, Lund C, Kleintjes S, Flisher A, Consortium TMRP (2010) Meeting the Millennium
Development Goals in Sub-Saharan Africa: what about mental health. Int Rev Psychiatry 22: 624–631.

View ArticleGoogle Scholar

18.Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O (2010) integration of targeted health interventions into
health systems: a conceptual framework for analysis. Health PolicyPlan 25: 104–111.

View ArticleGoogle Scholar

19.Belkin GS, Unutzer J, Kessler RC, Verdeli H, Raviola GJ, et al. (2011) Scaling up for the “bottom billion”:
“5×5” implementation of community mental health care in low-income regions. Psychiatr Serv 62: 1494–
1502.

View ArticleGoogle Scholar

20.Archer J, Bower P, Gilbody S, Lovell K, Richards D, et al. (2012) Collaborative care for depression and
anxiety problems. Cochrane Database Syst Rev 10: CD006525.

View ArticleGoogle Scholar

21.Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ (2006) Collaborative care for depression: a
cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 166: 2314–2321.

View ArticleGoogle Scholar

22.Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, et al. (2010) Collaborative care for
patients with depression and chronic illnesses. N Engl J Med 363: 2611–2620.

View ArticleGoogle Scholar

23.Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, et al. (2011) Lay health worker led intervention
for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months.
Br J Psychiatry 199: 459–466.

View ArticleGoogle Scholar

24.Araya R, Rojas G, Fritsch R, Gaete J, Rojas M, et al. (2003) Treating depression in primary care in low-
income women in Santiago, Chile: A randomised controlled trial. Lancet 361: 995–1000.

View ArticleGoogle Scholar

25.Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty K, et al. (2003) Group Interpersonal

psychotherapy for depression in Rural Uganda. JAMA 289: 3117–3124.

View ArticleGoogle Scholar

26.Rahman A, Malik A, Sikander S, Roberts C, Creed F (2008) Cognitive behaviour therapy-based

intervention by community health workers for mothers with depression and their infants in rural
Pakistan: a cluster-randomised controlled trial. Lancet 372: 902–909.

View ArticleGoogle Scholar

27.Ali BS, Rahbar MH, Naeem S, Gul A, Mubeen S, et al. (2003) The effectiveness of counseling on
anxiety and depression by minimally trained counselors: a randomized controlled trial. A J
Psychotherapy 47: 324–336.

View ArticleGoogle Scholar

28.Ngo VK, Centanni A, Wong E, Wennerstrom A, Miranda J (2011) Building capacity for cognitive
behavioral therapy delivery for depression in disaster-impacted contexts. Ethn Dis 21: S1-38–44.

View ArticleGoogle Scholar

29.Chibanda D, Mesu P, Kajawu L, Cowan F, Araya R, et al. (2011) Problem-solving therapy for
depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health
care intervention in a population with a high prevalence of people living with HIV. BMC Public Health 11:
828.

View ArticleGoogle Scholar

30.Chatterjee S, Chowdhary N, Pednekar S, Cohen A, Andrew G, et al. (2008) Integrating evidence-based

treatments for common mental disorders in routine primary care: feasibility and acceptability of the
MANAS intervention in Goa, India. World Psychiatry 7: 45–53.

View ArticleGoogle Scholar

31.Trivedi MH (2009) Treating depression to full remission. J Clin Psychiatry 70: e01.

View ArticleGoogle Scholar

32.Von Korff M, Tiemens B (2000) Individualized stepped care of chronic illness. West J Med 172: 133–
137.

View ArticleGoogle Scholar

33.Wagner EH, Austin BT, Von Korff M (1996) Organizing care for patients with chronic illness. Milbank Q
74: 511–544.

View ArticleGoogle Scholar

34.Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J
Gen Intern Med 16: 606–613.

View ArticleGoogle Scholar

35.Henke RM, Zaslavsky AM, McGuire TG, Ayanian JZ, Rubenstein LV (2009) Clinical inertia in depression
treatment. Med Care 47: 959–967.

View ArticleGoogle Scholar

36.Franco LM, Marquez L (2011) Effectiveness of collaborative improvement: evidence from 27

applications in 12 less-developed and middle-income countries. BMJ Qual Saf 20: 658–665.

View ArticleGoogle Scholar

37.Unutzer J, Chan YF, Hafer E, Knaster J, Shields A, et al. (2012) Quality improvement with pay-for-
performance incentives in integrated behavioral health care. Am J Public Health 102: e41–e45.

View ArticleGoogle Scholar

38.Samb B, Desai N, Nishtar S, Mendis S, Bekedam H, et al. (2010) Prevention and management of
chronic disease: a litmus test for health-systems strengthening in low-income and middle-income
countries. Lancet 376: 1785–1797.

View ArticleGoogle Scholar

39.Jenkins R, Baingana F, Ahmad R, McDaid D, Atun R (2011) Health system challenges and solutions in
improving health outcomes. Ment Health Fam Med 8: 118–127.

View ArticleGoogle Scholar

40.Balabanova D, McKee M, Mills A, Walt G, Haines A (2010) What can global health instituions do to
help strengthen health systems in low-income countries. Health Policy and Systems 8: 1–11.

View ArticleGoogle Scholar

41.Patel V, Jenkins R, Lund C (2012) Putting evidence into practice: The PLoS Medicine Series on global
mental health practice. PLoS Med 9: e1001226 .

View ArticleGoogle Scholar

#HealthyAtHome - Mental health

Credits

Looking after our mental health

As countries introduce measures to restrict movement as part of efforts to reduce the number of people
infected with COVID-19, more and more of us are making huge changes to our daily routines.

The new realities of working from home, temporary unemployment, home-schooling of children, and
lack of physical contact with other family members, friends and colleagues take time to get used to.
Adapting to lifestyle changes such as these, and managing the fear of contracting the virus and worry
about people close to us who are particularly vulnerable, are challenging for all of us. They can be
particularly difficult for people with mental health conditions.

Fortunately, there are lots of things that we can do to look after our own mental health and to help
others who may need some extra support and care.
Here are tips and advice that we hope you will find useful.

Keep informed. Listen to advice and recommendations from your national and local authorities. Follow
trusted news channels, such as local and national TV and radio, and keep up-to-date with the latest
news from @WHO on social media.

Have a routine. Keep up with daily routines as far as possible, or make new ones.

Get up and go to bed at similar times every day.

Keep up with personal hygiene.

Eat healthy meals at regular times.

Exercise regularly.

Allocate time for working and time for resting.

Make time for doing things you enjoy.

Minimize newsfeeds. Try to reduce how much you watch, read or listen to news that makes you feel
anxious or distressed. Seek the latest information at specific times of the day, once or twice a day if
needed.

Social contact is important. If your movements are restricted, keep in regular contact with people close
to you by telephone and online channels.

Alcohol and drug use. Limit the amount of alcohol you drink or don’t drink alcohol at all. Don’t start
drinking alcohol if you have not drunk alcohol before. Avoid using alcohol and drugs as a way of dealing
with fear, anxiety, boredom and social isolation.

There is no evidence of any protective effect of drinking alcohol for viral or other infections. In fact, the
opposite is true as the harmful use of alcohol is associated with increased risk of infections and worse
treatment outcomes.

And be aware that alcohol and drug use may prevent you from taking sufficient precautions to protect
yourself again infection, such as compliance with hand hygiene.

Screen time. Be aware of how much time you spend in front of a screen every day. Make sure that you
take regular breaks from on-screen activities.
Video games. While video games can be a way to relax, it can be tempting to spend much more time on
them than usual when at home for long periods. Be sure to keep the right balance with off-line activities
in your daily routine.

Social media. Use your social media accounts to promote positive and hopeful stories. Correct
misinformation wherever you see it.

Help others. If you are able to, offer support to people in your community who may need it, such as
helping them with food shopping.

Support health workers. Take opportunities online or through your community to thank your country’s
health-care workers and all those working to respond to COVID-19.

Don’t discriminate

Fear is a normal reaction in situations of uncertainty. But sometimes fear is expressed in ways which are
hurtful to other people. Remember:

Be kind. Don’t discriminate against people because of your fears of the spread of COVID-19.

Don’t discriminate against people who you think may have coronavirus.

Don’t discriminate against health workers. Health workers deserve our respect and gratitude.

COVID-19 has affected people from many countries. Don’t attribute it to any specific group.

Responding to Covid-19: The rules of good governance apply

now more than ever!

Good public governance is more important than ever

In times of crisis such as the current COVID-19 pandemic and its economic and social
repercussions, public governance matters more than ever. Governance arrangements have
played a critical role in countries’ immediate responses, and will continue to be crucial both to
the recovery and to building a “new normal” once the crisis has passed.

The OECD has been taking stock of country responses and developing analysis and
recommendations on a range of public governance topics. The resulting evidence-based policy
responses below are designed to help governments tackle the crisis and plan for a sustainable
recovery.

Evidence-based policy responses for a sustainable recovery

1.Public trust
ENHANCING PUBLIC TRUST IN COVID-19 VACCINATION
GOVERNANCE STATISTICS IN THE COVID-19 ERA: A PRAIA CITY GROUP GUIDANCE NOTE
BUILDING A NEW PARADIGM FOR PUBLIC TRUST coming soon
READDRESSING THE COVID-19 IMPACT WHEN MEASURING TRUST coming soon

ICEGOV '17: Proceedings of the 10th International Conference on Theory and Practice of
Electronic GovernanceMarch 2017 Pages 465–474https://doi.org/10.1145/3047273.3047388
Published:07 March 2017
 5citation
 142
Downloads


 


 Get Access
ICEGOV '17: Proceedings of the 10th International Conference on Theory and Practice of
Electronic Governance
Research Gaps on Public Service Delivery
Pages 465–474
PreviousNext
 

o ABSTRACT
o References
o Index Terms
o Comments

ABSTRACT
This paper follows the research framework for context-specific public service delivery
presented at ICEGOV 2016 [1]. The research has been conducted at the UNU-EGOV unit during
the last year. The paper presents the research landscape for ICT enabled public service delivery
scientific and policy literature. The findings are analyzed and presented in a conceptual
framework allowing us to identify the core dimensions and sub-dimensions of public service
delivery.
The paper concludes by outlining the research gaps identified by the study and a series of policy
recommendations to enhance public service delivery. The results showed that the Innovation
and Evaluation dimensions and their sub-dimensions, Innovating Public Procurement, Collective
Learning and Intelligent, Evidence-Based Policy Making and Social Media Impact are the areas
with less investigation.
References
RESEARCH-ARTICLE
Research Gaps on Public Service Delivery
Share on
Authors:

Nuno Vasco Lopes

Delfina Sá Soares

Morten Meyerhoff Nielsen

António Tavares

Authors Info & Affiliations

ICEGOV '17: Proceedings of the 10th International Conference on Theory and Practice of Electronic
GovernanceMarch 2017 Pages 465–474https://doi.org/10.1145/3047273.3047388

Published:07 March 2017

ABSTRACT

This paper follows the research framework for context-specific public service delivery presented at
ICEGOV 2016 [1]. The research has been conducted at the UNU-EGOV unit during the last year. The
paper presents the research landscape for ICT enabled public service delivery scientific and policy
literature. The findings are analyzed and presented in a conceptual framework allowing us to identify
the core dimensions and sub-dimensions of public service delivery.

The paper concludes by outlining the research gaps identified by the study and a series of policy
recommendations to enhance public service delivery. The results showed that the Innovation and
Evaluation dimensions and their sub-dimensions, Innovating Public Procurement, Collective Learning
and Intelligent, Evidence-Based Policy Making and Social Media Impact are the areas with less
investigation.

References

Sept 28/2021

https://developingchild.harvard.edu/qa-the-coronavirus-pandemic-
mental-health-one-year-later/
Q&A: The Coronavirus Pandemic: Mental Health One Year Later

Content in This Guide

Resources and Guides

Looking Ahead to a Post-COVID-19 World

You Are Here: Mental Health One Year Later

Racial Disparities in COVID-19 Impacts

Building Responsive Relationships Remotely

Build Resilience During COVID-19

Supporting Children (and Yourself)

COVID-19 Resources

Infographic: What is COVID-19?

Responding to the Coronavirus Pandemic

Podcast Episodes

Episode 3: Communities of Opportunity

Episode 1: A Different World

Episode 2: Self-Care Isn't Selfish

Episode 4: Addressing Domestic Violence

Episode 5: Mental Health in Lock Down

In the early stages of the pandemic, the threat of illness, the implementation of social distancing
measures, and the drastic changes in everyday life put mental health concerns at the forefront of many
conversations. In an episode of The Brain Architects released in March 2020, Dr. Archana Basu and Dr.
Karestan Koenen discussed how families and children can protect their mental health during an
unprecedented time. But now, a year later, how have those mental health concerns changed? Dr. Basu
and Dr. Koenen describe the mental health challenges ahead and what we can do to support one
another.

Dr. Archana Basu

Dr. Archana Basu

Dr. Karestan Koenen

Dr. Karestan Koenen

We last spoke in March 2020, when we were just beginning to learn about the pandemic and adjusting
to life in quarantine. Now that we’ve been living this way for a year, have any of your concerns about
mental health changed?

In March 2020, we were in the early stages of the pandemic. We clearly did not know how long the
pandemic would be ongoing. Most of us did not imagine that we would still be living the restricted lives
we are. When we spoke, we were in the immediate stages of grappling with acute pandemic-induced
restrictions and losses, big and small, but now we have now been living under a prolonged period of
stress, loss, and restrictions for a year. The viral and the economic impact of the pandemic, along with
major political and social upheaval stemming from U.S. elections and systemic racial inequities, are all
part of the collective experience in the past year.

Although data on children and families continues to be limited relative to data on adults, we now have
more data about the emerging mental health impact on parents and children. Overall, the pandemic and
the associated public health measures (distancing and isolating) are taking a toll on the mental health of
children and adolescents across a range of metrics, including concerns related to depression, self-harm,
etc. Other data on children and teens from the CDC show that the proportion of children’s mental
health-related emergency department visits has increased since April 2020. In terms of the impact on
parents, a recent survey by the American Psychological Association found that parents with children
under age 18 were more than twice as likely as non-parent adults to have worked with a mental health
professional and to have been diagnosed with a mental health disorder since the pandemic started.
Also, 75% of parents reported that they could have used more emotional support than they received
during the pandemic.

Of note, systematic data from the pregnancy and postpartum periods and data on young children under
the age of 6 remain sparse. However, available data suggest similar patterns of growing mental health
needs. For instance, our own research (paper under review) indicates high levels of anxiety/depression,
post-traumatic stress symptoms, and increased loneliness among pregnant and postpartum women.1
Whether and how this affects their infants’ development remains to be examined, but based on prior
research we know that experiencing stress during sensitive periods of development (pregnancy – age 3)
has important implications for parent-infant bonding and infant development, so we really need to
continue to learn and intervene more.

Importantly, we need to keep in mind that the pandemic impact is not uniform across society. Due to
the systemic inequities in the U.S., Black, indigenous, and people of color (BIPOC) communities have
borne the brunt of the pandemic2,3, which may have specific mental health implications for BIPOC
individuals in multiple ways4 and need to be understood to inform intervention efforts. Relatedly, as we
noted the impact of other events during the pandemic, such as the killing of Mr. George Floyd, and the
subsequent racial justice protests may also impact BIPOC individuals and communities differently. For
instance, in prior research, police killings of unarmed Black Americans have been associated with poor
mental health of Black Americans but not White Americans5 and detrimentally affect achievement of
BIPOC youth.

The availability of multiple efficacious vaccines, and improving access to vaccines and testing, give us
hope of a closer semblance of normalization and typical life. With improvements in the pandemic public
health response, and the recent economic stimulus, we would expect some relief for parents and
families, particularly for those who have been financially affected, and improvements in mental health
as well, even though we have a lot of work ahead of us in terms of building our bandwidth and
developing responsive public health and health care systems.

Have the kinds of mental health supports necessary for children and families changed since the
beginning of the pandemic? Are they more widely available?

The idea that mental health is central to health and well-being is a focus now more than ever before.
The pandemic has made conversations about mental health more common and perhaps less
stigmatized. So, the idea of mental health supports and ways to support children’s emotional health
appears to be part of many more settings, or at least in more consistent and explicit ways, such as in
school-based curriculums, primary care visits, and certainly conversations with parents or caregivers.

There have been important changes to health policies in Massachusetts (MA), making some types of
mental health care more accessible. A major change in this regard is the recent MA legislation that
mandates permanent payment parity for tele-mental health services with in-person services. This
includes both phone and video sessions, and this is important because access to reliable internet is not
always available to everyone due to existing digital access disparities.
Another element that is increasingly getting attention is the use of digital tools for mental health care
that may be an effective adjunct to working with a mental health professional. Also, the use of
multidisciplinary teams–whether it is through integrated care models such as integrating mental health
specialists in primary pediatric care, or through the inclusion of resource specialists in a care team in
addition to mental health or primary care health providers–are models that are increasingly gaining
momentum.

In addition to change in the format of delivering mental health care including more flexible formats –
both in terms of mode of delivery (telehealth, digital, or in-person) and the use of multidisciplinary
teams, there are at least two other areas that will continue to gain traction. This includes cross-sector
partnerships (e.g., mental health care collaborations with a range of community-based organizations
such as schools or with law enforcement), and an increased focus on prevention rather than primarily
ameliorative and tertiary care.

A new term–“pandemic fatigue”–has popped up recently. What advice do you have for families who
have grown weary of the physical isolation and social limitations and precautions? And for those who
may be struggling emotionally, mentally, and even financially?

The cumulative impact of various stressors – and there have been so many – makes this “last mile” as
vaccines ramp up, harder. Fatigue and burnout are ubiquitous. We have come pretty far in this journey,
and the horizon to safe in-person and more physically connected lives is visible with increasing vaccine
access. We also still need to stay cautious and support each other in getting through this period. Parents
and caregivers are the bedrock for their families, and anything we can do to prioritize caregivers’ needs
and well-being is critical.

While there are no easy answers, it is helpful to revisit some ideas. For instance, it can be helpful to
revisit familial rules and restrictions that people have been following. We know more about how the
virus is spread, and what we can do to stay safe. With winter in our rear view, we have more options for
safe outdoor meetings such as playdates for children and parents alike, while masking. Opportunities for
self-care through intentional, behavioral methods that we can control can cultivate resilience. Finally,
recognizing and giving ourselves permission that even as things may improve, we will likely still be
coping with grief, sadness, exhaustion, etc., and need to allow ourselves the time and opportunity to
process the impact of this communal trauma is key. Importantly, continue to reach out and connect-–to
your friends, loved ones, and medical and mental health professionals-–for support.

One way to think about this is that resilience is not a trait that we develop in isolation. It is more of a
process–often a messy one–that is primarily developed through experiencing responsiveness. For
instance, when our children are coping with stress or feeling overwhelmed, having a reliable supportive
caregiver makes that stressor tolerable, and children learn how to cope and adapt. In fact, at every stage
in life, including in adulthood, having responsive support through family, friends, and community is
important to our well-being. Indeed, one key lesson from the pandemic is the need for more family-
friendly policies. For instance, the Rescue Act provides economic stimulus for families with children,
includes an extension of Medicare for one-year postpartum for mothers, etc. Advocating for more family
friendly policy beyond a one-time effort is critical and something we can all do.

Thinking about the months and years ahead, are there signs we should be on the lookout for when it
comes to mental health consequences that might stem from the pandemic?

The longer-term impact will vary a lot based on each child and family’s individual experience of the
pandemic. For those who suffered major losses-–such as bereavement, housing or food instability, a
family member with significant COVID-related disease complications–there may be a long-term impact.
This does not necessarily mean that children or adults with such experiences will have diagnosable
mental health disorders. In fact, the majority of children and adults are unlikely to have long-term
diagnosable mental health disorders, and the current levels of mental distress are likely to improve
substantially, provided a consistent sense of stability can be established. However, even in the absence
of a mental disorder or mental disorder symptoms, peoples’ fundamental assumptions about safety and
predictability of the world are likely to be affected. This is how trauma affects us–and COVID-19 is a
global communal trauma–it fundamentally reshapes our world views, including our sense of trust in
others, in larger systems, and ourselves. It is important to note that even within this pandemic, many
people have come together with extraordinary outpouring of support for each other, and one
outgrowth of this experience may be that our hopes and efforts towards a more connected,
compassionate, and equitable society may increase.

What can we do to support each other now and in the future? Do you have any advice or suggestions for
policymakers, practitioners, or parents about resources they should know about or changes we need to
work on to address the emotional fallout of the past year?

Recognizing that there is no health without mental health is central to planning for the future. We need
significant investments in our mental health infrastructure and also to reconsider the ways in which
current systems are structured. We highlight four points to consider that include both long-term and
shorter-term ideas:
Flexible and integrative models of care such as telehealth, multidisciplinary teams, and cross-sector
partnerships, as discussed above, are important next steps that should be implemented, evaluated, and
expanded.

Centering health equity in all aspects of future planning and implementation is critical. The pandemic
has made clear that while we are all in the same storm, we are not all in the same boat. The impact of
systemic inequities in the U.S. on BIPOC communities has long since been established and reiterated and
exacerbated in the pandemic.

Prevention is a major area for growth. Data suggest that at least half of lifetime mental disorders begin
in childhood, and approximately 75% are diagnosed before age 25. This not only means that we need
much more investment in childhood mental health research and health care access, but also that we
need to support those who most closely care for our children and their emotional development-–
parents, early childhood caregivers, and educators. Given what we know about sensitive periods of
development especially in the pregnancy through age 3 period, greater investments in research and
clinical care in this period are essential.

These points also serve to highlight that to reshape health care, we also need to consider the practical
implications of training and education in mental health disciplines (e.g., psychiatry, psychology, social
work) but really all medical specialties, and school-based roles. Training that builds on intergenerational,
systemic, and life-course approaches in the science of early childhood development, trauma, resilience,
and what they mean for specific disciplines, is key.

References

Basu A, Kim H, Basaldua R, et al. A cross-national study of factors associated with women’s perinatal
mental health and wellbeing during the COVID-19 pandemic. under review. 2021.

Andrasfay T, Goldman N. Reductions in 2020 US life expectancy due to COVID-19 and the
disproportionate impact on the Black and Latino populations. 2021;118(5 e2014746118).

Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority
groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html.

Gur RE, White LK, Waller R, et al. The Disproportionate Burden of the COVID-19 Pandemic Among
Pregnant Black Women. Psychiatry Res. 2020;293:113475.

Bor J, Venkataramani AS, Williams DR, Tsai AC. Police killings and their spillover effects on the mental
health of black Americans: a population-based, quasi-experimental study. The Lancet.
2018;392(10144):302-310.