Scaling Up for the “Bottom Billion”: “5×5” Implementation of Community Mental Health Care in Low-Income Regions

Department ofPsychiatry, New York University Schoolof Medicine, New York, NY, USA.
Psychiatric services (Washington, D.C.) (Impact Factor: 2.41). 12/2011; 62(12):1494-502. DOI: 10.1176/
Source: PubMed


Common mental disorders pose tremendous health and social burdens in the poorest countries. This Open Forum describes a planning framework to advance effective, sustainable design and implementation of mental health services in these settings. It builds on research in treatment dissemination and on the authors' experience in several initiatives-including the Millennium Villages Project in sub-Saharan Africa and the Partners In Health system in Haiti (Zanmi Lasante). The authors describe a "pyramid of care" approach that specifies five key skill packages to address common mental disorders in low-resource settings and five implementation rules: assess context first; identify priority care pathways and map them across skill packages; specify decision supports, supervision, and triage rules; use quality improvement practices; and plan for sustainability and capacity building. The framework addresses the need for a shared vocabulary and a set of tools to coordinate and compare efforts to scale-up mental health treatment across diverse settings.

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    • "Recent mental health development efforts in Haiti are characterized by practical application of psychological constructs and systematic approaches to scaling up models of care ( Belkin et al . , 2011 ; Raviola , Eustache , Oswald , & Belkin , 2012 ) ."
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    ABSTRACT: Developing mental health care capacity in postearthquake Haiti is hampered by the lack of assessments that include culturally bound idioms Haitians use when discussing emotional distress. The current paper describes a novel emic-etic approach to developing a depression screening for Partners in Health/Zanmi Lasante. In Study 1 Haitian key informants were asked to classify symptoms and describe categories within a pool of symptoms of common mental disorders. Study 2 tested the symptom set that best approximated depression in a sample of depressed and not depressed Haitians in order to select items for the screening tool. The resulting 13-item instrument produced scores with high internal reliability that were sensitive to culturally informed diagnoses, and interpretations with construct and concurrent validity (vis-à-vis functional impairment). Discussion focuses on the appropriate use of this tool and integrating emic perspectives into developing psychological assessments globally. The screening tool is provided as an Appendix.
    Full-text · Article · Jul 2014 · Transcultural Psychiatry
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    • "First, they represent a large health burden: depression is the leading cause of disability-adjusted life years (DALYs) attributable to mental, neurological, and substance-use disorders in both high-income and low- and middle-income countries (LMICs) [17,18], and suicide accounts for one million deaths per year worldwide [19]. Second, to support the increasing efforts of the WHO and other organizations to implement task-shifting in mental healthcare in low-income settings [20], there is a need to identify optimal referral strategies and key risk factors for screening [21]. Third, known risk factors can be used to design prevention activities to minimize the incidence, morbidity, and mortality associated with depression and suicide in LMICs such as Haiti. "
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    ABSTRACT: Background Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti’s Central Plateau. Methods We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti’s Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively. Results The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5). Conclusions A large proportion of Haiti’s Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.
    Full-text · Article · Sep 2012 · BMC Psychiatry
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    • "Two sets of discussions—one among colleagues involved in planning a framework for integration of mental health into primary care as part of the Millennium Villages Project in sub-Saharan Africa, and one among members of a consortium that included Haiti-based institutions (PIH/ZL, Haitian Ministry of Health, and Interuniversity Institute for Research and Development) and U.S. academic medical centers (Program in Global Mental Health and Social Change at Harvard Medical School, and Program in Global Mental Health at New York University School of Medicine)—led to a systematic, collaborative process that facilitated the articulation of a scalable model for mental health service delivery within the ZL system called 5 × 5.4 In this stepwise process, structured, qualitative information on beliefs, practices, and local priorities about mental health conditions are used to develop a best practice–based template. "
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    ABSTRACT: Significant challenges exist in providing safe, effective, and culturally sound mental health and psychosocial services when an unforeseen disaster strikes in a low-resource setting. We present here a case study describing the experience of a transnational team in expanding mental health and psychosocial services delivered by two health care organizations, one local (Zanmi Lasante) and one international (Partners in Health), acting collaboratively as part of the emergency response to the 2010 Haiti earthquake. In the year and a half following the earthquake, Zanmi Lasante and Partners in Health provided 20,000 documented individual and group appointments for mental health and psychosocial needs. During the delivery of disaster response services, the collaboration led to the development of a model to guide the expansion and scaling up of community-based mental health services in the Zanmi Lasante health care system over the long-term, with potential for broader scale-up in Haiti. This model identifies key skill packages and implementation rules for developing evidence-based pathways and algorithms for treating common mental disorders. Throughout the collaboration, efforts were made to coordinate planning with multiple organizations interested in supporting the development of mental health programs following the disaster, including national governmental bodies, nongovernmental organizations, universities, foreign academic medical centers, and corporations. The collaborative interventions are framed here in terms of four overarching categories of action: direct service delivery, research, training, and advocacy. This case study exemplifies the role of psychiatrists working in low-resource settings as public health program implementers and as members of multidisciplinary teams.
    Full-text · Article · Feb 2012 · Harvard Review of Psychiatry
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