Dan Chisholm’s research while affiliated with Department of Mental Health and Substance Abuse Services, Tennessee and other places

Background Access to effective treatment for major depressive disorder remains limited and difficult to track across place and time. We analysed the available data on minimally adequate treatment (MAT) for major depressive disorder globally with the aim of providing a useful metric against which to monitor national responses to the growing public health burden imposed by major depressive disorder. Methods MAT was defined as pharmacotherapy (1 month of medication, plus four visits to a medical doctor) or psychotherapy (eight visits with any professional). From existing reviews, we identified mental health surveys that assessed major depressive disorder within the general population as well as health service uptake by individuals with major depressive disorder. Data by ethnicity were not available. Estimates of MAT, antidepressant use, or use of any mental health service were extracted. The latter two estimates were adjusted to reflect likely MAT rates via a network meta-analysis. Adjusted MAT estimates were analysed via a Bayesian meta-regression using the Disease Modelling Meta-Regression (DisMod-MR 2.1) tool. This analysis estimated MAT coverage among people with major depressive disorder by age, sex, location, and year. Final MAT estimates were standardised by age and sex against the existing age and sex distribution of people with major depressive disorder globally. People with lived experience were involved in the design, preparation, interpretation, and writing of this manuscript. Findings The analysed dataset included 145 estimates from 32 studies, covering 31 countries, 14 regions, and six super-regions. The proportion of people with major depressive disorder receiving MAT globally in 2021 was 9·1% (95% uncertainty interval 7·2–11·6), with 10·2% (8·2–13·1) of females and 7·2% (5·7–9·3) of males with major depressive disorder receiving MAT. MAT coverage was highest in high-income locations (27·0% [21·7–34·4]), with Australasia having the highest rate (29·2% [21·4–40·8]). MAT coverage was lowest in sub-Saharan Africa (2·0% [1·5–2·6]), within which western sub-Saharan Africa (1·8% [1·4–2·5]) had the lowest coverage. Seven countries (Australia, Belgium, Canada, Germany, the Netherlands, South Korea, and Sweden) were estimated to have MAT coverage exceeding 30%, while 90 countries were estimated to have coverage lower than 5%. Interpretation Despite many gaps in the available data, estimates show that, globally, most individuals with major depressive disorder do not receive MAT. Services must improve to reach a global coverage that better meets the mental health needs of those with major depressive disorder. Urgent attention should be given to the scale-up of effective intervention strategies, especially in low-income and middle-income countries, as well as further research into better quality treatment options for major depressive disorder. We present a means by which the MAT gap for major depressive disorder can be quantified, to monitor and inform action by governments and international partners. Funding Queensland Health and the Bill & Melinda Gates Foundation.

Introduction Despite the increasing interest in and political commitment to mental health service development in many regions of the world, there remains a very low level of financial commitment and corresponding investment. Assessment of the projected costs and benefits of scaling up the delivery of effective mental health interventions can help to promote, inform and guide greater investment in public mental health. Methods A series of national mental health investment case studies were carried out (in Bangladesh, Kenya, Nepal, Philippines, Uganda, Uzbekistan and Zimbabwe), using standardized guidance developed by WHO and UNDP and implemented by a multi-disciplinary team. Intervention costs and the monetized value of improved health and production were computed in national currency units and, for comparison, US dollars. Benefit-cost ratios were derived. Findings Across seven countries, the economic burden of mental health conditions was estimated at between 0.5%–1.0% of Gross Domestic Product. Delivery of an evidence-based package of mental health interventions was estimated to cost US$ 0.40–2.40 per capita per year, depending on the country and its scale-up period. For most conditions and country contexts there was a return of >1 for each dollar or unit of local currency invested (range: 0.0–10.6 to 1) when productivity gains alone are included, and >2 (range: 0.4–30.3 to 1) when the intrinsic economic value of health is also considered. There was considerable variation in benefit-cost ratios between intervention areas, with population-based preventive measures and treatment of common mental, neurological and conditions showing the most attractive returns when all assessed benefits are taken into account. Discussion and Conclusion Performing a mental health investment case can provide national-level decision makers with new and contextualized information on the outlays and returns that can be expected from renewed local efforts to enhance access to quality mental health services. Economic evidence from seven low- and middle-income countries indicates that the economic burden of mental health conditions is high, the investment costs are low and the potential returns are substantial.

Aims: Preventing the occurrence of depression/anxiety and suicide during adolescence can lead to substantive health gains over the course of an individual person's life. This study set out to identify the expected population-level costs and health impacts of implementing universal and indicated school-based socio-emotional learning (SEL) programs in different country contexts. Methods: A Markov model was developed to examine the effectiveness of delivering universal and indicated school-based SEL programs to prevent the onset of depression/anxiety and suicide deaths among adolescents. Intervention health impacts were measured in healthy life years gained (HLYGs) over a 100-year time horizon. Country-specific intervention costs were calculated and denominated in 2017 international dollars (2017 I$) under a health systems perspective. Cost-effectiveness findings were subsequently expressed in terms of I$ per HLYG. Analyses were conducted on a group of 20 countries from different regions and income levels, with final results aggregated and presented by country income group - that is, low and lower middle income countries (LLMICs) and upper middle and high-income countries (UMHICs). Uncertainty and sensitivity analyses were conducted to test model assumptions. Results: Implementation costs ranged from an annual per capita investment of I$0.10 in LLMICs to I$0.16 in UMHICs for the universal SEL program and I$0.06 in LLMICs to I$0.09 in UMHICs for the indicated SEL program. The universal SEL program generated 100 HLYGs per 1 million population compared to 5 for the indicated SEL program in LLMICs. The cost per HLYG was I$958 in LLMICS and I$2,006 in UMHICs for the universal SEL program and I$11,123 in LLMICs and I$18,473 in UMHICs for the indicated SEL program. Cost-effectiveness findings were highly sensitive to variations around input parameter values involving the intervention effect sizes and the disability weight used to estimate HLYGs. Conclusions: The results of this analysis suggest that universal and indicated SEL programs require a low level of investment (in the range of I$0.05 to I$0.20 per head of population) but that universal SEL programs produce significantly greater health benefits at a population level and therefore better value for money (e.g., less than I$1,000 per HLYG in LLMICs). Despite producing fewer population-level health benefits, the implementation of indicated SEL programs may be justified as a means of reducing population inequalities that affect high-risk populations who would benefit from a more tailored intervention approach.

Introduction Mental, neurological and substance use conditions lead to tremendous suffering, yet globally access to effective care is limited. In line with the 13th General Programme of Work (GPW 13), in 2019 the World Health Organization (WHO) launched the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health to advance mental health policies, advocacy, and human rights and to scale up access to quality and affordable care for people living with mental health conditions. Six countries were selected as ‘early-adopter’ countries for the WHO Special Initiative for Mental Health in the initial phase. Our objective was to rapidly and comprehensively assess the strength of mental health systems in each country with the goal of informing national priority-setting at the outset of the Initiative. Methods We used a modified version of the Program for Improving Mental Health Care (PRIME) situational analysis tool. We used a participatory process to document national demographic and population health characteristics; environmental, sociopolitical, and health-related threats; the status of mental health policies and plans; the prevalence of mental disorders and treatment coverage; and the availability of resources for mental health. Results Each country had distinct needs, though several common themes emerged. Most were dealing with crises with serious implications for population mental health. None had sufficient mental health services to meet their needs. All aimed to decentralize and deinstitutionalize mental health services, to integrate mental health care into primary health care, and to devote more financial and human resources to mental health systems. All cited insufficient and inequitably distributed specialist human resources for mental health as a major impediment. Conclusions This rapid assessment facilitated priority-setting for mental health system strengthening by national stakeholders. Next steps include convening design workshops in each country and initiating monitoring and evaluation procedures.

Background Poverty and mental illness are strongly associated. The aim of this study was to investigate the economic impact of implementing a district level integrated mental healthcare plan for people with severe mental disorders (SMD) and depression compared to secular trends in the general population in a rural Ethiopian setting. Methods A community-based, controlled before-after study design was used to assess changes in household economic status and catastrophic out-of-pocket (OOP) payments in relation to expanded access to mental health care. Two household samples were recruited, each with a community control group: (1) SMD sub-study and (2) depression sub-study. In the SMD sub-study, 290 households containing a member with SMD and 289 comparison households without a person with SMD participated. In the depression sub-study, 129 households with a person with depression and 129 comparison households. The case and comparison cohorts were followed up over 12 months. Propensity score matching and multivariable regression analyses were conducted. Results Provision of mental healthcare in the district was associated with a greater increase in income (Birr 919.53, 95% CI: 34.49, 4573.56) but no significant changes in consumption expenditure (Birr 176.25, 95% CI: -1338.19, 1690.70) in households of people with SMD compared to secular trends in comparison households. In households of people with depression, there was no significant change in income (Birr 227.78, 95% CI: -1361.21, 1816.79) or consumption expenditure (Birr -81.20, 95% CI: -2572.57, 2410.15). The proportion of households incurring catastrophic OOP payments at the ≥10% and ≥40% thresholds were significantly reduced after the intervention in the SMD (from 20.3% to 9.0%, p=0.002, and 31.9% to 14.9%, p< 0.001) and in the depression intervention (from 19.6% to 5.3%, p=0.003, and 25.2% to 11.8%, p= 0.015). Nonetheless, households of persons with SMD or depression remained impoverished relative to comparison groups at follow-up. Households of people with SMD and depression were significantly less likely to be enrolled in community-based health insurance (CBHI) than comparison households. Conclusions Our findings support global initiatives to scale up mental healthcare as part of universal health coverage initiatives, alongside interventions to support social inclusion and targeted financial protection for vulnerable households.