Purpose – Neuropsychiatric disorders account for a substantial proportion of disease burden and disability in Africa. Despite this, mental health systems are under-resourced in Africa, as in most parts of the world, creating a “treatment gap” and denying the African population the right to mental health achieved through access to mental health services. The paper aims to discuss these issues. Design/methodology/approach – The mental health systems of African countries were compared with figures for all low- and middle-income countries (LAMICS) using data from the World Health Organization Assessment Instrument for Mental Health Systems. Comparable global figures were also available for some indicators from the WHO's World Mental Health Atlas 2011. Findings – Selected indicators of mental health systems are presented for 14 African countries and shows that they are lower as compared to figures for all other LAMICS and also global figures. The treatment gap for mental disorders is much higher in Africa than comparable global figures. For example, the treatment gap for mood disorders has been estimated from 95 to 100 per cent for some African countries. Originality/value – There is an imbalance between need and service provision in the area of mental health across the world but particularly in Africa. Despite this, there are a greater number of outpatient than inpatient services in Africa which provides an opportunity for development of community-based services. There are also many encouraging examples of effective approaches to reducing the burden of neuropsychiatic disease in Africa.

An estimated 150 million children have a disability. Early identification of developmental disabilities is a high priority for the World Health Organization to allow action to reduce impairments through Gap Action Program on mental health. The study identified the feasibility of using the developmental screening and monitoring tools for children aged 0-3 year(s) by non-specialist primary healthcare providers in low-resource settings. A systematic review of the literature was conducted to identify the tools, assess their psychometric properties, and feasibility of use in low- and middle-income countries (LMICs). Key indicators to examine feasibility in LMICs were derived from a consultation with 23 international experts. We identified 426 studies from which 14 tools used in LMICs were extracted for further examination. Three tools reported adequate psychometric properties and met most of the feasibility criteria. Three tools appear promising for use in identifying and monitoring young children with disabilities at primary healthcare level in LMICs. Further research and development are needed to optimize these tools.

Purpose – The purpose of this paper is to examine sex differences in mental health service usage among upper-middle, lower-middle, and low-income countries (LICs). Design/methodology/approach – Data from 62 low- and middle-income countries (LAMICs) were collected with the World Health Organization – Assessment Instrument for Mental Health Systems (WHO-AIMS). Sex differences in mental health service utilization were assessed by comparing the proportion female in the general population with the proportion female treated for mental illness in five different types of mental health facility. Findings – Two-sided t-tests for significance (a=0.05) revealed a significant difference between the proportion female in the population and the proportion treated in inpatient facilities (community-based and mental hospitals) in LICs. There was also a trend toward decreased use of outpatient facilities by women in LICs (p=0.08). Lower-middle and upper-middle income countries showed no differences. In day treatment facilities for the entire sample, there was a significant difference between the proportion female in the population and the proportion treated female (weighted mean difference overall=0.10, p=0.035). Research limitations/implications – The authors found significantly reduced utilization of mental health services by women in LICs in community-based inpatient facilities and mental hospitals and a trend toward decreased use in outpatient facilities. Future studies investigating the factors contributing to the lower utilization of services by women in LICs are essential. Originality/value – This study presents the first comprehensive study of mental health service usage by sex in 62 LAMICs.

The chapter collates information from different international projects and outlines the current state of global mental health resources from the perspective of governance, finance, mental health services including those for special populations, and information systems. Training of mental health personnel and distribution of such personnel globally are discussed. However, a detailed description of human resources is provided in another chapter. Outline of some key initiatives in global mental health led by international and non-governmental organizations are provided. Though the chapter has a bias towards resources in low and middle income countries, resources in high income countries are also suitably highlighted. The implications of recent initiatives in global mental health on development of mental health resources around the world, and key lacunae that need to be filled-up, in future, are also discussed.

ED FROM Reed RV, Fazel M, Jones L, et al. Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors. Lancet 2012;379:250–65. Correspondence to: Dr Mina Fazel, Department of Psychiatry, Oxford University, Oxford OX3 7JX, UK; mina.fazel@psych.ox.ac.uk Sources of funding Not reported. CO M M EN TA RY Globally, 18 million children and adolescents are displaced due to conflict, threatening their mental health and well-being. Reed et al have completed an important systematic review of risk and protective factors for the mental health of displaced children in lowand middle-income countries. The review identifies protective and risk factors to help professionals identify (A) subgroups in need of intervention and (B) modifiable factors, which can be targeted by policies and interventions. Five risk factors were identified (exposure to violence, female sex, male sex, settlement in refugee camp and internal displacement) and one protective factor (repatriation). Given the broad nature of these correlates, it seems impossible to prioritise a particular group for intervention as almost all displaced children would have one or more risk factor. Moreover, since the majority of the risk factors are not modifiable, implications for intervention (other than protection) are limited. The dearth of practical applications for policy and practice raises the question whether descriptive epidemiology is the most efficient method to move towards evidence-based interventions for displaced children. Indeed, the review does not suggest changes to current global policy endorsed by international organisations. In our opinion, the investigators should direct their attention towards intervention research. The present review, coupled with existing knowledge about children in adversity, suggests that promising areas of enquiry include evaluation of interventions to improve parental mental health and family functioning, interventions to increase connections to schools and the local community, as well as interventions that aim to increase social support, and change attributions (such as cognitivebehavioural therapy). A recent study on research priority setting for mental health and psychosocial support in humanitarian settings highlighted the ‘excellence-relevance’ disconnect. The results of this review suggest that it is possible to do excellent research, but that does not necessarily mean that the study findings will have great relevance to the population studied. Jodi Morris, Mark van Ommeren, Chiara Servili Department of mental health and substance abuse, WHO, Geneva, Switzerland Competing interests None. REFERENCE 1. Tol WA, Patel V, Tomlinson M, et al. Relevance or excellence? Setting research priorities for mental health and psychosocial support in humanitarian settings. Harv Rev Psychiatry 2012;20: 25–36. 62 EBMH August 2012 Vol 15 No 3 Prevalence

BACKGROUND:Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue.METHODS AND FINDINGS:This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability.CONCLUSIONS:Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.

Combined psychosocial and nutrition interventions improve the development of infants. However, there is a paucity of studies examining the effectiveness of such interventions in humanitarian settings. This article examines the impact of combining a group-based psychosocial intervention with an existing emergency feeding program for internally displaced mothers in Northern Uganda. The intervention consisted of mother and baby group sessions and home visits for mothers attending 3 emergency feeding centers. Psychosocial outcomes were compared with a contrast group of mothers who received nutritional support alone. The outcomes investigated were infant stimulation and maternal mood. After controlling for the effects of interview site and baseline scores, mothers in the intervention group (n = 70) showed greater involvement with their babies, more availability of play materials, and less sadness and worry at follow-up in comparison to the contrast group (n = 77). The intervention was acceptable to the mothers and easily taught. A proportion of the mothers chose to continue the intervention spontaneously with other mothers in their neighbourhoods. Further research needs to be done to validate these preliminary findings and explore the longer term impact on child growth and intellectual development as well as maternal mood.

Background Treatment coverage for mental disorders ranges from less than 10% to more than 90% across low- and middle-income (LAMI) countries. Studies have yet to examine whether the capacity of mental health systems might be adversely affected by the burdens of unrelated conditions such as HIV/AIDS. Aims To examine whether the magnitude of disease burden from communicable, perinatal, maternal and nutritional conditions - commonly referred to as Group 1 diseases - is inversely associated with mental health system capacity in LAMI countries. Method Multiple regression analyses were undertaken using data from 117 LAMI countries included in the 2011 World Health Organization (WHO) Mental Health Atlas. Capacity was defined in terms of human resources and infrastructure. Regressions controlled for effects of political stability, government health expenditures, income inequality and neuropsychiatric disease burden. Results Higher Group 1 disease burden was associated with fewer psychiatrists, psychologists and nurses in the mental health sector, as well as reduced numbers of out-patient facilities and psychiatric beds in mental hospitals and general hospitals (t= −2.06 to −7.68, P < 0.05). Conclusions Evidence suggests that mental health system capacity in LAMI countries may be adversely affected by the magnitude of their Group 1 disease burden.

Data derived from the World Health Organization’s (WHO) Mental Health Atlas Project 2011 are presented. These data provide the latest estimates on available resources for the treatment and prevention of neuropsychiatric disorders covering 98 percent of the world’s population. Resources are defined in terms of governance, financing, mental health care delivery, human resources, essential medicines, and information systems. The Atlas project was initiated to guide policy and planning efforts in order to meet the large and growing burden of neuropsychiatric disorders worldwide. Results indicate that 60 percent of countries have a dedicated mental health policy; 71 percent possess a mental health plan; and 59 percent report having dedicated mental health legislation. Median mental health expenditures per capita are US$ 1.63, with large variation among income groups, ranging from US$ 0.20 in low income countries to US$ 44.84 in high income countries. Globally, 67 percent of financial resources are directed towards mental hospitals. The global median number of facilities per 100,000 population were; 0.61 outpatient facilities, 0.05 day treatment facilities, 0.01 community residential facilities, and 0.04 mental hospitals. There are 7.04 psychiatric beds per 100,000 population in mental hospitals in comparison to 1.4 psychiatric beds per 100,000 population in general hospitals. Higher income countries typically report more facilities and higher admission/utilization rates. Three quarters of patients admitted to mental hospitals remain there less than one year. There is a clear pattern whereby greater rates of human resources are observed in higher income countries. Globally, nurses represented the most prevalent professional group working in the mental health sector. User and family associations are present in about two thirds of the countries, with greater representation in higher income countries. Results from Mental Health Atlas 2011 reinforce the urgent need to scale up resources within countries to meet the high and growing burden of mental disorders.

OBJECTIVE To outline mental health service accessibility, estimate the treatment gap and describe service utilization for people with schizophrenic disorders in 50 low- and middle-income countries. METHODS The World Health Organization Assessment Instrument for Mental Health Systems was used to assess the accessibility of mental health services for schizophrenic disorders and their utilization. The treatment gap measurement was based on the number of cases treated per 100,000 persons with schizophrenic disorders, and it was compared with subregional estimates based on the Global burden of disease 2004 update report. Multivariate analysis using backward step-wise regression was performed to assess predictors of accessibility, treatment gap and service utilization. FINDINGS The median annual rate of treatment for schizophrenic disorders in mental health services was 128 cases per 100,000 population. The median treatment gap was 69% and was higher in participating low-income countries (89%) than in lower-middle-income and upper-middle-income countries (69% and 63%, respectively). Of the people with schizophrenic disorders, 80% were treated in outpatient facilities. The availability of psychiatrists and nurses in mental health facilities was found to be a significant predictor of service accessibility and treatment gap. CONCLUSION The treatment gap for schizophrenic disorders in the 50 low- and middle-income countries in this study is disconcertingly large and outpatient facilities bear the major burden of care. The significant predictors found suggest an avenue for improving care in these countries.

A challenge faced by many countries is to provide adequate human resources for delivery of essential mental health interventions. The overwhelming worldwide shortage of human resources for mental health, particularly in low-income and middle-income countries, is well established. Here, we review the current state of human resources for mental health, needs, and strategies for action. At present, human resources for mental health in countries of low and middle income show a serious shortfall that is likely to grow unless eff ective steps are taken. Evidence suggests that mental health care can be delivered eff ectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, aff ected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden. We also discuss scale-up costs, human resources management, and leadership for mental health, particularly within the context of low-income and middle-income countries.

Abstract A mental health policy is the official statement of a government about what they will do to improve the mental health situation in that country. Together with a mental health plan, which details concrete actions to implement the policy, they represent essential tools to improve the way mental health problems are addressed in countries. When well formulated, they can coordinate, through a common vision and plan, all programmes, services, and actions related to mental health. Without this type of organization, mental health problems are likely to be dealt with in an inefficient and fragmented manner. Mental health policies assist to maximize the effectiveness of mental health programmes, to ensure that funds are spent wisely, and to improve coordination among service providers in the community (Funk et al., 2005). The World Health Organization (WHO) has argued for developing national policies on mental health that are information and evidence based. Though the broad objectives of the policy may remain the same across countries, the starting points are likely to be different across countries (even within the same income category) so much so that background and contextual information become essential for the development of policy and plans.

OBJECTIVE:The authors describe characteristics and capacities of mental health systems in low- and middle-income countries.METHODS:The World Health Organization Assessment Instrument for Mental Health Systems was used to assess services in 42 countries (13 low-, 24 lower-middle, and five upper-middle income).RESULTS:Of 36 countries with a mental health plan, 90% include the goal of developing community services. However, inpatient facilities are the main service providers, with less than one community contact (.70) for each inpatient day. Mental hospitals consume 80% of mental health budgets, and outpatient care is limited.CONCLUSIONS:Mental health services in participating countries are limited and often hospital based.

Purpose: Despite the accomplishments, the economic and social reform program of Vietnam has had negative effects, such as limited access to health care services for those disadvantaged in the new market economy. Among this group are persons with mental disorders. This paper aims to understand the burden of mental disorders and availability of mental health services (MHS) in Vietnam.Methods: We reviewed both national as well as the international literature about the burden of mental disorders and MHS in Vietnam. This included academic literature (Medline, Pubmed), national ( government) reports, World Health Organization (WHO) reports, and grey literature.Results: The burden of mental disorders in Vietnam is similar to that of other Asian countries and occurs across all population groups. MHS have been made one of the national health priorities and more efforts are being made to promote equity of access by integrating MHS into other health care programs and by increasing MHS capacity. However, it is not yet sufficient to meet the care demand of persons with mental disorders. Challenges remain in various areas of MHS, including: lack of mental health legislation, human resources, hospital beds, shortage and diversification of MHS.Conclusion: Although MHS in Vietnam have considerably improved over the last decade, mainly in terms of accessibility, the care demand and the illness burden remain high. Therefore, more emphasis should be put on increasing MHS capacity and on human resource development. In that process, more representative epidemiological data and intervention research is needed. (C) 2011 Elsevier B.V. All rights reserved.

Background: Little is known about the treated prevalence and services received by children and adolescents in low- and middle-income countries (LAMICs). The purpose of this study is to describe the characteristics and capacity of mental health services for children and adolescents in 42 LAMICs. Methods: The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), a 155-indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower-middle, and 5 upper-middle-income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO-AIMS instrument. Results: The median one-year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health. Conclusions: Mental health services for children and adolescents in low-and middle-income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.

OBJECTIVE:To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs).METHODS:We used data from the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders.FINDINGS:All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239,000 full-time equivalent professionals to address the current shortage.CONCLUSION:Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs.