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Editorial

Evidence-based interventions for global mental health: role and mission of a new Cochrane initiative

Corrado Barbui, Marianna Purgato, Rachel Churchill, Clive E Adams, Laura Amato, Geraldine Macdonald, Jenny McCleery, Silvia Minozzi, Rebecca Syed Sheriff
Editorial Article

At a global level there are striking disparities in the provision of mental health care between rich and poor countries.[1] In low- and middle-income countries (LMICs) more than 75% of people with serious mental health conditions receive inadequate care, despite substantial disability and functional impairment.[2] These global disparities in mental health care have been mirrored in intervention research, with few trials being undertaken in LMICs, and with inadequate reflection of need and poor accessibility.[3]

In order to activate political and policy solutions, as well as population- and individual-level responses, the last decade has seen the consolidation of the field of global mental health as an area of research and practice, that places a priority on achieving equity in mental health for all people worldwide.[4] Expanding access to care, improving preventive strategies and treatment interventions, transforming health systems, and building human resource capacity are among the main research and implementation priorities for global mental health.[5,6]

A cross-cutting principle for activities in the field of global mental health is the value attributed to the evidence base, which, despite its limitations, can be a powerful argument against the view that nothing can be done.[5,7] All recent intergovernmental initiatives aiming to reduce the mental health treatment gap have been based on careful and systematic appraisals of the existing evidence. In 2008, for example, the World Health Organization (WHO) launched the Mental Health Gap Action Programme (mhGAP) to enhance the capacity of member states to respond to the growing burden of mental, neurological, and substance use disorders.[8] An essential component of mhGAP is an integrated package of evidence-based guidelines for high-priority conditions globally, and particularly in LMICs.[9,10] In May 2013 the 66th World Health Assembly adopted WHO's Comprehensive Mental Health Action Plan 2013-2020.[11] The plan recognizes the crucial role of mental health in achieving health for all people, and indicates that strategies and interventions for mental health treatment, prevention, and promotion need to be based on scientific evidence or best practice. The following year, the 67th World Health Assembly adopted a resolution on access to essential medicines, which urged member states to improve national policies for the selection of essential medicines and to promote better medicine availability, affordability, quality, safety, and appropriate use.[12] In 2016 the UN Human Rights Council issued a resolution urging states to implement actions towards eliminating discrimination, stigma, prejudice, violence, social exclusion and segregation, unlawful or arbitrary institutionalization, overmedication and treatment practices in persons with mental health problems and psychological disabilities.[13]

Even though these intergovernmental initiatives have been successful in putting mental health on the public health agenda, the task is far from complete. Further action is required to translate these policy documents into evidence-based implementation activities. One challenging issue is that promotion, prevention, and treatment interventions, whether psychosocial or pharmacological, simple or complex, should have an accessible evidence base to provide effective tools for programme planners, policy-makers, healthcare professionals, and people with mental health problems.

The production of reliable, relevant, and accessible evidence is the main purpose of Cochrane, and Cochrane systematic reviews of primary research in health care and health policy, are internationally recognized as the highest standard in evidence-based healthcare resources. Goal 2 of Cochrane's Strategy to 2020 is "to make Cochrane evidence accessible and useful to everybody, everywhere in the world".[14]

To contribute to this goal, we have established Cochrane Global Mental Health (globalmentalhealth.cochrane.org), a new partnership that brings together the five Cochrane Review Groups that cover mental health conditions with WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, based at the University of Verona, Italy. The scope is three-fold: (1) to support the production of systematic reviews with a focus on questions specifically relevant to mental health in LMICs; (2) to support the dissemination, access, and use of systematic reviews in LMICs; and (3) to provide input and training on evidence synthesis and implementation activities relevant to mental health in LMICs. Cochrane Global Mental Health aims to develop a mutual learning approach and exchange attitude between mental health workers in different parts of the world, actively involving professionals working in LMICs in the network's scientific activities and prioritization work. The mission is to facilitate the sharing of knowledge and experiences to prioritize, produce, disseminate and implement systematic reviews for optimizing mental health promotion, prevention and treatment interventions everywhere.

An international advisory board of experts working in LMICs with in-depth expertise spanning the fields of mental health promotion, prevention, treatment, health systems and services research, and policy development will be established. The advisory board will provide Cochrane Global Mental Health with support in terms of knowledge, strategic thinking, guide in quality improvement, and overall vision.

Activities in this area should consider that substantial criticisms has been raised to the foundations and epistemology of global mental health.[15-18] One line of criticism is that global mental health is dominated by a Western biomedical model of psychiatry that pays little attention to local sociocultural factors. For most people living in LMICs mental health problems are framed in a context of poverty and humanitarian stressors, so promoting a biomedical understanding and treatment may keep a focus on the consequences rather than on the causes of such problems. A second line of criticism is the emphasis given to common mental health problems managed in primary care settings, leaving people with severe mental disorders, disorders related to drugs and alcohol use, dementia, or other disabilities at serious risk of human rights violations, with little access to evidence-based community and rehabilitative care. A third, more general criticism is that global mental health is not effectively and properly hearing the voices of non-Western cultures, and in particular those from the most vulnerable and marginalized. This may imply, for example, lack of attention to the potential role of traditional medicines or traditional healers as a vehicle for the provision of adequate care, or little consideration to the need of adapting 'global' recommendations to local preferences, values, and feasibility issues.

Cochrane Global Mental Health will take these critical points into serious consideration by following some guiding principles. First, we will take the pragmatic approach of focussing on the evidence base irrespective of the intervention type being considered, therefore including approaches that are culturally appropriate, such as traditional, complementary, and alternative medicine. Second, we will focus not only on interventions that fit with a biomedical approach, but also on interventions that fit with a public health approach. This means aggregating and disseminating the evidence on effective interventions for mental health conditions as well as on effective promotion and prevention strategies, simple or complex. As one of the main benefits of Cochrane Reviews is to highlight existing gaps in knowledge, if most evidence is for intervention rather than for promotion or prevention, we will use Cochrane Reviews to flag this. Third, people with severe mental disorders will be considered a priority, as recently highlighted by the WHO mhGAP, which considered psychosis, including schizophrenia and bipolar disorder, a priority condition.[10] Pragmatically, this means aggregating and disseminating the evidence on effective individual-level interventions as well as on system-level interventions, including hospital versus community care, which are key determinants of outcome in this group. Effective actions to reduce stigma, discrimination, and to value the human rights of people with severe mental disorders and disabilities will also be carefully considered.

We aim to report on Cochrane Global Mental Health activities during the first Global Evidence Summit (globalevidencesummit.org), organized in Cape Town, South Africa, in September 2017 by Cochrane, the Guidelines International Network, the Campbell Collaboration, the International Society for Evidence-Based Health Care, and the Joanna Briggs Institute.