Publications by authors named "Shekhar Saxena"

165 Publications

An integrated community and primary healthcare worker intervention to reduce stigma and improve management of common mental disorders in rural India: protocol for the SMART Mental Health programme.

Trials 2021 Mar 2;22(1):179. Epub 2021 Mar 2.

The George Institute for Global Health, University of New South Wales, Sydney, Australia.

Background: Around 1 in 7 people in India are impacted by mental illness. The treatment gap for people with mental disorders is as high as 75-95%. Health care systems, especially in rural regions in India, face substantial challenges to address these gaps in care, and innovative strategies are needed.

Methods: We hypothesise that an intervention involving an anti-stigma campaign and a mobile-technology-based electronic decision support system will result in reduced stigma and improved mental health for adults at high risk of common mental disorders. It will be implemented as a parallel-group cluster randomised, controlled trial in 44 primary health centre clusters servicing 133 villages in rural Andhra Pradesh and Haryana. Adults aged ≥ 18 years will be screened for depression, anxiety and suicide based on Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorders (GAD-7) scores. Two evaluation cohorts will be derived-a high-risk cohort with elevated PHQ-9, GAD-7 or suicide risk and a non-high-risk cohort comprising an equal number of people not at elevated risk based on these scores. Outcome analyses will be conducted blinded to intervention allocation.

Expected Outcomes: The primary study outcome is the difference in mean behaviour scores at 12 months in the combined 'high-risk' and 'non-high-risk' cohort and the mean difference in PHQ-9 scores at 12 months in the 'high-risk' cohort. Secondary outcomes include depression and anxiety remission rates in the high-risk cohort at 6 and 12 months, the proportion of high-risk individuals who have visited a doctor at least once in the previous 12 months, and change from baseline in mean stigma, mental health knowledge and attitude scores in the combined non-high-risk and high-risk cohort. Trial outcomes will be accompanied by detailed economic and process evaluations.

Significance: The findings are likely to inform policy on a low-cost scalable solution to destigmatise common mental disorders and reduce the treatment gap for under-served populations in low-and middle-income country settings.

Trial Registration: Clinical Trial Registry India CTRI/2018/08/015355 . Registered on 16 August 2018.
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http://dx.doi.org/10.1186/s13063-021-05136-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923507PMC
March 2021

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health.

Lancet Psychiatry 2021 Feb 24. Epub 2021 Feb 24.

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Wellcome-DBT India Alliance, Sangath, New Delhi, India.

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.
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http://dx.doi.org/10.1016/S2215-0366(21)00025-0DOI Listing
February 2021

Editorial: Strengthening Child and Adolescent Mental Health (CAMH) Services and Systems in Lower-and-Middle-Income Countries (LMICs).

Front Psychiatry 2021 5;12:645073. Epub 2021 Feb 5.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Cambridge, MA, United States.

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http://dx.doi.org/10.3389/fpsyt.2021.645073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901940PMC
February 2021

Depression and Viral Suppression Among Adults Living with HIV in Tanzania.

AIDS Behav 2021 Feb 17. Epub 2021 Feb 17.

Department of Global Health and Population, Harvard T H Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA.

Limited information is available on the association between depression and viral suppression among people living with HIV (PLH) in sub-Saharan Africa. We conducted a prospective cohort study of 3996 adults initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania. Log-binomial models were used to assess the association between depression and the risk of an unsuppressed viral load (> 400 copies/mL) after 6 months of ART. Women who had depression at both initiation and after 6 months of treatment had 1.94 times (95% CI 1.22, 3.09; z = 2.78, p < 0.01) the risk of an unsuppressed viral load after 6 months of treatment as compared to women who did not have depression at either time point. Men with the top tertile of depressive symptoms after 6 months of treatment had 1.58 times the risk of an unsuppressed viral load (95% CI 1.04, 2.38; z = 2.15, p = 0.03) as compared to the lowest tertile. Research should be pursued on interventions to prevent and address depression among adults initiating ART to potentially support achievement of viral suppression.
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http://dx.doi.org/10.1007/s10461-021-03187-yDOI Listing
February 2021

Mental Health Consequences for Healthcare Workers During the COVID-19 Pandemic: A Scoping Review to Draw Lessons for LMICs.

Front Psychiatry 2021 27;12:602614. Epub 2021 Jan 27.

Department of Global Health, University of Washington, Seattle, WA, United States.

The COVID-19 pandemic has had a significant impact on the mental health of healthcare workers (HCWs) particularly in low and middle-income countries (LMICs). This scoping review provides a summary of current evidence on the mental health consequences of COVID on HCWs. A scoping review was conducted searching PubMed and Embase for articles relevant to mental health conditions among HCWs during COVID-19. Relevant articles were screened and extracted to summarize key outcomes and findings. A total of fifty-one studies were included in this review. Depressive symptoms, anxiety symptoms, psychological trauma, insomnia and sleep quality, workplace burnout and fatigue, and distress were the main outcomes reviewed. Most studies found a high number of symptoms endorsed for depression, anxiety, and other conditions. We found differences in symptoms by sex, age, and HCW role, with female, younger-aged, frontline workers, and non-physician workers being affected more than other subgroups. This review highlights the existing burden of mental health conditions reported by HCWs during COVID-19. It also demonstrates emerging disparities among affected HCW subgroups. This scoping review emphasizes the importance of generating high quality evidence and developing informed interventions for HCW mental health with a focus on LMICs.
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http://dx.doi.org/10.3389/fpsyt.2021.602614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873361PMC
January 2021

Mental Distress and Human Rights Violations During COVID-19: A Rapid Review of the Evidence Informing Rights, Mental Health Needs, and Public Policy Around Vulnerable Populations.

Front Psychiatry 2020 8;11:603875. Epub 2021 Jan 8.

University of Washington, Seattle, WA, United States.

COVID-19 prevention and mitigation efforts were abrupt and challenging for most countries with the protracted lockdown straining socioeconomic activities. Marginalized groups and individuals are particularly vulnerable to adverse effects of the pandemic such as human rights abuses and violations which can lead to psychological distress. In this review, we focus on mental distress and disturbances that have emanated due to human rights restrictions and violations amidst the pandemic. We underscore how mental health is both directly impacted by the force of pandemic and by prevention and mitigation structures put in place to combat the disease. We conducted a review of relevant studies examining human rights violations in COVID-19 response, with a focus on vulnerable populations, and its association with mental health and psychological well-being. We searched PubMed and Embase databases for studies between December 2019 to July 2020. Three reviewers evaluated the eligibility criteria and extracted data. Twenty-four studies were included in the systematic inquiry reporting on distress due to human rights violations. Unanimously, the studies found vulnerable populations to be at a high risk for mental distress. Limited mobility rights disproportionately harmed psychiatric patients, low-income individuals, and minorities who were at higher risk for self-harm and worsening mental health. Healthcare workers suffered negative mental health consequences due to stigma and lack of personal protective equipment and stigma. Other vulnerable groups such as the elderly, children, and refugees also experienced negative consequences. This review emphasizes the need to uphold human rights and address long term mental health needs of populations that have suffered disproportionately during the pandemic. Countries can embed a proactive psychosocial response to medical management as well as in existing prevention strategies. International human rights guidelines are useful in this direction but an emphasis should be placed on strengthening rights informed psychosocial response with specific strategies to enhance mental health in the long-term. We underscore that various fundamental human rights are interdependent and therefore undermining one leads to a poor impact on the others. We strongly recommend global efforts toward focusing both on minimizing fatalities, protecting human rights, and promoting long term mental well-being.
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http://dx.doi.org/10.3389/fpsyt.2020.603875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7820171PMC
January 2021

The Lancet Public Health Commission on gambling.

Lancet Public Health 2021 01;6(1):e2-e3

Harvard University, Cambridge, MA, USA.

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http://dx.doi.org/10.1016/S2468-2667(20)30289-9DOI Listing
January 2021

From adversity to resilience in the COVID-19 era: strengthening mental health systems in the Eastern Mediterranean Region.

East Mediterr Health J 2020 Oct 13;26(10):1148-1150. Epub 2020 Oct 13.

Regional Advisor for Mental Health and Substance Use, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

The global COVID-19 pandemic has demonstrated the impact of a major public health emergency on mental health, and the ways that individuals, communities, professionals and systems can react positively to such a crisis. The Eastern Mediterranean Region (EMR) has substantial experience in mental health and psychosocial support (MHPSS) in crises, and COVID-19 has driven further innovation to support mental health and well-being.

Global and regional guidance has been developed quickly, applying lessons learnt from previous disease outbreaks to respond to the pandemic at a systems level, for different population groups, and for countries of different income levels. Preliminary results from a global rapid assessment survey to assess the impact of COVID-19 on MHPSS services, indicate that 20 of the 22 EMR Member States have MHPSS as integral components of national COVID-19 response plans; one-third have allocated additional funding. However, MHPSS services have been severely impacted by the pandemic, including psychotherapy, psychosocial interventions, community services, and services for children/adolescents. Innovative solutions such as crisis hotlines, tele-consultations, digital self-help platforms, novel approaches to ensure supply of psychotropic medicines, and task sharing/shifting for basic psychosocial support, are being used in many countries to overcome service disruptions and maintain care for those with mental conditions.
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http://dx.doi.org/10.26719/2020.26.10.1148DOI Listing
October 2020

The Swiss Prison Study (SWIPS): Protocol for Establishing a Public Health Registry of Prisoners in Switzerland.

JMIR Res Protoc 2020 Dec 8;9(12):e23973. Epub 2020 Dec 8.

Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, United States.

Background: The health aspects, disease frequencies, and specific health interests of prisoners and refugees are poorly understood. Importantly, access to the health care system is limited for this vulnerable population. There has been no systematic investigation to understand the health issues of inmates in Switzerland. Furthermore, little is known on how recent migration flows in Europe may have affected the health conditions of inmates.

Objective: The Swiss Prison Study (SWIPS) is a large-scale observational study with the aim of establishing a public health registry in northern-central Switzerland. The primary objective is to establish a central database to assess disease prevalence (ie, International Classification of Diseases-10 codes [German modification]) among prisoners. The secondary objectives include the following: (1) to compare the 2015 versus 2020 disease prevalence among inmates against a representative sample from the local resident population, (2) to assess longitudinal changes in disease prevalence from 2015 to 2020 by using cross-sectional medical records from all inmates at the Police Prison Zurich, Switzerland, and (3) to identify unrecognized health problems to prepare successful public health strategies.

Methods: Demographic and health-related data such as age, sex, country of origin, duration of imprisonment, medication (including the drug name, brand, dosage, and release), and medical history (including the International Classification of Diseases-10 codes [German modification] for all diagnoses and external results that are part of the medical history in the prison) have been deposited in a central register over a span of 5 years (January 2015 to August 2020). The final cohort is expected to comprise approximately 50,000 to 60,000 prisoners from the Police Prison Zurich, Switzerland.

Results: This study was approved on August 5, 2019 by the ethical committee of the Canton of Zurich with the registration code KEK-ZH No. 2019-01055 and funded in August 2020 by the "Walter and Gertrud Siegenthaler" foundation and the "Theodor and Ida Herzog-Egli" foundation. This study is registered with the International Standard Randomized Controlled Trial Number registry. Data collection started in August 2019 and results are expected to be published in 2021. Findings will be disseminated through scientific papers as well as presentations and public events.

Conclusions: This study will construct a valuable database of information regarding the health of inmates and refugees in Swiss prisons and will act as groundwork for future interventions in this vulnerable population.

Trial Registration: ISRCTN registry ISRCTN11714665; http://www.isrctn.com/ISRCTN11714665.

International Registered Report Identifier (irrid): DERR1-10.2196/23973.
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http://dx.doi.org/10.2196/23973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755536PMC
December 2020

Implementing combined WHO mhGAP and adapted group interpersonal psychotherapy to address depression and mental health needs of pregnant adolescents in Kenyan primary health care settings (INSPIRE): a study protocol for pilot feasibility trial of the integrated intervention in LMIC settings.

Pilot Feasibility Stud 2020 22;6:136. Epub 2020 Sep 22.

George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, USA.

Background: Addressing adolescent pregnancies associated health burden demands new ways of organizing maternal and child mental health services to meet multiple needs of this group. There is a need to strengthen integration of sustainable evidence-based mental health interventions in primary health care settings for pregnant adolescents. The proposed study is guided by implementation science frameworks with key objective of implementing a pilot trial testing a full IPT-G version along with IPT-G mini version under the mhGAP/IPT-G service framework and to study feasibility of the integrated mhGAP/IPT-G adolescent peripartum depression care delivery model and estimate if a low cost and compressed version of IPT-G intervention would result in similar size of effect on mental health and family functioning as the Full IPT-G. There are two sub- studies embedded which are: 1) To identify multi-level system implementation barriers and strategies guided by the Consolidated Framework for Implementation Research (CFIR) to enhance perinatal mhGAP-depression care and evidence-based intervention integration (i.e., group interpersonal psychotherapy; IPT-G) for pregnant adolescents in primary care contexts; 2) To use findings from aim 1 and observational data from Maternal and Child Health (MCH) clinics that run within primary health care facilities to develop a mental health implementation workflow plan that has buy-in from key stakeholders, as well as to develop a modified protocol and implementation training manual for building health facility staff's capacity in implementing the integrated mhGAP/IPT-G depression care.

Methods: For the primary objective of studying feasibility of the integrated mhGAP/IPT-G depression care in MCH service context for adolescent perinatal depression, we will recruit 90 pregnant adolescents to a three-arm pilot intervention (unmasked) trial study (IPT-G Full, IPT-G Mini, and wait-list control in the context of mhGAP care). Pregnant adolescents ages 13-18, in their 1st-2nd trimester with a depression score of 13 and above on EPDS would be recruited. Proctor's implementation evaluation model will be used. Feasibility and acceptability of the intervention implementation and size of effects on mental health and family functioning will be estimated using mixed method data collection from caregivers of adolescents, adolescents, and health care providers. In the two sub-studies, stakeholders representing diverse perspectives will be recruited and focus group discussions data will be gathered. For aim 2, to build capacity for mhGAP-approach of adolescent depression care and research, the implementation-capacity training manual will be applied to train 20 providers, 12 IPT-G implementers/health workers and 16 Kenyan researchers. Acceptability and appropriateness of the training approach will be assessed. Additional feedback related to co-located service delivery model, task-shifting and task-sharing approach of IPT-G delivery will be gathered for further manual improvement.

Discussion: This intervention and service design are in line with policy priority of Government of Kenya, Kenya Vision 2030, World Health Organization, and UN Sustainable Development Goals that focus on improving capacity of mental health service systems to reduce maternal, child, adolescent health and mental health disparities in LMICs. Successfully carrying out this study in Kenya will provide an evidence-based intervention service development and implementation model for adolescents in other Sub-Saharan African (SSA) countries. The study is funded by FIC/NIH under K43 grant.
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http://dx.doi.org/10.1186/s40814-020-00652-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507720PMC
September 2020

Relevant Question but Precious Little Data to Answer It.

Authors:
Shekhar Saxena

Psychiatr Serv 2020 09;71(9):969-970

Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Cambridge, Massachusetts.

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http://dx.doi.org/10.1176/appi.ps.202000162DOI Listing
September 2020

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence.

Br J Psychiatry 2020 Aug 27:1-11. Epub 2020 Aug 27.

Professor of Psychiatry, Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.

Background: Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services.

Aims: To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3.

Method: Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach.

Results: A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62-0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60-0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46-0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates.

Conclusions: Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.
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http://dx.doi.org/10.1192/bjp.2020.144DOI Listing
August 2020

Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic.

Int J Ment Health Syst 2020 29;14:57. Epub 2020 Jul 29.

Global Health and Population Harvard T H Chan School of Public Health, Boston, USA.

Background: The COVID pandemic has been devastating for not only its direct impact on lives, physical health, socio-economic status of individuals, but also for its impact on mental health. Some individuals are affected psychologically more severely and will need additional care. However, the current health system is so fragmented and focused on caring for those infected that management of mental illness has been neglected. An integrated approach is needed to strengthen the health system, service providers and research to not only manage the current mental health problems related to COVID but develop robust strategies to overcome more long-term impact of the pandemic. A series of recommendations are outlined in this paper to help policy makers, service providers and other stakeholders, and research and research funders to strengthen existing mental health systems, develop new ones, and at the same time advance research to mitigate the mental health impact of COVID19. The recommendations refer to low, middle and high resource settings as capabilities vary greatly between countries and within countries.

Discussion: The recommendations for policy makers are focused on strengthening leadership and governance, finance mechanisms, and developing programme and policies that especially include the most vulnerable populations. Service provision should focus on accessible and equitable evidence-based community care models commensurate with the existing mental health capacity to deliver care, train existing primary care staff to cater to increased mental health needs, implement prevention and promotion programmes tailored to local needs, and support civil societies and employers to address the increased burden of mental illness. Researchers and research funders should focus on research to develop robust information systems that can be enhanced further by linking with other data sources to run predictive models using artificial intelligence, understand neurobiological mechanisms and community-based interventions to address the pandemic driven mental health problems in an integrated manner and use innovative digital solutions.

Conclusion: Urgent action is needed to strengthen mental health system in all settings. The recommendations outlined can be used as a guide to develop these further or identify new ones in relation to local needs.
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http://dx.doi.org/10.1186/s13033-020-00393-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7389161PMC
July 2020

Mental Health of Communities during the COVID-19 Pandemic.

Can J Psychiatry 2020 10 11;65(10):681-687. Epub 2020 May 11.

Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1177/0706743720926676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502878PMC
October 2020

How service users and carers understand, perceive, rephrase, and communicate about "depressive episode" and "schizophrenia" diagnoses: an international participatory research.

Soc Psychiatry Psychiatr Epidemiol 2020 Sep 22;55(9):1201-1213. Epub 2020 Feb 22.

EPSM Lille-Métropole, French WHO CC, Armentières, France.

Background: For ICD-11, the WHO emphasized the clinical utility of communication and the need to involve service users and carers in the revision process.

Aims: The objective was to assess whether medical vocabulary was accessible, which kinds of feelings it activated, whether and how users and carers would like to rephrase terms, and whether they used diagnosis to talk about mental health experiences.

Method: An innovative protocol focused on two diagnoses (depressive episode and schizophrenia) was implemented in 15 different countries. The same issues were discussed with users and carers: understanding, feelings, rephrasing, and communication.

Results: Most participants reported understanding the diagnoses, but associated them with negative feelings. While the negativity of "depressive episode" mostly came from the concept itself, that of "schizophrenia" was largely based on its social impact and stigmatization associated with "mental illness". When rephrasing "depressive episode", a majority kept the root "depress*", and suppressed the temporal dimension or renamed it. Almost no one suggested a reformulation based on "schizophrenia". Finally, when communicating, no one used the phrase "depressive episode". Some participants used words based on "depress", but no one mentioned "episode". Very few used "schizophrenia".

Conclusion: Data revealed a gap between concepts and emotional and cognitive experiences. Both professional and experiential language and knowledge have to be considered as complementary. Consequently, the ICD should be co-constructed by professionals, service users, and carers. It should take the emotional component of language, and the diversity of linguistic and cultural contexts, into account.
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http://dx.doi.org/10.1007/s00127-020-01836-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471108PMC
September 2020

An end to coercion: rights and decision-making in mental health care.

Bull World Health Organ 2020 Jan 17;98(1):52-58. Epub 2019 Oct 17.

Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, Massachusetts, MA02115, USA.

The requires a paradigm shift from a medical model of disability to a social model that emphasizes overcoming the barriers to equality created by attitudes, laws, government policies and the social, economic and political environment. The approach adopted by the social model recognizes that people with psychosocial disabilities have the same right to take decisions and make choices as other people, particularly regarding treatment, and have the right to equal recognition before the law. Consequently, direct or supported decision-making should be the norm and there should be no substitute decision-making. Although recent mental health laws in some countries have attempted to realize a rights-based approach to decision-making by reducing coercion, implementing the can be challenging because it requires continuous refinement and the development of alternatives to coercion. This article reviews the impact historical trends and current mental health frameworks have had on the rights affected by the practice of involuntary treatment and describes some legal and organizational initiatives that have been undertaken to promote noncoercive services and supported decision-making. The evidence and examples presented could provide the foundation for developing a context-appropriate approach to implementing supported decision-making in mental health care.
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http://dx.doi.org/10.2471/BLT.19.234906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933425PMC
January 2020

Achieving universal health coverage for mental disorders.

BMJ 2019 Sep 23;366:l4516. Epub 2019 Sep 23.

Harvard TH Chan School of Public Health, USA.

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http://dx.doi.org/10.1136/bmj.l4516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6753845PMC
September 2019

An Evolutionary Bootstrapping Development Approach for a Mental Health Conversational Agent.

Stud Health Technol Inform 2019 Jul;262:228-231

Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, United States of America.

Conversational agents are being used to help in the screening, assessment, diagnosis, and treatment of common mental health disorders. In this paper, we propose a bootstrapping approach for the development of a digital mental health conversational agent (i.e., chatbot). We start from a basic rule-based expert system and iteratively move towards a more sophisticated platform composed of specialized chatbots each aiming to assess and pre-diagnose a specific mental health disorder using machine learning and natural language processing techniques. During each iteration, user feedback from psychiatrists and patients are incorporated into the iterative design process. A survival of the fittest approach is also used to assess the continuation or removal of a specialized mental health chatbot in each generational design. We anticipate that our unique and novel approach can be used for the development of conversational mental health agents with the ultimate goal of designing a smart chatbot that delivers evidence-based care and contributes to scaling up services while decreasing the pressure on mental health care providers.
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http://dx.doi.org/10.3233/SHTI190060DOI Listing
July 2019

Developing a Digital Mental Health Platform for the Arab World: From Research to Action.

Stud Health Technol Inform 2019 Jul;262:392-395

Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, United States of America.

Individuals within the Arab world rarely access mental health services. One of the major reasons for this relates to the stigma associated with mental disorders. According to the World Health Organization (WHO), untreated and undiagnosed individuals living with moderate to severe mental health disorders are more likely to die 10-20 years earlier than the estimated life expectancy of the general population. Mental disorders also cause a large amount of costs to economies. Access to mental health services is out of reach for many individuals within in the Arab world due to insufficient planning, inadequate community resources, and military conflicts. Online mental health information and services are growing within the region; however, they are embedded and often sidelined within a wealth of other general health information. The purpose of this paper is to present the conceptual framework of the Mental Health Assistant (MeHA) digital platform being developed for the Arab world. The aim of this platform is to provide mental health information and educational resources through the use of a conversational agent, multi-media information, and to digitally connect patients with mental health service providers. The conceptual framework for the platform is based on mental health and information technology expert feedback, review of both academic and gray literature on mental health, and an examination of leading mental health digital platforms. As a result of this process, we developed a conceptual framework that will guide the development of the MeHA platform.
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http://dx.doi.org/10.3233/SHTI190101DOI Listing
July 2019

Global mental health - Authors' reply.

Lancet 2019 07 19;394(10193):119. Epub 2019 Jun 19.

Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.

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http://dx.doi.org/10.1016/S0140-6736(19)31108-0DOI Listing
July 2019

New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis.

Lancet 2019 07 12;394(10194):240-248. Epub 2019 Jun 12.

T H Chan School of Public Health, Harvard University, Boston, MA, USA.

Background: Existing WHO estimates of the prevalence of mental disorders in emergency settings are more than a decade old and do not reflect modern methods to gather existing data and derive estimates. We sought to update WHO estimates for the prevalence of mental disorders in conflict-affected settings and calculate the burden per 1000 population.

Methods: In this systematic review and meta-analysis, we updated a previous systematic review by searching MEDLINE (PubMed), PsycINFO, and Embase for studies published between Jan 1, 2000, and Aug 9, 2017, on the prevalence of depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder, and schizophrenia. We also searched the grey literature, such as government reports, conference proceedings, and dissertations, to source additional data, and we searched datasets from existing literature reviews of the global prevalence of depression and anxiety and reference lists from the studies that were identified. We applied the Guidelines for Accurate and Transparent Health Estimates Reporting and used Bayesian meta-regression techniques that adjust for predictors of mental disorders to calculate new point prevalence estimates with 95% uncertainty intervals (UIs) in settings that had experienced conflict less than 10 years previously.

Findings: We estimated that the prevalence of mental disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia) was 22·1% (95% UI 18·8-25·7) at any point in time in the conflict-affected populations assessed. The mean comorbidity-adjusted, age-standardised point prevalence was 13·0% (95% UI 10·3-16·2) for mild forms of depression, anxiety, and post-traumatic stress disorder and 4·0% (95% UI 2·9-5·5) for moderate forms. The mean comorbidity-adjusted, age-standardised point prevalence for severe disorders (schizophrenia, bipolar disorder, severe depression, severe anxiety, and severe post-traumatic stress disorder) was 5·1% (95% UI 4·0-6·5). As only two studies provided epidemiological data for psychosis in conflict-affected populations, existing Global Burden of Disease Study estimates for schizophrenia and bipolar disorder were applied in these estimates for conflict-affected populations.

Interpretation: The burden of mental disorders is high in conflict-affected populations. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden.

Funding: WHO; Queensland Department of Health, Australia; and Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S0140-6736(19)30934-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657025PMC
July 2019

Addressing the opioid crisis globally.

World Psychiatry 2019 Jun;18(2):231-232

Drug Prevention and Health Branch, United Nations Office on Drugs and Crime, Vienna, Austria.

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http://dx.doi.org/10.1002/wps.20633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502427PMC
June 2019

Countdown Global Mental Health 2030.

Lancet 2019 03 21;393(10174):858-859. Epub 2019 Feb 21.

Office of the Deputy Director-General for Programmes, World Health Organization, Geneva, Switzerland.

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http://dx.doi.org/10.1016/S0140-6736(19)30424-6DOI Listing
March 2019

A partnership for transforming mental health globally.

Lancet Psychiatry 2019 04 29;6(4):350-356. Epub 2019 Jan 29.

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.

The large and increasing burden of mental and substance use disorders, its association with social disadvantage and decreased economic output, and the substantial treatment gaps across country-income levels, are propelling mental health into the global spotlight. The inclusion of targets related to mental health and wellbeing in the UN's Sustainable Development Goals, as well as several national and global initiatives that formed during the past 5 years, signal an increasing momentum toward providing appropriate financing for global mental health. Drawing on the organisational and financial architecture of two successful global health scale-up efforts (the fight against HIV/AIDS and the improvement of maternal and child health) and the organisational models that have emerged to finance these and other global health initiatives, we propose a multi-sectoral and multi-organisational Partnership for Global Mental Health to serve two main functions. First is the mobilisation of funds, including raising, pooling, disbursing, and allocating. Second is stewardship, including supporting countries to use funds effectively, evaluate results, and hold stakeholders accountable. Such a partnership would necessarily involve stakeholders from the mental health field, civil society, donors, development agencies, and country-level stakeholders, organised into hubs responsible for financing, scale-up, and accountability.
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http://dx.doi.org/10.1016/S2215-0366(18)30434-6DOI Listing
April 2019

Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders.

World Psychiatry 2019 Feb;18(1):3-19

Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.
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http://dx.doi.org/10.1002/wps.20611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6313247PMC
February 2019

Rights-based mental health care.

Lancet Psychiatry 2019 01;6(1):9-10

Harvard T H Chan School of Public Health, Boston, MA, USA.

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http://dx.doi.org/10.1016/S2215-0366(18)30469-3DOI Listing
January 2019

Disparity between burden and budget for mental health.

Authors:
Shekhar Saxena

Lancet Public Health 2019 02 14;4(2):e75-e76. Epub 2018 Nov 14.

Harvard T H Chan School of Public Health, Boston, MA 02115, USA. Electronic address:

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http://dx.doi.org/10.1016/S2468-2667(18)30238-XDOI Listing
February 2019

New data to support much needed policy change.

Authors:
Shekhar Saxena

Lancet Psychiatry 2018 12 1;5(12):947-948. Epub 2018 Nov 1.

Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA. Electronic address:

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http://dx.doi.org/10.1016/S2215-0366(18)30390-0DOI Listing
December 2018

Global mental health: how are we doing?

World Psychiatry 2018 Oct;17(3):367-368

Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.

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http://dx.doi.org/10.1002/wps.20572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6127814PMC
October 2018