MIT Global Health and Medical Humanities lecture by Pamela Collins

1. Minding the Baby in the Bathwater:
setting a research agenda
for global mental health
Pamela Y. Collins, MD, MPH
National Institute of Mental Health
February 27, 2015

2. HOW DO WE MAKE AN IMPACT?

3. National Institutes of Health (NIH) &
National Institute of Mental Health (NIMH)
• NIH is a part of the US Department of Health and Human
Services and is the nation’s medical research agency
• Leading supporter of medical research in the world
• NIMH is one of the 27 institutes & centers that make up the
National Institutes of Health (NIH)

4. Mission:
To transform the understanding and treatment
of mental illnesses through basic and clinical
research, paving the way for prevention,
recovery, and cure.
NIMH
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5. NIMH Offices and Divisions
• Office on AIDS
• Office of Autism Research Coordination
• Office of Constituency Relations and Public
Liaison
• Office of Genomics Research Coordination
• Office for Research on Disparities and Global
Mental Health
• Office of Resource Management
• Office of Rural Mental Health Research
• Office of Science Policy, Planning, and
Communications
• Office of Technology Development and
Coordination
• Division of Intramural Research
Programs
• Division of Neuroscience and Basic
Behavioral Science
• Division of Translational Research
Division of Services and Intervention
Research
• Division of AIDS Research
• Division of Extramural Activities
Office of the Director NIMH Divisions

6. ORDGMH & ORMHR
Admin
Workforce
Diversity
Equity &
Disparities
Global
Mental
Health
Women’s
Mental
Health
Rural
Mental
Health
REPORTING
& ANALYSIS
RESEARCH
CAPACITY BUILDING
OUTREACH & COLLABORATION
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7. Guided by NIMH Strategic Plan
• Strategic Objective 1: Define the Mechanisms of
Complex Behaviors
• Strategic Objective 2: Chart Mental Illness Trajectories
to Determine When, Where, and How to Intervene
• Strategic Objective 3: Strive for Prevention and Cures
• Strategic Objective 4: Strengthen the Public Health
Impact of NIMH-supported Research
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http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml

8. Adapting to a Changing
Ecosystem
• Increasing Public Health Burden
• BRAIN Initiative
• Changing Mental Health Care
Landscape
• Technology
• Comparative Effectiveness
• New Sources of Research Support
and Collaboration
• Citizen-centered Science
NIMH Strategic Plan
Adaptation to Change and Cross-cutting Themes
http://www.nimh.nih.gov/about/strategic-planning-reports/introduction.shtml#intro-sub1
Cross-cutting Research
Themes
• Transforming Diagnostics
• Accelerating Therapeutics
• Role of the Environment
• Digital Enterprise
• Preemptive Medicine
• Global Mental Health
• Mental Health Disparities
• Partnerships
• Investing in the Future

9. Outreach &
Collaboration: HHS
Resolution- WHO Executive Board
Resolution –
World Health Assembly
Comments on draft document
Regional consultation process
ACTION PLAN!
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10. Understanding the systems in which
we operate
Health financing
Health
workforce
Mental
health
services

11. Global mental health operates within
the global health system
Set an
agenda
Allocate
resources
Research
and
develop
new
ideas
Implement
& deliver
services
Monitor,
evaluate,
learn
Moon et al. PLoS Med 2010

12. HOW ARE WE DOING?
Vos et al, 2012

13. GLOBAL GAME CHANGERS
“HIV prevention and treatment scale-up during the first decade of the
21st century qualifies as a game changer that has irreversibly changed
perceptions of and approaches to global health.”
De Cock et al, 2011
Radical innovations that fundamentally
change how something is done, thought about, or
approached.

14. RESEARCH & INNOVATION….and more
• Rapid development and scale up of
innovations
– Rapid HIV tests
– Early infant diagnostic tests
• Willingness to change when new
evidence appears
– Incorporate new activities into
longstanding programs
– Quick and coordinated changing
of antiretroviral drug regimens
• Targeted funding, “unorthodox”
partnerships (CBOs, gov, civil society,
professional societies)
De Cock et al 2011

15. What determines whether a problem
achieves prominence on the agenda ?
• Transnational influences
– Norm promotion
– Resource provision
• Domestic advocacy
– Policy community cohesion
– Political entrepreneurship
– Credible indicators
– Focusing events
– Clear policy alternatives
• National political environment
– Political transitions
– Competing health priorities
Shiffman AJPH 2007

16. A few key factors
• The policy community and its portrayal of the
issue
– How credible and how salient are the messages?
• Problem and solution claims
– What can be done?
• What institutions can this community build?
– Critical to keeping the issue on the agenda
See Shiffman, WHO Bull 2009

17. “The rise, persistence and decline of a
global health issue may best be
explained by the way in which its
policy community – the network of
individuals and organizations
concerned with the problem – comes
to understand and portray the issue
and establishes institutions that can
sustain this portrayal.”
Shiffman 2009

18. Global mental health stakeholders
• People with mental illness
• Families affected by mental illness
• Researchers/academics
• Mental health professionals
• Professional associations
• Advocacy organizations
• Funders
• Policymakers

19. The central variable is the frame –the way an
issue is understood and portrayed.
Shiffman, 2009

20. Disabling Disorders of Youth
Vos et al, 2012
Percentage of years lived with a disability in 2010 by cause and age.
Male individuals Female individuals

21. Mental disorders are ubiquitous
Vos et al, 2012

22. Mortality and the Global Burden of
Mental Disorders
• People with mental disorders have a mortality rate that is 2.2
times higher than the general population
• All cause mortality was elevated for psychoses, mood
disorders, and anxiety
• All cause mortality for psychoses > anxiety, depression, and
bipolar d/o
• Median of 10 years of potential life lost from all causes
• 8 million deaths a year are attributable to mental disorders
Walker et al. JAMA Psychiatry, 2015

23. 4/14/2015 23

24. Millennium Development Goals and
mental health: a salient frame
GOAL 5:
REDUCE
MATERNAL
MORTALITY
Miranda & Patel, 2004
GOAL 4:
REDUCE
CHILD
MORTALITY
GOAL 6:
Combat
HIV/AIDS,
Malaria, and
other
Diseases

25. Problem claims: Costly disorders
“The global cost of mental health conditions in 2010 was estimated at US$ 2.5
trillion, with the cost projected to surge to US$ 6.0 trillion by 2030 .”
“Currently, high-income countries shoulder about 65% of the burden, which is
not expected to change over the next 20 years.”
World Economic Forum, 2011

26. Problem claims:
Poor mental health financing
Globally, spending on
mental health is less
than $2 per person, per
year and less than $0.25
in low income countries
Mental health
expenditures per capita
are more than 200 times
greater in high income
countries
compared with low
income countries
WHO Atlas, 2011

27. Finding solutions around the globe:
Task shifting/sharing for mental health
• Good examples in many low- and middle-income countries
– India – MANAS trial (Patel et al., 2010)
– Pakistan – Lady Health Workers ( Rahman et al, 2008)
– Uganda – Group IPT for depression (Bolton et al, 2003)
– Chile – Treating depression in primary care (Araya et al, 2003)

28. Institutions for Global Mental Health
• Movement for Global Mental Health
• Global Mental Health Journal
• World Federation for Mental Health
• World Psychiatric Association
• -Considerable variability in the “norms and
strategies” adopted by our institutions

30. Is Global Mental Health (GMH)
on the Agenda?
• Institutions
– GMH institutions are insufficient
• Ideas
– Difficult to develop and promote a common construct
– Lack a widely accepted framework for classification,
course, treatment of disorders
– No distinction between internal and external debates
Tomlinson & Lund 2012

31. Is Global Mental Health on the
Agenda?
• Context
– Can we take advantage of key opportunities to
influence decision makers?
• Framing our problem
– Do we have credible indicators?
– How can we better demonstrate salience?
Tomlinson & Lund, 2012

32. What is the role of research?
--Creating transnational norms
--Credible solutions for national health systems
--Building the evidence for salience

35. Grand Challenges
in Chronic Non-communicable Diseases
Daar et al, 2007

36. NIMH-GACD Collaboration
• NIMH joined the Global Alliance for Chronic Disease in
November 2009
• The Alliance is a community of the world’s largest health
research funding agencies organized to collaborate in the
battle against chronic non-communicable diseases
• Mental health is on the agenda
• NIMH is leading the Grand Challenges in Global Mental
Health initiative

37. • Global Scope
• Use of the Delphi process
• Covers the full range of mental, neurological,
and substance use disorders
• Aims to build a community of global mental
health research funders
What’s new in the Grand Challenges?
Goodman, 1987

38. • Establish leadership structures
• Nomination of Delphi Panel
• 3 Delphi Rounds
• Leadership meeting
• Preparation and publishing of report
Overview of Procedures

39. • Three discrete leadership bodies are
responsible for the stewardship of the
initiative
• Executive Committee
• Scientific Advisory Board
• Administrative Board
GCGMH Leadership

40. Grand Challenges in Global Mental Health
7 JULY 2011 | VOL 475 | NATURE

41. Grand Challenge Goals
• Goal A: Identify root causes, risk, and protective factors
• Goal B: Advance prevention and implementation of early
interventions
• Goal C: Improve treatments and expand access to care
• Goal D: Raise awareness of the global burden
• Goal E: Build human resource capacity
• Goal F: Transform health system and policy responses

42. Credible solutions for national health systems

43. Goal: Research directions to reduce the
treatment gap in low- and middle-
income countries

44. Addressing the Gaps
Questions
– What research is needed
to reduce the treatment
gap?
– Which stakeholders
need to interact to
produce service-relevant
research? Scale up?
Participants
NGOs providing
Services
Mental Health
Policymakers
Implementation
researchers

45. COLLABORTIVE HUBS FOR INTERNATIONAL RESEARCH ON MENTAL
HEALTH (U19)
-Research component on task-shifting
-Research capacity-building for the region
-True collaborative partnerships with end-users

46. AFFIRM hub
South Africa*, Ethiopia, Ghana,
Malawi, Uganda, Zimbabwe
SHARE hub
India*, Pakistan, Afghanistan,
Bangladesh, Nepal, Sri Lanka
LATIN-MH hub
Brazil*, Peru, Colombia, Ecuador
Guatemala
Pam-D hub
Nigeria*, South Africa,
Kenya, Ghana, Liberia,
Collaborative Hubs for International Research on Mental Health
RedeAmericas hub
Chile*, Brazil, Argentina, Colombia, USA

47. RedeAmericas
• Improving the health of people
with psychosis
• Research mentoring for young
investigators
• Critical Time Intervention – Task-
Shifting
• Peer mentors assist people new
to treatment with links to health
care and community resources
www.nimh.nih.gov

48. South Asian Hub for Advocacy, Research &
Education (SHARE) on Mental Health
• Mental health of mothers
with depression
• Research capacity-building
• Thinking Healthy Program –
Peer Delivery
• Delivery by peers – lay
people with no formal
health training background
www.nimh.nih.gov

49. Africa Focus on Intervention Research
for Mental Health (AFFIRM)
• Maternal depression in South
Africa
• Community care for
schizophrenia in Ethiopia
• Short courses, Master’s program
• Task-shifting to community
health workers/primary health
workers
http://www.nimh.nih.gov/about/organization/od/globalhubs/africa-focus-on-intervention-
research-for-mental-health-affirm.shtml; http://www.affirm.uct.ac.za/

50. Partnership for Mental Health Development
in sub-Saharan Africa (PAM-D)
• Expanding service for
people with psychosis
• Research capacity-
building through targeted
training and mentoring
• Exploring complementary
and alternative providers
http://www.nimh.nih.gov/about/organization/od/globalhubs/
partnership-for-mental-health-
development-in-sub-saharan-africa-pam-d.shtml

51. Latin America Treatment and Innovation
Network in Mental Health (LATIN-MH)
• Research capacity-building
• Managing co-morbid
depression and hypertension or
diabetes
• Low-intensity psycho-
educational intervention
delivered via smartphones
http://www.nimh.nih.gov/about/organization/gmh/globalhubs/
latin-america-treatment-amp-innovation-network-in-mental-health-latin-mh.shtml

52. Building Salience
The Grand Challenge of Integration

53. Mental health and HIV
• Increasing attention to
integrated care
• Transnational norms
• Little evidence base on
how to integrate care
outside of high-income
countries

54. Integrating mental health:
a Grand Challenge
• Healthy Options: Group psychotherapy for
HIV+ depressed perinatal women – Tanzania
• Integrated care for co-morbid diabetes and
depression in India
• The depression hypertension COACH study –
China
• Integrating depression care for acute coronary
syndrome patients in low resource hospitals
in China
• COBALT: Co-morbid Affective disorders,
HIV/AIDS and Long-term Health – South Africa
• Improving mental health through integration
with primary care in rural Karnataka - India
PLoS Medicine series 2013

55. What’s next?
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