Summary of the impact

Research carried out by LSHTM into mental disorders in low- and middle-income countries has promoted new approaches to mental health care and influenced donors, practitioners and policy-makers, contributing to changing global priorities in this area. WHO launched a flagship action plan based on the research, governments and NGOs made substantial financial allocations for implementing the research innovations, and the findings have been translated into treatment guidelines used to train health workers in managing mental illness in many countries.

Underpinning research

Mental health problems make a substantial contribution to the global burden of disease. In low-and middle-income countries, more than 20% of all disability related to health conditions is caused by mental health problems. It is on these pressing issues that Professor Vikram Patel, who joined the LSHTM in 2000 (then Senior Lecturer), has focused his research. The research was carried out between 2000 and 2012 in collaboration with many LSHTM colleagues who have mental health expertise, and especially Alex Cohen (LSHTM from 2008 as Senior Lecturer), Mary De Silva (LSHTM from 2005, then Research Fellow, now Senior Lecturer) and Professor Betty Kirkwood (LSHTM from 1979, then Lecturer). Since 2009, they have been functioning under the umbrella of the Centre for Global Mental Health (CGMH) in partnership with King's College London.

The research fell into three areas:

• Evidence of the burden of mental health problems in low- and middle-income countries. Projects included the first systematic review of the burden of, and cost effective treatments for, mental disorders (along with other noncommunicable diseases — NCDs)^3.1 and the first nationally representative survey of suicide mortality in India in 2010.^3.2 Other research included population-based surveys carried out in 60 countries in 2006, examining the association of depression with other chronic conditions; identification of close association of mental health issues with maternal and child health and chronic physical health conditions (e.g. a cohort study demonstrating the impact of maternal depression on infant growth in India 1998-2000); and examination of the vicious cycle of disadvantage, social exclusion and mental health problems (e.g. a study of young women in five Indian states, 2002-2003).
• Demonstrating that evidence-based treatments can be delivered in low-resource settings by non-specialist health care workers.^3.3 Research projects included the Manas cluster randomised controlled trial, the largest trial in psychiatry in the developing world, in India (2007-2009),^3.4 which tested the effectiveness of an intervention led by lay health counsellors for people with depression and anxiety disorders, and the first trial for supporting caregivers of people with dementia in the developing world, also in India (2003).
• Demonstrating the great paucity and inequitable distribution of global mental health research resources and outputs (e.g. via a survey of researchers from 52 countries in the developing world, 2004-2005). This led to efforts to set the priority agenda for mental health research, policy and practice in the global context (e.g. through a global Delphi priority-setting research initiative involving 422 mental health stakeholders around the world, 2010-2011).^3.5 This body of evidence also formed the basis of a pivotal six-article Lancet series and a call to action led by Patel on global mental health.^3.6 Its publication was a key event in the emerging field of global mental health and was followed by several other high-profile series, including two in PLoS Medicine (2009, 2012) and another in The Lancet (2011), both led by Patel.

References to the research

Key grants

• Patel, A Community Cohort Study of the Relationship Between Gynaecological Morbidity and Common Mental Disorders in Goa, India, Wellcome Trust Career Development Fellowship in Clinical Tropical Medicine (UK), 10/2000-9/2005, £760,190.

• Patel, A Cluster Randomised Trial of a Primary Care Intervention for Common Mental Disorders in Goa, India, Wellcome Trust Senior Clinical Fellowship in Clinical Tropical Medicine, 10/2005-9/2010, £1.1m.

• Patel, The Development and Dissemination of the Lancet Series on Global Mental Health, MacArthur Foundation, 2006-2008, US$50,000.

• Wellcome Trust Strategic Award, to Ebrahim, Patel and others, 10/2008-2014, The South Asia Centre for Chronic Diseases, £4.5 million

• Patel, Cohen and De Silva, Evaluating Packages of Care for People with Severe Mental Disorders for Scaling-up in Low and Middle Income Countries, CBM, 10/2008-3/2011, €192,373.

• Patel, PREMIUM: A Program for Effective Mental Health Interventions in Under-resourced Health Systems, Wellcome Trust Senior Research Fellowship in Clinical Science, 10/2010-9/2015, £1.6m.

Details of the impact

LSHTM's research has played a key role in promoting new approaches to mental health care and influencing policy-makers and donors, in the following ways.

• Informing global and national policies for improving access to mental disorders. In 2008, WHO launched a flagship action plan to scale-up services for mental disorders (mhGAP). This referenced The Lancet mental health series in which Patel played a leading role.^5.1 This subsequently led to a WHO resolution for a Comprehensive Mental Health Action Plan approved by the World Health Assembly in 2013. In 2011, the Ministry of Health in India set up a mental health policy group, including Patel, to write India's first mental health policy and make recommendations for the scaling-up of mental health care. For example, Patel's research was extensively cited in the XIIth Plan District Mental Health Programme which is now being rolled out throughout the country.^5.2
• Enabling the launch of global civil society partnerships to advocate for mental health. In October 2008, the Movement for Global Mental Health was launched in direct response to LSHTM's research and Patel's call to action.^5.3 The Movement, a coalition of individuals and institutions aiming to improve services for people with mental disorders worldwide, now has over 3,000 individual and 150 institutional members from over 100 countries.
• Increased resources for global mental health. Grand Challenges Canada^5.4 has committed C$30m for innovations which address the Grand Challenges in Global Mental Health and the funding of a Global Mental Health Platform (led by LSHTM) to disseminate innovations to the wider communities of policy-makers, practitioners and civil society stakeholders. The US National Institute of Mental Health (NIMH) has also committed over US$15m to fund five hubs in developing countries involving partnerships between researchers, policy makers and civil society to implement these Challenges (LSHTM is the lead institution for one of the hubs). Both reference papers co-authored by Patel.
• Informing the mental health programmes of development agencies and NGOs. Various international agencies have cited the research of LSHTM as justification to initiate and expand their own mental health care programmes. For example, the World Federation for Mental Health (the world's largest mental health NGO) has aligned its global programme to be consistent with the research evidence generated by LSHTM and the call to action.^5.5
• Providing practical tools for mental health care in the field: (i) Patel's manual, Where There is No Psychiatrist, published in 2003 and providing practical guidance, has been translated into more than a dozen languages. Since 2010, the manual has been core reading for a new mental health nursing training programme in Liberia, and has been used by over 4,000 village doctors in Bangladesh since 2008. It is the core mental health manual for MSF programme staff.^5.6 In 2008 permission was given to reproduce the manual as 25,000 CD-ROMs, produced by WHO and the Inter-Agency Standing Committee (IASC) and disseminated to agencies working in emergency situations. The message of the value of lay health workers in mental illness care has been taken to a wide public audience, for example through a TED talk by Patel^5.7 which by end July 2013 has had 353,047 hits. (ii) A specially appointed WHO guideline development group, including Patel, developed guidelines^5.8 based in part on LSHTM's research for the management of mental disorders. Since its launch in October 2010, the resulting mhGAP Intervention Guide has been rolled out in Ethiopia, Jordan, Nigeria and Panama, and used in humanitarian settings in Haiti, Equatorial Guinea, Palestine, Syria and Lebanon.
• Establishing global mental health as a discipline for study and practice. The research has prompted several leading international universities to set up teaching programmes in global mental health (e.g. Duke, Harvard, New York University). Patel has led or been actively involved in the establishment of Centres for Public Mental Health in South Africa (at the Universities of Cape Town/Stellenbosch) and India (at the Public Health Foundation of India where he directs the new Centre for Mental Health).^5.9 Patel's work has been specifically cited by Arthur Kleinman, one of the most influential thinkers in global mental health: `Medical students who seem largely uninterested in academic psychiatric research are flocking to ... projects inspired by other models of community care such as those initiated by Vikram Patel and colleagues [see
  www.sangath.com; www.centreforglobalmentalhealth.org]. Among many others, these approaches appeal to those health professionals and students for whom social justice and care for the suffering of the poor are central, and have moral force.'^5.10

Sources to corroborate the impact

5.1 WHO (2008) mhGAP: Mental Health Gap Action Programme: Scaling Up Care for Mental, Neurological, and Substance Use Disorders. Geneva: WHO, pp. 9, 36 (citation 6),
http://www.who.int/mental_health/mhgap_final_english.pdf (accessed 11 September 2013).

5.2 Mental Health Policy Group (2012) XIIth Plan District Mental Health Programme. India: Mental Health Policy Group, p. 67 (citations 1, 2, 3, 5, 11, 12, 13), p. 68 (citations 3, 9, 10, 11)
http://mhpolicy.files.wordpress.com/2012/07/final-dmhp-design-xii-plan2.pdf (accessed 20 September 2013).

5.3 The Movement for Global Mental Health cites the 2007 Lancet series and LSHTM research as the rationale for its launch (http://www.globalmentalhealth.org/about/history).

5.4 Grand Challenges Canada (2012) Global Mental Health: Integrated Innovations to Improve Treatments and Expand Access to Care — Round 2. Canada: Grand Challenges Canada, p. 2 (ref. 5), p. 3 (ref. 6), http://www.grandchallenges.ca/wordpress/wp-content/uploads/globalmentalhealth-round2-requestforproposals-2012Nov05-EN.pdf (accessed 11 September 2013).

5.5 Former President, The World Federation for Mental Health.

5.6 Former mental health referent, Medicins sans Frontieres.

5.7 Patel, V (2012) Vikram Patel: Mental Health for All by Involving All. Edinburgh: TEDGlobal, June 2012 http://www.ted.com/talks/vikram_patel_mental_health_for_all_by_involving_all.html (accessed 11 September 2013). Over 353,000 hits since it was launched on the internet in September 2012.

5.8 WHO (2010) mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings: Mental Health Gap Action Programme (mhGAP). Geneva: WHO, http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf (accessed 11 September 2013). Patel was a member of the WHO mhGAP Guideline Development Group (p iv).

5.9 Launch of a new Centre of Excellence on Mental Health by the Public Health Foundation of India, India's leading public health training institution and appointment of Vikram Patel as its Director (http://www.phfi.org/our-activities/research-a-centres/centres-of-excellence/869-centre-for-mental-health).

5.10 Kleinman, A (2012) Rebalancing academic psychiatry: why it needs to happen — and soon, British Journal of Psychiatry, 201(421-422), doi:10.1192/bjp.bp.112.118695.