Title

Interventions for the improvement of mental health services at various levels of health system in LMICs : a systematic review

Date of Award

2017

Document Type

Thesis

Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)

Department

Community Health Sciences

Abstract

Mental health is recognized as an important area within global health and an essential development goal. The global burden of mental illnesses has increased in the past few years, with low and middle income countries (LMICs) being affected disproportionately. In LMICs, shortage of specialists, limited financial resources, double burden of disease and low attention given by policymakers exacerbates mental health conditions, leading to a huge treatment gap which represents a violation of basic human rights. A number of interventions have recently been conducted in LMICs. This systematic review is an attempt to map out the existing interventions that aim to improve mental health services at different levels of the health system in LMICs. Methodology: Three databases, including PubMed, CINAHL Plus and Cochrane Library were searched using a combination of keywords since the year 2000 till July 2017, with a focus on peer-reviewed literature that assessed the effectiveness of mental health interventions. The titles and abstracts of the initial search results (N=2397) were screened, out of which 2240 were excluded for numerous reasons, including studies based in high-income countries, those that did not provide data on outcomes, and where mental health was not the primary outcome. One hundred and fifty-seven articles were read in full, out of which 123 were included for the final analysis. Since a quantitative synthesis was not possible owing to the heterogeneity of search designs, a qualitative thematic synthesis was performed. Results: Findings indicated that a large number of randomized control trials have tested the effectiveness of different interventions. Majority of the interventions took place in Asia, with a particular focus in South Asia. There is an increasing role of non-specialist health workers including nurses, lady health workers and community health workers for service delivery. Role of service users, peers and caregivers is limited, although it is on the rise. Different models of service delivery including collaborative care and stepped care exist, which seek to maximize the existing resources of a country. A few countries have undertaken initiatives to integrate mental healthcare services in chronic diseases model or at the primary healthcare level to expand coverage. Interventions utilizing Information and Communication Technology (ICT) are also being increasingly implemented, although they are few compared to high-income countries. Strategies have focused primarily on depression and, anxiety. Very few studies assess the costs and costeffectiveness of interventions, which are important from a policy-maker's perspective. Conclusions: The review holds important lessons for resource-constrained settings like Pakistan, as it emphasizes the importance of a system's perspective, with a focus on task shifting under supervision of specialists and engagement of various stakeholders in order to improve mental health of its population.

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