In the last article of a five-part series providing a global perspective on integrating mental health, Vikram Patel and colleagues discuss the competencies, operational innovation, and packages of care needed, and argue that integration will complement primary care system strengthening. Please see later in the article for the Editors' Summary

Background Despite being one of the leading causes of disability worldwide, fewer than 10% of depressed individuals in low-resource settings have access to treatment. Mounting evidence suggests that nonspecialist workers are capable of providing counseling and case management at the community level. They often use brief psychiatric screening instruments as clinical tools to identify cases and monitor symptoms over time. In order for such tools to be used in diverse settings, they must demonstrate adequate reliability and validity in addition to cross-cultural relevance. To be used to guide routine care they also need to be flexibly adapted and sensitive to change. The goal of this paper is to assess the cross-cultural validity of brief psychiatric screening instruments in sub-Saharan Africa, identify best practices, and discuss implications for clinical management and scale-up of mental health treatment in resource-poor settings. Method Systematic review of studies assessing the validity of screening instruments for depression, anxiety, and mental distress in sub-Saharan Africa using Medline and PsycINFO. Results Sixty-five studies from 16 countries assessing the validity of brief screening instruments for depression, anxiety, and/or mental distress. Conclusions Despite evidence of underlying universality in the experience of depression and anxiety in sub-Saharan Africa, differences in the salience, manifestation, and expression of symptoms suggest the need for the local adaptation of instruments. Rapid ethnographic assessment has emerged as a promising, low-cost, and efficient strategy for doing so.

Developing mental health care capacity in post-earthquake Haiti is hampered by the lack of assessments that include culturally bound idioms Haitians use when discussing emotional distress. The current study describes a novel emic-etic approach to developing a depression screening for Partners In Health/Zanmi Lasante. In Study 1 Haitian key informants were asked to classify symptoms and describe categories within a pool of symptoms of common mental disorders. Study 2 tested the symptom set that best approximated depression in a sample of depressed and not depressed Haitians in order to select items for the screening tool. The resulting 13-item instrument produced scores with high internal reliability that were sensitive to culturally-informed diagnoses, and interpretations with construct and concurrent validity (vis-à-vis functional impairment). Discussion focuses on the appropriate use of this tool and integrating emic perspectives into developing psychological assessments globally. The screening tool is provided as an Appendix.

Demographic and health care utilization data associated with 14,910 pediatric enrollees, ages newborn to 5 years, enrolled at Kaiser Permanente Colorado were used to simulate the change in costs attributable to an innovative high-performance model of Well-Child Care. Simulation models and sensitivity analyses suggest it is likely to be relatively resource cost neutral in a managed care system, allowing for efficient reallocation of resources to higher-risk children.

Common mental disorders pose tremendous health and social burdens in the poorest countries. This Open Forum describes a planning framework to advance effective, sustainable design and implementation of mental health services in these settings. It builds on research in treatment dissemination and on the authors' experience in several initiatives-including the Millennium Villages Project in sub-Saharan Africa and the Partners In Health system in Haiti (Zanmi Lasante). The authors describe a "pyramid of care" approach that specifies five key skill packages to address common mental disorders in low-resource settings and five implementation rules: assess context first; identify priority care pathways and map them across skill packages; specify decision supports, supervision, and triage rules; use quality improvement practices; and plan for sustainability and capacity building. The framework addresses the need for a shared vocabulary and a set of tools to coordinate and compare efforts to scale-up mental health treatment across diverse settings.

Significant challenges exist in providing safe, effective, and culturally sound mental health and psychosocial services when an unforeseen disaster strikes in a low-resource setting. We present here a case study describing the experience of a transnational team in expanding mental health and psychosocial services delivered by two health care organizations, one local (Zanmi Lasante) and one international (Partners in Health), acting collaboratively as part of the emergency response to the 2010 Haiti earthquake. In the year and a half following the earthquake, Zanmi Lasante and Partners in Health provided 20,000 documented individual and group appointments for mental health and psychosocial needs. During the delivery of disaster response services, the collaboration led to the development of a model to guide the expansion and scaling up of community-based mental health services in the Zanmi Lasante health care system over the long-term, with potential for broader scale-up in Haiti. This model identifies key skill packages and implementation rules for developing evidence-based pathways and algorithms for treating common mental disorders. Throughout the collaboration, efforts were made to coordinate planning with multiple organizations interested in supporting the development of mental health programs following the disaster, including national governmental bodies, nongovernmental organizations, universities, foreign academic medical centers, and corporations. The collaborative interventions are framed here in terms of four overarching categories of action: direct service delivery, research, training, and advocacy. This case study exemplifies the role of psychiatrists working in low-resource settings as public health program implementers and as members of multidisciplinary teams. (Harv Rev Psychiatry 2012;20:68–77.)

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Background: In sub-Saharan Africa, mental and substance-related disorders account for 19% of all years lived with disability, yet the intersection between poverty and mental distress is poorly understood since most psychiatric research is conducted in high-income countries. Aims: To examine the prevalence of and associations between food insecurity, mental distress and suicidal ideation in three rural village clusters in sub-Saharan Africa. Method: Cross-sectional multivariate analysis of sociodemographic variables associated with mental distress and suicidal ideation in three countries. The sample included 1,142 individuals from three rural village clusters in Nigeria (n = 380), Uganda (n = 380) and Ghana (n = 382). Food insecurity was measured based on the number of months in the previous year that the respondent’s family reported being ‘unable to eat two square meals per day’. Mental distress was assessed using the Kessler non-specific psychological distress scale (K6) and suicidal ideation was measured using an item from PRIME-MD. Other sociodemographic variables included gender, age, literacy and occupation. Results: The prevalence of individuals with moderate or severe mental distress in Nigeria, Uganda and Ghana were higher than previously reported in the literature: 35.5%, 30.8% and 30.4%, respectively, and suicidal ideation rates were 29.7%, 21.3% and 10.9%. No differences were observed in mental distress between men and women in any of the sites. Being a farmer (vs student or other) was protective for mental distress in two sites (Uganda and Ghana) but no other social indicators, such as age, gender, literacy and food insecurity, were significantly associated with mental distress. Risk for suicidal ideation differed across sites: it was associated with food insecurity in Nigeria, female gender in Uganda, and older age in Uganda. Conclusions: Mental distress and suicidal ideation were highly prevalent in three settings of extreme poverty across all groups, in ways that were not always consistent with the global literature. These findings suggest that more research is needed in to better understand the social etiology of mental distress in sub-Saharan Africa.