Evidence-based mental health care and implementation science in low- and middle-income countries

Abstract

Although the evidence base for what to do about the mental health gap in low-and middle-income countries (LAMICs) has improved significantly over the last decade, mental health care in LAMICs still provide services to only a small minority of people with mental disorders. The problem is how to translate the relevant body of scientific knowledge into routine practice. It is clear from over two decades of research that the creation of evidence-based guidelines is necessary but not sufficient for evidence-based practice, whether in high-or low-income settings. In this Editorial, I discuss whether the recent development of 'implementation science' may offer an opportunity towards effective guideline implementation in low-and medium-income settings, so that clinical practice is more often based on evidence that does lead to patient benefit. First published online 28 May 2012Key words: Guidelines, implementation, low-and middle-income countries.If there can be 'no health without mental health' (Prince et al. 2007), then a health system does not function properly if it cannot protect and take care of the basic health rights and needs of people who are unwell or vulnerable -including people with mental illness (Chisholm et al. 2007). In most low-and middleincome countries (LAMICs), resources and services for mental health are meagre in the extreme, with lowincome countries allocating on average 0.5%, and lower-middle income countries 1.9% of their health budget to the treatment and the prevention of mental disorders, even though they represent over 10% of the overall disease burden World Health Organization, 2011). In LAMICs, there is on average one psychiatrist per 1.7 million inhabitants and one psychiatric inpatient bed per 42 000 inhabitants (Jacob et al. 2007). Most of the funds that are made available by governments are directed towards the running costs of mental hospital service provision. This limits the development of more equitable and cost-effective community-based services. The result of inadequate, inequitable and inefficient resourcing for mental health is a substantial treatment gap (Thornicroft, 2007). An international survey supported by WHO showed that 76-85% of people with severe mental disorders in low-income countries had not received any treatment in the previous 12 months ( Demyttenaere et al. 2004). The adverse consequences of this unmet need include the violation or abuse of human rights (Callard et al. 2012), long-term disability and ill-health (Chisholm et al. 2005), and increased mortality (Thornicroft, 2011;Wahlbeck et al. 2011).It is therefore clear that the quantity and quality of mental health care in LAMICs are grossly deficient. Is there sufficient relevant evidence from LAMICs on cost-effective interventions that do need to be put into practice? To date much of the mental health research undertaken in LAMICs has been on classification, epidemiology and identification of mental disorders. Yet recent developments include improved policy guidance, treatment guidelines and generation of...

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