Mental Health Recovery in Different Contexts: Lessons Learned from the Field

Jessica Maria-Violanda Spagnolo

The mental health recovery movement emerged in order to counter the overly biomedical view of mental illness that littered the era before deinstitutionalization (Anthony, 1993). After this era, community-based services for people living with mental illness were strongly encouraged, as illness is not merely the absence of disease, but a state of holistic well-being that goes beyond physicality (WHO, 1948). Therefore, mental health recovery includes ways of “living a satisfying, hopeful, and contributing life even with limitations caused by illness”; as well as finding “new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony, 1993, p. 527).

I have always been interested in understanding how this concept is seen and understood around the world. This post will report on examples of the cultural representation of mental health recovery in local communities where I worked.

Picture 1 (McGill Blog)

Photo 1

At a shelter in a small village in the Caribbean, mental health recovery meant developing new skills by learning how to plant vegetables, pineapple, and flowers, as well as care for chickens. This manual labor encouraged the presence of a daily routine, which can easily falter when one is affected by illness; learning through trial and error, which promotes patience and perseverance; as well as interacting with others, which can often be a limitation caused by illness. Photo 1 shows the chickens that the residents took care of until they were either sold to local community members or were used to feed the residents at the shelter. These same residents highlighted the importance of religion in their lives, which helped them find new meaning after illness. For example, when asked what inspired them, the majority of the residents said “God.” This reality is also apparent when visiting the shelter, as the walls are painted with religious images and symbols by local artists (Photo 2).

Picture 2 (McGill Blog)

Photo 2

In a small village in Central America, where many refugees sought protection after experiencing hardships in another country, often showing signs of post-traumatic stress, mental health recovery was seen through the development of new social ties. Arriving as strangers, women leaned on each other for support as well as hope for the future. Their children, through play, would do the same (Picture 3).

Picture 3 (McGill Blog)

Photo 3

The beauty of the mental health recovery movement is that it ensures the focus is not solely on mental disorders or symptoms. Not once during my work in these 2 communities did the residents mention the word “sick” or “ill,” but spoke about what was important in their own, unique, personal recovery journey from illness: developing new skills; generating hope for the future, creating social support and networks. These things are what innately make us human, and are anchored in what can help people living with any type of illness enjoy a satisfying and fulfilling life, despite symptoms.

 

Jessica Spagnolo is a Doctorate Candidate at the School of Public Health at the University of Montreal. Her research focuses on building system capacity for the integration of mental health at the level of primary care in Tunisia. Jessica is funded by les Fonds de recherche du Québec – Santé (FRQS) and MITACS Globalink. Jessica holds a Bachelor and a Masters of Social Work from McGill University.

Why The World Needs An Essential Diagnostics List

Lee Schroeder, Timothy Amukele and Madhukar Pai

This article was originally posted on Forbes website. See the original post here.

Without diagnostics, medicine is blind. And yet, diagnostics receive much less attention than vaccines and drugs. Imagine a sick infant with bacterial sepsis in sub-Saharan Africa. Without diagnostics, they will likely get incorrectly treated for malaria. Every year, 1 million patients with TB in India are either not diagnosed or not reported. Pregnant women with anemia, syphilis and diabetes are often missed in low-income countries where laboratory capacity is severely lacking. And where there is testing, it is often of low quality.

_DSC1743

Hepatitis and HIV diagnostic tool. Photo by Dr. Nitika Pai.

recent NEJM article proposes a simple way to improve access to critical diagnostics: make a list. In 1977, the World Health Organization started (and has since maintained) a Model List of Essential Medicines (EML). The EML, a global health success, has improved access to medicines. Sadly, there is no equivalent Model List of Essential Diagnostics (EDL). Such a list would be impactful for these reasons:

1.  Improve patient care and clinical outcomes

Patients will get consistent access to quality essential diagnostics that will be affordable and always available. When a diagnostic is added to an EDL, governments, funders and manufacturers will work to ensure availability and access.

2. Help detect emerging infectious threats

The Ebola and Zika epidemics have underscored the need for surveillance. While many countries have reference laboratories, laboratory capacity at lower health system tiers is often weak. By increasing laboratory capacity at all tiers, an EDL could help countries better prepare for epidemics and implement international health regulations.

3. Increase affordability

Bulk and advanced purchasing, volume discounts and pooling mechanisms are widely used for vaccines and drugs. Without such mechanisms, quality diagnostics can be unaffordable. Xpert MTB/RIF is a good TB test, but affordability is limited. An EDL could promote group purchasing by international organizations (e.g., Global Fund). With larger, predictable volumes, manufacturers can lower prices. Countries can use EDL to impose price controls and waive import duties to ensure affordability.

4. Reduce antimicrobial resistance (AMR)

Indiscriminate antimicrobial use drives AMR. Without adequate diagnosis,antimicrobials get widely abused. In half of malaria-endemic African countries over 80% of malaria treatments are applied without diagnostic testing, leading to legitimate concern for the emergence of drug resistance.

5. Improve regulation and quality of diagnostics

Unlike developed countries, regulatory agencies that approve the accuracy of diagnostic devices either do not exist or are weak in resource-poor settings. An EDL could focus such agencies on priority tests and help to harmonize regulation at the regional level. An EDL could aid in the identification of sub-standard diagnostics, as is already occurring formalaria rapid tests.

6. Facilitate laboratory accreditation and training

Even if a diagnostic test is of high quality, its impact can be crippled by improper use. In Kampala, Uganda, 95% of all laboratories failed to get the lowest score on the WHO laboratory quality checklist. Country-level laboratory accreditation groups could use the EDL to establish targeted and appropriate quality assurance programs. An EDL could also help shape in-country training of laboratorians.

7. Improve supply chain and laboratory infrastructure

As is too often the case in low-income settings, poor infrastructure and inconsistent supply chains render laboratory devices unusable. An EDL could encourage ministries of health to strengthen necessary infrastructures and develop targeted supply chains for the essential tests.

8. Facilitate change in healthcare provider behavior

Healthcare professionals trained in countries where laboratory testing is either unavailable or of low quality are likely to treat based on clinical suspicion. The impact of the Xpert MTB/RIF TB test has been blunted because of such issues. Likewise, in several settings, providers continue to give anti-malarial therapies, despite negative rapid test results. An EDL could improve providers’ confidence in test results and strengthen thediagnostic-treatment cascade.

9. Inform new technology development

Several teams are now developing point-of-care diagnostics for global health. An EDL could help develop target product profiles that can inform new product development. In fact, such initiatives already exist for several key diagnostics.

10. Facilitate epidemiological surveys, program evaluation and disease elimination

Policy makers need data on disease burden. An EDL could support national surveys and help track changes in disease burden and efficacy of interventions (e.g., diagnostics to support polio elimination).

Xpert cartridges [1032133]

TB diagnostic tools. Photo by Dr. Madhukar Pai.

In summary, essential medicines require essential diagnostics. The NEJM article has proposed an EDL to set the ball rolling. While many agencies could establish an EDL, WHO is the obvious choice, since they maintain the EML, make health policies, run prequalification programs and oversee international health regulations. So, we call upon WHO to take the lead in creating a List of Essential Diagnostics. We also call on key stakeholders (e.g., FINDPATHTDRCHAIASLMGHTCStop TB PartnershipRoll Back MalariaUNAIDS), civil society (e.g., MSFTAGACTION) and donors (e.g., Global FundBill & Melinda Gates FoundationUNITAIDUSAID) to support WHO to make this happen.

 

Dr. Lee Schroeder is assistant professor at the University of Michigan,  where he is director of Point-of-Care Testing and associate director of Chemical Pathology. Dr. Timothy Amukele is an assistant professor at the Johns Hopkins University School of Medicine, where he is the director of the Bayview Medical Center Clinical Laboratories. Dr. Madhukar Pai is a Canada Research Chair in Epidemiology & Global Health at McGill University, Montreal, Canada. He serves as the director of McGill Global Health Programs and associate director of the McGill International TB Centre.

 

This article was originally posted on Forbes website. See the original post here.

Global Mental Health Research for Sustainable Development

Sakiko Yamaguchi

The WHO’s global mental health action plan 2013-2020 relies on evidence-based practices. As such, today’s global mental health research is largely focused on the “evidence” to deliver effective mental health interventions in low- and middle-income countries. Although I have no intention to question the need and importance of scientific evidence, we hardly hear about the “sustainability” of evidence-based practice in global mental health despite the fact that “sustainable development” has been a core concept shaping the development agenda since the 1988 Bruntland Commission. Now that mental health and well-being are included in the UN’s Sustainable Development Goals, I would like to explore a question: “How can researchers link global mental health research with sustainable development?”

Sakiko leading a planning workshop in Sudan.

Sakiko leading a planning workshop for a health project in Sudan.

One answer may be found in implementation science, which provides tools and approaches to integrate evidence into health policy and practices (De Silva & Ryan, 2016). An intervention that is found to be effective in the idealized conditions of a research setting may meet a wide range of barriers in a real world context. The exclusive focus on evidence may divert our attention from the role of culture in a specific setting. In this context, global mental health research should find an answer of not only “what works” but also “how it works” by holistically examining the behavioural, organizational, economic, socio-cultural, and political dimensions of the context where evidence is implemented. Furthermore, researchers have the important role and responsibility to share pertinent individual knowledge available with those at the organizational, community, and society levels (Landry, Amara, Pablos-Mendes, Shademani, & Gold, 2006).

The exclusive focus on evidence may divert our attention from the role of culture in a specific setting.

 

While innovative instruments for knowledge sharing still seem lacking, my past work experience in international development reminds me of the notion of “ownership.” With an understanding that the sustainability of the project outcome results from the beneficial output shared among project participants, development partners generally make great efforts to foster a sense of ownership during the project implementation. In global mental health, community-based participatory research may be one possible approach to generate ownership by addressing the unequal power distribution between researchers and community people.

My initial question is still open for discussion. Meanwhile, the consideration of sustainability and ownership in global mental health research may shed light on the ethical aspects of our research process and application of knowledge.

 

About the Author:

Sakiko Yamaguchi is in the 2nd year of her PhD program in Division of Social and Transcultural Psychiatry, Department of Psychiatry at McGill. After working on government projects for social development in low- and middle-income countries, including post-conflict countries (Peru, Afghanistan, Sudan), she decided to pursue her PhD to better understand the long-term impact of violent conflict on mental health, and explore how international community can respond to the unmet needs of the affected people. She is currently in Ayacucho, Peru for her research project on alcohol misuse among the Andean highland population, who is still suffering from the consequence of political violence and the daily hardships rooted in poverty and socio-economic inequality.

 

The new McGill Global Mental Health Program was launched 30 May 2016. Like them on Facebook and learn more here.

 

 

References

De Silva, M. J., & Ryan, G. (2016). Global mental health in 2015: 95% implementation. The Lancet Psychiatry, 3(1), 15-17.

Landry, R., Amara, N., Pablos-Mendes, A., Shademani, R., & Gold, I. (2006). The knowledge-value chain: a conceptual framework for knowledge translation in health. Bulletin of the World Health Organization, 84(8), 597-602.

Blog authors are solely responsible for the content of the blogs listed in the directory. Neither the content of these blogs, nor the links to other web sites, are screened, approved, reviewed or endorsed by McGill University. The text and other material on these blogs are the opinion of the specific author and are not statements of advice, opinion, or information of McGill.