Including mental health in the global health and development agenda

Including mental health in the global health and development agenda

Why are mental disorders and substance use disorders treated so much differently than other health conditions? This is just one of the many questions that the World Bank Group, World Health Organization and other international partners will pose at their upcoming event — Out of the Shadows: Making Mental Health a Global Development Priority — on April 13th -14th ,  as part of the 2016 WBG/IMF Spring Meetings.

If mental health disorders are conditions of the brain, why do we treat these conditions so differently than heart conditions or cancer?   And in doing so, do we realize that this approach ignores all of the evidence that shows us that mental illness is a major disability burden worldwide? If untreated, mental disorders can negatively affect management of common co-occurring diseases, such as tuberculosis and HIV, diabetes, hypertension, cardiovascular disease, and cancer.

For all of these reasons and many more, the WBG-WHO are aiming to put the mental health agenda where it belongs — at the center of global health and development priorities and remove all disparities.

In his sobering and deeply touching memoir, A Common Struggle, former U.S. Congressman Patrick J. Kennedy, shares his personal struggle with mental disorders and substance abuse and unpacks some of the issues surrounding mental health.

In the United States, as well as in countries such as Chile, Colombia and Ghana, where they are trying to push for equality for mental illnesses and addiction treatment, a common barrier to overcome is preexisting conditions clauses that deny health insurance coverage.  And even if this hurdle is overcome, explained Congressman Kennedy, who will deliver a keynote at the event, the next big issue is to determine what is covered, funded, and enforced at the provider level.  And this leads to a whole host of additional questions, such as:

  • Would coverage be offered for common mental illnesses such as depression and anxiety disorders, or just for severe mental illnesses such as schizophrenia, bipolar disorder, and disabling clinical depression?
  • Would addictions be covered?
  • How to select the menu of evidence-based treatments to be offered by service providers at different levels of care, as is commonly done for other health conditions at the community level and on ambulatory clinics, local hospitals or specialized treatment centers?
  • We know that services for mental disorders depend heavily on adequate number of trained health personnel; how do we bridge the gap in their availability?
  • How about drugs, are they going to be brand name or equally effective generics?  Who decides and on what basis?
  • Would there be a mandate for all public and private insurance plans to cover mental health?
  • And how are these services going to be funded and reimbursed, particularly not to perpetuate medical discrimination in the subtle way of high deductibles, copayments, and lifetime limitations in coverage under health insurance arrangements?
  • What strategies can be used to integrate mental health care as part of services delivery platforms that focus on the patient as a whole rather than an aggregation of separate diseases?
  • And even if all these policy and service delivery changes are adopted, would affected persons who need mental healthcare and their families defy the stigma of being seen as “mental ill”” and get services and adhere to prescribed medication and psychotherapies?
  • What can be done to create facilitating workplace environments that help affected people overcome fear of losing a job or health insurance coverage if one were to disclose a mental health affliction and seek mental healthcare when needed?

At the same time that we pose these questions that have both political and financial implications, we also need to explore other “entry points” across sectors to bring mental health out of a centuries-old shadow—from school-based interventions, wellness and health in the workplace programs, initiatives to address the physical and mental health needs of displaced populations, refugees, and persons living in post-conflict, post-natural disasters, epidemics and post-epidemic (e.g., Ebola in West Africa) situations. To that end, we need to build upon social protection and employment initiatives that facilitate the reintegration of affected persons back into their communities as valuable members of society.  Hence, by accepting that mental health is a development challenge, we need to pursue different cross-cutting and multidisciplinary approaches, and funding streams.

We already have the evidence-based medical treatments and support therapies that can help alleviate the silent suffering for so many. Political will and commitment to sustainable funding, improved and scaled up service provision as a right of the population is required.  And besides the human toll, let’s not forget that the social cost of inaction is staggeringly high as measured in terms of broken families, less cohesive and inclusive  communities, labor supply losses, high rates of unemployment among mentally-ill persons, disability costs, absenteeism and reduced productivity at work from unattended depression and anxiety disorders.

Let’s remain optimistic that recent attention and interest on this issue will lead to increased commitments to implementing a global, multisectoral effort to scale up mental health services in primary care and community settings.

The original blog post was written by Patricio V Marquez and Shekhar Saxena and was published in the World Bank Blog blog. 

Smartphone-based CBT aims to reduce hospital readmissions 50%

Smartphone-based CBT aims to reduce hospital readmissions 50%

Smartphone-based CBT aims to help individuals with depression and bipolar disorder, since these are two of the leading causes of disability worldwide. Together, they account for nearly 50% of all morbidity and mortality due to mental and substance use disorders. Besides, patients with affective disorders are more frequently hospitalised than any other patient group.

In 2013, Danish authorities estimated that in Denmark, a country with 5.6 million people, patients with bipolar disorder and depression accounted for 20% of all psychiatric hospitalisations, which is the equivalent of more than 10,800 patients. The cost of these hospitalisations was estimated to be around 87 million Euros per year, which corresponds to 10,800 admissions with an average stay of 20 days at a cost of 400 Euros per day. The most effective treatment for both of these mental disorders includes medication and Cognitive Behavioural Therapy (CBT).


Smartphone-based CBT 

The RADMIS research project, which was granted a budget of 1.3 million Euros by the Danish Innovation Fund, will be done in collaboration with the Mental Health Services of the Capital Region of Denmark (RHP) and the Danish Technical University (DTU).

The project aims to establish clinical evidence that the Monsenso mHealth solution can reduce the number of hospital readmissions of patients with depression and bipolar disorder by 50%. It also seeks to decrease the symptoms and improve the quality of life of outpatients with depression or bipolar disorder receiving smartphone-based CBT.

The multi-disciplinary team involved in the project is comprised of scientific researchers, psychiatrists, psychologists, and computer scientists. This group has already shown promising scientific results with the MONARCA research project.

The use of an intelligent, smartphone-based CBT for the monitoring and treatment for depression and bipolar disorders has never been tried before.

  • The system combines automatic sensing and data collection with customisable self-assessment forms
  • It provides advanced data analysis and forecasting of disease progression, allowing patient and treatment personnel day-to-day assessment, prediction and insight into causes of changes in health state
  • It provides a platform for CBT treatment using innovative multi-media messages delivered ‘in-context’, tracking of medicine administration and compliance, as well as two-way communication between the patient and the clinic

Furthermore, smartphones have never been used in the research and collection of clinical evidence to reduce re-hospitalisation and improve treatment response among patients with depression and bipolar disorder.

After being discharged from the hospital, psychiatric patients undergo a high-risk period in which they are considered to have an increased risk of suicide of 300 times more during the first week and a high-risk of readmission. In fact, psychiatric patients are often afraid to leave the hospital, feeling alone and overwhelmed with the prospect of an appointment with a clinician in one or more months ahead.

A pilot study in Copenhagen involving 29 recently-discharged patients revealed the importance of continued contact with a care provider. In this study, patients used a daily computer system to self-monitor.

The study revealed that daily contact with a nurse using the bidirectional feedback system combined with a smartphone-based identifier of early-warning signs lowers the risk of relapse of depressive and (hypo-) manic symptoms. The pilot study also revealed that the incidence of suicide attempts and the rate of re-hospitalisation decreased.

The hypotheses to be investigated by the project

This project investigates two clinical questions related to the treatment of patients and one technical question related to online learning forecast systems:

  1. Can the risk and duration of psychiatric re-hospitalisation be reduced by using smartphone-based treatment?
  2. Can depressive and manic symptoms, psycho-social function, recovery, empowerment and quality of life be improved by using smartphone-based treatment?
  3. Can machine learning methodology, that runs on a smartphone app and adapts to data as it is collected, give users accurate forecasts and feedback on early warning signs of upcoming depression and hypomania/mania?

A bi-weekly workshop with 6-8 users will be conducted with a focus on the design of the features of the smartphone-based treatment system.

The questions will be investigated in two separate RCTs, focusing on the two patient groups (depressive and bipolar patients) with similar designs comparing the use of smartphone-based treatment with standard care. Each patient will be subject to the trial for six months. Recruitment, inclusion criteria and randomisation: 200 patients with recurrent depression and 200 patients with bipolar disorder at one of the five psychiatric centres in RHP. Patients aged 18 to 70 years will be screened with Schedules for Clinical Assessment in Neuropsychiatry (SCAN) to confirm the ICD-10 diagnosis.

Health outcomes:

Primary: Rate of re-hospitalisation and duration of hospitalisations.
Secondary: Severity of depression according to scores on the Hamilton Depression Rating Scale (36) and Young Mania Rating Scale (YMRS) (37) (for bipolar disorder patients only), at a given time point during the 6 month trial period. Functional assessment short test (FAST) (psychosocial function) (38).
Tertiary: Recovery Assessment Scale (39), empowerment according to Rogers empowerment scale (40), the WHO (Five) well-being index (41) and the Verona Satisfaction Scale-Affective Disorder (VSS-A) (42). Assessment of outcomes will be done by researchers blinded to allocation (single blinded).

Is social media increasing the levels of anxiety and depression amongst youths?

Is social media increasing the levels of anxiety and depression amongst youths?

During the last decade, social media has become a permanent part of people’s lives playing an important role in social interaction. In fact, social media is one of the most common activities among young people.

Based on a study made by the American Academy of Pediatrics, 75% of teenagers own cell phones, and more than 50% of adolescents log on to a social media site more than once a day. All websites or phone applications that offer social interaction are considered to be social media. Gaming websites, video websites, and blogs, which have grown exponentially in popularity in recent years, should also be considered in this category. All of these web applications offer today’s youth an unlimited number of communication portals, and boundless access to information. Taking this into consideration, parents should take more interest in what their children are browsing on the internet because many websites are not suitable for young people. [1]

Benefits of social media

Social interaction: Online, adolescents accomplish many social functions that are important to them: staying connected with friends and family, making new friends, sharing experiences, and exchanging ideas.

Become more involved in the community: Social networks are a powerful and accessible toolkit for showcasing and acting on issues and causes that affect the younger generations. These platforms can be used for sharing opinions and gathering people to stand up for causes that interest our society. [2]

New opportunities: Most of today’s companies and organizations have a strong online presence and also share their content and opportunities on social platforms. Therefore, young people can easily find volunteering placements, jobs, and learning opportunities, and can also develop real world skills on the internet. Managing an online presence and being able to interact effectively online is becoming an important skill that many employers require. [2]

Access to information: The free and unlimited access to information is by far the handiest and most satisfying advantage. Social media is encouraging learning and discovery. Even though books are still used for facts and theoretical information, the internet is a convenient source to learn more about any topic and read about different opinions to help develop a teenager’s personality.

With this self-learning method, young people can explore alone, building independence and developing the skills they need to recognise and manage risk, learn and evaluate situations, which leads to an open mind-set. [2]

Drawbacks of social media

While social networks offer an opportunity to connect and interact with friends and family, there are also many downsides to using social media. For example, cyberbullying, “Facebook depression”, sleep deprivation, sexting, anxiety, and exposure to inappropriate content.

Cyberbullying: takes place using electronic technology, for example, unkind text messages or emails, rumours sent by email or posted on social networking sites, embarrassing pictures, videos, websites, or fake profiles amongst other things.

Most parents fail to realize the huge influence social media has over tweens and teens. Cyberbullying is by far the most common, it can happen to anyone, and it may cause psychosocial outcomes including depression, anxiety, severe isolation, and even suicide. A recent survey by the American Academy of Paediatrics revealed that 20% of teens have sent or posted nude or semi-nude photographs or videos of themselves. [1]

Facebook depression: Researchers have found a new phenomenon called “Facebook depression”. This new disorder develops when teenagers spend great amounts of time on social networks and slowly become depressive. Peer acceptance and a sense of belonging are critical to adolescents, and when this fails to happen, they risk becoming depressed. Most of the time young people tend to share only what’s good on social media, leading others to believe that nothing bad ever occurs in their lives. Some people even go as far as posting positive matters about their life when in reality they might not be doing well just to impress their peers. [1] [3]

Sleep deprivation: Another negative aspect of social media is sleep deprivation. Lead researcher Dr. Cleland Woods said “While overall social media use impacts on sleep quality, those who log on at night appear to be particularly affected. This may be mostly true of individuals who are highly emotionally invested. This means we have to think about how our kids use social media, in relation to time for switching off.” [3]

Privacy concerns and the digital footprint: Privacy concerns are a good reason to be worried when your child is spending a lot of time on the internet. The misuse of social media can result in a lack of privacy, sharing too much information, or posting false information about themselves or others.

A matter that’s particularly disturbing is called the “digital footprint, which is one’s unique set of digital activities, actions, and communications that leave a data trace on the Internet. In other words, young people unaware of this on-going record of digital data may post inappropriate messages, pictures, and videos without understanding that “what goes online stays online”. Also, future jobs and university acceptances may be put in jeopardy. [1] [4]

Children’s mental health

The World Innovation Summit for Health (WISH) released a Report on Mental Health and Well-being for children titled “Healthy Young Minds. Transforming the mental health of children.”  The WISH report encourages local communities and countries to focus on 10 Action Plans to improve the mental health of children around the world.

  • Community action: Every local community should implement a child well-being strategy
  • Parity of esteem: Mental health care for children and their parents should be widely available
  • Universality: Health professionals should be trained to identify mental health problems in children Professionals: Countries should train more professionals in psychological therapy
  • Well-being in Schools: The well-being of students should be the priority of every school
  • Measurement: Schools should evaluate all students’ well-being on a continuous basis
  • Add life-skills to the teaching curriculum: Schools should provide explicit instruction in life throughout school life
  • Teacher Training: All teachers should be trained to notice and promote well-being and mental health
  • Use of smartphone technology: Implement a smartphone-based program to promote mental health and well-being of the children
  • The Sustainable development goals: The sustainable development goals should include physical and mental health

Monitoring  the well-being and mental health of children at risk

The Monsenso mHealth solution can help facilitate the achievement of six of the ten points included in the WISH Action Plan.

  • Use of smartphone technology and well-being at schools – The Monsenso smartphone app can help adolescents express any negative feelings they may be experiencing. This information can help caregivers identify problems such as depression, anxiety, eating disorders, ADHD or even more severe diagnoses such as bipolar disorder or borderline personality disorder.
  • Measurement – With help from the Monsenso mHealth platform, school personnel can identify if some students present any Triggers or Early Warning signs. Once symptoms are identified in a group of students, caregivers can monitor this group closely to ensure they are receiving the support and attention they need.
  • Teacher training – The Monsenso web portal is so easy to use that caregivers do not require any special training to use the system. However, since they are not trained as mental healthcare specialists, they will need some training to help them interpret the information provided through the self-assessments.
  • Parity of esteem – In most countries, there is a lack of resources and the waiting time to schedule an appointment with a mental healthcare specialist can be up to a year. The Monsenso mHealth solution can help school personnel identify the students who are experiencing symptoms of mental illness. Once a student has been monitored for a determined period and the symptoms continue, school personnel can recommend that the family seek professional help.
  • Add life-skills to the teaching curriculum – Since all students would be required to fill out the daily self-assessments to evaluate and monitor their mental health well-being, the class dialogue can be facilitated by the information on the system. Teachers can provide students with real, anonymous examples of a person experiencing symptoms. Additionally, students could be encouraged to talk to a school counsellor if they experience any of the symptoms discussed in class. Students could also be taught how to act if they notice any symptoms in their peers.


References:

[1]Clinical Report-The Impact of Social Media on Children, Adolescents, and Families. The American Academy of Pediatrics. 2011.
http://pediatrics.aappublications.org/content/pediatrics/early/2011/03/28/peds.2011-0054.full.pdf

[2]Benefits of internet and social media. Reach Out.
http://au.professionals.reachout.com/benefits-of-internet-and-social-media

[3]Pressure to be available on social media may harm teenagers. The British Psychological Society. 2015.
http://www.bps.org.uk/news/pressure-be-available-social-media-causes-teen-anxiety-and-depression

 [4]Digital footprint. Dictionary.com
http://dictionary.reference.com/browse/digital-footprint

[5]Healthy Young Minds. Transforming the mental health of children. Report of the WISH Mental Health and Well-being in Children Forum 2015
http://dpnfts5nbrdps.cloudfront.net/app/media/1432

An increasing demand for mental health services by university students

An increasing demand for mental health services by university students

In 2015, the increasing demand for mental health services by university students raised a huge concern amongst teachers, parents and society in general.

In fact, the Centre for Collegiate Mental Health (CCMH) released a report that included the participation of 139 college and university counselling centres, and more than 100,000 students seeking mental health care during the academic year 2014/2015.

It is necessary to mention that according to clinicians, anxiety has surpassed depression as the leading mental health issue being faced by college students.

However, students have become more self-aware and have started seeking help at counselling centres. In fact, students have taken over more than 50% of the centres’ total capacity, increasing the average demand for this type of service to at least five times more than the average institutional enrolment.

Why is this happening? During recent years, different theories that try to explain the growth of mental health issues have surfaced, and they range from different parenting styles to lack of resilience. While there are many reasons why a student could suffer from anxiety or depression, most of them are very personal and can be identified and treated with counselling.

Therefore, it is fundamental that institutions of higher education can accommodate the increasing demand for mental health services to help at-risk students. Another option could be monitoring students’ mental health on a regular basis and identifying early warning signs and triggers before they reach a critical point. This can easily be done with the help of mobile health (mHealth) technology such as the solution offered by Monsenso. In fact, the Monsenso platform will begin clinical trials to support the treatment of anxiety disorders.

The Monsenso mHealth platform is being used to collect patients’ self-rated status and sensor-based behavioural data (e.g., physical activity, phone usage, social activity) on a daily basis. It consists of a smartphone application for patients and a web portal for clinicians. The advantage of using this method is that at-risk students that develop critical mental health conditions can be treated before the condition has a negative impact on their daily lives.

Reference:
Annual Report on Mental Health. The Centre for Collegiate Mental Health. 2015.
https://assets.documentcloud.org/documents/2686415/Penn-State-CCMH-Annual-Report-on-Student.pdf