Showing papers by "Benedetto Saraceno published in 2016"

Overview of the mental health system in Mozambique: addressing the treatment gap with a task-shifting strategy in primary care

Abstract: Mozambique has gradually changed its action on mental health (MH) from an asylum-centric care with long-term hospitalization to an innovative approach to community and primary care. To collect essential information on Mozambique’s MH system for decision making, to improve quality of services delivered, update MH Strategy and Action Plan. The study used the WHO-AIMS to assess MH systems including policy and legislation, organization of services, MH in primary care, human resources, public education and link with other sectors, monitoring and research. A comparative analysis was conducted to present the evolution of relevant data from 2010 to 2014. There are two psychiatric hospitals in the country and beds in general hospitals. In the period, the number of beds in general hospitals remained stable (203), and the beds in psychiatric hospitals increased from 173 to 298. Mental health outpatient facilities have increased from 83 to 152. The number of psychiatrists (9 in 2010, and 10 in 2014) remained very low, with a significant increase in the number of psychologists (56–109) and occupational therapists (2–23). The number of Psychiatric Technicians has increased from 66 in 2010, to 241 in 2014. This increase allowed the mental health network to expand from 60 to 135 Districts, meaning an increase of coverage from 44 to 100 % of the country districts. The task-shifting strategy focused on services delivered in primary care by psychiatric technicians, mid-level professionals, allowed the expansion of mental health services for all the country districts and the reduction of treatment gap in Mozambique.

Global mental health: achievements, concerns and (unanswered) questions.

Abstract: The notion of global mental health (GMH) is widely and increasingly used in the scientific literature and in academic training; as an example, almost all important American universities have created a course of global health, which includes modules on GMH. Despite growing interest and popularity, GMH refers to concepts and contents that are quite difficult to clearly and rigorously define. Some authors like Patel & Prince (2010) or Becker & Kleinman (2013) have provided definitions, which capture some key concepts of GMH. However, these definitions only partially help answer a fundamental question: who is setting the GMH agenda? Four Editorials in this issue of Epidemiology and Psychiatric Sciences may hopefully contribute to address this key question (Bracken et al. 2016; Freeman, 2016; Patel, 2016; Saxena, 2016). Indeed, addressing this issue implies raising a number of additional and somehow controversial questions (Summerfield, 2008):

Social and environmental adversities, neurobiological processes and mental disorders.

Abstract: In this Issue of Epidemiology and Psychiatric Sciences Nikolas Rose provides a thought-provoking analysis of the relationship between clinical psychiatry and neurobiological research (Rose, 2015). The idea that mental disorders are disorders of brain circuits, and that the brain will eventually provide an objective basis for establishing a causal relationship between altered brain circuits, psychiatric symptoms, diagnostic features and treatment options, is described as a reductionist approach to the role of neurobiology in psychiatry. The unshakeable idea that ‘the brain holds the key’ – Nikolas Rose argues – has negative consequences: in terms of diagnostic categories, as when the Diagnostic and Statistical Manual, Edition 5 (DSM 5) was published there was not a single clinically validated biomarker for any psychiatric disorder; in terms of explanatory models, as we are a long way from identifying neural bases of mental disorders; in terms of pharmacological treatments, as few now believe in the basic explanatory form of neurotransmitter hypothesis of mental disorder. The Editorial then makes a proposal from which substantial progress might be made (Rose, 2015). Mental disorders should not be considered brain disorders but disorders of persons ‘always in transaction with a social and environmental setting’. These transactions may shape neurobiology across the life-span and should always be included in our conceptual models, surpassing the limits of, quoting Leon Eisenberg, a ‘brainless’ or ‘mindless’ psychiatry, which have either oriented exclusively to models excluding biological influences, or to models excluding psychological ones (Eisenberg, 1986). Sociological and epidemiological studies have consistently shown correlations between diagnoses of mental disorder and a whole range of social and environmental adversities. Therefore, adversities might affect neurobiological mechanisms and processes that might ultimately lead to mental disorders. Clearly, we do not know how adversities ‘get under the skin’, but Nikolas Rose describes some possible mechanisms (Rose, 2015). If you think this is too theoretical and difficult to translate into something real then you should read a second Editorial published by Carmine Pariante in the same Issue of Epidemiology and Psychiatric Sciences (Pariante, 2015). It gives a bright example of psychopathology arising outside the brain because of environmental factors. Carmine Pariante shows how social adversities, including exposure to personal maltreatment or violence, socioeconomic disadvantage or isolation, are factors associated with an increased immune activation, and this, for example high levels of inflammation, may predict future development of psychopathology. In experimental models, it is also possible to induce psychiatric symptoms administering an immune activator. This would suggest that transactions with adversities may shape neurobiological mechanisms, with a peripheral localisation, that may ultimately lead to neuropsychiatric symptoms such as depression, anxiety, or psychotic symptoms. Additionally, the evidence that adding an antiinflammatory to an antidepressant or an antipsychotic increases the efficacy of these medications – Carmine Pariante argues – is another piece of evidence in favour of a link between these factors (Pariante, 2015). As practicing doctor (C. B.) and policy expert (B. S.), we argue that these two Editorials, with the example of immune-related mechanisms as intermediate element between social factors and mental disorders, prompt the following considerations.