- Email: [email protected]
Mental health and wellbeing in the Sustainable Development Goals
Comment
treatment; investment in research; and the Government putting in place policies that realise their promise of parity of esteem. The contribution that psychiatrists make to the health of the nation is often underestimated and undervalued. Kamaldeep Bhui comments “the profession of psychiatry requires the brightest and the best, the most ethical and the most progressive to continue a journey towards the most humane and hopeful ways to recovery, while also helping the wider population to better understand the mind and how to look after ourselves, our families and our communities”.7 Psychiatry demands exceptional doctors.8 The NHS will be faced increasingly with choices that will affect its sustainability. This will bring challenges, opportunities, potential, ownership, and responsibilities. What is our engagement and commitment in this process of moving towards achieving parity, in which mental health is valued and resourced equally with physical health? Do we need to refresh our vision?
Veryan Richards Royal College of Psychiatrists’ Service Users and Carers Fora, Royal College of Psychiatrists, London E1 8BB, UK [email protected] I declare no competing interests. 1 2 3
4
5 6 7 8
Richards V. Respect and dignity through the use of language. Mental Health Today (Hove); 2013, July/August: 7. Public Health Wales,. Achieving prudent healthcare in NHS Wales. Cardiff: Public Health Wales, 2014. Cooper D, Limet N, McClung I, Lawrie SM. Towards clinically useful neuroimaging in psychiatric practice. Br J Psychiatry 2013; 203: 242–44. Curtis-Barton MT, Eagles JM. Factors that discourage medical students from pursuing a career in psychiatry. The Psychiatrist 2011; 35: 425–29. Greenaway D.Securing the future of excellent patient care. London: Shape of Training (GMC), 2013. Sharpe M. Psychological medicine and the future of psychiatry. Br J Psychiatry 2014; 204: 91–92. Bhui K. From the Editor’s desk. Translational research in psychiatry Br J Psychiatry 2014; 205: 421–22. The Lancet. Bipolar disorder: at the extremes. Lancet, 2013; 381: 1597.
Mental health and wellbeing in the Sustainable Development Goals
Li Muzi/Xinhua Press/Corbis
Sustainable development cannot be achieved without the inclusion of mental health as a key global priority.1,2 Until recently the international community had not mobilised the necessary attention, efforts, and resources for people with mental illness and disability, despite the knowledge that the economic cost of mental disorders is more than 4% of GDP worldwide,3 depression is a leading cause of disability,4 and more than 800 000 deaths by suicide occur every year,5 many of which are preventable. 2015 is historic because two UN global frameworks have included mental health and wellbeing and disability: the UN Sendai Framework for Disaster Risk Reduction 2015–306 and the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs).7 The 2030 Agenda for Sustainable Development and SDGs7 were adopted at the 70th Session of the UN General Assembly on Sept 25–27, 2015. The 2030 Agenda and the SDGs build on the lessons learned and the gaps identified in implementation of the Millennium Development Goals (MDGs), as well as identifying newly emerging development challenges. Whereas the Millennium Declaration and MDGs did not make reference to mental 1052
health and disability in any of the goals, targets, and indicators, the Agenda and the SDGs have included mental health and disability in several paragraphs. The vision of the 2030 Agenda is of “…a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured.” Under the Goal 3 (“ensure healthy lives and promote wellbeing for all at all ages”), target 3.4 is to “reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing”, and target 3.5 is to “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol”. Furthermore, Goals 4, 8, 10, and 11 include specific references to inclusion of people with disabilities, essential for protection and promotion of the rights of people with mental, intellectual, and psychosocial disabilities who have been among the most ostracised. The diplomatic, technical, and practical importance of the SDGs is that the goals will guide global, regional, and national efforts over the next 15 years in both www.thelancet.com/psychiatry Vol 2 December 2015
Comment
developed and developing countries. From 2016, each member state will need to report on their mental health policies, systems, and programmes to the international community. This will strengthen efforts to develop policies and laws related to mental health and disabilities; allocate sufficient resources; develop human resources for mental health care; monitor inclusion in health, education, employment, and social protection systems; improve access to treatment and care by people with mental illness and disability; and implement related programmes, all of which are consistent with the WHO Mental Health Action Plan. This is the most important global attempt to address the massive treatment gaps and grave human rights violations experienced by many people with mental illness and disability, and the representatives of many nations have already committed to incorporating the SDGs into their national development strategies. This achievement is the product of decades of sustained global efforts by many stakeholders, including UN systems, member states, non-government organisations, academia, organisations of and for people with disabilities, and others. Soon after World War 2, aspects related to mental health were included in the constitutions of WHO and the UN Educational, Scientific, Social, and Cultural Organisation (UNESCO) as well as in the UN International Covenant on Economic, Social, and Cultural Rights. Additionally, the UN has adopted about 370 UN resolutions related to mental health.8 Furthermore, under the leadership of WHO, there has been a great deal of work, including the publication of the World Health Report 2001: Mental Health: New Understanding, New Hope9 and the development of evidence-based treatment guidelines such as the mhGAP Intervention Guide.10 In 2010, based on the lessons learned from previous efforts, including the UN Declarations on the Rights of Mentally Retarded Persons (1971) and the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (1991), as well as the Convention on the Rights of Persons with Disabilities, UN and WHO issued the ground-breaking publication Policy Analysis on Mental Health and Development: Integrating Mental Health into All Development Efforts including MDGs2 to support inclusion of this neglected but important issue in the post-2015 development framework. The UN Expert Group Meeting on Mental Wellbeing, Disability and Development in Kuala Lumpur (2013)1 contributed to the inclusion of www.thelancet.com/psychiatry Vol 2 December 2015
mental health and wellbeing in SDGs. In 2013, the World Health Assembly adopted the Mental Health Action Plan 2013–20.11 It is now vital that the UN system and member states develop and implement specific global, regional, and national strategies to achieve targets for mental health and disability. Additionally, consideration of mental health in other goals should continue so that the development community appreciates that good mental health is a cross-cutting issue that contributes to the realisation of key indicators of sustainability, equality, inclusion, and resilience. Integration of perspectives of mental wellbeing and disability is also important in the peace and security arena, particularly the upcoming 2016 UN Humanitarian Summit as well as the Security Council. The many past UN resolutions that have included references to mental health8 are a sobering reminder that inclusion of mental health in the 2030 Agenda and the SDGs is not enough. It is vitally important that mental health is explicitly included in relevant indicators and that mechanisms to resource mental health development are identified and implemented. Full implementation of the Addis Ababa Action Agenda for Financing for Development12 will be an essential requirement. Additional key action points include full participation by people with mental, intellectual, or psychosocial disabilities in decision making and implementation, realising universal design and accessibility principles in every aspect of society, and supporting education and other activities including sports and arts, which promote full social engagement and reduce stigma. Although mental health has always been part of the WHO definition of health, the 2030 Agenda and the SDGs have potential to finally realise this definition in development practice. Takashi Izutsu, Atsuro Tsutsumi*, Harry Minas, Graham Thornicroft, Vikram Patel, Akiko Ito Komaba Organization for Educational Excellence, University of Tokyo, Tokyo, Japan (TI); International Institute for Global Health, United Nations University, Kuala Lumpur 56000, Malaysia (AT); Global and Cultural Mental Health Unit, Centre for Mental Health, University of Melbourne, Melbourne, VIC, Australia (HM); Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK (GT); London School of Hygiene and Tropical Medicine, London, UK (VP); and Department of Economic and Social Affairs, United Nations, New York, NY, USA (AI) [email protected] We declare no competing interests.
1053
Comment
1
2
3
4 5 6
UN, UNU. United Nations Expert Group Meeting on Mental Well-being, Disability and Development: Conclusions and recommendations for inclusion of mental well-being and disability into key goals and outcomes of upcoming international conferences. Kuala Lumpur: UN University, 2013. UN, WHO. Policy Analysis on Mental Health and Development: Integrating Mental Health into All Development Efforts including MDGs. New York: United Nations, 2010. OECD. Making Mental Health Count: The Social and Economic Costs of Neglecting Mental Health Care. Paris: Organisation for Economic Co-operation and Development, 2014. WHO, World Bank. World Report on Disability. Geneva: World Health Organization, 2011. WHO. Preventing suicide: A global imperative. Geneva: World Health Organization, 2014. UN. Sendai Framework for Disaster Risk Reduction 2015–2030. New York: United Nations, 2015.
7 8 9 10
11 12
UN. Transforming our world: the 2030 Agenda for Sustainable Development. NY: United Nations, 2015. UN, UNU. Mental Health and Well-being: A New Global Priority - Key United Nations Resolutions and Documents. New York, 2015. WHO. World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: World Health Organization, 2001. WHO. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization, 2010. WHO. Mental Health Action Plan 2013–2020. Geneva: World Health Organization, 2013. UN. Addis Ababa Action Agenda of the Third International Conference on Financing for Development. NY: United Nations, 2015.
Using GRADE to update WHO recommendations for MNS WHO is in the process of updating the Mental Health Gap Action Programme guidelines for the treatment of mental, neurological, and substance use (MNS) disorders. Little information exists about the best strategies to update guidelines for clinical practice.1 The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool does not provide specific guidance on the updating process, although the WHO Handbook for Guideline Development suggests giving priority to controversial areas or those in which new evidence has emerged.2 In this Comment, we report some challenges encountered during the use and adaptation of the GRADE approach to update the WHO guidelines on MNS disorders3, and based on this experience we provide some suggestions for regular update of guidelines (table). The first challenge was to identify recommendations in which an update was needed. Soon after the dissemination of WHO guidelines for MNS disorders, a plan for regular monitoring of the background evidence was developed to identify new potentially relevant evidence and to assess whether the new information might have a significant effect on the recommendations. Because monitoring had to be affordable and feasible in the long term, it was not based on full literature reviews but comprised searches of systematic reviews and other secondary products such as other evidence-based guidelines. Second, most systematic reviews include only randomised trials; however, some questions could not be easily answered by randomised trials only.4 For example, adverse outcomes associated with drug use were sometimes addressed in an unsatisfactory way by systematic reviews of experimental studies. Similarly, 1054
how health systems should best be organised to offer mental health care, a topic of particular interest to WHO,5 can rarely be answered by randomised evidence. It was therefore agreed to include systematic reviews of observational evidence in GRADE tables when available and to describe observational evidence in a narrative section of the evidence profiles when only individual observational studies were available. The evidence retrieved was assessed for quality using the GRADE approach.2 Because GRADE is based on subjective judgments, we developed and applied pragmatic instructions to harmonise the process of grading the quality of the evidence.6 Raters were asked to take these instructions into consideration, justifying choices with footnotes as suggested by the GRADE methodology, and working together to agree. Members of the guideline development group considered the ratings, alongside the meta-analyses and features of the included studies and finalised the quality ratings. Another problem was the absence of direct evidence for some interventions. Although WHO guidelines focus on interventions provided by non-specialist healthcare professionals working at a primary health care level in low-income settings, most studies assessed interventions in high-income settings, at secondary care levels, involving highly trained and educated staff. In these circumstances, available evidence was recorded in the GRADE tables as indirect, meaning that the question being addressed by the guideline panel was different from the available evidence. The panel of experts was required to take into consideration values, preferences, and feasibility issues www.thelancet.com/psychiatry Vol 2 December 2015
treatment; investment in research; and the Government putting in place policies that realise their promise of parity of esteem. The contribution that psychiatrists make to the health of the nation is often underestimated and undervalued. Kamaldeep Bhui comments “the profession of psychiatry requires the brightest and the best, the most ethical and the most progressive to continue a journey towards the most humane and hopeful ways to recovery, while also helping the wider population to better understand the mind and how to look after ourselves, our families and our communities”.7 Psychiatry demands exceptional doctors.8 The NHS will be faced increasingly with choices that will affect its sustainability. This will bring challenges, opportunities, potential, ownership, and responsibilities. What is our engagement and commitment in this process of moving towards achieving parity, in which mental health is valued and resourced equally with physical health? Do we need to refresh our vision?
Veryan Richards Royal College of Psychiatrists’ Service Users and Carers Fora, Royal College of Psychiatrists, London E1 8BB, UK [email protected] I declare no competing interests. 1 2 3
4
5 6 7 8
Richards V. Respect and dignity through the use of language. Mental Health Today (Hove); 2013, July/August: 7. Public Health Wales,. Achieving prudent healthcare in NHS Wales. Cardiff: Public Health Wales, 2014. Cooper D, Limet N, McClung I, Lawrie SM. Towards clinically useful neuroimaging in psychiatric practice. Br J Psychiatry 2013; 203: 242–44. Curtis-Barton MT, Eagles JM. Factors that discourage medical students from pursuing a career in psychiatry. The Psychiatrist 2011; 35: 425–29. Greenaway D.Securing the future of excellent patient care. London: Shape of Training (GMC), 2013. Sharpe M. Psychological medicine and the future of psychiatry. Br J Psychiatry 2014; 204: 91–92. Bhui K. From the Editor’s desk. Translational research in psychiatry Br J Psychiatry 2014; 205: 421–22. The Lancet. Bipolar disorder: at the extremes. Lancet, 2013; 381: 1597.
Mental health and wellbeing in the Sustainable Development Goals
Li Muzi/Xinhua Press/Corbis
Sustainable development cannot be achieved without the inclusion of mental health as a key global priority.1,2 Until recently the international community had not mobilised the necessary attention, efforts, and resources for people with mental illness and disability, despite the knowledge that the economic cost of mental disorders is more than 4% of GDP worldwide,3 depression is a leading cause of disability,4 and more than 800 000 deaths by suicide occur every year,5 many of which are preventable. 2015 is historic because two UN global frameworks have included mental health and wellbeing and disability: the UN Sendai Framework for Disaster Risk Reduction 2015–306 and the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs).7 The 2030 Agenda for Sustainable Development and SDGs7 were adopted at the 70th Session of the UN General Assembly on Sept 25–27, 2015. The 2030 Agenda and the SDGs build on the lessons learned and the gaps identified in implementation of the Millennium Development Goals (MDGs), as well as identifying newly emerging development challenges. Whereas the Millennium Declaration and MDGs did not make reference to mental 1052
health and disability in any of the goals, targets, and indicators, the Agenda and the SDGs have included mental health and disability in several paragraphs. The vision of the 2030 Agenda is of “…a world with equitable and universal access to quality education at all levels, to health care and social protection, where physical, mental and social wellbeing are assured.” Under the Goal 3 (“ensure healthy lives and promote wellbeing for all at all ages”), target 3.4 is to “reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing”, and target 3.5 is to “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol”. Furthermore, Goals 4, 8, 10, and 11 include specific references to inclusion of people with disabilities, essential for protection and promotion of the rights of people with mental, intellectual, and psychosocial disabilities who have been among the most ostracised. The diplomatic, technical, and practical importance of the SDGs is that the goals will guide global, regional, and national efforts over the next 15 years in both www.thelancet.com/psychiatry Vol 2 December 2015
Comment
developed and developing countries. From 2016, each member state will need to report on their mental health policies, systems, and programmes to the international community. This will strengthen efforts to develop policies and laws related to mental health and disabilities; allocate sufficient resources; develop human resources for mental health care; monitor inclusion in health, education, employment, and social protection systems; improve access to treatment and care by people with mental illness and disability; and implement related programmes, all of which are consistent with the WHO Mental Health Action Plan. This is the most important global attempt to address the massive treatment gaps and grave human rights violations experienced by many people with mental illness and disability, and the representatives of many nations have already committed to incorporating the SDGs into their national development strategies. This achievement is the product of decades of sustained global efforts by many stakeholders, including UN systems, member states, non-government organisations, academia, organisations of and for people with disabilities, and others. Soon after World War 2, aspects related to mental health were included in the constitutions of WHO and the UN Educational, Scientific, Social, and Cultural Organisation (UNESCO) as well as in the UN International Covenant on Economic, Social, and Cultural Rights. Additionally, the UN has adopted about 370 UN resolutions related to mental health.8 Furthermore, under the leadership of WHO, there has been a great deal of work, including the publication of the World Health Report 2001: Mental Health: New Understanding, New Hope9 and the development of evidence-based treatment guidelines such as the mhGAP Intervention Guide.10 In 2010, based on the lessons learned from previous efforts, including the UN Declarations on the Rights of Mentally Retarded Persons (1971) and the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (1991), as well as the Convention on the Rights of Persons with Disabilities, UN and WHO issued the ground-breaking publication Policy Analysis on Mental Health and Development: Integrating Mental Health into All Development Efforts including MDGs2 to support inclusion of this neglected but important issue in the post-2015 development framework. The UN Expert Group Meeting on Mental Wellbeing, Disability and Development in Kuala Lumpur (2013)1 contributed to the inclusion of www.thelancet.com/psychiatry Vol 2 December 2015
mental health and wellbeing in SDGs. In 2013, the World Health Assembly adopted the Mental Health Action Plan 2013–20.11 It is now vital that the UN system and member states develop and implement specific global, regional, and national strategies to achieve targets for mental health and disability. Additionally, consideration of mental health in other goals should continue so that the development community appreciates that good mental health is a cross-cutting issue that contributes to the realisation of key indicators of sustainability, equality, inclusion, and resilience. Integration of perspectives of mental wellbeing and disability is also important in the peace and security arena, particularly the upcoming 2016 UN Humanitarian Summit as well as the Security Council. The many past UN resolutions that have included references to mental health8 are a sobering reminder that inclusion of mental health in the 2030 Agenda and the SDGs is not enough. It is vitally important that mental health is explicitly included in relevant indicators and that mechanisms to resource mental health development are identified and implemented. Full implementation of the Addis Ababa Action Agenda for Financing for Development12 will be an essential requirement. Additional key action points include full participation by people with mental, intellectual, or psychosocial disabilities in decision making and implementation, realising universal design and accessibility principles in every aspect of society, and supporting education and other activities including sports and arts, which promote full social engagement and reduce stigma. Although mental health has always been part of the WHO definition of health, the 2030 Agenda and the SDGs have potential to finally realise this definition in development practice. Takashi Izutsu, Atsuro Tsutsumi*, Harry Minas, Graham Thornicroft, Vikram Patel, Akiko Ito Komaba Organization for Educational Excellence, University of Tokyo, Tokyo, Japan (TI); International Institute for Global Health, United Nations University, Kuala Lumpur 56000, Malaysia (AT); Global and Cultural Mental Health Unit, Centre for Mental Health, University of Melbourne, Melbourne, VIC, Australia (HM); Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK (GT); London School of Hygiene and Tropical Medicine, London, UK (VP); and Department of Economic and Social Affairs, United Nations, New York, NY, USA (AI) [email protected] We declare no competing interests.
1053
Comment
1
2
3
4 5 6
UN, UNU. United Nations Expert Group Meeting on Mental Well-being, Disability and Development: Conclusions and recommendations for inclusion of mental well-being and disability into key goals and outcomes of upcoming international conferences. Kuala Lumpur: UN University, 2013. UN, WHO. Policy Analysis on Mental Health and Development: Integrating Mental Health into All Development Efforts including MDGs. New York: United Nations, 2010. OECD. Making Mental Health Count: The Social and Economic Costs of Neglecting Mental Health Care. Paris: Organisation for Economic Co-operation and Development, 2014. WHO, World Bank. World Report on Disability. Geneva: World Health Organization, 2011. WHO. Preventing suicide: A global imperative. Geneva: World Health Organization, 2014. UN. Sendai Framework for Disaster Risk Reduction 2015–2030. New York: United Nations, 2015.
7 8 9 10
11 12
UN. Transforming our world: the 2030 Agenda for Sustainable Development. NY: United Nations, 2015. UN, UNU. Mental Health and Well-being: A New Global Priority - Key United Nations Resolutions and Documents. New York, 2015. WHO. World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: World Health Organization, 2001. WHO. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva: World Health Organization, 2010. WHO. Mental Health Action Plan 2013–2020. Geneva: World Health Organization, 2013. UN. Addis Ababa Action Agenda of the Third International Conference on Financing for Development. NY: United Nations, 2015.
Using GRADE to update WHO recommendations for MNS WHO is in the process of updating the Mental Health Gap Action Programme guidelines for the treatment of mental, neurological, and substance use (MNS) disorders. Little information exists about the best strategies to update guidelines for clinical practice.1 The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool does not provide specific guidance on the updating process, although the WHO Handbook for Guideline Development suggests giving priority to controversial areas or those in which new evidence has emerged.2 In this Comment, we report some challenges encountered during the use and adaptation of the GRADE approach to update the WHO guidelines on MNS disorders3, and based on this experience we provide some suggestions for regular update of guidelines (table). The first challenge was to identify recommendations in which an update was needed. Soon after the dissemination of WHO guidelines for MNS disorders, a plan for regular monitoring of the background evidence was developed to identify new potentially relevant evidence and to assess whether the new information might have a significant effect on the recommendations. Because monitoring had to be affordable and feasible in the long term, it was not based on full literature reviews but comprised searches of systematic reviews and other secondary products such as other evidence-based guidelines. Second, most systematic reviews include only randomised trials; however, some questions could not be easily answered by randomised trials only.4 For example, adverse outcomes associated with drug use were sometimes addressed in an unsatisfactory way by systematic reviews of experimental studies. Similarly, 1054
how health systems should best be organised to offer mental health care, a topic of particular interest to WHO,5 can rarely be answered by randomised evidence. It was therefore agreed to include systematic reviews of observational evidence in GRADE tables when available and to describe observational evidence in a narrative section of the evidence profiles when only individual observational studies were available. The evidence retrieved was assessed for quality using the GRADE approach.2 Because GRADE is based on subjective judgments, we developed and applied pragmatic instructions to harmonise the process of grading the quality of the evidence.6 Raters were asked to take these instructions into consideration, justifying choices with footnotes as suggested by the GRADE methodology, and working together to agree. Members of the guideline development group considered the ratings, alongside the meta-analyses and features of the included studies and finalised the quality ratings. Another problem was the absence of direct evidence for some interventions. Although WHO guidelines focus on interventions provided by non-specialist healthcare professionals working at a primary health care level in low-income settings, most studies assessed interventions in high-income settings, at secondary care levels, involving highly trained and educated staff. In these circumstances, available evidence was recorded in the GRADE tables as indirect, meaning that the question being addressed by the guideline panel was different from the available evidence. The panel of experts was required to take into consideration values, preferences, and feasibility issues www.thelancet.com/psychiatry Vol 2 December 2015