Series

www.thelancet.com Vol 370 October 6, 2007 1241

Global Mental Health 6
Scale up services for mental disorders: a call for action
Lancet Global Mental Health Group*
We call for the global health community, governments, donors, multilateral agencies, and other mental health
stakeholders, such as professional bodies and consumer groups, to scale up the coverage of services for mental
disorders in all countries, but especially in low-income and middle-income countries. We argue that a basic,
evidence-based package of services for core mental disorders should be scaled up, and that protection of the human
rights of people with mental disorders and their families should be strengthened. Three questions are critical to the
scaling-up process. What resources are needed? How can progress towards these goals be monitored? What should
be the priorities for mental health research? To address these questions, we rst estimated that the amount needed to
provide services on the necessary scale would be US$2 per person per year in low-income countries and $34 in lower
middle-income countries, which is modest compared with the requirements for scaling-up of services for other major
contributors to the global burden of disease. Second, we identied a series of core and secondary indicators to track
the progress that countries make toward achievement of mental health goals; many of these indicators are already
routinely monitored in many countries. Third, we did a priority-setting exercise to identify gaps in the evidence base
in global mental health for four categories of mental disorders. We show that funding should be given to research that
develops and assesses interventions that can be delivered by people who are not mental health professionals, and that
assesses how health systems can scale up such interventions across all routine-care settings. We discuss strategies to
overcome the ve main barriers to scaling-up of services for mental disorders; one major strategy will be sustained
advocacy by diverse stakeholders, especially to target multilateral agencies, donors, and governments. This Series has
provided the evidence for advocacy. Now we need political will and solidarity, above all from the global health
community, to translate this evidence into action. The time to act is now.
Introduction
We believe that scaling-up of services for people with
mental disorders is the most important priority for global
mental health. Every year up to 30% of the population
worldwide has some form of mental disorder, and at least
two-thirds of those people receive no treatment, even in
countries with the most resources.
1
In the USA, for
example, 31% of people are aected by mental disorder
every year, but 67% of them are not treated.
2
In Europe,
mental disorder aects 27% of people every year, 74% of
whom receive no treatment.
3
The proportions of people
with mental disorder who are treated in low-income and
middle-income countries are even lower than in the USA
and UK; for example, a global survey reported that only
111% of severe cases of mental disorder in China had
received any treatment in the previous 12 months. This
survey also reported that, in low-income and middle-income
countries, only a minority of treated people (as low as
104% in Nigeria) received adequate treatment.
4
Therefore,
we argue that the overall volume of services provided to
treat people with mental disorders needs to be substantially
increased in every countrybut especially so in
low-income and middle-income countriesso that the
available care is proportionate to the magnitude of need.
1

We refer to this process as scaling-up. We call on
governments, multilateral agencies, and donors (most of
whom frequently ignore mental health), public-health
organi sations, mental health professionals, and con sumer
groups that represent mental health stake holders to act
now to make this happen.
This Lancet Series on Global Mental Health has
presented evidence that mental health is an essential and
inseparable component of health. The burden of mental
disorders goes well beyond their eect on mental health.
Mental disorders are risk factors for, or consequences of,
many other health problems; they contribute to mortality
(most notably through suicide); and they directly aect
progress toward achievement of many of the Millennium
Development Goals (MDGs).
5,6
Mental disorders in all
world regions are associated with poverty, marginalisation,
and social disadvantage. Despite the body of evidence that
attests to the importance of mental disorders, health
systems around the world face enormous challenges in
delivery of mental health care and protection of the human
rights of people with severe disorders. Such challenges
include scarce nancial and human resources, iniquitous
distributions (between and within countries), and
ine cient allocation.
7
The neglect of mental health cannot
be accounted for by scarcity of evidence for eective
interventions for mental disorders. Indeed, evidence from
low-income and middle-income countries is now good,
especially for pharmacological and psychological
interventions for depressive and anxiety disorders, and for
schizophrenia.
8
Furthermore, these interventions have
been shown to be aordable in low-income and
middle-income countries,
9
and are just as cost eective as,
for example, antiretroviral treatment for HIV/AIDS.
8

Although mental health services have been scaled up to
country or regional level in a few places, attainment of
core mental health indicators varies widely between and
Lancet 2007; 370: 124152
Published Online
September 4, 2007
DOI:10.1016/S0140-
6736(07)61242-2
See Comment page 1195
This is the sixth in a Series of six
papers about global mental
health
*Writing group listed below in
alphabetical order and other
investigators at the end of the
article
Department of Health Systems
Financing, World Health
Organization, Geneva,
Switzerland (D Chisholm PhD);
Division of Child and
Adolescent Psychiatry and
Adolescent Health Research
Institute, University of Cape
Town, Rondebosch, South
Africa and Research Centre for
Health Promotion, University
of Bergen, Norway
(Prof A J Flisher PhD);
Department of Psychiatry and
Mental Health, University of
Cape Town, Rondebosch, South
Africa (C Lund PhD);
Department of Epidemiology
and Population Health, London
School of Hygiene and Tropical
Medicine, London, UK and
Sangath, Goa, India
(Prof V Patel PhD); Department
of Mental Health & Substance
Abuse, World Health
Organization, Geneva,
Switzerland (S Saxena MD);
Institute of Psychiatry, Kings
College London, UK
(Prof G Thornicroft PhD); and
Health Systems Research Unit,
Medical Research Council,
South Africa, and Department
of Psychology, Stellenbosch
University, South Africa
(M Tomlinson PhD)
Correspondence to:
Prof Vikram Patel, Sangath
Centre, Alto-Porvorim,
Goa 403521, India
Vikram.patel@lshtm.ac.uk
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1242 www.thelancet.com Vol 370 October 6, 2007
within countries, and most countries have no mechanisms
to monitor progress.
10
Mental health system reform faces
barriers in low-income and middle-income countries, but
we have discussed possible solutions, such as collaboration
between advocates for people with mental disorders, and
strengthening of their advocacy with consistent and
consensual calls for action.
11

Many possible avenues for action have been identied:
for example, the World Health Report in 2001 outlined
ten specic strategies for reform.
12
Our call for action has
been guided by these strategies, by the evidence presented
in this Series, and by discussions initiated by the Lancet
Global Mental Health Group at a meeting in London
(September 12, 2006). We were committed to ensuring
that the call should be specic and practicable. Although
we acknowledge that strengthening of general health
services (eg, interventions which improve perinatal care)
would help prevent and reduce suering associated with
mental disorder, we have reached the conclusion that
action to scale up services for people who already suer
from mental disorders is most urgently needed. This
scaling-up should consist of a basic, evidence-based
package of services for core mental disorders. Three
questions are critical to the implementation of our call for
action. What resources are needed for the scaling-up
process? How can progress towards these goals be
monitored? What should be the priorities for mental health
research? We address these questions and discuss
strategies for achieving the goal to scale up services.
What resources are needed?
The coverage of evidence-based services for people with
mental illnesses is extremely low in most low-income
and middle-income countries.
1,4
We calculated the
resource needs and costs associated with the scaling-up
of a core package of mental health interventions in
low-income and middle-income countries; the methods
and data sources for this costing exercise are reported
elsewhere.
13
We aimed to allow comparisons between
countries and between estimates for scaling up
mental health services and services for other diseases.
14,15

To assess the overall cost to scale up a core mental health
care package, we rst dened the health conditions and
interventions to be included in the package, then
estimated current levels of coverage and need in the
populations of interest, set targets for increasing these
levels, and calculated the resulting year-on-year resource
costs to reach these targets. We estimated costs for a
10-year period, from 2006 until 2015, which is the target
date for attainment of the MDGs; all costs have been
expressed as the equivalent of US$ in 2005.
We selected three mental disorders (schizophrenia,
bipolar aective disorder, and depressive episode), as
dened in the WHO International Classication of
Diseases (ICD-10),
16
and one risk factor for disease
(hazardous alcohol use, dened as more than an average
of 20 grams of pure alcohol per day for women, or
40 grams per day for men). These four conditions were
selected because of their contribution to the burden of
disease, their responsiveness to known interventions,
and the availability of data on service provision and
resource requirements for intervention.
8,12,17,18
Treatment
for patients with schizophrenia and bipolar aective
disorder consists of antipsychotics and mood stabiliser
drugs, respectively; some of these patients also receive
psychosocial care and support. We modelled scaling-up
World Bank
income category
Population
(millions)
Government
spending on
health per
person (US$)
Mental hospital
beds per 100 000
population
Acute psychiatric
beds* per 100 000
population
Sta per 100 000
population
Package
expenditure
per year (US$,
2005, millions)
Package
expenditure per
person (US$,
2005)
Current
(2003)
Current
(2006)
Target
(2015)
Current
(2006)
Target
(2015)
Current
(2006)
Target
(2015)
Current
(2006)
Target
(2015)
Current
(2006)
Target
(2015)
Albania Lower middle income 31 49 156 40 44 131 257 395 45 131 143 419
Chile Upper middle income 163 137 44 39 58 137 307 395 540 134 332 824
China (Hunan) Lower middle income 617 22 57 19 04 131 115 395 223 189 036 306
Ethiopia Low income 774 3 03 13 00 105 23 325 72 123 009 159
Iran Lower middle income 695 62 63 08 08 106 259 395 855 272 123 392
Morocco Lower middle income 315 24 30 10 11 104 92 395 148 913 047 290
Nepal Low income 271 3 01 04 02 111 10 325 34 533 013 196
Nigeria Low income 274 6 30 10 01 93 89 325 43 429 016 157
Paraguay Lower middle income 62 24 44 22 00 111 61 395 27 165 044 268
Thailand Lower middle income 642 47 186 25 23 132 102 395 808 257 126 400
Ukraine Lower middle income 465 40 266 23 65 203 299 395 134 173 288 371
Vietnam Low income 842 7 45 14 00 109 80 325 154 157 018 186
Data reproduced from Chisholm and colleagues.
13
*Beds in district general hospital settings. Full-time equivalent sta, which is the sum of input time by psychiatrists, medical o cers, psychologists, psychiatric
and general nurses, occupational therapists, social workers, community health workers, and primary health-care workers. WHO-AIMS data for six (of the 36) provinces/states of Nigeria. National Health
Accounts estimates, from the World Health Report, 2006.
20
Table 1: Selected summary indicators for a core mental health care package
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www.thelancet.com Vol 370 October 6, 2007 1243
of treatment coverage in clusters of provinces via a
district-based service model centred around mental health
units with inpatient, outpatient, and outreach services.
People with depression are treated with antidepressants,
psychosocial treatment, or both; those with hazardous
alcohol use are given brief psychological interventions.
We modelled scaling-up of coverage of these services via
a primary health and hospital outpatient care-based
service model (with opportunistic screening, treatment,
and follow-up).
13
We selected 12 countries for which data from the
WHO-Assessment Instrument for Mental Health
Systems (AIMS) had been collected.
19
This ensured
availability of up-to-date information on, for example,
numbers of hospital beds, residential-care places, and
outpatient users. We calculated service coverage and
rates of utilisation in the population for people with
mental disorders in general, and also for selected ICD-10
disease categories, including psychosis and mood
disorders.
16
These 12 selected countries encompass a
wide range of geographical, cultural, and socioeconomic
settings (table 1). One country, Chile, has an upper
middle-income level; seven have lower middle-income
levels (Albania, China (Hunan province), Iran, Morocco,
Paraguay, Thailand, and Ukraine); and four are
low-income countries (Ethiopia, Nepal, Nigeria, and
Vietnam).
Despite the sparse coverage of services for people with
schizophrenia and bipolar aective disorder in many
low-income countries, we set a high target, of 80%, for
improvement of coverage, since these two conditions
give rise to substantial disability and vulnerability. We set
much lower targets for coverage for services for hazardous
alcohol use and depression (25% and 33%, respectively).
These targets are in line with levels achieved in
high-income countries, and reect well established
challenges to treatment of these conditions, such as case
identication, access, and willingness to receive care.
Table 1 summarises indicators for the core mental-heath
care package in the 12 selected low-income and
middle-income countries, at existing and at target levels
of coverage. As coverage expands, the supply of
mental health services will need to change: for example
with increases in acute psychiatric admissions, outpatient
and community-care visits, and community residential-
care facilities. These service needs will translate into
large-scale investments in service infrastructure and
human-resource deployment. These increases will be
oset only by an expected reduction in the number of
mental hospital beds needed as countries move towards
community-based models of service delivery. Total current
expenditure per person on the delivery of the core package
of interventions is as low as $010020 in low-income
countries. In the one upper middle-income country
included in our analysis, Chile, where salaries and
inpatient-care costs are higher than the other selected
countries, total expenditure is more than $3.
If target coverage is to be reached within the next 10 years,
total expenditure (from new and existing allocations) in the
four low-income countries included here (Ethiopia, Nepal,
Nigeria, and Vietnam) would need to rise at least ten-fold
(to about $2 per person per year by 2015). Total expenditure
would need to rise between three-fold and six-fold (to
around $34 per person per year) in lower middle-income
countries such as Morocco, Thailand, and Iran. In the only
upper middle-income country (Chile) included in the
analysis, the estimated cost is $824 per person. The gure
shows the year-on-year extra investment, over and above
existing allocations, that would be needed per head of
population to reach target levels of coverage. For most
countries, this model suggests an initial period of
large-scale investment of $030050 per person per year
(mainly for construction or renovation of acute inpatient
and outpatient facilities), followed by gradual spending
increases per person of $010025 per person per year as
more provinces are covered.
Although such investments are not large in absolute
terms, they are nevertheless substantially higher than the
existing budgets allocated to mental health, especially in
countries with large constraints on resources, where the
projected building and refurbishment costs alone would
consume over 10% of the entire health budget. In such
settings, additional money (from domestic sources,
international donors, or both) is therefore likely to be
needed; in other countries, such as Albania or Ukraine,
the challenge will be reallocation of existing resources
and capital.
The scope and limitations of our costing exercise
should be emphasised. The small set of countries we
selected might not be representative of resource needs in
other low-income and middle-income countries. Equally,
some uncertainty inevitably remains about estimates of
epidemiological need, treatment coverage, service
utilisation, and prices, despite use of best available data.
Together with unavoidable variations in how the package
would actually be formulated and implemented in
Chile
Albania
Ethiopia
Thailand
China (Hunan province)
Iran
Nepal
Morocco
Nigeria
Ukraine
Vietnam
2006
0
1
2007 2008 2009 2010
Year
I
n
c
r
e
m
e
n
t
a
l

e
x
p
e
n
d
i
t
u
r
e

p
e
r

p
e
r
s
o
n

(
U
S
$
,

2
0
0
5
)
2011 2012 2013 2014 2015
2
3
4
5
6
Figure: Incremental expenditure for a core package of mental health interventions, 200615
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1244 www.thelancet.com Vol 370 October 6, 2007
countries, this uncertainty suggests that our nal
estimates should be viewed as indicative of the range of
investment that is likely to be needed in countries at
dierent levels of economic development to achieve
targets for intervention coverage. These targets were set
in line with those of high-income countries (on the
grounds of equitable access to needed care), but might
need to be revised downwards if su cient new resources
cannot be mobilised. Other low-income and
middle-income countries can use our methods and
analysis to estimate their own need, coverage, and
resource requirements.
13
Finally, we acknowledge that
this exercise did not address the costs of scaling-up of
services for mental disorders that aect children.
What indicators should be used to monitor
progress?
Following the dictum that what cannot be measured is
di cult to improve, reliable and valid indicators need to be
used to monitor progress on mental health. The Health
Care Quality Indicators Project of the Organisation for
Economic and Community Development (OECD) has
proposed three criteria with which to judge health-related
indicators: importance for health, scientic soundness,
and availability of data.
21
Some countries now routinely use
such indicators for specic conditions, typically with the
aim of improving the quality of care.
2123
The MDGs set the
overarching framework for global health improvement,
with a hierarchy of health-related goals, targets, and
indicators; however, these goals do not explicitly address
mental disorder.
22
Targets need to be transparent and
adaptable.
24
They should also be amenable to measurement
at individual, local, and national levels.
25
No consensus yet
exists about which mental health indicators should be used
routinely at any of these levels.
26

We set out to identify a set of core mental health
indicators, designed to monitor attainment of targets
related to scaling up the coverage of basic, evidence-based
services for mental disorders. The aim was to allow each
country to measure its own progress towards agreed
targets and to compare its status with that of other
countries.
2730
We propose a format that uses broad goals,
specic targets, and measurable indicators, similar to
that of the MDGs.
31

We initially identied 16 potential indicators. Members
of the Lancet Global Mental Health Group did a Delphi
exercise
32
to rate each of these indicators against six
criteria: meaningfulness to health planners; acceptability
Proposed indicators Existing
indicators*
Sources of data
Core indicators
Ensure that national and regional
health plans pay su cient
attention to mental health
1: Presence of o cial policy, programmes, or plans for mental health,
either including or accompanied by a policy on child and adolescent
mental health
Atlas,
AIMS (1.1.1, 1.2.1)
National government
Invest more in mental health care 2: Specied budget for mental health as a proportion of total health
budget
Atlas,
AIMS (1.5.1)
National government
Increase trained sta to provide
mental health care
3: Mental health and related professionals per 100 000 population AIMS (4.1.1) National government and
professional bodies
Make basic pharmacological
treatments available in primary
care
4: Proportion of primary health-care clinics in which a physician or an
equivalent health worker is available, and at least one psychotropic
medicine of each therapeutic category (antipsychotic, antidepressant,
mood stabiliser, anxiolytic, and antiepileptic) is available in the facility or
in a nearby pharmacy all year long
AIMS (3.1.7) National government
Increase the treatment coverage
for people with schizophrenia
5: People treated each year for schizophrenia as a proportion of the total
estimated annual prevalence of schizophrenia
AIMS (2.2.4.2,
2.4.4.2, 2.6.5.2)
National government and
statistical oracademic
organisations
Secondary indicators
Balance expenditure in hospital
and community services
6: Proportion of total mental health expenditure spent on community-
based services, including primary and general health-care services
AIMS (1.5.2) National government
Provide adequate basic training
in mental health
7: Proportion of the aggregate total training time in basic medical and
nursing training degree courses devoted to mental health
AIMS (3.1.1, 3.2.1) National government and
professional bodies
Distribute sta equitably
between urban and rural areas
8: Proportion of psychiatrists nationally who work in mental health
facilities that are based in or near the largest cities
AIMS (4.1.7) National government
Ensure least restrictive practice 9: Involuntary admissions as a proportion of all annual admissions AIMS (2.4.5,
2.6.6)
National government
Protect the human rights of
people with mental disorder
10: Presence of a national body that monitors and protects the human
rights of people with mental disorders, and issues reports at least every
year
AIMS (1.4.1) National government,
professional bodies, and
civil-society groups
Reduce the suicide rate 11: Deaths by suicide and self-inicted injury rate WHO Mortality
database
32
National government and
statistical organisations
*Atlas=WHO Mental Health Atlas.
17
AIMS=WHO Assessment Instrument for Mental Health Systems.
19
Figures in parentheses are AIMS indicator numbers.
Table 2: Selected mental-health targets, with core and secondary indicators
Series
www.thelancet.com Vol 370 October 6, 2007 1245
to stakeholders; validity; reliability of source of
information for the indicator; comparability over time;
and sensitivity to change. Each criterion was rated on a
ten-point scale. From this exercise we have selected ve
core indicators, and six secondary indicators (table 2).
17,19,33

We propose that the ve core indicators be used to assess
how well national mental health systems provide services
to people with mental disorders, and that the six
secondary indicators be used to assess health systems
that have attained expected targets for some or all of the
core indicators. Taken together, these 11 indicators
address the four most important overarching goals:
(1) su cient planning and investment for mental health
care; (2) a su cient workforce to provide mental health
services; (3) consistency of mental health care inputs and
processes with best practice and human-rights protection;
and (4) improved outcomes for people with mental
disorders.
Our ve primary and six secondary indicators are clear,
simple, feasible, and likely to be reliable and valid. Most
low-income and middle-income countries already collect
relevant data, through, for example, the WHOs Atlas
project
17
and WHO-AIMS assessments.
19
Other countries
will need to introduce systems to gather relevant data.
However, the absence of such information systems must
not be an excuse for not scaling up services. Taken
together, these indicators will provide a broad picture of
the progress made by a country or region over time, and
will provide a meaningful comparison of progress
between countries. We acknowledge that the usefulness
of these indicators should be continually assessed, and
that new indicators might need to be introduced for
health systems that make good progress with scaling up
services. Equally, existing indicators might prove to be
unreliable or insu ciently sensitive to change; for
example, questions remain about variability in the
reliability of reported national rates of suicide and the
extent to which these can be reduced by health-system
actions.
What are the priorities for mental health
research?
Research has a critical role to play in response to the
public-health challenge of mental disorders. The
development of evidence-based health policies and
practice in low-income and middle-income countries,
and the maturation of clinical medicine and public
health, are stunted by the fact that only 10% of the worlds
medical research addresses the health needs of the
90% of the global population who live in low-income and
middle-income countries.
3436
The adverse eect of this
gap is potentially greater for mental health, which is
heavily inuenced by sociocultural factors and for which
current practice and evidence is dependent on cultural
norms from high-income countries, especially Europe
and the USA. Three recent studies have reported that
only 36% of mental health research in high-impact and
indexed medical journals is from low-income and
middle-income countries.
35,37,38
Overall, the nancial
resources made available for global mental health
research remain pitiful. Panel 1 outlines the major
international sources of funding for mental health
research. Most major donors that we approached either
did not fund mental health research, or did not record
their mental health research funding.
The Child Health and Nutrition Research Initiative
(CHNRI) has developed a systematic method to identify
priorities for health-research investment that can be
applied at global and national levels and for dierent
purposes.
40
The method uses ve criteria: the likelihood
that the research option will generate new knowledge in
an ethical way; the likelihood that the intervention based
on this knowledge will be eective for reduction of the
burden of disease; the likelihood that the intervention
will be aordable, deliverable, and sustainable; the
maximum potential for reduction of disease burden; and
the predicted eect of the intervention on equity. In the
CHNRI approach, scores for each competing research
option are computed in a highly structured, transparent,
and systematic way by experts with dierent backgrounds.
This limits the potential for personal bias to aect the
nal score. The methodology has already been used to
identify research priorities aimed at reduction of global
child mortality and setting of child-health priorities at the
country level in South Africa.
41
Since this method avoids
Panel 1: Funding for global mental health research
We gathered data from bilateral agencies (the UK Department for International
Development [DfID], the US Agency for International Development [USAID], and the
Australian Agency for International Development [AusAID]); multilateral agencies (WHO
and the European Commission); and research institutions and private donors (the
Wellcome Trust, the Gates Foundation, and the US National Institute of Mental Health
[NIMH]). We aimed to ascertain whether funding from these sources for mental health
research over the past decade was identiable, and, if so, to assess the proportion of
overall health research and mental health research funding which was devoted to mental
health in low-income and middle-income countries. Many agencies we approached either
did not fund mental health research (eg, the Gates Foundation) or did not keep track of
mental health research funding (DfID, European Commission, AusAID, and USAID). DfID,
which spends about 16% of its bilateral budget specically on health, funded for the rst
time in 2005 a 5-year research programme consortium to promote policy-relevant
research on mental health and poverty in developing countries.
39
We were able to obtain
gures for mental health research funding for the NIMH and the Wellcome Trustwhich
are possibly the two largest funders for mental health research worldwide. Overall, in
10 years (1994 to 2004), the Wellcome Trust spent about 5% of its total mental health
research funding (US$ 55 600 604, at 2007 exchange rate), on global mental health.
NIMH receives, on average, about 5% of the total budget of the US National Institutes of
Health. From 1998 to 2006, the NIMH spent about 7% of its total research funding on
extramural global mental health. Funding for research groups in non-US developed
countries accounted for a large share of this. Thus, in 2006, although the NIMH spent
54% of its total extramural research funding (US$57 300 188), on global mental health,
mental health research that was related to low-income and middle-income countries
made up only about 06% of the total non-AIDS research-grant portfolio.
Series
1246 www.thelancet.com Vol 370 October 6, 2007
many of the limitations of early priority-setting
methodologies,
42,43
we applied it to identication of
priorities for mental health research.
The rationale, conceptual framework, and application
guidelines have been described in greater detail
elsewhere.
40
In the rst step, the Lancet Global Mental
Health Group, whose members represent both academic
and civil-society perspectives on global mental health,
generated research questions. The context was dened as
global mental health over the next 10 years. We focused
on the disease burden for four disorders: schizophrenia
and other psychotic disorders, major depressive disorder
and other common mental disorders, alcohol abuse and
other substance abuse disorders, and child and adolescent
mental disorders. Three members of the Lancet Global
Mental Health Group (MT, VP, and SS) coordinated the
process and synthesised the questions. 24 members
formed the technical working group, and scored all
research options. Every option was scored against the ve
CHNRI criteria, with three questions per criterion
according to the conceptual framework.
41
This yielded
ve intermediate scores per research option. In the nal
step, we merged research questions that were deemed to
overlap or be similar. The leading ve research questions
per disorder are shown in panel 2. Eight of the 12 research
options that received the highest priority scores address
either health policy and systems research involving
existing interventions, or epidemiological research to
inform priority setting.
The limitations of our priority-setting exercise include
a risk of bias due to consensus, but we sought to minimise
this by use of a clear theoretical framework with multiple
endpoints; a transparent procedure (in which all
rationales can be viewed and challenged); independent
scoring; quantitative scores; an established and systematic
method; and participation of a broad range of
mental health professionals and stakeholders.
This Series has highlighted the relative paucity of
trials that assess interventions for the treatment or
prevention of mental disorders in low-income and
middle-income countries, and especially to assess the
eectiveness of scaled-up interventions.
8
The results of
our priority-setting exercise indicated that funding
should concentrate on research to address this evidence
gapie, research to develop and assess interventions
for people with mental disorders that do not need to be
be delivered by mental health professionals, and to
assess how health systems can scale up such feasible
and eective interventions across all routine-care
settings.
44
This nding contrasts with trends in the
allocation of most research funding, and with the stated
priorities of organisations such as the US National
Institute of Mental Health, which reported, for example,
that its main priority for research in child and adolescent
mental health was the development of new
interventions.
45
Even new and highly eective
pharmacological treatments would need well functioning
Panel 2: Priorities for global mental health research
Research priorities for depressive disorders, anxiety disorders, and other common
mental disorders (CMD)
Cost-eectiveness trials of interventions for CMD in primary and secondary care
Research on social interventions designed to reduce risk of CMD (eg, micronance and
interventions for gender-based violence and other forms of interpersonal violence)
Research on health policies and systems to scale up eective strategies for detection
and treatment of CMD in primary care and other routine health-care settings
Eectiveness of innovative and simple cognitive and behavioural strategies for
treatment of CMD that can be administered by general physicians and community-
health workers
Health systems and epidemiological research to determine the economic and hidden
costs of untreated CMD, and assess the benets of reduction of disability or days out-
of-role for people with CMD
Research priorities for alcohol-use and other substance-abuse disorders
Research on health policies and systems to determine the most eective intersectoral
(social, economic, and population-based) strategies to reduce consumption in high-
risk groups (especially men)
Eectiveness of early detection and treatment methods that are brief and culturally
appropriate, and that can be implemented by non-specialist health workers in the
course of routine primary care
Eectiveness of new and innovative brief interventions for prevention of alcohol
abuse, especially in adolescents and young adults
Health systems and epidemiological research on how to quantify the economic
benets of reduction of disability or days out-of-role for people with substance-abuse
disorders
Eectiveness of dierent settings for delivery of substance-use interventions (such as
schools, religious institutions, community groups, and health-care settings)
Research priorities for child and adolescent mental disorders
Training, support, and supervision needed to enable existing maternal and child
health workers to recognise and provide basic treatment for common maternal, child,
and adolescent mental disorders
The eectiveness and cost-eectiveness of school-based interventions, including in
schools for children with special needs
Research on health policies and systems to integrate the management of mental
disorders in children and adolescents with existing management programmes for
physical diseases
The eectiveness of new culturally appropriate community interventions for child and
adolescent mental disorders
Research on health policies and systems to scale up feasible, eective, and cost-
eective parenting and social-skill interventions in early childhood care
Research priorities for psychotic disorders
Research on health policies and systems to develop eective and cost-eective
methods for delivery of family interventions in low-resource settings to decrease
relapses of psychotic disorders
Eectiveness and safety of dispensation of antipsychotic medication by general
community-health workers to reduce relapse and admission rates
Eectiveness of aordable models of community-based treatment and rehabilitation
services that are culturally appropriate and sustainable
Research on health policies and systems to identify barriers to access to care (such as
stigma), and to increase access to care, especially early in the course of these disorders
Eectiveness of partnerships with non-governmental and voluntary organisations to
rehabilitate patients with chronic schizophrenia and other psychoses
Series
www.thelancet.com Vol 370 October 6, 2007 1247
health systems to deliver them, and psychosocial
interventions to accompany them, if they were to be
eective.
46
Increased research funding would be wasted
without capacity building for mental health research in
low-income and middle-income countries.
47
The eect
of government and university eorts to stem the
so-called brain drain and strengthen mental health
research is evident in Brazil,
48,49
which now enjoys a
dynamic mental health research infrastructure,
including one of only a handful of indexed psychiatric
journals published from low-income and middle-income
countries.
We identied research about child mental disorders in
our list of priorities, and hope that, as services for adult
mental disorders are scaled up, such evidence will inform
scaling-up of services for this important demographic
group.
Finally, WHO should help to network researchers and
research institutions and to facilitate provision of
international training materials. We call on donors and
agencies that are committed to global-health research to
scale up the resources available for mental health
research in proportion to the burden of mental disorders
in low-income and middle-income countries.
Call for action
The coverage of services for people with mental disorders
in most low-income and middle-income countries is
grossly decient.
1,4,7,10
Most attempts to enhance coverage
have been inadequately planned and resourced. Many
training, pilot, and demonstration programmes have
been conducted in small geographic areas, but generally
without any plans for sustainability or scaling-up. As a
group of concerned scientists, public-health professionals,
and mental health advocates, we call for action to scale
up coverage of services for mental disorders, and to
strengthen protection of the human rights of those with
mental disorders. Our call targets global-health
stakeholdersgovernments, multilateral and bilateral
Panel 3: Global mental healththe call for action
To scale up services for mental disorders we ask that:
1 Government ministries should identify and scale up a
priority package of service interventions or components
that can form the backbone of a national mental health
system that provides eective interventions and human-
rights protection
2 International donors, multilateral and lending agencies,
and governments of high-income countriesespecially
those that benet from the so-called brain drainmust
place mental health on their priority agenda for health
assistance to low-income and middle-income countries,
and match this pledge with substantial increases in
resource allocation
3 Government ministries should place mental health service
development on a more secure nancial footing:
they should prepare detailed nancial plans that not
only assess the existing and projected service needs of
their populations but also appraise constraints in
human and other resources
they should increase budget allocations for mental
health, and aim to attain a minimum level of investment
within 10 years of US$2 per head in low-income
countries and $34 in lower middle-income countries
4 Government and intergovernmental agencies must
strengthen their data-collection and monitoring
mechanisms, and entrust the task of monitoring and
reporting to national or regional committees with
intersectoral representation
5 National and international stakeholders in health
research, such as research councils, donors, and
universities, must increase resources for priority research
in mental health, build research capacity, and improve the
dissemination of ndings from such research
Panel 4: Stakeholders and their responsibilities to scale up services for mental
disorders in low-income and middle-income countries
Governments of low-income and middle-income countries
Update mental health plans and policy as appropriate
Use consensus-based national mental health plans as proposals to international
donors to fund start-up costs of services
Designate a senior public-health manager in the Ministry of Health with a specic role
to oversee implementation of the national mental health plan
Promote adoption and implementation of national mental health legislation in
accordance with international human-rights instruments
Allocate a greater share of available nancial resources for health for scaling-up of
mental health services, including a specic primary mental health care component
Implement new human-resource development programmes in mental health
Monitor progress through recommended indicators
Strengthen mental health perspectives for assessment of the health consequences of
macroeconomic policies
Strengthen policies with proven benets for the prevention of mental disorders
(eg, taxation of alcohol)
Governments of high-income countries
Increase resource allocation for mental health in international-development funding
and technical assistance
Invest in capacity building for mental health in low-income and middle-income countries
Mental health professional groups (eg, psychiatric societies)
Move from a focus on interventions for individuals to a population-wide focus, to
support the planning and implementation of scaling-up of services
Advocate for a national mental health system that provides a strong evidence-based
framework for eective interventions and human-rights protection
Actively support and supervise mental health care in primary care and collaboration
with community-based agencies
Actively enable reduction of long-term mental hospital beds and development of
community mental health programmes
Promote the priority research agenda in mental health
Strengthen public-health perspectives in higher training for mental health professionals
(Continues on next page)
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1248 www.thelancet.com Vol 370 October 6, 2007
agencies, donors (who have frequently ignored mental
health), mental health and public-health practitioners,
researchers, civil society, and consumers. This call is
presented in panel 3. The responsibilities of specic
stakeholders to achieve this call are set out in panel 4. We
now discuss the strategies and implications for
implementation of our call.
We estimate that the extra cost, over a ten-year period,
to increase coverage of the core package specied is not
large in absolute terms: it would require an additional
investment of around $020 per person per year for
low-income countries, and $030 for lower middle-income
countries, which would result in a target expenditure
of $2 and $34 per head, respectively. Such investment is
not large or startling when compared with estimated
funding requirements for tackling other major
contributors to the global burden of disease; for example,
the full estimated costs of scaling up a neonatal
health-care package to 90% coverage have been put
at $510 per capita,
14,15
and the cost of providing universal
access to basic health services has been estimated to
exceed $30 per person per year.
50,51
Thus, the development
or upgrading of mental health services in low-income
and middle-income countries need not be derailed on the
grounds that it will make unreasonable or excessive
demands on future budgetary allocations. Rather,
national and international health agencies and donors
need to change the priority given to mental health. A
considered plan of action and investment should take
into account local barriers to progress and development,
and address the key issues of human resources for health
and human rights. Our call for the coverage of services to
be increased is directed to many partners, but the primary
responsibility rests with governments and the multilateral
and donor agencies that shape national health policies in
low-income and middle-income countries, especially the
WHO, the World Bank, and other donors and lending
agencies. We also call on high-income countries, notably
the UK, US, Canada, and Australia, which have been the
main beneciaries of the brain drain of mental health
professionals from low-income and middle-income
countries, to play a leading part in provision of resources
to meet this call for action.
52
However, more funding will
not be enough. Funding needs to be distributed equitably
and used e cientlyand we call on the public-health
and mental health professional communities in
low-income and middle-income countries to be active
partners to enable this to happen.
In this Series we identied ve key barriers to service
development.
11
Our call for action is bound to fail unless
we can nd strategies, such as those in panel 5, to
overcome these key barriers.
The rst barrier is the absence of mental health from
the public-health priority agenda. If governments allocate
only a pittance for mental health within their health
budgets, and if donor interest is lacking, nancing of
mental health is threatened. Indeed, some donors have
set health priorities that exclude mental health, despite
demand for mental health coverage from countries and
communities. WHOs spending on mental health has
(Continued from previous page)
Public-health professional groups (eg, government departments, public-health
academics, and international and local non-government organisations)
Include mental health in health-systems development, capacity development for
public-health practitioners and research
Expand programmes for people with disability (such as community-based
rehabilitation) to include mental disabilities
Integrate mental health perspectives into public-health programmes for other
health conditions
Promote the priority research agenda in mental health
Service users and family-member groups
Become mobilised to advocate for an improved national mental health policy and
plan which provides eective interventions and human-rights protection
Network with other user and health movements to support implementation of the
improved national mental health plan
Strengthen family-support networks and service development
Social-sector stakeholders (eg, Departments of Social Welfare and Education)
Facilitate the provision of social support (housing, work, social networks) for people with
mental disorders, building on local resources and adding external resources as needed
Facilitate livelihoods and interventions for inclusion of people with mental disorders
in their local communities
Development of school mental health programmes that include interventions for
both mental health promotion and for early detection and inclusion of children with
mental disorders
Human Rights groups
Monitor and protect the human rights of the mentally ill
Advocate for the rights of people with severe mental disordersespecially those living
in mental hospitalsand for mechanisms to protect those rights
UN agencies
Advocate for an improved national mental health system that provides eective
interventions and human rights protection
Initiate or increase technical assistance and resource allocation to countries to address
mental health service development
Provide international leadership to agree on implementation strategies for
development of services in low-income and middle-income countries
Improve coordination between UN agencies for mental health interventions
World Bank, other development banks, donor agencies in high-income countries,
philanthropists
Solicit technically sound proposals and appropriately fund scaling-up of mental health
services (especially funding for start-up costs)
Integrate scaling-up of mental health with existing development and health programmes
Invest in strengthening capacity of service users and family groups for advocacy and
support networks
Research funding agencies
Increase resources for priority mental health research in health systems and for
scaling-up of interventions
Develop capacity for sustained public mental health research in low-income and
middle-income countries
Series
www.thelancet.com Vol 370 October 6, 2007 1249
consistently remained below 1% of total programme
spending, though spending in total has increased.
Although several multilateral agencies, such as the World
Bank and UN agencies, have mentioned mental health
(often under the broad umbrella of psychosocial
interventions) as an important need, most have neither
committed sustained support for mental health action,
nor coordinated eorts to help countries attain basic
mental health goals. We are gravely concerned that,
despite the evidence reviewed in this Series, mental
health does not gure in any of the major new
global-health initiatives launched in recent years
53
that
have funding of several billion dollars. We concur with
concerns that the opportunities presented by this massive
increase in nancial resources for global health could do
more harm to health systems than good unless the goals
are broadened to strengthen basic health systems to
address a range of common health problems.
54
Absence
from the public-health priority agenda has serious
implications for implementation of mental health
policies, because mental health reform
11
requires political
will to overcome political risks when reforms threaten
the interests of unions, professional groups, or specic
government departments.
Unied and concerted advocacy is necessary to create
political will; such advocacy must target political leaders,
governmental and non-governmental agencies, and
donors. This advocacy eort must strengthen
collaboration with users of mental health services and
their families; these potentially powerful groups have
frequently not been engaged as equal partners, and have
not been eectively mobilised in mental health advocacy.
This Series provides a strong evidence base to inform
this advocacy drive. Our call for actionto scale up
services for mental disordersprovides a coherent,
evidence-based, and consistent message for advocacy.
The second barrier is the organisation of mental health
services. Thus, present mental health services are largely
centralised, with inadequate human rights protection
and weak links with community mental health and
general-health services. All centralised systems resist
change. The power, inuence, and funds for mental
hospitals need to be systematically and substantially
reduced as part of the reform of mental health systems.
However, funding for centralised mental hospitals
should be reallocated towards establishment of a
comprehensive range of mental health services,
including development of acute psychiatric units in
general hospitals, accessible psychiatric outpatient
clinics, integration of mental health into primary health
care, and community-based residential care and day
services. Other strategies to overcome this barrier
include incentive arrangements to overcome vested
interests that might block change; training and
supervision for sta at dierent levels of the health
system; and provision of adequate resources to work in
communities. Development of community-based
services will inevitably mean that concurrent running
costs for mental hospitals will have to be met during the
establishment of community-based services.
The third barrier, which is related to the second one, is
that although integration of mental health care into
primary health care is a popular policy recommendation
and some serious implementation eorts have been
made in the past, mental health care has not yet been
integrated in most countries. Primary health-care
systems in many low-income and middle-income
countries are excessively burdened, and there is a need
for regular supervision and specialist support for primary
mental health care. Therefore, innovative models of
primary health-care service provision, which have
Panel 5: Goals and strategies to scale up services for people with mental disorders
Place mental health on the public-health priority agenda
Develop and use uniform and clearly understandable messages for mental health
advocacy
Conduct advocacy in a coordinated manner with key stakeholders, including service users
Educate decisionmakers within governments and in donor and multilateral agencies
about the importance of mental disorders to public health and the cost eectiveness
of mental health care
Improve organisation of mental health services
Develop national policies, plans, and legislation to enable decentralisation of resources
and development of services in the community
Address incentive arrangements to overcome vested interests that block change
Provide the funds for concurrent running costs for mental hospitals and community
services, while infrastructure for community services is being developed
Organise international technical support to share lessons from countries that have
experienced successful mental health reform
Integrate the availability of mental health in general health care
Develop innovative models to ensure mental health care in primary health care, with
low-cost human resources for screening and provision of interventions, and
strengthening close links to specialist services
Provide a specic mental health budget in primary health care to fund additional
human resources, essential psychotropic medications, and specialist supervision
Appoint and train mental health professionals specically to support and supervise
primary health-care sta
Develop human resources for mental health
Improve quality of mental health training, to ensure that it is practical and occurs in
community or primary-care settings
Increase and diversify the professional and specialist workforce
Expand the non-specialist workforce to incorporate, where possible, ex-service users
and their family members
Provide the nancial means for ongoing supervision of trained workers
Strengthen public mental health leadership
Provide short courses and exchange opportunities for leaders in mental health and
public health
Appoint general public-health leaders to mental health leadership positions if necessary
Provide core training in public mental health to all university students trained in
mental-health care and to graduate degree students in public health, community
development, and public administration
Series
1250 www.thelancet.com Vol 370 October 6, 2007
additional human resources for screening patients and
for provision of ongoing support and supervision of
primary health-care providers, need to be implemented.
For example, Chile has implemented a pioneering model
for treatment of depression in primary care.
8

Mental health professionals will need to be retrained on
their role as trainers and supervisors in this process, as
will primary health-care sta in the recognition and
management of mental disorders. Primary health-care
budgets should therefore have a specied mental health
care component to fund supervision by mental health
specialists, in addition to funding of essential
psychotropic drug and psychosocial treatments.
The fourth barrier is caused by the very inadequate
human-resource base for scaling up mental health
interventions. We propose concurrent and systematic
training of more specialist professionals and expansion
of the non-specialist professional workforce. Countries
need to increase their capacity to train mental health
professionals and to enhance the scope and quality of
essential mental health training in their general-health
professionals. This capacity building will require
appointment of mental health specialists, who are
designated to train and supervise workers in primary and
general health-care settings. The non-formal workforce,
such as community volunteers and people with mental
disorders and their family members, must be included as
valuable resources who can supplement formal
mental health care.
The nal barrier is likely to be the scarcity of eective
public mental health leadership in most countries.
Mental health professionals who assume positions of
power within the ministries and departments of public
health all too often have insu cient knowledge and skills
to plan population-level interventions. On the other hand,
public-health leaders in most low-income and
middle-income countries tend to lack essential
mental health knowledge. More short courses and
exchange opportunities should be made available, but we
also need to develop more public-health skills in
mental health leaders, and mental health skills in
public-health practitioners, in a sustainable way. One of
the greatest public-health actions in the past century was
the establishment of public-health schools at major
universities, mostly in high-income countries. Many
low-income and middle-income countries are now also
expanding their public-health training infrastructure. We
strongly recommend that universities and training
institutes in all countries integrate mental health into
public-health training and establish public mental health
courses that cover policy, legislation, organisation of
services, prevention, and the epidemiology of mental
disorders and their risk factors.
Conclusion
We intend that this Series should provide ammunition
for advocacy by stakeholders in global mental health.
They must press for the reforms that are urgently needed
if people with mental disorders in low-income and
middle-income countries are to receive the basic care
that is eective, aordable and, above all, morally
justied. We know how mental disorders aect the
development potential of individuals and communities;
we have identied simple and eective treatments for
mental disorders; we know that scarce resources are
often used inappropriately or are inequitably distributed;
we understand better why the necessary reforms have
not been implemented; and we have a clear and consistent
call for action to scale up services and the strategies
needed to guide action in response to this call. As the
Lancet Global Mental Health Group, we commit ourselves
to hosting a Global Mental Health Summit in two years
time to take stock of the eect of our call. Change in
public health only comes about if three core elements are
present: a knowledge base, strategies to implement what
we know, and the political will to act.
55
In this Series, we
have presented the knowledge base and the strategies to
improve mental health. Now we need political will and
solidarity, from the global-health community, to put this
knowledge to use. The time to act is now.
Contributors
DC, AF, CL, VP, SS, GT, and MT developed the questions addressed in
this paper and gathered the information to answer them. Contributions
were sought from all members of the Lancet Global Mental Health
Group in four rounds of reviews and revisions of this manuscript. All
authors have seen and approved the nal version.
Acknowledgments
The Lancet Global Mental Health Series has been supported by a grant
from the John D and Catherine T MacArthur Foundation. BS, SS, MVO
and DC are employees of WHO; the views expressed in this article do
not necessarily represent the decisions, policy, or views of WHO.
Lancet Global Mental Health Group
Department of Psychiatry, Faculty of Medicine, Addis Ababa University,
Addis Ababa, Ethiopia (A Alem PhD); University of Bristol, Division of
Community Based Medicine, Bristol, UK (Prof R Araya PhD); Carter
Centre, Atlanta, GA, USA(Prof T Bornemann Ed.D); Sangath, Goa, India
(Sudipto Chatterjee MD, Prof V Patel PhD); Department of Health
Systems Financing (D Chisholm PhD), and Department of Mental
Health & Substance Abuse (B Saraceno MD, S Saxena MD,
M van Ommeren PhD) World Health Organization, Geneva,
Switzerland; Department of Social Medicine, Harvard Medical School,
Boston, USA (A Cohen PhD); Department of Epidemiology &
Population Health, London School of Hygiene & Tropical Medicine,
London, UK (M J De Silva PhD, S Plagerson MSc,
Prof B Kirkwood FMedSci, Prof V Patel PhD); Division of Child and
Adolescent Psychiatry and Adolescent Health Research Institute,
University of Cape Town, Rondebosch, South Africa and Research
Centre for Health Promotion, University of Bergen, Bergen, Norway
(Prof A J Flisher PhD); Department of Psychiatry, University of Ibadan,
University College Hospital, Ibadan, Nigeria (Prof O Gureje DSc);
London School of Hygiene and Tropical Medicine, London, UK
(Prof A Haines MD) Institute of Psychiatry, Faculty of Medicine,
University of Oslo, and Department of Psychiatry, Ulleval University
Hospital, Oslo, Norway (Prof Edvard Hau PhD); Australian
International Health Institute, University of Melbourne, Melbourne,
Australia (Prof H Herrman MD); Christian Medical College, Vellore,
India (Prof K S Jacob MD); Vrije Universiteit Medisch Centrum
Amsterdam, Netherlands, and Boston University School of Medicine,
Boston, USA (Prof J T V M de Jong MD); Department of Psychiatry and
Mental Health, University of Cape Town, Rondebosch, South Africa
(C Lund PhD); Department of Psychiatry, Second University of Naples,
Series
www.thelancet.com Vol 370 October 6, 2007 1251
Naples, Italy (Prof M Maj PhD); Universidade Federal de So Paulo,
Department of Psychiatry, So Paulo, Brazil (Prof J de Jesus Mari PhD);
Department of Public Health, Temple University College of Health
Professions, Philadelphia, PA, USA (J Maselko ScD); Department of
Epidemiology and Psychosocial Research, Ramn de la Fuente Muiz
National Institute of Psychiatry, Mexico City, Mexico
(Prof E Medina-Mora PhD); Centre for International Mental Health,
University of Melbourne, Melbourne, Australia (H Minas FRANCZP);
Institute of Psychiatry, Rawalpindi Medical College, University of Health
Sciences, Rawalpindi, Pakistan (Prof I Mirza MRCPsych,
K Saeed FCPS (Psych), A Rahman PhD); Beijing Suicide Research and
Prevention Center, Beijing Hui Long Guan Hospital, China and
Departments of Psychiatry and Epidemiology, Columbia University,
USA (Prof M R Phillips MD); Department of Health Services Research,
Institute of Psychiatry, Kings College London, UK
(Prof M Prince MD, Prof G Thornicroft PhD); Division of Psychiatry,
University of Manchester, UK (A Rahman PhD); Department of
Psychiatry, Clinical Hospital, University of Chile, Chile
(Graciela Rojas MD); Association for the Improvement of Mental Health
Programmes, Geneva, Switzerland (Prof N Sartorius MD); Department
of Psychiatry, University of Stellenbosch, Bellville, South Africa
(Prof S Seedat PhD); Department of Social Development, University of
Cape Town, Rondebosch, South Africa (S Sturgeon MSocSc-ClinSW);
Schizophrenia Research Foundation, Chennai, India (R Thara PhD);
Health Systems Research Unit, Medical Research Council, South Africa,
and Department of Psychology, University of Stellenbosch, Bellville,
South Africa (M Tomlinson PhD); and School of Population Health,
University of Queensland, Brisbane, Australia (Prof H Whiteford MD)
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