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This article describes the influence war and basic necessity shortages have on trauma development within a population. This is especially prevalent in children where trauma can disrupt cognitive, emotional, and social development causing later adverse mental health outcomes.

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ABSTRACT

Exposure to trauma is pervasive in societies worldwide and is associated with substantial costs to the individual and society, making it a significant global public health concern. We present evidence for trauma as a public health issue by highlighting the role of characteristics operating at multiple levels of influence - individual, relationship, community, and society - as explanatory factors in both the occurrence of trauma and its sequelae. Within the context of this multi-level framework, we highlight targets for prevention of trauma and its downstream consequences and provide examples of where public health approaches to prevention have met with success. Finally, we describe the essential role of public health policies in addressing trauma as a global public health issue, including key challenges for global mental health and next steps for developing and implementing a trauma-informed public health policy agenda. A public health framework is critical for understanding risk and protective factors for trauma and its aftermath operating at multiple levels of influence and generating opportunities for prevention.

KEYWORDS: Trauma, public health, prevention, early intervention, traumatic stress, disaster

PALABRAS CLAVE: Trauma, salud pública, prevención, intervención temprana, estrés traumático, desastre

关键词: 创伤, 公共健康, 预防, 早期干预, 创伤应激, 灾难

HIGHLIGHTS: * Exposure to trauma is pervasive in societies worldwide and is associated with substantial costs to the individual and society, making it a significant global public health concern.* We present factors at individual, relationship, community, and society levels-as explanatory factors in both the occurrence of trauma and its sequelae.* We highlight targets for prevention of trauma and early intervention at all of these levels.* We describe the essential role of public health policies in addressing trauma as a global public health issue.

La exposición al trauma es general en las sociedades de todo el mundo y está asociada con costos sustanciales para el individuo y la sociedad, lo que la convierte en un importante problema mundial de salud pública. Presentamos evidencia del trauma como problema de salud pública al destacar el papel de las características que operan en múltiples niveles de influencia -individuo, relación, comunidad y sociedad- como factores que explican tanto la ocurrencia del trauma como sus secuelas. En el contexto de este marco multi-nivel, destacamos objetivos para la prevención del trauma y sus consecuencias posteriores, y ofrecemos ejemplos de los casos en que los abordajes preventivos de salud pública han tenido éxito. Por último, describimos el papel esencial de las políticas de salud pública a la hora de abordar el trauma como problema de salud pública mundial, incluyendo los retos clave para la salud mental global y los próximos pasos para desarrollar e implementar una agenda de políticas de salud pública. Un marco de salud pública es fundamental para comprender los factores de riesgo y de protección para el trauma y sus secuelas, que operan en múltiples niveles de influencia y generan oportunidades de prevención.

摘要：创伤暴露在世界范围的社会中都普遍存在，且对个人和社会造成了重大的损失。这使得创伤暴露成为了一个显著的世界公共健康问题。我们强调有特色的应对（characteristics operating）在多重水平上（个人、关系、社区和社会）的影响是创伤的发生及其后果的解释因素，从而提出创伤是公共健康问题的证据。在这一多水平框架的背景下，我们强调了预防创伤的目标和随之带来的后果，并举出利用公共健康方法成功预防创伤的例子。最终，我们描述了公共卫生政策在解决作为全球公共健康问题的创伤时扮演的重要角色，全球精神健康面临的关键挑战，以及发展和实施针对创伤的公共健康政策日程的未来步骤。不论是理解创伤的危险和保护因素以及创伤后应对方式在多重水平上的影响，还是促发预防机会，公共健康框架都至关重要。

1. Public health impact of trauma

Exposure to trauma is pervasive in societies worldwide. Population-based data from various countries indicate that a majority of adults will experience a traumatic event at some point in their lives, despite cross-national variation in the prevalence of specific types of traumatic events (Benjet et al., 2016; Burri & Maercker, 2014). Trauma exposure is also common in children and adolescents around the world. A substantial proportion of children globally are exposed to trauma as a result of armed conflict, natural disasters, and other humanitarian emergencies (World Health Organization, 2013b). An estimated 230 million children currently live in countries impacted by armed conflicts (UNICEF, 2014), which increases risk of experiencing displacement, witnessing violence and death, and being orphaned, kidnapped, raped, or recruited as child soldiers (UNICEF, 2009).

Traumatic events do not only occur at random, but can be influenced by individual characteristics, peer group relationships, community characteristics, and socio-political factors. At the individual level, for example, the likelihood of experiencing particular types of trauma varies by sex, age, race/ethnicity, and sexual orientation (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; McLaughlin et al., 2013; Rees et al., 2011). Community and socio-political factors also influence the likelihood of trauma occurrence across geographic locations. Certain types of traumas (e.g. violence) are more likely to occur in certain locations (e.g. metropolitan areas and conflict zones) (McLaughlin et al., 2013; Perkonigg, Kessler, Storz, & Wittchen, 2000). Moreover, different communities will have diverse trauma recovery trajectories based on their pre-trauma community characteristics (Nakagawa & Shaw, 2004). Thus, it is important not to overlook these characteristics in considering both trauma exposure and outcome.

The public health impact of trauma exposure is staggering for both communities and individuals. Catastrophic events such as natural and man-made disasters and terrorist attacks can have devastating effects on the social fabric of society and communities, not only involving injuries and loss of life, but also related to property destruction and infrastructure damage. This aftermath, coupled with high levels of resulting migration, can create prolonged disruption in the delivery of social services and the dissolution of social support networks. These community-level consequences can persist for lengthy periods, often fundamentally changing the physical and social landscape of a community (Galea et al., 2002; Hollifield et al., 2008; Rosenbaum, 2006). Low and middle income countries (LMICs) are disproportionately affected. Collective violence (e.g. war, genocide) is 10 times more common in LMICs versus high income countries (HICs) (World Health Organization, 2002), and LMICs carry the brunt of migration problems caused by disasters and violence. In 2015, 65.3 million people were forcibly displaced, the vast majority from LMICs. According to the United Nations High Commission for Refugees (UNHCR), the top hosting countries are Turkey (2.5 million), Pakistan (1.6 million), Lebanon (1.1 million), and Iran (1.0 million).

Exposure to trauma is particularly detrimental when it occurs in childhood or adolescence, disrupting numerous aspects of development in cognitive, emotional, and social domains, leading to adverse mental health and educational outcomes (Cicchetti & Toth, 1995; Koenen, Moffit, Caspi, Taylor, & Purcell, 2003) with long-term consequences for learning and memory (Teicher, Anderson, & Polcari, 2012), emotional functioning (De Bellis et al., 1994; McCrory et al., 2011; McLaughlin & Hatzenbuehler, 2009; Pollak & Sinha, 2002; Pollak, Vardi, Putzer Bechner, & Curtin, 2005), social relationships, elevated risk of re-victimization (Cole & Putnam, 1992; DiLillo, 2001; Follette, Polusney, Bechtle, & Naugle, 1996), and mental disorders (Kilpatrick et al., 2003; McLaughlin et al., 2012, 2013).

Post-traumatic stress disorder (PTSD), which is inextricably linked with trauma, is in itself a profound public health burden. Individuals who develop PTSD following trauma experience impaired role functioning and reduced life course opportunities (Kessler, 2000). PTSD was associated with high levels of disability, and in developing countries disability associated with PTSD was higher than most common medical conditions except for headaches and chronic pain (Ormel et al., 2008). The economic costs of PTSD are staggering, with work impairment associated with the disorder estimated at 3.6 days per month per person with PTSD. The annual lost productivity due to PTSD is estimated at over $3 billion dollars in the U.S. alone (Kessler, 2000).

Because the development of PTSD is conditional on trauma exposure, PTSD may be the most preventable of mental disorders. We have the unique opportunity to reduce the population burden of PTSD both by preventing trauma exposure and by delivering timely interventions in the wake of trauma to those most at risk. The following sections explore these opportunities based on a public health approach, extending previous work (Magruder, Kassam-Adams, Thoresen, & Olff, 2016) by expanding examples and policy implications.

2. Public health model of traumatic stress

Current approaches to public health are explicitly multi-level and concerned with identifying causes of health states (Krieger, 1994; Susser, 1998) with the ultimate goal of preventing disease onset. With problems that have a behavioural component, a public health model encompasses factors operating at multiple levels of influence, such as family, school, and cultural levels (see Figure 1) (Bronfenbrenner, 1979) (Dahlberg & Krug, 2002).

In the case of trauma-related problems, the important components are the trauma itself, those who are exposed to trauma, their relationships, the variety of environmental factors playing a role in shaping the likelihood of both trauma exposure and outcome, and societal factors, attitudes, and characteristics that influence trauma likelihood and intervention. Such a multi-level approach provides a public health framework for developing an array of strategies aimed at preventing the occurrence and sequelae of trauma. Furthermore, these levels can be considered as points of intervention and opportunities for prevention. The classic prevention framework includes three levels: primary; secondary; and tertiary (Commission on Chronic Illness, 1957). The aim of primary prevention is to prevent the actual occurrence of the disease or illness. The purpose of secondary prevention is to intervene early in the disease process for cure or optimal outcomes. Tertiary prevention is aimed at preventing the disability that accompanies an illness or disease. Each of these levels of prevention can be implemented at different system levels, including society at large, the community, the family, and the individual. Subsequently, risk and protective factors can be translated into multi-sectoral, multi-modal, and multi-level preventive interventions (De Jong, 2010; Wiist et al., 2014). Table 1 provides a few examples of prevention strategies at each level.

Table 1.

From a public health perspective, preventing exposure to trauma is an obvious strategy, and such efforts can be targeted to all levels of the social-ecological model. A number of strategies are aimed at reducing the likelihood of trauma exposure in individuals. Alcohol education programmes for young adults, such as those implemented on U.S. college campuses, can reduce high-risk drinking which in turn may reduce exposure to traumatic events like physical and sexual assaults, accidents, or motor vehicle accidents (Katz & Moore, 2013). At the relationship level, there are programmes to strengthen the abilities and sensitivity of family caregivers as well as programmes to prevent bullying in schools. At the community level, examples include lighting parking lots, streets, and campuses to prevent crime. Even design of highways to reduce traffic accidents can be seen as an environmental response to reduce motor vehicle accidents and thus reduce trauma occurrence. Other examples include neighbourhood watch programmes to prevent crime and community members preventing sexual assaults in refugee camps. At the societal level, some traumas can be prevented by promoting appropriate social norms. For example, policy changes in Australia have been successful at reducing firearms deaths and injuries (Chapman, Alpers, Agho, & Jones, 2006). Because alcohol consumption is price sensitive, especially for those under 21 years old in the U.S., changes in pricing of alcohol have been proposed as a means of reducing hazardous drinking, and thereby reducing alcohol-related traumatic events, such as family violence and crimes (Chaloupka, 1993; Chaloupka, Grossman, & Saffer, 1998; Presley, Meilman, & Leichliter, 2002). Many targets are not thought of as trauma prevention even though they serve as such, for example, increased screening at airports and at major events (e.g. World Cup). Even seemingly unrelated approaches such as improving education levels, eradicating poverty, and decreasing social inequality may have positive primary prevention outcomes because these factors are important predictors of health, mental health, and human rights (Daar et al., 2007).

From some of these examples, it is clear that efforts aimed at preventing trauma may have multiple beneficial outcomes. In the case of reducing the number of motor vehicle accidents, physical trauma and death are the primary targets, and psychological sequelae are the secondary. The same is true of the United Nations' (UN) efforts to decrease political violence, to install war tribunals and prosecute perpetrators, and to stimulate efforts to have international laws which condemn human rights violations or ban landmines, or similarly when governments attempt to prevent mass terrorist attacks or the re-emergence of violence. Disaster preparedness training can also have a preventive effect, such as setting quality standards for buildings in earthquake- or landslide-prone areas or river beds, setting higher quality standards for the construction of nuclear power stations, providing better access to land in areas with landslides, creating better alarm systems for floods, cyclones, or hurricanes, and providing sheltered areas and evacuation plans in regions that are hit by volcano eruptions or typhoons (De Jong, 2011).

Secondary prevention can also be directed at various levels. Early intervention with those who have been trauma exposed and are symptomatic focuses on individuals within various settings and environments (rather than focusing on environments per se). There is evidence that for those exposed to trauma and disasters, ongoing non-traumatic stressors are also predictive of PTSD onset and course (as well as for other problems, such as alcohol use disorders) (Cerdá et al., 2013, 2014). Thus, minimization of these ongoing stressors may prevent the onset of PTSD and other psychiatric disorders. In fact, humanitarian relief operations aimed at large populations often focus on shelter, food, water, sanitation, and physical disease control. Evidence suggests that individual-level secondary prevention interventions aimed at bolstering resilience and reducing the likelihood of adverse effects following trauma are effective. For example, the military in several countries have developed pre-deployment programmes to prevent PTSD (Hourani, Council, Hubal, & Strange, 2011), and a recent meta-analysis suggests that intervention within one month can be effective in children and adolescents following a single trauma exposure (Kramer & Landolt, 2011). At the relationship level, examples include shelters for survivors of domestic violence, interventions aimed at couples where domestic violence has already occurred, and foster care for children who are abused or neglected and unable to live with their parents or another relative. Some secondary prevention approaches focus on communities. For example, community support, as in the case of vigils for survivors and their families following disasters or mass violence, is often seen as helpful. Safety considerations, such as providing food and shelter and reuniting families post-disaster, may go a long way to reassure disaster survivors and prevent the development of mental health symptoms. Such support and intervention does not occur successfully in poorly organized or disenfranchised communities; thus, efforts to develop and promote strong proactive communities and build capacity to respond to disasters can also be seen as secondary prevention (Laborde, Magruder, Caye, & Parrish, 2013). From the societal point of view, policies that promote early intervention are also helpful as secondary prevention measures.

With the aim of preventing the progression of disease and disability, most tertiary prevention programmes are squarely in the clinical arena and are seen as part of standard treatment for PTSD or other trauma-related mental health problems; however, there are some examples of societal level tertiary prevention. For example, in the international arena tertiary prevention may aim at peace-keeping and peace-enforcing troops, as well as peace agreements to prevent the reemergence of political violence. Lower rates of PTSD have been found in states that have legislated legal protections for lesbian, gay, bisexual, and transgendered individuals as compared to states that do not have protective legislation (Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010). Similarly, promotion of reconciliation and mediation skills between groups on the community level may be seen as tertiary prevention (De Jong, 2011). On the family and personal level, most tertiary prevention programmes aim at preventing the progression of disease and disability, and are seen as part of standard treatment for PTSD or other trauma-related mental health problems.

Recasting traumatic stress treatment as an approach to prevent the development of comorbidities (e.g. depression and substance use disorders) and to improve functioning (even if not eliminating symptoms entirely) may open the door for novel clinical approaches. For example, the use of support dogs may improve functioning and reduce disability by enabling someone with traumatic stress to enjoy greater societal participation - even if symptoms are not completely alleviated (Krause-Parello, Sami, & Padden, 2016). At the relationship level, there is evidence that training foster parents of children with significant psychological problems resulting from trauma exposure may help to prevent the development of additional problems (Leve et al., 2012). As with secondary prevention, both community and societal support can also be helpful. They can help to establish service availability and to promote use of services by reducing stigma.

3. The essential role of public health policies

Effective public policies can help to shape societal norms concerning public health issues and are ideally informed by an evidence base. Such policies have been critical in securing the 10 great public health achievements of the twenty-first century, including tobacco control, motor vehicle safety, and prevention and control of infectious diseases (Centers for Disease Control and Prevention, 2011). Policies must focus on preventing traumatic events, when possible, providing early intervention services for survivor communities at risk of poor post-trauma outcomes, and reducing stigma. There are currently several overarching mental health policy challenges facing communities and countries plagued by violence and trauma. Because trauma and mental health issues are inextricably linked, they also share many challenges.

Mental health issues (and thus trauma-related issues) have largely been ignored as a priority in the global public health agenda (Saracena et al., 2007; Saxena & Skeen, 2012). For example, the UN Millennium Development Goals (MDGs), a set of development targets agreed to by the international community, failed to include any specific focus on mental health or trauma (Saxena & Skeen, 2012). The main focus of the recent World Health Organization (WHO) Global Action Plan for the Prevention and Control of NCDs is on four specific types - cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes - and on four shared behavioural risk factors - tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Among the other conditions of public health importance that are explicitly mentioned in the plan are mental disorders, violence, and injuries (World Health Organization, 2013a). This indicates that mental health is beginning to gain impetus alongside other leading public health policy priorities; however, until full parity exists for mental health concerns, the issue of preventing trauma and intervening early in its aftermath will fail to receive sufficient global attention as a policy priority.

Much work remains ahead to understand the nature and treatment of mental disorders in global context. Greater investment is needed in global mental health research in high, middle, and low income countries. Cross-national population-based initiatives, such as the World Mental Health Surveys, can play an important role in understanding the prevalence, impact, and health systems' response to mental disorders (Patel, 2012). More research is needed to comprehend the broad physical health, mental health, and developmental impacts of childhood polyvictimization (Felitti et al., 1998; Finkelhor, Ormrod, & Turner, 2007). Additional priorities for improving global mental health research include a focus on adequately training researchers around the world, ensuring a bi-directional flow of information and partnerships in the global mental health research community (Patel & Prince, 2010). Recommendations for building global trauma research capacity include: providing quality training and distance learning opportunities, supporting international fellowships, promoting memberships in collaborative research teams, improving accessibility of the scientific literature, and encouraging researchers to share their knowledge with policymakers and key stakeholders (Fodor et al., 2014). Unlike other service sectors that rely heavily on equipment or supplies, mental health services are primarily dependent on human resources (World Health Organization, 2011). Many have identified shortcomings of the current global mental health workforce, including limitations on the number and types of workers trained in mental health care, perhaps due to poor working conditions and low status associated with the mental health professions (Saracena et al., 2007).

According to WHO, an immediate and sizeable investment is needed to scale up a well-trained global mental health workforce. One method suggested for expanding the workforce is task shifting, or redistribution of tasks from highly qualified health workers to health workers with shorter training and fewer qualifications (World Health Organization, 2008). An example of a task shifting approach is WHO's Problem Management Plus, a low-intensity intervention for adults with symptoms of common mental health problems. This intervention uses lay helpers supervised by skilled mental health professionals in communities exposed to adversity (Dawson et al., 2015). In addition to more general mental health workforce strategies, several important efforts are underway by leaders in the trauma field to develop trauma-focused competencies to help mental health professionals build foundational trauma knowledge and skills (Bisson et al., 2010; Cook, Newman, & The New Haven Trauma Competency Group, 2014; Layne et al., 2014).

In many countries, a wide gap exists between the need for mental health services and the availability of treatment (World Health Organization, 2011). This is particularly challenging for LMIC, which are home to over 80% of the global population, but utilize less than 20% of the mental health resources (Saxena, Thornicroft, Knapp, & Whiteford, 2007). Worldwide there exists a troubling cycle of disadvantage, social exclusion, and mental disorders. The consequent treatment gap is a contravention of basic human rights, as more than 75% of those identified with serious anxiety, mood, impulse control, or substance use disorders in the World Mental Health surveys in LMIC received no care at all, despite substantial role disability. Further, mental health resources are often inequitably distributed among countries, regions, and within communities. Such inequities can occur in access to care, use and outcomes of care, and by geographic region, race/ethnicity, gender, sexual orientation, and socioeconomic status (Ngui, Khasakhala, Ndetei, & Roberts, 2010). Governments must invest more of their health budgets toward these inequities in order to adequately address mental health and trauma-focused prevention and early intervention.

Much attention around the world has focused on the benefits of integrating mental health care into primary care and other settings where people receive services (Ngui et al., 2010; Patel & Prince, 2010; World Health Organization, 2001). Such integration of physical and mental health care is especially important for trauma-exposed populations, as they often seek help in primary care rather than mental health settings (U.S. Department of Veterans Affairs, 2002). While much of the global population is only seen in primary care, mental health issues (such as PTSD) often go undiagnosed in this setting (Üstün & Sartorius, 1995). Further, physical disease is often accompanied by psychological morbidity that is not always recognized by primary care providers (World Health Organization, 2001). The fact that medical comorbidities often develop with PTSD (and other psychiatric disorders) is yet another reason that primary care clinicians need training on the recognition and treatment of mental health conditions.

Many efforts are underway to integrate physical and mental health and provide trauma-informed training to health care providers, including in the Department of Veterans Affairs in the U.S. and a variety of European countries. This includes a policy of routine screening by health care providers for trauma exposure and resources to assist providers in addressing trauma and PTSD in primary care (U.S. Department of Veterans Affairs, 2002). Similar practices and policies are underway in other systems around the world; however, integration of mental health and trauma-informed services remains the exception and not the rule in many communities. Many suggest that a true public health approach requires mental health integration beyond primary care to include sectors such as education, justice, welfare, and labour through partnerships with government, non-governmental organizations, and the faith-based community (Collins, Insel, Chockalingam, Daar, & Maddox, 2013; Ko et al., 2008),

Stigma associated with mental health issues, such as traumatic stress, can serve as a barrier to mental health treatment and positive outcomes. According to the WHO (World Health Organization, 2010), those with mental health conditions are the most marginalized and vulnerable groups in society and may face restrictions in exercising their political and civil rights. In addition, they can have difficulty accessing health care, social services, and educational and employment opportunities. Efforts to address stigma and discrimination related to mental health issues are underway. Among the strategies used include social activism, public education, and contact with persons with mental illness. A recent meta-analysis of outcome studies revealed that both education and contact had positive effects on reducing stigma for adults and adolescents with a mental illness (Corrigan, Morris, Michaels, Rafacz, & Rusch, 2012).

4. Summary

A public health framework is critical for understanding risk and protective factors for trauma and its aftermath operating at multiple levels of influence and generating opportunities for prevention at each of these levels. Primary prevention efforts should be aimed at preventing exposure to trauma itself. Secondary prevention should be directed at the prevention of trauma-related sequelae, in particular post-traumatic stress disorder. Tertiary prevention should slow the progression of trauma-related illness and disability. Advantages to adopting a public health approach to trauma include involvement of families, communities, and policymakers - making them more informed, activated, and supportive of prevention and early intervention efforts. The task is not easy, as trauma is a general term that encompasses a variety of experiences that range from rape to earthquakes. Preventive efforts will be vastly different for different traumas; thus, public health trauma advocates may need to form strategic alliances with unlikely partners, for example, highway safety officials concerned with traffic accidents, university officials concerned with sexual assaults, or government officials in areas at high risk for natural disasters. Furthermore, given the global nature of trauma, approaches may need to adapted for different cultures. Despite these challenges, there have been some modest successes in implementing mental health and trauma policies around the world. Building on these successes will help to establish a public health approach to trauma.

Disclosure statement

No potential conflict of interest was reported by the authors.

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Exposure to trauma is pervasive in societies worldwide and is associated with substantial costs to the individual and society, making it a significant global public health concern. We present evidence for trauma as a public health issue by highlighting ...

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This article article connects war with the effects it has on mental health. The types of mental health issues that come out of war-torn countries and their citizens include trauma and physical/emotional support. In terms of types of population, women and children have a high prevalence of mental disorders.

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The year 2005 is significant in understanding the relationship between war and mental health. This is the 30th anniversary of the end of the Vietnam war and of the start of the war in Lebanon. Every day the media bring the horrors of the ongoing "war" situation in Iraq. Some recent quotations from the media depict the impact of war on mental health: "We are living in a state of constant fear" (in Iraq); "War takes a toll on Iraqi mental health"; "War trauma leaves physical mark"; "War is hell... it has an impact on the people who take part that never heals"; "War is terrible and beyond the understanding and experience of most people"; "A generation has grown up knowing only war".

Wars have had an important part in psychiatric history in a number of ways. It was the psychological impact of the world wars in the form of shell shock that supported the effectiveness of psychological interventions during the first half of the 20th century. It was the recognition of a proportion of the population not suitable for army recruitment during the Second World War that spurred the setting up of the National Institute of Mental Health in USA. The differences in the presentation of the psychological symptoms among the officers and the soldiers opened up new ways of understanding the psychiatric reactions to stress.

During the last year, a large number of books and documents have addressed the effects of war on mental health. They include the WPA book "Disasters and mental health" ( 1); the World Bank report "Mental health and conflicts - Conceptual framework and approaches" ( 2); the United Nations (UN) book "Trauma interventions in war and peace: prevention, practice and policy" ( 3); the United Nations Children's Fund (UNICEF) document "The state of the world's children - Childhood under threat" ( 4); the book "Trauma and the role of mental health in postconflict recovery" ( 5) and a chapter on "War and mental health in Africa" in the WPA book "Essentials of clinical psychiatry for sub-Saharan Africa" ( 6).

Though there have not been any world wars since the Second World War, there have been wars and conflicts throughout the last 60 years. For example, in the 22 countries of the Eastern Mediterranean region of the World Health Organization (WHO), over 80% of the population either is in a conflict situation or has experienced such a situation in the last quarter of century ( 7).

War has a catastrophic effect on the health and well being of nations. Studies have shown that conflict situations cause more mortality and disability than any major disease. War destroys communities and families and often disrupts the development of the social and economic fabric of nations. The effects of war include long-term physical and psychological harm to children and adults, as well as reduction in material and human capital. Death as a result of wars is simply the "tip of the iceberg". Other consequences, besides death, are not well documented. They include endemic poverty, malnutrition, disability, economic/ social decline and psychosocial illness, to mention only a few. Only through a greater understanding of conflicts and the myriad of mental health problems that arise from them, coherent and effective strategies for dealing with such problems can be developed.

The importance that the WHO attributes to dealing with the psychological traumas of war was highlighted by the resolution of the World Health Assembly in May 2005, which urged member states "to strengthen action to protect children from and in armed conflict" and the resolution of the WHO Executive Board in January 2005, which urged "support for implementation of programmes to repair the psychological damage of war, conflict and natural disasters" ( 8).

The WHO estimated that, in the situations of armed conflicts throughout the world, "10% of the people who experience traumatic events will have serious mental health problems and another 10% will develop behavior that will hinder their ability to function effectively. The most common conditions are depression, anxiety and psychosomatic problems such as insomnia, or back and stomach aches" ( 9).

This paper briefly reviews the evidence from published literature about the impact of war on the mental health of the general population, the refugees, the soldiers and specific vulnerable groups. For the purpose of this paper, the term "war" is used to include both wars waged between countries (e.g., the Iraq-Kuwait war) and conflicts within countries (e.g., Sri Lanka). The review presents data concerning some major wars/conflicts (the countries involved are considered in alphabetic order) and then briefly outlines the risk factors emerging from the literature.

IMPACT OF WAR ON MENTAL HEALTH

Afghanistan

More than two decades of conflict have led to widespread human suffering and population displacement in Afghanistan. Two studies from this country are significant in terms of both their scope and their findings.

The first study ( 10) used a national multistage, cluster, population based survey including 799 adult household members aged 15 years and above. Sixty-two percent of respondents reported experiencing at least four trauma events during the previous ten years. Symptoms of depression were found in 67.7% of respondents, symptoms of anxiety in 72.2%, and post-traumatic stress disorder (PTSD) in 42%. The disabled and women had a poorer mental health status, and there was a significant relationship between the mental health status and traumatic events. Coping strategies included religious and spiritual practices.

The second study ( 11), using a crosssectional multicluster sample, was conducted in the Nangarhar province of Afghanistan, to estimate the prevalence of psychiatric symptoms, identify resources used for emotional support and risk factors, and assess the present coverage of basic needs. About 1011 respondents aged 15 years and above formed the sample. Nearly half of the population had experienced traumatic events. Symptoms of depression were observed in 38.5% of respondents, symptoms of anxiety in 51.8% and PTSD in 20.4%. High rates of symptoms were associated with higher numbers of traumatic events experienced. Women had higher rates than men. The main sources of emotional support were religion and family.

The Balkans

The conflict in the Balkans is probably one of the most widely studied ( 12- 14) in recent years. Mental health of survivors of both sides was examined ( 15).

An initial study ( 16) among Bosnian refugees demonstrated an association between psychiatric disorders (depression and PTSD) and disability. A threeyear follow-up study on the same group concluded that former Bosnian refugees who remained living in the region continued to exhibit psychiatric disorders and disability after initial assessment ( 17).

A cross-sectional cluster sample survey among Kosovar Albanians aged 15 years or older found that 17.1% (95% CI 13.2%-21.0%) reported symptoms of PTSD ( 18). There was a significant linear decrease in mental health status and social functioning with increasing amount of traumatic events in those aged 65 years or older, and with previous psychiatric illnesses or chronic health conditions. Internally displaced people were at increased risk of psychiatric morbidity. Men (89%) and women (90%) expressed strong feelings of hatred towards the Serbs, with 44% of men and 33% of women stating that they would act on these feelings.

In a study of the mental health and nutritional status among the Serbian ethnic minority in Kosovo, the General Health Questionnaire (GHQ)-28 scores in the subcategories of social dysfunction and severe depression were high, with women and those living alone or in small family units being more prone to psychiatric morbidity ( 19). In a community sample of 2,796 children aged between 9 and 14 years, high levels of post-traumatic symptoms and grief symptoms were reported ( 20). This was related to the amount and type of exposure. Girls reported more distress than boys.

Cambodia

Cambodia has had a long history of violence, highlighted by the civil war in the 1960s, culminating with the "Khmer Rouge" rule that destroyed the social fabric of the society. Studies have found that refugees had high levels of psychiatric symptomatology after 10 years ( 21).

A household survey of 993 adults from Site 2, the largest Cambodian displaced- persons camp on the Thailand- Cambodia border, found that more than 80% felt depressed and had a number of somatic complaints despite good access to medical services ( 22). Approximately 55% and 15% had symptom scores that correlated with Western criteria for depression and PTSD, respectively. However, despite high reported levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents. Cumulative trauma continued to affect psychiatric symptom levels a decade after the original trauma events ( 23). This study also reported that there was support for the diagnostic validity of PTSD criteria, with the notable exception of avoidance. The inclusion of dissociative symptoms increased the cultural sensitivity of PTSD. Psychiatric history and current physical illness were found to be risk factors for PTSD ( 24).

Changes in the structure of the society have led to a breakdown of the existing protective networks such as the village chief and the elders in the village, especially for women ( 25). Traditional healers (monks, mediums, traditional birth attendants), who played an important role in maintaining the mental health of communities in the past, have lost their designated positions in the community following the conflict ( 26).

Twenty-seven Cambodian young people, who were severely traumatized at ages 8 to 12, were followed up 3 years after a baseline evaluation. A structured interview and self-rating scales showed that PTSD was still highly prevalent (48%) and that depression was present in 41% ( 27).

Chechnya

The human rights abuses in the Chechen population have been well documented ( 28). A report on a small number of Chechen asylum seekers in the UK adds to the evidence on the abuses and related psychological fallouts ( 29). Psychosocial issues were explored in a survey conducted in settlements housing displaced people (n=256) ( 30, 31). Two thirds of respondents agreed with the statement that the conflict has triggered mental disturbance or feelings of being upset. Nearly all respondents indicated that they had family members having difficulty in coping with their disturbance or upset feelings. Coping strategies used were praying, talking, keeping busy, and seeking the support of family members.

Iraq

Iraq has been at war at numerous times in history: a series of coups in the 1960s, the Iran-Iraq war (1980-1988), the anti-Kurdish Al-Anfal campaign within the country (1986-1989), the Iraqi invasion of Kuwait resulting in the Gulf war (1991), and the conflict starting in 2003. The UN-imposed economic sanctions following the Gulf war have had a profound impact on the health of Iraqis. The human rights abuses have also been recorded ( 32).

There are few studies on the impact of these conflicts on mental health. A study on 45 Kurdish families in two camps reported that PTSD was present in 87% of children and 60% of their caregivers ( 33). A study on 84 Iraqi male refugees found that poor social support was a stronger predictor of depressive morbidity than trauma factors ( 34). During the last three years of occupation by foreign forces, there have been many news reports about the mental health of the population, but no systematic study.

Israel

Israel has been in a situation of conflict for over four decades. A large number of systematic studies have been undertaken in different population groups. A recent study ( 35) found that 76.7% of subjects exposed to war-related trauma had at least one traumatic stress-related symptom, while 9.4% met the criteria for acute stress disorder. The most common coping mechanisms were active information search about loved ones and social support. Another study ( 36) reported that, twenty years after the war with Lebanon, an initial combat stress reaction, PTSD-related chronic diseases and physical symptoms were associated with a greater engagement in risk behaviours.

Lebanon

Lebanon has been ravaged by a civil war (1975-1990) and by an Israeli invasion in 1978 and 1982. The mental health impact of these conflicts has been studied extensively.

A random sample of 658 people aged between 18 and 65 years was randomly selected from four Lebanese communities exposed to war ( 37). The lifetime prevalence of DSM-III-R major depression varied across the communities from 16.3% to 41.9%. Exposure to war and a prior history of major depression were the main predictors for current depression.

The correlation between mother's distress and child's mental health was explored in a study in Beirut ( 38). The level of perceived negative impact of war-related events was found to be strongly associated with higher levels of depressive symptomatology among mothers. The level of depressive symptomatology in the mother was found to be the best predictor of her child's reported morbidity. In a study carried out in 224 Lebanese children (10-16 years), the number of traumatic experiences related to war was positively correlated to PTSD symptoms, with various types of war traumas being differentially related to the symptoms ( 39).

A cross-sectional study conducted among 118 Lebanese hostages of war ( 40) found that psychological distress was present in 42.1% of the sample compared to 27.8% among the control group. Significant predictors for distress were years of education and increase in religiosity after release.

Palestine

During the last decade a large number of studies have reported high levels of psychosocial problems among children and adolescents, women, refugees and prisoners in Palestine.

A study conducted by the Gaza Community Mental Health Programme among children aged 10-19 years ( 41) revealed that 32.7% suffered from PTSD symptoms requiring psychological intervention, 49.2% from moderate PTSD symptoms, 15.6% from mild PTSD symptoms, and only 2.5% had no symptoms. Boys had higher rates (58%) than girls (42%), and children living in camps suffered more than children living in towns (84.1% and 15.8% respectively).

A study on Palestinian perceptions of their living conditions during the Second Intifada ( 42) found that 46% of parents reported aggressive behaviour among their children, 38% noted bad school results, 27% reported bed wetting, while 39% stated that their children suffered from nightmares. The study also revealed that more refugee (53%) than non-refugee (41%) children behaved aggressively. Thirty-eight percent of the respondents said that shooting was the main influence, 34% stated that it was violence on TV, 7% cited confinement at home and 11% reported that it was the arrest and beating of relatives and neighbours. Seventy percent of refugees and non-refugees stated that they had not received any psychological support for the problems of their children.

In a series of studies during the last 10 years from the Gaza Community Mental Health Centre ( 43), the most prevalent types of trauma exposure for children were witnessing funerals (95%), witness to shooting (83%), seeing injured or dead strangers (67%) and family member injured or killed (62%). Among children living in the area of bombardments, 54% suffered from severe, 33.5% from moderate and 11% from mild or doubtful levels of PTSD. Girls were more vulnerable.

Rwanda

The physical and mental health problems of the survivors of the genocide in Rwanda have been well documented ( 44). In a recent community based study examining 2091 subjects ( 45), 24.8% met symptom criteria for PTSD, with the adjusted odds ratio of meeting PTSD symptom criteria for each additional traumatic event being 1.43. Respondents who met PTSD criteria were less likely to have positive attitudes towards the Rwandan national trials, suggesting that the effects of trauma need to be considered if reconciliation has to be successful. There have been reports on the state of health among the large numbers of refugees (500,000-800,000 in five days) who fled to Goma, Zaire following the capture of the capital Kigali, but none of them has considered the mental health dimension.

Sri Lanka

The conflict between the majority Sinhala and minority Tamil population in Sri Lanka has been ongoing for nearly 30 years. One of the first studies that looked into the psychological effects of the conflict on the civilian population was an epidemiological survey ( 46), which reported that only 6% of the study population had not experienced any war stresses. Psychosocial sequelae were seen in 64% of the population, including somatization (41%), PTSD (27%), anxiety disorder (26%), major depression (25%), alcohol and drug misuse (15%), and functional disability (18%). The breakdown of the Tamil society led to women taking on more responsibilities, which in turn made them more vulnerable to stress ( 47). Children and adolescents had higher mental health morbidity ( 48).

Somalia

A study carried out in ex-combatants in Somalia found high psychiatric morbidity and use of khat ( 49). A UNICEF study found evidence of psychological effects of the prolonged conflict situation in a high proportion of a sample of 10,000 children ( 50). There is near total disruption of the mental health services in the country.

Uganda

Sudanese refugees fled into northern Uganda in two major waves in 1988 and 1994. Symptoms of PTSD and depression were found to be highly prevalent among Sudanese children living in the refugee camps ( 51). Refugees had higher rates of individual psychopathology than the general population, and it was observed that the cumulative stress grew as the years in exile progressed. The consequences of long-term exile were still present 5-15 years later, with an increase in the rates of suicide and alcohol use.

RISK FACTORS

From the large amount of studies reviewed, some broad risk factors and associations can be drawn.

Women have an increased vulnerability to the psychological consequences of war. There is evidence of a high correlation between mothers' and children's distress in a war situation. It is now known that maternal depression in the prenatal and postnatal period predicts poorer growth in a communitybased sample of infants. Social support and traditional birth attendants have a major role in promoting maternal psychosocial well being in war-affected regions. The association between gender- based violence and common mental disorders is well known. Despite their vulnerability, women's resilience under stress and its role in sustaining their families has been recognized.

There is consistent evidence of higher rates of trauma-related psychological problems in children. The most impressive reports are those from Palestine. Of the different age groups, the most vulnerable are the adolescents.

The direct correlation between the degree of trauma and the amount of the psychological problems is consistent across a number of studies. The greater the exposure to trauma - both physical and psychological - the more pronounced are the symptoms.

Subsequent life events and their association with the occurrence of psychiatric problems have important implications for fast and complete rehabilitation as a way of minimizing the ill effects of the conflict situations.

Studies are consistent in showing the value of both physical support and psychological support in minimizing the effects of war-related traumas, as well as the role of religion and cultural practices as ways of coping with the conflict situations.

CONCLUSIONS

The occurrence of a wide variety of psychological symptoms and syndromes in the populations in conflict situations is widely documented by available research. However, research also provides evidence about the resilience of more than half of the population in the face of the worst trauma in war situations. There is no doubt that the populations in war and conflict situations should receive mental health care as part of the total relief, rehabilitation and reconstruction processes. As happened in the first half of the 20th century, when war gave a big push to the developing concepts of mental health, the study of the psychological consequences of the wars of the current century could add new understandings and solutions to mental health problems of general populations.

A number of issues have emerged from the extensive literature on the prevalence and pattern of mental health effects of war and conflict situations. Are the psychological effects and their manifestation universal? What should be the definition of a case requiring intervention? How should psychological effects be measured? What is the long-term course of stress-related symptoms and syndromes? ( 52). All these issues need to be addressed by future studies.

It is important to report that the WHO and some other UN-related bodies have recently created a task force to develop "mental health and psychosocial support in emergency settings" ( 53- 55), which is expected to complete its activity in one year.

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Mental health consequences of war: a brief review of research findings

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Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant. Studies of the general population show a definite increase in the incidence and prevalence of mental disorders. Women are more affected ...

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Mental Health Provisions in Low- and Middle-Income Countries

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Mental Health Provisions in Low- and Middle-Income Countries

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This article explains both the challenges and oppurtunities in addressing mental health concerns within low-middle income countries. Most of these challenges are due to specific cultural contexts within populations. As mentioned in the article, addressing these concerns can only be done through a multitude of policy changes such as "political will and strengthened legislation, improved resource allocation and strategic organisation, integrated packages of care underpinned by professional communication and training..." (Rathod et. al 2017).

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Abstract

This article discusses the provision of mental health services in low- and middle-income countries (LMICs) with a view to understanding the cultural dynamics-how the challenges they pose can be addressed and the opportunities harnessed in specific cultural contexts. The article highlights the need for prioritisation of mental health services by incorporating local population and cultural needs. This can be achieved only through political will and strengthened legislation, improved resource allocation and strategic organisation, integrated packages of care underpinned by professional communication and training, and involvement of patients, informal carers, and the wider community in a therapeutic capacity.

Keywords: Mental health services, low- and middle-income countries, service provision

Introduction

More than 85% of the world's population live in the 153 low- and middle-income countries (LMICs). More than 80% of people who have mental disorders are residing in LMICs, with mental illness and substance abuse disorders presenting as an important cause of disease burden, accounting for 8.8% and 16.6% of the total burden of disease in low-income and lower-middle-income countries, respectively. As an example, in Bihar, one of the most economically deprived areas in India, the number of people suffering from schizophrenia is more than that in the entirety of North America.

Social factors, such as poverty, urbanisation, internal migration, and lifestyle changes, are moderators of the high burden of mental illness in many LMICs. Demographic factors, including a significant proportion of the population being in the younger age range, increase the incidence of severe psychiatric disorders such as schizophrenia. As an example, 21.5% of the population in Pakistan are in the age range of 15 to 24 years; similarly, 47.1% of Saudi nationals and 41% of the total population in the Kingdom of Saudi Arabia (KSA) are below 24 years of age.

Both man-made and natural disasters, such as armed conflict, earthquakes (in Nepal, Haiti), epidemics (such as Ebola and Zika), and famine (Ethiopia), in developing countries increase the incidence of mental and emotional health problems in the affected communities, and at the same time, they divert limited resources to areas other than mental health.

Finally, the cultural views and institutional biases against women and certain sections of communities (eg, religious, certain castes) increase the burden of illness in these population subgroups.

This article aims to highlight the key challenges and opportunities in LMICs when delivering mental health services that meet the needs of their populations. We begin with an overview of the current status of mental health services in LMICs. We then discuss how the future development and delivery of mental health care in LMICs can be informed and influenced by evidence and successful service models.

Mental Health Services in LMICs

Each country in the LMICs group is on its journey of awareness of the burden of mental illnesses, acceptance by society and policymakers, and allocation of resources for development of mental health services. Therefore, there is a wide variability in the provision of mental health care between countries. Most countries share the mismatch between high need and persistent scarcity of financial resources, workforce, and infrastructure for mental health services.

The proportions of people with a mental disorder who receive treatment are low with an international survey reporting that only 11.1% of severe cases of the mental disorder in China and 10.4% in Nigeria had received any treatment in the previous 12 months. The proportions of people with mental illness who receive evidence-based treatments are likely to be even lower.

Comparisons between high- and low-income countries show a significant difference in the presence of a mental health workforce of psychiatrists, nurses, psychologists, and social workers. Compared with global averages of 3.96 psychiatrists per 100 000 people, China reported 1.55 psychiatrists per 100 000 of the population. Corresponding ratios of psychiatrists per 100 000 individuals in the most populous developing countries of Asia and Africa, ie, India, Pakistan, Nigeria, and Ethiopia, are 0.301, 0.185, 0.06, and 0.04, respectively. Chad, Eritrea, and Liberia, with national populations of 9, 4.2, and 3.5 million, respectively, each have just 1 psychiatrist per 100 000 people, whereas Rwanda, Afghanistan, and Togo each have just 2. Unequal geographical distribution of these limited resources accentuates the problem of poor access to mental health care. For example, the majority of psychiatrists in LMICs are based in the main urban centres, and due to transport issues, they are often not accessible to the rural populations.

Cultural and religious attributes of illness and belief systems that influence help-seeking behaviour further complicate access to services and outcomes for mental health. Many individuals first seek help from complementary practitioners or spiritual or faith healers as they have less faith in the therapeutic interventions as currently delivered. Such inadequacies lead individuals to use both traditional and as well as alternate healers. The stigma of mental illness compounds this issue further as people are more comfortable seeking help from agents that normalise their experiences, such as community leaders. As a consequence, some non-evidence-based interventions are taking a foothold and gaining popularity as alternatives to evidence-based treatments. Although this presents challenges, it is also an area that can be and has been utilised in many countries to engage people with mental illness early. There are global calls for using collaborative approaches with wider communities, psychotherapeutic principles, theories, and techniques to be adapted to LMICs to make them more user-friendly and acceptable while improving outcomes for mental disorders.

Some high-income countries, such as the United States, have developed mental health systems that are very expensive, fragmented, and not focused on outcomes relevant for the service users. There are lessons to be learnt from the mistakes of these countries when developing services in LMICs. On the contrary, some LMICs have developed their mental health systems creatively, and useful lessons can be highlighted from the countries that have demonstrated good practice through innovation.

However, with all its benefits, this familial approach to the care and treatment of mental illness in such countries also spreads the burden of the disease to multiple members of the family, further disadvantaging the economic status of the family, by removing members from national output related activities.

In recent years, much attention has been devoted to understanding the key challenges faced by mental health services in LMICs and generating solutions to improve the limited provision of evidence-based treatments in these countries. We discuss these key challenges here and make recommendations as to how we can create or grasp existing opportunities in LMICs to improve mental health care.

Key Challenges

The challenges facing mental health services in LMICs are related to many factors, including legislation and policy, finances and resources, organisation and planning, and availability of appropriately adapted evidence-based interventions and training. Underlying all of these is each specific population's worldview and cultural belief system and how it relates to mental health and illness. This can be both a strength and weakness but undoubtedly influences service utilisation.

Saraceno and colleagues studied the barriers to mental health service development through a qualitative survey of international experts and leaders. Their findings highlighted the following key challenges for mental health in LMICs: public health other than mental health takes priority in securing funding, mental health services are complex and confined to central geographical areas, mental health care in primary care settings is difficult to implement, and the low numbers and few types of workers that are trained and supervised in mental health care.

Challenge 1: legislation and policy

Many LMICs lack mental health policies and laws to direct their mental health programmes and services, which is of particular concern especially in Africa and South East Asia. Family and user associations are present in LMICs but do not have a strong influence in the development of policy and procedures; this is a serious oversight considering that the majority of people with mental illness in LMICs are supported by the large family unit as already discussed. The mental health policy and the service guidance by the World Health Organization (WHO) describe the necessary steps to follow but does not detail how this can be contextually relevant to a particular culture. It is not only the lack of policies, but also the content of the existing policies that have an impact. For instance, to what extent do the policies promote integration with the other sectors such as justice, social care, and development of services to ensure a more comprehensive (prevention, promotion, and treatment) and holistic approach to the delivery of mental health services are important. Sometimes, the inadequacy or negative impact of existing policies and how this influences the mental health burden is a factor. An example of a policy that has direct effects on the mental well-being of a population can be found in China, where under the household registration system ('Hukou' system), rural migrants into cities are not entitled to the housing and medical benefits enjoyed by city residents. Evidence suggests that these migrant workers are at increased risks of having mental disorders than the residents in major cities.

Although it is important to have policies, it is equally important to ensure that the policies are relevant and beneficial to the local populations. Implementation of the policies should be adequately planned and change process communicated. An example of a well-designed programme to achieve strategic localisation and implementation of evidence-based policy is PRIME (PRogramme for Improving Mental health carE). The aim of PRIME is to generate evidence on the implementation and scaling up of integrated packages of care for priority mental disorders in primary and maternal health care settings in Ethiopia, India, Nepal, South Africa, and Uganda. Breuer and colleagues described the use of the theory of change (ToC) as part of the PRIME initiative to develop integrated mental health care plans for specific districts in the above countries. This process has resulted in various outputs including an outcomes pathway, key interventions, the major assumptions, and the indicators, with a summary of applied ToC map. Although the authors have described the process as beneficial, they also argued that the approach compromised stakeholder buy-in and bottom-up development of the change process. Considering our discussion of the community as a strength in many LMICs, this is a missed opportunity, and future efforts should make efforts to obtain community feedback and buy-in to make programmes more successful.

Although local policies are very important, world leaders need to consider the role of the global architecture and the civil society in influencing mental health legislation. For example, is mental health given due priority, given its growing contribution to global health? Similarly, the attitudes towards mental health among policymakers have a very important role in mental health policy development and funding allocations.

Challenge 2: finances and resources

Globally, the expenditure on mental health is less than US$2 per year per capita across all countries and less than 25 cents in low-income countries. Many LMICs, including 15 of 19 African countries, allocate less than 1% of their health budgets to addressing mental illness. India, like other LMICs countries, has a federal government with devolved budgets to individual states. The federal budget allocates 4.6% of the gross domestic product (GDP) for health, which works out to per capita sum of US$0.22. Mental health only receives 0.06% of the general health budget. Pakistan spends 3.9% of the GDP on health, of which 0.4% is spent on mental health. The primary sources of mental health financing in descending order are out-of-pocket expenditure by the patient or family, taxes, social insurance, and private insurance. Although it is clear that funding allocation to mental health services is inadequate, it would be helpful to have a benchmark of the ideal distribution of budget for general health and mental health for countries to have a guideline to work towards in each country.

Challenge 3: organisation and planning

Organisation and planning of mental health services needs focussed attention on the infrastructure and systems that allow easy and early access with referral systems, resources including health personnel, evidence-based treatment guidelines and availability of interventions, a mental health information system, links with other sectors, the extent to which mental health is integrated into health and mental health policies, national strategic plans, and district operating plans. Literature highlights the key organisational barriers to mental health care in LMICs being difficulties in access, the competing public health priorities, low investment in mental health services, a paucity of specialist human resources, and resistance to decentralisation.

The availability of geographically spread practical facilities influences access and outcomes in mental health. Providing treatments in wide rural areas or where transport links are difficult especially when resources are concentrated in one central, usually urban base, is a difficult practical issue common in many developing countries. It might be difficult, indeed impossible, for some clients to return to a health facility for interventions on a regular basis. Alternative strategies using information technology may need to be considered in these situations. Telepsychiatry is being increasingly used even in countries such as the United States to provide services to rural and inaccessible areas, and this technology can easily be transferred and used in LMICs to streamline the provision of mental health services to rural areas.

As publicly funded mental health care is often difficult to access by rural communities in LMICs, there is a growing recognition that mental health services should be integrated into primary care so that the availability of evidence-based treatments can be widened and provided in a setting that is less stigmatising. As an example, in India, mental health services are integrated into primary health services with support and supervision from mental health teams at the district level. This system was set up to counter the stigma of mental illness and makes treatment available to rural communities. However, not all districts are covered under this programme, and many primary health care physicians have not received any up-to-date training in mental health. This demonstrates the lack of organisational planning in this important area. Individuals who cannot be treated at the primary care level are referred to mental health outpatient facilities, psychiatric wings of general hospitals, or dedicated psychiatric facilities. However, lack of resources is a key challenge in these facilities.

In some countries like the KSA, mental health services in primary care settings remain limited to prescribing a restricted list of antidepressants. This is due to restrictive national policy on the scope of practice of primary care providers. Psychopharmacology is the standard treatment for most mental health problems even among the most vulnerable populations, such as children and adolescents in many LMICs. In a recent survey of 63 mental health professionals from different regions of the KSA, the most common intervention used in clinical practice was pharmacotherapy (71%), followed by supportive therapy (40%), cognitive therapy (23%), combined approach (17%), psychodynamic and family therapies (8%), and group therapy (6%). There is some evidence that response to psychotropic medication may be influenced by ethnicity; therefore, the dosages of medications required in some LMICs may be different than the Western countries. Local guidelines based on some quality research could optimise pharmacotherapy for populations of individual countries.

Challenge 4: evidence-based interventions and training

Psychotherapeutic interventions are not included in mainstream treatments in many LMICs. This can be attributed to 2 main reasons: lack of resources and inadequate training. Moreover, in some countries, the religion and political landscape have a role to play too. As an example, in the KSA, up until the end of the 20th century, literature on psychoanalysis and psychoanalytic theory were banned due to the influence of religious scholars from the early decades of the century who declared much of Freud's contributions to be heretical based on a very poor and superficial understanding of some of his ideas.

Despite the strong evidence for its effectiveness, cognitive behaviour therapy (CBT) remains underutilised in clinical settings internationally due to the limited availability of comprehensive training programmes and qualified CBT mental health professionals. In addition, as currently delivered, CBT has been criticised as being West-centric and not in tune with different cultural beliefs. Scorzelli and Scorzelli conducted a survey of students in India and found that 82% of respondents felt that principles underlying CBT conflicted with their values and beliefs: 46% relating to their cultural or family values and 40% relating to their religious beliefs. Examples of beliefs held by some cultures that are incompatible with a West-centric CBT approach are our destiny is fixed and based on our previous good or bad deeds, people do not have free will and are controlled by a high power, the individual must abide by the rules and the values of their family or community to have a meaningful and conflict-free life, females will always need support from a stronger individual.

Although cultural relevance is essential and practice needs to be adapted to fit a variety of cultural backgrounds, this carries its challenges and should follow evidence-based methodology. Cost-effectiveness of adapted interventions will need to be evaluated in LMICs. Such adaptation of therapies requires specialised training and research which tends to suffer in economic downturns. Theory would suggest that training becomes one of the first casualties in cost-reducing public institutions; where private firms can gain a competitive advantage by heightened investment in training in a period of fiscal tightening, public entities such as in health care have no such incentives.

The use of physical activity and sport has received little attention with respect to improving mental health in LMICs. Evidence is well established that physical activity plays a major role in improving psychological, physical, and social health for individuals living with disorders such as depression, anxiety, schizophrenia, bipolar, and much more. Sport, too, can have a profound impact on overall mental well-being, specifically helping individuals living with mental illness develop a sense of purpose, strengthen their self-esteem, and working towards deepening their self-confidence. The concept of physical well-being would appeal naturally to many cultures in LMICs where somatisation is often the key presentation of mental health problems.

Despite the value of physical activity and sport, only a few studies have examined their impact on mental health in LMICs. A recent review by Hamilton and colleagues on the mental health impact of sport and physical activity programmes for adolescents in postconflict areas found three poorly executed studies. Studies were conducted in Uganda and Sierra Leone, mostly focused on boys, and showed mixed results with respect to symptom alleviation. The potential for physical activity and sport to be part of recovery is tremendous, but further research and training is needed to ensure relevant programmes are developed in a culturally appropriate manner and are sustainable.

Opportunities

Globalisation and advances in media and communication across the world have resulted in increased awareness and a better understanding of mental health issues by the public in all countries. There are increased training opportunities for psychiatrists and psychologists in LMICs, and local universities are supporting knowledge transfer for alternatives to institutionalisation and pharmacological treatments. In some countries, this awareness has also led to the formation of associations of psychotherapies such as the Pakistan Association of CBT and the Indian Association of CBT. These associations have begun the work of culturally adapting CBT interventions and testing their efficacy in their countries.

Despite these developments and increased awareness, in many LMICs and especially in the rural areas, culturally explained attributions to illness determine pathways into care, and often these do not lead to mental health professionals. Many people with mental illnesses prefer to see a faith healer or religious leader. Although this can present delays in accessing appropriate mental health care, knowledge of local cultural beliefs can suggest different ways of developing services. There are good examples where alternative pathways into care have been strategically used to engage people with mental health problems. For example, in Thailand, temples are the first port of call when people are unwell. To improve engagement of patients with mental illness, some psychiatric hospitals have actively integrated Buddha's teachings into community mental health work.

Some recently developed and successful therapies such as mindfulness-based CBT or yoga and mindfulness based cognitive therapy (Y-MBCT) are based on Buddhist teachings as well as on the ancient scriptural philosophies of the Vedas that many members of LMICs are familiar with and find it easy to accept and practise. One important aspect of Y-MBCT is that it could be used for wellness of families and caregivers as well as of persons with illness, and joint family practises can reduce stigma and isolation.

It is common in many Chinese, Japanese, Malayan, Tahitian, and other cultural groups to somatise psychological and emotional distress symptoms to different body parts, eg, abdomen, liver, intestines, or heart. The reason for this is that somatic symptoms are explained through a perceived imbalance in body functions and are considered less stigmatising than psychiatric symptoms. Appropriate training in physical and mental health care at primary and secondary care level can help identify mental health problems early, even when they manifest as physical complaints. Also, resources need to be utilised to conduct quality research in different countries to fine-tune the understanding of psychopathology and the effectiveness of various interventions for that particular country.

Family support systems and the larger community can be open and accepting of individuals with mental illness in most LMICs. A growing body of evidence through randomised trials now demonstrates that affordable and clinically effective interventions can be provided by the lay health workers in community-a process termed task shifting. Task shifting involves the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications to make more efficient use of the available human resources for health. One example is community-based rehabilitation for people with schizophrenia in rural India, which can be a feasible, acceptable, and efficient intervention for many people with psychotic disorders in low-resource settings. Community-based rehabilitation is a model of community care based on the active participation of people with physical disabilities and their families in rehabilitation that takes specific cognisance of prevailing social, economic, and cultural issues. A longitudinal study of outcomes in 207 patients with chronic schizophrenia contrasted community-based care (CBR) with outpatient care. The study reported feasibility of CBR with lower baseline disability scores, family engagement with the programme, medication adherence, and being a member of a self-help group as positive outcomes.

Culturally adapted low-intensity CBT for depression and psychosis has been developed and tested in both primary and the secondary care in Pakistan. There is also evidence that evidence-based interventions can be delivered by a family member at no cost to the system. These ideas might be less relevant in countries where financial resources are not a huge issue (eg, some Middle Eastern countries).

Task shifting often involves a stepped care approach. Araya and colleagues have used this approach successfully in Santiago, Chile. They found that nearly 70% of the patients treated for depression using a stepped care programme recovered, compared with 30% of patients who were treated as usual, at an additional cost of just 216 Chilean pesos (US$0.32) per depression free day.

Peer workers or mental health service users who have recovered can provide support, share personal experiences, and facilitate recovery for individuals who are currently experiencing mental illness. The role of peer workers and caregivers to potentially deliver evidence-based mental health interventions needs to be explored and expanded. One approach would be to train recovered service users and employ them in the mental health workforce. They can be located in their communities and help support and help individuals who become ill. Although this approach is not without its challenges, it can be an opportunity for the rehabilitation of mentally ill individuals combined with an expansion of the mental health workforce that is less expensive.

To scale up services using such community-based approaches, some changes would be required, including revising the roles of different professionals with appropriate responsibility and accountability. Systems for quality assurance to maintain fidelity to the intervention over a period of time are required. Although there is potential, further evidence is needed to establish the effectiveness of these approaches in LMICs.

Next Steps and Actions

There have been numerous calls at various levels to scale up the provision of mental health services and evidence-based treatments in LMICs. A commitment and global architecture to influence development of mental health services as priority is needed. The United Nations Human Rights Council adopted a Resolution on Mental Health and Human Rights that provides an impetus to address human rights in mental health and also signals a commitment by countries to achieve this. Different countries are developing mental health services at a different pace, so the onward journey should follow an iterative process with a targeted approach based on local culture and population needs.

The Global Mental Health initiative estimated that to provide services on the necessary scale, an additional cost of US$2 per person per year in low-income countries and US$3 to US$4 in lower middle-income countries is required, which is modest compared with the requirements for scaling-up services to treat cancer, another major contributor to the global burden of disease. We would argue that each country needs to conduct its own gap analysis while taking into account their areas of strengths to develop their expenditure plan. Countries need to set aside resources for quality research so that they better understand culture-specific psychopathology, adapt existing practices, and develop new ways of working that are relevant to the local population. A series of core and secondary goals and indicators to track the progress that countries make towards achievement of mental health service goals need to be identified. A priority-setting exercise to identify gaps in the evidence base in global mental health for some categories of mental disorders has already been conducted. Next steps need to include strategic implementation of legislative and organisational plans and a system of evaluation that enable remodelling and restructuring of policy and practice based on the guiding principles of WHO.

Conclusions

Despite these promising activities and the publication of high-profile reports in several countries, progress in mental health service development has been slow in most LMICs. Many of the barriers to improving mental health services can be overcome by political will, social enlightenment, and a public movement to improve the care of people who suffer with mental health problems. Scaling up mental health services in LMICs requires flexible policies, adequate resources, effective interprofessional communication, and evidence-based training, supplemented with an evaluation plan to measure successes against specific benchmark criteria. A number of opportunities exist in LMICs, including evidence of integrated stepped care packages through a task-shifting approach and collaborative arrangements with families and wider communities that enable proper care within limited resources. Mental health treatments and training programmes in LMICs need to be responsive to the local culture, incorporate a public health approach, and embrace the diverse needs of the population.

Footnotes

Peer review: Six peer reviewers contributed to the peer review report. Reviewers' reports totaled 1722 words, excluding any confidential comments to the academic editor.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions: SR and NF conceptualised the article. All other authors contributed to the development of the structure and arguments for the paper. All authors made critical revisions and approved the final version of the paper.

References

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Mental Health Service Provision in Low- and Middle-Income Countries

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This article discusses the provision of mental health services in low- and middle-income countries (LMICs) with a view to understanding the cultural dynamics-how the challenges they pose can be addressed and the opportunities harnessed in specific cultural contexts. The article highlights the need for prioritisation of mental health services by incorporating local population and cultural needs.

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This pie chart puts into perspective how prevalent mental health disorders really are. We, as a society, may think that only a few unlucky people may be associated with mental health disorders. But this is really not the case as 28% of diseases worldwide are mental health related.

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In this fight for a better global mental health, we need to be aware of the barriers in achieving it. One of the main barriers is inequitable accessibility. Very often, through both low-resource and high-resource countries, only the rich can afford mental health treatment. As public health officials, we need to realize these barriers and create policies/interventions in breaking them down. This political cartoon showcases the exact problem.

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This infographic showcases the types of ways everyday people can alleviate mental health stigmatization within their communities. Just one person can really make a difference in starting a conversation about such a topic through this 5 different means.

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Mental Health is one of the least obvious burden of diseases but also one of the most prevalent across the globe. This is especially relevant in lower-resource countries where war, less healthcare accessibility, and disease is most common. This fact is worsened by specific cultures and populations going out of their way and rejecting support for mental health diseases as well. In order to provide for better global mental health, fundamental policy changes need to be made as citizen mental health is a result/consequence of poor policy.