Improving the delivery of existing treatment may often bring much greater benefits than developing new treatments and technologies. To achieve this, clinical teams and organisations need to build capacity for sustained and systematic improvement. Organisations can build improvement capacity and skills by developing permanent multidisciplinary centres to provide sustained inspiration, research, training and practical support for implementation and innovation. In the longer term, organisations need to build an infrastructure for quality improvement that includes an information system to track change and dedicated improvement leads across the organisation.

This editorial introduces three papers in BJPsych International on community mental healthcare in the diverse cultures of Greece, Cambodia and Malawi.

At a time when nationalism has reappeared in Europe, when COVID-19 is not yet quarantined and when compassion coexists with grief, there is a need to consider the impact of these societal changes on international collaboration, frequency and management of perinatal mental disorder – and new roles for psychiatrists and other health professionals in the digital and AI (artificial intelligence) post-COVID era.

International multiprofessional teams in primary and secondary care have much to teach psychiatrists, researchers and service planners about the perinatal mental health field. This editorial introduces a new series of papers in BJPsych International on perinatal mental health around the world.

Maternal mental health disorders are a significant problem for mother–infant dyads in India, but have not received the attention that they should. However, recent major developments hold promise: the increase in coverage of the District Mental Health Programme; the growing emphasis in public health systems on newborn health; integration of maternal mental health into the Reproductive and Child Health Programme in the state of Kerala; and the Mental Health Care Act 2017, which mandates mother–infant joint care when a mother is admitted for mental illness, will lead to policy changes in services. Innovative implementation and translational research is needed to generate knowledge to strengthen maternal mental healthcare systems and improve maternal and child outcomes. Valuable ‘research rupees’ should be spent on ensuring equity of resources for physical and mental healthcare of mothers and providing optimal environments for every mother–infant dyad.

China's healthcare is improving together with rapid economic growth. Yet, mental healthcare is lagging behind. Prevalence of perinatal depression is high among women of the one-child generation, but access to qualified care is limited. Chinese healthcare professionals, policy makers and patients alike express concerns about insufficient knowledge among the public as well as healthcare providers regarding mental disorders. There appears to be a general lack of help-seeking behaviour for mental disorders owing to perceived risk of social stigmatisation. Social support through family and friends, use of online resources and community healthcare services are preferred, rather than seeking help from mental health specialists.

Psychiatric care in Greece has a long history of traditional in-patient treatment in large public institutions (the public asylum period), which lasted until 1983. European Economic Community (EEC) intervention in 1984 marked a transitional period (1984–1989) characterised by the beginning of the transformation of the mental healthcare system. The current reform era started in 1999 and has included new mental health law, the closure of six public mental hospitals and the establishment of several sectorised mental health services.

This paper gives a narrative account of how the Oxford Healthcare Improvement Centre has embedded continuous quality improvement (CQI) across both mental health and community services in Oxford, UK. The aim of the centre is to develop capability across healthcare services, with frontline staff leading CQI independently. The paper discusses the various methods employed to achieve this aim, including the provision of training, mentoring and support to those undertaking improvement work, alongside developing the required governance for CQI.

Region Jönköping County (RJC) in Sweden is a healthcare system that is characterised by sustainable work with quality in healthcare and long-term system-wide improvement. This article describes important factors behind the improvement work in RJC, and how the improvement methods and initiatives have been adopted also in mental healthcare. For example, patients otherwise eligible for admission to a psychiatric department were treated at home after introduction of home treatment teams. Patient satisfaction was high and the number of visits to the emergency department, hospital admissions and hospital stay decreased.

France has a long tradition of concern for maternal and perinatal mental health. However, the national organisation of psychiatric care does not yet provide structured guidelines on the organisation of perinatal psychiatric care. This paper provides an update on existing resources and their linkage to primary care and obstetric and paediatric services, as well as a review of current and future national priorities that are under development.

Mental health services in Cambodia required rebuilding in their entirety after their destruction during conflict in the 1970s. During the late 1990s there was rapid growth and development of professional mental health training and education. Currently, basic mental healthcare is available primarily in urban areas and is provided by a mixture of government, non-government and private services. Despite the initial rapid growth of services and the development of a national mental health strategy in 2010, significant challenges remain in achieving an acceptable, standardised level of mental healthcare nationally.

Sweden has a unique opportunity to identify and follow up women presenting with, or at risk for, perinatal mental health problems and disorders because universal screening programmes are provided by its primary healthcare system. Although they are implemented across almost the entire population, screening programmes are not necessarily leading to effective interventions because the multidisciplinary perinatal mental healthcare teams that provide for the assessment and treatment of moderate to severe disorders are very few in number and must be increased. In particular, efforts to reach immigrant parents must be intensified to achieve equal quality of care for all.

This is a reflective essay about the time I spent volunteering in mental healthcare in Malawi, prior to commencing my psychiatry training. The burden of illness I saw was enormous and the resources very limited; however, I describe some particular experiences where we were able to deliver excellent care, and which made me reflect about mental health services in low-income countries in general. Details of the patients discussed in this essay have been fully anonymised.

Patient suicide is one of the most frequent incidents in healthcare facilities to be reported to the National Observatory of Sentinel Events in Italy. Despite national initiatives, in Tuscany potentially preventable patient suicides still occur in both acute and community care settings. We describe here an aggregated qualitative analysis of 14 patient suicides that took place in public health services between 2017 and 2018. We outline the methodology and results of an improvement action we enacted in the healthcare system that involved reviewing and reinforcing relevant managerial strategies and clinical activities, with the aim of reducing potentially preventable patient suicides.

In Italy, most studies on perinatal mental health and initiatives aimed at improving the early detection and management of perinatal mental disorders have been carried out at the local level. National population-based studies are lacking. A study of pregnant women, recruited and diagnosed by a university hospital, found a 12.4% prevalence of minor and major depression during pregnancy, and a prevalence of 9.6% in the postpartum period. In a population-based surveillance system, covering 77% of national births, suicide was identified to be one of the main causes of maternal death within the first year after birth, yet half of those who were known to have a high suicide risk during the postpartum period had not been referred to a mental health service. The value of recognising depressive or anxiety symptoms early, during pregnancy, has been emphasised by recent research and should be linked to multi-professional psychosocial interventions. Since 2017, the Italian public primary care services that are dedicated to pregnancy assistance (Family Care Centres) have been tasked to provide free psychological assessment to pregnant and postpartum women. Action is now needed in order to improve access to Italian Family Care Centres for pregnant women and to develop an integrated care model involving obstetric and mental health services.

Africa is a diverse and changing continent with a rapidly growing population, and the mental health of mothers is a key health priority. Recent studies have shown that: perinatal common mental disorders (depression and anxiety) are at least as prevalent in Africa as in high-income and other low- and middle-income regions; key risk factors include intimate partner violence, food insecurity and physical illness; and poor maternal mental health is associated with impairment of infant health and development. Psychological interventions can be integrated into routine maternal and child healthcare in the African context, although the optimal model and intensity of intervention remain unclear and are likely to vary across settings. Future priorities include: extension of research to include neglected psychiatric conditions; large-scale mixed-method studies of the causes and consequences of perinatal common mental disorders; scaling up of locally appropriate evidence-based interventions, including prevention; and advocacy for the right of all women in Africa to safe holistic maternity care.

Research on the topic of poor perinatal mental health in South America is scarce. Nevertheless, studies have shown that it is not uncommon, and that it is linked to women's experience of sexual and intimate partner violence and to inequality, poverty and low educational attainment. High-quality research in large samples with rigorous methodology is a priority, so that data from this region may be compared and analysed in systematic reviews. The links with intimate partner violence need to be explored. Risk and protective factors must be investigated with a strong intercultural perspective. Service integration needs to be implemented. This will require improvements in the availability, accessibility and quality of obstetric and mental health services. There is a need for targeted evidence-based interventions for women and children at risk that incorporate a strong gender and rights perspective.

This is a reappraisal of psychiatric morbidity in North Americans from Indigenous backgrounds, or those from longstanding minority communities. Psychiatric morbidity is often no higher when compared with controls that are similar in other sociodemographic features. Interventions should therefore take into account that disadvantage is rarely from one cause.

Our attributes change. Sometimes they are changed so dramatically (for instance by organic brain disease, traumatic brain injury or psychiatric disease) that it is hard to see any significant continuity with the premorbid person. Sometimes this can have important ethical and legal consequences, but the problems are often ignored. This article highlights some of the difficulties.

Somaliland is experiencing an explosion of mental health problems that has received little coverage. The country has experienced devastating civil wars that have resulted in widespread trauma, and the lack of necessary mental health infrastructure is an obstacle to allowing the population to heal and recover. War trauma, poverty, unemployment and widespread substance misuse (khat) have all negatively affected the mental health of its citizens. This report provides an overview of a rapid needs assessment carried out across Somaliland that examined current service provision, gaps in services, and interviews with mental health professionals and caregivers.