Current coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment.

To identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.

In the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country's disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options.

Key challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries.

Including mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities.

D.C. is a staff member of the World Health Organization.

The well-known adverse consequences of maternal depression prompts consideration of the importance of learning more about intergenerational transmission in order to identify individuals at risk of developing depressive disorders.

To follow two generations of women with major depressive disorder (MDD) and to examine the risk of MDD in the third-generation children.

A register-based, retrospective cohort study of all women born in Sweden between 1973 and 1982 who had given birth during the study period, their mothers and their children. All generations were followed until 2013. Data was stratified into two cohorts: women born between 1973 and 1977 and those born between 1978 and 1982.

Second-generation women were twice as likely to be diagnosed with MDD if their mothers had been diagnosed with MDD. If both previous generations had been diagnosed with depression the likelihood of the third-generation child being diagnosed with MDD was markedly increased (odds ratio (OR) = 5.07, 95% CI 4.06–6.34 and OR = 7.20, 95% CI 4.41–11.77 in cohort 1 and cohort 2, respectively).

There is a strong intergenerational impact in the transmission of MDD. The risk of MDD is especially high in individuals with MDD in both previous maternal generations.

None.

There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).

To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.

Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.

Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.

Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.

None.

People with sensory impairments may be at increased risk of depression and anxiety but experience barriers to accessing treatment.

To investigate whether people with sensory impairment have more depressive and anxiety symptoms than people without, whether this is mediated by social functioning and whether they report greater non-treatment.

We analysed data from the English 2014 Adult Psychiatric Morbidity Survey using regression models, with the Clinical Interview Schedule-Revised (CIS-R) score as the primary outcome and self-reported hearing and vision impairment as exposures. A secondary outcome was self-reported receipt of mental health diagnosis and treatment. We used structural equation modelling to assess for mediation by social functioning.

A total of 19.0% of people with hearing impairment, and 30.9% and 24.5% with distance and near visual impairments, respectively, had clinically significant psychological morbidity. Adjusted mean CIS-R score was 1.86 points higher in people with hearing impairment compared with those without (95% CI 1.30–2.42, P<0.001). People with distance and near vision impairment had mean CIS-R scores 3.61 (95% CI 2.58–4.63, P<0.001) and 2.74 (95% CI 2.12–3.37, P<0.001) points higher, respectively, than those without. Social functioning accounted for approximately 50% of these relationships between sensory impairment and psychological morbidity. We found no evidence of an increased treatment gap for people with sensory impairment.

Social functioning, a potentially modifiable target, may mediate an association between sensory impairment and depressive and anxiety symptoms.

Paediatric acute-onset neuropsychiatric syndrome (PANS), an umbrella term that includes PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is suggested to be a psychiatric disorder of autoimmune aetiology. PANS is characterised by an acute onset of obsessive–compulsive disorder or restricted eating with multiple comorbid symptoms. The specificity of the PANS criteria is not fully understood.

To describe a cohort of patients with PANS and to determine if PANS features relating to symptoms, onset and course are more common in PANS than in other psychiatric conditions.

A case–control study comparing patients with interview-confirmed PANS with patients with suspected PANS and patients with a psychiatric condition but with no suspicion of PANS. Validated and non-validated measures of symptoms, onset and episodic course were used.

Illness in patients with interview-confirmed PANS featured an episodic course and multiple symptoms present at onset compared with the psychiatric controls. However, individuals with interview-confirmed PANS did not present a specific symptom profile.

PANS may be a distinct clinical entity featuring an acute onset, an episodic course and multiple symptoms at onset.

None.

The impact of mental disorders has been assessed in relation to longevity and quality of life; however, mental disorders also have an impact on productive life-years (PLYs).

To quantify the long-term costs of Australians aged 45–64 having lost PLYs because of mental disorders.

The Survey of Disability, Ageing and Carers 2003, 2009 formed the base population of Health&WealthMOD2030 – a microsimulation model integrating output from the Static Incomes Model, the Australian Population and Policy Simulation Model, the Treasury and the Australian Burden of Disease Study.

For depression, individuals incurred a loss of AU$1062 million in income in 2015, projected to increase to AU$1539 million in 2030 (45% increase). The government is projected to incur costs comprising a 22% increase in social security payments and a 45% increase in lost taxes as a result of depression through its impact on PLYs.

Effectiveness of mental health programmes should be judged not only in terms of healthcare use but also quality of life and economic well-being.

None.

Despite being a global problem, little is known about the relationship between severe mental illness (SMI) and homelessness in low- and middle-income countries (LMICs). Homeless people with SMI are an especially vulnerable population and face myriad health and social problems. In LMICs, low rates of treatment for mental illness, as well as differing family support systems and cultural responses to mental illness, may affect the causes and consequences of homelessness in people with SMI.

To conduct a systematic, scoping review addressing the question: what is known about the co-occurrence of homelessness and SMI among adults living in LMICs?

We conducted an electronic search, a manual search and we consulted with experts. Two reviewers screened titles and abstracts, assessed publications for eligibility and appraised study quality.

Of the 49 included publications, quality was generally low: they were characterised by poor or unclear methodology and reporting of results. A total of 7 publications presented the prevalence of SMI among homeless people; 12 presented the prevalence of homelessness among those with SMI. Only five publications described interventions for this population; only one included an evaluation component.

Evidence shows an association between homelessness and SMI in LMICs, however there is little information on the complex relationship and direction of causality between the phenomena. Existing programmes should undergo rigorous evaluation to identify key aspects required for individuals to achieve sustainable recovery. Respect for human rights should be paramount when conducting research with this population.

None.

In most low- and middle-income countries (LMIC), routine mental health information is unavailable or unreliable, making monitoring of mental healthcare coverage difficult. This study aims to evaluate a new set of mental health indicators introduced in primary healthcare settings in five LMIC.

A survey was conducted among primary healthcare workers (n = 272) to assess the acceptability and feasibility of eight new indicators monitoring mental healthcare needs, utilisation, quality and payments. Also, primary health facility case records (n = 583) were reviewed by trained research assistants to assess the level of completion (yes/no) for each of the indicators and subsequently the level of correctness of completion (correct/incorrect – with incorrect defined as illogical, missing or illegible information) of the indicators used by health workers. Assessments were conducted within 1 month of the introduction of the indicators, as well as 6–9 months afterwards.

Across both time points and across all indicators, 78% of the measurements of indicators were complete. Among the best performing indicators (diagnosis, severity and treatment), this was significantly higher. With regards to correctness, 87% of all completed indicators were correctly completed. There was a trend towards improvement over time. Health workers' perceptions on feasibility and utility, across sites and over time, indicated a positive attitude in 81% of all measurements.

This study demonstrates high levels of performance and perceived utility for a set of indicators that could ultimately be used to monitor coverage of mental healthcare in primary healthcare settings in LMIC. We recommend that these indicators are incorporated into existing health information systems and adopted within the World Health Organization Mental Health Gap Action Programme implementation strategy.

None.

With significant numbers of individuals in the criminal justice system having mental health problems, court-based diversion programmes and liaison services have been established to address this problem.

To examine the effectiveness of the New South Wales (Australia) court diversion programme in reducing re-offending among those diagnosed with psychosis by comparing the treatment order group with a comparison group who received a punitive sanction.

Those with psychoses were identified from New South Wales Ministry of Health records between 2001 and 2012 and linked to offending records. Cox regression models were used to identify factors associated with re-offending.

A total of 7743 individuals were identified as diagnosed with a psychotic disorder prior to their court finalisation date for their first principal offence. Overall, 26% of the cohort received a treatment order and 74% received a punitive sanction. The re-offending rate in the treatment order group was 12% lower than the punitive sanction group. ‘Acts intended to cause injury’ was the most common type of the first principal offence for the treatment order group compared with the punitive sanction group (48% v. 27%). Drug-related offences were more likely to be punished with a punitive sanction than a treatment order (12% v. 2%).

Among those with a serious mental illness (i.e. psychosis), receiving a treatment order by the court rather than a punitive sanction was associated with reduced risk for subsequent offending. We further examined actual mental health treatment received and found that receiving no treatment following the first offence was associated with an increased risk of re-offending and, so, highlighting the importance of treatment for those with serious mental illness in the criminal justice system.

Indigenous people are overrepresented in prison populations of colonised justice systems, and Indigenous prisoners in these countries are at a particularly high risk of poor mental health and well-being. There is an acute need to ensure the access of these groups to culturally appropriate, evidence-based interventions.

To conduct a systematic review, evaluating quantitative and qualitative evaluations of mental health and well-being interventions designed for Indigenous people in custody.

A search of relevant peer-reviewed journal articles to August 2019 was conducted. The focus was on colonised countries under a Western model of justice and health, including Canada, Australia, New Zealand and the USA. The review utilised Scopus, Web of Science, PubMed, PsycNET, EBSCO, Proquest Criminal Justice Database and Informit.

Of the 9283 articles initially found, only three quantitative and two qualitative evaluations of mental health or well-being interventions for Indigenous people in custody were identified. None were randomised controlled trials. Culturally based interventions appeared to have high acceptability and potential for increased recovery from trauma, reduced alcohol-related problems and lower reoffending. However, no studies quantitatively assessed mental health or well-being outcomes.

As yet there is no high-quality evidence on the impact on mental health and well-being from interventions specifically for Indigenous prisoners, although existing studies suggest programme features that may maximise acceptability and impact. There is a moral, social and practical imperative to build a strong evidence base on this topic.

Suicide attempts and non-suicidal self-harm (NSSH) are major public health concerns that affect millions of young people worldwide. Consequently, there is a strong need for up-to-date epidemiological data in this population.

To provide prevalence and trend estimates of suicidal thoughts and behaviours and NSSH thoughts and behaviour in university students.

Data are from a 2018 national health survey for higher education in Norway. A total of 50 054 full-time students (69.1% women) aged 18–35 years participated (response rate 31%). Suicidal ideation, suicide attempts and NSSH were assessed with three items drawn from the Adult Psychiatric Morbidity Survey, and thoughts of NSSH were assessed with one item from the Child and Adolescent Self-Harm in Europe study.

Lifetime suicidal thoughts were reported by 21.0%, and 7.2% reported having such thoughts within the past year. In total, 4.2% reported a suicide attempt, of whom 0.4% reported attempting suicide within the past year. The prevalence of lifetime NSSH behaviour and thoughts was 19.6% and 22.6%, respectively. All four suicidal behaviour and NSSH variables were more common among students who were single, living alone and with a low annual income, as well as among immigrants. There was an increase in suicidal thoughts from 2010 (7.7%) to 2018 (11.4%), which was evident in both men and women.

The observed high and increasing prevalence of suicidal thoughts and NSSH among college and university students is alarming, underscoring the need for further research, preferably registry-linked studies, to confirm whether the reported prevalence is representative of the student population as a whole.

None.

Caring for a child with intellectual disabilities can be a very rewarding but demanding experience. Research in this area has primarily focused on mothers, with relatively little attention given to the mental health of fathers.

The purpose of this review was to summarise the evidence related to the mental health of fathers compared with mothers, and with fathers in the general population.

A meta-analysis was undertaken of all studies published by 1 July 2018 in Medline, PsycINFO, CINAHL and EMBASE, using terms on intellectual disabilities, mental health and father carers. Papers were selected based on pre-defined inclusion and exclusion criteria.

Of 5544 results, 20 studies met the inclusion criteria and 12 had appropriate data for meta-analysis. For comparisons of fathers with mothers, mothers were significantly more likely to have poor general mental health and well-being (standardised mean difference (SMD) −0.38, 95% CI −0.56 to −0.20), as well as higher levels of depression (SMD, −0.46; 95% CI −0.68 to −0.24), stress (SMD, −0.32; 95% CI −0.46 to −0.19) and anxiety (SMD, −0.30; 95% CI −0.50 to −0.10).

There is a significant difference between the mental health of father and mother carers, with fathers less likely to exhibit poor mental health. However, this is based on a small number of studies. More data is needed to determine whether the general mental health and anxiety of father carers of a child with intellectual disabilities differs from fathers in the general population.

Early identification and diagnosis is beneficial for children with autism spectrum disorder (ASD). Universal early screening is recommended by many experts, but disputed because evidence is limited, and sensitivity and specificity in general populations are largely unknown.

To estimate the sensitivity and specificity of early population-based screening for ASDs.

The study was based on the Norwegian Mother and Child Cohort Study. The 36-month cohort questionnaire included the Social Communication Questionnaire (SCQ), a 40-item screening instrument for ASD.

A total of 58 520 mothers (58%) responded to the questionnaire. By the end of follow-up on 31 December 2015, 385 (0.7%) individuals with ASD had been identified among the responders' children. The distributions of SCQ scores in those with ASD and other children had large degrees of overlap. With the cut-off of 15 recommended in the SCQ manual, screening sensitivity was 20% (95% CI 16–24) for ASD overall. For children with ASD who had not developed phrase speech at 36 months, sensitivity was 46% (95% CI 35–57%), whereas it was 13% (95% CI 9–17) for children with ASD with phrase speech. Screening specificity was 99% (95% CI 99–99). With the currently recommended cut-off of 11, sensitivity increased to 42% for ASD overall (95% CI 37–47), 69% (95% CI 58–79) for ASD without phrase speech and 34% (95% CI 29–40) for ASD with phrase speech. Specificity was then reduced to 89% (95% CI 89–90).

Early ASD screening with a parent checklist had low sensitivity. It identified mainly individuals with ASD with significant developmental delay and captured very few children with ASD with cognitive skills in the normal range. Increasing sensitivity was not possible without severely compromising specificity.

C.L. receives royalty for the Social Communication Questionnaire, which she has co-authored.

Autonomy is a key factor in the reduction of inequitable physical healthcare among people with severe mental illness compared with the general population.

To clarify the critical mechanism underlying autonomy in physical health promotion based on the perspectives of people with severe mental illness.

We employed a conventional content analysis of narrative data from the Healthy Active Lives in Japan (HeAL Japan) workshop meetings.

‘Inhibited autonomy’ was extracted as a central component and shaped by the users’ experiences, both in a healthcare setting and in real life. This component emerged based on the lack of an empowerment mechanism in psychiatric services.

A barrier to the encouragement of autonomy in physical health promotion was found in current psychiatric services. An effective strategy should be explored to foster an empowerment mechanism in psychiatric and mental health services.

None.

Members of online bipolar disorder forums often report experiences of mood-stabilisation on the ketogenic diet, which has traditionally been used in the treatment of epilepsy. We examined the nature and extent of such reports.

To investigate associations between a ketogenic diet and mood stabilisation among individuals with bipolar disorder.

We undertook an observational analytic study of free-text comments in online forums about mood effects of dietary interventions (ketogenic, omega-3 enriched or vegetarian) classified by a priori categories of change in mood stabilisation in 274 people with bipolar disorder.

There were 141 (85.5%) free-text comments on ketogenic diets that reported a positive impact on mood stabilisation. Reports of significant mood stabilisation or remission of symptoms over a period were substantially higher for a ketogenic diet than for other diets (93/165, 56.4%, 95% CI 48.4–64.1) v. 14/94, 14.9%, 95% CI 8.4–23.7), odds ratio 7.4, 95% CI 3.8–14.1, P < 0.0001), many with detailed reports of the improvements experienced and several lasting for extended periods (months to years). Other reported associations included fewer episodes of depression (in 41.2%, 95% CI 30.6–52.4 of individuals); improved clarity of thought and speech (28.2%, 95% CI 19.0–39.0); increased energy (25.9, 95% CI 17.0–36.5); and weight loss (25.9%, 95% CI 17.0–36.5).

Despite the inherent limitations of the observational data based on self-reports posted online, the association strength and reports of sustained benefit support a hypothesis of a ketogenic diet being associated with beneficial effects on mood stabilisation. Caution should be exercised in interpreting this data until a controlled trial can be carried out to examine this hypothesis. These preliminary observations are generally consistent with a mitochondrial dysfunction component to bipolar disorder aetiology with ketones bypassing a block between glycolysis and the tricarboxylic acid cycle.

None.

Successful scale-up of integrated primary mental healthcare requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking.

To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda).

A qualitative study using semi-structured key informant interviews (n = 128) was conducted. The ‘Performance of Routine Information Systems’ framework served as the basis for a coding framework covering three main categories related to the performance of new tools introduced to collect data on mental health indicators: (1) technical; (2) organisation; and (3) behavioural determinants.

Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data-capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability.

Use of the newly developed, contextually appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating data on mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services.

None.