March 10 2017 – HS503f Global Mental Health

Heller School for Social Policy and Management, Brandeis University

International Health Policy and Management, Master of Science

HS 503f. Global Mental Health: Policy, Programs and Country Plans

Module II, Spring 2016

Wednesdays 9:00 am-11:50 am

Room 163

Instructor and Location: Mary Jo Larson, PhD, MPA, Senior Scientist, Room 251, , telephone 6-3834.
Office Hours: Tuesdays and Thursdays 10-11AM; I welcome your visit anytime. Please drop an email to schedule an appointment

Course Description:

Global mental health (GMH) is an emerging discipline with a growing body of literature, research, and practice examples. GMH topics are currently neglected in health care discussions of many regions and countries. There is an urgent need for policy and program practitioners that are well-trained in GMH including knowledgeable about topics ranging from alcohol and drug abuse, severe mental illness, and illnesses commonly seen in primary care settings (depression, anxiety).

Students who want to work with non-governmental organizations in international settings, work for international health policy organizations, or work with health ministries at the national or local level will be able to engage in discussions and formulate solutions to improve the reach of effective mental health services. We will focus on concepts, policy and programmatic responses that are appropriate for low-and middle-resourced countries. This course will:

  1. Introduce thekey concepts of mental health disorders including stigma
  2. Expose students toprinciples of evidence based and cost effectivepractices
  3. Examineapproaches to improve the mental health status of a country’s population

Course Objectives:

Upon successful completion of this module, students will be able to:

  • Analyze how the burden of mental health conditions contributes to a country’s total disease burden
  • Develop the case for increased country investment in informal and formal mental health care
  • Describe cost-effectivepackages of mental health services and strategies to increase the coverage or reach of a country’s mental health system

Recommended Prerequisites:

Non-MS/IHPM students are invited to take this course.

Course Requirements:

  1. Attendance: Please email me in advance if you must miss a session. You may be permitted to do an extra assignment for missed sessions.
  2. Assigned Video or Readings: Expect to spend about 3 hours each week reading required and supplementary materials.
  3. Participation: Each class we will break into groups for an exercise or small group discussion. I will ask you to self-report on your own contribution to the group. Good group participation includes sharing your own thinking and listening to others, asking clarifying questions, and restating what you think you have heard. Debate is welcome and must respect the dignity of others.
  4. BriefAssignments: Two sessions will ask you to prepare a brief assignment in advance of class. Please submit it the night before class on Latte.
  5. Finalpaper: You will submit a final paper on Latte before class 6, approx. 5-8 pages, double-spaced. References should be cited and are not part of the page count. You will finalize your topic and submit a one-page outline in class 5 that I will provide comments on (ungraded). You will make a brief presentation in class 7 (optionally, class 6).

University Notices:

  1. If you are a student with a documented disability on record at Brandeis University and wish to have a reasonable accommodation made for you in this class, please see me immediately.
  2. You are expected to be honest in all of your academic work. The University policy on academic honesty is distributed annually as section 5 of the Rights and Responsibilities handbook. Instances of alleged dishonesty are subject to possible judicial action. Potential sanctions include failure in the course and suspension from the University. If you have any questions about my expectations, please ask.

Academic integrity is central to the mission of educational excellence at Brandeis University. Each student is expected to turn in work completed independently, except when assignments specifically authorize collaborative effort. It is not acceptable to use the words or ideas of another person – be it a world-class philosopher or your roommate – without proper acknowledgement of that source. This means that you must use footnotes and quotation marks to indicate the source of any phrases, sentences, paragraphs or ideas found in published volumes, on the internet, or created by another student. If you are in doubt about the instructions for any assignment in this course, you must ask for clarification.

PLEASE EVALUATE THIS COURSE

I seek 100% participation in the Brandeis course evaluation system. Your feedback will help me improve my teaching and the course content for future students. Also, I welcome your private visit during office hours if you would like to offer additional feedback or make a request.

Student Evaluation

Essentially, I will look for evidence of your thoughtful engagement in the course. Your regular attendance, active participation, and research effort demonstrated in your final paper is most important.

Classroom Attendance/Participation -33% (Excused absences may require a brief assignment for credit)

Brief Assignments

  • Assignment 1 – 17%
  • Assignment 2 – 17%

Final Paper- 33%

  • Topic and one-page outline – Class 5
  • 5-8 page write up – Class 6
  • References for materials used
  • Class presentation – Class 7

Course Planner

Date / What / Content / Credit
March 29, Class 3 / Assignment 1 / Infographic or worksheet of disease prevalence and burden estimates / 17% of grade
April 12, no class / Assignment 2 / TBD / 17% of grade
April 26, Class 5 / Final paper Outline / Your topic choice and 1 page outline
May 3, Class 6 / Final Paper / Double-spaced not including references. 5-8 pages. Rubric provided / 33% inclusive of presentation
May 10, Class 7 / Class Presentation / Presentation with 5 slides / Option to present Class 6
May 10, Class 7 / Revised Final Paper (optional) / Option to Revise Paper for Grading

REFERENCES USEFUL FOR ASSIGNMENTS AND FINAL PAPER

Patel, Vikram; Minas, Harry; Cohen, Alex; Prince, Martin J. (eds.) Global Mental Health: Principles and Practice. New York NY: Oxford University Press, 2014. This textbook provides a wonderful summary. Available in on electronic reserve at Brandeis library.

Available through Links on Latte and on Course Google Drive

WHO, Mental Health Policy and Service Guidance Package, Improving Access and Use of Psychotropic Medicines, 2004.

[Accessed: 10th March 2017]

World Health Organization. (2010) mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings. [Online]. Available from: [Accessed: 10th March 2017].

WHO, Global Strategy to Reduce the Harmful Use of Alcohol, 2010.

World Health Association. "Mental Health Action Plan 2013–2020." Geneva: World Health Organization (2013).

WHO, Global Status Report on Alcohol and Health, 2014.

[Accessed: 10th March 2017]

World Health Organization. "Mental Health Atlas-2014, WHO, Geneva." Switzerland: World Health Organisation (2011).

Chisholm, D. "Investing in mental health: Evidence for action." World Health Organization (2013).

Inter-Agency Standing Committee. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Inter-Agency Standing Committee, 2007.

UNDOC, World Drug Report 2015. [Accessed: 10th March 2017]

UNDOC, World Drug Report 2016.

UNDOC, World Drug Report 2016, Briefing to Member States June 16, 2016.

WHO, Mental Health and Poverty.

March 15, Class 1. Introduction to Module Topics and Class Requirements

Background on global mental health. Overview of Class Topics.Introduction to the Course Requirements. Introduce yourself and one thing you want to take away from the class. Class exercise.

Required Readings and Videos:

Please watch brief video from WHO on Prevention of Suicide. Link on Latte

Please watch brief video from WHO on Mental Health – silent epidemic. Link on Latte

  1. Eaton J, Kakuma R, Wright A, and Minas H. A position statement on mental health in the post-2015 development agenda. International J of Mental Health Systems 2014, 8:28.
  2. South African scandal after nearly 100 mental health patients die. The Guardian, February 1, 2017.
  3. Ebola, war … but just two psychiatrists to deal with a nation’s trauma. The Guardian, January 20, 2017.

In Class Exercise:

●Introduce yourself - your profession, what you want to take away from the course.

●Small group exercise on special expression of distress in your culture

March 22, Class 2. Primary Care Perspective on Depression Treatment

Guest speaker: Mark R. Bauer, MD, a family physician with research experience in treatments for psychosomatic illness and chronic pain and the effectiveness of treatment approaches that are based on cognitive behavioral therapy, an approach consistent with WHO approaches.

●How do depression and anxiety manifest in your culture, in different cultures? What words or symptoms are common among people who may be clinically depressed?

●How frequently are antidepressants prescribed as part of treatment and how do people in your culture, in different cultures, react to being offered medication?

●How frequently is psychosocial treatment offered (therapy), what kinds of therapies are available, how are they organized and who provides these services (e.g., nurses, social workers, lay health workers, religious leaders)?

Required Readings:

Please consider these questions as you review these articles prior to class:

●What are the components of treatment based consistent with the WHO approach?

●What is the utility of delivering treatment services that are not diagnosis-specific?

●How do you evaluate the efficacy of treatments that are not diagnosis-specific in different healthcare settings?

  1. Rahman A, Hamdani SU, Awan NR, et al. Effect of a multicomponent behavioral intervention in adults impaired by psychological distress in a conflict-affected area of Pakistan: a randomized clinical trial. JAMA. doi:10.1001/jama.2016.17165
  2. Chibanda D, Weiss HA, Verhey R, et al. Effect of a primary care–based psychological intervention on symptoms of common mental disorders in Zimbabwe: a randomized clinical trial. JAMA. doi:10.1001/jama.2016.19102
  3. Neugebauer. Randomized Clinical Trials to Evaluate Mental Health Interventions in Resource-Poor Societies, JAMA 2016,316 (24): 2601-2603.

Supplementary Readings:

  1. Mendenhall E, De SilvaMJ, Hanlon C, et al. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc Sci Med. 2014;118:33-42.
  2. Patel V, Weiss HA, Chowdhary N, et al. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet. 2010; 376 (9758):2086-2095.
  3. Ertl V, Pfeiffer A, Schauer E, Elbert T, Neuner F. Community-implemented trauma therapy for former child soldiers in Northern Uganda: a randomized controlled trial. JAMA. 2011;306(5): 503-512.

In Class Exercise:

Class members will break into small groups and discuss culturally-informed approaches to interview patient(s) about symptoms of depression and culturally acceptable treatment. Consider whether the approach would differ if the patient was new versus long-standing in the practice, female vs male, older vs younger, educated vs not educated.

March 29, Class 3. Measuring the Country Burden of Mental Disorders

Until the very recent past we ranked the significance of health problems by impact on mortality. We continue to enhance disease burden methodologies. Using disability adjusted life year (DALY) estimates, it is apparent that neuropsychiatric conditions are responsible for 14% of the global burden of disease (GBD) worldwide. Estimates based on Years Living with Disability (YLL) yield a higher proportion of burden. Estimates of disease prevalence and burden in local population subgroups should guide plans for developing a mental health strategy. These assessment techniques are continually improved and there are unique aspects of mental disorders to consider.

Guest speaker: Daniel Vigo, MD, a psychiatrist and Research Fellow, Canada Program. Doctor of Public Health Candidate, Department of Global Health and Population, Harvard T.H. Chan School of Public Health.

Required Readings:

Please consider these questions as you review these articles prior to class:

●Why do the authors consider traditional estimates of burden of mental illness to be underestimates?

●What factors in your country/culture and in diverse cultures might contribute to an under-estimation of the burden of mental illness?

  1. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016; 3: 171–78.
  2. Vigo D, Thornicroft G, Atun R. Supplemental Appendix.

Supplementary Readings:

  1. Ferrari AJ, Norman RE, Freedman G, et al. The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010. PLoS One. 2014 Apr 2;9(4):e91936. doi: 10.1371/journal.pone.0091936. eCollection 2014. (see the supplemental tables as well)
  2. Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, et al. (2013) Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. PLoS Med 10(11): e1001547. doi:10.1371/journal.pmed.1001547 (See attachment Table 2).
  3. Whitehead – see last year’s syllabus, Class 3.

Assignment 1 due:

Use WHO resources from the References to identify various estimates of disease burden for a common mental disorder in two specific countries that you want to compare.

In Class Exercise:

Break into small groups, share your estimates of disease burden, to discuss how you would use this information to establish priorities in the countries reviewed.,

April 5, Class 4. Policies and Approaches to Reduce Alcohol and Drug Addiction

Guest speaker: Bulat Idrisov, MD, MS (Class of 2014), is Resident Physician at Bashkir State Medical University, Ufa, Russia; and, NIDA INVEST Research Fellow at Boston Medical Center, Boston University.

Required Readings:

Please consider these questions as you review these articles prior to class:

●What are examples of evidence-based treatment for persons who are addicted to alcohol or other drugs?

●What are examples of harm reduction approaches and how does it differ from treatment?

●What is the evidence that supports mandatory treatments or criminal punishment of people who possess or use illicit drugs?

  1. Lunze K, Idrisov B, Golichenko M, and Kamarulzaman A. Mandatory addiction treatment for people who use drugs: global health and human rights analysis. BMJ 2016;353:i2943 doi: 10.1136/bmj.i2943
  2. Idrisov B, Murphy SM, Morrill T, Saadoun M, Lunze K, and Shepard D. Implementation of methadone therapy for opioid use disorder in Russia – a modeled cost-effectiveness analysis. Subst Abuse Treat Prev Policy. 2017; 12: 4. doi: 10.1186/s13011-016-0087-9.

Supplementary Readings:

  1. World Health Organization (2009). Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: WHO Press.
  2. Windle J. Drugs and Drug Policy in Thailand. Center for 21st Century Security and Intelligence.
  3. Thailand’s “Failed” drug policy is full of lessons for the Phillipines. Buzzfeed, Sept 30, 2016.

In Class Exercise:

Break into groups to develop an argument to adopt or expand a specific approach to alcohol or drug treatment for one or several specific countries. One group will focus on expanding harm reduction strategies, another group on expanding addiction treatment to include pharmacological therapies, another group will propose possible civil and criminal sanctions.

Assignment 2 due: April 12.

Note: No Wednesday classes until April 26.

April 26, Class 5. Increasing community capacity to deliver mental health care

Guest Speaker:Richard Dougherty, PhD. Dr. Dougherty is the CEO of DMA Health Strategies in Massachusetts and President of the non-profit organization BasicNeeds US. As President of BasicNeeds US Inc., Dick is leading efforts to implement the model in the US drawing of a successful model used in BasicNeeds sites in Kenya, Ghana and elsewhere.

Required Readings:

  1. Yaro, Peter and de Menil, Victoria. (2010) Lessons from the African user movement: The case of Ghana. In: Barbato, A. and Vallarino, M., (eds.) Community Mental Health Care in Low-Income Countries: a Way Forward. Press Milan.
  1. Raja, Shoba, et al. (2012). Integrating mental health and development: A case study of the BasicNeeds Model in Nepal. PLoS Med 9.7 (2012): e1001261.

Supplementary Readings:

  1. De Menil et al. Cost-effectiveness…..
  2. Cohen, A., Eaton, J., Radtke, B., George, C., Manual,B.V., De Silva, M., Patel,V. (2011). Three models of community mental health services in low-income countries. Inter J Ment Health Syst, 5(3), 1-10.
  3. Supporting survivors of Ebola in Guinea.
  1. Healing invisible wounds of the Syrian Conflict.

May 3, Class 6. Improving the Mental Health System

Assignment Due:Turn in on Latte your final paper.

We will talk about principles that guide resource allocation and priority setting. These decisions require knowledge of the cost-effectiveness of available strategies and interventions. We will review and discuss the feasibility of the recommended bundles of care for high priority mental health conditions.

Please Watch before class the YouTube Video, Vikram Patel.

Required Readings:

1.Belkin, Gary S., et al. (2011). Scaling up for the “bottom billion”:“5× 5” implementation of community mental health care in low-income regions. Psychiatric Services, 62(12):1494-1502.

2.Caddick, Hannah, et al. (December 2016). "Investing in mental health in low-income countries." ODI Insights.

4.MacKenzie, Jessica and Kesner, Christie (May 2016). "Mental health funding and the SDGs: What now and who pays”, ODI Insights.

5. Chisholm D on behalf of WHO CHOICE (2005). Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organization. World Psychiatry4(1): 37-44.

6. De Silva, M. J., Lee, L., Fuhr, D. C., Rathod, S., Chisholm, D., Schellenberg, J., & Patel, V. (2014). Estimating the coverage of mental health programmes: a systematic review. Int J Epidemiol, 43(2), 341-353.

Class Discussion:

  • Students who have a conflict with class 7 have the option to present their final paper today.

May 10, Class 7. Paper Presentations

  • Students will present a 5-10 minute presentation of their final paper. No more than 5 slides.

1