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Standards on reporting outcomes of mental health system development in low resource settings are urgently needed

Posted by Renato on 21 Jun 2012 at 15:05 GMT

Dear Editor,
Although the author's description highlight major achievements on the implementation and scaling up of the integration of mental health care into the health system in Afghanistan, the paper by Ventevogel et al (1) does not allow us to fully understand the effectiveness of the management of severe mental disoders (SMD) and the mental health system model developed by the authors.
The only indicator of program results described for people with SMD is the annual average of 3.9 visits. I am afraid that this is very much below what we would expect as good clinical management of conditions that are in general chronic, compromise severely patient's functionality and quality of life and need at least 12 months of antipsychotic therapy as for example in the case of a first psychotic episode (2). As psychotropic drugs are in general delivered on a monthly basis, we would expect at least monthly consultations in order to guarantee the maintainance of the psychopharmachological treatment.
Being the management of SMD considered a priority in the key mental health and psychosocial support guidelines in humanitarian settings (3,4), we would suggest that future publications on the same topic also present the following outcome indicators:
1. A measure of how much patients adhere to the proposed treatment as a proxy for patient acceptability of the treatment prescribed.
2. A measure of changes on levels of symptomatology and functionality and an effect size describing the clinical magnitude of the improvement.
3. A measure on side effects and other possible harms appearing after the treatment. This of special importance as little is known about how psychotropic drugs affect ethnic groups that might have genetic variations of drug metabolism by the Cytocrome P450 system.
4. A measure reflecting changes on patient's and communitie's social and community roles and practices allowing us to better understand if the proper management of SMD reduces society discrimination and abuse against the severe mentally ill. (5)
Althought the author has illustrated the improvement of one patient with the diagnosis of a depressive disorder, this does not allow us to infer if the same happenent in the whole cohort of patients with SMDs.
The challenges on the integration of management of SMDs into health systems in low income countries and areas affected by long term armed violence as in this case are enormous.
We would hope that more efforts are put on the description of outcome indicators for priority mental health problems as SMDs. This will help the reader to be in the position to better understand the results of the health system model proposed. If the model can be consired effective for the majority of patients and without unintended harms, replicating it in other places in need will be a major boost to global mental health.

1. Ventevogel P, van de Put W, Faiz H, van Mierlo B, Siddiqi M, et al. (2012) Improving Access to Mental Health Care and Psychosocial Support within a Fragile Context: A Case Study from Afghanistan. PLoS Med 9(5): e1001225. doi:10.1371/journal.pmed.1001225

2. Duration of antipsychotic treatment in individuals with a first psychotic episode. Mental health Gap Action program. World Health Organisation (2012) accessed on the 19th of June 2012
3. Inter-Agency Standing Committee [IASC] (2007) IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC.

4. The Sphere Project (2011) Humanitarian Charter and Minimum Standards in Disaster Response - 2011 Edition. Geneva, Switzerland: The Sphere Project.

5. Puteh I, Marthoenis M, Minas H. (2011) Aceh Free Pasung: Releasing the mentally ill from physical restraint. International Journal of Mental Health Systems. doi:10.1186/1752-4458-5-10

No competing interests declared.

RE: Standards on reporting outcomes of mental health system development in low resource settings are urgently needed

peterventevogel replied to Renato on 13 Jul 2012 at 13:39 GMT

Dear Editor,

We thank Dr. Souza for his comment on our paper. He is concerned about the low retention rate for people with severe mental disorder within the primary health care system of Nangarhar province in Afghanistan. We share his concern and also endorse his plea for the use of routine outcome measuring as an avenue that can provide health care planners with much needed information the effectiveness of public mental health interventions. We wish however to make a few remarks in order to put our findings in perspective.

Firstly, with the extremely limited resources and the fragility of the health care system, one needs to be very cautious with adding extra tasks to the health care system, including the performance of routine monitoring and evaluation. The mental health interventions in the described project were not provided by dedicated or additional staff members, but by existing non-specialized health care workers in a health care system that was, at least initially, extremely dysfunctional. The programme covered an area of more than one million people and hundreds of health facilities in an area that was difficult to access and partly under control by anti-governmental groups. Within an Afghan health facility a small team of a doctor, a nurse and midwife is supposed to deliver a complete package of health services, which includes mother and child health and transmittable diseases. Our programme added mental health on top of all that. In such non-research settings it may be rather difficult of not impossible to include a wide variety outcome measures for mental health in the general health care system in order to document changes on levels of symptomatology, functionality and side effects or explore genetic variations of drug metabolism. If other medical specialties would demand that outcomes were routinely measured in such a comprehensively way, health workers in primary care would be even more overburdened than they already are.

Secondly, our paper was neither a research paper nor a formal evaluation, rather a description of a rapid scale up of a modest intervention within an existing governmental public health care system of a low resource setting. Within this process we emphasized ‘coverage’ and ‘sustainability’. The Nangarhar programme, though far from perfect, is one of the few documented examples of services that have been taken to scale [1].

Thirdly, the average of 3.9 visits annual visits for people with severe mental disorders we mentioned in the article is a crude average (all visits divided by all respondents). The recommended 12 annual visits are for patients in a clinical trajectory and not all respondents in the sample participate in such a trajectory. Some of them may visit only once, unfortunately, while others retain in a treatment trajectory. Unfortunately, we cannot detangle such information from the current data that are part of the standardized Health Information System of the Afghan health system.

Our publication should be seen against the grim reality for people in low resource settings, where an estimated 89% of the people with schizophrenic disorders in lower-income countries do not receive treatment [2] We must fight this treatment gap and we firmly believe that the only way to do this is by bringing the care close to the people, in general health services and in the community. We do agree that our results should be better tracked for impact. Currently there are interesting developments on their way that could provide health planners with much needed data to improve care for people with SDM in non specialized health settings [3].

Peter Ventevogel


1. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, et al (2011) Scaling up services for mental health in low and middle income Countries. Lancet 2001, 378:1592-1603.
2. Lora A, Kohn R, Levav I, McBain R, Morris J, et al. (2012) Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bull World Health Organ 90: 47–54.
3. Balaji M, Chatterjee S, Koschorke M, Rangaswamy T, Chavan A, et al (2012) The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India. BMC Health Services Research 12:42. doi: 10.1186/1472-6963-12-42

Competing interests declared: I am the first author of the paper that Renato comments on