The magnitude of and health system responses to the mental health treatment gap in adults in India and China

doi:10.1016/S0140-6736(16)00160-4

The Lancet

Volume 388, Issue 10063, 17 December 2016–6 January 2017, Pages 3074-3084

https://doi.org/10.1016/S0140-6736(16)00160-4 Get rights and content

Summary

This Series paper describes the first systematic effort to review the unmet mental health needs of adults in China and India. The evidence shows that contact coverage for the most common mental and substance use disorders is very low. Effective coverage is even lower, even for severe disorders such as psychotic disorders and epilepsy. There are vast variations across the regions of both countries, with the highest treatment gaps in rural regions because of inequities in the distribution of mental health resources, and variable implementation of mental health policies across states and provinces. Human and financial resources for mental health are grossly inadequate with less than 1% of the national health-care budget allocated to mental health in either country. Although China and India have both shown renewed commitment through national programmes for community-oriented mental health care, progress in achieving coverage is far more substantial in China. Improvement of coverage will need to address both supply-side barriers and demand-side barriers related to stigma and varying explanatory models of mental disorders. Sharing tasks with community-based workers in a collaborative stepped-care framework is an approach that is ripe to be scaled up, in particular through integration within national priority health programmes. India and China need to invest in increasing demand for services through active engagement with the community, to strengthen service user leadership and ensure that the content and delivery of mental health programmes are culturally and contextually appropriate.

Introduction

In recognition of the large gap between the need for treatment of mental disorders and the provision of that treatment, WHO's Mental Health Action Plan calls for an increase in service coverage for severe mental disorders by at least 20% by the year 2020.¹ The reduction of the treatment gap in India and China, the two most populous countries in the world, is crucially important for achievement of this goal. Systematic assessment of the scale of and health system response to the treatment gap could not only help these two countries to improve their mental health system performance, but also shed light on how other countries might achieve their mental health goals. In this Series paper we address four issues: estimation of the magnitude of the treatment gap; description of the response of the mental health-care systems; identification of the barriers to addressing the treatment gap; and identification of innovations with potential to overcome these barriers. We undertook a systematic review of the indexed literature and a non-systematic review of so-called grey literature on these four issues for depression, psychosis, bipolar disorder, epilepsy, dementia, and alcohol and drug use disorders, all deemed priority adult mental disorders by the WHO Mental Health Gap Action Programme.² We have focused on biomedical (modern) medicine, as traditional health-care systems, which are popular in both countries, are addressed in a dedicated paper in this Series.³

Section snippets

The magnitude of the treatment gap

We used two indicators to estimate the magnitude of the treatment gap: contact coverage to measure service use, and effective coverage to further measure the extent to which the service has effectively improved the health of people who used it.⁴

Governance and organisation

Nine papers from China28, 41, 42, 43, 44, 45, 46, 47, 48 and eight papers from India49, 50, 51, 52, 53, 54, 55, 56 addressed the health system response, in accordance with grey literature. Table 3 summarises the mental health-care systems in the two countries. Both countries have embarked on a restructuring of their mental health-care systems and advocating community-based care. However, health system responses, both across and within the two countries, vary substantially. The centralised

Barriers to improving access to care

In both India and China, some demand-side and supply-side barriers contribute to the treatment gap and limit timely access to mental health-care.79, 80

Innovations to improve access to care

A major strategy for addressing workforce shortages has been the use of task-sharing. Growing evidence has shown that non-specialists can be trained to identify, diagnose, and treat people with mental health problems, improving adherence and clinical outcomes in a range of mental disorders.17, 26, 110, 114 For example, a programme in Haryana, India, used peer educators to lead outreach activities for male drug users. In this programme, the proportion of injecting drug users who shared needles

Discussion

This Series paper describes the first systematic effort to review the unmet mental health needs for adults with priority mental disorders in China and India. Evidence shows that contact coverage for common mental disorders and alcohol use disorders, which together account for more than 60% of the mental health related burden of disease in the two countries, is very low.¹²³ Effective coverage is even lower, not only for common disorders but also for severe problems such as psychotic disorders

Search strategy and selection criteria

We carried out a systematic review using the steps recommended in the PRISMA statement. for papers published in English or Chinese between Jan 1, 2005, and Dec 31, 2014. We searched MEDLINE, Embase, PsycINFO, PubMed, the Cochrane Library, and the Web of Science; we also searched country-specific databases including IndMED, the only database of Indian medical journals, many of which are not indexed on any other international database, and SinoMed, the most comprehensive electronic database of

References (129)

MR Phillips et al.
Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey
Lancet
(2009)
S Chen et al.
Prevalence and natural course of late-life depression in China primary care: a population based study from an urban community
J Affect Disord
(2012)
SH Nizamie et al.
Health care delivery model in epilepsy to reduce treatment gap: World Health Organization study from a rural tribal population of India
Epilepsy Res
(2009)
X Pi et al.
Investigation of prevalence, clinical characteristics and management of epilepsy in Yueyang city of China by a door-to-door survey
Epilepsy Res
(2012)
PS Wang et al.
Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys
Lancet
(2007)
AV Cherian et al.
A 5-year prospective follow-up study of patients with obsessive-compulsive disorder treated with serotonin reuptake inhibitors
J Affect Disord
(2014)
E Liu et al.
Correlates of methadone client retention: a prospective cohort study in Guizhou province, China
Int J Drug Policy
(2009)
NP Varma et al.
Employment concerns of people with epilepsy in Kerala, south India
Epilepsy Behav
(2007)
V Patel et al.
Assuring health coverage for all in India
Lancet
(2015)
B Pereira et al.
The explanatory models of depression in low income countries: listening to women in India
J Affect Disord
(2007)

NK Aggarwal et al.

Using consumer perspectives to inform the cultural adaptation of psychological treatments for depression: a mixed methods study from South Asia

J Affect Disord

(2014)

S Grover et al.

Explanatory models in patients with first episode depression: a study from North India

Asian J Psychiatry

(2012)

X Li

Survey in Shanghai communities: the public awareness of and attitude towards dementia

Psychogeriatrics

(2011)

N Jain et al.

Pathway to psychiatric care in a tertiary mental health facility in Jaipur, India

Asian J Psychiatry

(2012)

T Luo et al.

Stigmatization of people with drug dependence in China: a community-based study in Hunan province

Drug Alcohol Depend

(2014)

G Thornicroft et al.

Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey

Lancet

(2009)

A Lasalvia et al.

Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey

Lancet

(2013)

S Li

Stigma and epilepsy: the Chinese perspective

Epilepsy Behav

(2010)

Mental health action plan 2013–2020

(2013)

mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings

(2010)

Thirthalli JZ, Zhou L, Kumar L, et al. Traditional, complementary, and alternative medicine approaches to mental...

T Tanahashi

Health service coverage and its evaluation

Bull World Health Organ

(1978)

S Lee et al.

Delay in initial treatment contact after first onset of mental disorders in metropolitan China

Acta Psychiatr Scand

(2007)

Z Wei et al.

The mental health service utilization in Shenzhen City

Chin Ment Health J

(2010)

K Demyttenaere et al.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys

JAMA

(2004)

YC Shen et al.

Twelve-month prevalence, severity, and unmet need for treatment of mental disorders in metropolitan China

Psychol Med

(2006)

J Thirthalli et al.

Prospective comparison of course of disability in antipsychotic-treated and untreated schizophrenia patients

Acta Psychiatr Scand

(2009)

MZ Raban et al.

Inequitable coverage of non-communicable diseases and injury interventions in India

Natl Med J India

(2010)

LH Yang et al.

Employment outcome for people with schizophrenia in rural v. urban China: population-based study

Br J Psychiatry

(2013)

WJ Gong et al.

Evaluation of the free medication program for people with schizophrenia in Liuyang communities. Doctoral Dissertation

(2015)

X Ma et al.

Generalized anxiety disorder in China: prevalence, sociodemographic correlates, comorbidity, and suicide attempts

Perspect Psychiatr Care

(2009)

X Ma et al.

Prevalence and sociodemographic correlates of depression in an early population living with family members in Beijing, China

Psychol Med

(2008)

S Pandey et al.

Prevalence and treatment gap in childhood epilepsy in a north Indian city: a community-based study

J Trop Pediatr

(2014)

M Li et al.

Rural-urban differences in the long-term care of the disabled elderly in China

PLoS One

(2013)

E Albanese et al.

Equity in the delivery of community healthcare to older people: findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria

BMC Health Serv Res

(2011)

JM Liu et al.

Treatment of epilepsy in China: Formal or informal?

Neural Regen Res

(2013)

H Wen et al.

An analysis of psychotic disorders in the 2011 database of Sichuan

Sichuan Mental Health

(2012)

JM Olivares et al.

Psychiatrists' awareness of partial and nonadherence to antipsychotic medication in schizophrenia: results from an Asia-Pacific survey

Neuropsychiatr Dis Treat

(2013)

S Chatterjee et al.

Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India

Br J Psychiatry

(2009)

KK Suresh et al.

Work functioning of schizophrenia patients in a rural south Indian community: status at 4-year follow-up

Soc Psychiatry Psychiatr Epidemiol

(2012)

H Ma et al.

An important pathway of mental health service reform in China: introduction of 686 program

Chin Ment Health J

(2011)

N Ma et al.

Treatment dropout of patients in National Continuing Management and Intervention Program for Psychoses in Guangdong Province from 2006 to 2009: implication for mental health service reform in China

Asia Pac Psychiatry

(2012)

Q Li et al.

Retrospective analysis of treatment effectiveness among patients in Mianyang Municipality enrolled in the national community management program for schizophrenia

Shanghai Arch Psychiatry

(2012)

S Grover et al.

Drug dependence in the geriatric age group: a clinic-based study

German J Psychiatry

(2008)

L Zhang et al.

Methadone maintenance treatment participant retention and behavioural effectiveness in China: a systematic review and meta-analysis

PLoS One

(2013)

Y Che et al.

Predictors of early dropout in methadone maintenance treatment program in Yunnan province, China

Drug Alcohol Rev

(2010)

X Cao et al.

Predictors of dropping out of methadone maintenance treatment in China: a six-year cohort study

J Int AIDS Soc

(2012)

J Gu et al.

Misconceptions predict dropout and poor adherence prospectively among newly admitted first-time methadone maintenance treatment clients in Guangzhou, China

Addiction

(2012)

A Sinha et al.

Factors associated with quality of life of patients with epilepsy attending a tertiary care hospital in Kolkata, India

Neurology Asia

(2011)

WZ Wang et al.

Global campaign against epilepsy: assessment of a demonstration project in rural China

Bull World Health Organ

(2008)

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SeriesThe magnitude of and health system responses to the mental health treatment gap in adults in India and China

Summary

Introduction

Section snippets

The magnitude of the treatment gap

Governance and organisation

Barriers to improving access to care

Innovations to improve access to care

Discussion

Search strategy and selection criteria

Lancet

J Affect Disord

Epilepsy Res

Epilepsy Res

Lancet

J Affect Disord

Int J Drug Policy

Epilepsy Behav

Lancet

J Affect Disord

J Affect Disord

Asian J Psychiatry

Psychogeriatrics

Asian J Psychiatry

Drug Alcohol Depend

Lancet

Lancet

Epilepsy Behav

Mental health action plan 2013–2020

mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings

Health service coverage and its evaluation

Bull World Health Organ

Delay in initial treatment contact after first onset of mental disorders in metropolitan China

Acta Psychiatr Scand

The mental health service utilization in Shenzhen City

Chin Ment Health J

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys

JAMA

Twelve-month prevalence, severity, and unmet need for treatment of mental disorders in metropolitan China

Psychol Med

Prospective comparison of course of disability in antipsychotic-treated and untreated schizophrenia patients

Acta Psychiatr Scand

Inequitable coverage of non-communicable diseases and injury interventions in India

Natl Med J India

Employment outcome for people with schizophrenia in rural v. urban China: population-based study

Br J Psychiatry

Evaluation of the free medication program for people with schizophrenia in Liuyang communities. Doctoral Dissertation

Generalized anxiety disorder in China: prevalence, sociodemographic correlates, comorbidity, and suicide attempts

Perspect Psychiatr Care

Prevalence and sociodemographic correlates of depression in an early population living with family members in Beijing, China

Psychol Med

Prevalence and treatment gap in childhood epilepsy in a north Indian city: a community-based study

J Trop Pediatr

Rural-urban differences in the long-term care of the disabled elderly in China

PLoS One

Equity in the delivery of community healthcare to older people: findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria

BMC Health Serv Res

Treatment of epilepsy in China: Formal or informal?

Neural Regen Res

An analysis of psychotic disorders in the 2011 database of Sichuan

Sichuan Mental Health

Psychiatrists' awareness of partial and nonadherence to antipsychotic medication in schizophrenia: results from an Asia-Pacific survey

Neuropsychiatr Dis Treat

Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India

Br J Psychiatry

Work functioning of schizophrenia patients in a rural south Indian community: status at 4-year follow-up

Soc Psychiatry Psychiatr Epidemiol

An important pathway of mental health service reform in China: introduction of 686 program

Chin Ment Health J

Treatment dropout of patients in National Continuing Management and Intervention Program for Psychoses in Guangdong Province from 2006 to 2009: implication for mental health service reform in China

Asia Pac Psychiatry

Retrospective analysis of treatment effectiveness among patients in Mianyang Municipality enrolled in the national community management program for schizophrenia

Shanghai Arch Psychiatry

Drug dependence in the geriatric age group: a clinic-based study

German J Psychiatry

Methadone maintenance treatment participant retention and behavioural effectiveness in China: a systematic review and meta-analysis

PLoS One

Predictors of early dropout in methadone maintenance treatment program in Yunnan province, China

Drug Alcohol Rev

Predictors of dropping out of methadone maintenance treatment in China: a six-year cohort study

Series
The magnitude of and health system responses to the mental health treatment gap in adults in India and China