Impact case study database

King’s research has been central to the continuing global call to address the gap in mental health infrastructure around the world, since underpinning the influential Lancet Call to Action in 2007. The multi-level approach King’s has advocated – combining change at national, governmental level with effective grass roots implementation – has helped instigate changes in policy and strategy at international and national levels, while providing evidence to implement and scale up mental health programmes on the ground. Collectively, this has brought much needed support to empower countries and communities with limited resources to fill the mental health treatment gap.

King’s research underpinned continuing development and updating of the WHO Mental Health Global Action Program (mhGAP). Based on research co-authored by King’s (1), the WHO launched its ongoing mhGAP programme (aimed at scaling up services for mental, neurological and substance use disorders especially in LMICs where healthcare resources are scarce) [A1, A2]. Subsequently, the programme also developed an Intervention Guide (IG) [A3] and Operations Manual (OM) [A4] on the basis of King’s evidence to provide implementation support to primary care staff in limited resource settings. The WHO also developed the mhGAP community toolkit [A5], which was influenced by King’s researcher Hanlon’s co-authored book Where There Is No Psychiatrist [A6, A7]. This toolkit supports progamme managers to identify local mental health needs, and tailor treatment accordingly.

Subsequent updates to these resources [A8] have drawn on the body of King’s research on mental health needs and service provision in low resource settings, for example acknowledging the value of proactive case-finding in the community (5), and the need to consider the differences between countries (1). Now available in online and smartphone app formats, the IG is produced in Arabic, Chinese, French, Greek, Hindi, Russian, and Spanish and is used in over 100 countries worldwide [A1, A3]. Given that this widespread uptake is sometimes in countries which do not provide feedback, measurements or evaluation, it is not possible to give an exact number of healthcare professionals trained, or number of people with mental illness reached. However, a review in 2018 found uptake of the IG in 90 countries, with positive evaluations available from 33 countries in Africa, the Middle East, Asia and South America [A9]. For example, the IG was used during a humanitarian crisis after a military operation in 2014 in Pakistan. 58 non-specialist healthcare workers working with internally displaced people were trained using mhGAP resources to detect mental illness, allowing people at high risk to access support that they would not otherwise have received [A10]. More recently, in 2019 an evaluation in Mozambique found that 177 health professionals and 1161 community health workers were trained to work with people with epilepsy, resulting in 89,869 consultations over four years, an increase of 67% [A11].

Importantly, King’s research has continued to make the case for improved global mental health care, providing new and valuable insights into how to make this happen on the ground for a broader range of resources and projects. For example, as a result of King’s economic analyses in collaboration with WHO on the cost and benefit of implementing mental health care (7), the United Nations introduced an updated MNS module to its OneHealth economic tool, the primary purpose of which is to assess public health investment needs in low and middle income countries [A7, A1].

By showing what works at a local and district level, King’s research has led to investment and scale up nationally of integrated mental health care.

Example (i): Nepal

As a result of King’s research showing successful implementation and evaluation of an integrated mental health care plan and joint working with local partners in Chitwan district in Nepal (6), there have been national policy changes and local initiatives developed beyond Chitwan. For example:

• Underpinned by findings from PRIME, the Nepalese Ministry of Health produced a Community Mental Health Care Package based on the mhGAP IG and standards, [B1].

• The mental health care training of primary health workers developed in Chitwan district was officially adopted by the Nepalese National Training Institute and Ministry of Health [B2].

• The Nepalese Ministry of Health endorsed the integrated mental health care plan and has included psychotropic medicines on the free drugs list for the first time [B1, B3].

• Similar integrated health care plans as the one used in Nepal have been appropriately adapted and scaled up to 94 facilities across the five countries participating in PRIME in close collaboration with governmental partners [B4].

• The community detection tool evaluated by King’s in Nepal [B5] (6) is now being implemented and tested in countries including Belize, Sri Lanka and South Africa [B6, B7,B8].

Example (ii): Ethiopia

As a result of King’s research on the effectiveness of task-sharing as an approach to integrate mental health care into primary care in the Sodo region of Gurage Zone Ethiopia (4), and by joint working with local partners, there have been a number of developments in the country:

• King’s research findings (4) shaped Ethiopia’s first National Mental Health Strategic Plan [C1].

• King’s researchers developed a participatory, integrated district level plan with key stakeholders, implemented and scaled-up care to the whole of the Gurage Zone [C2].

• More than 100 frontline health workers, 100 community health workers, as well as healthcare managers and pharmacy technicians were trained to support delivery of mental health care. More than 600 people with SMI (4), and 350 people with epilepsy [C3] have received care.

King’s researchers have co-developed mental health services with communities, making implementation more effective, and addressing barriers to treatment caused by stigma, reaching many more of those who need support. By working closely with communities, King’s research has identified and co-developed meaningful and effective routes to provide mental health services such as task-sharing and community detection tools. Based on King’s research around stigma (8) people living with mental illness have been engaged with the planning and delivery of services. In Nepal service users were involved in the training and supervision of primary healthcare workers and in Ethiopia service users shared their stories to teach community members and to train primary care staff.

With a focus on the reduction of stigma around mental health, the INDIGO partnership programme has implemented service user involvement in stigma reduction in 42 villages in Andhra Pradesh in India and showed significant improvements in knowledge, attitude and behaviour [D1]. In Ethiopia, the EMERALD program included experts with lived experience of mental illness into training for primary care workers, based on King’s evidence that social contact is the best approach to reduce stigma (8) [D2].

Service users report the benefit of access to psychological and pharmacological treatment, one saying “the support group taught me to understand myself and accept who I am ”, and another with SMI saying “the treatment has helped… now I can work… the drugs have worked a lot for me. Now my drugs are my food, they are my tea ”. Her mother comments “they no longer shun her. She’s no longer scared in her current state” [D3]**.