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The 'Treatment Gap' and Community-Based Interventions

The momentum created by the ‘call to action’ of MGMH coincided with the WHO launching international initiatives such as the Mental Health Gap (mhGAP) programme (WHO 2008, 2010). These programmes have proposed plans for scaling-up services to reduce the burden associated with priority psychiatric diagnoses. In recent years, there has been growing interest in the possibility of developing trans-diagnostic interventions to more generally address the experience of distress, rather than specific forms of diagnosis. This focus on ‘distress’ and other concepts such as ‘subjective wellbeing’ reflects a need to broaden the understanding about what constitutes a good outcome for individuals with a lived experience of mental health difficulties (White et al. 2016). The ‘Recovery Approach’ (Anthony 1993) has advocated the need for psychiatric services to move beyond focusing narrowly on reducing the severity of symptoms of mental illness, to instead move towards themes such as connectedness, hope, identity, meaning and empowerment (Leamy et al. 2011). Research has suggested that the ‘Recovery Approach’ may have utility across cultural groups (Leamy et al. 2011), and there are emerging attempts to introduce innovations such as ‘Recovery Colleges’ in low-resource settings. The chapter by Aldersley et al. in this volume provides further reflection on the ‘Recovery Approach’ and the implications that this has for GMH.

Borrowing language from GH, The Lancet Series on Global Mental Health (2007, 2011) and the mhGAP Action Programme (WHO 2008) and mhGAP Intervention Guide (WHO 2010) draw on the notion of the need to fill the ‘treatment gap’ (i.e., the gap between the numbers of people assumed to be suffering from mental illness and the numbers receiving treatment). As is the case for burdensome physical health conditions (such as HIV/AIDS and malaria), the urgency for ‘scaling-up’ services for mental health difficulties has in part been justified on the basis of the moral obligation to act (Patel et al. 2006; Kleinman 2009). The MGMH has been engaged in concerted efforts to mobilize stakeholders and lobby for policy change to address the ‘treatment gap’. Vikram Patel has stated that there is a need ‘to shock governments into action’, and that language should be employed strategically for this purpose (Bemme and D’Souza 2012, para. 24). For example, it is suggested that the ‘treatment gap’ for mental health difficulties is as high as 85% in low-income countries (Demyttenaere et al. 2004), and that urgent action needs to be taken to bridge it. However, the aforementioned concerns about the poor quality of epidemiological data relating to mental disorders in low- and middle-income countries (LMICs) (see Baxter et al. 2013) will have important implications for the accuracy of estimates of the ‘treatment gap’. In addition, critics have argued that the concept of the ‘treatment gap’ has privileged particular forms of treatment whilst simultaneously failing to recognize the important contribution that non-allopathic[1] forms of support and healing may bring to people living across the globe (Bartlett et al. 2014; Fernando 2014). The inference is that the rhetoric of the ‘treatment gap’ may well shock governments into taking action, but this action may not be inclusive of the pluralistic forms of support available. Researchers have suggested that pluralism and a multiplicity of treatment options might bring potential benefits for engagement and outcome for individuals experiencing mental health difficulties in LMICs—these themes are explored in more depth in the chapter by Orr and Bindi in this volume.

Jansen et al. (2015) pointed out that the concept of the ‘treatment gap’ has advocated a particularly individualistic approach to scaling-up services for mental health in LMICs. Fernando (2012) suggested that the burden of mental health problems experienced collectively by communities is likely to be greater than the sum of the burden on the individual members of that community, especially in the context of ‘collective traumas’ (see Audergon 2004; Somasundaram 2007, 2010). It is important, however, to appreciate that conceptualization of ‘communities’ vary across different settings, and there are also marked variations in the degree of cohesiveness in communities across the globe. Campbell and Burgess (2012) suggest that the tendency for GMH initiatives to prioritize interventions aimed at individuals has meant that the social circumstances that can foster improved health have been insufficiently addressed. Bemme and D’Souza (2014) observed that GMH initiatives have narrowly conceptualized ‘community’ as a method of service delivery. The rationale for community-based mental health care has been closely linked to the ideological shift towards deinstitutionalizing the care of people experiencing mental health difficulties and bringing services closer to where people live. Community care is also proposed as more cost-effective option (Das and Rao 2012; Saxena et al. 2007). Moving forward, there is a need to explore how the concept of ‘community’ can be promoted as a means of harnessing collective strengths and resources to promote mental wellbeing (Jansen et al. 2015). These efforts should, however, be cognizant of concerns that community action and volunteering in GH and GMH initiatives may take advantage of community workers by relying heavily on their unpaid and demanding work (Maes 2015; Kalofonos 2015). This has implications for both the sustainability and quality of care provided, particularly where there is inadequate investment in ongoing training and supervision.

  • [1] The term ‘allopathy’ was introduced by German physician Samuel Hahnemann (1755—1843) when heconjoined the Greek words ‘allos’ (opposite) and ‘pathos’ (suffering). It is defined as the treatment ofdisease by conventional means (i.e. with drugs having effects opposite to the symptoms).
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