Mental health services and public mental health: challenges and opportunities

K. Wahlbeck 1 presents an excellent overview and critical analysis of the current thinking, trends and challenges in public mental health. He also makes a strong case for the need to translate the existing evidence into practice, and for developing research in the key areas of public mental health. Acknowledging the fact that mental health issues have been largely neglected in public health agendas, Wahlbeck rightly highlights the importance of the new approach consisting in the use of arguments based on the impact of mental health on human, social and economic capital of countries, as an entry point to introduce mental health issues in the political agenda, instead of only using arguments based on the high prevalence of mental disorders. The results of research on social determinants of mental health and mental-ill health are now so strong, that it is easy to document the need of integrating mental health in all policies, reaching out to areas other than the health sector 2. We can now contribute to the improvement of mental health using information on social and economic determinants to inform service planning, organize programmes for promotion and prevention, develop advocacy for social change, and influence authorities outside the health sector to take action aimed at the promotion of mental health 3. Therefore, I agree that the integration of mental health into non-health policies should be actively pursued. In my view, however, other approaches should also be used. Given the high comorbidity between mental disorders and physical illnesses, the integration of mental health into other health policies should also be prioritized. This is particularly true regarding the integration of responses to mental disorders and other chronic diseases. Epidemiological studies have consistently showed the strong links between mental disorders, major non-communicable diseases and several communicable conditions such as HIV/AIDS and tuberculosis. They are chronic, they share common determinants, they have severe consequences in terms of disability, they are highly interdependent, and tend to co-occur 4. Although further research is needed, particularly in low-income countries, innovative models of integrated care have proved to be effective. In order to effectively respond to the challenges of integrated care, a public health approach is required, including a focus on disease prevention and health promotion, together with the provision of accessible, comprehensive and coordinated services 4. I also strongly agree that the design and evaluation of mental health services and systems are important elements of public mental health. The growing evidence of the huge burden that mental disorders represent, and the significant treatment gap existing both in developing and developed countries, confirm that the development of new models of mental health services initiated in the 1980s continues to be a major challenge for the improvement of mental health of the populations, and it can only be handled with a public health perspective 5. As noted by Wahlbeck, there is now a broad consensus on the need to shift from the model of care based on institutions to a system that relies much more on community-based care, and to integrate mental health in the general health system. According to the World Health Organization's “pyramid of care”, formal community-based mental health services, in conjunction with mental health services in general hospitals, are considered to have a central role in the improvement of mental health care for several reasons 6. They contribute to better accessibility. They are associated with continuity of care, greater users' satisfaction, increased adherence to treatment, better protection of human rights and prevention of stigmatization 7. They contribute to the establishment of a structured collaboration with the primary health care services, and facilitate collaborative models of care involving combinations of pharmacological and psychosocial interventions delivered in a stepped care manner, which are effective in the treatment of people with mental and physical comorbidities 8, 9. They facilitate the co-ordination, and in some cases the joint funding and management, of health and social care services, as well as the collaboration of health services with services of the employment sector, that are needed to ensure the psychosocial rehabilitation component of care provided to people with severe mental disorders 10. As highlighted by Wahlbeck, community-based services also provide better conditions to ensure respect for patients' human rights and recovery oriented care, as well as to empower and encourage such persons to make decisions affecting their lives, which is a core principle of the modern perspective of mental health care. There is, however, another important advantage of community mental health services that, in my view, should also be stressed: the potential they have to facilitate an effective coordination between care, prevention and promotion. First, because they share with prevention and promotion programmes a public health perspective. Second, because they are often organized according to the catchment area model, thus facilitating the creation of synergies, in a certain geographic area, between people with mental health professional expertise and people from other fields (primary care services, schools, work places, non-governmental organizations, and other key agents in the community). The implementation of policies and plans aimed at the transition to a model based on community services has proved to be a complex process, which usually faces important barriers 11. The integration of responses to mental disorders and other chronic diseases, as well as the coordination between community care and prevention and promotion programmes, will certainly also have to face significant barriers in their implementation. To overcome these barriers, studies on the effectiveness of prevention and promotion interventions should be extended to low-income countries, where they have been very scarce until now, and much more implementation research on mental health policy and services development should be performed.