OVERVIEW

The Grand Challenges in Global Mental Health Initiative was led by the National Institute of Mental Health (NIMH) and the Global Alliance for Chronic Disease in partnership with the Wellcome Trust, the McLaughlin-Rotman Centre for Global Health, and the London School of Hygiene and Tropical Medicine.

The Grand Challenges Initiative provided a critical opportunity to bring mental, neurological and substance use (MNS) disorders to the forefront of global attention and scientific inquiry. The aim of the initiative was to identify research priorities that, if addressed within the next decade, could lead to substantial improvements in the lives of people living with neuropsychiatric illnesses.  A grand challenge was defined as a specific barrier that, if removed, would help to improve the lives of those affected by mental, neurological, or substance use disorders.

For the purposes of the Grand Challenges Initiative, the broad category called ‘mental health’ referred to factors (including disorders) influencing the health of the mind, brain, and nervous system. These conditions account for approximately 10% of the global burden of disease, as indicated by disability-adjusted life years (DALYs) reported by the World Health Organization^[1] and the Global Burden of Disease 2010 study.^[2] As a group, they are the leading causes of disability worldwide.^[3] MNS disorders within the Initiative’s remit included depression, anxiety disorders, schizophrenia, bipolar disorder, alcohol and drug use disorders, mental disorders of childhood, migraines, dementias, epilepsy, etc. Conditions with a vascular or infectious etiology were excluded, as these were addressed in previous Grand Challenges initiatives.

The term ‘global’ encompasses mental health in any country of the world. A core focus in global mental health is to both reduce the overall burden of illness and to reduce -- and ultimately eliminate -- health inequities within and between countries. The term ‘global’ also refers to global influences on mental health -- for example, cross-national factors such as conflict, climate change or macroeconomic policies. The responsibility for improving global mental health transcends national borders, class, race, gender, ethnicity and culture; promoting global mental health requires collective action based on global partnerships.

BACKGROUND AND RATIONALE

Recognizing the importance of collective action for overcoming scientific hurdles, the global health community embraced the use of challenge initiatives for improving the lives of its global constituency. In 2003, the Grand Challenges in Global Health project promoted the discovery and development of new tools to fight infectious diseases that cause millions of deaths each year in developing countries.^[1] In 2007, the Grand Challenges in Chronic Non-Communicable Diseases study addressed non-communicable disorders (excluding mental health) which have reached epidemic proportions in both the developed and developing worlds.^[2] Both of these initiatives led to the commitment of significant new programs of funding from a community of private and federal organizations around the world.

In 2010, the Grand Challenges in Global Mental Health initiative was launched to focus our collective efforts on global mental health.

The 2010 Global Burden of Disease Study identified MNS/neuropsychiatric disorders as substantial sources of disease burden.^[3],[4] As a group, mental and behavioral disorders are the leading causes of disability worldwide. In combination with neurological disorders, these disorders account for around 10 percent of the total global burden of disease.

Disease burden is not the only factor that renders neuropsychiatric disorders a high-priority topic. Across the world, the treatment gaps for these conditions are large; thus, many in need of care do not receive adequate or effective interventions. People living with neuropsychiatric disorders often face systematic discrimination in diverse domains of their lives. Despite the suffering and disability that neuropsychiatric disorders can cause, relatively few resources are allocated worldwide to fund the necessary research to effectively prevent and treat neuropsychiatric disorders.

In order to assist in targeting the limited resources for action, several priority-setting exercises have resulted in proposed research strategies in global mental health. A series of papers in The Lancet in 2007 reference identified gaps in the evidence base for depressive disorders, alcohol and substance-use disorders, child and adolescent mental disorders, and psychotic disorders, with a focus on closing the 

treatment gaps in developing countries. This group suggested a prioritization of research on implementation science, for example health policy and systems research, research on affordable delivery of cost-effective interventions, and epidemiological research on childhood disorders and substance use disorders.^[1] In addition, WHO and the Global Forum for Health Research assessed priorities for research in low- and middle-income countries reporting that epidemiology, health systems, and social science research were top priorities. ^[2],[3]

The Grand Challenges in Global Mental Health Initiative built on these and other exercises to identify impediments to reducing the suffering associated with neuropsychiatric disorders. Identifying these challenges will help us determine the major scientific advances that are needed to make a significant impact on the lives of people living with neuropsychiatric disorders worldwide. The Initiative was unique in that its scope was global in perspective; it addressed a wide range of disorders that affect the nervous system; the consultation process involved a wide community of stakeholders; and, this initiative was explicitly linked to the support of a community of funders.

METHODOLOGY

The methodology was an adaptation of the Delphi method used for the Grand Challenges in Chronic Non-communicable Diseases study. A Delphi Panel consisting of approximately 400 stakeholders was surveyed three times. Panel members were selected to provide a representation of the diverse clinical, policy, advocacy, user and research communities whose interests are covered within the Initiative’s scope of global mental health.

Specifically, the Initiative's adapted Delphi method consisted of the following major steps:

1. The Scientific Advisory Board established the scope and question for the Initiative.
2. The Scientific Advisory Board guided the selection of a broad and representative Delphi Panel.
3. Round 1: Each member of the Delphi Panel submitted his or her suggestions in response to the Grand Challenges question.
4. The NIMH Working Group qualitatively synthesized the Round 1 responses.
5. Round 2: Each member of the Delphi Panel selected his or her top 40 challenges from the longer list of Grand Challenges identified in and synthesized following Round 1.
6. The NIMH Working Group compiled a consolidated list of the top 40 Grand Challenges from Delphi Panelists’ selections.
7. Round 3: Each member of the Delphi Panel rated the consolidated list of 40 Grand Challenges on four dimensions (Feasibility; Potential for disease burden reduction; Impact on equity in population; and Immediacy of impact).
8. The NIMH Working Group analyzed the results and presented them in summary form to the Scientific Advisory Board for interpretation.
9. The leadership teams published a manuscript in July 2011 describing the initiative and presenting the top 25 challenges.

RESULTS

The findings from the Grand Challenges in Global Mental Health initiative were published as a comment in the July 7, 2011 issue of Nature (PMC3173804 ).

Of the 594 individuals nominated to the Delphi panel, 422 agreed to participate.  They worked in 60 countries around the world, with the largest percentage (24%) working in Asia, followed by Africa and North America (both 20%), Central and South America (18%), Europe (16%), and Australia, and New Zealand (2%). 

The three rounds of the prioritization exercise yielded six grand challenge goals (Table 1) and 40 grand challenges (Table 2).  These identified priorities encompass a spectrum of research activities, ranging from basic, discovery science to implementation and policy research.  Four themes recurred throughout the data: 1) use a life-course approach to study MNS disorders; 2) use system-wide approaches to address suffering; 3) use evidence-based interventions for MNS disorders; and, 4) understand environmental influences on risk and resilience for MNS disorders.

List of 40 Grand Challenges in Global Mental Health

• Integrate core packages of mental health services into routine primary health care.
• Reduce the cost and improve the supply of effective psychotropic drugs for mental, neurological and substance use disorders.
• Train health professionals in low‐ and middle‐income countries to provide evidence‐based care for children with mental, neurologic, and substance use disorders.
• Provide adequate community‐based care and rehabilitation for people with chronic mental illness.
• Strengthen the mental health component in the training of all health care personnel to create an equitable distribution of mental health providers.
• Incorporate a mental health component into international aid and development programs.
• Develop treatments for mental disorders for use by non‐specialist health workers with minimal training.
• Develop school‐based mental health promotion programs for children and adolescents.
• Develop sustainable models to train and increase the number of culturally and ethnically diverse lay and specialist providers to deliver evidence‐based services for mental, neurological and substance use disorders.
• Improve access to evidence‐based interventions (i.e. screening and treatment) for mental, neurological and substance use disorders in populations affected by conflict and displacement.
• Develop an evidence‐based set of primary prevention interventions for a wide range of mental, neurological and substance use disorders.
• Integrate mental, neurological and substance use disorders into the chronic disease agenda at all levels of government.
• Reduce the duration of untreated illness by developing culturally‐sensitive early interventions for mental, neurological and substance use disorders across settings.
• Create parity between mental and physical illness in investment in research, training, treatment, and prevention
• Conduct screening for mental, neurological and substance use disorders during routine primary health care visits.
• Develop locally appropriate strategies to eliminate childhood abuse and enhance child protection.
• Develop culturally‐informed methods to eliminate the stigma, discrimination, and social exclusion of people with mental illness and their families across cultural settings.
• Increase capacity in low‐ and middle‐income countries by creating regional centers for mental health research, education, training and practice that incorporate the views and needs of local people.
• Develop mobile and IT technologies (e.g. telemedicine) to increase access to evidence‐based care for mental, neurological and substance use disorders.
• Establish and implement minimum health care standards for mental, neurological, and substance use disorders around the world.
• Develop national child and adolescent mental health policies.
• Redesign health systems to integrate mental, neurological and substance use disorders with other chronic diseases.
• Develop methods to improve parenting skills and promote secure attachment with caregivers in infancy and childhood.
• Enact a National Mental Health Plan for each country.
• Develop interventions to reduce the long‐term negative impact of low childhood socioeconomic status on cognitive ability and mental health.
• Support community environments that promote physical and mental wellbeing across the life course.
• Involve people living with or affected by mental, neurological and substance use disorders in policy and practice development.
• Incorporate functional impairment and disability into assessment methods for mental, neurological and substance use disorders.
• Enable family environments that promote physical and mental wellbeing across the life course.
• Promote awareness among researchers about the importance of cultural adaptation of interventions and development of context-appropriate concepts, instrumentation, and manuals.
• Establish cross‐national evidence on the cultural, socioeconomic, and services factors underlying disparities in the incidence, diagnosis, treatment, and outcomes of mental, neurological and substance use disorders.
• Foster resilience and enhance protective factors for mental, neurological and substance use disorders across developmental and life course stage.
• Identify modifiable social and biological risk factors across the life course.
• Develop methods for predicting (pharmaceutical or psychosocial) treatment response and side effects.
• Establish shared, standardized global data systems for collecting surveillance data on the prevalence, treatment patterns, and availability of human resources and services for mental, neurological and substance use disorders.
• Understand the impact of poverty, violence, civil conflict, and migration on mental, neurological and substance use disorders.
• Develop valid, reliable definitions, models, and measurement tools for the quantitative assessment of mental, neurological and substance use disorders at the individual and population levels for use across cultures and settings.
• Understand adaptive, normative, and resilient responses to daily life stress.
• Create a standardized diagnostic system based on symptom severity and brain functioning that is applicable across cultures.
• Identify biomarkers for mental, neurological and substance use disorders.

Supplementary information , which includes (1) a more detailed description of the results for each Delphi round; (2) a supplementary discussion; (3) acknowledgements, author contributions and conflict-of-interest disclosures; (4) descriptive information about the Delphi panel; (5) Round 2 results (both complete and separated between overall and basic scientists' rankings); (6) and Round 3 results across ranking criteria is available with the online version of the manuscript.

At a briefing held for the UK press in London on July 6, 2011, Drs. Shitij Kapur, Barbara Sahakian and Graham Thornicroft, members of the Initiative's Scientific Advisory Board, spoke to journalists from The Daily Mail, The Telegraph, The Guardian, BMJ, The Times, and Research Forthnight about the Grand Challenges in Global Mental Health initiative.

The U.S. National Institute of Mental Health announced the publication of the Grand Challenges in Global Mental Health commentary in an online press release and in a Director’s Blog entry.