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OVERVIEW AND DEFINITIONS

The Grand Challenges in Global Mental Health Initiative is led by the U.S. National Institute of Mental Health 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.

This Initiative provides the critical opportunity to bring neuropsychiatric disorders to the forefront of global attention and scientific inquiry. Its goal is to identify the grand challenges, and in so doing pinpoint research priorities that, within the next decade, can lead to substantial improvements in the lives of people living with neuropsychiatric illnesses.

The grand challenges in global mental health are those specific barriers that, if removed, would help to improve the lives of those affected by neuropsychiatric illnesses. The goal of identifying these challenges is to ultimately develop interventions that, if successfully implemented, would have a high likelihood of feasibility for scaling up and impact.

The working definition of ‘mental health’ for the purposes of this Initiative includes all conditions that affect the nervous system and are leading causes of disease burden, estimated on the basis of disability adjusted life years (DALYs). Conditions with a vascular or infectious etiology are excluded, as these would have been addressed in the previous Grand Challenges initiatives. This definition of ‘mental health’ further ensures that conditions that are leading causes of disease burden in one gender or specific age groups are also included. Based on the most recent Global Burden of Disease report, among the health conditions that are included within the Initiative’s remit are: depression, anxiety disorders, schizophrenia, bipolar disorders, alcohol and drug use disorders, mental disorders of childhood, migraines, dementias, and epilepsy. Thus, the list of health conditions includes disorders that clinicians may categorize as psychiatric, neurological or substance use disorders.

The term 'global’ mental health encompasses mental health in any country of the world. A core focus in global mental health is related to both reducing the overall burden of health conditions (i.e., effectiveness) and reducing and–ultimately–eliminating health inequalities within and between countries. In addition, the term 'global' refers to global influences on mental health, e.g. cross-national factors such as climate change or macroeconomic policies. The responsibility for improving global mental health transcends national borders, class, race, gender, ethnicity and culture; its promotion requires collective action based on global partnerships.

BACKGROUND AND RATIONALE

More than 100 years ago, mathematician David Hilbert formulated a list of important unsolved problems; Hilbert’s list of 23 challenges has spurred innovation in mathematics research ever since. Recognizing the importance of collective action for overcoming scientific hurdles, the global health community embraced this methodology 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.i 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.ii Both of these initiatives led to the commitment of significant new programs of funding from the Bill and Melinda Gates Foundation, the Wellcome Trust and the Canadian Institutes of Health Research; and from the Global Alliance for Chronic Disease, respectively.

Now, in 2010, it is time to focus our collective efforts on global mental health.

The World Health Organization’s (WHO) ongoing Global Burden of Disease analysis identifies neuropsychiatric disorders as substantial sources of disease burden. Thirteen percent of the total global burden of disease is due to neuropsychiatric disorders; similarly, these disorders account for a significant proportion of the burden from non-communicable diseases (which account for a proportion of the global disease burden as large as communicable diseases, maternal and perinatal illnesses combined).iii

Disease burden is not the only factor that renders neuropsychiatric disorders a high-priority topic, however. Across the world, the treatment gaps for neuropsychiatric disorders are large and lead to chronic disabilities and increased mortality. People living with neuropsychiatric disorders often face systematic discrimination in diverse domains of their lives. Despite the suffering and disability they 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, recent priority setting exercises have proposed research strategies in global mental health. The Lancet Global Mental Health Series 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. The results of the Lancet group’s priority-setting exercise suggested a prioritization of implementation science questions, 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.iv The WHO and the Global Forum for Health Research assessed priorities for research in low- and middle-income countries.v, vi These exercises also reported that epidemiology, health systems and social science research were ranked as top priorities.

The Grand Challenges in Global Mental Health Initiative seeks to build on these exercises to identify what stands between where we are now and where we want to be, ideally—the grand challenges. Identifying these challenges will help us ascertain the major scientific thrusts that will be needed to make a significant impact on the lives of people living with neuropsychiatric disorders worldwide. It differs from the preceding exercises in several distinct ways. First, its scope is global in perspective and it addresses a wide range of disorders that affect the nervous system. Second, the consultation process involves a wider community of stakeholders. Third, it is explicitly linked to the support of a community of funders.

METHODOLOGY

The methodology is 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 will be repeatedly surveyed. Panel members are 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 consists of the following major steps:

  • 1. The Scientific Advisory Board establishes the scope and question for the Initiative.
  • 2. The Scientific Advisory Board guides the selection of a broad and representative Delphi Panel.
  • 3. Round 1: Each member of the Delphi Panel submits his or her suggestions in response to the Grand Challenges question. Mid-April.
  • 4. The Administration Team qualitatively synthesizes the Round 1 responses.
  • 5. Round 2: Each member of the Delphi Panel selects his or her top 40 challenges from the longer list of Grand Challenges identified in and synthesized following Round 1. Mid-September.
  • 6. The Administration Team compiles a consolidated list of the top 40 Grand Challenges from Delphi Panelists’ selections.
  • 7. Round 3: Each member of the Delphi Panel rates the consolidated list of 40 Grand Challenges on four dimensions (Feasibility; Potential for disease burden reduction; Impact on equity in population; and Immedicacy of impact). November.
  • 8. The Administration Team analyzes the results and presents them in summary form to the Scientific Advisory Board for interpretation.
  • The Delphi method’s structured, sequential questioning with controlled feedback is ideal for attaining the goals of this Initiative: distilling knowledge and building reliable consensus.


    i Varmus, H., Klausner, R., Zerhouni, E., Acharya, T. Daar, A. S., & Singer, P. A. (2003). Grand challenges in global health. Science, 302, 398-399.

    ii Daar, A. S., Singer, P. A., Persad, D. L., Pramming, S. K., Matthews, D. R., Beaglehole, R., . . . Bell, J. (2007). Grand challenges in chronic non-communicable diseases. Nature, 450, 494-496.

    iii World Health Organization. (2005). World Health Organization preventing chronic diseases: A vital investment.

    iv Lancet Global Mental Health Group. (2007). Scale up services for mental disorders: A call for action. Lancet, 370, 1241-1252.

    v Tomlinson, M., Rudan, I., Saxena, S., Swartz, L., Tsai, A. C., & Patel, V. (2009). Priorities for global mental health research. Bulletin of the World Health Organization, 87, 438-446.

    vi Sharan, P., Gallo, C., Gureje, O., Lamberte, E., Mari, J. J., Mazzotti, G., . . . Saxena, S. (2009). Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean. British Journal of Psychiatry, 295, 354-363.