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SummaryIn this analysis, we argue that the ‘treatment gap’ for common mental disorders often reflects lack of demand, arising because services fail to address the needs of disadvantaged communities. We propose a route forward for global mental health, with explicit focus on action on the socioeconomic determinants of psychological suffering.

Background There is evidence of an association between life events and psychosis in Europe, North America and Australasia, but few studies have examined this association in the rest of the world. Aims To test the association between exposure to life events and psychosis in catchment areas in India, Nigeria, and Trinidad and Tobago. Method We conducted a population-based, matched case–control study of 194 participants in India, Nigeria, and Trinidad and Tobago. Cases were recruited through comprehensive population-based, case-finding strategies. The Harvard Trauma Questionnaire was used to measure life events. The Screening Schedule for Psychosis was used to screen for psychotic symptoms. The association between psychosis and having experienced life events (experienced or witnessed) was estimated by conditional logistic regression. Results There was no overall evidence of an association between psychosis and having experienced or witnessed life events (adjusted odds ratio 1.19, 95% CI 0.62–2.28). We found evidence of effect modification by site (P = 0.002), with stronger evidence of an association in India (adjusted odds ratio 1.56, 95% CI 1.03–2.34), inconclusive evidence in Nigeria (adjusted odds ratio 1.17, 95% CI 0.95–1.45) and evidence of an inverse association in Trinidad and Tobago (adjusted odds ratio 0.66, 95% CI 0.44–0.97). Conclusions This study found no overall evidence of an association between witnessing or experiencing life events and psychotic disorder across three culturally and economically diverse countries. There was preliminary evidence that the association varies between settings.

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

We aimed to map evidence on the development of mental health care in Central Asia after 1991. We conducted a scoping review complemented by an expert review. We searched five databases for peer-reviewed journal articles and conducted grey literature searching. The reference lists of included articles were screened for additional relevant publications. We included 53 articles (Kazakhstan: 13, Kyrgyzstan: 14, Tajikistan: 10, Uzbekistan: 9, Turkmenistan: 2, Multinational: 5). Only 9 were published in internationally recognised journals. In the 1990’s mental health services collapsed following a sharp decline in funding, and historically popular folk services re-emerged as an alternative. Currently, modernised mental health policies exist but remain largely unimplemented due to lack of investment and low prioritisation by governments. Psychiatric treatment is still concentrated in hospitals, and community-based and psycho-social services are almost entirely unavailable. Stigma is reportedly high throughout the region, psychiatric myths are widespread, and societal awareness of human rights is low. With the exception of Kyrgyzstan, user involvement is virtually absent. After many years of stagnation, however, political interest in mental health is beginning to show, along with some promising service developments. There is a substantial knowledge gap in the region. Informed decision-making and collaboration with stakeholders is necessary to facilitate future reform implementation.

Designing and implementing long-term management strategies for chronic biological invasions is amongst the most vexing ecological research problems. Two key challenges to resolving this problem are: (a) integrating science-based and values-based (e.g. spiritual, cultural, economic and ethical) knowledge sources and (b) developing durable knowledge generation and curation platforms to co-ordinate long-term research efforts. We begin by identifying knowledge sources (stakeholder values, forecasts of invader spread and impacts, management technologies and operational logistics) to guide the high-level actions (governance framework design, selection of ethical management technologies, definition of long-term objectives, design of management strategies and operational plans implementing strategies) required for management of chronic invasions. We use exotic conifer invasions in New Zealand as an example. Next, we propose a transdisciplinary knowledge ecology framework where each knowledge source is represented by a separate knowledge generation and curation platform (i.e. knowledge ecosystem) and linked through high-level actions. We detail the structure and function of a single knowledge ecosystem (forecasting spread and impacts), and document two case studies to illustrate how knowledge ecosystems might (a) increase participation of individual researchers within long-term research efforts, and (b) facilitate inclusion of non-researchers in developing a common knowledge base. Finally, we propose a set of guidelines for combining science-based and values-based reasoning in decision-making via localised governance structures. We suggest that viewing knowledge ecologies as an integrated collection of distinct knowledge ecosystems offers a promising approach for identifying, generating, curating and integrating the knowledge sources needed to improve management of chronic biological invasions.

ImportanceLess than 10% of research on psychotic disorders has been conducted in settings in the Global South, which refers broadly to the regions of Latin America, Asia, Africa, and Oceania. There is a lack of basic epidemiological data on the distribution of and risks for psychoses that can inform the development of services in many parts of the world.ObjectiveTo compare demographic and clinical profiles of cohorts of cases and rates of untreated psychoses (proxy for incidence) across and within 3 economically and socially diverse settings in the Global South. Two hypotheses were tested: (1) demographic and clinical profiles of cases with an untreated psychotic disorder vary across setting and (2) rates of untreated psychotic disorders vary across and within setting by clinical and demographic group.Design, Setting, and ParticipantsThe International Research Program on Psychotic Disorders in Diverse Settings (INTREPID II) comprises incidence, case-control, and cohort studies of untreated psychoses in catchment areas in 3 countries in the Global South: Kancheepuram District, India; Ibadan, Nigeria; and northern Trinidad. Participants were individuals with an untreated psychotic disorder. This incidence study was conducted from May 1, 2018, to July 31, 2020. In each setting, comprehensive systems were implemented to identify and assess all individuals with an untreated psychosis during a 2-year period. Data were analyzed from January 1 to May 1, 2022.Main Outcomes and MeasuresThe presence of an untreated psychotic disorder, assessed using the Schedules for Clinical Assessment in Neuropsychiatry, which incorporate the Present State Examination.ResultsIdentified were a total of 1038 cases, including 64 through leakage studies (Kancheepuram: 268; median [IQR] age, 42 [33-50] years; 154 women [57.5%]; 114 men [42.5%]; Ibadan: 196; median [IQR] age, 34 [26-41] years; 93 women [47.4%]; 103 men [52.6%]; Trinidad: 574; median [IQR] age, 30 [23-40] years; 235 women [40.9%]; 339 men [59.1%]). Marked variations were found across and within settings in the sex, age, and clinical profiles of cases (eg, lower percentage of men, older age at onset, longer duration of psychosis, and lower percentage of affective psychosis in Kancheepuram compared with Ibadan and Trinidad) and in rates of untreated psychosis. Age- and sex-standardized rates of untreated psychoses were approximately 3 times higher in Trinidad (59.1/100 000 person-years; 95% CI, 54.2-64.0) compared with Kancheepuram (20.7/100 000 person-years; 95% CI, 18.2-23.2) and Ibadan (14.4/100 000 person-years; 95% CI, 12.3-16.5). In Trinidad, rates were approximately 2 times higher in the African Trinidadian population (85.4/100 000 person-years; 95% CI, 76.0-94.9) compared with the Indian Trinidadian (43.9/100 000 person-years; 95% CI, 35.7-52.2) and mixed populations (50.7/100 000 person-years; 95% CI, 42.0-59.5).Conclusions and RelevanceThis analysis adds to research that suggests that core aspects of psychosis vary by historic, economic, and social context, with far-reaching implications for understanding and treatment of psychoses globally.

IntroductionThere are few robust and directly comparable studies of the epidemiology of psychotic disorders in the Global South. INTREPID II is designed to investigate variations in untreated psychotic disorders in the Global South in (1) incidence and presentation (2) 2-year course and outcome, (3) help-seeking and impact, and (4) physical health.MethodsINTREPID II is a programme of research incorporating incidence, case–control and cohort studies of psychoses in contiguous urban and rural areas in India, Nigeria and Trinidad. In each country, the target samples are 240 untreated cases with a psychotic disorder, 240 age-matched, sex-matched and neighbourhood-matched controls, and 240 relatives or caregivers. Participants will be followed, in the first instance, for 2 years. In each setting, we have developed and are employing comprehensive case-finding methods to ensure cohorts are representative of the target populations. Using methods developed during pilot work, extensive data are being collected at baseline and 2-year follow-up across several domains: clinical, social, help-seeking and impact, and biological.Ethics and disseminationInformed consent is sought, and participants are free to withdraw from the study at any time. Participants are referred to mental health services if not already in contact with these and emergency treatment arranged where necessary. All data collected are confidential, except when a participant presents a serious risk to either themselves or others. This programme has been approved by ethical review boards at all participating centres. Findings will be disseminated through international conferences, publications in international journals, and through local events for key stakeholders.

BackgroundDespite attempts to improve universal health coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand healthcare utilization and OOP expenditure patterns in people with depression. We examined associations between symptoms of depression and frequency and type of healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal.MethodsWe analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about healthcare utilization. We examined associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared utilization of specific outpatient service providers and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more.ResultsWe classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7–22%,p p ConclusionsIn this population-based sample from Central Nepal, we identified dose-dependent increases in healthcare utilization and OOP expenditure with increasing PHQ-9 scores. Future studies should evaluate whether provision of mental health services as an integrated component of UHC can improve overall health and reduce healthcare utilisation and expenditure, thereby alleviating financial pressures on families.

Our understanding of the nature and aetiological architecture of psychotic mental disorders has advanced notably in the past 20 years. It is now widely considered that psychotic disorders occur as consequence of a complex range of factors, spanning multiple domains and levels, that act on several psychological and biological mechanisms. In recent years, evidence has accumulated that exposure to, broadly, adverse social conditions and experiences over the course of development constitute part of this complex array of factors that influence onset. In this chapter, we will provide a critical overview of this evidence, including consideration of outstanding conceptual and methodological issues that limit the causal inferences that can be drawn from existing findings. From this, we will propose and sketch a sociodevelopmental pathway—as one of several pathways—to psychoses.

Background: Despite attempts to improve universal healthcare coverage (UHC) in low income countries like Nepal, most healthcare utilization is still financed by out-of-pocket (OOP) payments, with detrimental effects on the poorest and most in need. Evidence from high income countries shows that depression is associated with increased healthcare utilization, which may lead to increased OOP expenditures, placing greater stress on families. To inform policies for integrating mental healthcare into UHC in LMIC, we must understand general healthcare utilization and OOP expenditure patterns in people with depression. Aims: We examined associations between symptoms of depression and frequency and type of general healthcare utilization and OOP expenditure among adults in Chitwan District, Nepal. Methods: We analysed data from a population-based survey of 2040 adults in 2013, who completed the PHQ-9 screening tool for depression and answered questions about general healthcare utilization. We modelled associations between increasing PHQ-9 score and healthcare utilization frequency and OOP expenditure using negative binomial regression. We also compared sector-specific utilization of outpatient healthcare and their related costs among adults with and without probable depression, determined by a PHQ-9 score of 10 or more. Results: We classified 80 (3.6%) participants with probable depression, 70.9% of whom used some form of general healthcare in the past year compared to 43.9% of people without probable depression. Mean annual OOP healthcare expenditures were $118 USD in people with probable depression, compared to $110 USD in people without. With each unit increase in PHQ-9 score, there was a 14% increase in total healthcare visits (95% CI 7%-22%, p

Rationale and objective Fewer than 15% of adults who meet criteria for a depression diagnosis in India seek treatment for these symptoms. It is unclear whether this reflects limited supply of mental health services or lack of demand for medical intervention for these experiences. This paper aims to identify and describe self-reported barriers that contribute to this “treatment gap” in a rural district in central India, where depression treatment had recently become available in primary care facilities.MethodIn this qualitative study we conducted in-depth interviews with 35 adults who screened positive for depression and who had not sought treatment for their condition, and 15 of their relatives. We analysed the data using the framework approach.ResultsA key barrier to seeking health care for psychological symptoms was lack of perceived need for treatment for these symptoms. Low perceived need for health interventions arose because participants frequently attributed depression-like symptoms to their socio-economic circumstances, or to the stress of physical illness, which conflicted with the biomedical approach associated with health services. Despite widespread recognition of the links between psychological symptoms, social circumstances and physical health, it was believed that health care providers are equipped to treat only somatic symptoms, which were commonly reported.ConclusionsLow demand for depression treatment reflected discrepancies between the community's perceived needs and a narrow biomedical model of mental health. Meeting their needs may require a radical change in approach that acknowledges the social determinants of distress, and the interactions between mental and physical health. The capabilities approach may provide a framework for more holistically conceptualising people's needs.

Summary Just over 25 years have passed since the major sociopolitical changes in central and eastern Europe; our aim was to map and analyse the development of mental health-care practice for people with severe mental illnesses in this region since then. A scoping review was complemented by an expert survey in 24 countries. Mental health-care practice in the region differs greatly across as well as within individual countries. National policies often exist but reforms remain mostly in the realm of aspiration. Services are predominantly based in psychiatric hospitals. Decision making on resource allocation is not transparent, and full economic evaluations of complex interventions and rigorous epidemiological studies are lacking. Stigma seems to be higher than in other European countries, but consideration of human rights and user involvement are increasing. The region has seen respectable development, which happened because of grassroots initiatives supported by international organisations, rather than by systematic implementation of government policies.

In this second article on the theme of parents and teachers the letters sent by parents to teachers at an urban primary school are examined for indications of the nature of relationships between them. The setting for these relationships in therms of the parents' home experience and the teachers' school experience is also examined. The letters provide evidence of pressure on both the young parent, coping with the demands of family life and the teacher, coping with the demands of parents. A conflicting view of relationships between parents and teachers emerges since the letters show on the one hand the anxiety of parents to conform to school conventions and on the other their confident assumption that special treatment will be given to their own children. A further complication is the lack of facility in writing which many parents demonstrate and which may contribute a particular element of inequality to parent/teacher relationships as evidenced in letters. It is suggested that an occasional review of colle...

Summary. An examination was made of the ‘actions’ of early reading—analysis and synthesis—within the modalities of sound alone and sound with sight. The relative difficulty of these skills for a sample of forty 5 and 6-year-old children was established through an assessment of their performance of four different tasks of analysis or synthesis involving four word lists of equal difficulty. Purely auditory synthesis was found to be considerably easier than any other skill; analysis involving both sound and sight was found to be by far the most difficult.

Summary An attempt is made to reconsider the implications of Piaget's theories for the teaching of reading. It is argued that the way the theories have typically been interpreted in relation to reading is unhelpful and does not accord with the behaviour of young readers. Alternative ways of linking Piagetian theory to the teaching of reading are proposed. It is considered that they both provide a more adequate explanation and offer the teacher more helpful directions along which to develop reading.

Summary 168 five‐year‐old infants from six different Social Priority Schools were examined for their ability to perform tasks of auditory synthesis (sound blending). Voiced consonants were used although doubts about this practice are widely expressed in the literature. The majority of children were either competent or not competent, only 29 being in a transitional state of moderate competence. In one school, although this pattern of discontinuity remained, the number of competent performers was considerably greater than in any other school. This suggested that factors within the school may affect the ease with which children acquire sound blending ability at this early age.

Summary The accuracy rate of 125 second‐ and third‐year infants randomly selected from five infants departments was assessed by means of counting errors made in reading from a current reading book. Only .23 of the sample was reading at Instructional Level according to Betts’ definition, while .57 was at Frustration Level suggesting that teachers did not consider these defined Levels appropriate. In addition, in a sixth school, the total reading population of the infants department (N = 62) was assessed in this way and only .18 was found to be reading at Instructional Level, while .66 was at Frustration Level. In this school, however, children in the junior department were reading at an above‐average level of accuracy and comprehension and showed no signs of antipathy towards reading.

(1987). Teacher‐Centred In‐Service Education. British Journal of In-Service Education: Vol. 13, No. 3, pp. 172-176.

The ability of 112 first year junior children to read 20 words drawn from reading tests in common use was compared with their ability to write these words. The strategies for spelling used by good readers were examined and the extent to which setting the words in context affected their performance of the tasks was also investigated. It was found that while the children could read 92% of the words in context and 87% of them in isolation they could spell only 51% of them in context and 50% in isolation. Good readers who were also good spellers appeared to be more likely to use visual orthographic strategies for spelling than good readers who were comparatively poor spellers.

Summary. Reading ability and performance on the Matching Familiar Figures Test were compared for two samples of seven-year-old children, a sample of 70 constituting a complete top infant year group in two infant schools and a sample of 42 poor readers from nine top infant classes in the same city. Considerably more of the poor readers than the main sample were found to be impulsive. There was a consistent tendency for girls to be more reflective than boys.