Why focus on mental health systems?

The need for increased attention to and investment in mental health has been repeatedly highlighted, often with recommendations about what should be done [1]. Despite this, the situation for people with mental illness in low and middle-incomes countries remains dire [2]. In 2003 Time Asia ran a story [3] accompanied by a disturbing photoessay [4], that graphically illustrated the plight of people with mental illness is Asia. The response to the story was silence. UN Resolution 46/119 [5] was not invoked, there was no inquiry or action, and the story – and the issue of the human rights of people with mental illness, in general, – receded into oblivion. In many places hospitals lack the resources to provide effective and dignified care (Figure 1) and, in the community, families are forced by the lack of treatment and support services to restrain family members in unacceptable ways (figure 2).

Even in countries that have paid a great deal of attention to mental health system reform, and substantially increased investment in mental health services over the past decade, serious questions remain about the accessibility and quality of public mental health services [6].

In low- and middle-income countries the so-called treatment gap [7] is particularly wide, and appears to be getting wider [8], although it also exists in the richest countries with the most highly developed mental health services.

Many people with mental illness derive no benefit from the advances that have been made in understanding of and treatments for mental illness [8] because a substantial proportion receive inadequate treatment or no treatment at all.

There is an urgent need to focus on the development of effective, appropriate, affordable and equitable mental health systems. A major impediment to the achievement of this goal is the lack of evidence for what kinds of mental health systems are appropriate and effective in varying political, social and economic contexts [9].

The research effort in mental health is committed to neuroscience and clinical research – discovering causes of and treatments for mental disorders. Of course these areas of research are vital and will continue to be vigorously pursued. However, it is well to remember that the new and better treatments that are discovered cannot be delivered in the absence of functioning mental health systems.

In coming decades, the proportion of disability attributable to mental disorders is projected to increase [10]. We believe that the highest priority in global mental health research is mental health systems research.

Mental health system development requires attention to all of these areas and must be informed by evidence.

Bringing about substantial change in complex systems requires creative, sustained leadership at all levels of the system – in government, professional associations, clinical service organisations, and in communities. There is a need to foster and support the emergence of such leadership and to study the forms of leadership that are effective and constructive in different political, economic and socio-cultural settings. There is a particular need for mental health professionals to broaden their conceptual horizons beyond the purely clinical to include population health perspectives and to be active, informed and skilled participants in the pursuit of mental health system reform. Key issues in mental health system development and reform are how to improve health system performance [11] and how to promote the leadership at all levels that is required for change in complex health systems [12‐14].

Although important examples of mental health system development are to be found in all world regions evaluations and careful and systematic descriptions of such programs are rarely found in the scientific literature. The mental health systems literature that does exist is scattered across numerous professional journals in medicine, psychiatry, nursing, health policy, health economics, human rights, and health ethics. There is currently no single journal to which those who are engaged in mental health system development can turn for relevant research, debate and education.

The definition of open access published as part of the Bethesda Declaration [15] is:

"An Open Access Publication is one that meets the following two conditions:

1. The author(s) and copyright holder(s) grant(s) to all users a free, irrevocable, worldwide, perpetual right of access to, and a license to copy, use, distribute, transmit and display the work publicly and to make and distribute derivative works, in any digital medium for any responsible purpose, subject to proper attribution of authorship, as well as the right to make small numbers of printed copies for their personal use.

2. A complete version of the work and all supplemental materials, including a copy of the permission as stated above, in a suitable standard electronic format is deposited immediately upon initial publication in at least one online repository that is supported by an academic institution, scholarly society, government agency, or other well-established organization that seeks to enable open access, unrestricted distribution, interoperability, and long-term archiving (for the biomedical sciences, PubMed Central is such a repository)."

There is increasing research support for the view that publishing in open access journals has the potential to accelerate recognition and dissemination of research findings [16].

We intend that this will be the journal to which mental health system researchers, Health Ministers' advisers, policy makers, mental health consultants advising countries on mental health system development, teachers in psychiatry, nursing, psychology, social work and public health courses, clinicians involved in mental health system reform, and others will turn for the latest research and policy information on how to build equitable, accessible, efficient, high quality mental health systems.