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The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough. In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness—severe and persistent disorders as well as less serious mental health conditions—are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs—such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps—and the development of new treatments that are easier for patients to tolerate and for physicians to manage. The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The \"mainstreaming\" of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.

Major depressive disorder (MDD) is a leading cause of disability worldwide. To examine the: (a) 12-month prevalence of DSM-IV MDD; (b) proportion aware that they have a problem needing treatment and who want care; (c) proportion of the latter receiving treatment; and (d) proportion of such treatment meeting minimal standards. Representative community household surveys from 21 countries as part of the World Health Organization World Mental Health Surveys. Of 51 547 respondents, 4.6% met 12-month criteria for DSM-IV MDD and of these 56.7% reported needing treatment. Among those who recognised their need for treatment, most (71.1%) made at least one visit to a service provider. Among those who received treatment, only 41.0% received treatment that met minimal standards. This resulted in only 16.5% of all individuals with 12-month MDD receiving minimally adequate treatment. Only a minority of participants with MDD received minimally adequate treatment: 1 in 5 people in high-income and 1 in 27 in low-/lower-middle-income countries. Scaling up care for MDD requires fundamental transformations in community education and outreach, supply of treatment and quality of services.

In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing. A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction [d = 0.34] in AUD symptoms, 6.4-point reduction [d = 0.43] in psychosis symptoms, 7.2-point reduction [d = 0.58] in depression symptoms) at 12 months post-treatment. These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).

Resources for mental health include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. We discuss here the general availability of these resources, especially in low-income and middle-income countries. Government spending on mental health in most of the relevant countries is far lower than is needed, based on the proportionate burden of mental disorders and the availability of cost-effective and affordable interventions. The poorest countries spend the lowest percentages of their overall health budgets on mental health. Most care is now institutionally based, and the transition to community care would require additional funds that have not been made available in most countries. Human resources available for mental health care in most low-income and middle-income countries are very limited, and shortages are likely to persist. Not only are resources for mental health scarce, they are also inequitably distributed—between countries, between regions, and within communities. Populations with high rates of socioeconomic deprivation have the highest need for mental health care, but the lowest access to it. Stigma about mental disorders also constrains use of available resources. People with mental illnesses are also vulnerable to abuse of their human rights. Inefficiencies in the use of available resources for mental health care include allocative and technical inefficiencies in financing mechanisms and interventions, and an overconcentration of resources in large institutions. Scarcity of available resources, inequities in their distribution, and inefficiencies in their use pose the three main obstacles to better mental health, especially in low-income and middle-income countries.

Eager to build an integrated community-based mental health system, in 2004 China started the ‘686 Programme’, whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015–2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peerreviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China’s general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China’s general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China’s diverse populace. As China’s political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China’s mental health needs. 为建立以社区为基础的综合精神卫生体系, 中国于 2004 年启 动了” 686 项目”, 旨在整合重性精神疾病的医院和社区服 务。2015 年, 《全国精神卫生工作规划 （2015-2020 年）》 提出了实施这一项目的宏伟战略。本综述目的是评估将医院 和社区精神卫生服务整合到卫生体系中, 建立以社区为基础的 精神卫生体系可能面临的机遇和障碍。我们回顾了 7066 份 中英文文献, 包括同行审议的学术文献、精神卫生政策的灰色 文献, 以及政府和决策机构的文件。虽然中国提出了一系列有 创造性的项目来应对精神卫生负担, 但有部分提案尚未完全启 动, 尤其是关注综合服务的项目。将精神卫生服务纳入中国的 卫生保健体系有望提高精神卫生服务可及性, 改善精神卫生服 务质量, 消除精神疾病污名, 更有效地管理躯体合并精神疾 病。本文探讨了将精神卫生服务整合入中国卫生保健体系的 挑战, 尤其是在初级保健方面, 包括：准确估计精神卫生需求, 整合精神和躯体疾病保健, 加强人员发展和培训, 解决跨专业 问题, 筹资和资金, 建立可负担、可持续的精神卫生体系, 以 及为特定人群提供服务从而满足中国百姓多样化需求。随着 中国政府越来越重视健全精神卫生体系, 我们为未来解决中国 精神卫生需求的方向提供了建议。 Deseosa de construir un sistema integrado de salud mental basado en la comunidad, China inició en el 2004 el ‘Programa 686’, cuyo propósito era integrar servicios hospitalarios y comunitarios para pacientes con enfermedades mentales graves. En 2015, el Plan Nacional de Salud Mental (2015-2020) propuso una estrategia ambiciosa para la implementación de este proyecto. El objetivo de esta revisión es evaluar las potenciales oportunidades y barreras para la implementación exitosa de un sistema de salud mental basado en la comunidad que integre los servicios de salud mental del hospital y de la comunidad al sistema de atención médica general. Examinamos 7,066 fuentes tanto en inglés como en chino: la literatura académica revisada por pares, la literatura ‘gris’ sobre políticas de salud mental y los documentos del gobierno y de las agencias de formulación de políticas. Aunque China ha propuesto un número de programas innovadores para abordar su carga de salud mental, varias de estas propuestas aún no se han activado por completo, en particular las que se centran en la atención integrada. La integración de los servicios de salud mental en el sistema general de salud de China es una gran promesa para obtener un mayor acceso y una mejora de la calidad en los servicios de salud mental, así como un menor estigma y un manejo más efectivo de las comorbilidades físicas y de salud mental. Este artículo examina los desafíos de la integración de servicios de salud mental en el sistema de salud general de China, especialmente en la esfera de atención primaria, que incluye: estimar con precisión las necesidades de salud mental, integrar la salud mental y física, aumentar el desarrollo y capacitación de la fuerza de trabajo, la resolución de problemas interprofesionales, el financiamiento y los fondos, desarrollar un sistema de salud mental asequible y sostenible, y brindar atención a subpoblaciones específicas para satisfacer las necesidades de la población diversa de China. A medida que el compromiso político de China para expandir su sistema de salud mental evoluciona rápidamente, ofrecemos sugerencias para direcciones futuras para abordar las necesidades de salud mental de China.