Copyright 2015 American Medical Association. All rights reserved. Optimizing an Era of Global Mental Health Implementation Science The field of global mental health faces important chal- lenges. Access to mental health services is grossly inad- equate in many low- and middle-income countries (LMICs) despite the heavy burden of violent conflict and the association between exposure to human and natu- ral disasters in many LMICs and mental health prob- lems such as depression, anxiety, and traumatic stress reactions. Today, the percentage of individuals with se- vere mental disorders who remain untreated is esti- mated to be upwards of 97% in some countries, and even in high-income countries, there are vulnerable populations who have similarly unmet needs. In recent years, global mental health researchers have made tremendous strides in developing and test- ing innovative services. Major research trials have docu- mented that evidence-based mental health services can be delivered with effectiveness in contexts struggling with poverty, 1 violence, and chronic disease 2 in LMICs. Unfortunately, demonstrated effectiveness of interven- tions does not frequently translate into widespread use; research is greatly needed on the effectiveness of strat- egies to implement, sustain, and scale-up these inter- ventions for populations in need. There is growing interest in embedding evidence- based mental health interventions within alternative de- livery structures such as schools or primary care and the delivery of mental health services by community health workers and other paraprofessionals in LMICs. For in- stance, evidence-based mental health interventions based on cognitive behavioral therapy have been suc- cessfully delivered by “lady health workers” in Pakistan, 3 and other lay workers have effectively provided group interpersonal psychotherapy to war-affected youth. 4 An- other “disruptive innovation,” mental health informa- tion technology has enabled use of tablet- and PDA- based assessments for mental health screening and delivery of interventions from video-based counseling to long distance training and supervision of lay work- ers. These advances show promise but have yet to dem- onstrate population health impact. In 2011, Collins and colleagues 5 described 25 “Grand Challenges” for global mental health. The top 5 challenges, as ranked by impact on disease burden, equity, immediacy, and feasibility, all invoked imple- mentation science (IS)—the knowledge base to opti- mally embed and sustain effective interventions within clinical and community systems. The authors noted that health care worker training, integration of treat- ments into primary health care, improved supply of medications, and system redesign are needed to over- come both supply and demand barriers to evidence- based care; these are the areas where IS can make a sig- nificant impact. There are important efforts currently under way that offer great potential to address this need. Several Grand Challenges initiatives aim to raise awareness about mental illness globally and expand evidence-based approaches to care and prevention. Coordinated research funding has emerged across a range of institutions including the World Health Organi- zation (WHO), National Institute of Mental Health, and the Canadian Development Agency. 5 Similarly, leadership at the WHO and the World Bank has increased a focus on IS across multiple initiatives. The World Bank Director, Jim Yong Kim, MD, PhD, was well known for his global antiretroviral treatment implemen- tation efforts while at the WHO. Since he took the helm, the World Bank is increasingly recognizing the need to implement effective mental health practices that fit the context of trauma in a number of countries. Relatedly, the WHO Mental Health Gap project has provided a set of tools and procedures designed to implement improve- ments to mental health systems in LMICs. While these efforts are promising, additional op- portunities remain to more substantially advance IS in global mental health. For instance, while many projects have been studying “task sharing”—using lay health workers to deliver mental health interventions—there has been little effort to systematically understand how best to identify, train, supervise, and support these im- portant care deliverers. In addition, rather than replicat- ing effectiveness of evidence-based mental health in- terventions delivered by community health workers, one can systematically compare implementation strategies that vary community health workers by type of experi- ence and contrasting approaches to training and super- vision, and perhaps more fundamentally, investigate ad- aptation of evidence-based interventions to improve fit with setting and population needs. Also, while projects have succeeded in embedding services within LMIC set- tings, strategies are needed to scale-up these efforts across villages, countries, and regions. New research is also needed to test different models of government lead- ership, administrative support, and financing of ser- vices to optimize adaptation and sustainability of men- tal health services. The IS field is rapidly expanding, with multiple fund- ing opportunities available through federal, founda- tion, and nongovernmental organization initiatives, in- cluding landmark work on human immunodeficiency virus/AIDS services through WHO, PEPFAR, and the United States Agency for International Development (USAID), among others. The number of scientific meet- ings, research training opportunities, and peer- reviewed publications on IS continues to grow in size and quality. The confluence of global mental health and IS ac- tivities creates a perfect opportunity to form a global VIEWPOINT Theresa S. Betancourt, ScD, MA Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. David A. Chambers, DPhil Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland. Corresponding Author: Theresa S. Betancourt, ScD, MA, Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Ave, Bldg 1, Room 1213, Boston, MA 02115 (theresa_betancourt @harvard.edu). Opinion jamapsychiatry.com (Reprinted) JAMA Psychiatry Published online December 30, 2015 E1 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://archpsyc.jamanetwork.com/ by a Harvard University User on 12/30/2015