Improving access and rational use of psychotropic medications in low- and middle-income countries is an important factor in reducing the public health burden resulting from mental illness. This paper considers each component of the medications management cycle to identify current barriers to improvement. Selection is hindered by a lack of up to date local essential drugs lists, while procurement and distribution can be affected by the type of system used: centralised or decentralised, government-run or independent, push or pull. Rational use involves patients, prescribers and policy-makers and requires consideration of who is able to prescribe, how prescribing decisions are made and how to ensure patient-centred care. We include a number of recommendations based on these issues, while emphasising the importance of ensuring the broader context of mental illness and its management is not overlooked when improving access to psychotropic medications.

Individuals with serious mental illnesses such as psychosis still experience higher mortality rates than the general population, decades after data have linked the gap to increased rates of physical illness, delayed diagnosis, low treatment rates and worse outcomes from treatment received. The nature of the relationship between psychosis and comorbid physical illness is complex. Multiple strategies directed at different levels of disease process, health care systems and stakeholder culture are likely required to make sustained progress in reducing the mortality gap. Evidence for strategies that effectively reduce the burden of physical co-morbidity and lead to improved health outcomes are still in their infancy but growing at a reassuringly fast rate. This editorial considers the existing evidence base and makes suggestions for the development and future direction of this urgent research agenda and how this knowledge can be implemented in clinical practice.

Mental health consumers/survivors developed consumer-run services (CRSs) as alternatives to disempowering professionally run services that limited participant self-determination. The objective of the CRS is to promote recovery outcomes, not to cure or prevent mental illness. Recovery outcomes pave the way to a satisfying life as defined by the individual consumer despite repetitive episodes of disorder. Recovery is a way of life, which through empowerment, hope, self-efficacy, minimisation of self-stigma, and improved social integration, may offer a path to functional improvement that may lead to a better way to manage distress and minimise the impact of illness episodes. ‘Nothing about us without us’ is the defining objective of the process activity that defines self-help. It is the giving of agency to participants. Without such process there is a real question as to whether an organisation is a legitimate CRS or simply a non-governmental organisation run by a person who claims lived experience. In considering the effectiveness of CRSs, fidelity should be defined by the extent to which the organisation's process conveys agency. Unidirectional helping often does for people what they can do for themselves, stealing agency. The consequence of the lack of fidelity in CRSs to the origins of the self-help movement has been a general finding in multisite studies of no or little difference in outcomes attributable to the consumer service. This, from the perspective of the research summarised herein, results in the mixing of programmatic efforts, some of which enhance outcomes as they are true mutual assistance programmes and some of which degrade outcomes as they are unidirectional, hierarchical, staff-directed helping efforts making false claims to providing agency. The later CRS interventions may provoke disappointment and additional failure. The indiscriminate combining of studies produces the average: no effect.

This paper enumerates and briefly discusses WHO’s recent contributions to global mental health and the current challenges and opportunities in this area. It briefly discusses response to diversity across countries and communities, the need for innovations and global exchange of information, evidence and knowledge and raises issues like psychological interventions and human rights related to mental health.

Psychiatry is in one of its regular crises. It is a crisis of its diagnostic systems despite – perhaps because – of the recurrent claims about the extent of diagnosable ‘brain disorders’. It is a crisis of its explanatory systems despite – perhaps because – of its current wager on the brain as the ultimate locus for explanations of mental disorders. It is a crisis of its therapeutic capacities despite – perhaps because – more and more people are making use of its primary mode of intervention focussed on the brain – psychiatric drugs. In this editorial, I will suggest that this triple crisis of diagnosis, explanation and therapeutics arises from the dominant reductionist approaches to the role of neurobiology in psychiatry that priorities the analysis of brain mechanisms, at the expense of an understanding of the whole living organism in its milieu, and the processes which social experience shapes neurobiology from the moment of conception if not before. I shall suggest a different approach that starts from the experience of persons coping with adversity in their forms of life. This approach does not require giving up on our search for plausible explanations of mental health problems that engage neurobiological mechanisms, but it begins from a commitment to understanding, and hence intervening in, the ways in which social adversity shapes and blights the lives of so many of our fellow citizens.

Psychiatry is having a great time. Over the last few years, we have seen an exceptional explosion in neuroscience knowledge, and especially in our understanding of the molecular mechanisms through which environmental and genetic factors affect the brain and regulate behaviour, while at the same interacting with peripheral (‘body’) functions. While this explosion, and its translational implications, can be seen across a variety of fields, this editorial will focus on one particular area where these developments have been more noticeable: the interaction between neuroscience, mental health and the immune system. This editorial will focus on the broader impact of this discipline as an example of successful translational neuroscience overcoming the brain-mind-body trichotomy.

The World Health Organisation has defined health service responsiveness as one of the key-objectives of health systems. Health service responsiveness relates to the ability to respond to service users’ legitimate expectations on non-medical issues when coming into contact with the services of a healthcare system. It is defined by the areas showing respect for persons and patient orientation. Health service responsiveness is particularly relevant to mental health services, due to the specific vulnerability of mental health patients but also because it matches what mental health patients consider as good quality of care as well as their priorities when seeking healthcare. As (mental) health service responsiveness applies equally to all concerned services it would be suitable as a universal indicator for the quality of services’ performance. However, performance monitoring programs in mental healthcare rarely assess health service performance with respect to meeting patient priorities. This is in part due of patient priorities as an outcome being underrepresented in studies that evaluate service provision. The lack of studies using patient priorities as outcomes transmits into evidence based guidelines and subsequently, into underrepresentation of patient priorities in performance monitoring. Possible ways out of this situation include more intervention studies using patient priorities as outcome, considering evidence from qualitative studies in guideline development and developing performance monitoring programs along the patient pathway and on key-points of relevance for service quality from a patient perspective.

To date, antipsychotics remain the mainstay of treatment for schizophrenia and related disorders although other psychotropic medications and non-pharmaceutical interventions have been used adjunctively in some patients and settings. Regular surveys on access to and prescription patterns of psychotropic medications in clinical practice are an important and efficient way of examining the use and time trends of treatments in a given population and region. Unlike developed Western countries, Asian countries have not fully undergone deinstitutionalisation of the severely and chronically mentally ill, and community-based mental health services are still under-developed. As a result, a large number of psychiatric patients still receive treatments in psychiatric hospitals. Moreover, there have been very limited studies examining access to and prescription patterns of psychotropic medications for schizophrenia patients in Asian countries. In this paper, we focus on the only international project on the use of psychotropic medications in schizophrenia patients in selected East and Southeast Asian countries/territories summarising its major findings. Most of the first- and second-generation antipsychotics (FGAs and SGAs) are available in Asian countries, but the access to psychotropic medications is largely affected by socio-cultural and historical contexts, health insurance schemes, health care policy, medication cost and consumers’ preference across different countries/territories. Overall, the proportional use of FGAs, high dose antipsychotic treatment and antipsychotic polypharmacy have decreased, while the use of SGAs and antidepressants have increased and the utilisation of benzodiazepines and mood stabilisers has remained relatively stable over time. However, within these general trends, there is great inter-country variation regarding the psychotropic prescribing patterns and trends in Asian schizophrenia patients that also seems to differ from data in many Western countries.

The discipline of global mental health has been singularly associated with the generation of knowledge which seeks to reduce the treatment gap for mental disorders. Its priority research agenda has focused on delivery science, i.e. the science of implementing evidence-based interventions. Considerable new resources have furthered this agenda, leading to a flowering of innovations to address barriers to the delivery of interventions while also contributing to the growth and consolidation of research capacity in low and middle income countries. A significant, but as yet under-recognised, opportunity of this global mental health initiative is its potential contribution to discovery science, notably research aimed at identifying the aetiology of mental disorders and the development of novel interventions. This editorial considers a range of potential themes for such discovery science and its guiding principles. Given the limited knowledge that we currently possess about the nature of mental disorders or their effective prevention and treatment, this may well be the most important ultimate contribution of global mental health, i.e. generating knowledge which not only reduces the treatment gap but the actual global burden of mental disorders, and will finally do justice to the ‘global’ of this discipline.

Despite overwhelming evidence demonstrating a persisting gap in life expectancy between those with psychotic illness and the general population, there has been no widespread implementation of interventions to improve the physical wellbeing of people with psychotic illness. This article explores opportunities to ‘Bridge the Gap’ in life expectancy. We describe an Australian evidence-based intervention that has substantially improved the physical health of young people recently commenced on antipsychotic medication. Further epidemiological research, accompanied by cultural change within mental health services, is an essential precursor to the implementation of effective and sustainable lifestyle interventions. There are other relatively neglected areas of physical wellbeing for people with psychotic illness, such as screening and diagnosis of malignancies, which need more research and clinical attention. While there has been progress with intervention development and evaluation, translation of evidence-based short-term intervention studies into feasible and sustainable system-wide changes within routine mental health service settings remains a challenge. Developing an implementation framework to support such change is an urgent priority so as to bridge the persisting premature mortality in people living with psychotic illness.

Depression is an eminently treatable disorder, although estimates of treatment efficacy have been inflated by publication bias. Patients with less severe depressions respond to even nonspecific interventions, whereas patients with more severe depressions require treatments that mobilize specific mechanisms. The cognitive and behavior therapies can be as efficacious as medications in the treatment of severe depression and have an enduring effect that medications lack. Medications may interfere with those enduring effects when added in combination and may prolong the life of the underlying episode when used alone. Thus the cognitive behavioral interventions might be the optimal first-line treatments for depression.

Mental health for all is the main goal of the global mental health movement. Central characteristics to achieving this are examination of the social determinants of health and a more preventive approach; greater task shifting or task sharing; emphasis on common as well as serious mental disorder; a strong research base and a commitment to human rights. Putting the interventions in place in countries with limited resources and particularly African countries that will best promote mental health is challenging and requires a careful balancing of priorities and approaches. Evidence in the form of randomised control trials and cost-effectiveness studies are necessary but not sufficient to achieving the set objectives. This editorial points to various considerations that may contribute towards the quest for mental health for all.