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Salzburg Global Seminar has long been a leading forum for the exchange of ideas on issues in health and health care affecting countries throughout the world. At these meetings agendas have been re-set affecting policy and practice in crucial areas, such as patient safety and the engagement of patients in medical decision making. In 2010, Salzburg Global Seminar launched a multi-year series of seminars to crystallize new approaches to global health and health care in the face of emerging challenges affecting us now and set to continue on through the coming generation.


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Salzburg Global Fellows Call for Renewed Global Commitment to Mental Health
Salzburg Global Fellows Call for Renewed Global Commitment to Mental Health
Salzburg Global Seminar 
Fellows of the Salzburg Global session New Paradigms for Behavioral and Mental Health have called on the United Nation to make a "renewed global commitment to mental health." During the Salzburg Global program, it was recognized that the United Nations post-2015 Sustainable Development Goals (SDGs) have a critical part to play in setting priorities for the development and investment in healthcare systems, prompting the 70 international healthcare policy experts, practitioners and service users, who attended the December 2014 session, to collectively draft their Salzburg Statement.  The Statement calls on the UN and its Member States to make a "renewed global commitment to mental health, with clear and specific targets and indicators, particularly with a focus on mental health treatment coverage, strengthening community health, outreach and peer support." Upon the issuing of the Statement, Salzburg Global Fellow and professor of community psychiatry at the Institute of Psychiatry, King’s College London, Graham Thornicroft said: "As mental health problems contribute so much towards disability and mortality worldwide, it is right that the United Nations fully recognises this by agreeing strong mental health targets and indicators in the new Sustainable Development Goals." Paul Burstow, Salzburg Global Fellow, UK Member of Parliament and author of the UK government’s mental health strategy added: "Now is the time for the United Nations to fully reflect the impact of mental health problems worldwide by agreeing to clear and challenging mental health targets and indicators in the new Sustainable Development Goals." The Statement is now being shared with policy-makers and practitioners around the world.  You can read the statement in full below.

Salzburg Global Statement on
New Paradigms for Behavioral and Mental Health Care

Recommendations of Salzburg Global Fellows

 

We, the participants of the Salzburg Global session New Paradigms for Behavioral and Mental Health Care (listed below):

I. Recognize the central importance of mental health in the United Nations post-2015 Sustainable Development Goals (SDGs); II. Accept the case for fully including mental health in the SDGs given:
  1. The global prevalence of mental disorders and psychosocial disabilities, with 1 in 4 people experiencing mental health problems in their lifetime;
  2. The excessive treatment gap in low- and middle-income countries, where often over 90% of people with mental disorders receive no effective treatment;
  3. The global under-financing of the mental health sector, and the critical shortage of mental health services;
  4. The breach of the universal right to health for up to 600 million people with mental illness across the world each year;
  5. The growing global impact of mental disorders and psychosocial disabilities, which contribute 23% of the total global burden of disease;
  6. The often long-lasting disability caused by mental disorders and psychosocial disabilities, and the high impact of the excess mortality, and suicide;
  7. The global crisis, of human rights violations, social exclusion, stigma and discrimination of persons with mental disorders and psychosocial disabilities; 
III. Accept the importance of fully including mental health in the SDG targets and indicators, which will be necessary to provide reliable information, and measurable and comparable data, for policy makers, service providers, and service users, to enhance mental health systems and services worldwide; IV. Regret that, despite growing global awareness, until now there has been a lack of substantial progress in fully including mental health in the United Nations SDGs. We therefore call upon the United Nations, and its Member States, for a renewed global commitment to mental health, with clear and specific targets and indicators, particularly with a focus on mental health treatment coverage, strengthening community health, outreach and peer support.
Download the Salzburg Statement as a PDF

Signatories: Alvaro Aravena Molina, Community Mental Health Center Rinconada, Chile; Alvaro Arenas Borrero, Clinica La Inmaculada, Colombia; Ilirjana Bajraktari, Kosovo; Peter Bartlett, University of Nottingham, UK; Paulina Bravo, Pontificia Universidad Catolica de Chile, Chile; Paul Burstow, House of Parliament, UK; July Caballero, Peruvian National Institute of Mental Health, Peru; Dawn Carey, Dartmouth Center for Health Care Delivery Science, USA; Joshua Chauvin, Canada; R. Chellamuthu, M.S.Chellamuthu Trust and Research Foundation, India; Trina Dutta, USA; Byron Good, Harvard University, USA; Shpend Haxhibeqiri, University Clinical Centre of Kosovo, Kosovo; Jonida Haxhiu, Institute of Public Health of Albania, Albania; Prince Bosco Kanani, Rwanda NGO’s Forum on AIDS and Health Promotion, Rwanda; Gloria King, Rainbow Healing, USA; Bernadette Klapper, Germany; John Lotherington, Salzburg Global Seminar, UK; Hafsa Lukwata, Ministry of Health, Uganda; Marie-Josee Maliboli, Rwanda Biomedical Center, Rwanda; Lisa Marsch, Dartmouth Center for Health Care Delivery Science, USA; Maria Elena Medina Mora, National Institute on Psychiatry Ramon de la Fuente Muniz, Mexico; Susan Mende, USA; Nancy Misago, Rwanda Biomedical Center / Ministry of Health, Rwanda, Martha Mitrani Gonzales, National Institute of Mental Health HD-HN, Peru; Anna Moore, UCL Partners, UK; Albert Mulley, Dartmouth Center for Health Care Delivery Science, USA; Gloria Nieto De Cano, Asociacion Colombiana Personas con Esquizofrenia y Familias, Colombia; Angela Ofori-Atta, University of Ghana School of Medicine & Dentistry, Ghana; Sally Okun, PatientsLikeMe, USA; Emmanuel Owusu Ansah, The Ministry of Health of Ghana, Ghana; Merritt Patridge, Dartmouth Center for Health Care Delivery Science, USA; Thara Rangaswamy, Schizophrenia Research Foundation (SCARF), India; Veronique Roger, USA; Rodrigo Salinas, Universidad de Chile, Chile; Ronald Stock, USA; Ezra Susser, Columbia University, USA; Graham Thornicroft, Kings College London, UK; Chris Underhill, BasicNeeds UK, UK; Jose Miguel Uribe, Colombia; Dale Walker, Oregon Health & Science University, USA; Peter Yaro, BasicNeeds Ghana, Ghana; Cynthia Zavala, Pontificia Universidad Catolica de Chile, Chile; Ericka Zimmerman, University of Charleston, USA
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Fellows Propose Plans to Help Mental Health Patients
Fellows Propose Plans to Help Mental Health Patients
Louise Hallman 
After four days of intense plenary and group discussions, the Salzburg Global Seminar session on New Paradigms in Behavioral and Mental Health concluded with presentations of the expert Fellows’ country action plans – and input provided by Minister for Health of Rwanda, Dr. Agnes Binagwaho. The 70 Fellows, who consisted of clinicians, policymakers, academics, patient advocates, service users and their family members, came from across five continents, all with the purpose of improving mental health services and wellness for service users in their home countries. In Europe, proposals included the “iMum” project – “improving Mums’ Mental Health” – seeking to help women suffering with post-natal depression in the UK; promotion of self-management of mental health conditions in Germany by supporting patients, their families and communities; and the introduction and expansion of peer-run support services in the Western Balkans. Fellows from India sought to promote positive mental health on college campuses. Young people were also the focus of proposed projects in Uganda; the Ugandan team developed the beginnings of a pilot project to expand mental health care services to children and adolescents, by raising awareness and identifying conditions early and providing access to age-appropriate care. Also in Africa, the team from Ghana plan to focus their efforts on lobbying the government to end the shortage of psychotropic medicines. In Rwanda, Fellows proposed using the omnipresent mobile technology to promote mental health wellness. In South America, Fellows proposed a range of projects; from pushing for legislative change in Chile which would see the consolidation of mental health provisions and patients’ rights into one law; to the better use of primary care centers rather than psychiatric hospitals in the detection and treatment of mental health issues, particularly depression and alcohol abuse, in Colombia and Peru. Two teams came from North America; one concerned with the wider US population and another focused on mental health care provision for Native Americans. The general USA team proposed a number of measures to promote better integration and collaboration of mental and general health services. The Native American team highlighted the need for cultural sensitivities when dealing with indigenous peoples, such as collaborating with traditional healers. They also proposed a follow-up session at Salzburg Global Seminar focusing on the specific health concerns of indigenous peoples across the world. All the plans were presented not only to the group, which included representatives of the three sponsors of the Salzburg Global session – The Dartmouth Center for Health Care Delivery Science, the Robert Johnson Wood Foundation and the Robert Bosch Stiftung – but also Minister Binagwaho who joined the session via Skype from Rwanda for the fourth year in a row. Binagwaho offered advice on the next steps for the projects and how Fellows could best to approach ministers and policymakers in their respective countries. The final outcomes of the five-day session will now be compiled in a substantive report to be published in the New Year and in a special edition of the Journal of Dual Diagnosis to be edited by session chair, Dr. Robert Drake, Professor of Psychiatry, Dartmouth Psychiatric Research Center in the USA.
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What are the best and worst practices in mental health care?
What are the best and worst practices in mental health care?
Louise Hallman and Jonathan Elbaz 
At the most recent session in the Salzburg Global Seminar series Health and Health Care Innovation in the 21 Century, New Paradigms in Behavioral and Mental Health, we asked representatives from each country present: "What are the best and worst practices with regards to mental health care in your country?"
“One of the best practices of mental  health in Uganda has been primary health care provision...unpacking the complex concepts of mental health and making them easily digestible by the general health worker... and also understanding the links when running a maternal health clinic and being able to pick up on the issues around mental health. But one of the things that is impacting our growth is that our laws continue to be oppressive... If we can get this bill that we will presenting to Parliament next year right, then we can revolutionize how mental health services are provided.”  Tina Ntulo, Chief Executive Officer, BasicNeeds Foundation, Uganda 
“The previous system in Kosovo was hospital-based, so when we talk about mental health services in Kosovo from a systems perspective, I think we have achieved success in [working towards] establishing community-based mental health centers. But this could be further improved in terms of the engagement of patients and their families and the communities in the process of medical decision-making and the process of care delivery.”  Ilirjana Bajraktari, Founder, Healthcare Professionals for Peace and Social Responsibility, Kosovo 
“The best practices are that we have a very strong consumer movement in the USA and there are more and more peer-run support services for people with addictions and mental health problems... And that has empowered people. But our system, to a very large extent, is determined by an alliance between the pharmaceutical industry and the American Psychiatric Association – what somebody [at the session] called today ‘the medical industrial complex’ – and I think that’s led us to a really awful level of over-diagnosis, over-treatment, and over-medication that’s extremely harmful to people.”  Robert Drake, Professor of Psychiatry, Community and Family Medicine, Geisel School of Medicine, Dartmouth College, USA 
“In Colombia, one of the best changes in the last few years is the increasing presence of advocacy groups from patients and families that have been organizing and have effectively changed practices at different levels of the delivery system. But the health system is still very fragmented; there are too many actors, and so there is not a unified policy in the mental healthcare delivery system.”  Miguel Uribe, Former Medical Director, Clinica La Inmaculada, Colombia 
“I think the best thing in Korea is the revising of the Mental Health Act entirely; it hasn’t been enacted yet but will be hopefully by 2015. But many of the mental health illnesses or problems are not insured which means people have to pay extra treatment costs so they have difficulties in accessing treatment, especially low-income people. And the worst thing is the Korean mental health path is following the Western path, treating people only with medication.”  Jong Hye (Kelly) Rha, Assistant Manager, National Health Insurance Service, South Korea 
“Our best practice in India is that we are involving basic community health workers, and also the opinion leaders from the community in mental health management. For example, we involve teachers, faith-healers, and the families in mental health treatment.  One of the biggest handicaps is that still, most of the people are unaware of the mental health issues. They have many false beliefs: that the mental conditions are due to black magic or evil spirits. They are taken to religious places, and subjected to all kinds of treatments, and often victimized with human rights violations. Valuable time is lost and some illnesses become incurable.”  Ramasubramanian Chellamuthu, Founder of M.S. Chellamuthu Trust and Research Foundation, India 
“In Croatia, we have a universal health care system. Every person can approach the system and receive health care. What I also find good is the movement toward community mental health care, which is at its very beginning, but gives people more control and makes them feel they are the captains of their ship.  People believe more in institutions than in the community and community support. It’s something from previous years, from the socialist way of thinking, that whatever problem you have there is an institution for that. We should break the walls and bring people back to the community.”  Radmila Stojanovic Babic, President of the Association for Psychosocial Support, Croatia 
“One of the best things is that we have good quality acute care in the [American] Indian health service programs. They’ve done a tremendous job treating communicable diseases like tuberculosis.  The downside of that program is that about 70 percent of the Native American Indian population lives in big, urban areas where access to services is limited… It’s a changing population in terms of geography, and that system doesn’t address that geography adequately.”  Pat Walker, Research Assistant Professor in Public Health and Preventative Medicine, Oregon Health & Science University, USA
“The best practice in Chile in terms of policy-making was to recognize the ‘burden of disease.’ We used to establish priorities according to mortality, so mental health conditions were always underrated. But in 2000, we established the new system, which gives an important weight to disability. Mental health became relevant.  In my country, stigma is still very important, particularly for serious mental health conditions like schizophrenia. Depression is not as stigmatized as it used to be, but schizophrenia still has a huge stigma surrounding it.”  Rodrigo A. Salinas, Clinical Neurologist and Assistant Professor at University of Chile, Santiago 
“We have good access to our mental health care system. All over Germany, you have good access to general practitioners, specialists, psychiatrists and psychologists.  Our biggest problem is related to this same system: with so much institutionalized, there is no focus on real community-based health care. Everything goes through big psychiatric hospitals and psychiatrists, so access is limited to diagnostics and medication.”  Harald Kolbe, Behavioral Profiler and Organizational Ethnographer for Forensic Services of the Westfalia-Lippe, Germany 
“We started to provide outreach services, and some of these services can cover the patient’s whole life, That is good, but it is unbalanced in different areas. The east of China is a priority, so the services are good. It’s better than in the west, which has very low resources.  The worst part is that in the very beginning we recognized the human resources will be our bottleneck. Some provinces only had one hospital. So the government gave them money to build a new hospital, but up until now, they still have only one. So it becomes very difficult for people in the west to reach services.”  Hong Ma, Professor at Mental Health Institute, Peking University, China
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New Paradigms for Behavioral and Mental Health - Day 3: Human Rights and Overcoming Resistance
New Paradigms for Behavioral and Mental Health - Day 3: Human Rights and Overcoming Resistance
Jonathan Elbaz 
  How can we view mental health care as an extension of basic human rights? And in liberal democracies, how does the legal system either support or challenge that objective? These were the central questions posed during a panel discussion on the third day of the Salzburg Global Seminar program New Paradigms for Behavioral and Mental Health Care. One Fellow from Uganda has been working to empower service users in her country through the lens of human rights. Patient training sessions aim to transform basic mindsets, encouraging patients to view themselves not as victims but as agents for change. Patients learn to speak up about their preferences and challenge the institutions that serve them. This involves literacy courses, public speaking training, and civics lessons about local government and methods to enact political change. Ugandan officials are often awed at how clearly patients can articulate their wishes. In the UK, one Fellow is working to ensure human rights by fighting the discrimination and stigma surrounding mental health. Time-to-Change leads campaigns that target specific populations, spreading patients’ stories and exposing the traumatic effects of discrimination. One powerful video begins like a horror film, flashing messages about the dangerous “schizos” living among us, before cutting to the reality, just a man in his kitchen living a peaceful life. Other videos target students and urge them to treat classmates with respect and compassion. Meanwhile, another Fellow spoke about the intersection of human rights and the law. While most would agree on the value of promoting human rights and championing shared decision-making from a moral or theoretical perspective, the issues become much hazier when considering their legal application. For example, there’s a fine line between promoting human rights around the world and imposing values on a community. Does practising shared decision-making mean that patients are giving an enforceable interest to their doctors and practioners? Many such legal questions need further, careful deliberation. How can we overcome resistance to better mental health care? Multi-national panel discusses human rights challenges in their countries.As much as we can herald integrated, community-based mental health care, there remain innumerable challenges in both developed and developing economies in enacting lasting, positive change. The United States’ system, as one Fellow pointed out, is riddled with major, systemic issues, including issues with cost, the failure to treat large populations, the inadequate communication between patients’ doctors, the little emphasis on substance abuse treatment, and the fact that most de facto mental health providers are US prisons. The situation isn’t much brighter in other countries. During the discussion, Fellows listed the major issues operating as barriers to better care. Those include lack of clear political leadership, change fatigue among medical professionals, segregated physical and mental health treatments, and enormous cost for access. But there is hope. One bright example is Dual Diagnosis Anonymous, a peer group in Oregon that bypassed government failures and set up a joint mental health/substance abuse support community that thrives today.
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New Paradigms for Behavioral and Mental Health - Day 2: Patient-centeredness and technology
New Paradigms for Behavioral and Mental Health - Day 2: Patient-centeredness and technology
Louise Hallman and Jonathan Elbaz 
“Treat the person in front of you and not the schizophrenic!” – wise words from the floor during a discussion on patient-centeredness on the second day of the Salzburg Global session New Paradigms in Behavioral and Mental Health. All too often in health care provision, patients are merely seen as their diagnosis, especially when treating mental health issues. While shared decision making has been embraced in some areas of medicine, especially when considering aggressive treatments versus palliative care for terminal patients, it is poorly applied in mental health care provision. Patients might be the best placed people to determine what would the most effective treatment for them, but they are often assumed to have a diminished sense of responsibility and thus are denied personal agency. “Every time you relapse, you learn something,” insisted one Fellow who had been diagnosed as bipolar. Another Fellow who is in recovery from a teenage-diagnosis of schizophrenia told the audience, primarily of clinicians, advocates and policy-makers, that over several years, they had come to learn what can trigger their episodes, thus formulating coping mechanisms and better informing their doctors of what medication does and does not work for them. For many of the service users in the room who generously shared their own experiences, their families and communities had proven to be valuable assets in their recovery. Mental health services in many countries now strongly advocate for “care in the community.” But much like the fact that not all medications work for all people, not all patients are “lucky” enough to have supportive families and communities; in fact for some patients, these people can be a great hindrance to their recovery. Clinicians need to have the time and resources necessary to adequately consider each of their patients’ individual circumstances – a huge challenge for GPs who might only have ten minutes per consultation. New Technologies New technological tools—along with the growing ubiquity of phone access worldwide—are providing both health care practitioners and patients unprecedented abilities. Doctors can treat people remotely, decreasing costs and allowing them to treat more patients. Meanwhile, some new mobile applications allow patients in-the-moment support, like one self-management tool for schizophrenic patients that provides coping functions that help them avoid the escalation of symptoms. Thara Rangaswamy’s organization SCARF – Schizophrenia Research Foundation – created one of the world’s first mobile psychiatric treatment buses, which treats patients and dispenses medication remotely. It travels to many poor regions of India and allows psychiatric patients to talk with doctors in Chennai through a video screen. The company also leverages mobile technology with appointment reminders, alarms for taking medication, and provides emergency contact information. Some concerns about mobile health technology include questions about confidentiality, the potential for mobile apps to replace doctors and nurses, the validity of information, fighting tenuous connectivity in many regions, and the potential for mobile consultations to lead to over-medicating.
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New Paradigms for Behavioral and Mental Health - Day 1: “I wouldn’t start from here...”
New Paradigms for Behavioral and Mental Health - Day 1: “I wouldn’t start from here...”
Louise Hallman 
As the old joke goes: There was a man lost in the countryside and he asks a passing farmer for directions to the city; helpfully he responds, “Well, I wouldn’t start from here!” If we were to design an ideal mental health care system, we probably wouldn’t start from “here”, admitted Salzburg Global Program Director, John Lotherington in the opening session of the Salzburg Global Seminar program New Paradigms for Behavioral and Mental Health. Mental health service provision has come a long way since the days of Victorian “insane asylums”, but the Western model (especially that of the USA) of “over-diagnosis, over-treatment, and over-medication” is hardly one to be emulated by developing countries which are expanding their mental health services provision. Even if Western medicine were the best example to follow, much evidence-based mental health care is based on the dominant cultural group of the country in which the research has been conducted, and as such should not be necessarily be applied wholesale to other minorities, communities or cultures. Individualization of care is important; there should not be a one-size-fits-all approach. So, where would be the best place to start building a better mental health service? Answers from the 70 participants – who include psychiatrists, policy makers and patients – gathered in Parker Hall included: avoid big costly hospitals, provide more community housing and support for families, introduce better information on mental health and education in schools, and ensure patients keep their sense of agency. One of the greatest challenges within mental health is stigma that the patients and their families often face in their communities and workplaces. One possible way to help reduce that stigma would be to integrate mental health better into the broader health field and to focus on mental “wellness” instead of mental “illness.” Over the next five days, through panel discussions, role play and group discussions, Fellows will consider best practices from across the world and how best to apply these to their home contexts, looking closely at human rights, patient-centeredness, new systems, existing resources and cultures, and new technologies. But they should avoid searching for a modern day panacea – even much-heralded “big data” is no silver bullet.
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New Paradigms for Behavioral and Mental Health Care
New Paradigms for Behavioral and Mental Health Care
Jonathan Elbaz 
More than 70 health care policy experts will gather at Schloss Leopoldskron this week to examine strategies for providing better behavioral and mental health care.  In partnership with the Dartmouth Center for Health Care Delivery Science, “New Paradigms for Behavioral and Mental Health Care” will explore innovative approaches to fighting mental and substance use disorders—the leading causes of years lost to disability worldwide.
Even though wealthy countries lead the global mental health movement, they still exhibit systemic issues in providing treatment. Many patients face exorbitant costs, and individuals’ preferences and local culture are often disregarded and decisions come from government or industry experts.
Meanwhile, developing nations have vital opportunities to learn from Western health care systems and to avoid their pitfalls.
Program Director John Lotherington said the “New Paradigms” session will heavily emphasize empowering patients and communities through a shared decision-making approach. With shared decision-making, doctors and patients rigorously scrutinize available treatment options together and use all available evidence about treatments and their consequences.
“People often hear the phrase ‘shared decision-making’ and they think that it simply means that doctors are being nice,” Lotherington said. “But it’s a lot more than that. It means that all the options are explained and the patient and doctor reach a treatment plan together.”
“New Paradigms” marks the seventh session in Salzburg Global’s “Health and Health Care Innovation in the 21st Century” series, which since 2010 has crystallized new approaches to solving health care challenges for present and future generations. Past sessions have focused on the right to health, innovation in health care delivery, and improving health care in developing economies.
“Salzburg Statements”— the comprehensive reports from past Health and Health Care Innovation sessions—have been presented at conferences and in venues around the world, including at the House of Commons in London, the World Health Assembly in Geneva, and the ISQua African Regional Meeting in Accra.
The upcoming session October 7-12 gathers policy experts from five continents, including Fellows from Peru, Columbia, Rwanda, Uganda, Ghana, India, Germany, the UK, China, South Korea and Balkan countries. Some U.S. representatives come from Native American communities, which Lotherington said will add a fresh and important perspective to the discussions.
The first half of the session will revolve around plenary discussions presented through an interview format. Fellows will then participate in a “knowledge café,” an exercise of “intellectual speed dating” where they’ll be placed in three intimate discussions that cover a variety of topics, such as health care in post-conflict countries and depression management.
Later, Fellows will convene according to their countries to develop action plans that outline the next steps needed for positive change. In both developed and developing economies, mental and behavioral health care can be improved by empowering citizens and families, training more health care workers, decreasing the reliance on prescribed medication, and by utilizing emerging health technology.
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