A predictive model of the development of national mental health systems

An emerging body of research in the field of international mental health, in part stimulated by the World Mental Health Survey Initiative, has made only limited progress in understanding variations in levels of development in mental health services across nations. However, the World Health Organization's recent initiatives involving the Assessment Instrument for Mental Health Systems (WHO-AIMS) and its publication of the Mental Health Atlas now present new opportunities for understanding transnational mental health policy development.

This study, thus, aims to increase understanding of the dimensions and conditions associated with the differential levels of development of national mental health. Specifically, it addresses two questions: Are there one or multiple dimensions characteristic of this development? What are the relative contributions of demographic, economic, political, social, cultural, and geographic conditions in predicting the levels of various nations on these dimensions?

This study employs a secondary analysis of existing data derived from both WHO's Mental Health Atlas and other archival sources to address the above questions. Analyses of patterns of missing data supported decisions to restrict the sample to 138 nations. The first question on dimensions of development was addressed with a Varimax factor analysis using a matrix of polychoric, tetrachoric, and Pearson correlations. Factor scores were calculated for the resulting three factors, and to address the second question on predictors, these were each analyzed with multiple regression models.

Three orthogonal or uncorrelated dimensions were identified that are characteristic of the 138 nations: (i) General Mental Health Services (professionals and inpatient beds), (ii) Public Mental Health Program; and (iii) Community Mental Health that collectively accounted for 45% of the variance in the database of WHO predictors. Only one, General Mental Health Services, was substantially explained (Adj. R2 = .641) by the predictors, specifically, by democratization, distance from Paris, gross domestic product, and Inglehart's measure of self-expression (versus survival) values.

This analysis reveals a complexity and diversity of developmental patterns that are not apparent in statistical results that have been previously reported. Specifically, these results show that there is no unilinear pathway of development or of associated environmental conditions, but rather national mental health systems vary dramatically in respect to three dimensions -- General Mental Health Services, Public Mental Health Programs, and Community Mental Health -- which are unrelated to one another.

The multiple dimensions of mental health development identified in this study reinforce the importance of a multi-pronged strategy for the continuation of multiple developmental efforts. Mental health manpower development, including both education and training, regulation and standard setting, public mental health services, both inpatient and the range of community mental health services, are among some of the most vital elements of a comprehensive strategy on the part of both national and international authorities

Limitations of this study that include the unknown reliability and validity of the WHO Mental Health Atlas data suggest the need for such data collection initiatives to utilize multiple informants for each nation. As better data is gathered, it will become increasingly feasible to undertake multi-level studies of variations not only between nations, but within them.