The overall collated top 22 questions, each mentioned by more than 100 respondents, were then taken to the ﬁnal prioritisation workshop. At the ﬁnal prioritisation workshop, patients, carers and clinicians, using an inclusive facilitated approach developed by the James Lind Alliance, agreed the ﬁnal order of the 22 presented research questions in a series of three rounds of discussion and decision-making. The ﬁnal top ten research priorities for eating disorders focus on important aspects of treatment, prevention, and the role of carers in the recovery process (panel). All true uncertainties identiﬁed via this Priority Setting Partnership will be uploaded to the James Lind Alliance website, where it publishes the output of all its Priority Setting Partnerships. This research agenda for eating disorders should now inform the scope and future activities of funders and researchers. We declare no competing interests. This project was supported by funding provided by the Netherlands Foundation for Mental Health (Fonds Psychische Gezondheid, 2014 6837). EvF was involved in all phases of this research project and had the idea for the project. AvdM was involved in data collection, data analysis, data interpretation and writing. KC was involved in the planning of the project, study design, data interpretation and writing.
Eric F van Furth, Angela van der Meer, Katherine Cowan [email protected]
Rivierduinen Eating Disorders Ursula, POB 405, 2300 AK Leiden, the Netherlands (EFvF, AvdM); Department of Psychiatry, Leiden University Medical Centre, Leiden, the Netherlands (EFvF); and James Lind Alliance, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, Southampton, UK (KC) 1 2
Treasure J, Claudina AM, Zucker N. Eating disorders. Lancet 2010; 375: 583–93. Schmidt U, Adan R, Böhm I, et al. Eating disorders: the big issue. Lancet Psychiatry 2016; 3: 313–15. MQ Landscape Analysis. UK Mental Health Research Funding, April 2015. http://b.3cdn. net/joinmq/1f731755e4183d5337_ apm6b0gll.pdf (accessed June 3, 2016). The James Lind Alliance Guidebook, version 6, 2016. http://www.jla.nihr.ac.uk/guidebook (accessed June 3, 2016).
www.thelancet.com/psychiatry Vol 3 August 2016
Investment in mental health services urgently needed in Nepal We applaud Dan Chisholm and colleagues1 for their work on scaling up treatment for depression and anxiety as published in The Lancet Psychiatry. The researchers used the global point prevalence rate of 7·3% for anxiety disorders, 3·2% for depression in men, and 5·5% for depression in women.1 For countries in crisis, the burden of mental health illness might be higher. In Nepal, a decade-long armed conﬂict was responsible for more than 10 000 deaths, and displacement of more than 100 000 people between 1996 and 2006.2 Violent agitations, killings, and destruction of public property continued to 2015. On April 25, 2015, a major earthquake followed by several aftershocks left the country with more than 9000 deaths, 23 000 injured,2 and more than 2 million homeless people. This disaster was exacerbated by economic blockade that further hampered recovery. We searched MEDLINE on Feb 25, 2016, using the search terms: “mental health” or “mental disorder” and “Nepal”, limiting the search to studies published in the English language. We identiﬁed two reviews (2010 and 2015)3,4 that included eight individual studies and summarised that there was a high (37·5%) prevalence of mental health disorders in the general population in Nepal: 4 depression (30%), anxiety (28%), and distress (42%) in rural community settings.3 Among specific groups, there were similar high rates of disorders;4 for example, 3–4% of Bhutanese refugees had post-traumatic stress disorder (PTSD); 34% had anxiety, and 14% had depression; 53% of internally displaced people had PTSD, 81% had anxiety, and 80% had depression; 60% of torture survivors had PTSD
60%, 86% had anxiety, 81% had depression; and 55% former child soldiers had PTSD, 46% had anxiety, and 53% had depression. Chisholm and colleagues1 estimated that total economic returns would be 2·3 to 3·0 times higher than the investment and 3·3 to 5·7 times higher if all health benefits were included. Their estimates did not include PTSD; therefore, the figures could be an underestimation for a country like Nepal with a high PTSD burden. However, the current health system of Nepal does not have a major focus on mental illness. Lack of institutional and financial capacity, no insurance system, and inadequate human resources compound the problem. We argue that mental health problems should no longer be treated only as a health problem but as a socioeconomic concern. Therefore, there is a need for increased political commitment, resource mobilisation, and integration of mental health services in primary health care in Nepal. Such investment in mental health services in a crises-stricken country such as Nepal is imperative for higher health and economic gains. Both authors have equally contributed in designing the idea of the manuscript, data collection and analysis via review, and interpretation of ﬁndings. Both authors agreed on the opinion expressed on the ﬁnal version of manuscript. We declare no competing interests.
*Vishnu Khanal, Shiva Raj Mishra [email protected]
Nepal Development Society, Bharatpur, Chitwan, Nepal 1
Chisholm D, Sweeny K, Sheehan P, et al. Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry 2016; 3: 415–24. Mullan Z. Rebuilding Nepal. Lancet Global Health 2015; 3: e654. Tol WA, Kohrt BA, Jordans MJ, et al. Political violence and mental health: a multi-disciplinary review of the literature on Nepal. Soc Sci Med 2010; 70: 35–44. Mishra SR, Neupane D, Bhandari PM, Khanal V, Kallestrup P. Burgeoning burden of non-communicable diseases in Nepal: a scoping review. Global Health 2015; 11: 32.