How can access to mental health services be improved for people with disabilities?

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Question & problem

Evidence shows that people with physical, sensory and/or intellectual disabilities (herein referred to as ‘people with disabilities’) are at higher risk of mental health conditions. This may be due to a range of personal, social and economic factors, for example, difficulties in activities and functioning and barriers to social and economic participation experienced by people with disabilities. People with disabilities are also more likely to experience violence, abuse and discrimination, major risk factors for mental health conditions. There is some evidence, mainly from high income countries (HICs), of effective mental health interventions for people with disabilities; including accessible mainstream mental health services and interventions developed/adapted for specific impairment types. However, people with disabilities can face a range of barriers accessing mental health interventions, especially in low- and middle-income countries (LMICs) where mental health services and personnel are sparse. There is increasing evidence around the effectiveness of mental health intervention models in LMICs, including stepped-care and task-shifting programmes, however there is limited information about how to make them disability-inclusive. 

This evidence brief explores what we know about how to improve access to mental health care for people with disabilities in low-resource settings.

Recommendations

Integrate disability inclusion into mental health care systems and interventions

Key recommendation

Integrate disability inclusion into mental health care systems and interventions

Action

With limited and underfunded mental health systems and programmes in many LMICs, there is an emphasis on innovative implementation of community-level interventions, task-sharing and stepped care models, to reduce the treatment gap. This provides an important opportunity for disability inclusion to be considered from the outset as these interventions are designed, developed and scaled up.

Provide reasonable accommodations so that mental health services and interventions are accessible to people with disabilities

Key recommendation

Provide reasonable accommodations so that mental health services and interventions are accessible to people with disabilities

Action

These could include accessibility audits (e.g. using the Sightsavers audit tool), adaptations to psychosocial interventions (e.g. provision of regular breaks, shorter session times, sign-language interpreters, visual aids) as well as scaling-up community level delivery and use of digital technology (e.g. tele-health) to promote access.

Train mental health care workers to deliver services for people with disabilities.

Key recommendation

Train mental health care workers to deliver services for people with disabilities.

Action

Include training on disability inclusion as part of core and continuing professional development for mental health workers. This should include training delivered by people with disabilities. Training on disability inclusion should also be built into task-sharing models for mental health that are increasingly advocated in LMICs.

Improve the identification of mental health difficulties among people with disabilities

Key recommendation

Improve the identification of mental health difficulties among people with disabilities

Action

Work with researchers to develop and test mental health assessment methods and screening tools for use with people with specific impairment types. Promote multi-sectoral collaboration; among people with disabilities and their families, health care providers (impairment-specific and general health) and teachers, increase mental health literacy and raise awareness of the mental health for disability risk and how to assess and refer accordingly. Consider integration of screening for common mental disorders within impairment-specific (e.g. vision, hearing) services. Research on efforts to integrate screening and treatment of depression in HIV services may provide important lessons here.

Engage people with disabilities in the design and implementation of mental health policies and services.

Key recommendation

Engage people with disabilities in the design and implementation of mental health policies and services.

Action

Consultation with people with disabilities is often recommended, but evidence of it happening is lacking and there is a need to understand the most effective mechanisms to do this meaningfully. Rights based and advocacy training for people with disabilities and their families may facilitate a role in policy development, though evidence is limited.

Conduct research on ‘what works’ to promote access to mental health services

Key recommendation

Conduct research on ‘what works’ to promote access to mental health services

Action

There is an emphasis in LMIC on the scale-up of community level delivery of mental health interventions by less specialised health workers and the use of digital technologies to educate and increase diagnosis and treatment coverage. However, evidence is urgently needed on how to ensure these interventions, as well as hospital based services, are accessible and effective for people with disabilities. Work with research institutions to develop, test and evaluate accessible interventions and engage with people with disabilities in this process.

Challenges

Challenge #1: People with disabilities experience multiple barriers to accessing mental health services.

  • Mental health services and mental health specialists in LMICs are often limited in availability and concentrated in urban areas, creating physical and financial barriers to access. Reviews suggest that the needs and provision of reasonable accommodation for people with disabilities are often not prioritised. For example, mental health care workers lack appropriate communication skills (e.g. sign-language) and written information may not be accessible for people with visual or intellectual disabilities.
  • Eligibility criteria for some mental health interventions and research can explicitly exclude people with disabilities, especially intellectual and sensory disabilities.
  • Community-level interventions and digital models of service delivery are recommended to improve access to mental health services generally in LMICs. However, the needs of people with disabilities must be considered in their design and delivery. 
  • One review suggested delivery of mental health interventions in schools may be effective for improving mental health for young people with hearing loss, though evidence was mainly from high and upper middle income countries. [Only include if published in time]

Challenge #2: Mental health care workers lack training and skills on working with people with disabilities.

  • Although reviews from LMICs are lacking, evidence from HICs highlights low awareness, confidence and skills among mental health workers about how to adequately address the needs of people with disability. Most of this evidence comes from reviews focussed on people with intellectual disability.
  • There is a need for improved training for mental health workers on disability inclusion, particularly for strengthening skills and attitudes. This should include training delivered by people with disabilities. However, evidence on this is lacking from LMIC.
  • There is an emphasis on task-shifting within mental health in LMICs. Disability inclusion, including staff training, should be built into these models. 

Challenge #3: Insufficient identification and referral of people with disabilities experiencing mental health difficulties.

  • People with disabilities and their carers may not recognise signs of mental health problems or know how to seek support. Reviews suggest that, for people with intellectual disabilities, ‘diagnostic over-shadowing’ is common; that is misattributing symptoms of mental health disorders to a person’s intellectual disability. Stigma may also prevent help-seeking.
  • There are a lack of validated mental health assessments and screening tools for use with people with different impairment types in LMIC. Existing screening tools for depression, for example, may not be appropriate for people with severe intellectual disability or adequately capture how Deaf people communicate feelings. These tools are needed to identify and refer people with mental health problems and as outcome measures to assess the impact of interventions.
  • There is a lack of integrated care; impairment-specific services (e.g. audiology, physical rehabilitation) typically only focus on physical aspects of impairment and not on psychological well-being. Improved awareness among health care workers (in specialised impairment-specific and primary care services) and teachers of the elevated risk of mental health conditions may help increase identification, referral and treatment. However, this will also require scaling up of mental health services in LMIC. Although literature from HIC suggests coordinated multi-sectoral care can have positive results, evidence on models that work in LMIC are absent.

Challenge #4: People with disabilities are not prioritised or consulted in mental health care policies and service provision.

  • Reviews note that i) the needs of people with disabilities should be considered in mental health policies and ii) people with disabilities should be involved in mental health policy and service planning. However, there is little evidence that this is happening.
  • Where mental health policies mentioning disability inclusion are in place, one review suggests, they are not implemented effectively.  There is some evidence, from LMIC, that rights based and advocacy training for mental health service users with intellectual disabilities and their families may facilitate a role policy development.

Challenge #5: Lack of evidence on service needs and ‘what works’ to improve mental health of people with disabilities.

  • There is a lack of data on the prevalence and determinants of mental health difficulties of people with physical, sensory and intellectual disabilities in LMIC. People with disabilities can be excluded from mental health research, through narrow eligibility criteria.
  • There is some evidence, mainly from HIC, on the effectiveness of adapting psychosocial therapies (e.g. providing regular breaks and shorter sessions, visual aids and sign-language interpretation) and training of mental health workers to promote disability inclusion. However, for LMICs, there is a major evidence gap about effective disability-inclusive mental health interventions, models of service delivery and training of mental health workers.

Finding the answers

These recommendations come from a review of reviews on the topic of access to mental healthcare for people with disabilities. One single study which included analysis of data from 5 LMICs was also included. The reviews primarily draw on evidence from high income countries and intellectual disability was most commonly the focus. Two reviews from LMIC were focussed on mental health services and included only brief mention of disability.  Although some recommendations from high-income settings may be relevant there is an urgent need for more evidence specific to LMIC. Further, there is absence, in the review literature on specific evidence-based recommendations concerning best practice.

Recommendations & actions

Integrate disability inclusion into mental health care systems and interventions

Key recommendation

Integrate disability inclusion into mental health care systems and interventions

Action

With limited and underfunded mental health systems and programmes in many LMICs, there is an emphasis on innovative implementation of community-level interventions, task-sharing and stepped care models, to reduce the treatment gap. This provides an important opportunity for disability inclusion to be considered from the outset as these interventions are designed, developed and scaled up.

Provide reasonable accommodations so that mental health services and interventions are accessible to people with disabilities

Key recommendation

Provide reasonable accommodations so that mental health services and interventions are accessible to people with disabilities

Action

These could include accessibility audits (e.g. using the Sightsavers audit tool), adaptations to psychosocial interventions (e.g. provision of regular breaks, shorter session times, sign-language interpreters, visual aids) as well as scaling-up community level delivery and use of digital technology (e.g. tele-health) to promote access.

Train mental health care workers to deliver services for people with disabilities.

Key recommendation

Train mental health care workers to deliver services for people with disabilities.

Action

Include training on disability inclusion as part of core and continuing professional development for mental health workers. This should include training delivered by people with disabilities. Training on disability inclusion should also be built into task-sharing models for mental health that are increasingly advocated in LMICs.

Improve the identification of mental health difficulties among people with disabilities

Key recommendation

Improve the identification of mental health difficulties among people with disabilities

Action

Work with researchers to develop and test mental health assessment methods and screening tools for use with people with specific impairment types. Promote multi-sectoral collaboration; among people with disabilities and their families, health care providers (impairment-specific and general health) and teachers, increase mental health literacy and raise awareness of the mental health for disability risk and how to assess and refer accordingly. Consider integration of screening for common mental disorders within impairment-specific (e.g. vision, hearing) services. Research on efforts to integrate screening and treatment of depression in HIV services may provide important lessons here.

Engage people with disabilities in the design and implementation of mental health policies and services.

Key recommendation

Engage people with disabilities in the design and implementation of mental health policies and services.

Action

Consultation with people with disabilities is often recommended, but evidence of it happening is lacking and there is a need to understand the most effective mechanisms to do this meaningfully. Rights based and advocacy training for people with disabilities and their families may facilitate a role in policy development, though evidence is limited.

Conduct research on ‘what works’ to promote access to mental health services

Key recommendation

Conduct research on ‘what works’ to promote access to mental health services

Action

There is an emphasis in LMIC on the scale-up of community level delivery of mental health interventions by less specialised health workers and the use of digital technologies to educate and increase diagnosis and treatment coverage. However, evidence is urgently needed on how to ensure these interventions, as well as hospital based services, are accessible and effective for people with disabilities. Work with research institutions to develop, test and evaluate accessible interventions and engage with people with disabilities in this process.

Policy priorities

Prioritise disability inclusion within the scaling up of mental health services and programmes in LMIC to ensure mental health for all. The emphasis on innovative community and remote mental health interventions provides an important opportunity to build this into new models from the outset. This requires political will and should be guided by understanding of what it means to reasonably accommodate people with disabilities, including through consultation with people with disabilities. Multi-sectoral collaboration between government ministries/departments, health care providers, research organisations, NGOs and community based organisations is needed to promote holistic and integrated physical and mental health care for people with disabilities.

Conclusion

In general, there is a lack of review evidence from low- and middle-income countries specifically on improving access to mental health care for people with disabilities. This aligns with limited evidence on access to health care for people with disabilities generally. There is some encouraging evidence from HIC that adapting mental health interventions to be accessible, training of mental health care workers and school-based mental health interventions can promote mental health. There is a need to build the evidence base around these approaches in LMIC. There is an emphasis on scaling up innovative community level, task-sharing and remote mental health interventions to improve access to mental health care generally in LMIC and disability inclusion must be considered within models to ensure mental health for all. There is an urgent need for rigorous research to identify the best way to achieve this.

Gaps & research needs

Given that people with disabilities are at increased risk of mental health difficulties, there is an urgent need for rigorous research to develop/adapt, pilot test and assess the effectiveness of accessible mental health services and interventions. Mental health research in general should include people with disabilities. There is also need for testing of mental health assessment & screening tools for people with different impairment types. This will be important to improve identification and referral as well as expand the epidemiological data on mental health difficulties and impact of interventions.

Acknowledgements

Peer review: This brief was reviewed Nathaniel Scherer, Research Fellow, ICED, LSHTM and Onaiza Qureshi, Knowledge Exchange Officer at Disability Evidence Portal.

Publication details: © London School of Hygiene & Tropical Medicine, July 2021.

Suggested citation: Sarah Polack. Evidence Brief: How can access to mental health services be improved for people with disabilities? Disability Evidence Portal, 2021.

Disclaimer: The views expressed in this publication are those of the author/s and should not be attributed to Disability Evidence Portal and/or its funders