Mental illness is a major global health burden (1) with substantial societal and economic consequences. (2) In developed countries, around 66% of people with mental disorders do not receive treatment, but in developing countries this figure reaches 90%. (3,4)
In Europe, after cardiovascular illness, mental disorders account for the second-highest burden of disease. (5) his is particularly the case in the Russian Federation and the countries in economic and social transition around them. Following the collapse of the Soviet Union, this region experienced increased mental illness and high suicide rates along with widened socioeconomic inequalities, high mortality from alcohol and tobacco-related diseases, rapidly rising HIV incidence and declines in life expectancy. (6-10)
The WHO Global Burden of Disease study--which used limited data from the Russian Federation (11)--estimated unipolar depression to account for 4% of the country's total burden of disease in 2002. (12) The suicide rate peaked in the mid-1990s, when for men aged 50-54 years this was over six times that seen in the United States of America: 139 and 22.5 deaths per 100 000 population, respectively. (13) In 2002, Russian men had the second-highest rates of suicide in WHO European Region, with rates of 69.3 per 100 000 males and 97.2 per 100 000 in the 45-54 year old age group. (13,14) Between 1990 and 2000, the number of individuals registered as disabled because of mental illness increased by 17.4% to reach 861 650. This accounts for 20% of all people registered as disabled in the Russian Federation. (l5,16)
The isolation of Russian psychiatry during Soviet times and limited funding of mental health services severely curtailed access to new evidence (7,18) Consequently, most practitioners lack the knowledge and skills required to deliver a range of effective medical and psychosocial treatments necessary for community-based care.
Moreover, despite the high burden of mental illness globally, the Millennium Development Goals do not directly include targets for mental disorders; thus these illnesses attract meagre investment by international donors. (19) Consequently, donor investment to reform mental health services in eastern Europe, when available, has been sparse, short-term and unisectoral. (10)
Although a Declaration and Action Plan endorsed by all WHO European Member States prioritized mental health in Helsinki in 2005, (21,22) the Russian Federation and post-communist countries have yet to introduce reforms to enable innovative treatments to be embedded in routine care. (23,24)
We summarize the main interventions employed and outcomes achieved by a research project funded by the United Kingdom (UK) Department for International Development. This project adopted an integrated and multifaceted approach to mental health reform in the Russian Federation that aimed to promote social inclusion of people with mental illness.
The study was implemented between 2002 and 2004 in Sverdlovsk oblast (available at: http:// www.iop.kcl.ac.uk/departments/ ?locator=430&project=10256) in three pilot areas: urban, semi-urban and rural. It was directed by a multidisciplinary group of UK-based and Russian professionals led by the Institute of Psychiatry in London and the government of the Sverdlovsk oblast, (1) in collaboration with the Russian Federal Government, WHO, and local municipalities and universities.
We employed action research, (25) using qualitative and quantitative methods of enquiry in three interlinked stages. We paid particular attention throughout to participation of local researchers and stakeholders, and to reflexivity and methodological relativism to avoid cultural bias and understand behaviours and practices in the Russian context. (26,27) Data emerging from the study were regularly discussed at individual meetings and workshops with local collaborators and key stakeholders to reinforce our inductive approach and triangulate findings. …