Improving mental health diagnosis through standardised assessment

Methods for assessing the mental health of people and making a diagnosis can vary between healthcare settings both in the UK and globally, with few options for rapid, day-to-day standardised assessments in clinical settings. One tool developed by experts in the NHS has become a viable option for health professionals and organisations needing to make such assessments quickly and easily – with the tool being tested by the UK Home Office, and attracting increasing interest from a range of countries.

Work on the Global Mental Health Assessment Tool (GMHAT) began in the 1990s, when Professor Vimal Sharma and colleagues in the NHS realised that mental health assessments carried out in primary and specialist care settings varied in quality. At the time, there was an increasing emphasis on evidence-based assessments, but the variety of tools available were mainly for research purposes.

"At that point, I thought perhaps we should take the principles of evidence-based assessments, and apply that in day-to-day clinical care," Professor Sharma explains.

"The idea was that if early detection of mental disorders is done at primary care level, then it would be easy to manage and help these people – meaning that they don't end up at the severe end of mental health disorders if remained untreated. Early detection and early intervention - that was the objective at that point in time."

Developing the Global Mental Health Assessment Tool

Originally, two versions of the tool were developed: one for use in primary care by trained health workers, GPs, nurses and other health professionals (GMHAT/PC), and a full version (GMHAT - Full) for secondary care, enabling specialist doctors, nurses and psychiatrists to make comprehensive assessments.

One of the advantages of the Full version of GMHAT is the range of factors it considers (holistic assessment) when making a diagnosis. More recently, the Full version has been further advanced by Professor Sharma and his colleagues at the Centre for Autism and Neuro-developmental Disorders (CANDIDD) to be used in learning disability services (GMHAT - Full/ID).

Professor Vimal Sharma

Vimal is Professor of Global Mental Health Research at The University of Manchester, and Consultant Psychiatrist at Cheshire and Wirral Partnership NHS Foundation Trust.

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"In day-to-day assessments, professionals tend to make a judgement quite early on, without keeping their objectivity in gathering multi-dimensional information in making a full assessment," Professor Sharma says.

"For instance, if somebody feels down or low, we automatically assume that this person is suffering from 'depression'. We just focus on the present depression and don't really explore other issues, whether it's related to social factors, drinking, eating disorders and so on. So, we came up with GMHAT for assessments that cover all aspects of mental health."

 GMHAT/PC is a computer-assisted clinical assessment tool consisting of a set of questions developed to identify potential mental health disorders. Assessments take up to 20 minutes to complete, making them ideal for health professionals with a busy caseload. The questions cover a range of areas, and if no issues are identified in one particular area, the tool moves on to the next section.

More than 20 areas are covered by GMHAT, including anxiety and depression, eating disorders, other neurotic disorders like obsessive compulsive disorder, phobias, psychotic disorders, dementia and organic disorders, and personality disorders, as well as substance misuse and post-traumatic stress disorder. Several new questions were recently added to the tool to cover areas such as attention deficit hyperactivity disorder and autistic spectrum disorder.

"GMHAT gives a clinical diagnosis that reaches a clinical threshold level. So, for instance, if you have anxiety and depression, and they are both significant, then it captures both," Professor Sharma explains. "Whereas in clinical practice, we tend to focus on just one diagnosis."

The primary care version of the tool (GMHAT/PC) has been validated against ICD-10 diagnosis in a number of field studies, including one that was carried out in the Wirral.

GMHAT training

Guided by Professor Sharma, a team from CANDIDD at Cheshire and Wirral Partnership NHS Foundation Trust has developed a standardised training package lasting two to three days.

The training package aims to provide knowledge about mental disorders and interviewing and communication skills and competencies in making a professional judgement when identifying mental health symptoms. The sessions in the training programme are interactive using videos and roleplaying exercises.

Global demand

Once the tool was made available to frontline health workers, it became obvious that there was a significant demand from other countries for GMHAT/PC to be offered in different languages. The tool was first translated into Spanish, followed by Asian languages including Hindi, Marathi, Kannada, and Tamil. Other translations included Dutch, German, Welsh, Cantonese and Mandarin.

In 2016, a collaboration between the Home Office, Public Health England and the UN's International Organization for Migration (IOM) piloted the tool with 200 Syrian refugees at a clinic in Beirut, Lebanon. The refugees had been approved for resettlement to the UK, and the pilot suggested that mental health assessments could help UK local authorities to prepare for new refugee arrivals, as well as provide important information to GPs for their initial consultations.

Following the pilot, the Home Office and the IOM initiated the rollout of assessments using GMHAT/PC for UK-bound refugees. The first set of training in GMHAT/PC has been successfully carried out in Kenya, Jordan and Pakistan.

Additionally, GMHAT/PC training is routinely provided in Colombia (Spanish version) and in India for health workers at different organisations.

"The feedback from all the training programmes, wherever we carried them out, has been extremely positive," Professor Sharma says.

"The ultimate mission is to integrate mental health with health and wellbeing. In my view, GMHAT/PC, if used by frontline health workers alongside other health assessment, could certainly assist with integrating mental health, whether it's in primary care, general health settings, non-governmental organisations, specific populations like refugee population or homeless people, or in other vulnerable populations."

The future

The team are also considering the possibility of empowering individuals to carry out self-assessments so that they can approach the relevant services for help, which could be particularly useful in rural regions where there is little access to mental health services. A project funded by the Indian Council of Medical Research in a remote part of Rajasthan has suggested that this could be useful.

In addition to GMHAT's clinical uses, researchers may increasingly turn to GMHAT for epidemiological projects, enabling the tool to contribute to mental health research. The tool is already being used for training purposes in medical teaching at RHUS College of Medical Sciences, Jaipur, and could be rolled out to other medical schools to provide mental health training to future medics.

"It doesn't matter whether they take their medical career as surgeons or physicians," Professor Sharma says. "Having mental health assessment training early on will always help them. The ultimate objective is to bring mental health to mainstream health, and to reach out to as many people around the world as possible."