What is Harm Reduction?


Harm reduction, or harm minimisation, refers to a range of public health policies designed to lessen the negative social and/or physical consequences associated with various human behaviours, both legal and illegal. Harm reduction is used to decrease negative consequences of recreational drug use and sexual activity without requiring abstinence, recognising that those unable or unwilling to stop can still make positive change to protect themselves and others.

Harm reduction is most commonly applied to approaches that reduce adverse consequences from illicit drug use, and harm reduction programmes now operate across a range of services and in different regions of the world. As of 2020, some 86 countries had one or more programs using a harm reduction approach to substance use, primarily aimed at reducing blood-borne infections resulting from use of contaminated injecting equipment.

Needle-exchange programmes reduce the likelihood of people who use heroin and other substances sharing the syringes and using them more than once. Syringe-sharing often leads to the spread of infections such as HIV or hepatitis C, which can easily spread from person to person through the reuse of syringes contaminated with infected blood. Needle and syringe programmes (NSP) and Opioid Agonist Therapy (OAT) outlets in some settings offer basic primary health care. Supervised injection sites are legally sanctioned, medically supervised facilities designed to provide a safe, hygienic, and stress-free environment for people who use substances. The facilities provide sterile injection equipment, information about substances and basic health care, treatment referrals, and access to medical staff.

Opioid agonist therapy (OAT) is the medical procedure of using a harm-reducing opioid that produces significantly less euphoria, such as methadone or buprenorphine to reduce opioid cravings in people who use illegal opioid, such as heroin; buprenorphine and methadone are taken under medical supervision. Another approach is Heroin assisted treatment, in which medical prescriptions for pharmaceutical heroin (diacetylmorphine) are provided to heroin-dependent people.

Media campaigns inform drivers of the dangers of driving drunk. Most people who recreationally consume alcohol are now aware of these dangers and safe ride techniques like ‘designated drivers’ and free taxicab programmes are reducing the number of drunk-driving accidents. Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. Since 1999 some countries have legalised prostitution, such as Germany (2002) and New Zealand (2003).

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in people who inject substances and sex-workers. HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk of acquiring and transmitting the HIV virus.

Substance Use

In the case of recreational substance use, harm reduction is put forward as a useful perspective alongside the more conventional approaches of demand and supply reduction. Many advocates argue that prohibitionist laws criminalise people for suffering from a disease and cause harm; for example, by obliging people who use substances to obtain substances of unknown purity from unreliable criminal sources at high prices, thereby increasing the risk of overdose and death. The website Erowid.org collects and publishes information and first-hand experience reports about all kinds of substances to educate people who use or may use substances.

While the vast majority of harm reduction initiatives are educational campaigns or facilities that aim to reduce substance-related harm, a unique social enterprise was launched in Denmark in September 2013 to reduce the financial burden of illicit substance use for people with a drug dependence. Michael Lodberg Olsen, who was previously involved with the establishment of a substance consumption facility in Denmark, announced the founding of the Illegal magazine that will be sold by people who use substances in Copenhagen and the district of Vesterbro, who will be able to direct the profits from sales towards drug procurement. Olsen explained: “No one has solved the problem of drug addiction, so is it not better that people find the money to buy their drugs this way than through crime and prostitution?”


Depressants (Alcohol)

Traditionally, homeless shelters ban alcohol. In 1997, as the result of an inquest into the deaths of two people experiencing homelessness who recreationally used alcohol two years earlier, Toronto’s Seaton House became the first homeless shelter in Canada to operate a “wet shelter” on a “managed alcohol” principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, people experiencing homelessness who consumed excessive amounts of alcohol opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. The programme has been duplicated in other Canadian cities, and a study of Ottawa’s “wet shelter” found that emergency room visit and police encounters by clients were cut by half. The study, published in the Canadian Medical Association Journal in 2006, found that serving people experiencing long-term homelessness and who consume excessive amounts of alcohol controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that programme participants cut their alcohol use from an average of 46 drinks a day when they entered the programme to an average of 8 drinks and that their visits to emergency rooms dropped from 13.5 to an average of 8 per month, while encounters with the police fall from 18.1 to an average of 8.8.

Downtown Emergency Service Centre (DESC), in Seattle, Washington, operates several Housing First programmes which utilize the harm reduction model. University of Washington researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs taxpayers less than leaving them on the street, where taxpayer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation appeared in the Journal of the American Medical Association in April 2009. This first controlled assessment in the US of the effectiveness of Housing First, specifically targeting chronically homeless alcoholics, showed that the programme saved taxpayers more than $4 million over the first year of operation. During the first six months, the study reported an average cost-savings of 53% (even after considering the cost of administering the housing’s 95 residents) – nearly $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among people experiencing homelessness who recreationally use alcohol.

A high amount of media coverage exists informing people of the dangers of driving drunk. Most people who recreationally consume alcohol are now aware of these dangers and safe ride techniques like ‘designated drivers’ and free taxicab programmes are reducing the number of drunk-driving accidents. Many cities have free-ride-home programmes during holidays involving high amounts of alcohol use, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programmes including the aforementioned ‘designated driver’ and ‘late night patron transport’ schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.

Moderation Management is a programme which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behaviour.

The HAMS Harm Reduction Network is a programme which encourages any positive change with regard to the use of alcohol or other mood altering substances. HAMS encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. The choice of the goal is up to the individual.

Harm reduction in alcohol dependency could be instituted by use of naltrexone.

Opioids (Heroin Maintenance Programmes, HAT)

Providing medical prescriptions for pharmaceutical heroin (diacetylmorphine) to heroin-dependent people has been employed in some countries to address problems associated with the illicit use of the drug, as potential benefits exist for the individual and broader society. Evidence has indicated that this form of treatment can greatly improve the health and social circumstances of participants, while also reducing costs incurred by criminalisation, incarceration and health interventions.

In Switzerland, heroin assisted treatment is an established programme of the national health system. Several dozen centres exist throughout the country and heroin-dependent people can administer heroin in a controlled environment at these locations. The Swiss heroin maintenance programme is generally regarded as a successful and valuable component of the country’s overall approach to minimising the harms caused by illicit drug use. In a 2008 national referendum, a majority of 68% voted in favour of continuing the Swiss programme.

The Netherlands has studied medically supervised heroin maintenance. A German study of long-term heroin addicts demonstrated that diamorphine was significantly more effective than methadone in keeping patients in treatment and in improving their health and social situation. Many participants were able to find employment, some even started a family after years of homelessness and delinquency. Since then, treatment had continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May 2009.

A heroin maintenance programme has existed in the United Kingdom (UK) since the 1920s, as drug addiction was seen as an individual health problem. Addiction to opiates was rare in the 1920s and was mostly limited to either middle-class people who had easy access due to their profession, or people who had become addicted as a side effect of medical treatment. In the 1950s and 1960s a small number of doctors contributed to an alarming increase in the number of drug-addicted people in the UK through excessive prescribing – the UK switched to more restrictive drug legislation as a result. However, the British government is again moving towards a consideration of heroin prescription as a legitimate component of the National Health Service (NHS). Evidence has clearly shown that methadone maintenance is not appropriate for all opioid-dependent people and that heroin is a viable maintenance drug that has shown equal or better rates of success.

A committee appointed by the Norwegian government completed an evaluation of research reports on heroin maintenance treatment that were available internationally. In 2011 the committee concluded that the presence of numerous uncertainties and knowledge gaps regarding the effects of heroin treatment meant that it could not recommend the introduction of heroin maintenance treatment in Norway.

The first, and only, North American heroin maintenance project is being run in Vancouver, B.C. and Montreal, Quebec. Currently, over 80 long-term heroin addicts who have not been helped by available treatment options are taking part in the North American Opiate Medication Initiative (NAOMI) trials. However, critics have alleged that the control group gets unsustainably low doses of methadone, making them prone to fail and thus rigging the results in favour of heroin maintenance.

Critics of heroin maintenance programmes object to the high costs of providing heroin to people who use it. The British heroin study cost the British government £15,000 per participant per year, roughly equivalent to average person who uses heroin’s expense of £15,600 per year. Drug Free Australia contrast these ongoing maintenance costs with Sweden’s investment in, and commitment to, a drug-free society where a policy of compulsory rehabilitation of drug addicts is integral, which has yielded the one of the lowest reported illicit drug use levels in the developed world, a model in which successfully rehabilitated people who use substances present no further maintenance costs to their community, as well as reduced ongoing health care costs.

A substantial part of the money for buying heroin is obtained through criminal activities, such as robbery or drug dealing. King’s Health Partners notes that the cost of providing free heroin for a year is about one-third of the cost of placing the person in prison for a year.

Opioids (Naloxone Distribution)

Naloxone is a drug used to counter an overdose from the effect of opioids; for example, a heroin or morphine overdose. Naloxone displaces the opioid molecules from the brain’s receptors and reverses the respiratory depression caused by an overdose within two to eight minutes. The World Health Organisation (WHO) includes naloxone on their “List of Essential Medicines”, and recommends its availability and utilisation for the reversal of opioid overdoses.

Formal programmes in which the opioid inverse agonist drug naloxone is distributed have been trialled and implemented. Established programmes distribute naloxone, as per WHO’s minimum standards, to people who use substances and their peers, family members, police, prisons, and others. These treatment programmes and harm reduction centres operate in Afghanistan, Australia, Canada, China, Germany, Georgia, Kazakhstan, Norway, Russia, Spain, Tajikistan, the United Kingdom (UK), the United States (US), Vietnam, India, Thailand, Kyrgyzstan, Denmark and Estonia.

Opioids (Opioid Agonist Therapy, OAT)

Opioid agonist therapy (OAT), or opioid substitution therapy (OST), uses prescription of legal, prescribed opioids, often long-acting, to diminish injection of illegal opioids and associated risk of infection or overdose. Methadone or buprenorphine are the most commonly used medicines, with methadone generally taken daily and buprenorphine available both in daily doses or long-acting implantable or injectable formulations used for a week, month or six-month period. Oral/sublingual formulations of buprenorphine incorporate the opioid antagonist naloxone to prevent people from crushing the tablets and injecting them.

In some countries, such as Switzerland, Austria, and Slovenia, patients are treated with slow-release morphine when methadone is deemed inappropriate due to the individual’s circumstances. In Germany, dihydrocodeine has been used off-label in OAT for many years, however it is no longer frequently prescribed for this purpose. Extended-release dihydrocodeine is again in current use in Austria for this reason. Research into the usefulness of piritramide, extended-release hydromorphone (including polymer implants lasting up to 90 days), dihydroetorphine and other substances for OAT is at various stages in a number of countries. In 2020 in Vancouver, Canada, health authorities began vending machine dispensing of hydromorphone tablets as a response to elevated rates of fatal overdose from street drugs contaminated with fentanyl and fentanyl analogues.

The driving principle behind OAT is the programme’s capacity to facilitate a resumption of stability in the person’s life, while they experience reduced symptoms of withdrawal symptoms and less intense drug cravings; however, a strong euphoric effect is not experienced as a result of the treatment drug. In some countries (not the US, UK, Canada, or Australia), regulations enforce a limited time period for people on OAT programmes that conclude when a stable economic and psychosocial situation is achieved. (Patients suffering from HIV/AIDS or Hepatitis C are usually excluded from this requirement.) In practice, 40-65% of patients maintain complete abstinence from opioids while receiving OAT, and 70-95% are able to reduce their use significantly, while experiencing a concurrent elimination or reduction in medical (improper diluents, non-sterile injecting equipment), psychosocial (mental health, relationships), and legal (arrest and imprisonment) issues that can arise from the use of illicit opioids.

Opioids (Opioid Substitution Therapy, OST)

NSP and opioid substitution therapy (OST) outlets in some settings also offer basic primary health care. These are known as ‘targeted primary health care outlet’- as these outlets primarily target people who inject drugs and/or ‘low-threshold health care outlet’- as these reduce common barriers clients often face when they try to access health care from the conventional health care outlets. For accessing sterile injecting equipment clients frequently visit NSP outlets, and for receiving pharmacotherapy (e.g. methadone, buprenorphine) they visit OST clinics; these frequent visits are used opportunistically to offer much needed health care. These targeted outlets have the potential to mitigate clients’ perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible, acceptable and opportunistic services which are responsive to the needs of this population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.

Opioids (Psychedelics)

The Zendo Project conducted by the Multidisciplinary Association for Psychedelic Studies uses principles from psychedelic therapy to provide safe places and emotional support for people having difficult experiences on psychedelic drugs at select festivals such as Burning Man, Boom Festival, and Lightning in a Bottle without medical or law enforcement intervention.

Substances such as MDMA (commonly sold by the slang names “ecstasy” and “molly”) are often adulterated. One harm reduction approach is drug checking, where people intending to use drugs can have their substances tested for content and purity so that they can then make more informed decisions about safer consumption. European organisations have offered drug checking services since 1992 and these services now operate in over twenty countries. As an example, the non-profit organization DanceSafe offers on-site testing of the contents of pills and powders at various electronic music events around the US. They also sell kits for people who use substances to test the contents of the substances themselves. PillReports.com invites people who use ecstasy to send samples of substances for laboratory testing and publishes the results online.

Opioids (Cannabis)

Specific harms associated with cannabis include increased accident-rate while driving under intoxication, dependence, psychosis, detrimental psychosocial outcomes for adolescents who use substances, and respiratory disease. Some safer cannabis usage campaigns including the UKCIA (United Kingdom Cannabis Internet Activists) encourage methods of consumption shown to cause less physical damage to a person’s body, including oral (eating) consumption, vaporisation, the usage of bongs which cool and to some extent filters the smoke, and smoking the cannabis without mixing it with tobacco.

The fact that cannabis possession carries prison sentences in most developed countries is also pointed out as a problem by European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), as the consequences of a conviction for otherwise law-abiding people who use substances arguably is more harmful than any harm from the substance itself. For example, by adversely affecting employment opportunities, impacting civil rights, and straining personal relationships. Some people like Ethan Nadelmann of the Drug Policy Alliance have suggested that organized marijuana legalisation would encourage safe use and reveal the factual adverse effects from exposure to this herb’s individual chemicals.

The way the laws concerning cannabis are enforced is also very selective, even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates. Drug decriminalisation, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms. Where decriminalisation has been implemented, such as in several states in Australia and United States, as well as in Portugal and the Netherlands no, or only very small adverse effects have been shown on population cannabis usage rate. The lack of evidence of increased use indicates that such a policy shift does not have adverse effects on cannabis-related harm while, at the same time, decreasing enforcement costs.

In the last few years certain strains of the cannabis plant with higher concentrations of THC and drug tourism have challenged the former policy in the Netherlands and led to a more restrictive approach; for example, a ban on selling cannabis to tourists in coffeeshops suggested to start late 2011. Sale and possession of cannabis is still illegal in Portugal and possession of cannabis is a federal crime in the United States.

Stimulants (Tobacco)

Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco, especially combustible forms, without abstaining completely from tobacco and nicotine. Some of these measures include switching to safer (lower tar) cigarettes, switching to snus or dipping tobacco, or using a non-tobacco nicotine delivery systems. In recent years, the growing use of electronic cigarettes for smoking cessation, whose long-term safety remains uncertain, has sparked an ongoing controversy among medical and public health between those who seek to restrict and discourage all use until more is known and those who see them as a useful approach for harm reduction, whose risks are most unlikely to equal those of smoking tobacco. “Their usefulness in tobacco harm reduction as a substitute for tobacco products is unclear, but in an effort to decrease tobacco related death and disease, they have a potential to be part of the strategy.

It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate smokers who are unable or unwilling to achieve abstinence. Harm reduction may be of substantial benefit to these individuals.

Routes of Administration

Needle Exchange Programmes (NEP)

The use of some illicit drugs can involve hypodermic needles. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, people who use heroin and other substances frequently share the syringes and use them more than once. As a result, infections such as HIV or hepatitis C can spread from person to person through the reuse of syringes contaminated with infected blood. The principles of harm reduction propose that syringes should be easily available or at least available through a needle and syringe programmes (NSP). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries people who use substances are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name.

A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour. It has been shown in the many evaluations of needle-exchange programmes that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programmes have reduced HIV incidence by 33% in New Haven and 70% in New York City.

The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated for a protracted time period. Research organisation the Burnet Institute completed the 2013 ‘North Richmond Public Injecting Impact Study’ in collaboration with the Yarra Drug and Health Forum, City of Yarra and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing “widespread, frequent and highly visible” nature of illicit drug use in the areas. During the period between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the local government area the City of Yarra, of which Richmond and Abbotsford are parts of, 1550 syringes were collected each month from public syringe disposal bins in 2012. Furthermore, ambulance callouts for heroin overdoses were 1.5 times higher than for other Melbourne areas in the period between 2011 and 2012 (a total of 336 overdoses), and drug-related arrests in North Richmond were also three times higher than the state average. The Burnet Institute’s researchers interviewed health workers, residents and local traders, in addition to observing the drug scene in the most frequented North Richmond public injecting locations.

On 28 May 2013, the Burnet Institute stated in the media that it recommends 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area’s drug culture continues to grow after more than ten years of intense law enforcement efforts. The institute’s research concluded that public injecting behaviour is frequent in the area and inappropriately discarding injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken open syringe disposal bins to reuse discarded injecting equipment.

The British public body, the National Institute for Health and Care Excellence (NICE), introduced a new recommendation in early April 2014 due to an increase in the presentation of the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services are not advised for people under the age of 18 years, but the organisation’s director Professor Mike Kelly explained that a “completely different group” of people were presenting at programmes. In the updated guidance, NICE recommended the provision of specialist services for “rapidly increasing numbers of steroid users”, and that needles should be provided to people under the age of 18 – a first for NICE – following reports of 15-year-old steroid injectors seeking to develop their muscles.

Supervised Injection Sites (SIS)

Supervised injection sites (SIS), or Drug consumption rooms (DCR), are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers.

The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counselling, hygienic and other services of use to itinerant and impoverished individuals. Most programmes prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be people who inject substances, but generally in Europe they do not exclude people with substance use disorders who consume their substances through other means.

The Netherlands had the first staffed injection room, although they did not operate under explicit legal support until 1996. Instead, the first centre where it was legal to inject drug was in Berne, Switzerland, opened 1986. In 1994, Germany opened its first site. Although, as in the Netherlands they operated in a “gray area”, supported by the local authorities and with consent from the police until the Bundestag provided a legal exemption in 2000.

In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000. As did the two existing facilities outside Europe, with Sydney’s Medically Supervised Injecting Centre (MSIC) established in May 2001 as a trial and Vancouver’s Insite, opened in September 2003. In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility. As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities.

The European Monitoring Centre for Drugs and Drug Addiction’s latest systematic review from April 2010 did not find any evidence to support concerns that DCR might “encourage drug use, delay treatment entry or aggravate problems of local drug markets.” Jürgen Rehm and Benedikt Fischer explained that while evidence show that DCR are successful, that “interpretation is limited by the weak designs applied in many evaluations, often represented by the lack of adequate control groups.” Concluding that this “leaves the door open for alternative interpretations of data produced and subsequent ideological debate.”

The EMCDDA review noted that research into the effects of the facilities “faces methodological challenges in taking account of the effects of broader local policy or ecological changes”, still they concluded “that the facilities reach their target population and provide immediate improvements through better hygiene and safety conditions for injectors.” Further that “the availability of safer injecting facilities does not increase levels of drug use or risky patterns of consumption, nor does it result in higher rates of local drug acquisition crime.” While its usage is “associated with self-reported reductions in injecting risk behaviour such as syringe sharing, and in public drug use” and “with increased uptake of detoxification and treatment services.” However, “a lack of studies, as well as methodological problems such as isolating the effect from other interventions or low coverage of the risk population, evidence regarding DCRs – while encouraging – is insufficient for drawing conclusions with regard to their effectiveness in reducing HIV or hepatitis C virus (HCV) incidence.” Concluding with that “there is suggestive evidence from modelling studies that they may contribute to reducing drug-related deaths at a city level where coverage is adequate, the review-level evidence of this effect is still insufficient.”

Critics of this intervention, such as drug prevention advocacy organisations, Drug Free Australia and Real Women of Canada point to the most rigorous evaluations, those of Sydney and Vancouver. Two of the centres, in Sydney, Australia and Vancouver, British Columbia, Canada cost $2.7 million and $3 million per annum to operate respectively, yet Canadian mathematical modelling, where there was caution about validity, indicated just one life saved from fatal overdose per annum for Vancouver, while the Drug Free Australia analysis demonstrates the Sydney facility statistically takes more than a year to save one life. The Expert Advisory Committee of the Canadian Government studied claims by journal studies for reduced HIV transmission by Insite but “were not convinced that these assumptions were entirely valid.” The Sydney facility showed no improvement in public injecting and discarded needles beyond improvements caused by a coinciding heroin drought, while the Vancouver facility had an observable impact. Drug dealing and loitering around the facilities were evident in the Sydney evaluation, but not evident for the Vancouver facility.


Safer Sex Programmes

Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. This runs contrary to abstinence-only sex education, which teaches that educating children about sex can encourage them to engage in it.

These programmes have been found to decrease risky sexual behaviour and prevent sexually transmitted diseases. They also reduce rates of unwanted pregnancies. Abstinence only programmes do not appear to affect HIV risks in developed countries with no evidence available for other areas.

Legalised Prostitution

Since 1999 some countries have legalised prostitution, such as Germany (2002) and New Zealand (2003). However, in most countries the practice is prohibited. Gathering accurate statistics on prostitution and human trafficking is extremely difficult. This has resulted in proponents of legalisation claiming that it reduces organised crime rates while opponents claim exactly the converse. The Dutch prostitution policy, which is one of the most liberal in the world, has gone back and forth on the issue several times. In the period leading up to 2015 up to a third of officially sanctioned work places had been closed down again after reports of human trafficking. Prostitutes themselves are generally opposed to what they see as “theft of their livelihood”.

Sex Work and HIV

Despite the depth of knowledge of HIV/AIDS, rapid transmission has occurred globally in sex workers. The relationship between these two variables greatly increases the risk of transmission among these populations, and also to anyone associated with them, such as their sexual partners, their children, and eventually the population at large.

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in injecting drug users and sex-workers. HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease. Peer education as a harm reduction strategy has especially reduced the risk of HIV infection, such as in Chad, where this method was the most cost-effective per infection prevented.

The threat of criminal repercussions marginalises sex-workers and people who inject substances, often resulting in high-risk behaviour, increasing the rate of overdose, infectious disease transmission, and violence.

Decriminalisation as a harm-reduction strategy gives the ability to treat substance use disorder solely as a public health issue rather than a criminal activity. This enables other harm-reduction strategies to be employed, which results in a lower incidence of HIV infection.

One of the first harm reduction models was called the “Mersey Harm Reduction Model ” in 1980s Liverpool, and the success of utilising outreach workers, distribution of education, and providing clean equipment to drug users was shown in the fact that an HIV epidemic did not happen in Mersey. This catapulted the model into International conferences on drug related harm in the midst of the AIDS epidemic, making it an internationally recognized model of preventing HIV/AIDS specifically within injecting drug user populations. There was much connection between San Francisco (an epicentre of HIV/AIDS advocacy in the US) and Liverpool. Harm reduction slowly began to transform the action around drug use from an individualistic approach that mainstream US healthcare often relies on, towards a more holistic population-based approach.

The AIDS epidemic, which began in the 80s and peaked in 1995, further complicated the politicisation of drug users and drug use in the US. The implementation of harm reduction faced much resistance within the US due to the demonisation of particular drugs associated with stigmatised groups, such as sex workers and drug-injecting users.


Decriminalisation as a harm-reduction strategy gives the ability to treat substance use disorder solely as a public health issue rather than a criminal activity. This enables other harm-reduction strategies to be employed, which results in a lower incidence of HIV infection.

Psychiatric Medications

With the growing concern about psychiatric medication adverse effects and long-term dependency, peer-run mental health groups Freedom Centre and The Icarus Project published the Harm Reduction Guide to Coming Off Psychiatric Drugs. The self-help guide provides patients with information to help assess risks and benefits, and to prepare to come off, reduce, or continue medications when their physicians are unfamiliar with or unable to provide this guidance. The guide is in circulation among mental health consumer groups and has been translated into ten languages.


Critics, such as Drug Free America Foundation and other members of network International Task Force on Strategic Drug Policy, state that a risk posed by harm reduction is by creating the perception that certain behaviours can be partaken of safely, such as illicit drug use, that it may lead to an increase in that behaviour by people who would otherwise be deterred. The signatories of the drug prohibitionist network International Task Force on Strategic Drug Policy stated that they oppose drug use harm reduction “…strategies as endpoints that promote the false notion that there are safe or responsible ways to use drugs. That is, strategies in which the primary goal is to enable drug users to maintain addictive, destructive, and compulsive behaviour by misleading users about some drug risks while ignoring others.”

In 2008, the World Federation Against Drugs stated that while “…some organisations and local governments actively advocate the legalisation of drugs and promote policies such as “harm reduction” that accept drug use and do not help people who use substances to become free from substance use. This undermines the international efforts to limit the supply of and demand for drugs.” The Federation states that harm reduction efforts often end up being “drug legalisation or other inappropriate relaxation efforts, a policy approach that violates the UN Conventions.”

Critics furthermore reject harm reduction measures for allegedly trying to establish certain forms of drug use as acceptable in society. The Drug Prevention Network of Canada states that harm reduction has “…come to represent a philosophy in which illicit substance use is seen as largely unpreventable, and increasingly, as a feasible and acceptable lifestyle as long as use is not ‘problematic'”, an approach which can increase “acceptance of drug use into the mainstream of society”. They say harm reduction “…sends the wrong message to…children and youth” about drug use. In 2008, the Declaration of World Forum Against Drugs criticized harm reduction policies that “…accept drug use and do not help drug users to become free from drug abuse”, which the group say undermines “…efforts to limit the supply of and demand for drugs.” They state that harm reduction should not lead to less efforts to reduce drug demand.

Pope Benedict XVI criticised harm reduction policies with regards to HIV/AIDS, saying that it was “a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems”. This position was in turn widely criticised for misrepresenting and oversimplifying the role of condoms in preventing infections.

Neil Hunt’s article entitled “A review of the evidence-base for harm reduction approaches to drug use” examines the criticisms of harm reduction, which include claims that it is not effective; that it prevents addicts from “hitting a rock bottom” thus trapping them in addiction; that it encourages drug use; that harm reduction is a Trojan horse strategy for “drug law reform”, such as drug legalisation.

What was the National Mental Health Development Unit (UK)?


The National Mental Health Development Unit (NMHDU) was a governmental organisation in England charged with supporting the implementation of mental health policy.

The unit worked to achieve this by advising on best practice for improving mental health and mental health services. NMHDU closed on 31 March 2011.

The NMHDU was funded by the Department of Health and the National Health Service, and aimed to work in partnership with the NHS’s strategic health authorities and all stakeholders. The unit was launched in 2009, following the abolition of the National Institute for Mental Health in England (NIMHE). The director of the NIMHE, Ian MacPherson, became the director of the NMHDU.

The Unit had several specific programmes of activity, including to support the Improving Access to Psychological Therapies (IAPT) scheme. The Unit also supported the government’s strategy for mental health, New Horizons, which was published in December 2009 following the end of the National Service Framework plans.

The NMHDU replaced the National Institute for Mental Health in England (NIMHE) in 2009.

What is a Non-Departmental Public Body (UK)?


In the United Kingdom, non-departmental public body (NDPB) is a classification applied by the Cabinet Office, Treasury, the Scottish Government and the Northern Ireland Executive to public sector organisations that have a role in the process of national government but are not part of a government department.

NDPBs carry out their work largely independently from ministers and are accountable to the public through the Parliament; however, ministers are responsible for the independence, effectiveness and efficiency of non-departmental public bodies in their portfolio.

The term includes the four types of NDPB (executive, advisory, tribunal and independent monitoring boards) but excludes public corporations and public broadcasters (BBC, Channel 4 and S4C).

Types of Body

The UK Government classifies bodies into four main types, whilst the Scottish Government has five:

  • Advisory NDPBs:
    • These bodies consist of boards which advise ministers on particular policy areas.
    • They are often supported by a small secretariat from the parent department and any expenditure is paid for by that department.
  • Executive NDPBs:
    • These bodies usually deliver a particular public service and are overseen by a board rather than ministers.
    • Appointments are made by ministers following the Code of Practice of the Commissioner for Public Appointments.
    • They employ their own staff and are allocated their own budgets.
  • Tribunal NDPBs:
    • These bodies have jurisdiction in an area of the law.
    • They are co-ordinated by Her Majesty’s Courts and Tribunals Service, an executive agency of the Ministry of Justice, and supervised by the Administrative Justice and Tribunals Council, itself a NDPB sponsored by the Ministry of Justice.
  • Independent Monitoring Boards:
    • These bodies were formerly known as “boards of visitors” and are responsible for the state of prisons, their administration and the treatment of prisoners.
    • The Home Office is responsible for their costs, and has to note all expenses.
  • NHS Bodies:
    • Scotland only.

Examples include the Mental Welfare Commission for Scotland and Mental Health Tribunals.

Contrast with Executive Agencies, Non-Ministerial Departments and Quangos

NDPB differ from executive agencies as they are not created to carry out ministerial orders or policy, instead they are more or less self-determining and enjoy greater independence. They are also not directly part of government like a non-ministerial government department being at a remove from both ministers and any elected assembly or parliament. Typically an NDPB would be established under statute and be accountable to Parliament rather than to Her Majesty’s Government. This arrangement allows more financial independence since the government is obliged to provide funding to meet statutory obligations.

NDPBs are sometimes referred to as quangos. However, this term originally referred to quasi-NGOs bodies that are, at least ostensibly, non-government organisations, but nonetheless perform governmental functions. The backronym “quasi-autonomous national government organisation” is used in this usage which is normally pejorative.

Brief History

In March 2009 there were nearly 800 public bodies that were sponsored by the UK Government including:

  • 198 executive NDPBs;
  • 410 advisory bodies;
  • 33 tribunals;
  • 21 public corporations;
  • The Bank of England;
  • 2 public broadcasting authorities; and
  • 23 NHS bodies.

However, the classification is conservative and does not include bodies that are the responsibility of devolved government, various lower tier boards (including a considerable number within the NHS), and also other boards operating in the public sector (e.g. school governors and police authorities).

These appointed bodies performed a large variety of tasks, for example health trusts, or the Welsh Development Agency, and by 1992 were responsible for some 25% of all government expenditure in the UK. According to the Cabinet Office their total expenditure for the financial year 2005-2006 was £167 billion.


Critics argued that the system was open to abuse as most NDPBs had their members directly appointed by government ministers without an election or consultation with the people. The press, critical of what was perceived as the Conservatives’ complacency in power in the 1990s, presented much material interpreted as evidence of questionable government practices.

This concern led to the formation of a Committee on Standards in Public Life (the Nolan Committee) which first reported in 1995 and recommended the creation of a “public appointments commissioner” to make sure that appropriate standards were met in the appointment of members of NDPBs. The Government accepted the recommendation, and the Office of the Commissioner for Public Appointments was established in November 1995.

While in opposition, the Labour Party promised to reduce the number and power of NDPBs. The use of NDPBs continued under the Labour government in office from 1997 to 2010, though the political controversy associated with NDPBs in the mid-1990s for the most part died away.

In 2010 the UK’s Conservative-Liberal coalition published a review of NDPBs recommending closure or merger of nearly two hundred bodies, and the transfer of others to the private sector. This process was colloquially termed the “bonfire of the quangos”.

Classification in National Accounts

NDPBs are classified under code S.13112 of the European System of Accounts (ESA.95). However, Statistics UK does not break out the detail for these bodies and they are consolidated into General Government (S.1311).

What are the Principles for the Protection of Persons with Mental Illness?


The Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (MI Principles) were adopted by the United Nations General Assembly in 1991.


The MI Principles provide agreed but non-legally-binding basic standards that mental health systems should meet and rights that people diagnosed with mental disorder should have.

Although the document underwent extensive drafting for 20 years and remains the international human rights agreement most specifically concerned with mental health, it has been criticised for not offering stronger protections in some areas.

It should now be read in the context of the United Nations Convention on the Rights of Persons with Disabilities.

The Principles

There are 25 principles:

  1. Fundamental freedoms and basic rights.
  2. Protection of minors.
  3. Life in the community.
  4. Determination of mental illness.
  5. Medical examination.
  6. Confidentiality.
  7. Role of community and culture.
  8. Standards of care.
  9. Treatment.
  10. Medication.
  11. Consent to treatment.
  12. Notice of rights.
  13. Rights and conditions in mental health facilities.
  14. Resources for mental health facilities.
  15. Admission principles.
  16. Involuntary admission.
  17. Review body.
  18. Procedural safeguards.
  19. Access to information.
  20. Criminal offenders.
  21. Complaints.
  22. Monitoring and remedies.
  23. Implementation.
  24. Scope of principles relating to mental health facilities.
  25. Saving of existing rights.

What is the Fixated Threat Assessment Centre?


The Fixated Threat Assessment Centre (FTAC) is a UK police/mental health unit, whose function is to manage the risk to public figures from stalkers and others fixated on celebrity.

It was formed in 2006 in acknowledgement that such offenders overwhelmingly suffered from psychosis, and could often be identified in advance from behavioural signs. Preventive treatment could then be applied, for the protection of the relevant public figures as well as the families and neighbours of the sufferer.

Refer to Chronology of UK Mental Health Legislation.


The rationale for a joint police/mental health unit was the finding that the main danger of death or serious injury to politicians in Western Europe came from attacks by people suffering from a mental health illness, who had given warnings of what they might do in the form of inappropriate, harassing or threatening communications or approaches towards the politicians in question. A similar picture was found in a study of historical attacks on the British royal family. A separate detailed study of recent inappropriate communications and approaches to members of the royal family found that 83% of the individuals concerned were suffering from psychosis.

Similar findings have come from the United States, where Park Dietz has written: “Every instance of an attack on a public figure by a lone stranger in the United States for which adequate information has been made publicly available has been the work of a mentally disordered person who issued one or more pre-attack signals in the form of inappropriate letters, visits or statements….” The role of FTAC in the UK is to detect such signals, to evaluate the risks involved and to intervene to reduce them. Such intervention often entails the obtaining of treatment and care for the fixated individual from psychiatric and social services and general practitioners in their town of residence.

The Fixated

The word ‘fixated’ in the name of the unit indicates that the main motivational drives behind the stalking of public figures are pathologically intense fixations on individuals or causes, these being obsessive pre-occupations pursued to an abnormally intense degree. In the case of those pursuing the Royal Family, these fixations divide between beliefs that the individual was a member of the family or married to a member of the family; that the royal personage was involved in plots to persecute them; and that the Royal Family were culpable for failing to redress a particular grievance, often delusional, with which the individual was angrily obsessed.

Staffing and Role

FTAC was set up in 2006, jointly managed by the Home Office, the Department of Health and Metropolitan Police Service. It is staffed by ten police officers, three full-time senior forensic nurses, a full-time senior social worker and a number of senior forensic psychiatrists and psychologists from the Barnet Enfield and Haringey NHS Trust and the Oxleas NHS Foundation Trust. FTAC receives around 1,000 referrals a year of people who have engaged in threatening or harassing communications towards politicians or the Royal Family. Around half are assessed as being of low risk after initial enquiries. The remainder are investigated by FTAC staff. They may then be referred to local health services for further assessment and potential involuntary commitment. In some cases, they may be detained by police under the section 136 powers of the Mental Health Act 1983 prior to referral.

Although run by London’s Metropolitan Police Service, FTAC is responsible for dealing nationally with the stalking or harassment of public figures by lone individuals. According to its founder, David James, it attempts not only to provide protection for the subjects of obsessive attention, but also to help people with obsessions who have mental illnesses that might otherwise have gone undiagnosed or untreated. The basis of the approach arises from the fact that the majority of the fixated are driven by delusional beliefs based in potentially treatable mental disorders. Treating those with evident mental illness will have an important effect in reducing the level of risk to public figures, whilst at the same time improving the health and welfare of the individuals concerned. The strap-line on FTAC’s stationery is ‘Preventing Harm and Facilitating Care’.

According to a statement made in June 2007 by the then Minister of State at the Home Office, Tony McNulty,

“FTAC does not detain people in psychiatric hospitals. When it encounters an individual in need of mental health care it alerts their general practitioners and psychiatrists, who then provide appropriate help under existing legislation. FTAC may make use of police powers under section 136 of the Mental Health Act 1983 to take a person who appears to be suffering from mental disorder, and in immediate need of care or control, to a place of safety. When people are removed to hospital under section 136, they are examined by a registered medical practitioner and interviewed by an approved social worker, not associated with FTAC, in order to make any necessary arrangements for their treatment or care.


In a parliamentary reply made in June 2009, the then Minister of State for Security, Counter-Terrorism, Crime and Policing, David Hanson said: “Since 2006, when FTAC began operation, 246 people have been detained under the Mental Health Act following a referral from FTAC and a subsequent decision by local health services. No individual has received a custodial sentence as a result of FTAC involvement.”

He also stated that during that same period, 27 people had been conveyed to a “place of safety” by FTAC staff under section 136 of the Mental Health Act 1983.

FTAC published the details of its interventions in its first 100 cases in the Journal of Forensic Psychiatry & Psychology in 2010. Eighty-six per cent of those assessed by FTAC were diagnosed as suffering from psychotic illness; 57% of the sample group were subsequently admitted to hospital, and 26% treated in the community. In 80% of cases, the risk level was reduced to low by FTAC intervention, the remainder of cases remaining under continued FTAC management

In protection terms, FTAC’s activities are said to benefit the families of the fixated individuals and the general public as much as the public figures that they are hounding. This is because those close to the fixated are more regularly exposed to their irrational and threatening behaviour than the public figures they target. This finding is similar to that made in the USA by Dietz and Martell in a report prepared for the National Institute of Justice:

“The persons most at risk of violence from the individual mentally ill person who pursues public figures are not the public figures or those that protect them – assuming they have the necessary security arrangements – but rather the private citizens who are the family members and neighbours of the mentally disordered subject.”


The setting up of FTAC was the main recommendation of the report of Fixated Research Group (FRG) which undertook a major research project on behalf of the Home Office between 2003 and 2006. This looked at inappropriate communications and approaches to members of the Royal Family, and systematically examined 8,000 files held by SO14, the royalty protection division of the Metropolitan Police Service’s Protection Command. The Fixated Research Group was composed of forensic psychiatrists and psychologists from the UK, Australia and the USA, who are experts in the field of stalking. They included Paul Mullen and Michele Pathé from Australia, co-authors of ‘Stalkers and their Victims’, and J. Reid Meloy from San Diego, editor of The Psychology of Stalking. The series of research papers published by the group in peer-reviewed scientific journals forms the evidence base for the FTAC.

Other Applications of the Model

The researchers at FTAC contend that the joint police-NHS model has other possible applications within the UK, such as in police responses to stalking of ordinary people and in homicide prevention. In their view, a logical further development would be the modification of the role of NHS police-liaison psychiatric nurses, so that they become embedded in police responses at borough or county level in order to perform an enabling role, to the benefit of individual patients and of public protection.


FTAC won an Association of Chief Police Officers’ Excellence Award in 2009.

Book: A Manifesto for Mental Health

Book Title:

A Manifesto for Mental Health: Why We Need a Revolution in Mental Health Care.

Author(s): Peter Kinderman.

Year: 2019.

Edition: First (1st).

Publisher: Palgrave Macmillan.

Type(s): Paperback and Kindle.


A Manifesto for Mental Health presents a radically new and distinctive outlook that critically examines the dominant ‘disease-model’ of mental health care. Incorporating the latest findings from both biological neuroscience and research into the social determinants of psychological problems, Peter Kinderman offers a contemporary, biopsychosocial, alternative. He warns that the way we care for people with mental health problems is creating a hidden human rights emergency and he proposes a new vision for the future of health organisations across the globe.

The book highlights persuasive evidence that our mental health and wellbeing depend largely on the society in which we live, on the things happen to us, and on how we learn to make sense of and respond to those events. Kinderman proposes a rejection of invalid diagnostic labels, practical help rather than medication, and a recognition that distress is usually an understandable human response to life’s challenges. Offering a serious critique of establishment thinking, A Manifesto for Mental Health provides a well-crafted demonstration of how, with scientific rigour and empathy, a revolution in mental health care is not only highly desirable, it is also entirely achievable.

What is the Impact of COVID-19 & Lockdown on the Mental Health of Children & Adolescents?

Research Paper Title

Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations.


COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. The quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection.

This paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection.


The researchers conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the COVID-19 pandemic. They selected articles and thematically organized them.


The researchers put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organisations. They have also provided recommendations to the above.


There is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. There is a need to ameliorate children and adolescents’ access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis.

For this innovative child and adolescent mental health policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary.


Singh, S., Roy, D. Sinha, K., Parveen, S., Sharma, G. & Joshi, G. (2020) Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Research. 293, pp.113429. doi: 10.1016/j.psychres.2020.113429. Online ahead of print.

Mental Health Care, Policy, and COVID-19: The Renewed Role for Psychiatric and Addiction Nursing

Research Paper Title

Mental Health Care, Policy, and COVID-19: The Renewed Role for Psychiatric and Addiction Nursing.


Kovner (2020) has importantly highlighted the role that health care workers play in the 21st century to fight pandemics, such as the recent COVID-19 outbreak, in Canada and around the world. The heroic actions, determination, selflessness, and compassion of nurses and many health care providers worldwide have become the highlighted story of COVID-19 pandemic (Kovner, 2020). This is particularly significant, as 2020 has been called the Year of the Nurse and the Midwife by the World Health Organization and the International Council of Nurses to celebrate the birth of renowned nurse Florence Nightingale on her 200th anniversary. While this year has already signified the critical position of nurses in primary care, policy, and clinical practice, the role of psychiatric nurses and their contributions to primary care have often been overlooked by society, government policy makers, and many academics.

This is particularly true, as most provinces/states do not have dedicated bachelors’ degrees in psychiatric nursing, except for British Columbia (BC), Alberta, Saskatchewan, and Manitoba in Canada. Additionally, BC remains the only province/State in North America that has a fellowship program in Addiction nursing (Jozaghi & Dadakhah-Chimeh, 2018). Momentously, it was also the first province/state in North America to enact a provincial ministry dedicated to mental health and addiction (BC Gov News, 2017). This is remarkably significant in the current pandemic as many North American are asked to work from home, have been laid off, ordered to self-isolate, or practice social distancing. The cumulative effects of financial strain and self-isolation have already been reflected in a higher frequency of police calls for mental health and domestic assault cases in many provinces, territories, and states (Hong, 2020; Seebruch, 2020). The latest research also highlights a projected increase in suicide cases in North America linked to the COVID-19 pandemic (McIntyre & Lee, 2020). Self-isolation measures and the ongoing opioid crisis have also caused sharp increases in mortalities linked to synthetic opioids to their highest levels (Johnston, 2020). Finally, some researchers have warned about the potential misuse of alcohol during the current pandemic (Clay & Parker, 2020).

Therefore, the rise in mental health and domestic abuse calls, potential suicides, overdose deaths, and alcohol abuse serves as a reminder that COVID-19 is not our only health crisis. We must tackle and plan for the potential tsunami of mental health and addiction cases. While the Federal government in Canada has promised investment to improve long-term care, Kovner (2020) rightly pointed out that COVID-19 pandemic is about politics and policy and we similarly urge the governments and municipalities to invest to improve public health. More importantly, dedicated mental health care and training in psychiatric and addiction nursing is long overdue. We also recommend that cities, states, and federal housing agencies to increase funding for dedicated mental health and harm reduction programs during the current pandemic for people who have mental health or substance use disorders.


Dadakhah-Chimeh, Z. & Jozaghi, E. (2020) Mental Health Care, Policy, and COVID-19: The Renewed Role for Psychiatric and Addiction Nursing. Policy, Politics& Nursing Practice. doi: 10.1177/1527154420957305. Online ahead of print.

Book: London and Its Asylums, 1888-1914 – Politics and Madness

Book Title:

London and Its Asylums, 1888-1914 – Politics and Madness.

Author(s): Robert Ellis.

Year: 2020.

Edition: First (1ed).

Publisher: Palgrave Macmillan.

Type(s): Hardcover and Kindle.


This book explores the impact that politics had on the management of mental health care at the turn of the nineteenth and twentieth centuries. 1888 and the introduction of the Local Government Act marked a turning point in which democratically elected bodies became responsible for the management of madness for the first time.

With its focus on London in the period leading up to the First World War, it offers a new way to look at institutions and to consider their connections to wider issues that were facing the capital and the nation.

The chapters that follow place London at the heart of international networks and debates relating to finance, welfare, architecture, scientific and medical initiatives, and the developing responses to immigrant populations.

Overall, it shines a light on the relationships between mental health policies and other ideological priorities.

A Review of Effective/Cost Effective Interventions of Child Mental Health Problems in Low- and Middle-Income Countries (LAMIC)

Research Paper Title

Effective/cost effective interventions of child mental health problems in low- and middle-income countries (LAMIC): Systematic review.


This systematic review protocol aims to examine the evidence of effectiveness and cost-effectiveness of interventions for children and adolescents with, or at risk of developing mental disorders in low- and middle-income countries (LAMICs).


The researchers will search Medline Ovid, EMBASE Ovid, PsycINFO Ovid, CINAHL, LILACS, BDENF and IBECS. We will include randomised and non-randomised controlled trials, economic modelling studies and economic evaluations.

Participants are 6 to 18 year-old children and adolescents who live in a LAMIC and who present with, or are at high risk of developing, one or more of the conditions: depression, anxiety, behavioural disorders, eating disorders, psychosis, substance abuse, autism and intellectual disabilities as defined by the DSM-V.

Interventions which address suicide, self-harm will also be included, if identified during the extraction process.

The researchers will include in person or e-health interventions which have some evidence of effectiveness (in relation to clinical and/or functional outcomes) and which have been delivered to young people in LAMICs.

They will consider a wide range of delivery channels (e.g., in person, web-based or virtual, phone), different practitioners (healthcare practitioners, teachers, lay health care providers) and sectors (i.e., primary, secondary and tertiary health care, education, guardianship councils).

In the pilot of screening procedures, 5% of all references will be screened by two reviewers.

Divergences will be resolved by one expert in mental health research.

Reviewers will be retrained afterwards to ensure reliability. The remaining 95% will be screened by one reviewer.

Covidence web-based tool will be used to perform screening of references and full text paper, and data extraction.


The protocol of this systematic review will be disseminated in a peer-reviewed journal and presented at relevant conferences.

The results will be presented descriptively and, if possible, meta-analysis will be conducted. Ethical approval is not needed for anonymised secondary data.


The systematic review could help health specialists and other professionals to identify evidence-based strategies to deal with child and adolescents with mental health conditions.


Grande, A.J., Ribeiro, W.S., Faustino, C., de Miranda, C.T., Mcdaid, D., Fry, A., de Moraes, S.H.M., de Oliveira, S.M.D.V.L., de Farias, J.M., de Tarso Coelho Jardim, P., King, D., Silva, V., Ziebold, C. & Evans-Lacko, S. (2020) Effective/cost effective interventions of child mental health problems in low- and middle-income countries (LAMIC): Systematic review. Medicine (Baltimore). 99(1):e18611. doi: 10.1097/MD.0000000000018611.