OVERLOOKING GLOBAL MENTAL HEALTH
The burden of mental health care in developing countries is a global challenge. Welcome to the Clinician's Roundtable. I am your host, Dr. Maurice Pickard, and joining me today is Dr. Vikram Patel. Dr. Patel is professor of International Health and Wellcome Trust Clinical Research Fellow and Tropical Medicine at the London School of Hygiene and Tropical Medicine.
DR. MAURICE PICKARD:
Thank you Dr. Patel for joining us.
DR. VIKRAM PATEL:
Thank you for having me Maurice.
DR. MAURICE PICKARD:
To begin with, could you speak to the importance of mental illness in developing countries particularly in the context of the enormous burden they face of social adversities and physical health problems?
DR. VIKRAM PATEL:
Well, I think firstly mental disorders are just as important a health concern in developing countries as they are in any other part of the world and in fact the sorts of issues and challenges that you mentioned Maurice, the issues of social adversities and physical health problems make, in fact, mental disorders even more important in developing countries because both of these challenges are intimately associated with the risk for mental illness.
DR. MAURICE PICKARD:
I know that you are involved with an organization called Sangath. It is the winner of the John and Catherine MacArthur Award recently. Could you tell me what the mission of that organization is?
DR. VIKRAM PATEL:
Sangath is a nonprofit organization based in India whose primary mission is the promotion of emotional and mental health of children, adolescents, and families and it does so both by providing services, but more importantly by innovating new mechanisms of delivering mental health services in low resource environment and carrying out the research to demonstrate its effectiveness.
DR. MAURICE PICKARD:
I know Lancet several years ago you wrote about healthcare in Goa which is where I believe Sangath is maintained or where it has its main office. Could you tell me something about your research then and has your conclusions then changed over the last four or five years.
DR. VIKRAM PATEL:
Actually, more of my research in mental health in developing countries stretches back to more than 10 years. In fact, I started working in Zimbabwe in Southern Africa before I moved to Goa, and if you ought ask me what is the most important lesson I have learned over these last 10 or 12 years of researching mental illness in developing countries, the first was that I was initially very skeptical that conditions like depression actually could be identified and were important courses of suffering in developing countries, I have certainly changed my view on that, and secondary we needed highly trained mental health specialists to deliver mental health care in these settings. Again, I have had to revise my view on that as well.
DR. MAURICE PICKARD:
There are 1 billion people in India and I read some place that there are 3000 psychiatrists and you bring up an interesting point, who is going to be the provider of care in countries where professional psychiatrists and psychologists are so limited.
DR. VIKRAM PATEL:
Well, that's really been the most singular challenge to scaling up mental healthcare in developing countries. The enormous human resource crunch, I should add, this is not only true of developing countries, all my friends in America also remind me there are vast tracks in this country which also suffer from a shortage of skilled human resources. My solution has been the same solution that has been adopted in other areas of public health which is to look at less specialized health workers within the health system such as primary care doctors, nurses, community health workers, and even non-health workers, what some people might call lay health workers who are appropriately trained and supervised by specialists to deliver a variety of specific treatments for mental health problems.
DR. MAURICE PICKARD:
Well, how do you improve mental health literacy? I mean that's what you are talking about. How do you go about training people like this?
DR. VIKRAM PATEL:
Well, that's a very important challenge. We won't have to first of all identify what is the evidence based treatment that once wishes to deliver, let me give you one example. For example, cognitive behavior therapy for people suffering from depression. We know when given by properly trained specialists, this is a very effective treatment for depression. What our challenge then is to identify which of these ingredients of CBT can be translated into feasible and acceptable packages that can be delivered, say for example, by a lay health worker and then evaluating whether the lay health worker delivered CBT is as effective as a specialist delivered CBT.
DR. MAURICE PICKARD:
What does your data show, has it been as effective?
DR. VIKRAM PATEL:
Well, there are data are not just from our work in India, but in fact also work in the West that shows that is properly trained lay health workers or non-specialist health workers can deliver a whole range of psychological treatments with appropriate training and supervision.
DR. MAURICE PICKARD:
Your patients or clients have not been exposed to psychiatric modalities. Even in the United States, it is very difficult in my office practice sometimes to convince somebody that they might benefit from psychotherapy. I have wondered that this might be even a greater problem in India or other countries where they are used to having physical treatment when they see their doctors, laying on of hands rather than as we know psychotherapy involves.
DR. VIKRAM PATEL:
You are absolutely right and this is precisely one more reason why the acceptability of non-mental health specialist to deliver care for mental health problems is much greater because the stigma often attached to seeing a mental health specialist prohibits, in fact, the use of such services even if they exist. So our use of lay health workers actually makes mental health care more acceptable and more accessible to a much wider range or proportion of the population.
DR. MAURICE PICKARD:
My initial response is that very often patients respond better when a physician hands them a medication and you are suggesting that somebody in your community who gives you a medication, you might incorporate, respond, and get even a placebo effect that you might not have gotten before.
DR. VIKRAM PATEL:
Well, no. Let me actually correct that point of view. What I am saying is that in the absence of a qualified specialist, M.D., we can think of innovative ways of delivering mental health care without having necessarily to rely on a specialist to arrive in that clinic.
DR. MAURICE PICKARD:
I see, I know you've written a book Where There Are No Psychiatrists.
DR. VIKRAM PATEL:
Yes.
DR. MAURICE PICKARD:
Could you comment on that book because it is that book that is into what you and I are now discussing.
DR. VIKRAM PATEL:
Absolutely. I am talking about vast tracks of the world where simply there are no psychiatrists, there are no psychologists, there are no social workers. It is in these vast tracks of the world where one has to think of alternative ways of providing mental health care and that book was written for those sorts of settings.
DR. MAURICE PICKARD:
In the book, which I have looked at, various vignette, so are various clinical situations are mentioned. From these situations, can a trained technician learn how to recognize them and possibly use them in a clinic situation?
DR. VIKRAM PATEL:
Well, that's certainly the intention. I mean the book was meant to be a manual about a <_____>, a practical guide for community health workers to be able to understand, to detect, and to provide simple mental health first aid to people suffering from mental disorders, but of course, I do recognize that a book alone is never going to be sufficient to give you the sort of practical experience and confidence to deal with such complex problems, but it is a start.
DR. MAURICE PICKARD:
What are the medications that you feel comfortable would be adequate to treat say depression or anxiety in a rural area.
DR. VIKRAM PATEL:
I think just as you might have in the US, no different really. Low cost, evidence based antidepressants such as the old SSRIs or even tricyclic antidepressants, any of these medicines provided they are affordable and you can ensure a regular supply chain would be the medicines of choice.
DR. MAURICE PICKARD:
There is some suggestion that these medications may be as cost effective as treatment for AIDS, how would you respond to that?
DR. VIKRAM PATEL:
Now, that's absolutely right. In fact, the World Health Organization has carried out analyses of the cost effectiveness of treatment for different conditions and in fact we do know that depression, the pharmacological treatment of depression is as cost effective as the use of antiretrovirals for the treatment of HIV/AIDS. I think what that just confirms is that it is not inexpensive or unaffordable intervention to treat depression in developing countries.
DR. MAURICE PICKARD:
Is there a problem locally to get patients to come to a clinic? Is there a stigma that they don’t want to go to and also we know that it's very difficult to give up any time from work to come to see your doctor, actually people in India and other countries live on a day-to-day basis to survive, to have food and shelter and to miss a day of work is really a problem, how do you get them to come to a clinic and give up time from work?
DR. VIKRAM PATEL:
I think that's a very accurate observation. Well, first of all, we plan to provide care for people who are already coming to the clinic, so our focus is on treating those people who are already attending their primary care centers or their primary care physician clinics, improving the detection of depression in these patients and then providing a package of psychological and social interventions in addition to antidepressants that their doctor might choose to give. I think the fact that many people are on day wages and that every visit to the clinic often means that they lose that day's income means that we have to think very carefully about how we minimize the number of visits that a patient needs to make to the doctor's office. So, for example, by providing more generous amounts of medication and by spacing out psychotherapy appointments so that they coincide with the appointments to see the doctor.
DR. MAURICE PICKARD:
I see, and coming to the village clinic doesn’t present a stigma. I know in many countries, India certainly comes to mind. There is a real stigma to things like epilepsy, tuberculosis that may even effect women in particular that their chances of becoming married are affected by this, does this also apply to mental health?
DR. VIKRAM PATEL:
Oh, absolutely, absolutely. In fact, an author in India, Amita Dhanda, has written about the double burden of stigma that women with mental illness face or indeed people with HIV and mental illness might face, so absolutely. Mental illness is a source of enormous stigma and discrimination in India as it is in almost all parts of the world.
DR. MAURICE PICKARD:
It sounds like you are merging mental health into other functions of a clinic so that (1) it empowers the community and it empowers actually the patient to take charge of his illness, especially when it's done locally.
DR. VIKRAM PATEL:
That's right, I think what we are trying to do is to de-stigmatize mental illness in a number of different ways, and as you mentioned, one of them is by integrating mental health care with the physical healthcare that people receive in their regular clinic so that we don’t split mental health off from their other health interests and needs, but also by using non-specialists to provide healthcare for mental illness, what we are doing is demystifying mental illness.
DR. MAURICE PICKARD:
Is there a problem with adherence with antidepressants. We know in the United States, certainly patients begin to feel better and then stop their medication. Also, they often have side effects and they have to deal with their doctor on a day-to-day or frequent basis to try to work through the side effects, does the same thing exists in your model?
DR. VIKRAM PATEL:
Oh, absolutely. I think adherence is the great challenge for all chronic diseases, whether it's depression or schizophrenia in the mental disorder spectrum or it's TB/HIV infectious diseases or heart disease and diabetes. I think one has to accept the adherence as a challenge and plan on a number of different strategies, evidence based strategies that might be utilized to promote and improve adherence with medications.
DR. MAURICE PICKARD:
I want to thank Dr. Patel for being our guest and we've been discussing mental health in developing countries.
I am Dr. Maurice Pickard and you've been listening to the Clinician's Roundtable. To comment or listen to our full library of pod casts, visit us at www.reachmd.com. Register with promo code radio and receive six months free streaming for your home or office. Thank you for listening.
