HEALTHCARE IN THE UNDEVELOPED WORLD AND VARIOUS NEEDS IN MENTAL HEALTH
For depression and epilepsy in the Third World countries one needs to ask is help on the way. Welcome to the Clinician's Roundtable. I am your host, Dr. Maurice Pickard and joining me today is Dr. Vikram Patel. Dr. Patel is a Professor of International Mental Health and the Wellcome Trust Clinical Research Fellow in Tropical Medicine at the London School of Hygiene and Tropical Medicine.
DR. MAURICE PICKARD:
Thank you very much Dr. Patel for joining us.
DR. VIKRAM PATEL:
Thanks for having me Maurice.
DR. MAURICE PICKARD:
To begin with I would like to ask you could you speak the importance of mental illness in developing countries particularly in the context of the enormous burden they face as social adversities and physical health problems.
DR. VIKRAM PATEL:
Sure, Maurice, mental disorders are just as important a cause of human suffering in all countries of the world, developing and developed. We now have abundant evidence showing that these disorders can be recognized and cause huge amount of disability in all societies. In fact, the very conditions that you describe of adversity both social and the high burden of physical health problems contribute to the risk for mental disorders in developing countries.
DR. MAURICE PICKARD:
Where professional psychiatrists are so limited and so few in number, for example, in India a population of a billion people and there are roughly 3000 psychiatrists. Is there a model that you are developing that brings healthcare to the masses of India that are really without medical care for this field.
DR. VIKRAM PATEL:
Yes that's been the focus of my work in the last decade. The model that we have been developing is shifting the task of clinical encounter that psychiatrist traditionally engage in to lesser trained or lesser specialized health workers and reorienting the role of psychiatrist in such settings.
DR. MAURICE PICKARD:
You have written a book - Where There Is No Psychiatrist - and this is a book that is to be used by psychiatric technicians. Can this book be used in this kind of setting? There is a change from location to location and is there are ways that technicians can feel comfortable in recognizing problems and medicating them?
DR. VIKRAM PATEL:
Yes, that’s certainly the aim of the book, but Maurice one has to always recognize the limitations of books. Books are very useful guides that it may comes, but they do not ever substitute for proper training, support, and supervision and so ideally the book must be used as part of a comprehensive program to equip lay health workers or non-specialist health workers to deliver mental healthcare.
DR. MAURICE PICKARD:
I can't help, but feel that certainly in our country, mental illness begins in the young often 12 to 15 and it's not recognized until much later. Is there something that can be done in India where say in a rural area somebody may have mental illness not be recognized and certainly would have tremendous impact as far as his development and may be the perpetuation of poverty that he lives in or she lives in?
DR. VIKRAM PATEL:
That's been again one of the major focus of my work, which is the development of interventions to promote mental health and prevent mental disorders in children and young people. Our focus has been largely by strengthening school health services that integrate mental health with a range of other health concerns affecting children in India, for example, nutrition and physical health difficulty such as visual difficulties.
DR. MAURICE PICKARD:
Have you had any luck over help as far as violence or self-harm, substance abuse, and reproductive and sexual health of young people when you incorporate mental health in this model.
DR. VIKRAM PATEL:
Well that's certainly the approach we are taking and Maurice I am hoping that this approach will be successful, it's still early days. At this stage, what we have got at the moment is a package of services that we are delivering in schools, developmentally appropriate packages for primary and secondary and then college level, adolescents and children and what we are hoping to do is to demonstrate over the next few years as we scale this up in a larger number of schools that the package actually leads to better health and social outcomes for children and adolescence amongst which violence, depression, and self-harm, and smoking and tobacco use are all critically important outcomes.
DR. MAURICE PICKARD:
I would imagine this model might be helpful because I am sure children in India are no different here in that they don't like to be stigmatized with mental illness. They certainly do not want to go to a psychologist or a psychiatrist or even a high school counselor for any type of help, but mainly if they are what you would might say mainstream through other health services this might be more acceptable to them.
DR. VIKRAM PATEL:
That’s certainly the philosophy. You are absolutely right. In the past, we have experimented with setting up what we considered were youth friendly centers. I would find a school setting, but very quickly people associated the center with mental health issues and young people were reluctant to come there only until they had very severe problems, then of course by then we have already lost half the battle and so our current work is largely based within schools and combining both promotion strategies combined with early detection and frequent strategies for that smaller group of adolescents who have frank mental disorders.
DR. MAURICE PICKARD:
In some of your articles in Lancet, you use a phrase and I would like you to come and explain it to me. It's called scaling up. Would you tell me what that means and how it's used in the context we are talking about?
DR. VIKRAM PATEL:
Scaling up is actually a very popular term in public health in developing countries. What it simply means is closing the gap between the number of people, who need healthcare and a number who are actually receiving it, so that when we talk about scaling up, we are talking about increasing the coverage of affordable, equitable, and evidence-based health services to target of 100% of the population. Everyone in the community should have equitable, affordable access to such healthcare.
DR. MAURICE PICKARD:
I have noticed though in one of your articles you referred to Chile having a model for scaling up. What have they done that's so different?
DR. VIKRAM PATEL:
Chile is a very interesting example Maurice. Chile has scaled up across its entire nation, a depression treatment program delivered through primary health centers based on a stepped care program. This was partly the consequence of a trial led by Ricardo Arayaand his colleagues in Chile including American collaborators such as Gregory Simon from Seattle, which showed that this relatively low cost intervention produced dramatic benefits for women suffering from depression in the primary health centers in Santiago city, so the scaling up analogy really is that from that 1 trial the Ministry of Health has actually taken this model and made it a national program guaranteeing all its citizens access to a free and publicly funded depression treatment program.
DR. MAURICE PICKARD:
Are other countries following this model?
DR. VIKRAM PATEL:
Absolutely, there are many countries particularly in Latin America that are seeing mental health care as a right for people and that the state must fulfill that right by providing affordable services. So, for example, in Brazil, this model is being extended to severe mental illness where there is a program for enabling people, who have been institutionalized in mental hospitals to return home back to their communities some of them after 40 years in an institution, but empowered now with a pension that the state provides them to help them maintain their livelihoods in an independent fashion.
DR. MAURICE PICKARD:
We have touched on an ethical issue and a human rights issue and having said that is there a role or a place for psychiatrist in United States, who make up a large part of this audience to take some kind of leadership in this area?
DR. VIKRAM PATEL:
Absolutely Maurice. I think there are some exemplar individuals in the United States, indeed in other developed countries, who have actually been at the forefront of the reform of mental health care in the developed world. In fact, I would say that it is these reform movements, which helped in my own inspiration for trying to implement a reform in developing countries. I think 1 of the lessons that perhaps psychiatrist in developed countries could take back from the developing world is to understand that a lot of the task of mental health care need not require highly expensive specialist to deliver.
DR. MAURICE PICKARD:
Is there a role for our associations to also take a leadership position?
DR. VIKRAM PATEL:
Oh absolutely, I always advocated the important role that strong institutions in rich countries such as, for example, The American Psychiatric Association could and should play to promote mental healthcare in developing countries that I think is a role of all professional bodies. I think the associations must step beyond their national interest and look at the more global concerns around the professional specialty of the field.
DR. MAURICE PICKARD:
You know, you just mentioned in Chile, the not looking to the large custodial care hospitals that exists not only in Chile, but in the United States that there may even be a question of the tremendous waste of our resources that do go into mental health with the patients being deposited in these long-term facilities. How do you respond to that?
DR. VIKRAM PATEL:
Absolutely, I completely agree, the waste of resources in large mental hospitals, the inefficiency of the use of these resources is dark. In India, for example, we have very few mental health beds in the country, but even the few that we have are inefficiently utilized because 80% of these beds are located in mental hospitals. So we have a double burden here. We have scarce resources and on top of that these resources are inefficiently used and inequitably distributed so that the vast proportion of theses resources are in urban areas whereas the majority of the population lives in the countryside.
DR. MAURICE PICKARD:
The dollars that we are putting into mental health social investments then shouldn’t be looked upon simply as another expense on our health budget. Is that correct?
DR. VIKRAM PATEL:
That’s right because I firmly believe that improving the mental health of our population will have great benefits in terms of social and economic benefits.
DR. MAURICE PICKARD:
We look upon something that’s called DALY, disability-adjusted life year. Very often this is what the academician will look at to substantiate some healthcare initiative. Has that been shown to be of a positive nature when we look at mental health?
DR. VIKRAM PATEL:
The DALY is a health metric, a relatively new health metric developed only about 10 or 15 years ago, which allows us to measure the burden of whole range of conditions using the same metric. What that then allows us to do is therefore compare the relative burden of 1 condition compared to another for every setting in the world. It is the use of the DALY that has actually propelled the importance of mental illness in developing countries to the forefront of global health debates because by using DALY, we could now demonstrate that even in the poorest countries of the world such as in sub-Saharan Africa fully 10% of the total burden of disease in these countries is attributable to mental disorders.
DR. MAURICE PICKARD:
You know you talk about multiple countries that rely on traditional healthcare givers, by tradition they could be a shaman or some other village person, who they have often gone to with mental health problems or any other problems. Is there a conflict or how do you incorporate this cultural custom into providing medication?
DR. VIKRAM PATEL:
This is I think a great challenge. You are absolutely right, there is a vast human resource available in many, many societies that comprise traditional and complementary healthcare practitioners and a large proportion of their work in fact would be considered to be mental illness care, mental healthcare. However, I am not familiar with any national level initiative that has successfully integrated the traditional healthcare provider with the mainstream medical healthcare system. There is a great deal of interest of course in this sort of integration not least because of the enormous resource that’s available, but unfortunately we are stuck with one great challenge and that challenge is the very different perspective on what causes illness and misfortune and therefore how one must treat it.
DR. MAURICE PICKARD:
I want to thank Dr. Vikram Patel, who has been talking about healthcare in the undeveloped world and the various needs in mental health in particular.
I am your host, Dr. Maurice Pickard. To comment or listen to our full library podcasts, visit us at reachmd.com. Register with promo code radio and receive 6 months free streaming for your home or office. Thank you for listening.
