Mental health for all by involving all - Vikram Patel

I want you to imagine this for a moment: two men, Rahul and Rajiv, living in the same neighborhood, from the same educational background, similar occupation, and they both turn up at their local accident emergency, complaining of acute chest pain. Rahul is offered a cardiac procedure, but Rajiv is sent home. What might explain the difference in the experience of these two nearly identical men? Rajiv suffers from a mental illness.

The difference in the quality of medical care received by people with mental illness is one of the reasons why they live shorter lives than people without mental illness. Even in the best resource countries in the world, this life expectancy gap is as much as twenty years. In the developing countries of the world, this gap is even larger. But of course, mental illnesses can kill in more direct ways as well; the most obvious example is suicide.

It might surprise some of you here, as it did me when I discovered that suicide is at the top of the list of the leading causes of death in young people in all countries of the world, including the poorest countries of the world. But beyond the impact of a health condition on life expectancy, we're also concerned about the quality of life lived.

Now, in order for us to examine the overall impact of a health condition, both on our life expectancy as well as on the quality of life lived, we need to use a metric called a "dolly," which stands for disability-adjusted life year. Now, when we do that, we discover some startling things about mental illness from a global perspective. We discover that, for example, mental illnesses are amongst the leading causes of disability around the world.

Depression, for example, is the third leading cause of disability, alongside conditions such as diarrhea and pneumonia in children. When you put all the mental illnesses together, they account for roughly 15% of the total global burden of disease. Mental illnesses are also very damaging to people's lives. But beyond just the burden of disease, let us consider the absolute numbers.

The World Health Organization estimates that there are nearly four to five hundred million people living on our tiny planet who are affected by mental illness. Now some of you here look a bit astonished by that number, but consider for a moment the incredible diversity of mental illnesses, from autism and intellectual disability in childhood, through to depression, anxiety, substance misuse, and psychosis in adulthood, all the way through to dementia in old age.

I’m pretty sure that each and every one of us present here today can think of at least one person—at least one person—who is affected by mental illness in our most intimate social networks. I see some nodding heads there. But beyond the staggering numbers, what's truly important from a global health point of view, what's truly worrying from a global health point of view, is that the vast majority of these affected individuals do not receive the care that we know can transform their lives.

And remember, we do have robust evidence that a range of interventions—medicines, psychological interventions, and social interventions—can make a vast difference. And yet, even in the best resource countries, for example here in Europe, roughly 50% of affected people don't receive these interventions. In the sorts of countries I work in, that so-called treatment gap approaches an astonishing 90%.

It isn't surprising then that if you should speak to anyone affected by mental illness, the chances are that you will hear stories of hidden suffering, shame, and discrimination in nearly every sector of their lives. But perhaps most heartbreaking of all are the stories of the abuse of even the most basic human rights, such as the young woman shown in this image here, that are played out every day, sadly even in the very institutions that were built to care for people with mental illnesses—the mental hospitals.

It's this injustice that has really driven my mission to try and do a little bit to transform the lives of people affected by mental illness. A particularly critical action that I focused on is to bridge the gulf between the knowledge we have that can transform lives, the knowledge of effective treatments, and how we actually use that knowledge in the everyday world.

An especially important challenge that I've had to face is the great shortage of mental health professionals, such as psychiatrists and psychologists, particularly in the developing world. Now, I trained in medicine in India, and after that, I chose psychiatry as my specialty, much to the dismay of my mother and all my family members, who thought neurosurgery would be a more respectable option for their brilliant son.

In any case, I soldiered on with psychiatry and found myself training in Britain and some of the best hospitals in this country. I was very privileged; I worked in a team of incredibly talented, compassionate, but most importantly highly trained specialized mental health professionals. Soon after my training, I found myself working first in Zimbabwe and then in India, and I was confronted by an altogether new reality.

This was a reality of a world in which there were almost no mental health professionals at all. In Zimbabwe, for example, there were just about a dozen psychiatrists, most of whom lived and worked in Harare City, leaving only a couple to address the mental health care needs of nine million people living in the countryside. In India, I found a situation that was not a lot better. To give you perspective, if I had to translate the proportion of psychiatrists in the population that one might see in Britain to India, one might expect roughly 150,000 psychiatrists in India.

In reality, take a guess; the actual number is about 3,000—about two percent of that number. It became quickly apparent to me that I couldn't follow the sorts of mental health care models that I had been trained in, one that relied heavily on specialized, expensive mental health professionals to provide mental health care in countries like India and Zimbabwe. I had to think out of the box about some other model of care.

It was then that I came across these books, and in these books, I discovered the idea of task-shifting in global health. The idea is actually quite simple: when you're short of specialized healthcare professionals, use whoever is available in the community and train them to provide a range of healthcare interventions. In these books, I read inspiring examples of how ordinary people had been trained to deliver babies and diagnose and treat early pneumonia to great effect.

It struck me that if you could train ordinary people to deliver such complex healthcare interventions, then perhaps they could also do the same with mental health care. Well, today I’m very pleased to report to you that there have been many experiments in task-shifting in mental health care across the developing world over the past decade. I want to share with you the findings of three particular such experiments, all three of which focused on depression, the most common of all mental illnesses in rural Uganda.

Paul Bolton and his colleagues, using villagers, demonstrated that they could deliver interpersonal psychotherapy for depression and, using a randomized control design, showed that 90 percent of the people receiving this intervention recovered, as compared to roughly 40 percent in the comparison villages. Similarly, using a randomized control trial in rural Pakistan, Aarti Freeman and his colleagues showed that lady health visitors—who are community maternal health workers in Pakistan's healthcare system—could deliver cognitive behavior therapy for mothers who were depressed, again showing dramatic differences in the recovery rates: roughly 75 percent of mothers recovered as compared to about 45 percent in the comparison villages.

In my own trial in Goa, in India, we again showed that lay counsellors drawn from local communities could be trained to deliver psychosocial interventions for depression and anxiety, leading to 70 percent recovery rates as compared to 50 percent in the comparison primary health centers. Now, if I had to draw together all these different experiments in task-shifting—and there have, of course, been many other examples—and try to identify what the key lessons are that we can learn that makes for a successful task-shifting operation, I'd coined this particular acronym: "SUNDAR."

What "SUNDAR" stands for in Hindi is "attractive." It seems to me that there are five key lessons that I've shown on this slide that are critically important for effective task-shifting. The first is that we need to simplify the message that we're using, stripping away all the jargon that medicine has invented around itself. We need to unpack complex healthcare interventions into smaller components that can be more easily transferred to less strained individuals.

We need to deliver healthcare not in large institutions but close to people's homes, using whoever is available and affordable in our local communities. Importantly, we need to reallocate the few specialists who are available to perform roles such as capacity building and supervision. But for me, task-shifting is an idea with truly global significance.

Because even though it has arisen out of the situation of the lack of resources that you find in developing countries, I think it has a lot of significance for better-resourced countries as well. Why is that? Well, in part because healthcare in the developed world—the healthcare costs in the developing world—are rapidly spiraling out of control, and a huge chunk of those costs are human resource costs.

But equally important is because healthcare has become so incredibly professionalized that it has become very remote and removed from local communities. For me, what's truly "sundar" about the idea of task-shifting, though, isn't that it simply makes healthcare more accessible and affordable, but that it is also fundamentally empowering. It empowers ordinary people to be more effective in caring for the health of others in their community and, in doing so, to become better guardians of their own health.

Indeed, task-shifting is the ultimate example of the democratization of medical knowledge and, therefore, medical power. Just over 30 years ago, in the nations of the world assembled in Alma-Ata, made this iconic declaration. Well, I think all of you can guess that 12 years on, we're still nowhere near that goal. Still today, armed with that knowledge that ordinary people in the community can be trained and, with sufficient supervision and support, can deliver a range of health care interventions effectively, perhaps that promise is within reach now.

Indeed, to implement the slogan of "health for all," we will need to involve all in that particular journey. In the case of mental health in particular, we would need to involve people who are affected by mental illness and their caregivers. It is for this reason that some years ago, the movement for global mental health was founded as a sort of a virtual platform upon which professionals like myself and people affected by mental illness could stand together, shoulder to shoulder, and advocate for the rights of people with mental illness to receive the care that we know can transform their lives and to live a life with dignity.

In closing, when you have a moment of peace, acquired in these very busy few days, or perhaps afterwards, spare a thought for the person you thought about who has a mental illness, or persons that you thought about who have mental illness and the care for them. Thank you.