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ADDRESSING the GLOBAL MENTAL-HEALTH GAP 1 How EP ADDRESSING THE GLOBAL MENTAL-HEALTH GAP 1 How EP Helps Democratize the Delivery of Mental Health Services Globally Common mental illnesses such as depression, anxiety and posttraumatic stress currently account for the largest percentage of the global burden of disease, in terms of years lost to disability. Currently mental illnesses are on par with cardiovascular disease in terms of disability-adjusted life years (Vigo, Thornicroft, & Atun, 2016). This is due in part to a shortage of mental health professionals in low and middle income countries (LMICs). Scarcity, inequity, and inefficiency of resources are most severe in LMICs where often, mental health services account for the lowest percentages of overall health budgets and where there is typically an over concentration of resources in large centrally located institutions rather than in community settings (Saxena, Thornicroft, Knapp, & Whiteford, 2007). Despite current World Health Organization (WHO) guidelines that suggest the utilization of professionally trained lay community members in low-resource circumstances (IASC, 2007), there have been few studies of mental health interventions that can be facilitated by trained lay community-members in community settings where and when professional resources are scarce. There is, however, evidence to suggest that evidence-based mental health interventions can be delivered by professionally trained lay community workers in low-resource community settings (Wainberg, et al., 2017). Community-based interventions can refer to a wide range of interventions. McLeroy, Norton, Kegler, Burdine, and Sumaya (2003) categorize community-based interventions into four groups. Community-based interventions targeting a particular geographical community, are described by these authors as targeting community as a setting; interventions that address a targeted community through community-based institutions of service and policy are described as community as target; interventions that promote a high degrees of community-ownership and ADDRESSING THE GLOBAL MENTAL-HEALTH GAP 2 participation and come from larger sources and public policy are described as community as resource: and intervention that aim to support the natural adoptive resources existing in the community without the benefit of direct professional intervention are described as utilizing community as an agent of change. According to these authors, the goal of the last three forms of community-based interventions described above has the dual purpose of strengthening health of communities, and building community capacity to address health issues. These authors note that there is inevitably some amount of overlap of these community-based interventions. They point out that community as an agent of change is the least utilized category of community-based intervention in public health. Identifying the problem The WHO has estimated the global burden of mental health at 13% (WHO, 2012). Vigo, Thornicroft, and Atun (2016) estimated the global health burden at 32.4%, factoring in substance abuse disorders, epilepsy, and closed head injuries. Vigo, et al. calculate that persons with severe mental illness in low-income countries die 30 years younger than their peers; persons with severe mental illness in high-income countries die 10-20 years younger than their peers; and persons with severe mental illness in low-income countries have a 60% chance of dying prematurely of communicable disease. Between 76% and 85% of persons with mental illness in LMICs and 35% and 50% of persons in high income countries go untreated due in part to scarce and inadequate professional resources (WHO, 2012). There is as few as one psychiatrist for every 500,000 people even per million people in many places of the world. In these places, the most severely mentally ill take up most of the available professional mental health resources. The goal of providing mental health services to all cannot be obtained in these circumstances (Patel, 2002). ADDRESSING THE GLOBAL MENTAL-HEALTH GAP 3 The prevalence of posttraumatic stress disorder (PTSD) contributes to this global burden. Prevalence rates of PTSD from 4% to 88% were identified following large-scale disasters, in a review of 13 studies in 11 countries (Desjarlais, Eisenberg, Good, & Kleinman, 1995). These authors noted that presently, few who live in disaster-prone areas receive needed mental health services. One out of every 20 men and 2 out of every 20 women globally, will suffer from PTSD in any one year according to Kastrup and Ramus (2007). PTSD has been predicted to be the leading cause of death and disability by the year 2020 (McLeigh, & Sianko, 2011). Toward a solution In 2007, Hobfoll et al. (2007) assembled a panel of world experts in an effort to develop a consensus on intervention strategies for those exposed to large-scale trauma. The panel concluded that interventions should be made available to large numbers of individuals in a way that would not quickly deplete local professional resources. These experts found that interventions that were effective promoted a sense of safety, calm, self- efficacy, and focused on implementing self-help skills delivered at the community level rather than the reliance on experts The Executive Board of the WHO met in Geneva in 2002 to develop suggested guidelines for the implementation of programs that could address the psychological damage following natural and man-made disasters (Ghosh, Mohit, & Murthy, 2004). Responding to the recognized mental health gap in LMICs following large-scale disasters and conflict, the WHO Department of Mental Health and Substance Dependence (2003), issued a document, which among other things, stressed the importance of maximizing community resources and specifically recommended the education of community members in core psychological care ADDRESSING THE GLOBAL MENTAL-HEALTH GAP 4 skills. The Inter-Agency Standing Committee (IASC) completed these guidelines (IASC, 2007). The completed ISAC guidelines for emergency relief efforts suggest that at the first and immediate tier, there is a basic need for services and security. At the second tier, there is a need for family and community support for some individuals and families. At the third tier, there remains, for a smaller number of individuals, a need for focused non-specialized support that could potentially be delivered by trained non-professional community members, saving scarce professional resources. Mental-health professionals would form the fourth tier and would be able to help those most in need. Thought field therapy -Kigali, Rwanda In a 2008 randomized waitlist controlled trial, Connolly and Sakai (2011) examined the efficacy of thought field therapy (TFT), in reducing posttraumatic stress disorder symptoms in survivors of the 1994 Genocide in Rwanda. Participants included 145 adult genocide survivors randomly assigned to an immediate TFT treatment group or a waitlist control group. Community-members selected by a locally respected women’s organization, Women’s Foundation Ministries, attended a two-day training in facilitating the TFT self-help treatments. The treatment involves the participant thinking about a specific problem while they are guided to tap on specific acu-points on their face and fingers. The study took place in Kigali, the capital city of Rwanda. The trained community-members assisted in the administration of the Trauma Symptom Inventory (TSI) (Briere, J., 1995) and the Modified PTSD Symptom Inventory (MPSS) (Falsetti, Resnick, Resnick, & Kilpatrick, 1993) under the supervision of the researchers. The newly trained Rwandan TFT facilitators then paired one-to-one with study participants in the treatment ADDRESSING THE GLOBAL MENTAL-HEALTH GAP 5 group, in a one-time TFT self-help intervention while the individual study participants were thinking about their individual traumas. The average one-time treatment time was 55 minutes. Group differences adjusted for pretest scores and repeated measures anovas were statistically significant at p < 0 .001 for 9 of 10 TSI trauma subscales and at p < 0 .001 for both scales (severity and frequency) of the MPSS. Study participants in the waitlist group received treatment after having completed the posttest and received treatment reductions similar to the original treatment group. Reductions in trauma symptoms for both groups were sustained at a two-year follow-up assessment. Thought field therapy - Byumba, Rwanda In 2009, Connolly, Roe-Sepowitz, Sakai, and Edwards, (2013) conducted a second randomized controlled trial to determine if the results of a 2008 study (Connolly, & Sakai, 2011) conducted in Kigali, the capital city of Rwanda, could be duplicated in the rural area of Byumba, Rwanda that had been especially hard-hit during the 1994 genocide. The researchers wondered if, in this more remote area, there would be a significant difference in the reduction of trauma symptoms between the treated group and the untreated group. Prior to the study, Rwandan community-members, selected by a local Catholic Priest, received a two-day training in TFT self-help techniques. The newly trained community-members then provided one-time individual trauma-focused TFT interventions to 100 adult survivors of the 1994 Rwandan genocide who had been randomly selected to be in the treatment group. Pre- and post-intervention assessments of trauma symptoms used were the Trauma Symptom Inventory (TSI) (Briere, J., 1995), and the Modified Posttraumatic Stress Disorder Symptom scale (MPSS) (Falsetti, Resnick,
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