(2017) Treating Depression Where There Are No Mental Health Professionals

View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by LSHTM Research Online Patel, Vikram; Fleck, Fiona (2017) Treating depression where there are no mental health professionals. BULLETIN OF THE WORLD HEALTH ORGANIZATION, 95 (3). pp. 172-173. ISSN 0042-9686 DOI: https://doi.org/10.2471/BLT.17.030317 Downloaded from: http://researchonline.lshtm.ac.uk/4651369/ DOI: 10.2471/BLT.17.030317 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: http://creativecommons.org/licenses/by/2.5/ News Treating depression where there are no mental health professionals Many people with depression and other mental health problems can be treated successfully by community health workers, but so far no country has scaled up this approach. Vikram Patel talks to Fiona Fleck. Q: Why did you become interested in mental health? Vikram Patel is a pioneer in the provision of mental health A: I went into psychiatry at a time care in settings without mental health professionals. He when it was an extremely unattractive is a Professor and Wellcome Trust Principal Research field and far more stigmatized than it is Fellow at the London School of Hygiene & Tropical today. Having ranked at the top of the Medicine and will join Harvard Medical School as the final university medical examinations Pershing Square Professor of Global Health in April in Mumbai, I could have chosen any 2017. He is an Adjunct Professor and Joint Director of specialty. At first I was interested in the Centre for Chronic Conditions and Injuries at the neurology, fascinated by the brain and Patel Vikram Courtesy of its mysteries. But during my medical Vikram Patel Public Health Foundation of India and a co-founder of studies it struck me that in neurology Sangath, an Indian nongovernmental organization that the symptoms and signs of the condition has won many international prizes. He is a Fellow of the Academy of Medical were all important. Psychiatry was the Sciences in the United Kingdom of Great Britain and Northern Ireland and only field where the person was central. has served on World Health Organization expert and Government of India Also, psychiatry presented a unique committees. He has researched mental health in many countries in Asia and bridge between medicine and society. Africa. Patel graduated from the University of Mumbai in medicine in 1987. He qualified in psychiatry from the Royal College of Psychiatrists in 1992 and Q: This year’s World Health Day is de- earned his PhD from the University of London in 1997. voted to addressing depression, can you tell us about the burden and causes of this condition? A: Depression is probably the most forget suicide. While this is classified as in January. Most of these trials testify well researched mental disorder globally. a health outcome in its own right and to the effectiveness of these treatments A 2013 systematic review for the Global not as a consequence of a mental health in promoting remission and recovery. Burden of Disease project identified problem, many people who attempt There is a smaller evidence base for more than 100 studies from around the suicide are depressed. antidepressants. Both talking treatment world estimating the prevalence of the and drugs are most effective in people condition. It found that 4–5% of adults with severe depression. For a significant might meet diagnostic criteria for de- proportion of people with mild to mod- pression, which we could extrapolate to What I think does erate depressive symptoms, self-care and hundreds of millions of people world- “work is disclosure: low-intensity care provided by com- wide. The global literature on depres- people coming out munity members are just as effective as sion shows that common risk factors and talking about more structured clinical interventions associated with depression are related their experience of such as psychotherapy. to social disadvantage and deprivation, depression. such as low level of education, job loss, Q: The World Health Day theme “depres- indebtedness, social exclusion or mar- ” sion: let’s talk” is about seeking help. ginalization and violence. Women are How can we counter the stigma that also at higher risk of having depression, often prevents people from seeking help? this is partly related to interpersonal Q: Is depression curable? What treat- A: Stigma is a major challenge and violence and other consequences of ment is needed for this condition? there is no simple solution. A recent gender inequity. review showed limited evidence for A: Globally, the strongest evidence many strategies to address stigma. For is for brief psychological treatments Q: What does that mean for societies? example, promoting the concept of de- based on cognitive, behavioural and A: Depression not only affects an in- pression as a biological brain disorder interpersonal mechanisms. We recently dividual. In a mother, it affects her child’s actually led to more negative attitudes, conducted a systematic review of studies growth and development. Depression as it suggested that the condition was of psychological treatments delivered by affects a person’s ability to work, mak- an immutable aspect of the person’s non-specialist providers and identified ing that person less productive. This biology. What I think does work is dis- 27 randomized controlled trials from not only affects households but the closure: people coming out and talking low- and middle-income countries. entire economy. A group of economists about their experience of depression. Since our review, the findings of at least recently modelled the overall cost of de- In this respect, the World Health Day two major trials have been published, pression for the World Economic Forum message is spot on. In addition, even if including our own study on the Healthy and came up with estimates that ran into it’s hard to change people’s attitudes, we Activity Program in India in the Lancet trillions of dollars. In addition, let’s not can enforce laws that reduce discrimina- 172 Bull World Health Organ 2017;95:172–173 | doi: http://dx.doi.org/10.2471/BLT.17.030317 News tion, for example removing barriers to Q: Has this approach been scaled up? scription of medications is customary. education and employment for people A: Despite the robust evidence for However, people in developed countries with mental health problems. Address- the acceptability and effectiveness of are increasingly seeking non-pharma- ing discrimination is perhaps more using community workers to deliver cological options for their recovery, valuable and feasible than trying to ad- psychosocial interventions, I cannot ranging from biomedical psychological dress stigma. Many people may have a think of one country or region where treatments to spiritual and traditional negative attitude to people with mental this approach has been taken to scale. approaches, such as yoga. The idea of health problems, but what matters most For example, in India there are many using lay people in the delivery of mental is that they do not deny them a job or small-scale projects delivering mental health care is often resisted by mental education. health care in places where there are no health professionals, including clinical psychiatrists but what we really need psychologists, who argue that it is not Q: How can we encourage people to seek is the full integration of this approach safe or effective, in spite of evidence to care for mental health conditions? into government health-care systems, the contrary. Perhaps they see this as a A: We recently published a paper for delivery at the primary care level. threat to their professional authority and in Lancet Psychiatry describing a pro- This is what the PRIME (programme control over these treatments and health gramme in rural India where, over an to reduce the treatment gap for mental conditions. 18-month period, we brought about a disorders) consortium funded by the six-fold increase in the proportion of British government, in five low- and Q: How did you start the Sangath non- people with depression seeking care. middle-income countries, is trying to governmental mental health organiza- Our approach emphasized a grassroots achieve. tion in Goa? What was new about it? approach in which local people raised A: I founded Sangath with six col- awareness using language understood leagues in 1996. Today it ranks among by the community, avoided reference Mental health is India’s leading public health research to depression as a psychiatric problem, institutions. Sangath started primarily a global public good discussed issues such as being in debt “ as a centre for children with develop- and domestic violence, championed in and of itself. We mental and mental health problems self-care as a first-level intervention, and must strive to deliver that later broadened to providing care used culturally appropriate media such whatever works to for all population groups. There was as clips from Bollywood films. We only those who need it. a huge demand for such care and we referred to depression as a biomedical were inundated with referrals. How- problem when it was severe and clinical ” ever, many families could not afford the interventions were needed. The aware- long-term specialist care and were often ness raising interventions were provided unable to come to our facility regularly. by community-based workers and lay Q: How would the approach work if So we started delivering care in com- counsellors, meanwhile evidence- scaled up? munity and primary-care settings by based interventions for depression and A: The idea is to train millions non-specialist workers and evaluating alcohol-use disorders were made more of community health workers and the effects.

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