Rethinking Mental Health Care: Bridging the Credibility Gap

Patel Opinion Rethinking mental health care: bridging the credibility gap

Vikram Patel

Innovations in global mental health have focused on mental health care should comprise; who is addressing the ‘supply side’ barriers to reduce the a mental health care provider; and where treatment gap and, in doing so, have rede¢ned three mental health care should be provided. core assumptions regarding mental health care, Before I turn to the issue of the credibility namely, what comprises a mental health care inter- gap, I will brie£y consider how innovations vention, who is a mental health care provider and addressing the treatment gap are rede¢ning what is a mental health care setting. However, such each of these assumptions. innovations alone will not reduce the treatment gap becauseofthegapbetween the understandingofmen- tal disorder that mental health specialists use, best Rede¢ning assumptions illustrated through the diagnostic systems and the First, consider the assumption of what com- epidemiological instruments arising from them, prises mental health care. Much of the dis- and how the rest of the world conceptualises psycho- course on mental health care has focused logical su¡ering. It is this ‘credibility’gap that needs on structured treatment guidelines, best to be bridged in three key ways: ¢rst, to distinguish exempli¢ed by the World Health Organiz- mental disorders that could bene¢t from biomedical ation’s Mental Health Gap Action Programme interventions from milder distress states; to o¡er (mhGAP) guidelines, emphasising drug and interventions for distress states mainly through low psychological interventions (Dua et al., intensity psychosocial interventions delivered out- 2011). At the heart of these guidelines is the side the formal health care system; and to base the privileged status of biomedical diagnostic descriptions of diagnostic categories on the patterns categories, such as depression and schizo- of phenomena observed in general populations, phrenia. However, it is now clear that the rather than those observed in specialist settings. use of these labels and their associated biomedical explanations is often not necessary Keywords: diagnosis, explanatory models, and may even be counterproductive. Inte- global mental health, treatment gap grating culturally appropriate explanatory models and nonspecialist labels into interventions, going even as far as not using terms Introduction such as depression at all, is the hallmark of Global mental health has been heavily in£u- accessible and e¡ective mental health care enced by the concept of the ‘treatment’gap, interventions (Patel et al., 2011). Incorporat- i.e. the proportion of people with a mental ing interventions that target the outcomes disorder in a population who are not in con- tha matter to a¡ected persons and their tact with services and bene¢ting from evi- families—for example, independent social dence based treatments (Patel & Prince, functioning in people with schizophrenia— 2014). In an e¡ort to reduce this gap, a grow- has equal status to or even greater salience ing number of innovative models of care than treatments focused on psychiatric have emerged across a range of low resource symptoms (Balaji et al., 2012). Mobilising settings that are challenging three core personal and community resources, for assumptions about mental health care: what example existing social welfare schemes, is

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critical to address the practical social deter- in a range of other‘non health’platforms, nota- minants and consequences of mental dis- bly in the homes of patients and in schools orders. Mental health interventions, then, for children. In doing so, some of the major must go well beyond narrowly de¢ned bio- time, stigma and cost barriers to treatment medical constructs and treatments. access and adherence are being addressed, Second, consider the assumption of who is a leading to higher treatment completion rates mental health care provider.The assumption and, consequently, better outcomes. that mental health care providers are analo- gous to mental health specialists has been robustly challenged by innovations that Demand and the credibility gap include task sharing, frontline mental health While much of the innovation in global men- interventions involving community and lay tal health summarised above has focused health workers. A substantial body of evi- on addressing the ‘supply side’ barriers to dence, probably the largest for any noncom- reduce the treatment gap, for example the municable disease, is testimony to the shortage of specialist human resources, this e¡ectiveness of this approach (van Ginneken gap can also be attributed to demand side et al.,2013).Bybeingabletoutilise suchwidely barriers related to the vastly di¡erent views available and a¡ordable human resources to held by the community about mental dis- deliver frontline care, we achieve a paradigm orders. Indeed, the primary hypothesis shift from focusing on the lack of specialist posed by this article is that supply side strat- human resources to the e¡ective mobilisation egies alone will not signi¢cantly reduce the ofavailablehuman resources.Ofcourse,these treatment gap. Even in the richest countries human resources need carefully designed of the world that enjoy a universal health trainingand,evenmoreimportantly,continu- care system with free, multidisciplinary, ingsupervisiontodelivercarewithsustainable community oriented, comprehensive and quality. Reliance on specialists to train and coordinated mental health care (such as conduct supervision presents another poten- countries in western Europe), a substantial tial bottleneck to improving access to task proportion (even the majority in some sharing models of care. However, recent countries) of persons with a mental disorder, empirical evaluation has shown that, as com- in particular mood, anxiety and substance petency is achieved, laycounsellors can assess use disorders, diagnosed in surveys have the quality of counselling sessions with com- not accessed specialist mental health care parable accuracy to specialists (Singla et al., services (Wang et al., 2007). While recon¢- submitted). This model of task sharing of guring the content of interventions, task supervision means that the role of specialists sharing to non specialist human resources becomeseven morefocusedon designing pro- and delivering care in non health platforms grammes, quality assurance and providing may address these gaps to some extent, they referral for complex or treatment resistant are unlikely to be su⁄cient. I propose that cases,thuspermittingmuchlargerpopulation a key problem lies in the gap between the coverage for each specialist. understanding of mental disorder that men- Third, consider the assumption of where tal health specialists use, best illustrated mental health care can be provided. A through the diagnostic systems and the epi- unique aspect of innovations in global men- demiological instruments arising fromthem, tal health is that virtually none are delivered and how the rest of the world conceptualises within specialist settings. Primary health psychological su¡ering. In short, this is the care centres are, of course, a predictable gap, which I refer to as the ‘credibility’gap, delivery platform, but, perhaps more crea- we need to bridge and, to do so, we may need tively, mental health care is now delivered to substantially review our concepts of

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mental disorder and be prepared to abandon arti¢cial dichotomies imposed on naturally some devoutly held beliefs. occurring dimensions of psychological However,¢rst,Ineedtoclarifythatmypropo- responsesto common humanlifeexperiences. sal does not deny the existence of mental dis- Of course, imposing arti¢cial dichotomies is orders nor their biological underpinnings. also true of many physical health conditions There is no doubt (in my mind at least) that such as hypertension and diabetes, but, as I the phenomena that we describe as features pointed out earlier, there is a marked di¡er- of mental disorders and that we further ence in how communities view these physical categorise based on observed patterns of clus- health conditions, notably that they are seen tering have a biological basis in the brain. as‘diseases’that are distinct and separate from How else could we explain the universal one’s personal identity. On the other hand, human experiences of fatigue, anhedonia thevastmajorityofpeoplewhohaveadiagno- (theprofoundlossofinterestthatcharacterises sis of depression or harmful drinking, based the experience of depression), hallucinations on a psychiatric interview or clinical diagno- orthecravingforaharmfulsubstance?Never- sis, do not understand their problem as a dis- theless, of course, these experiences are also tinct health condition with a biomedical inextricablylinkedtopowerful socialandcul- causation; instead, they utilise culturally tural determinants and, perhaps uniquely to meaningful labels and causal explanations mental disorders, with aperson’sown identity for their distress as being inextricably linked of oneself. In this respect, mental disorders to their personal lives. Of course, in this are quite distinct from physical health con- respect, their views are completely consistent ditions: there is simply no similarity between with the epidemiological literature on the apainfulboilandfeelingdepressedorbetween determinants of these mental disorders. a high fever and hearing voices. In the desire None of what I have proposed is new; several ofsomesectionsofthementalhealthspecialist authors have long argued that there was a community (arguably, the more dominant need to review our concepts of mental dis- sections) to belong to the powerful guild of orders to accommodate the prevalent views medicine, there has been a deliberate tilt in of the community.Put simply,this credibility the balance between the personal narrative gap between the mental health specialist and the biomedical concept towardthe latter, communities and the rest of the world is adopting an increasingly arcane jargon of one of the major reasons for the treatment diagnostic categories to communicate with gap in all regions of the world. The credi- each other and, perhaps, to impress our col- bility gap is exempli¢ed by three critical leagues in other branches of medicine. How- observations: the medicalisation of ever, in so doing, we seem to have lost the emotional worlds and the imposition of arti- ability to communicate with virtually every- ¢cial dichotomies on dimensions of psycho- one else in our own communities. logical experiences that are normative; the TherecentcontroversiesaroundtheDiagnostic use of ever more complex jargon terms, such and Statistical Manual-V (Frances, 2013) are, in as the new diagnostic label of Disruptive Mood large measure, a re£ection of this credibility Dysregulation Disorder in children; and the gap. The criticisms focus on concerns that increasing emphasis on a biomedically someofthediagnosticcategoriesre£ectamed- oriented mental health care as the primary icalisation of normative phenomena and are solution to these problems. guilty of privileging the biological over the In many respects, the approaches adopted by social.This is perhaps most true of diagnoses global mental health innovators described of mood and anxiety disorders, substance use earlierspeci¢callyaimtoaddresssomeofthese disorders andchildhoodemotionalandbeha- challenges. Many eschew the use of compli- vioural disorders, all of which represent cated diagnostic categories and jargon (for

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example, most of the successful trials for the this were done, perhaps up to half of those psychological treatment of depression in who receive diagnoses of substance use or developing countries do not use the term mood and anxiety disorders, between them ‘depression’ in their educational component for accounting for 75% of the global burden of patients), use lay health workers to deliver mental disorders, would probably no longer interventions,broadenthede¢nitionofamen- qualify as ‘disordered’. P e r h a p s t h e l a b e l o f talhealthinterventiontoincorporatemobilis- ‘distress’, which carries less biomedical signi¢- ing personal and community resources and cance, without further distinction into subca- strategies that are contextually relevant, and tegories, may o¡er a way to describe these delivertheinterventionswherethepersonpre- individuals who, while not meeting the fers, even intheir own homes or in other com- threshold criteria for a speci¢c disorder munity settings. However, global mental diagnosis, are still not quite functioning health innovators need to beware of falling optimally. This proposal is supported by into the same trap that mental health care the substantial empirical evidence that, systems ¢nd themselves in rich countries, i.e. at the milder end of the dimensions of care that is heavily professionalised and common mental health syndromes, it is in£exible, driven by biomedical diagnostic exceedingly di⁄cult (and, arguably, entirely categories and narrowly de¢ned treatment arti¢cial) to distinguish subcategories of models, and with top-down delivery systems ‘disorders’. that exclude communities from playing an Second, we need to recognise that, while active role. I propose a set of strategies that, I individuals who are ‘distressed’(butnot‘dis- hope, might reducethe yawning, andperhaps ordered’) could be helped to cope better, with even widening, credibility gap between men- help provided in completely di¡erent ways tal health professionals and their commu- outside the formal health care system, for nities. example through low-cost social interventions such as befriending, providing practical Strategies help for economic di⁄culties, mobilising First, we need to abandon our use of preva- and strengthening existing nonbiomedical lence estimates generated by epidemiological sources of help that are contextually accepta- surveys as the source of evidence to de¢ne ble (such as spiritual interventions in some the denominator of the fraction that indicates places) and promoting self-help delivered the treatment gap. This is likely to be a pro- through books or the Internet (Fairburn & vocative suggestion; however, to be sure, only Patel, 2014). These are not only cheaper, but a small fraction of the global population are also consistent with the person’s under- truly believes any of the astonishingly large standing of their problem, the course and ¢gures that these surveys throw up. Those outcome of these distress states and the ¢gures simply lack face validity because they treatment evidence. con£ate emotional distress with mental Third, as I have argued elsewhere (Jacob & disorders that need speci¢c biomedical inter- Patel, 2014), the descriptions of diagnostic ventions. Of course, diagnoses matter. Never- categories must be based on the patterns of theless, perhaps the way to bridge the phenomena observed in general populations, credibility gap in this context is to set rather than those observed in specialist set- thresholds for diagnoses of speci¢c disorders tings. If we were to follow this axiom, then not solely on the clustering of symptoms there would probably be no justi¢cation for and their impact, but also on the likelihood the diagnostic separation of mood, anxiety of bene¢tting from available biomedical and somatoform disorders (at least in nonspe- interventions, particularly in reducing cialist settings), as, for the vast majority of impairments in key tasks of daily living. If people, the phenomena associated with these

diagnoses co-occur, and, not surprisingly, Acknowledgments these disorders share similar aetiologies The author is supported by a Wellcome Trust and bene¢t from similar interventions. The Senior Fellowship in Clinical Science and grants concept of common mental disorders, cham- from UKAid, Grand Challenges Canada and pioned for over two decades by primary care NIMH. mental healthpractitioners, remainsthemost valid construct to describe these hetero- geneous experiences in the population. References Balaji, M., Chatterjee, S., Brennan, B., Rangas- wamy, T., Thornicroft, G., & Pate,l, V. (2012). Conclusion Outcomes that matter: a qualitative study with In conclusion, mental disorders are real persons with schizophrenia and their primary forms of human su¡ering, observed globally caregivers in India. Asian Journal of Psychiatry, in all populations, with remarkable simil- 5(3),258-65. arities in phenomenology across cultures. This does not, however, imply that the top-d- Dua, T., Barbui, C., Clark, N., Fleischmann, A., own, biomedical, psychiatric constructs Poznyak,V., van Ommeren, M., ... & Saxena, S. and therapeutic paradigms are universally (2011). Evidence-Based Guidelines for Mental, applicable and helpful. There is a yawning Neurological, and Substance Use Disorders in gulf, which I refer to as the credibility gap Low- and Middle-Income Countries: Summary in this article, between such paradigms and of WHO Recommendations. PLoS Medicine, 8 (11), the beliefs held by vast sections of the com- e1001122. munities in all countries. This gap is to a Fairburn, C.G. & Patel, V. (2014).The global dis- large extent due to the fundamental di¡er- semination of psychological treatments: a road ences between ‘somatic’and‘psychological’ ill- map for research and practice. AmericanJournal of nesses in the way they are conceptualised, Psychiatry,171(5),495-8. in£uenced by social determinants and addressed by interventions.This observation Frances, A. (2013).The past, present and future of is by no means original nor novel: the com- psychiatric diagnosis.WorldPsychiatry,12(2), 111-112. munities of professionals and advocates working in humanitarian settings have Jacob, K. S. & Patel, V. (2014). Classi¢cation of o¡ered a similar perspective about the mental disorders: a global mental healthperspect- conceptualisation of the mental health con- ive. Lancet, 383,1433-1435. sequences of con£icts and other emergencies. Patel,V.& Prince, M. (2010).Globalmental health: These fundamental di¡erences that set the a new global health ¢eld comes of age. JAMA, practice of mental health care apart from 303(19), 1976 -1977. physical health care are, in fact, the very essence of its uniqueness and attraction. Patel,V., Chowdhary, N., Rahman, A. & Verdeli, Rather than being glossed over in the desire H. (2011).Improving access to psychological treat- to become respected by and part of the ments: Lessons from developing countries. Beha- monolith of medicine, these di¡erences need viour Research andTherapy,49(9), 523-528. to be championed and emphasised, if we are to close the credibility gap between men- Singla, D.R., Weobong, B., Nadkarni, A., tal health specialists and the communities Chowdhary, N., Shinde, S., Anand, A., Patel, V. we serve. In doing so, we would only reassert Improving the scalability of psychological treat- our rightful place in the unique space ments in developing countries: a study of peer- between medicine and society that mental led supervisionandtherapyquality in India. Beha- health practice has historically occupied. vioral Research andTherapy. In Press.

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Van Ginneken, N., Tharyan, P., Lewin, S., Rao, anxiety, mood, and substance disorders in 17 G.N.,Meera,S.,Pian,J,...Patel,V. (2013). Non- countries in the WHO world mental health sur- specialist health worker interventions for the care veys. Lancet, 370(9590), 841-850. of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Review,11, CD009149 http:// onlinelibrary.wiley.com/doi/10.1002/14651858. Vikram Patel is Professor of International Mental CD009149.pub2/pdf. Health andWellcomeTrust Senior Research Fellow in Clinical Science, the London School of Hygiene Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., & TropicalMedicine,London,UK,andthePublic Angermeyer, M. C., Borges, G., Bromet, E. J., Health Foundation of India and Sangath, India. et al. (2007). Use of mental health services for email:[email protected]