In the latest installment of the Speaking of Medicine series of Q&A blog posts, we hear from Pamela Collins, the corresponding author of a series of Policy Forum articles in PLOS Medicine that provides a global perspective on integrating mental health. Pamela Collins M.D., M.P.H., is the Director of the Office for Research on Disparities and Global Mental Health at the National Institute of Mental Health (NIMH). I asked her about some of the topics discussed in the new series, which will be published in PLOS Medicine weekly for the next five weeks, starting with the publication today of a Policy Forum article discussing integration in research, policy, and practice.
1. Why is the integration of mental health care so important?
Integration of mental health care is important on several levels. First, there is a need to integrate mental health concerns into the broader discussions in global public health because of the tremendous disability and suffering that mental disorders cause around the world. Mental disorders are global problems which, untreated, result in increased morbidity and mortality, as well as increased health system and societal costs. Second, we know that mental disorders co-occur with many other medical conditions, including cardiovascular disease, diabetes, and HIV-related disease. Depression is a good example. When depression co-occurs with these conditions, the risk of poor outcomes, including death, increases. Third, integration of mental health interventions into other areas of routine care (e.g. primary care or maternal health care) has the potential for improving access to needed services, enabling health care providers to deliver holistic care. Establishing access to evidence-based, effective care for depression in settings where women receive routine health services may increase the likelihood that women with depression receive the care they need.
2. What were your main motivations for initiating the series?
NIMH and its partners completed the priority setting initiative, the Grand Challenges in Global Mental Health, in 2011. One of the Grand Challenges identified by the group of international stakeholders was to “redesign health systems to integrate mental, neurological, and substance use (MNS) disorders with other chronic disease care, and create parity between mental and physical illness in investment to research, training, treatment and prevention.” Notably, meeting this challenge requires the cooperation of stakeholders within and outside of the mental health arena. It is timely, too. Much of the global health community is now focused on how to leverage resources efficiently in order to achieve the best health outcomes for populations in need. Integrating mental health services that build on existing platforms may be one way to introduce efficiency.
3. How did you get interested in this area of research?
My past research focused on the intersection of mental health care and HIV-related care in high-, middle-, and low-income country settings. I entered this arena of integration while first working to reduce the risk of HIV infection among women with schizophrenia, bipolar disorder, and depression in New York City in the 1990s, and I subsequently began to work with providers in South Africa and Rwanda around similar issues. People with severe mental illnesses have a much higher prevalence HIV infection in the United States. Yet, this is not a population that we usually hear about in public health efforts to prevent HIV and care for people with HIV. But the risk for HIV infection is not solely a high-income country phenomenon. Studies from sub-Saharan Africa also show a high prevalence of HIV infection among people hospitalized in psychiatric facilities. This population also has higher rates of mortality and earlier mortality from non-communicable diseases. These findings point to the possibility of integrated care as a means of insuring that people with mental illnesses gain access to the prevention and care they need for other health conditions. At the same time people who develop a mental illness while being treated for other health conditions need access to services where the symptoms of mental illness will be recognized and treated appropriately.
4. What are the main barriers to moving this field forward?
One critical barrier is the inequity in human resources for health care around the world. There is a dearth of mental health care providers in many parts of the world. The 2011 WHO Mental Health Atlas tells us that nearly half of the world’s population lives in a setting with one psychiatrist or less serving 200,000 people. But, barriers also provide opportunities. The mental health community has long experimented with using non-specialists to deliver mental health services including community health workers, nurses, or primary care doctors. We now have a growing number of rigorous studies that provide evidence that effective mental health interventions can be delivered by non-specialists in settings where the specialist workforce is simply insufficient.
5. What further research is needed in this area?
Given that the resources allocated for mental health care are limited in many settings, we need to understand the best methods of equipping available health care providers to deliver evidence-based mental health services, in tandem with interventions for other disorders, in a variety of health system environments. We have tools, through the WHO Mental Health Gap Action Programme, to assist with screening for some MNS disorders, but we need more understanding of how disease processes interact to affect the course of illness. As we will see in the concluding paper in the series, Vikram Patel and colleagues argue that at the systems level, we have more to learn about how and where to integrate services for people with different kinds of mental illnesses, such as chronic psychosis, dementia, or childhood mental disorders. Furthermore, most of the studies that provide the evidence base for integrating mental health services into other delivery platforms have been carried out in high-income countries, so we need more data from settings with fewer resources that show how best to provide these services. Last year NIMH published a funding opportunity announcement called “Grand Challenges in Global Mental Health: Integrating Mental Health into Chronic Disease Care Provision in Low- and Middle-Income Countries.” We hope the studies to be funded through this initiative will answer some of these questions.