In the latest installment of the Speaking of Medicine series of Q&A blog posts, we hear from Vikram Patel, one of the guest editors of the PLoS Medicine Global Mental Health Practice series. Vikram Patel is Professor of International Mental Health and Wellcome Trust Senior Research Fellow in Clinical Science at the London School of Hygiene & Tropical Medicine. I asked him about some of the topics discussed in the Global Mental Health Practice series, which continues in PLoS Medicine this week with the publication of a case study from Nepal by Shoba Raja and colleagues.
Why is mental health an important global health issue?
Mental health is important because, in one way or another, it affects us all. Mental illnesses are a diverse range of conditions affecting people across the life course, from autism and intellectual disability in childhood, to depression, substance abuse and psychoses in adulthood to dementia in old age. Given this diversity it is not surprising, then, that it is estimated that at least 1 in 10 persons worldwide is directly affected by a mental illness, amounting to over 500 million people. Apart from the sheer scale of numbers, mental illnesses are of global health importance for several other reasons. They are associated with reduced life expectancy, both due to direct causes such as suicide, as well as because people with mental illnesses often have poorer physical health and receive poorer quality medical care for physical health problems. They are associated with chronicity and disability. Their combined contribution to reduced life expectancy and poorer quality of life leads them to contribute to about 15% of the overall global burden of disease. Put simply, there is no health without mental health.
What were your main motivations for initiating the Global Mental Health Practice series?
The central issue, from a global perspective, is not just the enormous burden and staggering numbers of people affected by these problems, but that the vast majority of these persons do not receive the care we know can greatly improve their lives. Even in the best resourced countries of the world, up to half of affected families suffer alone. In the least resourced countries, this figure reaches an astonishing 90%! This, despite the robust knowledge of the specific treatments, from medicines to psychological treatments to social interventions, that we possess. The consequences are tragic. Speak to anyone who has been affected by a mental illness, either directly or as a caregiver, and the chances are that you will hear stories of hidden suffering, shame, and frank discrimination in school, in the community, at work. The most heart-breaking stories of all are those of the countless thousands who are abused, chained and imprisoned in ancient mental hospitals, the very institutions we have built to care for them, around the world. Thus, there is a huge gulf between what we know can help improve the lives of people of mental illness and what we do with that knowledge. There are several major barriers to reducing these treatment gaps, from the low priority given to mental health by policy makers to the lack of adequately skilled human resources in front-line health care services. The primary motivation of the Global Mental Health Practice series is to profile initiatives from any country, with a particular focus on low-resource settings, which have sought to address these barriers and improve access to mental health care and promote the rights of people affected by mental illness.
Why is ‘practice-based evidence’ so important for informing mental health interventions in the developing world?
Evidence based practice has become a widely accepted norm in biomedicine with a great emphasis placed on experimental evaluations of health interventions. However, we also now know that there is a significant gap between what is observed in such experiments and the implementation of that knowledge in the ‘real-world’. This highlights the importance of ‘practice-based evidence’, by placing value on the experiences of interventions in real-world settings as evidence for implementation. Such real-life experiences have traditionally been neglected in mainstream medical journals and this niche is especially important to fill for global mental health interventions which may be difficult to subject to a definitive evaluation of effectiveness, for example through a controlled trial. Nonetheless, we believe that such case studies provide useful evidence that is important to disseminate widely so that they can contribute to further practice developments, especially in the context of scaling up services to reduce the treatment gap and promote the rights of persons affected by mental disorders. Thus, this series seeks to expand the evidence base of global mental health by publishing case studies of global mental health in practice.
At what point in your career as a psychiatrist did you start thinking about the gap between public health approaches to mental health and clinical approaches to addressing mental disorders?
Pretty much as soon as I stepped out of the major teaching hospital environments in the UK where I trained into the low resource settings where I have worked since 1996, initially in Zimbabwe and subsequently in India. In Zimbabwe, we were just about 10 psychiatrists, mostly foreigners who barely spoke the local language and almost all living in the capital city of Harare. How could we possibly provide appropriate care to 10 million people, most of whom lived in rural areas outside of Harare? If India, a country of over a billion people, had the same proportion of psychiatrists to the population as the UK or the US, for example, she would have about 150,000 psychiatrists. In reality, she had less about 2% of that number. It was clear to me that I needed to think differently about improving access to mental health care in places like Zimbabwe and India. Adopting a specialised medical approach, based in specialised clinics, led by highly trained and expensive people, was a non-starter. We needed to think out of the box and, in doing so, learn from other global health fields which had also confronted similar human resource (and other resource) challenges to improve access to evidence based care. An example of such innovations was task-sharing mental health care delivery with less specialized, community and primary health care based, human resources and this particular innovation has been the focus of my own work for the past decade.
What further research is needed in this area?
Implementation research, describing the process of development and evaluating the impact of interventions needed to improve access to evidence based mental health care, particularly in low resource settings. Such research should ideally be nested in real-world clinical and public health contexts, and will necessarily be inter-disciplinary. The interventions may span a range of innovative actions, from those which are carried out at the levels of health administration and policy making to front-line health care delivery and empowerment of individuals affected by mental illnesses. Ultimately, I would hope to see a robust body of case studies of global mental health practice provide a compelling foundation to close the gulf between what we know can make a difference and how we use that knowledge in the real-world.