Rethinking mental health care: what the developed world can learn from the developing
The litany of seemingly random incidents of violence in the US, from mass murders in schools and cinemas to commuters being pushed in front of oncoming trains, has placed a spotlight on the scandal of the poor quality of care, and access to it, for people with mental health problems in the world’s best resourced country. The attention is both misplaced and welcome.
It is misplaced because “it is important to recognize that mental illness is an insufficient explanation for mass murder. The pathway to mass murder is inexplicably complex, involving a confluence of factors that come together only rarely” . Indeed, it’s worthwhile remembering that these kinds of violence are exquisitely uncommon in countries which have much fewer mental health resources, and much poorer levels of access to care. Beyond easy access to guns, there are a range of other social, cultural, and economic determinants of violence, many of which seem to be particularly common in the US, from the gratuitous levels of violence in its cinema to the massive income disparities and inequalities that exist there. So, for those who are primarily concerned with preventing violence, the solutions lie in fixing these determinants. Improving access to mental health care plays an important, but limited, role.
But the attention that these incidents have placed on a broken mental health care system is nevertheless welcome. The conundrum of mental health care in the US is that, despite the apparent richness of resources, so many people with mental health problems (by one recent estimate, nearly half ) do not access the care which we know can enhance their chances of recovery and of achieving the state of well-being which they are entitled to. As with violence, the likely explanations are diverse and include factors relating to the nature of mental health problems, beliefs about their causes and treatment, and the costs and inaccessibility of biomedical mental health care.
My hypothesis is that, lying at the heart of these factors, is the remoteness of psychiatry and its allied professions from the communities they serve. Interventions are heavily medicalized, do not engage sufficiently with personal and community resources, are delivered in highly specialized,expensive settings, and use language and concepts which alienate ordinary people. In all these respects, innovations to improve access to mental health care in the developing world might inform a rethink of the way in which rich countries provide care.
At the core of these innovations is a reassessment of who provides mental health care. In most countries of the world the number of mental health professionals is a small fraction of the numbers in the developed world.There are, for example, fewer psychiatrists for the entire continent of Africa with a population of almost a billion than in the state of Massachusetts with a population of less than 7 million. In such settings, the only way mental health care can be delivered is through non-specialist workers.
Although this is hardly a novel idea, much of the focus of this so-called ‘task-shifting’ has been on training primary care doctors to provide appropriate medicines. This effort has failed in most places for a number of reasons – primary care doctors are not motivated (or are simply too busy) to get their hands dirty with mental health care, medicines are not available in the clinics, or patients need more than medicines to make a difference. In contrast, recent innovations which have used other types of human resources, from community health workers to lay people, to provide psychosocial interventions have had impressive results . These human resources work in settings, and at times, that are convenient to the patient (even in their homes and outside regular working hours) They offer a range of contextually appropriate interventions tailored to the needs of the individual, and use familiar labels and concepts.
The ongoing controversies around the diagnostic systems used by psychiatry, notably the DSM system of the American Psychiatric Association, are, at least in part, due to the large disconnect between the jargon invented by psychiatry and everyone else’s understanding of mental health problems. Practical and simple diagnostic systems, such as the one employed by the WHO’s mhGAP initiative , are now being widely adopted in developing countries precisely because they are meaningful to non-specialist providers and local communities(and I would argue, for most mental health specialists as well!), where other systems are not.
Of course, none of these ideas are unique to the developing world and there are several champions in developed countries who have worked tirelessly to innovate improving access to mental health care by challenging the hegemony of a narrow biomedical perspective of mental health care. Such innovations include peer-led care and self-help interventions based on evidence-based treatments, for example through self-help manuals (fancifully referred by some as ‘bibliotherapy’) and the internet. But, the reality remains that mental health care is still too heavily professionalized, and specialised, for the majority.
Reforming mental health care, with the goal of improving access and outcomes, requires a fundamental review of our ideas of who, and how, such care should be provided to communities. The innovations which are capturing the imagination of the young discipline of global mental health offer a window of hope for those who aspire to such reform . As the cliche goes, health is too important to be left to health professionals alone, and this is, I would argue, even more true for mental health care.
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