Meeting participants included Claudine Cayetano (l), technical advisor for mental health to the Ministry of Health of the government of Belize. In photo at right is Willem van de Put, general director of HealthNet TPO, a Netherlands-based NGO that works to aid populations in countries disrupted by disaster or poverty. Beside him is Sylvester Katontoka, founder of the Mental Health Users Network of Zambia.
By 2030, according to the World Health Organization, depression will be the second leading cause of years of life lost to death and disability, not just in wealthy countries, but throughout the world. With this global reality as a backdrop, NIMH convened a diverse group of speakers recently to discuss the kinds of research most needed to answer the worldwide need for better access to effective mental health care.
A central issue for the meeting’s participants is the scale of the gap between the need for mental health care and access to effective care in developing countries. WHO has reported that in low income countries, as many as 85 percent of serious cases of mental illness receive no treatment. Even in wealthy nations like the United States, the gap between need and access to care is large: in these countries, as many as half of serious cases of mental illness occurring within a year receive no treatment. Several participants pointed out that research aimed at solving issues of health care delivery in poor countries can inform the delivery of mental health care in wealthy nations.
In her opening remarks, Pamela Collins, director of the Offices for Special Populations, Rural Mental Health Research, and Global Mental Health at NIMH, said that in convening the meeting, the goal for NIMH was to determine how to use science to find answers for public health needs in a way that would make it possible to have the biggest impact in the next few years. In both rich and poor countries, she said, there is insufficient access to mental health care.
Speaking the day before the meeting as part of the NIMH Director’s Innovation Speaker Series, meeting participant Vikram Patel, a professor at the London School of Hygiene and Tropical Medicine, argued that focusing on conditions of mental health is as important as addressing physical diseases with high mortality. He noted that among young people ages 15 to 24, suicide is in the top three causes of death, even in places like Africa. Also among the top three causes of death in this age group are accidents, often fueled by alcohol and substance use. Other mental conditions, such as schizophrenia and dementia, directly cause mortality, and poor mental health contributes to illness and mortality of other comorbid conditions such as heart disease and HIV.
Participants in the meeting—On the Pulse of Mental Health Action: Identifying Strategic Research Opportunities—included representatives of non-governmental organizations (NGOs) who work on the ground to improve mental health care in developing countries, academic researchers engaged in studies aimed at developing and evaluating innovative means of delivering health care, and officials from government and international agencies. Speakers described their experiences working in countries like Uganda, India, Korea, Belize, and Chile to provide sustainable access to care for people with mental health disorders and to influence health care policy decisions and legislation by governments.
Some recurring themes at the meeting were the difficulty of providing mental health care in countries where the health care system in general is dysfunctional—or nonexistent—and where trained specialists are scarce; the challenges posed by illiteracy, poverty, and stigma; the importance of using assessments and interventions that are culturally relevant; and the need for data on whether treatments are effective and how exactly patients benefit. Despite the importance of efficacy research, balancing the need for data collection and the already overwhelming workload of care providers is difficult.
Several participants also discussed the training of nonmedical and lay health workers as a strategy to provide care in developing countries where medical specialists are scarce. Lay caregivers have provided effective care for conditions like schizophrenia and depression. Psychiatrist Ricardo Araya, now at the University of Bristol in England, recounted the long-term outcome of an effort that began as a clinical trial, supported by NIMH, of an intervention for low-income women in Chile with depression. Women receiving a 3-month program of care for depression, carried out largely by non-medical health workers (social workers and nurses) responded well in the trial. Chile now has greatly expanded a national depression treatment program, administered in primary care clinics throughout the country, which follows guidelines developed in the trial. The number of patients being treated in the program has multiplied since its inception in 2001: well over 200,000 now receive treatment each year. The poor, said Araya, face a double burden of poverty and mental illness. This effort was an example of the information research can provide on treatment efficacy that will be the basis for “scaling up” of health care approaches to reach large populations.
Patel pointed out that most health research is carried out on a small slice—perhaps 10 percent—of the world population. Expanding the evidence base to include more of the remaining 90 percent is likely to lead to discoveries that benefit people with mental illness in wealthy as well as poor countries. According to NIMH director Thomas Insel, the institute has recently joined the Global Alliance for Chronic Disease, an international consortium of major national funding agencies in several countries. NIMH will be leading a Grand Challenge project with the Alliance to identify best opportunities in global mental health research. “We look forward to working with WHO, the new Center for Global Mental Health in London, and many other partners as we develop this new important area for the NIMH portfolio,” said Insel.