Have Your Say on the Treatment Gap in Global Mental Health

This entry is a repost from the London School of Economics' Health and Social Care blog. The original entry by Victoria de Menil and Valentina Iemmi can be found here: "Have Your Say on the Treatment Gap in Global Mental Health".

Lord Crisp chairing the APPG on global mental health (c) Victoria De Menil

Lord Crisp chairing the APPG on global mental health
(c) Victoria de Menil

An historic first took place in Portcullis House on 10 June. The UK All Party Parliamentary Groups (APPGs) on global health and mental health convened a joint hearing to discuss global mental health. The event, chaired by Lord Nigel Crisp together with James Morris MP, was the first of two oral evidence sessions to address the question of whether the UK government should be “doing more or doing differently” to address the treatment gap in global mental health. Three additional Parliamentarians, Meg Hillier MP, Vicount Eccles and Peter Bottomley MP, were also in attendance.

The session opened with evidence from three speakers: Professor Vikram Patel of the London School of Hygiene and Tropical Medicine, Professor Graham Thornicroft of the Institute of Psychiatry, and Dr Gary Belkin, director of New York University’s Global Mental Health Programme. Their task was to answer two questions: how significant a problem is mental illness in low- and middle-income countries; and what evidence is there for cost-effective ways to address mental health needs in low- and middle-income countries?

Startling statistics

Vikram Patel highlighted a few startling statistics. Suicide kills more young women globally than maternal causes. Furthermore, the life expectancy of people with schizophrenia is 15-20 years shorter than the general population. Finally, mental disorders are the cause of one-quarter of years lived with disability globally, which places it above cardiac disease and cancer in terms of disability. Equally noteworthy, however, was a positive scenario: if maternal depression were eliminated, then 25% of childhood stunting and malnourishment would disappear in South Asia.

Professor Patel also emphasised the timeliness of this hearing and cited four changes that make today an opportune time to invest in mental health:

  1. The WHO has issued a new Comprehensive Mental Health Action Plan that establishes an international consensus on priorities and solutions in addressing the gap;
  2. Middle-income countries such as Brazil, India and China have increased public investments in mental health care and need technical support to make best use of those funds;
  3. In spring 2015, the World Bank will devote a session to mental health within its annual finance meeting;
  4. Evidence has emerged that appropriately trained and supervised non-specialist health workers can deliver mental health treatments successfully, which Vikram Patel deemed one of the most exciting innovations for mental health care in years.

Fear of contagion

Graham Thornicroft’s specialty is stigma, and he recounted how an Ethiopian nurse did not want to touch the case notes of a patient with mental illness for fear of contamination. Many individuals say that stigma and social exclusion are more painful than the primary symptoms of their condition. Reporting findings from the INDIGO study, Professor Thornicroft explained that some individuals internalize stigma and stop trying to make friends or find jobs. However, the evidence suggests the best antidote to stigma is personal contact.

What gap?

Professor Patel corrected a common myth that there is no mental health treatment in low- and middle-income countries: “We shouldn’t assume that people aren’t getting treatment. They are getting treatment, but they are getting the wrong treatment.” Most people with a common mental disorder in India are prescribed sleeping medicines (benzodiazepines) and vitamins. Professor Thornicroft is also likely to have shocked more than one person in the public with an image of the shackled feet of a mentally ill person who had been “treated” with hyenas by a traditional healer in Somalia. The gap for mental health care is not for any treatment, but for evidence-based treatment.

Professor Thornicroft quantified the gap, pointing out that low- and middle-income countries are not the only ones with this problem. Whereas in the UK treatment is available for one-third of people with mental disorders (varying by illness type), only 10% of people access evidence-based treatments in low- and middle-income countries.

Diagram for root-cause analysis presented by Dr Belkin (c) Victoria de Menil

Diagram for root-cause analysis presented by Dr Belkin
(c) Victoria de Menil

Gary Belkin spoke in absolute terms about the gap, estimating it to be “one billion minds and lives” – the name of a project he is working on with the Institute for Healthcare Improvement. He believes that to tackle a problem of that scale requires standardized quality improvement tools. The Billion Minds and Lives project is expected to test a set of quality improvement tools in large-scale projects in Ghana, Kenya, Ethiopia, Zambia and Rwanda. In a show-and-tell moment, Dr Belkin projected a large image of what is cryptically known as a “fishbone diagram for root-cause analysis,” a group problem-solving technique that maps proximate and underlying causes of a problem. The outcome – a meaningful mess of squares and arrows (see photo) – was observed by several audience members to capture the true complexity of factors at play in addressing mental health problems.

Dr Belkin closed with a rousing invocation to the British government to take action: “The only people that can make this change happen are governments.” He advised a two-way approach to scaling up mental healthcare: “Take mental health with you when you go out; and bring others in.” In other words, mental health policy makers need to branch out to non-mental health arenas, such as the G8, and also to bring non-specialist actors, such as schools and primary care providers, into the discussion about mental health.

Voices of dissent

The hearing was not without controversy. When it opened up for questions, a service user said he had heard that outcomes for schizophrenia were better in low- and middle-income countries and asked whether that was related to their taking less antipsychotics or to being less isolated. Professor Patel responded that the claim that outcomes are better in developing countries is based on a single study conducted by the WHO 25 years ago. All studies conducted locally since then have demonstrated the contrary. He stated firmly, “The life expectancy of someone with schizophrenia in India is half that in England – I see that as a bad outcome.”

Derek Summerfield, a psychiatrist of South African origin affiliated with the Institute of Psychiatry, challenged the speakers, particularly Professor Thornicroft, declaring that it was “slick and facile” to say that stigma is the reason people in low-income countries don’t seek services. He argued that they don’t seek services because they live in absolute poverty and are struggling to survive. They don’t have depression, they have poverty. He called the desire to spread mental healthcare globally a “new imperialism.”

In response to Dr Summerfield, Professor Patel stated,“What Dr. Summerfield is pointing out is failures in our Western medical system, and I wish him and his colleagues the best of luck in sorting that out. What we are concerned with is the mental health systems in the rest of the world.” Professor Thornicroft agreed with Dr Summerfield that poverty is central to mental health problems in low-income countries and that the two problems should ideally be addressed in tandem. He cited the work of BasicNeeds as exemplary of this two-pronged approach to tackling health and poverty. Lord Crisp closed the debate by inviting Dr Summerfield to “tell us what you think we should do as parliamentarians – and not just to avoid mental health.”

The second parliamentary hearing was held on 7 July 2014. Lord Crisp brought together four expert witnesses to discuss the UK's role in addressing the global mental health gap; to understand current endeavors to help low and middle income countries improve mental health and if more should be done. A blog post will be published later this week on the second parliamentary hearing.

For more on the proceedings of global mental health hearings on Twitter, follow @APPGGlobHealth,@ThornicroftG@abillionminds

About the authors

Victoria de Menil is a PhD Student within the Personal Social Services Research Unit at the London School of Economics and Political Science.

Valentina Iemmi is Research Officer within the Personal Social Services Research Unit at the London School of Economics and Political Science.

Policy and legislation
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