#studyGMH: student perspectives from the Yale Global Mental Health Program

Mental illness around the world: more commonalities than differences?

Stephanie Cohen is a current Yale Medical Student. 

At the end of 6 weeks of psychiatry electives in 2 different cities and 3 different clinics in Peru, I reflect on the lessons and experiences I have gained. When I left, I thought perhaps I would see mental illness that I have never seen in the states. I know that culture plays a large role in how mental illness is expressed (i.e. local idioms of distress), and I was eager to look for differences between my culture and another. However, I saw more commonalities than differences. This perhaps points to the organic origin of human mental illness or could also be because I saw patients through a lens of Western training.

In the past, I have heard the idea that mental health is a privilege that comes after basic necessities are  met (such as food, water, shelter). If one is to attribute depression or anxiety to being inherent to lower socio-economic status, then by that logic, those of high status should not exhibit these conditions (which we know is false). Mental health services should be implemented in conjunction with development work and are as important as treating hypertension or acid reflux. In fact, people will have a higher likelihood of escaping poverty if mental illness is first addressed. Unfortunately, violence in Peru has not ended with the end of terrorism in the late 1990s. It was far too common to see women who were psychologically and/or physically abused by their husbands. This intra-familial violence appeared to stem from the amount of chauvinism (“machismo”) that exists in Peru.

In Peru I have learned the importance of involving family in the treatment of mental illness, especially in a Latin American country where “familismo” is a principal value. For instance, one of the holistic addiction treatment programs in Lima dedicates 12 hours/week of group therapy for parents, siblings, or children of addicts. This model represents a paradigm shift whereby instead of the patient being the sole focus of treatment, the family is required to participate as well.

Furthermore, I saw the importance of rehabilitation or occupational therapy especially in cases of chronic schizophrenia. In a developing country with limited resources and psycho-pharmaceuticals, behavioral therapies are crucial. I saw full workshops replete with kitchen and mock bedroom in order to teach daily tasks to patients who lack these skills.

“If we are to see change in global health we have to become a truly global community”

While, as a student, my main contribution to patient care will come after finishing residency, part of my contribution now will be using this experience to inform my future decisions and those of my colleagues – and to pass on this sense of urgency. I am incredibly grateful for the superior faculty mentorship I have received from my institution, others in the U.S., and at COSMA, Cayetano Heredia, and Noguchi hospitals. While wealth might be concentrated in the northern hemispheres, thanks to excellent faculty mentorship and the funds from Yale University to go to Peru, we are breaking down this boundary. If we are to see change in global health we have to become a truly global community. My contribution does not start and end in the 6-week time frame of my elective; it has only just begun.

To read further about discrimination experienced by women in Peru, see here and here.

The value of an academic project

Dr. Anna Fiskin is a current Yale Psychiatry Resident.

During my Psychiatry residency training at Yale, I had the opportunity to work as a research collaborator with the Programme for Improving Mental Healthcare (PRIME). PRIME is a consortium of research institutions and Ministries of Health in Ethiopia, India, Nepal, South Africa & Uganda, with partners in the UK and the World Health Organization (WHO). The goal of PRIME is to generate world-class research evidence on the implementation and scaling up of treatment programs for priority mental disorders in primary and maternal health care contexts in low resource settings. I have an MSc in Medical anthropology, and I was really excited to work on a project dedicated to developing culturally appropriate mental health services based on needs and input of local stakeholders.

As part of our second year of residency, we have three months to pursue an academic project of our choice. During that time, I was able to spend six weeks at the London School of Hygiene and Tropical Medicine being mentored by Dr. Mary De Silva, deputy director at the Centre for Global Mental Health. There, I was able to analyze data from focus groups and interviews with Nepalese stakeholders and later drafted sections on mental health delivery and recovery for the PRIME report that is being used in development of a mental healthcare plan for Nepal. During my fourth year, I took an elective month to travel to Nepal. I visited districts in different parts of the country where the mental health program is being implemented and had opportunities to meet with health workers, psychosocial counsellors, volunteers and patients, and learn about their perspectives first-hand. Psychosocial counsellors participated in exercises about hearing voices based on trainings I conducted.

The Yale Psychiatry residency program provided me with the time, financial resources and academic support to make this work happen. Dr. Rohrbaugh, our residency program director, advocated for me to have the elective time to travel to the UK and Nepal. I was fortunate to receive funding from the residency program through the Bertram H. Roberts Memorial fund, which provides support for medical students and residents to complete projects in the field of social psychiatry. I am currently working on a publication comparing findings on attitudes towards task sharing from different districts of Nepal, and I am fortunate to have Dr. Carla Marienfeld as my faculty mentor at Yale, in addition to my mentors at PRIME.

Because of this opportunity during residency, I am now collaborating with the group at the University of California San Francisco (UCSF) to develop a clinical fellowship in global mental health based in Nepal and the Navajo nation. I think that students and residents can make a substantial contribution in global mental health research. You do not have to be an expert to be of service and projects always need people with good analytical and writing skills. In order to empower students to contribute, there needs to be an institutional commitment to provide time, funding and academic supervision so that students and residents can develop in this field.

What are the problems faced when interacting with vulnerable populations?

Dr. Kali Cyrus is a current Yale Psychiatry Resident.

The medical students piled in one after the other and picked up the wrapped sandwiches, sodas, and chips I meticulously laid out for them. I anxiously waited for them to sit down at the table, profusely sweating in the warm classroom, loathing the Capetown weather. Funded by a Global Health grant through the Yale Department of Psychiatry, I came to South Africa to explore the problems medical students face when interacting with vulnerable populations. “Vulnerable” referring to those that face discrimination due to race, gender, sexual orientation, and ethnicity. Given the recent end of Apartheid, I expected to find a gold mine for studying this issue; race I figured would be particularly rich. Like the United States, South Africa has a complex racial past, cradled in a nation of diversity. However, in the U.S. we teach cultural competency, and it’s unclear how students fared here, where such tools were unavailable.

“I came to South Africa to explore the problems medical students face when interacting with vulnerable populations”

Although my task had been to conduct research, I was also on a self-exploratory mission of discovering what it felt like to be an African American in Africa for the first time. Through focus groups, I learned that race was minimized as a major issue when connecting with patients. Yet, personally I felt the opposite in my interactions with many South Africans. While students stated, “we don’t see race,” I often felt the opposite, for example as the only black person in the restaurant. I have attempted to describe this disconnect in my research, which is a mixed methods project consisting of five focus groups with students from various races and a survey gauging cultural competency. I hope that my work can impact the field of medical education and serve as a curriculum expansion tool for the South African medical school that so graciously took me in. This experience was an amazing opportunity, both personally and professionally, that could add depth to the career of any physician in training. 

Insights into barriers for global mental health

Dr. Rajiv Radhakrishnan is a current Yale Psychiatry Resident. I spent 2 weeks in India working with the MAANASI project, a rural mental health program run by the Departments of Psychiatry and Community Medicine at St. Johns Medical College, Bangalore, India. The project provides mental health care to women in rural areas and currently covers about 187 villages around Bangalore. The aim of my study was to evaluate reasons for poor treatment adherence, and explore barriers to treatment among women with Major Depressive Disorder in the rural population and to assess attitude towards use of technology, such as text-messaging and appointment reminder devices, in improving treatment adherence. I conducted focus-group discussions with women enrolled in the project who were or were not seeking care at the present time. The experience provided me with insights into barriers to care such as lack of transport and the reluctance to adopt new technology for fear that it would intrude into the privacy of their closed family unit.

The factor that was most important in enabling me to contribute to the MAANASI project was the grant support provided by Yale Global Mental Health Program and Yale New Haven Hospital. Additionally, the presence of local mentors was invaluable to the success of this study.

I think students can play a very important role in global mental health by undertaking short-term projects that are of relevance to the local community. Students are also in a position to access funds and garner philanthropic support for projects in resource-poor settings that would otherwise be inaccessible to them. The challenge of establishing a good working relationship with the local community would require structured mentorship and including local mentors in the process would be important. The availability of funding, protected time and institutional support for global mental health activities would go a long way in helping students make substantial contributions.