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Mental health for all - by all
Vikram Patel
Professor of International Mental Health Wellcome Trust Senior Research Fellow in Clinical Science
London School of Hygiene & Tropical Medicine, UK
Sangath, India Public Health Foundation of India
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2 Courtesy: Abhay Bang, SEARCH, India
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Relevance to global mental health?
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“an area for study, research and practice that
places priority on improving mental health and achieving equity in mental health for all
people worldwide”
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Suicide is a leading cause of death of young people globally
8 10 Patel et al, Lancet 2012
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Depression is a LEADING CAUSE of the global burden of disease
Mental illnesses account for 15% of the global burden of disease
About 500 MILLION people on our planet suffer from a mental illness
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People with mental disorders die younger
1/28/2015 10
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November 2003 11
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7 JULY 2011 | VOL 475 | NATURE
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Synthesizing evidence on what works
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The treatment gap is over 50% in all countries
Reaches an astonishing 90% in low income countries
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Low political will Resistance to decentralization
Difficulties to integration of mental health in primary care
Lack of public mental health leadership Weak human resource capacity
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India’s population 1.2 billion
132000 psychiatrists
3000 psychiatrists
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Lay health workers delivering group Interpersonal therapy for depression in rural Uganda
(Bolton et al, JAMA 2005, 2007)
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Lady health visitors using CBT to treat postnatal depression in rural Pakistan
(Rahman et al, Lancet 2008)
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The MANAS trial for depression and anxiety disorders
(Patel et al, Lancet 2010)
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95%
73% 70%
45%
41%
50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bolton et al, JAMA 2003 Uganda Rahman et al, Lancet 2008 Pakistan Patel et al, Br J Psych 2012 India
Intervention arm
Control arm
Reco
very
Rat
e Fr
om D
epre
ssio
n
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Relevance to trauma
• Trauma is a major determinant of several mental health problems, including depressive and anxiety disorders
• The burden of trauma related life experiences is arguably greater in LMIC, not least in the context of humanitarian crises
• Is there evidence specifically for trauma related disorders?
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SUNDAR Simplify the message
UNpack the treatment
Deliver it where people are
Affordable and available human resources
Reallocation of specialists to train and supervise
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Old wine in a new bottle?
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2009
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Findings
• 5 trials comparing paraprofessionals with control condition (n=220) – SMD 0.34 (0.13 to 0.88) in favour of
paraprofessionals
• 5 trials comparing paraprofessionals with
professionals (n=106) – SMD 0.09 (-0.23 to 0.4)
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Concerns
• Dismisses role of specialists – Specialists play critically important roles, for e.g. in
developing the treatments and building capacity
• Dumbs down mental health care – It expands the range of interventions to achieve a
larger coverage of services to address unmet needs
• Subversive – Practical avatar of the idea that mental health is too
important to be left to professionals alone
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Challenges
• Limited efficacy of some task-shifting, e.g. for severe mental health problems
• Lack of political will and professional support
• Practical barriers to integration in routine care
• No evidence for task-shifting for diagnosis
• No evidence for task-shifting for pharmacotherapy
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What’s in store for me
• Developing culturally appropriate treatments – for severe depression and harmful drinking (PREMIUM) – For autism (PASS) – for delivery by peers for maternal depression (SHARE)
• Scaling up task-sharing within functioning health systems – In district health systems in five countries (PRIME) – In rural communities in India (VISHRAM) – District Mental Health Program (Government of India)
• Building competency in PTs through e-learning platforms
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Why task-shifting is SUNDAR
Utilitarian
Equitable
Acceptable
Empowering
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Anjana’s story At first I was known as Ambadas’s
wife. But, now I am well known all over my village as Anjana - Health worker. The villagers have selected me for various posts on many organizations.
I have been respected as I am the
health worker of ‘Search’ organization. I have even given talks about my work at Delhi and Ranchi. Also I have got an opportunity to travel by airplane only due to my employment as a health worker.
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The Movement for Global Mental Health aims to improve services for people with mental disorders worldwide
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Acknowledgements
The Wellcome Trust
DFID NIMH
Sir Dorabji Tata Trust MacArthur Foundation
Autism Speaks
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www.sangath.com 40