Mental Health – For all, By all.

Shreyas Gadge, a student at IISER Mohali provides a detailed coverage of a talk on mental health which was delivered by Vikram Patel, at India Science Festival 2022.

Demystifying and democratizing mental health involves not just the understanding of mental health by all but also being empowered by the ability to assist and help others in the community, believes Dr. Patel. Over 97% of the attendees believed the importance of mental health is at par with physical health and about 66% believed they started paying more attention to their mental health during the lockdown. The global challenge posed by mental health issues is huge and data shows that the burden of disease due to mental health conditions (as a relative share of overall burden) has risen 50% over the last 25 years (1991- 2016) in developing and developed countries alike, with a higher value of the relative burden in developed countries due to successfully controlling other diseases. Also, about a quarter to a fifth of the entire burden of health problems in young adults (20-24 yrs) is due to mental health problems such as substance abuse and self-harm in India and the effect of it is pretty dramatic.

Investments in science and its application have been significant in the declining prevalence of mortality associated with conditions like strokes, heart ailments, cancer, etc. but not so much for mental health conditions. Evidence suggests that despite enormous resources and money spent by the US, there is no impact or reduction in the prevalence of mental health conditions through the years, in fact, it has risen for the young adult population. In young Americans, suicide mortality has increased by 50% in the last 10 years. Despite spending about 20 billion dollars during his tenure as the director of NIMH, Tom Insel mentions the rise in suicide mortality, mental illness burden, and even social indicators such as crimes and homelessness in the US by 30-40%. This situation has only been exacerbated by the pandemic. There was about a 28% increase in the cases of major depressive disorders globally due to the COVID-19 pandemic.

The challenge, therefore, arises due to the failure of all countries to address mental health equitably regardless of investments and efforts. This gigantic failure isn’t observed in tackling other health issues and so there is something fundamentally wrong with the approach to tackling mental health issues globally.”

One of the key challenges is the narrow, binary, framing of mental health problems, which are, in their very nature, dimensional and do not map onto diagnostic categories. It essentially misses the fact that at every point in our life each and every one of us is somewhere on a spectrum from good to poor mental health. There is also a lack of attention to social determinants in prevention and care programs that largely influence growth and recovery. There’s a lack of a life course approach during the early years as mental health problems predominantly have their onset before the age of 24. Initiatives must be organized to act on improving the first 15-20 years of life. We are also short of skill providers due to a pipe hole vision towards looking at qualifications and degrees to provide skills in mitigating mental health problems. There is also a reluctance to seek help from ‘professionals’ due to enormous stigma, costs, and inaccessibility. Disempowerment of available resources has also compelled scientists to address the lack of specialized resources by collaborating with certain communities.

Professor Patel was inspired by the book, ‘People’s Health in People’s Hands,’ by Dr. NH Antia which is a collection of essays about the marriage of medical science with community participatory action which meets the highest quality science. For instance, a study published in Lancet Medical Journal talked about a field trial in the Gadchiroli rural area in Maharashtra that demonstrated a home-based approach of community workers or helpers diagnosing and treating newborn infections dramatically reduces neonatal mortality. This led to the government rolling out one of the largest community health worker programs in the world dramatically reducing the infant mortality rate in India. Inspired by this Professor Patel wrote a mental health care manual, ‘Where there is no Psychiatrist’ when there was no evidence of
these kinds of trials being safe and effective.

In order to build robust evidence for the same, Professor Patel found an opportunity in the rising field of Global (Mental) Health which is an area of study, research, and practice that places a priority on improving (mental) health and achieving equity in (mental) health for all people worldwide. He led a series of articles in the Lancet Journal ending with a Call for Action which was to scale up the coverage of services for mental disorders in all countries but especially in low-income populations. This was based on the principles that the interventions that were being scaled up should have a solid scientific foundation on their evidence and it shouldn’t be done without strengthening the protection of human rights of persons with mental disorders and their families. The ‘Grand Challenges in Global Mental Health,’ a research priority setting exercise launched by NIMH, co-chaired by Professor Patel talked about the research priorities in declining the burden of mental health problems being efficiently using the knowledge in hand and making it more accessible rather than new discoveries.

Initiatives like the friendship therapy for mothers with depression in Zimbabwe, Sangath in India working on designing interventions for the delivery of lay and community health providers for a wide range of mental health conditions are perfect examples of unpacking affordable and available human resources in the form of community intervention to mitigate mental health issues. Professor Patel coined the term ‘SUNDAR’ to break down the complexity of these medical interventions into their active components – Simplify the message, UNpack the treatment, Deliver it where people are, Affordable and available human resources, Reallocation of specialists to train and supervise. This evidence has transformed mental health globally and the WHO’s plan mental action plan, the World Bank’s disease control priorities program, India’s National Mental Health Policy cite the building of skills in the community of non-specialist providers to deliver psychosocial interventions as the single most priority to transform mental health care around the world.

The amount of money spent is not just about how many specialists the country has but also about re-imagining who is a mental health provider, what mental health care do they provide and where that care is provided.

“It is also significant to show the importance of the entire scientific pathway from basic science discovery and early human trials to clinical trials and implementation, each stage of which requires proportionate investments, and the impact is created by also investing in the later stages of implementation along with basic science discoveries.”

Based on these and a lot of other pieces of evidence and interventions such as the onset of digital technologies, mental health can be re-imagined and reframed as a system.

We need to look beyond the diagnosis and prescription system of evaluating mental health
issues and intervene across degrees of severity and dimensions. We also need to build preventions through actions that target structural and social determinants and a rights-based approach to eliminate coercion and institutionalization in mental health care. The foundations of the mental health care system have to be on scaling up psychosocial interventions using task-sharing, peer support, and community-based providers.

Due to the rising demand for mental health services, this is a historic opportunity to invest in mental health while also spending it wisely, guided by the best science and social justice. It is the diversity of experiences and strategies that must be embraced by the mental healthcare systems.

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