Mental health and substance use disorders are the top cause of disability worldwide, but only a quarter of people who need mental health services get them. NIMH & other groups are spearheading many interventions to expand the reach of mental health care.
All too often, countries with the fewest mental health providers also have the most stressors, including violence, poverty, forced migration, social unrest and political instability. According to the World Health Organization (WHO), even though mental health and substance use disorders are the top cause of disability worldwide, only a quarter of the people who need mental health services get them.
“Mental disorders are the most neglected of the global health problems,” says Vikram Patel, MBBS, PhD, a psychiatrist and professor of global health and social medicine at Harvard Medical School.
That’s slowly changing as the field of global mental health gains prominence. Psychologists are among the health-care professionals working to improve mental health in parts of the world touched by poverty, disaster and war. To close the mental health treatment gap, they’re training community health workers to deliver psychosocial interventions and developing new models for delivering care in low- and middle-income regions.
“In the last few years, evidence-based treatments [in global mental health] have been scaling up and gaining steam,” says Deepa Rao, PhD, a clinical psychologist, professor and associate director of the global mental health program at the University of Washington in Seattle. “There are a lot of success stories.”
Expanding access to care
The global mental health field got a big boost in 2013, when WHO launched the first global mental health action plan with the support of health ministers worldwide. “That plan was a landmark,” says psychiatrist Shekhar Saxena, MD, formerly of WHO and now a professor of global mental health at the Harvard T.H. Chan School of Public Health. Since then, there’s been an uptick in attention, resources and political commitment devoted to global mental health, he adds.
The field is undoubtedly interdisciplinary, but psychologists are essential to many of these efforts. Groups including WHO and the U.S. National Institute of Mental Health (NIMH) are spearheading many interventions on the ground, nonprofits such as United for Global Mental Health provide advocacy and funding support, and academic scientists are making strides on the research side, Saxena says. One of the most important developments has been the finding that lay health workers can be trained to deliver sophisticated psychological interventions to improve mental health, says Brian J. Hall, PhD, a clinical psychologist and global mental health researcher at the University of Macau in China. “People without extensive and specialist training in psychology are delivering interventions to members of their own community. This innovation expands access to care.”
In a systematic review of 27 trials, Patel and colleagues found that psychological treatments delivered by community health workers or peers in primary-care settings had moderate to strong effects in reducing the burden of mood disorders in low- and middle-income countries (Singla, D.R., Annual Review of Clinical Psychology, Vol. 13, No. 1, 2017).
When health workers can deliver treatments for common problems such as depression, anxiety and post-traumatic stress disorder, they reach more patients—and free up the few mental health specialists to address more complex problems. “We’re not talking about substituting psychologists, but extending mental health care to people who aren’t getting any care,” Patel says.
Now, organizations and governments are working to expand the availability of such interventions. NIMH has established 10 “Scale-Up Hubs” to study how to expand the reach of mental health care and foster evidence-based mental health policy in low-resource settings.
Rao, for example, is a principal investigator within the southern Africa hub. With psychologists Inge Petersen, PhD, at the University of KwaZulu-Natal, and Arvin Bhana, PhD, at the South African Medical Research Integrating mental and physical health care not only improves mental health, it also helps people with chronic illness engage in care and adhere to medications.
Council, she is training nurses and other health-care workers in primary-care settings in South Africa to deliver cognitivebehavioral therapies to treat depression in people with diabetes, HIV and other chronic diseases. Integrating mental and physical health care not only improves mental health, it also helps people with chronic illness engage in care and adhere to medications, Rao says. “We’re trying to build a sustainable model where psychotherapy is the norm in treatment.”
In another example of an NIMH-funded scale-up project, psychologist Kimberly Hoagwood, PhD, at New York University Grossman School of Medicine, and colleagues are studying family group interventions for children with disruptive behaviors in several African countries, comparing the effectiveness of group programs led by family peers versus community health workers (Kivumbi, A., et al., BMC Psychiatry, Vol. 19, No. 1, 2019).
Global mental health professionals are also trying to make mental health care more accessible by distilling interventions down to their essential components and finding ways to deliver them in as few sessions as possible. “There’s a big push to understand how short we can get these treatments and what the key mechanisms of action are,” says Laura Murray, PhD, a psychologist and professor in the department of mental health and international health at the Johns Hopkins Bloomberg School of Public Health.
Mental health problems often go hand in hand with poverty, interpersonal violence and substance use, Murray notes, so it’s more efficient to target multiple problems at once. She and her colleagues developed a multiproblem approach called the Common Elements Treatment Approach (CETA), which can be customized to address symptoms of depression, anxiety and traumatic stress, as well as substance use and violence. It’s usually delivered in eight sessions but can be made longer or briefer as needed. In initial trials, Murray and her team found CETA effective in Ethiopia, Iraq, Thailand and Zambia, among other countries (Cognitive and Behavioral Practice, Vol. 21, No. 2, 2014; Global Mental Health, Vol. 5, article e16, 2018). The intervention is now being rolled out and evaluated in other locales. “One rarely ever sees one mental health problem alone,” she says. “We developed CETA to address multiple problems.”
While Western psychotherapies often form the basis of mental health treatment programs, global mental health workers take care to adapt them in culturally sensitive ways. Health workers using a tool like cognitive reprocessing—in which people learn to identify and reframe unhelpful thoughts—might have to take a storytelling approach in some African countries or draw on biblical examples in religious communities. Whereas psychologists help local providers understand the core elements of a psychotherapeutic intervention, local team members take the lead on shaping those elements for their population. “You don’t have to invent entirely new treatments to be culturally sensitive, but you have to be flexible and adjust the implementation,” Murray says.
Psychologists have a lot to offer the field, says Hall, who is working with WHO to culturally adapt and test digital mental health innovations for migrant workers in China and Chinese adults. But to excel, he adds, psychologists need to practice cultural humility and embrace working in multidisciplinary settings with psychiatrists, primary-care physicians, public health experts and other health-care workers from different cultures and backgrounds.
Most opportunities for global mental health training at U.S. institutions are found in departments of public health, and aren’t always well integrated into psychology training, says Murray. But more psychologists are getting involved, and dedicated training opportunities are helping them dive in—including the APA–International Union of Psychological Science (IUPsyS) Global Mental Health Fellowship, which provides an opportunity for a psychologist to contribute to the work of WHO’s Department of Mental Health and Substance Abuse for one year.
And psychologists’ contributions to the emerging field are vital—in research, diagnostics, training, treatment and policy advice, says Saxena. “Psychologists can and should play a very large role in global mental health.”
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