sponsored links
TEDGlobal 2012

Vikram Patel: Mental health for all by involving all

June 27, 2012

Nearly 450 million people are affected by mental illness worldwide. In wealthy nations, just half receive appropriate care, but in developing countries, close to 90 percent go untreated because psychiatrists are in such short supply. Vikram Patel outlines a highly promising approach -- training members of communities to give mental health interventions, empowering ordinary people to care for others.

Vikram Patel - Mental health care advocate
Vikram Patel helps bring better mental health care to low-resource communities -- by teaching ordinary people to deliver basic psychiatric services. Full bio

sponsored links
Double-click the English subtitles below to play the video.
I want you to imagine this for a moment.
00:15
Two men, Rahul and Rajiv,
00:18
living in the same neighborhood,
00:21
from the same educational background, similar occupation,
00:23
and they both turn up at their local accident emergency
00:26
complaining of acute chest pain.
00:29
Rahul is offered a cardiac procedure,
00:32
but Rajiv is sent home.
00:35
What might explain the difference in the experience
00:38
of these two nearly identical men?
00:40
Rajiv suffers from a mental illness.
00:43
The difference in the quality of medical care
00:47
received by people with mental illness is one of the reasons
00:50
why they live shorter lives
00:53
than people without mental illness.
00:55
Even in the best-resourced countries in the world,
00:56
this life expectancy gap is as much as 20 years.
00:59
In the developing countries of the world, this gap
01:04
is even larger.
01:06
But of course, mental illnesses can kill in more direct ways
01:08
as well. The most obvious example is suicide.
01:11
It might surprise some of you here, as it did me,
01:15
when I discovered that suicide is at the top of the list
01:17
of the leading causes of death in young people
01:20
in all countries in the world,
01:23
including the poorest countries of the world.
01:24
But beyond the impact of a health condition
01:28
on life expectancy, we're also concerned
01:31
about the quality of life lived.
01:33
Now, in order for us to examine the overall impact
01:36
of a health condition both on life expectancy
01:38
as well as on the quality of life lived, we need to use
01:40
a metric called the DALY,
01:43
which stands for a Disability-Adjusted Life Year.
01:45
Now when we do that, we discover some startling things
01:49
about mental illness from a global perspective.
01:52
We discover that, for example, mental illnesses are
01:54
amongst the leading causes of disability around the world.
01:58
Depression, for example, is the third-leading cause
02:02
of disability, alongside conditions such as
02:05
diarrhea and pneumonia in children.
02:08
When you put all the mental illnesses together,
02:11
they account for roughly 15 percent
02:13
of the total global burden of disease.
02:16
Indeed, mental illnesses are also very damaging
02:19
to people's lives, but beyond just the burden of disease,
02:23
let us consider the absolute numbers.
02:29
The World Health Organization estimates
02:32
that there are nearly four to five hundred million people
02:34
living on our tiny planet
02:37
who are affected by a mental illness.
02:39
Now some of you here
02:41
look a bit astonished by that number,
02:42
but consider for a moment the incredible diversity
02:45
of mental illnesses, from autism and intellectual disability
02:47
in childhood, through to depression and anxiety,
02:51
substance misuse and psychosis in adulthood,
02:53
all the way through to dementia in old age,
02:55
and I'm pretty sure that each and every one us
02:57
present here today can think of at least one person,
03:00
at least one person, who's affected by mental illness
03:03
in our most intimate social networks.
03:07
I see some nodding heads there.
03:11
But beyond the staggering numbers,
03:14
what's truly important from a global health point of view,
03:17
what's truly worrying from a global health point of view,
03:20
is that the vast majority of these affected individuals
03:23
do not receive the care
03:26
that we know can transform their lives, and remember,
03:28
we do have robust evidence that a range of interventions,
03:31
medicines, psychological interventions,
03:34
and social interventions, can make a vast difference.
03:36
And yet, even in the best-resourced countries,
03:40
for example here in Europe, roughly 50 percent
03:42
of affected people don't receive these interventions.
03:45
In the sorts of countries I work in,
03:48
that so-called treatment gap
03:50
approaches an astonishing 90 percent.
03:52
It isn't surprising, then, that if you should speak
03:57
to anyone affected by a mental illness,
04:00
the chances are that you will hear stories
04:03
of hidden suffering, shame and discrimination
04:06
in nearly every sector of their lives.
04:10
But perhaps most heartbreaking of all
04:13
are the stories of the abuse
04:15
of even the most basic human rights,
04:18
such as the young woman shown in this image here
04:21
that are played out every day,
04:23
sadly, even in the very institutions that were built to care
04:26
for people with mental illnesses, the mental hospitals.
04:29
It's this injustice that has really driven my mission
04:33
to try to do a little bit to transform the lives
04:36
of people affected by mental illness, and a particularly
04:39
critical action that I focused on is to bridge the gulf
04:41
between the knowledge we have that can transform lives,
04:45
the knowledge of effective treatments, and how we actually
04:48
use that knowledge in the everyday world.
04:51
And an especially important challenge that I've had to face
04:54
is the great shortage of mental health professionals,
04:57
such as psychiatrists and psychologists,
05:00
particularly in the developing world.
05:02
Now I trained in medicine in India, and after that
05:05
I chose psychiatry as my specialty, much to the dismay
05:07
of my mother and all my family members who
05:11
kind of thought neurosurgery would be
05:13
a more respectable option for their brilliant son.
05:15
Any case, I went on, I soldiered on with psychiatry,
05:18
and found myself training in Britain in some of
05:20
the best hospitals in this country. I was very privileged.
05:23
I worked in a team of incredibly talented, compassionate,
05:25
but most importantly, highly trained, specialized
05:29
mental health professionals.
05:32
Soon after my training, I found myself working
05:34
first in Zimbabwe and then in India, and I was confronted
05:36
by an altogether new reality.
05:39
This was a reality of a world in which there were almost no
05:41
mental health professionals at all.
05:45
In Zimbabwe, for example, there were just about
05:47
a dozen psychiatrists, most of whom lived and worked
05:49
in Harare city, leaving only a couple
05:52
to address the mental health care needs
05:54
of nine million people living in the countryside.
05:57
In India, I found the situation was not a lot better.
06:00
To give you a perspective, if I had to translate
06:04
the proportion of psychiatrists in the population
06:06
that one might see in Britain to India,
06:09
one might expect roughly 150,000 psychiatrists in India.
06:11
In reality, take a guess.
06:17
The actual number is about 3,000,
06:20
about two percent of that number.
06:22
It became quickly apparent to me that I couldn't follow
06:25
the sorts of mental health care models that I had been trained in,
06:27
one that relied heavily on specialized, expensive
06:30
mental health professionals to provide mental health care
06:33
in countries like India and Zimbabwe.
06:36
I had to think out of the box about some other model
06:38
of care.
06:41
It was then that I came across these books,
06:42
and in these books I discovered the idea of task shifting
06:46
in global health.
06:49
The idea is actually quite simple. The idea is,
06:51
when you're short of specialized health care professionals,
06:53
use whoever is available in the community,
06:56
train them to provide a range of health care interventions,
06:59
and in these books I read inspiring examples,
07:02
for example of how ordinary people had been trained
07:05
to deliver babies,
07:08
diagnose and treat early pneumonia, to great effect.
07:09
And it struck me that if you could train ordinary people
07:13
to deliver such complex health care interventions,
07:16
then perhaps they could also do the same
07:18
with mental health care.
07:20
Well today, I'm very pleased to report to you
07:22
that there have been many experiments in task shifting
07:25
in mental health care across the developing world
07:28
over the past decade, and I want to share with you
07:31
the findings of three particular such experiments,
07:33
all three of which focused on depression,
07:35
the most common of all mental illnesses.
07:38
In rural Uganda, Paul Bolton and his colleagues,
07:40
using villagers, demonstrated that they could deliver
07:43
interpersonal psychotherapy for depression
07:47
and, using a randomized control design,
07:50
showed that 90 percent of the people receiving
07:52
this intervention recovered as compared
07:54
to roughly 40 percent in the comparison villages.
07:56
Similarly, using a randomized control trial in rural Pakistan,
08:00
Atif Rahman and his colleagues showed
08:04
that lady health visitors, who are community maternal
08:06
health workers in Pakistan's health care system,
08:09
could deliver cognitive behavior therapy for mothers
08:12
who were depressed, again showing dramatic differences
08:14
in the recovery rates. Roughly 75 percent of mothers
08:17
recovered as compared to about 45 percent
08:20
in the comparison villages.
08:22
And in my own trial in Goa, in India, we again showed
08:24
that lay counselors drawn from local communities
08:27
could be trained to deliver psychosocial interventions
08:30
for depression, anxiety, leading to 70 percent
08:33
recovery rates as compared to 50 percent
08:35
in the comparison primary health centers.
08:37
Now, if I had to draw together all these different
08:41
experiments in task shifting, and there have of course
08:43
been many other examples, and try and identify
08:45
what are the key lessons we can learn that makes
08:47
for a successful task shifting operation,
08:49
I have coined this particular acronym, SUNDAR.
08:53
What SUNDAR stands for, in Hindi, is "attractive."
08:56
It seems to me that there are five key lessons
09:01
that I've shown on this slide that are critically important
09:03
for effective task shifting.
09:05
The first is that we need to simplify the message
09:08
that we're using, stripping away all the jargon
09:11
that medicine has invented around itself.
09:13
We need to unpack complex health care interventions
09:16
into smaller components that can be more easily
09:19
transferred to less-trained individuals.
09:22
We need to deliver health care, not in large institutions,
09:24
but close to people's homes, and we need to deliver
09:27
health care using whoever is available and affordable
09:29
in our local communities.
09:32
And importantly, we need to reallocate the few specialists
09:34
who are available to perform roles
09:37
such as capacity-building and supervision.
09:39
Now for me, task shifting is an idea
09:43
with truly global significance,
09:45
because even though it has arisen out of the
09:48
situation of the lack of resources that you find
09:50
in developing countries, I think it has a lot of significance
09:54
for better-resourced countries as well. Why is that?
09:57
Well, in part, because health care in the developed world,
10:00
the health care costs in the [developed] world,
10:03
are rapidly spiraling out of control, and a huge chunk
10:06
of those costs are human resource costs.
10:08
But equally important is because health care has become
10:12
so incredibly professionalized that it's become very remote
10:14
and removed from local communities.
10:18
For me, what's truly sundar about the idea of task shifting,
10:21
though, isn't that it simply makes health care
10:25
more accessible and affordable but that
10:26
it is also fundamentally empowering.
10:29
It empowers ordinary people to be more effective
10:32
in caring for the health of others in their community,
10:35
and in doing so, to become better guardians
10:38
of their own health. Indeed, for me, task shifting
10:40
is the ultimate example of the democratization
10:43
of medical knowledge, and therefore, medical power.
10:46
Just over 30 years ago, the nations of the world assembled
10:51
at Alma-Ata and made this iconic declaration.
10:54
Well, I think all of you can guess
10:57
that 12 years on, we're still nowhere near that goal.
10:59
Still, today, armed with that knowledge
11:03
that ordinary people in the community
11:05
can be trained and, with sufficient supervision and support,
11:08
can deliver a range of health care interventions effectively,
11:11
perhaps that promise is within reach now.
11:15
Indeed, to implement the slogan of Health for All,
11:18
we will need to involve all
11:22
in that particular journey,
11:24
and in the case of mental health, in particular we would
11:25
need to involve people who are affected by mental illness
11:28
and their caregivers.
11:31
It is for this reason that, some years ago,
11:33
the Movement for Global Mental Health was founded
11:35
as a sort of a virtual platform upon which professionals
11:37
like myself and people affected by mental illness
11:41
could stand together, shoulder-to-shoulder,
11:44
and advocate for the rights of people with mental illness
11:47
to receive the care that we know can transform their lives,
11:49
and to live a life with dignity.
11:53
And in closing, when you have a moment of peace or quiet
11:56
in these very busy few days or perhaps afterwards,
11:59
spare a thought for that person you thought about
12:02
who has a mental illness, or persons that you thought about
12:05
who have mental illness,
12:07
and dare to care for them. Thank you. (Applause)
12:09
(Applause)
12:13
Translator:Joseph Geni
Reviewer:Morton Bast

sponsored links

Vikram Patel - Mental health care advocate
Vikram Patel helps bring better mental health care to low-resource communities -- by teaching ordinary people to deliver basic psychiatric services.

Why you should listen

In towns and villages that have few clinics, doctors and nurses, one particular need often gets overlooked: mental health. When there is no psychiatrist, how do people get care when they need it? Vikram Patel studies how to treat conditions like depression and schizophrenia in low-resource communities, and he's come up with a powerful model: training the community to help.

Based in Goa for much of the year, Patel is part of a policy group that's developing India's first national mental health policy; he's the co-founder of Sangath, a local NGO dedicated to mental health and family wellbeing. In London, he co-directs the Centre for Global Mental Health at the London School of Hygiene & Tropical Medicine. And he led the efforts to set up the Movement for Global Mental Health, a network that supports mental health care as a basic human right.

From Sangath's mission statement: "At the heart of our vision lies the ‘treatment gap’ for mental disorders; the gap between the number of people with a mental disorder and the number who receive care for their mental disorders."

The original video is available on TED.com
sponsored links

If you need translations, you can install "Google Translate" extension into your Chrome Browser.
Furthermore, you can change playback rate by installing "Video Speed Controller" extension.

Data provided by TED.

This website is owned and operated by Tokyo English Network.
The developer's blog is here.