TEDGlobal 2012
Vikram Patel: Mental health for all by involving all
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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
Vikram Patel helps bring better mental health care to low-resource communities -- by teaching ordinary people to deliver basic psychiatric services. Full bio
Double-click the English transcript below to play the video.
00:16
I want you to imagine this for a moment.
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Two men, Rahul and Rajiv,
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living in the same neighborhood,
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from the same educational background, similar occupation,
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and they both turn up at their local accident emergency
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complaining of acute chest pain.
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Rahul is offered a cardiac procedure,
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but Rajiv is sent home.
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What might explain the difference in the experience
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of these two nearly identical men?
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Rajiv suffers from a mental illness.
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The difference in the quality of medical care
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received by people with mental illness is one of the reasons
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why they live shorter lives
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than people without mental illness.
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Even in the best-resourced countries in the world,
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this life expectancy gap is as much as 20 years.
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In the developing countries of the world, this gap
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is even larger.
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But of course, mental illnesses can kill in more direct ways
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as well. The most obvious example is suicide.
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It might surprise some of you here, as it did me,
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when I discovered that suicide is at the top of the list
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of the leading causes of death in young people
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in all countries in the world,
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including the poorest countries of the world.
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But beyond the impact of a health condition
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on life expectancy, we're also concerned
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about the quality of life lived.
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Now, in order for us to examine the overall impact
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of a health condition both on life expectancy
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as well as on the quality of life lived, we need to use
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a metric called the DALY,
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which stands for a Disability-Adjusted Life Year.
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Now when we do that, we discover some startling things
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about mental illness from a global perspective.
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We discover that, for example, mental illnesses are
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amongst the leading causes of disability around the world.
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Depression, for example, is the third-leading cause
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of disability, alongside conditions such as
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diarrhea and pneumonia in children.
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When you put all the mental illnesses together,
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they account for roughly 15 percent
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of the total global burden of disease.
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Indeed, mental illnesses are also very damaging
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to people's lives, but beyond just the burden of disease,
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let us consider the absolute numbers.
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The World Health Organization estimates
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that there are nearly four to five hundred million people
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living on our tiny planet
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who are affected by a mental illness.
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Now some of you here
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look a bit astonished by that number,
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but consider for a moment the incredible diversity
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of mental illnesses, from autism and intellectual disability
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in childhood, through to depression and anxiety,
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substance misuse and psychosis in adulthood,
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all the way through to dementia in old age,
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and I'm pretty sure that each and every one us
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present here today can think of at least one person,
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at least one person, who's affected by mental illness
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in our most intimate social networks.
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I see some nodding heads there.
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But beyond the staggering numbers,
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what's truly important from a global health point of view,
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what's truly worrying from a global health point of view,
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is that the vast majority of these affected individuals
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do not receive the care
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that we know can transform their lives, and remember,
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we do have robust evidence that a range of interventions,
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medicines, psychological interventions,
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and social interventions, can make a vast difference.
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And yet, even in the best-resourced countries,
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for example here in Europe, roughly 50 percent
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of affected people don't receive these interventions.
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In the sorts of countries I work in,
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that so-called treatment gap
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approaches an astonishing 90 percent.
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It isn't surprising, then, that if you should speak
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to anyone affected by a mental illness,
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the chances are that you will hear stories
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of hidden suffering, shame and discrimination
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in nearly every sector of their lives.
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But perhaps most heartbreaking of all
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are the stories of the abuse
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of even the most basic human rights,
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such as the young woman shown in this image here
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that are played out every day,
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sadly, even in the very institutions that were built to care
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for people with mental illnesses, the mental hospitals.
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It's this injustice that has really driven my mission
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to try to do a little bit to transform the lives
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of people affected by mental illness, and a particularly
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critical action that I focused on is to bridge the gulf
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between the knowledge we have that can transform lives,
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the knowledge of effective treatments, and how we actually
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use that knowledge in the everyday world.
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And an especially important challenge that I've had to face
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is the great shortage of mental health professionals,
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such as psychiatrists and psychologists,
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particularly in the developing world.
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Now I trained in medicine in India, and after that
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I chose psychiatry as my specialty, much to the dismay
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of my mother and all my family members who
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kind of thought neurosurgery would be
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a more respectable option for their brilliant son.
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Any case, I went on, I soldiered on with psychiatry,
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and found myself training in Britain in some of
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the best hospitals in this country. I was very privileged.
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I worked in a team of incredibly talented, compassionate,
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but most importantly, highly trained, specialized
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mental health professionals.
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Soon after my training, I found myself working
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first in Zimbabwe and then in India, and I was confronted
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by an altogether new reality.
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This was a reality of a world in which there were almost no
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mental health professionals at all.
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In Zimbabwe, for example, there were just about
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a dozen psychiatrists, most of whom lived and worked
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in Harare city, leaving only a couple
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to address the mental health care needs
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of nine million people living in the countryside.
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In India, I found the situation was not a lot better.
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To give you a perspective, if I had to translate
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the proportion of psychiatrists in the population
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that one might see in Britain to India,
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one might expect roughly 150,000 psychiatrists in India.
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In reality, take a guess.
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The actual number is about 3,000,
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about two percent of that number.
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It became quickly apparent to me that I couldn't follow
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the sorts of mental health care models that I had been trained in,
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one that relied heavily on specialized, expensive
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mental health professionals to provide mental health care
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in countries like India and Zimbabwe.
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I had to think out of the box about some other model
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of care.
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It was then that I came across these books,
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and in these books I discovered the idea of task shifting
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in global health.
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The idea is actually quite simple. The idea is,
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when you're short of specialized health care professionals,
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use whoever is available in the community,
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train them to provide a range of health care interventions,
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and in these books I read inspiring examples,
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for example of how ordinary people had been trained
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to deliver babies,
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diagnose and treat early pneumonia, to great effect.
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And it struck me that if you could train ordinary people
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to deliver such complex health care interventions,
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then perhaps they could also do the same
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with mental health care.
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Well today, I'm very pleased to report to you
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that there have been many experiments in task shifting
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in mental health care across the developing world
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over the past decade, and I want to share with you
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the findings of three particular such experiments,
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all three of which focused on depression,
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the most common of all mental illnesses.
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In rural Uganda, Paul Bolton and his colleagues,
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using villagers, demonstrated that they could deliver
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interpersonal psychotherapy for depression
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and, using a randomized control design,
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showed that 90 percent of the people receiving
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this intervention recovered as compared
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to roughly 40 percent in the comparison villages.
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Similarly, using a randomized control trial in rural Pakistan,
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Atif Rahman and his colleagues showed
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that lady health visitors, who are community maternal
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health workers in Pakistan's health care system,
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could deliver cognitive behavior therapy for mothers
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who were depressed, again showing dramatic differences
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in the recovery rates. Roughly 75 percent of mothers
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recovered as compared to about 45 percent
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in the comparison villages.
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And in my own trial in Goa, in India, we again showed
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that lay counselors drawn from local communities
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could be trained to deliver psychosocial interventions
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for depression, anxiety, leading to 70 percent
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recovery rates as compared to 50 percent
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in the comparison primary health centers.
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Now, if I had to draw together all these different
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experiments in task shifting, and there have of course
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been many other examples, and try and identify
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what are the key lessons we can learn that makes
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for a successful task shifting operation,
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I have coined this particular acronym, SUNDAR.
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What SUNDAR stands for, in Hindi, is "attractive."
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It seems to me that there are five key lessons
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that I've shown on this slide that are critically important
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for effective task shifting.
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The first is that we need to simplify the message
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that we're using, stripping away all the jargon
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that medicine has invented around itself.
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We need to unpack complex health care interventions
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into smaller components that can be more easily
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transferred to less-trained individuals.
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We need to deliver health care, not in large institutions,
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but close to people's homes, and we need to deliver
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health care using whoever is available and affordable
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in our local communities.
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And importantly, we need to reallocate the few specialists
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who are available to perform roles
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such as capacity-building and supervision.
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Now for me, task shifting is an idea
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with truly global significance,
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because even though it has arisen out of the
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situation of the lack of resources that you find
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in developing countries, I think it has a lot of significance
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for better-resourced countries as well. Why is that?
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Well, in part, because health care in the developed world,
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the health care costs in the [developed] world,
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are rapidly spiraling out of control, and a huge chunk
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of those costs are human resource costs.
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But equally important is because health care has become
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so incredibly professionalized that it's become very remote
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and removed from local communities.
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For me, what's truly sundar about the idea of task shifting,
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though, isn't that it simply makes health care
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more accessible and affordable but that
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it is also fundamentally empowering.
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It empowers ordinary people to be more effective
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in caring for the health of others in their community,
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and in doing so, to become better guardians
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of their own health. Indeed, for me, task shifting
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is the ultimate example of the democratization
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of medical knowledge, and therefore, medical power.
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Just over 30 years ago, the nations of the world assembled
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at Alma-Ata and made this iconic declaration.
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Well, I think all of you can guess
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that 12 years on, we're still nowhere near that goal.
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Still, today, armed with that knowledge
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that ordinary people in the community
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can be trained and, with sufficient supervision and support,
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can deliver a range of health care interventions effectively,
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perhaps that promise is within reach now.
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Indeed, to implement the slogan of Health for All,
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we will need to involve all
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in that particular journey,
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and in the case of mental health, in particular we would
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need to involve people who are affected by mental illness
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and their caregivers.
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It is for this reason that, some years ago,
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the Movement for Global Mental Health was founded
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as a sort of a virtual platform upon which professionals
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like myself and people affected by mental illness
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could stand together, shoulder-to-shoulder,
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and advocate for the rights of people with mental illness
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to receive the care that we know can transform their lives,
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and to live a life with dignity.
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And in closing, when you have a moment of peace or quiet
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in these very busy few days or perhaps afterwards,
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spare a thought for that person you thought about
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who has a mental illness, or persons that you thought about
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who have mental illness,
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and dare to care for them. Thank you. (Applause)
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(Applause)
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ABOUT THE SPEAKER
Vikram Patel - Mental health care advocateVikram 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."
Vikram Patel | Speaker | TED.com