Mental Health Team Expanding Innovative, Pioneering Care
Dr. Giuseppe “Bepi” Raviola has provided pro bono mental health support for Partners In Health staff since 2000 and formally joined the organization in 2010. As PIH’s Director of Mental Health, he oversees a growing program that, among other initiatives, is caring for thousands of people in Haiti and Rwanda; developing a safe house program for women with chronic mental illness in Peru; and launching a collaborative to treat common mental disorders in communities in eight countries. Few other organizations are doing as much, or have expanded as quickly. Ahead of World Mental Health Day, Raviola sat down for a quick talk about bringing care and treatment to the communities and homes that need it most.
Tell us a little about the progression of mental health programs across PIH sites in recent years.
Over the past seven to eight years, we’ve developed a lot of experience delivering mental health care in Haiti and Rwanda. In each of those countries we have several thousand people receiving care. And over the past five years, we’ve been working with all the other sites to support further integration of mental health care within existing primary care platforms.
A lot of that work has focused on care of severe mental disorders—psychotic disorders, schizophrenia, bipolar disorder—because those are the people who tend to present to our hospitals in crisis. But we have also wanted to address common mental disorders, such as depression, post-traumatic stress, anxiety, and somatic disorders.
Over the past year, we’ve increasingly moved a number of sites toward thinking about how to address common mental disorders with non-specialists.
Those conversations have really accelerated recently.
What has tended to happen with our small mental health teams at the sites is that they’ve at times been so overwhelmed with the care of people living with psychotic disorders. It’s been difficult to give time and attention to common mental disorders, which are a significant burden in communities and societies globally. The challenge of providing clinical supervision for common mental disorders is also a challenge we face at our sites.
A year ago, Dr. Vikram Patel, who is a preeminent thinker in global mental health, became a new professor at Harvard, in the Department of Global Health and Social Medicine, where I also am on the faculty. He has been a leader in research on the mobilization of community health workers for care of common mental disorders. He is a founder of Sangath, which is a community-based organization in India that has both mobilized community health workers for mental health care and done significant research on that process.
As he and I put our heads together, we thought it would be great to bring together implementers and researchers on the topic of community-delivered care for common mental disorders, and the bottleneck that affect groups like PIH who are at the front line. We had a significant meeting at the Harvard Center for Global Health Delivery-Dubai to support this aim.
That led to a lot of groundbreaking ideas on best practices, supported by everyone from community health workers to academic researchers. What was one concrete result?
We are working toward an important consensus statement from that meeting, with recommendations for best practices in community-delivered care for common mental disorders. This month, we will be announcing a new initiative at PIH called the Many Voices Collaborative in Community Mental Health at PIH.
Our cross-site mental health team will provide support, including seed funding, to eight sites in deepening community health worker-delivered care of common mental disorders.
How else has academia shaped PIH’s global mental health work recently?
We have a fellowship in global mental health delivery at PIH, shared with Harvard Medical School. It’s called the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery. We have fellows in Haiti and Rwanda, and we’re expanding the fellowship to West Africa, southern Africa, and Latin America. The West Africa fellowship will be shared between Sierra Leone and Liberia, southern Africa will be shared between Lesotho and Malawi, and Latin America will be shared between Mexico and Peru.
So our cross-site team is growing, and mental health care delivery is expanding. We are also increasingly engaged in advocacy for the need for greater commitments to global mental health delivery. Paul Farmer and I published a commentary on October 10, World Mental Health Day, in support of the Lancet Commission on Mental Health and Sustainable Development.
Can you share a sense of the need for mental health care in low- to middle-income countries, particularly regarding depression?
Mental disorders represent the greatest collective cause of disability today. Depression is the most common mental disorder. It affects 350 million people globally, it represents the leading cause of disability around the world—more than ischemic heart disease, road traffic accidents, cerebrovascular disease, and chronic obstructive pulmonary disease.
Although mental disorders significantly impact people in low- and middle-income countries and 80 percent of the world’s population live in these regions, greater than 90 percent of mental health resources are spent in high-income countries.
And furthermore, the treatment gap for people with mental disorders—that is, the gap between how many people have disorders and how many are receiving care—exceeds 50 percent in all countries worldwide, but it approaches rates as high as 90 percent in the least-resourced countries. And 75 percent of lifetime cases of mental health conditions begin by age 24, which tells us that we need to be thinking about prevention and early intervention as well as treatment.
How do community health workers begin to address these problems?
Community health workers can provide basic psychosocial and psychological interventions, both clinical and preventive. In Haiti, for example, we have developed a toolkit for community health workers that starts with basic information about the origins of mental illness and human rights; the role of culture and traditional belief systems; and basic skills in delivering psychological interventions that are helpful and effective. Also, it includes information on how to talk about mental health with people in the community. Helping people understand that mental disorders are highly treatable—and linked to human rights, as well as to stigma and potential discrimination—is really important.
Let’s talk more about the Many Voices Collaborative, what it is and what it might mean for country sites.
The Many Voices Collaborative will provide seed funding and implementation support to the sites, to either build a basic level of management capacity and care delivery capacity that they haven’t had, with a focus on common mental disorders, or to enable sites to deepen their engagement on a range of mental health conditions in the community.
For example, in Liberia, for two years, a small, local mental health team has been delivering care to hundreds of people. Mostly people are living with psychosis and are homeless on the streets of Harper. The team has been getting incredible results and the work has been very well-received and very important in reducing stigma in the community. For many people served, it’s been lifesaving. But the team has been limited in its ability to address common mental disorders, so we’ll be hiring additional community health workers and build this other component into the work in Liberia.
In the countries where PIH works, how often are mental health problems seen as shameful or disgraceful, and how do you address that?
Stigma can be embedded not just in communities, but also in the health system. It’s a huge barrier. What we’ve found is that possibly the most effective counteraction to stigma is delivery of care. Often it’s remarkable, the degree to which providing people with effective care dramatically improves lives, and eradicates stigma.
We’ve talked about a lot of growth in mental health programming and support: the Many Voices Collaborative, new staff, new funding. What’s helping us turn the corner?
Our mental health team is small, but what we are doing is quite innovative. We have an essential focus on building systems of care that are safe, effective, evidence-based, and culturally sound. Our work integrates research evidence from science, but at our core we provide accompaniment to local teams implementing needed services at the front line, where not many people work. We’re having success because our teams have real-world experience with the challenges of delivering care in difficult circumstances. And when you meet the people we serve, you’ll see that people’s lives are greatly improved.