Research: Delivering Much-Needed Mental Health Care Where None Existed

There were few, if any, mental health care options for the 64-year-old woman in Chiapas, Mexico, who suffered from depression, anxiety, and social isolation. That’s because for every 100,000 residents in the country, there is barely a single psychiatrist, and most work in major urban cities. People who live in rural regions with mental health conditions must travel as much as six to nine hours for such care, according to a report in the journal Intervention. 

Enter Problem Management Plus, or PM+, a novel psychological support intervention developed by the World Health Organization and adapted in different countries and contexts by the cross-site mental health team at Partners In Health. Through PM+, the woman* from Chiapas was able to receive help that not only improved her symptoms, but also her outlook on life.  

“She was very content when we finished PM+ sessions,” reported Carolina Guzmán Roblero, her community mental health worker  with Compañeros En Salud, as PIH is known in Mexico.  “I would continue visiting her every once in a while…because we are also part of the community and our patients will always be regarded as our patients, so we will never abandon them. Whenever I found her listening to the radio, I would feel very joyful.” 

Problem Management Plus 

Over 5 billion people worldwide suffering from mental health conditions cannot access appropriate care, contributing to already-high disease burdens for nations around the world. According to the World Health Organization: “The failure to deliver effective mental health care to over 80% of people who need it represents the single most significant challenge for global mental health.” 

To bridge this gap, the WHO developed the PM+ intervention, which can be provided by lay practitioners and licensed mental health clinicians alike, to support adults living in poverty and afflicted with emotional, psychological, or daily life problems. Its goals are straightforward: to alleviate disabling symptoms and assist patients to develop new coping skills, such as stress management, general problem solving, behavioral change, and a stronger social support system. 

The five-session program “gives the space for people to narrate their stories for the very first time,” said Dr. Fátima Rodriguez, mental health coordinator for Compañeros En Salud. “Some arrive saying they haven’t told this story before, like telling about their abuse as a child…also knowing that other people have been through the same situation, have the same symptoms, it brings hope to know these symptoms can be treated.”  

Mental Health Care Across Sites 

Mental health care is embedded within primary care and at every PIH site, said Sarah Singer, PIH’s associate director of program & partnerships for mental health.  “The cross-site mental health program is an innovative and unique example of clinical integration and knowledge across sites.”  

Since 2016, working closely with local practitioners and community mental health experts, PIH has adapted the PM+ model in Peru, Rwanda, Mexico, and Malawi—with other sites exploring future adaptation of the intervention. Analyzing the cross-site development of these programs in a 2021 article published as well in Intervention, PIH authors concluded: “Our experience demonstrates PM+ is translatable across cultures and feasible for use in real-world public sector primary care and community contexts.” 

Every aspect of the program is refined to meet the needs of each site. In Mexico, for example, providers undergo three weeks of mental health training, including modules on basic mental health topics and accompaniment, specific PM+ skills, trauma-informed care and also suicide risk assessment. Other sites offer variations of this training, including ongoing clinical supervision.  

Symptoms are ‘Culture Bound’ 

Mental health is, of course, cultural, so listening and adapting to each region's customs, language, and beliefs is critical, said Dr. Ksakrad Kelly, PIH’s cross-site senior psychotherapy technical advisor.  

“There’s a recognition that symptoms are culture bound,” Kelly said. “Depression, anxiety, and trauma can be very different, even within one household.” It’s this degree of specificity that is explored and developed in PIH’s adaptation process, she said, adding, “there’s not a specific standard approach; we let the sites take the lead.” 

For example, Kelly said, one standard question on a widely used depression screening tool is, “How often do you feel angry?” In Liberia, where the team implements other types of psychotherapy, the word “angry” is not used, so instead a word closer to “vexxed” replaced it in the questionnaire.   

In Mexico, for instance, one measure used to evaluate a person’s clinical functioning is whether they look disheveled or haven’t taken the time to arrange themselves. But “being disheveled doesn’t reflect if you’re depressed or not,” said Rodriguez, also the lead author on a paper detailing the adaptation of PM+ in Chiapas. 

The disheveled question is gone, Rodriguez said. Now, there are four questions that remain as the most relevant when assessing daily life functioning. Patients are asked whether they are having trouble sleeping, eating, with interpersonal relationships, or dealing with routine domestic tasks.  

Care delivery focuses on each individual patient’s needs and can include a combination of cognitive behavioral therapy, a kind of intentional reframing of problems, as well as relaxation techniques and “behavior activation,” which involves the deliberate practice of certain healthy behaviors to jump-start a more positive emotional state.  

In Malawi, for instance, the team adapted PM+ materials for group settings and trained lay mental health counselors to screen mothers for depression at routine prenatal visits in an effort to treat depression in pregnant and postpartum women. Like all of PIH’s mental health work, care delivery sites determine the priority needs of their communities and tailor the relevant interventions to fit those needs. 

Establishing a Connection 

Rodriguez cited another example in Mexico that involved flipping a script with patients to work through barriers. This, of course, could only be done by establishing strong relationships, she said. 

Initially, patient evaluations began with a checklist of clinical signs and symptoms, followed by a discussion that delved deeper into personal and psychological challenges, Rodriguez said. Health workers noticed that people were somewhat hesitant when the visit launched straight into a just-the-facts medical questionnaire, so they decided to begin each visit with conversation to try to establish rapport with patients who may have been hesitant to reveal personal information. Now, the health workers spend “a considerable amount of time,” around 20 minutes, conversing, before they ask about symptoms.   

“We inverted that order, because the patients told us they would feel the conversation was very abrupt” when workers launched right into the clinical checklist, Rodriguez said. “That’s how Mexico works. We are a lot about conversation, being warm.” 

Clear Mental Health Impact 

Data on the program in Chiapas shows the program’s success: 

About 70% of people who have been through PM+ reported a reduction in clinical symptoms, Rodriguez said. Currently 280 patients have enrolled in the program, and its managers have now widened the criteria for eligibility to include people experiencing gender or sexual violence, which impacts more than 68% of women in the community.   

“Through COVID, there weren’t any other providers addressing any of this, so we opened up criteria [for participation],” Rodriguez said.  

To date, almost 7,000 people have received PM+ across PIH’s four sites implementing the intervention, administrators said. 

And the approach continues to spread. PIH’s mental health adaptations around the world are now extending to the U.S., Singer said. Currently, PIH is working with a Massachusetts-based foundation and the nonprofit, The Family Van—through its Healthy Roads Program—to provide technical assistance on how to adapt PM+ for community-based organizations looking to provide mental health support across the Commonwealth of Massachusetts.

“Here’s a genuine opportunity for bi-directional knowledge exchange,” Singer added. “This is core to PIH’s mission and here’s a true example of making it work.”  

*Name has been withheld to protect the patient’s privacy