'Societal Challenges, Global Health and Humane AI'

Monday 9 January, 2023

Honorary doctor Vikram Patel: ‘Every country is a developing country when it comes to mental health’

Despite vast amounts of funding flowing into the mental health care systems in many high-income countries, outcomes for patients have not improved over the past decades. This, Professor Vikram Patel of Harvard Medical School argues, is due to fundamentally wrong decisions in the systems of care driven by professional hierarchy and commercial stakes. 

During a lecture at the symposium Societal Challenges, Global Mental Health, and Humane AI, Patel highlighted what countries like the US and the Netherlands could learn from insights into effective mental healthcare that were gained in low and middle-income countries over the past 15 years. The symposium was organized by the Centre for Urban Mental Health on January 9th to celebrate the honorary doctorates awarded by the UvA to Patel and to Chris Manning, professor in Machine Learning at Stanford University.

Prescription based on a five-minute consult

During his lecture, Patel emphasized the effectiveness of psychosocial interventions. For depression, for example, the effectiveness of therapy is similar to that of antidepressants, while the chances of relapse are lower after therapy. Regardless, the overwhelming majority of patients reporting mental health problems get subscribed pills, rather than therapy. In the US, 90%of patients receive medication, while 23% get therapy. ‘And in most places in Africa and Asia, a prescription based on a five-minute consult is all that mental healthcare entails.’ That is for those individuals lucky enough to receive any type of care, which in low and middle-income countries is only a minority of the population. 

In search of alternative strategies, Patel pleas for utilising what is there. ‘How can we do better with the evidence we have?’ His proposition: identifying the essential ingredients of interventions like cognitive behavioral therapy and teaching a broad range of people within underserved communities to provide others with these ingredients. As an example, he mentions grandmothers in Zimbabwe that were trained to deliver a basic version of cognitive behavioral therapy to women suffering from a major depressive disorder. It proved very effective, in one of the pivotal studies on task shifting. Many randomized controlled trials have since corroborated the effectiveness of these non-specialist interventions.  

Waiting lists

According to Patel, these interventions should not take place at hospitals or clinics, but in schools, primary care centers, or people’s homes. They should be provided by whoever is available and trusted within the community, whether they’re nurses, midwives, or grandmothers. And they should not replace the existing mental healthcare structure in place, but widen its footprint and allow it to infiltrate further into communities. 

These interventions have proven effective over the past fifteen years in settings of scarcity. But, Patel argues, countries with a larger healthcare budget could also benefit from them, since they are also failing to alleviate the burden for people suffering from psychological problems. ‘When it comes to mental health, every country is a developing country.’ In the Netherlands, for example, long waiting lists hamper access to mental healthcare for those in need. 

The messy world of implementation

For these psychosocial interventions to make a mark, they need to reach the approximately 1 billion people worldwide who are currently suffering from mental health problems. This would require a break in existing hierarchies, where professionals welcome and recognize the added value that non-specialists can bring. Furthermore, it requires scaling up interventions that are currently available. ‘If it were a new pill that we’d been testing and that proved to be so effective, it would have been widely available by now, because there would be a commercial incentive. However, it is not. So as academics, we cannot afford to think: we study these interventions and someone else will scale them up. I’m afraid we have to enter the messy world of implementation ourselves.’

Patel does so through Empower, a not-for-profit effort of Harvard Medical School’s Global Mental Health at Harvard Initiative,  that delivers digital training and supervision ‘to anyone, anywhere to master the delivery of evidence-based psychological treatments and behavioral interventions.’

During the symposium, alongside Patel, Professor Claudi Bockting, co-director of the Centre for Urban Mental Health, discussed the potential of technology-driven interventions in Global Mental health. Furthermore, intercultural health communication specialist Barbara Schouten presented her research on increasing the availability, approachability, acceptability, and appropriateness of mental healthcare for refugees residing in the European Union.  

An honorary doctorate for professor Vikram Patel 

Patel was trained as a psychiatrist in London and worked in Zimbabwe and India before starting at Harvard University as The Pershing Square Professor of Global Health. He is one of the driving forces behind the rising recognition of mental health in low and middle-income countries as well as in the field of international aid. Upon suggestion by professor Reinout Wiers and professor Claudi Bockting, co-directors of the Centre for Urban Mental Health, Patel was awarded an honorary doctorate by the University of Amsterdam during the Dies Natalis on January 9th.

For more insights, please visit the relevant Twitter thread, here, and check out his talk on the left hand side...