IIn most low-income countries less than 1 psychiatrist exists per 100,000 people and national budgets spend less than $1 per person on mental health. But mental illnesses are just as common in low-income countries as they are in high-income countries – and even higher in regions plagued with war, conflict, and displacement. Illustrating the kernel of truth that necessity is the mother of invention, there has been an explosion of innovation in low-income settings to advance desperately needed mental health services.
Columbia University Global Mental Health Program affiliated professor, Richard Negeubauer, recently highlighted important research and clinical work coming from diverse low and middle-income country settings that is changing the way we think about delivering mental health care. The lessons learned are valuable for us all – because better care for more people delivered effectively and efficiently is needed everywhere.
1. Local Community members without formal mental health education can be trained to deliver basic psychotherapy services in Uganda. One of the first randomized controlled trials for mental health in low and middle income countries was a landmark study of group interpersonal therapy in war-affected Uganda. The intervention led to large and significant reductions in depression for participants. Given its success, the World Health Organization has made the intervention manual available for widespread dissemination and use in countries around the world.
2. Chile includes depression treatment in their national insurance plan. An innovative study in Chile demonstrated that stepped-care for depression in primary care works better than treatment as usual. The intervention, led by non-medical health workers, includes psycho-education, regular follow-up appointments, and medication for individuals with severe depression. The Chilean government has already translated the research into policy. Depression is now a priority health condition, and depression treatment is included in Chile’s national insurance plan.
3. In Pakistan, cognitive behavioral therapy delivered by members of the local community not only reduces mother’s depression; it’s good for kids, too. The intervention, called Thinking Healthy reduces depression among new mothers AND the benefits extended to their infants who are also less likely to have frequent diarrheal episodes and are more likely to be immunized. Once again, this evidence led to policy recommendations, and Thinking Healthy was adopted by WHO in 2015. The manual is available in English and Spanish, and WHO is encouraging countries to implement it within maternal and child health services.
4. Therapy in the Eastern Democratic Republic of the Congo works even in conflict-laden contexts to improve mental health; no need to wait till things “calm down.” War-torn communities, political instability, and social and ethnic challenges are the norm here. But that didn’t stop researchers from conducting a randomized controlled trial of group cognitive processing therapy for survivors of sexual violence — 40% of women in the region have experienced sexual violence, a key weapon in the on-going war. The intervention, delivered by community-based paraprofessionals, works to reduce depression, anxiety, and PTSD symptoms.
5. When mental health interventions team up with primary care, good things happen in Zimbabwe. In two different programs, lay health workers are screening for common mental disorders, including depression and anxiety, in primary care in Zimbabwe. That is already innovative, but there’s more. For those who screen positive, a lay health worker delivers problem-solving therapy with education and support. Those who received the intervention improve and still look better at 6 months compared to usual outcomes. These results are being used to advocate for nation-wide scale-up.
The innovative work in Uganda, Chile, Pakistan, DRC, and Zimbabwe represents collaborations that have brought together global knowledge and local expertise. The results are contributing to building evidence-based mental health practices and policies around the world. I am reminded that creative solutions are born of necessity; they are realized when complementary resources and ideas come together for the greater good.