Can Global Mental Health Change Your Mind?

Women were waiting in the heat with their children. Shaded by the canopy of a lovely tree with minute leaves swaying in the warm breeze, the kids were napping on their mothers’ capulana, a rectangular piece of cloth, usually in beautiful vibrant colors with traditional Mozambican designs. They were waiting to be seen at the one-stop clinic in XAI-XAI, Mozambique, where both mother and child would be cared for no matter what their ailments, the epitome of patient-centered care.

Our research team was there to visit a clinic piloting a World Health Organization (WHO) program to identify and treat people with epilepsy. As we prepared to launch our new study, which would leverage the infrastructure of this program to address other mental health problems, getting a sense of how the program works was essential. In most of the developing world, epilepsy is considered a mental health problem, but in some places it is believed to be the result of possession by spirits and also contagious. WHO has been determined to introduce systematic screening and treatment, and Mozambique is one of four countries selected to participate along with Vietnam, Myanmar, and Ghana.

We learned that patients were coming for treatment in droves. Yet, the nurses and medical technicians were excited rather than overwhelmed, exhilarated rather than burned out. Naturally, they were touched that the director for mental health from the Ministry of Health and the international visitors were interested in their work and how they were doing. But they also spoke about the excitement of treating people who were suffering from epilepsy and their pleasure at seeing the transformation in their patients’ lives rendered by that treatment.

Most people are perplexed when I tell them this story. “Wait. Why are you doing capacity building in Mozambique?” In a way, I cannot blame them. Having grown up in Puerto Rico and given my deep ties to Latin America, it is not at all obvious why “Moz,” as we call it affectionately, should be a focus of work for me. However, like many good things in life, it was fortuitous that I am able to do some of my global mental health research capacity building there. My dear colleague Milton Wainberg and I partnered with Brazil’s Universidade Federal de Sao Paulo to build psychiatric research capacity after an inspiring conversation with Sten Vermund from Vanderbilt. Sten is a pediatrician who had conducted research for decades to stem the HIV epidemic in Mozambique and other countries. He knew that the mental health needs of the country were vast and encouraged us to consider applying for NIH funding to do the work.

The stunning reality of mental health care in a country like Mozambique, which is the seventh poorest country in the world and has 13 psychiatrists for a population of 26 million, is that innovative strategies are being used. There will not be enough psychiatrists to treat all the patients who need care any time soon. Thus, they have embraced the notion that people can be trained to provide care, and it does not have to be a physician or nurse, let alone a specialist. The Ministry of Health is training psychiatric technicians to prescribe psychiatric medications and supervise community health workers, who in turn are being trained to provide evidence-based therapies such as motivational interviewing or interpersonal counseling.

You might assume that the situation in the United States is different. But think about it: even with 13 psychiatrists per 100,000 people, because 25 percent of the population has a mental health/substance use disorder, that translates into caseloads of about 2,000 patients per psychiatrist. Can you manage such a caseload? I don’t think I can. In some states, there are only six psychiatrists per 100,000 people, and in most parts of the country, psychiatrists are concentrated in urban or peri-urban settings. Given the actual numbers, even telepsychiatry will not make it possible for psychiatrists to treat all those in need.

Thus, we must be realistic. We need physician extenders to provide mental health care. We need to set up systems that utilize caseworkers, physician assistants, nurses, and social workers. The workflow needs to follow models such as those proposed in integrated care, with psychiatrists’ work reserved to manage the most complex or treatment-refractory cases and to supervise the rest of the team.

Now, think back to Mozambique. Together with WHO, the Ministry of Health is demonstrating that these strategies work for the treatment of epilepsy, which can be just as complex as the treatment for many psychiatric condition. They are finding that nurses and medical technicians can change the lives of patients and feel extremely rewarded by their work. They are showing that under-resourced health care systems can use novel strategies to address the needs of the population.

Can this example from global mental health change your mind? If strategies such as the one being used in Mozambique can increase access to health care in developing countries, there is every reason to believe that they can work here. Let’s open our minds and make that happen. ■