For decades, many psychiatrists believed depression was a uniquely western phenomenon. But in the last few years, a new movement has turned this thinking on its head.
When Vikram Patel first began to study mental health, he believed depression only existed in rich nations. But today, he is the single most influential figure in the growing global movement to treat mental illness in poor countries, especially the most common disorder, depression.
Sadness is an appropriate response to adversity. But depression is not the same. (While the poor are more likely to be depressed, the vast majority of the poor are not, so poverty alone does not lead to depression.) Depression is a fog of negative thoughts that debilitate and paralyse the sufferer so she cannot respond to terrible events. “The question is how quickly you are able to get past distressing emotions so they don’t themselves acquire an independent effect on your life, and become a problem in themselves,” Patel said. “If your negative thoughts are coming in the way of solving a problem, if your sleeplessness affects work – that is compounding whatever triggered it.”
The disability caused by depression is actually much wider-ranging than the data from World Bank’s 1993 report suggested, because the numbers only measured depression’s direct effect on health. But depression also takes a huge indirect toll. It makes other diseases much worse. People who are depressed are more likely to get other illnesses, and less likely to be treated successfully. Depressed patients, for example, do not take their HIV medicine, and are less able to support their families or take care of others: babies of depressed mothers often aren’t well nurtured and fail to thrive.
Far from a luxury, treating depression is often a necessary first step towards solving other problems. Addressing poverty sometimes brings about a small improvement in people’s mental health, said Kari Frame, the programme director at Strong Minds, an organisation that helps depressed women in Uganda treat their illness by forming self-help groups. But addressing mental health very often leads to a big decrease in poverty.
In 2007, Patel and several other experts published a series of articles on global mental health that inaugurated a profound change in approaches to treatment worlwide. The series, in the prominent British medical journal The Lancet, warned that mental health disorders are neglected and stigmatised, and pointed to the critical shortage in mental health care. This was – and still is – true in rich countries: more than half of Americans who need treatment don’t get it, for example. But in poor countries, virtually no one was getting the care they needed.
In low- and low-middle-income countries, budgets for mental health treatment were less than 3% of an already meagre health provision. Most of that went to institutions housing people with severe mental illnesses such as schizophrenia. Such institutions were almost always understaffed, manned by poorly trained workers and dedicated to containing rather than treating their patients, using methods that often amounted to torture. Depression and anxiety got no treatment at all.
The Lancet articles proposed a massive expansion of mental health treatment worldwide. Richard Horton, the Lancet’s editor, urged people to join a new social movement to provide effective care for the world’s neediest populations. “The time to act is now,” the authors wrote.
Psychiatrists and psychologists were costly to train and pay. And how would poor countries keep them? Medical professionals often studied at their government’s expense – and then emigrated, to practise in North America or Europe.
The Lancet writers noted that one of the most important trends in global health was shifting tasks from professionals to lay people. Community health workers, who offer basic health information and services in the communities where they live, were not new – China’s “barefoot doctors” programme of the late 1960s was one example – but they had fallen out of favour. In the early 2000s, however, there was a resurgence of interest. Developing countries were training and paying (albeit poorly) millions of community health workers to teach nutrition, weigh babies, treat pneumonia and organise campaigns to clean up standing water.
Lay health workers didn’t deal with depression, but there was no reason they couldn’t, Patel and his colleagues argued. For all the suffering it causes, it turns out that diagnosing and treating many episodes of depression is actually not that complex.
To see the role that a lay person could play in addressing depression, I visited Santa Cruz high school in the Indian state of Goa. In September 2016, Mamta Verma set up a table and two plastic chairs in a crammed storeroom, and installed herself there on Monday and Wednesday mornings. For the first time, the school could offer its students counselling.
Verma exudes gentleness and warmth. She had studied psychology in college, and was getting her master’s degree through distance learning. But she was not a psychologist yet – and that was the whole point. If she were, she wouldn’t be working in a storeroom at a high school. She was testing a new programme created by Sangath, a Goa-based organisation founded by Patel and six colleagues in 1996.
Sangath – the name means “together” in Konkani, the official language of Goa – designs and studies ways to make mental health care as cheap and accessible as possible. When a programme works, Sangath then chips away at it to see how much it can shed without sacrificing results. If eight weeks of counselling bring success, how about six weeks? Could group therapy leaders get two weeks’ training instead of four? If someone with a high school education is leading the group, what about a community health worker with less education – or none? If the patient is a child, can his parents learn to deliver the therapy?
While I sat in her storeroom, a steady stream of students visited Verma to talk about parents who fight, classmates who bully, anger management, boy trouble, their weight, their skin, their concentration, their difficulties in Hindi or maths. Verma uses a workbook featuring Priyanka and Ajay, two fictional teenagers with typical teenage issues. Verma asked students to analyse what Priyanka and Ajay were facing and come up with solutions for them to try. Then the students applied these techniques to their own problems. This method is called problem-solving therapy.
Sangath is by far the most influential research organisation on mental health care in poor countries. It has 300 employees and fellows, and has published dozens of studies, many of which describe real breakthroughs in care. People visit from around the world to learn Sangath’s strategies for preventing or treating conditions such as postnatal depression, problem drinking, schizophrenia, depression in the elderly, stress in people with HIV and their caregivers, and teen depression and behaviour problems. All of these strategies involve lay therapists like Verma, and many use a version of the sort of problem-solving therapy she applies.
One example is Sangath’s health activity programme. The organisation trained lay people to give around eight weekly sessions of counselling to patients suffering from severe depression. The focus is helping patients stop doing things that make them feel bad – staying in bed, neglecting personal hygiene – and start doing healthy activities, such as talking to friends, engaging in hobbies or taking a walk. Counsellors also ask patients to brainstorm possible solutions to their problems, pick the best one and try it. It seems absurdly simple, but three months later, the patients who had been through just that brief programme were 64% more likely to be in remission than those that hadn’t.
Abas, the Institute for Psychiatry reader, said that although Sangath has been seminal, its approach to depression focuses too narrowly on single episodes. “Depression for most people is really a chronic illness,” she said. “I don’t think they’ve done enough to emphasise that. It’s important to get treatment when you’re really low, but if this relapses, what next?”
For most patients in wealthy countries, what’s next – or often what’s first – is an antidepressant. Abas points out that medicines are curiously absent from the global mental health movement. “It’s become very fashionable to talk about talk therapy,” she said. “A lot of people do really well with it. But some are too unwell to even start. If you are very depressed and your brain is shutting down, are you even able to talk?”
In the 12 years since Patel and his colleagues published their groundbreaking series of articles, global mental health has become a movement. When they were drafted in 2000, the UN’s millennium development goals for 2015 made no mention of mental health. Now, “mental health care for all” is a pillar of the UN sustainable development goals for 2030. Dozens of low-cost mental health care projects have sprung up around the world. Various networks, including the Mental Health Innovation Network, help them share information and ideas.
But an archipelago of small programmes is far from a global solution. China and India are trying to expand mental health care in rural areas, but it will be a long time coming. More than a decade after the articles that changed the debate on global mental health, there has been no real growth in access to treatment, in poor countries’ spending on mental health care, or in mental health care funding from wealthy countries.
There is one place, however, where mental health care has become a routine part of medical care, and that is Harare, Zimbabwe. The nation that proved to Patel that depression was universal has come up with a form of psychotherapy accessible to all – one that is effective, easy to duplicate and cheap.
When Patel taught psychiatry at Harare Central hospital in the early 1990s, Dixon Chibanda was one of his students. After graduation, the other five psychiatry students in Chibanda’s class all left Zimbabwe for richer countries. Chibanda stayed. He treated private patients to make money, but also worked in the psychiatric hospital, where much of his work consisted of prescribing medicine and trying to make sure people took it. “I got into psychiatry to connect with people and nurture the human spirit,” he told me. “But I was beginning to feel increasingly disconnected from the people I was trying to help.”