Mental Health for All by Involving All | Vikram Patel | TED Talks

Summary

The script addresses the disparity in medical care for individuals with mental illnesses, contributing to a significant life expectancy gap. It highlights the global burden of mental illnesses, including their prevalence and impact on disability and life quality, measured by DALYs. The speaker advocates for 'task shifting' in mental health care, training community members to provide interventions, as a solution to the shortage of professionals, especially in developing countries. The effectiveness of this approach is demonstrated through various studies, emphasizing the empowerment and democratization of medical knowledge.

Takeaways

• 😔 Mental illness significantly impacts the quality and duration of life, with affected individuals living up to 20 years less than those without mental health conditions, even in developed countries.
• 🏥 The disparity in medical care received by individuals with mental illness contributes to their shorter life expectancy and is a global concern.
• 🔪 Suicide is a leading cause of death among young people worldwide, highlighting the urgency of addressing mental health issues.
• 📊 The DALY (Disability-Adjusted Life Year) metric reveals that mental illnesses are among the top causes of disability globally, with depression ranking third.
• 🌐 When considering the total burden of disease, mental illnesses account for about 15% of the global health burden, emphasizing their widespread impact.
• 🌍 The World Health Organization estimates nearly 400-500 million people globally are affected by mental illnesses, underscoring the scale of the issue.
• 🤔 The vast majority of those affected by mental illness do not receive adequate care, with treatment gaps reaching up to 90% in some regions.
• 💊 Evidence-based interventions such as medication, psychological, and social interventions can significantly improve mental health outcomes but are underutilized.
• 🌱 The concept of 'task shifting' in global health involves training community members to deliver healthcare interventions, offering a solution to the shortage of mental health professionals.
• 🌟 Successful task shifting in mental health care has been demonstrated in various settings, with high recovery rates achieved through trained non-specialists.
• 🔑 The acronym SUNDAR (attractive in Hindi) encapsulates key lessons for effective task shifting, emphasizing simplification, unpacking, accessibility, reallocation of specialists, and empowerment of community members.

Q & A

What is the disparity in medical care that Rahul and Rajiv experienced in the script?

Rahul and Rajiv, despite being nearly identical in background and presenting similar symptoms, received different treatments at the emergency department due to Rajiv's mental illness, which may have led to a difference in the quality of care and outcomes.

Why do people with mental illness tend to have shorter life expectancies?

People with mental illness often receive lower quality medical care, which contributes to their shorter life expectancies. Additionally, mental illnesses can lead to more direct causes of death, such as suicide.

What is the life expectancy gap between people with and without mental illness in the best-resourced countries?

In the best-resourced countries, the life expectancy gap between people with mental illness and those without can be as much as 20 years.

What metric is used to examine the overall impact of a health condition on life expectancy and quality of life?

The metric used to examine the overall impact of a health condition on life expectancy and quality of life is the DALY, which stands for Disability-Adjusted Life Year.

What is the global ranking of mental illnesses in terms of disability?

Mental illnesses are among the leading causes of disability worldwide. For example, depression is the third-leading cause of disability.

What percentage of the total global burden of disease is attributed to mental illnesses when combined?

When all mental illnesses are combined, they account for roughly 15 percent of the total global burden of disease.

How many people are estimated by the World Health Organization to be affected by mental illness globally?

The World Health Organization estimates that nearly four to five hundred million people globally are affected by mental illness.

What is the treatment gap for mental illnesses in the countries where the speaker works?

In the countries where the speaker works, the treatment gap for mental illnesses approaches an astonishing 90 percent, meaning that a vast majority of affected individuals do not receive the necessary care.

What is the concept of 'task shifting' in global health, and how does it relate to mental health care?

Task shifting in global health is the idea of training non-specialized or less-specialized individuals in the community to provide health care interventions when there is a shortage of specialized health professionals. In mental health care, this concept has been applied to train individuals like lay counselors to deliver psychosocial interventions for mental illnesses.

What are the key lessons for a successful task shifting operation in mental health care according to the acronym SUNDAR?

The acronym SUNDAR stands for five key lessons: simplify the message, unpack complex interventions, deliver care close to home, use available and affordable local resources, and reallocate specialists for capacity-building and supervision.

How does task shifting in mental health care contribute to the democratization of medical knowledge and power?

Task shifting contributes to the democratization of medical knowledge and power by empowering ordinary people to provide effective health care in their communities, making health care more accessible and fostering better guardianship of health at a local level.

What was the goal declared at Alma-Ata 30 years ago, and how does task shifting relate to achieving this goal?

The goal declared at Alma-Ata was 'Health for All.' Task shifting relates to achieving this goal by enabling the training of community members to deliver health care interventions, thus involving all in the journey towards universal health coverage, especially in mental health.

Outlines

00:00

😔 Inequality in Healthcare for the Mentally Ill

The first paragraph introduces the disparity in medical treatment received by individuals with mental illnesses compared to those without, using the hypothetical scenario of two similar men, Rahul and Rajiv. It emphasizes that mental illnesses can significantly reduce life expectancy and contribute to higher mortality rates, especially through suicide, which is a leading cause of death among young people globally. The speaker introduces the DALY metric to assess the overall impact of health conditions on life expectancy and quality of life, revealing that mental illnesses are a major cause of disability worldwide. The paragraph concludes by highlighting the vast number of people affected by mental illnesses and the lack of adequate care, even in developed countries.

05:00

🌐 Task Shifting in Global Mental Health

The second paragraph discusses the shortage of mental health professionals, particularly in developing countries, and the innovative approach of task shifting to address this issue. The speaker shares personal experiences from Zimbabwe and India, illustrating the stark contrast between the availability of mental health professionals in developed and developing nations. Task shifting involves training community members to deliver healthcare interventions, inspired by successful examples in other areas of healthcare. The speaker reports on three studies from Uganda, Pakistan, and India, showing the effectiveness of task shifting in treating depression with high recovery rates. The paragraph concludes with the acronym SUNDAR, summarizing key lessons for successful task shifting in healthcare.

10:04

🌟 The Empowerment and Democratization of Healthcare

The final paragraph emphasizes the importance of task shifting not only for making healthcare more accessible and affordable but also for empowering communities to take charge of their health. It argues that task shifting is a form of democratizing medical knowledge and power, allowing ordinary people to become effective caregivers within their communities. The speaker reflects on the Alma-Ata declaration and the ongoing struggle to achieve 'Health for All,' suggesting that involving affected individuals and caregivers in the process is crucial. The Movement for Global Mental Health is mentioned as a platform for advocacy and unity. The speaker concludes with a call to action, encouraging the audience to consider and care for those with mental illnesses in their lives.

Keywords

💡Mental Illness

Mental illness refers to a wide range of mental health conditions that affect mood, thinking, and behavior. In the video, mental illness is highlighted as a significant global health issue that impacts life expectancy and quality of life. The speaker emphasizes that mental illnesses, such as depression, anxiety, and psychosis, contribute to a substantial portion of the global disease burden, yet are often inadequately treated, particularly in developing countries.

💡Life Expectancy Gap

The life expectancy gap is the difference in average lifespan between people with and without mental illness. The video discusses how this gap can be as large as 20 years, even in well-resourced countries, due to disparities in the quality of care and the neglect of mental health issues. The concept is central to understanding the broader impact of mental illness on both individual lives and public health.

💡Disability-Adjusted Life Year (DALY)

The Disability-Adjusted Life Year (DALY) is a metric used to assess the overall burden of disease by considering both years of life lost due to premature death and years lived with disability. In the context of the video, DALY is used to illustrate the significant impact of mental illnesses, which account for a substantial portion of the global disease burden, underscoring the need for better mental health care.

💡Treatment Gap

The treatment gap refers to the difference between the number of people who need care for mental illnesses and those who actually receive it. The video highlights that this gap is particularly wide in developing countries, where up to 90% of individuals with mental illness do not receive appropriate care, contributing to ongoing suffering and discrimination.

💡Task Shifting

Task shifting is a strategy in global health where less specialized workers are trained to deliver specific health care services, traditionally provided by highly trained professionals. The speaker discusses task shifting as a solution to the shortage of mental health professionals in developing countries, providing examples from Uganda, Pakistan, and India, where community members were successfully trained to deliver mental health interventions.

💡Depression

Depression is a common mental illness characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities. In the video, depression is mentioned as one of the leading causes of disability worldwide. The speaker presents various studies where community health workers were trained to treat depression, resulting in significant recovery rates, highlighting the effectiveness of task shifting in mental health care.

💡Global Mental Health

Global mental health is a field of study and practice focusing on improving mental health care worldwide, particularly in low- and middle-income countries. The video discusses the global disparities in mental health care, emphasizing the need for innovative solutions, like task shifting, to address the challenges faced by people with mental illnesses globally.

💡Human Rights

Human rights in the context of mental health refer to the basic rights and freedoms that all individuals, including those with mental illness, are entitled to. The speaker highlights the frequent violation of these rights, particularly in mental hospitals where patients may experience abuse and neglect, advocating for the dignity and proper care of individuals with mental illness as a fundamental human right.

💡Empowerment

Empowerment in this context refers to enabling ordinary people to provide health care, thereby enhancing their ability to care for themselves and others in their community. The video describes how task shifting empowers community members by training them to deliver mental health interventions, which not only improves access to care but also democratizes medical knowledge and power.

💡Health for All

Health for All is a global health movement that aims to ensure that everyone has access to the health care they need. The video concludes by linking the concept of task shifting to the broader goal of Health for All, suggesting that involving communities in delivering care is essential for achieving universal health coverage, particularly in the area of mental health.

Highlights

The significant disparity in medical care received by individuals with mental illness, contributing to their shorter life expectancy.

The life expectancy gap between people with mental illness and those without can be up to 20 years in developed countries and even larger in developing ones.

Mental illnesses, including suicide, are among the leading causes of death in young people globally.

The use of DALY (Disability-Adjusted Life Year) as a metric to measure the impact of health conditions on life expectancy and quality of life.

Mental illnesses account for approximately 15% of the total global burden of disease.

Nearly 400-500 million people worldwide are affected by mental illnesses, highlighting their prevalence and diversity.

The vast majority of individuals with mental illnesses do not receive adequate care, even in resource-rich countries.

The stark reality of untreated mental illness leading to hidden suffering, shame, and discrimination.

Horrifying accounts of abuse of basic human rights within mental health institutions meant to care for the mentally ill.

The speaker's personal mission to transform the lives of those affected by mental illness through bridging the gap between knowledge and practice.

The critical shortage of mental health professionals, especially in developing countries, as a major challenge.

The concept of task shifting in global health as a solution to the shortage of specialized health professionals.

Successful examples of task shifting in mental health care in rural Uganda, Pakistan, and India, demonstrating the effectiveness of non-specialist interventions.

The acronym SUNDAR as a framework for successful task shifting operations in mental health care.

The empowerment of ordinary people through task shifting to improve community health care and their own health guardianship.

Task shifting as a democratization of medical knowledge and power, making health care more accessible and affordable.

The Alma-Ata declaration and the ongoing struggle to achieve 'Health for All', emphasizing the need for community involvement.

The establishment of the Movement for Global Mental Health as a platform for joint advocacy by professionals and those affected by mental illness.

A call to action for individuals to consider and care for those with mental illnesses in their social networks.

Transcripts

Translator: Joseph Geni Reviewer: Morton Bast

I want you to imagine this for a moment.

Two men, Rahul and Rajiv,

living in the same neighborhood,

from the same educational background, similar occupation,

and they both turn up at their local accident emergency

complaining of acute chest pain.

Rahul is offered a cardiac procedure,

but Rajiv is sent home.

What might explain the difference in the experience

of these two nearly identical men?

Rajiv suffers from a mental illness.

The difference in the quality of medical care

received by people with mental illness is one of the reasons

why they live shorter lives

than people without mental illness.

Even in the best-resourced countries in the world,

this life expectancy gap is as much as 20 years.

In the developing countries of the world, this gap

is even larger.

But of course, mental illnesses can kill in more direct ways

as well. The most obvious example is suicide.

It might surprise some of you here, as it did me,

when I discovered that suicide is at the top of the list

of the leading causes of death in young people

in all countries in the world,

including the poorest countries of the world.

But beyond the impact of a health condition

on life expectancy, we're also concerned

about the quality of life lived.

Now, in order for us to examine the overall impact

of a health condition both on life expectancy

as well as on the quality of life lived, we need to use

a metric called the DALY,

which stands for a Disability-Adjusted Life Year.

Now when we do that, we discover some startling things

about mental illness from a global perspective.

We discover that, for example, mental illnesses are

amongst the leading causes of disability around the world.

Depression, for example, is the third-leading cause

of disability, alongside conditions such as

diarrhea and pneumonia in children.

When you put all the mental illnesses together,

they account for roughly 15 percent

of the total global burden of disease.

Indeed, mental illnesses are also very damaging

to people's lives, but beyond just the burden of disease,

let us consider the absolute numbers.

The World Health Organization estimates

that there are nearly four to five hundred million people

living on our tiny planet

who are affected by a mental illness.

Now some of you here

look a bit astonished by that number,

but consider for a moment the incredible diversity

of mental illnesses, from autism and intellectual disability

in childhood, through to depression and anxiety,

substance misuse and psychosis in adulthood,

all the way through to dementia in old age,

and I'm pretty sure that each and every one us

present here today can think of at least one person,

at least one person, who's affected by mental illness

in our most intimate social networks.

I see some nodding heads there.

But beyond the staggering numbers,

what's truly important from a global health point of view,

what's truly worrying from a global health point of view,

is that the vast majority of these affected individuals

do not receive the care

that we know can transform their lives, and remember,

we do have robust evidence that a range of interventions,

medicines, psychological interventions,

and social interventions, can make a vast difference.

And yet, even in the best-resourced countries,

for example here in Europe, roughly 50 percent

of affected people don't receive these interventions.

In the sorts of countries I work in,

that so-called treatment gap

approaches an astonishing 90 percent.

It isn't surprising, then, that if you should speak

to anyone affected by a mental illness,

the chances are that you will hear stories

of hidden suffering, shame and discrimination

in nearly every sector of their lives.

But perhaps most heartbreaking of all

are the stories of the abuse

of even the most basic human rights,

such as the young woman shown in this image here

that are played out every day,

sadly, even in the very institutions that were built to care

for people with mental illnesses, the mental hospitals.

It's this injustice that has really driven my mission

to try to do a little bit to transform the lives

of people affected by mental illness, and a particularly

critical action that I focused on is to bridge the gulf

between the knowledge we have that can transform lives,

the knowledge of effective treatments, and how we actually

use that knowledge in the everyday world.

And an especially important challenge that I've had to face

is the great shortage of mental health professionals,

such as psychiatrists and psychologists,

particularly in the developing world.

Now I trained in medicine in India, and after that

I chose psychiatry as my specialty, much to the dismay

of my mother and all my family members who

kind of thought neurosurgery would be

a more respectable option for their brilliant son.

Any case, I went on, I soldiered on with psychiatry,

and found myself training in Britain in some of

the best hospitals in this country. I was very privileged.

I worked in a team of incredibly talented, compassionate,

but most importantly, highly trained, specialized

mental health professionals.

Soon after my training, I found myself working

first in Zimbabwe and then in India, and I was confronted

by an altogether new reality.

This was a reality of a world in which there were almost no

mental health professionals at all.

In Zimbabwe, for example, there were just about

a dozen psychiatrists, most of whom lived and worked

in Harare city, leaving only a couple

to address the mental health care needs

of nine million people living in the countryside.

In India, I found the situation was not a lot better.

To give you a perspective, if I had to translate

the proportion of psychiatrists in the population

that one might see in Britain to India,

one might expect roughly 150,000 psychiatrists in India.

In reality, take a guess.

The actual number is about 3,000,

about two percent of that number.

It became quickly apparent to me that I couldn't follow

the sorts of mental health care models that I had been trained in,

one that relied heavily on specialized, expensive

mental health professionals to provide mental health care

in countries like India and Zimbabwe.

I had to think out of the box about some other model

of care.

It was then that I came across these books,

and in these books I discovered the idea of task shifting

in global health.

The idea is actually quite simple. The idea is,

when you're short of specialized health care professionals,

use whoever is available in the community,

train them to provide a range of health care interventions,

and in these books I read inspiring examples,

for example of how ordinary people had been trained

to deliver babies,

diagnose and treat early pneumonia, to great effect.

And it struck me that if you could train ordinary people

to deliver such complex health care interventions,

then perhaps they could also do the same

with mental health care.

Well today, I'm very pleased to report to you

that there have been many experiments in task shifting

in mental health care across the developing world

over the past decade, and I want to share with you

the findings of three particular such experiments,

all three of which focused on depression,

the most common of all mental illnesses.

In rural Uganda, Paul Bolton and his colleagues,

using villagers, demonstrated that they could deliver

interpersonal psychotherapy for depression

and, using a randomized control design,

showed that 90 percent of the people receiving

this intervention recovered as compared

to roughly 40 percent in the comparison villages.

Similarly, using a randomized control trial in rural Pakistan,

Atif Rahman and his colleagues showed

that lady health visitors, who are community maternal

health workers in Pakistan's health care system,

could deliver cognitive behavior therapy for mothers

who were depressed, again showing dramatic differences

in the recovery rates. Roughly 75 percent of mothers

recovered as compared to about 45 percent

in the comparison villages.

And in my own trial in Goa, in India, we again showed

that lay counselors drawn from local communities

could be trained to deliver psychosocial interventions

for depression, anxiety, leading to 70 percent

recovery rates as compared to 50 percent

in the comparison primary health centers.

Now, if I had to draw together all these different

experiments in task shifting, and there have of course

been many other examples, and try and identify

what are the key lessons we can learn that makes

for a successful task shifting operation,

I have coined this particular acronym, SUNDAR.

What SUNDAR stands for, in Hindi, is "attractive."

It seems to me that there are five key lessons

that I've shown on this slide that are critically important

for effective task shifting.

The first is that we need to simplify the message

that we're using, stripping away all the jargon

that medicine has invented around itself.

We need to unpack complex health care interventions

into smaller components that can be more easily

transferred to less-trained individuals.

We need to deliver health care, not in large institutions,

but close to people's homes, and we need to deliver

health care using whoever is available and affordable

in our local communities.

And importantly, we need to reallocate the few specialists

who are available to perform roles

such as capacity-building and supervision.

Now for me, task shifting is an idea

with truly global significance,

because even though it has arisen out of the

situation of the lack of resources that you find

in developing countries, I think it has a lot of significance

for better-resourced countries as well. Why is that?

Well, in part, because health care in the developed world,

the health care costs in the [developed] world,

are rapidly spiraling out of control, and a huge chunk

of those costs are human resource costs.

But equally important is because health care has become

so incredibly professionalized that it's become very remote

and removed from local communities.

For me, what's truly sundar about the idea of task shifting,

though, isn't that it simply makes health care

more accessible and affordable but that

it is also fundamentally empowering.

It empowers ordinary people to be more effective

in caring for the health of others in their community,

and in doing so, to become better guardians

of their own health. Indeed, for me, task shifting

is the ultimate example of the democratization

of medical knowledge, and therefore, medical power.

Just over 30 years ago, the nations of the world assembled

at Alma-Ata and made this iconic declaration.

Well, I think all of you can guess

that 12 years on, we're still nowhere near that goal.

Still, today, armed with that knowledge

that ordinary people in the community

can be trained and, with sufficient supervision and support,

can deliver a range of health care interventions effectively,

perhaps that promise is within reach now.

Indeed, to implement the slogan of Health for All,

we will need to involve all

in that particular journey,

and in the case of mental health, in particular we would

need to involve people who are affected by mental illness

and their caregivers.

It is for this reason that, some years ago,

the Movement for Global Mental Health was founded

as a sort of a virtual platform upon which professionals

like myself and people affected by mental illness

could stand together, shoulder-to-shoulder,

and advocate for the rights of people with mental illness

to receive the care that we know can transform their lives,

and to live a life with dignity.

And in closing, when you have a moment of peace or quiet

in these very busy few days or perhaps afterwards,

spare a thought for that person you thought about

who has a mental illness, or persons that you thought about

who have mental illness,

and dare to care for them. Thank you. (Applause)

(Applause)