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Psychiatry alone won’t solve the global mental health crisis

Sangath’s youth-led mental health campaign, It’s OK to Talk, which engenders dialogue and help-seeking among India’s young people. Credit: Sangath website.
October 10, 2021

The lone child living in the international dormitory at Eden Theological Seminary in Missouri, Simone was raised by her aunties and uncles from all over the world. She is now a psychiatrist and global mental health practitioner-in-training who seeks to reignite whole person healing through togetherness in pursuit of the Beloved Community. Currently, she is an MD/MSc student on full scholarship at the London School of Hygiene & Tropical Medicine/King’s College London and The David Geffen School of Medicine at UCLA. She graduated from The University of Iowa in 2014 with honors in Neurobiology and International Studies and a minor in Philosophy. Simone worked with the Friendship Bench to conduct a qualitative research project on Circle Kubana Tose (CKT)s which are peer-led groups that provide the Friendship Bench clients with ongoing support.

We are approaching nearly two years of human life living in the COVID-19 pandemic. In this time, 4 million loved ones have been lost, frontline workers have been pushed to the brink, and longstanding social and economic inequities have been laid bare. Also in this time, pockets of human creativity and resilience have emerged as we strive for social connection in the wake of physical restriction. Within the cycle of devastation and adaptation that we’ve collectively experienced, conversations on COVID-19 have consistently shared the spotlight with conversations on mental health.

As a psychiatrist-in-training, these conversations – among friends, celebrities, and world leaders alike – have been exciting to witness. Each conversation chips away at stigma and reminds us that to experience mental illness is to be human and therefore worthy of support.

However, while the COVID-19 pandemic has certainly made the global mental health pandemic more salient, those in the field have been alerting us to its arrival for decades. According to the World Health Organization, depression is one of the leading causes of disability worldwide, accounting for 46.5 million years of healthy life lost in 2019. Suicide is the second leading cause of death in young people in all countries of the world and 75% of those suicides occur in low- and middle-income countries. Even without the direct threat of suicide, people with severe mental illness die 10-30 years younger from medical conditions than the general population. Mental illness is, without a doubt, killing us.

Yet even in high-resourced countries – such as Canada, well-regarded for its health care system – accessible mental health support remains conspicuously absent. In the United States, where I receive my training, 57 percent of people with a mental illness receive absolutely no treatment. If we were to translate the number of psychiatrists that we have in the United States per capita (already at a shortage relative to need) to the population of India, we would expect to see about 119,000 practicing psychiatrists. In reality, there’s just 9,000 – 7.5% of that number. In Zimbabwe, there are only 18 psychiatrists for a country of 14 million people. It is often said among my colleagues that when it comes to mental health, all countries are developing countries.

The global mental health movement – an international community of lived experience activists, family and community members, researchers, psychologists, psychiatrists, and others – is working to reduce the staggering gap between burden of mental illness and the provision of affordable, accessible, and equitable mental health services worldwide. This includes advocating for increased funding, building capacity of health systems to train and equip more psychiatrists, psychiatric nurses, and psychologists, and improving access to psychotropic medication. However, I believe the greatest strength of this movement to be the community mobilization and collective healing being experienced from within.

In all corners of the world, non-specialist health workers deliver interventions to their community – from health education to case identification to direct care – for a wide range of diseases. When it comes to mental health, psychological therapies can be broken down into easy-to-deliver components and applied to multiple mental health diagnoses such as anxiety, depression, and somatoform disorders. Through a process called task-sharing, community members with no prior experience in mental health care are trained to deliver these psychological interventions close to home.

The research of my colleagues has demonstrated the effectiveness of these treatments in multiple settings where psychiatrists are lacking. For example, in primary health centers in Goa, India, the non-profit Sangath trains lay counsellors to deliver a 6- to 8- week psychological treatment for severe depression with specialist referrals as needed. In a randomized controlled trial, these counsellors did better than primary care physicians at reducing depressive symptoms, suicidal thoughts, and levels of disability for their clients.

Through the Friendship Bench in Harare, Zimbabwe, a similar effect has been seen. A cadre of grandmothers comprise the lay counsellor workforce, providing brief psychological therapy to clients from benches stationed outside of health clinics. These effects are expanded and integrated through the formation of peer-led support groups known as Circle Kubatana Tose, which means “holding hands together.” During these weekly circles, clients combine mutual psychological and social support with income-generation activities such as gardening, bag-making, and micro-loan schemes.

There are logistical benefits to these interventions: reduced burden on the mental health workforce; cost savings; release of specialists for training, supervision, and more complex cases; and improved quality of the therapeutic relationship (we respond better to someone who “gets us”). However, these practices are also fundamentally empowering. Creating communities of care where ordinary people promote mutual mental wellbeing – where we recognize how unshakably reliant we are on one another – is the cornerstone of liberation through healing.

The greatest lesson I’ve learned as a future psychiatrist is that my profession won’t solve the mental health crisis – it is people who are given the proper support to care for their community within their community and the evidence to back it up.So let us share in each other’s fate for a while and act with the knowledge that that fate influences our own. Whether we place our efforts in fighting for policies that dismantle the social and structural determinants of mental illness (wealth inequality, climate change, institutional racism/ableism/sexism, cultural imperialism, etc.), in working or volunteering as a lay counsellor (you can look online for your local crisis hotline), or in better understanding and supporting those we love, we are the change we seek. This World Mental Health Day, my deepest wish is that we start to couple conversations that recognize the realities of mental ill-health with conversations that recognize our collective power to heal from it. 

The grandmothers who provide psychological talk therapy through the Friendship Bench in Zimbabwe. Credit: Friendship Bench Zimbabwe.