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Post by Former NIMH Director Thomas Insel: Help Wanted: Making Workplaces Work in Mental Health Care

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World Mental Health Awareness Day is on October 10, 2011, and this year’s theme of “investing in mental health” calls attention to a persistent problem. In a given year, as many as one in four adults worldwide are living with a diagnosable mental disorder.1 Frequently, these disorders are chronic and disabling.

It’s generally easier to point out problems than to develop solutions. In the case of mental health care, both in the U.S. and abroad, it’s also frustratingly easier to develop solutions than to implement them in the community. While I’ve previously noted several reasons for this gap between bench and bedside, a common denominator worldwide is the shortage in care providers.

To address this problem, in 2008, the World Health Organization published recommendations and guidelines to promote greater adoption and optimization of task-shifting in HIV care.2 Task-shifting aims to use the available workforce more efficiently by assigning certain aspects of care to less specialized providers. For example, if a region has few doctors, trained nurses may prescribe and administer appropriate treatments, while nursing assistants and community health workers take blood samples and perform other routine procedures. Such a strategy may also help with workforce shortages and treatment disparities that occur in mental health care. The results are promising thus far for mental health services in some LMICs. Lady Health Workers in Pakistan –– community health workers who routinely visited peripartum women –– were successfully trained to deliver a cognitive behavioral intervention to depressed rural women. Community and other lay health workers as well as primary care staff have successfully provided care for depression in Chile,3 Uganda,4 and India.5

Three new NIMH grants seek to explore that very idea, awarded as part of the Collaborative Hubs in International Research on Mental Health (CHIRMH) in low- and middle-income countries (LMICs) program:

  • Crick Lund, Ph.D., of the University of Cape Town; Atalay Alem, M.D., Ph.D., of Addis Ababa University; Ezra Susser, M.D., Dr.P.H., of Columbia University; and colleagues with the Africa Focus on Intervention Research for Mental Health will establish a Hub for research and capacity development to improve the delivery of cost effective interventions for mental disorders in sub-Saharan Africa. The partner countries include Ethiopia, Ghana, Malawi, Uganda and Zimbabwe.
  • Vikram Patel, M.D., Ph.D., of the London School of Hygiene and Tropical Medicine; Atif Rahman, Ph.D., of the University of Liverpool; and colleagues with the South Asian Hub for Advocacy, Research & Education on Mental Health will establish a collaborative network of institutions in South Asia focusing on research addressing policy questions related to reducing the treatment gap for mental disorders in the region. Activities will be centered in Pakistan and India, with partners in the United Kingdom and United States.
  • Ezra Susser, M.D., Dr.P.H, of Columbia University; Sandro Galea, M.D., Dr. P.H., of Columbia University; Ruben Alvarado, M.D., Ph.D., & Graciela Rojas, M.D., of the University of Chile; and colleagues with the Hub for Latin America will work with researchers from Chile, Brazil, Argentina, and Colombia to test interventions for community health care for people with severe mental disorders.

NIMH recently published a second CHIRMH request for applications (RFA-MH-12-110), which expires on January 12, 2012.

In addition to expanding on the WHO initiative, these studies respond to the Grand Challenges in Global Mental Health6—specifically, the challenge to “increase research capacity in low- and middle-income countries by creating regional centers for mental-health research, education, training and practice that incorporate the views and needs of local people.” With the relative scarcity of resources for mental health research in low and middle income countries (LMICs),7 supporting these scientists certainly benefits mental health care in their native countries. At the same time, with domestic research dollars outpaced by inflation, we must increasingly be open to seeking answers for U.S. mental health care questions beyond our national borders.


1 Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, Angermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell BE, Zaslavsky AM, Ustun TB, Chatterji S; WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA. 2004 Jun 2;291(21):2581-90. PubMed PMID: 15173149.

2 World Health Organization. Task shifting : rational redistribution of tasks among health workforce teams : global recommendations and guidelines.

3 Araya R, Rojas G, Fritsch R, Gaete J, Rojas M, Simon G, Peters TJ. 2003. Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial Lancet, 361: 995-1000.

4 Bolton P, Bass J, Neugebauer R, Verdeli H, et al. 2003. Group Interpersonal Psychotherapy for depression in rural Uganda, JAMA, 289 (23): 3117-3124.

5 Patel V, Weiss HA, Chowdhary N, Naik S et al. 2010. Effectiveness of an intervention led by lay health counselors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomized controlled trial. The Lancet, 376 (9758):2086-2095.

6 Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS; Scientific Advisory Board and the Executive Committee of the Grand Challenges on Global Mental Health, Anderson W, Dhansay MA, Phillips A, Shurin S, Walport M, Ewart W, Savill SJ, Bordin IA, Costello EJ, Durkin M, Fairburn C, Glass RI, Hall W, Huang Y, Hyman SE, Jamison K, Kaaya S, Kapur S, Kleinman A, Ogunniyi A, Otero-Ojeda A, Poo MM, Ravindranath V, Sahakian BJ, Saxena S, Singer PA, Stein DJ. Grand challenges in global mental health. Nature. 2011 Jul 6;475(7354):27-30. doi:10.1038/475027a. PubMed PMID: 21734685; PubMed Central PMCID: PMC3173804.

7 Razzouk D, Sharan P, Gallo C, Gureje O, Lamberte EE, de Jesus Mari J, Mazzotti G, Patel V, Swartz L, Olifson S, Levav I, de Francisco A, Saxena S; WHO-Global Forum for Health Research Mental Health Research Mapping Project Group. Scarcity and inequity of mental health research resources in low-and-middle income countries: a global survey. Health Policy. 2010 Mar;94(3):211-20. Epub 2009 Oct 28. PubMed PMID: 19846235.