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Dr. Pamela Collins on Global Mental Health Challenges

Dr. Pamela Collins on global mental health challenges and NIMH initiatives.

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Dr. Thomas Insel: For the last several decades NIMH has been clearly the place in the United States to lead the efforts on research on mental illness and that has largely meant mental illness in the United States, sometimes in Canada; all of a sudden lots of conversation about this new emerging exciting area called Global Mental Health. Dr. Collins, tell us a little bit about this. What it is, why now and what does this mean?

Dr. Pamela Collins: Well I think the type of question could actually be why hasn’t this happened before? I mean, we know that mental disorders are the leading causes of disability around the world. I think there’s been a perception that these are problems of wealthy countries and that with so many other competing health priorities in low middle income countries, how could you possibly think about mental disorders. But we know now that these create an incredible burden of illness, that they create an incredible burden of disability and they have to be addressed.

Dr. Thomas Insel: One of the things that come about when you talk about global mental health is people start to say, my goodness, I mean the problems are so enormous. We have enough of a challenge just trying to deal with issues in the United States. We could take the entire NIMH budget and put it into global mental health and we still wouldn’t see any impact. Did the Grand Challenges effort actually address that? Tell us a little bit about what that did and how it worked and what it came up with.

Dr. Pamela Collins: Well I think what’s important to remember about the Grand Challenges in global mental health is that global truly means global. And we are part of the globe. So these are priorities that people working in more than 60 different countries around the world came to some consensus on and there are priorities that I think reflect needs in every country. And certainly if you look at the top 25 Challenges that were published in Nature, you’ll see issues that the United States mental health system needs to address, but you’ll also see issues that are relevant to countries on the other side of the world, countries that don’t have the health infrastructure that we do as well. So I think that’s important to recognize first of all, is that global means all of us. I think the advantage of this is that it’s an opportunity for us to learn from each other. So it’s an opportunity to address some of the daunting issues around access to care, around getting people the services they need that will be just as relevant to people in the United States who don’t have mental health services as they are to people in other parts of the world.

Dr. Thomas Insel: So in this Grand Challenge the idea was that people from 60 countries came together and tried to set priorities for the most important research schools, is that right?

Dr. Pamela Collins: The idea was, yes. The idea was that people were asking well what are the big problems, what are those challenges, those problems that if we could solve could transform the field in some way. It’s also important to remember that this is an initiative that address mental, neurological and substance use disorders understanding that the those are often comorbid and that these are also disorders of the brain that we can use the same kinds of research approaches and many times to address. But yeah, the idea was to really say well what are those big questions, let’s get them on paper, let’s identify them and then the next part of this, we took our cues really from the Grand Challenges in chronic and non-communicable diseases which lead to the organization of an alliance of funders to try and address some of these questions through research.

Dr. Thomas Insel: So let me go into one particular issue that sometimes people have asked about because it’s so clear that cell phones have just become ubiquitous, whether you’re in East Africa or a poor island in the Caribbean and wherever you look people who may not have fresh water, they may not have electricity, they actually have access to cell phones. Is there a sense that from Global Mental Health that will become a kind of bed net that could really change the way that care is delivered and that mental health is insured?

Dr. Pamela Collins: That’s a really good question. And I think there is certainly a lot of potential in that area. If you look at some of the work that we and I mention funding right now in the realm of HIV and behavioral interventions in HIV, we see that there is some good evidence that people can use cell phones to deliver health behavior intervention. So there are cell phone interventions to increase adherence to care. And I don’t think there’s no reason why this couldn’t also happen for mental disorders; that these same kinds of interventions could be used in these particularly remote areas for both for adherence, but also for delivering treatments as well.

Dr. Thomas Insel: Right, so there’s a lot we can learn actually from other areas of global health --

Dr. Pamela Collins: Exactly.

Dr. Thomas Insel: -- which has been an emerging area. Mental health in some ways is kind of late to the party. Obviously this has been such a big area for tropical medicine, infectious disease; increasingly we’re seeing this for other chronic non-communicable diseases. Now that we’ve become a player in this area, what do you see first as the major challenges to really moving this field forward and second; I’d love to hear about where you think this is going to go over the next five to ten years.

Dr. Pamela Collins: That’s a good question. I think this goes back to the question you asked earlier which is that you know, one could say there’s so many daunting issues that how in the world can we do anything? So I think we should take a lesson from the global AIDS effort which is that we know that the global AIDS effort has . . . many initiatives have lead to an incredible progress in getting people access to care and treatment for HIV. And we’ve seen a means and reduction in mortality in the arena of HIV and that was done with a lot of concentrated funding, but it was also done by choosing very specific goals. And I think that that’s probably what needs to happen in Global Mental Health as well; that we need to, as a community, choose some very specific goals and perhaps direct efforts toward those.

One of the things that we have been thinking about as you know, NIMH and certainly this is in line with what our colleagues in other parts of the world have also been thinking, is that there is such clear, clear inequities and access to care that the treatment gap is tremendous in many low and middle income countries where you simply don’t have the mental health specialists, you don’t have the psychiatric nurses, you don’t have the psychiatrists, you don’t have psychologists, and how can we actually extend services in those settings. Are there other people that can provide those settings that are not necessarily the psychiatrists or is there an alternative role for psychiatrists in those settings where we don’t have specialists; meaning are they able to train others to provide these kinds of services in order to get people the very basic health care they need. I think this is probably one area that’s worth investing in, actually extending services. This has been called task shifting, it’s been called many things, but being able to extend the mental health workforce by enabling others than the most specialized, specially trained mental health care providers to provide mental health services.

Dr. Thomas Insel: In the time that you’ve been generating this whole new focus for NIMH the last couple of years, it's clear there is a lot of parallel efforts going on. So there’s a new initiative just announced in Canada that’s quite large on Global Mental Health. As you know in the UK there are not only new academic programs, but Wellcome Trust has announced a new initiative around Global Mental Health. Expecting to see other things like this in other parts of the globe and I guess in addition to the scientific opportunities that you talked about like task shifting, is there an opportunity for us to work in a different way. What better place to do it than in global mental health but for us to work with global partners maybe to make more things happen. How could you imagine that happening?

Dr. Pamela Collins: Yeah I think that’s a wonderful idea and I think that’s actually at the heart of this Grand Challenges initiative that’s really how can we build a community of people that are working on these same issues. One way is certainly one of the goals of this initiative and certainly one of the outcomes of the Grand Challenges and chronic and non-communicable diseases was that the Global Alliance for Chronic Disease, a group of federally funded research agencies from around the world, have been able to come together to come to consensus around funding opportunities that can be . . . and focusing on particular topics and putting up the money to fund research on a particular topic. I think something similar can be done with the Grand Challenges in global mental health. I think certainly we are already working with the World Health Organization and supporting some of those efforts in the Mental Health Gap Action Program. But continuing to build these kinds of collaborations, both with perhaps other funding agencies, but also encouraging others to do that, encouraging . . . I think this is a chance for people to pick their own piece of this pie. This is not something that we want to do alone but this is an invitation really for researchers, for universities, for governments to get involved in mental health and we’d like to see that kind of collaboration happen.