Dr Vikram Patel is Professor of Global Health & Social Medicine, Harvard Medical School; Honorary Professor, London School of Hygiene & Tropical Medicine, United Kingdom; and Adjunct Professor & Joint Director, Centre for Chronic Conditions & Injuries, Public Health Foundation of India.
A psychiatrist and a researcher, Dr Patel is best known for his work on mental health in low-resource settings. He is also Co-founder and Member of Managing Committee, Sangath, a research NGO headquartered in Goa which works on multiple projects involving mental health, child development and adolescent health.
Dr Patel was listed as one of the world’s 100 most influential people by TIME magazine in April 2015.
In an exclusive interview with India Medical Times, Dr Vikram Patel shares his insights on mental healthcare in India, especially community based care, primary care, and mental health research and discusses the challenges that lie ahead.
One of the prime areas of your work has been the effective provision of mental healthcare in low-resource settings. Please tell us something about its core principles and how they apply in the Indian context.
Our work has championed the approach of task-sharing of mental healthcare tasks to non-specialist workers (whom we refer to as ‘counsellors’) working in primary care or community settings. Our research has shown the effectiveness of using front-line workers or counsellors to carry out a range of mental health tasks, from promotion of mental health in schools and raising awareness about mental health problems in rural communities, to the treatment and care of autism, schizophrenia, depression and harmful drinking. The main lessons from this work has shown that this approach is acceptable to communities, patients and their families, much superior to usual care in promoting recovery, and is very good value for money. For such models to work, the counsellor must be adequately trained in acquiring the core competencies related to the particular task, their work must be supervised by their peers, and the programme must have oversight from a mental health professional to monitor the overall quality of care and offer consultations to patients who do not respond as hoped.
All our studies have been carried out in partnership with government healthcare or school settings and are thus examples of work which is highly appropriate for scaling up in India.
Community-based mental healthcare has been on our agenda for a long time now. How far do you think have we been successful with it and what more needs to be done in this direction today?
To be absolutely blunt, there is no community care for mental health problems in India, beyond the care provided by the family. Mental health professionals are mostly content working in mental hospitals, private nursing homes or clinics. While the National Mental Health Policy and the recently approved Mental Health Care Bill calls for community based care, the implementation of this vision will need nothing less than a radical reform of our current mental healthcare approach away from hospital based specialists to primary care based non-specialists. We need to implement the team based approach for mental healthcare, in which the physician (or psychiatrist where available) works as a member of a team of counsellors who implement a range of mental healthcare tasks in primary care and community settings, in partnership with community based organisations.
Seemingly, we haven’t had much success with mental healthcare provision at the primary care level. With the importance of primary care being increasingly realised, how do you think can we achieve a better integration of mental health with primary care in India?
The new policy instruments I mentioned above, and the Government’s commitment to universal healthcare, offer a unique opportunity to achieve the radical reform of the mental healthcare system by embedding a mental health curriculum, based on the large number of clinical trials of psychosocial interventions for mental health problems, into the training of counsellors in primary care and the community. The curriculum should be competency based, for example the competencies needed to assess mental health or deliver behavioural activation therapy, rather than theoretical, and should be primarily practice based learning rather than classroom learning. Primary care itself will need a complete re-engineering from its focus on doctor led, medication focused, acute care to the management of the complex needs of people with chronic conditions (including mental health problems) which typically requires a team approach, a long-term person-centred perspective, and addressing health problems holistically through appropriate use of both medication and counselling as needed for the individual.
What, according to you, is the key to achieving universal mental health coverage in India and reducing the glaring treatment gap in mental disorders?
The essence of universal healthcare for mental health problems, and indeed all chronic conditions, is the sharing of healthcare tasks to different providers who work as a team with primary care as the nodal delivery platform.
How important is it to bolster mental health research in India, and which areas do you think need the most attention?
I think the primary priority is to conduct implementation research on how the evidence based packages of care for mental health problems, we have shown can be delivered by counsellors in primary care settings, can be scaled up through both the public and private systems. I also strongly believe that India should have a fully enabled capacity to conduct basic and translational neuroscience research; the brain is truly the final frontier in our understanding of the human body, and we should be contributing to the essential knowledge which is needed to unravel the origins of mental health problems in partnership with world-leading research groups globally.
Your views on how we can strengthen mental health as an academic discipline and build the next generation of leaders in public mental healthcare?
We need to make psychiatry and related mental health disciplines exciting for the younger generation by embracing the principles of global mental health which challenge the highly reductionist biomedical approach that focuses on diagnoses and medications. Exposure to mental healthcare in primary care and community settings and to public health research is key to building the next generation of leaders in public mental healthcare. One opportunity which is easily accessible is the annual Leadership in Mental Health course run by Sangath every November in Goa.
by Dr Soham D Bhaduri