Mental health disorders are common and disabling throughout the world. Rich and poor countries experience the devastating consequences of these disorders, representing approximately 20% of the global burden of diseases in Latin America and the Caribbean, with mental health disorders representing only 0.4% of all public healthcare funding globally. Besides, there are massive inequalities in access to mental health services depending on socio-economic status, with the poorest, the most badly affected, the least likely to have access to help.
The COVID-19 pandemic has laid bare how fragile is the mental health of the world and the need to invest more and better to improve this situation. We now have a unique window of opportunity in which governments, international organizations, and civil society all agree that it is fundamental to increase investment in mental health. Now the challenge is to move from words to deeds. Declarations and reports without appropriate action can lead to cynicism and despair. In some quarters, we are beginning to hear an ever louder call to ring-fence taxes or other income to secure funding for mental health services.
Public Health Interventions on Mental Health
We are aware that changing the socio-economic determinants of mental health can be powerful. There are things that we know (common sense) can decrease or prevent mental health disorders, such as better working conditions or better public transport and so on, and actions at this cross-sectoral level can take place now. There is no need to wait for the results of any research study to act on these things. Similar effective approaches are used to prevent other chronic diseases, such as higher taxes for cigarettes or alcohol. But prevention is still incipient in mental health, and many of these powerful actions won’t help those who have fallen behind and are too ill to reap their benefits.
Individual Interventions on Mental Health
Regarding treatment, there are two basic types of interventions, which are complementary: therapy (or talking therapies) and medication. Both require a trained workforce to deliver these interventions, but we are faced with the reality of the scarcity of mental health workers in most countries, particularly but not only in the poorest countries around the world.
Task shifting can be a pertinent answer to mitigate the scarcity of mental health staff.
The strategy of task-shifting or a more efficient ‘redistribution of tasks’ among all those who can contribute to help people with mental health disorders has proven to be effective. It is no longer needed to use the time of the most expensive professionals (psychiatrists and psychologists) to deliver some tasks to improve mental health. Community health workers, auxiliary nurses, or social workers can deliver many of those tasks effectively and at a much lower cost.
Task shifting was at the heart of a successful mental health intervention for the care of depression in primary health care in Chile. The scheme was based on:
- Group psychoeducation, consisting of five group sessions led by a trained social worker;
- The addition of medication prescribed by the primary health doctor, for the more severe cases;
- And derivation to mental health centers for persons who did not respond to the intervention.
A cost-effectiveness study showed that the cost of each day free of depression gained through the intervention was lower than the price of a bottle of soda, something that the Chilean government was in a position to pay for, and it did.
The Use of Technology in Mental Health Interventions
The use of technology can also help increase access (for example, during the pandemic) and the cost-effectiveness of the interventions. In the Allillanchu project in Peru, when a person visited a health center due to a physical chronic condition, this person was screened for depression with a brief questionnaire. As a follow-up, the patient received information if treatment was needed and available resources near home were suggested, and a series of reminders to seek help. The result was impressive: 55% of the persons with a high likelihood of depression ended up accessing qualified mental health human resources.
Task shifting and technology are promising alternatives that synergize to provide accessible and affordable mental health services.
In the PROACTIVE intervention in Brazil, community health workers of the Brazilian Unified Health Service were trained to work on depression with older persons in their community. They were trained to deliver psychosocial support and equipped with an app that contained videos with information on how to overcome depression. These videos were watched by health workers and older persons together and fostered a planning of activities that the older person could complete during the week to improve their mood.
Scalable interventions are those that include available human resources for each function (for example, a social worker instead of a psychologist for the group sessions) and always include training and support (given that what is taught in tertiary education is not necessarily what is most cost-effective).
Digital interventions have increased during the COVID-19 pandemic, but we still need to learn what works. Technology is good, but users say they want something hybrid. They may want the first meeting in person, occasional telephone contact, or some other arrangement that ensures human contact.
The turnover of personnel in mental health services is high. This is a major challenge for scaling up interventions. Training resources that can stay and will provide an affordable and feasible way of dealing with mental health disorders is essential.
Cost-effective mental health interventions require an investment, but we must not fall into the paralysis trap of doing nothing because we do not have the financing to do all that is needed. Task shifting and the use of technology can help us implement cost-effective interventions, and this is the moment to start.
Want to learn more about digital inventions to combat NCDs and improve mental health? Check out the publication “Digitalizing Public Services” here.