Depression and anxiety are rapidly overtaking a huge swath of the world’s population even as it battles the Covid-19 pandemic. New solutions are emerging in the form of community-based services and technological innovations that promise to reach care even in remote locations. Yet, the biggest stumbling block is that mental health care remains grossly underfunded.
Coming out of the covid-19 pandemic, we’re facing a global mental health crisis with prevalence of depression and anxiety increasing by a staggering 25%. Countries, rich and poor, are facing a wake-up call. Yet, funding for mental health is minimal, at a fraction of 1% of total global health funding. Unlike tuberculosis, malaria, and HIV, there is no ‘global fund’ for non-communicable diseases like mental health.
The good news? We understand the problem and have solutions that are both proven and cost-effective. There is also a burgeoning community of innovators working to deliver better services to the most vulnerable. I outline four strategies below that countries might consider to ensure mental healthcare for all: Equipping the frontlines, implementing community-based models, integrating mental and physical health, and leveraging digital technology.
Fortify the frontlines
The most glaring challenge in the global mental health crisis is the dearth of trained mental health care professionals. According to the World Health Organization, there are about .25 and .75 psychiatrists per 100,000 people in the African and South Asian regions, respectively.
To address the shortage, many low- and middle-income countries (LMIC) have been training and equipping engaged community members to serve at the frontlines. For decades Professor Vikram Patel of the Harvard T.H. Chan School of Public Health has been pioneering community mental health care models, leveraging lay health workers. Ministries of health have started to adopt similar models. In Kenya, for example, the health ministry has trained community health volunteers in mental health first aid to identify potential clients in the community and link them to services.
Even in the US, with 12 psychiatrists per 100,000, the need for mental health services far outweighs capacity. Unable to access care, many Americans with mental illness land in the criminal justice system where jails and prisons are home to the largest psychiatric facilities in the country. Primary care doctors, pediatricians, police officers and prison wardens are at the frontlines of the mental health crisis in the US, and yet have little to no training in mental health care.
As in LMICs, innovators in the US have been piloting successful programmes to enable frontline workers. In 2014, a new Medicaid demonstration project incentivises new approaches to mental health care, such as a pilot in Oklahoma that equips police with mental health training and decision support tools. It’s clear that there will never be enough psychiatrists. Countries need to rethink the paradigm of who can deliver mental health services.
Scale community-based services nationally
Even as we train and equip the frontlines to deliver mental health care, we need programmes and infrastructure in communities. For too long, vulnerable people have been forced to leave their family and communities due to stigma and lack of mental health care services.
Community-based approaches worldwide tackle stigma and access head-on. In Uganda a non-profit called Strong Minds facilitates community-based group interventions for people living with depression and anxiety. Patients build a supportive community with peers and avoid the cost of a faraway institution. The Mental Health Innovation Network, a global community of mental health innovators, catalogues successful community-based interventions. Unfortunately, with limited funding few models have scaled.
The US faces similar challenges. In the 1960s President John F Kennedy laid out a bold plan for thousands of community-based mental health care clinics in the US. While his vision was never realised due to lack of sustained financing, elements of it are now being revitalised. In 2020, the federal government rolled out the 988 Suicide and Crisis hotline, which connects callers to services in their communities. Other countries are looking to establish similar national hotlines as a step towards a unified national programme.
Integrate mental and physical health
Perhaps the best solution to inadequate community services is integrating mental health into primary care. Mental and physical health have been treated separately in Western thought and medicine for centuries. But now most experts agree it’s time to rethink the dualist approach.
For inspiration, we can look outside the Western paradigm. Iran is one of the few countries to have successfully scaled up an integrated model for community-based mental health—rural primary care clinics and staff are equipped to deal with both mental and physical conditions. Learning from the Iranian experience, Medtronic LABS, a health systems innovator, is launching an integrated mental health model in sub-Saharan Africa to demonstrate how community health workers and primary health clinics can address depression and anxiety directly, alongside other conditions like diabetes or HIV.
Integration may also be a solution to funding shortages. Many donors, Global Fund included, are shifting away from strictly disease verticals, recognising the need for strengthened health systems and patient-centred approaches.
Invest in technologies
Given the resource constraints, both in human capital and funding, digital technology has a major role to play. We’re already seeing new technology with the potential to transform diagnosis and treatment for mental illness.
Globally, organisations like Northwell Health in Ecuador and Medtronic LABS in sub-Saharan Africa are working with national health systems to enable basic tele-psychiatry and tele-counselling for patients with any type of phone. Online platforms also have the potential for transnational scale. An organisation called 7 Cups provides a free online peer-to-peer counselling platform and its community of trained listeners have served millions of people seeking emotional support.
Emerging technologies also show promise. For instance, point-of-care diagnostics company, Sonde, is using artificial intelligence to help diagnose mental health issues from the sound of a person’s voice. Studies have also shown how data from google or meta may detect early mental health conditions. Dozens of start-ups are developing digital therapeutics and virtual treatment programmes. From online games as behavioural therapy to remote addiction interventions, the technology revolution in mental health is just beginning.
So, who’s stepping up?
Expanded mental health training at the frontlines, community-based delivery models, integrated mental and physical primary care, and technology-enabled services hold promise for improved mental health. We understand the problems. We know the solutions. They work. They’re cost-effective. And yet there is no ‘global fund’ for mental health. So, who will step up before it’s too late?
The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.