Q&A: Mental health, the most cross-cutting issue of our time?

Mental health is “about as cross-cutting an issue as you can get,” said Paul Bolton, the U.S. Agency for International Development’s first mental health and psychosocial support coordinator.

Present in all geographies and across all demographics, mental health issues can impact a person’s overall health as well as their ability to earn, learn, benefit from other programming, and contribute to the overall economy.

“Ten to 20% of our populations have one or more of the common mental conditions — depression, anxiety, post traumatic stress [disorder], or substance abuse,” said Bolton, whose role includes integrating mental health and psychosocial support, or MHPSS, services across USAID and developing MHPSS policy and guidance. “And those have an effect on people’s ability to function as they would wish, ability to make decisions, to take care of themselves.”

An integrated approach to programming could yield gains not only for mental health but other conditions such as HIV, tuberculosis, and malnutrition, he added. “If we could integrate programs that treated mental health conditions and therefore improve the uptake and self-care of people in those programs, those programs would improve.”

Speaking to Devex, Bolton shared more about USAID’s approach to mental health programming, his thoughts on an integrated approach, and suggestions for rolling out mental health programs in low- and middle-income countries.

This conversation has been edited for length and clarity.

Mental health care and its role in the global health continuum has been a bigger topic of conversation in recent years. What is needed to translate that talk into action?

Mental health conditions in low- and middle-income countries may not attract international policy or programming attention or initiatives. Thus, many in senior positions may have limited access to knowledge of the progress made in the mental health field as it relates to international development. There's a big need for an orientation for those folks about what we currently know.

Another thing … I think that many people stigmatize those with mental illness. I’ve had the opportunity to work in a lot of cultures, and I've never yet encountered a culture or population in which mental illness was not stigmatized … So when we approach government funders or stakeholders about mental health, we’re starting from a negative position, not from a neutral position. We have to overcome that.

Lack of funding hampers program development and research, which hampers progress on the impact of mental health programming, which in turn hampers funding. Finding people who are willing to champion mental health, to put more funds into research and development of programming to demonstrate the case of what mental health programming can do — not only for people's ability to function as they would like, but for the cooperation in their own self-development and self-well-being — those would all be useful things.

What are some of the key barriers to accessing mental health services and how can they be overcome?

Many people with mental conditions, if they suspect that they have them, don't want anyone to know about it. That prevents them from seeking care. In many places where people do think that mental conditions run in families, other family members may not want the person to seek care because of concerns that the associated stigma will extend to the whole family.

In many countries, there’s little or no mental health care, and what exists is psychiatrists and psychiatric nurses who are very often few in number and based in the capital city.

If you think that mental illness is inevitable or you think that it's genetic, you may also think that there's nothing that can be done. So you have no hope. When we implement programs where people go for counseling as treatment and get better that's often very surprising to people. That blows up the myth that this is something that can't be dealt with, that it's genetic, that it's inevitable, and there’s nothing you can do about it. That creates hope for people.

How might an integrated approach help?

I think that integration is preferable. It's good to have standalone services, but there's a couple of problems with that. One is that standalone services attract stigma because in order to go to a standalone service, everyone knows you have a mental condition. If you could go to a service that is integrated into other services, that’s less of an issue.

Also, integration into other programs can actually make those programs more effective. We have a lot of data to suggest that mental health problems worsen the uptake and outcomes for lots of different types of programming, such as HIV, tuberculosis, education, nutrition, maternal health, early childhood development, etc. … The problem is that even though there's a lot of evidence to show that mental health problems are associated with worse outcomes, there's not a whole lot of research that's looked into what happens to these outcomes when you do integrate mental health services into these programs.

Do you have any lessons learned or best practices when it comes to rolling out mental health programs in LMICs?

Before starting a program, conduct a lot of preliminary discussions with populations, including qualitative research on how people view the problem, which aspects of mental health are considered priorities, what people see as causes of problems, what people see as possible solutions, what people currently do now. Understanding all of those things is critical to developing an integrated program that's locally acceptable.

Once you've developed a program, you need to identify local people who can do the program … They don't have to be professionals, they don't have to have advanced training as long as they have time, an interest, and some aptitude for this kind of work.

We need systems of care rather than introducing a single intervention or program, which is the norm. It is important this system works at all levels of need from prevention all the way up to specialized treatment, with assessment and triage between all levels. For example, for the larger populations, programs might work on changes in the social, economic, and safety environment, providing information on stress and mental health conditions, and stress reduction skills, while also facilitating self-assessment and triage. Those that have mental health problems are then encouraged to seek help with referral to those with mental health training. This system can handle most issues but also connects to any specialized mental health providers — like psychiatrists — who are available for other less common but severe conditions.

What are you most excited to see come to fruition over the next decade in mental behavioral health care globally?

I think the acceptance of community-based services and their widespread implementation based on local actors. It's been around for a long time, but I think it's just becoming increasingly accepted that this is the way to go.

I'm excited about the progress that we're making in convincing health and social services, both in governments and in funding organizations, that mental health is a critical part of implementation. There’s an increasing interest in behavioral science overall and the use of behavioral science to improve cooperation in programming. I think on the back of that, mental health is an important subcategory of behavioral science, and that as behavioral science becomes more widely applied, mental health will become more accepted as well.

This post is made possible through a USAID grant to the Johns Hopkins Bloomberg School of Public Health’s Department of Mental Health.