In his assessment of governments’ work to provide sufficient mental health resources to their citizens, Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, warned that “good intentions are not being met with investment.”
Though many countries have implemented policies, plans, and laws to improve mental health care, they haven’t offered enough leadership and governance for community-based mental health resources and sufficient promotion and prevention for mental health. Both the pace of spending on behavioral health and getting mental health services into primary care settings has been slow.
Innovative approaches being taken by smaller countries like Ecuador could help reverse the horrific fact that among 15- to 29-year-olds globally, suicide is the fourth leading cause of death, or that people with severe mental health conditions die 10 to 20 years earlier than the general population.
Today, there is often no care for individuals suffering from mental illness. That’s as true in low-income countries like Zimbabwe, which has 19 psychiatrists for its population of 15 million, as it is in the United States.
The seeds of possible new resources are being planted in Ecuador, a country with significant mental health challenges: nearly nine of every 100,000 Ecuadorans die by suicide, somewhat under the rate in the U.S. But only about 25% of the population has access to mental health services.
To provide more access to mental health services, the Ecuadoran Ministry of Health, the Universidad San Francisco de Quito (USFQ), and New York-based Northwell Health, where I work, have established a mental health test model in the District of Yaruqui. It includes 10 clinics that feed into a local hospital.
The program aims to increase the capacity of clinics to identify, diagnose, and treat people with mental illness. Clinic staff learn how to implement simple tools to identify individuals with possible depression, anxiety, and other conditions such as bipolar disorder or schizophrenia. Bachelors-level psychologists are trained to screen and assess patients, provide evidence-based psychoeducation for depression and anxiety based on cognitive behavioral therapy principles, and refer those with more complex problems to psychiatrists.
Studies and interventions in the Global South and in areas like the United Kingdom have shown that non-licensed, non-professionals can be trained to deliver empirically supported psychosocial interventions that are effective for many people. At the same time, family practitioners in those regions have been trained to prescribe medications for anxiety and depression, and telepsychiatrists are also available to provide consultation and guidance to both psychologists and family practitioners as needed.
The pilot for the program in Ecuador reduced turnaround times for mental health consults from two months to two weeks.
The USFQ team also created a program that offers psychosocial support to pregnant women and mothers to give them the resources they need to parent and build emotionally healthy, supportive families. These are great, low-cost strategies modeled after the World Health Organization’s Mental Health Gap Action Programme, collaborative care initiatives in the U.S., and the Improving Access to Psychological Treatments in the U.K.
Like all starting points, these efforts may be imperfect. But the perfect needn’t be the enemy of the good, especially when it may yield intriguing, effective solutions that could work in countries of any income level.
What is different in the Ecuador program is the partnership across borders between a local university and its school of medicine, the country’s ministry of health, and a large health system in the U.S. Each stakeholder is leveraging a strength and perspective that alone is not enough to solve a country’s mental health problems. Put together, however, the right resources and willingness to experiment can make a meaningful difference.
In this case, the local university has bachelors-level students in psychology who want to learn how to provide evidence-based interventions; the ministry of health has the vision, flexibility, and primary health centers to support such an intervention; and Northwell Health has resident psychiatrists with supervisors willing to provide telepsychiatry support.
The United States does not have a national plan to increase access to mental health care, but it does have the ability to encourage — and perhaps even incentivize — relationships among universities, medical schools, health systems, and government entities. It’s possible to create more paths to mental health services by expanding the base of providers this way, training students looking to get into the field to provide screening and low-intensity psychosocial and coaching services in areas where these resources may not exist or be difficult to access.
When I met with new psychologists and psychologists-in-training in Ecuador in September, their energy and willingness to create new programs and try new strategies to reach those in need was infectious. I found their openness about their work and patients inspiring. That enthusiasm certainly exists in other countries, including the U.S., as well. It can be tapped into by developing and nurturing a pipeline of behavioral health professionals by creating opportunities for them to obtain training, help patients, and, in the process, reinvent some of the ways and places people receive mental health care.
A country’s approaches to mental health problems can speak volumes about how it responds to one of the most fundamental human experiences: suffering. Ecuador is doing that with fresh ideas and few resources. Even with limited tools, it is showing the way to reshaping how mental illness is diagnosed, treated, and managed.
John Q. Young is a psychiatrist, senior vice president of behavioral health for Northwell Health, and professor and chair of the Department of Psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
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