Getting treatment for a mental illness when you live in the developing world is hardly as easy as making an appointment with a therapist or psychiatrist. Mental illness is often not treated with the same sense of urgency as physical illness, and resources to provide care are simply not available in many areas.

In this moving talk at TEDGlobal 2012, mental health care advocate Vikram Patel gave a startling statistic — that in developed countries roughly 50 percent of people don’t receive appropriate care for mental disorders but that, in developing countries, the treatment gap rockets sky-high to 90 percent.

Why? Another statistic from Patel’s research illuminates the problem. If you translate the percentage of psychiatrists in the population in the United Kingdom to India, you’d expect to see about 150,000 of them. But in the world’s second most populous country, the actual number of psychiatrists is closer to 3,000. The situation is as dire in other countries, too. In Zimbabwe — a country of nearly 3 million — there are only about a dozen psychiatrists, almost all of them practicing in the same city.

Below, read some more startling statistics about mental illness, followed by Patel’s promising ideas on how to get people the care they need.

• More than 450 million across the globe suffer from mental illnesses. [World Health Organization]
• Schizophrenia, depression, epilepsy, dementia, alcohol dependence and other mental, neurological and substance-use disorders make up 13% of the global disease burden, surpassing both cardiovascular disease and cancer. [National Institutes of Health]
• By 2030, depression will be the second highest cause of disease burden in middle-income countries and the third highest in low-income countries. [WHO]
• In the United States, people with severe mental illness die 25 years earlier than the general population on average. [Time] In Denmark, the life expectancy gap has been shown to be as high as 18.7 years with certain disorders. [Psychiatric News] And the differential in life expectancy is believed to be even wider in developing countries.
• In the last 45 years suicide rates have increased by 60% worldwide. [WHO] More than 90% of people who kill themselves have a diagnosable mental disorder. [NIH]
• Suicide is among the three leading causes of death among those ages 15-44 years in some countries, and the second leading cause of death in the 10-24 years age group. [WHO]
• In the UK, 70% of people affected by mental illness experience discrimination, and discrimination is believed to be worse in developing countries. [The Guardian]
• Mental and psychosocial disabilities are associated with rates of unemployment as high as 90%. [WHO]
• Meanwhile, those with severe mental illnesses are more likely to have other health risk factors, as well. In the Untied States, while about 22% of the general population smokes, more than 75% of people with severe mental illness are tobacco-dependent. And people with depression or bipolar disorder are about twice as likely to be obese as the general population. [Time]

But Patel — the co-director of the Centre for Global Mental Health  and the co-founder of Sangath, an NGO dedicated to mental health – believes that a lot can be done to disrupt these statistics worldwide.

In his powerful talk, Patel describes a novel approach — training whoever is available, be it a local nurse or a family member, to provide mental health interventions — no psychiatrist required. Inspired by books like Where There Is No Doctor: A Village Health Care Handbook, Patel focuses on empowering everyday people to help the members of their community. In 2003, he published the tome Where There Is No Psychiatrist, which explains more than 30 clinical disorders to readers, teaching them to problem-solve when they encounter each. Sections in the book range from “Assessing someone who refuses to talk” to “When to suspect physical complaints are related to mental illness.”

So far, Patel notes that approaches similar to his are making a big difference. In rural Uganda, villagers were taught to deliver psychotherapy for depression — and 90% of those who received it recovered. Meanwhile in Pakistan, maternal health workers were taught to give cognitive therapy to depressed mothers, leading to 73% of the new moms recovering. And in Patel’s own study, he found that training lay counselors to give depression and anxiety interventions helped 70% of patients recover. In his comparison group, who went to primary health care centers, only 50% bounced back.

“It doesn’t simply make healthcare more accessible and affordable, but it is fundamentally empowering,” says Patel. “It empowers ordinary people to be more effective for caring for the health of others in their community, and in doing so to become better guardians of their own health.”

A vast gulf in care

Vikram Patel asks us to imagine two men who live in the same town. They have the same education, the same jobs, and everything else the same. Both present at a hospital with chest pains — but one is treated and one is not. Why? The second one has a mental illness.

That is one of the biggest reasons people with mental illness live shorter lives. (In some places, the gap in life expectancy is 20 years.) Of course, there are more direct ways that mental illness can kill you, such as suicide — one of the leading causes of death, even in the poorest countries in the world. The World Health Organization estimates that 400 million to 500 million people are affected by mental illness. The number sounds surprising, he says. “But imagine the diversity of mental health problems… Everyone knows someone with such a condition.”

Those are staggering numbers, but what’s truly worrying, Patel says, is that “the vast majority of these individuals do not receive the care that can vastly improve their lives.” Even in developed countries as many as 50 percent of people don’t receive appropriate care. In developing countries, it’s close to 90 percent.

If you talk to someone with mental illness, or their caregiver, you will find stories of extraordinary pain — and learn that people with mental illness often experience the worst abuses. And some of the worst abuse happens in the place created to cure them, the mental hospital.

Imagining a bridge

There is a gulf, says Patel, between the knowledge we have of how to improve lives, and what we do with it. This is the gulf he is trying to bridge. He trained as a psychiatrist in Britain, surrounded by talented, compassionate, skilled and highly trained colleagues.

Then he went to Zimbabwe.

There he found just about a dozen psychiatrists in the whole country. Most of those serving the needs of those in the city, leaving almost no one for the rural population. In India, the situation was not much better. India should have 150,000 psychiatrists to have the same proportion as the UK, but the number is actually about 3000. It was simply not feasible or affordable to develop quality care. He had to think about different resources to deliver the care.

Then he found some simple books on how to train laypeople to deliver health care — such as, “Where There Is No Doctor” and “People’s Health in People’s Hands.” Those books talk about ways to train people to do all kinds of complex medical tasks. If you could get people to do that, why not mental health care?

Beginning the construction

He reports that there have been some experiments in doing exactly that. He has three examples, all about depression, the most common of mental illnesses.

One trained locals to deliver psychotherapy, leading to 90 percent recovery, compared to about 45 percent in surrounding areas. A second group did a randomized trial of cognitive behavioral therapy, producing 75 percent recovery, compared to about 45 percent. In his own trial they trained ley counselors to deliver psychosocial therapies, and got 70 percent recovery, compared to around 50 percent.

He has an acronym to summarize what’s needed to train these people: SUNDAR.

• Simplify the message
• UNpack the treatment
• Deliver it where people are
• Affordable and available human resources
• Reallocation of specialists to train and supervise

The need for a very large bridge

In the developed world, mental health costs are spiraling out of control, and “a huge chunk of those costs are human resources.” What’s spectacular about SUNDAR, Patel says, is that it is fundamentally empowering. It lets people care for others, and become more invested in their own care as well.

“In order for us to achieve health for all,” says Patel, “we will have to involve all in that particular journey. And in the case of mental health, we will need to involve those affected by mental illness and their caregivers.” As part of that, The Movement for Global Mental Health established as a platform where doctors and those with mental illness can stand together.

In closing, he asks us, “If you have a moment for peace and quiet, spare a moment for the person you know with mental illness, and dare to care for them.”

Photos: James Duncan Davidson