At the meeting, Patel, Prince and Saxena made a strong case that there was
enough scientific evidence and enough need for discussion that a special
issue on mental illnesses was warranted. Horton agreed. “My feeling was the
time had come,” he recalls. “Global mental health was totally ignored. It
was very clear we needed to jump in and seize this opportunity.”
Still, while they had an idea of the global impact of mental disorders, in
2005 research on diagnosis and treatment in underserved areas was thin.
Just a handful of randomized controlled trials — the gold standard in
medical science — had been done in low-resource environments. In 2003, Paul
Bolton of Johns Hopkins University and colleagues published a study in the
Journal of the American Medical Association showing that group therapy
could treat people with depression in Uganda. That same year, Ricardo Araya
of the U.K. showed success helping poor women with depression in Santiago,
Chile. Studies from other places showed that group therapy,
antidepressants, individual counseling and talk therapies all worked.
Patel published the results of a clinical trial on drug and psychological
treatment, and he was working on other trials that assessed whether
laypeople could be effective counselors. Could they help people with
depression, schizophrenia or alcoholism understand their illness? Could the
lay counselors teach their patients that taking a walk, or talking with
their counselor, or taking their medication could help them get through a
In 2007, The Lancet published its first special issue on mental disorders,
which included descriptions of these trials and more. Dozens of randomized
controlled trials since have shown clear benefits in diagnosing and
treating mental illnesses. “I was surprised to see the size of the effect,”
Patel says now. “They were much bigger than I thought, in some cases bigger
than you’d seen in the West.”
In January 2017, The Lancet published two more studies of people in
developing countries: One group had moderately severe to severe depression;
a second group had alcoholism. The analyses used economics to determine the
cost effectiveness of therapy provided by lay counselors. It’s a wonky
process, but it had a clear and simple conclusion: Using lay counselors to
provide and deliver therapy was an economic win. (See “When Treatment
Works,” page 34.)
Effects of Poverty?
What criticism there has been comes from a field called psychiatric (or
psychological) anthropology, which considers how mental conditions play out
within different cultures. Derek Summerfield, a consultant psychiatrist
with the British National Health Service, is one of the few people to speak
out against the premise that mental illnesses are common in developing
countries. In 2012, Summerfield and Patel were both invited to give talks
at McGill University. Patel’s talk was titled “Why mental health matters to
global health.” Summerfield’s talk was titled “Against ‘global mental
Summerfield said that global mental health amounted to Westerners telling
people in developing countries what was abnormal and what was not. He said
it involved exporting treatments that don’t necessarily work well, and
intimated that the pharmaceutical industry was a little too interested.
Today, Summerfield says he’s even more convinced that the issue for people
with depression is really just poverty. “This is all ridiculous,” he says,
adding that those with depression “are not pointing to their mental health.
They are pointing to their poverty and lack of rights.”
Patel says he shares the concerns about poverty, and about pharmaceutical
companies. He doesn’t take money from drug companies, and his trials focus
on counseling and behavior-modifying therapies provided by Indians. Local
laypeople who are attuned to local culture are the caregivers.
When Patel first went to Zimbabwe in 1993, he believed in conditions like
schizophrenia and epilepsy. But he himself expected that most of the cases
of “depression” would be what Summerfield thought — a result of misery
rather than a psychiatric disorder. He changed his mind after two years.
“Telling people that they’re not depressed, they’re just poor, is saying
you can only be depressed if you’re rich,” he says.