Mental Health

Program in Global Mental Health and Social Change

Giuseppe Raviola, MD, Program Director

Background

The Program in Global Mental Health and Social Change, housed in the Department of Global Health and Social Medicine at Harvard Medical School, brings together scholars, researchers, educators, and health care practitioners to address the global burden of mental disorders, with a focus on improving and expanding mental health care to those who live on less than one dollar per day.

Mental health problems impose a serious and widespread health burden, yet remain a neglected and under-resourced domain of global health. Lack of access to safe and effective services remains a significant barrier to mental health care globally. Neuropsychiatric conditions, including depression, alcohol and drug dependence, bipolar disorder, schizophrenia, dementia, and anxiety disorders comprise approximately one-third of “years lost due to disability” (YLD) among people older than 14. Depression is the leading cause of disease burden in most regions of the world; by 2030 it is predicted to be the leading single cause of disease burden globally, particularly among women. With the onset of approximately half of all adult mental health disorders occurring before the age of 14, it is estimated that 20 percent of children aged 9 to 17 have a diagnosable mental health condition that impairs their ability to function. Mental disorders significantly compound physical illness, reducing life expectancy from communicable diseases such as HIV and tuberculosis, and promote the advance of other noncommunicable health problems such as heart disease and diabetes. Stigma related to mental disorders prevents those afflicted with mental illness from seeking access to mental health care, and ultimately compromises their human rights. Globalization and broader social phenomena such as migration and access to technology serve as key forces affecting biology, psychology, and health in contemporary society. Poverty compounds the factors that perpetuate mental disorders, and leaves those in the “bottom billion” particularly vulnerable to illness, and lack of safe and effective treatments.

The Program draws together departmental expertise in the clinical, evaluative, and social sciences—including medical and psychological anthropology, social medicine, and history of medicine, as well as methodologies in quantitative and qualitative research—and seeks to build upon a generation of knowledge regarding service delivery and capacity-building in health services. Program research efforts focus on the innovation of models of care that bridge the preventive and the clinical, the community and the hospital, and the indigenous and the biomedical. By harnessing the resources, passion, and best practices of health care systems worldwide, the Program’s faculty and trainees aim to place the care of patients with mental health disorders squarely within the dialogue on health and human rights.

References

Martin Prince, Vikram Patel, Shekhar Saxena, Mario Maj, Joanna Maselko, Michael R Phillips, Atif Rahman. No health without mental health. The Lancet. September 4, 2007.

World Health Organization. Caring for children and adolescents with mental disorders: setting WHO directions. 2003.

World Health Organization. The global burden of disease: 2004 update. 2004.

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Program Objectives

Projects undertaken by the Program in Global Mental Health and Social Change are linked to ongoing clinical, research and advocacy efforts in the Americas, Africa, and the Caribbean. Program objectives include:

  • Supporting, monitoring, and evaluating community-based initiatives that integrate prevention, diagnosis, and management of mental health problems in coordination with other health services along the care spectrum, from the community to referral centers.
  • Training medical students, newly minted physicians, and other health care professionals at in-country centers in partnership with Harvard-affiliated hospitals.
  • Training US-based and visiting health care professionals, postdoctoral fellows, graduate students, and medical students in research methods that will advance excellence in global mental health care delivery. Research projects will emphasize evaluation of clinical assessment and diagnosis; implementation of evidence-based treatments; analysis of effectiveness and quality of care delivered; community participatory research by those engaged in devising, implementing, and adjusting policies and those directly responsible for delivery of care; and equity concerns at affiliated sites. Training programs are coordinated with existing fellowships, including the Fogarty International Mental Health Training Program for psychiatrists from Shanghai and Beijing, China.
  • Describing, documenting, and understanding complex forces—social, political, and cultural—affecting mental health in the regions where we work.
  • Investigating the potential links between global mental health care delivery strategies and platforms developed for noncommunicable and infectious diseases.
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Featured Initiatives

Strengthening Systems of Care in Haiti for the Long-term

The Haitian Ministry of Health (Ministère de la Santé Publique et de la Population; MSPP) has prioritized mental health as a central component of the rebuilding effort, with the ultimate goal of a national mental health plan and decentralized mental health services. PIH and its Haitian sister organization, Zanmi Lasante (ZL) and the PGMHSC have been working closely with the MSPP toward a coordinated national response, to develop within the ZL system locally feasible and lasting structures for community- and clinic-based mental health care and, over time, to establish generalizable models for systems of mental health service delivery for Haiti and its people.

Supporting Service Delivery in Haiti in Response to Acute and Chronic Disaster

Since the 2010 earthquake, PIH and ZL have worked to implement a comprehensive, Haitian-led response to mental health needs for a catchment area of more than 1.4 million people. The adverse mental health impacts of ensuing acute and profound losses were compounded by a subsequent cholera epidemic, chronic manifold social adversities, and longstanding resource gaps for mental health care. Measures taken since the earthquake have included more than tripling the size of the pre-existing mental health and psychosocial team, and the integration of mental health services with both medical and community-based psychosocial interventions. By September, 2010, the ZL mental health and psychosocial support team had offered more than 10,000 support services in Port-au-Prince spontaneous settlements alone, including psycho-education, counseling, and individual and group therapy. With the construction of a world-class teaching hospital at Mirebalais, there exists a timely opportunity to develop a model hospital-based, public-sector mental health service.

Developing Research Capacity for Mental Health Interventions for Youth in Central Haiti

Numerous cultural and social barriers undermine access to mental health care in Haiti, particularly among youth. An important foundation for addressing this in central Haiti was established with the development of the “Tout Timoun Se Moun” (“Every Child is a Person”) Program by ZL in 2006-8, through federal US funding. This psychosocial support group helps to improve communication and coping for adolescents and their HIV-positive parents living in rural Haiti. Empirically supported interventions to improve access to mental health care for youth continue to be urgently needed. The goals of this work are to develop local institutional capacity for mental health implementation research in Haiti within ZL, while also implementing and evaluating a school-based pilot program to promote access to care for Haitian youth with mental disorders.

Strengthening Mental Health Service Delivery, Infrastructure and Research Capacity in Rural Rwanda

With two psychiatrists and two neurologists for more than nine million people, hospitals and clinics in rural Rwanda are faced with a high burden of neuropsychiatric problems. The Rwandan Ministry of Health (MoH) is committed to addressing mental health problems, and innovating community-based approaches to decentralized mental health care. PIH, with its Rwandan sister organization, Inshuti Mu Buzima (IMB), supports the Rwandan MoH in its efforts to combat this burden of mental illness through preventive and clinical approaches. PIH/IMB provide technical support to district hospital and health center staff—including physicians, hospital and clinic nurses, psychologists, psychiatric nurses and social workers—at three sites in rural Rwanda. These sites mobilize large numbers of community health workers (CHW) to attend to both infectious and noncommunicable diseases, with the imminent elaboration of a CHW mental health component. This initiative builds on Rwanda’s MoH efforts to expand its successful HIV initiatives through scalable approaches to health care delivery for chronic conditions common in rural areas, including heart disease, diabetes, hypertension, hemato-oncologic and neuropsychiatric conditions. With the recent opening of a world-class teaching hospital at Butaro in northern Rwanda, there exists a timely opportunity to develop model hospital- and health center- based public-sector mental health services.

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The Program in Global Mental Health and Social Change is dedicated to developing strong institutional ties that result in complementary strengths and synergies to advance shared health care quality and equity goals, including with ministries of health, other governmental agencies, national and international nongovernmental agencies, and academic and clinical institutions. In addition to close working partnerships with volunteers, personnel, and/or faculty at Partners In Health, the Division of Global Health Equity at the Brigham and Women's Hospital, and other Harvard-affiliated teaching hospitals, current collaborations include those with personnel and faculty within the Government of Haiti, the Government of Rwanda, New York University, University of Miami, Institute Interuniversitaire de Recherche et de Développement (INURED-Haiti), the Peter C. Alderman Foundation, and Tiyatien Health.

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