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Three key insights from the NIMH global mental health conference
Here's my summary.
This week I attended the Global Mental Health conference at the National Institutes of Health (NIH) campus in Bethesda, Maryland. It was so stimulating that I decided to move today’s essay to next week and use this post to share three key insights from the conference. They have broad implications for understanding public health and other facets of the common good.
Insight 1. Closing the treatment gap
Perhaps the most prominent theme permeating the conference—though not often named explicitly—was that of the treatment gap. This term refers to the fact that while about 15% of the world population suffers from mental illness in any given year, only a small minority of these people actually receive treatment. The size of the treatment gap differs a lot between countries; it is estimated to be about 63% in high-income countries such as Germany and about 86% in lower-middle-income countries such as Nigeria. In any case, the majority of people with mental illness in the world are not getting the help they need.
When you look at this issue for the first time, you might think that we simply don’t know how to treat mental health problems. But that is not true. For the most common disorders, such as depression and anxiety, we have good treatments available (usually a combination of behavioral activation, talk therapy, and medication if needed). A large part of the treatment gap, therefore, can be explained by an implementation gap. This refers to the difference between knowing what works and actually delivering it to the people who need it. In a way, the implementation gap is what should make us all really angry, because it implies that people suffer needlessly.
At the conference, research teams from around the world shared new insights on solving the issues that cause the implementation gap.
Funding. In many countries around the world, treatment for mental health problems is still not covered by insurance, even though the business case for treating mental illness is overwhelmingly positive. As Devora Kestel, department director of Mental Health and Substance Abuse at the World Health Organization, said in an interview on stage, most mental health funding goes to psychiatric institutions. But while those institutions are important, they rarely provide entry-level care and they lack the capacity needed to close the implementation gap. Instead, we need to fund accessible, community-based mental health care and implement first-line treatment for anxiety and depression in primary care facilities. The WHO is working hard to provide more insight into the state of play of mental health care funding worldwide and outline challenges to solve in the next 10 years.
Human resources. Even if we manage to fund professional mental health care around the world, we will simply not have enough professionals to provide all that care. One exciting avenue to solving this is task-sharing. In plain language, task-sharing is the idea that we can shift some of the burden of providing mental health care to nurses, community health workers, or even laypersons. What they need to make this work is good training. Harvard professor Vikram Patel and his team presented an update on their project with task-sharing in India. They developed a cool smartphone-based training program for Accredited Social Health Activists (ASHAs), community health workers who live and work in villages all over the country. With this training, ASHAs learn to implement a behavioral activation treatment for people in their community who suffer from depression. Results have been very promising, so I hope to see this method applied elsewhere in the world in years to come.
Implementation science. Even with sufficient funding and human resources, there remain many barriers to providing mental health care to all. There is a vibrant research field uncovering these barriers and strategies to overcome them—implementation science. This is a world I’m only beginning to explore, so I found myself just trying to wrap my head around all the developments at the conference. But one picture stuck with me: the 5 S’s of non-profit organization Partners in Health. Researchers use these as a simple framework to start evaluating the strength of a health system.
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Insight 2. Integrating climate change and mental health
One of the highlights of the conference for me was an interview with Nobel Prize-winning economist Esther Duflo, whom I greatly admire. Duflo pioneered the use of field studies and randomized controlled trials to study what works for economic development. For instance, she famously tested the effectiveness of microfinance loans on development outcomes (surprising finding: it does not seem to yield the expected beneficial effects on health, education, and women’s empowerment).
In her interview at the conference, Duflo mentioned a striking figure from a Climate Impact Lab analysis of climate change-related illness: in the year 2100, climate change will cause an additional 73 deaths per 100,000 people, on par with the current mortality caused by all infectious diseases combined. Shockingly, this projection already accounts for the adaptation humans are likely to make to climate change itself.
For more on this, read my earlier post about the impact of climate change on health and the mass migration that is likely to follow from it:
By naming this alarming figure, Duflo effectively positioned climate change at the heart of global health. Many other researchers at the conference unpacked this further by showing how climate change shapes mental health specifically.
In one inspiring talk, Courtney Welton-Mitchell from the Colorado School of Public Health reported that people in Nepal and Haiti suffer a great deal of anxiety and depression about how climate change is destroying their livelihoods. These mental health problems, in turn, can make it much harder to adequately respond and adapt to change (though there is some data suggesting that anxiety is actually associated with greater preparedness). She proposed an approach that integrates knowledge on climate adaptation with mental health support, akin to a mental health-integrated emergency preparedness program she developed for the United States. I think these approaches that combine knowledge across research fields will become more prominent in public mental health in the future. The talk can be viewed here (starting around 3:30:00).
Insight 3. Tackling the social determinants of mental health
One speaker in the Connecting Climate Minds consortium described climate change as a “risk multiplier” for mental health. This hit home for me, as climate change exacerbates risk factors that we already knew about, such as poverty, housing insecurity, and social connectedness. (The same point has been made about COVID-19 byand other researchers.) This links climate change directly to a third cross-cutting theme of the conference: the “social determinants of mental health”, or the social and economic conditions that directly shape our mental health.
In his keynote lecture on the topic, field icon Crick Lund told the story of his work with people in townships of South Africa. He showed the various pathways through which poverty is associated with worse mental health in these communities, including food insecurity and hindered education. These pathways reveal that mental health is not an individual problem, but results from the environment in which we live. The positive implication of this is that population mental health can be significantly boosted if we improve and stabilize people’s living conditions. I’ve written about this idea before on this platform:
In recent years, research has progressed from cross-sectional findings to demonstrating that poverty actively causes mental illness via several mechanisms such as increased exposure to early-life trauma, worse physical health, and greater uncertainty and worry. It is no surprise, then, that giving money to people in need improves both mental health and subjective well-being.
Unfortunately, achieving wealth redistribution is often unrealistic in many countries around the world. This is why Lund and his colleagues are exploring alternative pathways to reducing the adverse impact of poverty on mental health. One promising example is the skill of self-regulation: the ability to adaptively modulate your own thoughts, feelings, and behavior to achieve your goals in life. Some promising research suggests that better self-regulation can help buffer against the health impacts of living in poverty. So in a major international trial called ALIVE, researchers are attempting to help adolescents in Bogota, Cape Town, and Kathmandu develop better self-regulation skills. The next couple of years will show whether this allows people to more effectively cope with adverse living conditions and thereby escape the cycle of poverty and poor mental health.
Although Lund spoke about adolescents in low- and middle-income countries, I think his insights apply to all of us. In a world facing great change and crisis, including climate change but also artificial intelligence and a reorganization of world powers (see for instance‘s work on this), we can all benefit from psychosocial skills that help us deal with adversity and change. I will keep writing about this topic, so subscribe to stay in the loop.
Next week: another educated guess.