I was recently intrigued by the claims made — and that went completely unchallenged — by Vikram Patel, a psychiatrist who was interviewed by Wired Science’s Greg Miller. I guess my expectations for something appearing on Wired should be readjusted.
Patel claimed that specially-trained health professionals could provide enough care to people that they may be able to treat clinical depression successfully. (The article suggests these are the same as “laypeople,” but really, they’re not.) With skills learned in as little as 2 days.
An amazing claim? You bet. One based in reality? Let’s find out…
Here’s what Patel told Wired’s Greg Miller about the research that backs his claims that you could take health care professionals (sorry, not “laypeople”), give them a few days of training (and then followup with longer supervision), and they could successfully treat depression:
Can you train people off the streets, with little education, to be counselors?
We’re training them to do very specific tasks. It’s a bit like training a community midwife: You’re not training her to be an obstetrician; you’re training her to deliver a baby safely and to know when to refer the mother to a doctor.
The training can be as short as two days or it can be two months, but the classes are the least important part. There’s a much longer period of supervised learning that happens through direct contact with patients. You don’t have much theory. You go directly to the skills you need to actually help people recover.
Well, first, these aren’t just “people off the streets.” They are existing healthcare professionals in these countries, most often nurses. Health care professionals already have some experience and understanding that health and disease don’t exist in a vacuum — that there are psychological components to life that impact our health and well-being. So they have a lot of background and experience already in this general sphere.
The research mentioned below looks primarily at these health care professionals who’ve had this extra training, not laypeople.
And your research suggests that this is effective?
It’s not only me saying so. We just completed a systematic review of more than 25 randomized, controlled trials from around the developing world. There’s one clear message: SharÂing tasks works, and it works across a range of mental health problems.
The review Patel is referring to a Cochrane Database Systematic Review, published just last month. The study (van Ginneken et al., 2013) examined 38 studies from seven low- and 15 middle-income countries. Out of the 38 studies, 22 studies used health workers, and most addressed depression or post-traumatic stress disorder (PTSD).
The primary problem with this review was that the studies examined in it are not very well designed, implemented, and/or the data analysis was poor. This is not robust data — so much so that the studies to arrive at this specific conclusion include notes such as “serious study limitations” because of study/researcher bias, and “serious inconsistency” in the data presented.
So unfortunately this review study should be taken with a grain of salt, despite it being a Cochrane Review, because of this issue about the low quality research in this area. There are inconsistencies and bias in virtually every study they looked at. In fact, the review says as much: “Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.” In other words, new research could completely change the effect we observe here — and it could be in the opposite direction.
The effects of training a health professional in third-world countries with specialized mental health training are generally beneficial. In a hypothetical sample size of 1000 people in one of these countries (like Uganda), if you had 300 people with depression with usual care, you’d have only 91 with this additional training in place. But this finding is based upon only 3 studies — all of which had serious methodological problems.
Third-world countries generally don’t have a lot of specialists available across the board. There simply are few mental health professionals — such as psychiatrists or therapists — available. In countries or regions that have such shortages, it makes sense that if you give a health professional that is there (like a doctor) some mental health training, well, they can help people better with mental health issues.
But this doesn’t automatically — or easily — generalize to first-world countries. For example, most physicians trained today already receive some basic mental health training and deal with a great deal of mental disorders in their practice. In America, family physicians prescribe the most antidepressants — far more than psychiatry does.
Why This Doesn’t Translate to First-World Countries
The interview over at Wired Science concluded with this claim:
According to US statistics, about 60 percent of people with mental health problems received no care at all in the previous year. The normal reaction to that kind of figure is to say we need more psychiatrists. But here’s the thing: The US already has more psychiatrists and spends more money on mental health care than any other country in the world. You don’t need doctors to provide all of the things you’re paying them to provide.
The reason that 60 percent of Americans don’t receive care for mental health problems isn’t lack of access to treatment — the problem in the third- and second-world countries this research addressed. And generally, it also isn’t because treatment is too expensive (since most people get their treatment for their depression from a family physician, not a mental health professional). Most Americans’ health insurance covers mental health treatment, so the vast majority of the tab is picked up.
It’s instead because of the remaining stigma, discrimination and prejudice people have about mental disorders. It’s because when they do access treatment or care, it’s ineffective. It’s because we’re using the age-old practice of trial-and-error for medications to try with a person — something that many people simply don’t tolerate well (or want to be subjected to).
And it’s because, despite decades’ worth of research, we still don’t have a “Match.com”-like website matching patients with the best therapist for them. Choosing a good therapist remains a hit-or-miss proposition for most, and the consequences of getting a bad therapist means you have to repeat your life story over and over and over again to total strangers.
None of which would be solved by training health workers with more mental health training.
So no, healthcare professionals won’t be replacing specialists in mental health care any time soon here in the U.S., any more than a family physician could replace a brain surgeon. It’s a silly claim to make that, if given the choice and opportunity, someone would choose a lesser-trained provider over a specialist.
Read the full article: How to Treat Depression When Psychiatrists Are Scarce
Reference
van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, Chandrashekar S, Patel V. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in lowand middle-income countries (Review). The Cochrane Library, 11.
4 comments
With people who say to me the idiotic things as said above by Dr Patel, I suggest why don’t all trained and seasoned therapists stop working for just 2 weeks and let the general public fill in for us. And that is all it will take, just 2 weeks, because those who have been getting responsible and efficacious interventions will quickly realize that just talking to a family member, friend, neighbor, or the guy/gal who got a few days to weeks of “intense on the job training” won’t really be providing therapy, just a proverbial hand on the shoulder and the textbook “you’ll get through this, just be tough”.
What just pisses me off the most in reading this post is simply this: why do I have colleagues who say such stupid, irresponsible, and reckless things that only demean and diminish our true abilities and responsibilities for the mental health field? If I was in the room hearing the absolute idiocy being uttered by Dr Patel, I would just blatantly ask back, “so are you basically saying psychiatric and psychological training programs are a waste of time, and we should eliminate these professions, so we can dumb down the importance of providing appropriate psychotherapy to people who would agree to see people every 2-4 weeks a visit, just go by some ITP manual to define progress by satisfying checklist simplifications like going to automobile repair shop to check the fluids and replace the brakes every 30,000 miles?!”
Oh, my mistake, that has already been done by some in the profession these past couple of decades. So, maybe we don’t even need social workers now, just anyone who completes a community college degree, or wait, why go that far, just teach basic psychology in high school and get a vocational degree from “Psychology Shop”?
We can summarize mental health with just the basics taught in 1 week:
don’t hurt yourself or others.
if you are depressed, think happy thoughts.
if you are anxious, let go of the fear.
if you are obsessive, think about other things.
if you are traumatized, stay away from further trauma and think safe thoughts.
if you are feeling panic, take deep breaths.
But, if you are manic, or psychotic, or cognitively impaired, or so depressed you can’t let go of suicidal thoughts, don’t talk to me, find a doctor!
Oh, but all those doctors were deemed unnecessary after these “replacements” were set up to take over and simplify psychotherapy.
I guess the Dr Patels of the world just want to work in chronic inpatient units, or correctional facilities, or sit in academic offices and write books that claim to set the standards for mental health care that no doctors will ever provide anyway.
It really is idiocy to hear doctors say such lame and irresponsible things. But, it is what psychiatry as a whole has done, it is solely a biochemical imbalance anyway, so at the end of the day, why should people with mental health problems need to talk, just open their mouths and swallow these pillS, and then sit back and feel better tomorrow.
Oops, you psychopharmacologists didn’t think that one through fully, it doesn’t take a psychiatrist to do this now either. After all, those PCPs, NPs, psychologists in states allowing Rx access, and I wouldn’t be surprised if PAs are writing psychotropic Rxs these days as well, they all can diagnose and write for psych meds without psychiatric expertise.
Oh, my bad, they got it in those weekend CME courses Dr Patel sells for non physicians now.
And the circle is complete. Sorry for this rant, but, it is what lack of vision and attention to the detail leads to, by forfeiting defense not only the value of the profession, but the needs of the patients we took an oath to protect and heal, and thus this lack of vision leads to the demise of the profession, by either indirect or misguided self destruction. Or, maybe it is intentional?
Hey, just my opinion.
I appreciate Dr. Grohol’s skeptical analysis of this proposal. One major problem with it is encapsulated in this quote from Dr. Patel:
“Most of our patients are women with depression linked to an unhappy marital relationship. So a counselor would identify the relationship as the reason the patient is feeling withdrawn and not sleeping well…”
But without appropriate professional assessment, it is not possible for a paraprofessional “counselor” to conclude that a person’s depression and insomnia are caused by an unhappy relationship–though this may indeed be one contributing factor.
Depression, anxiety, and insomnia are often due to a multiplicity of interacting factors, ranging from medical problems (such as sleep apnea) to undiagnosed substance dependence to the early stages of dementia.
Increased ease of access to professional medical and psychological care is not an easy goal to achieve, but it is still an essential part of a good national health care system.
Ronald Pies MD
I hear you very well Doctors and understand your argument. One question, in which countries do you practice in? I am no doctor and have no mental health training, but I do have a mental health illness. I have had it for over 16 years. The disorder took the better chunk of my life, something I can never get back. I barely remember my teenage years let alone my early adulthood. My experience with conversion disorder was challenging, confusing and excruciating. I can still remember how all my limbs would become stiff and cold that I could not afford to stand or walk. I dreaded the tremors, the fits and persistent dystonia as they rendered my tiny body powerless and lifeless. My chest got so tight and breathing became very difficult and painful. It was a nightmare turned into reality that never seemed to have a last season. I felt like it was my last day every-time I had these attacks. I was never able to make a word as my jaws would be locked. I dreaded the memory loss that is present till now. I sought help from every specialized doctor I could think of, from cardiologists to neuron-surgeons but no test could explain the cause of these neurological or medical symptoms I had. In the end some of them said that I was faking these things to get attention while others never believed me. I was often told that all this was in my head and not real. My family,friends and teachers were not supportive either. It was a nightmare knowing that something was wrong with me yet no one knew anything about it. So I sunk deeper and now I have Borderline personality disorder with dissociative symptoms.
Had my doctors been equipped enough, they would have provided me with mental health first aid or referred me early enough and the problem wouldn’t have escalated. Had my family, friends and teachers been aware of this they would have provided me with basic mental health care. I think when it comes to this issue, everyone should and must be involved. Living in a developing country, Swaziland, where there is only one psychiatrist and four qualified psychologists, Dr. Patel’s approach applies. If these ‘lay people’ are trained and are under constant supervision of mental health specialists, I think this concept can really be a success story. Swaziland has a population of 1.2million, centralized psychiatric services, has the highest HIV prevalence in the world, gender inequality, high rate of sexual abuse and other forms of abuse, over 60% living below the poverty line and life expectancy is at 47years. The country is also scarcely populated and many have to travel long distances to access psychiatric services. Don’t you think this is already overwhelming enough for just 5 people?
I think Dr. Patel is trying to provide an option that I think would be very workable in places like Swaziland. There are so many countries in Africa without even a psychiatrist let alone a mental hospital, for example Mozambique.
I think training key people like say the police, teachers, community leaders etc would be very vital. These people interact a lot with the public and just providing them with basic mental knowledge like; skills to be able to identify early signs of mental health problems, how to use basic mental health assessment tools, how to support those with mental illness, how care for themselves are caregivers and when and how to refer this person-nothing to do with prescriptions.
For general health workers, the same thing applies, except they get in-depth training on diagnosis and other assessment tools and also when to refer the client.
We have had cases of the police shooting mentally ill people because they were holding a knife or a stone. We have had people attempting suicide, taken to hospital and after recovery they are sent back home without any psychological help. We have had cases of young children being psychologically and physically abused by their female relatives after finding out that the father or uncle has been abusing them. The children are seen as rivals by the female relative(s).
My partner and I (has no mental health training) started an organization to promote mental health in Swaziland and currently we have a Clinical Psychologists from the abroad who is helping train different groups to be able to provide basic mental health care. We are also in contact with the country’s only Psychiatrist. We don’t have mental health resources but we are making use of the human resources we have and building their skills and I think that counts.
I am a layperson with my own ideas about what types of interactions would be helpful to me. I would like someone to take an interest in my life and ask me lots of questions about how my experiences throughout my life and how I have responded to them. I would to feel that the person I was talking to was genuinely interested in understanding my experiences and responses and would like to have the person share their true thoughts about me, and not hold back anything negative that they were thinking. I don’t want to feel that the person is trying to protect themselves by putting me into categories that subconsciously help the other person to feel secure while simultaneously attaching to me negative descriptors. I see no way that this can serve me or be helpful. I’d like to feel as though we are on a search for understanding together, and so I would want to hear what has led the other person to develop their beliefs and responses to life and me and to life in general. I believe this focus on common humanity is what everyone needs and it will become more and more possible in the future.
I have not found in therapy the situation I have described above. I believe therapists will protest that this is what they provide, but I do not believe it is. I do believe that everyone can help each other, they just need to have some type of preparation.
Rather than the platitudes suggested above, here is what lay people can do for one another. Start with engaging in an awareness exercise, where you pay attention your thoughts, moment to moment experiences. Discuss it at each session. Over time, discuss ways in which automatic habits are becoming less unconscious. Discus the small details about what efforts the person has made to achieve their goals and what they perceive to be the obstacles preventing them from achieving what they would like to achieve in life. Gaining more awareness can help with any type of difficult experiences. It may not be the perfect answer at all times, but everyone needs to feel that they matter, that people truly see them, and care about their struggles. Since we all need this, we all have an intuitive understanding of what others need! If this can be nurtured in the future – I am not sure if there will be reasons why lay people cannot have helpful discussion sessions.
Looking forward to hearing any responses by others!