Lessons from Ecuador to improve access to mental health care

IIn his assessment of governments’ work to allocate adequate resources to the mental health of their citizens, Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, warned that “good intentions are not met with investment”.

Although many countries have introduced policies, plans, and laws to improve mental health care, they have not provided sufficient leadership and governance for community-based mental health resources and adequate mental health promotion and prevention. Both the pace of behavioral health spending and the uptake of mental health services into primary care have been slow.

Innovative approaches from smaller countries like Ecuador could help reverse the horrifying fact that suicide is the fourth leading cause of death among 15-29 year olds globally, or that people with serious mental illness die 10-20 years earlier than the general population.

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Today there is often no care for people with mental illnesses. This is true in low-income countries like Zimbabwe, which has 19 psychiatrists per 15 million people, as well as in the United States.

The seeds of potential new resources are being planted in Ecuador, a country with significant mental health challenges: Nearly nine in every 100,000 Ecuadorians die by suicide, slightly fewer than in the US. But only about 25% of the population has access to mental health services.

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To increase access to mental health services, the Ecuadorian Ministry of Health, the Universidad San Francisco de Quito (USFQ) and Northwell Health, based in New York where I work, established a mental health testing model in the Yaruqui District. It includes 10 clinics feeding into a local hospital.

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The program aims to increase the capacity of clinics to identify, diagnose and treat people with mental illness. Clinicians learn how to use simple tools to identify individuals with possible depression, anxiety, and other conditions such as bipolar disorder or schizophrenia. Psychologists at the bachelor’s level are trained to examine and assess patients, provide evidence-based psychoeducation for depression and anxiety based on the principles of cognitive behavioral therapy, and refer patients with more complex problems to psychiatrists.

Studies and interventions in the Global South and areas such as the UK have shown that unlicensed lay people can be trained to deliver empirically supported psychosocial interventions that are effective for many people. At the same time, GPs in these regions have been trained to prescribe medication for anxiety and depression, and telepsychiatrists are also available to provide counseling and guidance to psychologists and GPs when needed.

The pilot program for the program in Ecuador reduced the turnaround time for psychological counseling from two months to two weeks.

The USFQ team has also developed a program that provides psychosocial support to pregnant women and mothers to give them the resources they need to become parents and build emotionally healthy, supportive families. These are great, low-cost strategies modeled after the World Health Organization’s Mental Health Gap Action Programme, collaborative care initiatives in the US and improving access to mental health treatments in the UK

Like all starting points, these efforts can be imperfect. But perfect doesn’t have to be the enemy of good, especially when it can produce fascinating, effective solutions that could work in countries of any income level.

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What is different about the Ecuador program is the cross-border partnership between a local university and its medical school, the country’s Department of Health and a major health care system in the United States. Each stakeholder brings a strength and perspective that alone is not sufficient to solve a country’s mental health problems. Taken together, however, the right resources and willingness to experiment can make a significant difference.

In this case, the local university has undergraduate psychology students who want to learn how to provide evidence-based interventions; the Department of Health has the vision, flexibility and primary health centers to support such an intervention; and Northwell Health has resident psychiatrists with supervisors who are willing to provide telepsychiatric support.

The United States does not have a national plan to increase access to mental health care, but it does have an opportunity to encourage — and maybe even incentivize — relationships between universities, medical schools, health care systems, and government agencies. It is possible to create more pathways to mental health services by expanding the base of providers in this way and training students who wish to enter the field to provide screening and low-intensity psychosocial and coaching services in areas , where these resources may not exist or be difficult to access.

As I met with new psychologists and psychologists in training in Ecuador in September, their energy and willingness to develop new programs and try new strategies to reach those in need was infectious. I found her openness towards her work and her patients inspiring. This craze certainly exists in other countries, including the US. It can be unlocked by developing and nurturing a range of behavioral health professionals by creating opportunities for them to receive training, to help patients, and in the process reinventing some of the ways and places people receive mental health care.

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A country’s approach to mental health problems can tell volumes about how it responds to one of the most fundamental human experiences: suffering. Ecuador does this with fresh ideas and few resources. Even with limited tools, it shows the way to diagnose, treat, and treat mental illness.

John Q. Young is a psychiatrist, senior vice president of behavioral health at Northwell Health, and professor and chair of the department of psychiatry at the Donald and Barbara Zucker School of Medicine in Hofstra, Northwell.


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