Non-specialists effective at delivering mental health help

Evidence is mounting that we need not rely solely on specialist practitioners to make a dent in the growing burden of mental illness. Speaking with Chris Smith, Miya Barnett, at the University of California Santa Barbara, has been looking at how non-specialists, given the right training, can be enormously valuable, especially in resource-poor settings…

Miya - So we have known for many years - before Covid 19 - that mental health problems are a huge prevalent issue in the population and a growing issue, especially for children and adolescents. So, prior to Covid, people were saying that 30% of the population worldwide experienced a mental disorder. Those estimates are actually really increasing at this point. Some are saying one in eight may be experiencing depression. Certain locations like low and middle income countries, 70 to 90% of individuals don't receive care that they need. And unfortunately, even highly resourced places like the UK or the United States also have many populations that don't get the care that they need.

Chris - Big problem, then. How do you propose we deal with it?

Miya - Absolutely. So there's a lot of strategies that need to be put into place and one of the solutions that I'm especially interested in is how we engage non-specialist providers in the delivery of mental health services. So non-specialist providers are individuals who have not necessarily gone to school to be mental health providers, not you know, counselors or psychologists or psychiatrists, but people who work with different communities already. Maybe nurses in a doctor's office, community health workers, who are able to learn some of these skills and help provide different types of treatment or link people into treatment so that they are getting the care that they need, which is so important for people to do well in their lives.

Chris - But how would these people find the people that they need to help? Because if part of the problem is that, as you've said, up to 70% of people in some places are not getting the help they need, is that partly because we just don't know that they need help?

Miya - That's exactly it. That is why non-specialist providers could be a really important part of the workforce, because they are more likely to be embedded within community settings where people are going to for help. So what kind of settings could these be? They could be the doctor's office where people are going to often for their physical health but also bringing up concerns with their mental health. Churches, community centers, schools, these are the individuals that community members who might not trust a mental health professional are going to interact with more naturally. So we want to make sure that they have the skills that they need and the knowledge that they need to be able to help when people ask for it.

Chris - And what would the shape of that help take? Would it be things like cognitive behavioural therapy, someone to talk to, someone who's well versed in the different sorts of things that could be done for that person and who they should go and see? Or is it softer than that?

Miya - A lot of research has been done in different low and middle income countries, Kenya, Ethiopia, looking at if these providers could do interventions like cognitive behavioural therapy. And the evidence is actually quite strong that individuals get better if they work with a non-specialist providing a cognitive behavioural therapy intervention. So that's really exciting that we know that that can happen. There are other models that are being used in places where there may be are more professional providers like the United States where these individuals possibly are going to be more the link to services. The people who say, oh, I hear what's going on with you, let's call this mental health agency. They have those types of services. Oh wait, you have a question about that? You're concerned, you feel some stigma around that. Let me talk you through what that might be like. So the roles can be diverse, but the goal is that individuals will get linked with excellent evidence-based care.

Chris - When governments in some countries have tried to introduce interventions a bit similar to this, but for other aspects of health, cynics have said this is medicine on the cheap. Rather than training a proper practitioner, you train people who are not so well trained, they're a bit more focused, but they're also less skilled generally and they're cheaper. And so as a result you get lots of them, but it is medicine on the cheap. How would you answer that?

Miya - I think that's a really important point and I think that from the most cynical place, we don't wanna be providing care, especially to more vulnerable and marginalised populations that's just cheaper care. What we want is to recognise that we need to have high quality training available to these individuals. So more people are able to provide this, but not necessarily because it's such a cost savings way. So I focused a lot on a recent paper that I published on how it's imported that you are providing a lot of, not only training, but ongoing supervision and making sure that this is high, high quality care that's being provided, not just cheap care that's being provided.

Chris - And have you got any evidence yet that as an intervention this would work or can work and not just work in a place where it's relatively easy to start the wheels turning, but in some places on the planet where infrastructure's, poor funding's poor; education overall is poor and therefore they've got everything not going for an initiative like this?

Miya - You know, as a researcher located in the United States, which is a place that you know supposedly has a lot of resources, I actually look to the countries with lower resources, a lot of things like you said where it's not going for them for the strongest evidence of how this can work. Places that have done a lot of innovation on how to really increase the quality and access of care through the task sharing with non-specialist providers. The studies that have been run in places like Kenya, Iraq, Thailand, places that maybe are not considered to be having as many mental health resources really are paving the way for where we might want to go in the United States or the UK to, with the struggles we're having on reaching enough of our population. So I think learning from places that have done these types of projects successfully with less resources is really important. We really have to learn from places that have done this work successfully so that we could be reaching our most marginalised populations in places that are considered to have more resources I think.