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SOCIAL MEDICINE Considering What Works: Book Documents Mental Health Care Successes in Poor Nations There is a growing awareness that mental health has been given short shrift in health budgets and priorities internationally and that mental disorders put an undue burden on individuals and families when untreated. But in developing countries with few resources to devote to specialized mental health services, it is unclear what kinds of programs would be most effective in delivering care. A new book from the Department of Social Medicine at HMS begins to answer this question by documenting a series of case studies of mental and social health programs that have succeeded in relatively resource-poor areas. Alex Cohen and colleagues are moving beyond the identification of mental illness to finding models for care and prevention that work in low-income countries. (Photo by Pam Murray) "We decided that really what was needed was a book that looked at why programs work," said Arthur Kleinman, the Maude and Lillian Presley professor of medical anthropology and professor of psychiatry at HMS. "The social sciences have very much emphasized why programs fail. It's astonishing we don't know why programs succeed." Kleinman and co-editors Alex Cohen, HMS instructor in social medicine, and Benedetto Saraceno, director of the Department of Mental Health and Substance Dependence at the World Health Organization, developed the World Mental Health Casebook to begin the process of documenting and evaluating programs that seem to have succeeded in making improvements in mental health in the context of few resources. "There's very little detailed information about mental health programs in low-income countries," said Cohen. Given how little documentation there has been, a strictly quantitative approach to evaluation is not yet feasible or adequate. Instead, the co-editors aimed to collect in-depth, qualitative descriptions of the programs and their impact on communities. Rather than simple success stories, the cases examine all the problems and logistical details that can make or break an operation. "People find this kind of information extremely fascinating and important, yet no one writes about it," Cohen said. Shanghai's Model Ideally, the cases can be used as models for similar programs around the world. Kleinman was part of a team that evaluated the Shanghai model of rehabilitation for schizophrenic patients in China. China is home to nearly eight million people with schizophrenia, and families shoulder much of the responsibility for care. The country's largest city, Shanghai, has developed a widely regarded system for delivering treatment and ongoing support to patients. In addition to outpatient services at primary care centers and support services in factories throughout the city, Shanghai has a guardianship network of volunteers who act as case managers for patients. Occupational therapy and a rehabilitation association help to integrate schizophrenic patients into society through employment. But despite the success of the program, it has not been replicated in other places, which Kleinman thinks is a shame. "That's a model that could be applied in the U.S., not just in Shanghai," he said. Cohen traveled in northern India, documenting several literacy programs aimed at poor women. Although a case study on a literacy program may seem out of place in a book on mental health, the risk factors for mental disorders--female gender, poverty, stressful life events, illiteracy, chronic illness--point to how closely mental health is linked to social factors. "We should also look at social interventions as integral components of mental health programs," Cohen said. He found that although some of the programs were flawed, in general, they helped women feel more empowered in their daily lives. One of the most extraordinary cases shows that mental health can be a critical component of other kinds of medical care. Partners in Health, in cooperation with Socios en Salud, works in poor areas of Lima, Peru, to treat patients with multidrug-resistant tuberculosis, requiring a complex regimen of treatment and strict adherence. To see if they could enhance adherence to medication while addressing some of the psychosocial consequences of the disease on patients, Partners in Health initiated regular group psychotherapy sessions among some of the patients. During the sessions, patients were able to confront the extreme difficulties of treatment, as well as the emotional toll of sickness, the death of family members, and poverty. In one example, José, a 31-year-old man who had initially failed one round of treatment, wanted to abandon his therapy because physical ailments kept him from providing for his family. After several sessions, he began to see hope in his situation. Eventually, he began offering support and consolation to other patients. None of the regular members of these group sessions had abandoned treatment at the time the case was written. Best Practices in Mental Health The casebook is a follow-up to a book published in 1995, World Mental Health, which detailed the unique mental health problems faced by developing countries and the burden that such disorders cause. Since then, the Global Burden of Disease study also helped to reframe the impact of disease, emphasizing the social and economic burden of largely nonfatal diseases like mental illness. In response to these issues, the WHO launched a yearlong campaign in 2001 to draw attention to mental illness and reduce the stigma and discrimination attached to it. This attention may help bring funding and resources to mental health--which currently receives a scant one percent of the health expenditure in most developing countries--but it does not address the problem of how to design programs to deliver better care. Cohen and Kleinman hope that the casebook, published in April by Kluwer Academic/Plenum Publishers, will help advance the idea that mental health programs in developing areas need to be documented and evaluated in order to have a larger impact on world mental health. Only by describing the programs can mental health researchers and practitioners begin to make generalizations about best practices in low-income countries. --Courtney Humphries