Accent Image for Episode 36: Frontline Insights on Global Mental Health

For Clinicians

Episode 36: Frontline Insights on Global Mental Health

Dr. Kerry Horrell, Dr. Stephanie Smith, Dr. Bob Boland
Dr. Bob Boland  00:02
Welcome to the mind dive podcast brought to you by the Menninger Clinic, a national leader in mental health care where your host, Dr. Bob Boland,
Dr. Kerry Horrell  00:11
and Dr. Kerry her L. twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in.
Dr. Bob Boland  00:42
We're delighted to have Dr. Stephanie Smith. Dr. Stephanie Smith is the director of the program in global Mental Health Equity at the Brigham Women's Hospital and co director of mental health at the global nonprofit partners in health. She also works clinically within the Division of Medical Psychiatry at BWH, that's the Brigham and Women's and holds an affiliation with the Department of Global Health and Social Medicine at Harvard Medical School. Wow. Wow. So we're talking about global mental health today,
Dr. Kerry Horrell  01:11
which is super freaking cool. Welcome. Dr. Smith we're so excited to talk with you.
Dr. Stephanie Smith  01:16
Thank you. Thanks for having me.
Dr. Bob Boland  01:18
 So let's let's just start with you. Tell us a bit about your career, like how you got interested in global health. I can't wait. No, you don't want to do that.
Dr. Kerry Horrell  01:26
No, no, you're right. I'm am. I'm wondering, I'm gonna pull a Bob here for a second. If you could also define what is global mental health? I wouldn't. I mean, the name is sort of self explanatory. But maybe you could also just orient us to what that is, or how you got interested. Bob always does that. That's all right. That's my favorite question.
Dr. Bob Boland  01:45
Now I forget the other question now. But go ahead. All right. What is global mental health?
Dr. Stephanie Smith  01:50
Well, my interest in global health really started prior to my interest in psychiatry, I would say I went to Ghana, prior to medical school, actually, and, was very moved and struck by the poverty and the injustice of the accident of birth and growing up in low resource settings. And so that was just prior to medical school. And so that inspired a lot of work during medical school in global settings. I really focused at that time on human rights and human rights advocacy, and started a chapter of physician for human rights and did a lot of HIV advocacy and other global health areas. And then it wasn't until I then went into psychiatry, when I started considering how is this how is this actually going to work? Because I haven't been engaged in mental health. And there there certainly at that time, were, I hate to say naysayers, but people who said, Well, what are you going to do in that field? Maslow's Hierarchy, you know, people are dying of malaria, they're dying of other things. And so, you know, what are you gonna do about depression, if someone's dead of malaria? Well, it turns out there are a lot of people who are not dead of malaria and global health, global mental health and mental health conditions are one of the highest contributors to the global burden of illness across the globe, it is pretty much the highest contributor to disability in the world. And so you can really do a lot with psychiatry, and there are very few, psychiatrists in the world. Actually, in most of the settings where I work, there are anywhere from zero to just a handful. And so there you can really make a big difference in that field. And so, you know, global mental health, I mean, I really think of it as its own field, and a lot of it has focused on how do we think about the tasks of mental health and mental health care, and think about the broad spectrum of providers who can provide it. So there's a focus on task sharing, because again, there are very few psychiatrists and psychologists. And so we're thinking about delivery, we're thinking about how do we actually get services where, essentially, there are none. And so that's really I would say, global mental health delivery is is a lot of my current focus.
Dr. Kerry Horrell  04:10
I'm thinking about a paper you wrote about getting mental health services into primary care clinics in Rwanda, if I'm not mistaken. And I wonder, you know, that's been a part of your work is integrating in this mental health piece into places in which medical services are already happening in primary care locations? And I wonder like, what need you saw? Or like, how did you start seeing that as like a place to integrate it in what was the state of mental health, if you will, when you kind of visited those sort of clinics or saw what was going on there?
Yeah, so backing up. I'll just say a little about Partners in Health, which is the organization I've been with for 12 years. So Partners in Health is a health system strengthening organization, we work in eleven country across the globe. And it's it's really focused on the right to health and preferential option for the poor and where we work, we work in the public sector. So we're working in government health facilities, we're not, you know, setting up shop or hanging our sign in, in another country, but it's really focused on supporting the ministry and the government health services. And so when I went to Rwanda, specifically, because that's where most of my work has been right out of residency I, I went to Rwanda at you know, at that time, so they're going back in terms of Rwanda, as you may know, there was a genocide in 1994, where a million Tutsi and were killed over the course of about three months and essentially destroyed the fabric of the country. And so there was no government, there was no health system, certainly. And so they been in a process of rebuilding it since then. And so then I went and people Partners in Health was invited in 2005, to go to Rwanda and focus on health system strengthening, and then I arrived in 2011. And at that point, in terms of mental health system development, you know, the government had written a very progressive policy after the genocide. And they had really focused on decentralization deinstitutionalization, moving mental health care into the general health system, away from a kind of centralized model, you know, an asylum model, essentially, which is what had been exported from colonial, you know, countries throughout the 19th century and 20th century. Not that that's what we would want to model but they that was the policy. And so taking that together with, you know, partners in health systems strengthening, where we were at rural continuums, like general hospitals, primary care centers, and the community thinking about how do we incorporate mental health into that continuum. There were at the time very, there are a couple practitioners that each district in the government had been successful at getting one psych nurse and one psychologist at each district hospital about 40 or so in the country. But if you think that there's a, you know, population of, you know, 10 million or so it's not very many. And so again, going back to the idea of how do we parse out the skills that are needed in a working mental health system into this continuum? Well, integrating into primary care makes a lot of sense. You look at the existing providers, and think about what can you know, what can we do at this level? How do we think about the basic pieces that can be done by nonspecialist providers in the kind of continuum where they're supported by the specialists, including myself? And so we really looked at, you know, how do we incorporate into the General Hospital, sort of a consult kind of model, the primary care setting, basic care delivered by primary care nurses, and then the community level where these community health workers are this liaison between villages and people's communities and the health system? So hopefully, that makes sense. But that was that was the sort of thinking like, you know, we have to, and it's all tied together, what is what is the government's fundamental plan for what they'd like to accomplish visa vie mental health care?
Dr. Bob Boland  08:30
Right. I mean, so it's you describe it, it sounds, I mean, to me, it sounds a bit overwhelming sometimes to hear  about in terms of the need and sort of the resources. I mean, like, what did you prioritize? Because mental health care can mean many things, what are the things you focused on?
Dr. Stephanie Smith  08:46
So if you can, you know, if you can imagine that a place where there aren't a lot of art yet a lot of formal mental health services, but we're in a health system, and we're doing health system strengthening, often, where we started was really with the sickest individuals and the people who came to attention. Honestly, you know, people who have very significant severe mental health problems are very visible, and disruptive, in communities often if they haven't had any treatment, and so those were the individuals who were usually brought to the health system. And so we focused a lot on the most severe mental health problems to start with, within this, this health system. And so, schizophrenia, you know, bipolar disorder, and then neurologic disorders are often in the same basket, anything from the neck up, the brain, in the mind belongs to belongs to psychiatry, and so neurologic conditions as well. Epilepsy. And so that  was really where we focus and we also did informal discussions with health center nurses, and this is what they were seeing as well. This is where these were the individuals who really presented to care at that point, and so that was really where we started sort of a triaging so that we could care for, you know, the sickest individuals to start with,
Dr. Bob Boland  10:10
I'm just going to follow up on that including sounds from URI kind of said it. But to go into more detail, you're really describing sounds like it sounds like a collaborative care model where you weren't the one directly treating at least not all the time, I imagine, you're consulting to non-psychiatric clinicians and nurses or I don't know, even maybe lay people.
That's right. At the hospital level, there were general practitioners and general nurses. And there were, as I mentioned, a couple, like once a couple of psych nurses and psychologists who would, who would be called kind of for consults and I supported that the delivery of care within that framework. So I didn't do a lot of direct patient care myself there. But it was really accompaniment of the local providers in thinking, how can we how can we incorporate a consult like this was at the hospital level? How can we incorporate a council liaison type of model here, although we did also care for people with primary psychiatric disorders who were really being admitted for primary psychiatric problems, because again, some of the goal of decentralization was that people didn't get transferred away from the community and away from these rural continuums. But we were able to care for them in their communities.
Dr. Kerry Horrell  11:31
This is maybe an overly simplified question. But like when we're thinking about care in this setting, was it primarily like psychopharmacology? Was it primarily psycho Ed, both those was there like a therapy components available?
Well, we've built it in over the years. So at the beginning, there, there was a lot of focus on safe medication management for individuals, and basic psycho psycho education and some of the more limited interventions around things like sleep hygiene for people with bipolar disorder, for example, and some other less intensive type of interventions that could be done, and more quickly, but then over the course of time as we strengthen this continuum, and as the government was able to provide more resources, and as well, we were able to get more financial resources, leveraging our successes, then we did start to incorporate psychotherapies. And I believe it was in about 20, you know, 2016 2017, that we started using an intervention called Problem Management Plus, which is a very basic low intensity, cognitive behavioral based intervention, it's five sessions and focus on problem solving and relaxation techniques, etc. And that we were also able to teach and capacitate at the primary care level, this intervention. And so it's like over the court, we started with the sickest. And over the course of time, you're kind of building in different building blocks to have psychotherapy. And then now we have a pretty robust psycho-psychosocial rehab curriculum, and kind of focus on vocational and work for people with severe mental health problems. And so it's been a slow kind of building blocks within this this framework
Dr. Bob Boland  13:29
Now how are you received going there? I mean, I sounds like the there's already a presence, I guess, for partners in health care. But
yeah, I think people were people were thrilled to have the psychiatrists. So I'll say, and it was interesting, because in the US, I think psychiatry is often a little bit of the stepchild, or, you know, in medicine, it can be a little bit marginalized, or a lot depending on where you are. But I, my, my personal experience, there was that, you know, I was a physician. And I happen to specialize in psychiatry, but everybody was a doctor, and I was the psychiatrist. And so that was the how I was perceived, I believe. And so it was different. And it's really, you know, with the tools of psychiatry going to a place where you are, there are no other psychiatrists, you really do learn how important and valuable the skills are of psychiatry, in those kinds of settings. And so I really felt very, very valued, actually, within the health system in a way that perhaps is less so in the United States.
Dr. Kerry Horrell  14:38
This makes me think of if if you felt like you guys collected any data empirically, were anecdotally that by carving out these psychiatric treatments, and being able to focus on that part of a person's health, was there again data or did you notice that people's physical health and utilization of health services declined at all? Because I imagine that's probably true that like, again, like you were saying psychiatry concerns be like, well, we can't worry about that we have bigger fish to fry. And then at times not recognizing, yeah, but when we actually look at this issue, sometimes physical issues and other things that lead to people chronically using
Dr. Stephanie Smith  15:15
the body mind thing? Yeah. I'm not sure if we have data specifically on utilization of sort of physical, you know, it's sort of like the other parts of the, of the mental health system. But I certainly think that in incorporating it and kind of raising the profile of, again, that, you know, there are psychiatric presentations of medical illness, and that, you know, there's just, there's, there's this false dichotomy and, and once again, you know, that because there was not it sort of established kind of separation of that thus far that I think that kind of integration and expectation that it can happen at the kind of general hospital level, and psychiatry can just be a part of it, there's mental health care, there's physical health care, and I think that I found it to be not that difficult to kind of mix the two again, because there's this perception of you know, you're a physician, and you're doing the brain in the mind, and that's fine. It's another organ system, just like the others. And, yeah, I think we do have data just on, like, some of the kind of, you know, outcomes, like, symptoms and functioning, you know, we would look at, you know, what, how are people doing when they're cared for in the system by non-specialist providers? Primarily? How are they doing? And can we, you know, can we kind of have something to hang our hats on in terms of the outcomes and the individual level outcomes. And we do, I think, when you're when you are, you know, starting from very little, and going to much less than much more than very little than can really demonstrate pretty big effects. You know, many people had not ever received any mental health care. And so, you know, they would report significant improvements.
Dr. Bob Boland  17:05
So you talked about sort of the possible barriers of being a psychiatrist there and being a positive experience. What about just the notion of being not from there? And probably not, I'm guessing, not looking much like people who live now.
Dr. Stephanie Smith  17:18
And, you know, I'll be honest, I think there were definitely, towards the end of my stay, some of our team had told me that, you know, there were members of the community who wondered if I were a witch. And, you know, it's it's quite fascinating. For example, if because, again, I said, we were dealing with a lot of the most severe challenges. And so there were times when people who were had been very severely catatonic for example, who were brought in and then give them a little bit of diazepam, and then now they're walking and talking, that's quite something to witness seems magical, especially, it isn't anywhere, anywhere in the world. I mean, in this, in this country, it's still the tell us this people are like, wow, that's really it's like our thing in psychiatry that we can, we have this quick improvement, we don't have any of those. And so I think those like those particular episodes, were very notable. I think, though, that people appreciated the visibility of, of mental health care, and by psychiatrists coming, you know, not looking like people and not being from the area, it also kind of heightened the awareness and visibility, like this is something that's now being prioritized. And so I think that that was used to the advantage of the program by a lot of our, our team on the ground, you know, within communities to say, look, we've brought in somebody from the outside, and it's gonna, you know, we're really trying to build this within the system. But again, you know, the work was all locally led. And so I certainly played a role in supporting it and conceptualizing like how do we build this system, but fundamentally, our providers, they are the ones who I was supporting and in, in their work, and so they were the ones doing the direct service delivery that the vast majority of the time.
Dr. Kerry Horrell  19:13
 No, it makes me think about, you know, in your work in Rwanda, but also perhaps in your work as the program director for a global health, global mental health kind of program, you know, thinking about cultural differences and how, I mean, this isn't my thoughts are not particularly clarified, because it's an impossible question that I'm trying to ask, but just so you know, like, how do you approach cultures perhaps that are more likely to be resistant to medication? Or like how, how do you think about that with, especially these programs where we're taking people on we're implanting them into communities, I wonder if there are sort of like tools and methods or even just ways of thinking about that that come to your mind? Again, appreciating that that was not an easy question.
Dr. Stephanie Smith  19:57
Well, you know, I would say that what fascinating is that, you know, I wouldn't say that there's anywhere that I've been where people are kind of anti-medication, or they're skeptical necessarily, it's really a matter of having witnessed effective treatment. And so if you are able to show how the tools of psychiatry, including medications are able to be helpful, and you are showing that somebody who previously was catatonic or who was disorganized, and kind of roaming around the community without much purpose is now able to, you know, in an organized way, have a job that's very visible. I mean, that is incredibly powerful. I think that that sort of thinking that there are, there are cultures, or there are certain areas that are sort of would be resistant, I think it has one probably, they've never actually been had the experience of having good services that are available. And so I think that that's really probably where a lot of it stems from. And so if you have, you know, if you're able to demonstrate that people improve with mental health treatment, that is a huge Well, it's a huge stigma Buster, but it's also I think, you know, it changes the way anybody would think, you know, Paul Farmer founded Partners in Health, and I don't want to simplify, you know, his work in Haiti, but he had treated people with tuberculosis, and there was a message, well, people aren't going to take the medications, because they think that it's caused by a spirit. And so people won't, you know, they won't take anti, you know, anti tuberculosis medications. And it turns out that they do, in fact, because what they want is they want to be cured, or they want to get better. And so he went back and asked people like you saw, you know, you think that tuberculosis is caused by a spirit. So why did you take these medications? And they said, you know, aren't you capable of complexity?
Dr. Bob Boland  22:08
So, we have to think more broadly.
Dr. Stephanie Smith  22:11
And so it sort of feels like, you know, if there were, you know, there were, a lot of individuals who consider that what was affecting them were, were caused by spirits, or were caused by possession. But often, we could say, you know, well, you know, I have these treatments that hopefully can help these symptoms. And perhaps you can work on the cause, and also take these medications, which will could be helpful in, you know, reducing some of the suffering. But I frankly, don't think that's very different from people's conception of mental illness and what might be causing it anywhere in the world, including, yeah, I
Dr. Bob Boland  22:53
was thinking that we've wrestled with the same things, ideology in the States. So it's really not that different.
Dr. Kerry Horrell  22:58
That's my question was coming from, you know, my, my background is in religion and spirituality, and just there's so much there can be in some religions, pretty heavy stigma against psychiatry, and against, like, the mental health field. And so yeah, just thinking about like, does that exists in other places? And I mean, of course, I? Of course it does. But yeah, wondering about maybe like psychiatry is also in mental health work is just less prevalent. In some places, there's less stigma, the treatment,
Dr. Bob Boland  23:30
what were the most common things you saw? What kind of disorders were the most, most usual that you would encounter and have to do with?
Dr. Stephanie Smith  23:37
Yeah, well, as I mentioned, the, again, when you're when you're in a place where there are few mental health resources, and many people in the communities have not had the experience of any kind of formal mental health care, although some have had traditional treatments and others, we would, we would often see a lot of the most severe mental health problems which are very, you know, they are easy to spot across the globe, schizophrenia, bipolar disorder, obviously, epilepsy and the neurologic problems, but even things like depression and other what they call more common mental health problems, I think, are, are recognizable. And there are ways that people describe what ails them in different ways. But fundamentally, it felt because I was very worried about that. When I got there. I thought, well, I just trained in psychiatry, but am I going to have any idea what to do here? Or how to approach anything like what is this going to look like? And I was surprised perhaps to sort of find out that actually, no, it's it's, you know, it's a familiar it's a familiar setting, even if it's in other other places in the world. But what I you know, what I did find is, you know, that But there's ways in which, for example, we would if we see people in, in hospital settings or in clinic settings in the US, oftentimes, you know, we discharge them or we kind of send them on their way. And we don't know if we'll see them again, or we don't know what's happened. And they're, I think that the communities are closer, and they have community health workers and others who are really liaisons. And so there's ways in which you would see people but then be able to actually follow them and find out like, Oh, I haven't seen this person, or what would happen to them, like, Let's go figure out where they are, and where the community health worker can find them. And we can sort of follow up. And so there was this sort of continuum of, you know, treatment that maybe it's sometimes difficult even to, to get in the US.
Dr. Kerry Horrell  25:49
Well, and it makes me think about, I'm assumingly, you're not in Rwanda anymore. And so I wonder, like, how did you know? And I'm gonna hold on to, as the Haitian save complexity here for a moment, but there's likely lots of factors that went into this, like, how did you know it was time to like, move on? Was there a sense of like, the program had been built enough? Like, how was how was that for you decided?
Dr. Bob Boland  26:14
Is that true? Like, do you go back on occasion? Oh, yeah, absolutely. Yeah, I think it's still ongoing. Yeah, it's still ongoing.
Dr. Stephanie Smith  26:21
And so I think that my role has shifted, I'm not living there on the ground anymore. But we continue with the work and like I said, we're sort of building parts, you know, building it up as we go. And we're actually, the University of Global Health Equity is a university in Rwanda. Now, that's part of PIH, but it has a medical school. And the first cohort is going to be doing a psychiatry rotation starting this year. So now we're organizing a psychiatry rotation for medical students at our partners and health sites. So we've, we've come a long way, and being able to actually host something like that, and that we have enough service delivery that we can, you know, teach medical students, so it continues to grow. And I think that going back to what the philosophy of Partners in Health is, is, this is why we work in the public sector. And this is why we're strengthening ministry systems, because it's incorporated into the health system delivery so that things like this program will outlive, you know, one person leaving, but I continued to be very closely involved with our local teams, many of whom have been there since I lived there. So now our relationship is, you know, a decade plus long and it's wonderful to just continue to see how they grow.
Dr. Stephanie Smith  26:21
Yeah, but to Carrie's point, I guess it's still well taken. Are there other ways you ensure the sustainability of
Dr. Stephanie Smith  27:31
it? Yeah, well, I think that we all need to learn to lobby for increased funding for mental health care. Of course, this is, this is always a an ongoing challenge that mental health care within any system is often the most neglected in terms of funding allocations. And that's very true in the global health world as well. And in ministries, it's usually less than 1% of the budget is even for health care. And then, well, less than 1% of that would be for mental health care. So it's very small amounts of money. And so I think that we are always in a process of looking for funding or thinking about how do we how do we continue to grow this work, and there has been slow changes over over the years, for example, the Global Fund to Fight AIDS, tuberculosis, and malaria now incorporates mental health care into their funding application. And so there are ways in which there can be other mechanisms leveraged, but but we just have to continue to lobby that, you know, there's increased funding on a global level for mental health and mental health care. And then, of course, the capacity building, because many places don't have a lot of people who are mental health providers to begin with. And so we do task sharing. And that's, you know, that's one one way to help bring mental health care into systems. But we still do fundamentally need more people with mental health backgrounds and anywhere in the world in this country, as well as certainly in places with low resources. So working on the training and education and kind of building up capacity for human resource capacity is the other way. I think that I think in the long term that we're working to sustain that. So training programs, like I'm talking about medical students and others.
Dr. Bob Boland  29:33
It's correct me if I'm wrong, but I think global mental health is much more popular now than it was. I think there was, I mean, I might be wrong about this. But I think when I was like a resident many, many years ago, it was kind of a bias that like you can't move to another culture and be helpful, like you can treat infectious disease or something, but you can't really treat this, whereas it seems like a lot more people come in now very interested in training in that.
Dr. Stephanie Smith  29:57
So I think that that tidal shift was maybe happening when I was in training, but I certainly, as I mentioned, encountered that sentiment, like, really? Why do you shouldn't go into psychiatry, if you want to do global health, you won't speak the language. So how can you be helpful? Exactly, but it turns out that, you know, the population health aspect, the collaborative care aspect of what we do, and the system strengthening and strengthening care delivery itself is a hugely important part of growing mental health care globally, perhaps more than me individually seeing some patients in another country. So I do think that the tide has shifted, and there are more and more I get residents every year who are interested in the work, and we'd like to think about how to engage. But once again, I think we in we need to create career pathways for people also, because it's still pretty unique to be able to forge a career in this space. And so I think that's a probably a life project of mine to think about, how do we how do we then, you know, build it within the field of psychiatry?
Dr. Kerry Horrell  31:07
This is a really incredible and interesting work. I wonder, and this is always our last question, kind of a broad question. But for our listeners, who are typically kind of people in the mental health field, do you have a last word for them on this subject, or any advice or thoughts for people who maybe are getting interested in global mental health?
Dr. Stephanie Smith  31:25
I think that well, for trainees and young people that you just continue to pursue it, I really, I think that there are there are different avenues that you can get into this, this kind of space. Some people use research and others, you know, kind of go advocacy routes. And so I would say that we don't want to lose people. And so I think I would, I would say that there are ways also that again, that kind of principles of of doing it are available in the United States to like collaborative care and population health. And so these are the kinds of fields that actually are, are very related. And so pursuing those kinds of paths really sets you in a good place for doing global work. And, you know, for kind of more broadly, psychiatry, of course, I would just, you know, like, like I said, my, one of my life projects, I guess, would be that we would engage with the field of psychiatry more more broadly within this this area, beyond just trainees but thinking about how we as psychiatrists can affect population health and think about the fact that there are so few human resources and so few of us and think about how are we actually going to parse out our own skills and be able to serve larger populations than we do?
Dr. Bob Boland  32:47
Well, thank you for the work you do. It's been fascinating. Yeah, we've been talking to Dr. Stephanie Smith, and we're the Mind Dive Podcast. I'm Bob Boland.
Dr. Kerry Horrell  32:57
I'm Kerry Horrell. Thanks for diving in.  The Mind's Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen. For more
Dr. Bob Boland  33:11
episodes like this, visit www dot Menninger
Dr. Kerry Horrell  33:15
To submit a topic for discussion, send us an email at
Call us today & let us help you or a loved one.