Five Questions with Global Mental Health Experts: A conversation with Professor Arthur Kleinman


Harvard T.H. Chan School of Public Health student, Davy Deng, interviews Dr. Arthur Kleinman, Professor of Medical Anthropology and Psychiatry, Harvard Medical School and Rabb Professor of Anthropology, Harvard University and Chair of the GlobalMentalHealth@Harvard Advisory Group.


Davy Deng:
You are known as one of the world’s leading experts on global mental health, particularly in East Asia. How did you first become interested in this topic?

Professor Kleinman:
I began my work in Taiwan in 1969, I was seconded there to the US Naval Medical Research Unit in Taipei because of the Vietnam War from the NIH. My responsibility was primarily to study infectious diseases and I was particularly interested in the stigma associated with Tuberculosis (TB) and leprosy. After spending a few years there, I realized that, as bad as the stigma of TB and leprosy was, comparatively, the level of mental health stigma was worse, so I became interested in this subject.

In 1978, after having done research on Taiwan’s healthcare system, I switched to mainland China where I began studying depression. I remember a conversation I had with the minister of health in China at the time. He adamantly told me that there are no such things as mental illnesses in China because it is a communist country, and that mental illnesses only existed in capitalist countries. I then became aware that there was a particular Chinese way of diagnosis for some of the depressive symptoms that people exhibited, called “neurasthenia” or literally in Chinese “nerve weakness”(神经衰弱). This was an obsolete medical term abandoned by the US at the time, but it was still widely used in China, so I decided to put my emphasis on introducing modern terms of diagnosis for mental illnesses to China and that began my decades of work on mental health in Chinese culture.

Davy Deng:
Since you began your work roughly 50 years ago, China has undergone a dramatic societal and economic transformation, how would you comment on the mental health care and mental health stigma in Chinese culture now?

Professor Kleinman:
There have been big changes in China’s mental health system. For example, mental health care has definitely become much more patient centric. In terms of mental health stigma, I would say it is still fairly high for chronic severe mental illnesses such as schizophrenia but not nearly as serious as it was in the past for depressive and anxiety disorders. This is particularly salient for generations that are under 40 years of age right now.

Another big change is the attitudes towards help-seeking behaviors. I’ve noticed that mental health problems in younger people exhibit more psychological distress and less somatic distress as seen in the older generations. This could be understood as the legitimation of a more affective idiom for youth, but surely it is also related to the fact that in the past a language of psychological distress and psychotherapies were seen as humiliating or simply western concepts that are not applicable to Chinese society. And now I would say there is a “therapy trend” (心理热) in China — people are very interested in counseling services and psychological treatments. Even for severe mental illnesses that require hospitalization, China’s mental hospitals are dramatically improved in quality from before. And health insurance for such care is increasingly available.

Lastly there is an emphasis on empowering the self and making changes in one’s life on one’s own, instead of relying on families, networks and institutions for decisions when it comes to mental health. This rise of individualism is not the same in my view as in the west because it is a more relational individualism.

Davy Deng:
China has traditionally been thought of as an example of a collectivistic society, do you think this brings challenges to eradicate mental health stigma?

Professor Kleinman:
I do not believe it is necessarily harder to eradicate stigma in Chinese culture. Chinese society is in fact both collectivistic and individualistic, and its society has undergone a turn toward individualism. If you look at Chinese society nowadays, you notice that the connections in Chinese culture are built around individuals and not families. What happens is that individuality is downplayed in cultural narratives and the interpersonal connections are emphasized. In contrast in the US, we emphasized the opposite and hyper-focus on individualism. And yet networks are very important in American society too. So in my opinion it would be a myth to call Chinese society only a collectivistic culture.

Davy Deng:
How would you comment on the mental health system in the US? What do you think is the main challenge here in the US?

Professor Kleinman:
The mental health system in the US definitely needs major reform. I am more optimistic about the mental health system in China than the one in the US. And I would argue that the mental health system in China is already equally good, if not better than that in the US. In my opinion, what’s happening is that in the US, we did a lot of research showing community-centered service can bring about positive outcomes for mental health patients by means of social re-integrations among other things. This led to deinstitutionalization. That in turn led politicians to argue for massive cuts in funding of mental health services, so that it is increasingly difficult to provide community mental health care in the US. Politicians did not use the money saved from de-institutionalization to build better mental health infrastructure for community services. The result is that lots of patients were discharged from mental health facilities but did not receive proper community services to help them recover, which contributed to a broken and chaotic system. That is what needs fixing.

Davy Deng:
What do you think of the progress we have made so far in global mental health?

Professor Kleinman:
Global mental health research has blossomed more than I expected with lots of excellent researchers, for example Vikram Patel, who are really moving the field forward. Just look at all the academic and media attention to mental health impact of the COVID-19 pandemic. If this were 20-30 years ago, there wouldn’t be a fraction of the attention to this issue. However, I think there is still a lot of work to be done. To begin with much more work needs to be done on improving the quality of care. Studies of community mental health workers are suggesting that this is an important way to move forward, especially in settings of poverty and marginality. But what we really require is amoral movement for mental illnesses such as the one that took place for HIV/AIDS in the late 1980s and early 1990s. Absent such a movement, ministers of finance are unlikely to greatly increase funding for mental health care to the level required that would greatly improve quality of services by increasing the numbers of mental health practitioners and the availability of mental health services in the community. And families will be left, as in the past, with the great burden of mental health problems and care, which they will have to continue to carry with inadequate resources. That is why I helped organize the World Bank’s project “Out of the Shadows” which addressed the financial needs of mental health care in societies.


Davy Deng obtained three bachelor’s degrees in psychology, chemistry and genetics from the University of California, Berkeley in 2019 and came to Harvard T.H Chan School of Public Health to pursue a S.M. in Biostatistics with an interdisciplinary concentration in population mental health. He is interested in topics related to humanitarian aids/human rights, political polarization, health equity and LGBTQ+ mental health. Additionally he has also been working on research with Dr. John Naslund in the Mental Health for All Lab at Harvard Medical School that investigates effective ways of designing digital peer support programs and the utilization of art therapy in re-socialization.

Professor Arthur Kleinman’s numerous publications have included works on social suffering, mental health, stigma, moral experience, and caregiving. Most recently, he co-edited a textbook on global health (Reimagining Global Health: An Introduction. 2013, UC Press), co-authored a book on moral life in China with his former students (Deep China. 2012, UC Press), and a book on humanitarianism in social sciences (A Passion for Society. 2016, UC Press). He is the author of What Really Matters: Living a Moral Life Amidst Uncertainty and Danger (OUP, 2006), Writing at the Margin: Discourse between Anthropology and Medicine (UC Press, 1995), and The Illness Narratives: Suffering. Healing and the Human Condition (Basic Books, 1988), amongst others. His new book is The Soul of Care: The Moral Education of a Husband and a Doctor (Penguin, 2019).

He is also the author of articles in The Lancet and New England Journal of Medicine on caregiving as moral experience; global mental health; values in health; reforming medical education via the medical humanities; the search for wisdom; and on culture, bereavement and psychiatry. He has co-authored articles on stigma and mental illness; on the appropriate uses of culture in clinical practice; and on medical anthropology. His current project is a collaborative study of social technologies for aging and eldercare in China. Kleinman is a member of the National Academy of Medicine and the American Academy of Arts and Sciences.

The unmet needs for care for mental health problems have always been large; they have only increased during the current pandemic. Mental Health Care Leadership Champions will help narrow this gap by training and mentoring forward-thinking leaders. For more information visit: Mental Health Care Leadership Champions Program

EMPOWERING LEADERS FOR IMPROVED HEALTH OUTCOMES

The Certificate of Specialization comprises three programs, taught by faculty from the Harvard School of The Certificate of Specialization comprises three programs, taught by faculty from the Harvard School of Public Health, the GlobalMentalHealth@Harvard Initiative and an international pool of experts, embracing both empirical evidence and real-world lessons. Through this training and mentoring program, professionals from around the world will empower themselves to scale-up evidence-based and innovative programs to address the mental health needs of their communities with knowledge, skills, and peer support.

Those who complete both Foundations of Mental Health Care and Scaling Up Mental Health Care programs are invited to join a third program: a peer-learning collaborative to support and learn from one another as they embark on their journey of being champions for mental health.

Learn From the Experts

Foundations of Mental Health Care will be led by renowned faculty who have held both public health research and real-world leadership roles. Core instructors include Shekhar Saxena, former Director of the Department of Mental Health and Substance Abuse at the World Health Organization, Vikram Patel, co-leader of GlobalMentalHealth@Harvard, and Giuseppe Raviola, Director of Mental Health for Partners In Health (PIH), and the Director of the Program in Global Mental Health and Social Change (PGMHSC) at Harvard Medical School.  

To learn more and apply visit: Foundations of Mental Health Care | Executive and Continuing Professional Education | Harvard T.H. Chan School of Public Health

Written by: Ankita Shah, Program Coordinator, Sangath Bhopal Hub
Edited by: Juliana Restivo, Program Coordinator, Harvard Medical School

“Our experience today reinforced that ASHAs (Accredited Social Health Activists) have the potential to revolutionize mental healthcare. Their interpersonal skills were heart-warming and their strong ties to the community form the needed foundation to deliver accessible, patient-centered care. These lessons are relevant across India but also the rest of the world including North America”

Daisy Singla, Ph.D., C.Psych, Clinician Scientist, Center of Addiction and Mental Health, University of Toronto, Lunenfeld Tanenbaum Research Institute

Depression is the leading mental health cause of the global burden of disease[i] and estimated global costs of untreated depression are up to 16 trillion US dollars.[ii] Brief psychological treatments are among the most effective and cost-effective interventions in medicine[iii] and recommended as the first line of care[iv] to address this global burden. The major supply-side barrier of inadequate numbers and inequitable distribution of mental health specialists has been addressed by global mental health practitioners by task-sharing of these treatments to NSPs—including community health workers, lay therapists, peers, nurses, and teachers. There is now a robust evidence base demonstrating that NSP can effectively deliver brief psychological treatments for depression and other common mental health problems in a wide range of contexts.[v],[vi] Dr. Anant Bhan, Site PI for Sangath Bhopal Hub, shared why it is so important to engage with NSPs in this work, particularly in India, “ASHAs are the backbone of the community healthcare India, and by extension, our work. It is indeed an honour to be able to work with these community health change agents with such levels of dedication, commitment and hard work. We believe that the involvement of frontline health workers such as ASHAS is crucial for integrating mental health into primary health care provision.”

Despite the availability of NSPs-delivered, effective and cost-effective psychological treatments, the treatment gap for mental disorders remains a big challenge to be addressed. From the service-delivery perspective, clinical supervision of NSP-delivered psychological treatments positively impact the therapist in training, therapy quality and patient outcomes and thus it essential to ensure the quality of the treatment delivered. Previous approaches to clinical supervision have focused on mental health expert-led, applying ungeneralizable metrics to supervise delivery. This is particularly relevant in India as our country has limited, adequately trained specialists in psychological treatments who are available to provide expert supervision.

This study, funded by Grand Challenges Canada, and led by Principal Investigator of the study is Dr. Daisy R Singla, Clinician Scientist, University of Toronto, Sinai Health System, Lunenfeld Tanenbaum Research Institute, seeks to address the barriers by scaling up measurement-based peer supervision, and innovation the study investigators have designed, piloted and evaluated over the past decade, using the digital platforms for supporting NSP-delivered care in global health. This peer-supervision study is a component of the overall EMPOWER project. EMPOWER is a priority work-stream of the GMH@Harvard Initiative with the goal of increasing health system capacity for the prevention and care of mental health problems across the life course, globally. Using digital training, supervision, and quality assurance tools for specific evidence-based psychosocial interventions EMPOWER will train, and supervise, frontline health workers to deliver these interventions with assured quality. Learn more about EMPOWER’s mission and programs at EMPOWER.care. “The field of global mental health has reached an inflection point where we have sufficient evidence about ‘what works’ but do not understand ‘how to make it work’.” reflects Dr. Abhijit Nadkarni, Site PI for Sangath Goa Hub, “Studies such as the GCC EMPOWER peer-supervision project allow us to answer this critical question which will help the scaling up evidence based psychosocial interventions so that they are accessible to those who need them the most”

This supervision component of the EMPOWER project seeks to address the barriers posed by the orthodox approach to supervision, a key pedagogical and quality assurance tool in treatment delivery which is known to positively impact the therapist in training,[vii],[viii],[ix] therapy quality [x]  and patient outcomes.[xi],[xii] The Harvard Medical School Co-Investigators for the project are Professor Vikram Patel and Dr. John Naslund. The Investigators are collaborating with research teams at Dimagi and Sangath to adapt Dimagi’s well known CommCare digital platform for supporting NSP delivered care in global health.

In collaboration with projects based out of two Sangath hubs in Bhopal and Goa, the study will be conducted in primary care facilities in the Sehore district of Madhya Pradesh (14 facilities in rural settings), and the state of Goa (urban/peri-urban with 24 facilities). The NSPs will be trained to deliver a brief psychological treatment for depression called the Health Activity Program (HAP). In December 2021 the teams met in Hoshangabad district in Madhya Pradesh, India to test a beta version of Dimagi’s CommCare app for peer-supervision. There were 10 NSPs in total who attended the CommCare platform training consisting of five Accredited Social Health Activist (ASHA) supervisors and five ASHAs. “It was so inspiring, and humbling, to witness ASHAs, the formidable cadre of India’s public health workforce, demonstrate such commitment, motivation and comfort  in learning to engage with cutting-edge technologies to support their new roles as mental health care providers”. Professor Vikram Patel shared about his time meeting with the ASHAs during the pilot testing. The NSPs travelled from 9 to 60 kilometres to participate in the training. This set of NSPs has a diverse variety of qualifications, ranging from high school to post-graduate studies, with eight NSPs having completed either secondary or post-secondary education. The rest held a bachelor’s degree (BA). The NSPs ages ranged from 30 to 50 years old. This particular group of NSPs owned a smartphone and were well-versed in the procedure.

Study team members who also attended the pilot testing and met with ASHA’s included:

  • Deepak Tugnawat, Director of projects in Sangath Bhopal
  • Nitish Dube, Associate Director, Dimagi
  • Ankita Shah, Project Coordinator, Sangath Bhopal
  • Azaz Khan, Project Intervention Coordinator, Sangath Bhopal
  • Deepali Vishwakarma, Project HAP supervisor, Sangath Bhopal
  • Phool Singh, Project HAP supervisor, Sangath Bhopal
  • Radhika Tak, Project HAP supervisor, Sangath Bhopal
  • Akshat Purohit, Project HAP supervisor, Sangath Bhopal

[i] Ferrari AJ, Charlson FJ, Norman RE, et al. Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010. PLoS Med 2013; 10(11): e1001547.

[ii] Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development. The Lancet 2018; 392(10157): 1553-98.

[iii] Organization WH. Update of the Mental Health Gap Action Programme (mhGAP) guidelines for mental, neurological and substance use disorders, 2015: World Health Organization; 2015.

[iv] World Health Organization. Mental Health Global Action Programme Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological, and Substance Use Conditions in Humanitarian Emergencies. Geneva: WHO, 2015.

[v] Singla DR, Kohrt B, Murray LK, Anand A, Chorpita BF, Patel V. Psychological treatments for the world: lessons from low-and middle-income countries. Annual Review of Clinical Psychology 2017; 13(1).

[vi] Van Ginneken N, Tharyan P, Lewin S, et al. Non‐specialist health worker interventions for the care of mental, neurological and substance‐abuse disorders in low‐and middle‐income countries. The Cochrane Library 2013.

[vii] Saxon D, Firth N, Barkham M. The relationship between therapist effects and therapy delivery factors: Therapy modality, dosage, and non-completion. Administration and Policy in Mental Health and Mental Health Services Research 2016: 1-11.

[viii] Fairburn CG, Allen E, Bailey-Straebler S, O’Connor ME, Cooper Z. Scaling Up Psychological Treatments: A Countrywide Test of the Online Training of Therapists. J Med Internet Res 2017; 19(6): e214.

[ix] Kühne F, Maas J, Wiesenthal S, Weck F. Empirical research in clinical supervision: a systematic review and suggestions for future studies. BMC psychology 2019; 7(1): 54.

[x] Weck F, Jakob M, Neng JM, Höfling V, Grikscheit F, Bohus M. The effects of bug‐in‐the‐ eye supervision on therapeutic alliance and therapist competence in cognitive‐behavioural therapy: A randomized controlled trial. Clinical psychology & psychotherapy 2016; 23(5): 386-96.

[xi] Saxon D, Barkham M, Foster A, Parry G. The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical psychology & psychotherapy 2017; 24(3): 575-88.

[xii] Singla DR, Hollon SD, Velleman R, et al. Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India. Psychological Medicine 2019: 1-9.

Written by: Udita Joshi, Research Coordinator, Sangath Bhopal Hub
Edited by: Juliana Restivo, Program Coordinator, Harvard Medical School

Project EMPOWER (India) completes pilot training of more than 40 community health workers in Gujarat, India to provide evidence-based psychological treatment

According to the latest survey by WHO, COVID-19 pandemic has disrupted critical mental health services in 93% of the countries worldwide. This has led to a prolonged exposure and upsurge in mental health conditions and exposed the deficiencies of India’s mental health care system which reaches less than 5% of the population and is under-resourced. This burden of mental health conditions is expected to rise as the socio-economic ramifications of the pandemic unfolds. 

EMPOWER is a priority work-stream of the GMH@Harvard Initiative with the goal of increasing health system capacity for the prevention and care of mental health problems across the life course, globally. Using digital training, supervision, and quality assurance tools for specific evidence-based psychosocial interventions EMPOWER will train frontline health workers to deliver these interventions with assured quality. Learn more about EMPOWER’s mission and programs at EMPOWER.care.

The relationship between mental health and COVID-19 has led to increasing demand but due to inadequate resource allocation, staggering gaps in the workforce capacity, service provision is suffering. Growing evidence from Low-and Middle-Income Countries (LMICs) demonstrates that frontline healthcare providers, with appropriate training and supervision, can effectively deliver brief psychological treatments for depression. However, scaling up this evidence is hampered by reliance on face to face methods for training, supervision, and quality assurance barriers. One of GlobalMentalHealth@Harvard’s effector arm implementing partners in India, Sangath, has sought to address these barriers efficiently and at scale, by using digital approaches to train and support by building on extensive formative work with the target participants, and developing learner-centered and focused content. ESSENCE is a National Institute of Mental Health funded U19 Scale Up Hubs research project which is one of the foundational research projects to inform the EMPOWER program. ESSENCE developed and evaluated digital approaches to train non-specialist providers (in India these are government accredited community health workers, also known as Accredited Social Health Activists) in Madhya Pradesh, India. 

The Sangath Bhopal Hub are the leading implementers for EMPOWER India. The Sangath Bhopal team has now recently expanded on the ESSENCE project with the recently concluded Project EMPOWER in Gujarat. The project led by Dr. Vikram Patel, Principal Investigator, Harvard Medical School and Dr. Anant Bhan, Principal Investigator, Sangath Bhopal Hub has successfully trained 43 community health workers in the Health Activity Program, an evidence-based psychological treatment for mental health issues like depression, anxiety and substance use or alcoholism. The pilot phase of the project was initiated in August 2020 and was implemented in the tribal district of Jhagadia in the Bharuch district of Gujarat. 

Participants and project partners during a project dissemination event at Gujarat Institute of Mental Health (GIMH), Ahmedabad.

The objective of the project was to engage the frontline health workers in digital training and build capacities for delivering mental health treatment at the grassroots. The frontline health workers were trained in providing evidence-based psychological treatment in rural communities that are underserved. 

The pilot phase was implemented with 29 Accredited Social Health Activists (ASHAs) and 14 Community Health Officers (CHOs) of Jhagadia block in selected primary healthcare settings of Gujarat (7 Primary Healthcare Centers and 2 Community Healthcare Centers). The training was delivered in the Gujarati language to all the participants with the help of an online learning management system (LMS) nested within the TeCHO platform which is used across the state by the health system as per the advice of local partners. The LMS contained educational content in various forms such as audio, video and PDF files. The audio and video content made it easy for the participants to learn and understand the training modules. The project team also conducted focused group discussions (FGDs) and competency assessment tests to understand the level of knowledge and awareness the frontline health workers acquired from the program. 

The results are encouraging and key findings will be shared soon. The Sangath Bhopal team took the opportunity to discuss the findings and appraise the work with State officials in Gujarat and discussed opportunities for future work.

The findings of the pilot were presented by Dr. Udita Joshi, Research Coordinator, Sangath Bhopal Hub and Aakrushi Brahmbhatt, Research Assistant, Sangath Bhopal Hub with the participants and project partners during a project dissemination event at Gujarat Institute of Mental Health (GIMH), Ahmedabad. The team also presented the success stories from the field and a project dissemination report.  Experiences were also shared by the participants of the digital training from Jhagadia during this presentation. 

The pilot was implemented by Sangath Bhopal Hub in collaboration with SEWA Rural, Harvard Medical School, and the National Health Mission, Government of Gujarat. The project was funded by the Tata Trusts via The Lakshmi Mittal and Family South Asia Institute Harvard University

For any further updates contact: Dr. Udita Joshi udita.joshi@sangath.in

Is care coordination the missing piece to combatting the mental health crisis? A top mental health expert joins the podcast dedicated to successful care coordination to review how intertwined these subjects are, or should, be.

ACMA Podcast Page: acmaweb.org/podcast

Podcast Platform Links:

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The United States has devoted more resources, attention and industry professionals to positively impact mental health in America, including suicide and substance abuse mortality rates. Despite this increased attention, mental health metrics in the US have increased in the last 20 years, especially with youth and minorities. What’s broken and why is it broken? While the pandemic has had a noticeable impact, research shows that mental health in the US was declining before COVID-19 due to various factors, including dialogue about its implications.

Dr. Vikram Patel, MBBS, Ph.D. and Harvard professor, joins the Care Transitions Today podcast to discuss reimagining mental health care. Joined by host and longtime healthcare leader Deb McElroy, hear Dr. Patel explain the mental health care implications of the pandemic, review innovative approaches to enhance access to quality care and examine how these approaches can be scaled to reduce mental health disparities. To listen to this episode, visit acmaweb.org/podcast or search “Care Transitions Today” on any podcast platform.

Dr. Patel is the Pershing Square Professor of Global Health and Wellcome Trust Principal Research Fellow at the Harvard Medical School. Over the past two decades, he has focused on reducing the treatment gap for mental disorders in low resource countries. He is also a Fellow of the UK’s Academy of Medical Sciences and has served on WHO expert and Government of India committees. Dr. Patel is the co-founder of Sangath, a local NGO dedicated to mental health and wellbeing. He has led efforts to set up the Movement for Global Mental Health, a network that supports mental health care as a fundamental human right.

About Care Transitions Today

Care Transitions Today is a biweekly podcast created by the American Case Management Association (ACMA), currently in its second season. The podcast is hosted by Deb McElroy and is dedicated to discussing topics related to all things case management and transitions of care with experts from across the country. Deb brings her extensive experience in the public health sector to embrace frank conversations and share experiences, wisdom and expertise to help health care professionals respond and adapt to today’s health care environment.

About the American Case Management Association  

The American Case Management Association (ACMA) is a professional membership organization for nurses, social workers, physician leaders and other health care professionals in case management and transitions of care practice. Founded in 1999, ACMA is comprised of more than 8,000 members nationwide, making it the largest non-profit professional membership association for case management and transition of care (TOC) professionals. ACMA provides resources, solutions and support to over 40,000 educational subscribers. For more information, visit http://www.acmaweb.org.

Write up written by Jon Vickers
American Case Management Association
jvickers@acmaweb.org

LITTLE ROCK, ARK
July 28, 2021

The below is originally posted in full on HMS News & Research – read it here

A $10 million Lone Star Prize was awarded to Meadows Mental Health Policy Institute for its competition entry, the “Lone Star Depression Challenge.”

In collaboration with the Department of Global Health and Social Medicine in the Blavatnik Institute at Harvard Medical School, the Center for Depression Research and Clinical Care at UT Southwestern Medical Center, and The Path Forward for Mental Health and Substance Use, the Meadows Institute aims to increase the rate of recovery from depression in Texas from less than 10 percent today to more than 50 percent through early detection and treatment in primary care.

The Lone Star Prize, awarded by Lyda Hill Philanthropies and managed by Lever for Change, is a Texas-based competition that was launched in early 2020 to find and fund bold solutions focused on building healthier, stronger communities.

Vikram Patel, the HMS Pershing Square Professor of Global Health, will lead the HMS portion of the collaboration. He will use the EMPOWER initiative to deploy a suite of digital tools to train, supervise, and support community health workers in delivering brief, psychological treatments that have proven effective for treating depression in primary care and community settings around the world. 

“We’re at the start of a journey to build the world’s community-based mental health force, which is essential for addressing the vast unmet need for high quality mental health care,” Patel said. “Our initiative uses both established and novel digital tools to leverage decades of clinical and implementation research, giving community health workers the power to implement evidence-based treatments for patients with depression.”

Throughout his career, Patel has led pioneering studies that quantified the health, social, and economic costs of mental illness in low-resource contexts globally. He has developed and tested models of care delivery that leverage available low-cost resources, such as community health workers, to deliver the high quality mental health care described in his book, Where There Is No Psychiatrist. This work is embodied in his long-standing collaboration with the Indian nongovernmental community health organization Sangath.  

“The Lone Star Depression Challenge is a fantastic opportunity to build a project at scale in one of the largest states in the U.S.,” Patel said. “Ultimately, we hope our approach will greatly expand the footprint of the existing mental health care system into the community, in particular reaching those who have historically had limited access to mental health care, and show the potential of this innovation to help millions of other people around the nation and around the world.”

Paul Farmer, chair of the HMS Department of Global Health and Social Medicine, offered heartfelt congratulations for Patel and to the other collaborators in the Lone Star Depression Challenge, noting that the prize rightly acknowledges the importance of addressing mental health as a matter of highest importance.

“Every careful study of the afflictions that burden communities, regardless of how they’re bounded, shows that mental illness is at the top of list, while resources to address it remain the lowest of our priorities,” Farmer said. “From India to the United States, Vikram has sought to correct this mismatch, not only by calling it out but by developing effective, safe, inexpensive, and novel community- and family-based interventions to address this imbalance. The world has reason to join us in celebrating this prize.”

In Texas today, an average of eight to ten years passes before depression is diagnosed after symptoms emerge. Because of this, fewer than 1 in 15 of the 1.5 million Texans suffering from depression each year receive sufficient care to recover.

The Meadows Institute says that once fully realized, the Lone Star Depression Challenge will free Texans affected by depression by scaling clinical solutions in health systems, empowering marginalized communities to achieve equitable outcomes, and harnessing purchaser-driven market forces to accelerate adoption of these changes. The Lone Star Prize will enable the collaborators to combine and scale up three innovative programs.

These programs include:

EMPOWER, a suite of digital solutions enabling community-based frontline providers to learn, master, and deliver brief psychological treatments, therefore extending their reach to marginalized communities with limited access to quality care. EMPOWER builds on two decades of research demonstrating that frontline providers can be trained to deliver brief psychological treatments for depression.

Patel will direct the implementation of EMPOWER for the Lone Star Depression Challenge along with project co-lead John Naslund, instructor in global health and social medicine at HMS.

Naslund noted that there are many gaps in mental health coverage across the large, diverse population of Texas, accentuated by deep disparities in coverage between urban and rural communities, racial and ethnic groups, and social and economic strata. 

“One of our main goals is to close those gaps, particularly around equity,” Naslund said. Because specialist mental health care is scarce in many communities with high rates of depression, it’s especially important to expand the reach of mental health services to primary care and to strengthen the community health system, he said.

Over the course of the five-year term of the Lone Star Depression Challenge, EMPOWER will train hundreds of community health workers and reach many thousands of Texans in need. Community health workers will learn to recognize depression and to use an evidence-based treatment called behavioral activation, which seeks to break the vicious cycle of social withdrawal and retreat that characterizes depression and replace it with a virtuous cycle of engagement and recovery, Naslund and Patel said. The initiative will also train frontline workers to recognize when patients require specialized care, for example in acute crisis situations, and support a referral system, they added.

The Cloudbreak Initiative, which will scale detection and treatment in primary care centered on two proven approaches: measurement-based care, the routine use of repeated, validated measures to track symptoms and functional outcomes in clinical settings, and the collaborative care model, an integrated approach to the treatment of depression that involves care managers and consultant psychiatrists engaging directly within primary care settings. Together, these approaches have been proven in multiple studies to help at least 40 percent of people treated in primary care achieve full symptom relief and another 25 percent to recover substantially.

The Path Forward, an existing partnership between leading North Texas health purchasers and their national counterparts, harnesses the power of public and private health leaders to reform payment approaches to incentivize health systems to accelerate adoption of effective depression care provided to employees and their dependents.

The Lone Star Depression Challenge deploys proven approaches to overcome the systemic barriers preventing Texans with depression from accessing care sooner and more effectively.

Cloudbreak is redesigning primary care for depression to function just like primary care does today for heart disease and cancer, EMPOWER is making access to evidence-based care more equitable by building a community-based mental health workforce which can link people in the least resourced communities to care sooner, and The Path Forward is harnessing market forces to speed implementation of both approaches.

The Meadows Institute, which will oversee the Lone Star Depression Challenge, was founded in 2014 to help Texas legislators, state officials, members of the judiciary, and local leaders identify equitable systemic solutions to mental health needs and has become Texas’s most trusted source for data-driven mental health policy. The Meadows Institute has begun to make a significant impact in multiple areas, helping Texas leaders shift the focus of new investments toward early intervention, address the mental health crisis in jails and emergency rooms, expand the mental health workforce, and improve access to care for veterans and their families.

“The Lone Star Prize will make possible the first-of-its kind, wide-scale expansion of three proven initiatives to improve the lives of Texans living with depression,” said Andy Keller, president and CEO of Meadows Mental Health Policy Institute. “On behalf of the Meadows Institute and our partners in this project, we are immensely grateful to Lyda Hill, Lyda Hill Philanthropies, and Lever for Change for the opportunity and encouragement to dream big and share these bold solutions across our great state.”

EMPOWER is one of five workstreams in GlobalMentalHealth@Harvard, a University-wide interdisciplinary initiative based at HMS that Patel launched in 2018 to work toward a world where mental health is valued and realized by all through a combination of transformative education, research, innovation, and engagement.

“I am excited to bring evidence-based interventions emerging from global contexts to the U.S. Our rollout in Texas builds on critically important formative work to adapt these interventions for the U.S. and to test the use of digital technologies for training frontline workers,” Patel said, noting that crucial support for the development of EMPOWER’s work on the Lone Star Depression Challenge came from Mala Gaonkar and the Surgo Foundation, Natasha Müller, the National Institute of Mental Health, the Wellcome Trust, and the American Psychological Association.

View the full Lone Star Prize announcement from Lyda Hill Philanthropies and Lever for Change here.

Portions of this story are adapted from a Meadows Institute news release.

Over the next few weeks, GMH@Harvard will be featuring a five-part series on the largest mental health genetics study in Africa and the project’s corresponding training initiatives. The study and training efforts are a collaboration between scientists in Ethiopia, Kenya, South Africa, Uganda, and Boston at the Harvard T.H. Chan School of Public Health and the Broad Institute. The series explores issues of equity, ethics, building the next generation of psychiatric geneticists, and what it takes to recruit more than 35,000 people.


Introducing NeuroGAP-Psychosis
Get a glimpse of the study that aims to chip away at what we know about the genetics of schizophrenia and bipolar disorder. Click here to watch video.

Capacity Building & Training: Dr. Asha Omari
Hear Dr. Felicita Omari speak about ensuring sustainability in global research and the joint efforts of NeuroGAP-Psychosis and GINGER. Click here to watch video.


Addressing Stigma, Advancing Diversity, and Overcoming Inequity 
NeuroGAP-Psychosis scientists explain the taboo around mental illness in Kenya and Uganda and why genetic diversity is so important to the study of mental health disorders. Click here to watch video

Capacity Building & Training: Dr. Allan Kalungi
Hear Dr. Allan Kalungi, former GINGER Research Fellow and recent Brain and Behavior Research Foundation Young Investigator grant recipient, speak about the GINGER program’s impact. Click here to watch video


NeuroGAP-Psychosis: Reaching out to participants 
Study staff from Uganda and Kenya share what it takes to recruit more than 35,000 people and what their goals are in the end for NeuroGAP-Psychosis. Click here to watch video.

Capacity Building & Training: Dr. Jackline Mmochi
Hear Kenyan psychiatrist, Dr. Jackline Mmochi, discuss beliefs surrounding mental illness in Kenya and the importance of integrating genetics research in fighting stigma. Click here to watch video.


NeuroGAP-Psychosis: Presenting Early Findings
The Moi University team in Kenya discovers interesting ethnolinguistic findings from the first genetic and demographic data they collected. Click here to watch video.

Capacity Building & Training: Mowlem Pierre
NeuroGAP-Psychosis is helping people like lab technician, Mowlem Pierre, access the data and training he needs to complete a master’s degree and further his research career. Click here to watch video.


NeuroGAP-Psychosis: Hopes for the Future  

Investigators share the outcomes they hope to see from the study: reducing stigma around mental health disorders, new treatments for several mental illness, and increasing research infrastructure at their institutions. Click here to watch the video.

Bioethics: Autonomy, Equity, and Cultural Considerations
Three bioethicists from Kenya and Uganda talk about how they address ethics in genetics and mental health genetics, scientific fields still new to many parts of Africa. Click here to watch the video.


Written by GMH@Harvard Ambassador Board Members: Sarah Coleman, Amruta Houde, Bill Kriebel, Anna Bartuska

This year’s World Mental Health Day theme, Move for Mental Health: Let’s Invest, is timelier than ever. Mental health concerns and needs are growing and expected to substantially increase moving forward. Yet, mental health services have been consistently underfunded. During the COVID-19 pandemic, mental health services have been disrupted or halted in 93% of countries worldwide. As the treatment gap continues to widen, significant investment is needed to  increase access to care for the most vulnerable worldwide. In the first two articles of this 3-part series, we discussed what it means to invest in mental health broadly (part 1)  and how to invest in your own mental health (part 2). But, the question remains, how can we financially invest in mental health? This article emphasizes why the #TimetoInvest is now and offers an introduction to two types of funding mechanisms.

“World Mental Health Day is an opportunity for the world to come together and begin redressing the historic neglect of mental health. We are already seeing the consequences of the COVID-19 pandemic on people’s mental well-being, and this is just the beginning. Unless we make serious commitments to scale up investment in mental health right now, the health, social and economic consequences will be far-reaching.”

-Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization
Watch WHO’s Big Event for Mental Health Here

The Problem: Why Now? 
The greatest cause of disability globally is poor mental health, compounded by poverty, conflict, climate change, systemic racism, economic instability, and most recently, the COVID-19 pandemic. This unprecedented global pandemic has significantly affected many people’s mental health and restricted access to care for those with existing mental health conditions. The mental health impacts of COVID-19 include everything from increased anxiety and fear about the spread of the virus, loss of social networks, stressful experiences of healthcare workers on the frontlines, and a higher risk of substance use. Despite these significant impacts, mental health has not been at the forefront of global health funding. In LMICs, less than 1% of national health budgets are spent on mental health and only 0.4% of health development assistance is spent on mental health, despite the fact that for every US $1 invested in scaled-up treatment for common mental disorders there is a return of US $5 in improved health and productivity according to the WHO. Even more, a recent analysis by the World Health Organization estimated that the cumulative global impact of mental disorders in terms of lost economic output will amount to US $16 trillion over the next 20 years. Such an estimate marks mental health out as a highly significant concern not only for public health but also for economic development and societal welfare (WHO/WEF).

The Solution: Discrete and integrated funding streams 

Though mental health funding streams have expanded in the last decade, more investment is urgently needed. Investing in mental health also offers opportunities for return on investment for individuals, families, and communities as individuals can return to meaningful work. We propose a call to action for the global mental health community to invest in expanding two types of funding for global mental health: discrete mental health funding streams and integrated funding streams. To illustrate these two funding streams, we draw upon and cite examples from various leaders in the field of global health, including Partners In Health. Partners In Health (PIH) is a non-profit, global health organization that fights social injustice by bringing the benefits of modern medical science to the most vulnerable communities around the world.

Discrete mental health funding streams provide the opportunity to pilot new models and treatments. Current funding is often predominantly research-focused, which is essential in growing our understanding of mental health conditions and strengthening the toolkit of effective, evidence-based strategies and treatments. Discrete funding can also support implementation of evidence-based practices into routine care delivery. For example, Grand Challenges Canada (GCC) helped support the establishment of a community-based mental health program in Haiti with Partners In Health/Zanmi Lasante which is now a model for national scale and continues to support global mental health projects worldwide today. Private organizations or foundations (such as corporations, pharmaceutical companies, etc.); and individual donors, many of whom often have lived or personal experience and understand the impact of mental health conditions, can also be key partners. 

The second type of funding stream is mental health funding integrated with other health conditions as a wedge issue. Given the high comorbidities with mental health and physical conditions, integrated funding streams have the potential to not only improve mental health outcomes but have an impact more broadly, for example, to improve adherence to tuberculosis treatment or to provide psychosocial support to people with cancer. Alternatively, grants to promote HIV treatment can include mental health components around social support or counseling. COVID-19 offers yet another opportunity to incorporate mental health as a wedge issue into funding for health systems strengthening or emergency response initiatives. There are numerous examples of integrated models of mental health care, proving its impact for both the delivery of quality mental health care and as an advocacy tool. Partners In Health sites across the globe have taken this approach in integrating mental care into primary care in Haiti, Rwanda, and Mexico; with care for multi-drug resistant tuberculosis patients in Lesotho and Kazakhstan; with homeless care programs in Liberia and Sierra Leone; with care for non-communicable diseases in Malawi; and with maternal health care systems in Peru. The link between physical health and mental health is clear, and research indicates that integration of services improves patient experience and efficiency of health systems. 

Both types of funding streams are needed to address the immense burden of disease globally. However, with any mental health funding, buy-in from service users is needed from onset to ensure that mental health programs reflect the priorities and needs of beneficiaries. Involving individuals with lived experience in developing and driving funding priorities is also essential for ensuring the appropriateness and impact of funded initiatives. 

How can you invest in mental health? 

World Mental Health Day was on October 10th, but the movement continues. In the spirit of this year’s theme “Move for Mental Health: Let’s Invest” here are a few ways that you can support your own, your community’s, and global mental health: 

  • Invest in the strengthening of mental health care delivery to the most vulnerable by donating to organizations that are actively addressing these important needs like: 
  • View recordings of virtual events celebrating World Mental Health Day such as “The Big Event for Mental Health” organized by the World Health Organization. 

Share a photo or video of how you are “Moving for Mental Health” on social media and tag #MoveForMentalHealth and @GMHatHarvard.

Written by GMH@Harvard Ambassador Board Members: Bill Kriebel, Sarah Coleman, Anna Bartuska, and Amruta Houde
All artwork by Bill Kriebel

October, World Mental Health Month, begins at the end of this week! Saturday October 10th is World Mental Health Day and the theme this year is Move For Mental Health: Let’s Invest. The World Health Organization, for the first time ever will be hosting a global online advocacy and fundraising event on Mental Health.

We have aligned our three-part series to coincide with this important theme.In our first article of the series we discussed with Elisha London, Founder and CEO of United for Global Mental Health, about what it means to invest in mental health and how we can take action to improve global mental health. In this article, we share ways that you can invest in your own mental health, especially through mindfulness and expressive arts.  Our third article of the series will be released after World Mental Health Day and explore financial investment in global mental health.

It’s time to invest in your own mental health

Let’s get real.  COVID 19 is stressful and impacts how we feel, what we say to ourselves, and what we do.  Our lead author went through a lot of stress leading 13 teams in nine countries and turned to mindfulness and expressive arts to stay mentally healthy.  Now he shares these experiences as a Certified Peer Specialist and through this article seeks to share these strategies with others. In this article, we offer ways and resources to help you stay emotionally and mentally healthy during these challenging times. The following list of strategies is not mean to be comprehensive, but instead help you begin to invest in your own mental health. You may wish to start with these articles to set the stage. 

Links: Harvard COVID Mental Health, PIH tips, Invest in yourself

Invest in relaxing

Pretend like we are meeting in a big living room with a nice warm fireplace

Rest

Talk

Be comfortable and mindful

Meditate: Rest with your body and breath

Why? You are investing in reducing stress, staying calm, and improving your immune system

Links: relax, meditate, yoga, mobile apps, ADAA apps, stress apps, anxiety apps, app efficacy

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Invest in gratitude every day

Find greatness in being at home

Appreciate everything

Living is a miracle!

Savor your cuisine, it nurtures you

Why? You are investing in staying positive no matter what

Links: Giving thanks, gratitude science, gratitude journals, gratitude praise

Invest in being deeply aware of what is

If you can go outside, let nature speak to you

If you are spiritual, take time to cultivate spirituality

Now is the only time you actually live

Why? Investing in connecting with your inner and outer world will raise awareness of how you really are.

Links: Self awareness matters, self awareness benefits

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Invest in your body and your health

Walk, Exercise, Yoga, Run, Hike, Swim, Breath

Eat well, regularly and diversely

Consistently maintain your hygiene

Why?  Investing in your body is essential as science shows exercise can reduce symptoms of anxiety and depression

Link: Invest in your health

Invest in creating and expressing yourself

Dance, Sing, Play music

Photograph, Look

Draw, Paint, Watercolor

Why? Investing in playful heart energy and being present to boost your health and stay happy

Links: Artistic passion, Healing art

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Invest in challenging and strengthening your mind

Take classes, read, play games, etc

The importance is to keep your mind strong

Why? Investing in a strong mind keeps you young, active and healthy

Links: Stay young, brain exercises

Invest in building community!

This may be tricky with COVID.  Definitions of community can change to fit the times.

Call family and friends, Zoom

Make sure your friends and family have the social support they need, especially if they are in quarantine or part of a vulnerable population

Check in on people you care about who are on the front lines such as clinicians, teachers, public health workers, etc

Join the global movement of COVID-19 response such as at Partners In Health and share success stories to lift each other up

Why? Investing in community keeps you connected with others which can become essential

Links: Socializing benefits, mental health communities, group mental health, PIH Covid response

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Invest in your wellness recovery action plan

Who are the people that you will call in a mental health emergency?

Who will take you to the hospital?

Which doctors, medications, and allergies do the emergency room staff need to know

Which medical information do you need to have on hand?

Why? Investing in emergency preparation while you are mentally strong, is essential if you may need help

Link: WRAP plan

Invest in keeping your bills paid and finances well managed

Simplify and keep a consistent process

Save money now in case you need money for healthcare emergencies or lost work

Why? Investing in your finances now will greatly reduce mental health concerns when sick

The following provides a good workbook for finances and the above topics 

Link: 8 Dimensions of Wellness

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What if all of this is too much?  Invest in getting help!

You may have a treatable mental health concern

Speak with a therapist or doctor

You could look up your concerns on the web, but this has dangers if you have a true concern

Why? Investing in one-on-one communication with a professional can isolate a specific concern that needs your attention

Links: Therapists, Crisis lines

What if you know you have an illness?  Invest in making connections!

Ok, this is not for everyone and is harder with Covid

Still, make the effort

Join a recovery community

Why? Investing in connecting with other people can be essential to healing, or at least beneficial

Links: Metro Boston RLC, McLean Hospital Waverly Place

What if your illness is much more serious?  Invest more!

If you have a serious condition and have tried many alternatives, you may need more

There are many residential programs throughout the US

Why? Investing in a residential program can help you treat your health holistically

Link: Residential treatment programs

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Invest in learning about mental health concerns

Why? Investing in learning about mental health can help you and others take the best actions

Links: NIH, NAMI, SAMHSA, CDC, WHO, MIND UK

Healthy and ready to help others?

Invest in the greater good of the world

We are in a time of multiple crises- public health, racial, economic, police brutality: all affecting our mental health and compounded by potential COVID-19 mental health related challenges

Why? This improves everyone’s mental health collectively, while helping ourselves

Links: Volunteering, Investment needed, racial tensions, COVID concerns

Don’t forget to invest in yourself and in your communities on World Mental Health Day, Saturday October 10!

Are you ready to #MoveForMentalHealth? Visit United for Global Mental Health and join the virtual #WMHD activities!  Stay tuned for our third and final article Investing in Mental Health later this month!

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Authors:

Anna D. Bartuska, Program Coordinator, Community Psychiatry PRIDE, Massachusetts General Hospital 

Sarah Coleman, Cross-Site Mental Health Officer, Partners In Health

Amruta Houde, Mental Health Program Associate, Partners in Health

William Kriebel, Master’s of Liberal Arts Student at the Harvard Extension School, studying Management. Certified Peer Specialist, Boston Medical Center

Written by GMH@Harvard Ambassador Board Members: Anna D. Bartuska, Sarah Coleman, William Kriebel

People worldwide are facing ongoing uncertainty and stress as a result of the COVID-19 pandemic, economic instability, and racial injustice. Prior to this year, research found that one out of ten people in the world had a mental health condition (with severe cases leading to a 10-25 year decrease in life expectancy). The cumulative burden of current events further threatens mental health and well-being worldwide. As a mental health wave looms, access to mental health services is limited with up to 90% of individuals not able to receive needed care in some low- and middle-income countries. 

Image from the #ReturnOnTheIndividual report released this year by the Speak Your Mind Campaign

Now more than ever, it is #TimetoInvest in mental health.

But what does it mean to invest in mental health and how do we—as individuals, communities, and societies—take action? To answer these questions, we spoke with Elisha London, co-founder and CEO of United for Global Mental Health. Motivated by her own experience recovering from Post-Traumatic Stress Disorder (PTSD) and chronic depression, Elisha aims to galvanize greater action for mental health so that everyone, everywhere has access to mental health support. Prior to founding United for Global Mental Health, Elisha was the Campaign Director for Heads Together, a mental health campaign spearheaded by Their Royal Highnesses, The Duke and Duchess of Cambridge and Prince Harry.

What does it mean to invest in mental health?

When we talk about investing in mental health we are often discussing finances, but Elisha London emphasized that investing in mental health is broader than the bottom line. “Investing in mental health really means looking at how individuals, business, societies, and funders are prioritizing action on mental health,” she stated. Investing can include each of us promoting and prioritizing our own mental health, businesses supporting the wellbeing of their employees, universities supporting their students and staff and governments allocating resources to prevent and treat mental health conditions.

ElishaLondon
Elisha London, Founder and CEO,
United for Global Mental Health

How has investment in mental health changed over time?

Recalling her professional experience in the past decade, Elisha noted that global mental health is a novel investment stream for many funders. Although individuals and organizations in a position to provide or support funding are likely to know someone who has suffered with a mental condition, a lack of historical precedent has stifled direct investment. Elisha shared insight to the reality that funding global mental health has previously not been on the minds of our local, national, and global investors, and changing mindsets that overlook mental health will take time. As a funding priority, progress on mental health has been limited by stigma, lack of available financial resources, finite human resource capacity, and prioritization of competing health concerns. Nevertheless, efforts emphasizing ‘no health without mental health’ and positioning mental health as a backbone of both emergency and long-term health systems strengthening efforts have helped support the integration of mental health into current priorities and funding streams.

When asked about the current state of global mental health funding, Elisha noted there continues to be a paucity of public dialogue on mental health. “Investing in mental health as we know it today began as a conversation in the research community and moved slightly to the political arena, but we have never had a strong citizen voice calling for action,” Elisha remarked. She further emphasized that the lack of public voice coupled with a need for more data continues to limit investments in mental health.

For future funding in mental health, Elisha suggests that we not only persuade governments to act but look toward the “new next generation of billionaires and new foundations” to help accelerate support, particularly for the non-profit sector. New funders and voices have already begun to emerge. Recently, Beyoncé and Jack Dorsey, the CEO of Twitter, committed $6 million to support mental health during COVID-19. As the dialogue continues to grow and advocacy expands the hope is for strong leaders in mental health funding to arise.

In 2018, when United for Global Mental Health was founded and hired their first employee, they only knew of one other organization that had funding for a professional with the job title of global mental health advocate. Since then the number of professional advocates has grown slowly and investments in mental health are increasing. Many organizations which historically focused on infectious disease, such as Partners In Health, have significantly expanded their mental health programs in the past ten years. Similarly, Sangath in India has been working in the mental health field since the 1990s but began to be internationally recognized over the past ten years for their work with children, adolescents, community health workers, and families. Momentum in the field of global mental health is reflected in increasing investments. According to the Institute for Health Metrics and Evaluation (IHME), US$160 million were invested in mental health in 2019—more than four times greater than a decade prior, but still a fraction of the US$9.7 billion invested in HIV/AIDS during the same year. 

How can we invest in mental health?

There are many ways that we can invest in mental health and all are needed. “Everyone has to invest in different ways and that has to cover promotion, prevention, treatment, and recovery,” Elisha encourages. These types of investments are critical to the expansion of dialogue and action around mental health.

As a growing movement and burgeoning field, the conversation around global mental health has begun to take root. As more individuals find their voice and share their own story, Elisha reminds us that we also must be ready to meet their mental health needs: “We need to make sure there is a supportive system.” This includes investments in innovative interventions, novel delivery platforms, and increased workforce development programs. The growing advocacy has also spurred investors to ask what works and how it can be scaled. To answer these questions, effectiveness and implementation research will be imperative. Addressing the research community, Elisha encourages individuals to “look for the things that the world really needs answers to.”

When founding United for Global Mental Health, Elisha and her team asked, “Where are the gaps? How can we fill them with the skills we have?” Today, we can ask ourselves the same question. Whether you are a researcher, clinician, person with lived experience, student, or organization member—consider how you can prioritize mental health.

The GlobalMentalHealth@Harvard Initiative, will be releasing a mini-series to highlight ways to invest in the mental health of our communities and ourselves during COVID-19, and encourage further discussion about the return on investment in mental health. In upcoming articles, we will be featuring different ways individuals within our communities are investing in their mental health. Let us know how you have been prioritizing investing in your mental health by tagging us on Twitter @GMHatHarvard or emailing us at gmh_admin@hms.harvard.edu.

One way to prioritize mental health today is to add your voice to the rapidly growing global movement for mental health advocacy. Speak Your Mind powered an Open Letter calling on world leaders to protect and scale up mental health support in all COVID-19 responses both now, and for the future. We invite you to invest in mental health by adding your name to the letter. And to learn more about mental health and COVID-19 you can join this webinar series organized by UnitedGMH and partners. 

Image from the #ReturnOnTheIndividual report released this year by the Speak Your Mind Campaign

__________

Authors:

Anna D. Bartuska, Program Coordinator, Community Psychiatry PRIDE, Massachusetts General Hospital 

Sarah Coleman, Cross-Site Mental Health Officer, Partners In Health

William Kriebel, Master’s of Liberal Arts Student at the Harvard Extension School, studying Management. Certified Peer Specialist, Boston Medical Center

On September 12th, the GlobalMentalHealth@Harvard Initiative and the Harvard Law School Project on Disability hosted a presentation and excerpt performances from “The Center Cannot Hold,” an opera composed by psychiatrist Kenneth Wells. The opera is based on law professor Elyn Saks’ memoir on her experience with schizophrenia. The event was held in the Hilles Performance Center for over 150 attendees.

“The Center Cannot Hold” focuses on Saks’ history of mental illness and her frequent hospitalization. Wells, a close friend, adapted the memoir into an opera in an effort to dispel ignorance surrounding mental health. Wells addressed his reasoning for collaborating on the project, saying that “it’s really the use of art to humanize experiences that people distance themselves from.”

According to Mental Health America, a community nonprofit, over 11 million Americans experience psychotic symptoms in their lifetime. Symptoms typical of schizophrenia are auditory or visual hallucinations, abnormal behavior, and personality alterations, among others. Saks’ and Wells’ goal is to destigmatize these maladies, providing an informative platform to better understand the underlying struggles of mental illness sufferers.

Other professors agree that engaging in opera performances is quintessential to educating audiences. Allison Voth, an associate opera professor at BU, feels that operas are unique artistic spaces for discussion. “They’re safe vehicles and expressive vehicles to talk about these issues and to open people up,” Voth said. Saks, a professor at USC Gould School of Law, hopes to reach listeners by providing a visual, artistic medium and emotionally addressing public stigma. Her purpose for putting on the production is to bring attention to poor mental health treatment, apathetic hospitalization, and “how toxic and traumatic some of the responses can be.”

The program included excerpts from the original opera, with three singers and Wells on piano. The singers included, Maggie FinneganRyne Cherry, and Wes Hunter. More information about the singers can be found here in the event program. Maggie Finnegan portrayed Saks in the song titled, “I Could Be That Person.” The scene focuses on Saks’ sudden surge of hope in the face of her schizophrenia. “I really just think it’s about perseverance,” Finnegan said, after her performance. “If… you stick with the will to have the life that you want, it can happen.” Lyrically and musically, Saks believes the opera allows sufferers to see hope personified through song and feel less alone. According to Saks, her goal was to make mental illness digestible for all audiences, creating a safe space for productive discussion and support.

Speaking before the performance, Saks emphasized the importance of schizophrenics seeking help. “There’s actually a lot of evidence that ‘length of untreated psychosis leads downstream to more brain damage,’” Saks said, “so it’s really important to get treatment early.” According to the Canadian Journal of Psychiatry, symptoms of schizophrenia left unchecked can result in increased neurological damage and complications with treatment.

Composer Wells, a proponent of recovery through the arts, explained that music encourages persistence in the face of anxiety and fear. Wells shared his impact on low-income neighborhoods in providing artistic healing to patients. “[Community partners] felt the arts were very important, so we supported some of our clients, patients, in doing plays about their lives,” Wells said. Wells believes that combating mental illness with low-cost methods, such as writing and performing, empowers under-resourced areas to fight diseases typically left untreated.

In regards to musical therapy, Professor Voth addressed how opera is an important venue for offering dialogue. “When you pair music with extraordinary stories that are very powerful, it’s incredible,” Voth said. “It can really take people to different levels of understanding and feelings about a subject matter that they might normally be closed to.”

Jack Schultz, a Harvard graduate student, remarked that the opera encourages mental illness education and efficiently disseminates information to audiences. Schultz thought “The Center Cannot Hold” was an appropriate place to discuss the incubation of insensitivity in regards to mental illness.“I’m fascinated [by] the role that education plays in producing stigma,” Schultz said. “And particularly the kind of tragically ignorant comments that Elyn [Saks] received.”

The opera stages violent scenes of forced restraint and intensive medication. Saks, having experienced aggressive hospital staff and severe lack of emotional care while hospitalized, felt abandoned in a world that seemed not to care for her well-being. Due to modernized medical technologies, Saks recalls that her schizophrenia has become less severe and that fewer symptoms appear in her daily life. Saks stresses that personalized, diversified treatment is paramount to mental illness recovery. “Everybody’s different; different people respond in different ways,” Saks said. “It’s not one-size-fits-all.”

In the hopes of motivating audiences to reflect on their own mental health and the health of those around them, Wells and Saks aspire to reach wider audiences and impact viewers in a profound way. Wells reiterated that “the opera is, in a sense, saying it is possible to recover your life.” Wells is currently composing his next opera, which focuses on veteran resilience and recovery. Saks’ memoir, “The Center Cannot Hold: My Journey Through Madness” is available now.

Event synopsis article written by GMH@Harvard guest blog writer Cameron MorsbergerCameron is a sophomore at Boston University studying journalism and psychology. She attended the event because she is fascinated by public perception of mental health issues and the underlying difficulties in communicating mental illness to audiences. As a personal issue for her, she was seeking to learn about mental illness to advocate for those afflicted by it. She finds that music has an incredible therapeutic element, and wanted to witness that healing process first-hand.