I was recently intrigued by the claims made — and that went completely unchallenged — by Vikram Patel, a psychiatrist who was interviewed by Wired Science’s Greg Miller. I guess my expectations for something appearing on Wired should be readjusted.
Patel claimed that specially-trained health professionals could provide enough care to people that they may be able to treat clinical depression successfully. (The article suggests these are the same as “laypeople,” but really, they’re not.) With skills learned in as little as 2 days.
An amazing claim? You bet. One based in reality? Let’s find out…
Here’s what Patel told Wired’s Greg Miller about the research that backs his claims that you could take health care professionals (sorry, not “laypeople”), give them a few days of training (and then followup with longer supervision), and they could successfully treat depression:
Can you train people off the streets, with little education, to be counselors?
We’re training them to do very specific tasks. It’s a bit like training a community midwife: You’re not training her to be an obstetrician; you’re training her to deliver a baby safely and to know when to refer the mother to a doctor.
The training can be as short as two days or it can be two months, but the classes are the least important part. There’s a much longer period of supervised learning that happens through direct contact with patients. You don’t have much theory. You go directly to the skills you need to actually help people recover.
Well, first, these aren’t just “people off the streets.” They are existing healthcare professionals in these countries, most often nurses. Health care professionals already have some experience and understanding that health and disease don’t exist in a vacuum — that there are psychological components to life that impact our health and well-being. So they have a lot of background and experience already in this general sphere.
The research mentioned below looks primarily at these health care professionals who’ve had this extra training, not laypeople.
And your research suggests that this is effective?
It’s not only me saying so. We just completed a systematic review of more than 25 randomized, controlled trials from around the developing world. There’s one clear message: Sharing tasks works, and it works across a range of mental health problems.
The review Patel is referring to a Cochrane Database Systematic Review, published just last month. The study (van Ginneken et al., 2013) examined 38 studies from seven low- and 15 middle-income countries. Out of the 38 studies, 22 studies used health workers, and most addressed depression or post-traumatic stress disorder (PTSD).
The primary problem with this review was that the studies examined in it are not very well designed, implemented, and/or the data analysis was poor. This is not robust data — so much so that the studies to arrive at this specific conclusion include notes such as “serious study limitations” because of study/researcher bias, and “serious inconsistency” in the data presented.
So unfortunately this review study should be taken with a grain of salt, despite it being a Cochrane Review, because of this issue about the low quality research in this area. There are inconsistencies and bias in virtually every study they looked at. In fact, the review says as much: “Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.” In other words, new research could completely change the effect we observe here — and it could be in the opposite direction.
The effects of training a health professional in third-world countries with specialized mental health training are generally beneficial. In a hypothetical sample size of 1000 people in one of these countries (like Uganda), if you had 300 people with depression with usual care, you’d have only 91 with this additional training in place. But this finding is based upon only 3 studies — all of which had serious methodological problems.
Third-world countries generally don’t have a lot of specialists available across the board. There simply are few mental health professionals — such as psychiatrists or therapists — available. In countries or regions that have such shortages, it makes sense that if you give a health professional that is there (like a doctor) some mental health training, well, they can help people better with mental health issues.
But this doesn’t automatically — or easily — generalize to first-world countries. For example, most physicians trained today already receive some basic mental health training and deal with a great deal of mental disorders in their practice. In America, family physicians prescribe the most antidepressants — far more than psychiatry does.
Why This Doesn’t Translate to First-World Countries
The interview over at Wired Science concluded with this claim:
According to US statistics, about 60 percent of people with mental health problems received no care at all in the previous year. The normal reaction to that kind of figure is to say we need more psychiatrists. But here’s the thing: The US already has more psychiatrists and spends more money on mental health care than any other country in the world. You don’t need doctors to provide all of the things you’re paying them to provide.
The reason that 60 percent of Americans don’t receive care for mental health problems isn’t lack of access to treatment — the problem in the third- and second-world countries this research addressed. And generally, it also isn’t because treatment is too expensive (since most people get their treatment for their depression from a family physician, not a mental health professional). Most Americans’ health insurance covers mental health treatment, so the vast majority of the tab is picked up.
It’s instead because of the remaining stigma, discrimination and prejudice people have about mental disorders. It’s because when they do access treatment or care, it’s ineffective. It’s because we’re using the age-old practice of trial-and-error for medications to try with a person — something that many people simply don’t tolerate well (or want to be subjected to).
And it’s because, despite decades’ worth of research, we still don’t have a “Match.com”-like website matching patients with the best therapist for them. Choosing a good therapist remains a hit-or-miss proposition for most, and the consequences of getting a bad therapist means you have to repeat your life story over and over and over again to total strangers.
None of which would be solved by training health workers with more mental health training.
So no, healthcare professionals won’t be replacing specialists in mental health care any time soon here in the U.S., any more than a family physician could replace a brain surgeon. It’s a silly claim to make that, if given the choice and opportunity, someone would choose a lesser-trained provider over a specialist.
Read the full article: How to Treat Depression When Psychiatrists Are Scarce
van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, Chandrashekar S, Patel V. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in lowand middle-income countries (Review). The Cochrane Library, 11.