Collaborative Care Goes Global

This month’s column by Bibhav Acharya, M.D., shows that delivering integrated mental health care is possible in even the most challenging of environments when we take a population-level approach and engage all of the resources available. His work in Nepal reminds us that we will need everyone—from specialty providers to family members—if we want to scale up mental health care in the United States and around the world. —Jürgen Unützer, M.D., M.P.H.

Mental health care in low-income countries is in bad shape. If you have severe mental illness and can’t get to the only public psychiatric hospital, you may be chained to a tree next to your home. If you are a psychiatrist, you may be racing against time to get through 100 patients a day. If you are an officer at the Ministry of Health, you have only 0.7% of the total health budget to tackle the number-one cause the chronic disease burden.

After we built a hospital in rural Nepal, we wanted to integrate mental health services and quickly faced this fundamental question: can you cost-effectively expand access while maintaining quality? If you train generalists in all corners to provide mental health services, it might be cheaper than hiring a psychiatrist, and you may be able to reach the person chained to the tree but how do you make sure that the care is of high quality? Conversely, if you hire a psychiatrist to directly treat patients, you may improve the quality of care, but how do you keep costs low as you try to cover all the patients? We found ourselves trapped within the fabled “Iron Triangle”.

Thirty years ago, a team at the University of Washington recognized the same fundamental problem and developed the collaborative care model (CoCM). The scale of the problem is substantially higher in rural Nepal—the nearest psychiatrist is 14 hours away, and the average income is 50 cents a day—but the basic principles are just as relevant: train all the generalists in evidence-based care, recruit on-site care managers, modify treatment to meet specific clinical outcomes, and hire a part-time psychiatrist to review the treatment plan for all patients. Generalists expand access, the psychiatrist maintains quality, and studies have shown that the program is cost-effective. We seemed to have found the model that could achieve the “Triple Aim” in rural Nepal.

With support from the University of California, San Francisco, the Harvard Medical School Center for Global Health Delivery-Dubai, Possible, and the Nepal Ministry of Health, we are adapting and implementing CoCM at the Nepal site. We began by asking our generalists about the model and the challenges they anticipated in implementing it. Their insights, which we recently publishedin BMC Health Services Research in September 2016, can provide guidance for similar settings. Generalists liked the idea of integrating mental health into primary care and were mainly concerned about reliability of an off-site psychiatrist, their own ability to screen and treat patients with mental illness, and the impact of workplace hierarchies between generalists and care managers. They recommended providing mental health training for all generalists, recruiting young and academic psychiatrists (because they may be more interested in CoCM), and training generalists as care managers to blur the line between the two groups.

We incorporated their recommendations and trained them using the World Health Organization’s guidelines, which we have converted to translated protocols and narrated lectures in Nepali. We have partnered with several stakeholders with complementary skills to build a program that is now adding more than 50 patients every week in a remote corner of Nepal.

We have encountered several challenges and refreshing opportunities. An important challenge in low-income countries is cross-cultural validation of mental health tools and treatments. Furthermore, many countries lack legal protection and social services for people with mental illness. Nonetheless, we encounter three positive factors that are conspicuously missing in the United States: an extensive family and community support system, a public sector that recognizes health care as a public good, and a network of 5,000 women community health workers (CHWs). These three factors are not without flaws: people with mental illness face abuse and discrimination from the society, the public sector struggles to operationalize its lofty goals of health care for all, and the CHWs do not receive adequate compensation.

These limitations notwithstanding, it is inspiring to be able to discharge a patient to more than 10 family members waiting to take the patient home, obtain psychotropic medications directly from the government for the poorest patients, and have a CHW do weekly check-ins on a patient who lives three hours away from the hospital.

This is an exciting time in global mental health. By adapting, customizing, and testing the CoCM, we may be able to transform the health care landscape by leapfrogging to a system that provides high-quality, cost-effective integrated mental health services close to where the person lives, no longer chained to a tree. ■