Psychiatrist Goes Global in Effort to Close MH Care Gaps

A psychiatrist who has spent much of her career exploring the factors that increase risk for other illnesses, such as AIDS/HIV, among women with severe mental illness is now using that experience to ensure that underserved populations around the world receive the treatment they need.

Pamela Collins, M.D., M.P.H., and her colleagues are trying to level the playing field among disparate populations in the United States and in middle- and low-income countries where mental health care is scarce through her posts at the National Institute of Mental Health (NIMH). Collins is associate director for special populations, director of the Office for Research on Disparities and Global Mental Health, and director of the Office of Rural Mental Health Research.

The Office for Research on Disparities and Global Mental Health was formed by the 2010 merger of the Office for Special Populations and the Office of Global Mental Health.

“The office reflects our understanding that taking a global perspective may enable us to better understand diverse communities in the U.S., as we learn from those outside of our borders,” Collins told Psychiatric News. “Our goal is to help NIMH set a research agenda that will address gaps in mental health care for underserved populations domestically and globally.”

One strategy for achieving this goal involves broadening the mental health workforce by funding the training of U.S. mental health researchers from diverse backgrounds.

Collins explained that “a diverse community of researchers here at home helps deepen the pool of innovation and creativity that benefits the full range of mental health-relevant research—from the study of basic neuroscience to health services research.” NIMH also helps build mental health research capacity in low- and middle-income countries, with the expectation that innovations that can benefit the global community will originate in these settings. U.S. investigators collaborate with teams in several regions—including Africa, Asia, and the Caribbean—while at the same time strengthening research capabilities as they undertake activities ranging from AIDS research to genetic studies to implementation research.

In 2010, as a first step toward setting an agenda for global mental health research, Collins and her colleagues convened a group of mental health service providers in low- and middle-income countries, along with policymakers, users of mental health services, and researchers. A major focus was to discuss how research can meet the needs of those receiving services, those providing mental health care, and officials responsible for developing mental health policies or budgets.

Out of such discussions the NIMH team developed a funding opportunity focused on creating infrastructure for mental health research that could help reduce the treatment gap. The initiative—Collaborative Hubs for International Research on Mental Health—is being implemented in low- and middle-income countries to establish regional research hubs to increase the evidence base for mental health interventions. Each regional hub will conduct research and research-capacity-building activities that benefit countries in their networks (see Collaborative ‘Hubs’ Developed).

Early Experiences Highlight Cultural Context

The path that led Collins to global mental health started as an undergraduate when she decided to major in psychology. “At the time, I couldn’t think of anything more interesting than understanding why we think and behave as we do,” she noted.

She said she owes the decision to attend medical school “in part to my [college] advisor, who explained to me the potential benefits of training in psychiatry. The idea of understanding the whole person, which medicine could offer, appealed to me,” she said.

Her first global health experience followed her first summer in medical school at Cornell University, when she worked as a researcher with the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections.

“Even though I wasn’t focusing on mental health, the experience piqued my interest in the influence of social and cultural context on health,” Collins said. Other elements of working in Haiti also left a lasting impression. “It was my first time in a predominantly black country—my first experience of being part of the majority. And yet, this was obviously a very different cultural context from what I knew. As an African-American woman, this really raised a lot of questions for me about context and mental health.”

At the end of her psychiatry residency at the New York State Psychiatric Institute and Columbia Presbyterian Hospital in the mid-1990s, Collins became involved in global mental health issues and went on to be an NIMH clinical research fellow at Columbia. During her residency, Collins visited mental health facilities and research centers in India, South Africa, and Argentina. An initial visit to a treatment and rehabilitation program for people with severe mental illness in the Argentine region of Patagonia led, eventually, to a collaborative effort to train primary care doctors and nurses to manage mental disorders in the province of Neuquén.

Later, an opportunity to consult on deinstitutionalization in South Africa led the team to work toward enhancing HIV prevention and care in psychiatric facilities in that country. Collins subsequently received a fellowship with the fogarty International Center AIDS International Training and Research Program that enabled her to further develop research in South Africa on these themes.

Simultaneously, her work in the United States complemented these efforts abroad. “At home my research focused on the HIV prevention needs of women with severe mental illness. Most of these women were African American, Afro-Caribbean, or Latina, and I had the chance to ask questions about how social context—specifically race/ethnicity, poverty, gender, immigration status, and stigma associated with mental illness affected health behaviors—particularly those related to HIV risk” she explained.

HIV Research Benefits Mental Illness

From 2000 to 2003, Collins and her colleagues conducted the HIV in Psychiatric Institutions training project in HIV care and prevention at the Midlands Psychiatric Complex in KwaZulu Natal, South Africa. During that time, she also joined the secretariat of the Mother to Child transmission-Plus project, an HIV treatment initiative based at the Mailman School of Public Health at Columbia University, and gained experience as a trainer in psychosocial issues for multidisciplinary HIV care teams in Zambia and Uganda.

Collins has published several journal articles examining the intersection of HIV risk, mental illness, and aspects of gender and cultural background and has developed strategies designed to reduce HIV risk in women with mental illness. Initially, she wondered how women with mental illness might be different from other women who are vulnerable to HIV infection and, in particular, whether stigma related to mental illness may shape the types of risk to which these women are exposed.

She later explored how, beyond living with mental illness, living with other potentially stigmatizing identities—such as being poor, an immigrant, or an ethnic minority, for example—also affects HIV risk.

“These are complex concepts to be carefully explored in the context of care and in communities,” she stated.

Collins brings multiple perspectives to her current job—from experiences with mental health providers on the ground in Africa and Latin America to the first-hand accounts of women with severe mental illness in urban, inner-city America—experiences that she hopes will inform the global research agenda she and her colleagues work to shape at NIMH.

Collaborative ‘Hubs’ Developed

In an effort to increase access to mental health care for underserved populations around the world, the National Institute of Mental Health (NIMH) developed the Collaborative Hubs for International Research on Mental Health, which pair academic research centers in various parts of the world with underserved areas elsewhere.

Three academic centers recently received awards from the project, and the centers will collaborate with mental health teams on research and training activities in India, Pakistan, South Africa, Malawi, Ethiopia, Ghana, Zimbabwe, Argentina, Chile, Brazil, and Colombia.

Specifically, Ezra Susser, M.D., of Columbia University, and colleagues with the hub for Latin America will work with researchers from Chile, Brazil, Argentina, and Colombia to test interventions for community health care for people with severe mental illness.

Crick Lund, Ph.D., of the University of Cape Town and colleagues with the Africa Focus on Intervention Research for Mental Health will establish a hub for research and capacity development to improve delivery of cost-effective interventions in sub-Saharan Africa. Partner countries are Ethiopia, Ghana, Malawi, Uganda, and Zimbabwe.

In addition, Vikram Patel, M.D., Ph.D., of the London School of Hygiene and Tropical Medicine and colleagues in the South Asian Hub for Advocacy, Research, and Education on Mental Health are using NIMH funding to establish a collaborative network of institutions in South Asia focusing on research to reduce the treatment gap for mental disorders in the region. Activities will be centered in Pakistan and India.

The grant announcement for the NIMH Collaborative Hubs for International Research on Mental Health is posted at <grants.nih.gov/grants/guide/rfa-files/RFA-MH-11-070.html>.