To Meet a ‘Tsunami’ of Need, a Daring Proposal to Train Thousands of Lay Mental Health Workers
Taking a lesson from the developing world
Even before COVID-19 killed 160,000 Americans, caused massive unemployment and left millions more feeling isolated and stressed, the United States was grappling with a mental health crisis and a huge shortage of mental health workers and professionals.
Now, as health planners and policy advocates search for ways to expand the mental health workforce, the US can learn from strategies employed in other countries. In the developing world, where there are even fewer mental health professionals, innovators have trained ordinary people to deliver mental health care in their communities.
Vikram Patel, an Indian psychiatrist and the Pershing Square professor of global health at the Department of Global Health and Social Medicine at Harvard Medical School, has been a pioneer in this work. Early in his career, he began hearing about people who were trained to deliver babies and treat pneumonia. He thought: If they can learn to deliver health care interventions, why not mental health care?
Patel and like-minded colleagues showed they could do precisely that. In controlled studies in several countries, hundreds of community mental health workers have been recruited and trained to deliver care. In Uganda, villagers learned to deliver brief psychotherapy for depression. In Pakistan, maternal health workers provided cognitive behavior therapy to depressed mothers. In Goa, India, lay counselors delivered psychosocial interventions for depression and harmful drinking. In all three trials, more than 70 percent of those cared for by trained community members recovered. In comparison groups, fewer than half recovered.
Now Patel is bringing this model to the US — adapted for the digital age. His EMPOWER initiative is developing an online, interactive training program that will teach community health workers to deliver mental health interventions for different conditions. The first stop for this new effort will be Texas, where the Meadows Mental Health Policy Institute is laying plans to partner with four health systems in North Texas to hire and train 100 community health workers using Patel’s digital curriculum.
Rebecca Brune, the institute’s chief strategy officer and regional executive director, says the hiring and online training will begin in the late fall. Starting early next year, the health workers, each embedded with a clinical team, will be assigned patients diagnosed with mild depression and will begin treating them under the supervision of a psychiatrist or psychologist.
The workers will also follow the progress of their cases together in a learning collaborative that will allow them to feel that they’re “not on an island by yourself — you’ve got colleagues you’re learning from and with,” Brune said. If all goes well, she said, the Institute hopes to scale the program to South Texas, especially in the Rio Grande Valley, and to build the case to federal health officials for more robust funding of community health workers.
I spoke with Patel by Skype from India in April. The interview has been edited for length and clarity.
What are you trying to do with EMPOWER in this era of coronavirus?
The two most important consequences of COVID-19, apart from the mortality, are the massive numbers of young people rendered unemployed and the massive need for care. I fear we are going to see an absolute tsunami of mental health problems across the world because of the recession. EMPOWER provides an answer to both problems. We need caregivers who are skilled and supported, and we have people who need that care. This is a way to redeploy that mass of unemployed people towards those jobs of caregiving.
We are building on a body of science including the design of a brief psychological treatment for depression called behavioral activation. We call it the Healthy Activity Program and we designed and tested it in a clinical trial in India with support from the Wellcome Trust. Now, thanks to the Surgo Foundation, we are adapting the curriculum for the U.S. and plan to start the roll-out early next year in Texas. The problem with the work on community health workers in the mental health space is they’re all basically research trials. Not a single one has gone to scale. We want to break the dam of translation between effectiveness trials and real-world implementation.
Tell me about the history of using lay community health workers in developing countries.
The inspiration goes back 50 years to the barefoot doctor movement and the paraprofessional movement. In most developing countries, including India, it entered the area of midwifery and other areas of maternal and child health and has been a major factor behind dramatic reductions in maternal and infant mortality.
In the late 90s, this approach was extended to infectious diseases, particularly HIV-AIDS, which fueled the peer support-worker movement. I witnessed this as a budding global health practitioner, and I began to ask: Why is mental health care seen as being so complex that you can deliver babies, diagnose newborn pneumonia, and administer antibiotics, but you can’t do mental health care?
How will you roll this out?
The first step is digitizing the content of existing, evidence-based, psychosocial treatments which are manualized and have been shown to be effective when delivered by non-specialists. The second is development of a competency assessment, which is essentially a validated on-line exam.
The third step is peer supervision. After completing the digital course, a health worker that’s being trained would work with patients and participate in peer-group supervision moderated by an expert, in order to become accredited. Then the health worker could begin taking on clients, with supervision. Ultimately, we also hope to look at data on the quality of therapy provided by a particular worker and match it to the outcome of his or her patients. This will help us understand which ingredients of an intervention seem to work best so we can emphasize them in future trainings.
A unique aspect of EMPOWER is that we are simultaneously implementing it in India and the U.S. In India we are working with the state governments in Madhya Pradesh and Gujarat, while in the U.S., we’re working with the Meadows Mental Health Policy Institute in Texas. We have a lot to learn in the months ahead.
In previous trials, community health workers were trained face to face. What’s the evidence that a digital approach can work?
Yes, that’s always been the model, which is why nothing goes to scale. There’s a significant body of evidence showing that well-designed digital training is as good as classroom training — and much cheaper. With Covid-19, it’s also safer. We just completed tests of digital versus face-to-face learning and they demonstrated equivalence, particularly when a remote coach supported the digital training. The chair of our advisory board, Chris Fairburn, has scaled up a treatment for anorexia nervosa to all of the Republic of Ireland. If you can train providers to treat one of the most severe mental health conditions using an internet-based platform, it’s certainly something you can explore for briefer treatments using community health workers.
In any case, we don’t have a choice. Even if digital learning was not as good as face to face — so what? We’ve been doing business as usual for 100 years and look where we are today. We have to keep improving digital learning until it gets as good as face to face — which I think it already is — and even outdoes it.
How would people be credentialed to provide clinical treatment?
We would adapt the criteria for competency and quality based on local regulations. Learning a skill takes practice, not just training. In India, for example, we’ve agreed that after you complete the digital training, you have to successfully treat at least two cases of depression and reach a minimum quality standard.
Also, the providers we train won’t function independently. We work within an organized health care system, so anyone who doesn’t respond to first-level care from our health care workers can be referred to a more specialized provider. EMPOWER doesn’t replace specialists, it simply expands the footprint of mental health care, because the current number of behavioral providers is insufficient to provide for the needs of America.
Your program requires digitizing content, pilot testing and training competent providers. But COVID requires quick action — can you do that?
Absolutely. If someone gave me $10 million, I’d have a COVID-ready system in three months, going beyond depression to include acute crisis counseling and self-care. COVID-19 initially derailed us, but I now believe it presents an opportunity. The importance of mental health care has never been clearer.
So how quickly could you recruit, train, and get people working?
Our depression treatment can be learned in three to four weeks, so once the curriculum is live, it should be possible to train hundreds if not thousands within six months. That’s the scale a digital model offers. Obviously, all of this is contingent on resources but we’re talking a relative pittance, when you think about the costs of business as usual.
Say I’m suffering from severe anxiety. How do I get help from your trained community mental health workers?
It will vary, but in a generic way it would look like this. You complain of depression to your primary care physician. Instead of being given an appointment with a therapist in six months, the physician’s team checks the database of trained community mental health workers and assigns one. The therapy could begin immediately via telemedicine or in person. Again, this provider is not working on his own, he or she is reporting to peers and to a supervisor. If a red flag is identified — say the person has active suicidal ideas — the provider would follow protocols and bring in a behavioral specialist.
I imagine you’ll get pushback from psychotherapists guarding their turf.
There may be pushback, but there is also growing recognition that we face a mental health crisis in America. We know psychotherapy is incredibly effective — but very few people get it. As scientists, it’s deeply frustrating.
I don’t think one size fits all in mental health care. Sending everyone with depression to a PhD or MD is inefficient — two out of three people with depression can do just as well with a far cheaper and more accessible provider. This clears time for specialists to allocate their time to people with complex mental health problems and to supervising the army of front-line workers that EMPOWER can build.
EMPOWER is not replacing sophisticated mental health care; it is expanding access to low-intensity first-responder therapies. The people we’re working with are the foot soldiers that America’s mental health care system desperately needs.
