MENTAL healthcare is too important to be left to psychiatrists or psychologists alone. In low-resource settings like ours, unaddressed mental health issues are growing at an alarmingly high rate and there are just not enough specialised mental health experts.

Around 1,000 psychiatrists and 3,000 psychologists in a country of 240 million-plus people cannot possibly deal with this burden of disease. Specialist mental health care, by both psychiatrists and psychologists, is too expensive, inaccessible, and inefficient. Psychology practice is not even regulated. Sadly, a somewhat similar situation exists in most low- and middle-income countries (L&MICs).

For an acute depressive episode, for example, either antidepressant medicines are prescribed or psychological therapy is provided. There is growing evidence now that psychological treatments outperform medication on the important outcome of keeping people well in the longer term following an initial episode. But how many people can access psychotherapy? The majority are irrationally prescribed anti-depressants, which are also used irrationally.

Due to an extreme dearth of specialists, mental health researchers have developed a number of evidence-based psychological interventions for non-specialised settings employing a task-shifting approach. A former colleague at the World Health Organisation (WHO), Dr Shekhar Saxena, spent years studying, analysing and selecting such interventions with mental health researchers around the world.

Then, with the help of a large and dive­r­­se group of experts, Dr Saxena managed to put together a mental health gap intervention guide (mhGAP) in 2010. The second version of the WHO mhGAP Intervention Guide was published in 2016. It spanned interventions for depression, psychosis, epilepsy, child and adolescent mental and be­­h­avioural disorders, dementia, disorders due to sub­­stance use, self-harm, suicide, and other significant mental health complaints. This work serves as an important milestone in mental health care in L&MICs.

The WHO Thinking Healthy manual is based upon research conducted in Pakistan.

The mhGAP Intervention Guide refers to Thinking Healthy: A Manual for Psychosocial Management of Perinatal Depression, which was produced by WHO in 2015 as the first of a series of manuals created as an extension of mhGAP. It describes evidence-based, effective psychological interventions to address perinatal depression.

Depression is about 50 per cent more common in women. Globally, one in four to five women suffer from pregnancy-related depression — perinatal and postnatal depression, the prevalence of which would be even higher in Pakistan. A depressed mother has serious consequences for child care and development. Sixty-five per cent of adult mental disorders have their origins in childhood and adolescence.

The WHO’s Thinking Healthy manual is based upon research conducted in Pakistan, led by Dr Atif Rahman and his team under the auspices of the Human Development Research Foundation located in a rural setting close to Mandra, a small town on GT Road near Rawalpindi.

The foundation was set up by Dr Rahman, an accomplished psychiatrist and mental health expert who divides his time between Pakistan and the UK. As a professor of Child Psychiatry & Global Mental Health at the University of Liverpool, he has quietly made significant contributions to the field of mother and child mental health in L&MICs.

The Thinking Healthy Programme is based upon psychological intervention — cognitive be­­haviour therapy (CBT) — which was tested in one of the largest randomised controlled trials to be conducted in the developing world. This research was undertaken in 40 union council clusters in rural Rawalpindi.

Nine hundred depressed pregnant women in their third trimester, and living in poor communities, were identified and THP was administered to 463 of them. From pregnancy to one year postnatal, these mothers received eight to 16 sessions of psychological treatment. They were followed up, evaluated, and compared to 440 depressed pregnant women in the control group.

The results were astounding. In a poor rural community with hardly any access to mental hea­lth care, the integration of CBT into the routine work of trained community health workers more than halved the rates of perinatal depression am­­ong the women compared to the control group, and these positive effects were sustained later in life.

THP includes simple CBT strategies aimed at identifying and modifying maladaptive styles of thinking and behaving that lead to poor self-esteem, inability to care for infants, and disengagement from social networks.

These are substituted with more adaptive ways of thinking and behaving. Behavioural activation is employed to rehearse more adaptive behaviours, such as self-care, attention to diet, and positive interactions with the infant between sessions. Women are also guided in problem-solving to overcome barriers to practising such strategies.

The research also showed positive results in the infants of these mothers through higher rates of immunisation and fewer episodes of diarrhoea. They were also likely to use contraception and both parents reported spending more time playing with their infants.

After its adoption by the WHO, THP has been implemented in more than 30 diverse countries including China, Vietnam, India, and Peru. The programme is extremely cost-effective. Community health workers require a brief training period of only five days. The programme has even trained peer counsellors such as women selected from the same community.

The challenge, however, is scaling it up to a national level whilst maintaining its quality. Dr Atif Rahman and his team are continuing this work on these lines through innovative uses of technology. A school mental health programme has also been developed and tested for its effectiveness.

I was motivated to write this article when recently in a mental health meeting one participant referred to the WHO Thinking Healthy Programme. When asked if she knew that this WHO programme was developed on the basis of research conducted in Pakistan by Pakistanis, she said she didn’t know!

Readers who want to know more about the THP can google the above-mentioned resources and can also download an interesting article recently published by Vikram Patel and Atif Rahman in the Journal of the American Academy of Arts and Sci­ences, entitled ‘Empowering the (Extra)Ordinary’.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, WHO adviser on UHC, and member of the Pakistan Mental Health Coalition.

zedefar@gmail.com

Published in Dawn, December 15th, 2023