It's a problem around the world: People who need mental health care don't get it.
A new kind of treatment strategy in India — delivered by nonprofessionals — offers a potential solution. And it's one that could be adopted in other countries, including the U.S.
In India, providing mental health care is a special challenge. Many people, especially in rural areas, don't understand much about mental health or mental illness.
"The vast majority of people with drinking problems or depression have neither received a diagnosis in their life nor have they been exposed to psychotherapy before," says psychiatrist Vikram Patel, one of the founders of Sangath, a nonprofit health care organization with headquarters in Goa, India.
Even if people know they need help, it's not easy to find. There are only three psychiatrists for every million people, compared to 124 per million in the U.S. The ratio for psychologists is even worse.
What to do?
Their answer is lay counselors — people who come from the community and have at least a 10th grade education but have never had mental health training. They go through a three-week workshop taught by mental health professionals where they learn how to talk to people with depression or alcoholism or other problems, and how to give those people tasks that will refocus their minds. It's an adaptation of cognitive behavioral therapy, a popular treatment around the world that's aimed at changing harmful patterns of thinking or behavior.
The Sangath group's goal is to provide access to treatment in the many places in India where there are no highly trained health professionals available or with the time to deliver care.
Here's what the treatment involves. People identified by professional staff at primary health clinics as having depression or being alcoholic are invited to see a counselor weekly, either at the clinic or at home, four to eight times. If medication is deemed necessary (which doesn't happen often), a doctor will write a prescription.
Then they receive "talk therapy." Their counselors talk to them about their daily lives and what they liked to do before their problems started. The counselors give "prescriptions" of activities: Take a walk every day. Make a plan to visit a friend. Go play soccer. That's it — pretty simple.
Those who received lay counseling were compared to others who had that initial visit and diagnosis, received information and maybe some suggestions about how to feel better but not the short-term intensive counseling.
In trials, Patel and his fellow researchers compared 466 people with moderately severe to severe depression who saw lay counselors to 236 people who didn't, and 336 alcoholics who saw counselors to 172 who did not.
In the two studies, 7 out of 10 patients attended all the sessions with their lay counselors. "That's comparable to the best treatment completion rate from Western scientific literature," says Patel.
"In the depression trial we found significantly higher recovery rates," says Patel. And the alcohol trial showed significantly less drinking.
The results of the trial, and smaller ones that came before it, were already the talk of the mental health community in India. Psychiatrist Rahul Shidhaye is with the Public Health Foundation of India and has worked with Patel on other trials. Shidhaye says there's now enough evidence to take the approach beyond the pilot stage.
"We are moving a step further," he says. "We are now taking it to the facilities where mental health has not been a priority at all."
Alan Kazdin, a professor of psychology at Yale University, says the information gained from the studies should go beyond India. "The research is very clear," he says. "Effective treatment does not require professional degrees." The studies "should be used to change mental health care in the world and not be just elegant scientific demonstrations."
The first place on Kazdin's list is the U.S., where many people with mental illness do not have access to care.