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Improving Health Care Quality

Making It Easy to Get Mental Health Care: Examples from Abroad

Thrive Gulu Counseling Session

In Uganda, Thrive Gulu trains lay people to serve as counselors, who then offer help for mental health and social problems. Photo courtesy of Thrive Gulu.

In Uganda, Thrive Gulu trains lay people to serve as counselors, who then offer help for mental health and social problems. Photo courtesy of Thrive Gulu.

Even before the pandemic, many people in the United States experiencing depression, anxiety, or other mental health problems did not get treatment. We investigated how other countries have expanded access to mental health care in recent years. Their strategies include paying general practitioners to deliver mental health services and hire mental health staff; leveraging telehealth platforms to assess and treat mild-to-moderate symptoms; deploying community health workers to screen people and help them navigate the system; and strengthening the capacity of nonprofit organizations to address problems such as unemployment and social isolation.

 

Even before the COVID-19 pandemic, most Americans with mental health conditions did not get treatment because of provider shortages, lack of insurance coverage, and a dearth of treatment models that worked for them.

But other high-income countries have managed to expand access to mental health care in recent years. Some have developed national strategies to promote well-being and prevent mental health problems, often prompted by evidence that untreated conditions sap economic productivity. They’ve launched public health campaigns to raise awareness of mental health problems, encouraging people struggling with common conditions like anxiety or depression to seek help. And many have made it easier to find and access treatment. Certain low- and middle-income countries, meanwhile, have leveraged community health workers and technology to bring services to more people.

Even though other countries’ health systems differ from ours in many ways, their approaches to expanding mental health services offer the United States lessons on how to prioritize mental health, make care more convenient, and scale treatment approaches to help many more people.

When the Commonwealth Fund fielded a survey exploring the early effects of the pandemic on the mental health and financial stability of residents in the U.S. and other high-income countries, researchers found that Americans were faring the worst. A third said they had been experiencing stress, anxiety, or sadness that was hard to cope with since the outbreak of the pandemic. And nearly a third (30%) reported having trouble paying for food, rent, or other necessities, causing them to use up their savings or seek loans to get by. Both rates were higher in the U.S. than those reported by residents in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, and the United Kingdom, and in some cases much higher.

The survey was fielded between late March and late May 2020. Given the duration of the pandemic, many more people may now be in distress — financial or otherwise. In recent months, we reached out to mental health advocates, researchers, and providers in several of the countries we surveyed to explore how the pandemic has been affecting people’s well-being and how their mental and public health systems have been responding. What we heard was similar to reports in the U.S., where the pandemic has had negative effects on broad swaths of society: isolated elders, families juggling work and schooling, stymied young people, and populations that had been disproportionately affected by COVID-19, particularly people of color, indigenous groups, and refugees. The findings accord with other surveys, including one by the U.S. Centers for Disease Control and Prevention that found increases in adult mental health problems, substance use, and suicidal thoughts.

Engaging More People with Mild-to-Moderate Symptoms

Several countries have sought to expand access to care for people with mild to moderate mental health problems, particularly depression and anxiety. People with these conditions are often not identified or treated in either low- or high-income countries, according to a 2013 report from the World Health Organization.

In 2008, the United Kingdom launched Improving Access to Psychological Therapies (IAPT), thought to be the most ambitious effort by any country to expand mental health services. The goal is to engage many more people with anxiety and depression in treatment, primarily cognitive behavioral therapy (CBT), which the U.K.’s clinical evidence review body, the National Institute for Health and Care Excellence, has recommended as effective for these and other conditions. In the early 2000s, the NHS spent some £80 million (USD 113 million) a year on counseling, out of an annual budget of £100 billion (USD 141 billion). Advocates argued that investing substantially more in these services would pay for itself by helping more people get back into the workforce.

IAPT differs from predominant models of mental health care in the U.S. in several ways. First, it promotes a standardized approach. Frontline therapists (known as psychological well-being practitioners) receive a year’s training in a national CBT curriculum. People with symptoms of mild-to-moderate depression or anxiety are offered treatment by these practitioners, typically over the phone or via text messaging. For patients who find this insufficient, treatment shifts to face-to-face therapy with psychologists.

IAPT is also unusual in that treatment outcomes — the degree to which people feel better — are measured at each session, and aggregated data about treatment retention and results are reported on a public dashboard. There is minimal gatekeeping: people with general practitioners can refer themselves to the program, can pursue therapy as well as pharmacological treatment, and incur no costs. The program has grown steadily over the years; during 2019–20, nearly 1.7 million Britons were referred to it and more than half of those who completed treatment recovered.

The success of the initiative in reaching patients with less complex needs (those needing more specialized services still face challenges) has encouraged adaptations in other countries, including Australia, New Zealand, and Norway. Starting in 2012, Norway piloted a program known as Prompt Mental Health Care in 12 regions and then rolled it out to 49 sites. As the name indicates, an explicit goal of the program is to speed time to treatment, with responses to requests for services mandated within 48 hours. Because Norway has few mental health professionals offering treatment for people with mild as opposed to serious mental illnesses, waiting times for such treatment under the usual system can be months long and general practitioners — who may have some training in CBT — are often the only option.

Under Prompt Mental Health Care, people with symptoms of depression or anxiety can refer themselves. After initial screening, they are offered low-intensity treatments by therapists with one year of CBT training — including guided exercises and group courses — or face-to-face therapy by clinical psychologists. A randomized controlled trial found that Norwegians who received treatment under Prompt Mental Health Care were more likely to report reduced symptoms of anxiety or depression at six months follow-up than those who received usual care, which mostly included referrals to their general practitioners for therapy and references to books or other self-help resources (58.5% vs. 31.9%).

Integrating Physical and Mental Health Care

Some countries have sought to expand access by offering mental health services in primary care clinics. Advocates have long called for such integrated care in recognition that many people with mental health conditions also have physical health conditions, and the two can affect each other. But in the U.S., many primary care providers lack the time, training, and staff members to treat behavioral health conditions.

Beginning in 2014, the Netherlands increased funding for general practitioners (GPs) working alongside other health professionals to provide mental health care to patients with mild-to-moderate mental symptoms. Today, 90 percent of general practices have at least one team member trained to identify mental health issues. They support patients in managing stress, anxiety, insomnia, and other common problems, or refer them to specialists for more complex conditions. These services may be provided directly by physicians or more commonly by “general practice mental health workers,” who have up to a year’s training in screening, diagnosis, and intervention, and support GPs in managing mental health issues.  

Australia has broadened access to mental health services through the country’s Better Access to Psychiatrists, Psychologists and General Practitioners through Medicare Benefits Schedule, which since 2006 has paid general practitioners to offer early intervention, assessment, and management to people with mental disorders, as well as referrals to community-based mental health care providers. Patients are eligible for up to 10 individual therapy sessions and 10 group therapy sessions per year.

In the U.K, the National Health Service (NHS) has been experimenting with different ways of integrating physical health, mental health, and social services. In some regions, primary care practices have been grouped together and made responsible for 30,000 to 50,000 residents, with support from multidisciplinary teams including nurses, mental health professionals, social workers, and community health service workers.

Using Digital Platforms to Offer Convenient, Customized Care

Mental health care providers have been ahead of most other types of clinicians in adopting telehealth tools, with psychiatrists and psychologists delivering therapeutic services via phone and video for decades and accumulating evidence that these approaches can be just as effective as in-person visits for some patients. And well before the pandemic, in the U.S. and many other countries, digital health innovators had begun leveraging telehealth tools as well as chatbots and other forms of artificial intelligence to engage people with behavioral health conditions, both as a way of making care more accessible and to make up for workforce shortages.

In the Netherlands, many digital health tools are evaluated by a division of the Ministry of Health, Welfare, and Sport, and evidence of their effectiveness is tracked in a national database that clinicians can search before prescribing them. “Many GPs have received training on how to use and offer digital mental health interventions,” says Laura Shields-Zeeman, a 2018–19 Commonwealth Fund Harkness Fellow who leads the department of mental health and prevention for the Trimbos Institute, the country’s national institute of mental health and addiction. Many of these tools are free or are available for a small subscription; those that combine face-to-face treatment with online modules are reimbursed by insurers, as they are part of treatment delivered by clinicians.

For people with mild-to-moderate complaints, there are a lot of self-help and self-management digital support options available, which helps to reduce caseloads in clinics that provide specialized mental health care.

Laura Shields-Zeeman Head of Mental Health and Prevention at the Netherlands Institute for Mental Health and Addiction

Among the apps and digital platforms that Dutch leaders and private insurers have supported are ones to help patients manage particular problems such as postpartum depression, insomnia, and excess alcohol consumption. “We even have online modules on how to manage working from home during the pandemic,” says Shields-Zeeman.

The Australian government also funds a variety of digital platforms, including MindSpot and This Way Up, virtual mental health clinics that offer screenings using online and telephone assessments as well as referrals, recommendations for treatment, and access to web-based courses, including ones focused on managing depression, anxiety, and post-traumatic stress disorder. Since the pandemic began, MindSpot and This Way Up have seen a ninefold increase in requests for counseling services. The country’s two major health plans also offer help navigating mental health services via telephone 24/7, and crisis lines run by the nonprofits Lifeline and Beyond Blue have received more federal support to increase access to trained professionals.

In mid-April 2020, as the pandemic got underway, the Canadian government launched Wellness Together Canada, a digital portal that connects citizens of all ages to self-guided tutorials, text-messaging, confidential chat sessions, and phone counseling with peer support workers, social workers, psychologists, and other professionals at no cost. The portal also offers self-assessments that allow users to monitor their progress.

Addressing the Social Determinants of Mental Health Problems

Some countries have begun to recognize that mental health issues are often rooted in or exacerbated by societal problems such as racism, workplace stress, and unemployment. To promote well-being, leaders have sought to ameliorate such systemic factors while also offering support to those coping with their effects.

New Zealand’s government is attempting to do so by dedicating the bulk of its NZD 1.9 billion (USD 1.4 billion) budget for mental health and well-being (the 2019 Wellbeing Budget) over five years to community-based organizations that address both. One is Emerge Aotearoa, which offers peer and community-based supports as well as therapeutic services to people with mental health problems, substance use disorders, or disabilities. It also helps them find housing, employment, or other social supports.

The budget also includes additional funding for housing, employment, and poverty reduction initiatives and directs money to general practitioners to hire community health workers, mental health counselors, and health coaches who work in partnership with community-based organizations to promote well-being and offer support to people with mental health and addiction challenges.

In rolling out the program, New Zealand’s leaders prioritized practices that operate in low-income communities or serve the indigenous Māori population. “We’re finding in the practices that have had this model for a while, the outcomes have been really positive,” says Barbara Disley, who led New Zealand’s first Mental Health Commission and now serves as CEO of Emerge Aotearoa. “The level of pharmacological interventions is much lower when you get people connected in the right way to the right sorts of community support.”

In Australia, mental health initiatives involve large employers. This summer, employers in the road transport and logistics sector joined forces to develop Healthy Heads in Trucks and Sheds, a program that seeks to promote good mental health among truck drivers and distribution and warehouse staff, who often feel the strains of long hours, isolation, and pressure to meet delivery schedules.

Australia and other countries have also sought to engage young people. Since 2006, Australia has funded brick-and-mortar centers that serve as a one-stop shop for young people (ages 12 to 25) who need mental health services or social supports, including help in finding jobs. Run by a nonprofit, the 100 headspace centers have a casual atmosphere designed to appeal to young people. Staff, including physicians, psychologists, social workers, occupational therapists, nurses, peer counselors, and specialists in substance abuse treatment, invite questions about how to cope with depression and anxiety, anger, bullying, and other challenges.

“The emphasis is on supporting mental health and well-being in the community and in a way that’s non-stigmatizing for young people,” says Jane Burns a 2004–05 Harkness Fellow and an enterprise professorial fellow in the University of Melbourne’s Faculty of Medicine, Dentistry, and Health Sciences. Increased funding during the pandemic has enabled the nonprofit to expand access to online services and phone help lines that are available to youth seven days a week. 

Youtube poster

Headspace centers serve as a one-stop shop for young Australians who need mental health services or social supports.

Frugal Innovations in Expanding Mental Health Care Access

Expanding access to mental health supports doesn’t need to be expensive, as advocates working in low- and middle-income countries have demonstrated. In Pakistan, Uganda, and Zimbabwe — countries that have as few as one psychiatrist or psychologist per million residents — nonprofits have leveraged community health workers and and/or technology to offer counseling, education about mental illnesses, and referrals to higher-intensity care.

Zimbabwe

One such approach is the Friendship Bench, developed in 2007 by Dixon Chibanda, M.D., a psychiatrist in Zimbabwe, after one of his patients in a remote village committed suicide. The program trains grandmothers to offer CBT to people experiencing depression or traumatic events such as intimate partner violence. The first group of grandmothers had already been working as community health workers and had earned the respect of peers.

A 2016 randomized controlled trial found people who engaged with the grandmothers in problem-focused conversations had significantly lower scores on a scale measuring symptoms of common mental health disorders at six months than did members of a control group who received brief counseling from nurses, evaluations for medication, and psychoeducation.

To scale the model in Zimbabwe and other countries including the Netherlands, Chibanda and his colleague Robin van Dalen created a digital platform known as Inuka, which means “arise” in Kiswahili. Users complete an automated survey that asks about their symptoms of anxiety or depression as well as their sleep habits and sense of purpose; the app provides an immediate rating (green for resilient, yellow for at-risk, and purple for “in a tough place”). Users are connected with a coach who typically spends between 60 and 90 minutes exploring their challenges and developing practical steps for tackling one of them — all through text-based chats. Subsequent chat sessions are shorter and most problems are resolved within four sessions, says van Dalen, Inuka’s CEO. An evaluation found that 82 percent of people who were initially determined to be in the highest-risk category returned to the lowest-risk one within four coaching sessions.

Inuka digital platform

Users of the Inuka app complete surveys about their symptoms and then receive coaching via text. Courtesy of Inuka.

Uganda

Another program, Thrive Gulu, was established a decade ago to help residents of Northern Uganda cope with the traumatic effects of a civil war that led to genocide, the abduction of children to become soldiers, and rampant sexual abuse. Thrive Gulu operates Northern Uganda’s only drop-in counseling center and has developed individual and group counseling programs. It is run by mental health professionals who train lay people to serve as counselors and gender-based violence monitors. These frontline workers offer help to meet people’s mental health and social needs, the latter through approaches such as literacy training and economic empowerment programs. Both are important, says Mick Hirsch, Thrive Gulu’s executive director: “You don’t want to empower people economically without also providing them with some mental health support. You can’t predict when past trauma will return.”

Thrive Gula

Thrive Gulu provides both mental health and social supports, including suicide prevention and health literacy programs. Photo courtesy of Thrive Gulu.

The organization also works to combat stigma surrounding mental illness. In Uganda, people who exhibit signs of mental illness may be shunned. “We’ve learned those few initial contacts with clients have such power especially in a society where there is so much stigma,” Hirsch says. “Having someone affirm their experience gives them something they may never have received.” Since COVID-19, the organization has provided tele-counseling services and promoted positive mental health via radio shows.

Pakistan

In Pakistan, where there are just 125 psychiatrists in a country of 216 million, staff of Interactive Research and Development (IRD), a nonprofit that pilots public health interventions in low-income countries, trained more than 65 community health workers (CHWs) to screen people for depression and anxiety in three low-income areas of Karachi. For those who screen positive, the CHWs offer instruction in basic coping skills, provide counseling using CBT techniques, and make referrals to psychologists and psychiatrists for more severe problems.

“Given the stigma around mental illness, I thought fewer than 40 percent of people we approached would be willing to participate,” says Aneeta Pasha, country director of IRD Pakistan. “But when the first team went out, 85 percent of people said they were willing and ready to enroll in counseling.”

The program, known as Pursukoon Zindagi (Urdu for “peaceful life”), is funded through grants and other philanthropy, and has since expanded to include 100 CHWs, some of whom are  assigned to medical clinics to support patients with tuberculosis (TB). They found high rates of depression and anxiety among TB patients and that those receiving support were significantly more likely to attend medical visits and adhere to medication regimens (92% versus 75%) than patients whose mental health problems went untreated.

A review of more than 1,700 transcripts of the CHWs’ sessions with clients revealed that economic problems were one of the greatest sources of distress, prompting staff to connect people to vocational training and microfinance programs, as well as housing and food supports. During COVID-19, the CHWs have offered support via telephone, videoconferencing, and medical clinics.

Lessons for Mental Health Policy and Practice in the U.S.

While expanding access to mental health treatment is increasingly a priority for many countries, these efforts are still a work in progress. Commonwealth Fund survey findings suggest there’s still much work to be done: during the early months of the pandemic, only half of adults in Australia (54%) and Canada (47%) were able to get mental health services when they wanted them, while only a third of adults in the U.K. (32%) and U.S. (31%) were able to do so.

Still, the U.S. can learn from other countries’ efforts to expand access to mental health treatment to meet widespread need.

Funding and strategy matter.

Across most high-income countries, mental health services are insufficiently funded, as compared to services for physical health problems. Setting clear targets for increased funding — as has been done in Australia, Canada, New Zealand, the U.K., and other countries — is an important first step in expanding access to care.

Canada’s first mental health strategy, published in 2012 by the government’s Mental Health Commission, called for an increase in mental health’s share of public health care spending from 7 percent to 9 percent. Eventually, the federal government transferred CAD 5 billion (USD 3.9 billion) to provincial and territorial governments to improve access to mental health services for a decade, starting in 2017 — a significant investment but one that fell short of the recommended target.

In the U.S., efforts to institute a national mental health strategy have proceeded in fits and starts. Some policies were designed to broaden access to coverage. A 2008 law mandates that insurers provide coverage for mental health and addiction treatment that is on par with what they provide for services treating physical health conditions. Changes made to Medicare regulations, meanwhile, allow payment for depression screening and management of mental health conditions by primary care providers. But the success of these initiatives depends on having enough providers trained and willing to deliver mental health services. Some psychiatrists and psychologists in the U.S. don’t accept Medicaid or Medicare — or any insurance coverage at all — and general medicine physicians have yet to fill the gap.

In Canada, the process of developing a national mental health strategy took place in tandem with strategy development by the 13 provincial and territorial governments. This was helpful in creating a “community of practice” around mental health policy across the country, according to Mary Bartram, Ph.D., director of COVID-19 policy at the Mental Health Commission and a lead author of the report outlining the mental health strategy. Canada’s experience may provide a roadmap for coordinating approaches at the federal and state levels and spurring action in the U.S.

Care should be convenient, customizable, and scalable to meet need.

Normalizing mental health problems and reducing the hassle factor in getting help may encourage more people to seek and stay in treatment. The success of the U.K.’s IAPT program and other countries’ adaptations point to the importance of having easy on-ramps for people to get care in the manner they want. That can mean receiving treatment in their own homes or via text, chat, or phone — whether for a few days, several weeks, or even longer. In Australia, the largest health insurer, Bupa, partnered with mental health providers, advocates, and developers, to create video and audio recordings offering wellness tips to men, who are often unwilling or unable to engage in traditional treatment.

Youtube poster

Australia’s largest insurer and its partners created videos and podcasts offering wellness tips to men, who are often unwilling or unable to engage in traditional treatment.

Delivering low-intensity therapeutic and self-help treatments through tutorials, group classes, chatbots, and other approaches could help meet demand. Experiences in Kenya, Pakistan, and Uganda suggest that a little help can go a long way for some people, and that having some support is better than having none.

In the U.S., many digital apps have been designed with the “worried well” and affluent customers in mind, because it’s easier for tech developers to market their products than to enlist insurers to pay for them. It will be important to measure whether digital tools are reaching — and are tailored to — patients with low income, including those enrolled in Medicaid, who account for a disproportionate share of spending on mental health services.

Different types of mental health care professionals may be needed.

Substantially expanding access to treatment may also mean training and empowering professionals other than psychiatrists, psychologists, or clinical social workers to provide screening or treatment. In Norway and the U.K., some counselors receive a year’s specialized training in CBT; in the Netherlands, some receive up to a year’s training to help screen and treat people in primary care practices. Less-wealthy countries have trained community health workers to assess people’s mental health and offer basic supports.

“We need to come up with novel ideas on how to get help to more people,” says Benjamin Miller, Psy.D., chief strategy officer of Well Being Trust, a U.S. foundation that works to advance mental, social, and spiritual health. “Since we don’t have enough mental health professionals where we need them when we need them, why not democratize the knowledge around mental health to enable a new and community-based workforce to take on issues we have traditionally left to the specialty health care sector?”

Jane Burns of the University of Melbourne suggests that the economic upheaval of the pandemic may offer an opportunity. “We need a workforce to care for people who are aging, disabled, or mentally ill,” she says. “This could be a reset and opportunity to think through what the new workforce will look like.”

To encourage more people to engage in mental health treatment, we need to earn their trust.

Some people may be hesitant to use mental health tools or services perceived to be promoted by the government or by their health plans or health care institutions. In Canada, it remains to be seen whether Canadians will be comfortable disclosing personal information to the country’s government-run mental health platforms. To date, take-up is a work in progress, the Mental Health Commission’s Bartram says.

Greater transparency around the results of mental health treatments could build public trust. The U.K. created an easily accessible database to share results of its national CBT program. Also needed is evidence on the effectiveness of digital health tools, and a strategy for making that knowledge part of clinical practice. One model for this is the Netherlands’ database of evaluated and recommended digital health tools.

Efforts such as Australia’s Beyond Blue initiative, which has engaged employers, schools, senior centers, and other community institutions in promoting well-being, also show the benefits of a collaborative approach to reducing the stigma of mental illness and encouraging more people to get treatment.

Given that so many people are feeling the strains of the pandemic and its repercussions, it’s crucial that we find and spread cost-effective ways of making mental health supports more broadly available.

Publication Details

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Contact

Martha Hostetter, Consulting Writer and Editor, Pear Tree Communications

[email protected]

Citation

Martha Hostetter and Sarah Klein, Making It Easy to Get Mental Health Care: Examples from Abroad (Commonwealth Fund, Feb. 25, 2021). https://doi.org/10.26099/dj88-5254