How to Close the Mental Health Gap in Low- and Middle-Income Countries

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By: Tricia Bolender, Faculty and Senior Improvement Advisor, Institute for Healthcare Improvement

This month on October 10th, we celebrate Mental Health Day. Indeed, there is much to celebrate, from the development of the WHO’s Comprehensive Mental Health Action Plan (2013-2020), to policy reforms and new drugs to treat schizophrenia and other mental health diseases.mother child woman pregnant nigeria mental health antenatal care

Yet there is still more to be done.  It is estimated that in low- and middle-income countries, there is a treatment gap of one billion individuals in need of mental health care.[1] Given daunting statistics like this, the question remains: what can be done to scale up the knowledge we have on treating mental illness during pregnancy? 

The issue of maternal depression has recently taken on new meaning for me, as I am currently six months pregnant with my first child. In her book Origins: How the Nine Months before Birth Shape the Rest of Our Lives, Annie Murphy Paul’s own reflections on her sixth month of pregnancy have made me acutely aware of the prevalence of maternal depression. Her research reveals that “maternal depression occurs at least as often as pregnancy-induced hypertension, and five to ten times as often as gestational diabetes, both of which are screened for in the course of routine prenatal care.”[2]

While we have all heard of postpartum depression, I was stunned to learn that depression during pregnancy is even more common. Paul points to a study published in the British Medical Journal: “More mothers moved above the threshold for depression between eighteen weeks and thirty-two weeks of pregnancy than between thirty-two weeks of pregnancy and eight weeks postpartum.”[3] This is significant since depressed pregnant women are more likely to deliver premature babies.[4] Yet for me and many of my peers approaching or well into our third trimesters, we have yet to receive any screening for depression using a standardized, validated tool – as recommended by the American Congress of Obstetricians and Gynecologists.[5]

This is but one example of the gap between what we know should be done and what is actually done, and serves as a reminder that what stands in the way of implementing and scaling quality mental health care is not a deficit of knowledge, but a deficit in the use of effective implementation methods to translate and deliver this knowledge.  At the Institute for Healthcare Improvement, where I work as Faculty, this challenge of implementation and scale up is exactly the problem we try to solve. We propose that improved access and use of evidence-based improvement and change management tools can address this deficit in the field of global mental health.

Earlier this year with funding from Sanofi’s Access to Medicines Department, we launched the One Billion Minds and Lives initiative, which utilizes a Continuous Quality Improvement (CQI) approach to close the mental health gap. Our aim is simple but ambitious: to ensure that the one billion people in low- and middle-income countries who need mental health care receive this by 2020.  Founded by Dr. Gary Belkin, we are currently working with innovators in five sub-Saharan African countries—Ghana, Kenya, Nigeria, Rwanda, and Zambia—who are using quality improvement methods to implement mental health treatment packages, including those that address common perinatal mental disorders.

This Early Adopter Network is a learning community that shares knowledge, setting the foundation for scale. Looking forward, we hope to partner with a growing number of mental health innovators committed to using the tools of quality improvement towards effective implementation of existing knowledge and protocols.

We are halfway through this 18 month collaborative and already seeing results. In Ghana, two of our members, Philomina Amofah and Fiifi Ayetey, are leading innovative work through the National Catholic Health Service, bringing the tools of CQI to improve outcomes in maternal depression and epilepsy. Primary health nurses now screen all pregnant and postpartum women for depression and identified 332 women with maternal depression over the last year. Through counseling, 55% of these women were successfully treated for their depression within twelve weeks.

These results have inspired another member, Timothy Adebowale, Director of Clinical Services and Coordinator of the Primary Care Programme at Aro Neuro-Psychiatric Hospital in Nigeria, to begin screening for maternal depression in its largest primary care maternity center, which conducts approximately fifty deliveries per month.

Building on these early learnings, we are working to build a movement that accelerates the spread of clinical knowledge through the proven tools of improvement science.  Let’s see what we can all achieve together by next year’s Mental Health Day.

The opinions expressed in this article are the author’s own and do not reflect the view of Institute for Healthcare Improvement.

Photo: “Mother and child, ante-natal care clinic, Jigawa, Nigeria, December 2011” © Susan Elden/DFID – UK Department for International Development, used under a Creative Commons Attribution license:

[1] This figure is based on WHO estimates that one in four people will experience an episode of mental disorders or psychosocial disabilities in their lifetime, the population in low- and middle-income countries, and estimates for the percentage of individuals already receiving mental health care and treatment.

[2] The Mood and Anxiety Disorders Resource Center, Massachusetts General Hospital.  Annie Murphy Paul, Origins: How the Nine Months before Birth Shape the Rest of our Lives; Free Press, 2010.

[3] Jonathan Evans et al., “Cohort Study of Depressed Mood During Pregnancy and After Childbirth,” British Medical Journal (2001), vol. 323, no. 7307.  Annie Murphy Paul, Origins: How the Nine Months before Birth Shape the Rest of our Lives; Free Press, 2010.

[4] Rogers CE, Lenze SN, Luby JL, “Late preterm birth, maternal depression, and risk of preschool psychiatric disorders,” Journal of the American Academy of Child and Adolescent Psychiatry; February 4, 2013.

[5] The American Congress of Obstetricians and Gynecologists, “Committee Opinion: Screening for Perinatal Depression”, Number 630, May 2015.