Patel, one of the three Indians on Time Magazine’s list of 100
most influential people in the world, is a bit of an antithesis. He’s a
“non-psychiatric” psychiatrist, in some ways more of an anthropologist. He
disdains “ivory tower” academia, though he’s a tenured professor at the London
School of Hygiene and Tropical Medicine. He founded his NGO Sangath in Goa but
at any given time he’s working on at least a handful of projects, a few
research papers, and shuttling between Delhi, London, Goa and a few other
He’s also a man in a rush. Ask him though and he’ll tell you it’s not him, it’s the “thousands of mentally ill people suffering, chained to their beds” who can't wait.
Patel spearheads Global Mental Health, a movement that aims to reclaim psychiatry from “psychiatrists and the categories they've invented”, and plant it firmly in local cultures and mores. To do this he’s taken psychiatric interventions out of the clinic to lay community workers and local health centers, in an approach he labels “task-sharing”.
In this approach, community health workers consult and support each other. They are supervised by doctors at local health centres, who are in turn supervised by psychiatrists based at district hospitals. It’s a pyramidal structure where a patient’s treatment is collaborative, information flows in both directions.
It’s iconoclastic, challenging some of the most commonly held medical beliefs—that mentally ill patients cannot help themselves; non-specialist workers are of little consequence; and that the “labels and compartments” of mental illness are essential to treatment.
His work is, however, firmly grounded in science, using randomised controlled trials, “the most scientific instrument psychiatrists have”. He’s used them to create and test community treatment protocols for everything from depression to chronic schizophrenia in different parts of India.
Of late he’s veering towards the view that neuroscience has a lot to contribute to his endeavour. He could be barking up the wrong tree, but he says he’s always “open to a challenge”.
On a cool spring evening in Delhi, he lounges in his elegant but spare living room. His usually neatly combed back shock of white hair is slightly ruffled from just having woken up. He’s in shorts, and the eyes are slightly bleary from the morning flight back from Zimbabwe. But it only takes a cup of coffee and a question or two for his intensity and enthusiasm to surface.
Zimbabwe was the first place that you worked in after finishing your studies in London in 1995. You’ve said earlier that those were the best years of your life. Why is that?
It was the first time I was exposed to the real world. It’s quite interesting how hermetically sealed urban Indians are from the state of healthcare in rural India. In Bombay where I grew up and in London where I trained it never seemed that anything was lacking. There were no shortages.
In Zimbabwe I came face to face with an absolutely different world, with very few resources even in the capital of the country, and few medicines. I realised that it was so difficult to apply everything that I’d learned in this environment. Business as usual wasn’t going to work there.
There were maybe nine or 10 psychiatrists in the country at that time, all of them in Harare, of whom eight or nine worked in a medical school, none of whom spoke the language. So that meant that really there was one psychiatrist for the whole of country. If you’re working in the area of behavioural medicine you do need to speak the language.
Zimbabwe was an eye-opener. It set me on a course I have been on since then.
You are reclaiming
mental health from the clinic, from psychiatric practice. In some ways you’re
attempting a scientific renaissance—where instead of universalising conditions
you are also looking at local contexts. This seems like a fairly radical
Actually I don’t know whether it’s that radical. The idea that healthcare is not the doctors’ business alone, that it’s too important to be left to doctors alone and therefore by extension that mental health is too important to be left to psychiatrists is not a new one. It’s been around in this country for a long time. In fact India is one of the pioneers in culturally appropriate interventions that are sensitive to the needs of the local communities. We have frontline workers, like accredited social health activists (ASHAs) who’ve delivered these interventions. Theirs is the largest workforce of community based agents in the world.
I serve on the National Rural Health Mission (NRHM) ASHA mentoring group, and one of the discussions we’re having currently is whether ASHAs should have an added role. We’ve made significant progress in maternal and child health. We’re wondering whether these health workers should have a role in interventions for the treatment of chronic diseases, including mental illnesses. So I don’t think my approach is that radical.
Lots of NGOs have also been working with non-specialists, exploring non-clinical, psycho-social interventions. I think what’s different about the work I have done is its scientific temper. Instead of assuming that mental health problems are connected to people’s situations and social conditions, I have sought to apply a scientific lens to examining whether this idea is correct. In that sense my research is original and has set the ground for a very large new field called 'global mental health'.
You talk about the
need for a re-categorisation of mental illnesses. The categories into which
they have been boxed are too restrictive. For example, you say depression,
hypertension and the physiological manifestations of these need to be considered
together. You’ve talked about how from the perspective of primary health care
workers, a lot of psychiatric categories do not make sense, they don’t reflect
the reality on the ground at all.
I am challenging the hegemony of a very biomedical approach to mental health problems in several ways: first, in the way they are diagnosed. This extremely complex categorical system championed by psychiatrists that is not applicable, certainly not in India, in the communities that I work in.
I am challenging the biomedical approach for making us ignore a whole lot of community resources, for example local social networks that can be used to deal with mental illnesses.
I am challenging the notion of who is a healthcare provider. I’m also challenging the notion of where mental healthcare should be provided. People need to be helped in their homes, in their local situations. I only see clinics and hospitals as a small part of the stepped healthcare model that I’m championing. I’m looking at healing at the base of the pyramid.
My allies in these challenges are people in community health in India. We have icons like Abhay Bang. His work has been pioneering in community health. All I’ve done is to apply a scientific approach—randomised controlled trials---to that work. For me Abhay is a role model, because he also applies that same scientific approach of randomised controlled trials and epidemiological studies that I do.
I believe strongly in science, especially in the environment we have in India where there are so many scamsters, not least in the area of mental health, and where there are so many wacky solutions. We need to be very cautious in adopting anything radical and new. Data must drive anything new we do in mental healthcare.
Can you tell us a
little more about the organisational structure of these interventions?
At the base of the pyramid, at the village level you have ASHAs or their equivalent. Then at the next level, which is typically a cluster of ASHAs – an ASHA supervisor. Then above that the healthcare centre; and then the district hospital.
So the base needs to be promotive and preventive. The quality assurance is done by supervisors. The primary healthcare facility level offers out-patient pharmacological treatment. The district hospital deals with more specialised, complex problems.
There are 4 Cs to the system. The first is it’s Coordinated. Within the pyramid you can move up or down depending on you level of need. This movement has to be seamless. The second is that it’s Collaborative—the top of the pyramid is as important as the people at the base. A schizophrenic who comes to the district hospital goes back to the village when he is better. Someone at the district hospital needs to work with the ASHA in the village to apprise her of the patient’s course of treatment.
It’s Continuing since these are lifelong conditions. And it’s Community-based, not facility-based. The healthcare facility (or district hospital) is an additional resource; you go there very rarely when you need it, not because there’s nothing available down here.
This is a huge step up
from the current system. The fact that someone on top has to be in constant
touch with the people down the pyramid is a huge task.
You’re right. This is not a small step, it’s a huge ambition. But that’s the whole point. We have to grasp that now before a whole range of chronic diseases, including mental health conditions, cripple our healthcare systems and families. The fact is that the healthcare system is completely unprepared for this coming tide of chronic diseases, as a consequence the burden is entirely being borne by families. These problems are only going to keep increasing.
It is a long journey ahead, but if we don’t start on it now, we will never get to our destination. We now have to develop models that integrate these disease specific packages into a integrated systems approach
Have you faced
resistance from the psychiatric and medical establishment?
There was a time when I did but it’s changed. Ten years ago when I started writing about this approach there was suspicion. I remember in one of my proposals we had developed a programme for supporting people with chronic schizophrenia, one of the most debilitating diseases in the world.
We pitched the Indian Council of Medical Research (ICMR) for external peer review since it was an international study. But they rejected it with comments to the effect that there is no place for community health workers in helping people with this devastating illness. That, felt the reviewer, has to be done by psychiatrists. That is the kind of hostility there was in mainstream psychiatry against innovations of this kind. As it happened we still did the trial since we had ethical approval. The approach worked and we published the paper in Lancet last year.
I’m not going to be cowed by this stubborn denial of facts and the need for science to address these questions. We were asking a question that this reviewer thought was not sound. But we actually showed that not only was the question sound but it showed positive results.
Today things are different. I’m invited to speak at World Psychiatric Association, Indian Psychiatric Society meetings. I play a leadership role in both. I believe that mainstream psychiatry is beginning to recognise that if we’re going to get mental healthcare out to the population we’re going to have to give up some of our power and that we actually have a role in doing that. In my view doing so increases our power. We become more meaningful to society rather than being seen as a small coterie of professionals who want to keep their business in their own territory.
If you were to
approach psychiatrists today, you’re saying they’d be open to collaborating
with public healthcare workers?
Absolutely. Take the government of Maharashtra for example. There has been a spate of farmer suicides over the last three months. The chief minister had a conclave in Yavatmal to discuss this and one of the approaches talked about is to go beyond the usual socio-economic-political approaches to suicide to recognise that there is a health component. This is the first time I’ve heard this. Last week my NGO Sangath was asked whether it would draft the community proposal for this programme. If this happens, it would be a tremendous source of happiness for me.
Suicide is not just an economic disease, it also has a mental health component. We have an ongoing programme in 32 villages in Vidarbha that deals with suicides among farmers.
This is a bottom-up approach in which community workers like ASHAs have been trained in a range of different tasks like raising awareness, early detection, recognising who is at risk of suicide. They’ve been taught to look out for signs like domestic violence and heavy drinking. At the first level there are social support interventions, then recognising danger signals and potentially referring the person up the pyramid to a trained counselor.
So here’s an example of how an empirical evaluation of a programme acts as support to scaling up, as opposed to someone just asserting that this is the right approach.
We’re also having a meeting with the ministry to talk about healthcare workers who can play a role in all behavioural interventions–this could include tobacco cessation, palliative care, mental health, psycho-social treatment. On the face of it these look separate, but the skills that you need to encourage someone to quit tobacco are the same that you need for alcohol. The skills needed to persuade people to take their diabetes medication are the same that you need to get them to take their anti-psychotic drugs.
Because we’ve been applying a hospital approach we treat each of these as separate. But when you look at the skills needed for most interventions there’s a huge overlap. We’re trying to develop a curriculum for community workers who are trained in providing interventions across settings, in schools for youngster with stress related problems, in facilities for people with depression.
We’re doing this using the modules we’ve developed in Sangath. I’ve spent the last 10 years showing that this approach works in the case of specific disorders.
Now we’re moving to the health systems phase: how do wrap all this up together into a resource that the country can afford, that can be used for a range of conditions?
Wouldn’t this approach
need to be adapted for a range of local conditions and areas? How much of this
can you put down in a manual?
A part of this learning here is in the classroom, but the majority happens in the ground. The way that learning happens is a key issue for us to unpack. How do you progress from the classroom to the community? And this is not just for the community, it’s for the individual.
In mental illness one size does not fit all. It’s different for malaria. Let’s take two people who come in with malaria. It doesn’t matter what they eat, what their caste is, they’d get the same medicine. This is not true for drinking problems, depression or schizophrenia—where you come from, who you live with, what you eat, your gender, caste, is going to determine the solutions, and how you are going to recover.
So we need a model of personalised care to deal with these chronic diseases. I have a piece coming up in Lancet about my mother, who has got multiple chronic diseases—diabetes, depression, cancer—the whole lot. It’s about the model of care that we have in India that for people like her, how catastrophically wrong it is, and how it is going to bankrupt us.
This is the next phase of my work, moving from a disease specific model to a health systems approach.
Do we have
classification of mental illness available for primary healthcare workers in
A very simplistic classification is one that I have in my book Where there is no Psychiatrist, and then there’s the more comprehensive one WHO is developing. But latter however needs far more simplification for it to be useful.
What I worry about is that the classifications are too heavily influenced by western models of illness. I would like to have seen a genuinely more pluralistic international system of classification.
When you are trying to create a classification of illnesses in populations you need people who work in populations, for example, public health workers. Sadly, these are very few of them in so-called 'expert' groups.
This approach requires
more people at the community level. How feasible is it economically, or in
terms of manpower?
Given that 50-60 per cent of deaths in this country are due to chronic diseases this needs to be done.
This approach only requires one more ASHA worker at the community level, and we’ve got a million of them. We could either have the same ASHA doing more for fewer households, or another one for chronic diseases. Both of these have their pros and cons. I prefer the former. Finally the decision rests with the government.
You’ve done a lot of
randomised controlled trials for conditions ranging from schizophrenia to
autism. There’s now a fair body of evidence. From this what do you envision as
the most workable system?
We are moving aggressively towards a mobile platform for training supervision and delivery. There’s a trial going on right now in Haryana and Karnataka that trains primary care facility workers in managing multiple conditions like hypertension, alcoholism etc. It’s a target-based support system so it lends itself to being monitored by this mobile tool.
This mobile platform will help us leapfrog. We already have tools like the Swasthya slate, a tablet that has 40 diagnostic tests.
I’m working on a proposal that deals with adolescent mental illnesses. We want to do this entire project: from the training of healthcare workers to supervision and case records in a format that is easily linked with specialists. We want to see how we can empower health workers with tablets. India is the best place in the world to do this.
A condition like
depression could have different manifestations in Karnataka, Mumbai and Ladakh.
In some places symptoms might be described in physiological terms and in others
in more mental terms. This demands a fair degree of adaptability in your
There is a need for flexibility in training. At the base of the pyramid mental health interventions do require cultural adaptations. The healthcare worker at the base needs that flexibility to modify, to look at symptoms that are locally important.
I do think there are some degrees of local adaptation required, but my work has shown that there’s a huge degree of commonality. Within India for example, whether you’re in Ladakh or Kanyakumari there are more similarities in the way mental health problems are expressed and understood than there are differences. I’m always surprised by how much commonality there is.
I’ve just gotten back from Zimbabwe. Talking to students in a classroom there I mentioned that few people in India know what depression is, that word is meaningless. We understand it through words like tension, ghabrahat (being scared, of my husband who drinks a lot, comes back late at night, shouts and often beats me). It is linked to peoples’ understanding of their personal lives. How is it in your country, I asked?
And every single student said that’s exactly the way it is in Zimbabwe. You go to Uganda it’s exactly the same.
What we need to have is a core architecture for treatment into which we can accommodate diversity. There is, of course, a tension between contextual sensitivity and scalability. But we have to find that balance. This is iterative, a bit of trial and error. But whatever you do it has to be scalable.
So we’re saying let’s design something that is scalable, and let’s see how far down we can go with that into contextual sensitivity. There will be a point where you will reach a degree of complexity that is not scalable, and at that point you will have to pull back.
Why not go the other
A lot of people have done that. That’s how trials have been done, and then you discover that there’s so much in common. If you look at trials of depression across say twenty odd settings you’ll find there’s lots in common, say nearly 80 per cent. So we’ve taken that common core and made that the foundation of the programme. The remaining 20 per cent is left to the discretion of the healthcare worker.
You’ve spoken about
the credibility gap in psychiatry—the expectations people have of mental
healthcare workers and what you get. What are some of the aspects of this?
There are a couple. The first is the tendency to medicalise every disturbance in human behaviour. For example today even a child with a temper tantrum has a psychiatric label attached to him. We forget that we are heavily influenced by the American system that has a very particular context: the insurance industry. The insurance industry requires a diagnosis every time a parent comes to you.
But that approach makes no sense here.
Secondly, everything is reduced to medicine. We assume that everyone with mental health conditions needs biomedical help. That is wrong.
And thirdly we assume that people who’re at the milder end of the spectrum can’t help themselves. We need to create supporting and enabling systems for self-help instead of medicalising everything.
Even neuroscientists have these concerns—they’re also questioning this highly categorical approach to diagnosis—because it has no scientific basis. It’s only based on what some psychiatrists have seen in the clinic, but that is very different from what is seen in the community. By the time someone, especially in India, gets to the clinic they only represent someone who is very sick, or is very unusual. Going to the psychiatrist is rare here; you’re not representative.
So if you base your whole approach depending on who comes at the top of the pyramid you’re bound to come up with a solution that is not meaningful that is for the base of the pyramid. We’ve got to turn the whole pyramid around and start from the bottom, then build up a classification.
When we do that we start with symptoms rather than diagnosis. Then we look at the severity of systems—that’s an approach people understand.
Have you tried to develop
interventions where the ideal outcomes are determined by the patients, and
their idea of normal?
Yes, many interventions have been developed on patient based outcomes, where we’ve asked them what they think is the most important thing they’d like to see changed. The psychosocial intervention we’ve designed is to address those outcomes. But you can’t have it so patient-led that the healthcare workers don’t know what they’re getting into.
What about the role of
the pharmaceutical industry?
There’s probably a lot of conflict of interest in research. The operations of this industry are very hidden so it’s difficult to say. Interestingly, in many part of the world the industry is not even targeting practitioners, they’re targeting patients. So there are patient groups demanding diagnosis and medicines—I wouldn’t be surprised if the pharmaceutical industry has played a role in manipulating these groups.
In some of the studies
you’ve done on community intervention the results have been equivocal. The
intervention in the schizophrenia trial worked in rural areas but not in urban
areas. Were you surprised by these results?
Some of the results were disappointing. The urban-rural disparity was because in urban areas private care is much better, it tends to address a lot of mental health needs that the public health system does not. They also have better quality of medication.
So I think the models for urban and rural areas are very different. I think we learnt one big lesson: that this model works best in areas where people only have public health care, and strong community networks. We have to go back to the drawing board to see how we can improve outcomes in urban settings.
The costs of
interventions in this trial were high—Rs 9,500 per additional community worker.
Given the success rates even in rural areas wouldn’t it make more sense to
invest in a healthcare facility based approach there rather than community
Yes, on the basis of this particular trial I would not advocate community interventions. I would advocate community-based workers for early detection and to mobilise people to go to facilities, but that’s about it. That would be their only role.
At the current stage, and given the level of investments required the results we’ve got don’t justify a total scale up.
involvement is not a blanket solution?
It does have a role in every community, but the shape of that can vary widely. The urban-rural differences are vast. In our studies in rural areas we had people coming in with severe problems who’d been to a psychiatrist maybe once in the last 10 years. Community workers have very different roles to play in these situations. In urban areas where access to care is easy, the community workers should just play an on-demand role.
In none of the trials
that you’ve done has there been room for traditional systems of medicine,
traditional healers? Why is that?
All our interventions encourage practices that people find are helping them. And very often those include religious practices. However we don’t practice these ourselves, because we’re not trained in them.
Collaborations with traditional systems and healers haven’t worked out because often they don’t want to want to practice our way of seeing things. They conceptualise what they’re doing very differently, in a spiritual-religious paradigm.
There have been lots of experiments, especially in Africa, but 30-40 years of effort has yielded nothing. There seems to be no true integration. These are people working in parallel.
You chose to set your
NGO Sangath in Goa. Why?
I love it. I love it. Everything else comes second. I’ve loved it since I was 16 or 17 when I first went there on a ship from Bombay as a medical student. My heart was set on living in Goa. So much so that I contrived to spend the last year of my medical training in Bombay in Goa, since medical college there came under Bombay University. I was convinced that I’d never leave Goa. As luck would have it, I got a scholarship to go to Oxford.
But I knew I wanted to go back. So I followed my heart. Everyone told me I was leaving the best medical school in the world to go to a backwater. It was a backwater, it's still is a backwater when it comes to medical work, but it’s my home.
There were pragmatic reasons also. It was the last phase of my medical training in India. I knew the medical school very well, so when I did want to come back I got a letter of support for my research grant very quickly.
Secondly, I didn’t want to work in Bombay because I knew I’d be subject to the psychiatric system. I wanted to work in a place where there weren’t many psychiatrists, and there was a semblance of a rural area where I could test some of the ideas that I was developing in Zimbabwe.
In the early 1990s I couldn’t have gone to a place like Bihar or Vidarbha where there was no medical infrastructure; nobody would even countenance projects like mine. I would have been laughed out of there. In Goa things were different—they’d moved beyond infant mortality but there were issues like alcoholism to deal with.
You mention that in
Zimbabwe there was a shift in your thinking, from 'cultural' psychiatry to
public health. Any significant shifts since then?
There’s been one major shift since then, which is still evolving. Some of my colleagues are worried about this. I’m beginning to review my early rejection of neuroscience as an influence on public health. I now see some credible parallels between how neuroscience is rethinking mental illness and the community perspective on mental health. It’s really quite peculiar.
The descriptions of mental illness that come out of the community approach are very similar to those from neuroscience, like the descriptions of fear associated with anxiety disorders.
Another great example is early child development on the role of stimulation in children. We know that children who’ve had parents playing with them in first six months of life do better than those kids who have not had stimulation. Had we known the neuro-scientific basis for this we would have been able to advance the field much earlier.
Now we know that the brain in a newborn child is a very plastic, it responds very quickly to the environment. When you stimulate a child the brain develops more neurological connections.
Had we know about neuronal plasticity we would have been able to design interventions a long time ago to stimulate the brain. We’re running a big trial in Haryana to test this.
This can help us shape policy interventions. By looking at how the environment shapes the brain, we can look at modifying the environment. In this particular case, it can help us make a recommend making six months of paid maternity leave mandatory. And we can back it up with science, not just saying that it would be good to have the mother around. This is fascinating stuff.
I’m hoping that 'global mental health' is increasingly going to work with neuroscience in a two way learning process to understand mental health problems and design interventions. This is my next phase of work, I have no proof of concept.
How will this be a
Most of the neuro-scientific work that has happened so far has taken place in five per cent of the worlds’ population. The only way I think you can understand the human brain is by looking at diversity, different contexts, cultures etc. Working in countries like India affords us great opportunities in basic neuroscience; and basic neuroscience gives us great opportunities to design better interventions.
What are the questions
in global mental health that you’d like to be able to answer in the next few
How do we detect these conditions and diagnose them in low resource settings? It’s a real challenge. At the moment we rely on symptom checklists for common disorders or other complex diagnostic algorithms that are used for conditions like schizophrenia, dementia, etc. Those are not scalable. It’s difficult to train community workers for those.
Even the detection systems that we have right now are not particularly sensitive; if a patient sits quietly in a corner they go undetected. A lot of people with no problem get referred, and a lot of people with problems are ignored.
So how do you diagnose people? That’s the first area that I’d like to work in. Neuroscience has an important role to play here. We’re developing a platform with partners like the National Brain Research Institute to see how we can take a basic understanding of say autism and translate it into tablet based tests.
Second area, the management of emergencies. The most visible end of mental illness in our society is the person lying on the road. He could be psychotic or severely drunk—we have no humane mechanisms to treat these sick individuals.
I continue to work with different populations. One of my current programmes works with adolescents, the highest suicide risk group in India. We’re looking at how we can develop behavioural and psychological interventions for them.
You talked about Abhay
Bang as an influence. Other major influences?
I am very inspired by the treatment action campaign for HIV AIDS in Africa. The South African story has been one of the drivers of global mental health. It was a truly global movement: there was the big, mean multinational corporation that was denying drugs; the president of the US trying to pressure the South African government not to buy drugs from India; and there were civil rights groups from all over the world. It was an incredible partnership between HIV/AIDS groups, scientists who showed that these drugs worked, and public health groups that said they could deliver these drugs and had infrastructure for monitoring.
In some ways my engagement with mental health is also about a movement—in working with people with mental issues, families, governments, across disciplines—to create a coalition of people who agree that something needs to be done now.
We’re bound to make mistakes. I have made mistakes, and I have course corrected, and I intend to continue making mistakes because that's the only way you can learn and keep improving.
Some people see you as
a crusader, often a pejorative term in academia. Do you have a problem with
No, I’m very passionate about mental illness. It troubles me a great deal that we have academic discourses on culture and psychiatry in academic institutions around the world when tens of thousands of people of people are suffering appallingly. This is a global emergency. It amazes me that there are academic debates about cultural psychiatry when there are thousands of people chained in their own homes, even in India. I have no patience with this.
That 'we shouldn’t do anything until we understand the ethnography of mental illness'—that is classic ivory tower philosophy. Please understand the ethnography of mental illness, but don’t stop me from doing something now for the person who is suicidal, psychotic, having seizures. Don’t stop me now because I’m in a rush here.
I’m a psychiatrist and I believe in the power of psychiatry in offering amazing interventions. I want to make sure that those who can benefit get it. So I’m a crusader for that.