By Bibhav Acharya, Mental Health Advisor at Possible and first author on the publications referenced in this column, with co-authors David Citrin, Affiliate Instructor of Global Health at UW and Scott Halliday, Program Coordinator of the UW Nepal Studies Initiative.
Mental health care in low-income countries is in bad shape. If you have severe mental illness and can’t get to the only public psychiatric hospital, you may be chained to a tree next to your home. If you are a psychiatrist, you may be racing against time to get through 100 patients a day. If you are an officer at the Ministry of Health, you have only 0.7% of the total health budget to tackle the number-one cause the chronic disease burden.
After we built a hospital in rural Nepal, we wanted to integrate mental health services and quickly faced this fundamental question: can you cost-effectively expand access while maintaining quality? If you train generalists in all corners to provide mental health services, it might be cheaper than hiring a psychiatrist, and you may be able to reach the person chained to the tree but how do you make sure that the care is of high quality? Conversely, if you hire a psychiatrist to directly treat patients, you may improve the quality of care, but how do you keep costs low as you try to cover all the patients? We found ourselves trapped within the fabled “Iron Triangle”.
Thirty years ago, a team at the University of Washington recognized the same fundamental problem and developed the collaborative care model (CoCM). The scale of the problem is substantially higher in rural Nepal—the nearest psychiatrist is 14 hours away, and the average income is 50 cents a day—but the basic principles are just as relevant: train all the generalists in evidence-based care, recruit on-site care managers, modify treatment to meet specific clinical outcomes, and hire a part-time psychiatrist to review the treatment plan for all patients. Generalists expand access, the psychiatrist maintains quality, and studies have shown that the program is cost-effective. We seemed to have found the model that could achieve the “Triple Aim” in rural Nepal.