Raymond Aborigo, PhD, right, briefs one of our community health nurses on our mental health/high blood pressure care plan.
Every May, as we recognize Mental Health Awareness month, the global implications of ignoring mental well-being continue to grow. As early as 1953, the head of the World Health Organization declared that “without mental health there can be no physical health.” Vikram Patel, a psychiatrist who transformed global mental health by demonstrating that even lay people can provide effective therapy for depression and anxiety, said the same 15 years ago.
In the intervening decades, we have learned ever more about how depression and isolation make cardiovascular and other chronic disease worse—and, conversely, how those chronic illnesses can worsen mental health. The United States Surgeon General, for example, has declared that loneliness is therefore now a public health crisis.
But worldwide, due to a shortage of health workers, funding, and political will, we remain far from interrupting this vicious cycle.
Globally, depression is the leading cause of disability, whereas cardiovascular disease is the leading cause of death—so the two go hand in hand. Some four to six percent of the world lives with depression, and as many as 30 percent of adults live with high blood pressure and other heart diseases.
There is some good news, however: We know that simple behavior counseling can treat both diseases and others—not just one at a time, but together. For example, behavioral activation therapy for depression, pioneered by Dr. Patel and others, can also treat tobacco, alcohol, and other substance misuse—a major risk factor for heart and lung disease, cancer, and countless other chronic diseases. Conversely, motivational interviewing, another simple peer-counseling technique, can help those with chronic illness to stick to their medications, and enhance the impact of behavioral activation on depression.
In partnership with our colleagues at the Navrongo Health Research Centre in Ghana, we therefore developed and piloted a program—called COMBINE—in which community volunteers provide a single counseling intervention to persons living with depression or high blood pressure.
Combining behavioral activation and motivational interviewing, this home visit initiative offers strategies for improving mood, embracing healthy activities, and taking medication daily. Nurses and physician assistants support participants by providing primary care at clinics within walking distance. After 90 days, 93 percent of participants remained in the program, and 97 percent of them achieved control of their condition. In time, we aim to expand this program to include persons with other chronic conditions, like diabetes or asthma.
We hope to ensure that all persons with chronic disease have access to mental health counseling, regardless of depression or other mental health diagnosis—and that those living with mental illness can learn how physical exercise and other healthy actions can help improve mental health.
Despite the practical benefits of integrating mental health into chronic disease care, these care models remain underfunded and underused. Yet as more research shows how and why such programs work, we now have a playbook for how to change that. The road map includes using evidence-based treatments; reducing mental health stigma through community outreach; creating effective but simple measures to track patient progress; and recruiting respected community members to deliver care. Implementing these seemingly simple components requires ongoing efforts from national policymakers and local leaders.
The details will differ across communities, but the strategy grows clearer yearly even as the need for action expands in tandem. Mental health care is an ever-bigger part of health than we realized—but with timely action rooted in health research, that means it can also be a central tool in achieving primary care for all.
Evan Alvarez, MA, MS, is a Program Coordinator with the Arnhold Institute for Global Health and the Department for Global Health and Health System Design at the Icahn School of Medicine at Mount Sinai.
David Heller, MD, MPH, is an Assistant Professor at the Arnhold Institute for Global Health and the Department for Global Health and Health System Design and co-director of the Arnhold Institute’s global partnership in Ghana.