Yet the poorest countries also have the fewest mental health professionals. According to the World Health Organization (WHO), only 1-in-4 people in the developing world have access to a psychiatrist, psychologist or psychiatric nurse. In the lowest-income countries, which are also those most likely to be wrecked by war and food shortages, there can be as few as one psychiatrist for every two million people, the WHO found. Most mental health specialists work in cities, leaving remote and rural areas bereft of any support.
“In mental health, human resources are essential. We don’t have equipment that can replace human treatment,” explains Ricardo Araya, codirector of the Centre for Global Mental Health, a collaboration between the London School of Hygiene & Tropical Medicine and King’s College London, both in the United Kingdom. “So we have to use the people who are available, providing support and training to doctors, nurses and healthcare workers.”
To achieve that, the WHO created the Mental Health Gap Action Programme in 2009, which includes guidelines to help general doctors and nurses identify and treat mental, neurological and substance use disorders. Their training includes depression, anxiety, epilepsy, psychosis and autism.
“In some places, mental health problems are seen as spiritual problems, involving witchcraft or possession”
Peter Hughes, University College London, United Kingdom
But mental and neurological diseases are poorly understood in many parts of the world, and the associated stigma discourages people from seeking help, says Peter Hughes, a consultant psychiatrist based at University College London, United Kingdom, who trains health workers around the world for the WHO using the Mental Health Gap guidelines.
“In some places, mental health problems are seen as spiritual problems, involving witchcraft or possession,” Hughes explains.”
Sometimes, mental health patients can be taken to private hospitals and subjected to cruel traditional healing methods involving forced restraints and denial of food or water. Last October, campaigners Human Rights Watch published a review of neglect in private mental healthcare in Somaliland, an autonomous region of Somalia. 
“Only the people who have the money and the resources can make their way to the town and get good treatment for their relatives,” Hughes says.
In India, awareness about mental health is rising, says Maneesh Gupta, a consultant psychiatrist in New Delhi. But local governments still make little effort to understand causes of mental health disorders, which affects available treatments, he explains. “Everyone sees it as a social issue,” he says.
Extreme situations such as war, natural disasters and displacement can compound shortages of mental health professionals. These drastically reduce treatment options, forcing communities to deal with mental illness themselves, says Peter Ventevogel, the senior mental health officer with UNHCR, the refugee agency of the United Nations. He describes how devastating this can be for the patient.
Tapping into primary care
Ventevogel notes that medical care and medication are essential to treat some mental health disorders, like epilepsy or schizophrenia. But for problems such as depression, many general doctors in developing countries —who often see up to 200 patients a day — lack the time to provide the support the patient needs.
“Every psychiatrist who has been to Sub-Saharan Africa will tell you about people who have been tied to a tree... and being neglected”
Peter Ventevogel, UNHCR
“Every psychiatrist who has been to Sub-Saharan Africa will tell you about people who have been tied to a tree, very disturbed, aggressive, self-neglecting and being neglected.” And yet a short spell of drug treatment would help many, he says.
This is something the developing world has started to pick up on. Many countries are using the WHO Mental Health Gap guidelines to train primary healthcare providers to spot and treat mental health issues.  In Sri Lanka, where there are only about 50 psychiatrists for the country’s 20 million people, the programme is used to train doctors in communities displaced by war or disasters.
“The health system is strong in the country, but the mental health [system] is lagging behind,” says Chesmal Siriwardhana, a public health professor at Anglia Ruskin University in the United Kingdom, who trains doctors in Sri Lanka about mental health conditions. Siriwardhana is expanding the Sri Lankan programme to include nurses, midwifes and public health officials. “They are the point of contact with the community. They visit people. They can identify those with mental health problems even if they are not looking for help with that,” he says. “These health workers can also help to reduce the stigma associated with mental health.”
An alternative solution is to train laypeople to help each other. In Zimbabwe, the Friendship Bench project uses lay health workers called ‘community grandmothers’. These grandmothers (older women play an important role in supporting their communities) are trained to provide cognitive behavioural therapy — a form of therapy that aims to change thinking patterns — to people with HIV/AIDS who are depressed or have other mental health problems. This talking therapy takes place on benches in the grounds of a health clinic, and is free for patients.
The treatment involves six sessions of 45 minutes, including a home visit and, if needed, referral to other health or social services or to career centres. A study of the project, due to be published later this year, found that only around 1-in-10 people who received treatment were still depressed after six months, compared with 3-in-10 of those who got none. The success of the initiative means it will be rolled out to 60 primary healthcare clinics in Harare and two neighbouring cities.
In Pakistan, a similar strategy is being used to help children with intellectual disabilities and autism, and their families. According to the latest research  such disabilities affect around seven per cent of children in the country, or more than 13 million individuals. But most are not treated because of discrimination around mental disability and a lack of knowledge about such diseases among healthcare workers. This is why Pakistan’s Human Development Research Foundation (HDRF) started the Creating Family Networks project, which is funded by the health ministry.
“I can see myself that mentally ill people are more likely to get treatment now than they used to.”
Peter Hughes, University College London, United Kingdom
The programme trains the parents (usually the mother) of children with mental disabilities in proper care, and provides supervisors to give continued support. Then each trained ‘champion’ educates other families who are in a similar situation, explains HDRF assistant director Usman Hamdani. According to Hamdani, this helps reduce stigma in the community and encourages people to seek treatment for their children.
“For the mothers, it’s a game changer,” says Hamdani, as the programme not only improves the lives of their families, but also helps others around them. “Each champion creates a network of about five to seven families.”
Another way to extend the reach of health workers is through technology. In Brazil and Peru, a pilot project called CONEMO uses a smartphone app to treat depression in people with chronic diseases such as diabetes and high blood pressure. The app sends them messages, videos and activities several times a week, and health workers can monitor patients’ activity.
A soon-to-start project in Brazil will provide community health workers with tablets and apps in the shape of games, animations and activities to treat depression in elderly people. Health workers carry a tablet with them on home visits, says Araya from the Centre for Global Mental Health, who is involved with both projects. “They identify patients who are depressed and can benefit from the app.” Ventevogel of the UNHCR adds that mobile technologies can be valuable for supervising local healthcare workers — especially when few local experts are available. “In Chad, for example, there are no specialised nurses and one psychiatrist in the whole country,” Ventevogel explains, so remote supervision and provision of long-distance training is essential.
However, Hughes from University College London says technology also has pitfalls. Although mobile phones are popular in the developing world, people frequently change number, making it hard to keep track of patients and staff, he says. In addition, poor phone reception and internet access haunt rural areas, where mental health training is needed most, he says.
But when it comes to training mental health professionals, even the smallest effort can do a lot of good, Hughes says. In Somaliland, the Mental Health Gap guidelines have been included in the curriculum of medical schools, along with online training from the WHO.
“And the situation has definitely improved,” Hughes says. “The doctors have a better knowledge of mental health. I can see myself that mentally ill people are more likely to get treatment now than they used to.”
This Spotlight article features a researcher from INASP’s AuthorAID programme.
This article is part of our Spotlight on Mental health matters.
References “Chained like prisoners” abuses against people with psychosocial disabilities in Somaliland (Human Rights Watch, 25 October 2015)
 mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings (WHO, 2010)
 Prevalence and associated impairments of mild mental retardation in six- to ten-year
old children in Pakistan: a prospective study (Acta Paediatr, 2002)