We’re the Partners In Health Mental Health team, we’re here to answer any questions you may have for mental health awareness month.

Hey I support PIH through John & Hank Green and their efforts to fund a maternal centre of excellence in Sierra Leone! Do you have plans for more mental health care in that country?

In Sierra Leone, starting in 2018, we have rebuilt the oldest psychiatric hospital in Africa, opened in 1820, in Freetown. In a country of 8 million people, with 2 psychiatrists, we have started a new psychiatry residency program that was last year accredited by the West African College of Physicians. Separately, but linked, in Eastern Sierra Leone, in Kono, and linked to Koidu Government Hospital, we have developed a continuum of mental health care that includes a range of providers. They go into the community and work with people directly. The heart of this work is non-specialists, that is, community members who provide support at a household level. We are excited to continue this commitment!

Learn more: https://storymaps.arcgis.com/stories/f133e3f4f4a64710ba559944eb10777c

In my state (WA), at minimum, there's maybe one assisted living facility for disabled who aren't seniors or have 'severe' developmental disorders. Its where I currently live, and despite having autism, I didn't qualify for other facilities because I'm literally too smart. The only other place we could go is possibly a group home, which wouldn't afford the same dignity.

IMO, us 'low care' mentally disabled who aren't seniors are an under-served, under-acknowledged demographic. We can't live on our own, or hold a job, but are too, ahem, 'high-functioning' and young to qualify for anywhere else. I suspect many like us are homeless in the streets, even.

Can I get your opinion on this?

We must solve the mental health systems crisis in the US! We are so sorry that you are experiencing this challenge.

What are your thoughts on self-screening and an apparent trend in self-diagnosing mental disorders? If someone is using a self-screening tool, what's the most realistic call to action beyond their results page?

I work in public health in Missouri, and we're kicking into high gear with mental health programming. I appreciate the time you're taking to do this! It's so important to talk about how we can increase access and decrease stigma!

Self-screening for a mental health condition using validated scales could be one way that someone can begin to describe what is happening in their lives. It would be important for people screening positive for any mental health condition to be linked to care and to be able to access professional evaluation as a follow-up. This is much easier said than done given the limitations in mental health care availability and delivery across the US and in other settings. Across our Partners In Health sites, we focus on building human resource capacity among both mental health providers and non-specialist providers to deliver care in places where there are few mental health resources. 

Learn more: https://www.pih.org/mental-health/program-planning-and-clinical-guidelines-development

Do you have any advice for the parent of a 13 year old girl in these modern times? It seems like a desire for a diagnosis or ailment is ubiquitous amongst her friend group and many others. She likely does struggle with ADD and we are taking action on that front.

I just want to fix everything wrong with her and while she has started counselling, anything suggested she works on just feels like more work and stress. She's overwhelmed by school a lot of the time.

Thank you for this question. Parenting is a challenge for us all!  First and foremost, a thorough mental health evaluation can help you to sort out whether there is ADHD, anxiety, depression or something else happening. The US Surgeon General also came out with useful guidelines for social media. The advice I keep hearing from others is to keep the dialogue open. Keep having conversations and discussions about things that matter to your child. Try to be present as best you can, in order to connect frequently and with quality on your child's terms.

Do you know of any mental health trainings accessible to the general public? I am aware of psychological first aid and emotional CPR, for example, but I'd welcome your thoughts on these, as well as any other courses, trainings or certifications you might recommend for someone looking to deepen their own knowledge of the field.

Psychological first aid and mental health first aid trainings are great first approaches to learning about mental health. There are multiple trainings available to the public. Here are a few links:

https://www.coursera.org/learn/psychological-first-aid

https://www.futurelearn.com/courses/psychological-first-aid-for-children-and-young-people

https://www.mentalhealthfirstaid.org/population-focused-modules/teens/

https://www.mentalhealthfirstaid.org/population-focused-modules/youth/

https://www.mentalhealthfirstaid.org
https://www.who.int/publications/i/item/9789241548205

Following natural (or manmade) disasters, what are the most effective mental health support strategies for children, teenagers, or young adults to minimize long-term effects?

We have so many events worldwide (war, political violence, earthquakes) and often talk about the physically injured, but I wonder what support we can/should advocate for to ensure survivors feel whole.

Helping children and young people in the face of disaster is critically important. Here is a link to psychological first aid strategies for children and young people, which can be a good starting point. https://resourcecentre.savethechildren.net/collection/save-children-psychological-first-aid-training/

Are personality disorders (specifically cluster B's like sociopathy, narcissism, bpd) considered the same as a mental illness? How are treatments for said disorders similar/different from other common mental illnesses (like depression, bipolar, etc)?

We think of mental health along a spectrum from well-being to distress to disorder and disability. This is a public health approach. We think about health promotion and prevention when thinking about well-being and distress. We think about treatment and care when thinking about a disorder. In the US, where personality disorders are diagnosed, they can be considered a disorder if they impact functioning and cause distress to a significant degree.
In the diagnostic and statistical manual of mental disorders, personality disorders are defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Treatments for personality disorders are complex and can include more significant psychotherapy as well as medication. Usually, the treatments take a longer period of time to work. 

Are there any concerted efforts in the mental health field to help family members who may be living with and trying to help manage those suffering from mental illness?

In my experience, families often suffer tremendously when living with those with mental disorders, even when those with the disorder are receiving therapeutic interventions. Counseling for family members might not only help family members to cope but ultimately, possibly by reducing stress and improving family interactions, help the member of their family directly disabled by mental health challenges.

It is true that family members often suffer terribly when a family member has a mental health problem. There are some national organizations such as NAMI, Al-Anon and others which focus on helping caregivers and supporting family members in their ongoing journey to help their loved ones. There surely need to be more resources available to help families and caregivers.  

Across our PIH sites, we work to support families and caregivers for people living with mental health problems including programs that address socio-economic stressors, home visits and other psychological supports directly for family members 

Link for NAMI: https://nami.org/Support-Education/Support-Groups/NAMI-Family-Support-Group

Working across all these different locations, what is something your team has learned has been helpful in supporting mental health?

We’ve learned that collaborative, comprehensive, community-based care can be delivered in resource-limited contexts for people living with complex problems related to mental health. We’ve learned that mentoring and supporting people in delivering care is really important, including paying community health workers. We’ve learned that people living with mental health concerns benefit from social support and care as well as “treatment”. We’ve learned that mental health remains sorely underfunded across all countries and contexts. We’ve learned that effective mental health care strengthens health systems and communities. With climate change, human migration and other coming challenges of the future, we’ve learned that integration mental health outside of health systems, in communities and other sectors, will be essential in enhancing societal resilience. 
AND we've learned that most people feel and get better, and quickly, with mental health care!

Do you have any tips to support my mental health? Asking this more because sometimes life gets tough with work, bills and the news on TV.

When COVID-19 hit we developed 10 tips for the situation. Most of these tips still apply today. Here they are: https://www.pih.org/article/10-mental-health-tips-coronavirus-social-distancing

What can one do to deal with extreme anxiety?

It is helpful to know what kind of anxiety, specifically, in order to develop a comprehensive treatment plan that factors in biological, psychological, or social factors contributing to the problem. For example, generalized anxiety, panic disorder, social anxiety or obsessive-compulsive disorder all look and feel different, and have different approaches. Evidence-based psychotherapies, such as Cognitive-Behavioral Therapy, delivered by a mental health professional, can be an important first step. Some people benefit from medication also, which might require an evaluation by a psychiatrist. Starting with a primary care physician can also be a first step in accessing care, if that person is available. 

Relaxation and mindfulness techniques can also be helpful in reducing anxiety. However, sometimes it may not be enough.

Thank you all for asking your questions, we're hoping off but here are some resources if you want to learn more, have any questions, or want to stay up to date:

Learn more about work - PIH Cross-Site Mental Health Program

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How does PIH go about building comprehensive, community-based mental healthcare delivery systems? Do you start in one location (with more comprehensive services) and build out, or do you start distributed across a larger area (with less comprehensive services) and build up? I’m curious to hear what the process looks like, from initial planning stages to fully functioning mental healthcare systems. Thanks!

Separate from mental health care, we recently heard one of PIH's founders, Dr. Jim Kim, speak to the legacy of Dr. Paul Farmer on the anniversary of his passing.

Dr. Kim described:

1) a preferential option for the poor;

2) the highest possible quality of care for those who need it;

3) be truly present with the suffering of others;

4) "accompaniment" as the core of clinical and social innovation;

5) the "hermeneutic of generosity"- always assume the best intentions in others;

6) start with a single patient or program and then go;

7) invest in students;

8) commit to communities and stay the course;

9) build systems (and support staff, stuff, space and social support).

These ideas were helpful to us 15 years ago as we were starting to get going. HIV and TB care had strengthened the primary care systems within which PIH worked through the 1990's and early 2000's. But there were few formal mental health services.

We started by building small systems out of disasters: the 1994 Rwanda Genocide Against the Tutsi, the 2010 Haiti earthquake, the 2014-16 Ebola crisis in West Africa, and a number of other crises. We used these situations as opportunities to strengthen mental health support. We collaborated closely with our site based leaders to build out systems. We supported the professional development of committed, local providers. We took care of the sickest people, initially. We showed that people could get better. We collected data and measured outcomes. We adapted the concept of a health care delivery value chain, published by Farmer, Kim and Porter in the Lancet in 2013, and built out a value chain for mental health car delivery that we felt reflected the realities of where were were working. But really, we started small, as our team is small, and there are few providers.

We've tried to be responsible in not growing work too fast, beyond the capacity of the individuals providing care to meet the very significant need. Here are some resources that might build out your explorations on this topic.

Here are some links to learn more:

https://www.pih.org/MHMatrix

https://www.cambridge.org/core/journals/global-mental-health/article/expanding-mental-health-services-in-low-and-middleincome-countries-a-taskshifting-framework-for-delivery-of-comprehensive-collaborative-and-communitybased-care/43537788DF743160294EE33C618B4D9F

https://pubmed.ncbi.nlm.nih.gov/32180989/

https://pubmed.ncbi.nlm.nih.gov/23697823/

https://www.researchgate.net/publication/283580084_Taskshifting_translating_theory_into_practice_to_build_a_community_based_mental_health_care_system_in_rural_Haiti

Can you please share your thoughts on the permanence of telehealth as a mental health treatment modality going forward and what obstacles you see ahead?

Also, to what end will telehealth service communities across Latin America, Africa and the Caribbean?

Thank you for your time, thoughts and the work that you do.

Telehealth is certainly here to stay and has changed so much of the ways mental health care is delivered, for the better. In the news, we have read about various problems with care being provided by people without credentials to do comprehensive evaluations, medication shortages, as well as other safety concerns, related to telehealth. Yet telehealth is certainly increasing access in many positive ways. If we want to develop person-centered care, many people prefer the convenience of telehealth as well. In many instances, however, meeting with a person in person is essential to obtain the most accurate information and to provide the best quality care. It is such an interesting time to be human, to be experiencing so much rapid social change, and to be struggling to keep up with all of the technology. (No one has asked about chat gpt yet! )

What are the biggest challenges you face in getting mental health care to people in places without strong healthcare systems? Stigma, funding, lack of HCPs? How much does your approach change by location?

Additionally, what can those of us in developed nations do to support your efforts?

Thanks for doing this AMA!

To respond to your question we encourage you to look at our Storymaps website, which details some of the significant challenges. We have a number of papers linked to that site which document the biggest challenges. We are going to turn this question on its head a bit. Would that be ok? In the US there are 42,000 psychiatrists (we hear) and last year 42 percent of people in a mental health crisis could not access care. All countries are "developing" in terms of mental health care. The problem of mental health care delivery might be the biggest one that we face—how do we get actual services to people when they need them and where they need them. To support our efforts you can write to us and we can tell exactly how, as well as share with you our great gratitude. Thank you in advance for your support!

You can write to us at: [[email protected]](mailto:[email protected])