Mental Health Conversation with Dr. Shekhar Saxena

Countries with great resources And those with very few have at least one major challenge in common: the need to meet the growing demand for mental health care and improve brain health at the population level. Globally, the unmet need for equitable, high-quality prevention and treatment resources has led to a high level of disease burden from mental, substance use, and neurological disorders. A constant stream of global crises – armed conflict, natural disasters and the COVID-19 pandemic – has left more people than ever feeling stressed, anxious and emotionally vulnerable.

Shekhar Saxena, MD, has dedicated his professional life to improving brain health around the world. He worked for more than 20 years at the World Health Organization (WHO), serving as director of the Department of Mental Health and Substance Use for eight of those years. He is currently Professor of the Practice of Global Mental Health at the Harvard TH Chan School of Public Health. He advises policymakers, researchers, and practitioners around the world on how to promote better systems for the prevention and management of mental health, developmental, neurological, and substance use problems.

Saxena recently sat down for a chat with Kana Enomoto, director of brain health at McKinsey Health Institute, and shared her definition of health, why mental health is a borderless issue, actions that could improve health outcomes mindset and the importance of adopting innovative approaches. The following is an edited version of her conversation.

Kana Enomoto: Shekhar, thank you so much for joining the Health Conversations series. It is inspiring to see what he has accomplished in mental health and beyond over the course of his career. Given his experience as a world leader in health policy, why is it important to adopt a broader, more holistic definition of health and how physical, social, and spiritual health are connected to mental health?

Shekhar Saxena: I worked for many years for the WHO, which defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 This definition encompasses the interconnectedness of health, a concept that goes go back to ancient cultures. It is important that we return to this holistic and integrated concept of health instead of taking each component separately. The inclusion of spiritual wellness is also quite important because it fits well within the concept of health and wellness.

I also feel that modern medicine has focused on disease causation and finding solutions. This has been extremely helpful and has saved millions of lives, but there is also an unintended consequence: losing sight of the whole person. We need to get back to the interconnectedness of the various aspects of health and wellness without losing the details of each of them.

Kana Enomoto: As we work to take a whole person approach to health, help us understand why mental health is a global issue and what we can learn from each other.

Shekhar Saxena: During my time at WHO, I had the opportunity to interact with professionals in more than 100 countries. I learned that when it comes to mental health, all countries are developing countries, including economically developed countries like the United States. Every country is trying to improve the mental health of its citizens; the starting point is different, but the direction and destination are the same.

In parts of the world that are poor in resources, there is an urgent need to innovate so that they can serve more people and provide quality care because business as usual is not working. But the flow of knowledge, data, ideas and innovations must be multidirectional. Mental health knows no national borders. We all need to learn from the experience that is accumulating around the world.

Kana Enomoto: When we think of mental health as a global issue without borders, who are the critical stakeholders?

Shekhar Saxena: The main stakeholder of brain and mental health is us as individuals, because it is something that we all must cherish, protect and preserve. But health systems, governments, the nonprofit sector, business leaders, and of course mental health professionals are important stakeholders. Unfortunately, they tend to think of their role not in association with others, but in isolation, and that is a waste of resources and energy. People with lived experiences of mental health problems are important stakeholders, but we often forget about them. They have knowledge based on experience and can go a long way in planning services that meet your interests and needs. We need to include them in our conversation at all stages.

Kana Enomoto: Do you see different winning strategies for engaging people with lived experiences in different cultures?

Shekhar Saxena: Some groups in high-income countries have focused too much on the right to refuse treatment, while many other groups in low-resource countries and cultures are still seeking better care, or at least some care. I see it as an integrated agenda. People must have the resources to seek help when they need it. And, of course, they need the right to decide what they can and cannot access.

We can expand care by making every health worker a mental health worker. This means training all health professionals in the essentials of brain health so that they can diagnose and treat mental health problems, at least to some extent.

Shekhar Saxena

Kana Enomoto: Are there some critical actions that you think would dramatically improve mental health outcomes on a global scale?

Shekhar Saxena: We can expand care by making every health worker a mental health worker. This means training all health professionals in the essentials of brain health so that they can diagnose and treat mental health problems, at least to some extent. We know that most health care providers have very rudimentary knowledge, or sometimes no knowledge at all, about brain health and behavioral health, and as a result, these conditions go undiagnosed and untreated. I don’t want to say that all health workers become psychiatrists, but they can do a lot to improve mental health outcomes.

In fact, this will help improve not just mental health care but all medical care because those providers will provide better care overall. Countries can adopt policies that involve a greater focus on brain health in pre-service training as well as in-service training, ensuring that all health care providers have at least basic capacity to deliver this care. This will be fully in line with a holistic definition of health and the principles of universal health care.

Kana Enomoto: Do you see other innovations that could help overcome labor shortages and help meet the growing demand for mental health services?

Shekhar Saxena: We know that there are not enough mental health professionals to provide the care we need globally, especially in most low- and middle-income countries. The ways that we have expanded care are not working, so we really need to think outside the box to find solutions for high and low resource settings. Studies have shown that trained teachers and even laymen can provide mental health support and basic psychological interventions. There is a lot of experimentation going on around the world. Middle-aged women in Africa were trained to provide care to their peers. Educators have been trained to screen for mental health issues in schools and colleges. Another approach is to use more digital channels, which have helped tremendously during the COVID-19 pandemic, to provide telehealth services for mental health.

Kana Enomoto: How is the global mental health community responding to trauma associated with COVID-19, global conflict, climate change, and other crises?

Shekhar Saxena: Mental health has always been important, so it’s not like it’s suddenly become more important. Rather, it is that awareness and evidence of effectiveness have increased substantially. Obviously, some people are affected much more than others by all these global crises. But needs across the board are also increasing, and service capacity has either stayed the same or shrunk. The gap between what is needed and what is available has widened. It is timely that we talk more and do more about mental health in our countries and communities as we prepare to face even more crises in the future.

I would also like to refer to the impact of all this on young people. We thought, when the pandemic started, that the mental health of older people would be the most affected. And that has been shown to be completely wrong. It is the young adults, who are finishing their education, entering a job or hoping to establish a family, who are the most affected. This will affect them throughout their lives, so we need to be very careful about providing the kind of ongoing support these young people need within the community and the health care system. These are urgent priorities.

It is timely that we talk more and do more about mental health in our countries and communities as we prepare to face even more crises in the future.

Shekhar Saxena

Kana Enomoto: How do you see us addressing the needs of today’s young adults, Generation Z, who might be different from previous generations, such as millennials, Gen Xers, and baby boomers?

Shekhar Saxena: We must ask them what they need, of course, but there are a few other things to remember. First, we must provide the full spectrum of care, with much more emphasis on prevention, protection and promotion of mental health than on treatment. Second, this generation is already much more open to talking about their mental health than people my age, for example, and we need to guide them to take care of themselves and help others. These are non-clinical interventions that are going to be much more useful to you than standard clinical ones. And third, we need to deliver these types of interventions where people are because they are unlikely to visit a clinic. We need to look at how to support mental health at school and in the workplace in a non-stigmatizing environment. Resources for youth mental health care will have an excellent return on investment.

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