Shifa Naeem  ( Psychiatrist & mental health trainer, Karachi )

When I was asked to review “Where There is No Psychiatrist” I excitedly agreed as I had been following Vikram Patel’s work in the field of Mental Health and I have to say I was not at all disappointed.Vikram Patel is a Professor of Global Health at Harvard Medical School and works with the Public Health Foundation of India, while Charlotte Hanlon is an Associate Professor of Addis Ababa University in Ethiopia. In the preface they explain that the manual is meant for any worker in a health care or community setting who is not specially trained to work with mental health problems. This includes community health workers, social workers, primary care nurses and family doctors. Though it can be of use anywhere in the world, “it has been designed specifically to meet the needs of health workers in low- and middle-income countries and lowresourced settings of high-income countries”. As this is the 2nd edition they also describe how it builds on the 1st edition which was written over fifteen years back. One of the most important revisions that has been done is that the treatment recommendations have been aligned with the World Health Organization’s Mental Health Gap Action Programme Guidelines. Paul Farmer, in his Foreword, describes it as a ‘life-saving book’ and points out that even though it’s about disturbing behavior, sadness,grief, addiction and abuse, it’s not grim because it underlines “just how much can be done to ease suffering, fear and stigma”. The manual is divided into five parts and the authors recommend the readers to familiarize themselves with
Part 1(which is an overview of Mental Health Problems) before moving on to the others. Part 2 talks about Specific Treatments for mental health problems. Part2 takes the reader through common clinical scenarios, using a problem-solving strategy and instead of a top-down medical diagnosis-based approach, a person-centred approach has been taken. Part 4 is about Integration of Mental Health into other platforms while Part 5 lets the readers record information to localize the manual for their specific areas. Part 1 (the Overview of Mental Health Problems) provides a basic foundation of knowledge in mental health to the worker. It comprises of 4 chapters. Chapter 1 introduces a simple approach to classifying types of mental health problems seen in community or primary health care settings as ‘distress’, disorders and disabilities instead of ‘jargon-based’ categories and gives examples of each. It then goes on to discuss why mental health problems are and should be of concern to all health workers (a fact that is still often ignored in planning and implementing Health Programs especially in low-resource settings). I really appreciated the use of simple language in describing the different features of mental health problems. And instead of trying to cover all the disorders under the sun, they have lumped similar issues/problems together into just six categories. a) Common Mental Disorders such as Anxiety & Depression. b) Dependence on Alcohol/Drugs. c) Severe Disorders or Psychoses. d) States of Confusion. e) Mental Health Problems of Children & Adolescents.f) Other conditions such as Epilepsies & Suicide. These categories are very similar to those given in W.H.O’s Mental Health Gap Manual and so the two manuals can conveniently be used in conjunction with each other. The problems in each category are discussed with the help of case vignettes and ‘discussion points’ in a reader-friendly style. In addition, boxes give the main features in bullet points alongwith appropriate illustrations. This chapter includes a section touching upon different cultural perspectives on mental health. I appreciated the inclusion of “coping strategies & resources which have evolved in one’s own culture”. The chapter ends with stories of some people describing their own first-hand experiences of problems in their own words. And of course, there’s a useful ‘summary box’ at the end of each chapter. Chapter 2 focuses on Core Skills for working with people with Mental Health Problems, which are required in order to make a proper assessment and to be able to manage them in an appropriate manner. These include Communication skills & Self-care skills. (Most health workers should already be trained in these areas, but for dealing with Mental Health issues these skills need to be especially strengthened). It was heartening to see “communicating respect and preserving dignity”as the most important aspect of Communication, followed by “being warm, encouraging, empathetic and not judging the person”. Listening actively, asking questions in the right way, keeping calm, being observant, being respectful of religion and respecting confidentiality are the other components of this section. Besides tips on ‘engaging the person’, ‘keeping a professional distance’ and ‘communicating with families’. I appreciatively noticed the use of ‘person’ instead of ‘patient’ whenever anyone with a mental health problem is mentioned. This curbs the tendency to ‘label’ people and helps the reader to remember how we all are vulnerable to any mental health problem and prevents workers from falling into the ‘them and us’ way of thinking. The second part of the chapter dealing with self-care skills talks about ‘staying safe’, ‘keeping on learning’ and ‘managing stress’. This is a much-needed and practical section as it has been seen how common it is in mental health workers for Burnout to set in and other effects of Stress. This is one of the ‘blind spots’ of mental health workers. Hence the list of ‘signs to watch out for’ is most useful. Chapter 3 is about how a health worker can carry out an interview to diagnose the type of mental health problem. It starts off by removing the barriers that a health worker may experience in making such an
assessment e.g fears and lack of confidence in their own skills. They are reminded to treat a person with a mental health problem with the same respect and compassion as any other person. What is emphasized is the importance of giving enough time for this process. And how the time spent at this stage can save
time later on. A lot of important information is given in bullet form in boxes. Some myths are also dispelled e.g “the most common image of such a person is of
someone behaving bizarrely or talking nonsense, while in reality the vast majority of people with mental health problems look, behave and talk no differently
from people with a physical illness”. Suggestions are given on how to conduct the interview, what to look for and how to reach a diagnosis. Cross-referencing
has been used most effectively in the manuale.g where a suggestion is given to use good communication skills, the relevant section is given in brackets. Also, generous use of illustrations is helpful. This chapter ends with ‘symptom checklists’ of common mental disorders. Chapter 4 (the last chapter of Part 1) is probably one of the most useful in the whole manual. It is titled‘General Approach to the Treatment of Mental Health Problems’. It addresses many ways of thinking that act as barriers e.g “many people cannot understand how ‘talking’ to someone (or ‘counselling’) can be considered a treatment”. Also how tackling a person’s social difficulties can help to alleviate mental distress. Two important points are emphasized in this chapter. a) General health workers equipped with basic knowledge such as given in this manual, can treat most mental health problems and need not refer to specialists. b) There are many effective methods of treating mental health problems instead of many approaches in use, which are unhelpful in the long run e.g ‘sleeping pills for sleep’ problems. The various sections in this chapter are titled ‘Treating the Whole Person’, ‘putting the person at the centre of care’, ‘thinking beyond the individual’, ’tracking progress’, ‘taking a long-term perspective’, ‘supporting the person for self-care’, ‘working as a team’& Referral (to whom, when and how ) when needed.
Part 2 looks at the three main types of treatment modalities in detail : Medications, Counselling and Social interventions. The section on Medications quite comprehensively describes various anti-depressants, anti-psychotics, mood stabilizers and anxiolytics. Even medications to manage Opioid & Alcohol Abuse are mentioned. My concern here (probably stemming from my psychiatric background) would be about the unsupervised and rampant use by health workers of these medications. I would feel safer if these medications (both oral & injectable) were only prescribed and dispensed by trained doctors or nurses only. It would be very interesting to have a discussion with the authors on this issue. This section contains a very useful box on “Good Practices in UsingMedication” which would be useful even for practicing psychiatrists! The next section is on Counselling. A simple table highlights the difference between ‘professional counselling’ and a ‘friendly chat’. The General Principles and Do’s & Don’ts of Counselling are explained in a very clear manner with lots of examples and ‘cases’. This section contains numerous helpful tables.Some titles are ‘Issues that may arise during counselling & how to approach them’, ‘Psychological First Aid’, ‘Problem-solving’, ‘Relaxation Exercises’, ‘Getting Active’, ‘Thinking healthy’, ’Improving Relationships’, ‘Controlling Anger’ and ‘Improving Motivation’. Later on all these strategies are explained systematically in a most ‘do-able’ manner.
The third section of this Part is on Social Interventions. Beginning with general interventions, it goes on to specific social interventions like improving functioning and skills for independent living and for social situations. There is a very interesting table on ‘tackling underlying causes of poverty’ which touches upon the two-way relationship between poverty and mental health. Suggestions are given to combat stigma and discrimination. There’s a section on ‘supporting families’ where constructive ways of communication are encouraged as opposed to unhelpful ways. ‘Befriending’ and Support Groups have also been touched upon. Part 3 of the book/manual is titled “Clinical Problems” and is based on the PBL (Problem-based Learning) model. It is divided into six chapters (Chapters 6 to 11) and it becomes clear at this stage why the authors recommend going through Part 1 before coming to this part. As many of the skills learnt in Part 1 would be necessary in handling the problems/situations described here. In introducing Chapter 6, the authors say ”Chapter6 covers emergency presentations where an immediate response is required. The approach to assessing the emergency and providing intervention is laid out in flow charts which you can refer to quickly. You can copy the charts and put them up on the wall so that anyone can find them easily if they need them”. Chapter 7 covers non-emergency situations/problems e.g a person in a state of ‘confusion’ or when a person is unaware of one’s surroundings. This is followed by suggestions on what to ask, what to look for, what to do and when to refer. Similarly other situations have been addressed i.e the aggressive person, the person who’s ‘hearing voices’, the person who’s miserable and withdrawn, the person who has severe mood
swings or the person who wants to harm himself/herself. Pregnancy and Childbirth-related problems are also dealt with in depth. So are mentalhealth problems of the elderly. Throughout the chapter the format is in the form of bullet-point tables and illustrations which make it easy to find what one is looking for. e.g there is an excellent table on Practical tips for caring for a person with Dementia. Although Chapter 8 is titled ‘Symptoms that are Medically Unexplained’ and touches upon various physical complaints such as headaches, tiredness, dizziness, aches& pains ; it also discusses sleep and sexual problems. Chapter 9 focuses on problems due to habits. The habits addressed are ‘drinking too much alcohol’, abusing drugs, prescription medications and tobacco. In fact, even gambling and internet addiction are touched upon! Chapter 10 deals with problems arising from loss and violence. Using a problem-based and problem-solving approach, family & sexual violence have been discussed in detail with important do’s and don’ts. A useful portion on Bereavement is added. Chapter 11 covers problems in Childhood and Adolescence. Starting off with a general approach, tables are given of developmental milestones. After describing the problem of a child developing slowly, general guidelines are given for parents on helping their child learn daily activities (with illustrations). Other problems addressed are in communicating, in studies, ‘difficulty being still’, behaving badly and bedwetting. There’s a special section on the child who’s being abused. This has been appropriately and sensitively written and would be helpful not only for health workers but parents and teachers as well. Adolescent Depression has been discussed too, including a useful Suggestion Box for Adolescents on Coping with Stress. Part 4 deals with the Integration of the care of people with mental health problems in different settings or ‘platforms’ which have been broadly categorized as primary health care and those in the community. For integration with Primary Health Care, the authors suggest a “5 C” model i.e Collaborative, Coordinated, Continuing, person-Centred and Compassionate. Barriers to such integration have been discussed, particularly resistance from specialists who may not want to ‘share’ their role with those not having a specialist degree; but persistence has been recommended. I also believe that specialists need to learn to ‘share’ their responsibilities and focus more on ‘training & supervision’ and attending to complex cases. Suggestions have also been given on using appropriate technology. The second chapter in Part 4 deals with integrating mental health care into community platforms e.g during humanitarian crises like armed conflicts and natural disasters when large populations are displaced. The impact of such crises is greatest on communities in low and middle-income countries as they have few resources to begin with. The guiding principle suggested here is to integrate mental health with other areas e.g ensuring basic services and security, and addressing the needs of all sections of the community & involving them in decision-making and providing Psychological First Aid (described elsewhere in the manual). Suggestions have also been given on how to establish a helpful alliance with Traditional & Faith Healers. Where integrating with schools is concerned, many useful suggestions are given on how to make schools ‘healthpromoting’. Also various interventions for dealing with drop-outs are discussed. There’s a comprehensive Box on General Parenting Advice. Other areas touched upon are ‘Street Children’ and ‘Integrating mental health care in Prisons’. Prevention of Mental Illness and Substance Abuse in the Community is discussed here again, including Mental Health Promotion & Advocating for Social Change, especially in poor communities. The suggestions are simple and do-able and need to be taken seriously by Health Planners all over the world. Part 5 has been designed to localize the manual for the area in which it is to be used e.g where a quick reference guide for different medications is given, space has been provided to write local brand names & costs. All the medications given in WHO’sMhGAP formulary have been highlighted here. Another chapter gives a suggested format for recording locally available resources. The last chapter is a glossary of terms used for mental health problems and their symptoms; and space provided to fill in equivalent terms in local languages. On the whole, it’s a very comprehensive, practical manual which can be used as a basic curriculum for primary care doctors, nurses, social workers, rehab workers and community health workers for Mental Health Problems. It also needs to be read by Public Health Policy-makers.

Dr. Shifa Naeem
Consultant Psychiatrist, Karachi