Lifting the burden of mental health
In South Africa, along with many other low and middle-income countries (LMI) around the world, there is a growing burden of mental illness. There is a need to find ways of addressing this burden and building solutions that create positive changes for the future. Professor Crick Lund has taken this need to heart, pioneering the development of policies and services designed to address mental health.
Developing policies and methodologies
His scientific work has had a significant impact on the creation of norms for mental health services address the cycle of poverty. He has also played a part in the development of World Health Organisation (WHO) guidelines for mental health policy and services, as well as in identifying major social causes of mental illness in LMI countries.
New community-based care
“While I was doing my training as a clinical psychologist, I was struck by the way in which mental health services were organised,” says Professor Crick Lund, director of the Alan J Fisher Centre for Public Mental Health, department of psychiatry and mental health, University of Cape Town. “Communities with the most pressing mental health needs — those living in poverty with minimal resources — had the least access to mental healthcare.”
One of Lund’s first roles after qualifying was to become involved in a study to develop the first post-apartheid norms for mental health services for the department of health. It was also when he became fascinated with developing new community-based models of care and the health systems and policies which could make them possible.
He then became involved in international work and has been inspired by innovations in primary mental healthcare in countries like Chile, India, Brazil, Pakistan and, more recently, Zimbabwe.
A vicious cycle
“Poverty, violence and inequality are major social determinants of mental health,” explains Lund. “Poverty and mental illness interact in a vicious cycle. People living in poverty have increased risk for a range of mental illnesses through stress, food insecurity, exposure to life events such as violence, illness and loss, and a lack of resources or social safety net to protect them from the consequences of life events.”
He says that, conversely, people living with mental illness tend to drift into, or remain in, poverty because of the disability of their condition, reduced economic productivity, stigma and the higher cost of healthcare.
The Mental Health and Poverty Project
The Mental Health and Poverty Project ran from 2005 to 2010 and was funded by the UK department for international development (DfID). The consortium created and evaluated mental health policy in poor countries to provide new knowledge regarding approaches to breaking the negative cycle of poverty and mental illness.
“I was involved in facilitating policy or plan development for a number of countries, including Lesotho, Namibia, South Africa and Indonesia,” says Lund. “The content was determined by the stakeholders who participated, for example, through national consultation workshops. I think the impact these policies have had on mental health awareness in the countries has varied a lot, depending on the level of commitment from the [various] ministries of health.”
He says that there is a growing awareness among governments and international development agencies about the importance of mental health for broader social and economic development.
Lund’s interest in the key role poverty plays as both a cause and consequence of mental illness saw him lead the first systemic literature review of poverty and common mental disorders in LMIC, published in Social Science & Medicine.
He was then invited by the WHO Commission on the Social Determinants of Health to contribute to a treatise on the social determinants of depression. Lund also led an article on breaking the cycle of poverty and mental illness in LMI countries as part of the 2011 Lancet series on global mental health.
Since 2011, Lund has been at the helm of the Programme for Improving Mental Healthcare (Prime), funded by the DfID to a total of £6-million from 2011-2017. Prime is developing, evaluating and scaling up core packages of mental healthcare in primary healthcare settings across Ethiopia, India, Nepal, South Africa and Uganda.
Mental health research
Lund is the lead in a collaborative hub for mental health research in sub-Saharan Africa, Africa Focus on Intervention Research for Mental health (Affirm). It is funded by the National Institute of Mental Health.
Along with being chief executive of Prime, Lund is principal investigator of Affirm and director of the Centre for Public Mental Health. This means he now leads public mental health research across eight countries, with responsibility for a budget of more than R180-million.
“We are very excited about the new interest from governments, especially in Ethiopia, India and South Africa, in scaling up mental healthcare through primary care, linked to the Prime project,” says Lund. “Other countries, such as Fiji, Mozambique, Jamaica and Zimbabwe are interested in using our tools and experience from Prime.”
“We are putting a lot of work into developing novel, cost-effective interventions that can be used by governments and scaled up to much larger populations,” concludes Lund. “By working closely with ministries of health and addressing research questions that are relevant for them, I hope that this can benefit a much larger number of people, especially vulnerable groups such as people living in poverty.”
He is also becoming interested in understanding more about the mechanisms of poverty and mental illness cycles and designing interventions to break these cycles. Lund shows no sign of slowing down as he focuses his research on creating a better future for those suffering from mental illness.