 Welcome back everybody. I guess by now you really noticed it's a beautiful day out there. And some of you might start thinking about Friday night. Some of you have plans, exciting stuff to do. Some of you don't have plans and are totally fine with that. For myself, if I didn't have work to do tomorrow, I would really regret that I didn't have some social activity or dinner or party to go to. But for those of you who feel the same way and don't have work tomorrow or maybe you're just stronger than I am, I have the good news that we have some free tickets and seats for the meal and music arrangement event tonight at the Music Hall. If this gets you curious, you have to go to the reception in the break and talk to them about joining this evening's dinner. Pretty soon we'll have our fourth keynote. After that we will have a small exercise and after that we will have almost a one hour break. So as far as the exercise is concerned, I strongly urge you to stay in the room for just like seven minutes exercise. It's in the spirit of networking and making connections. So I really hope you will support the exercise coming up after the keynote. Our final keynote will address the very important theme of mental health and the importance of putting this on the very top of the global agenda. The title of the keynote is addressing the mental health crisis lessons of the global south. And please remember you can ask questions using Slido. But joining us now from Harvard is Professor Vikram Patel. Are you with us? Yes, I am. Can you hear me? You're with us, but we missed the sound Vikram Patel. Hi, good morning from Boston. Can you hear me? Yeah, we're working on it. Hi, can you hear me now? Vikram, I think we can hear you by now. How is spring in Boston? It's actually a very beautiful day and I wish I was, you know, with you in person, especially for your musical concert this evening. But I think like in like where you are, Boston is enjoying a beautiful spring right now. Sounds good. And we got the volume adjusted now. So we are almost ready to take it away for your keynote presentation. But before I set you off, please enjoy this big round of applause from the audience. Thank you. Thank you very much. I haven't even started giving my lecture, but thank you in advance. Please go ahead. So I hope you can see my slides. Are my slides visible to everyone there? Let me check. Is there anyone there to confirm the slides are visible? Oh, they are. Okay, thank you. All right, great. So what I'm going to be doing today is to really share with you what I think is one of the most exciting innovations that has emerged from low-resourced settings in the global south, which as you will see from my remarks, has a very important bearing, not just on how one can address the mental health crisis in the global south, but also in fact in wealthy countries. I'm not going to speak much about the nature of the mental health crisis, except to say that unlike most other health conditions, mental health problems seem to have shown no change in their prevalence or incidence over the last 50 years in virtually any country of the world, regardless of how much money that country is spending on mental health care. And one could have a great discussion on why that is. In contrast, for example, to how certainly wealthy countries, but I would say most countries in the world have been successfully able to address many health challenges, such as, for example, the challenges of cardiovascular health and cancer. Mental health somehow has not followed the same storyline. Today, what I'm really going to be addressing is one aspect of that mental health crisis. There are many aspects, of course, you know, the risk factors and protective factors, but one particular aspect of the mental health crisis is access to evidence-based care. And a particular area of care that I will focus on are psychosocial interventions. Psychosocial interventions in brief are interventions that are targeting either the psychological or internal mechanisms of mental health or the social mechanisms, the mechanisms that operate in the relationships that we have between ourselves and others in our social networks, but also the more distal social factors that influence our health and well-being. On this slide, I'm going to summarize what is really an enormous body of evidence on the effectiveness of psychosocial interventions for mental health problems. In short, as you read each of these bullet points, you will conclude that there is no individual who is struggling with their mental health who cannot benefit from a psychosocial intervention. For a whole range of mental health conditions, such as, for example, PTSD, psychosocial interventions are the first line and most effective treatment. For other conditions like depression, where there is a choice between medication or psychosocial interventions, psychological interventions have much better long-term outcomes. And for those conditions like the psychosis, where medication has a very important role, psychological interventions or rather psychosocial interventions can greatly improve upon the overall social and clinical outcomes when they are supplementing medications. In other words, everyone can benefit from a psychosocial intervention. So given this very strong evidence-based, let us pause and ask the question, what is the proportion of people with a mental health condition who access evidence-based psychosocial interventions, who receive evidence-based psychosocial interventions? And let me use the US as a case study. I use the US primarily because the US is the wealthiest country in the world, but also because the US spends the most in dollars per capita on mental health care. And the US enjoys amongst the highest numbers of mental health professionals, psychiatrists, psychologists, psychiatric social workers and so on, per capita in the world. So you'd expect, as you see for many other health conditions, that the effective coverage of evidence-based interventions should be really high in a country that is as wealthy and spends so much on specialist mental health care as the US does. It turns out, though, that when people with depression go and seek care, typically they do so in primary care, the overwhelming majority will only receive a prescription, only a minority receive the evidence-based psychological treatment. This is in spite of the fact that people with depression overwhelmingly express a preference for psychological interventions. And this is especially true for low-income and minority groups. And of course, as you can imagine, if you receive the treatment that you want, that you prefer, you're going to engage much more with that intervention and therefore you're going to derive much more of a benefit from that intervention. Now, I often do a thought experiment with my students and I'm going to do one with you today. Imagine if we were not talking about depression, but we were talking about breast cancer. And imagine we had two interventions, like you do for depression, two different interventions. In the case of depression, we have psychological treatments and medication. Let's assume we had a similar kind of choice of two different interventions for breast cancer. The equivalent of psychological treatments was just as good as the equivalent of medication when it came to remission. That is to say the breast cancer was no longer present. But the psychological treatment was associated with lower relapse rates, lower recurrence rates of breast cancer. And women overwhelmingly preferred to receive the psychological treatment for their breast cancer. Can you imagine a health system that only made medication available for the breast cancer? That, my friends, is a situation in the US today. And in fact, this is actually also true for most countries around the world. I can't speak for the country you're in right now, but hopefully the discussion will hear more about that. In the global South context, which is where 80% of the world's people live, in fact, almost nobody receives an evidence-based psychosocial intervention. And therefore, really what I would say is that one aspect of the mental health crisis is that it is a crisis of care. A crisis not of the lack of political will. A crisis not of the lack of resources. But the crisis is that we do not deliver the interventions that we know work, that people prefer to receive. And this has been beautifully documented from a very particular US point of view by Thomas Insel's recent book Healing. Thomas Insel was the director of the National Institute for Mental Health, which is the world's most powerful and richest mental health research funding body. It's a taxpayer-funded body in the US, in Tom's own words. While he was director of the NIMH for about 15 years, I think, he describes that the NIMH spent more than $20 billion on mental health research. And during this very period, every single metric related to mental health of the American people got worse. Unlike every other National Institute of Health, where investments in research seem to actually produce a dramatic reduction in the burden of that particular National Institute's health focus, not so with the NIMH. So I guess the question we have to ask ourselves is why do such powerful interventions that we've known work for more than 50 years not get scaled up? Well, there are many reasons that I've arrived at through my conversations with colleagues. The first is the hierarchies of health care, and particularly in the mental health care landscape. The biomedical or prescription disciplines, physicians, and particular psychiatrists have a much higher status. And because these higher status professionals prefer to use medication, medication will trauma psychosocial or behavioral interventions. But there are also problems to do with the interventions themselves. They are very complex. There are hundreds of different packages. Every group seems to develop their own particular package. Because they're very complex, they're very difficult to learn, and one has to go through many years of expensive higher education to learn these interventions. Ask any clinical psychologist, and they will tell you. And similarly, then you have professional skills, just like the skills for physicians and psychiatrists, you have skills for psychologists, which will resist allowing anyone else to be licensed to deliver these interventions. Because these interventions were largely developed within very specific laboratories of people working in university settings, mostly in the US and Britain and a few other countries. There were questions about whether these observations, which were really reflecting the psychological mechanisms that these academics were making, could apply across cultural settings. But I think the real elephant in the room is the fact that there is no money, there's no commercial incentive in the scale up of psychosocial interventions. As I argued in a recent commentary in the Lancet, if psychosocial interventions could be packaged into a pill that could be manufactured and sold under a patent agreement by a company, they would be the single most widely used intervention in all of mental health care, maybe all of health care around the world today. But because psychosocial interventions can't be packaged as a pill, pretty much no one is actually profiting from their wider scale up. So I'm going to turn to the opportunity. And the opportunity comes from, again, an initiative that Tom Insil, while he was director of the NIMH, launched. This was a research priority setting exercise that Tom invited me and Pamela Collins to co-chair. Many of you will have heard of the Grand Challenges in Global Health. So this was really an addition of the Grand Challenges priority setting methodology, but specifically focusing on mental health. The instructions we got was this. The NIMH was funding billions of dollars, almost entirely in biological research, but there was virtually no new dramatic discovery that was helping us understand any mental health condition. And so what they asked us is, can you go find out what are the other kinds of research questions that the NIMH should invest in, which may have a good or a better chance of shifting the needle on the burden of mental health problems globally. We conducted a pretty typical research priority setting exercise, a multi-stage Delphi panel, nearly 400 people in the panel, spanning all the different disciplines and a very global panel. And we arrived finally at about a 25 or 30 leading research priorities, which if invested in could shift the needle on the burden of mental health problems and perhaps not surprisingly, the leading research priorities were those that were addressing the no-do gap. That is to say, the gap between what we know in this instance, the effectiveness of psychosocial interventions and what we do with that knowledge, which is to say, how do we make sure that people who can benefit from these interventions actually receive them? This paper was published in 2011. And so about 11 years later, I can tell you that at least a billion dollars of new money has been invested by the NIMH and a number of other funding agencies around the world. Most of that money has gone to the global south and most of that money has sought to address one or more of these different grand challenges. And thanks to this enormous investment, there has been a flourishing of new implementation science or delivery science around the world. And just last year, the Cochrane Reviews published a updated finding of this body of evidence, a synthesis of this body of evidence, more than 100 randomized controlled trials across the full range of mental health conditions, clearly demonstrating that even in the settings where there are virtually no mental health professionals, the settings that I started my work in, such as what you see in this image in Zimbabwe, where when I started working there back in the mid-90s, I was one of 10 psychiatrists for a country of roughly 9 million people. And about eight or nine of those psychiatrists lived and worked in the capital city of Harare, leaving just one psychiatrist for 9 million people. So, you know, really what we really needed to do was to have a completely reimagined way in which mental health care could be delivered. And what I really want to tell you a little bit more about is the innovation that you see pictured in this slide. This is an innovation in which is called the friendship bench and you can see why. What you see in this slide is a primary health center in the capital city of Harare in Zimbabwe. And on this bench, you see two ladies. This lady is a lady with depression who has been screened and identified as suffering from a significant number of depressive symptoms by a nurse in the clinic at the back there. She's also, as you can see, the mother of a young child. And the lady on the right who looks like a nurse, but she isn't actually a nurse. She actually is a grandmother who works in the community that is served by this clinic. And she has been trained in a brief form of psychotherapy based on cognitive behavior principles. The treatment is called problem-solving intervention. And she has been trained to deliver this intervention to women who are depressed, to people who are depressed actually. And because the clinic is so crowded and there is no privacy in the clinic to deliver therapy and because Harare enjoys very good weather all around the year, unlike Boston, what the innovator, the program is led by Dixon Chibanda as a baboon psychiatrist. And he basically said, well, let's actually deliver the therapy outdoors in the garden of the clinic. And because you need a place to sit and give a sense of a physical sense that you need a virtual sense that you have, privacy, he came up with the idea of having a bench. He then ran a randomized controlled trial which demonstrated this approach associated with very high recovery rates from depression. And this is one of the hundreds of randomized controlled trials that were included in the synthesis. There are many systematic reviews now that I have examined this body of evidence. Here are two examples from colleagues of mine, mentees of mine that I've really examined on the left-hand side, interventions for psychosis and on the right-hand side for mood, anxiety, and trauma-related conditions. And what this very exciting body of evidence is teaching us is how we can redefine mental health care in four ways. Firstly, the what. These are very brief interventions. They are intended to be the first step in care. The interventions have anywhere for as little as a single session to up to maybe the maximum I've seen as six to eight sessions. They comprise only one or two active ingredients so that they're very easy to learn. And by this, I mean, not just for the individual delivering care but also for the individual receiving care because most psychosocial interventions are skills building in nature. These are delivered where people are, for example, in community settings, primary health care or schools. They're delivered by whoever in the community is available and authorized to deliver care. My own work has predominantly focused with lay people and community health workers. But you also see other programs that have been used by grandmothers, for example, peer support workers, nurses, and so on. And typically, this is seen as the first step of care in a stepped care model in which there is a coordination of this frontline worker delivered care with the specialist system, whatever it might be in that country. So there's coordination and collaboration and people then receive the care that they need. And there is actually a continuity of care, recognizing that mental health problems can often be chronic conditions for many people. There are many benefits of this approach. Of course, the most important one that's obvious is improved access to evidence-based care. But beyond that, it helps free up the few specialists that are available around the world to work at the top of their license, which means to help address the needs of people with particularly resistant complex or severe mental health problems. It helps receive stigma, because when you receive care from somebody who's also addressing your other needs, your social needs, your physical health needs, who's visiting you at your own home to deliver care, well, obviously, that's going to help address the stigma and the shame associated with mental health care. It's very person-centered because it provides care when you need it rather than putting you on a waiting list to see a psychiatrist after three months. And of course, it also benefits the providers. All the qualitative work that's been done with frontline workers who are delivering this care has typically described how these workers feel fulfilled. They feel a new sense of purpose. They feel empowered by this new knowledge. And interestingly, how they use this knowledge for their own mental health and the mental health of their family members and friends. This exciting body of evidence is transforming mental health globally. Here you see examples of policy documents, both global policy documents, such as the Mental Health Action Plan of the World Health Organization, or the Disease Control Priorities Program of the World Bank. And on the right-hand side, you see country-level documents, such as the National Mental Health Policy of India, on the drafting committee of which I served, or the Rand Corporation's report on the U.S. mental health system. Across the board, you will find that policy documents are embracing this new evidence and calling for a diversification of the workforce to deliver evidence-based psychosocial interventions. And what this means is investing at the base of the pyramid of care on community health workers, peer support specialists, nurses, midwives, a whole range of other kinds of providers who are not trained in specialist mental health care, which has traditionally been the focus of financing and investment in the mental health care sector. So the question really is the how. That's where we are today. The large body of evidence is just about a decade old, and policy makers have embraced this. They say, we want to now invest in building and diversifying our workforce. And so we're now at that very interesting time in global health to ask the question, how do we rapidly scale up evidence-based psychosocial interventions? Now, we can't use the methods that are used by delivery scientists because obviously in randomized control trials you use a lot of resources. You use experts in small groups, workshop-based training of frontline workers, you're running a randomized control trial. You want to ensure that the intervention is delivered at the highest quality, but of course that is not scalable in the real world. So over the last three years, we have launched a new program at Harvard Medical School in partnership with my organization that I worked with for 30 years in India called Sangat, which has been really a pioneering organization. In fact, I think Sangat has conducted maybe at least 10 of the trials that were included in the Cochrane review to use digital tools to enable frontline providers to learn, master, and deliver quality-assured psychosocial interventions. The mission of MPOWER is literally to empower anyone anywhere to deliver these interventions with high quality. We use the accompaniment model that my late department chair, Paul Farmer Coingey was describing accompaniment really as the process in which a health worker accompanies an individual on their journey to recovery. Paul worked mostly with people with HIV and TB, chronic infectious diseases, but you could argue the accompaniment model is just as relevant for mental health problems. But we use the accompaniment model in a somewhat different way. We use it to describe how we need to build the capacity of the workforce. Imagine a community health worker who's never done mental health work before. To accompany them on their journey, we first need to ensure that they learn a new treatment skill. We then, once they have learned the new skill, we then provide them with supervision to actually master those skills by treating people with the target mental health condition. We then assess their competencies so that they can now be licensed to deliver care, allowing others who are licensed on a lifelong journey of supervision and quality assurance, ultimately so that a community health worker has a career progression to becoming an expert who can then support the learning journey of a new generation of community health workers, not only providing them with a long-term career progression opportunity for themselves, but also having a sustainable way of replenishing a new generation of community health workers. I mentioned digital tools, so let me give you four examples of how we use digital technology to rapidly facilitate this career progression pathway. First, of course, we deliver the curricula in a digital format on any learning management system. We use remotely delivered assessments of competency, including critically important the assessment of skills through role-plays. We are designing with the Boston Bay's community health worker tech enterprise called Dimagi a bespoke digital app for supervision and quality measurement. And we're developing data science-driven protocols for the evaluation of the rich digital data that arises from the training and competencies ultimately linked to patient outcomes to do all kinds of exciting things, including understanding better and predicting patient outcomes. Let me give you a quick example of one such treatment that we're scaling up. About 10 years ago, one of the trials that I led with Sangata was the evaluation of a six-session treatment for severe depression based on the active ingredient called behavioral activation. We call the treatment the healthy activity program. Here you can see the results of the trial at three months. The treatment was just six-session over eight to 12 weeks. About 60% of people with severe depression in primary care that treatment was delivered by lay people in primary care had permitted. At 12 months that was still nearly 60% and you can see the control arm was only about 30%, so doubling the rates approximately of remission. And recently we completed a five-year follow-up and showed again statistically significant differences five years later after receiving just about two hours of therapy for a severe depressive episode. We just completed a large randomized control trial demonstrating the digital training for this particular treatment especially when supported with a coach that's the DGT Plus here, showed significant improvements in competency but also importantly, it was non-inferior or equivalent to the gold standard face-to-face expert-led workshop-based model. We have now applied this to the field in the real world and as I speak to you today hundreds of community health workers of India's national health system that called the Ashas are delivering this brief six-session treatment to people in their own community, thousands of individuals in just a few months and we will soon be publishing our findings of this first scale-up of brief depression care in the hands of frontline workers in the coming months. But what's really exciting, if you remember I started my talk by talking about how there is a huge shortage, huge levels of unmet needs for care in the U.S. in spite of the large numbers of mental health professionals indicating that even in countries where there are lots of mental health professionals, there's a lot we do to diversify the workforce. A couple of years ago, right in the middle of the pandemic, in partnership with the Meadow's mental health policy institute and the American Psychological Association we reverse engineered the healthy activity program. We adapted it for use in the U.S. You typically hear about treatments being developed in the global north and being adapted for the global south. Not very often do you hear the opposite exactly what's happening right now. As I speak to you, we were very, very delighted that we won a prize in the middle of the pandemic. This was a competition to transform the lives of people living in Texas affected by the pandemic and we won the bid that we had to bring community health workers in Texas to deliver care for people struggling with their mental health and as I speak to you, the first batch of community health workers in the U.S. are delivering a treatment that was originally designed for community health workers in India and it just goes to show how the world is becoming a much smaller place and knowledge is flowing in all directions. In the interest of time, I'm not going to say much more so I can have some question and answer, but this slide just shows you how we're developing a suite of interventions across the full range of mental health problems from very early intervention early intervention, but always based on evidence-based treatment components all the way through to promoting the recovery of people struggling with their poor mental health. Some of these interventions are already funded so we're my lab in Harvard and Sangat are already working for example for emotional disorders and adolescents for autism and for peer support workers for serious mental illness. For others like trauma related mental health problems and harm for drinking, we're currently working towards providing support for our lab to roll out these different curricula and tools. And finally, what we're really in the midst of right now is that Harvard Medical School is working towards spinning off a enterprise that can actually then take all these tools and make them available very widely to people across the US and around the world, implementers like hospital systems, governments and so on because obviously a university is not the right kind of platform for actually delivering these tools and products around the world and so Empower now has a new enterprise called Empowered Scale that will take all the stuff that we're developing in our labs and make them more widely available. This is my last slide just simply to say that the big lesson from this exciting body of delivery science from the global south is that for all countries in the world that's why the global is underlined because it means every country in the world can benefit from this knowledge which is really the scaling up of psychosocial interventions by deploying digital tools and products to rapidly build the capacity of a frontline workforce to learn master, deliver and evaluate these interventions for those of you who want to know more about Empowered here is the website there is a paper that we just published last year which I'm happy to share with the match point organizers and you can also see the email address of my colleague Natalie Carmeo who is the program manager of the Empower Lab at Harvard Medical School so thank you very much for your patience and I think we still have about at least 15 minutes for Q&A and I look forward to the discussion. I can't hear you, now I can. Thank you so much Vikram Basil and thank you for leaving some time for questions. Here I have an iPad with questions from the audience but let's just get started by noting that what you really do is breaking down the monopoly I guess of university and professionals. Do you face resistance due to that? That's a great question honestly of course there would be resistance as you can imagine when you're trying to disrupt when you're trying to disrupt an orthodox way of doing things and in this instance the disruption is that you're disrupting the power and the hierarchy that very highly trained practitioners hold in global health. Of course there's going to be a pushback however the evidence speaks for itself and I think this is the power of science here. I would really encourage all of you in the audience to think about the power of science. If I was just simply saying what I was saying today with not a single body of research to back me up you could rightly critique me you could rightly say what you're saying is completely ideological and it's potentially even dangerous but when you have 100 randomized controlled trials all saying the same thing you see the power of science silences many of the critics and instead what I'm seeing right now is that wealthy countries are embracing this knowledge in the US today the government is actually rolling out hundreds of millions, billions of dollars actually to build a more diverse workforce the surgeon general of the US Dr Vivek Murthy who is very passionate about youth mental health himself is now calling for all the states in the US to start building a community-based workforce this would have been unthinkable 10 years ago so I do think one should put a lot of credit on the science the second thing I will say is that it's important to build alliances and I have done that you will have maybe noticed that I built an alliance with the American Psychological Association and we're very lucky that the American Psychological Association has adopted a completely new vision instead of spending all its time as it used to on protecting the territory of psychologists it's now decided to make its mission the expansion of the wonderful science that comes from psychology to the population it's launched its population mental health science program in fact in September there will be a major event of thought leaders around the US to examine exactly the questions that I've spoken to you about today and by allying with the APA it automatically means that the most powerful guild that is associated with these interventions is in fact fully on board with their scaling let's take a few questions from the participants one is about the stigma that's surrounding mental health issues so how can we work around the stigma surrounding mental health in many countries of the world I have maybe a slightly different view on how many stigma researchers have described stigma my view is that much of the stigma to do with mental health has been created by the mental health care industry let me explain what I mean for the last 100 plus years mental health care in most countries in the world was a very carceral model that means people were removed from their homes and placed into institutions with eye walls and locked doors within which there used to be profound levels of abuse and violence where people were treated against their will with medications that often left them completely unable to think clearly and oftentimes they had no freedom they had no freedom to leave now those models of care continue to be the most common models of care in many countries in Africa, Latin America and Asia because these are the remnants of the colonial systems that were built before these countries became independent now if in your society having a mental health problem meant you were going to be removed from your home, medicated against your wish and locked away in what could easily look like a prison wouldn't there be a stigma attached to seeking mental health care and why is that surprising and are we going to simply address that stigma by having campaigns oh it's the normal problem everyone has a norm, no I don't think it is just like the stigma with HIV AIDS you do need to address that stigma by providing care in a way that is non coercive that respects the dignity of the individual that is community based and that is evidence based I remember when I worked in Zimbabwe in the mid 1990s there was huge stigma to do with HIV AIDS and why was it a stigmatized because people feared the care delivery system if you went to the care delivery system back in the mid 1990s A you never received evidence based care back then the miraculous drugs that were transforming the lives of people with HIV were not available to Africans so you basically went there you didn't even care you were humiliated because you had HIV AIDS in some parts of the world you were locked up so that you wouldn't be actually spreading this disease to other people and you were very intensely feared today HIV AIDS is not a stigmatized condition and we need to draw lessons from the HIV AIDS story for mental health and I'll finish with one more lesson actually what are the most important lessons which I think is of course the single most important story about global health it is a story that it brings in not only elements of social justice and science but also it brings in a very important element of the power of the community and the lived experience and over the last 10 or 15 years I personally invested a lot of my time to make sure that the lived experience of mental illness is bang in the center of all our advocacy science and delivery of mental health care and I'd urge you all to look at the global mental health peer network which is a service user or lived experience network that was launched by Charlene Sunkel who is a person with schizophrenia from South Africa which now has a presence in 40 or 50 countries around the world Charlene is a dear friend and she won a very major human rights award last year that is what we need to see in the mental health conversation a far greater presence of people with a lived experience speaking for and on behalf themselves you mentioned in your presentation the hierarchy of health care how do you tip that hierarchy in favor of putting more focus to mental health so I say that well you have to always work against our hierarchies and this is not only true of mental health care this is true of society more generally I'm not going to go into all the other areas in which power relations creates such huge imbalances in the way we create a harmonious society but in the mental health space I would say we should be promoting a team based approach where every individual in the team has a very specific role in mental health care and of course psychiatrists play a very important role they are experts for example in the management of very complex mental health problems they are of course experts in the judicial use of medication and so on clinical psychologists similarly play a very important role so I think we should never pitch this as a competition between different providers what we really have to say is that the patient is the king or the queen and what we have to make sure is they get the time that they need it and in order to do that we need to have a team a team that is able to respond very quickly when someone needs care typically that first point of care should be a frontline provider who delivers brief interventions but equally if that person needs more it doesn't respond or needs more specialized care there needs to be a rapid referral system in place so that more specialized providers can see that person what I would say is that team-based approach and continuum of care are the key words that I will leave you with in terms of how we address the hierarchy of mental health care I'm sorry but the next question is a big question too but you will give some good answers the question is how can we shift the focus from treatment to addressing the underlying determinations of poor mental health that's a really great question I'm sure I'm really glad whoever posed that question asked that so let's be first of all very honest no global health problem has been addressed by only treatment let's be completely clear if maternal mortality and infant mortality have fallen it isn't only because of institutionalized delivery although that is of course very important if HIV incidence rates are falling it isn't only because about treatment of course in fact HIV is almost entirely prevention the best example is heart disease heart disease mortality has been falling across the world actually it's one of the most dramatic improvements that I can think of in recent years cardiologists think it's because they're putting in stands it's not it's actually because people are adopting healthier lifestyles they're smoking less they're embracing exercise more etc so prevention is extremely important now in the mental health space prevention means targeting the upstream social determinants as the question the person who asked the question rightly points out and we've often felt very very helpless how do you address things like poverty you know these are almost like political solutions how do you address things like inequality how do you address the fact that the global arms industry is fueling so much conflict including in Europe right now and those of us who work in this in global health feel very helpless these are powerful forces that are beyond our reach so I would suggest to you that what we really need to look at is the pathways through which these distal determinants affect our mental health and try to identify the mechanisms through which they affect the individual and look at whether interventions can help mitigate or modify the effect of those pathways and I want to leave you with two examples great examples I think of how prevention can be delivered within the context of healthcare systems or delivery systems more generally the first is cash transfers there is now a rich body of evidence I have a colleague of mine working in Brazil who is demonstrating that the massive cash transfer program the Bolsa Familia has led to dramatic reductions in suicide mortality particularly in indigenous and black Brazilians that's one example so you may not change the global taxation systems that ultimately should be changed but instead what you can do is have direct cash transfers the people who live in conditions of poverty so that income insecurity is no longer a daily lived experience the second example is supporting families who are living in low income context the children of those families to reduce the exposure to adversities in early childhood are the most well replicated risk factors for poor mental health I call it the tobacco of mental health that is to say adversities in childhood are the most powerful predictors across all contexts of poor mental health later in life we know how we can mitigate those adversities by parenting interventions home visiting interventions to support children growing up in poverty particularly their parents these are two examples even if we can't change the structural factors that lead to poverty inequality and violence all right we're running out of time but I'll try to squeeze in maybe one, maybe two questions the first is from the audience how do we address the mental health issues in indigenous communities who do not get their needs in life met by colonizing countries well you know I won't speak on behalf of indigenous people but I will paraphrase what I have learned from colleagues of mine who are indigenous in North America and work in this area what's really important in the context of indigenous peoples around the world is that we cannot address the high burden of mental health problems without a full acknowledgement of the historical trauma that these communities have experienced and the trauma is immense you know it's of course I think the person who has asked the question would know what I'm referring to it goes back hundreds of years the loss of culture has been profoundly important and I think in order for us to address the mental health of these communities we have to think of it from a community approach rather than an individual approach alone of course individuals do need care and I'm not denying the importance of that but we also need healing strategies and that is required to begin with an acknowledgement of the historical violence that these communities have faced of the provision of greater control on how they determine their own futures the incorporation of a range of cultural healing practices in community healing and so on there's a lot written about that the time doesn't permit me to go into all of that but I think in response to your question a narrow biomedical model is completely and totally insufficient All right, wrapping up I'd like to ask you the contrast to physical diseases when it comes to physical diseases you tend to measure success in terms of numbers of lives saved for you how do you measure success when it comes to psychosocial interventions? Well I mean that's a great question and it's been one of the big challenges of holding mental health programs accountable we just count the number of people we are treated rather than what happened to them and it is a huge issue what I will say is that what we need to do is to have systems in place where we evaluate the function of an individual rather than their symptoms person-centered outcomes are the most important and I believe with the advent of mobile technologies being so widespread being able to actually reach out to individuals let's say three to six months after they have been in a care encounter to identify how they're doing is not an improbable way of assessing people's well-being functional outcomes and that's the kind of way that we have to be thinking imaginatively about we can't use mortality for obvious reasons although I will say that suicide and drug use related mortality may be two examples of mortality as well as premature mortality that is to say one of the biggest crises for people with serious mental illness is that they die 10 to 20 years earlier than people without even though these are not fatal conditions and so looking at premature mortality in mental health problems I think it's also an important outcome that we should be thinking about Alright Mr Patel when I look at the audience I see many happy faces so please receive a well-deserved applause Thank you Thank you very much and I wish you all the very best for the rest of your day and the music this evening as I said I wish so much I could be with you but I am teaching right now in Boston and I could not have travelled so Thank you very much for inviting me and all the very best Thank you so much for your time