Small money, big difference
5 December 2008
Professor Ricardo Araya studied medicine in Chile where he was a classmate and good friend of the current President, Michelle Bachelet.
After getting his medical degree in Chile, Araya came to the UK and trained as a psychiatrist and epidemiologist in the Institute of Psychiatry at the Maudsley Hospital in London, where he remained for eight years. But with the return of democracy to Chile in the early nineties, it was time to go home. There he took up a post as adviser to the Ministry of Health and Women’s Ministry, but after several years of working as a high-ranking public servant, Araya wanted to return to the academic world. He joined the University of Chile, where he set up a mental health research unit aiming to support the process of improving services for people with mental health problems. He remembers those early days: “I managed to get a large grant from the European Union in collaboration with Professor Glyn Lewis at the University of Bristol to carry out a large survey in Santiago, but at that time there was no real research infrastructure in the University of Chile – it was a project that had to be built up from scratch.” During the next six years of hard work, researchers were trained and equipment acquired to set up a unit that eventually accommodated more than ten staff members.
Throughout this period, Araya maintained a collaboration link with the UK and in 2002 he became a member of staff at the University – “Glyn Lewis and I have been friends and collaborators for almost 20 years now,” he says. They have carried out several studies, including the largest household and primary care mental health survey ever undertaken in Chile, but “eventually people got fed up with surveys and what they considered an exercise in counting the ill and dead. The real question was what could be done to improve the situation?” However, financial support was difficult to find. The Ministry of Health considered that the depression found among Chilean people on low incomes was caused by their poverty and social deprivation, so priority was given to social programmes aimed at alleviating those problems.
As luck would have it, while Araya was in Chile, a well-established mental health services researcher from the US, Dr Greg Simon, decided to take a sabbatical in Chile and between them Araya and Simon persuaded the US National Institute of Mental Health to give them some funding to try an improved treatment programme for depression among low-income people. What they did not anticipate at the time was that, along with other Chilean colleagues, they were going to dramatically alter the delivery of treatment for depression in Chile.
They did not anticipate that they would dramatically alter the delivery of treatment for depression in Chile
The team decided to test a depression-treatment programme in government-funded primary care clinics, since such clinics are the major source of healthcare for the poor in Chile. The idea was to improve on what was already available by increasing the involvement of non-medical personnel, since doctors’ time is expensive. Several nurses and social workers were trained to teach simple problem-solving techniques to depressed women visiting the clinic, as well as to monitor treatment progress and act as care managers. If a patient was severely or persistently depressed, her care manager would consult with a clinic doctor about treatment. If the doctor decided to prescribe an antidepressant for her, it would be a generic one, not a named brand, which is considerably cheaper.
The women were randomly divided so they either received the improved depression-treatment programme or the usual care. After six months, subjects in the intervention group showed large improvements relative to those in usual care, and although the ‘improved’ programme turned out to be slightly more expensive, the extra cost per person per year to keep them depression-free was only in the order of £13. This compares very favourably with the costs of innovative depression-treatment programmes in the UK and US, which usually cost hundreds of pounds extra per person per year. “But in the developing world,” Araya explains, “you are usually starting from a place where people aren’t getting any care at all, so there is a lot more room for improvement. Thus with a relatively modest investment, you can get more out of it.”
Nurses and social workers were trained to teach simple problem-solving techniques to depressed women visiting the clinic
Then came the biggest challenge of all – getting the Chilean government to implement the programme in its public healthcare system. There were both scientific and political issues. “You have to have the evidence that it is effective, but you also have to establish connections with people who have the decision-making power. So we pursued both those issues – doing the study to generate the scientific evidence, but also working with people in the Ministry of Health to make it happen.” And it did. The programme has now been scaled up at a national level and more than 400,000 depressed people have been treated in the past three years.
These studies have led to significant changes in government policy towards the treatment of depression in Chile, and the model is increasingly viewed as one likely to be adopted in other countries around the world. At present, a similar but much larger programme is being tried out in India with funding from the Wellcome Trust, and Araya, in collaboration with others from the University, is working on projects in Lebanon and Brazil. A recent large grant from the Wellcome Trust will allow Araya and his team to test an intervention to prevent depression in schools from low-income areas in Santiago, Chile. This is a natural and welcome extension of the work to reach the community, especially children and young people, outside health clinics. In the meantime, Araya has become a member of the prestigious Lancet Global Mental Health Initiative, a group of 40 international experts that launched a movement to improve services for common mental problems in resource-poor settings. “So much is needed in poor countries around the world and there are so many opportunities to make a huge impact with small investments,” he enthuses. “The University has a great opportunity to take a leading role in this field and I am so happy to be part of this much-needed and timely initiative.”