Meet Shekhar Saxena, Distinguished Fellow

Dr Saxena is a psychiatrist by training, and past Director of the Department of Mental Health and Substance Abuse at World Health Organisation.

His work has involved evaluating evidence on effective public health measures and providing advice and technical assistance to ministries of health on prevention and management of mental, developmental, neurological and substance use disorders and suicide prevention, establishing partnerships with academic centres and civil society organisations and global advocacy for mental health and substance use issues.

Dr Saxena led WHO’s work to implement the Comprehensive Mental Health Action Plan adopted by the World Health Assembly in May 2013, scaling up care for priority mental, neurological and substance use disorders.

What drew you to psychiatry as a profession at the outset?

I was attracted to psychiatry within the first few months of starting my medical degree in 1973. It fascinated me, because it went beyond the physical attributes of a person and involved higher functioning of brain, including cognition, emotions, and much more importantly, people’s behaviour. I saw psychiatry as a subject with lots of exciting developments in the coming few decades, which has turned out to be right.

What have been the main changes that you have seen in the past 40 years working in the field of mental health?

Mental health has changed enormously in these 40 years - it has come out of the shadows! It was a subject that was not talked about or recognized as an important discipline within the health and medical area. But now it is. Knowledge on mental health was very rudimentary, now it is much better. Understanding of the causation of mental illnesses, as well as the range of effective treatments, has improved a lot.

There is also an increasing convergence of various areas of scientific discipline related to mental health. The neuroscientists are now contributing much more to understanding mental disorders. Social scientists are working very closely with the mental health professionals to understand human behaviour, and how sometimes it can be maladaptive and abnormal. Clinical scientists are working on finding out the most effective treatments for mental disorders. Psychotherapy specialists are finding out newer ways of delivering psychotherapies. Pharmacologists are working towards finding out newer medicines for mental disorders. And finally, there are people who are working in the public mental health area to aggregate all of this information, and make a change in the policy and service delivery to reach people who need help.

When I started clinical work, mental health was still stigmatized. Only people with severe mental disorders would come for clinical care and often after much delay. There was misinformation. Mental disorders were not recognized as valid disorders or the domain of doctors to treat. During my career in mental health, I have seen a major change. People are now more inclined to take help, and much earlier. The stigma still remains, but is less.

In the 20 years that I worked at WHO, I witnessed the public mental health scenario also changing substantially. Earlier, policy makers in many low and middle-income countries would not acknowledge that they had a mental health problem in their country. It was seen as a problem for “the highly developed countries”. They also felt they didn’t need to tackle this issue because they viewed it was the responsibility of families to look after people.

The increasing understanding of public mental health means it is now seen as an important area of public health planning. Ministers of Health not only unanimously agreed with the Mental Health Action Plan of WHO in 2013, but also started asking for more guidance to implement it. Over the years, I have worked alongside my colleagues in many countries to help establish effective evidence-based, community mental health systems.

Mental health is in a much better shape than one could have imagined 40 years back. However, it still remains one of the most challenging areas for public health policy, and the amount of resources that are going into it are a very small fraction of what is needed. Understanding of mental health among policy makers has improved, but their actions are still not commensurate with the large and increasing needs.

What role do different stakeholders play in shaping mental health policy?

Mental health is an area that requires a large number of stakeholders working closely together. At WHO I had an opportunity to work with government ministries of health as the primary partners, alongside academic institutions, to stimulate public health oriented research, distil research findings, and use them for policy planning and service development.

Another important stakeholder in the mental health field is the civil society; NGOs and civil society can use scientific information and evidence-based guidelines like WHO’s mental health Atlas and mhGAP to advocacy and influence the government policy.  I have found interacting with civil society, and especially people with lived experience of mental disorders to be a very rewarding and gratifying experience. Their voices sometimes made far more impact than the efforts of research centres.

Is there a treatment gap?

In spite of this major progress, the gap between what is needed and what is available, is a still very large. The vast majority of people in low and middle-income countries who have a mental disorder are not able to access any help. Even in highly developed economies, almost 50% of people who have depression are not able to get professional help. No other health condition has that kind of treatment gap and the disparities exist not only in low and middle-income countries, but also in high income countries. That's why I say that when it comes to mental health, all countries are developing countries. Some are a little ahead of others, but they all have a lot to do to advance mental health for their citizens. Disparities also exist within communities, and within urban and rural areas, particularly between the rich and the poor. Trained mental health care providers are missing almost completely from rural areas in some countries, so people have to travel 200, sometimes 500 kilometres to access mental health care. Many people are unable to do this because of financial, or other reasons.

What tools and resources are available to assist in decreasing the treatment gap?

The mental health care system is starved of human and financial resources. Although it is improving, improvements are taking time. Mechanisms to help strengthen mental health care system are extremely important. One of them is to use primary health professionals such as general doctors, general nurses, as well as community health care workers, to assist in identifying and treating at least some of the basic mental health disorders. They can identify and treat the majority of mental disorders at least at a very basic level.

The mhGAP package developed by WHO provides very useful information about how to train non-specialist providers, in identifying and treating mental, neurological and substance use disorders. It has been successfully used in more than hundred countries and proven to be a very useful tool to increase the capacity of mental health care system to deliver care.

The second innovation is the use of technology, which can help in a variety of ways. It can deliver information, and sometimes even care, directly to people. Using websites or mobile phone apps people can access care when there is no health care worker around. Technology can also help in training primary care providers, wherever they are, in identifying and taking care of mental disorders, as well as in collecting useful information, which can be used by the health care system to improve care.

What else do you see as key drivers of change in the near future?

One of key drivers for change is the rise in number of people with lived experience of mental disorders in leadership roles, reinforcing ‘it should be nothing about us without us’. This is transforming the whole discussion around mental health. Every policy initiative, every change in the way services are organised, and every new treatment needs to have inputs from people and families who have experienced mental health issues in their lives. This is happening increasingly and it has the largest potential to make a positive change, but there is still a lot of ground to cover.

You have dedicated your career to championing the cause of mental health. What drives you?

What drives me is the fact that the needs are very high in mental health; it is one of the areas where people have suffered in silence for a long time. The support and encouragement from colleagues from all over the world, from very diverse backgrounds, motivates me to continue to work in this area. Now that people are willing to work together, there is a chance to make a real difference.