August 19, 2005

Taking a global view of mental health

As a hospital to a melting-pot city, the MGH has long held an international
perspective on patient care. Interpreters help patients describe their illnesses and injuries in more than two dozen languages. Telemedicine makes consultations possible between MGH doctors and clinicians thousands of miles away. But what of the cultural, social and other issues that arise when it comes to mental health care? And what — if anything — can the MGH offer in the worldwide struggle against the
burden of disease attributed to mental illnesses?

In 2003, Jerrold Rosenbaum, MD, chief of MGH Psychiatry, established the first division of International Psychiatry in a U.S. academic medical center, with Chester Pierce, MD, as founder, and Gregory Fricchione, MD, as director. Fricchione previously had spent two years at the Carter Center in Atlanta, an organization founded by former President Jimmy Carter and Rosalynn Carter to implement peace, democracy and health programs around the world. At the Carter Center, Fricchione developed a particular interest in Africa, where depression is a significant problem compounding the burdens of war and poverty as well as diseases such as AIDS, tuberculosis and malaria. "Working with the Ethiopian Public Health Training Initiative and the University of Addis Ababa Department of Psychiatry, I learned that psychiatry could make a difference in resource-poor settings, but also that psychiatrists could learn from the experience," Fricchione says.

Bidirectionality — the notion that American psychiatrists working in the Third World will get as much as they give — is the central tenet on which the division was built. Numerous initiatives exist to train a new generation of psychiatrists who are global in their scope. Since 2004, the division has offered its own chief residency. Residents can pursue electives around the world. During the last two years, residents have spent time in Nepal, Indonesia, Belize and Brazil, and an Australian elective is being planned. Residents also have the opportunity to study at the Harvard Program for Refugee Trauma and at the Harvard Department of Social Medicine.

At the end of 2004, the division received a grant from the U.S. Department of Education's Program for Mobility in North American Higher Education to develop a core curriculum in public mental health leadership. Together with Canada's Dalhousie University Medical School and McMaster University Medical School; the National Institute of Psychiatry and the National Institute of Neurology and Neurosurgery in Mexico; and Tufts New England Medical Center, the MGH will educate two or three teams of residents each year. Three senior psychiatry residents — one from each country — will complete three months of study. They will spend one month in each country studying mental health policy and legislation as well as cultural and logistical issues related to service delivery, access to care, stigma and advocacy. Participants will conduct clinical observations, make field trips and attend expert seminars, interacting in English and Spanish. At the end of the program, teams will prepare a report evaluating the three mental health systems relative to one another and offer recommendations for an improved approach to care.

MGH chief resident Guiseppe Raviola, MD, will spend March through May of 2006 participating in the project. "The collaboration with Canadian and Mexican psychiatrists-in-training is particularly exciting for me as an opportunity to gain greater proficiency in addressing mental health problems with Latino patients," he says.

Fricchione hopes the division also will establish clinical programs with partners in developing countries where resources are scarce. "I realize many experts see efforts to improve mental health in areas of the world where so many other monumental
problems exist as hopeless," he says. He takes his cue from his mentor at the Carter Center, William Foege, MD, the man considered most responsible for eradicating smallpox from the world. "He once told me that of the many visions of global mental health, some are optimistic, some are realistic and some are pessimistic," says Fricchione. "He urged me to remember journalist James Reston's advice and stick with the optimists, because the task will be tough enough even if they are right."