Lessons from Ecuador on responding to the mental health crisis in the United States and around the world

Lessons from Ecuador on responding to the mental health crisis in the United States and around the world

IIn his assessment of governments’ work to provide sufficient mental health resources to their citizens, Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, warned that “good intentions do not translate into investments”. .

Although many countries have implemented policies, plans and laws to improve mental health care, they have not provided enough leadership and governance for community mental health resources and enough promotion and prevention for mental health. The pace of spending on behavioral health and the integration of mental health services into primary care settings has been slow.

Innovative approaches taken by smaller countries like Ecuador could help reverse the horrific fact that among 15 to 29-year-olds worldwide, suicide is the fourth leading cause of death, or that people with serious health problems mental health die 10 to 20 years earlier than the general population.


Today, there is often no care for people with mental illness. This is as true in low-income countries like Zimbabwe, which has 19 psychiatrists for a population of 15 million, as it is in the United States.

The seeds of possible new resources are being sown in Ecuador, a country struggling with significant mental health issues: nearly nine in every 100,000 Ecuadorians die by suicide, slightly less than the rate in the United States . But only about 25% of the population has access to mental health. services.


To provide better access to mental health services, the Ecuadorian Ministry of Health, San Francisco University of Quito (USFQ) and Northwell Health, based in New York, where I work, have implemented a test model of mental health in Yaruqui district. It includes 10 clinics that feed a local hospital.

The program aims to increase the capacity of clinics to identify, diagnose and treat people with mental illness. Clinic staff learn to implement simple tools to identify people with depression, anxiety and other conditions such as bipolar disorder or schizophrenia. License-level psychologists are trained to screen and assess patients, provide evidence-based psychoeducation for depression and anxiety based on the principles of cognitive-behavioral therapy, and refer those with more complex issues to psychiatrists .

Studies and interventions in the Global South and in areas such as the UK have shown that unlicensed lay people can be trained to provide evidence-based psychosocial interventions that are effective for many people. At the same time, family physicians in these areas have been trained to prescribe medication for anxiety and depression, and telepsychiatrists are also available to provide consultation and advice to psychologists and family physicians as needed.

The program’s pilot project in Ecuador reduced turnaround times for mental health consultations from two months to two weeks.

The USFQ team also created a program that offers psychosocial support to pregnant women and mothers to give them the resources they need to parent and build emotionally healthy and supportive families. These are great low-cost strategies inspired by the World Health Organization’s Mental Health Gap Action Agenda, collaborative care initiatives in the United States, and improving access to treatment. psychology in the UK.

Like all starting points, these efforts can be imperfect. But the perfect doesn’t have to be the enemy of the good, especially when it can produce intriguing and effective solutions that could work in countries of any income level.

What is different about the Ecuadorian program is the cross-border partnership between a local university and its medical school, the country’s health ministry, and a large health system in the United States. Each stakeholder draws on a strength and perspective that alone is not enough to solve a country’s mental health challenges. Together, however, the right resources and the willingness to experiment can make a significant difference.

In this case, the local university has undergraduate psychology students who want to learn how to deliver evidence-based interventions; the Ministry of Health has the vision, the flexibility and the primary health centers to support such an intervention; and Northwell Health has resident psychiatrists with supervisors ready to provide telepsychiatric support.

The United States does not have a national plan to increase access to mental health care, but it does have the ability to encourage — and perhaps even incentivize — relationships between universities, medical schools , health systems and government entities. There is an opportunity to create more pathways to mental health services thereby broadening the base of providers, training students looking to enter the field to provide screening and low-intensity psychosocial support and coaching services in areas where these resources may not exist or be difficult to obtain. to access.

When I met new psychologists and psychologists-in-training in Ecuador in September, their energy and willingness to create new programs and try new strategies to reach those in need was infectious. I found their openness about their work and their patients inspiring. This enthusiasm certainly exists in other countries, including the United States. It can be harnessed by developing and nurturing a pipeline of behavioral health professionals by creating opportunities for them to get trained, help patients, and in doing so, reinvent some of the ways and places people receive mental health care.

A country’s approaches to mental health issues can tell a lot about how it responds to one of the most basic human experiences: suffering. Ecuador is doing it with new ideas and few resources. Even with limited tools, he is leading the way to reshaping the way mental illness is diagnosed, treated and managed.

John Q. Young is a psychiatrist, Senior Vice President of Behavioral Health for Northwell Health, and Professor and Chair of the Department of Psychiatry at the Donald and Barbara Zucker School of Medicine in Hofstra/Northwell.

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