Q & A with PIH's new mental health fellows

This year, Partners In Health begins an exciting new initiative in global mental health delivery. Dr. David Grelotti and Dr. Stephanie Smith are the recipients of the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery, which provides PIH an opportunity to more formally integrate psychiatric and community-based mental health services at project sites. Dr. Grelotti will work with PIH's sister organization in Haiti, Zanmi Lasante; and Dr. Smith will work with Inshuti Mu Buzima, PIH's Rwandan sister organization. Both fellows say their focus will be on improving mental health care through training and capacity building over the next year.

We had a chance to sit down with PIH’s first Pagenel Fellows as they prepared to begin their new roles. 

Q: What goals do you have in mind as you prepare to head to Haiti and Rwanda?

Both David and Stephanie say that their focus will be on improving mental health care through training and capacity-building over this next year.

Dr. Grelotti: In much the same way PIH has revolutionized the treatment of HIV and TB in low-income countries through primary care, one of my goals is to expand access to mental health services through primary care and consultation-based psychiatry in the Zanmi Lasante and MOH hospitals. ZL has a growing mental health team, and I hope to accompany them clinically in addition to working with them behind the scenes to help Haitians in need. There is much concern for stigma related to mental illness – also similar to HIV and TB and cholera for that matter. Whereas stigma is probably as much of an issue as it is in the US, a bigger difference is access. When I went to Petite Riviere for the first time in March to do a clinic with the psychologist there, we had 30 patients lining up for us before I got there. If there is stigma, it’s certainly not keeping many patients away.

Dr. Smith: Mental health is a key component of overall well-being, and mental health needs must be addressed in order to fulfill the right to health. One important goal for achieving the right to health is to provide community-based services for people with mental disorders and to integrate mental health care into primary care. People with mental disorders do best when they are treated in their communities and are not excluded from everyday life. The Rwandan government has prioritized mental health care with a goal of integrating it into the primary care system. This includes establishing an infrastructure for mental health services which includes helping physicians and nurses learn how to identify and treat patients with mental disorders.

Q: Both Haiti and Rwanda have experienced catastrophic and traumatic events; do you expect to see similarities in their impacts on mental health?

Dr. Smith: Catastrophic events certainly always have a context, which can mediate the reaction people have to those events. It’s also possible to see differing patterns in emotional and behavioral responses across cultures. Traumatic events can cause a range of reactions, and whether you’re in Haiti or Rwanda, it’s important not to assume one standard set of feelings following an event. One important component of a good mental health system is to ensure that many different types of mental health needs and presentations of emotional distress can be addressed.

Dr. Grelotti: Traumatic events have likely impacted many Haitians and Rwandans, but everyone handles trauma differently. People in Haiti have shown remarkable resilience. But if someone is having difficulties – no matter what the difficulties – they should be able to access help. The goal should be to build a mental health care system that is always there to aid those who are suffering and that can respond effectively to things that affect individuals and groups.

Q: What role do you believe medication can play in treating mental illnesses in Haiti and Rwanda?

Dr. Grelotti: Medication is one important tool, part of a toolbox for treating psychiatric and neurologic illness that includes both pharmacologic and non-pharmacologic strategies. These can be both psychosocial and psychotherapeutic. However, there can be biological reasons for the illnesses that we treat, and medications can be helpful. PIH has made some of the most important medications in treating psychiatric and neurologic illness available to Haitians free of charge, and one of my most important responsibilities as a psychiatrist will be to transfer knowledge of how to safely and effectively use these medications to ZL doctors and psychologists.

We often talk about the disability caused by mental illness from the context of the person. This is true, but it is also true that medication can free up resources and reduce the burden on the family. One of the patients with schizophrenia who I met in Hinche was so disorganized that he needed constant supervision. It is my hope that with medication he will do better and his family will not need to be by his side all the time.

Most patients we are treating with medication have not been on psychiatric medication before, and for medication to be most effective we have to be mindful of adherence. Much like HIV and TB, we need to make sure that people start and stop medications under close supervision and not because they feel better or seem to be doing better. For example, the mother of one little boy with epilepsy from St. Marc had not refilled his medication because his seizures had stopped. She came to see us because his seizures came back. Medications are important, but so is regular follow up and education about the illness and its treatment.

Dr. Smith: Medications are important for treating the symptoms of mental illness such as anxiety, insomnia or psychosis. There are a number of psychiatric medications on the WHO essential medicines list, and to fulfill the right to health for people with mental disorders, it’s very important to ensure access to these medications. It’s also important to make sure that medication management is combined with community support in order to best treat severe mental disorders. 

Q: How do you offer therapy to patients if you don’t speak the same language?

Dr. Grelotti: Stephanie’s and my role will be primarily to support our local colleagues in the provision of care, with them as the main point of contact with patients and families. I learned from the many dedicated PIH staff who work in Haiti that it’s possible to learn a new language as an adult, and I’m committed to improving my Creole! However, one of the most important aspects of any therapy is creating what we call a therapeutic alliance. It’s important that the patient feel that you understand them and are on their side. I probably won’t be doing a lot of therapy myself, but if I’m sitting in on a session I’ll be listening and reacting to body language and hope that even in these small ways will make the talk as therapeutic as possible.

Dr. Smith: Without a firm grasp of the language, therapy can work well when you have a trusted interpreter, although it’s important to take into account that there are three people in the room and incorporate this difference into the psychotherapeutic work. Our primary goal as clinician-teachers is to accompany Rwandan clinicians and healthcare workers to care for people with mental disorders using the most sound treatment for the clinical situation. This also includes an ongoing dialogue with the clinician about their training, and the cultural context.

Q: Is there more stigma in Rwanda around mental health than other countries?

Dr. Smith: There is stigma around mental illness in many places. Treating patients in their communities helps to reduce this stigma. People with mental disorders can then continue to have relationships, work, and participate in community life. It also helps others to see that mental disorders can be treated and that people can recover from them.

Q: What are the largest challenges facing these countries as they integrate psychiatric care?

Dr. Smith: One of the largest challenges will be to integrate mental health services into the current health system and to provide appropriate diagnosis and treatment for those with mental health disorders, including ensuring the rights and dignity of people with mental disorders.

Dr. Grelotti: First, probably sustainability. We can’t just go in, start treatment, and leave. Any intervention needs to be part of a long-term commitment, and we need to be thoughtful in our approach. Another challenge is the integration of mental health services into existing medical service infrastructure. People with mental disorders may have medical problems that contribute to their psychiatric difficulties and certainly need primary care, but often they do not or cannot access services. All patients will benefit if mental health care is valued in the healthcare system. I think other challenges might also present opportunities to do things better than in the U.S., including actively trying to identify people at risk for mental illness through the involvement of community health workers, educational programs, and other partnerships.

About the Pagenel Fellows

Dr. David Grelotti

Dr. David Grelotti will be accompanying our Haitian colleagues in identifying core challenges to the delivery of quality mental health care and help to devise collaborative plans for providing hospital-based, public sector mental health services.

During an earlier trip to Haiti with PIH, David administered improvised neurological exams to patients using office supplies, scraps of paper, and a cell phone – an experience that inspired him to develop and strengthen methods of delivering specialty care in resource-poor areas in Haiti and beyond. 

With a background in anthropology, David’s work aims to collapse the barriers too often separating mental health care and local cultures. Prior to joining PIH’s sister project in Haiti, David worked to improve mental health systems in Singapore and Australia.

David completed residencies in both adult psychiatry and child and adolescent psychiatry at Massachusetts General Hospital and McLean Hospital. He holds an MD from Johns Hopkins, and graduated from Dartmouth College with honors in anthropology and government.

Dr. Stephanie Smith

Dr. Stephanie Smith will be working with PIH’s sister organization in Rwanda, Inshuti Mu Buzima. Her work seeks to enhance IMB’s capacity to develop practitioner skills in hospital settings, particularly at the new teaching hospital at Butaro. Beyond her work with IMB, she will support Rwanda’s Ministry of Health as it integrates mental health services nationwide.

Stephanie champions a rights-based approach to mental health care, one that upholds human dignity by removing barriers to treatment. She has worked alongside health practitioners throughout Africa and Latin America.

A passionate advocate for human rights and health policy change, Stephanie has worked with victims of torture and political violence in Zimbabwe. In her role as a researcher, she monitors the impact World Bank health policies have in aid-dependent countries. 

Stephanie completed her residency in psychiatry at Boston Medical Center. She holds an MD from the University of Minnesota – where she co-founded and chaired a chapter of Physicians for Human Rights. While there she also completed a medical ethics fellowship at Harvard Medical School. She graduated, with honors, from Cornell University, where she studied philosophy.

About Dr. Mario Pagenel

Among the hundreds of thousands of victims of the January 12, 2010 earthquake in Haiti was a beloved doctor, Dr. Mario Pagenel, from PIH’s sister organization Zanmi Lasante. Dr. Pagenel was the ZL Director for Training and Medical Education and the Director of the Caribbean HIV/AIDS Regional Training Center — a collaboration between ZL, the University of the West Indies in Jamaica, the U.S. Centers for Disease Control, and the University of Washington I-TECH program. Dr. Pagenel had advanced training in Family Practice at the Justinian Hospital program in Cap Haitian and had studied community health in Montreal, Canada. With these credentials, he returned to Haiti in 2007 to work in Haiti’s rural, isolated Central Plateau to serve the poor and raise the academic standards of medicine within ZL's programs. “Dr. Pagenel truly lived the term preferential option for the poor,” said Dr. Louise Ivers, Senior Health and Policy Advisor to PIH. “He could have worked anywhere but he decided to work in one of the most isolated parts of Haiti to serve his people."