Title: CASE STUDY: BOSNIA AND HERZEGOVINA (BiH)
1CASE STUDY BOSNIA AND HERZEGOVINA (BiH)
- Harvard Program in Refugee Trauma (HPRT)
- Richard F. Mollica MD, MAR
- Michael P. Massagli, PhD
- James Lavelle, LICSW
- Aida Kapetanovic, MD
2Social and Health Indicators 1981 1991 2000
Population 4,124,256 4,395,643 3,683,665
Refugees - - 643,250
Displaced Persons - - 501,000
Employed Unemployed - 3.171 11
Monthly Income in US 190 299 174
3Major Objectives of World Bank-HPRT Project in
BiH Middle Bosnian Canton (Travnik)
- Mental health training and technical assistance
to primary care providers (PCPs) - Create network of PCPs skilled in mental health
and trauma-related disorders - Develop with cantonal MOH mental health services
integrated at all levels, including CBRs - Integrate results into BiH health reform
- Prepare Lessons Learned for dissemination
throughout BiH
4ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND
DISABILITY, BOSNIAN REFUGEES, 1996 (N533)
SOURCE JAMA v282437, 1999
5Persistence of Mental Health Symptoms Over 3 Years
6Change in Symptom Status 1996-1999
7Effect of Trauma, 1996
8Effect of Trauma, 1999
9THE MENTAL HEALTH COST OF MASS VIOLENCE
SERIOUS MENTAL ILLNESS PSYCH. INCAPACITATION SERIO
US FAMIILY CONFLICT CLNICAL DEPRESSION/PTSD FEAR
OF GOVERNMENT SEEKING JUSTICE/REVENGE PHYS,
MENTAL EXHAUSTION DEMORALIZATION
SOURCE Scientific American, v282, June 200054-57
10Feeling No Trust in Others, Past Week
112001 Living Standards Measurement Survey (LSMS)
in BiH (N12,954)
- 23 report depressive symptoms consistent with
DSM-IV diagnosis of major depression - 6 report reexperiencing trauma symptoms
- 15 report limitations in physical functioning
- Women 2x more depression, PTSD, functional
limitations than men
12Primary Health Care Patients Middle Bosnian
Canton, 2003 (N184)
SCID Structured Clinical Interview for DSM-IV
- 32 psychiatric diagnosis (DSM-IV/SCID)
- 16 major depression
- 10 Generalized Anxiety Disorder
- 3 PTSD only
- 3 Dysthymia other
13Providers Needs Assessment 2000
- 40 (30-80) of patients have mental health
problems - 65 of PCPs are not able to make DSM-IV (ICD-10)
diagnoses - PCPs reported very low confidence in treatment
of mental health crises - PCPs reported almost no confidence or very low
confidence in treatment of different groups of
traumatized patients
14Providers Needs Assessment 2000 (contd)
- 33 of PCPs didnt know about CBRs
- 54 of PCPs never referred patients to CBRs
- 30 of those who did refer never received
feedback from the CBR
15EDUCATION
- 105 PCPs and psychiatrists trained
- Curriculum completed
- Trauma Story
- Psychosocial interviewing skills
- Screening Instruments
- Identification and management of the most common
psychiatric disorders mood disorders, neurotic
stress-related and somatoform disorders,
substance abuse, organic mental disorders,
psychosis - Identification and management of disability
- Management skills/health reform
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17ON-SITE VISITS/SUPERVISION
- Case-Oriented
- Goals
- To sustain the knowledge
- To improve relations between PCPs and mental
health professionals - To prevent burnout
18Level of Trauma Experienced by PCPs and PCPs
Families
19PCPs Confidence in Eliciting and Listening to
Trauma Stories Pre-training vs. Post-training
Mean confidence
20PCPs Confidence in Diagnosing Certain Medical
and Psychiatric Problems Pre-training vs.
Post-training
Mean confidence
21MENTAL HEALTH SERVICES OPTIMAL MODEL
Community
Police
Emergency Room General Hospital
Primary Health Care
General Hospital In-patient
Mental Hospital Criminally Insane
22MENTAL HEALTH SERVICES IN BOSNIA
Community
Community Rehabilitation Centers
Primary Health Care
Psychiatric Hospital
23MENTAL HEALTH SERVICES IN BOSNIA
Community
Primary Health Care
Community Rehabilitation Centers
General Hospital In-patient
24FRAMEWORK FOR MENTAL HEALTH RECOVERY
I. Policy/Legislation
RECOVERY
VI. Linkage to Economic Development/ Human
Rights
II. Financing
V. Role of International Agencies
III. Science-Based Mental Health Services
IV. Multi-Disciplinary Education
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27BiH Mental Health (MH) Case Study
- I. Policy/Legislation
- MH integrated into health reform
- LSMS MH data integrated into BiH health
statistics - Future role of CBRs
28BiH Mental Health (MH) Case Study
- II. Financing
- Sustainable financing of MH in PHC
- Psychiatry PHC linkage
- Job training and social services in PHC/CBRs
- Cost-effective MH training and services
29BiH Mental Health (MH) Case Study
- III. Science-Based MH Services
- HPRT Model
- Needs assessment
- Implementation of field-tested curriculum
- On-site supervision
- Monitoring assessment and feedback
30BiH Mental Health (MH) Case Study
- IV. Multi-Disciplinary Education
- Pedagogy of Trauma in BiH medical schools
- Integration into family medicine
- CME
31BiH Mental Health (MH) Case Study
- V. Role of International Agencies
- Coordination/collaboration among BiH MOH UN
NGO donors universities
32BiH Mental Health (MH) Case Study
- VI. Linkage to Economic Development (ED) and
Human Rights (HR) - Violence-induced trauma has negative impact on MH
- Both provider and patient exposed to violence
- MH has negative impact on social capital and
physical functioning - Undiagnosed and untreated MH problems place
significant burden on health care system
33Harvard Program in Refugee Trauma
- 22 Putnam Avenue
- Cambridge, MA 02139
- http//www.hprt-cambridge.org