CASE STUDY: BOSNIA AND HERZEGOVINA (BiH)

1
CASE 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

2
Social 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
3
Major 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

4
ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND
DISABILITY, BOSNIAN REFUGEES, 1996 (N533)
SOURCE JAMA v282437, 1999
5
Persistence of Mental Health Symptoms Over 3 Years
6
Change in Symptom Status 1996-1999
7
Effect of Trauma, 1996
8
Effect of Trauma, 1999
9
THE 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
10
Feeling No Trust in Others, Past Week
11
2001 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

12
Primary 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

13
Providers 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

14
Providers 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

15
EDUCATION

• 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

16
(No Transcript)
17
ON-SITE VISITS/SUPERVISION

• Case-Oriented
• Goals
• To sustain the knowledge
• To improve relations between PCPs and mental
  health professionals
• To prevent burnout

18
Level of Trauma Experienced by PCPs and PCPs
Families
19
PCPs Confidence in Eliciting and Listening to
Trauma Stories Pre-training vs. Post-training
Mean confidence
20
PCPs Confidence in Diagnosing Certain Medical
and Psychiatric Problems Pre-training vs.
Post-training
Mean confidence
21
MENTAL HEALTH SERVICES OPTIMAL MODEL
Community
Police
Emergency Room General Hospital
Primary Health Care
General Hospital In-patient
Mental Hospital Criminally Insane
22
MENTAL HEALTH SERVICES IN BOSNIA
Community
Community Rehabilitation Centers
Primary Health Care
Psychiatric Hospital
23
MENTAL HEALTH SERVICES IN BOSNIA
Community
Primary Health Care
Community Rehabilitation Centers
General Hospital In-patient
24
FRAMEWORK 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
25
(No Transcript)
26
(No Transcript)
27
BiH 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

28
BiH 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

29
BiH 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

30
BiH Mental Health (MH) Case Study

• IV. Multi-Disciplinary Education
• Pedagogy of Trauma in BiH medical schools
• Integration into family medicine
• CME

31
BiH Mental Health (MH) Case Study

• V. Role of International Agencies
• Coordination/collaboration among BiH MOH UN
  NGO donors universities

32
BiH 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

33
Harvard Program in Refugee Trauma

• 22 Putnam Avenue
• Cambridge, MA 02139
• http//www.hprt-cambridge.org