Mental Health Programmes

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Mental Health Programmes
International Medical Corps
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Agenda

• The needs
• Our response
• Future plans

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The problem

• 450 million people suffer from mental and
  behavioural disorders worldwide
• Mental illness is one of the most significant non
  - communicable diseases
• Mental illness accounts for 6 of the top 20
  leading causes of disability worldwide
• Stigma, fear, therapeutic nihilism, poor
  training, and lack of resources all result in
  those suffering being among the worlds most
  dispossessed

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Mentally ill people (are)

• Bad Good
• Violent Non-violent
• Lazy Hard working
• Stupid Intelligent
• Unable to learn Learn fast
• Have no feelings Have feelings
• Must take medicine for life Can stop
  taking medicines
• Cannot marry Can marry
• Unable to have children
  Can have children
• Should be locked or tied up
  Can live at home
• Should not vote Can Vote
• Have no rights Should have
  their rights

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Lack of resources
Region percentage of countries percentage of countries
  less than 1 psychiatrist per 100,000 more than 10
Africa 89 0
SE asia 100 0
Europe 2 43
Low income 88 (97) 0
High income 0 50 (67)

• (n) percentage of population covered
• Most psychiatrists in low income countries are
  in urban areas leaving the rural population with
  none

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Available means of care
Psychiatric hospital Jalalabad, Afghanistan
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The Shrine, Jalalabad, Afghanistan
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Mental health needs in complex emergencies
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• Self recovery the norm for majority
• 30 have symptomatic responses that would benefit
  from professional assistance
• 10 more enduring problems
• Most vulnerable are those who had previous
  problems

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Our role in acute emergencies
Kosovo/Macedonian border 1999 15 cases of
hyperventilation a day 1 acute psychosis per day
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Grief and Loss

• Everyone in an emergency has suffered some kind
  of loss, many have suffered multiple overwhelming
  losses

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• Massive losses that affect whole communities
  deprive each individual of the normal support
  they would have received if their loss had been a
  singular occurrence ...

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• Outsiders have a role
• Support
• Listen
• Witness
• Help to mourn
• Help reconnect

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Serious psychiatric disorders in emergency
contexts

• Stigma
• Fear
• Neglect
• Disruption of medication
• Loss of social support

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Indigenous systems of care

• Can be effective
• Disrupted by disaster

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Some practices can be harmful
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An example of collaborative care
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Crisis provides an opportunity

• Existing psychiatric services limited to major
  cities, hospital based, little contact with
  indigenous systems
• Disaster and conflict disrupt/destroy existing
  services, referral and communication network
• Ministries of Health identify need for community
  based services
• Need for increased capacity at primary health
  care level
• International media and donor attention provides
  funding opportunity
• Development of community based services requires
  example, capacity building and training

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Examples of IMC responses
Bassian camp, Balakot NWFP, Pakistan January
2006
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IMC mental health programmes in complex
emergencies

• Caucasus
• Afghanistan
• Indonesia (Bali, Java and Sulawesi)
• Sierra Leone
• Chad
• Sri Lanka
• Aceh
• Mississipi
• Pakistan

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Programme principles

• Prioritize social interventions
• Community identifies needs
• Address severe stress and grief through community
  based mental health services
• Integrate into the primary health care system
• Ensure sustainability by capacity building
• Avoid brief programmes and short courses
• Service should be appropriate to the local
  context
• Interventions require an evidence base
• Provide a continuum of care

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Issues confronting service providers

• Access
• Security
• Disrupted social networks
• Lack of employment/schooling
• Minimal or absent infrastructure
• Dependence on indigenous healing systems (also
  disrupted)
• Lack of medications
• Stigma
• Human rights abuses

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How we work

• Understand and engage in national strategy
• Understand existing health care system
• Baseline assessments of need
• Assess health care provider capacity
• Engage with indigenous healing system
• Continuing ethnographic research

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• Engage with psychosocial agencies to create
  continuum of care
• Train PHC providers in psychological first aid
• Identify most suitable mental health care
  providers in PHC system
• Set up clinical mental health service in PHC
  setting
• On the job training plus in service theoretical
  training
• Community psycho-education programme
• Foster the reintegration of social networks

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Pakistan, NWFP

• NWFP population 30 million,
• 70 psychiatrists, all in urban areas
• Earthquake Oct 8
• 78000 dead
• 3 million homeless
• 1.9 million in tents
• 400,000 stayed in own destroyed villages

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Mental health needs

• High rates of depressive and anxiety disorders,
  women in the rural population (72 of women and
  44 of men in one study).
• Disorders associated with
• less education (in younger women)
• low financial status
• longer duration of marriage
• interpersonal conflicts with husband or in-laws
• husband's unemployment
• lacking a permanent source of income
• lack of autonomy in making decisions
• North West Frontier Provinces are one of the
  poorest and most deprived areas of Pakistan.
• All vulnerability factors present and exacerbated
  by earthquake

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Earthquake exacerbated problems

• Forced unemployment in men
• Crowded, cold living situations
• Lack of occupation
• Greater restriction for women
• Forced early marriage.
• Feelings of aggression and thoughts of self harm
• Increased domestic violence
• Boredom
• Fear of future earthquakes

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Current programme
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Sierra Leone

• Sierra Leone is one of the most impoverished
  countries in the world
• Population 5 million, 60 Muslim
• Life expectancy of 33/35 years
• HALE index of 28.6 (expected years lived from
  birth without health related loss)
• Civil war 1991 2002
• Both sides commit atrocities and recruit child
  soldiers. Revolutionary United Front
• (RUF) notorious for mass rape and amputations

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Kailahun district, Eastern Sierra Leone

• Population c. 300,000
• 80 houses destroyed
• gt 80,000 displaced, gt 8000 registered
  ex-combatants
• 1 psychiatrist and 120 bed hospital in Freetown
  (14 hours away)
• 52 PHCUs, indigenous healers strong role
• High levels untreated psychosis and substance
  abuse in community

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Sierra Leone IMC mental health programme

• IMC pilots training of community mental health
  officer
• International supervisor provides 6 months
  on-the-job training
• Regular training of 52 PHC workers
• Joint clinics and training with local indigenous
  healers

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Aceh province, Indonesia

• Population 4.5 million, 97 Muslim
• Life expectancy of 63 years
• Conflict since 1976
• Martial Law 2003
• 26 December, 2005, Tsunami 131,000 dead
• Peace treaty August 2005
• Problems of post conflict community plus natural
  disaster

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Aceh IMC mental health programme

• Government committed to developing community
  based services
• Key provider community mental health nurse
• IMC piloting field training of community mental
  health nurses at four PHC sites (4 supervisors)
• Training PHC staff in mental health at all sites
• Community development programme at all sites
  (music, culture, sport, school activities)
• Livelihood programme at all sites

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Aceh February 2005
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Top 10 Reasons for Referral
ACEH, PROBLEMS POST TSUNAMI n ACEH, PROBLEMS PREDATING TSUNAMI n KAILAHUN, SIERRA LEONE n
Losses (remembering, sleep problems, somatic complaints) 21 Crazy behaviour or diagnosed psychotic illness 14 Fits 113
Anxiety/worry/fear 17 Longstanding anxiety or panic 6 Out of head 15
Sleep problems 14 Mental retardation/deafness 3 Strange behaviour 14
Low mood 10 Losses with somatic symptoms 3 Not correct in mind 9
Somatic complaints 7 Longstanding sleep problems 3 Crazy 8
Palpitations 7 Epilepsy 2 Headache 5
Childhood fears 3 Wanting medication 2 Not making sense 3
Poor appetite 2 Long term or recurring depression 2 Trembling attack 3
Guilt over losses 2 Forgetful 2 Aggressive behaviour 2
Forgetful 2 Unclear speech 1 Dizziness and falling 2
Total patients March June 2005 123 Total patients March June 2005 42 Total October -April 05 204
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Diagnoses Sierra Leone

• Epilepsy 64
• Psychosis (unspecified) 24
• Depression 4
• Substance abuse 3.5
• Mania 2
• Mental retardation 1
• Schizophrenia 1

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Attended indigenous healer priorto IMC clinic
visit
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Continuing Problems

• In the affected country
• No baseline assessment of mental health needs
• Governments lack resources to ensure sustainable
  services
• Mental health remains low priority
• Lack of policy, strategy and modern mental health
  legislation
• Drug supply lines inadequate and inconsistent
• Newer effective treatments are not on WHO or
  government essential drug lists
• Minimal training in mental health in nursing and
  medical schools
• Heavily stigmatised patients and profession

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Problems for NGOs

• Donors are still PTSD focused
• Serious mental illness still does not receive
  enough attention from humanitarian community
• On the job training is labour and time intensive
• Trainers require comprehensive background
  (general, child, adolescent and substance abuse)
• Global shortage of mental health professionals
• Effective evaluation of programmes e.g.
  randomised trials difficult to combine with
  emergency service provision
• Need for culturally appropriate interventions

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Other activities

• IASC task force
• Mental health in complex emergencies course
• Advocacy and research
• Future programming
• Development of current projects
• New projects nutrition and mental health
• Respond to new emergencies

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Development of current projects

• MOHs in Indonesia, Sri Lanka, Sierra Leone and
  Pakistan requested IMC to extend training
  programme to government employed staff in wider
  area.
• Training materials and model of training adopted
  by MOH in Sri Lanka
• UNHCR requested IMC to train others in programme
  design in Chad

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Future programmes

• Integrate mental health with nutrition programmes
• Collaborate with WFP
• Food for education
• Therapeutic feeding

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Integrating food and mental health

• 220 million children aged less than 5 years in
  the developing world have significantly impaired
  growth.
• World Bank called for mainstreaming nutrition
• WHO guidelines on mental health and severe food
  shortage emphasizes need to address both combined
  programmes

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END