Transcript Definition - Western Cape

Mental Health
25 June 2007
Presenter: Joanne Corrigall
1
The MH workgroup…
• Authors:
•
•
Joanne Corrigall, Catherine Ward, Kathryn
Stinson, Patricia Struthers, Jose Frantz,
Crick Lund, John Joske, Alan Flisher
Expert group:
Crick Lund, Alan Flisher, Dan Stein, Petro
Brink, Venecia Barries, Carol Bower, Carol
Dean, Fadia Gamieldien, Bronwyn Myers,
Bruce Phillips
Peer Reviewers:
Vikram Patel, Andy Dawes
2
Presentation Content
• Definitions
• Burden of mental illness
• Risk factors for mental illness
• Interventions & Recommendations
• Mental Health and Development
3
Definitions
• Mental Health:
“a state of well-being in which the individual realizes his
or her own abilities, can cope with the normal stresses
of life, can work productively and fruitfully, and is able to
make a contribution to his or her community” (WHO)
• Mental illness : group of disorders defined by specific
criteria which describe
– a particular severity of symptoms
– duration of symptoms
– the effects of these symptoms on a person’s ability to function
(socially and occupationally) i.e. symptoms result in DISABILITY
Example: Depression
4
Spectrum of mental health
Mental Illness
Mental Health
•Self-esteem
•Coping skills, problem solving
•Self-efficacy
•Impulsivity
•Sub-clinical symptoms
5
Burden of Mental Disorders
Socio-economic impacts
• Unemployment, poverty
• Poor housing
• Decreased school completion, academic
performance
• Decreased Social capital
• Increased violence
6
Burden of Mental Illness
Macro-economic:
• $ 147 billion annual cost in USA
• SA: no data but drug & alcohol costs
alone total R10billion
• Loss is mainly through effects on
productivity, absenteeism
7
Burden of Mental Illness
Disability
• Globally: 5 of 10 leading causes of
disability are psychiatric
• SA: neuropsychiatric disorders are 2nd
leading cause of BoD
• BoD figures exclude the impact of MH on
other BoD components…
8
Mental ill-health strongly
associated with…
CHILD
HEALTH
Injuries
CHILD HEALTH
HIV
Unsafe sex
Multiple partners
Early sexual debut
CVD
CVD
HIV
Smoking
Alcohol Abuse
Drug Abuse
9
Western Cape 2000 (YLLs)
HIV/AIDS
Homicide/violence
Tuberculosis
Road traffic accidents
Ischaemic heart disease
Stroke
Trachea/bronchi/lung ca
Lower respiratory infections
Suicide
Diarrhoeal diseases
Diabetes mellitus
COPD
Fires
Low birth weight
Septicaemia
Hypertensive heart disease
Breast ca
Nephritis/nephrosis
Asthma
Epilepsy
14.1
12.9
7.9
6.9
5.9
4.6
2.7
2.4
2.3
2.3
2.1
2.1
1.8
1.7
1.5
1.2
1.1
1.1
1.0
1.0
Source: Bradshaw et al, 2005
10
Prevalence in Western Cape
• South Africa: SASH study 30% life-time
prevalence
• No data for Western Cape
• Proxy measures: injury data specifically
homicide and RTAs
11
Proxy measures
MI proxy WC
GP
indicators:
Homicide 12.9% 8.3%
KZN
SA
4.7%
6.8%
Road
Traffic
Suicide
6.9%
4.4%
2.8%
3.7%
2.3%
1.5%
<1%
<1%
14.2% 7.5%
10.5
%
% of total 22.1
YLL
%
12
Aim of MH workgroup
1. Prevention of common mental disorders
 Depression
 Generalised Anxiety Disorder
 Substance disorders (includes abuse and


dependence)
Post Traumatic Stress Disorder
Childhood behavioural disorders
2. Promotion of mental health
13
Risk/protective factors
Living environment
Health
•Access to recreation
•Built environment
•Mental
illness
Safety
(housing,
•Health systems
neighbourhoods)
• HIV
••Basic
services
Violence
• Substance
use
• Crime illness
• Physical
• Disability
Social capital
Human capital
•Income
•Food security
MENTAL
Employment
•
Social
• Educationgrants
HEALTH
•Pre-school
•Transport
•Family systems
•School climate
• Death/trauma in
family
Material goods
•Unemployment
•Underemployment
• Social capital
•Occupational stress
Family
environment
• Social support
14
•Spatial segregation
Findings continued
• Majority of relationships are bi-directional:
Multiple deprivation
mental illness
• Cumulative effects
15
Conflict with neighbours
Basic services
Family environment
Food insecurity
Unemployment
Domestic Violence
16
Focus Areas selected
• Multiple Deprivation
•
•
•
•
•
o Unemployment
o Social assistance
o Food insecurity
o Housing
o Poverty
Trauma (preventing MI after exposure)
Pre-school education
Recreation
Mental Health Services
Substance use (Tik, alcohol & other drugs exlc. Nicotine)
17
Multiple Deprivation
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Interventions
• Employment programmes: JOBS programme,
•
•
•
•
•
public works etc.
Community development, micro-credit
Adult literacy, food security
Child care
Increase access to social assistance
Built environment:
o Housing
o Neighbourhoods
19
Trends in Status Quo
Existing interventions targeting housing,
unemployment, social assistance, literacy,
food security
BUT insufficient to meet need and/or not
optimally effective
AND insufficient cognisance of health
(including mental health)
20
Example: Housing
Housing factors associated with mental health
Type
Quality
•Single vs multidwelling
•High floor vs low
floor dwelling
HOUSING
•Structural deficiencies
•Pest control
•Dampness
•Housing satisfaction
Other
•Tenure
•Overcrowding
•Involuntary relocation
•Affordability of housing
21
Evidence for interventions
• Housing improvements consistently improved
•
•
•
Mental Health and decreased Mental Illness
Dose-response relationship
Other positive outcomes: physical health;
perceptions of safety; crime reduction; social
participation (social capital) ; improved
perception of the area as a whole
Effects of neighbourhood improvements : 50%
reduction in prevalence of mental illness
22
Housing recommendations
• Improve quality of state-subsidised
housing
• Increase housing subsidy amount per
applicant
• Improve capacity of housing applicants to
make financial contributions for their
homes
• Foster community participation & support
• Expand neighbourhood renewal projects 23
Example: Federation of Urban
Poor
24
Likely outcomes
Suitable housing
Social Capital
Human Capital
Increased income
Economic participation
Physical Health
Improved
Mental Health
HOW housing is provided can make a big
difference!
25
Pre-school
Pre-School
26
Window of opportunity
Early childhood is a sensitive period, and
competencies become cumulative. Thus,
without intervention, gaps between better
and worse-off children widen over time;
the earlier the intervention, the less it
costs and the lower the gap (Heckman,
2006).
27
Outcomes of high quality preschool:
•Improved school
• Decreased antisocial
readiness
behaviour
••Improved
40%
increase
in
cognitive
•Decreased
substance
abilities
Benefits of preschool have beenemployment
noted up to rates
27yrs!!
abuse
••Lower
Improved
maternal
failure
rates
•40%
reduction
in
employment
and
•Higher school
arrest
rates
education
completion rates
28
In Western Cape
• ECD a priority of WCED and DSD
• Audit done by DSD shows lack of access
to pre-school and poor quality of existing
preschools, unqualified teachers
• Another audit currently underway by DSD
29
Recommendations
• Develop high quality teacher training
programmes
• Develop high quality pre-school
programmes
• Resource roll-out of pre-school across
Province (urgently in high risk areas:
15 high priority areas)
30
Recreation
31
Evidence
? Arts, music, dance
Physical exercise
Leisure
boredom
Recreation
? Other
Recreational environments
Mental Health
32
Major Gaps
• Focus on team/competitive sports
• Relative exclusion of other forms of
recreation
• Insufficient facilities, access to facilities,
resources
• Lack green spaces
• Lack of access: cheap transport
33
Recommendations
• Review & support provision of sports AND
recreation activities
• Protect and promote green and natural spaces
• Provide affordable and safe transport to
recreational facilities or areas
• Support S&R interventions that build social
capital
34
Trauma
Trauma
35
Violence
•Community (gangs or crime)
•Domestic violence
•Rape
•Child Abuse
Psychological
trauma
•Individual
•Family
•Community
•Police
Increased mental illness:
• Drug and alcohol abuse & dependence
• Post-traumatic stress disorder
• Depression, anxiety
Decreased Mental Health:
• Hostile/harsh parenting
•Loss self-esteem, self-efficacy, coping skills
36
Drug & Alcohol abuse
Itself a mental health problem
Psychological trauma
Psycho-behavioural
Outcomes
•Decreased inhibition, reasoning
•Increased risk-taking
•Increased libido
•Increased mental illness
•Decreased mental health
•Decreased parenting skills
•Poor interpersonal relationships
Violence
•Community (gangs or crime)
•Domestic violence
•Rape
37
•Child Abuse
Bottom line
Preventing and treating mental illness is an
important part of violence prevention
Violence prevention is an important part of
preventing mental illness
Preventing mental illness and restoring mental
health after exposure to violence is crucial
38
Recommendations
•
•
•
•
Training: trauma-informed non-health sectors
Consistently fund, support & roll-out NGOs
Develop resources for emergency placement
Provide mental health services in workplaces
with high trauma exposures
(police, teachers, social workers, NGO workers)
• Make sufficient provision for psychosocial
•
needs in disaster management
Develop post-graduate training programmes in
trauma
39
Recommendations cont.
Health:
• Training: trauma-informed general health
sector
• Integration of mental health staff into
general health services e.g. surgery
• Provide adequate mental health services
• Create strong referral networks with
trauma-related NGOs
40
Substance use
Substance use
41
Background
• Substance use e.g. nicotine, alcohol, ‘tik’,
heroin
• Substance abuse/dependence are defined
mental disorders
• Substance abuse/dependence also
increases risks for other mental illnesses;
high comorbidity
42
Alcohol
• Likely to be the commonest SOA in the Western
Cape
• Why?
 Socially acceptable
 Legal production and consumption
 Active promotion (media)
 Perceived to be benign
 Norms: culture of excessive use (abuse)
 Dop system
 Wine country
 Cheap!
43
Impact of alcohol
Violence
Out of he
Social impact
Road Traffic Incidents
Economic impact
HIV
Mental Health
CVD
Child Health (FAS)
44
Tik
• High profile
Why?
•
•
•
•
Illegal: associated with criminal activity incl. gangs
Socially unacceptable
New drug
Negative consequences of use occur sooner: abusers
deteriorate more quickly
• Severe effects in users
BOTH problems need to be addressed
45
Evidence for interventions
• Not effective
• Media campaigns with no other measures
• Scare tactics
• School-based information interventions
• Law enforcement of DUI laws
46
Recommendations
Decrease Demand
• Restrict advertising of alcohol
• Conduct concurrent anti-alcohol and drug
media campaigns that challenge prevalent
beliefs and ‘norms’
• Increase references to substance abuse in other
health promotion messages
• Include evidence-based substance prevention
programmes in school curricula
• Training of primary care and other health
workers
• Provide adequate treatment services
47
Decrease Supply:
•
•
•
•
Substantially increase the cost of alcohol & drugs
Reduce the availability of alcohol & drugs
Enforce existing laws on alcohol and other drugs.
Incorporate addressing substance abuse into multifaceted community development interventions
General
• Improve co-ordination of involved departments: DSD,
DEADP, DOH, DCS
48
Mental Health Services
49
Background
• Mental Health services:
Hospital to community based
• Scope
Promotion, Prevention, Treatment,
Rehabilitation
• Nature of mental illness
Typically chronic requiring long-term service
use
50
The greatest risk factor for mental illness is
previous mental illness…
51
Major Gaps
• Insufficient community-based services (schools,
•
workplace, home-visits, community-based care)
Community-based care for mentally ill:
• Residential care
• Day services
– Need post deinstitutionalisation
• Poor integration of services: particularly need in
•
•
maternal health, HIV, trauma services
Grossly insufficient MH services across the board but
esp. community-based health services
Impact of general health services on mental health
52
General approach to all
interventions
53
Targeting interventions
• Areas with highest violence and highest
Multiple Deprivation Index (including 15
priority areas)
• Vulnerable groups
• Critical periods
• Some interventions universal
54
Content & Process of
interventions
• Importance of multi-faceted interventions:
growing human, economic and social capital
(multiple deprivation)
• Participative justice : community participation
and empowerment is vital
• Address cross-cutting risk factors e.g. alcohol
55
Relationship to PGDS
Intervention Group
Multiple Deprivation
Substances of Abuse
Pre-school
Trauma
Recreation
Mental Health Services
Intervention Group
Multiple Deprivation
Substances of Abuse
Pre-school
Trauma
Recreation
Mental Health Services
Strategy 1:
Economic
Participation
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Strategy 5:
Resilient
communities
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Strategy 2:
Connectivity
infrastructures
Strategy 3:
Effective
transport
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Strategy 6:
Spatial
Integration
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Strategy 7:
Tolerance,
respect for
diversity
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Strategy 4:
Liveable
Communities
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Strategy 8:
Effective
governance
institutions
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56
Relationship to development
• Development impacts on mental health
• Small investments in health have large impacts
on income, education, democracy
• Global MDG interventions: MH component
embedded in these
• Mental Health is an essential Capability
(economic approach)
57
Where to from here?
58
Discussion points
• General comments
• What are the most appropriate forums for
taking this work further?
• Most feasible recommendations/ least
feasible?
59