Transcript Global Mental Health_Henderson_5-1-10_2

Need for Global Psychiatric Help
David C. Henderson, MD
Director, Chester M. Pierce, MD Division of Global
Psychiatry
Massachusetts General Hospital
Associate Professor
Harvard Medical School
Mental health has become a major
international public health concern
• "We believe that mental health is just
as important as physical health, maybe
even more so.“ Donna Shalala, former
Secretary of the Department of Health
and Human Services
• "The challenge to humanity is to adopt
new ways of thinking, new ways of
acting, new ways of organizing itself in
society in short, new ways of living.”
Our Creative Diversity, UNESCO
http://www.who.int/msa/mnh/ems/dalys/table.htm
High Burden of Disease Worldwide due to Mental
Disorders
Leading global causes of YLD, high-income
and low- and middle-income countries, 2004
“Resources for mental health are scarce and inequitably
distributed between countries, between regions, and within
local communities.” (Saxena et al., 2007)
Historical Space
Mass violence creates in a society a new
historical space. Ordinary attitudes, feelings,
and behaviors are transformed. The healer and
sufferer find recovery in a therapeutic solidarity.
Within this historical space, justice forms the
core of the survivor-perpetrator relationship.
This is a Global Issue
• The aftermath of mass violence has the effect
of eroding the social, economic, mental and
physical health of affected nations and the
world
• Our evidence-based theoretical model reveals
the relationship between economic
development, social capital, human rights, and
health and mental health recovery in societies
affected by mass violence.
This is a Public Health Issue
40
PTSD LIFETIME PREVALENCE
IN FOUR POST-CONFLICT SETTINGS, 1997-1999
35
Percent
30
25
20
15
10
5
0
BASELINE
ALGERIA
SOURCE: JAMA 2001, v286:555-562
CAMBODIA
ETHIOPIA
GAZA
Culture, Context and Western Imports
• Concern about imposing western approaches to
psychiatry on diverse cultures – undermining
indigenous healing
• Risk of bringing in the “worst”: old and riskier drugs,
institutionalization, stigma
• At same time, neglect of MI is major practical/HR
issue in p-c environment (Lancet 2000)
• Principle: High level of critical awareness in melding
essentials of western psychiatry with local traditions
and customs
• Dilemma: Is this “marriage” always feasible.
Unintended dangers (stigma, adverse effects,
disruption of traditional care systems).
Influence of Culture on
Mental Illness and Mental Health
• How patients communicate
• How patients manifest symptoms
• How patients cope
• Range of family and community support
• Willingness to seek treatment
U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001
18
Explanatory Model
• Cultural explanations of the individual’s
illness
– It is important to understand how distress or the
need for support is communicated through
symptoms (nerves, possessing spirits, somatic
complaints, misfortune).
– The meaning and severity of the illness in
relation to ones’ culture, family, and community
should be determined.
– This “explanatory model” may be helpful when
developing an interpretation, diagnosis, and
treatment plan.
DSM-IV
Differences in Presentation of
Illness
• There are cultural differences in the
presentation of psychiatric illnesses.
– Cambodian woman may present with complaints of
fatigue and back pain, while ignoring other
neurovegatative sx. & unable to describe dysphoria.
– This same patient may admit to hearing the voices
of her ancestors, which is culturally appropriate.
– In many traditional, non-Western societies
• spirits of the deceased are regarded as capable of
interacting with and possessing those still alive.
20
Consequences of stigma
They died as they had lived
in chains: in Yerwadi, a
tiny but popular pilgrim
centre about 30 km from
Ramanathapuram in
Tamil Nadu. On August 7,
residents of Moideen
Badsha Mental Asylum,
their minds trapped in
another world and
bodies shackled in
"therapeutic chains",
were heard shrieking
into the night as flames
licked their bodies.
www.the-week.com/21aug19/ events12.htm
Chained till the end:
The charred remains
of inmates at Yerwadi
Consequences of stigma
BASAVARAJ
He suffers from
chronic
schizophrenia. He was
chained for 15 years
at his home in
Bangalore till
Vidyakar (below left)
brought him to Udavum
Karangal five years
ago. Now in his
forties, he is on
medication and seems
far happier
SEM’s
SM’s
The Ethnopsychopharmacological Approach
• Assessment
– Cultural formulation for Diagnosis
• Choice of Medication
– Use medical history, concurrent medications, diet
and food supplements / herbals combined with
knowledge of enzyme activity in certain ethnic
groups
• Monitor Patient
– Proceed slowly- Involve family
– If side effects intolerable - lower dosage, or
choose drug metabolized through different route
– If no response-check compliance, raise dose and
monitor levels, add inhibitors, switch drug
Principles of task-shifting
• Basing our choice of components for a package on the best
evidence available and perceived need
• Task-shifting to relatively low cost health workers or other
non-health professionals, supported and supervised by
specialists
• Collaborative stepped care delivery model
• Developed in a systematic process with consultation with
stakeholders and formative and piloting work
• Delivery through existing public systems
• Robust evaluation, with preference for RCTs wherever
feasible
Effective Collaborative Care Programs
• Effective multidisciplinary practice
– Efficient use of limited resources: mental health focuses on
patients who present diagnostic challenges or are not improving
– Shared workflows and accountability, effective communication
– Co-location is not collaboration
• Population focused
– Caseload-focused proactive care instead of ‘psychiatric urgent
care’ for individual patients: registries to prevent people from
‘falling through the cracks’
• Measurement-based stepped care
– Systematic application of evidence-based treatments, taking into
account patient and provider preferences and resources and
clinical outcomes
Thank You!
“You must be the change you
want to see in the world.”
Mahatma Gandhi