Mental Health Integration and Community Care

Global Perspective on Mental Health

• Speaker: Susmita Chandramouleeshwaran, Assistant Professor, Staff Geriatric Psychiatrist, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute.

Conflict of Interest and Bias

• Conflict of Interest: Nil
• Bias: Possible bias due to training as a mental health specialist, tempered by work in the Global South.

Perspectives on Mental Health

• Diverse Perspectives: Different lived experiences, fields of specialization, and cultures shape perspectives on what constitutes global mental health, mental illness, and best approaches.

Background

• Training: Christian Medical College, India (a tertiary referral center serving multiple populations from South Asia).
• Work Experience (India): Diverse settings including faculty at alma mater, urban slums in Delhi, and remote mountainous districts.
• Further Training (Canada): Geriatric Psychiatry at University of Toronto.
• Current Position: Faculty at University of Ottawa since 2021.

Current Work

• Amalgamation: Combining previous experiences and interests.
• Clinical/Research Focus: Geriatric psychiatry, global mental health programs.
• Collaborations: Partner organization (KCMC) in Tanzania, leading global mental health program at Ottawa, building capacity in geriatric mental health in Tanzania.
• Publications/Roles: Editor of PLOS Global Public Health.

What Shaped Perspectives?

• Gudalur Adivasi Hospital (2016): Remote town, tiger reserve, 20,000 people, marginalized population, widespread poverty, malnutrition, limited access to services, exploitative situations..

Mental Health in 2005 and After

• Untreated Mental Disorders: Serious mental disorders were largely untreated in some areas, with people facing mental illness with schizophrenia and bipolar disorder not receiving treatment.
• High Rates: High rates of alcohol use and suicide existed amongst youth.
• Community Programs: Successful community mental health programs have emerged in some regions.
• Access to Specialists/Medication: Access to medications and specialists remains limited in certain areas.

How Big is This Global Problem?

• Prevalence: Close to one billion people live with a mental disorder.
• Pandemic Impact: 53 million and 76 million additional cases of depression/anxiety during pandemic.
• Global Mental Illness: 13% of world’s population experienced mental illness in 2021
• Harmful Use of Alcohol: 3 million people die from harmful use of alcohol annually
• Suicide: 1 person dies every 40 seconds by suicide.

Global Mental Health Distribution

• Resource Allocation Imbalance: Low- and middle-income countries (LMICs) are home to over 85% of the global population but command less than 20% of mental health resources.
• Lack of Access: Over 75% of people with serious mental disorders in LMICs surveyed by World Mental Health received no care despite significant disabilities. This highlights significant disparities in access to care in these regions.

• High-Income Countries: Underserved populations also exist in high-income countries.

Worldwide Mental Health Expenditure

• **Significant Gaps:**Huge differences in spending between high- and low-income countries for mental health expenditures and mental hospitals.

Mental Health Workforce Distribution

• Short Supply: The global median for mental health workers is 9 per 100,000 population.

Global Disease Burden

• DALYs = Disability-Adjusted Life Years: A more substantial measure of the burden of mental disorders, since it combines years lost to death with years lost due to disability, giving a broader measure of a community's health and well being.
• High Risk: Mental disorders are the 6th highest cause globally.

Gaps in Global Mental Health

• Information Gap: Insufficient research, less than 5% of mental health research funding directed to LMICs.
• Resources Gap: Only 2% of health budgets spent on mental health. Lack of essential medications and a workforce shortages are present.
• Governance Gap: Most funds directed to psychiatric hospitals, rather than addressing community needs.
• Service Gap: Limited psychological resources available in primary care settings. Limited income, employment, or educational support for people in low-income communities and countries.

Mental Health Care System Issues

• Current System: Diagnosis-based, specialist-centered, hospital-based, and medication-oriented.

Alternative Approaches and Solutions

• Beyond Healthcare Sector: Integrating mental health care into pre-existing programs, the life-cycle approach, integrated care, task shifting, scaling-up interventions, addressing stigma, deinstitutionalization, and ongoing evaluations, are all part of the solution to systemic mental health problems.
• Community Integration: Mental health services directly integrated within primary care, maternal health, school health, and HIV programs are examples of integrated mental health programs that can help to target groups of people who need those services.

Integrated Care

• Implementation: Mental health care integrated within pre-existing healthcare programs, with collaborative care models, and a wider integration to care including primary care, maternal health, education, and HIV programs.
• Training: Training non-specialists.

Task Shifting

• Role Redefinition: Trained health workers sharing specific tasks, redefined roles for specialists.
• Training: Supervision and support for trained individuals.
• Results: Examples included in Nepal and Uganda.

Scaling Up

• Wider Provision: Population-wide provision of simple, effective interventions.
• mhGAP: Mental Health Gap Action Programme (using WHO evidence-based guidelines).

Technology Harnessing

• Digital Solutions: Reducing travel time, expense, and promoting anonymity, increasing access for people with mental health problems.
• EMPOWER: Online training program for community health workers to deliver mental health interventions.

Inclusive Care

• Addressing Stigma: Active participation with people with mental health problems and their caregivers, campaigns, and training.


Deinstitutionalization

• Community Care: Shifting care from institutions to communities, promoting effective and cost-effective care, addressing quality of care, reducing stigma, and a caution about reducing mental health expenditure.

Ongoing Evaluation

• Program Effectiveness: Assessing the effectiveness of programs, looking at ways to expand effective programs.
• Global Sharing of Information: Sharing, communicating and disseminating strategies that work across cultures globally.

Gudalur Adivasi Hospital Case Study

• Community-Based Model: Grassroots health programs, with volunteers acting as health workers, supporting community-based and common mental health issues, and referral to more specialized areas as needed.
• Mental Health Program: Ongoing education for health workers on prevalent mental illness, identifying people in need (with substance use issues and bereavement), and supporting local support groups.

Community Mental Health Program

• Assessment: Trained nurses conducting assessments of mental health, using questionnaires.
• Support: Crisis counseling and telehealth, possible diagnosis, and referral based on severe symptoms.

This quiz explores the critical aspects of community health care in the context of mental health. It examines concepts such as early identification, intervention strategies, and the impact of socio-economic factors on mental health. Test your understanding of the integration of health care services and their importance in addressing mental health inequities.