Week 9 Slides: GMH Susmita PDF

A Global Perspective on Mental Health Susmita Chandramouleeshwaran Assistant Professor Staff Geriatric Psychiatrist Department of Psychiatry University of Ottawa | Université d'Ottawa The Ottawa Hospital | L’Hôpital d’Ottawa...

A Global Perspective on Mental Health Susmita Chandramouleeshwaran Assistant Professor Staff Geriatric Psychiatrist Department of Psychiatry University of Ottawa | Université d'Ottawa The Ottawa Hospital | L’Hôpital d’Ottawa Clinician Investigator Ottawa Hospital Research Institute. Faculty Disclosure Conflict of Interest: Nil Bias: Possible bias due to training as mental health specialist, tempered by work in Global South  We come from: Different lived experiences Different fields of specialization Different cultures Perspectives on mental health Today, We hope to think about what “global mental health” means How we may approach it These shape our perspectives on what is mental health, mental illness and how best to approach them  Background Trained at Christian Medical College, India. Tertiary referral center serving multiple populations from South Asia as well as primary catchment area in three provinces in South India Worked in various settings in India: faculty in alma mater, urban slum in Delhi, and remote mountainous district Move to Canada: further training in Geriatric Psychiatry at University of Toronto Working as faculty at University of uOttawa since 2021  Current work Amalgamation of previous experiences and interests Clinical work and research in geriatric psychiatry Work with partner organization KCMC at Tanzania Lead the global mental health program at uOttawa Help build capacity in Geriatric Mental Health at KCMC, Tanzania Editor, PLOS Global Public Health What shaped my perspectives? - Gudalur Adivasi Hospital  Remote town in tiger reserve Catchment of 20,000 “Adivasi” people Very exploited, marginalized population Spread out over 100 villages, most accessible by foot only Widespread poverty and malnutrition, loss over traditional lands and way of life Nearest psychiatric hospital 3 hours away. Joined work here as only psychiatrist in the district, young and experienced in tertiary care center. I did not have an idea there were such underserved people in my country, this is true even in global north, esp in the case of mental health. For the first time, I heard the term global mental health. Needed to unlearn a lot of what I learnt, and to redefine my role as a psychiatrist to be able to serve this population. Approach to providing quality mental health to all in this setting is not very different on a larger scale in different parts of the world. https://ashwini.org/history/  Up until 2005, serious mental disorders went largely untreated People with schizophrenia or bipolar disorder lived without treatment all their life High rates of alcohol use, suicide among youth Yet, this place has a successful community mental health program today Despite the fact that there is still limited access to medications / specialists I am a small cog in the wheel in this change that was largely driven by the need of the population themselves. Learnt the principles of global mental health, gaps in providing good mental health for all, and an approach to providing quality mental health in these settings, which is valid in most populations across the globe. The hospital was started by the Adivasi people to take care of their health needs, as they felt they would not be served well in the govt hospitals. It is staffed and run entirely by the indigenous population. My day here: teaching village health workers about depression / anxiety, planning a meeting with primary care doctors, traveling to a remote village without internet access to see one patient who did not come out of his house in days, or talking to school teachers at local school about adding a module on life skills.  Any guesses ? Life was very different from how it was earlier, had to unlearn much of what I thought was “psychiatry”.  What is Global Mental Health? Global health is “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide”. (Patel and Prince, 2010) Global mental health is the application of these principles to the domain of mental ill-health. Or simply, it is just mental health viewed through the lens of achieving equitable health care for all.  Global Mental Health No health without mental health Martin Prince, Vikram Patel, Shekhar Saxena, Mario Maj, Joanna Maselko, Michael R Phillips, Atif Rahman Resources for mental health: scarcity, inequity, and inefficiency Field came into prominence with Shekhar Saxena, Graham Thornicroft, Martin Knapp, Harvey Whiteford Lancet series on GMH in Sep 2007 Treatment and prevention of mental disorders in low-income and middle-income countries Vikram Patel, Ricardo Araya, Sudipto Chatterjee, Dan Chisholm, Drew together experts to highlight Alex Cohen, Mary De Silva, Clemens Hosman, Hugh McGuire, Graciela Rojas, Mark van Ommeren the gaps in mental-health services worldwide, and to formulate a clear Mental health systems in countries: where are we now? KS Jacob, P Sharan, I Mirza, M Garrido-Cumbrera, S Seedat, JJ call to action Mari, V Sreenivas, Shekhar Saxena Barriers to improvement of mental health services in low- income and middle-income countries Benedetto Saraceno, Mark van Ommeren, Rajaie Batniji, Alex Cohen, Oye Gureje, John Mahoney, Devi Sridhar, Chris Underhill Scale up services for mental disorders: a call for action Lancet Global Mental Health Group  Foundations of the field… Mental illnesses are universal despite differences in models of understanding and dealing with them. They are a leading cause of suffering and death in all world regions. People living with mental disorders face massive discrimination and human rights violations worldwide. There are cost effective, efficacious treatments available for mental illness, which can be easily provided by primary care.  Just how big is this problem? Close to 1 billion people live with a mental disorder. Additional 53 m and 76 m cases of depression /anxiety during pandemic. 13% of the world population experienced mental illness in 2021! 3 m people die every year from the harmful use of alcohol 1 person dies every 40 seconds by suicide.  How is this problem distributed? LAMIC home to more than 85% of the global population but command < 20% of the share of the mental health resources. Over 75% of those identified with serious mental disorders in the World Mental Health surveys in LAMIC received no care at all despite substantial disability. There are multiple underserved populations in high income countries too! Mental health expenditure worldwide Mental health workforce distribution  How about the global disease burden? While mental disorders can cause direct mortality due to suicide / eating disorders, YYL: Years of Life Lost are typically low A better measure of burden would be DALY or Disability Adjusted Life Years 1 DALY = 1 year of healthy life lost Mental disorders are the 6th highest cause of global health loss worldwide Slightly more in women, depression and anxiety which are common mental disorders account for over 60% of DALYs due to mental disorders Global disease burden due to mental disorders Stayed similar or even slightly increased over the decades, despite improvements in understanding of mental illness, more specialized Rxs. Similar to the prevalence data, we see an interesting trend. Higher DALYs/ 100k population in developed countries! This is despite the much higher allocation of funding toward health and mental health, more specialists per population, and more services available. No real measurable impact on impact on mental health in terms metrics in US, suicide mortality rates / homelessness due to mental health is increasing healthdata.org What are the gaps in global mental health? IRGS Information gap: Insufficient Resources gap: 2% of health budget research, < 5% of mental health spent on mental health, lack of research funding to LAMIC. essential medicines, workforce. Governance gap: most money on Service gap: Limited psychosocial Rx in primary care, few income / mental health goes towards employment or education supports in psychiatric hospitals. LAMIC.  Failure of humanity Widespread humanitarian violations in the name of mental health. Loss of freedom, dignity and basic human rights. Not limited to global South Lack of community health care causes prisons or psych institutions, religious healing centers to become only means of care. Global mental health: a failure of humanity. Kleinman, Arthur, The Lancet  Current mental health care system is: dont stop HIM Diagnosis based Are we doing something Specialist centered wrong? Hospital based Medication oriented Institutional Clearly there is an approach issue, and this is something we will be looking at in detail in the following slides. An alternative approach to address gaps 1. Beyond health care sector 2. Life cycle approach to mental health 3. Integrated care BI(c)LT: 4. Task shifting Beyond Health Care Sector Integrated Care 5. Scaling up Life cycle approach to mental Health Task shifting 6. Address stigma 7. Deinstitutionalize 8. Evaluate Approaches to address gaps: beyond health Provision of minimum standard of life to all people Poverty, conflict, famine, pandemic and humanitarian disasters associated with increase in mental health concerns Sexual minorities, immigrants, indigenous populations “ individual distress is a symptom of societal distress” Approaches to address this inequity: life stages approach Focus on identifying problems early 20% of world’s children and adolescents have a mental health condition. Pandemic affected youth disproportionately Suicide is the second leading cause of deaths among youth. Acting early can prevent lifelong mental health concerns. Can help tackle stigma Approach to address gaps: Integrated Care Integrate mental health care into pre- existing programs Collaborative care models identified as effective ways to treat depression in high income countries. Integration of mental health with primary care, maternal health, school health, and HIV programs Integrated Care (eg) In Nepal, mhGAP was implemented as part of a comprehensive mental health care plan in Chitwan district. Non-specialists in primary care facilities were trained and supervised to detect, diagnose and begin treatment for priority mental health conditions using the mhGAP-IG.  Approaches to address gaps: task shifting Task-shifting: highly qualified health workers share specific tasks with health workers having less training and fewer qualifications Redefine role of specialists: training, supervision, and support (eg) StrongMinds Uganda trains volunteers to provide interpersonal therapy for depression. 80% recover, results sustained 6 months post intervention  Approaches to address gaps: scaling up Population -wide provision of simple and effective interventions. mhGAP (Mental Health Gap Action Program): WHO evidence - based guidelines for managing mental, substance use disorders by nonspecialist health workers in routine health care settings. Approaches to address gaps: harness the power of technology Digital technologies: reduce travel time, expense, provide anonymity, and more easily available than mental health professional! Support non specialist providers, remote care or self help EMPOWER is an online, interactive training program that teaches supervised community health workers to deliver mental health interventions for different conditions. It is being simultaneously developed in India and the United States. Approaches to address gaps: Inclusive care Address stigma: Active (eg) INDIGO is a collaboration of participation and contact with research colleagues in over 40 people with mental disorders and countries worldwide committed to their caregivers. developing knowledge about mental illness related stigma and discrimination, both in terms of their Educational campaigns, training origins and their eradication. and learning activities  Approaches to address gaps: deinstitutionalize Shifting care from institutions to “Trieste model” communities Dr Franco Basagilia Cost effective Global standard for community health care Improved QOI, met needs of Psychiatric hospital to community mental people health centers Reduces stigma Caveat: not an excuse to reduce mental health expenditure We move away from…...toward seeing people as a diagnosis understanding people’s life stories and life plans (diagnosis-based) => L (life cycle appraoch to mental health) hierarchical relationships that elevate clinicians, social horizontal relationships between people; kinship workers or staff over clients punitive rules or requirements empowerment through mutually negotiated strategies the sterility of institutional life the warmth of a home or family ethos deinstitutionalize => community centered care prohibition against or avoidance of chores or voluntary participation in daily community life responsibility social isolation from neighbors, family, friends or full participation in community life in all its aspects community being “cared for” caring for others through work, service, purposeful engagement Approaches to address this inequity: ongoing evaluation Evaluation of programs: Ongoing research into effectiveness of programs Research into scaling up of effective programs Global communication about strategies that work. Case study  Gudalur Adivasi Hospital Different “Adivasi” groups formed a registered society standard Campaigned for basic std of life: establishment of a school and hospital for indigenous population Obtained access to government programs such as food rations, electricity, and higher education Promotion of health at village level: sports clubs for youth, cultural programs  Gudalur Adivasi Hospital Grass-root based health program: volunteers in each village trained as “health workers” Village health workers: promote health practices, provide education, treat common health concerns Identified people with increased health needs and refer to next level Eight area centers with trained health nurses One central hospital: general physicians and specialists  Community mental health program Ongoing education provided to village health workers on common mental disorders, causes, and symptoms. Identify people with emotional concerns, increased substance use, or at increased risk of mental health concerns (eg) bereavement. Provided education and support, regular follow ups Connect to local support groups (eg) AA Refer to area centers  Community mental health program Area center: health nurse able to do a psychiatric assessment, questionnaires (eg) PHQ 9 /GAD 7 and reach possible diagnosis Provide crisis counseling Telehealth consultation with physician at hospital General physicians: common and some severe mental disorders Referred in case of severe symptoms to psychiatrist  Gains made through community mental health program Increased reporting of mental Challenges: continued funding health concerns. Disseminating results broad platform. Marked reduction in suicide deaths Scaling this models in other by 50%. communities worldwide. Reduction in time taken to see care provider in case of severe mental disorders to < 1 week. This is a microcysm of the big picture, widespread nature of mental disorders, gaps, simple effective Rx approaches provided by non specialist workers. This / similar models are not to be implemented / effective only in a remote /underserved or rural population. It would be equally effective in an underserved population right in our city: sexual minorities, indigenous people, new immigrants or minorities, homeless.  The way forward Mental Health included by UN as part of sustainable development goals 2015 WHO Member States have adopted the Comprehensive Mental Health Action Plan 2013-2030 Committing them to meet ten global targets for improved mental health.  Looking forward… While we do not know the future, there are reasons to be optimistic Increasing awareness about importance of mental health Increasing evidence on low cost-effective mental health treatments Newer affordable technology available to overcome treatment gap Needed: political will and funding to scale up effective treatments Needed: evaluation of ongoing programs and bi- directional communication between global north and south. “ Our vision is a world where mental health is valued , promoted and protected ; where mental health conditions are prevented ; where anyone can exercise their human rights and access affordable , quality mental health care ; and where everyone can participate fully in society free from stigma and discrimination.” Thank you! 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