Mental Health in Africa

1. Mental Health in Africa Jarrett Richardson MD http://www.youtube.com/watch?v=Goc6FIUbnZM http://www.who.int/topics/mental_health/en/

2. This 14 year old boy has been tied up for six years. His mother refuses to have him admitted to Gulu Hospital which is only two kilometers away. Gulu, Northern Uganda. April 2011. (Photo by Robin Hammond/Panos)

3. Due to insufficient staff numbers, family members are encouraged to stay with patients at Brothers of Charity Sante Mental. This relative would often beat, tie up and drag the patient when she did not obey his instructions. Goma, The Democratic Republic of Congo. June 2011. (Photo by Robin Hammond/Panos

4. A mentally ill woman, who wardens identify as Sandy, stands naked in a squalid cell, in Juba's Central Prison, in South Sudan, Oct 22, 2012. There are no dedicated mental health facilities in Africa's newest country, so families often dump sick relatives at the nearest jail, where staff have little training or medication with which to treat them. (Photo: Getty Images)

5. Abstract: • Mental Health Problems are among the most common health problems in any culture and location in the world. • The burden of disease for mental health problems is as greater in economically deprived settings as in other settings. • Recognition and treatment of mental health problems with available resources is one of the major challenges to third world medical practice. • This presentation and discussion will focus on the evidence-based epidemiology and approaches to major mental health problems.

6. Special challenges of diagnosing and caring for people suffering from mental health challenges in Africa will be addressed. Educational Objectives 1- Participants will be able to describe the two most common mental health challenges in Africa 2-Participants will be able to choose to identify and begin treatment for the most common mental health challenges in Africa No conflict of interest to declare.

7. Concepts • Global Burden of Disease [DALY] • Epidemiology • Resource distribution • Prioritization • Stigmatization • General medical responsibility • Diagnosis not complex • Evidence based treatments not complex

8. Global Burden of Disease analysis provides a comprehensive and comparable assessment of mortality and loss of health due to diseases, injuries and risk factors for all regions of the world. The overall burden of disease is assessed using the disability-adjusted life year (DALY) A time-based measure that combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health.

9. The silent crisis: Mental health in Africa Modupeola Dovi Monday, 04 February 2013 • Steadily approaching the title of the second highest cause of disability in the world, mental health disorders are an international health concern that is gaining considerable attention. • Of the global burden of disease, 14% is attributed to neuropsychiatric disorders, indicating a 2% growth since the year 2000. • It is believed that the figure will have increased by another percent by 2020.

10. Risk Factors: Youth as an issue • According to the Mental Health and Poverty Project, one in five individuals will suffer from a diagnosable mental disorder in their lifetime. • Among the adults who suffer from these disorders, 75% are found to have developed them in their youth. • In fact, sufferers of persistent mental disorders in adulthood tend to be those whose condition first arose between the ages of 12 and 24. • African demographics……

11. Risk factors in the African context • Mental health issues among African populations are instigated by an assortment of factors. • The financial standing of populations in many African countries may be predisposing them to mental health problems. • Various studies state that individuals of a lower socio-economic status are twice as likely to suffer from common mental health disorders, as compared to the wealthy.

12. Furthermore, populations in East African countries such as Somalia, Ethiopia, Sudan, Rwanda and the Democratic Republic of Congo (DRC) have encountered armed conflicts and natural disasters in varying degrees. • This has resulted into the displacement of more than 1.5 million individuals from the East African region.

13. A consequence of these hardships may be the emergence of mental disorders. • The WHO estimates that 50% of refugees have mental health problems ranging from post-traumatic stress disorder to chronic mental illness. • The rise in the numbers of individuals who present with mental health problems places an even greater burden on an already under-resourced healthcare service in Africa.

14. Sample Epidimiology: Lifetime prevalence of psychiatric disorders in South Africa Lifetime prevalence of DSM–IV/CIDI disorders was determined for: • anxiety disorders (15.8%), • mood disorders (9.8%), • substance use disorders (13.4%) and • any disorder (30.3%). • Lifetime prevalence of substance use disorders differed significantly across ethnic groups. Median age at onset was earlier for substance use disorders (21 years) than for anxiety disorders (32 years) or mood disorders (37 years). The British Journal of Psychiatry (2008) 192: 112-117

15. The psychiatrist-to-patient ratio in Africa is less than 1 to 100,000, • 70% of African countries allocate less than 1% of the total health budget to mental health. • Liberia is a case in point. This is pre-Ebola data!!! • A 2008 report compiled by the WHO states that there are only 0.06 mental health professionals per 100,000 people in Liberia where, the S. Grant Mental Health Hospital is the sole inpatient facility for those suffering from mental disorders. • A study conducted by the American Medical Association found that 44% of Liberian adults exhibit symptoms indicative of post-traumatic stress disorder

16. The likelihood that these individuals are receiving treatment is very low, when taking into account the scarcity of mental health facilities in that country. • The Liberia National Mental Health Policy found that of those living in low income areas that need mental health services, only 15% actually receive treatment.

17. Mental Health Stigma • In many African countries, communities are often not empathetic towards mental health patients. • The mentally ill face discrimination, social ostracism and the violation of basic human rights, all due to an on-going stigma associated with mental health problems. • Ironically, some of these violations occur in institutions where people with ill mental health seek treatment. • Mental health facilities have been found with unhygienic and inhumane living conditions, such as the use of caged beds with netting or metal bars to restrain patients.

18. There are documented cases of individuals having been tied to trees and logs far from their communities for elongated periods of time without adequate food or shelter. • A study performed in Uganda revealed that the term ‘depression’ is not culturally acceptable amongst the population, suggesting that mental health issues are not acknowledged or considered a legitimate affliction.

19. In another study conducted in Nigeria, participants generally responded with fear, avoidance and anger to those who were observed to have a mental illness. • The stigma linked to mental illness in that country can be attributed to a variety of factors, including lack of education, fear, religious reasoning and general prejudice.

20. When surveyed on their thoughts on the causes of mental illness, over a third of Nigerian respondents (34.3%) cited drug misuse, including alcohol, marijuana and street drugs as the main cause. • Divine wrath and the will of God were seen as the second most prevalent reason (18.8%), followed by witchcraft/spiritual possession (11.7%). • Very few cited genetics, family relationships or socioeconomic status as possible triggers.

21. Declaration on mental health in Africa: moving to implementationAbdallah S. Daar, Marian Jacobs, Stig Wall, Johann Groenewald, Julian Eaton, Vikram Patel, Palmira dos Santos, Ashraf Kagee, AnikGevers, Charlene Sunkel, Gail Andrews, Ingrid Daniels, David Ndetei • Urgent action is needed to address mental health issues globally. • In Africa, where mental health disorders account for a huge burden of disease and disability, and where in general less than 1% of the already small health budgets are spent on these disorders, the need for action is acute and urgent. • Members of the World Health Organization, including African countries, have adopted a Comprehensive Mental Health Action Plan. • Africa now has an historic opportunity to improve the mental health and wellbeing of its citizens, beginning with provision of basic mental health services and development of national mental health strategic plans (roadmaps). • There is need to integrate mental health into primary health care and address stigma and violations of human rights. • We advocate for inclusion of mental health into the post-2015 Sustainable Development Goals, and for the convening of a special UN General Assembly High Level Meeting on Mental Health within three years. • Responsible Editor: Peter Byass, Umeå University, Sweden. • (Published: 16 June 2014)Citation: Glob Health Action 2014, 7: 24589 - http://dx.doi.org/10.3402/gha.v7.24589

22. World Mental Health Day 10 October 2014 • The theme for 2014 is “Living with schizophrenia”. The focus of the World Health Organization will be living a healthy life with schizophrenia • The 2011 World Health Organisation (WHO) Mental Health Atlas reveals that 110 of its 184 member states have an identifiable mental health policy.(8) • Of the 45 African member states surveyed, 19 reported to have mental health policies in place.(9) • http://www.mentalhealthafrica.com/

23. Public Health Conclusion • Africa has the lowest rate of mental health outpatient facilities, 0.06 per 100,000 people. • Given the steady rise in the number of mental health sufferers, African countries need to optimize the delivery of mental health care services and take steps towards making this crisis silent no longer.

24. The action plan outlines four broad targets, for member states to: • update their policies and laws on mental health; • integrate mental health care into community-based settings; • integrate awareness and prevention of mental health disorders; and • strengthen evidence-based research

25. http://www.searo.who.int/EN/Section1174/Section1199/Section1630_12925.htmhttp://www.searo.who.int/EN/Section1174/Section1199/Section1630_12925.htm http://www.searo.who.int/EN/Section1174/Section1199/Section1630_12925.htm

26. WHO Mental Health Gap Action Programme (mhGAP) http://www.who.int/mental_health/mhgap/en/

27. http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf?ua=1http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf?ua=1

28. mhGAP module Assessment Management of Conditions Specifically Related to Stress

29. Needed Paradigm Changes • From exclusion to inclusion • From biomedical to biopsychosocial [spiritual] • From short-term treatment to long-term care • From single disease focus to co-morbidity care • Recognition that MI interventions are as cost-effective as communicable disease interventions

30. Interventions • Anxiety Disorders: • Generalized anxiety • Panic Disorder • Acute PTSD • Persistent PTSD • Mood Disorders: • Bipolar • Unipolar Depression • Subsyndromal Depression • Somatazated depression

31. http://tinyurl.com/PFA-EbPsychological First Aid for Ebola Virus Disease Outbreak

32. Schizophrenia Cost EffectivenessUS $ per DALY averted Choose best answer: • Older [typical] antipsychotic drug • Newer [atypical] antipsychotic drug • Older antipsychotic drug plus psychosocial treatment • Newer antipsychotic drug plus psychosocial treatment

33. Schizophrenia • Improvements compared to no treatment of 18-19% for antipsychotic • 30-31% [antipsychotics with adjunctive psychosocial treatment] • Disability scaleof 0-1, average case of scz moves from level of 0.63 to 0.43-0.54 [treated]

34. Depression Cost-effectivenessUS$ per DALY averted Choose best answer: • Episodic treatment: TCAs • Episodic treatment: SSRI • Episodic psychosocial treatment • Episodic psychosocial treatment plus TCA • Episodic psychosocial treatment plus SSRI • Maintenance psychosocial treatment plus TCA • Maintenance psychosocial treatment plus SSRI

35. Bipolar Disorder US$ per DALY averted Choose best answer: • Older mood stabilizing drug • Newer mood stabilizing drug • Older mood stabilizing drug plus psychosocial treatment • Newer mood stabilizing drug plus psychosocial treatment

36. Panic Disorder US$ per DALY averted Choose best answer: • Anxiolytic drug [benzodiazepine] • Older antidepressant [TCA] • Newer antidepressant [SSRI] • CBT alone • TCA plus CBT • SSRI plus CBT

37. Principles of Mental Health Policy and Interventions • Community Care is better than hospital care • Drugs are not a panacea • Older drugs are relatively cost effective • Population-level prevention can be cost effective

38. Using TCAs • Often under-dosed. • Pearl: If no unwanted effects like constipation, dry mouth, orthostasis, visual accommodation changes, urinary hesitance--- dose may not be therapeutic • Cardiac arrhythmia concern mostly in combination with SSRI or other drugs that suddenly escalate TCA blood level.

39. Using TCAs • Unwanted effects precede wanted effects • Need to support and counsel patient through first couple of weeks till they start getting wanted effects. • Most will tolerate and benefit in time • Do not declare non-responsive until about 12 weeks

40. Using Antipsychotics • Unwanted effects precede wanted effects by hours to days • Acutely sedation may be most beneficial effect- precedes antipsychotic effect by hours/days • Full antipsychotic benefit may be weeks after adequate doses reached • If patient is not having any Extra-pyramidal Symptoms (EPS)= not likely at therapeutic levels

41. Using Antipsychotics • Unwanted effects: • cardiac- can monitor ECG qTc, or pulse, but risk/benefit for psychosis leans toward adequate dosing • Weight gain: manage from the beginning. • EPS: low dose benzo or anticholinergic agent as needed

42. Using Lithium • Narrow toxic/therapeutic ration • Unwanted effects precede wanted effects • Blood level monitoring if possible • Can monitor levels with unwanted effects. These suggest level too high. • Diarrhea • Tremor • Confusion • Polyuria/polydypsia [Neph DI]

43. Using Benzodiazepines • Do not use as sole anxiety treatment • Always combine with TCA/SSRI and psychosocial treatment • Short acting for panic attacks • Lorazepam etc [avoid Alprazolam] • PO or SL to abort panic • Right dose is dose that works • May be up to 6-10 mg per panic attack • Long acting for maintenance [not optimal treatment] • Diazepam

44. ECT

45. Psychosocial and Spiritual Care • Evidence based therapies that are effective for anxiety, depression. • Cognitive Behavioral Therapy • Interpersonal Psychotherapy

46. Psychosocial and Spiritual Care • Other psychosocial care • Supportive counseling • Case management • Family education and support • Living skills education • Spiritual Community Care • Chaplain, pastor, Bible Study groups, education of church deacons and leadership about mental illness

47. Concepts • Global Burden of Disease [DALY] • Epidemiology • Resource distribution • Prioritization • Stigmatization • General medical responsibility • Diagnosis not complex • Evidence based treatments not complex

48. Conclusions/Discussion • Mental Health is a real medical issue • Poor Mental Health is a major burden • Africa has more mental health burden than.. • Africa has much fewer mental health resources • The problem is not going to be solved by mental health professionals alone • General medical care must begin to engage with mental health • Mental Health treatments are as effective as other medical treatments • Since most medical care in Africa is provided by mission or Christian hospitals, the answer is with us.

49. A few websites • http://www.who.int/topics/mental_health/en/ • http://www.globalhealthaction.net/index.php/gha/article/view/24589 • http://www.consultancyafrica.com/index.php?option=com_content&view=article&id=1213:the-silent-crisis-mental-health-in-africa&catid=61:hiv-aids-discussion-papers&Itemid=268 • http://www.mentalhealthafrica.com/ • http://guardianlv.com/2014/07/mental-health-patients-all-but-condemned-in-africa/ • http://africamentalhealthfoundation.org/ • http://news.yahoo.com/photos/robin-hammond-s-condemned-mental-health-in-african-countries-in-crisis-slideshow/ • http://globalhealthafrica.org/2014/05/18/responding-to-the-needs-of-the-vulnerable-the-state-of-mental-health-care-in-africa/ • http://wn.com/Mental_Health_Care_in_Africa • http://mentalhealthnigeria.org/about.php • http://www.africaportal.org/articles/2012/09/18/improving-mental-health-treatment-gap-ghana • http://www.youtube.com/watch?v=Goc6FIUbnZM • http://www.youtube.com/watch?v=7vUwcCEXf7Y