Need for Global Psychiatric Help

1. 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

3. 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

4. http://www.who.int/msa/mnh/ems/dalys/table.htm

5. High Burden of Disease Worldwide due to Mental Disorders

6. Leading global causes of YLD, high-income and low- and middle-income countries, 2004

7. “Resources for mental health are scarce and inequitably distributed between countries, between regions, and within local communities.” (Saxena et al., 2007)

10. 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.

11. 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.

15. This is a Public Health Issue PTSD LIFETIME PREVALENCEIN FOUR POST-CONFLICT SETTINGS, 1997-1999 SOURCE: JAMA 2001, v286:555-562

16. 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).

18. 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

19. DSM-IV 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.

20. 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 neurovegatativesx. & 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.

21. 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

22. 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

23. SEM’s SM’s

24. 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

25. 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

26. 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

27. Thank You! “You must be the change you want to see in the world.” Mahatma Gandhi