Addressing the growing global mental health burden facing Low and middle income countries (LMICs)

1. Akwatu Khenti Director, Transformative Global Health, CAMH Assistant Professor, Dalla Lana School of Public Health, University of Toronto September 2012 Addressing the growing global mental health burden facing Low and middle income countries (LMICs)

2. Outline of the discussion The scale of the growing problem Why its such a huge burden for LMICS The nature of the challenges What can be done 2

3. Some Background • The addiction and mental health needs of the low and middle countries (LMICs) of the world are great….and growing • By 2020, 15% of GBD is mental and neurological disorders • Depression would be the number #2 source of burden of disease • About 30% of the world’s population (6.5 billion people) are experiencing mental health problems with about 2/3 of these people not receiving treatment…even in wealthy countries • There were also specific, related challenges, in our region of the world, the Americas • Substance abuse identified as the leading cause of adult mortality, related violence and injury in Latin America and the Caribbean (PAHO).

4. Big global gaps are growing Lack of skills at the primary health care level • Too few doctors and nurses know how to recognize and properly treat mental disorders. In 41% of countries there are no mental health training programmes for primary health care professionals • Lack of rational and comprehensive mental health policies and legislation • 40% of countries do not have a mental health policy; • 25% of countries do not have mental health legislation; and • 30% of countries do not have a national mental health programme.

5. Mental illness & addiction are huge public health challenges • About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to common mental disorders, alcohol-use and substance-use disorders, and psychoses. (Prince et al., 2007) • People with mental disorders are, or can be, particularly vulnerable to abuse and violation of human rights. (WHO, 2005) • Negative attitudes towards people with mental illness/addiction are recognized as a major public health problem as well as one of the main obstacles to the provision of care for people with this disorder. (Putnam, 2008)

6. Mental illness & addiction are huge public health challenges • The stigma associated with mental illness/substance problems harms the self-esteem of many people who have serious mental illnesses. (Link et al., 2001) • Negative opinions overemphasis social handicaps that can accompany mental disorders contributing to social isolation, distress and difficulties in employment by sufferers. (Crisp & Gelder , 2000) • There is evidence of institutional discrimination against people labeled with mental illness/substance use problems. (Link & Phelan, 2001; Verhaeghe & Bracke, 2007)

7. Imbalance sustains a treatment gap Most developing countries (alternatively LMICs) are under-resourced 1/3 lack access to needed medications; up to ½ in parts of Africa and Asia Even MICs like India need much more resources to meet population needs Limited support for CME & medical necessities 7

8. The Scale of the Problems One can only guess at the imbalance!!! 8

9. At the heart of the problem are: Inadequate health and poor mental health funding Too few mental health professionals Lack of mental health training for primary health care professionals Cultural beliefs and pervasive stigma 9

10. Huge training and capacity building needs Training of health professionals, knowledge exchange and capacity building in LMICs could have significant impact: • According to the World Health Organization, the enormous gap between the need for treatment of mental disorders and the ability of current health systems to meet this need were growing fast. • In developed countries with well-organized health care systems, it found that between 44% and 70% of people with mental disorders do not receive treatment. In developing countries the figures are even more startling with a treatment gap approaching 90%. • Many countries lack both human and material resources. “ The serious shortage of psychiatrists in low-income countries is illustrated by Chad, Eritrea and Liberia (with populations of 9, 4.2, and 3.5 million, respectively,), which have only one psychiatrist in each country, and by Afghanistan, Rwanda and Togo (with populations of 25, 8.5, and 5 million respectively) which have just two psychiatrists each”) (Lancet, 2007:35)

11. Strategic Goals • Build system capacity to meet addiction and mental health challenges in select regions of Latin America and the Caribbean, sub-Saharan Africa and South Asia (Basic and advanced training) • Engage and support 10-20 health professionals annually from select areas across the world to receive on-site training and follow up support (capacity building) • Foster the growth of new ideas and strategies, particularly in areas that have not been the object of much research or enquiry (knowledge translation) • Develop a strong academic component integrated into all aspects of our international health work (university teaching, poster presentations etc) (Global networking)

12. Key Activities - Capacity building • Chile, Santiago (April 2010 – March 2011): evaluation of mental health and addiction initiatives started in January 2009 with the participation of around 45 people from 17 institutional teams from Chile. The participant teams are already implementing their evaluations and will present them at the end of January 2011. • On site: (June - August 2010, jointly with CICAD/OAS: 10 academics from LA & Caribbean; June-August, 2009). • Brazil (Aracaju, Sergipe): Addiction Capacity Building Program for primary and secondary care (November, 2010): 73 participants: Psychologist, Psychiatrist, Nurses and Nursing Assistants, Social Worker in a 1 week program. • Mexico (Mexico City, Instituto Nacional de Psiquiatria): Institutional capacity building (Sepetember 2009): 40 participants from different sectors of the institution participate in needs based planning and consultation

13. Key Activities - Training • On site (March 2009):International metal Health and Addiction Leadership Training Program (Toronto, Canada): 18 professionals from PAHO and other national institutions in Latin American countries with regional responsibilities, as well as 4 key professionals from CAMH, participated. Eleven countries were represented. • Trinidad and Tobago (June 2010) : Basic and advanced addiction training provided to 55 health and allied professionals from 6 Caribbean countries • Panama: August, 2010: Meeting of Medicine Schools of Latin America about the Drug Phenomenon. Presented model to Deans and Directors of Medical Schools. • Tanzania (Aug. 2009/Dec. 2010): Strengthening addiction and mental health in primary care. 25 health professionals from across Tanzania participate in joint CAMH-Ministry of Health and Social Development progam • Panama (January - Dcember 2011): Mental Health management for Central America and the Dominican Republic): 16 mental leaders participate in joint PAHO-CAMH program with on line and face to face components.

14. Key Activities - Knowledge Exchange • Chile, Santiago (June 2009/Nov. 2010): International Seminar on Alcohol as a Determinant of Health: alternatives for policy development: 145 people attended. A CAMH support document was presented. • Panama (August, 2010): Meeting of Medicine Schools of Latin American about the Drug Phenomenon. CAMH presented. 45 participants attended, including all Deans and Directors of Medical Schools. • Enugu State, Nigeria (April 2009): Lectures provided to 100 medical students, mental health hospital staff and community health workers on the basics of addiction, mental health and concurrent disorders • Brazil, Mexico, Tanzania, Ontario, Peru/Chile (October 2009): Joint world mental health day activities involving 300 participants

15. Guiding Principles • The process begins with the need for training identified by the region or country in which the program will be conducted, • Set in local socio-political context • Places the primary leadership and ownership of training/education programs with the host country, • Operates on the principle of knowledge exchange/reciprocity • Looks first for local expertise • Determine appropriateness • Respect for the culture, especially how addiction and mental health are viewed • Training builds capacity and is sustainable