Danger, Uncertainty, and Suffering: Existential versus Institutional Perspectives on Human Problems

1. Danger, Uncertainty, and Suffering:Existential versus Institutional Perspectives on Human Problems Arthur Kleinman, Harvard University Stockholm 2007

2. Mental Health and Social Suffering in Africa Arthur Kleinman November 22, 2007

3. Social Experience and Health • Cross-culturally we see health gradients that show that those with the highest socioeconomic status have better health status, including lower mortality and morbidity. • Those countries with greatest economic inequality have, relative to their overall economic status, the poorest health status • Mental health problems occur in clusters and those clusters correlate with economic and social problems like poverty, crime, and disintegrating inner cities. • We see higher rates of depression in women, in those who are not economically and politically integrated, and in the relatively powerless.

9. Epidemiologic Transition: Disease Typography

10. Gender Differences in Mental Health Problems WorldwidePercentage of DALYs* Lost

11. Social and Psychiatric Morbidity Several recurring social processes are sources of social and psychiatric morbidity • Repressive gender practices have widespread devastating consequences; empowerment and education of women, and support for families and youth, are crucial for diminishing many problems • Ethnic conflict breeds violence, displacement, trauma, and depression • Economic policies that create inequities in wealth and social resources, that isolate communities from political power, and that remove security systems for those in need, spawn cycles of poverty and desperation associated with ill health

12. Social-Psychiatric Clusters • Shanty towns, slums, vulnerable or marginal migrant populations • Alcohol and substance abuse, violence, depression and PTSD cluster and coalesce • How to respond? • Identify clusters in combined ethnographic and epidemiological research • Develop new modes of preventative and therapeutic intervention directed at such clusters

13. Suicide Rates in the World

14. Relationship of Suicide and Mental Illness • According to US psychiatrists, 90% of those who commit suicide have a diagnosed mental illness, most often major depressive disorder. This is disputed.

15. Kerala: Good Health Indices, Poor Mental Health Indices

16. Mozambique • Mental health is part of the primary health care system and there is little regular training of primary care providers on issues of mental health. • Few epidemiological data on mental illnesses are available. A government study1 found rural/urban divide to be significant for rates of psychoses, mental retardation, and epilepsy. A retrospective study2 on deaths from injuries of pregnant and postpartum women (n=27) found suicide was the cause in one third of cases. • As of 2005, there was no mental health policy, although a draft policy awaiting approval and a substance abuse policy has been in place since 1997. (SOURCE: Mental Health Atlas 2005. WHO) • Ministry of Health (2002-3) Community Mental Health Study. Mental Health Program. Department of Community Health. Mozambique • Granja, A.C. et al. (2002) Violent deaths: the hidden face of maternal mortality. BJOG, 109, 5-8.

17. Nigeria • Compared to other African countries, there is a great deal of epidemiological data on mental health in Nigeria. • Since 1991, a mental health policy has been in place whose major components are: advocacy, promotion, prevention, treatment, and rehabilitation. This is implemented through a national mental health program. • Mental health is part of the primary care system. Providers are regularly trained on mental health issues and actual treatment of severe mental disorders is available at the primary care level. (SOURCE: Mental Health Atlas 2005. WHO)

18. Rwanda • Although there is a paucity of epidemiological data, a 2002 study1 estimated that 5 years after the war, a significant part of the population had seriously disabling depression. • Both mental health (components: advocacy, promotions, prevention, and treatment) and substance abuse policies have been in place since 1995 and 1% of the national budget is spent on mental health. • Mental health is part of primary care and providers are regularly trained on these issues. • There are also community care facilities for mental health; however, problems in motivating staff to work in these areas and reinforcing pro-community behavior are common. (SOURCE: Mental Health Atlas 2005. WHO) 1) Bolton, P. et al. (2002) Prevalence of depression in rural Rwanda based on symptom and functional criteria. Journal of Nervous and Mental Disease, 190, 631-7.

19. Sierra Leone • There is no significant epidemiological data on mental health, as well as no national mental health or substance abuse policy. • A mental health coordination group has been formed of various stakeholders and is working on drafting legislation as well as developing models for community based care. • Mental health is part of the primary care system and despite little training for providers, care for severe mental illness is available. Although there is currently no community-based care, traditional healers and general practitioners fill the gap providing care in these settings. (SOURCE: Mental Health Atlas 2005. WHO)

20. Uganda • Epidemiological studies have found a high prevalence of mental disorders. A 2002 study1 found 30.7 % prevalance of mental disorders in adults in a particular district, supplementing an earlier (1979)2 finding of 20% suffering from a probable mental disorder and another 5% from a definite disorder, largely depression, hypomania and anxiety. • The national mental health policy, in place since 2000, emphasizes advocacy, promotion, prevention, treatment, and rehabilitation. • Community-based programs are in place that combine traditional medicine with western medical services and provide treatment as well as health education. (SOURCE: Mental Health Atlas 2005. WHO) Kasoro, S. et al. (2002) Mental illness in one district of Uganda. International Journal of Social Psychiatry, 181, 354-9. Cox, J.L. (1979) Psychiatric morbidity and pregnancy: a controlled study of 163 semi-rural Ugandan women. British Journal of Psychiatry 134, 401-5.

21. Comparing Resources

22. Burden vs. Budget

23. Number of Psychiatrists per 100,000 Population

24. Problem Areas • Primary Care • Early Intervention • Mental Health Care Financing • Quality of Care • Ethics and Forensics

25. Major Obstacles • Funding • Stigma • Infrastructure • Leadership

26. Financing • Intersectoral • Increasing Ministry of Health Support • Mobilizing International and Local Partners

28. Ways to Do It • Global Mental Health Research Collaborations • Global Mental Health Research Centers • Research Training Programs • Population Laboratories • Collaborative • Interdisciplinary • Basic • Applied • Surveillance • Local policy agendas • Intervention studies • Evaluation

29. Mental Health Population Laboratory • Sample size of approximately 100,000 • Potentially piggy-back onto existing population laboratories • Integration of basic science, ethnographic, epidemiological and clinical research • Generation of baseline population data as platform for intervention programs (e.g., suicide reduction programs) • Research in developed and developing world • Over-sample ethnic and class diversity

30. Community Research and Socio-Cultural Research • Poverty and Labor Conditions • Stigma • Substance Abuse • Gender • Infectious Disease • Political Violence and Refugee Populations • Epidemiology and Ethnography • Mental Health Services Research

31. Key Needs in Global Mental Health Research • Demonstration projects tied to rigorous external evaluation and funding for generalization of programs if outcomes are positive • Network of global mental health policy research centers in the developed and developing worlds • Networking Centers, Researchers, and Trainees