1 geography of mental health where are mental health patients located? what are the attitudes of the...

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Geography of Mental Health

• Where are mental health patients located?

• What are the attitudes of the community towards the mentally ill and mental health facilities?

• Policies of deinstitutionalization – what is the public’s reaction?

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Geography of Mental Health

• In 1866, Edward Jarvis noted that mental hospitals were “much more local in their usefulness‘” than they were intended to be

• “Jarvis's Law”, as it came to be known, postulated that distance from a mental hospital predicted utilization.

• In district after district, the farther the distance from the hospital, the lower the utilization.

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Geography of Mental Health …

• For example over a 23 year period in Oneida County in the District of New York, the geographic area closest to the hospital sent an average of 1 patient for every 2,772 residents.

– second closest district, the ratio was 1 in 5,820 – third closest it was 1 in 7,351, – in the farthest district it was 1 in 11,535.

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• Jarvis concluded that distance counts.

• Patients are hospitalized in direct proportion to their nearness to the institution.

• Secondly, the closer individuals were to transportation corridors, the higher the hospital utilization.

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• Counties that were situated along the course of rivers, canals, or roads leading directly to the hospitals, sent proportionately more patients than counties of equal distance but not within easy access to transportation corridors.

• He understood the problem to be one of under-utilization in remote areas and argued that large and far-away regional hospitals should be replaced by smaller local hospitals located in the very midst of the populations they were intended to serve.

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• Jarvis's Law has been replicated numerous times and been found to apply to both inpatient and outpatient care settings

• The generalizability of this finding across different treatment locations suggests that distance-decay factors should be a key consideration when determining the placement of mental health services or facilities

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Social ecology of mental disorders

• By charting the place of residence of persons admitted to hospital for psychiatric evaluation or treatment in large US cities, Farris and Dunham (1960) identified what came to be known as a “typical ecological distribution” or gradient of mental disorders.

• The highest rates were found in the city centers and the lowest in the suburban areas.

• This gradient was subsequently replicated in Europe and in the United States.

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Social ecology of mental disorders

• These studies generated a broad range of possible explanations– Social selection (though migration or infant

mortality); – Geographic variability in the definitions of

mental illness (bias); – Social support or the lack of capacity of some

households to maintain the mentally ill without public assistance; and

– Social causation, both the direct and indirect effects of the living environment on mental health.

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A Global Understanding of Mental Health

• Globalization has meant that concepts of mental health are now increasingly applied across borders and cultures.

• The World Health Organization (WHO) developed the International Classification of Diseases (ICD-10), which, also indicated that culture plays a significant role in the manifestation, treatment, and course of psychiatric disorders.

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A Global Understanding of Mental Health

• Many people have challenged the prevailing diagnostic system, claiming it is too based in the culture and values of the West.

• Given the extent to which understanding of behavior is mediated by cultural norms, it is not surprising that psychopathology, which manifests itself behaviorally, must be to some extent contingent on cultural forces.

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A Global Understanding of Mental Health…

• It is the interaction between universal biological aspects of psychiatric disorders and contextual cultural forces that creates the challenge in understanding and treating them.

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Cultural beliefs and practices impact the recovery of people with mental illness

• What society considers a healthy and meaningful life is inextricably bound up with cultural values and belief systems.

• For people with psychiatric disabilities, while they may share diagnoses with people from different cultures, how they manifest and respond varies considerably.

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A comparison of psychosocial rehabilitation of mental illness in India and the US

• Stanhope, 2002

• Whereas the West has generated much of the theoretical and clinical knowledge about psychiatric disorders, there have not always been corresponding good outcomes for people with psychiatric disabilities in these countries.

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A comparison of India and the US…

• In fact, the developing countries with far less resources and services, have often produced better prognoses for those with disorders such as schizophrenia.

• So what role has culture played in the treatment and rehabilitation of people with psychiatric disabilities?

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India vs. US

• Significant factors in caring for people with psychiatric disabilities in India– an emphasis on interdependence, – externalized locus of control – family involvement

• Significant factors in caring for people with psychiatric disabilities in US– focus upon independence – individual productivity.

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India vs. US…

• Prevalence Rates of Psychiatric Disorders in India and United States

• It is estimated that 10 to 30% of the population in India have a psychiatric disorder at some point in their life

• Hence, India experiences psychiatric disorders among its population at similar rates to Western countries including US

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India vs. US…

• However, beyond incidence, differences in manifestation and prognosis rates indicate that culture is a significant determining factor.

• Indigenous understanding of psychiatric disorders, help-seeking behaviors, available services, social structures, and rehabilitation strategies all combine to shape the course of psychiatric disorders.

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Help-Seeking Behaviors: India vs. US

• Help-seeking behaviors in India are dictated as much by community perception and beliefs about the nature of a psychiatric disorder as by resources and availability of services.

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Help-Seeking Behaviors: India vs. US …

• In a study of 300 patients with psychiatric disorders, 55% attributed their psychiatric disorders to supernatural forces including ghosts, evil spirits, and witchcraft, and chose to consult traditional healers before seeking mental health services

• In rural areas with populations of lower socio-economic status, studies have found that up to 80% of people who have psychiatric disorders seek help from healers rather than physicians

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Help-Seeking Behaviors: India vs. US…

• However, there is also a pragmatic side to many of the help-seeking behaviors among Indian communities.

• Although traditional healers are the first care choice, if symptoms are acute and persistent, alternative services including modern medicine will be pursued.

• And there is often a close relationship between modern medicine and traditional healing systems in India.

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Prognosis for People with Psychiatric Disabilities in Developing Countries

• The shortage of psychosocial rehabilitation facilities in India leaves many people with psychiatric disabilities, especially in rural areas, without access to services.

• And those with access to services often do not choose to utilize them due to discrimination and alternative beliefs about the nature of psychiatric disorders.

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Prognosis for People with Psychiatric Disabilities in Developing Countries …

• However, despite large numbers of people with psychiatric disabilities being untreated, studies have found better prognoses for people with psychiatric disabilities in India and other developing countries.

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• Example:

• The International Pilot Study of Schizophrenia was a WHO sponsored study to investigate if similar symptom clusters for schizophrenia occurred in differing areas of the world.

• While incidence rates were found to be comparable throughout the world, follow-up studies revealed that outcomes for schizophrenia were significantly better in the developing countries

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• With 51% showing good outcomes in India as compared with 7% in Russia and 6% in Denmark (WHO, 1979).

• Subsequent studies, such as the Determinants of Outcome of Severe Mental Disorders have confirmed the findings that outcomes for people with psychiatric disabilities are more favorable in developing countries.

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• Patients in developing countries experience a more benign course or remission from psychiatric disorders at almost twice the rate as those in the industrialized countries (Warner, 1994).

• These unexpected findings strongly indicate that cultural context is a major factor in the course of psychiatric disorders.

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• They also raise questions about the appropriateness of developing countries basing their models of mental health care on theory and practices generated by the West.

• Instead, exploring the role of culture as a mediating factor in the course of psychiatric disorders has the potential to improve our understanding and practice in the field of psychosocial rehabilitation.

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Role of Cultural Beliefs and Values

• Belief systems play a large role in the formulation and outcome of the rehabilitation process

• Some have argued that just the adoption of western diagnostic interpretations of psychiatric disorders in India has negatively impacted prognosis for psychiatric disorders.

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Role of Cultural Beliefs and Values …• Indian healing systems have always recognized and

treated acute short psychotic episodes, but now the trend is to diagnose these conditions as schizophrenia

• The labeling process has brought with it all the discrimination and implied severity that surrounds schizophrenia in the West.

• Therefore, better prognosis rates in India may be due in part to bypassing the labeling process and, instead, subsuming a psychiatric disorder and its symptoms into ongoing social rituals, including indigenous healing systems.

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Role of Cultural Beliefs and Values …

• The World Health Organization has now recognized the strengths of integrating traditional healing into systems of care for psychiatric disorders.

• Traditional healing methods provide a cultural compatible, holistic approach, strong therapeutic alliance, and close connections with family and community (WHO, 1994).

• Another important element is the approachability of indigenous healers.

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Role of Cultural Beliefs and Values …

• People seeking help are able to avoid the stigma of seeking out a mental health professional by going to their local healer.

• Stigma plays a significant role in the response of Indian society to those with psychiatric disorders.

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The Role of Family • A key part in the process of subsuming psychiatric

disorders within sociocultural settings is the role of the family.

• The extent of family support for people with psychiatric disabilities has often been cited as a major factor in the rehabilitation process:

• Family support, which is so easily available in the developing countries, is the anchor for treatment and rehabilitation of the mentally ill in the outpatient management

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The Role of Family …

• A family's tolerance for a psychiatric disorder, even when symptoms are at their most acute, helps them take on caregiving responsibilities.

• In developing countries, up to 90% of people with psychiatric disabilities live with their families, whereas in the industrialized countries it is only half this number.

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• The existence of extended families and kinship networks particularly helps the caregiving process.

• In a study of a tribal community, researchers described how the strain of caring for a person with a psychiatric disorder is absorbed by all clan members, who take turns in providing social interaction and thereby reducing the burden on individual family members.

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• The existence of extended family and kinship networks can serve as an important buffering mechanism both for the person with a mental illness and their caregivers.

• When a family does seek care for a relative with a psychiatric disorder, be it through a healer or mental health professional, members are usually highly involved in this treatment.

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• The healer will be familiar with the family and a part of the community, and the whole family will be expected to be involved in care.

• This expectation is in contrast to Western models of care, which, in the treatment of schizophrenia in particular, are still tainted by theories purporting that psychogenic families cause psychiatric disorders.

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• Often, therapists perceive their role as empowering people so they can separate from a dysfunctional family, rather than facilitating transition back to the family.

• Even if the family is seen as functional, promotion of independent living is a common treatment goal.

• Mental health services in India, both inpatient and outpatient, not only encourage family involvement, but also often make it a prerequisite of care.

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Independence vs. Interdependence

• Despite better access to services and a high level of professionalization in community mental health systems in the industrialized countries, the rehabilitation of those with psychiatric disabilities is often undermined by cultural expectations of independence and productivity.

• In contrast, the central goal for psychosocial rehabilitation in India is interacting within a society that stresses interdependence.

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Independence vs. Interdependence …

• Individual needs and goals are secondary to living successfully within the family and community setting.

• This emphasis upon interdependence means that there

is more tolerance for a family member who needs more supports.

• The family member requiring extra support does not find this dependent role alien and threatening.

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• In the industrialized countries, the profound self-disorganization and ensuing loss of independence that is associated with onset of a psychiatric disorder is especially devastating for adults (Lefley, 1999).

• Western notions of identity are very much based on the ability to be independent, to pursue individual goals, and to have a sense of control over one's environment.

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• The transition from this to a more paternal form of care is extremely stressful for those seeking services in the West, as it indicates to the person a significant decrease in status.

• Personhood, a concept which includes self-mastery,

dignity, self-respect, and self-esteem, has becomes an increasingly important goal in psychosocial rehabilitation services in the United States.

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Changing Cultural Contexts

• Cultural arrangements and values are not constant.

• Such is the case in India and other developing countries.

• It is not clear that Indian society can continue to sustain this model of familial care or that it can be replicated in the West.

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Changing Cultural Contexts …

• But more significant is the fact that joint families are becoming less and less frequent in India, especially in urban areas.

• Some view this shift to more "modern" family arrangements as indicative of increased focus on individual rather than communal needs.

• Nuclear families living in urban areas with both partners employed full-time face the same challenges and dilemmas as many families in the West when it comes to caring for people with psychiatric disabilities.

1 geography of mental health where are mental health patients located? what are the attitudes of the...

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