case study: bosnia and herzegovina (bih) harvard program in refugee trauma (hprt) richard f. mollica...
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CASE STUDY: BOSNIA AND CASE STUDY: BOSNIA AND HERZEGOVINA (BiH)HERZEGOVINA (BiH)
Harvard Program in Refugee Trauma (HPRT)Harvard Program in Refugee Trauma (HPRT)
Richard F. Mollica MD, MARRichard F. Mollica MD, MAR
Michael P. Massagli, PhDMichael P. Massagli, PhD
James Lavelle, LICSWJames Lavelle, LICSW
Aida KapetanoviAida Kapetanovićć, MD, MD
Social and Health Social and Health IndicatorsIndicators
19811981 19911991 20002000
Population 4,124,256 4,395,643 3,683,665
Refugees - - 643,250
Displaced Persons - - 501,000
Employed:
Unemployed
- 3.17:1 1:1
Monthly Income
in US$
190 299 174
Major Objectives of World Bank-HPRT Project in Major Objectives of World Bank-HPRT Project in BiH Middle Bosnian Canton (Travnik)BiH Middle Bosnian Canton (Travnik)
Mental health training and technical assistance to primary care providers (PCPs)
Create network of PCPs skilled in mental health and trauma-related disorders
Develop with cantonal MOH mental health services integrated at all levels, including CBRs
Integrate results into BiH health reform
Prepare Lessons Learned for dissemination throughout BiH
ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND DISABILITY, BOSNIAN REFUGEES, 1996 (N=533)DISABILITY, BOSNIAN REFUGEES, 1996 (N=533)
SOURCE: JAMA v282:437, 1999
0
10
20
30
40
50
60
Per
cen
t
Asym PTSD Alone Dep Both
Total %Disabled %
Persistence of Mental Health Symptoms Persistence of Mental Health Symptoms Over 3 YearsOver 3 Years
Refugee cohort (n=378) - mental health status
0
10
20
30
40
50
60
70
1996 1999
Survey Year
Pe
rce
nt asymptomatic
depression
PTSD
depression and PTSD
Change in Symptom Status 1996-1999Change in Symptom Status 1996-1999
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
A (n=209) D (n=70) PTSD (n=20) D & PTSD(n=78)
1996 symptom status
Pe
rce
nt Asymptomatic - 1999
Depression
PTSD
Depression and PTSD
Effect of Trauma, 1996Effect of Trauma, 1996
Distribution of mental health symptoms - 1996
0
10
20
30
40
50
60
70
0-2 3-5 6 or more
Number of trauma events
Pe
rce
nt
asymptomatic
depression
PTSD
depression and PTSD
Effect of Trauma, 1999Effect of Trauma, 1999
Distribution of mental health symptoms - 1999
0
10
20
30
40
50
60
70
0-2 3-5 6 or more
Number of trauma events
Pe
rce
nt asymptomatic
depression
PTSD
depression and PTSD
THE MENTAL HEALTH COST THE MENTAL HEALTH COST OF MASS VIOLENCEOF MASS VIOLENCE
0 50 100
Percentage of General Population
SOURCE: Scientific American, v282, June 2000:54-57
SERIOUS MENTAL ILLNESS
PSYCH. INCAPACITATION
SERIOUS FAMIILY CONFLICT
CLNICAL DEPRESSION/PTSD
FEAR OF GOVERNMENT
SEEKING JUSTICE/REVENGE
PHYS, MENTAL EXHAUSTION
DEMORALIZATION
Feeling No Trust in Others, Past WeekFeeling No Trust in Others, Past Week
010
2030
4050
60
Symptom Status, 1999 (378 refugees)
Pe
rce
nt Not at all
A little
Quite a bit
Extremely Often
2001 Living Standards Measurement Survey 2001 Living Standards Measurement Survey (LSMS) in BiH (N=12,954)(LSMS) in BiH (N=12,954)
23% report depressive symptoms consistent with DSM-IV diagnosis of major depression
6% report reexperiencing trauma symptoms
15% report limitations in physical functioning
Women 2x more depression, PTSD, functional limitations than men
Primary Health Care Patients: Middle Primary Health Care Patients: Middle Bosnian Canton, 2003 (N=184)Bosnian Canton, 2003 (N=184)
32% psychiatric diagnosis (DSM-IV/SCID)• 16% major depression• 10% Generalized Anxiety Disorder• 3% PTSD only• 3% Dysthymia; other
SCID = Structured Clinical Interview for DSM-IVSCID = Structured Clinical Interview for DSM-IV
Providers Needs Assessment: 2000Providers Needs Assessment: 2000
40% (30-80%) of patients have mental health problems
65% of PCPs are not able to make DSM-IV (ICD-10) diagnoses
PCPs reported very low confidence in treatment of mental health crises
PCPs reported almost no confidence or very low confidence in treatment of different groups of traumatized patients
Providers Needs Assessment: 2000 (cont’d)Providers Needs Assessment: 2000 (cont’d)
33% of PCPs didn’t know about CBRs
54% of PCPs never referred patients to CBRs
30% of those who did refer never received feedback
from the CBR
EDUCATIONEDUCATION105 PCPs and psychiatrists trained
Curriculum completed:
1) Trauma Story
2) Psychosocial interviewing skills
3) Screening Instruments
4) Identification and management of the most common psychiatric disorders: mood disorders, neurotic stress-related and somatoform disorders, substance abuse, organic mental disorders, psychosis
5) Identification and management of disability
6) Management skills/health reform
ON-SITE VISITS/SUPERVISIONON-SITE VISITS/SUPERVISION
Case-Oriented
Goals:
To sustain the knowledge
To improve relations between PCPs and mental health professionals
To prevent burnout
Level of Trauma Experienced by PCPs and Level of Trauma Experienced by PCPs and PCPs’ FamiliesPCPs’ Families
0%
10%
20%
30%
40%
50%
60%
70%
80%
None Mild WarTrauma
Moderate WarTrauma
Severe WarTrauma
Extreme WarTrauma
PCP
PCP's Family
PCPs’ Confidence in Eliciting and Listening to Trauma PCPs’ Confidence in Eliciting and Listening to Trauma Stories: Pre-training vs. Post-trainingStories: Pre-training vs. Post-training
0
1
2
3
4
5
6
Eliciting Trauma Story Listening to TraumaStory
Listening to EmotionalSuffering
Pre-training
Post-training
Mea
n co
nfid
ence
PCPs’ Confidence in Diagnosing Certain Medical and PCPs’ Confidence in Diagnosing Certain Medical and Psychiatric Problems: Pre-training vs. Post-trainingPsychiatric Problems: Pre-training vs. Post-training
0
1
2
3
4
5
6
Somatic SymptomsCaused by Trauma
Mental HealthProblems
Depression PTSD
Pre-training
Post-training
Mea
n co
nfid
ence
Primary Health Care
Community
PoliceEmergency RoomGeneral Hospital
General HospitalIn-patient
MENTAL HEALTH SERVICES: OPTIMAL MODELMENTAL HEALTH SERVICES: OPTIMAL MODEL
Mental HospitalCriminally Insane
Primary Health Care
Community
Psychiatric Hospital
MENTAL HEALTH SERVICES IN BOSNIAMENTAL HEALTH SERVICES IN BOSNIA
Community Rehabilitation
Centers
Primary Health Care
Community
General HospitalIn-patient
MENTAL HEALTH SERVICES IN BOSNIAMENTAL HEALTH SERVICES IN BOSNIA
Community Rehabilitation
Centers
FRAMEWORK FOR MENTAL HEALTH RECOVERYFRAMEWORK FOR MENTAL HEALTH RECOVERY
RECOVERY
I. Policy/Legislation
V. Role ofInternational Agencies
III. Science-BasedMental Health Services
IV. Multi-Disciplinary Education
II. FinancingVI. Linkage to
Economic Development/ Human Rights
BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study
I. Policy/Legislation
• MH integrated into health reform
• LSMS MH data integrated into BiH health statistics
• Future role of CBRs
BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study
II. Financing
• Sustainable financing of MH in PHC
• Psychiatry – PHC linkage
• Job training and social services in PHC/CBRs
• Cost-effective MH training and services
BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study
III. Science-Based MH Services HPRT Model:
• Needs assessment
• Implementation of field-tested curriculum
• On-site supervision
• Monitoring assessment and feedback
BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study
IV. Multi-Disciplinary Education
• “Pedagogy of Trauma” in BiH medical schools
• Integration into family medicine
• CME
BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study
V. Role of International Agencies
• Coordination/collaboration among BiH MOH – UN – NGO – donors – universities
BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study
VI. Linkage to Economic Development (ED) and Human Rights (HR)
• Violence-induced trauma has negative impact on MH
• Both provider and patient exposed to violence
• MH has negative impact on social capital and physical functioning
• Undiagnosed and untreated MH problems place significant burden on health care system
Harvard Program in Refugee TraumaHarvard Program in Refugee Trauma
22 Putnam Avenue22 Putnam Avenue
Cambridge, MA 02139Cambridge, MA 02139
http://www.hprt-cambridge.org