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4/21/12
Harischandra GambheeraSri Lanka
Pathways of careSouth Asian perspectives
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The vast majority of people with mental,neurological and substance use disordersdo not receive even the most basic care.Yet such services are essential if we are
to offer hope to some of the mostmarginalized people in the world,
especially in developing countries, to livetheir lives in dignity.
WHO world mental health daymessage
Treatment Gap
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Treatment gap is bimodal
Either no treatment orPoor quality treatment
[The treatment I refer here is modern
(allopathic) treatment]
Treatment Gap Ctd.
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The responsibility of treatment gap inSouth Asia does not depend merely on
availability and accessibility of servicesbut largely on health seeking
behaviour of the people,
The health seeking behaviour dependsmainly on socio cultural factors in
South Asia
factors on
Treatment Gap
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South Asia that includes the large Indiansubcontinent has inherited a culture developedover thousands of years and it inherits manyculturally endemic beliefs and value systems.
These beliefs ingrained in the South Asianculture hinders the scientific mediation in
general population.
This obviously has great impact on health
seeking behaviour that prevents using evidence
Effect of culture on health seekingbehaviour
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Therefore, even though there is acultural aspect to Psychiatry, specially in
its manifestations, it hinders thedevelopment of Modern PsychiatricServices and increase the disability
associated with mental illnesses bothshort and long term.
Cultural Psychiatry
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Pathway of care is defined as the sequenceof contacts with individuals andorganizations, initiated by the distressedpersons efforts and those of his significantothers to seek appropriate help
(Rogler et. al., 1993).
In other words, Pathway of care is an outlineof anticipated care, placed in an appropriatetimeframe, to help a patient with a specificcondition for a positive outcomes.
Pathways of care
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Pathways of care is directly related to the
treatment gap, good quality treatment andDUP .
Therefore, explorations of underlying hidden
factors playing vital roles in help seekingbehaviour of affected persons and their familymembers, which determine the pathway of careleading to place of appropriate management is
mandatory.
This is even more important in case of serious
psychiatric disorder e.g. psychosis, where delayin initiation of appropriate treatment, due to any
Pathways of care Ctd.
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Patients with longer duration of untreatedpsychosis have poorer outcomes with respect torelapse rates, control of symptoms, and remissionrates
(Black et al, 2001; Drake RJ et al, 2000; Verdoux H et al, 1998;Johnstone et al, 1986).
Long duration of untreated psychosis is alsoassociated with ineffective and demoralizinghelp-seeking and a variety of traumatic events,
including high rates of involuntary hospitaladmission (Johnstone et al, 1986)
and
poorer response to antipsychotic medicationsand treatment outcome (Loebel AD et al, 1992).
Long DUP
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Empirical studies have shown that theduration of untreated psychosis (DUP) ofindividuals with psychosis averages 1 to 2years.
(Loebel AD et al, 1992; Beiser M et al, 1993; Larsen TK et al, 1996;McGlashan TH, 1999),
This could even be more in developingnations,
the reasons of which has yet to beex lored from athwa s studies.
DUP Ctd.
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Reducing DUMI improve the prognosis not
only in non affective Psychoses but also inbipolar disorder.
Therefore it is important to modify factors that
could be lead to prolong the DUMI. Hence there is need for exploring the factors
prolonging DUMI, which determine helpseeking behaviour and consequently give a
direction to pathway of care.
May be achieved by interventions like early
catchments / educational / advertisement
ura on o n rea e en aIllness
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Basically depends on
Sociodemographic and cultural profile
Awareness and mental health literacy
Attitude of family/society towards mentalillness
Myths/beliefs regarding causation and modeof treatment of mental illness
Stigma attached with psychiatric disorders Experiences with previous health services
availability/accessibility of psychiatric
services
Pathways of care in South Asia
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Aetiology
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Biological aetiologicalfactors
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Psychological distress causedby
Death of loved ones
Relationship problems
Failures (eg. exams)
Loss of Employment / livelihood
ETC
Psychological aetiologicalfactors
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Effects ofkarma (activities) of previous birthinfluence ofevil spirits,
effects ofplanetal organization on the individual
charms and poisoning
are widely considered as causative
factors of mental illness in the region.Therefore people suffering from mentalillnesses and their carers tend to seek helpfrom traditional healers whom their
treatment methods are based on the above
Myths about causation ofmental illness
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Myths Ctd.. Social factors inaetiology
Dead peopleDevils (yaksha)Christianity/Islam / Judaism
Governed byHoroscopebased on Time ofbirth
BuddhismEffects of activities ofPrevious birth
Punishment by the god for
sin
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opinion of relatives regardingaetiology by educational status
Others- Psychosocial problems, Stress, Excessive thoughts, socialupbringing, Poor coping,
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Devil Dancing
Traditionalhealingmethods in
Sri Lanka
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Management
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Rituals Devil dancing (shanthikarma)
Worshipping Trees
(Bo-tree The tree under which Lord Budda attained nibbana)
Mantra
Religious rituals
I would certainly place Aurvedic treatmentmethods also into the group of rituals as it too isnot evidence based.
Treatment methods
opinion of relatives regarding treatment
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opinion of relatives regarding treatmentmethods
by educational status
Others- Meditation, Hypnotism, Rehabilitaion, Social support
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Devil dancing
Traditionalhealingmethodsin
Sri Lanka
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Poorly developed / accessible healthservices
Shortages of Human resources
Deficiencies in infrastructure
due toBrain drain
Poor socio-economic conditions
Other causes oftreatment gap
Availability of services in developing
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Availability of mental health services indeveloping country is very limited. Ingeneral, they are available in the rangeof 1/50 to 1/1000 of what is available in
well developed countries (Srinivasa MR, 2004).
For enormous rural populations (up to
70% of the total population of mostdeveloping countries) modern psychiatrydoes not seem to exist
(Farooq S et al, 2001).
Availability of services in developingcountries
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Country Mental healthpolicy
Mental healthlegislation
India + +
Pakistan ? +
Bangladesh + +
Nepal +_ _
Sri Lanka + +
Bhutan + _
Maldives _ _
Availability of policy &legislation
WHO
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No of psychiatrists per 100.000
Developed Countries >10
India 0.4
Maldives 0.36 Bhutan 0.3
Sri Lanka 0.2 (1:500,000)
Human Resources
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No. of nurses 0-1 / 100,000
No. of Psychologists No data available
No. of PSW No dataNo. of OT No data
No. Nurses in developed countries 1-50
WHO
Availability of other mental healthprofessionals in South Asia
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Europe 9.3America 3.6
Western pacific 1.0
EasternMediterranean
0.8
Africa 0.4
South East Asia 0.3Sri Lanka 1.3
Psychiatric beds per 10,000
WHO
P l d l d i
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Ignorance about the mental illnesses andremedies
Increased DUP
Increases relapses
Inadequate / ineffective Treatment
Poor quality treatment
No rehabilitation
Resulting in
Poorly developed servicescauses
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The term mental health literacy was coinedby Australian national Anthony Jorm in 1977.He defined it as knowledge and belief about
mental disorders which aid their recognition,management or prevention. It includes theability to recognize specific disorders,knowing how to seek mental health
information knowledge of risk factors andcauses of self-treatment and of professionalhelp available and attitudes that promote
recognition and appropriate health seeking.
Mental Health literacy
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Awareness about psychiatric disorders ingeneral is poor, mental health literacy is lowand Less knowledge about mental illness andits symptoms, as well as possible treatmentapproaches are negatively associated withhealth care use
(Chen H et al, 2000; Scott TL et al, 2002 Jorm AF, 2000).
In other words, what the public believes about
mental illness, e.g. its aetiology, treatmentand prognosis, and what the public considersto be the role of, and effectiveness of,modern health services in managing mental
illness would influence health-seeking
Mental Health Literacy Ctd.
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In India and other regional countries, themajor source of awareness about psychiatricdisorder and psychiatric services in communityare due to exposure with the patients suffering
from psychiatric disorder, not the role playedby media advertisement, news paper andvarious agencies as in the Western countries.
This observation may be common to all SouthAsian region
Media effect on Literacy
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Programme
Media effect on behaviour
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Many programme
Changed only know ledge
not the health
seeking behaviour
Media effect on behaviour
Sti
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Myths prevalent in South Asia aboutthe
causation of mental illness
Mentally ill persons are dangerousMental illnesses are incurable
Impact on
Mentally ill person
Family with a mentally ill person
Mental health services
Stigma
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Effect of Stigma on the help seeking behaviour global
but Comparable to Western countries its effect on indeveloping countries more devastating.
The effect is not limited to the health seekingbehaviour but also on families with mentally ill
individuals and establishing mental health services. Stigma hinders access to the mental health services as
well as general medical care (Liggins J et al, 2005)
The stigma associated with mental disorder maychange the pathway of care, as well as the choice offirst service provider. Stigma is one of the reasonsfor many to seek help from traditional healers as
the prime service provider.
Stigma of mental illness:
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Effects of
Myths / Poor services / stigma
Lead to
Prolongation of duration of untreated Psychosis (DUP)
Inadequate and ineffective treatment
Frequent relapses
Resulting
increased long term
disability
Effect of socio cultural factorson outcome
opinion of relatives regarding
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opinion of relatives regardingOutcome
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One of the biggest menace in SouthAsia is traditional healers
Do they provide services to the
consumers satisfaction Do they fill the service gap?
Do they complement withPsychotherapeutic effect?
Do they make appropriate referral?
Traditional Healer in southAsia
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Shorten the DUP
Shorten the pathways of care
improve mental health literacy
eradicate traditional healers [Make it
illegal]Establish a Community Psychiatric service
Fight stigma
Eradicate myths
Recommendations
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Thank
You