Need for Global Psychiatric Help

David C. Henderson, MDDirector, Chester M. Pierce, MD Division of Global

PsychiatryMassachusetts General Hospital

Associate Professor Harvard Medical School

Mental health has become a major international public health concern

• "We believe that mental health is just as important as physical health, maybe even more so.“ Donna Shalala, former Secretary of the Department of Health and Human Services

• "The challenge to humanity is to adopt new ways of thinking, new ways of acting, new ways of organizing itself in society in short, new ways of living.” Our Creative Diversity, UNESCO

http://www.who.int/msa/mnh/ems/dalys/table.htm

High Burden of Disease Worldwide due to Mental Disorders

Leading global causes of YLD, high-income and low- and middle-income countries, 2004

“Resources for mental health are scarce and inequitably distributed between countries, between regions, and within

local communities.” (Saxena et al., 2007)

http://www.time.com/time/photoessays/wtc/2.html

Historical SpaceMass violence creates in a society a new historical space. Ordinary attitudes, feelings, and behaviors are transformed. The healer and sufferer find recovery in a therapeutic solidarity. Within this historical space, justice forms the core of the survivor-perpetrator relationship.

This is a Global Issue

• The aftermath of mass violence has the effect of eroding the social, economic, mental and physical health of affected nations and the world

• Our evidence-based theoretical model reveals the relationship between economic development, social capital, human rights, and health and mental health recovery in societies affected by mass violence.

This is a Public Health IssuePTSD LIFETIME PREVALENCE

IN FOUR POST-CONFLICT SETTINGS, 1997-1999

0

5

10

15

20

25

30

35

40

BASELINE ALGERIA CAMBODIA ETHIOPIA GAZA

Per

cen

t

SOURCE: JAMA 2001, v286:555-562

Culture, Context and Western Imports• Concern about imposing western approaches to

psychiatry on diverse cultures – undermining indigenous healing

• Risk of bringing in the “worst”: old and riskier drugs, institutionalization, stigma

• At same time, neglect of MI is major practical/HR issue in p-c environment (Lancet 2000)

• Principle: High level of critical awareness in melding essentials of western psychiatry with local traditions and customs

• Dilemma: Is this “marriage” always feasible. Unintended dangers (stigma, adverse effects, disruption of traditional care systems).

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Influence of Culture on Mental Illness and Mental Health

• How patients communicate

• How patients manifest symptoms

• How patients cope

• Range of family and community support

• Willingness to seek treatment

U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001

DSM-IV

Explanatory Model

• Cultural explanations of the individual’s illness – It is important to understand how distress or the

need for support is communicated through symptoms (nerves, possessing spirits, somatic complaints, misfortune).

– The meaning and severity of the illness in relation to ones’ culture, family, and community should be determined.

– This “explanatory model” may be helpful when developing an interpretation, diagnosis, and treatment plan.

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Differences in Presentation of Illness

• There are cultural differences in the presentation of psychiatric illnesses. – Cambodian woman may present with complaints of

fatigue and back pain, while ignoring other neurovegatative sx. & unable to describe dysphoria.

– This same patient may admit to hearing the voices of her ancestors, which is culturally appropriate.

– In many traditional, non-Western societies• spirits of the deceased are regarded as capable of

interacting with and possessing those still alive.

Consequences of stigmaThey died as they had lived in

chains: in Yerwadi, a tiny but popular pilgrim centre

about 30 km from Ramanathapuram in Tamil

Nadu. On August 7, residents of Moideen

Badsha Mental Asylum, their minds trapped in

another world and bodies shackled in "therapeutic

chains", were heard shrieking into the night as flames licked their bodies.

www.the-week.com/21aug19/ events12.htm

Chained till the end: The charred remains of inmates at Yerwadi

Consequences of stigma

BASAVARAJ

He suffers from chronic schizophrenia. He was chained for 15 years at his home in Bangalore till Vidyakar (below left) brought him to Udavum Karangal five years ago. Now in his forties, he is on medication and seems far happier

SM’s

SEM’s

The Ethnopsychopharmacological Approach

• Assessment– Cultural formulation for Diagnosis

• Choice of Medication– Use medical history, concurrent medications, diet

and food supplements / herbals combined with knowledge of enzyme activity in certain ethnic groups

• Monitor Patient– Proceed slowly- Involve family– If side effects intolerable - lower dosage, or

choose drug metabolized through different route– If no response-check compliance, raise dose and

monitor levels, add inhibitors, switch drug

Principles of task-shifting

• Basing our choice of components for a package on the best evidence available and perceived need

• Task-shifting to relatively low cost health workers or other non-health professionals, supported and supervised by specialists

• Collaborative stepped care delivery model

• Developed in a systematic process with consultation with stakeholders and formative and piloting work

• Delivery through existing public systems

• Robust evaluation, with preference for RCTs wherever feasible

Effective Collaborative Care Programs

• Effective multidisciplinary practice– Efficient use of limited resources: mental health focuses on

patients who present diagnostic challenges or are not improving– Shared workflows and accountability, effective communication – Co-location is not collaboration

• Population focused – Caseload-focused proactive care instead of ‘psychiatric urgent

care’ for individual patients: registries to prevent people from ‘falling through the cracks’

• Measurement-based stepped care– Systematic application of evidence-based treatments, taking into

account patient and provider preferences and resources and clinical outcomes

Thank You!

“You must be the change you want to see in the world.”

Mahatma Gandhi