pathways of care

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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

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