Transcript Document

Mental Health
in
International Settings
Sally Mathiesen, PhD, LCSW
Professor
San Diego State University
School of Social Work
Council on Social Work Education | www.cswe.org
Purpose of This Module
• To help social workers appreciate the
human rights issues that may
accompany mental health disorders
around the world
• To provide an opportunity to discuss
the variety of treatments available
• To further develop critical thinking
skills regarding evidence-based
interventions for the population
Suggested Use of the Module –
Location in Curriculum
• The module could be presented in an
elective course on mental health or
international studies or placed within
an advanced practice course
• The module could be presented over
one 3-hour course period (the
equivalent of one class session in a
semester), with the readings done in
advance and small group critique and
discussion of the assignment at the
end of the class period.
Learning Objectives
• Develop enhanced understanding of the
complexity of services needed for the
population of individuals with mental illness.
• Compare and contrast the available
resources for treatments for individuals with
mental illness in countries around the world.
• Incorporate knowledge of mental disorders
into treatment planning with enhanced
understanding of individual and cultural
differences.
• Understand and critique evidence-based
practices for those diagnosed with mental
illness.
Connections to EPAS Core
Competencies
EPAS competencies addressed in this module:
• EPAS 2.1.3: Apply critical thinking to inform
and communicate professional judgments.
• EPAS 2.1.4: Engage in diversity and
difference in practice.
• EPAS 2.1.5: Advance human rights and
social and economic justice
• EPAS 2.1.6: Engage in research-informed
practice and practice-informed research.
Why Global Learning Is
Important
• Understanding the nature of mental
health as a global concept is crucial
given the diversity of individuals and
families within the United States
• Research that has been conducted on
a global scale informs social workers
working in any location about effective
treatment strategies
Relevance of Global Learning
for Practice
• Global learning prepares social
workers to understand inherent
differences in complex mental health
issues
• Knowledge of effective practices that
have been used in diverse settings
increases social workers’ ability to
respond appropriately to clients that
have different backgrounds and
experiences
The Right to Health
• The right to the enjoyment of the
highest attainable standard of
physical and mental health, to give it
its full name, is not new.
• Internationally, it was first articulated
in the 1946 Constitution of the World
Health Organization (WHO).
•
Source: Committee on Economic, Social & Cultural
Rights, and the Office of the High Commissioner for
Human Rights.
The Right to Health
The WHO preamble defines health
as “a state of complete physical,
mental and social well-being and
not merely the absence of disease
or infirmity.”
Source: Committee on Economic, Social & Cultural Rights,
and the Office of the High Commissioner for Human Rights.
What Is
Mental Health?
Mental Health
“There is no health
without mental health.”
(WHO, 2007)
Mental Health
Mental health…
is more than the
absence of
mental disorders
Mental Health
It is the foundation for wellbeing and effective functioning
for the individual and the
community
This view of mental health is
consistent with wide and varied
interpretations across cultures
Mental Health
Mental health…
is linked to behavior
• Mental, social, and behavioral
health problems may interact to
intensify their effects on behavior
and well-being
Mental Health
Mental health…
is determined by
socioeconomic and
environmental factors
Mental Health
“Mental health: A state of
well-being in which the
individual realizes his or her
own abilities, can cope with
the normal stresses of life,
can work productively and
fruitfully, and is able to
make a contribution to his or
her community” (WHO, 2007)
Mental Health
Greater vulnerability to mental health
disorders for disadvantaged people
may be related to factors such as
– insecurity and hopelessness,
– rapid social change,
– risks of violence,
– physical ill health
(WHO, 2007)
Connecting Effectively With
Diverse Communities
• The greater need for mental health
services for disadvantaged
individuals requires service providers
to bridge some of the barriers that
may exist
• Cultural competence is a key factor in
facilitating mental health treatment for
all groups
Accessing Communities:
Cultural Competence
What Is Cultural Competence?
Davis (1997) operationally defined cultural
competency as the integration and
transformation of knowledge, information, and
data about individuals and groups of people
into specific clinical standards, skills, service
approaches, techniques, and marketing
programs that match the individual’s culture
and increase the quality and appropriateness
of health care and outcomes.
Cultural Competence
In the United States diverse communities
often do not have adequate access to
mental health treatment because of a
“variety of barriers, including lack of
knowledge about available interventions,
transportation difficulties, competing
familial responsibilities such as child care,
family privacy or shame, or community
stigma associated with seeking help from
mainstream providers” (Saldana, 2001, p.
16).
Outreach Strategies to
Diverse Communities
Saldana (2001) provides strategies
useful for connecting with those in
diverse communities that may also be
used internationally:
• Enlist local residents of the community
• Use a home visit to support
information and education
Outreach Strategies to
Diverse Communities
• Become knowledgeable about
indigenous healing resources
• Establish a mentor/buddy system with
one who is knowledgeable about
mainstream approaches and who
knows individual families
• Consider using some interventions in
places that represent community
gathering spots (schools, centers,
stores, etc.)
What Do We Know About
Global Mental Health Needs?
• Who is being treated for mental
health issues around the world?
• How can we estimate the current
gaps and prepare for future
needs?
World Health Organization
(2011)
• WHO launched Project Atlas in
2000 to respond to the large
gaps in the collection and
dissemination of information
about mental health service
delivery in countries around the
world
• “It replaces impressions and
opinions with facts and figures”
(WHO, 2011, p.7).
WHO Project Atlas
WHO Mental Health Atlas
2011
FOUR
MAIN FINDINGS
1: RESOURCES TO TREAT AND PREVENT
MENTAL DISORDERS REMAIN
INSUFFICIENT (WHO, 2011)
• Globally, spending on mental health is
less than two U.S. dollars per person,
per year and less than 25 cents in lowincome countries.
• Almost half of the world's population
lives in countries where, on average,
there is one psychiatrist or fewer to
serve 200,000 people.
2: RESOURCES FOR MENTAL HEALTH ARE
INEQUITABLY DISTRIBUTED
(WHO, 2011)
 Only 36% of people living in low-income
countries are covered by mental health
legislation.
 In contrast, the corresponding rate for highincome countries is 92%.
Dedicated mental health legislation can help
to legally reinforce the goals of policies and
plans in line with international human rights
and practice standards.
Mental Health Legislation
INEQUITABLE RESOURCE DISTRIBUTION
(cont.)
• Outpatient mental health facilities are
58 times more prevalent in highincome compared with low-income
countries.
• User/consumer organizations are
present in 83% of high-income
countries in comparison to 49% of
low-income countries
Mental Health Personnel
3. RESOURCES FOR MENTAL HEALTH ARE
INEFFICIENTLY USED (WHO, 2011)
• Globally, 63% of psychiatric beds are
located in mental hospitals, and 67%
of mental health spending is directed
toward these institutions.
4. INSTITUTIONAL CARE FOR MENTAL DISORDERS
MAY BE SLOWLY DECREASING WORLDWIDE
(WHO, 2011)
Though resources remain concentrated
in mental hospitals, a modest decrease
in mental hospital beds was found from
2005 to 2011 at the global level and in
almost every income and regional
group.
Changes in Hospital Beds
From 2005 to 2011
Mental Health
Substance abuse, violence, abuse of
women and children, HIV/AIDs,
depression, and anxiety are more
prevalent and difficult to cope with when
combined with
•
•
•
•
•
•
•
•
high unemployment
low income
limited education
stressful work conditions
gender discrimination
social exclusion
unhealthy lifestyle
human rights violations
(WHO, 2007)
Mental Health & Human
Rights
The Universal Declaration of
Human Rights:
“All human beings are born
free and equal in dignity and
rights.”
But human beings are
flawed in their actions
toward each other
Mental Health & Human
Rights
• In many cases, persons with
psychosocial or intellectual
disabilities suffer. “They are
treated without their free and
informed consent—a clear and
serious violation of their right to
health” (Committee on Economic,
Social & Cultural Rights, p. 6)
Mental Health & Human
Rights
• In other cases these disabilities
are neither diagnosed nor treated
or accommodated for, and their
significance is generally
overlooked.
• “E.g., in 2001, most middle- and
low-income countries devoted
less than 1 percent of their health
expenditures to mental health.”
• .
Mental Health & Human
Rights
• “As a result, mental health care,
including essential medication
such as psychotropic drugs, is
inaccessible or unaffordable to
many” (Committee on Economic,
Social & Cultural Rights, and
Office of the High Commissioner
for Human Rights, p. 6)
Mental Health & Human
Rights
Human rights
violations for those
with mental disorders
have been documented
around the world.
Examples
• Continuous shackling and beatings due
to cultural beliefs that mental illness is
evil
• Children tied to their beds without
stimulation or rehabilitation for their
condition
• Keeping patients lock in “caged beds”
for days or weeks or longer
(Source: WHO Resource Book on Mental Health, Human
Rights and Legislation)
Common Human Rights Violations
of People With Mental Disorders
• Lack of Access
– Some countries may lack adequate
services; others may limit access to certain
population segments.
– 32% of countries have no community care
facilities
– 30% of countries have no specified budget
for mental health; of those that do, 20%
spend less than 1% on mental health
– Number of psychiatrists ranges from 10 per
100,000 to 1 per 300,000
• WHO recommendation: Mental health
care should be available at the
community level for anyone who needs it
Human Rights Violations
(cont.)
• Inappropriate forced admission or
treatment in mental health facilities
– Informed consent is often not sought
– People are forced to remain against their will for
weeks, months, years in psychiatric institutions or
other mental health facilities
WHO recommendation: Informed consent
must form the basis of all mental health
care; rigorous and ongoing procedural
safeguards need to be in place to protect
against abuse of involuntary admission
and treatment
Human Rights Violations (cont.)
• Violations within psychiatric
institutions
– People restrained with rusting metal
shackles, caged beds, other inhumane
treatment
– People living in filthy conditions, lacking
clothes, clean water, food, heating, proper
bedding, or hygiene facilities
– People isolated from society in large
institutions, far from family and loved ones
• WHO recommendation: Countries should
set up monitoring bodies to ensure that
human rights are being respected in all
mental health facilities
Human Rights Violations (cont.)
• Inappropriate detention in
prison
– In some countries people with mental
disorders are in prison due to a lack of
mental health services or lack of a
diagnosis/treatment for their condition;
“prisoners” continue to go unnoticed,
undiagnosed, untreated
• WHO recommendation: People with
mental disorders should be diverted
away from criminal justice systems and
toward mental health services
Human Rights Violations (cont.)
 Due primarily to stigma, people
experience discrimination and
violations of basic rights
– People often deprived of civil rights (right to vote,
marry, have children)
– People experience discrimination in all areas of life
(employment, education, right to shelter)
• WHO recommendation: People with
mental disorders have the same human
rights as everyone else; due to
vulnerability, countries have a
responsibility to protect them from
discrimination
Gender as an Example
(WHO Atlas, 2005)
• Communication between health
workers and women patients is
extremely authoritarian in many
countries, making a woman's
disclosure of psychological and
emotional distress difficult and often
stigmatized
• Up to 20% of those attending primary
health care in developing countries
suffer from anxiety and/or depressive
disorders.
Gender as an Example
(cont.)
• In most centers these patients
are not recognized and therefore
not treated. When women dare to
disclose their problems, many
health workers tend to have
gender biases that lead them to
either overtreat or undertreat
women.
Effective Strategies
Research shows that three main factors are
highly protective against the development of
mental problems, especially depression:
1. Psychological support from family, friends,
or health providers is powerfully protective.
2. Having sufficient autonomy to exercise
some control in response to severe events.
3. Access to some material resources that
allow the possibility of making choices in the
face of severe events.
(WHO Atlas, 2005)
• If there is tremendous unmet
need for treatment and
widespread violations of human
rights….
• If we are fallible in our
observations and beliefs, how
can we be sure that what we are
doing with our clients is
effective?
Which direction is best for treatment of
this vulnerable population?
Evidence-Based
Practices
World Health Organization Efforts
 WHO has identified low cost, high
impact evidence-based interventions
to promote mental health, even in
poor populations.
 WHO is working with governments
and provides technical material and
advice to implement policies, plans,
and programs.
Interventions
• Early childhood interventions (e.g., home
visiting for pregnant women, prevention of
alcohol abuse by mothers, preschool
psychosocial interventions, combined
nutritional and psychosocial interventions for
disadvantaged populations)
• Support to children (e.g., skill-building
programs, child and youth development
programs)
• Socioeconomic empowerment of women
(e.g., improving access to education,
microcredit schemes)
Interventions (cont.)
• Social support for older populations (e.g.,
befriending initiatives, community and day
centers for older adults)
• Programs targeting vulnerable groups
including minorities, indigenous people,
migrants, and those affected by conflicts and
disasters (e.g., psychosocial interventions
after disasters)
• Mental health promotion activities in schools
(e.g., supporting ecological changes in
schools, child-friendly schools)
Interventions (cont.)
• Mental health interventions at work
(e.g., stress prevention)
• Housing policies (e.g., housing
improvement)
• Violence prevention programs (e.g.,
community policing initiatives)
• Community development programs
(e.g., “Communities That Care”
initiatives, integrated rural
development)
Major Effort: Mental Health GAP
Action Programme by WHO
(2008)
• Focus on mental, neurological, and
substance use (MNS) disorders in
low- and low-middle income countries
• Multicountry study showed that 35%–
50% of serious cases in developed
countries and 76%–85% in lessdeveloped countries had received NO
TREATMENT in prior 12 months
Worldwide Treatment Gaps
Treatment gaps as reported by
WHO’s world literature review:
• Schizophrenia:
32%
• Depression:
56%
• Alcohol use disorders: 78%
Mental Health Gap Program
• To reinforce commitment of
governments, international
organizations, and other
stakeholders to increase financial
and human resource allocation to
MNS disorders
• To achieve higher coverage of
key interventions in low- and
lower-middle income countries
with large proportions of MNS
disorders
Gap Program…
• Priority conditions were identified
– Common in all countries where
prevalence has been examined
– Substantially interfere with abilities
of children to learn and with the
abilities of adults to function with
families, at work, in society
– Disability and premature mortality
is substantial
– Economic burdens are devastating
for poor countries
Priority Conditions
• Depression
• Schizophrenia and other psychotic
disorders
• Suicide
• Epilepsy
• Dementia
• Disorders due to alcohol use
• Disorders due to illicit drug use
• Mental disorders in children
Gap Program…
• Intervention packages presented
– Prevention/management of each
priority condition
– Chosen based on evidence of
effectiveness, feasibility of scaling
up the intervention
– Interventions should be delivered in
a variety of packages, not
freestanding
– Will need to be adapted for
countries, regions on basis of
prevalence and burden, cost,
feasibility, and acceptability of the
interventions
GAP Program…
• Countries chosen for intensified support
– Most of global burden of MNS disorders
occurs in low- and lower-middle income
countries; they also have the highest
resource gaps
• Three rank-ordered lists created:
1. Total number of lost DALYs (disabilityadjusted life years) was used as a
summary measure of population health
2. MNS burden (added if not included in #1)
3. Gross national income was used as an
indicator of relative poverty (added if not
already on prior lists)
Examples: Intensified Support
African Region
• Nigeria: Low-income (GNI per capita=640
US in 2006)
• Large population
• DALYs=1780/100,000 due to MNS
• Mental health professionals=4.13/100,000
Americas Region
• Colombia: Low middle income (GNI per
capita=2740 US in 2006)
• Smaller population than Nigeria
• DALYs=3054/100,000 due to MNS
• Mental health professionals: 2/100,000
Depression & Example
• Treatment with antidepressant
medications (use trained primary
health-care professionals)
• Psychosocial interventions (e.g.,
cognitive-behavioral therapy or
problem solving; referrals and
supervisory support by specialists)
• View video clip: “I had a black
dog…his name was depression.”
http://www.youtube.com/watch?v=XiCrn
iLQGYc
Schizophrenia & Other
Psychotic Disorders
• Treatment with antipsychotic
medications (use trained primary
health-care professional within
community)
• Family or community
psychosocial interventions (e.g.,
community-based rehabilitation,
referral and supervisory support
by specialists)
Suicide
• Restriction of access to common
methods of suicide (multisectoral
measures related to public health such
as restricted availability of toxic
pesticides, secure storage of supplies)
• Prevention and treatment of
depression and alcohol and drug
dependence (see interventions for
depression, disorders due to alcohol
and illicit drug use)
Example From WHO
• View video clip:
Hidden Pictures: A Personal Journey
Into Global Mental Health
http://www.youtube.com/watch?v=dv_ex
aj2ofg&feature=youtu.be
Who Is Responsible
for Treatment?
According to WHO GAP Plan...
• Scaling up for mental health care is a
social, political, and institutional
process
• Joint responsibility lies with
–
–
–
–
–
–
Governments
Health professionals for MNS disorders
Civil society
Communities
Families
Support from the international community
Selected Personal Observations
• Americas
• Mexico: Effects of growth of tourism in Cabo on
quality of life, environment
• South East Asia
• Thailand: Effects post-tsunami; grassroots
organizations developing to rebuild area
• Mental health treatment is difficult in rural areas
• Africa
• Zimbabwe: Effects of immigration between
countries in Africa on crime, family structure,
mental health
Selected Personal Observations
• Western Pacific
– Caribbean: In recent past, only the UN Declaration
of Human Rights served as basis for social workers
removing children from unfit parents (no specific
legal support); now have Child Abuse Law
• Europe
– Immigration issues interacting with mental health,
such as French laws permitting asylum seekers to
enter country, many from Northern Africa; but 95%
are assessed and deemed ineligible for services and
remain in country
– Drug treatment in Hungary: strong alcohol/driving
laws, but treatment is focused on drug use (up to 1year residential paid for largely by government)
Social Workers
WHO Definition:
– Social worker: A professional
having completed a formal
training in social work at a
recognized, university-level
school for a diploma or degree
in social work. (WHO-AIMS, 2005,
p.11).
Availability of Social Workers
• Globally, WHO reported that in 2011
there were more nurses
(5.15/100,000) than any other mental
health professional group
• A much smaller pool of psychologists,
psychiatrists, social workers, and
occupational therapists graduated in
the past year
• (See complete details by region in
charts in Human Resource Chapter,
WHO, 2011)
Provide Hope
Focus on Strengths, Not Problems
Small Group Discussion
• Form small groups to discuss the class
exercise provided
• Focus on one of the top three priority
conditions: depression, schizophrenia,
suicide
• Explore changes from 2005–2011
(chapter in Atlas, 2011)
• Consider how evidence-based practice
may be used most effectively and the
challenges presented, based on the
evidence from the Atlas.
Resources for Small Group
Discussion
• Amnesty International: Mental Health
http://www.amnesty.ie/mentalhealth-0
• British National Health Service (NHS)
http://www.nhs.uk/NHSEngland/AboutNHS
services/mentalhealthservices/Pages/Availabl
services.aspx
• Human Rights Watch: Mental Health
http://www.hrw.org/taxonomy/term/704/all
• MH GAP Report: Intervention Guide.
http://whqlibdoc.who.int/publications/2010/9789241548069_en
g.pdf
• YouTube
http://www.youtube.com/watch?v=dv_exaj2ofg&feature=youtu.
be
http://www.who.int/features/mental_health/
sustaining_mental_health/en/index.html
Resources for Small Group
Discussion
•
WHO-AIMS (Assessment Instrument for Mental Health
Systems (Version 2.2) (2005). Geneva, Switzerland.
•
World Health Organization (WHO) (2005). World health
statistics. Geneva, Switzerland
http://www.who.int/whr/2005/en/
•
World Health Organization (WHO) (2007). World health
statistics. Geneva, Switzerland
http://www.who.int/whr/2007/en/
• WHO (2011). Mental health country
profiles.
http://www.who.int/mental_health/evidence/
atlas/profiles/en/index.html
• World Bank MDGs
http://www.worldbank.org/mdgs/
Selected References
Davis, K. (1997). Race, health status, and managed care, In L. Epstein &
F. Brisbane (eds.), Cultural competence series. Rockville, MD: Center for
Substance Abuse Prevention.
Institute of Medicine. (2001). To err is human: Building a safer
health system. Available from
http://www.iom.edu/Reports/1999/to-err-is-human-building-asafer-health-system.aspx
Sackett, D. L., Rosenberg, , W. M., Gray, J. A., Haynes, R.B ., &
Richardson, W. S. (1996). Evidence-based medicine: What it is
and what it isn’t. British Medical Journal, 312, 71–72.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W.
M., & Haynes, R. B. (2000). Evidence-based medicine: How to
practice and teach evidence-based medicine (2nd ed.). London,
UK: Churchill Livingston.
Saldana, D. (2001). Cultural competency: A practical guide for
mental health service providers. Austin, TX: Hogg Foundation
for Mental Health, University of Texas Austin.
Selected References
•
United Nations Committee on Economic, Social & Cultural Rights,
Office of the High Commissioner for Human Rights:
http://www.ohchr.org/EN/HRBodies/CESCR/Pages/CESCRIndex.aspx
•
World Health Organization (WHO). (2005). WHO atlas of 2005.
Retrieved from
http://www.who.int/mental_health/evidence/Atlas_training_final.pdf
•
World Health Organization (WHO). (2005). WHO resource book on
mental health, human rights and legislation. Retrieved from
http://www.who.int/mental_health/policy/who_rb_mnh_hr_leg_FINAL_1
1_07_05.pdf
•
World Health Organization (WHO). (2008). Mental health gap project.
Retrieved from
http://whqlibdoc.who.int/publications/2010/9789241548069_eng.pdf
•
World Health Organization (WHO). (2011). Mental health atlas of 2011.
Geneva, Switzerland: Author.
Hyperlinks for Video Clips
• Hidden Pictures: A Personal Journey Into
Global Mental Health
http://www.youtube.com/watch?v=dv_exaj2o
fg&feature=youtu.be
• I Had a Black Dog…His Name Was
Depression
http://www.youtube.com/watch?v=XiCrniLQ
GYc
Slides developed by
Sally Mathiesen, PhD, LCSW
Professor
SDSU School of Social Work
[email protected]