Transcript Document 7221646

Psycho-social Health in Fragile
States: The Forgotten Emergency
Willem van de Put
General Director HealthNet - TPO
Discussant: Amy Bess
Senior Practice Associate, Human Rights
and International Affairs
National Association of Social Workers
Chair: Isabel Guerrero
Vice President South Asia Region,
World Bank
Structure of argument
1. Mental health & social suffering: defining the field
– Cases: two examples illustrating that effects are on individual and community
levels
2. Intervention in ‘recovery’ phase: stretching from relief to development
3. A multisectoral approach:
– Health includes well-being and there is a clear need for mental health care
– Integration of mental health is proven to be effective and cheap – yet it remains
to be done.
4. But the issue is not limited to the health sector. The core of psychosocial
interventions is linking between sectors.
5. Examples of how dynamics can be brought back in communities following
simple and cheap interventions.
6. Work is done on developing the methodology to measure their costeffectiveness – but this can be said: costs are limited to building basic
capacity for action in existing public services and community levels.
How common are
mental disorders in fragile states?
• Many epidemiological studies have been done in last 10 years –
mental disorders 15-18%, psychological distress 50-70% [1-29] – but
validity of current data and applied methology are too easily contested
[30-35].
• Patterns are seen:
– Methods: higher quality surveys show lower rates
– Geography : rates are relative low in Asia, relative high in Americas
– Risk factors: life events (eg loss, trauma) and unsupportive environment
are among risk factors for wide range of disorders
• Given importance of environment, it is a fair assumption that rates are
elevated in fragile states compared to what they would have been if
the same state had been stable
• Fact is, that even a small percentage of people with burdensome
disorders would still imply an enormous public health problem
Thanks to Mark van Ommeren, WHO
Psychosocial consequences of
collective trauma
Severe
mental
disorders
3-4%
Mild and moderate
mental disorders
5-10% increase 15%
after years
Moderate or
severe psychological distress
30-50%
Mild psychological distress
20- 40%
IASC Guidelines on Mental health and
Psychosocial support
The Inter-Agency Standing
Committee (IASC) issued Guidelines
to protect and improve people’s
mental health and psychosocial wellbeing in the midst of an emergency.
Populations affected by
emergencies frequently experience
enormous suffering. Humanitarian
actors are increasingly active to
protect and improve people’s mental
health and psychosocial well-being
during and after emergencies.
IASC Guidelines on Mental health and
Psychosocial support
Mental health and psychosocial problems in
emergencies are highly interconnected, yet
may be predominantly social or psychological
in nature. Significant problems of a
predominantly social nature include:
• Pre-existing (pre-emergency) social
problems (e.g. extreme poverty;
discrimination, exclusion)
• Emergency-induced social problems
(family separation; disruption of social
networks; destruction of community
structures; increased gender-based
violence)
IASC Guidelines on Mental health and
Psychosocial support
Similarly, problems of a predominantly
psychological nature include:
• Pre-existing problems (e.g.
severe mental disorder; alcohol
abuse);
• Emergency-induced problems
(e.g. grief, non-pathological
distress; depression and anxiety
disorders, including post-traumatic
stress disorder (PTSD))
From mental disorders
to psychological distress
How bad is psychological distress?
Sorrow, grief, loss, sadness, in combination with poverty, ongoing
crises, inability to cope, insecurity, destruction of social networks
and loss of material possessions leads to hopelessness and
despair.
Not only individuals are touched, but the relations between
individuals, the community as such, may be broken.
"Social suffering" and “Structural violence” are interesting
concepts – apart from their rhetoric value, they break down
boundaries between specific scholarly disciplines, and offer a
cross-disciplinary perspective.
The effect on families and groups
In Sri Lanka, fundamental changes in the functioning of
the family and the community were observed. While the
changes after the tsunami were not so prominent, the
chronic war situation caused more fundamental social
transformations.
At the family level, the dynamics of single parent families,
lack of trust among members, and changes in significant
relationships, and child rearing practices were seen [1].
Effects on communities and society
Communities tended to be more dependent,
passive, silent, without leadership, mistrustful,
and suspicious.
Additional adverse effects included the breakdown
in traditional structures, institutions and familiar
ways of life, and deterioration in social norms
and ethics.
Other examples of interrelatedness:
social cohesion
Group
Albanian
Kosovars
Afghan
Pashtun
Dinka’s in
Kakuma
Bosnians
Rwandese in
Katale
Rwandese in
Benaco
Cambodians
Social
Interaction
Remarks
High
Shared cause, shared objective
High
Negotiate security for acceptance of
strict rules
Close group as defined against others
High
Mixed
forced
‘cohesion’
Low
Low
Shifting from strong urban cohesion to
shattered groups
Same group (political perspective and
‘participants’) controlled by militia
Different groups, anxiety, ‘keeping low’
Low level social integration, cohesion
destroyed
Workfield: fragile states
• Fragile states have a disproportionately high disease
burden compared to other low-income countries [1].
• Home to only 15% of the developing world’s population,
more than a third of maternal deaths and half of the
children who die before the age of five occur in fragile
states.
• Poverty and exclusion remain most visible manifestation
of ‘structural violence’ in fragile states;
• So that ‘fragile states’ now underpin the concept of ‘state
security’
Where are 10 million children
dying every year?
Black et al 2003
What needs to be done
• Integration of (primary) mental health in
the (primary) health care system;
• Addressing psychosocial problems;
• Starting immediately when disaster strikes,
working into the development phase.
Primary Mental Health in PHC
Psychosocial work
Early Recovery
Reconstruction
Development
Development
Emergency
Response
Thanks to Egbert Sondorp, LSHTM
Primary interventions on community and
family level
• Creating self-help groups
• Connect to income-generating models, e.g. rural
development activities
• Organize public (health) education
• Through community mapping, preservation of social
infrastructure
• Support community empowerment and capacity-building
• Training, education and sensitization of health workers,
social workers, and teachers
• Support for community leaders
• Family reunion and family tracing
Intervention in the community
Source: Green, Friedman, De Jong et al. (2003)
Psycho-education in Cambodia
Self-help groups
Understand
local
values
Reaching out to people in distress
Is there an evidence base
for interventions?
• In terms of successful treatment, yes.
• In terms of cost-effectiveness, a beginning
evidence base for mental health.
• Confusion on how to measure the impact and
cost-effectiveness of psychosocial interventions.
Mental disorders impose a substantial
burden if left untreated
In 2002, mental and substance use disorders accounted for
13% of the global burden of disease, defined as premature
death combined with years lived with disability. [1]
When taking into account only the disability component of the
burden of disease calculation, mental disorders accounted for
31% of all years lived with disability.
And this figure is rising. By 2030, depression alone is likely to
be the second highest cause of disease burden. In highincome countries, depression will become the single highest
contributor to the overall disease burden.[2]
Cost of scaling up mental health care in
low- and middle-income countries
Question: To estimate the expenditures needed to scale up the delivery of an
essential mental health care package over a 10-year period (2006^2015), a core
package was defined, comprising pharmacological and/or psychosocial treatment
of schizophrenia, bipolar disorder, depression and hazardous alcohol use.
Current service levels in12 selected low- and middle income countries were
established using the WHO^AIMS assessment tool. Target level resource needs
were derived from published need assessments and economic evaluations.
Results: The cost per capita of providing the core package at target coverage
levels (in US dollars) ranged from $1.85 to $2.60 per year in low-income countries
and $3.20 to $6.25 per year in lower-middle income countries, an additional annual
investment of $0.18^0.55 per capita.
Conclusions: Although significant new resources need to be invested, the
absolute amount is not large when considered at the population level and against
other health investment strategies.
DAN CHISHOLM, CRICK LUND and SHEKHAR SAXENA, 2007
Cost effective mental health
Depression: In resource-poor regions, each DALY averted by efficient
depression treatments in primary care costs less than1year of average per
capita income,making such interventions a cost effective use of health
resources.
However, current levels of burden can only be reduced significantly if there is a
substantial increase intreatment coverage [1] .
Schizophrenia: In Chile, Nigeria and Sri Lanka the most cost-effective
interventions were those using older antipsychotic drugs combined with
psychosocial treatment, delivered via a community-based service model.
By moving to a community-based service model and selecting efficient
treatment options, the cost of substantially increasing treatment coverage is not
high (less than I$ 1 investment per capita). Taken together with other prioritysetting criteria such as disease severity, vulnerability and human rights
protection, this study suggests that a great deal more could be done for
persons and families living under the spectre of this disorder [2].
Cost effective mental health
Epilepsy: A significant proportion of the current burden of epilepsy in
developing countries is avertable by scaling up the routine availability of lowcost antiepileptic drug (AED) treatments. Across nine developing WHO
subregions, extending AED treatment coverage to 50% of primary epilepsy
cases would avert between 150 and 650 DALYs per one million population
(equivalent to 13–40% of the current burden), at an annual cost per capita of I$
0.20–1.33.
Critical factors in the successful implementation of such a scaled-up level of
service delivery, apart from renewed political support and investment, relate to
appropriate training and continuity of drug supply [1].
Treatment to prevention
The Global Burden of Disease study ranked depression as the
fourth leading cause of burden among all disease, accounting for
4.1% of total burden. By 2020 it will rise from the fourth to the
second leading cause of DALYs. It will then be second only to
ischaemic heart disease for DALYS among both sexes.
Taking the example of ischaemic heart disease, risk factors such
as smoking and high blood pressure have been identified, and
public health interventions target those risk factors and try to
reduce their frequency in the population.
We need such public health oriented research into depression that
will then lead on to primary preventive programmes and to
improved access to efficacious treatment for people with
depression.
Is there an evidence base
for psychosocial interventions?
Psychosocial interventions: the relatively modest additional cost of adjuvant
psychosocial treatment is expected to reap significant health gains, thereby
making such a combined strategy for schizophrenia and bipolar disorder
treatment more cost-effective than pharmacotherapy alone. For people with
depression or anxiety, psychotherapy is expected to be as cost-effective as
newer (generic) antidepressants. Clearly, however, there remains a major
human resource constraint in making psychosocial interventions more widely
available [1].
Financial and human resource needs: Based on the use of efficient
interventions, the financial implications of scaling-up the effective coverage of
key mental health care strategies need not be overwhelming (less than US$ 10
in middle-income countries, and well below US$ 5 per capita in low-income
countries; in countries such as Nigeria or Sri Lanka, for example, it is expected
to be in the range of just US$ 1 per capita) [1].
HealthNet TPO has estimated the cost to install basic capacity for psychosocial
interventions on the community level at 0.28 USD/per capita/year.
Is there an evidence base
for psychosocial interventions?
A worldwide panel of experts on the study and treatment of those exposed
to disaster and mass violence assembled (…) to gain consensus on
intervention principles that should be used to guide and inform intervention
and prevention efforts at the early to mid–term stages [1].
These are promoting these five principles:
•
a sense of safety,
•
calming,
•
a sense of self– and community efficacy,
•
connectedness, and
•
hope.
What is hope?
…Nevertheless, what is amazing about
the human spirit is that many people, who
have been down so long that everything else
looks like up, often do retain a sense of optimism,
self–efficacy, and belief in both strong
others and/or a God who will intervene on their
behalf (Antonovsky, 1979; Lomranz, 1990; Shmotkin, Blumstein, & Modan, 2003).
Five Essential Elements of Immediate
and Mid–Term Mass Trauma Intervention:
Empirical Evidence
Stevan E. Hobfoll,
Psychosocial rehabilitation…
• Helps families care for their dysfunctional members;
• Helps people cope with loss, regain resilience, and
find strength to ‘go on’;
• Stimulates groups to take care of themselves;
• Restores community ties, brings back dynamic in
communities;
• Links services of different sectors to the people who
need them most;
• Connects various public sectors with community
dynamics;
• Creates a platform for human security and
willingness to participate in rebuilding society.
…and all these opportunity
costs should be included
Model approach in…Afghanistan
Questions?
36