Mental Health

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Mental Health

• 25 June 2007
• Presenter Joanne Corrigall

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The MH workgroup

• Authors
• Joanne Corrigall, Catherine Ward, Kathryn
  Stinson, Patricia Struthers, Jose Frantz, Crick
  Lund, John Joske, Alan Flisher
• Expert group
• Crick Lund, Alan Flisher, Dan Stein, Petro
  Brink, Venecia Barries, Carol Bower, Carol Dean,
  Fadia Gamieldien, Bronwyn Myers, Bruce Phillips
• Peer Reviewers
• Vikram Patel, Andy Dawes

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Presentation Content

• Definitions
• Burden of mental illness
• Risk factors for mental illness
• Interventions Recommendations
• Mental Health and Development

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Definitions

• 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)
• Mental illness group of disorders defined by
  specific criteria which describe
• a particular severity of symptoms
• duration of symptoms
• the effects of these symptoms on a persons
  ability to function (socially and occupationally)
  i.e. symptoms result in DISABILITY
• Example Depression

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Spectrum of mental health
Mental Illness
Mental Health

• Self-esteem
• Coping skills, problem solving
• Self-efficacy
• Impulsivity
• Sub-clinical symptoms

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Burden of Mental Disorders

• Socio-economic impacts
• Unemployment, poverty
• Poor housing
• Decreased school completion, academic performance
• Decreased Social capital
• Increased violence

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Burden of Mental Illness

• Macro-economic
• 147 billion annual cost in USA
• SA no data but drug alcohol costs alone total
  R10billion
• Loss is mainly through effects on productivity,
  absenteeism

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Burden of Mental Illness

• Disability
• Globally 5 of 10 leading causes of disability
  are psychiatric
• SA neuropsychiatric disorders are 2nd leading
  cause of BoD
• BoD figures exclude the impact of MH on other BoD
  components

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Mental ill-health strongly associated with
CHILD HEALTH
Injuries
CVD
CHILD HEALTH
HIV
CVD
HIV
Unsafe sex Multiple partners Early sexual debut
Smoking
Alcohol Abuse Drug Abuse
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Mental health/illness
Source Bradshaw et al, 2005
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Prevalence in Western Cape

• South Africa SASH study 30 life-time
  prevalence
• No data for Western Cape
• Proxy measures injury data specifically homicide
  and RTAs

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Proxy measures
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Aim of MH workgroup

• Prevention of common mental disorders
• Depression
• Generalised Anxiety Disorder
• Substance disorders (includes abuse and
  dependence)
• Post Traumatic Stress Disorder
• Childhood behavioural disorders
• 2. Promotion of mental health

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Risk/protective factors
Living environment
Human capital
Health

• Access to recreation
• Built environment (housing, neighbourhoods)
• Basic services

• Income
• Food security
• Social grants
• Transport

MENTAL HEALTH

• Mental illness
• Health systems
• HIV
• Substance use
• Physical illness
• Disability

Safety
Employment

• Education
• Pre-school
• School climate

• Violence
• Crime

• Family systems
• Death/trauma in family

Social capital
Material goods

• Unemployment
• Underemployment
• Occupational stress

• Social capital
• Social support
• Spatial segregation

Family environment
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Findings continued

• Majority of relationships are bi-directional
• Multiple deprivation mental illness
• Cumulative effects

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Conflict with neighbours
Basic services
Family environment
Food insecurity
Unemployment
Domestic Violence
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Focus Areas selected

• Multiple Deprivation
• Unemployment
• Social assistance
• Food insecurity
• Housing
• Poverty
• Trauma (preventing MI after exposure)
• Pre-school education
• Recreation
• Mental Health Services
• Substance use (Tik, alcohol other drugs exlc.
  Nicotine)

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Multiple Deprivation
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Interventions

• Employment programmes JOBS programme, public
  works etc.
• Community development, micro-credit
• Adult literacy, food security
• Child care
• Increase access to social assistance
• Built environment
• Housing
• Neighbourhoods

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Trends in Status Quo

• Existing interventions targeting housing,
  unemployment, social assistance, literacy, food
  security
• BUT insufficient to meet need and/or not
  optimally effective
• AND insufficient cognisance of health (including
  mental health)

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Example Housing
Housing factors associated with mental health
Type
Quality

• Single vs multi- dwelling
• High floor vs low floor dwelling

• Structural deficiencies
• Pest control
• Dampness
• Housing satisfaction

HOUSING
Other

• Tenure
• Overcrowding
• Involuntary relocation
• Affordability of housing

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Evidence for interventions

• Housing improvements consistently improved Mental
  Health and decreased Mental Illness
• Dose-response relationship
• Other positive outcomes physical health
  perceptions of safety crime reduction social
  participation (social capital) improved
  perception of the area as a whole
• Effects of neighbourhood improvements 50
  reduction in prevalence of mental illness

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Housing recommendations

• Improve quality of state-subsidised housing
• Increase housing subsidy amount per applicant
• Improve capacity of housing applicants to make
  financial contributions for their homes
• Foster community participation support
• Expand neighbourhood renewal projects

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Example Federation of Urban Poor
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Likely outcomes

• Suitable housing
• Social Capital
• Human Capital
• Increased income
• Economic participation
• Physical Health

Improved Mental Health
HOW housing is provided can make a big difference!
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Pre-school
Pre-School
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Window of opportunity

• Early childhood is a sensitive period, and
  competencies become cumulative. Thus, without
  intervention, gaps between better and worse-off
  children widen over time the earlier the
  intervention, the less it costs and the lower the
  gap (Heckman, 2006).

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Outcomes of high quality pre-school

• Improved school
• readiness
• Improved cognitive
• abilities
• Lower failure rates
• Higher school
• completion rates

• Decreased antisocial
• behaviour
• Decreased substance
• abuse
• 40 reduction in
• arrest rates

• 40 increase in
• employment rates
• Improved maternal
• employment and
• education

Benefits of preschool have been noted up to
27yrs!!
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In Western Cape

• ECD a priority of WCED and DSD
• Audit done by DSD shows lack of access to
  pre-school and poor quality of existing
  preschools, unqualified teachers
• Another audit currently underway by DSD

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Recommendations

• Develop high quality teacher training programmes
• Develop high quality pre-school programmes
• Resource roll-out of pre-school across Province
  (urgently in high risk areas 15 high priority
  areas)

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Recreation
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Evidence
? Arts, music, dance
Physical exercise
Recreation
Leisure boredom
Recreational environments
? Other
Mental Health
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Major Gaps

• Focus on team/competitive sports
• Relative exclusion of other forms of recreation
• Insufficient facilities, access to facilities,
  resources
• Lack green spaces
• Lack of access cheap transport

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Recommendations

• Review support provision of sports AND
  recreation activities
• Protect and promote green and natural spaces
• Provide affordable and safe transport to
  recreational facilities or areas
• Support SR interventions that build social
  capital

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Trauma
Trauma
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• Violence
• Community (gangs or crime)
• Domestic violence
• Rape
• Child Abuse

• Psychological
• trauma
• Individual
• Family
• Community
• Police

• Increased mental illness
• Drug and alcohol abuse dependence
• Post-traumatic stress disorder
• Depression, anxiety
• Decreased Mental Health
• Hostile/harsh parenting
• Loss self-esteem, self-efficacy, coping skills

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• Psycho-behavioural
• Outcomes
• Decreased inhibition, reasoning
• Increased risk-taking
• Increased libido
• Increased mental illness
• Decreased mental health
• Decreased parenting skills
• Poor interpersonal relationships

Drug Alcohol abuse Itself a mental health
problem

• Violence
• Community (gangs or crime)
• Domestic violence
• Rape
• Child Abuse

Psychological trauma
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Bottom line

• Preventing and treating mental illness is an
  important part of violence prevention
• Violence prevention is an important part of
  preventing mental illness
• Preventing mental illness and restoring mental
  health after exposure to violence is crucial

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Recommendations

• Training trauma-informed non-health sectors
• Consistently fund, support roll-out NGOs
• Develop resources for emergency placement
• Provide mental health services in workplaces with
  high trauma exposures
• (police, teachers, social workers, NGO workers)
• Make sufficient provision for psychosocial needs
  in disaster management
• Develop post-graduate training programmes in
  trauma

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Recommendations cont.

• Health
• Training trauma-informed general health sector
• Integration of mental health staff into general
  health services e.g. surgery
• Provide adequate mental health services
• Create strong referral networks with
  trauma-related NGOs

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Substance use
Substance use
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Background

• Substance use e.g. nicotine, alcohol, tik,
  heroin
• Substance abuse/dependence are defined mental
  disorders
• Substance abuse/dependence also increases risks
  for other mental illnesses high comorbidity

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Alcohol

• Likely to be the commonest SOA in the Western
  Cape
• Why?
• Socially acceptable
• Legal production and consumption
• Active promotion (media)
• Perceived to be benign
• Norms culture of excessive use (abuse)
• Dop system
• Wine country
• Cheap!

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Impact of alcohol
Violence Road Traffic Incidents HIV Mental
Health CVD Child Health (FAS)
Out of he
Social impact Economic impact
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Tik

• High profile
• Why?
• Illegal associated with criminal activity incl.
  gangs
• Socially unacceptable
• New drug
• Negative consequences of use occur sooner
  abusers deteriorate more quickly
• Severe effects in users
• BOTH problems need to be addressed

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Evidence for interventions

• Not effective
• Media campaigns with no other measures
• Scare tactics
• School-based information interventions
• Law enforcement of DUI laws

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Recommendations

• Decrease Demand
• Restrict advertising of alcohol
• Conduct concurrent anti-alcohol and drug media
  campaigns that challenge prevalent beliefs and
  norms
• Increase references to substance abuse in other
  health promotion messages
• Include evidence-based substance prevention
  programmes in school curricula
• Training of primary care and other health workers
  
• Provide adequate treatment services

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• Decrease Supply
• Substantially increase the cost of alcohol
  drugs
• Reduce the availability of alcohol drugs
• Enforce existing laws on alcohol and other drugs.
• Incorporate addressing substance abuse into
  multi-faceted community development interventions
  
• General
• Improve co-ordination of involved departments
  DSD, DEADP, DOH, DCS

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Mental Health Services
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Background

• Mental Health services
• Hospital to community based
• Scope
• Promotion, Prevention, Treatment, Rehabilitation
• Nature of mental illness
• Typically chronic requiring long-term service use

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• The greatest risk factor for mental illness is
  previous mental illness

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Major Gaps

• Insufficient community-based services (schools,
  workplace, home-visits, community-based care)
• Community-based care for mentally ill
• Residential care
• Day services
• Need post deinstitutionalisation
• Poor integration of services particularly need
  in maternal health, HIV, trauma services
• Grossly insufficient MH services across the board
  but esp. community-based health services
• Impact of general health services on mental
  health

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• General approach to all interventions

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Targeting interventions

• Areas with highest violence and highest Multiple
  Deprivation Index (including 15 priority areas)
• Vulnerable groups
• Critical periods
• Some interventions universal

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Content Process of interventions

• Importance of multi-faceted interventions
  growing human, economic and social capital
  (multiple deprivation)
• Participative justice community participation
  and empowerment is vital
• Address cross-cutting risk factors e.g. alcohol

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Relationship to PGDS
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Relationship to development

• Development impacts on mental health
• Small investments in health have large impacts on
  income, education, democracy
• Global MDG interventions MH component embedded
  in these
• Mental Health is an essential Capability
  (economic approach)

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• Where to from here?

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Discussion points

• General comments
• What are the most appropriate forums for taking
  this work further?
• Most feasible recommendations/ least feasible?