Psycho-social Health in Fragile States: The Forgotten Emergency

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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
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Structure of argument

• Mental health social suffering defining the
  field
• Cases two examples illustrating that effects are
  on individual and community levels
• Intervention in recovery phase stretching from
  relief to development
• 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.
• But the issue is not limited to the health
  sector. The core of psychosocial interventions is
  linking between sectors.
• Examples of how dynamics can be brought back in
  communities following simple and cheap
  interventions.
• Work is done on developing the methodology to
  measure their cost-effectiveness but this can
  be said costs are limited to building basic
  capacity for action in existing public services
  and community levels.

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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
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Psychosocial consequences of collective trauma
Severe mental disorders 3-4
Moderate or severe psychological distress 30-50
Mild psychological distress 20- 40
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IASC Guidelines on Mental health and Psychosocial
support
The Inter-Agency Standing Committee (IASC) issued
Guidelines to protect and improve peoples mental
health and psychosocial well-being in the midst
of an emergency. Populations affected by
emergencies frequently experience enormous
suffering. Humanitarian actors are increasingly
active to protect and improve peoples mental
health and psychosocial well-being during and
after emergencies.
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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)
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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))
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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.
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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.
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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.

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Other examples of interrelatedness social
cohesion
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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 worlds
  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

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Where are 10 million children dying every year?
Black et al 2003
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(No Transcript)
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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.

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Primary Mental Health in PHC
Psychosocial work
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Early Recovery
Thanks to Egbert Sondorp, LSHTM
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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

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Intervention in the community
Source Green, Friedman, De Jong et al. (2003)
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Psycho-education in Cambodia
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Self-help groups
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Under-stand local values
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Reaching out to people in distress
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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.

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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 high-income
countries, depression will become the single
highest contributor to the overall disease
burden.2
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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
(20062015), 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
WHOAIMS 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 0.180.55 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

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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 priority-setting
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.
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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 low-cost 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 1340 of
the current burden), at an annual cost per capita
of I 0.201.33. 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.
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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.
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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.
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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 midterm stages 1.

• These are promoting these five principles
• a sense of safety,
• calming,
• a sense of self and community efficacy,
• connectedness, and
• hope.

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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, selfefficacy, 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 MidTerm
Mass Trauma Intervention Empirical
Evidence Stevan E. Hobfoll,
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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.

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and all these opportunity costs should be
included
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Model approach inAfghanistan
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Questions?
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