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
MI proxy indicators WC GP KZN SA
Homicide 12.9 8.3 4.7 6.8
Road Traffic 6.9 4.4 2.8 3.7
Suicide 2.3 1.5 lt1 lt1
of total YLL 22.1 14.2 7.5 10.5
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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?