Download Key Needs in Global Mental Health Research

Danger, Uncertainty, and
Suffering:
Existential versus Institutional Perspectives on
Human Problems
Arthur Kleinman, Harvard University
Stockholm 2007
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Mental Health and Social
Suffering in Africa
Arthur Kleinman
November 22, 2007
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Social Experience and Health
 Cross-culturally we see health gradients that show that
those with the highest socioeconomic status have better
health status, including lower mortality and morbidity.
 Those countries with greatest economic inequality have,
relative to their overall economic status, the poorest
health status
 Mental health problems occur in clusters and those
clusters correlate with economic and social problems like
poverty, crime, and disintegrating inner cities.
 We see higher rates of depression in women, in those
who are not economically and politically integrated, and
in the relatively powerless.
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Epidemiologic Transition:
Disease Typography
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Gender Differences in
Mental Health Problems Worldwide
Percentage of DALYs* Lost
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Social and Psychiatric Morbidity
Several recurring social processes are sources of
social and psychiatric morbidity
 Repressive gender practices have widespread
devastating consequences; empowerment and
education of women, and support for families and youth,
are crucial for diminishing many problems
 Ethnic conflict breeds violence, displacement, trauma,
and depression
 Economic policies that create inequities in wealth and
social resources, that isolate communities from political
power, and that remove security systems for those in
need, spawn cycles of poverty and desperation
associated with ill health
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Social-Psychiatric Clusters
 Shanty towns, slums, vulnerable or marginal migrant
populations
 Alcohol and substance abuse, violence, depression and
PTSD cluster and coalesce
 How to respond?
• Identify clusters in combined ethnographic and epidemiological
research
• Develop new modes of preventative and therapeutic intervention
directed at such clusters
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Suicide Rates in the World
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Relationship of Suicide and
Mental Illness
 According to US psychiatrists, 90% of those who
commit suicide have a diagnosed mental illness,
most often major depressive disorder. This is
disputed.
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Kerala: Good Health Indices, Poor
Mental Health Indices
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Mozambique
 Mental health is part of the primary health care system and there is
little regular training of primary care providers on issues of mental
health.
 Few epidemiological data on mental illnesses are available. A
government study1 found rural/urban divide to be significant for rates
of psychoses, mental retardation, and epilepsy. A retrospective
study2 on deaths from injuries of pregnant and postpartum women
(n=27) found suicide was the cause in one third of cases.
 As of 2005, there was no mental health policy, although a draft
policy awaiting approval and a substance abuse policy has been in
place since 1997.
(SOURCE: Mental Health Atlas 2005. WHO)
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Ministry of Health (2002-3) Community Mental Health Study. Mental Health Program. Department of Community Health.
Mozambique
Granja, A.C. et al. (2002) Violent deaths: the hidden face of maternal mortality. BJOG, 109, 5-8.
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Nigeria
 Compared to other African countries, there is a great
deal of epidemiological data on mental health in Nigeria.
 Since 1991, a mental health policy has been in place
whose major components are: advocacy, promotion,
prevention, treatment, and rehabilitation. This is
implemented through a national mental health program.
 Mental health is part of the primary care system.
Providers are regularly trained on mental health issues
and actual treatment of severe mental disorders is
available at the primary care level.
(SOURCE: Mental Health Atlas 2005. WHO)
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Rwanda
 Although there is a paucity of epidemiological data, a 2002 study1
estimated that 5 years after the war, a significant part of the
population had seriously disabling depression.
 Both mental health (components: advocacy, promotions, prevention,
and treatment) and substance abuse policies have been in place
since 1995 and 1% of the national budget is spent on mental health.
 Mental health is part of primary care and providers are regularly
trained on these issues.
 There are also community care facilities for mental health; however,
problems in motivating staff to work in these areas and reinforcing
pro-community behavior are common.
(SOURCE: Mental Health Atlas 2005. WHO)
1) Bolton, P. et al. (2002) Prevalence of depression in rural Rwanda based on symptom and functional criteria. Journal of
Nervous and Mental Disease, 190, 631-7.
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Sierra Leone
 There is no significant epidemiological data on mental health, as
well as no national mental health or substance abuse policy.
 A mental health coordination group has been formed of various
stakeholders and is working on drafting legislation as well as
developing models for community based care.
 Mental health is part of the primary care system and despite little
training for providers, care for severe mental illness is available.
Although there is currently no community-based care, traditional
healers and general practitioners fill the gap providing care in these
settings.
(SOURCE: Mental Health Atlas 2005. WHO)
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Uganda
 Epidemiological studies have found a high prevalence of mental
disorders. A 2002 study1 found 30.7 % prevalance of mental
disorders in adults in a particular district, supplementing an
earlier (1979)2 finding of 20% suffering from a probable mental
disorder and another 5% from a definite disorder, largely
depression, hypomania and anxiety.
 The national mental health policy, in place since 2000,
emphasizes advocacy, promotion, prevention, treatment, and
rehabilitation.
 Community-based programs are in place that combine
traditional medicine with western medical services and provide
(SOURCE:
Mental Health Atlas
WHO)as health education.
treatment
as2005.well
1)
2)
Kasoro, S. et al. (2002) Mental illness in one district of Uganda. International Journal of Social Psychiatry, 181, 354-9.
Cox, J.L. (1979) Psychiatric morbidity and pregnancy: a controlled study of 163 semi-rural Ugandan women. British
Journal of Psychiatry 134, 401-5.
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Comparing Resources
Psychiatric Beds and Professionals
Mozambique
Nigeria
Rwandai
Sierra
Leoneii
Uganda
Total psychiatric beds per 10,000 population
0.23
0.4
0.2
0.47
0.44
Psychiatric beds in mental hospitals per 10,000 population
0.2
0.3
0.2
0.32
0.22
Psychiatric beds in general hospitals per 10,000 population
0.04
0.04
0
0.11
0.22
Psychiatric beds in other settings per 10,000 population
0.01
0.01
0
0.03
0.009
Number of psychiatrists per 100,000 population
0.04
0.09
0.03
0.02
1.6
Number of neurosurge ons per 100,000 population
0.01
0.009
0.02
0
0.009
Number of psychiatric nurses per 100,000 population
0.01
4
0.8
0.04
2
Number of neurologists per 100,000 population
0.01
0.02
0
0.02
0.1
Number of psychologists per 100000 population
0.05
0.02
0.3
0
2
Number of social workers per 100,000 population
0.01
0.02
0
0.06
2
i
ii
There are 200 other mental health personnel
There are 200 psychiatric assistants
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Burden vs. Budget
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Number of Psychiatrists per 100,000 Population
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Problem Areas
 Primary Care
 Early Intervention
 Mental Health Care Financing
 Quality of Care
 Ethics and Forensics
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Major Obstacles
 Funding
 Stigma
 Infrastructure
 Leadership
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Financing
 Intersectoral
 Increasing Ministry of Health
Support
 Mobilizing International and Local
Partners
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Ways to Do It

Global Mental Health Research Collaborations
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Global Mental Health Research Centers
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Research Training Programs
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Population Laboratories
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Collaborative
Interdisciplinary
Basic
Applied
Surveillance
Local policy agendas
Intervention studies
Evaluation
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Mental Health Population Laboratory
 Sample size of approximately 100,000
 Potentially piggy-back onto existing population
laboratories
 Integration of basic science, ethnographic, epidemiological
and clinical research
 Generation of baseline population data as platform for
intervention programs (e.g., suicide reduction programs)
 Research in developed and developing world
 Over-sample ethnic and class diversity
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 Community Research and Socio-Cultural
Research
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Poverty and Labor Conditions
Stigma
Substance Abuse
Gender
Infectious Disease
Political Violence and Refugee Populations
 Epidemiology and Ethnography
 Mental Health Services Research
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Key Needs in Global Mental Health
Research
 Demonstration projects tied to rigorous
external evaluation and funding for
generalization of programs if outcomes are
positive
 Network of global mental health policy
research centers in the developed and
developing worlds
 Networking Centers, Researchers, and
Trainees
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