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 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.

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 Bass J, Neugebauer R, Clougherty KF, Verdeli H, Wickramaratne P, Ndogoni L, Speelman L, Weissman M, Bolton P. Group interpersonal psychotherapy for depression in rural Uganda: 6-month outcomes: randomised controlled trial. Br J Psychiatry. 2006;188:567-573. Bolton P, Bass J, Betancourt T, Speelman L, Onyango G, Clougherty KF, Neugebauer R, Murray L, Verdeli H. Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial. JAMA. 2007; 298:519-527. Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P, Speelman L, Ndogoni L, Weissman M. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. 2003; 289:3117- 3124. Carstairs GM. (1973) Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972. Br J Psychiatry 123 :271-7. Chatterjee S, Chowdhary N, Pednekar S, Cohen A, Andrew G, Andrew G, Araya R, Simon G, King M, Telles S, Verdeli H, Clougherty K, Kirkwood B, Patel V. (2008) Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India. World Psychiatry 7:39-46. Chisholm, D.,Gureje,O., Saldivia, S., et al (2007) Schizophrenia treatment in the developing world: an inter-regional andmulti-national cost-effectiveness analysis. Bulletin of theWorld Health Organization, in press. Chisholm, D.,Van Ommeren,M., Ayuso-Mateos, J.-L., et al (2005) Cost-effectiveness of clinical interventions for reducing the global burden of bipolar Chisholm,D., Sanderson,K., Ayuso-Mateos, J. L., et al (2004b) Reducing the global burden of depression: population-level analysis of intervention cost-effectiveness in14 world regions. British Journal of Psychiatry, 184, 393^403. Cohen, A. (2001). The effectiveness of mental health services in primary health care: the view from the developing world. Geneva, World Health Organization. de Jong, Joop T. V. M; Komproe, Ivan H; Van Ommeren, Mark; El Masri, Mustafa; Araya, Mesfin; Khaled, Noureddine; van de Put, Willem; Somasundaram, Daya (2001). Lifetime events and posttraumatic stress disorder in 4 postconflict settings. JAMA 286: 555-562. disorder. British Journal of Psychiatry, 187, 559^567. Ganesan, M. (2006) Psychosocial response to disasters--some concerns. International Review of Psychiatry 18: 241-247.26 J. Bass, R. Neugebauer and K.F. Clougherty et al.(2006). Group interpersonal psychotherapy for depression in rural Uganda: 6-month outcomes—randomised controlled trial, Br J Psychiatry 188: 567–573. Krishnakumar, G; Sivayokan, S; Somasundaram, D. Coordination of psychosocial activities at the Jaffna District level in Sri Lanka. Intervention 6: 270-274. Kumakech, E., Cantor-Graae, E.Maling, S.,Bajunirwe F. (in press). Peer-group support intervention improves the psychosocial well-being of AIDS orphans: Cluster randomized trial. Social Science & Medicine. Mollica, Richard F; Cardozo, B. Lopes; Osofsky, H. J; Raphael, B; Ager, A; Salama, P. (2004) Mental health in complex emergencies. Lancet 364: 2058-2067. Bolton P., J. Bass and T. Betancourt et al. (2007) Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial, JAMA 298: 519–527. Patel,V. & Kleinman, A. (2003) Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, 609^615. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet. 2007; 370:859-877. Richters, A, Dekker, C & Scholte, W.F. (2008) Community based sociotherapy in Rwanda. Intervention 6(2): 100-116. (See; www.interventionjournal.com) Somasundaram, Daya (2007) Collective trauma in northern Sri Lanka: A qualitative psychosocial-ecological study. International Journal of Mental Health Systems. ArtID 5. Somasundaram, Daya; Jamunanantha, Chelliah S. (2002) Psychosocial consequences of war. In: De Jong, Joop (Ed). Trauma, war, and violence: Public mental health in socio-cultural context. (pp. 205-258). New York, NY, US: Kluwer Academic/Plenum Publishers. Thara, R (2004) Twenty-Year Course of Schizophrenia: The Madras Longitudinal Study. Canadian Journal of Psychiatry 49: 564-569. Tol WA, Komproe IH, Susanty D, Jordans MJ, Macy RD, De Jong JT. (2008) School-based mental health intervention for children affected by political violence in Indonesia: a cluster randomized trial. JAMA 13: 655-62. World Health Organization (1996) Public Mental Health: Guidelines for the Elaboration and Management of National Mental Health Programmes. WHO. World Health Organization (2001) The World Health Report 2001. Mental Health: New Understanding, New Hope. WHO. World Health Organization (2003a) Organization of Services for Mental Health (Mental health policy and service guidance package). WHO. World Health Organization (2003b) Planning and Budgeting to Deliver Services for Mental Health (Mental health policy and service guidance package). WHO. World Health Organization (2005a) Mental Health Atlas. WHO. World Health Organization (2005b) Methodology and Assumptions Used to Estimate the Cost of Scaling Up Selected Child Health Interventions. WHO. Bolton & Betancourt (2004) Mental health in postwar Afghanistan. JAMA 292:626-8. Miller, Omidian, Rasmussen et al (2008) Daily stressors, war experiences, and mental health in Afghanistan. Transcult Psychiatry 45:611-38. Miller, Omidian, Kulkarni et al (2009) The Validity and Clinical Utility of Post-traumatic Stress Disorder in Afghanistan. Transcult Psychiatry. 46:219-37 Ibrahim Zai, Mismahl & Herzberg (2009) Mental Health Services and Existing gaps in Afghanistan. In: Mental Health in Fragile States, conference report, sept 2008. LSHTM&HealthNet TPO Ventevogel, de Vries, Scholte et al. (2007) Properties of the Hopkins Symptom Checklist-25 (HSCL-25) and the Self Reporting Questionnaire (SRQ-20) as screening instruments used in primary care in Afghanistan. Social Psychiatry Psychiatric Epidemiology 42: 328–335. Ventevogel, P. (2005). Psychiatric epidemiological studies in Afghanistan: a critical review and future directions. Journal of Pakistan Psychiatric Society 2: 9-12. Available at: http://www.jpps.com.pk Thanks to Mark van Ommeren, WHO

Psychosocial consequences of collective trauma Mild and moderate mental disorders 5-10% increase 15% after years Severe mental disorders 3-4% 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 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 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. Richard G Wilkinson (2005) The Impact of Inequality: How to Make Sick Societies Healthier. 355pp, Routledge,

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]. Somasundaram, Daya (2007) Collective trauma in northern Sri Lanka: A qualitative psychosocial-ecological study. International Journal of Mental Health Systems. ArtID 5.

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

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’ Dollar, D. Levin, V. (2005). The forgotten states; aid volume and volatility in difficult partnership countries. Summary paper for DAC learning and advisory process on difficult partnerships.

Where are 10 million children dying every year? Over 10 million children aged under 5 years die every year, almost 90% of them in a few countries in sub-Saharan Africa and South Asia.1–6 Landmark series on child and neonatal survival suggested that this high mortality persists despite low cost solutions being known and that almost 60-70% of these deaths could be prevented by making these interventions widely available. Is this an emergency? The Tsunami took 200.000 lives. See Zulfiqar A Bhutta, Asim Belgaumi, Mohammad Abdur Rab, Zein Karrar, Mohamed Khashaba and Nezha Mouane: Child health and survival in the Eastern Mediterranean region. BMJ 2006;333;839-842, or click here: http://www.bmj.com/cgi/content/full/333/7573/839/DC1 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 Recovery Emergency Response Reconstruction Development Emergency Response Reconstruction Recovery 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

Under-stand 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 high-income countries, depression will become the single highest contributor to the overall disease burden.[2] World Health Report 2004: Changing history. Geneva, World Health Organization, 2004. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLos Medicine, 2006, 3:2011–2030.

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. See: DAN CHISHOLM, CRICK LUND And SHEKHAR SAXENA: Cost of scaling up mental health care in low- and middle-income countries. BRITISH JOURNAL OF P SYCHIATRY (2007), 191, 528 ^ 535 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 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]. Reducing the global burden of depression. Population-level analysis of intervention cost-effectiveness in 14 world regions. Dan Chisholm, Kristy Sanderson, Jose Luis Ayuso-Mateos and Shekhar Saxena. BRITISH JOURNAL OF PSYCHIATRY (2004), 184, 393^403 Schizophrenia treatment in the developing world: an interregional and multinational cost-effectiveness analysis. Dan Chisholm,a Oye Gureje,b Sandra Saldivia,c Marcelo Villalón Calderón,d Rajitha Wickremasinghe,e Nalaka Mendis,f Jose-Luis Ayuso-Mateosg & Shekhar Saxenah. Bulletin of the World Health Organization. July 2008, 86 (7)

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 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]. 1. Cost-effectiveness of First-line Antiepileptic Drug Treatments in the Developing World: A Population-level Analysis. Dan Chisholm, Epilepsia, 46(5):751–759, 2005

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. Vikram Patel: Is Depression a Disease of Poverty? Regional Health Forum – Volume 5, Number 1, 2001

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. Dollars, DALYs and Decisions: Economic Aspects of the Mental Health System. Dan Chisolm a.o., WHO http://www.who.int/mental_health/evidence/dollars_dalys_and_decisions.pdf

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. Hobfoll, Watson, Bell, Bryant, Brymer, Friedman, Gersons, de Jong, Layne, Maguen, Neria, Norwood, Pynoos, Reissman, Ruzek, Shalev, Solomon, Steinberg, Ursano: Five Essential Elements of Immediate and Mid–Term Mass Trauma Intervention: Empirical Evidence. Psychiatry 70(4) Winter 2007.

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