Integrating traditional health practitioners in mental health: Is it possible? Results from a pilot project in Kenya The 8th Pan-African PCAF Psychotrauma Conference Christine Musyimi, BSc; MSc, PhD (c) Africa Mental Health Foundation 13 th -16 th July, 2015

Trauma, PTSD and Depression  Continued stress long after trauma may lead to Post Traumatic Stress Disorder (PTSD) and consequently depression.  Depression one of the common long term mental disorders after trauma, comorbid with PTSD.  The trauma that caused PTSD also may cause depression.  PTSD and depression treatment similar.

Traditional Health Practitioners (THPs)  Traditional Health Practitioners (THPs) do not all perform the same functions.  They are categorized into diviners, herbalists, prophets, faith healers and traditional birth attendants (Pretorius, 1999).  THPs have been well known to provide holistic care (Mhame et al, 2010).  Kenya experiences a dearth of primary health care workers and abundance of THPs (Management Sciences for Health, 2012).  80% of people with health problems consult traditional healers (THs) as their first contact persons (World Health Organization (WHO), 2003).

Traditional Health Practitioners’ role  There are no rules and regulations in Kenya that guide the traditional healers and this places their patients at risk of sub standard care.  THPs seem to be the key to greater understanding of depression in rural communities (Johnson-Bashua, 2012).  There is need to include THPs in mental health service provision due to a high number of patients they receive and presence of priority mental illnesses (Ndetei et al, 2013; Havenaar et al, 2008).  Depression accounts for the greatest burden among mental disorders

Challenges of THPs in relation to conventional care  Lack of respect and mutual trust  Weak referral systems  Illiteracy and inadequacy of training opportunities

Solutions  Establish trust and mutual respect between formal and the informal sectors  Establish and strengthen collaboration and referral systems  Training opportunities for THPs especially on conventional methods of care in order to reduce sub standard care.  THPs integration in to the health care system Current state: Solutions achieved through dialogue

Methodology  Training of 100 randomly selected THPs to screen and manage depression using mhGAP-IG.  In order to confirm THPs diagnosis, a sample of 100 patients (50 positive and 50 negative for depression) were randomly selected from a group of patients seen by THPs.  Referred to be screened for depression by a mental health professional using clinical judgment as per DSM-IV guidelines (reference standard).

Results  A total of 4081 patients were screened for depression over a period of three months by 78 THPs.  This translated to two patients per day.  Traditional healers and faith healers screened 1515 and 2566 patients respectively.  More than half of all screened patients (66.3%) were female.

Results  The prevalence of depression among THP patients was found to be 22.9% (95% CI ). Table 2: Prevalence of depression Depression Prevalence of depression n95% CI Overall depression prevalence22.9% Traditional healers’ patients with depression 22.4% Faith healers’ patients with depression 23.3%

Comorbidity and Correlates of depression  The most frequently co morbid condition among patients with depression was suicidal behavior (32.9%, OR=5.94, p=<0.0001), followed by presentation of at least one psychotic symptom (26.3%, OR=3.65, p=<0.0001).  Depression was significantly higher with increase in age (p<0.0001).  Females were 1.20 times likely to have depression.  The rate of depression was higher among single and separated or divorced persons as compared to those who were married.  Patients who were not employed or schooled reported higher levels of depression.

Measure of accuracy  The ability of THPs to correctly identify a patient with depression, also known as sensitivity is 46% while the likelihood that the patient will actually have depression (positive predictive value) is 79%.  Their ability to correctly exclude depression referred to as specificity from patients is 86% and the likelihood that the patient will have no depression (negative predictive value) is 57.8%. Clinical judgement True positive: 46%; True negative: 86%; False positive: 14%; False negative: 54%; specificity: 86.1%; sensitivity: 46%, Positive predictive value: 79%; Negative predictive value: 57.8% POSITIVENEGATIVETOTAL Traditional health practitioners’ mhGAP-IG screening POSITIVE NEGATIVE63743 TOTAL296493

Estimated Mean scores Improvement of depression post mhGAP-IG intervention

 12% resolution of symptoms 6 weeks post intervention  39% improvement in depression symptoms 3 months post intervention.  Similar improvement expected at primary health care level and 6-9 months without any intervention.  Therefore, THPs accelerated recovery of patients.

Recommendations  Majority of THPs are the first contact persons for community members in need of health care.  Inclusion of THPs in provision of mental health services particularly the priority conditions should be strengthened.  Community support networks particularly for more vulnerable groups such as women may aid in reducing the cycle of unemployment, poverty and depression and development of other mental disorders related to poverty.  Most of these traditional healers are illiterate, training opportunities using evidence based practices should be available at the community level.

Issuance of certificates to THPs 3 months post training and supervision

Conclusion  Acknowledge THPs role in mental health care and integrate depression assessment in to their routine service provision.  Avoid performing parallel programmes.  Depression, a priority condition listed under the WHO mhGAP-IG can be psycho socially managed by THPs.  This same approach can be used for related conditions such as PTSD and mental disorders.

Reducing mental health treatment gap with traditional healers: It is possible

Final remarks  It is possible  Let’s embrace dialogue and work collaboratively.

References Havenaar, J.M., Geerlings, M.I., Vivian, L. et al (2008) Common mental health problems in historically disadvantaged urban and rural communities in South Africa: prevalence and risk factors. Soc Psychiatry Psychiatr Epidemiol 43(3):209–15. Johnson-Bashua, A. (2012) Yoruba traditional healers and mental illness: Causes, Diagnosis and Treatment. Philosophy, Religion and Politics in Africa, pp. 34–46. Management Sciences for Health. (2012) Traditional and complementary medicine policy. Mhame, P.P., Busia, K. and Kasilo, O.M. (2010) Clinical Practices of African Traditional Medicine. African Heal Monit, (14). Ndetei, D.M., Mbwayo, A.W., Mutiso, V.N. et al (2013) Traditional healers and provision of mental health services in cosmopolitan informal settlements in. Afr J Psychiatry 16(2):134–40. Pretorius, E. (1999) Traditional Healers. 249–56. World Health Organization. (2003) Traditional Medicine. Fact sheet N° Available from: accessed 5 April 2015.