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Unique Challenges and Opportunities for Child Mental Health in Africa: Practice and Policy Myron L. Belfer, MD, MPA Professor of Psychiatry, Harvard Medical School Children’s Hospital Boston Mbarara University of Science and Technology August 15-16, 2011
“No health without mental health” WHO WHO mental health budget approximately 1.8% of total budget and no line item for child mental health. Only recently has CAMH become a priority condition.
Much talk about infant, child and adolescent mental health, but a challenge to see it embraced by governments, academia and institutions.
Why child and adolescent mental health lags. History…value of the child Adult psychiatrists often lack a developmental perspective while focusing on major mental illness The image of mental illness equated with violence and possession is etched in people’s minds STIGMA – cannot marry, bad genes, evil
Gain a Developmental Perspective Children evolve over time across a number of parameters…cognitive, physical, emotional. Crucial importance of the early mother-child relationship. Great variability in rates of development but consistency in the progression of development. Brain architecture continues to change through adolescence. Emotional traumas can influence brain development with long-lasting consequences. Children have the capacity for resilience.
African Context More than 50% of the population of most African countries are children and adolescents. Urban migration. Absence of mental health and child mental health policy limits development of programs…complex reasons. Absent child mental health professionals. Absent resources for child and adolescent mental health…competition for scarce resources…non-communicable disease versus communicable disease. Political and economic uncertainty. Some of the most innovative programs originating in Africa.
Global Numbers 50% of all adult mental disorders begin before age 14 Every year approximately 800,000 individuals commit suicide, almost 90% from low and middle income countries. Adolescents account for 50% of all new HIV infections 70% of premature adult deaths link to behavior that develops in adolescence More than 12 million children have been displaced from their homes as a result of war and associated human rights violations during the period 1985 – 1995 and the pace continues to the present.
Epidemiological Data Earliest comparative epidemiological studies done in Africa. 20% of children aged 9 to 17 have a diagnosable mental disorder with impairment in functioning, smaller percentage with severe disorder. Depression is occurring earlier in life and may predict more severe disorder later in life. Suicide is the 2rd leading cause of death in the 10 – 14 year olds. Epilepsy is a mental disorder in the African context. Demonstrated continuities from infancy into adulthood, such as, observed violent behavior, persistent psychopathology. No surprises in global epidemiological data. Variance due to differing methodology, inadequate sampling, inappropriate use and analysis of instruments. Use of instruments for a single disorder distorts epidemiological findings…”more or less” of the disorder being studied. Benefit to utilizing “cultural epidemiology” melding quantitative and qualitative data.
When worldwide epidemiological data for psychiatric disorders shows remarkable similarity/comparability, why the widely divergent prevalence for “PTSD”?
Consequences of Poor Child and Adolescent Mental Health Lack of compliance with medication regimens for health…excess use of health care resources (Knapp, 2001) Increased and continuing pursuit of risk behaviors leading to premature deaths Suicide Substance abuse Bullying Gang formation/juvenile delinquency/homelessness/societal destabilization Inability to achieve optimal opportunities for productive lives - underemployment and unemployment Economic costs to families, governments and societies (Scott, 2003; Knapp, 2003) Underachievement and school drop-out
Challenges Provide “rational care”. Support program development consistent with national priorities…do not let NGO priorities dictate national policy or programs. Avoid the pitfalls of “Western” program development. Avoid distortions of program development resulting from categorical program development. Use the provisions of the UN Convention on the Rights of the Child and the UN Convention on the Rights of People with Disabilities to support program development. Make the needed economic arguments for stabile program support enabling a decreased reliance on NGO support. Value children in a way that may not always fit with cultural norms. Achieving multi-sectorial collaboration. Child mental health services are of necessity multi-sectorial. Programs need to be informed by “needs assessment” and engage child mental health professionals. Adhere to ethical standards in research with vulnerable populations.
Can we really train primary care workers…those who are needed to provide child mental health interventions?
Child Mental Health Policy Absent as noted in Atlas In fact, African nations do better than most of the world in developing policy, but always a question of implementation WHO has a manual on child mental health policy development---cookbook. Without policy not possible to sustain program development or ensure accountability
Millennium Development Goals Absence of Mental Health Goal Vital to success of the MDGs If further MDGs opportunity for mental health development
Disability rights is now a powerful force…will mental health be included?UN Convention on the Rights of the DisabledDisability Rights Fund – African focus Think of maximal inclusion and abandon the investment in a deficit model.
Public Health Policy Need for a public health infra-structure. Structural realignment has weakened public health in countries. Will child mental health clinicians engage in public health?
Clinical Challenges Danger of premature diagnosis of psychopathology in children and adolescents. Co-morbidities a sign of what we do not know. Difficulty of evaluating symptoms versus disorder in children and adolescents. Symptoms do not equal a disorder. Great overlap. “Probable PTSD”, “PTSS”, “Symptoms of PTSD” not equal to PTSD. Inadequacy of the diagnostic nomenclature – DSM-IV or ICD-10. DSM V and ICD 11 better? Disorder versus impairment, distress and suffering. Adherence and follow-up care. Providing mental health care in school settings.
Trauma Not all trauma is the same…war, natural disaster, accidents. Panter-Brick approach. Kindling. Impact on brain development. Are there protective factors? Resilience versus late appearing suicide.
Single disorder advocacy has eclipsed the concern for providing “rational care”. A Dangerous Situation…on other hand shows power of focused advocacy.
Commercialization of care worldwide…categorical program
Balance psychosocial intervention with need to address psychopathology: current polarization with undo emphasis on resilience is stifling program development
Lessons Learned NGO support fails to provide an incentive to governments to develop services or policies. Targeting specific populations may bring about unintended consequences…OVCs versus general support. Expanding the reach and breadth of categorical programs can stimulate comprehensive care. Mental health is embedded in health and therefore needs to be part of all health care. Employment and/or school are essential for good mental health. The mental health needs of children and adolescents are paramount, but in early childhood linked to maternal health and mental health.
Maternal Mental HealthExperiences, Lessons Learned, and Recommendations Barbara Gottlieb, MD, MPH Brookside Community Health Center Harvard Medical School & Harvard School of Public Health
Maternal mental health“A state of well-being in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her community.”(WHO, per Herman and Swartz, 2007)
Maternal Mental Health Mood disorders “baby blues” depression chronic depression/dysthymia during pregnancy postpartum maternal distress Psychosis
Prevalence of Maternal Mood Disorders “Probable major depressive disorder” 34.7% females 24.2% males (14 districts in Uganda, Kinyanda, et al, 2011) Maternal depression-15-57% (Wachs et al, 2009) 25% antenatal, 28% postpartum, > 50% depressed after 1 year (Rawalpindi, Pakistan, Rahman et al, 2003) 15-28% (Africa and Asia, Husain, et al, 2000) 10% (semi-rural Uganda, Cox, 1979) 16% (semi-rural Uganda, Assael et al, 1972) 6.1% (peri-urban Kampala, Uganda 6 weeks, Nakku et al, 2006) 34.7% (peri-urban settlement South Africa, Cooper, et al, 1999)
Impact of Maternal DepressionWoman’s Health and Well-being Poorer perinatal care, increased risk of perinatal morbidity and mortality Less likely to seek and benefit from prenatal care (Pagel et al, 1990) Less likely to seek help with delivery Less likely to seek and benefit from postpartum care Less ability to complete daily activities (Patel et al, 2002) High risk of subsequent episodes of depression Prenatal depression increases risk of pp depression (Dennis et al, 2004) PP depression increased risk for chronic depression (Murray et al, 1999)
Impact of Maternal Depression(Infant/Child Health and Well-being) Disruption in maternal self-perception and maternal-infant bonding Negative perceptions of infant (Foreman et al, 2002; Edhborg et al, 2000; Hart et al, 1999; Galler et al, 2004) Poor problem solving (Campbell et al, 2004) Impaired bonding (Martins et al, 2000 Low care-giver responsiveness (Martins et al, 2000 Increased rates of paternal depression (Goodman, 2004)
Impact of Maternal Depression(Infant/Child Health and Well-being) Emotional/developmental Insecure attachment (Martins et al, 2000 Slower cognitive development (Sohr-Preston et al, 2006; Black et al, 2007)) Childhood behavioral problems (Goodman et al, 1999, Murray et al, 1999) Low academic achievement (Galler et al, 2004) Childhood depression (Galler et al, 2000; Patel et al, 2003)
Impact of Maternal Depression(Infant/Child Health and Well-being) Physical health Lower birth weight (Cooper et al, 1996) Low birth weight and prematurity (Hedegaard et al, 1993; Hoffman et al, 2000)) Breast feeding difficulties (Cooper et al, 1993; Falceto et al, 2004) Stunting, undernutrition (Rahman et al, 2004; Anoop et al, 2004) Eating and sleeping difficulties (Righetti-Veltema et al, 2005) Reduction in preventative health services (all services, Minkovitz et al, 2005; vitamins, Leiberman, 2002) Diarrhea (Rahman et al, 2007; Thongkrajai et al, 1990)
Impact of Maternal Depression(Community/Society) Reduced economic productivity Contributes to inter-generational cycle of depression Compromises social justice Diagnosable depression may be tip of the ice-berg. Similar patterns in women with symptoms of distress. Impact is greater for those with chronic rather than episodic depression
Maternal Depression(Low- and Middle-Income Countries) Risk Factors Protective Factors Poverty/high levels of economic stress* Illiteracy, low educational achievement* Low social support Single parenthood* Maternal age< 20* Multi-parity* Marital strife, divorce, polygyny Stressful life events in previous year* Domestic violence* Chronic maternal illness* Maternal HIV Maternal anemia Lack of awareness of depression by health providers Social stigma of family member with mental illness Preterm or low birthweight infant Child with physical problems Unplanned or unwanted infant* Sex of child not preferred* Lack of control by mother in reproductive /financial/family resources decisions *Factors noted in studies of Uganda Maternal literacy, education Partner support Family support Housemaid at time of delivery Social support (outside of family/household) Responsive health care environment
Ecologic Framework for Maternal Mental Health Resiliency factors Exposure to stressors
Ecologic Framework for Maternal Mental Health Mother-child dyad Parenting, massage, sensitivity Mother-partner Reduce violence, parenting Family unit Exposure to stressors Resiliency factors Exposure to stressors
Ecologic Framework for Maternal Mental Health Mother-child dyad Parenting, massage, sensitivity Mother-partner Reduce violence, parenting Family unit Exposure to stressors Health Sector Capacity, training for mental health Community resources Jobs, police and safety Inter-sectoral collaboration Public education to de-stigmatize mental disorders Resiliency factors Exposure to stressors
Ecologic Framework for Maternal Mental Health Gender equality Educational policies Safety Control of alcohol Promotion of mental health programs Budgetary priorities Mother-child dyad Parenting, massage, sensitivity Mother-partner Reduce violence, parenting Family unit Exposure to stressors Health Sector Capacity, training for mental health Community resources Jobs, police and safety Inter-sectoral collaboration Public education to de-stigmatize mental disorders Resiliency factors Exposure to stressors
Ecologic Framework for Maternal Mental Health Gender equity Educational policies Safety Control of alcohol Promotion of mental health programs Budgetary priorities GLOBAL POLICY Gender equality De-stigmatize mental disorders Mother-child dyad Parenting, massage, sensitivity Mother-partner Reduce violence, parenting Family unit Exposure to stressors Health Sector Capacity, training for mental health Community resources Jobs, police and safety Inter-sectoral collaboration Public education to de-stigmatize mental disorders Resiliency factors Exposure to stressors
Maternal Depression and Human Rights UN 1989 Convention on the Rights of the Child actions states must take to ensure children’s rights Most widely ratified UN convention (all countries except US)right to survival and development, universality of rights, indivisibility of rights, and the best interests of the child Article 2 – children should not face discrimination based on parents’ disability, including mental illness; governments should actively support parental childrearing efforts and promote facilities and services focusing on the care of children Article 27 – governments should recognize the right of every child to a standard of living adequate for the child’s physical, mental, spiritual, moral and social development and assist parents in ensuring this right
Maternal Depression and Human Rights UN Convention on the Rights of Persons with Disabilities Article 1 - recognizes depression as a disability Article 6 – recognizes that women and girls with disabilities are subject to multiple discrimination and governments shall take measures to ensure the full and equal enjoyment by them of all human rights and fundamental freedoms Requires governments to provide medical and social support Challenges stereotypes about mental illness Argues for creative strategies including self-help groups, occupational training, lifeskills education, parenting skills and local healing traditions
Maternal Depression and Human Rights UN Fund for Population Activities and the WHO expert group panel – Consensus Statement on the interface between maternal mental health and child health and development in low-income countries (UNFPA, 2007) Mental health recommendations Reduce the factors that lead to maternal depression Promote maternal and child health and development Increase availability of low-cost evidence-based interventions for maternal mental health problems
Maternal Depression and Human Rights UNFPA: Recognized that maternal health is fundamental to 5 of the 8 Millennium Development Goals Improving maternal health Reducing child mortality Promoting gender equality and empowering women Achieving universal primary education Eradicating extreme poverty and hunger
Maternal Depression and Human Rights UNFPA concluded:“political will, concerted action by global stakeholders and resources are needed now to integrate maternal mental health in endeavors to achieve the Millennium Development Goals” Recommendations: Early detection with validated tools, appropriate treatment through clearly defined protocols, provision of low cost medications when needed Psychoeducational interventions that combined information with psychological support Interventions to enhance mother-child relationships (sensitivity, stimulation, interaction, comfort and responsiveness) Improvement in partner relationships by promoting gender equality, improved mother-father work sharing and parenting, reductions in partner and family violence Culturally sensitive, solution focused brief psychological therapies Improvement in social support for women Improvement in access to education and vocational training for girls and women (WHO, 2007)
Interventions for maternal depression – What is the evidence? Interventions by professionals Psychotherapy Cognitive-behavioral therapy Antidepressant medications (Appleby et al, 1997; Patel et al, 2007) Interventions by non-professionals Home visits by Community Health Workers (Elliot et al, 2001; Baker-Henningham et al, 2005) Psycho-social support groups (Cooper et al, 2002; Chen et al, 2000; Ali et al, 2003) Psycho-educational groups (Barlow et al, 2002) Group therapy by lay health workers in Uganda* Not specifically maternal depression, but successful in reducing depression among males and females, and reducing dysfunction in nearly all specific tasks for females (Bolton et al, 2003)
Challenges: Need > Resources Low priority of mental health issues (Chisholm et al, 2007; Saxena et al, 2007) Stigma of mental health issues (Engle, 2009) Low priority of women’s health; unfavorable entrenched gender policies Barriers to interventions centered on professionals Few psychiatrists (Patel et al, 2004) High cost of antidepressant medications (Bolton et al, 2003) Low rates of patient adherence (Kirkmayer, 2001) Frontline health providers Not trained to screen, identify, address maternal depression Not aware of magnitude or seriousness of the problem Competing demands for time and resources
Challenges: Knowledge & Translation Evidence base is sparse Difficult to extrapolate interventions High income to low- and middle-income countries From one low- or middle-income country to another Outcomes measured vary between studies Maternal vs child health indicators Mediating variables vs health outcomes Few long-term studies Requires shift from traditional child health programs Traditional child health programs – short-term, technology-dependent with high rates of clear-cut success Maternal mental health programs – long-term; household/community focus
Opportunities Build bridges Child health and maternal health Mental health and physical health Primary care and reproductive care Holistic, ecologic approach Requires cooperation between health care and public health Health and other social systems, including education Synergy and impact on multiple health outcomes
Make strategic use of all levels of health care providers
Design multifaceted rather than single-issue programs
Interventions in non-mental health domains may improve mental health
Link mental health programs to community-based programs
Integration of mental health into primary health services Ownership and buy-in Community (“consumers” and stakeholders) Providers Realistic expectations Link screening –assessment-intervention-referral Brief, user-friendly tools Multi-faceted screening where possible Quality Improvement approach Data loop and feedback to providers & stakeholders Engage providers in continuous improvement
Lessons from my own experiences Provider resistance and inertia can be overcome Research, experimental design important; replicate on-the ground conditions as much as possible Responsiveness and accountability to all stakeholders – key to sustainability In primary care settings, sensitivity is more important than specificity Reducing distress does not always require a mental health intervention Consistency of screening and assessment methods will improve yield over time On-going training is key. Best cases come from the health workers themselves
Opportunities Tradition of caring families and mothers’ attachment to their infants and children. Goodwill with potential partners. International focus on concerns on the African continent. Evidence of creative programming with few resources. Demonstration platform for “task shifting”. HIV/AIDS has given a window into the understanding a host of mental health issues. West African MacArthur Foundation initiative for a Masters in child mental health. African Association for Child and Adolescent Mental Health – Olayinka Omigbodun, MD, from Nigeria, also President of IACAPAP. Collaborative training opportunities in clinical and research areas. Clinical training exchanges with requirement to return to country of origin. MDG focus for the next generation. Needs assessment strategies for policy and program development…stakeholder involvement.
Mobilizing a global response: Setting priorities Criteria:
NIMH/NIH Support for Collaborative Programs Supporting African Development
Innovative Programming Infant and mother/child observation in the context of vaccination programs Microfinance leading to improved health and mental health outcomes Rights based programs leading to reduced HIV transmission, improved self-esteem and improvement in family life…development of “agency” – Felton Earls, MD in Tanzania Home based care for autistic children Juvenile justice outreach and intervention. Direct involvement of youth Focus on inclusion (disability rights).
Academic global health initiatives need to incorporate mental health and infant, child and adolescent mental health in particular. This is a vital part of the educational process to reduce stigma, enhance preventive efforts, and ensure healthier and more productive societies.