Belfer gottlieb maternal and child mental health

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”?

Preventive intervention at early ages/early child development programs cost effective (Heckman, 2007)

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?

Policy Considerations

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)

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)

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

Mother-child dyad
Parenting, massage, sensitivity
Mother-partner
Reduce violence, parenting
Family unit
Resiliency factors

Mother-child dyad
Mother-partner
Family unit
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

Gender equality
Educational policies
Safety
Control of alcohol
Promotion of mental health programs
Budgetary priorities
Mother-child dyad
Mother-partner
Family unit
Health Sector
Community resources
Resiliency factors

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
Mother-partner
Family unit
Health Sector
Community resources
Resiliency factors

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

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

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

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

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

Lessons learned - translation
Utilize and enhance existing delivery system
Integrate mental health into primary care
Incorporate maternal assessment and care into Integrated Management of Childhood Illness package
Integrate mental health into maternal care
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

Multi-faceted Screening-Assessment Tool

Depression

Substance/Alcohol Use

Domestic Violence

Mental health training – Community Health Workers in Rural Guatemala

Moving Forward

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:
High burden (mortality, morbidity, disability)
Large economic cost
Effective intervention available
Priority conditions:
Depression
Schizophrenia
Suicide prevention
Epilepsy
Dementia
Disorders due to use of alcohol
Disorders due to illicit drug use
Child mental disorders

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.

Thank you

Belfer gottlieb maternal and child mental health

by jasonharlow on Aug 19, 2011

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