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    Belfer gottlieb maternal and child mental health Belfer gottlieb maternal and child mental health Presentation Transcript

    • 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
      Substance abuse
      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.
      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”
      chronic depression/dysthymia
      during pregnancy
      maternal distress
    • 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)
      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*
      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
      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
      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
      Control of alcohol
      Promotion of mental health programs
      Budgetary priorities
      Mother-child dyad
      Parenting, massage, sensitivity
      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
      Control of alcohol
      Promotion of mental health programs
      Budgetary priorities
      Gender equality
      De-stigmatize mental disorders
      Mother-child dyad
      Parenting, massage, sensitivity
      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”
      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
      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)
      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
      • 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