Psychosomatic Medicine and its Relevance to Mental Health in Africa Gregory Fricchione, MD Associate Chief of Psychiatry Director, Division of Psychiatry and Medicine Director, Benson Henry Institute Senior Scientist, Pierce Division of Global Psychiatry Massachusetts General Hospital Professor of Psychiatry Harvard Medical School
Objectives To Review: Scope of the global mental health crisis The Importance of Psychosomatic Medicine in helping to address it Implications for modern medicine and the quest to improve mental health in Africa.
International Psychiatry 1972-73 British J Psychiatry : prevalence of mental illnesses ~ equal in developed and developing worlds; services very unequal 1993 HSPH, HDSM, World Bank, WHO: --GBD=gap between current health status and ideal of life into old age free of disease/disability --DALYs= sum of yrs of life lost due to premature death (YLL) + yrs lost due to disability (YLD) for incident cases of the health condition.
Background Murray CJL and Lopez AD, eds.1996; The GBD: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. HSPH on behalf of WHO and World Bank, Cambridge, MA. WHO GBD: 2004 Update (WHO, 2008): --Depression, schizophrenia, epilepsy, dementia, alcohol dependence and other neuropsychiatric and substance use disorders constitute 13% of GBD surpassing CV disease and cancer. --Depression alone is the 3rd leading cause of GBD. By 2020, suicide is estimated to result in 1.5 million deaths a year and up to 30 million will attempt it.
Background WHO Solutions: 1. Treat in Primary Care, 2. Make psychotropics available, 3. Community care, 4. Educate the public, 5. Involve communities, families and consumers, 6. National policies, programs and legislation, 7. Develop human resources, 8. Link with other sectors, 9. Monitor community health, 10. More research. Recent Lancet Series: “mental health is essential for general health”; psychiatric disorders can predispose to physical illnesses and exacerbate them and vice versa. This is a Psychosomatic Medicine argument.
Chester M. Pierce Division of Global Psychiatry at MGH 2002 African Diaspora Meeting at MGH 2003 Global Division Established 2009 Named for Prof Pierce and David Henderson takes over from Greg Fricchione as Director. Bauer AM, Fielke K, Brayley J, Araya M, Alem A, Frankel BL, Fricchione GL. Tackling the global mental health challenge: a psychosomatic medicine/consultation-liaison psychiatry perspective. Psychosomatics. 2010 May;51(3):185-93. --depression in primary care --neuropsychiatry --consultant/supervisory model
Prevalence of Depression Med Illness % Prev Rate Cardiac Disease 17-27 Cerebrovascular 14-19 DAT 30-50 PD 4-75 Epilepsy (controlled) 3-9 Epilepsy (intractable) 20-55 DM 9(interview)-26 (self-report) Cancer 22-29 Pain 30-54 Obesity 20-30 General Pop 10.3 [Evans et al, Biol Psychiatry 2005; 58: 175-189]
Depression Primary prevention or early detection of depression should be a major focus of primary care practice Only ~ half of those patients who present to their primary care physician with major depression are accurately diagnosed (Eisenberg, 1992.) A diagnosis of major depression is often missed in patients who present with unexplained somatic symptoms or a symptomatic worsening of a chronic medical illness (Kirmayer, 1993).
Improving Outcomes in Primary Care Psychiatry Randomized controlled trials Consultation Liaison Primary Care Collaborative Model: patients with depression received two visits with a psychiatrist in the primary care clinic and two visits with the primary care physician within the first six weeks of treatment. (Katon, 1997).
Automated pharmacy data for primary care physicians to aid in monitoring patient compliance.
Improving Outcomes in Primary Care Psychiatry Brief Therapy in Primary Care
Four to six visits with a psychologist, cognitive behavioral therapy.
Psychiatrist supervised both the psychologist and the primary care physician
70% of intervention patients with major depression compared to 40% of usual primary care controls improved 50% or more on depression scores at four-month follow-ups. Cost of providing collaborative care was actually less per successfully treated patient than usual care. (Katon, 1997).
Improving Outcomes in Primary Care Psychiatry Guideline Based Treatment: Schulberg and colleagues (1996) randomized primary care patients to guideline based antidepressant treatment, guideline based IPT or usual primary care; found that 70% of patients who completed the interventions were significantly improved after eight months, 20% of patients in usual care Active Treatment: Mynors-Wallis and colleagues (1995) problem solving therapy, active medication treatment with amitriptyline, better outcomes than those receiving placebo and supportive visits.
Improving Outcomes in Primary Care Psychiatry 5) Stepped Care: Comparison of “stepped-care” with usual care in Santiago, Chile ( Araya et al, 2003, Lancet): 3 primary care clinics, n= 240 female adults Stepped care: 3-month multicomponent intervention by health worker (group psychoeducation; structured, systematic f/u; meds by PCP for severe depression) Stepped care: 78% improved (HDRS< 50% baseline), 73% recovered (HDRS < 8) at 6 mos Usual care: 32% improved; 30% recovered at 6 mos.
Depression Research Chisholm et al, 2004: --Estimated the population-level cost-effectiveness of evidence-based primary-care-based depression interventions in 14 epidemiological subregions of the world and their contribution towards reducing current burden. -- Total population-level costs and effectiveness (DALYs averted) were combined to form average and incremental cost-effectiveness ratios. -- Interventions can reduce the burden of depression by 10-30%. -- So conclusion was more intervention is needed if burden to be reduced.
The Role of Psychosomatic Medicine Psychosomatic medicine is a discipline dedicated to 1) Advancing understanding of connections between psychological and social forces and human physiology, including health and disease; and 2) Advocating the application of holistic integrative principles to patient care The field of psychosomatic medicine with its practical arm consultation–liaison (C–L) psychiatry is well-positioned to contribute to global mental health through expertise in: Understanding and managing co-morbid conditions and Working in systems at the interface of psychiatry and medicine.
The Role of Psychosomatic Medicine Disease burden attributable to mental illness is likely underestimated, given the interrelationship between psychiatric and both communicable (e.g., acquired immune deficiency syndrome [AIDS]) and noncommunicable diseases (e.g., cardiac disease, diabetes). Worldwide, depression is associated with poorer health among those with chronic medical conditions. Patients with mental disorders have increased mortality from common conditions, including cancer, stroke, cardiovascular disease, respiratory diseases, and accidents. These patients receive fewer guideline based interventions, which may account for some of their excess mortality.
The Role of Psychosomatic Medicine Similarly, psychiatric disorders predispose to health-risk behaviors, including use of tobacco, alcohol, and other substances; inactivity; overeating; and high-risk sexual behaviors, all of which are common among individuals with mental disorders. Taken together, the direct and indirect effects of psychiatric disorders on GBD are substantial. The nature of the interrelationship of mental and physical bodily events is such that there can truly be no health without mental health. High disease burden, together with lack of resources for specialty treatment and a substantial treatment gap, provide the basis for a link between primary care and mental health care C–L psychiatrists are well-equipped to provide consultations and assist primary care physicians in treating patients with mental disorders.
The Role of Psychosomatic Medicine One of the best-studied C–L models is the collaborative-care model for primary-care depression management, developed out of the outpatient C–L service at the University of Washington Drawing on the insights of those leaders who envisioned C–L psychiatry as central to the development of primary-care treatment of mental disorders, the extension of C–L psychiatry to global mental health is a logical one because the field fosters development of a skill-set well suited to advancing the global mental health agenda.
The Role of Psychosomatic Medicine By efficiently using specialist resources, a primary care model may improve access to care in underserved areas. Moreover, such a model is consistent with important principles of high-quality care, specifically, that services should be community-based and patient-centered with an emphasis on improving daily functioning. Treatment of mental disorders in the primary-care setting may lead to higher acceptance by patients and may reduce the stigma of seeking help. By modeling professional behavior toward patients with mental illness, C–L psychiatrists may help allay fears of primary-care providers and other allied healthcare workers and thus contribute to reducing stigma.
The Role of Psychosomatic Medicine Two notable features include the specialized knowledge at the interface of medicine, neurology, and psychiatry; and the ability to function primarily in the role of a consultant-educator and supervisor, rather than as a primary service provider. These skills are of critical importance in the international arena and can result in psychiatrists diagnosing a range of disorders with neuropsychiatric presentations, including: -- infectious diseases (such as TB, malaria, and AIDS-related neuropsychiatric conditions) --neurological disorders (epilepsy, stroke, dementias) --endocrinological conditions (thyroid disease), --nutritional deficiencies (B12 and folate deficiencies, Wernicke’s encephalopathy), -- autoimmune disorders (multiple sclerosis and lupus), and -- a host of other conditions, including other causes of delirium and dementia, and substance intoxication and withdrawal. Bidirectionality: HIC psychiatrists can learn a great deal about neuropsychiatry of infectious diseases from collaborations in Africa.
Example: South Australia RRMHS has successfully used a C–L approach in primary care to facilitate a seamless, integrated mental health system with an economy of scale (fewer than 10 full-time-equivalent psychiatrists) across a vast state. The service has tailored the strengths of the C–L approach to provide subspecialist support to local, community-based primary providers and has expanded the capacity of local primary-care services to provide high-quality mental health care.
Example: Ethiopia The Ethiopian model represents a prototypical solution opportunity that promises to address the country’s basic mental health needs by concurrently training a primary-care workforce (EPHTI) and a specialized workforce (TAAPP) that can serve consultant and supervisory functions. Training C–L psychiatrists is a next logical step, given both the high comorbidity of infectious and nutritional diseases and the plan to distribute the psychiatrists around the country. There is a Consultation Service with training opportunities now at St Paul’s Hospital.
Implications for Mental Health in Africa Problem: Lack of psychiatric resources to manage direct burden of the neuropsychiatric illnesses and indirect burden from complications of co-morbidities with physical illnesses. Needs 1) Resource development and capacity building through psychosomatic medicine and consultation psychiatry education of native psychiatrists, primary care doctors, psychiatry residents, nurses, health workers. 2) Need for research into cultural diagnosis and treatment of psychiatric illnesses in primary care settings; 3) Need for research in the new molecular psychosomatic medicine and the neuropsychiatry of disease; 5) Need for research in the use of resiliency enhancing strategies to see if goals in primary, secondary and tertiary prevention can be advanced.
Summary Are mental health problems too big to be tackled? William Foege, MD, MPH: Conqueror of Smallpox -Never let the perfect be the enemy of the good. -“Of the many visions of global mental health, some are optimistic, some are realistic, and some are pessimistic. I urge you to remember James Reston’s advice: ‘Stick with the optimists. It will be tough enough even if they are right!’ ” - Global health is a field fueled by “unwarranted optimism” that allows us to go beyond what seems to be possible. And Psychosomatic Medicine can help!