The Current Condition of Mental Health in Afghanistan:  Integrating Mental Health into Primary Healthcare     Nahid Aziz, ...
OUTLINE <ul><li>Brief History </li></ul><ul><li>The State of Mental Health in Afghanistan </li></ul><ul><li>Mental Health ...
<ul><li>Brief History </li></ul>
Afghanistan :  No single disaster but a  series  of disasters… <ul><li>1979: Soviet invasion and guerilla war by mujahedee...
II.  State of Mental Health in Afghanistan
Impact on Health Status <ul><li>Life expectancy at birth 43 years (WDR, 2004) </li></ul><ul><li>Under-5 mortality rate 257...
Prevalence of MH Disorders Post Taliban,  East Afghanistan <ul><li>Estimated prevalence rates -  </li></ul><ul><li>Depress...
Other Estimates on Prevalence of MH Problems Among Afghans <ul><li>Afghan MoPH, 2008 </li></ul><ul><ul><li>50-60% depressi...
Prevalence of MH Problems Among Children in Afghanistan <ul><li>Multi-stage random sample of 1,011 schoolchildren (between...
MH & Psychosocial Problems after Collective Trauma MH  in General Health Care Community  Interventions
III.  Mental Health Country Strategies
Afghanistan’s Current Health Priorities
Basic and Essential Packages of Health Services (BPHS & EPHS  ) Afghan health system’s referral system
What is Being Done in MH Area? <ul><li>A public MH approach: </li></ul><ul><ul><li>Integration of (primary) mental health ...
Current MH Capacity <ul><li>Currently, there are:  </li></ul><ul><li>Two trained psychiatrists (total pop. 30 million!!) <...
Strategy Implementation <ul><ul><li>Create  MH awareness in general population </li></ul></ul><ul><ul><li>Improve  MH know...
1. General Population <ul><li>Goals: </li></ul><ul><li>Increase mental health awareness (mental health literacy) </li></ul...
2. General  Health Care Professionals <ul><li>Goal:   </li></ul><ul><li>   D evelopment of MH competencies  in  general  ...
3. Mental Health Professionals <ul><li>Mental health workers: </li></ul><ul><ul><li>Psychiatrists/ or doctors designated f...
3. (cont.) Mental Health Professionals:  Psychosocial Counselors   <ul><li>Certification courses : Not just classroom teac...
3. (cont.) Mental Health Professionals:  Nurses/Doctors <ul><li>Certification course for nurses and doctors, with mental h...
3. (cont.) Mental Health Professionals:  Psychiatrists <ul><li>Specialist training for psychiatrists in other countries </...
4. MH Trainers <ul><li>Group of trainers </li></ul><ul><li>Training of Trainers approach: rapid build up of capacity throu...
Referral System of Mental Health Services Within BPHS
MH Addressed in BPHS
IV.  Recent Developments in Mental Health in Afghanistan
Important Recent MH Activities  Within Afghanistan’s MoPH <ul><li>Revision of BPHS </li></ul><ul><li>More attention for MH...
(cont.) Important Recent Developments Within Afghanistan’s MoPH <ul><li>The psychosocial counseling approach is now integr...
(cont.) Important Recent MH Activities  Within Afghanistan’s MoPH <ul><li>Integration of MH into primary healthcare in 7 p...
V.  Remaining Challenges
However,  Major Challenges  Remain… <ul><li>Funding for MH activities lacking. </li></ul><ul><li>Sustainability of integra...
<ul><li>Thank You </li></ul>
Literature on problems with ‘prevalence’ of Mental Disorder in Afghanistan <ul><li>Bolton & Betancourt (2004) Mental healt...
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The Current Condition of Mental Health in Afghanistan: Integrating Mental Health into Primary Healthcare

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The Current Condition of Mental Health in Afghanistan: Integrating Mental Health into Primary Healthcare

Nahid Aziz, Argosy University

CORE Group Spring Meeting, April 29, 2010

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  • Role of nurses Competency: Lacan Medication
  • The Current Condition of Mental Health in Afghanistan: Integrating Mental Health into Primary Healthcare

    1. 1. The Current Condition of Mental Health in Afghanistan: Integrating Mental Health into Primary Healthcare   Nahid Aziz, PsyD Associate Professor Argosy University Clinical Psychology Programs April 29 th , 2010 CORE Group Spring Meeting
    2. 2. OUTLINE <ul><li>Brief History </li></ul><ul><li>The State of Mental Health in Afghanistan </li></ul><ul><li>Mental Health Country Strategies </li></ul><ul><li>Recent Developments in Afghanistan </li></ul><ul><li>Remaining Challenges </li></ul>
    3. 3. <ul><li>Brief History </li></ul>
    4. 4. Afghanistan : No single disaster but a series of disasters… <ul><li>1979: Soviet invasion and guerilla war by mujahedeen </li></ul><ul><li>1989: Soviet withdrawal. Afghan communists continue to fight </li></ul><ul><li>1992: Communists fall, mujahedeen fight among themselves. </li></ul><ul><li>1992-4: Destruction of Kabul </li></ul><ul><li>1996: Taliban </li></ul><ul><li>2001: US led invasion and start guerilla by alliance of Taliban and some former mujahedeen. </li></ul>
    5. 5. II. State of Mental Health in Afghanistan
    6. 6. Impact on Health Status <ul><li>Life expectancy at birth 43 years (WDR, 2004) </li></ul><ul><li>Under-5 mortality rate 257/1000 (4th highest in world) </li></ul><ul><li>Maternal mortality rate 1900/100,000 (second highest in the world) (UNICEF, 2004) </li></ul>
    7. 7. Prevalence of MH Disorders Post Taliban, East Afghanistan <ul><li>Estimated prevalence rates - </li></ul><ul><li>Depression : total 38% </li></ul><ul><li> women 58%  men 16% </li></ul><ul><li>Anxiety : total 52% </li></ul><ul><li> women 78%  men 22% </li></ul><ul><li>PTSD : total 20% </li></ul><ul><ul><li>women 32%  men 7% </li></ul></ul><ul><li>(Ventevogel, Scholte, Olff, JAMA, 2004 ) </li></ul>
    8. 8. Other Estimates on Prevalence of MH Problems Among Afghans <ul><li>Afghan MoPH, 2008 </li></ul><ul><ul><li>50-60% depression in clinical settings </li></ul></ul><ul><ul><li>10% severe depression </li></ul></ul><ul><li>IAM, 2007 </li></ul><ul><ul><li>50 female suicides in 2007 in a small town of 1500 </li></ul></ul><ul><li>Medica Mondiale, 2009 </li></ul><ul><ul><li>1320 patients: 69% family conflict with domestic violence </li></ul></ul><ul><li>Caritas, 2009 </li></ul><ul><ul><li>11,123 patients in 3 years </li></ul></ul><ul><ul><li>65.4% depressive symptoms </li></ul></ul><ul><ul><li>35.4% with a severe family conflict </li></ul></ul><ul><ul><li>80% domestic violence </li></ul></ul>
    9. 9. Prevalence of MH Problems Among Children in Afghanistan <ul><li>Multi-stage random sample of 1,011 schoolchildren (between 11 and 16 yrs) </li></ul><ul><li>Experiences of trauma, suffering and adversity. </li></ul><ul><li>Risk factors for poor child mental health outcomes: </li></ul><ul><ul><li>Exposure to trauma events </li></ul></ul><ul><ul><li>MH of the child’s caregiver </li></ul></ul><ul><li>(Panter-Brick C. et al., Lancet, 2010) </li></ul>
    10. 10. MH & Psychosocial Problems after Collective Trauma MH in General Health Care Community Interventions
    11. 11. III. Mental Health Country Strategies
    12. 12. Afghanistan’s Current Health Priorities
    13. 13. Basic and Essential Packages of Health Services (BPHS & EPHS ) Afghan health system’s referral system
    14. 14. What is Being Done in MH Area? <ul><li>A public MH approach: </li></ul><ul><ul><li>Integration of (primary) mental health in the (primary) health care system </li></ul></ul><ul><ul><li>Addressing psychosocial problems in the communities </li></ul></ul>
    15. 15. Current MH Capacity <ul><li>Currently, there are: </li></ul><ul><li>Two trained psychiatrists (total pop. 30 million!!) </li></ul><ul><li>A few psychiatric nurses </li></ul><ul><li>No psychologists </li></ul><ul><li>No other MH professionals </li></ul><ul><li>(WHO, Mental Health Atlas, 2005) </li></ul>
    16. 16. Strategy Implementation <ul><ul><li>Create MH awareness in general population </li></ul></ul><ul><ul><li>Improve MH knowledge and skills of general health workers  integrating MH into primary health </li></ul></ul><ul><ul><li>Strengthen the MH professional workforce </li></ul></ul><ul><ul><li>Build MH training capacity </li></ul></ul>
    17. 17. 1. General Population <ul><li>Goals: </li></ul><ul><li>Increase mental health awareness (mental health literacy) </li></ul><ul><li>Improving coping mechanisms </li></ul><ul><li>Identification of possible cases </li></ul><ul><li>Combating stigma </li></ul><ul><li>How: </li></ul><ul><li>Not imposing views, interactive, simple, adaptive, not using written materials due to high illiteracy rate  flipcharts, radio programs, radio drama, narrative theatre. </li></ul>
    18. 18. 2. General Health Care Professionals <ul><li>Goal: </li></ul><ul><li> D evelopment of MH competencies in general health care professionals : </li></ul><ul><li>Appropriate to their role within the health care system (BPHS/EPHS). </li></ul><ul><li>Competency based : immediately useful for them in their everyday clinical practice. </li></ul><ul><li>Teaching only realistically available treatment options </li></ul>
    19. 19. 3. Mental Health Professionals <ul><li>Mental health workers: </li></ul><ul><ul><li>Psychiatrists/ or doctors designated for mental health </li></ul></ul><ul><ul><li>Psychiatric nurses </li></ul></ul><ul><ul><li>Psychosocial counselors </li></ul></ul><ul><ul><li>Social workers </li></ul></ul><ul><ul><li>Clinical psychologists </li></ul></ul>
    20. 20. 3. (cont.) Mental Health Professionals: Psychosocial Counselors <ul><li>Certification courses : Not just classroom teaching but: Practical skills, on the job training!! With supervision </li></ul><ul><li>Psychosocial counseling should help the patient to (re) gain a “ Sense of Coherence ” </li></ul><ul><li> Comprehensibility </li></ul><ul><ul><ul><li>understanding the situation, learning from the situation </li></ul></ul></ul><ul><li> Manageability </li></ul><ul><ul><ul><li>being able to influence such situations in the future </li></ul></ul></ul><ul><li> Meaningfulness </li></ul><ul><ul><ul><li>discussing values of living acoording to ones values </li></ul></ul></ul>
    21. 21. 3. (cont.) Mental Health Professionals: Nurses/Doctors <ul><li>Certification course for nurses and doctors, with mental health as a sub-specialization, e.g. 3-12 month courses </li></ul><ul><li> psychiatric nurses, doctors who are focal points for mental health or work in mental health ward of hospitals or of general hospitals. </li></ul>
    22. 22. 3. (cont.) Mental Health Professionals: Psychiatrists <ul><li>Specialist training for psychiatrists in other countries </li></ul><ul><ul><li>Brain-drain </li></ul></ul><ul><ul><li>Non-adapted curriculum </li></ul></ul><ul><li>Need for adapted curriculum in collaboration with neighboring countries (Iran, Pakistan, India) </li></ul><ul><ul><li>Brief (1-3 yr) </li></ul></ul><ul><ul><li>Modular system (combat brain flight!) </li></ul></ul><ul><ul><li>Adapted to the role of the psychiatrist in the health care system </li></ul></ul>
    23. 23. 4. MH Trainers <ul><li>Group of trainers </li></ul><ul><li>Training of Trainers approach: rapid build up of capacity through addressing </li></ul><ul><ul><ul><li>Specific contents/skills </li></ul></ul></ul><ul><ul><ul><li>Training skills </li></ul></ul></ul>
    24. 24. Referral System of Mental Health Services Within BPHS
    25. 25. MH Addressed in BPHS
    26. 26. IV. Recent Developments in Mental Health in Afghanistan
    27. 27. Important Recent MH Activities Within Afghanistan’s MoPH <ul><li>Revision of BPHS </li></ul><ul><li>More attention for MH (each new version of BPHS since 2003 has more MH!) </li></ul><ul><li>Strengthening of the psychosocial aspects of treatment </li></ul><ul><li>Installing psychosocial counselors (m & f) in Comprehensive Health Clinics </li></ul><ul><li>Appointment of focal point MH in District Hospital </li></ul><ul><li>MH materials in PHC revised (comprehensive package for all levels of health care system: MD, nurses/Midwives, PS counselors, CHW </li></ul><ul><li>Pilot with integrated approach (training primary care staff + psychosocial counselors) </li></ul><ul><li>A comprehensive Mental Health Strategy was finalized by MoPH (March, 2010) which will be of great help to all stakeholders </li></ul>
    28. 28. (cont.) Important Recent Developments Within Afghanistan’s MoPH <ul><li>The psychosocial counseling approach is now integrated into the MH component of the BPHS services AND linked by a referral system to community based social services: </li></ul><ul><li>Capacity building </li></ul><ul><li>Social protection programs </li></ul><ul><li>Income generation </li></ul><ul><li>Legal services </li></ul>
    29. 29. (cont.) Important Recent MH Activities Within Afghanistan’s MoPH <ul><li>Integration of MH into primary healthcare in 7 provinces with the funding of EU. </li></ul><ul><li>Outcome evaluations conducted on the recent integration which showed good results. </li></ul><ul><li>(Le Roy, J., 2008. External Evaluation Report Integrating Mental Health into the Primary Health Care system of Afghanistan) </li></ul>
    30. 30. V. Remaining Challenges
    31. 31. However, Major Challenges Remain… <ul><li>Funding for MH activities lacking. </li></ul><ul><li>Sustainability of integration of MH in the health facilities is at risk. </li></ul><ul><li>The psychosocial community-based services are not yet sustainable. </li></ul><ul><li>The PS treatment in the health care system tends to be given less emphasis. </li></ul><ul><li>The financial sustainability is a matter of high concern both for the BPHS and MH center in Afghanistan </li></ul><ul><li>Stigma is a significant barrier for many to come and seek help. </li></ul><ul><li>Building up a pool of national Trainers in MH for MDs as well as for Psychosocial Counselors </li></ul><ul><li>Mental health is on the verge of becoming medicalized  prescribing and abusing psychotropic medications is a big problem. </li></ul><ul><li>Recent survey showed that 30% of Afghan population abusing tranquilizers. </li></ul><ul><li>(Afghanistan Research and Evaluation Unit, 2008) </li></ul>
    32. 32. <ul><li>Thank You </li></ul>
    33. 33. Literature on problems with ‘prevalence’ of Mental Disorder in Afghanistan <ul><li>Bolton & Betancourt (2004) Mental health in postwar Afghanistan. JAMA 292:626-8. </li></ul><ul><li>Miller, Omidian, Rasmussen et al (2008) Daily stressors, war experiences, and mental health in Afghanistan. Transcult Psychiatry 45:611-38. </li></ul><ul><li>Miller, Omidian, Kulkarni et al (2009) The Validity and Clinical Utility of Post-traumatic Stress Disorder in Afghanistan. Transcult Psychiatry. 46:219-37 </li></ul><ul><li>Ibrahim Zai, Mismahl & Herzberg (2009) Mental Health Services and Existing gaps in Afghanistan. In: Mental Health in Fragile States, conference report, sept 2008. LSHTM&HealthNet TPO </li></ul><ul><li>Ventevogel, de Vries, Scholte et al. (2007) Properties of the Hopkins Symptom Checklist-25 (HSCL-25) and the Self Reporting Questionnaire (SRQ-20) as screening instruments used in primary care in Afghanistan. Social Psychiatry Psychiatric Epidemiology 42: 328–335. </li></ul><ul><li>Ventevogel, P. (2005). Psychiatric epidemiological studies in Afghanistan: a critical review and future directions. Journal of Pakistan Psychiatric Society 2: 9-12. Available at: http://www.jpps.com.pk </li></ul>

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