Paparan Prof Byron Good Ph.D. Profesor Medical Anthropology dari Universitas Harvard Amerika Serikat.

1. The Urgent Need to Establish an
Indonesian NIMH
to Shape the Future of Research of
Research for the Implementation of
the National Mental Health Law
Byron J. Good, Ph.D.
Professor of Medical Anthropology
Department of Global Health and Social Medicine
Harvard Medical School
RSJ Dr Soeharto Heerdjan
Grogol, Jakarta
July 28, 2016

2. What should be the role of an
NIMH for Indonesia?
How can an Indonesian National
Institute for Mental Health support the
implementation of UU Keswa?
Should it support the development of
policy?
Should it do research?
Should it support research nationally?
What kind of research?

3. I. The Challenges of
Implementing MH Services in
Indonesia
Very low human resources
Indonesia among lowest number of
psychiatrists in all SE Asia: ca .25/100,000
population
Only above Cambodia, Laos, Papua New
Guinea in SE Asia
Example: Jogya: 25 psychiatrists for
3.6 million (= .74/100,000)
But if Australia, 500 psychiatrists for Jogya!
Huge disparities in distribution

4. The Challenges of
Implementing MH Services in
Indonesia
High burden of mental illnesses
globally
Ca 1,177,600 persons w schizophrenia
(4.6/1000 point prevalence), perhaps
2,560,000 (1%) with severe mental illnesses
Estimated 11-12% w treatable depression,
anxiety disorders (>25 million persons)
Children’s disorders? DK!
Increased risk in settings of natural disasters or
conflict

5. II. Emerging Models of Care
Traditionally MH low priority. Still less
than 1% of national health budget.
WHO: mhGAP
Huge new commitment: UU Keswa
Psychiatrist-based models profoundly
inadequate
New models – e.g. ‘Aceh Model’
CMHN, DSSJ, sistem rujukan…
But almost no evidence-based
models of care

6. III. Importance of
Implementation Research
Critical to focus not only on policy,
but on implementation!
Even more important since decentralization
Simple example: Aceh model
CMHN – 3 levels of training required, but most
have only basic training
Enormous initial investment. Today funding
very low, services very limited.
Almost no research on the effectiveness of the
‘Aceh model’ – on what is needed to implement
the model most efficiently

7. III. Importance of
Implementation Research
Critical role of linking universities to
DinKes to conduct action research
and evaluations of implementation
‘Community laboratories’!
Importance of developing evidence-
based models of mental health
services
Importance of scaling up new
models, if effective

8. IV. Examples from our research
in Aceh and in Jogya:
A. Implementation of Existing
Policies
Study of Bebas Pasung projects in Aceh
and Central Jawa
USAID funding – collaboration of UGM,
UnSyiah and Harvard with RSJ and DinKes
Aceh: interviewed 50 caregivers of persons
unlocked in Bireuen in past 1-2 years
Central Java: interviewed 65 caregivers of
persons unlocked after treatment in RSJ in
Magelang in past 1-2 years

9. IV. Examples from our research
in Aceh and in Jogya:
Major findings:
Aceh – 47% pasung lagi during 2 years,
and 18% pasung during time of visit
Magelang – 25% pasung lagi during 2
years
Biggest criticism of program by
caregiver – failure of follow-up care
Comparison with China: <8% relocked
during 7 years!
Conclusion: unlocking not enough!

10. IV. Examples from our research
in Aceh and in Jogya:
B. Needs Assessments
Aceh: Post-Conflict Psychosocial
Needs Assessment – IOM, UnSyiah,
Harvard (international funding)
Jogya: preliminary studies of specific
problems in mental health services
delivery – with UGM/Harvard and
DinKes, funds from USAID

11. IV. Examples from our research
in Aceh and in Jogya:
C. Pilot Interventions and Evaluation
– Action Research Projects
Aceh: IOM/UnSyiah/Harvard and
Dinkes – develop model mental health
outreach teams
Jogya/Aceh (USAID project) –
develop action research projects,
focused on identified problems

12. IOM/DinKes Outreach Teams

14. Medication Clinic

15. Evaluations

16. Time 1: Patient Clinical Diagnoses
by Treatment Team
Diagnoses Total patient sample
n=1137
% of patient sample
suffering disorder
Depression 65 6%
General Anxiety
Disorder
480 42%
Depression and Anxiety 177 16%
PTSD 366 32%
Somatoform, Insomnia 159 14%
Organic disorders 16 1%
Psychotic disorder 24 2%

17. Since you received treatment by IOM, have your mental health
symptoms (from stress or trauma) become worse, stayed the
same, gotten better?
Valid
Percent
% worse,
same,
better
Much worse - -
1%Somewhat worse 3 .3%
A little worse 9 .8%
The same 173 16% 16%
A little better 391 36%
83%Somewhat better 410 38%
Much better 91 8%
Total 1077 100%

18. Ability to Work
Mean number of hours patients say they
could work per week
Before Sick: 28 hours
When Sick: 10 hours
At Time 3: 41 hours

19. USAID/Harvard Dubai Project
Evaluating specific models for
improving services
Discharge/rujukan balik
Psycho-ed by puskesmas staf
Training kader desa keswa
KPSI – consumer group
Improved bebas pasung policies and
methods
Now bringing together in 5 PKM

20. V. Role of NIMH in US:
National Institutes of Health
Premier source of funding health
research in the United States
Made up of 27 Institutes and Centers
Includes 20 Institutes [e.g., National
Cancer Institute (1937), National
Institute of Mental Health (1949),
National Institute of Minority Health
and Health Disparities (1993)]

21. Role of NIMH in US
Sets research priorities
Provides funds through peer-
reviewed grants
Supports research training
Also supports policy development

22. Overall Goals of American NIMH
I. Support scientific research related
to mental health
I. ‘Basic’ research (biological, behavioral,
social, environmental)
II. Translational research – translating
basic research into prevention and
treatment
III. Mental health services research –
including implementation research
II. Support training of investigators

23. US NIMH: Division of Services and
Intervention Research – Components
Adult Treatment and Preventive
Intervention Research Branch
Child and Adolescent Treatment and
Preventive Intervention Research Branch
Services Research and Clinical
Epidemiology Branch
Office of Research Training and Career
Development
Ethics of Mental Disorders Research
Program

24. Areas of High Priority
Develop innovative interventions, including
treatment regimens, prevention strategies, and
innovative service delivery approaches
Test interventions through effectiveness
research and practical clinical trials
Reduce the significant burden and mortality
associated with suicidality
Identify effective dissemination and
implementation processes
Employ strategic partnerships and community
engagement

25. VI. Role of Indonesian NIMH?
Relevance of American NIMH?
Critical Role: Support the implementation
of the mental health law, and improve
quality of mental health services
Recommendation: by supporting critical
research!
Establish research priorities
Use method of peer-reviewed research –
supporting research nationally
Could also ‘contract’ specific projects

26. Role of Indonesian NIMH?
How establish priorities?
Develop task forces for critical areas
of research – could be broad or narrow
Examples:
Depression
Improving capacity for treating depression in
puskesmas
Improving recognition and treatment of post-
partum depression

27. Establishing research priorities
Schizophrenia
Developing new models for hospital-
based rehabilitation and
psychoeducation
New models for improved community-
based care for persons with
schizophrenia
Community-based medical rehabilitation
Care for elders with schizophrenia
Models for early intervention

28. Establishing research priorities
More effective ways to prevent
‘pasung lagi’…
Economics of mental health care
Estimating economic benefits of mental
health services for families
Improving BPJS for mentally ill persons
Evidence-based models for school-
based programs
Mental health services for elders

29. Establishing research priorities
Mental health systems research
Developing evidence-based models for
community-based services
Evaluating models for training CMHN
Evaluating benefits of psychologists in
puskesmas
Linking hospitals to puskesmas more
effectively
Developing monitoring softward
Models for very low resource settings

30. Added roles
Maintain file of validated research
instruments available to all
researchers – to standardize
research
Support research training
Support training in use of specific
instruments
Develop collaborative grants (e.g. w
LPDP) for linking biological research
with mental health services research

31. Conclusion
Critical role for an Indonesian NIMH
for improving implementation of the
national mental health law
Primary focus might be on supporting
research, nation-wide, on evidence-
based services
Use model of peer-reviewed
research grants of small to medium
size
Maintain library of instruments