An electronic publication for mental health in developing

countries - promoting fresh ideas to reduce suffering worldwide.

MentalHealthAmajorglobalhealthissue

Edition 5

So far, mental health has not been considered a global health priority compared to communicable diseases and some of the major non-communicable diseases like cardiovascular disorders and cancer.

However, following the World Health Organisation’s (WHO) 2001 World Health Report “Mental health – new understanding, new hope” there has been a growing awareness of the fact that mental disorders contribute significantly to Years Lived with Disability (YLD) i and to the global burden of disease reflected in their contribution to the Disability Adjusted Live Years (DALYs).ii

The life-time risk of developing a mental disorder is nearly the same for people living in low and middle income countries compared to the risk in high income countries. Mental disorders affect people of all ages. Around 20% of the world’s children and adolescents suffer from mental disorders or problems.iii

Mental disorders are risk factors for other diseases. They cause long term disability and dependency. As mental health is strongly connected to physical health the WHO coined the slogan of “No health without mental health”.

Among the determinants of mental health are internal (individual) as well as social, cultural, economic, political and environmental factors. Internal factors are, for example, the ability to manage one’s thoughts, emotions and behaviour,

the physical condition, and interactions with others. External factors comprise national policies, social protection, living standards, working conditions, and social support by the community. Wars, conflicts, traumata, and disasters have a huge impact on mental health.iv

Over the past 15 years a number of research and lobby organisations have been formed and recently the World Health Organisation adopted the Mental Health Action Plan 2013-2020 that sets clear targets for improving global mental health. The latest important recent development is the inclusion of mental health in the Sustainable Development Goals (SDGs) to be implemented in 2016-2030.

Developing Mental Health

Areas of concern (with a focus on low income countries)1. Lack of mental health literacy, stigma and discrimination, human rights violations Mental health literacy, i.e. knowledge of mental disorders which is needed for their recognition, management or prevention is still low. Often mental disorders are not considered as illnesses and there is poor knowledge as regards their causes and possible treatments.v To some degree mental disorders are still a taboo issue in society and in politics. Lack of mental health literacy causes misconceptions of mental disorders. Often they are attributed to substance abuse and spiritual causes like being possessed by an evil spirit, and to God’s punishment. Such misconceptions lead to the stigmatisation and discrimination of people with mental disorders and their relatives. In some countries patients are subject to severe human rights violations.vi

2. Mental health treatment gap

So far, health systems don’t respond sufficiently to the challenge of mental disorders. It is estimated that in many low-income countries up to 75% of the people with mental disorders do not have access to the treatment they need. With regard to psychoses, in sub-Saharan Africa the treatment gap is estimated to exceed 90%.vii This treatment gap is due to: •Shortage of financial resources for mental health The proportion of total health expenditure allocated to mental health is an indicator of the priority given to mental health within the health sector. The allocation rate is, e.g., considerably higher in Europe (5%) than in Africa (0.62%). Low-income countries spend about 0.5% of their limited health budgets on mental health in spite of them causing 25.5% of YLDs.viii •Shortage of human resources for mental health The average rate of psychiatrists ranges from 0.05% per 100.000 in Africa to 8.59 per 100.000 in European countries. Psychologists and occupational therapists are even scarcer in Africa.ix In low- and middle-income countries training facilities for mental health professionals are too few to educate adequate numbers of qualified personnel. In addition, some of the well trained specialists in low- and middle-income countries migrate to countries with higher incomes.x •Institutionalisation of mental health care – lack of integration in primary health care settings

In most low-income countries mental health care is mainly provided for in mental hospitals that are far away from those who are in need of treatment. 8 out of 10 psychiatric beds are located in mental hospitals, but these facilities treat only about 7% of all service users. These mental hospitals are often “stand-alone” institutions that are disconnected from the other levels of mental health services and of the primary health care system. Only about 57% of all African countries have a system of community-based mental health care.xi There is evidence that integrating mental health services into a primary health care system has the best treatment results.xii Accordingly, the WHO recommends the development of community-based mental health services by integrating mental health into existing primary health care systems and mobilising community resources. Mental health services should be provided at the level of health centres, health posts (village clinics), and also at community level. 3. Unavailability of psychotropic drugs

Until now medication remains the main treatment of mental disorders in low-income countries. As many of these countries have adopted the WHO List of Essential Medicines, there are only few options for patients receiving treatment at public health facilities. Though restriction to a limited number of drugs in general is widely accepted, there are some challenges in terms of limiting the number of psychotropic drugs available in resource limited settings. For example, patients often don’t respond to an initial treatment. Together with the limited availability of psychotropic drugs patients and their families have few chances to make an informed decision about the kind of treatment they undergo.xiii

Christian responses to global mental health challenges

There are two main areas in which churches and Christian health services have special resources to contribute to global mental health, namely by improving mental health literacy and by closing the treatment gap. 1. Improvement of mental health literacy As there is still a strong belief that mental diseases are caused by spiritual forces, Christian churches and health services can transform such misconceptions through creating awareness and providing sound information about the determinants and causes of mental diseases.

i Data from National Institute of Mental Health, online: http://www.nimh.nih.gov/health/statistics/global/global-ylds-contributed-by-mental-and-behavioral-disorders.shtmlii Cf. Votruba, Nicole; Eaton, Julian; Prince, Martin; Thornicroft, Graham: The importance of global mental health for the Sustainable Development Goals: Journal of Mental Health, 2014, 23(6), 283- 286, p. 283; Patel, Vikram, and Saxena, Shekar : Transforming Lives, Enhancing Communities – Innovations in Global Mental Health: New England Journal of Medicine 2014; 370: 498-501, p. 498.iii WHO: Ten facts about mental health, http://www.who.int/features/factfiles/mental_health/mental_health_facts/en/iv Cf. Ibid.v Jorm, A.F., Korten, A.E.; Jacomb, P.A. et al: ‘Mental health literacy’: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia 1997, 166, 182-186.vi vi World Health Organisation, Investing in Mental Health, WHO, 2003, p.13vii vii Patel, V., and Prince, M.: Global Mental Health: a new global health field comes of age, JAMA.2010 May; 303 (19): 1976-1977, p. 1976.viii WHO Mental Health Atlas 2011, p. 25.ix Ibid.56.x Saxena, S./ Thornicroft, G./Knapp, M./Whiteford, H., Global Mental Health 2. Resources for mental health: scarcity, inequity, and inefficiency, in: Lancet 2007; 370: 878-89, p.881.xi Hanlon, C./Wondimagegn, D./Alem, A.: Lessons learnt in developing community mental health care in Africa, World Psychiatry 2010; 9:185-189, p. 185.xii Cf. e.g. Farooq, S.:Collaborative care for depression: a literature review and a model for implementation in developing countries. . Int Health 2013; 5 (1):24-28.xiii Cf. Dharmawardene, V. and Menkes, D.: Psychotropic drugs in low-income countries, published online: http://www.thelancet.com/pdfs/journals/lanpsy/

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Causes!of!mental!problems!!

• !War,!conflicts,!traumata!increase!the!vulnerability!for!mental!illnesses!�  Liberia:!Pos9rauma:c!stress!disorders!post!Ebola!�  Democra:c!Republic!of!the!Congo:!!!!!!!!Trauma:zed!women!�  Refugees!and!internally!displaced!people!!

• !Poverty!and!hunger!– !!!!Malawi:!Crop!failure,!low!tobacoo!price!

• !Marginaliza:on!!• !Soma:c!illnesses,!e.g.!HIV&AIDS!• !Alcohol,!drugs!• !Domes:c!violence!!Epidemiology ! ! !!!• !Life:me!risk!for!mental!problems!(incl.!epilepsy)!worldwide!appr.!25!%!• !Half!a!billion!people!worldwide!have!a!neuropsychiatric!disorder!or!are!!!!dependent!on!alcohol!or!drugs!• !More!than!80!%!of!these!people!live!in!lowUincome!countries!• !75U85!%!of!these!pa:ents!without!access!to!treatment!!!Global!years!lived!with!disability!(YLDs)!

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!•  !Counteract!misconcep:ons!•  !Promote!a!comprehensive!approach!to!health!!!!!!!!including!the!social!and!spiritual!dimensions!•  !!Train!church!health!professionals!!!and!church!leaders!in!mental!!health!

!!!!!„Access!to!quality!health!care!for!ALL“!

Source:!WHO!Mental!Health!Atlas!2014!

1! Low!back!pain!2! Major!depression!3! Iron–deficiency!anaemia!4! Neck!pain!5! Other!hearing!loss!6! Migraine!7! Diabetes!8! COPD!9! Anxiety!Disorders!10! Other!musculoskeletal!

11! Schizophrenia!12! Falls!13! Osteoarthri:s!14! Refrac:on!&!accommoda:on!15! Asthma!16! Dysthymia!17! Bipolar!disorder!18! Medica:on!overuse!headache!19! Other!mental!and!substance!20! Derma::s!

!!!!!!!!!!!!Leading!causes!of!global!disability!2013!

Source:!Global!Burden!of!Disease!Study!2013!

Facts! Chris:an!Responses!Challenges!

Dr.!Beate!Jakob!

German!Ins>tute!for!!

Medical!Mission*!

*German!Ins:tute!for!Medical!Mission!!Mohlstr.!26,!72074!Tübingen!|!www.difaem.de!

Therefore, Christian churches and health services can make a change by promoting:

- Integration of mental health in the training curricula for health professionals and theologians.

- Provision of further training for pastors and health professionals serving in church health services.

- Information of congregation members about the causes and possible ways of treatment of mental illnesses.

2. Integration of mental health in community-based healthcare servicesChurch health services can be pioneers in integrating mental health in existing community-based healthcare services. Through training of community health workers in mental health, offering mental health services in church health posts, clinics and hospitals, through awareness creating and caring for mentally sick people in congregations, churches can contribute significantly to closing the mental health treatment gap and thus become important partners of the formal health system.

Dr Beate Jakob

Dr Beate Susanne JakobBeate Jakob, a physician and theologian, works with the German Institute for Medical Mission (DIFÄM) as consultant for medical ethics, theological studies, and community based approaches to health and healing.

From 1980 to 1983 she practised internal medicine at the University Hospital in Tübingen. She served at a mission hospital in rural western Kenya from 1990 to 1992. There she gained valuable experience in CBHC programmes. Since 1993 she has been working for DIFAEM. Her focus is on topics at the interface of medicine and theology. She cooperates closely with the “Health and Healing” programme of the World Council of Churches (WCC).

Her passion is about including local communities in improving their health with a focus on basic health issues like nutrition and sanitation. An evolving theme is the integration of mental health in community based approaches to health.

Beate Jakob is author and co-author of various publications on health and healing. One of her publications titled “Health, Healing and Spirituality. The Future of the Church's Ministry of Healing” is available on the websites of WCC and DIFAEM.

During Scottish Mental Health Week (held around World Mental Health Day on October 10th each year) I was invited to an ecumenical gathering to lead a discussion about how local congregations might support and care for people experiencing mental illness.

The discussion

During the evening, four main issues were identified: -

• concern from some of the group who had visited psychiatric wards on behalf of their local church and had been met with suspicion from health care staff

• that there is a clear role for congregations in offering support to families caring for someone who has a mental illness

• recognition that care and support requires long-term commitment and that this can be difficult, especially when - due to the nature of their illness - people may give little indication that the efforts of the carer are appreciated. Discussion around this led to the awareness of the value of understanding care as the responsibility of the whole congregation - i.e. that those church members directly involved with supporting people who have a mental illness can receive the encouragement and recognition they need from others within the congregation.

• the need to challenge prejudice against people with mental illness.

Local congregational support during mental illness

Significance of topics identified

It is worrying that ‘historical’ suspicion between the disciplines of psychiatry and theology continues to affect psychiatric care. Taking time to build trusting relationships between individuals involved in the various aspects of patient care is essential in order to ensure that appropriate care and support is offered. When mental health staff and faith group leaders are encouraged to work together, and can acknowledge both the benefits and the potential disadvantages of their own way of offering care, then the support and encouragement of people affected by mental illness can be significantly improved.

That caring congregations recognise the contribution they can make by supporting family members is significant. In the UK so much emphasis is put on care of the individual that the needs of the family and close friends of a person with a mental illness can easily be overlooked. Cultures in which the well-being of the whole family is understood as an important aspect of supporting the person who is ill have much to teach to western health care.

Recognising the importance of mutual support is also vital to good mental health care. All people are inter-dependent, and everyone needs caring and supportive relationships in order to live well. The community dimension of caring through mental illness is a aspect of care that needs to be developed.

Many who live with mental illness experience prejudice. Challenging stigma and injustice is an important dimension to care.

Summary

Caring for people who live with mental illness requires sensitive, patient listening, acceptance, and assurance of an ongoing supportive relationship. Challenging injustice and speaking out for the rights of vulnerable people are also important. No individual can do it all; caring during mental illness benefits from commitment by the whole congregation. The pastoral and spiritual care that a congregation can offer involves seeking justice and showing love. Some people coping with mental illness may appreciate, or benefit from, conversation about God, or prayer ; others may not. For the caring congregation, however, it is in their ‘walking with God’ (also Micah 6.8) that they are sustained and encouraged.

Lorna Murray - Mental Health Chaplain

PRIME has been committed since its outset to support holistic medical education, and the Developing Mental Health journal has sprung from the desire to see this model adopted more widely worldwide. As such, we were delighted to see that Professor Dinesh Bhugra, former president of the Royal College of Psychiatry, is now calling for a new approach to international medical education which sees medical humanities being taught in undergraduate education, acknowledging the biological model offers only limited understanding of psychiatric symptoms; and an interesting linked article by MF Fathalla (2000) argues that medicine has lost its previous pivotal pastoral role. It is good that the case is building for a change in education in this area.

Read Professor Bhugra’s article here: www.rcpsych.ac.uk (“Social sciences and medical humanities: the new focus of psychiatry.” Dinesh Bhugra and Antonia Ventriglio p79)

And MF Fathalla’s article here: www.who.int/bulletin

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In the current edition of the Christian Journal for Global Health, Dr Alison Morgan reviews the three Lancet articles from earlier this year examining the role of faith-based health. Whilst this isn’t strictly mental health focused, the reflections do have resonance with the mental health agenda.

http://journal.cjgh.org/index.php/cjgh/article/view/89/249

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