INCREASING ACCESS TO MENTAL HEALTH INCREASING ACCESS TO MENTAL HEALTH CARE FOR RURAL TRAUMATIZED CARE FOR RURAL TRAUMATIZED POPULATIONS: RECENT RESEARCH POPULATIONS: RECENT RESEARCH ADVANCESADVANCES

SEGGANE MUSISI MD, FRCP(C)Department Of Psychiatry College of Health Sciences

Makerere University Kampala, Uganda.

E-mail: segganemusisi@yahoo.ca

INTRODUCTIONMany years of conflict destroy infrastructure and systems of healthcare and

support.

This causes not only physical maiming of many people but also a more pervasive psychological traumatisation of the population which often remains largely unaddressed .

Post-conflict communities continue to experience more traumatic events even after the guns go silent.

Traditional methods of managing mental ill-health at individual, family or community level often lack .

Introduction cont.• The situation is made worse by stigma and non-

prioritization of mental health by government & agencies

• An important question in global mental health today in LMIC is how to increase access to affordable yet effective mental health care in rural PHC settings

• The most affected populations are those in conflict/Post-conflict communities and HIV victims, the latter both infected and affected.

Introduction Contd.

• Natural disasters are also increasing in LMIC e.g. floods, earthquakes, volcanoes, landslides, tsunamis.

• Traditional vulnerable populations make up the bulk of the victims - children, orphans, women, elderly etc

• The emphasis has been on addressing key Mental, Neurological and Substance Use disorders (MNS).

• Resources, both human & material are always scarce in these settings & governments non-supportive

RESEARCH EFFORTS TO ADDRESS THE FOLLOWING: RESEARCH EFFORTS TO ADDRESS THE FOLLOWING:

• Culture-sensitive user friendly mental health screening tools

• Culture-sensitive therapeutic approaches and interventions

• Integrating Mental Health Care in general health care

• Availability of affordable mental health drugs

• Sustainability

WHY THIS PRESENTATION? There is considerable ongoing research in this area with a

number of funded projects mainly by NIH, GCC, Welcome Trust, DFID, UKAID, USAID, EU etc.

The aim is to improve access to mental health services for

the rural and scattered rural populations.

The research findings should help guide policy in planning for mental health services in PHC settings especially those in conflict/post-conflict situations.

This presentation discusses evidence from recent research findings in addressing this quest

SOME SELECTED PROJECTSSOME SELECTED PROJECTS

PRIME PROJECT (NIH)

C. Hanlon, N. Luitel, T. Kathree et al (2014): Challenges And Opportunities For Implementing Integrated Mental Health Care : A District Level Situation Analysis From 5 LMIC (South Africa, Ethiopia, Uganda, Nepal , India). PLoS Medicine 2014 http://www.plosone.org/article

Major Finding: The study districts faced significant contextual and Health Systems problems in delivering mental health care generally and specific to each country

Recommendation: Develop solutions specific to each country to improve MHC in PHC settings.

AFFIRM (NIMH)C. Lund, A. Alem, M. Schneider, J. Burns, D. Chibanda, F. Cowan, S. Musisi, M. Prince, D. J.

Stein, G. Thornicroft, et al (2015): Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: Rationale, overview and methods of AFFIRM. Epidemiology and Psychiatric Sciences. doi:10.1017/S2045796015000281

Ethiopian RCT: i) Task Sharing For The Care Of Severe Mental Disorders In A Low- Income Country: A Randomized, Controlled Non- inferiority Trial (Tascs)

ii) Development and Validation of a culturally sensitive Schizophrenia screening instrument

South African RCT: AFrica Focus on Intervention Research for Mental health – South Africa (AFFIRM-SA). Screening & Interventions for Maternal Depression

AFFIRM Capacity building component: MPhil in Public Mental Health

INDEPTH – Uganda (NIH)G Wagner, V Ngo, P Glick, E Obuku, S Musisi & D Akena (2014): INtegration of

DEPression Treatment into HIV Care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial. Trials, 15:248. doi:10.1186/1745-6215-15-248 http://www.trialsjournal.com/content/15/1/248

Method: A cluster randomized controlled trial - Compared two task-shifting models of depression care - A protocolized model Vs a model that relied on the acumen of clinicians - The protocolized model implemented a nurse-driven approach to diagnosis

using PHQ-9 and administering antidepressants (Imipramine)

Finding: The protocolized model was superior to the clinician acumen model in effecting correct diagnosis and treatment , arguing for an integrated nurse-driven task shifting model for depression care in PHC HIV clinics

GCC: Mental Health Beyond Facilities (mhBEF): GCC: Mental Health Beyond Facilities (mhBEF): By F. Baingana By F. Baingana www.musph.com/index.php/publications/50-mhbef report. uganda

Purpose: To inform the design and implementation of an evidence-based a sustainable “Comprehensive Community-based Mental Health Services” PHC package for Uganda.

Method: i) To establish training & skills needs for management of severe mental disorders & epilepsy (SMDE) in PHC

ii) To assess acceptability and feasibility of use of smart mobile phones in strengthening the clinical skills of PHC workers in Liradistrict, northern Uganda.

Findings: i) Competence of PHC workers to handle mental illness was inadequate due to lack of appropriate training, skills, knowledge, attitudes, support and motivation.

ii) Psychotropic drugs, though free were scarce in HC

E. Nakimuli-Mpungu, K. Wamala, J. Okello, S. Alderman, R. Odokonyero, R. Mojtabai, E.Mills,S.Kanters, J.Nachega, S. Musisi (2015): Group Support Psychotherapy (GSP) For Depression Treatment In People With HIV/AIDS In Northern Uganda: A Single-centre Randomized Controlled Trial . The Lancet HIV-D-14-00105r2 0069 S2352-3018(15)00041-7 - GCC

Group Support Psychotherapy (GSP) is a culturally sensitive intervention that aims to treat depression by enhancing social support, teaching coping skills, & income-generating skills.

Methods: An open-label randomized controlled trial, - compared GSP with Group HIV Education (GHE) for treatment

of depression in 150 HIV +ve men & women aged ≥19 years. - Participants were followed up at 0 months and 6 months - Outcomes were change in depressive symptom- scores

measured by SRQ-20 and in Mean Function Scores (MFS)

GSP RESULTSAt 0 Months: Mean SRQ depression scores and Mean Function scores (MFS)

did not differ between groups (0·19, 95% CI 1·77-1·39, p=0·78 & 0·24, 0·41- 0·88; p=0·41 respectively).

At 6 Months: The GSP group had lower SRQ depression scores than the GHE group (2·50, 3·98-1·02, p value=0·005), and lower MFS scores (0·74, 0·17-1·65, p=0·09)

CONCLUSION :The benefits of existing HIV educational interventions in HIV care services

could be improved by the addition of GSP content.Potential benefits of the integration of GSP into existing HIV interventions, such as adherence counseling or group HIV educational programs, should be addressed in future studies.

GCC: Family Group Interpersonal Psychotherapy GCC: Family Group Interpersonal Psychotherapy Intervention(IPT-F) For Caregivers Of Patients With NS. Intervention(IPT-F) For Caregivers Of Patients With NS. By MUTAMBA BB By MUTAMBA BB http://musph.mak.ac.ug/index.php/resources/bonus-page/fbifcn#sthash.MPuPI7KA.dpufhttp://musph.mak.ac.ug/index.php/resources/bonus-page/fbifcn#sthash.MPuPI7KA.dpuf

Study Aim: To investigate the effectiveness of a family based, group interpersonal psychotherapy intervention(IPT-F) for caregivers of patients with NS

Method: Compared IPT-F intervention to standard care as provided for in the national NS response plan. The IPT-F was delivered by trained Village Health Team members who were supervised by trained health workers

Results:• There was significant improvement in the Depression scores in the

caretakers of the children with NS which resulted in better care and

improvement in the NS children’s wellbeing.

GCC: FRIENDSHIP BENCH By D. CHIBANDA, ZIMBABWE

D Chibanda, Mesu, L Kajawu, F Cowan, R Araya & A Abas (2011): Problem solving therapy for depression & common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV . BMC Public Health 2011, 11:828 doi:10.1186/1471-2458-11-828 http://www.biomedcentral.com/1471-2458/11/828

Aim & Methods: There is limited evidence that interventions for CMD can be integrated sustainably into PHC settings in Africa. The study investigated the feasibility & effectiveness of a low-cost multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy (PST) and delivered by trained and supervised female lay workers

Findings: There was a clinically meaningful improvement in CMD associated with locally adapted PST delivered by lay health workers through routine PHC in an African setting, calling for possible scale up.

USING MOBILE MENTAL HEALTH CLINICS TO USING MOBILE MENTAL HEALTH CLINICS TO EXPAND ACCESS TO MENTAL HEALTH CARE IN EXPAND ACCESS TO MENTAL HEALTH CARE IN POST CONFLICT SOROTI DISTRICT, UGANDAPOST CONFLICT SOROTI DISTRICT, UGANDA

Julius Muron, Seggane Musisi, Charles Okadhi & Juliet Nakku

Grand Challenges of Canada Grant # 0324-04

OBJECTIVEOBJECTIVE

Aim: To improve access to mental health services for the war-affected and scattered rural population of Soroti district

Hypotheses:• A community-based model of mental health promotion

targeting survivors of past and ongoing trauma in the Soroti district communities will increase access to mental health services

• An intervention delivered by lay people in their community will reduce the psychological distress caused by the trauma and not associated by stigma.

SPECIFIC OBJECTIVES1. To train and mentor PHC general health workers using the WHO MhGAP

Intervention Guide (W.H.O MhGAP IG 2010).

2. To train community health workers (VHT) to deliver standardized Psychological First Aid (PFA) to people experiencing traumatic life events in their communities.

3. To mobilize communities to participate and reduce stigma and discrimination of persons with mental illness.

4. To improve medicine supply by setting up Service User Groups to operate Service Owned Users Pharmacies and give loans to consumers

APPROACH: i. To Establish Mobile Mental Health Clinics At Village Posts ii. To Conduct An Intervention Study To Assess The Outcome.

METHODS I: METHODS I: Step by Step Introduction of Mobile Mental Health Clinics (MMHC)

• Soroti Regional Hospital was the focal Mental Health Clinic. The Mobile clinics set off here as outreaches to far parishes

• Each Mobile Clinic consisted of PHC workers from the MHC:- PCO/Nurse, 2 Counselors trained on the WHO - MhGAP manual They would recognize and treat CMD and refer severe ones. They worked with the local VHT, trained on the WHO – PFA manual

• April 2014: Pilot Mobile Mental Health Clinics were set up as parish outreaches in Katine and Asuret sub-counties (11 parishes, 204 patients)

• October-Dec 2014: Arapai, Gweri Tabur and Soroti sub-counties were added (26 parishes, 970 patients)

METHODS II: METHODS II: Training The Community In Psychological First Aid Intervention

The aim here was to deliver Psychological First Aid intervention to Survivors of trauma in the community by its members

Over two days, 30 existing VHTs from each sub-county were trained to deliver PFA to survivors of trauma (past & present) in their communities, using a culturally adapted WHO-PFA Manual

MMHC members mentored the VHTs to deliver the PFA in their

communities and gave ongoing support via mobile phones. The Psychosocial outcomes of the PFA intervention delivered by VHTs

were then evaluated.

METHODS III: METHODS III: Setting up Service Users Groups – The Service Owned & Operated Users’ Pharmacy &VSLAs.

• Service user groups, were set up as components of Village Savings and Loans Associations (VSLA ) to help community members address the stock-outs of government medicine supply

• The scheme employed the Service Operated Users Pharmacy using the principle of private public partnership whereby the health workers prescribed the medicines and provided advice on dispensing while the Service Users Procured, Stored, Counted and Documented the medicines supplied to fellow Service Users.

• Service users voluntarily paid UShs 1,000/= (US$ 0.50) at each clinic visit irrespective of the amount or type of medicine dispensed or service rendered. This scheme formed the VSLA.

• The money was banked and used to supplement payment of the medicines for the pharmacy or to advance loans for any other needs of the users . This reduced on drug stock-outs and erratic medicine supply and helped users procure loans for their other needs.

• The Mental health drugs were supplied by NMS right from the lower units to the regional referral hospital with only a few missing. After buying the few missing drugs, the excess money which was realized from the VSLA was thus banked to help community members access loan schemes for their various needs.

EVALUATION OF PSYCHOSOCIAL OUTCOMESEVALUATION OF PSYCHOSOCIAL OUTCOMES

• A Cluster Randomized Control Trial was used to evaluate the outcomes of the intervention in two intervention sub-counties (cases) and two control sub-counties.

– Psychological distress was measured using SRQ at baseline and at 6 weeks follow up at a cut off point of 9 for caseness

– Social indicators were identified by nature of trauma, types of practical actions undertaken and level of social support received after the trauma.

– A multi-stage comparative analysis was done for cases and controls.

DATA ANALYSIS• Baseline, 6-month and 12-month end-point measurements were done and

compared.

• A cluster (parish) randomized control trial was carried out to test the efficacy of the PFA intervention

• Quantitative data was analyzed using SPSS software package with the help of a statistician

• Qualitative data of consumer (user)and service provider satisfaction was carried out.

THIS PROJECT IS STILL ONGOING AND ONLY PRELIMINARY RESULTS WILL BE SHOWN

RESULTS

• 84 mobile clinic visits were conducted from April 2014 to December 2014 in Asuret, Katine, Tubur, Gweri, Arapai and Soroti sub-counties.

Total number of mental disorders seen in mobile clinics from April-December 2014

TRENDS OF MENTAL HEALTH DISEASE BURDEN IN OPD

MENTAL ILLNESSES IN OPD 2012/2013 2013/2014 2014/2015 TOTALS

Depression 178 236 588 1002 Psychosis 224 137 149 510Anxiety Disorders 41 30 24 95Alcohol & Drug Abuse 53 52 50 155Childhood Mental Disorders 62 71 94 227Epilepsy 1889 1822 2505 6216Dementia 23 81 23 127

Trends of Mental Health Disease Burden in OPD

Trends Of Mental Health Disease Burden In IPD (Ward)

MENTAL ILLNESSESIN IPD 2012/2013 2013/2014 2014/2015 TOTALS

Depression 56 27 27 110

Psychosis 185 135 137 457

Anxiety Disorders 42 7 9 58

Alcohol & Drug Abuse 42 35 45 122

Childhood Mental Disorders 2 4 06

Epilepsy 100 88 58 246

Dementia 3 0 4 7

Trends of Mental Health Disease Burden in IPD (Ward)

VHT Training To Deliver PFAOut of the 207 VHTs Trained, 80 were capable of delivering PFA at

different level of skills and confidence. Parish coordinators took on skills well and were able to support village VHTs.

Some of the trained VHTs could not write but were motivated to deliver the intervention (More of these were women).

Qualitative outcomes: Improved communication to deal with conflicts More social support was given to victims Survivors took charge of dealing with their situations

Quantitative data: Survivors of trauma who had engaged with trained VHTs were more

likely to have their depression diagnosed and managed by health workers compared to areas with no PFA no intervention

The latter were more likely to use alternative modes of healing including traditional healers, prayers and use of law enforcement agencies (LDUs).

OUTCOME OF PSYCHOLOGICAL FIRST AID INTERVENTION

Variable Control group(N=65)

Intervention group(N=70)

Sex (Male) 29% 24%

SRQ>9 (Distressed)

48% 59%

Depression diagnosed

15% 37%

Survivors not correctly referred

38% 24%

SERVICE USER GROUPS: Pharmacy & LOANService

User Group

Number of

Members

Total Savings (Ushs)

Amount Purchase Savings

Box (Ushs)

Pharmacy Medicines Purchases

(Ushs)

Amount spent on

Loans (Ushs)

Number of

Members Loaned

Merok 33 625,300 40,400 590,000 22

Ocokican 32 707,000 110,000 597,000 26

Adacar 48 570,000 160,000 410,000 20

Mukura 15 270,000 - 34,000 236,000 8

Ojama 9 210,000 - 30,000 180,000 7

TOTAL 137 2,252,000 374,400 2,127,000 83

Summary Of Service User Groups • 137 active members participated in the VSLA.

• Total savings for all the 5 user groups amount to 2,252,000/=.

• Total Welfare fund for medicine supply was 374,400/= so far collected .

• A sum of 2,127,000/= given out as loans.

• A total number of 83 members were given loans .

• 3 groups have fully purchased saving boxes: Adacar, Merok and Ocokican.

CONCLUSIONS• Village health workers can be trained to deliver psychosocial

interventions with significant reduction of psychological distress and increased coping of the mentally distressed in their communities

• Providing Psychological First Aid by VHTs helped people who were diagnosed with CMD (depression)to open up & get help.

• There was a noticeable reduction in numbers of in-patients in the Regional Referral Hospital hence reducing the inpatient care burden and thus concentrating care on SMI and epilepsy.

• Communities were able to set up and operate Service User Groups, and purchase medicines which helped mitigate the erratic supply of drugs and to give loans to needy members using the excess money.

• THE PALEAT CLINIC, SOROTI

RECOMMENDATIONS• Government Health Units (In-charges) need to work hand-in-hand with

service user leaders in providing mental health services: THERE IS A NEED TO SET UP MMHC COUNTRYWIDE.

• There is a need to train VHTs to deal with psychological distress/mental illness among clients in their communities.

• There is a need to mobilize all community stakeholders in the care of the mentally ill: Community leaders, religious leaders, schools, political leaders to provide support and to encourage mentally affected people to embrace the services.

• For sustainability of the VSLA, the project needs to register at sub county level as CBOs with more training and empowering of the groups in VSLA methodology and how to participate in the provision of healthcare.

THE PROPOSED PACKAGETHE PROPOSED PACKAGESet up MMHCs to reach the people, integrated in general outreach health care

The intervention will be GSP, PFA, FB, IPT & Employ Task shifting/Sharing approaches

Sustainability:• In Govt run MHC in PHC settings• Use existing VHTs• Form Service User Groups to mitigate against erratic medicine supply,

IGA & give loans to fight poverty – ppp

IT: mhBEF – Use mobile phones to send mental health messagesTarget Group : Integrated in General Health Care In PHC settings

REMARKS• THERE IS A NEED FOR THE VARIOUS RESEARCH GROUPS TO GET

TOGETHER AND FORM ONE COMMON PACKAGE TO SELL TO POLICY

MAKERS FOR AN EFFECTIVE , AFFORDABLE AND DOABLE INTERVENTION

PACKAGE THAT IS SUSTAINABLE IN OUR LMIC.

• THE PACKAGE SHOULD INVOLVE A TASK-SHIFTING APPROACH USING

ALREADY EXISTING PHC WORKERS IN GOVT CLINICS, VHTs AND HAVE

VOLUNTARY SERVICE USER ASSOCIATIONS TO ENSURE CONSTANT

MEDICINE SUPPLY AND GIVE LOANS - PPP

LET’S GO HELP THE MENTALLY ILL IN THEIR COMMUNITIES .LET’S GO HELP THE MENTALLY ILL IN THEIR COMMUNITIES .THANK YOU !!!THANK YOU !!!