RECENT ADVANCES IN EVIDENCE FOR PREVENTION OF MENTAL DISORDERS II

Rural Mental Health Initiatives Professor S. Rajkumar University of Newcastle Bloomfield Hospital – Australia World Psychiatric Association Athens Conference on Advances in Psychiatry 12-15 March 2005 Presented in the symposium entitled: “WPA Section on Preventive Psychiatry” The burden of ill health in rural settings Just as there is inequity between countries (developed and developing) there is significant inequity within all countries when it comes to rural and remote areas Drawing from Australia and India, a comparison of initiatives is made, against the background of the paradox and practicalities of different settings. Poverty & remote areas The poorest people are often found in remoter areas, e.g. North-eastern Brazil, Zambia away from the line of the rail), lower Ukambani in Kenya; tribal districts of central India; hills of Nepal (Robert Chambers, 2000: Whose Reality Counts, Putting the First Last) Background in rural settings.  Mental Health Literacy: “Knowledge & beliefs about mental health disorders, which aid their recognition, management & prevention” (Jorm et al 1997).  Inability to recognise mental disorders-depression  Negative attitudes about mental health disordersfailure to seek medical help & lack of compliance with treatment. Failure to seek help early.  Potential for rural social networks to detect mental health problems early & direct to appropriate treatment (Judd et al 2002) World health report 2001 … Highlights that: Rural life is fraught with isolation, lack of transport and communication, limited educational and economic opportunities Rural suicide rates (88.3/100 000) than in urban areas (24.4/ 100 000) of Hunan province of China (Xu et. al 2000) NIMH rural mental health  NIMH report suggests that prevalence of mental illness, substance abuse and disability is = or > in the 60 million rural and frontier populations in US  More than 800 rural counties have high poverty rates, but only 25% qualify for medical aid  Women head 46 % of rural households, with 26% of these families living below poverty level  The elderly are disproportionately represented in rural people Challenges in rural psychiatry Ideological versus technological division  Rural population is technologically disconnected, making it difficult to innovate or adopt foreign technologies  Is caught in the poverty trap  Problems of tropical infectious disease  Low agricultural productivity  Environmental degradation Social integration & rural life  Brown and Prudo compared two western Hebridean Islands with Camberwell in London and observed that prevalence is similar  Stronger social capital and social integration in rural communities, with an emphasis on religious beliefs and activities, was thought to be protective against some type of mental illness  (Source: Scott Henderson: Nature and distribution of mental illness in rural areas in “Directions in Rural Psychiatry”, July 2000) Background in rural settings.  Greater number of adults/children experience mental health problems than receive professional help (Zubrick et al 1995, Andrews et al 2001)  Rural and remote areas- less availability of psychiatrists & psychologists (Parslow & Jorm (2000) –  Seek treatment from GP. Also need to consider shortfall in mental health workforce & quality of mental health care. Commonalities & Contrast Population over 1 billion 70% Rural Population over 20 million 30% Rural Glimpses of rural India  Access and approach to services in slow and difficult  Water, sanitation, ecological problems, remain a major issue of rural life Source: Australian Bureau of Statistics (2003) In Year Book Australia, 2003 Remote communities in Australia  Small groups of people.  Vast areas.  Changing socio-economic situations.  Unpredictable ecological issues.  Poor mental health facilities. Priority groups needing targeted interventions     Youth suicide (in particular males). Co-morbid issues. Indigenous mental health. Farming and ecological issues.  Ageing issues in rural settings. Youth suicide High in rural male youth in Australia:  Multiplicity of factors.  Immediate interpersonal context.  Underlying vulnerabilities.  Childhood adversity, social disadvantage and psychiatric morbidity. Farming & mental health Male farm workers and agricultural labourers observed to have higher suicide rates. The dilemma of farmers plight Increased suicide and depression Out-migration of younger people Ecological issues Isolation -e.g:Tragedy of Andhra farming families Indigenous populations     Increasing mortality and morbidity. Unemployment. Co-morbid problems. Incarceration. Remoteness & general practice  Remote areas have many of the markers of poor health, e.g. poverty, unemployment, inadequate housing and alcohol missuse  Wider social issues, e.g. closure of local schools, post offices and banks  There is no effective, integrated public transport  Seasonal employment, often poorly paid  Onerous work hours for general practitioners  (Steve McCabe, GP, Isle of Skye, BMJ 2002: 324:S121, 20 April ) Lessons from WHO Lessons from WHO The spectrum for interventions of mental health problems and mental disorders Promotion, prevention and early intervention for mental health A Monograph 2000 Australian National Mental Health Strategy Key paper on: Promoting mental health and preventing mental illness. Spectrum of health and illness Positive Health (well-being) •Support Illness (distress) •Strength •Stresses •Traits There are major public health initiatives in India. Mental health promotion and prevention of illness needs to be incorporated into the following:  Maternal and child mental health.    Ageing and dementia. Macro economics & health. Infectious diseases control  Nutritional (noon meal) programs There are over 30,000 Non-government organisations in India. Excellent models in mental health: SCARF, SNEHA, SANGATH Mental health care delivery  Levels of care Primary Health Care  Setting of Care Tertiary Hospital setting  Factors impacting delivery of care Ecological issues Flooding & displacement Drought Inter-relatedness of health Mental health Health Development Strategies in promotion and prevention  Promoting wellbeing and quality of life  Resilience; social capital  Disease specific programmes  Schizophrenia, dementia, depression  Population specific programmes  Mental health promotion  Preventive intervention  Primary health care / Rural mental health  Anganwadis; Village workers Summary  Snippets on India and Australia highlight commonalities and differences between both countries. Mental Health situation can change with effective promotion activities. Priorities in intervention research & training are needed. Collaborative development of projects which are effective and efficient would be timely and useful.   