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Definition

VIEWS: 19 PAGES: 59

									Mental Health




         25 June 2007

   Presenter: Joanne Corrigall
                                 1
    The MH workgroup…
• Authors:
    Joanne Corrigall, Catherine Ward,
    Kathryn Stinson, Patricia Struthers, Jose
    Frantz, Crick Lund, John Joske, Alan
    Flisher
•   Expert group:
    Crick Lund, Alan Flisher, Dan Stein, Petro
    Brink, Venecia Barries, Carol Bower, Carol
    Dean, Fadia Gamieldien, Bronwyn Myers,
    Bruce Phillips
•   Peer Reviewers:
    Vikram Patel, Andy Dawes                   2
        Presentation Content

• Definitions
• Burden of mental illness
• Risk factors for mental illness
• Interventions & Recommendations
• Mental Health and Development

                                    3
            Definitions
• Mental Health:
  “a state of well-being in which the individual realizes his
  or her own abilities, can cope with the normal stresses
  of life, can work productively and fruitfully, and is able to
  make a contribution to his or her community” (WHO)

• Mental illness : group of disorders defined by specific
  criteria which describe
          – a particular severity of symptoms
          – duration of symptoms
          – the effects of these symptoms on a person‟s ability to function
            (socially and occupationally) i.e. symptoms result in DISABILITY
  Example: Depression

                                                                               4
       Spectrum of mental health




Mental Health                                     Mental Illness


                •Self-esteem
                •Coping skills, problem solving
                •Self-efficacy
                •Impulsivity
                •Sub-clinical symptoms
                                                                   5
     Burden of Mental Disorders
Socio-economic impacts
• Unemployment, poverty
• Poor housing
• Decreased school completion, academic
  performance
• Decreased Social capital
• Increased violence
                                          6
Burden of Mental Illness

Macro-economic:
• $ 147 billion annual cost in USA
• SA: no data but drug & alcohol costs
  alone total R10billion
• Loss is mainly through effects on
  productivity, absenteeism


                                     7
         Burden of Mental Illness

Disability
• Globally: 5 of 10 leading causes of
  disability are psychiatric
• SA: neuropsychiatric disorders are 2nd
  leading cause of BoD
• BoD figures exclude the impact of MH on
  other BoD components…

                                            8
      Mental ill-health strongly
      associated with…

                                     CHILD
                                    HEALTH

                                     Injuries
                     CHILD HEALTH     CVD
    HIV                 CVD            HIV
Unsafe sex             Smoking      Alcohol Abuse
Multiple partners                   Drug Abuse
                                                9
Early sexual debut
                                Western Cape 2000 (YLLs)

                 HIV/AIDS                                                      14.1
        Homicide/violence                                               12.9
               Tuberculosis                                       7.9
     Road traffic accidents                                 6.9
  Ischaemic heart disease                             5.9
                      Stroke                    4.6
   Trachea/bronchi/lung ca                2.7
Lower respiratory infections            2.4
                     Suicide           2.3
       Diarrhoeal diseases             2.3
         Diabetes mellitus            2.1
                      COPD            2.1
                       Fires        1.8
           Low birth weight         1.7
               Septicaemia        1.5
Hypertensive heart disease      1.2
                  Breast ca     1.1
        Nephritis/nephrosis     1.1
                    Asthma     1.0
                   Epilepsy    1.0


       Source: Bradshaw et al, 2005                                             10
      Prevalence in Western Cape

• South Africa: SASH study 30% life-time
  prevalence
• No data for Western Cape
• Proxy measures: injury data specifically
  homicide and RTAs




                                             11
  Proxy measures

MI proxy WC    GP        KZN    SA
indicators:
Homicide 12.9% 8.3%      4.7%   6.8%

Road      6.9%    4.4%   2.8%   3.7%
Traffic
Suicide   2.3%    1.5%   <1%    <1%

% of total 22.1   14.2% 7.5%    10.5
YLL        %                    %      12
       Aim of MH workgroup
1. Prevention of common mental disorders
 Depression
 Generalised Anxiety Disorder
 Substance disorders (includes abuse and
    dependence)
   Post Traumatic Stress Disorder
   Childhood behavioural disorders

2. Promotion of mental health


                                            13
             Risk/protective factors
                      Living environment
            Health                           Human capital
  •Access to recreation                      •Income
  •Built illness
•Mental environment                          •Food security
  (housing,Safety             MENTAL             Employment
•Health systems                              • Social grants
                                          • Education
  neighbourhoods)             HEALTH
• HIV                                     •Pre-school
  ••Basic services                           •Transport
• Substance use
     Violence                            •Family systems
                                          •School climate
   • Crime
• Physical illness                       • Death/trauma in
• Disability
           Social capital                family
                                              Material goods
                                     •Unemployment
                                     •Underemployment
            • Social capital         •Occupational stress
                         Family environment
            • Social support
            •Spatial segregation                            14
       Findings continued

• Majority of relationships are bi-directional:

Multiple deprivation          mental illness

• Cumulative effects


                                               15
Conflict with neighbours
   Basic services
 Family environment
  Food insecurity
  Unemployment
 Domestic Violence




                           16
            Focus Areas selected
• Multiple Deprivation
        o Unemployment
        o Social assistance
        o Food insecurity
        o Housing
        o Poverty
•   Trauma (preventing MI after exposure)
•   Pre-school education
•   Recreation
•   Mental Health Services
•   Substance use (Tik, alcohol & other drugs exlc. Nicotine)
                                                                17
Multiple Deprivation




                       18
       Interventions

• Employment programmes: JOBS programme,
    public works etc.
•   Community development, micro-credit
•   Adult literacy, food security
•   Child care
•   Increase access to social assistance
•   Built environment:
       o Housing
       o Neighbourhoods

                                           19
       Trends in Status Quo

 Existing interventions targeting housing,
 unemployment, social assistance, literacy,
 food security

BUT insufficient to meet need and/or not
 optimally effective
AND insufficient cognisance of health
 (including mental health)
                                           20
            Example: Housing
     Housing factors associated with mental health
    Type                                Quality
•Single vs multi-                      •Structural deficiencies
dwelling                               •Pest control
•High floor vs low                     •Dampness
floor dwelling       HOUSING           •Housing satisfaction

                      Other
                       •Tenure
                       •Overcrowding
                       •Involuntary relocation
                       •Affordability of housing          21
         Evidence for interventions

• Housing improvements consistently improved
    Mental Health and decreased Mental Illness
•   Dose-response relationship
•   Other positive outcomes: physical health;
    perceptions of safety; crime reduction; social
    participation (social capital) ; improved
    perception of the area as a whole
•   Effects of neighbourhood improvements : 50%
    reduction in prevalence of mental illness
                                                 22
         Housing recommendations

• Improve quality of state-subsidised
  housing
• Increase housing subsidy amount per
  applicant
• Improve capacity of housing applicants to
  make financial contributions for their
  homes
• Foster community participation & support
• Expand neighbourhood renewal projects 23
Example: Federation of Urban
Poor




                               24
        Likely outcomes

Suitable housing
Social Capital
Human Capital                        Improved
                                    Mental Health
Increased income
Economic participation
Physical Health

     HOW housing is provided can make a big
                  difference!                   25
      Pre-school
Pre-School



               26
      Window of opportunity

Early childhood is a sensitive period, and
competencies become cumulative. Thus,
without intervention, gaps between better
and worse-off children widen over time;
the earlier the intervention, the less it
costs and the lower the gap (Heckman,
2006).


                                         27
    Outcomes of high quality pre-
    school:


                              •Improved school
                              • Decreased antisocial
                                readiness
                                behaviour
                             ••Improved cognitive
                               40% increase in
                              •Decreased substance
                               employment 27yrs!!
Benefits of preschool have been abilities to rates
                                 noted up
                                abuse
                             ••Lower failure rates
                               Improved maternal
                              •40% reduction in
                              •Higher school
                               employment and
                                arrest rates
                               education rates
                                completion


                                                  28
        In Western Cape

• ECD a priority of WCED and DSD
• Audit done by DSD shows lack of access
  to pre-school and poor quality of existing
  preschools, unqualified teachers
• Another audit currently underway by DSD



                                               29
       Recommendations

• Develop high quality teacher training
  programmes
• Develop high quality pre-school
  programmes
• Resource roll-out of pre-school across
  Province (urgently in high risk areas:
  15 high priority areas)

                                           30
Recreation




         31
             Evidence

   Physical exercise                          ? Arts, music, dance


                            Leisure boredom
                              Recreation


Recreational environments                             ? Other


                             Mental Health
                                                                32
         Major Gaps

• Focus on team/competitive sports
• Relative exclusion of other forms of
  recreation
• Insufficient facilities, access to facilities,
  resources
• Lack green spaces
• Lack of access: cheap transport
                                                   33
        Recommendations
• Review & support provision of sports AND
   recreation activities

• Protect and promote green and natural spaces

• Provide affordable and safe transport to
   recreational facilities or areas

• Support S&R interventions that build social
   capital

                                                34
Trauma



     Trauma
              35
                                                          Psychological
Violence                                                  trauma
•Community (gangs or crime)
                                                          •Individual
•Domestic violence
                                                          •Family
•Rape
                                                          •Community
•Child Abuse
                                                          •Police




               Increased mental illness:
               • Drug and alcohol abuse & dependence
               • Post-traumatic stress disorder
               • Depression, anxiety
               Decreased Mental Health:
               • Hostile/harsh parenting
               •Loss self-esteem, self-efficacy, coping skills
                                                                        36
                                  Psycho-behavioural
Drug & Alcohol abuse              Outcomes
 Itself a mental health problem
                                  •Decreased inhibition, reasoning
                                  •Increased risk-taking
                                  •Increased libido
                                  •Increased mental illness
                                  •Decreased mental health
                                  •Decreased parenting skills
                                  •Poor interpersonal relationships




                                  Violence
  Psychological trauma            •Community (gangs or crime)
                                  •Domestic violence
                                  •Rape
                                  •Child Abuse             37
       Bottom line

 Preventing and treating mental illness is an
     important part of violence prevention

 Violence prevention is an important part of
           preventing mental illness

Preventing mental illness and restoring mental
   health after exposure to violence is crucial

                                                  38
             Recommendations

•   Training: trauma-informed non-health sectors
•   Consistently fund, support & roll-out NGOs
•   Develop resources for emergency placement
•   Provide mental health services in workplaces
    with high trauma exposures
    (police, teachers, social workers, NGO workers)
• Make sufficient provision for psychosocial
    needs in disaster management
•   Develop post-graduate training programmes in
    trauma
                                                      39
       Recommendations cont.

Health:
• Training: trauma-informed general health
  sector
• Integration of mental health staff into
  general health services e.g. surgery
• Provide adequate mental health services
• Create strong referral networks with
  trauma-related NGOs
                                             40
Substance use


Substance use




            41
       Background

• Substance use e.g. nicotine, alcohol, „tik‟,
  heroin
• Substance abuse/dependence are defined
  mental disorders
• Substance abuse/dependence also
  increases risks for other mental illnesses;
  high comorbidity

                                             42
         Alcohol
• Likely to be the commonest SOA in the Western
  Cape
• Why?
 Socially acceptable
 Legal production and consumption
 Active promotion (media)
 Perceived to be benign
 Norms: culture of excessive use (abuse)
 Dop system
 Wine country
 Cheap!
                                              43
       Impact of alcohol
                          Violence
                   Out of he
Social impact
                         Road Traffic Incidents
Economic impact
                         HIV

                         Mental Health

                         CVD

                         Child Health (FAS)
                                          44
                        Tik
• High profile

Why?

•   Illegal: associated with criminal activity incl. gangs
•   Socially unacceptable
•   New drug
•   Negative consequences of use occur sooner: abusers
    deteriorate more quickly
•   Severe effects in users


BOTH problems need to be addressed                           45
    Evidence for interventions

• Not effective
     • Media campaigns with no other measures
     • Scare tactics
     • School-based information interventions
     • Law enforcement of DUI laws




                                                46
       Recommendations
Decrease Demand
• Restrict advertising of alcohol
• Conduct concurrent anti-alcohol and drug
    media campaigns that challenge prevalent
    beliefs and „norms‟
• Increase references to substance abuse in
    other health promotion messages
• Include evidence-based substance prevention
    programmes in school curricula
• Training of primary care and other health
    workers
• Provide adequate treatment services

                                                47
Decrease Supply:

•   Substantially increase the cost of alcohol & drugs
•   Reduce the availability of alcohol & drugs
•   Enforce existing laws on alcohol and other drugs.
•   Incorporate addressing substance abuse into multi-
    faceted community development interventions

General
• Improve co-ordination of involved departments: DSD,
  DEADP, DOH, DCS


                                                         48
Mental Health Services




                         49
      Background
• Mental Health services:
Hospital to community based
• Scope
  Promotion, Prevention, Treatment,
  Rehabilitation
• Nature of mental illness
Typically chronic requiring long-term service
  use
                                            50
The greatest risk factor for mental illness is
 previous mental illness…




                                                 51
              Major Gaps
• Insufficient community-based services (schools,
  workplace, home-visits, community-based care)
• Community-based care for mentally ill:
        • Residential care
        • Day services
    – Need post deinstitutionalisation
• Poor integration of services: particularly need in
    maternal health, HIV, trauma services
•   Grossly insufficient MH services across the board but
    esp. community-based health services
•   Impact of general health services on mental health

                                                            52
General approach to all
     interventions



                          53
       Targeting interventions


• Areas with highest violence and highest
  Multiple Deprivation Index (including 15
  priority areas)
• Vulnerable groups
• Critical periods
• Some interventions universal
                                             54
          Content & Process of
          interventions
• Importance of multi-faceted interventions:
  growing human, economic and social capital
  (multiple deprivation)

• Participative justice : community participation
  and empowerment is vital

• Address cross-cutting risk factors e.g. alcohol

                                                    55
               Relationship to PGDS
Intervention Group       Strategy 1:     Strategy 2:       Strategy 3:   Strategy 4:
                         Economic        Connectivity      Effective     Liveable
                         Participation   infrastructures   transport     Communities

Multiple Deprivation                                                           
Substances of Abuse                                                              
Pre-school                                                                       
Trauma                                                                           
Recreation                                                                     
Mental Health Services           

Intervention Group       Strategy 5:     Strategy 6:       Strategy 7:   Strategy 8:
                         Resilient       Spatial           Tolerance,    Effective
                         communities     Integration       respect for   governance
                                                           diversity     institutions
Multiple Deprivation                                                          
Substances of Abuse                                                            
Pre-school                                                                     
Trauma                                                                         
Recreation                                                                    
Mental Health Services                                                               56
         Relationship to development
• Development impacts on mental health
• Small investments in health have large impacts
  on income, education, democracy


• Global MDG interventions: MH component
  embedded in these

• Mental Health is an essential Capability
  (economic approach)
                                                   57
Where to from here?




                      58
         Discussion points

• General comments
• What are the most appropriate forums for
  taking this work further?
• Most feasible recommendations/ least
  feasible?




                                         59

								
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