1 Mental Health 25 June 2007 Presenter: Joanne Corrigall.

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Mental Mental HealthHealth

25 June 200725 June 2007

Presenter: Joanne CorrigallPresenter: Joanne Corrigall

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The MH workgroup…The MH workgroup…• AuthorsAuthors::

Joanne Corrigall, Catherine Ward, Joanne Corrigall, Catherine Ward, Kathryn Stinson, Patricia Struthers, Kathryn Stinson, Patricia Struthers, Jose Frantz, Crick Lund, John Joske, Jose Frantz, Crick Lund, John Joske, Alan FlisherAlan Flisher

• Expert group:Expert group:

Crick Lund, Alan Flisher, Dan Stein, Crick Lund, Alan Flisher, Dan Stein, Petro Brink, Venecia Barries, Carol Petro Brink, Venecia Barries, Carol Bower, Carol Dean, Fadia Gamieldien, Bower, Carol Dean, Fadia Gamieldien, Bronwyn Myers, Bruce Phillips Bronwyn Myers, Bruce Phillips

• Peer Reviewers:Peer Reviewers:

Vikram Patel, Andy DawesVikram Patel, Andy Dawes

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Presentation ContentPresentation Content

• DefinitionsDefinitions

• Burden of mental illnessBurden of mental illness

• Risk factors for mental illnessRisk factors for mental illness

• Interventions & RecommendationsInterventions & Recommendations

• Mental Health and DevelopmentMental Health and Development

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DefinitionsDefinitions

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

• Mental illnessMental illness : group of disorders defined by : group of disorders defined by specific criteria which describe specific criteria which describe

– a particular a particular severityseverity of symptoms of symptoms– durationduration of symptoms of symptoms – the the effectseffects of these symptoms on a person’s ability to function of these symptoms on a person’s ability to function

(socially and occupationally) i.e. symptoms result in DISABILITY(socially and occupationally) i.e. symptoms result in DISABILITY

Example: DepressionExample: Depression

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Spectrum of mental Spectrum of mental healthhealth

Mental Health Mental Illness

•Self-esteem•Coping skills, problem solving•Self-efficacy•Impulsivity•Sub-clinical symptoms

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Burden of Mental Burden of Mental DisordersDisorders

Socio-economic impactsSocio-economic impacts

• Unemployment, povertyUnemployment, poverty

• Poor housingPoor housing

• Decreased school completion, Decreased school completion, academic performanceacademic performance

• Decreased Social capitalDecreased Social capital

• Increased violenceIncreased violence

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Burden of Mental IllnessBurden of Mental Illness

Macro-economic:Macro-economic:

• $ 147 billion annual cost in USA$ 147 billion annual cost in USA

• SA: no data but drug & alcohol SA: no data but drug & alcohol costs alone total R10billion costs alone total R10billion

• Loss is mainly through effects Loss is mainly through effects on productivity, absenteeismon productivity, absenteeism

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Burden of Mental Burden of Mental IllnessIllness

DisabilityDisability

• Globally: 5 of 10 leading causes of Globally: 5 of 10 leading causes of disability are psychiatricdisability are psychiatric

• SA: neuropsychiatric disorders are 2SA: neuropsychiatric disorders are 2ndnd leading cause of BoDleading cause of BoD

• BoD figures exclude the impact of BoD figures exclude the impact of MH on other BoD components…MH on other BoD components…

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Mental ill-health strongly Mental ill-health strongly associated with…associated with…

Unsafe sexMultiple partnersEarly sexual debut

Smoking Alcohol AbuseDrug Abuse

HIV HIV

CVD

CVD

CHILD HEALTH

CHILD HEALTH

Injuries

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Western Cape 2000 (YLLs)

14.1

12.97.9

6.95.9

4.62.7

2.42.3

2.32.12.1

1.8

1.71.5

1.21.1

1.11.01.0

HIV/AIDS Homicide/violence

TuberculosisRoad traffic accidents

Ischaemic heart diseaseStroke

Trachea/bronchi/lung caLower respiratory infections

SuicideDiarrhoeal diseases

Diabetes mellitusCOPD

FiresLow birth weight

SepticaemiaHypertensive heart disease

Breast caNephritis/nephrosis

AsthmaEpilepsy

Source: Bradshaw et al, 2005

Mental health/illness

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Prevalence in Western Prevalence in Western CapeCape

• South Africa: SASH study 30% life-South Africa: SASH study 30% life-time prevalencetime prevalence

• No data for Western CapeNo data for Western Cape

• Proxy measures: injury data Proxy measures: injury data specifically homicide and RTAsspecifically homicide and RTAs

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Proxy measuresProxy measures

MI proxy MI proxy indicatorindicators:s:

WCWC GPGP KZNKZN SASA

HomicideHomicide 12.912.9%%

8.3%8.3% 4.7%4.7% 6.8%6.8%

Road Road TrafficTraffic

6.9%6.9% 4.4%4.4% 2.8%2.8% 3.7%3.7%

SuicideSuicide 2.3%2.3% 1.5%1.5% <1%<1% <1%<1%

% of % of total YLLtotal YLL

22.122.1%%

14.2%14.2% 7.5%7.5% 10.510.5%%

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Aim of MH workgroupAim of MH workgroup

1.1. Prevention of common mental disordersPrevention of common mental disorders

DepressionDepression Generalised Anxiety DisorderGeneralised Anxiety Disorder Substance disorders (includes abuse and Substance disorders (includes abuse and

dependence)dependence) Post Traumatic Stress DisorderPost Traumatic Stress Disorder Childhood behavioural disordersChildhood behavioural disorders

2. 2. Promotion of mental healthPromotion of mental health

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Risk/protective factorsRisk/protective factors

MENTALHEALTH

Health

Safety

Social capital

Employment

Material goods

Living environment

Human capital

Family environment

•Access to recreation

•Built environment (housing, neighbourhoods)

• Basic services

•Mental illness•Health systems• HIV• Substance use• Physical illness• Disability

• Violence• Crime

• Social capital• Social support•Spatial segregation

•Family systems

• Death/trauma in family

•Income

•Food security

• Social grants

•Transport

•Unemployment•Underemployment•Occupational stress

• Education•Pre-school•School climate

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Findings continuedFindings continued

• Majority of relationships are bi-Majority of relationships are bi-directional:directional:

Multiple deprivationMultiple deprivation mental mental illnessillness

• Cumulative effectsCumulative effects

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Domestic Violence

Unemployment

Food insecurity

Family environment

Basic services

Conflict with neighbours

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Focus Areas selectedFocus Areas selected

• Multiple DeprivationMultiple Deprivationo UnemploymentUnemploymento Social assistanceSocial assistanceo Food insecurityFood insecurityo HousingHousingo PovertyPoverty

• Trauma Trauma (preventing MI after exposure)(preventing MI after exposure)

• Pre-school educationPre-school education• RecreationRecreation• Mental Health ServicesMental Health Services• Substance use Substance use (Tik, alcohol & other drugs exlc. Nicotine)(Tik, alcohol & other drugs exlc. Nicotine)

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Multiple Deprivation

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InterventionsInterventions

• Employment programmes: JOBS Employment programmes: JOBS programme, public works etc.programme, public works etc.

• Community development, micro-creditCommunity development, micro-credit• Adult literacy, food securityAdult literacy, food security• Child careChild care• Increase access to social assistance Increase access to social assistance • Built environment:Built environment:

o HousingHousingo NeighbourhoodsNeighbourhoods

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Trends in Status QuoTrends in Status Quo

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

BUT insufficient to meet need and/or BUT insufficient to meet need and/or not optimally effectivenot optimally effective

AND insufficient cognisance of health AND insufficient cognisance of health (including mental health)(including mental health)

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Example: HousingExample: Housing

HOUSING

Type Quality

Other

•Single vs multi- dwelling•High floor vs low floor dwelling

•Structural deficiencies•Pest control•Dampness•Housing satisfaction

•Tenure•Overcrowding•Involuntary relocation•Affordability of housing

Housing factors associated with mental health

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Evidence for Evidence for interventionsinterventions

• Housing improvements consistently Housing improvements consistently improved Mental Health and decreased improved Mental Health and decreased Mental Illness Mental Illness

• Dose-response relationship Dose-response relationship

• Other positive outcomes: physical health; Other positive outcomes: physical health; perceptions of safety; crime reduction; social perceptions of safety; crime reduction; social participation (social capital) ; improved participation (social capital) ; improved perception of the area as a wholeperception of the area as a whole

• Effects of neighbourhood improvements : Effects of neighbourhood improvements : 50% reduction in prevalence of mental 50% reduction in prevalence of mental illnessillness

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Housing Housing recommendationsrecommendations

• Improve quality of state-subsidised housingImprove quality of state-subsidised housing

• Increase housing subsidy amount per Increase housing subsidy amount per applicant applicant

• Improve capacity of housing applicants to Improve capacity of housing applicants to make financial contributions for their homesmake financial contributions for their homes

• Foster community participation & supportFoster community participation & support

• Expand neighbourhood renewal projectsExpand neighbourhood renewal projects

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Example: Federation of Example: Federation of Urban PoorUrban Poor

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Likely outcomesLikely outcomes

Suitable housingSuitable housing

Social CapitalSocial Capital

Human CapitalHuman Capital

Increased incomeIncreased income

Economic participationEconomic participation

Physical HealthPhysical Health

Improved Mental Health

HOW housing is provided can make a big difference!

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Pre-schoolPre-School

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Window of opportunityWindow of opportunity

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

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Outcomes of high quality Outcomes of high quality pre-school:pre-school:

•Improved school Improved school readinessreadiness•Improved cognitive Improved cognitive abilitiesabilities•Lower failure rates Lower failure rates •Higher school Higher school completion ratescompletion rates

• Decreased antisocial behaviour•Decreased substance abuse•40% reduction in arrest rates

• 40% increase in employment rates• Improved maternal employment and education

Benefits of preschool have been noted up to 27yrs!!

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In Western CapeIn Western Cape

• ECD a priority of WCED and DSDECD a priority of WCED and DSD

• Audit done by DSD shows lack of Audit done by DSD shows lack of access to pre-school and poor quality access to pre-school and poor quality of existing preschools, unqualified of existing preschools, unqualified teachersteachers

• Another audit currently underway by Another audit currently underway by DSDDSD

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RecommendationsRecommendations

• Develop high quality teacher training Develop high quality teacher training programmesprogrammes

• Develop high quality pre-school Develop high quality pre-school programmesprogrammes

• Resource roll-out of pre-school across Resource roll-out of pre-school across Province (Province (urgently in high risk urgently in high risk areas: 15 high priority areasareas: 15 high priority areas))

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Recreation

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EvidenceEvidence

Recreation

Recreational environments ? Other

? Arts, music, dancePhysical exercise

Mental Health

Leisure boredom

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Major GapsMajor Gaps

• Focus on team/competitive sportsFocus on team/competitive sports

• Relative exclusion of other forms of Relative exclusion of other forms of recreationrecreation

• Insufficient facilities, access to Insufficient facilities, access to facilities, resourcesfacilities, resources

• Lack green spacesLack green spaces

• Lack of access: cheap transportLack of access: cheap transport

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RecommendationsRecommendations

• Review & support provision of sports AND Review & support provision of sports AND recreation activities recreation activities

• Protect and promote green and natural Protect and promote green and natural spacesspaces

• Provide affordable and safe transport to Provide affordable and safe transport to recreational facilities or areasrecreational facilities or areas

• Support S&R interventions that build social Support S&R interventions that build social capitalcapital

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Trauma

Trauma

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Violence•Community (gangs or crime)•Domestic violence•Rape•Child Abuse

Psychological trauma•Individual•Family•Community•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

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Drug & Alcohol abuseItself a mental health problem

Psycho-behavioural Outcomes•Decreased inhibition, reasoning•Increased risk-taking•Increased libido•Increased mental illness•Decreased mental health•Decreased parenting skills•Poor interpersonal relationships

Violence•Community (gangs or crime)•Domestic violence•Rape•Child Abuse

Psychological trauma

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Bottom lineBottom line

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

Violence prevention is an important part of Violence prevention is an important part of preventing mental illness preventing mental illness

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

crucialcrucial

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RecommendationsRecommendations

• Training: trauma-informed non-health Training: trauma-informed non-health sectors sectors

• Consistently fund, support & roll-out NGOsConsistently fund, support & roll-out NGOs• Develop resources for emergency placementDevelop resources for emergency placement• Provide mental health services in workplaces Provide mental health services in workplaces

with high trauma exposureswith high trauma exposures (police, teachers, social workers, NGO workers)(police, teachers, social workers, NGO workers)

• Make sufficient provision for psychosocial Make sufficient provision for psychosocial needs in disaster managementneeds in disaster management

• Develop post-graduate training programmes Develop post-graduate training programmes in trauma in trauma

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Recommendations Recommendations cont.cont.

Health:Health:• Training: trauma-informed general Training: trauma-informed general

health sectorhealth sector• Integration of mental health staff into Integration of mental health staff into

general health services e.g. surgerygeneral health services e.g. surgery• Provide adequate mental health Provide adequate mental health

servicesservices• Create strong referral networks with Create strong referral networks with

trauma-related NGOstrauma-related NGOs

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Substance use

Substance use

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BackgroundBackground

• Substance use e.g. nicotine, alcohol, Substance use e.g. nicotine, alcohol, ‘tik’, heroin‘tik’, heroin

• Substance abuse/dependence are Substance abuse/dependence are defined mental disordersdefined mental disorders

• Substance abuse/dependence also Substance abuse/dependence also increases risks for other mental increases risks for other mental illnesses; high comorbidityillnesses; high comorbidity

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AlcoholAlcohol

• Likely to be the commonest SOA in the Likely to be the commonest SOA in the Western CapeWestern Cape

• Why?Why? Socially acceptableSocially acceptable Legal production and consumptionLegal production and consumption Active promotion (media)Active promotion (media) Perceived to be benignPerceived to be benign Norms: culture of excessive use (abuse)Norms: culture of excessive use (abuse) Dop systemDop system Wine countryWine country Cheap!Cheap!

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Impact of alcoholImpact of alcohol

Social impact

Economic impact

Out of heViolence

Road Traffic Incidents

HIV

Mental Health

CVD

Child Health (FAS)

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TikTik

• High profileHigh profile

Why?Why?

• Illegal: associated with criminal activity incl. gangsIllegal: associated with criminal activity incl. gangs• Socially unacceptableSocially unacceptable• New drugNew drug• Negative consequences of use occur sooner: Negative consequences of use occur sooner:

abusers deteriorate more quicklyabusers deteriorate more quickly• Severe effects in usersSevere effects in users

BOTH problems need to be addressedBOTH problems need to be addressed

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Evidence for Evidence for interventionsinterventions

• Not effectiveNot effective•Media campaigns with no other measuresMedia campaigns with no other measures

•Scare tacticsScare tactics

•School-based School-based informationinformation interventions interventions

•Law enforcement of DUI lawsLaw enforcement of DUI laws

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RecommendationsRecommendations

Decrease DemandDecrease Demand• Restrict advertising of alcohol Restrict advertising of alcohol • Conduct concurrent anti-alcohol and drug Conduct concurrent anti-alcohol and drug

media campaigns that challenge media campaigns that challenge prevalent beliefs and ‘norms’ prevalent beliefs and ‘norms’

• Increase references to substance abuse in Increase references to substance abuse in other health promotion messages other health promotion messages

• Include evidence-based substance Include evidence-based substance prevention programmes in school prevention programmes in school curriculacurricula

• Training of primary care and other health Training of primary care and other health workers workers

• Provide adequate treatment servicesProvide adequate treatment services

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Decrease Supply:Decrease Supply:

• Substantially increase the cost of alcohol & drugsSubstantially increase the cost of alcohol & drugs• Reduce the availability of alcohol & drugs Reduce the availability of alcohol & drugs • Enforce existing laws on alcohol and other drugs.Enforce existing laws on alcohol and other drugs.• Incorporate addressing substance abuse into Incorporate addressing substance abuse into

multi-faceted community development multi-faceted community development interventions interventions

GeneralGeneral• Improve co-ordination of involved departments: Improve co-ordination of involved departments:

DSD, DEADP, DOH, DCSDSD, DEADP, DOH, DCS

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Mental Health Services

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BackgroundBackground

• Mental Health services:Mental Health services:Hospital to community basedHospital to community based• ScopeScope

Promotion, Prevention, Treatment, Promotion, Prevention, Treatment, RehabilitationRehabilitation

• Nature of mental illnessNature of mental illnessTypically chronic requiring long-term Typically chronic requiring long-term

service useservice use

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The greatest risk factor for mental The greatest risk factor for mental illness is previous mental illness…illness is previous mental illness…

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Major GapsMajor Gaps

• Insufficient community-based services (schools, Insufficient community-based services (schools, workplace, home-visits, community-based care)workplace, home-visits, community-based care)

• Community-based care for mentally ill: Community-based care for mentally ill: • Residential careResidential care• Day servicesDay services

– Need post deinstitutionalisationNeed post deinstitutionalisation

• Poor integration of services: particularly need in Poor integration of services: particularly need in maternal health, HIV, trauma servicesmaternal health, HIV, trauma services

• Grossly insufficient MH services across the board Grossly insufficient MH services across the board but esp. community-based health servicesbut esp. community-based health services

• Impact of general health services on mental healthImpact of general health services on mental health

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General approach to all General approach to all interventionsinterventions

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Targeting interventionsTargeting interventions

• Areas with highest violence and Areas with highest violence and highest Multiple Deprivation Index highest Multiple Deprivation Index (including 15 priority areas)(including 15 priority areas)

• Vulnerable groupsVulnerable groups

• Critical periodsCritical periods

• Some interventions universalSome interventions universal

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Content & Process of Content & Process of interventionsinterventions

• Importance of Importance of multi-faceted interventionsmulti-faceted interventions: : growing human, economic and social capital growing human, economic and social capital (multiple deprivation)(multiple deprivation)

• Participative justice : community Participative justice : community participation and empowerment is vitalparticipation and empowerment is vital

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

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Relationship to PGDSRelationship to PGDS

Intervention Group Strategy 1: Economic Participation

Strategy 2: Connectivity infrastructures

Strategy 3: Effective transport

Strategy 4: Liveable Communities

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

Intervention Group Strategy 5: Resilient communities

Strategy 6: Spatial Integration

Strategy 7: Tolerance, respect for diversity

Strategy 8: Effective governance institutions

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

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Relationship to Relationship to developmentdevelopment

• Development impacts on mental healthDevelopment impacts on mental health

• Small investments in health have large Small investments in health have large impacts on income, education, democracyimpacts on income, education, democracy

• Global MDG interventions: MH component Global MDG interventions: MH component embedded in theseembedded in these

• Mental Health is an essential Capability Mental Health is an essential Capability (economic approach)(economic approach)

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Where to from here?Where to from here?

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Discussion pointsDiscussion points

• General commentsGeneral comments

• What are the most appropriate What are the most appropriate forums for taking this work further?forums for taking this work further?

• Most feasible recommendations/ Most feasible recommendations/ least feasible?least feasible?