Pathways of care South Asian perspectives

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Harischandra Gambheera Sri Lanka

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Treatment Gap
The vast majority of people with mental, neurological and substance use disorders do not receive even the most basic care. Yet such services are essential if we are to offer hope to some of the most marginalized people in the world, especially in developing countries, to live their lives in dignity.

WHO world mental health day message

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Treatment Gap Ctd.

Treatment gap is bimodal Either no treatment or Poor quality treatment [The treatment I refer here is modern (allopathic) treatment]
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Effect of Socio Cultural factors on Treatment Gap

The responsibility of treatment gap in South Asia does not depend merely on availability and accessibility of services but largely on health seeking behaviour of the people,
The health seeking behaviour depends mainly on socio cultural factors in South Asia
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Effect of culture on health seeking behaviour

South Asia that includes the large Indian subcontinent has inherited a culture developed over thousands of years and it inherits many culturally endemic beliefs and value systems. These beliefs ingrained in the South Asian culture hinders the scientific mediation in general population. This obviously has great impact on health seeking behaviour that prevents using evidence
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Cultural Psychiatry
Therefore, even though there is a cultural aspect to Psychiatry, specially in its manifestations, it hinders the development of Modern Psychiatric Services and increase the disability associated with mental illnesses both short and long term.

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Pathways of care
Pathway of care is defined as the sequence of contacts with individuals and organizations, initiated by the distressed persons efforts and those of his significant others to seek appropriate help
(Rogler et. al., 1993).

In other words, Pathway of care is an outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition for a positive outcomes.
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Pathways of care Ctd.

Pathways of care is directly related to the treatment gap, good quality treatment and DUP . Therefore, explorations of underlying hidden factors playing vital roles in help seeking behaviour of affected persons and their family members, which determine the pathway of care leading to place of appropriate management is mandatory. This is even more important in case of serious psychiatric disorder e.g. psychosis, where delay in 4/21/12 initiation of appropriate treatment, due to any

Long DUP
Patients with longer duration of untreated psychosis have poorer outcomes with respect to relapse rates, control of symptoms, and remission rates
(Black et al, 2001; Drake RJ et al, 2000; Verdoux H et al, 1998; Johnstone et al, 1986).

Long duration of untreated psychosis is also associated with ineffective and demoralizing help-seeking and a variety of traumatic events, including high rates of involuntary hospital admission (Johnstone et al, 1986) and poorer response to antipsychotic medications 4/21/12 and treatment outcome (Loebel AD et al, 1992).

DUP Ctd.
Empirical studies have shown that the duration of untreated psychosis (DUP) of individuals with psychosis averages 1 to 2 years.
(Loebel AD et al, 1992; Beiser M et al, 1993; Larsen TK et al, 1996; McGlashan TH, 1999),

This could even be more in developing nations, the reasons of which has yet to be 4/21/12 explored from pathways studies.

Duration of Untreated Mental Illness

Reducing DUMI improve the prognosis not only in non affective Psychoses but also in bipolar disorder. Therefore it is important to modify factors that could be lead to prolong the DUMI. Hence there is need for exploring the factors prolonging DUMI, which determine help seeking behaviour and consequently give a direction to pathway of care. May be achieved by interventions like early catchments / educational / advertisement

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Pathways of care in South Asia

Basically depends on

Sociodemographic and cultural profile Awareness and mental health literacy Attitude of family/society towards mental illness Myths/beliefs regarding causation and mode of treatment of mental illness Stigma attached with psychiatric disorders Experiences with previous health services availability/accessibility of psychiatric services

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Aetiology

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Biological aetiological factors

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Psychological aetiological factors

Psychological distress caused by
Death of loved ones Relationship problems Failures (eg. exams) Loss of Employment / livelihood ETC
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Myths about causation of mental illness

Effects of karma (activities) of previous birth influence of evil spirits, effects of planetal organization on the individual charms and poisoning

are widely considered as causative factors of mental illness in the region.

Therefore people suffering from mental illnesses and their carers tend to seek help from traditional healers whom their treatment methods are based on the above

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Myths Ctd.. Social factors in aetiology

Buddhism Effects of activities of Previous birth Punishment by the god for sin

Dead people Devils (yaksha) Christianity/ Islam / Judaism

Governed by Horoscope based on Time of birth

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opinion of relatives regarding aetiology by educational status

Others- Psychosocial problems, Stress, Excessive thoughts, social upbringing, Poor coping, 4/21/12

Devil Dancing
Traditional healing methods in Sri Lanka

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Management

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Treatment methods

Rituals Devil dancing (shanthikarma) Worshipping Trees

(Bo-tree The tree under which Lord Budda attained nibbana)

Mantra Religious rituals

I would certainly place Aurvedic treatment methods also into the group of rituals as it too is not evidence based.
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opinion of relatives regarding treatment methods by educational status

Others- Meditation, Hypnotism, Rehabilitaion, Social support 4/21/12

Devil dancing
Traditional healing methods in Sri Lanka

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Other causes of treatment gap

Poorly developed / accessible health services Shortages of Human resources Deficiencies in infrastructure due to Brain drain Poor socio-economic conditions
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Availability of services in developing countries

Availability of mental health services in developing country is very limited. In general, they are available in the range of 1/50 to 1/1000 of what is available in well developed countries (Srinivasa MR, 2004). For enormous rural populations (up to 70% of the total population of most developing countries) modern psychiatry does not seem to exist
(Farooq S et al, 2001).
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Availability of policy & legislation

Country India Pakistan Bangladesh Nepal Sri Lanka Bhutan Maldives Mental health policy + ? + +_ + + _ Mental health legislation + + + _ + _ _
WHO

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Human Resources
No of psychiatrists per 100.000

Developed Countries India Maldives Bhutan Sri Lanka 0.4 0.36 0.3

>10

0.2 (1:500,000)

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Availability of other mental health professionals in South Asia

No. of nurses No. of PSW No. of OT 0-1 / 100,000 No data No data No. of Psychologists No data available

No. Nurses in developed countries 1-50 WHO

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Psychiatric beds per 10,000

Europe America Western pacific Eastern Mediterranean Africa South East Asia Sri Lanka 9.3 3.6 1.0 0.8 0.4 0.3 1.3

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WHO

Poorly developed services causes

Ignorance about the mental illnesses and remedies Increased DUP Increases relapses Inadequate / ineffective Treatment Poor quality treatment No rehabilitation Resulting in
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Mental Health literacy

The term mental health literacy was coined by Australian national Anthony Jorm in 1977. He defined it as knowledge and belief about mental disorders which aid their recognition, management or prevention. It includes the ability to recognize specific disorders, knowing how to seek mental health information knowledge of risk factors and causes of self-treatment and of professional help available and attitudes that promote recognition and appropriate health seeking.
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Mental Health Literacy Ctd.

Awareness about psychiatric disorders in general is poor, mental health literacy is low and Less knowledge about mental illness and its symptoms, as well as possible treatment approaches are negatively associated with health care use
(Chen H et al, 2000; Scott TL et al, 2002 Jorm AF, 2000).

In other words, what the public believes about mental illness, e.g. its aetiology, treatment and prognosis, and what the public considers to be the role of, and effectiveness of, modern health services in managing mental illness would influence health-seeking 4/21/12

Media effect on Literacy

In India and other regional countries, the major source of awareness about psychiatric disorder and psychiatric services in community are due to exposure with the patients suffering from psychiatric disorder, not the role played by media advertisement, news paper and various agencies as in the Western countries.
This observation may be common to all South Asian region

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Media effect on behaviour

Programme
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Media effect on behaviour

Many programme Changed only know ledge not the health seeking behaviour

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Stigma
Myths prevalent in South Asia about the causation of mental illness Mentally ill persons are dangerous Mental illnesses are incurable Impact on Mentally ill person Family with a mentally ill person
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Mental health services

Stigma of mental illness:

Effect of Stigma on the help seeking behaviour global but Comparable to Western countries its effect on in developing countries more devastating. The effect is not limited to the health seeking behaviour but also on families with mentally ill individuals and establishing mental health services. Stigma hinders access to the mental health services as well as general medical care (Liggins J et al, 2005)

The stigma associated with mental disorder may change the pathway of care, as well as the choice of first service provider. Stigma is one of the reasons for many to seek help from traditional healers as the prime service provider.
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Effect of socio cultural factors on outcome

Effects of

Myths / Poor services / stigma

Lead to Prolongation of duration of untreated Psychosis (DUP) Inadequate and ineffective treatment Frequent relapses

Resulting

increased long term disability 4/21/12

opinion of relatives regarding Outcome

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Traditional Healer in south Asia

One of the biggest menace in South Asia is traditional healers Do they provide services to the consumers satisfaction Do they fill the service gap? Do they complement with Psychotherapeutic effect? Do they make appropriate referral?
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Recommendations
Shorten the DUP
Shorten the pathways of care improve mental health literacy illegal] eradicate traditional healers [Make it Establish a Community Psychiatric service Fight stigma Eradicate myths
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Thank You
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