Impact of the Community Mental Health System Sthrengthening Project in Aceh, Indonesia

(2009-2011)

Hervita Diatri, Harry Minas

Disaster in Aceh

• Laboratory for better MH system development in Indonesia

• More than one hundred local and international MH and psychosocial agencies arrived in Aceh after the tsunami

• Training for primary health professionals was a key strategy

Tsunami, 26 December 2004

30 years military conflict

About Research Location

Bireuen• Affected by both

disasters• Bireuen District

8,7% of population of Aceh, >75% living in rural areas*

*Indonesia Statistics Center 2010

About ResearchItems Number

Number of Sub-districts 18Number of Primary Health Care Centres (PHCs) 18Number of GP1 participants 37GP+2 : non GP+ 24 13Number of patient participants 556With mental illness3 : with comorbidity4 : without mental illness

460(82,7%)

360(64,7%)

96(17,2%)

Number of treated patients5 372 (80,9%)Medication: Psychoeducation and or counseling: Both

279(60,7%)

363(78,9%)

343(74,6%)

1Primary care doctors2GPs with additional mental health training3According to MINI-ICD X4Have more than one mental illness5Medication and or psychosocial intervenstion (psychoeducation and counseling

Mental Health Diagnosis

All of GP GP+ non GP+62

64

66

68

70

72

74

76

Prevalence of Any Mental Disorder

GPs who had received some additional mental health training (GP+) are more likely to make a diagnosis of mental disorder in patients who have a MINI diagnosis of mental disorder than are non-GP+

Mental Health Treatment

Depression Anxiety Psychosis PTSD Manic0

100

200

300

400

500

600

700

Treated by Non GP+Treated by GP+Number of patients

GPs who had received some additional mental health training (GP+) are more likely to give treatment to people with mental

disorder than are non-GP+

Mental Disorder and Disability

Mental Health ProblemsDepression

Global Burden Study, 2010

Research result:

The Multivariate regression model suggests that the presence of a mental disorder is associated with a substantially increased risk (OR = 6.0) of having disability. Risk is a little higher (OR = 6.2) if there is comorbidity.

Disability Recognition

Disability Severity 1 Severity 2 Severity 30

50

100

150

200

250

300

350

400

450

500

WHO-DASSGP

22.7%

78.6%

Psychosocial SupportDisability

(WHO-DAS)Psychosocial support by GP 81,50%

(89,5% have MINI Diagnosis)Psychosocial support (perceived by patients) 46,70%

• Different perceptions among GPs and patients related to psychosocial support.

• More than 95% of the psychosocial support provided is psychoeducation and counseling

• GP are more likely to give psychosocial support to patients with mental disorder than patients without mental disorder

Mental Disorder – Disability - Poverty

• Being below the poverty line is associated with a moderately increased risk (OR = 2,1) of having disability

• One of the main forms of rehabilitation for persons with mental disorder in Aceh has been support with income generation activities.

Opportunities andDevelopment Enablers

Mental Health Diagnosis

Depression Anxiety Psychosis PTSD Manic0

10

20

30

40

50

60

70

MINIGP+Non GP+

Government Commitments

• Province and District Health Offices provide training to PHC staff 2-3 times/year. There is an opportunity to modify and enhance this training, and possibly to introduce continuing supervision and mentoring.

• The Ministry of Health has prioritized PHC development as the core of the national health service in the 5 year strategic health plan (2015 – 2019)

Research RecommendationsGPs with some mental health training are more likely to recognise and diagnose mental disorder, and to provide

treatment than are untrained GPs

There is a need to enhance disability recognition and assessment, and referral to rehabilitation programs

GPs need to be able to develop appropriate rehabilitation plans for persons with significant disability

There is a need to go beyond short-term clinical training, to include training in disability, and to provide continuing skills development,

supervision and mentoring of GPs.

Research RecommendationPast and Current Training Topics %GPPsychosis 43,2%Anxiety 40,5%Substance Abuse 37,8%PTSD 37,8%Depression 8,1%

Training specifically related to Depression, Anxiety, PTSD, Disability and Psychosocial Rehabilitation still

need to be improved

Research Recommendations

• The majority (72,1%) of patients say they know about mental disorder

• Knowing about mental disorders is associated with more accurate self-identification of mental health problems (79%, p = 0,049)

• More accurate self-identification of mental health problems makes it more likely that the GP will recognise, accurately diagnose and appropriately treat when necessary.

• Community psychoeducation can empower people to participate in an appropriate response to the presence of mental health problems and response to disability.

Role of MH Clinic in PHC

PHC+1

PHC+2

PHC+3

PHC+4

PHC+5

PHC+6

PHC+7

PHC+8PHC1

PHC2PHC3

PHC4PHC5

PHC6PHC7

PHC8PHC9

PHC100

20

40

60

80

100

120

GP PrevalenceMINI Prevalence

PHC with MH clinic are more likely to make a diagnosis of mental disorder in patients who have a MINI diagnosis of mental disorder

than PHC without MH Clinic

Research Recommendation

• Nearly 99% of the patients believe that mental disorders can be treated, and 96,2% among them believe that PHC can effectively treat mental health problems

• The PHC is needed by the community to be more active and capable in recognition of and response to mental health problems in PHC attenders.

• The roles of PHC in mental disorder management has been explicitly stated by the Indonesia’s New MH Law (2014) to include MH promotion and illness prevention, early diagnosis and treatment, and facilitating rehabilitation in collaboration with other sectors (especially the Social Affairs Office) and protection of the rights of persons with mental disorder.

TERIMA KASIH