Mental Illness among Trauma-Affected PopulationsPaul Bolton, MBBS, DTMH, MPH, MSBloomberg School of Public Health

Section A

The Nature of Mental Illness after Trauma

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Leading Causes of Disabilityin the World

19901. Lower resp. infections2. Diarrhoeal diseases3. Perinatal conditions4. Unipolar major depression5. Ischaemic heart disease6. Cerebrovascular disease7. TB8. Measles9. Road traffic accidents10. Congenital abnormalities

20201. Ischaemic heart disease2. Unipolar major depression3. Road traffic accidents4. Cerebrovascular disease5. COPD6. Lower resp infections7. TB8. War injuries9. Diarrhoeal diseases10. HIV

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Conflict and Population Displacement

Global mental health issues receiving most attention are those due to conflict and population displacement

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War Has Changed for Civilians

Battle of Gettysburg—one civilian casualtyWW I—18% casualties civilianWW II—60% casualties civilianCurrently—90% casualties civilian

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Psychological Trauma

Civilians now commonly experience psychological trauma

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Mental Results of Psychological Trauma

No effectSorrow, anger, hopeless, etc., but no illnessMental illness– Directly caused by trauma– Increased incidence of other mental

illnesses

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What to Assess?Issues

Importance– Numbers affected– Severity (suffering and dysfunction)– Impact on communityMeasurabilityAssess problems requiring mental health expertise

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Advantages of AssessingMental Illness

Trauma-induced mental disorders are known to be common among refugeesCause intense suffering and dysfunction resulting in effects beyond individualHave well-defined diagnostic criteriaLessons learned in one population may be applicable to othersRequire specific mental health interventions

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Disadvantages of Assessing Mental Illness

Do these mental illnesses occur across most cultures?– Evidence for some cultures– Others?If so, are there differences?May require focus on selected individualsLack of evidence for effective interventions

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How Does Trauma Cause Mental Illness?

Severe challenge to a person’s world viewFailure to adapt mental illness

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Why Does Trauma CauseMental Illness?

Loss of normal coping mechanisms loss of sense of security/safetyUnless effective coping mechanisms/sense of security is restored, the following are permanently heightened:– Vigilance (anxiety disorders)– Despair (mood disorders)– Previous mental illnesses

Continued

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Why Does Trauma CauseMental Illness?

Capricious trauma increases likelihood of mental illness

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Causes of Psychological Trauma Violence

Injury/disability/disfigurementTorture/imprisonment/deprivationWitnessing atrocities and destructionLiving in contact with perpetratorsLiving in contact with victims

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Causes of Psychological Trauma Violence

Sexual ViolenceCommon element of ethnic violenceWomen and childrenUsed as a weapon/strategy– Humiliates– Bearing enemy children– Destabilizes families and communities

Continued

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Causes of Psychological Trauma Violence

Domestic violenceSecondary to drug and alcohol abuse

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Causes of Psychological Trauma Losses

Loved ones and friendsPhysical capacityHome and social institutions/supportEducation, job, career, financesIndependence, identityLoss of sense of securityLoss of a future

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Causes of Psychological Trauma Threats

Threaten with violence or lossThreat can be as damaging as the actuality

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Mental Illnesses Resulting from War and Displacement

Anxiety disorders—especially Post Traumatic Stress Disorder (PTSD)Mood disorders—especially depressionSocialization to violenceExacerbation of pre-existing disorders– Psychoses– Personality disorders

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Post Traumatic Stress Disorder (PTSD)

Result of traumatic eventDisorder of heightened vigilanceRe-experience traumatic eventIncreased arousalAvoidance behaviorNumbingFunction affectedLasts more than one month

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Depression

Disorder of despairMood depressedLoss of interest/pleasure (tired of life)Change in appetite/weightProblems sleepingPsychomotor agitation/retardation and fatigue

Continued

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Depression

Feeling worthless or guiltyDifficulty thinkingRecurrent thoughts of death or suicideFunction affectedNot due to bereavement or lasts more than two months

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Socialization to Violence

Disorder of abnormal coping mechanismsEspecially child soldiers– Amoral behavior– Loss of empathy, sympathy– Dehumanized social relationships

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Which Disorder?

Nature of trauma– Violence and threats PTSD– Losses depression– Chronic violence from childhood

socialization

Section B

Interventions

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“Non-Psychological”Interventions

Reunification and family tracingWorkRecreationBuild/rebuild infrastructureSecurityReintegration (soldiers)

Continued

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“Non-Psychological”Interventions

Spiritual support of religious leaders, eldersPhysical health servicesJustice and accountabilitySelf-determinationDecent environment

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Psychological Interventions

Psycho-education and psychotherapy“Work through” experiencesAssist local people to conduct their own healing processesDrugs

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Psycho-Education and Psychotherapy

Not much used (yet)Need to adapt to local understanding of illnessDiscussion of triggering events (debriefing)Normalization of illnessReinterpretation of events

Continued

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Psycho-Education and Psychotherapy

Individual or group/family therapy or activities– Cognitive behavioral therapy– Interpersonal psychotherapy– Eye movement desensitization and

reprocessing

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Working through Experiences

Talking therapies– Story tellingCreative therapies– Drawing, collagePlay therapies– Drama, dance, play

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Facilitate Local Approaches

Healing treatmentsHealing ceremoniesAcceptance procedures

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Drugs

Not currently usedCurrently no long term roleShort term anxiolytics/sedatives may be beneficial

Section C

Issues

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Issues

Psychosocial vs. psychiatricWellbeing model vs. disease model

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Evidence for Mental Illness

Most is based on Western instrumentsAre Western concepts of illness applicable across cultures?How to assess function?

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Guhahamuka

Failure to sleep †Despair, hopelessness †AngerFailure to eat †Failure to talk Loss of intelligenceAttempting suicide †ConfusionActing crazyEasily startled

Mixed feelings and thoughts in your head at the same time †Feeling extremely weak †AbsentmindednessToo many thoughts †Feeling worthless †Feeling you would be better dead †Lack of concentration †

Continued

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Guhahamuka

Feel you have a “cloud”withinFeeling disconnectedOften falling sickKeep dreaming of bad experiences Fleeing from people and hidingLack of trustFeeling like fightingBeing quarrelsomeExcessive crying †

Talking to anybody who comes by about your painChaos in the mind (flashback)Instability of the mind.Feeling like you are having an epileptic episode (collapse).Acting without thinkingHaving nightmares about fighting.Deep sadness that can lead to death †

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Agahinda

IsolationLack of self care †Loss of mind Being very talkativeNot caring to work †DrunkennessFeeling life is meaningless †Committing suicideDon’t feel like talkingExcessive alcohol drinking causing crazy behavior

Sadness †Being displeased with your living conditions/situationNot pleased by anything †Inability to withstand whatever happens to youBurying one’s cheek in his/her palm (hopeless) †Difficulty interacting with others (poor relationships)

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Important Tasks in Rural Rwanda

MenWashDressAdvise the familyAttend meetingsSocializeManual laborEarn money

WomenWashDressCookWash clothesClean houseCare for childrenAttend meetingsSocializeTransmit culture

How to Distinguish Mental Illness from a

Poor Environment

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Little Evidence for Effectiveness

Impact of all post-disaster interventions unprovenImpact of most disease-specific interventions unknown in most developing countries

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Recommendations

1. First focus on “non-psychological”interventions while studying the community (ethnographics)

2. Delay psych interventions until non-psych interventions have been implemented– Adapt psych instruments and

interventions to local situation3. Assess for common major illness

Continued

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Recommendations

4. Specific treatment with adapted psych interventions

5. Assess impact of psych interventions

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Non-Mental Health Workers

What can a non-mental health person do about trauma if they are working in an area where this is happening?