Belfer gottlieb maternal and child mental health

Unique Challenges and Opportunities for Child Mental

Health in Africa: Practice and Policy

Myron L. Belfer, MD, MPAProfessor of Psychiatry, Harvard Medical School

Children’s Hospital BostonMbarara University of Science and Technology

August 15-16, 2011

“No health without mental health” WHO

WHO mental health budget approximately 1.8% of total budget and

no line item for child mental health.Only recently has CAMH become a

priority condition.

Much talk about infant, child and adolescent mental health, but a challenge to see it embraced

by governments, academia and institutions.

Why child and adolescent mental health lags.

History…value of the child Adult psychiatrists often lack a

developmental perspective while focusing on major mental illness

The image of mental illness equated with violence and possession is etched in people’s minds

STIGMA – cannot marry, bad genes, evil

Gain a Developmental Perspective

Children evolve over time across a number of parameters…cognitive, physical, emotional.

Crucial importance of the early mother-child relationship.

Great variability in rates of development but consistency in the progression of development.

Brain architecture continues to change through adolescence.

Emotional traumas can influence brain development with long-lasting consequences.

Children have the capacity for resilience.

African Context

More than 50% of the population of most African countries are children and adolescents.

Urban migration. Absence of mental health and child mental

health policy limits development of programs…complex reasons.

Absent child mental health professionals. Absent resources for child and adolescent

mental health…competition for scarce resources…non-communicable disease versus communicable disease.

Political and economic uncertainty. Some of the most innovative programs

originating in Africa.

Global Numbers

50% of all adult mental disorders begin before age 14

Every year approximately 800,000 individuals commit suicide, almost 90% from low and middle income countries.

Adolescents account for 50% of all new HIV infections 70% of premature adult deaths link to behavior that

develops in adolescence More than 12 million children have been displaced

from their homes as a result of war and associated human rights violations during the period 1985 – 1995 and the pace continues to the present.

Epidemiological Data

Earliest comparative epidemiological studies done in Africa. 20% of children aged 9 to 17 have a diagnosable mental

disorder with impairment in functioning, smaller percentage with severe disorder.

Depression is occurring earlier in life and may predict more severe disorder later in life.

Suicide is the 2rd leading cause of death in the 10 – 14 year olds.

Epilepsy is a mental disorder in the African context. Demonstrated continuities from infancy into adulthood,

such as, observed violent behavior, persistent psychopathology.

No surprises in global epidemiological data. Variance due to differing methodology, inadequate sampling, inappropriate use and analysis of instruments.

Use of instruments for a single disorder distorts epidemiological findings…”more or less” of the disorder being studied.

Benefit to utilizing “cultural epidemiology” melding quantitative and qualitative data.

When worldwide epidemiological data for

psychiatric disorders shows remarkable

similarity/comparability, why the widely divergent

prevalence for “PTSD”?

Preventive intervention at early ages/early child development programs

cost effective (Heckman, 2007)

Rates of Return to Human Development ― Investments Across All Ages

Pre-school Programs

School

Job Training

ReturnPer $

Invested

R

2

4

6

0 6 18Age

Pre-school School Post-school

Source: P. Carneiro & J. Heckman, Human Capital Policy, NBER, 2003.

8

Consequences of Poor Child and Adolescent Mental Health

Lack of compliance with medication regimens for health…excess use of health care resources (Knapp, 2001)

Increased and continuing pursuit of risk behaviors leading to premature deaths

Suicide Substance abuse Bullying Gang formation/juvenile

delinquency/homelessness/societal destabilization Inability to achieve optimal opportunities for

productive lives - underemployment and unemployment

Economic costs to families, governments and societies (Scott, 2003; Knapp, 2003)

Underachievement and school drop-out

Challenges

Provide “rational care”. Support program development consistent with national

priorities…do not let NGO priorities dictate national policy or programs.

Avoid the pitfalls of “Western” program development. Avoid distortions of program development resulting from

categorical program development. Use the provisions of the UN Convention on the Rights of the Child

and the UN Convention on the Rights of People with Disabilities to support program development.

Make the needed economic arguments for stabile program support enabling a decreased reliance on NGO support.

Value children in a way that may not always fit with cultural norms.

Achieving multi-sectorial collaboration. Child mental health services are of necessity multi-sectorial.

Programs need to be informed by “needs assessment” and engage child mental health professionals.

Adhere to ethical standards in research with vulnerable populations.

Can we really train primary care workers…those who are needed to provide child

mental health interventions?

Policy Considerations

Child Mental Health Policy

Absent as noted in Atlas In fact, African nations do better than

most of the world in developing policy, but always a question of implementation

WHO has a manual on child mental health policy development---cookbook.

Without policy not possible to sustain program development or ensure accountability

Millennium Development Goals

Absence of Mental Health GoalVital to success of the MDGs

If further MDGs opportunity for mental health development

Disability rights is now a powerful force…will mental health be included?

UN Convention on the Rights of the DisabledDisability Rights Fund – African focus

Think of maximal inclusion and abandon the investment in a

deficit model.

Public Health Policy

Need for a public health infra-structure. Structural realignment has weakened public health in countries.

Will child mental health clinicians engage in public health?

Clinical Challenges

Danger of premature diagnosis of psychopathology in children and adolescents.

Co-morbidities a sign of what we do not know. Difficulty of evaluating symptoms versus disorder

in children and adolescents. Symptoms do not equal a disorder. Great overlap.

“Probable PTSD”, “PTSS”, “Symptoms of PTSD” not equal to PTSD.

Inadequacy of the diagnostic nomenclature – DSM-IV or ICD-10. DSM V and ICD 11 better?

Disorder versus impairment, distress and suffering.

Adherence and follow-up care. Providing mental health care in school settings.

Trauma

Not all trauma is the same…war, natural disaster, accidents.

Panter-Brick approach. Kindling. Impact on brain development. Are there protective factors? Resilience versus late appearing

suicide.

Single disorder advocacy has eclipsed the concern for providing “rational

care”.

A Dangerous Situation…on other hand shows power of focused advocacy.

Commercialization of care worldwide…categorical

program

Balance psychosocial intervention with need to address psychopathology: current polarization with

undo emphasis on resilience is stifling program development

Lessons Learned

NGO support fails to provide an incentive to governments to develop services or policies.

Targeting specific populations may bring about unintended consequences…OVCs versus general support.

Expanding the reach and breadth of categorical programs can stimulate comprehensive care.

Mental health is embedded in health and therefore needs to be part of all health care.

Employment and/or school are essential for good mental health.

The mental health needs of children and adolescents are paramount, but in early childhood linked to maternal health and mental health.

Maternal Mental HealthExperiences, Lessons Learned,

and Recommendations

Barbara Gottlieb, MD, MPHBrookside Community Health Center

Harvard Medical School &Harvard School of Public Health

Maternal mental health“A state of well-being in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her community.”(WHO, per Herman and Swartz, 2007)

Maternal Mental Health

• Mood disorders– “baby blues”– depression

• chronic depression/dysthymia• during pregnancy• postpartum

– maternal distress• Psychosis

Maternal Mental Health

• Mood disorders– “baby blues”– depression

• chronic depression/dysthymia• during pregnancy• postpartum

– maternal distress• Psychosis

Prevalence of Maternal Mood Disorders

• “Probable major depressive disorder” – 34.7% females– 24.2% males (14 districts in Uganda, Kinyanda, et al, 2011)

• Maternal depression-15-57% (Wachs et al, 2009)

– 25% antenatal, 28% postpartum, > 50% depressed after 1 year (Rawalpindi, Pakistan, Rahman et al, 2003)

– 15-28% (Africa and Asia, Husain, et al, 2000)

– 10% (semi-rural Uganda, Cox, 1979)

– 16% (semi-rural Uganda, Assael et al, 1972)

– 6.1% (peri-urban Kampala, Uganda 6 weeks, Nakku et al, 2006)

– 34.7% (peri-urban settlement South Africa, Cooper, et al, 1999)

Impact of Maternal DepressionWoman’s Health and Well-being

• Poorer perinatal care, increased risk of perinatal morbidity and mortality– Less likely to seek and benefit from prenatal care (Pagel et al,

1990)

– Less likely to seek help with delivery– Less likely to seek and benefit from postpartum care

• Less ability to complete daily activities (Patel et al, 2002)

• High risk of subsequent episodes of depression– Prenatal depression increases risk of pp depression (Dennis et

al, 2004)

– PP depression increased risk for chronic depression (Murray et al, 1999)

Impact of Maternal Depression(Infant/Child Health and Well-being)

• Disruption in maternal self-perception and maternal-infant bonding– Negative perceptions of infant (Foreman et al, 2002;

Edhborg et al, 2000; Hart et al, 1999; Galler et al, 2004)

– Poor problem solving (Campbell et al, 2004)

– Impaired bonding (Martins et al, 2000

– Low care-giver responsiveness (Martins et al, 2000

• Increased rates of paternal depression (Goodman, 2004)


• Emotional/developmental– Insecure attachment (Martins et al, 2000

– Slower cognitive development (Sohr-Preston et al, 2006; Black et al, 2007))

– Childhood behavioral problems (Goodman et al, 1999, Murray et al, 1999)

– Low academic achievement (Galler et al, 2004)

– Childhood depression (Galler et al, 2000; Patel et al, 2003)


• Physical health– Lower birth weight (Cooper et al, 1996)

– Low birth weight and prematurity (Hedegaard et al, 1993; Hoffman et al, 2000))

– Breast feeding difficulties (Cooper et al, 1993; Falceto et al, 2004)

– Stunting, undernutrition (Rahman et al, 2004; Anoop et al, 2004)

– Eating and sleeping difficulties (Righetti-Veltema et al, 2005)

– Reduction in preventative health services (all services, Minkovitz et al, 2005; vitamins, Leiberman, 2002)

– Diarrhea (Rahman et al, 2007; Thongkrajai et al, 1990)

Impact of Maternal Depression(Community/Society)

• Reduced economic productivity• Contributes to inter-generational cycle of

depression• Compromises social justice Diagnosable depression may be tip of the ice-

berg. Similar patterns in women with symptoms of distress.

Impact is greater for those with chronic rather than episodic depression

Maternal Depression(Low- and Middle-Income Countries)

Risk Factors• Poverty/high levels of economic stress*• Illiteracy, low educational achievement*• Low social support• Single parenthood*• Maternal age< 20*• Multi-parity*• Marital strife, divorce, polygyny• Stressful life events in previous year*• Domestic violence*• Chronic maternal illness*• Maternal HIV• Maternal anemia• Lack of awareness of depression by health providers• Social stigma of family member with mental illness• Preterm or low birthweight infant• Child with physical problems• Unplanned or unwanted infant*• Sex of child not preferred*• Lack of control by mother in reproductive /financial/family resources

decisions

*Factors noted in studies of Uganda

Protective Factors

• Maternal literacy, education

• Partner support• Family support• Housemaid at time of

delivery• Social support (outside of

family/household)• Responsive health care

environment

Ecologic Framework for Maternal Mental Health

IndividualResiliency factorsExposure to stressors


Family


Mother-child dyadParenting, massage, sensitivity

Mother-partnerReduce violence, parenting

Family unitExposure to stressors


Community

Family





Health SectorCapacity, training for mental health

Community resourcesJobs, police and safety

Inter-sectoral collaborationPublic education to de-stigmatize mental disorders


Social policy, laws

Community

Family








Gender equalityEducational policies

SafetyControl of alcohol

Promotion of mental health programsBudgetary priorities


Social policy, laws

Community

Family








Gender equityEducational policies

SafetyControl of alcohol

Promotion of mental health programsBudgetary priorities

GLOBAL POLICYGender equalityDe-stigmatize mental disorders

Maternal Depression and Human Rights

• UN 1989 Convention on the Rights of the Child actions states must take to ensure children’s rights Most widely ratified UN convention (all countries except

US) right to survival and development, universality of rights, indivisibility of rights, and the best interests of the childArticle 2 – children should not face discrimination based on parents’

disability, including mental illness; governments should actively support parental childrearing efforts and promote facilities and services focusing on the care of children

Article 27 – governments should recognize the right of every child to a standard of living adequate for the child’s physical, mental, spiritual, moral and social development and assist parents in ensuring this right


UN Convention on the Rights of Persons with Disabilities

Article 1 - recognizes depression as a disabilityArticle 6 – recognizes that women and girls with disabilities are

subject to multiple discrimination and governments shall take measures to ensure the full and equal enjoyment by them of all human rights and fundamental freedoms

Requires governments to provide medical and social supportChallenges stereotypes about mental illnessArgues for creative strategies including self-help groups,

occupational training, lifeskills education, parenting skills and local healing traditions


UN Fund for Population Activities and the WHO expert group panel – Consensus Statement on the interface between maternal mental health and child health and development in low-income countries (UNFPA, 2007)

Mental health recommendations1. Reduce the factors that lead to maternal depression2. Promote maternal and child health and development3. Increase availability of low-cost evidence-based interventions

for maternal mental health problems


UNFPA: Recognized that maternal health is fundamental to 5 of the 8 Millennium Development Goals

1. Improving maternal health2. Reducing child mortality3. Promoting gender equality and empowering women4. Achieving universal primary education5. Eradicating extreme poverty and hunger


UNFPA concluded: “political will, concerted action by global stakeholders and resources are needed now to integrate maternal mental health in endeavors to achieve the Millennium Development Goals”

Recommendations:• Early detection with validated tools, appropriate treatment through clearly

defined protocols, provision of low cost medications when needed• Psychoeducational interventions that combined information with psychological

support• Interventions to enhance mother-child relationships (sensitivity, stimulation,

interaction, comfort and responsiveness)• Improvement in partner relationships by promoting gender equality, improved

mother-father work sharing and parenting, reductions in partner and family violence

• Culturally sensitive, solution focused brief psychological therapies• Improvement in social support for women• Improvement in access to education and vocational training for girls and women(WHO, 2007)

Interventions for maternal depression – What is the evidence?

• Interventions by professionals– Psychotherapy– Cognitive-behavioral therapy– Antidepressant medications (Appleby et al, 1997; Patel et al, 2007)

• Interventions by non-professionals– Home visits by Community Health Workers (Elliot et al, 2001; Baker-

Henningham et al, 2005)– Psycho-social support groups (Cooper et al, 2002; Chen et al, 2000; Ali et al, 2003)– Psycho-educational groups (Barlow et al, 2002)

– Group therapy by lay health workers in Uganda* • Not specifically maternal depression, but successful in reducing depression

among males and females, and reducing dysfunction in nearly all specific tasks for females

(Bolton et al, 2003)

Challenges: Need > Resources • Low priority of mental health issues (Chisholm et al, 2007; Saxena et al, 2007)

• Stigma of mental health issues (Engle, 2009)

• Low priority of women’s health; unfavorable entrenched gender policies

• Barriers to interventions centered on professionals– Few psychiatrists (Patel et al, 2004)

– High cost of antidepressant medications (Bolton et al, 2003)

– Low rates of patient adherence (Kirkmayer, 2001)

• Frontline health providers– Not trained to screen, identify, address maternal depression– Not aware of magnitude or seriousness of the problem– Competing demands for time and resources

Challenges: Knowledge & Translation• Evidence base is sparse• Difficult to extrapolate interventions

– High income to low- and middle-income countries– From one low- or middle-income country to another

• Outcomes measured vary between studies– Maternal vs child health indicators– Mediating variables vs health outcomes

• Few long-term studies• Requires shift from traditional child health programs

– Traditional child health programs – short-term, technology-dependent with high rates of clear-cut success

– Maternal mental health programs – long-term; household/community focus

Opportunities

• Build bridges – Child health and maternal health– Mental health and physical health– Primary care and reproductive care

• Holistic, ecologic approach– Requires cooperation between health care and public

health– Health and other social systems, including education– Synergy and impact on multiple health outcomes

Lessons learned - translation

• Utilize and enhance existing delivery system– Integrate mental health into primary care

• Incorporate maternal assessment and care into Integrated Management of Childhood Illness package

– Integrate mental health into maternal care– Make strategic use of all levels of health care providers

• Design multifaceted rather than single-issue programs• Interventions in non-mental health domains may

improve mental health• Link mental health programs to community-based

programs

Integration of mental health into primary health services

• Ownership and buy-in– Community (“consumers” and stakeholders)– Providers

• Realistic expectations– Link screening –assessment-intervention-referral– Brief, user-friendly tools– Multi-faceted screening where possible

• Quality Improvement approach– Data loop and feedback to providers & stakeholders– Engage providers in continuous improvement

Lessons from my own experiences• Provider resistance and inertia can be overcome• Research, experimental design important; replicate on-

the ground conditions as much as possible• Responsiveness and accountability to all stakeholders –

key to sustainability• In primary care settings, sensitivity is more important

than specificity• Reducing distress does not always require a mental health

intervention• Consistency of screening and assessment methods will

improve yield over time• On-going training is key. Best cases come from the health

workers themselves

Multi-faceted Screening-Assessment Tool

Depression

Substance/Alcohol Use

Domestic Violence

Mental health training – Community Health Workers in Rural Guatemala

Moving Forward

Opportunities

Tradition of caring families and mothers’ attachment to their infants and children.

Goodwill with potential partners. International focus on concerns on the African continent. Evidence of creative programming with few resources. Demonstration platform for “task shifting”. HIV/AIDS has given a window into the understanding a host of mental

health issues. West African MacArthur Foundation initiative for a Masters in child

mental health. African Association for Child and Adolescent Mental Health – Olayinka

Omigbodun, MD, from Nigeria, also President of IACAPAP. Collaborative training opportunities in clinical and research areas. Clinical training exchanges with requirement to return to country of

origin. MDG focus for the next generation. Needs assessment strategies for policy and program development…

stakeholder involvement.

Mobilizing a global response:Setting priorities

Criteria: High burden (mortality, morbidity, disability) Large economic cost Effective intervention available

Priority conditions: Depression Schizophrenia Suicide prevention Epilepsy Dementia Disorders due to use of alcohol Disorders due to illicit drug use Child mental disorders

NIMH/NIH Support for Collaborative Programs

Supporting African Development

Innovative Programming

Infant and mother/child observation in the context of vaccination programs

Microfinance leading to improved health and mental health outcomes

Rights based programs leading to reduced HIV transmission, improved self-esteem and improvement in family life…development of “agency” – Felton Earls, MD in Tanzania

Home based care for autistic children Juvenile justice outreach and intervention. Direct involvement of youth Focus on inclusion (disability rights).

Academic global health initiatives need to incorporate mental health and infant, child and adolescent mental health in particular.

This is a vital part of the educational process to reduce stigma, enhance preventive efforts, and ensure healthier and more

productive societies.

Thank you

Health & Medicine

Belfer gottlieb maternal and child mental health