Metro-Urbam Mental Health in Developing countries: From Origin to Outcome: An Indian Experience

Transcription

1 Western University From the SelectedWorks of Amresh Srivastava Summer May, 2009 Metro-Urbam Mental Health in Developing countries: From Origin to Outcome: An Indian Experience Amresh Srivastava, University of Western Ontario Available at:

2 Metro-Urban Mental health in developing countries: from origins to outcome: an Indian experience Amresh Shrivastava: Executive Director: Mental Health Resource Foundation, & Prerana Charitable Trust, Mumbai, India. Department of Psychiatry, University of Western Ontario, London, Ontario, Canada 467, Sunset Drive, Regional Mental Health care, St.Thomas, Ontario, Canada, N5H 3V9

3 Mumbai URBAN AGE Mental Multi-cultural, health multi-religious, in Labour Mumbai intensive, slums, Bollywood, Land of opportunities Indian mental health 1 Understanding the Maximum City Our experiments in mental health 5 th Largest today City of 2 end largest by 2015 Unique mental health issues in Mumbai Considering this, development of mental health services has been linked with general India s health largest services city and primary health care. Training opportunities for various Its Need financial kinds for capital of mental strategic health personnel focus. are A gradually Framework increasing for in various academic 10% of all institutions factory employment in the country and recently, there has been a major initiative intervention disparities 40% of national in the growth income of & tax private prevention. collection psychiatric services to fill a vacuum that the public 40% of mental Foreign health trade services ( 800 M have US$) been slow to address. Per capita Income INR ( US$ 980). 3 times national average Khandelwal th in SK, worldwide Jhingan HP, Ramesh centre S, Gupta RK, Srivastava of commerce VK. India mental health index country profile. Int Rev Psychiatry Feb-May;16(1-2): th in top 10 cities for billionaires

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6 Victoria Terminus now Chhatrapathi Shivaji Terminus, Bombay in 1908 (exactly 100 years back)

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9 When cities are urbanizing Growth Overcrowding Loneliness Insecurity Migration Disconnectedness Poor hygiene Poor nutrition Child labour

10 How life has changed in Mumbai Lost neighborhood Declining social interaction Decreasing support system Increasing paranoia

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15 18 million 21/9/

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18 Urban-rural What does Urbanization comes with?? because migration, population increases slum dwellers, are largely among urban poverty, the urban poor (Bhattacharya, imrovishment, 2002). poverty unemployment, and size housing, (i) All The discrimination, mental disorder (national): urban morbidity rate loneliness, Table I: National prevalence rates for all mental disorders (All India rates/1000 was population). 2 per 1000 Rural Urban Combined Median higher stigma, than the rural rate loss 3 of social Range (ii) Specific disorders: Table II: National prevalence rates for specific disorders (Rates/ median and range). Not poor the awareness, prevalence but complexity connectivity Median Range & and nature Schizophrenia Affective disorder - depression (psychotic and neurotic) Anxiety homelessness, increasing Neurosis Hysteria Mental Retardation deprivation, suspiciousness, Murali Madhav S.Epidemiological Study of Prevalence of Mental Disorders in India Indian Journal of Community Medicine, (2001) 26, 4 :10-12

19 Complexity of mental health in Mumbai Prevalence Causation of illness Service utilization Clinical settings Stigma Response & outcome

20 Stress Effects of trauma, violence Suicide Psychosomatic illness Child mental health School mental health Elderly

21 How treatments were done in India? Stigma and beliefs drives patients to alternative therapies People often understand mental illness as coming from outside forces 1979 MH is low priority Facilities only in cities Both ECT & Drugs are preferred by patients and doctors 80% patients depend upon non-medical healers.

22 Changes in MH spectrum Ecological influence of metroculture Enhanced mental health challenges Variety of clinical syndromes Changes the way people utilize services Need for change in education and awareness Demands innovative services

23 Changes the way people utilize services 1983 Pattern of psychiatric morbidity in ER of a general Teaching Hospital ( KEM ).2000 Bed Multispecialty referral centre + Basic health care 100 Consecutive referrals from ER Physician Commonest diagnosis was Neurotic disorder now called CMD Majority of psychiatric emergencies reported between 8 PM to 2 AM Non-emergent illness were also perceived as emergency Recommended Psychiatric social worker/crisis worker stationed in ER Shrivastava A, shah L.P. Pattern of Psyhiatric Referrals in Emergency room of a general teaching Hospital, MD Dessertation, University of Mumbai, 1983in

24 Psychiatric referrals determines service development

25 Variety of clinical syndromes

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28 Stress-induced disorders, environment & Psychosomatic illnesses became main focus for research & services 1974

29 Culture can influence biology in Mental disorder. Newer treatments focused on stress-management & psychophysiology found place in mainstream psychiatry. Yoga

30 Suicide behavior is a window to mental health

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32 Outcome in Schizophrenia at 10 Years How Good is Good Outcome Schizophrenia in Long-term in Developing countries. Amresh Shrivastava 1, Meghan Thakar 2, Nilesh Shah 3, Larry Stitt 4 1. Department of Psychiatry University of Western Ontario, 32 Canada. & Director, PRERANA Psychiatric Services & Silver Mind Hospital, Mumbai, India 2. Clinical psychologist. Silver Mind Hospital, Mumbai, India 3. Professor & Head of Psychiatry, LTMG Hospital, Mumbai, India 0 CGIS, N= Criteria N=67 13 Criteria, N= department of Biostatics & Epidemiology, University of Western Ontario, London, Ontario, Canada 55 Outcome

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34 Persistent Psychopathology despite ten year s continuous treatment 21/9/2008 dr.amresh@gmail.com 33

35 Why does schizophrenia show poor outcome in developing Countries as well. Changing culture Treatment response Changing phenomenology: Needs studies Changing families Late intervention Treatment design, Lack of continuity Lack of support system, resource, accessibility Stigma Poor advocacy and awareness 21/9/

36 Suicide Helpline-An urban community experience Amresh Shrivastava M.D.,D.P.M. Varsha S.Dawani D.N.B.,D.P.M, Meghana Thakkar Sunita Iyyer Gopa Sakhel Prerana Psychiatric Services, Mumbai E Mail : minds100@hotmail.com http// &

37 Help lines Provide opportunity to talk: some one to talk to in a society which has growing disconnectedness

38 Exam stress in Mumbai

39 . Usage of Crisis help line Counseling in Mumbai Results No. of clients calling suicide helpline in 5 years. No. of clients visiting the center following the call. No. of clients visiting with suicidal ideation (15.43%) 709 (4.67%)

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41 . Stigma and discrimination in Nature of stigma seen in Schizophrenia Schizophrenia (January 1999) Yes {%} No Personal Schizophrenia Support Mumbai Initiative Amresh Shrivastava Social no Executive Familial Director Mental 81 Health 5 42% Foundation Of India (overseas affiliate: PRERANA Psychiatric Society) Occupational Marital Any other positive 58% Can stigma be effectively removed?

42 Consequences of stigma & discrimination

43 Measures to reduce Stigma

44 What do the experiments, services & research in Mental health of Mumbai indicate 1.Services & systems to provide earliest possible intervention 2. Interventions to address causes & Consequences Increasing psych care SMI CMD PSYCHOSOMATIC/HE ALTH PSYCHOLOGY PSYCHOSOCIAL ISSUES SOCIAL ISSUES/ SOCIAL CARE PSYCH CARE GEN.HOSP. CARE SOCIAL CARE

45 Maximize Intervention opportunities: Psychiatric illness presenting as medical illness and Co morbidity General medicine Organ transplant Ob & Gynaec Clinical psychiatry General surgery Paediatrics Trauma Neurology

46 GHPU programs ER C-L Child & adolescent Neuropsychology Clinical Psychology Behavioral Psychology Movement disorders Organic mental disorder & neuropsychiatry Perinatal psychiatry Addictions Trauma Suicide prevention Psychophysiological therapies

47 Develop a model for services which is feasible, accessible, affordable & effective EI Home Primary Care Social Agency General Secondary/tertiary Hospital Mental health services Better outcome Minimum stigma Easy accessibility Minimum disability Opportunity for dealing with comorbidity Integrated family system Living in the community

48 Need for Comprehensive, innovative, new experiments Ambition Growth Loneliness Over-work Education psychiatric No recreation. input in Long-travel Medicine time Focus on Lifestyle Stress Addiction Social care Life-style Medical care Health psychology De-stigmatize. Psychology- Psychiatry

49 In United Nations Assembly, 1970 Its people its problem We need to develop services where people live, where problems arise