Mental health care should be integrated into primary health care

Dear Editor,

The Caribbean Voice notes that a recent editorial on mental health in a local newspaper was significant for what it omitted as much as what was included. So we offer the following:

The World Health Organization has long stressed the need for mental health care to be decentralized and integrated into primary health care with the necessary tasks carried out, as far as possible, by general healthcare workers rather than by specialists in mental health. This is especially critical in developing nations like Guyana where mental health specialists are in very short supply, but the need for the delivery of mental health care is acute. According to the WHO, “By making health care workers sensitive to the presence of mental health problems and by equipping them with skills to deal with those problems, much wastage of efforts in general health care can be avoided and health care can be made more effective. Furthermore, “research has shown that emotional and psychological distress may be an early manifestation of physical disease processes, or may itself cause such diseases (the mind/body connection).” Thus, “an important concept in primary health care is that health activities should develop horizontally to involve other sectors working within the community…intersectoral collaboration, involving governmental and non-governmental organizations is important in all areas of health.”

In fact this approach has been highly successful in Sri Lanka and Zimbabwe in particular, among many other nations. In Zimbabwe lay health workers are screening for common mental disorders, including depression and anxiety, in primary care. For those who screen positive, a lay health worker delivers problem-solving therapy with education and support. Those who received the intervention improve and still look better at 6 months compared to usual outcomes.  As well, local community members without formal mental health education can be trained to deliver basic psychotherapy services as is happening in Uganda. One of the first randomized controlled trials for mental health in low and middle income countries was a landmark study of group interpersonal therapy in war-affected Uganda. The intervention led to large and significant reductions in depression for participants.  Given its success, the World Health Organization has made the intervention manual available for widespread dissemination and use in countries around the world.

Incidentally also Chile includes depression treatment in their national insurance plan.  An innovative study in Chile demonstrated that stepped-care for depression in primary care works better than treatment as usual. The intervention, led by non-medical health workers, includes psycho-education, regular follow-up appointments, and medication for individuals with severe depression. The Chilean government has already translated the research into policy. Depression is now a priority health condition, and depression treatment is included in Chile’s national insurance plan. This is certainly something that Guyana needs to consider as a proactive approach to mental health.

Furthermore, The Caribbean Voice is among entities and commentators that have been calling for teachers, police officers, general health care workers, priests, moulvis/imams and pandits as well as social science majors at the University of Guyana to be trained in basic mental health care. In fact, among the attendees at the Launch of our Train the Trainer programme at the Imam Bacchus Library Centre, Affiance, Essequibo on March 25, there are religious leaders, educators, police officers and general health care workers. So it is clear that the interest in and willingness to be trained exist. A survey carried out by Dr Vishnu Bisram, on behalf of The Caribbean Voice in 2016, also indicated that Guyanese in general are quite willing to be trained to help address mental health issues at a community level.

This need for an inclusive, holistic approach to mental health care is imperative, given that, according to a 2008 WHO report on Guyana, “75,000 to 112,500 Guyanese suffer from mental disorders and require some level of mental health care services. Of these, approximately 22,500 to 37,500 would be expected to suffer from severe mental illness. These projections do not include the number of patients with epilepsy and mental retardation (developmentally disabled), which are not surveyed in typical psychiatric epidemiologic studies, but are included in the population serviced by mental health care services in Guyana.”

As well, it has been pointed out in the local media that, “Mental illness is the major contributor to displacement of the children…It explains the growing band of young criminals who seem to have no regard for life or limb.” It was also recently reported that, “Mental health related illnesses account for more morbidity than HIV/AIDS, tuberculosis and malaria combined”.

Also, it is generally accepted that a correlation exists between a nation’s mental health (as a component of overall health) and its economic growth. According to the World Health Organization, the positive impact that health has on growth and poverty reduction occurs through a number of mechanisms, such as a reduction of production losses due to fewer worker illnesses, the increased productivity of adults as a result of better nutrition, lower absenteeism rates and improved learning among school children. This relationship also allows for the use of resources that had been totally or partially inaccessible due to illnesses. Finally, it allows for an alternative use of financial resources that might normally be destined for the treatment of ill health.

Given these realities, it is so important that the collaborative approach to mental health care be regularized across Guyana instead of being applied in a piecemeal, random manner. For example, there is one social and welfare office located at Anna Regina in Region Two, manned by three probation officers and one child protection officer. Additionally, that region also has an advocacy centre which offers forensic interviews, crisis intervention, counselling, trauma focused therapy, parenting sessions, child and family advocacy, referrals (medical examination), social services, case review, tracking, and education and prevention – teenage pregnancy, gender based violence. Why not have both centres offer the full range of combined services as well as services related to other mental health issues such as suicide, alcoholism, rape and incest, drug use and so on? And why not expand the child advocacy centres in Regions Two, Three, Four and Five to include this entire set of services as well? Already these centres bring together, in one place, professionals involved in the investigation and treatment of suspected child abuse cases as well as those who provide support to victims, witnesses and their families, so some of the required staff would already be in place for the additional services.

As well, where possible, buildings owned by NGOs can be used to set up such similar centres. For example the New Jersey Arya Samaj Humanitarian Mission’s Port Mourant Centre is available according to Pandit Suresh Sugrim. And The Caribbean Voice is aware that other such buildings may also be available for this purpose and can help to source them. This level of collaboration would save capital expenses and maximize resource deployment and utilization, while ensuring the delivery of quality mental health care, especially when operating in tandem with a decentralized and integrated primary health care system. Additionally, it can be the basis on which every region can have at least two such offices as probably a short to midterm plan.

Simultaneously, while the government must be commended for its intention to undertake minor repairs to the National Psychiatric Hospital, it is quite disappointing that much needed rehabilitation will not commence any time soon. This, in spite of the fact that the Region Six Health Committee Chairman, Haseef Yusuf, has disclosed that the condition of the institution is inhumane and it is equipped with supplies of poor and sub-standard quality; an inoperable canteen; an acute shortage of basic items in the kitchen; leaky roofs; no fans in the ward; shortage of beds; dysfunctional washrooms; and a deplorable laundry facility, including shortage of clothes-lines. Additionally, there are issues such as a huge, unfenced gas tank next to the kitchen, lengthy delays in processing purchase orders, and the constant flooding of the compounds, among others.

Alarmingly too, the myth that dealing with counselling and the psych ward or the psychiatric institution means someone is ‘mad’, holds tremendous sway in Guyana and that may be why transparent and obvious warning signs are ignored by caregivers and loved ones. Far too often, after a suicide, we hear or read that so and so had talked about wanting to take his or her life but those around him/her thought he/she was joking and/or did not take that person seriously. Thus TCV strongly urges the Ministry of Health to embark on a sustained education campaign to combat this myth. As well, we urge the Ministry of Health to make sure that mental health professionals are available 24/7 at public hospitals, especially where there are psych wards, and that mechanisms, including signage providing directions, be put in place to make access to such wards easy and quick for anyone seeking help, given that delays and consequential frustration/anger can lead to loss of lives.

Yours faithfully,

Annan Boodram

Caribbean Voice

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