Westernization versus indigenization in the context of global mental health: training and services in Ethiopia – University of Gondar in focus

Abstract

Ethiopia is one of the ancient countries inhabited by well over a hundred million people of diverse cultures and languages. Such diversity requires mental health training and services to be tailored to those diverse needs of the people. Consequently, there are important implications for mental health training and services. The gap in mental health knowledge is attributed perhaps to a lack of trained professionals in relevant fields in awareness and understanding of advances made in global mental health (GMH) and blended with indigenous wisdom. Training is Western orientated and lacks integration with local culture and wisdom. The study intends to explore the extent to which mental health training and services have customized Western mental health traditions into the indigenous knowledge, skills, and practices of Ethiopia. The study employed an exploratory design, and data was collected through focus group discussions (FGD) from a total of eighteen faculty, alumni, and practitioners working at the University of Gondar. Data was collected using semi-structured interview guides from the different groups. Mental health knowledge in our training and service providers is perceived to be culture specific rather than universal. However, it is highly influenced by the Western culture diffused through various media. This has resulted in faculty and practitioners being dependent on Western resources without adapting them into indigenous wisdom and cultures. This has prevented them from exploring and practicing what is available in our specific cultures and traditions, such as books written by the religious scholars and traditional healers.     

Mental health services in the Solomon Islands

The Solomon Islands comprise an archipelago of nearly 1,000 islands and coral atolls and have an estimated population of 549,574 people. Formal mental health services date back to 1950 when an asylum was established. Since then the process of mental health service development has been largely one of incremental change, with a major boost to community services in the last two decades. During the 1990s a mental health outpatient clinic was established in Honiara, together with attempts to recruit nursing staff as psychiatric coordinators in the provinces. In 1996, the Ministry commenced sending registered nurses for psychiatric training in Papua New Guinea. By 2010, there were 13 psychiatric nurses and one psychiatrist, with a second psychiatrist in training. A National Mental Health Policy was drafted in 2009 but is yet to be endorsed by Cabinet. A significant portion of the population still turns to traditional healers or church leaders for purposes of healing, seeking help from Western medicine only after all other alternatives in the community have been exhausted. There is still a long way to go before mental health services are available, affordable and accessible to the whole population, including people living in geographically remote areas. Realization of this vision requires increased resourcing for mental health services; improved communication and collaboration between the centrally‐based, national mental health services and the provincial health services; and closer, ongoing relationships between all stakeholders and partners, both locally and internationally.     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

Meeting employees where they are: The rise of workplace mental health services

Many key organizations have called attention to the importance of addressing workplace mental health. In this Open Forum piece, two academic psychiatrists present recommendations from their experiences providing psychiatric care in a corporate setting. A literature review using the PubMed database was performed. The search found no peer review articles that discuss the topic of employer-sponsored mental health services outside of traditional employee assistant programs. Based on first-hand experience, the authors of this forum describe key issues and best practices to ensure employer-sponsored mental health services are a successful treatment for patients and mental health providers alike.     

What should non‐US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.     

Mental health services and young people with intellectual disability: is it time to do better?

Background There is evidence that the mental health needs of children with disabilities are inadequate. The aim of the present study was to determine the extent of specialist health service use during adolescence by a group of individuals with intellectual disability (ID) and mental health problems. Method The study population consisted of 80 young people with ID, who were examined in childhood and adolescence for psychiatric and behaviour disorder. These young people were interviewed again in early adult life for the presence of psychiatric and behaviour disorder. Evaluation questionnaires were used during the follow‐up study to assess service use from adolescence. Results The key finding was that the great majority (64%) of subjects with persistent challenging behaviour from childhood into adult life and those with an established childhood psychiatric disorder received no specialist mental health care. Conclusions The development of mental health services for this vulnerable group with complex psychiatric and behaviour disorders has been poor for a number of reasons, including lack of recognition at the primary care level and insufficient numbers of trained professionals within specialist services.     

Pakistan mental health country profile

The Republic of Pakistan is a South East Asian country with a population of over 140.7 million. Its population is fast growing and the majority (70%) live in rural areas with a feudal or tribal value system. The economy is dependent on agriculture and 35% of the population live below the poverty line. Islam is the main religion and ‘mental illnesses’ are stigmatized and widely perceived to have supernatural causes. The traditional healers along with psychiatric services are the main mental health service providers. The number of trained mental health professionals is small as compared to the population demands and specialist services are virtually non-existent. Lack of data on prevalence of various mental illnesses and monitory constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the ‘Community Mental Health Programme’ and ‘Schools Mental Health Programme’ have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a ‘National Mental Health Policy’ and ‘Mental Health Act’ in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery and safeguarding the rights of mentally ill people. A favourable political will and the help of international institutions like the World Health Organization are required to achieve these aims.     

Pakistan mental health country profile

The Republic of Pakistan is a South East Asian country with a population of over 140.7 million. Its population is fast growing and the majority (70%) live in rural areas with a feudal or tribal value system. The economy is dependent on agriculture and 35% of the population live below the poverty line. Islam is the main religion and 'mental illnesses' are stigmatized and widely perceived to have supernatural causes. The traditional healers along with psychiatric services are the main mental health service providers. The number of trained mental health professionals is small as compared to the population demands and specialist services are virtually non-existent. Lack of data on prevalence of various mental illnesses and monitory constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the 'Community Mental Health Programme' and 'Schools Mental Health Programme' have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a 'National Mental Health Policy' and 'Mental Health Act' in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery and safeguarding the rights of mentally ill people. A favourable political will and the help of international institutions like the World Health Organization are required to achieve these aims.     

Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan

Objectives The aims of the present study were to examine health characteristics and healthcare utilization in relation to people with intellectual disability (ID) having psychiatric disorders in Taiwan. Methods A cross-sectional study was employed; study subjects were recruited from the National Disability Registration Database. Taiwan, stratified by administrative geographical area for the study. Statistical analysis of 1026 carers for people with ID was made to examine the health status and healthcare utilization of individuals with ID having psychiatric disorders. Results Approximately 12.1% of people with ID had psychiatric disorders. These individuals were more likely to be poorer in health condition and consuming more medical services (in the outpatient, inpatient and emergency care areas), than those individuals without psychiatric disorders. These individuals with psychiatric disorders were also taking medicines regularly at a far greater percentage than did those without psychiatric disorders. Conclusions Given the high prevalence of psychiatric disorders among individuals with ID, the healthcare system should take further steps to develop an appropriate health status monitoring system and community-based and easily accessible mental health services for them.     

Mental health care in Fiji

Fiji is one of the largest island nations in the South Pacific. It is multicultural and has an economy based on tourism and sugar production. Like many developing countries Fiji faces the double burden of communicable and non‐communicable diseases as well as a third emerging burden of accidents and injuries. Fiji lacks data on the national prevalence and burden of disease of mental disorders. Using World Health Organization estimates there is over a 90% treatment gap for mental disorders. Contributing to this treatment gap are the misconceptions and stigma surrounding mental illness leading people to seek alternative treatments. Fiji's mental health services were established in 1884, comprising a single ward to care for mentally ill expatriates. Services have since expanded to include a 136‐bed inpatient facility (St. Giles Hospital), which provides outpatient, psychosocial rehabilitative and community psychiatric services. Mental health services remain centralized at St. Giles, with follow‐up in the community supported by a well‐established public health hierarchy and by medical personnel at the divisional hospitals. St. Giles is also responsible for conducting mental health awareness and training for health workers and the public and provides input at a national level for mental health policy, plans and legislation. Psychiatric training is available at the undergraduate nursing and medical levels. The Fiji School of Medicine is in the process of developing a postgraduate psychiatric program. With its limited resources Fiji needs to integrate mental health services into the general and public health systems to achieve a comprehensive and integrated mental health system.     

成都市精神卫生服务资源五年发展分析

目的 对比分析2012年及2017年成都市精神卫生资源,了解成都市精神卫生医疗机构建设发展的现状和问题,为制定下一步精神卫生体系、人力和服务发展规划提供参考。 方法 于2018年1月-3月,采用成都市精神卫生资源调查表对2017年成都市行政区域内精神卫生医疗机构的床位、人力资源、业务开展情况等进行调查。 结果 2017年成都市实有开设精神科并开展业务的医疗机构共60家,编制床位数4 503张,床位密度3.14张/万人,分别较2012年增长了43.73%、17.60%;实有床位数9 647张,床位密度为6.65张/万人,分别较2012年增长了82.09%、47.12%。2017年成都市精神卫生医疗机构有精神科医生677人（4.71人/每10万人）、精神科护士1 511人（10.53人/每10万人）,分别较2012年增长了2.17%、5.94%。2017年成都市精神科共接收门诊患者792 874人次,住院患者43 981人次,分别较2012年增长了76.09%、78.08%。平均每名精神科医生年负担门诊患者1 171人次、住院患者65人次,分别较2012年增长了40.75%、41.30%。 结论 与2012年相比,2017年成都市的精神卫生医疗机构数量急增;精神科开放床位数量已可以满足中等需求,精神科医疗服务量明显增加,但精神科医护人员并无明显增长。     

THE PROBLEM OF DEMENTIA IN AUSTRALIAN ABORIGINAL AND TORRES STRAIT ISLANDER COMMUNITIES: AN OVERVIEW

The concept of dementia in old age in Australian Aboriginal and Torres Strait Islander communities is intrinsically paradoxical. Firstly, few indigenous people reach old age. Secondly, from some indigenous points of view, dementia is either not recognized as a condition or as a problem, or, in the case of the more disruptive manifestations of cognitive impairment, is perceived as ‘madness’. Moreover, in the wider context of profound political, social and economic inequality experienced by most indigenous people, the western medical category of dementia may appear to be of relatively minor importance. However, government initiatives in aged care generally and dementia care in particular which are designed to address the ageing of the Australian population as a whole also include the nation's older indigenous people. This article—based on a review of published work, supplemented by discussions with indigenous and non-indigenous individuals involved in indigenous aged care and mental health—examines some of the issues surrounding cognitive decline in old age for Aborigines and Torres Strait Islanders. More specifically, it looks at the problems involved in assessing and diagnosing cognitive decline and dementia, especially among people who follow more traditional ways of life, and in providing services to sufferers and their carers. In doing so, it considers some of the relative meanings of ‘old age’, ‘abnormal old age’, ‘mental disorder’, ‘sickness’ and ‘dementia’. © 1997 John Wiley & Sons, Ltd.     

The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case‐register study

ObjectivesThe general practitioners'' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross‐boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions.MethodsWe compared a local and a centralized model of mental health care. Service utilization over a 5‐year period was studied.ResultsFindings suggest that a local institution‐based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all.ConclusionLocal inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network‐oriented treatment philosophy.     

Introduction: research at the interface of medicine and psychiatry

Linkages between psychiatry and other medical specialties have become increasingly evident over the past decade. Reinstatement of the medical internship for psychiatric trainees, expansion of psychiatric liaison services, growth of general hospital psychiatric units, determination of the extensive role served by nonpsychiatric physicians in providing mental health care, and research evidence of the economic benefits of incorporating mental health services in general health settings all have served to break down artificial boundaries between mental health and general health concerns. The psychiatric consultation-liaison service initiated in 1981 by the NIMH at the NIH Clinical Center in Bethesda has afforded opportunity for numerous collaborative research projects with clinical investigators of various categorical disease programs. In addition to offering new etiological insights into psychiatric and general medical illnesses, the work described in this symposium promises to move clinical practice closer toward the Engel model of biopsychosocial medicine.     

Norms for mental health services in South Africa

Background In the aftermath of apartheid, South Africa has inherited a fragmented, under-resourced and inequitable public sector mental health service. Attempts are being made to reform mental health services, in keeping with new health policy, which proposes the downscaling of psychiatric institutions and the development of community-based services. This study set out to develop a set of service norms for the care of people with severe psychiatric conditions (SPC) in South Africa, to assist the implementation of the new policy. Methods A national situation analysis of current public sector mental health services was conducted. A model was developed for estimating the mental health service resource needs of people with SPC. Following consultation with provincial stakeholders, a set of service norms were developed taking into account national indicators from the situation analysis (as a baseline level) and proposals of the model (as a target level). Results The study recommends an increase in the number of acute psychiatric beds in general hospitals; development of community-based residential care; redistribution of staff from hospital to community services, particularly in rural areas; and the development of information systems to monitor the transitions to community-based care. Conclusions The norms proposals presented in this study express mental health service needs in terms of quantifiable service resource and utilisation levels. In doing so, the study attempts to make explicit the assumptions and values on which planning is based.     

Bringing changes to Asian mental health

Asian Psychiatry like the Asian continent has a very diverse and complex history of development that has led to enormous gaps in level of advancement. The very affluent countries have very well developed medical services; but most Asian psychiatric services, training and state of advancement leaves a lot to be desired. The marginalization of psychiatric services and mental health in health care in Asia has led to very irregular development of basic services for the mentally ill. Concepts such as counseling, psychotherapy, rehabilitation are far behind in practice compared to medication in Asia. There are also poor human and material resources for the 21st century's practice of psychiatry in the community or hospital settings. This paper discusses some of these problems and suggests some alternative ways to overcome them.     

U.S. Cambodian refugees' use of complementary and alternative medicine for mental health problems

OBJECTIVE: This study examined U.S. Cambodian refugees' use of complementary and alternative medicine and Western sources of care for psychiatric problems. Analyses assessed the extent to which complementary and alternative medicine was used in the absence of Western mental health treatment and whether use of complementary and alternative medicine was associated with decreased use of Western services. METHODS: Face-to-face interviews were conducted with a representative sample drawn from the largest Cambodian refugee community in the United States. The sample included 339 persons who met criteria in the past 12 months for posttraumatic stress disorder, major depression, or alcohol use disorder. Respondents described contact with complementary and alternative medicine and Western service providers for psychological problems in the preceding 12 months. Bivariate and multivariate logistic regression analyses were used. RESULTS: Seventy-two percent of the sample sought Western mental health services, and 34% relied on complementary and alternative medicine in the past year. Seeking complementary and alternative medicine was strongly and positively associated with seeking Western services, contrary to the hypothesis that use of complementary and alternative medicine inhibits seeking Western mental health treatment. CONCLUSIONS: Only a small percentage of Cambodian refugees used complementary and alternative medicine exclusively (5%), and utilization of complementary and alternative medicine was positively associated with seeking Western sources of care for mental health problems. Complementary and alternative medicine use does not appear to be a significant barrier to mental health treatment in this population, contrary to the Surgeon General's conclusion that Asian Americans' use of alternative resources may inhibit their utilization of Western mental health care.     

Mental health care in Germany

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17–18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.     

Some recommendations to assess depression in Chinese people in Australasia

OBJECTIVE: To provide some general recommendations for psychiatric assessment of depression among Chinese patients within a predominately Western society. METHOD: A literature review is provided with interpretive comments. RESULTS: The prevalence of depression reported in community studies undertaken in Chinese communities is very low. To what extent Chinese people experience and seek help for depression, and how they report depressive symptoms have long been topics of some importance. The impact of acculturation as well as concepts and interpretations of illness in traditional Chinese medicine are discussed. Awareness of sensitive issues and practices within the Chinese culture will facilitate communication between medical professionals and patients, resulting in more accurate identification and diagnosis of depressive disorders. CONCLUSION: Direct but culturally sensitive and empathic questioning of psychological symptoms is needed to unveil patients' explanatory models, as most Chinese initially nominate only somatic symptoms to health practitioners. Successfully treated patients can promote earlier and wider utilization of mental health services to other Chinese people.