Mental health and the urban poor
According to the World Health Organization (WHO), more than 450 million people worldwide suffer from mental disorders. These illnesses are particularly common, and are especially destructive among the poor, those with chronic health conditions, minority groups, and communities exposed to conflict and disasters. Moreover, almost 75 percent of the Global South's mentally ill remain untreated.
In recognition of World Mental Health Day (October 10th), read on to find out what is being done to resolve this issue in Bangalore, Cape Town, Accra, Bogotá, and São Paulo, and then join the discussion in the comments below.
2013 marks a new direction in India's mental health care
Carlin Carr, Bangalore Community Manager
This year marks an important turning point in mental health care in India. The landmark Mental Healthcare Bill 2013 has been introduced and is under review to be passed as law. The new bill decriminalizes suicide and protects the rights of the mentally ill from inhumane treatment. It also "aims to ensure that proper medical treatment is provided to mentally ill patients" and "seeks to regulate the public and private mental health sectors and establish a mental health system integrated into all levels of general health care," says an article in the Indian Express. Gaps in care have been filled by NGOs that not only work to provide treatment but to increase public awareness around issues of mental illness that have added to stigmatization of these patients.
In Bangalore, the Richmond Fellowship Society has been operating services since 1986, though it is part of the world's largest global charity network focusing on mental illness. The organization says that over 10 million people in India suffer from schizophrenia, "while the figure for those suffering bipolar affective disorder, depression and anxiety disorders stands at a colossal 150 million." While the numbers cut across socio-economic status, the poor, especially the homeless, are inordinately affected. Experts estimate that by 2020, mental health disorders will be the second leading cause of disability and death. The World Health Organization (WHO) has created a comprehensive Mental Health Action Plan 2013-2020 to increase awareness and services.
The Fellowship focuses on a Therapeutic Community approach which emphasizes using skill and compassion to enable the mentally ill to rebuild their lives with dignity. Outreach services include halfway homes, long-term stays, and public awareness campaigns as well as development, research and advocacy on related issues. Importantly, the Richmond Fellowship has also launched a training program for care providers to improve services on the ground. The Fellowship runs Asia's only M.S. degree in psychosocial rehabilitation and counseling "to address the paucity of trained manpower" in the field. The degree is affiliated with the Rajiv Gandhi University of Health Sciences in Bangalore.
While organizations such as the Richmond Fellowship are working to fill the gap in services to the mentally ill, the 2013 bill marks an important step in integrating effective steps for mental illness care into community health centers. The biggest challenge will be training care providers to be aware of symptoms and to create a chain of intervention points so that more serious cases can be referred outside. After all, NGOs such as the Richmond Fellowship are few and far between across the country, and a tiered approach — as the Fellowship uses, depending on the length and seriousness of care needed — is essential in providing long-term rehabilitation for healthier and happier people.
Photo credit: Huw Thomas
Bridging boundaries and bisecting binaries: New openings for drug rehab and drug-related mental disorder at the Sultan Bahu Drug Rehab Centre
Tariq Toffa, Cape Town Community Manager
In South Africa, many factors including disease, poverty, abuse, violence, and changing social structures contribute to the high occurrence of mental health issues (over 16.5 percent of adults). Another contributing factor is substance abuse, as South Africa is one of the top ten narcotics and alcohol abusers in the world (15 percent of the population has a drug problem). In many ways a legacy of apartheid's disenfranchisement and dislocation, substance abuse in the Western Cape is higher than any other South African province, particularly in Cape Town's non-white urban hinterlands known as the Cape Flats; and has been linked to cognitive deficits, mental health problems, aggression, depression, anxiety, sexual risk behavior, crime and violence.
Within such harsh conditions, one notable project on the Cape Flats is the Sultan Bahu Drug Rehab Centre in Mitchell's Plain, which has achieved the highest drug addiction recovery rate (87 percent) and retention rate (83 percent) in the entire province (its three drug rehab centres in the Western Cape also form some of the only internationally accredited facilities of their kind on the continent). This is all the more remarkable given that most rehab centers have a success rate of less than 3 percent.
The success of the facility, in part, lies in attending to both the complex needs of the individual (based on 'cognitive behavioral' therapy constructs) as well as to the affected families at all stages of the rehab process, and in appropriateness to context, culture, and religion. Thus, within a generally poor community, the services are made physically and financially accessible; and both the two primary religious affiliations of Mitchell's Plain (Christian and Muslim) are accommodated, by providing for an imam and a priest to serve the interests of both Christian and Muslim patients — a pluralism that startled parliamentarians in a recent visit to the facility. Practitioners at the Centre are also enrolled for post-graduate studies in addictions care — a first in South Africa.
The Rehab Centre is a social outreach project of the Sultan Bahu Centre (SBC), a faith-based NPO which provides a wide range of social projects throughout the country, and its achievements have not gone unnoticed by Provincial Government. To improve service delivery to the poor, the government has increasingly recognized the need for partnerships with other stakeholders, such as faith-based organisations (FBOs) or NGOs. Thus, the Department of Social Development in the Western Cape recently announced that the Rehab Centre would be awarded the first pilot outpatient opiate replacement program in the country, which allows patients "a fine line of functioning" not based on intoxication and withdrawal. With this the SBC will form one of the beneficiaries of the R87 million (US$ 8.7 million) pledged to fight the province's drug scourge. Moreover, National Government has requested that it provide rehab programs throughout the country.
While in some respects the SBC example may be a hard one to emulate (its open door policy, free treatment to the unemployed, etc.); yet in providing a complex synthesis of services appropriate and sensitized to multiple contexts (physical, psychological, social, economic, religious), the SBC appears to be charting a new and multifaceted model for social service provision in a 'new' democratic South Africa. As an FBO that now extends the most current modern rehab treatment in South Africa, it also positions a middle path to the taboo issue of mental disorder in South Africa, often viewed solely as a spiritual problem to be solved by traditional healers or church alone. In bisecting such modern-traditional binaries, and in bridging governmental and non-governmental resources, new openings for treatment of drug abuse and related mental disorder in the Western Cape are emerging.
Fighting mental health stigmatization in Accra
Felix Nyamedor, Accra City Community Manager
The issue of mental health stigmatization in Accra is of great concern to individuals, families, civil society groups, and many religious bodies. There is stigmatization about the condition, stigmatization concerning the persons with the condition, and stigma is also attached to the people who work in the area of mental illness. These concerns affect the resources and quality of life of the mentally challenged. In addition, its economic and social impact on the person, the family, and the workers are enormous.
In Accra, mental health patients are confined to specific institutions such as Pantang Hospital and Accra Psychiatric Hospital, among others. It is common to see mental health patients with tattered clothes, looking poor, dirty, hungry, neglected, isolated, and some are sometimes even lynched.
The stigma associated with mental health issues stresses some family members, who then fail to associate with such patients even after treatment, making their integration into their families very problematic. Some relatives ultimately abandon their family member in state institutions in order to limit the negative perceptions others will have towards them.
Ghana's Mental Health Bill, which seeks to increase the rights of the mentally challenged, was passed in 2012. Unfortunately, the provisions made in the Bill have not been fully implemented. Plans are in place at the Ministry of Health to form a permanent board to address issues concerning mental illness stigmatization in the country. In the absence of government action, the mental health advocacy group For All Africa Foundation (FAAF) is pushing to change societal perceptions of persons with mental disorders through education. FAAF's work includes a variety of different approaches aimed at changing the major structural and attitudinal barriers to achieving positive mental health outcomes in Accra. In addition, it critiques actions of Ghana's government and encourages policy makers to improve services and treatment of the mentally ill. The Accra Psychiatric Hospital, spearheaded by Dr. Akwasi Osei, has embarked on an integration process of the inmates back to their families. Working together with the Kintampo Health Research Institute, they have also introduced helpers into the communities to educate residents about mental health stigmatization. This process has helped to lessen the level of stigmatization in Accra, and families have been increasingly encouraged to accept and care for patients.
The Mental Health Society of Ghana is an organization that works to educate and advocate for the needs of people with mental health concerns in Ghana. It aims to represent the mentally ill in a unified organization, to protect their rights and wellbeing, and to reduce society's stigmatization through advocacy projects.
Support for the eradication of mental illness stigmatization through proper education and institutional capacity-building for mental health institutions can go a long way to change the lives of the mentally ill.
Prevención y tratamiento de los problemas de salud mental de los habitantes de la calle
Jorge Bela, Gestor Comunitario de Bogotá
La situación de los habitantes de la calle se considera como uno de los problemas más complicados de resolver en las grandes ciudades latinoamericanas. Según un censo elaborado en 2011 por la Secretaría de Integración Social (SIS), en Bogotá se identificaron 8.385 habitantes de calle, un 86.9 por ciento de los cuales son hombres, y el 8.4 por ciento son menores de 18 años. El 17.9 por ciento son jóvenes entre 19 y 25 años, y el 38.9 por ciento son adultos entre 26 y 40 , quedando un 32 por ciento, de adultos mayores. Otro dato interesante de este sondeo es que el 58 por ciento se dedica a la recolección de objetos de reciclaje, el 34 por ciento a mendigar, el 28 por ciento a servicios no cualificados y el 10.7 por ciento a delinquir. Aunque es posible que estas cifras no recojan el número total de habitantes de la calle, quizá en una proporción considerable, sí que son reveladores en su estructura demográfica y en sus ocupaciones.
Existe una vinculación estrecha entre trastornos mentales, consumo de estupefacientes y los habitantes de la calle. Según el estudio de la SIS, en Bogotá el 68.1 por ciento consumen bazuco y el 80.5 por ciento de ellos lo hace todos los días. Además, el 64.6 por ciento consumen marihuana, el 63 por ciento de estos de forma diaria. Aunque la Secretaría de Salud de Bogotá reduce la incidencia de este tipo de problemas al 30 por ciento, y es muy difícil establecer una cifra exacta, es sin duda demasiado elevada. La falta de acceso a los sistemas de prevención y tratamiento agrava aún más los problemas de los habitantes de la calle, que se ven forzados a acudir a las salas de emergencia en momentos de crisis, poniendo una fuerte sobrecarga en estas salas, que en todo caso no están preparadas para solventar los problemas de fondo de este colectivo.
Por todo ello cabe destacar un programa lanzado por la Secretaría de Salud de Bogotá, que busca crear 130 camas adicionales, repartidas en cuatro centros en distintos puntos de la ciudad, y destinadas a atender a personas con problemas de salud mental y derivados del consumo de estupefacientes, en especial a los habitantes de la calle. El plan prevé también la creación de un nuevo centro de salud dedicado específicamente a los jóvenes con estos problemas, entre los que se ha detectado un alarmante aumento del nivel de suicidios. La Alcaldía busca con este reforzamiento especializado combatir y prevenir problemas de salud mental, al tiempo que se contribuye a liberar la presión a la que, por diferentes motivos, están sujetas las salas de emergencia de Bogotá.
Hasta ahora se han abierto 30 camas, de las 50 previstas para este centro, en la clínica Fray Bartolomé de las Casas; 12 camas en el Hospital San Blas; y una unidad móvil destinada a jóvenes y adolescentes. Otras iniciativas están en marcha. Con las primeras camas abiertas en 2013, es aún muy temprano para evaluar el resultado de este proyecto, y si en efecto se consigue llegar a los habitantes de la calle. En todo caso, es una orientación adecuada el dedicar recursos para la prevención y el tratamiento de los problemas de salud mental de los habitantes de la calle, en vez de dejar que estos se acaben por resolver en las salas de emergencia, con un coste superior y una efectividad mucho menor.
Preventing and treating mental health issues in the homeless population
Jorge Bela, Bogotá Community Manager
Homelessness is one of the most complex and difficult to address problems in all large Latin American cities. A census led in 2011 by the Secretaría de Integración Social (SIS), found 8,385 homeless people in Bogotá. Of those, 86 percent were male. 8.4 percent were under 18 years old, 17.9 percent between 19 and 25, 38 percent between 26 and 40, and 32 percent were older than 40. As for their occupation, 58 percent were garbage recyclers, 34 percent begged, and 10.7 percent stole and robbed as a form of living. Although it is almost certain that this survey did not register much of the homeless population, it is still quite revealing regarding the population's demographics and occupation.
There is a close link between mental disease, drug abuse, chronic illness. and homelessness. The SIS study found that 68.1 percent of homeless in Bogotá use bazuco (similar to crack). Of those, 80.5 percent use it on a daily basis. Furthermore, 64.6 percent smoke marijuana, 63 percent of those on a daily basis. It is very difficult to establish a precise rate of drug abuse (the Secretaría de la Salud de Bogotá estimate sets it at 30 percent), but it is dramatically higher than in the general population, and constitutes a major problem for the homeless population. Lack of access to treatment and prevention aggravates the situation, as the homeless often get treated only in emergency rooms during acute crises. This is far from desirable, as emergency rooms in Bogotá are operating beyond full capacity, and are not prepared to treat the underlying problems, only to mitigate the effects of the crisis.
In order to tackle these problems the Secretaría de Salud de Bogotá has launched a program to create 130 new hospital beds, distributed in four health centers around the city. These beds are specifically targeted to treat mental health and drug abuse patients, specifically the homeless. The program also includes the creation of a new health center reserved for treatment of young patients, as suicide rates within this population have risen abruptly in the past few years. This program, launched by the City Government in 2012, seeks to better treat and prevent mental health problems, while at the same time improving the overcrowding in the emergency rooms.
To date, 42 hospital beds (30 at the Fray Bartolomé de las Casas clinic, and 12 at the Hospital de San Blas) have been put into place, as well as a mobile unit to treat young patients. It is still too soon to evaluate this program (the first beds were only put into service in 2013). Also, the homeless are often difficult to convince to seek treatment, so it will be necessary to monitor whether they use the new facilities. Nevertheless, it is good policy to use resources to treat and prevent mental health problems in the homeless population, instead of letting these problems end up in emergency rooms, where the costs are much higher and the treatment less apt.
Menos hospitalizações e mais atenção nos serviços de reintegração social
Catalina Gomez, Coordenadora da Rede em São Paulo
Segundo a Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas, três por cento da população brasileira sofre de transtornos mentais severos que precisam cuidados contínuos e nove por cento da população apresenta transtornos leves que precisam de tratamentos eventuais.
Para atender o grande desafio da atenção à saúde mental, o governo brasileiro vem apresentando avanços importantes liderados pelo Ministério da Saúde. No tema regulatório, o ministério aprovou no ano 2001 a Politica Nacional de Saúde Mental que estabelece importantes orientações de política afastando-se das hospitalizações e dando prioridade aos serviços de terapia e reintegração social. Adicionalmente, a legislação orienta que os municípios são as unidades encarregadas de providenciar os serviços de saúde mental no seu território.
Demos uma olhada sobre como funciona a resposta municipal no cuidado da saúde mental numa cidade. São Paulo, por exemplo, é uma das cidades que tem sido líder neste tema; sua resposta à saúde mental é coordenada pela Secretaria Municipal de Saúde. Aquela Secretaria tem adotado uma abordagem integral, compreendendo que a saúde mental faz parte fundamental da saúde em geral; seu diagnostico e tratamento deve estar acompanhado pelos diferentes serviços de saúde. Por exemplo, aqueles pacientes que tenham doenças mentais leves são referidos aos serviços de saúde básica para controle e monitoramento.
Para o tratamento de doenças mais severas, a Secretaria vem implantando os Centros de Atenção Psicossocial, conhecidos como CAPS, os quais são instituições que visam à substituição dos hospitais psiquiátricos focados no isolamento dos pacientes. Os CAPS oferecem serviços gratuitos mais humanos focados no cuidado, no tratamento e na interação social dos pacientes. Cada centro tem equipes conformados por psiquiatras, enfermeiros, psicólogos, terapeutas ocupacionais, auxiliares de enfermagem e monitores.
Atualmente operam vários CAPS distribuídos pela cidade, incluindo 20 CAPS para adultos e mais outros 20 CAPS com foco na atenção de drogas e álcool, uma das doenças que estão preocupando mais às autoridades públicas. Também a cidade tem 13 CAPS para crianças e adolescentes com doenças mentais que precisam de tratamento terapêutico. Estes centros fomentam um trabalho junto com as famílias e tentam evitar ao máximo a internação dos pacientes para evitar seu isolamento.
Embora exista uma necessidade de ampliar estes serviços, a cidade tem avançado com o estabelecimento de serviços adequados. Para complementar estes esforços, a Secretaria Municipal de Saúde organiza atividades para indivíduos com doenças menores com objetivo de promover sua integração social. A Secretaria, conjuntamente com outros órgãos públicos e em parceria com organizações da sociedade civil, organizam caminhadas pela cidade, visitas a museus e atividades comunitárias para que os pacientes consigam interatuar, compartilhar experiências e ainda mais importante, consigam se sentir cidadãos ativos e valorados.
Foto: Secretaria Municipal de Saúde
Less hospitalization, more social reintegration
Catalina Gomez, São Paulo Community Manager
According to Brazil's National Coordination of Mental Health, Alcohol, and Other Drugs, three percent of the country's population suffers from severe mental disorders that require continuous treatment, care, and support, and around nine percent of the population has mild mental disorders that require sporadic treatment.
To address mental health issues, the Brazilian government, through its Ministry of Health, has moved forward with key steps. On the regulatory side, the country approved the 2001 Mental Health Policy, which marked a strategic change of policy from a focus on hospitalization towards a greater emphasis on therapeutic care and social reintegration. Additionally, the legislation emphasizes that although mental health care is a shared responsibility within the various levels of government, municipalities should be the main implementors of care services.
Given that mental health care provision is considered a municipal responsibility, let's take a look at what this implies at the city level — São Paulo has been one of the leading cities in this respect. Its response to mental health care is coordinated by the Municipal Secretariat of Health, which has adopted a comprehensive approach. This means that the city understands mental health as a fundamental part of overall health, and it therefore promotes its diagnosis and treatment in coordination with other health services, and never in isolation. This also means that individuals who present mild and temporary mental illness are referred to the basic health care system.
To address more severe mental illnesses, the Secretariat has put into place Psycho-Social Attention Centers, known as CAPS (Centros de Atenção Psicossocial). These aim to replace the traditional psychiatric hospitals that used to isolate patients with more human interventions focused on care, support, and social interaction. The CAPS conduct proper diagnosis and offer free care and support services to people with different levels of mental illness. Each center has a specialized team assigned composed of psychiatrists, nurses, psychologists, occupational therapists, and social monitors.
Currently, São Paulo has several CAPS operating throughout the city, including 20 CAPS for adults and 20 additional CAPS that focus specifically on treating alcohol and drug abuse, which are some of the most pressing concerns from public authorities nowadays. In addition, there are 13 CAPS for children and adolescents with mental illnesses that require therapeutic treatment. The centers targeted to youth tend to avoid committing children to institutions in order to prevent their isolation from their families and communities. Their work focuses on promoting social integration and family involvement in their treatment.
Although there is an urgent need to expand these services, the Secretariat of Health has certainly moved forward in implementing an adequate service model. To complement these efforts, it organizes free activities targeted to individuals with mild mental illness in order to promote their integration within society and to avoid their exclusion and stigmatization. The Secretariat, along with other government institutions and in partnership with non-governmental organizations working in this field, organizes walks around the city, museum visits, and other social activities to help patients interact with other peers, share experiences, and crucially, feel like active and valuable citizens.
Photo: Secretaria Municipal de Saúde