Improving Mental Health in Crisis Zones: WHO, What, Where, When, and How?

 

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ICCPP27 – 2414439

International Organizations 2 Blog Post

Sam Dye

 

Mental Health has become an increasingly relevant topic in recent years. Public awareness campaigns and increased coverage of the benefits of good mental health are common in our society. The Coronavirus pandemic brought mental health advocacy back into mainstream thought as the mental effects of the pandemic unfolded; the negative effects of lockdown for those in isolation, as well as the mental toll on front line healthcare workers. However even pre-pandemic there has been an increase in people with common mental health problems receiving therapy even back till 2000. The cause behind the increasing number of people seeking treatment is unclear, whether this is due to increased awareness, better diagnostic capabilities or a genuine worsening state of mental health is an area I’d like to gain a better understanding of. The task to meet the increased demand for mental health care is one that lower-middle income countries (LMICs) have long struggled with. Known as the treatment gap, the disparity in the number of people suffering from mental illness and those that are able to receive treatment, is particularly evident in LMICs where between 76-85% of people living with acute mental illnesses do not receive treatment. With western countries now facing similar issues, there is potential for new research into improved mental health care programs with aspects applicable to LMICs.

Founded in 1948 as one of the first United Nations (UN) agencies, the World Health Organization (WHO) implement infrastructure and promote practices to better the health of people across all UN member states. The WHO seeks to improve health in a comprehensive manner by always addressing health in all aspects; improving and maintaining both physical and mental health. The WHO plays a vital role in assisting people worldwide who otherwise may not receive proper diagnosis, support, and treatment. By fulfilling some of the roles traditionally held by governments such as the delivery of aid, vaccine distribution, and other health initiatives, the WHO serves to offer support to countries that are unable to provide these services for their populations. The geographic areas where the WHO operates are, in many cases, dealing with combinations of disruptive conditions such as conflict, disease outbreak and poverty. In these areas suffering from crises, already overburdened healthcare services are often stretched thin, prioritising communicable diseases or the effects of conflict over mental illnesses. Whilst the immediate effects of these may take precedent, the link between ones mental and physical health is well documented. As such, dedicated mental health programs and services are critical to improving and maintaining public health.

Improving mental health in a crisis zone is a difficult task. Many of the factors that induce a humanitarian crisis such as poverty, famine and conflict are also very likely to take a toll on a population’s mental wellbeing. At the same time, these same events present barriers to the delivery of effective treatment. This catch-22 situation worsens the previously mentioned treatment gap and is an issue which the WHO has attempted to address with its Mental Health Gap Action Program (mhGAP). The mhGAP seeks to help governments in middle-low income countries provide better mental health services to their populations. By offering both preventative measures as well as aid for those with existing mental health problems, mhGAP aims to provide the comprehensive tools required to improve mental health in demanding conditions. Even without the additional barriers of pervasive poverty or conflict, accessing mental health care can be a struggle in developed countries such as the UK. Understanding this from my own perspective, I am able to appreciate the immense difficulties that must be faced when trying to implement structures for mental care in less developed countries facing these issues.

Below is a short video highlighting some of the key work done by the mhGAP and explains its mandate.

Issues with mental health can stem from a variety of catalysts. Ranging from substance abuse and environmental pollutants, to external factors such as trauma and stress. The varied reasons for the onset of mental illnesses, many of which present similar symptoms is a topic I find facinating. These complex and often coinciding brain disorders are known under an umbrella term as Mental, Neurological and Substance use disorders (MNS disorders). The mhGAP seeks to address the root causes of declining mental health as well as the effects MNS disorders have on quality of life through a number of channels. As well as performing their own aid work, via the mhGAP, the WHO aims to support governments in the efficient allocation of funding and resources.

Given the somewhat intangible nature of many MNS disorders, finding an appropriate and effective course of action can often be troublesome. Reluctance to recognise or accept a mental health issue and complications during diagnosis can all be barriers to receiving effective treatment, if any at all. The two main approaches for treating MNS disorders are therapy and pharmaceuticals, with both having positive and negative aspects. Even in stable countries not suffering through a crisis, pharmaceutical treatment of MNS disorders can be a difficult and lengthy process. In LMICs, already poor infrastructure and other causes of instability can impact supply chains meaning pharmaceuticals can be unreliable. Therapy is a common, often preferred alternative to medication and has been seen to be just as effective at treating certain illnesses such as depression. A specific focus of the mhGAP is to implement further education and training to increase the number of healthcare workers as well improve the quality of care they can provide. An important facet of treating mental conditions is that the chosen method of treatment must be appropriate for the patient in terms of their situation, needs and wants in order to be best effective. This involves considering the cultural differences, which can impact all stages of mental health treatment. From initially seeking treatment, to the presentation and interpretation of symptoms, a firm understanding of individual cultures and the effects they can have on mental health disorders is imperative to the success of mhGAPs mandate. It is therefore important that health workers are well educated to ensure that they are able to provide mental health support no matter the cultural differences. Below is an example of the mhGAP Intervention Guide, a practical manual to be used by healthcare workers to aid with correctly diagnosing MNS disorders and effective treatment plans.

 

By implementing visual tools such as flow charts and colour coding, the mhGAP-IG is designed for ease of use, with little barrier to entry. It offers strategies promoting mental wellness as well as advice and instructions for diagnosing disorders. Where applicable it gives guidance for follow up care, helping to ensure the long term management of conditions. Whilst the mhGAP-IG is an exceptional tool, it is aware of its clinical limitations and in certain circumstances recommends specialist treatment or advice which is recognised as beyond its remit.

 

In order to provide cost effective and easily effective mental health care, the mhGAP aims to offer an approach that can be suited to small scale healthcare centres, often with limited resources. By removing barriers to entry, mhGAP hopes to improve uptake by governments and communities where capital is in short supply. In situations where funding and resources are limited, by implementing and supporting the uptake of the mhGAP, the WHO is initiating mental health advocacy and betterment on a community level. An article by R.Keynejad analysed numerous studies on the effectiveness of the mhGAP and found it to be successful in its mandate. A promising sign is how the WHO have responded to criticisms of the program. Based on reports that replacing paper based training manuals with one accessible via internet would be beneficial, it was implemented into the next augmentation of the manual.

The above video shows the impact the mhGAP program had after being implemented in 3 districts in Uganda. The programs goal of increasing awareness of MNS disorders was found to be successful, with 91%  of people being able to recognise symptoms, and improved mental state reported in those involved in the program.

Meeting with representatives from the WHO is an opportunity I am really looking forward to, for both academic and personal reasons. The opportunity to learn from people currently in positions I hope to one day achieve is invaluable and I am eagerly anticipating hearing about their experiences. I hope to be able to ask them about the decisions they made that led them to this point in their careers. I’d love to learn more about the mhGAP and their work. Specifically, the differences between diverse cultures and the different views they hold on mental health. The requirement for flexibility to allow for these cultural differences is a vital part of any program aiming for global uptake. I’d like to better understand the pre-publication process that was carried out in regards to research and policy making. Approaching the issue of poor mental health in underdeveloped countries comes with some obvious challenges, however I’d be curious to hear some unexpected challenges that arose during the design or implementation of the program and how they were negotiated. Something I have struggled with in the past is a sense of uncertainty in my future goals and a lack of direction. By speaking to experts in the field I’m aiming to work in, I hope to build a better picture on what my next steps after graduating might look like. I am hoping that this will allow me to better motivate myself personally, academically, and professionally. As well receiving advice, I anticipate the trip to provide an insight into what life working for an international organisation such as the WHO is like, particularly for a recent graduate. This will also be my first time visiting Geneva. Since so many organisations are based in the city I hope I can get a feel for the place to see if I can picture myself living there.

 

 

 

 

 

 

 

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