Opportunities for Integrating Mental Health into HIV, MCH, and Other Health Service Platforms

Joy Noel Baumgartner, PhD, MSSW Assistant Professor of Global Health Director, Evidence Lab Duke Global Health Institute CORE Group Fall 2016 Conference October 14, 2016

NCDs, Mental Disorders & DALYs

Depression is the 3rd leading cause of disability adjusted life years, 2nd for YLD. Cost of MNS is $2.5 Trillion = 3x the cost of heart disease (World Economic Forum, 2013)

Global burden (HIC+LMIC), Figure from Prince et al. 2007, Lancet

Magnitude of depression in LMICs

• Mental disorders account for 11% of the total burden of disease in LMICs with depression being the leading neuropsychiatric cause

• Leading global policy, practice and research organizations are increasingly taking notice and prioritizing mental health

World Bank & WHO, April 2016

A global community of mental health innovators http://mhinnovation.net/

Global burden of suicide

WHO 2014, Preventing Suicide

Moderate-Severe Depression (mhGAP-IG)

• Experiences depressed mood, loss of interest and enjoyment, and reduced energy leading to diminished activity for at least 2 weeks. Many people with depression also suffer from anxiety symptoms and medically unexplained somatic symptoms

• Has difficulties carrying out his or her usual work, school, domestic or social activities due to symptoms of depression

WHO, 2010

Depression Treatment (mhGAP-IG)

• Basic Psychosocial treatment for depression – Psychoeducation – Addressing current psychosocial stressors (e.g. domestic violence) – Reactivate social networks – Structured physical activity program – Follow-up (re-assess)

* Medication as indicated

• Advanced psychosocial interventions – Defined as an intervention that takes more than a few hours of a health-care

provider’s time to learn and typically more than a few hours to implement. Such interventions can be implemented in non-specialized care settings, but only when sufficient human resource time is made available. Eg…

• Cognitive behavioural therapy (CBT) • Interpersonal psychotherapy (IPT) • Problem-solving counselling or therapy

Depression and HIV in LMICs

• Depression is more common among people living with HIV (PLWH) than general population in high-income countries (~5%–20% prevalence); data from LMICs indicates even higher prevalence levels (~7-30% prevalence)

• Poor mental health affects disability and quality of life for PLWH and it also impacts their ability to engage with HIV care and treatment services including adherence to antiretroviral therapy (ART)

• Evidence that mental disorders also associated with HIV risk behaviors such as substance abuse, multiple sexual partners and unprotected sex

• Addressing depression among both general populations and higher risk populations such as PLWH is paramount

Burden of maternal mental health

• Common perinatal mental disorders (CPMDs), which includes depression, anxiety and somatic disorders, are a major cause of disability during and after pregnancy

• Burden of perinatal depression (pregnancy period + 12 months postpartum) is high globally but even higher in LMICs with estimates from 18% to 25%

• Burden of CPMDs can be reduced through mental health interventions delivered by supervised non-specialists

• Implementation of depression interventions in primary care settings is cost-effective

• Addressing maternal mental health benefits women, children and their families

Key References: Fisher et al., Bull World Health Organ 2012;90:139G–49G; Rahman et al., Bull World Health Organ 2013;91:593–601I ; Chisholm et al, BJP; 2004, 184(5):393-403; Araya et al., Am J Psychiatry 2006; 163:1379–1387.;Siskind et al., J Mental Health Policy Econ; 2008;11(3):127-33.

Risk factors for CPMDs • Poverty • Gender-based violence • Lack of reproductive

autonomy • Having an unintended

pregnancy • Lack of social support

Impact of perinatal depression

Impact on Mother • Disability, poor quality of life • Poor social functioning • Decreased productivity • Negative cognitions • Suicidal ideation

Impact on Child • Undernutrition, stunting, diarrhea • Problems in breastfeeding • Low academic achievement • Socio-emotional and cognitive delays • Childhood depression • Behavior problems

Wachs, et al. (2009). Maternal Depression: A global threat to children’s health, development, and behavior and to human rights. Child Development Perspectives 3(1):51-59. Fisher, et al. (2012). Prevalence and determinants of common perinatal mental disorders in women in LMICs: a systematic review. Bull World Health Org 90:139-149G. Rahman, et al. (2013). Grand Challenges: Integrating Maternal Mental Health into Maternal and Child Health Programmes. PLoS Med 10(5).

Global mental health policies and guidance

Recommendation to assess mother 10-14 days postpartum for resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms persist, further assessment and evaluation.

Evidence-based maternal mental health interventions for low-resource settings increasingly publicly available

Integration opportunities within maternal health care continuum

• Mental health integrated into maternal health services – Facility-level

• E.g. antenatal care, PMTCT, HIV care & treatment, family planning, and well-child/immunization visits

– Community-level • E.g. Screening and referral by health extension workers (Ethiopia) or

church-based lay counsellors within antenatal program (Nigeria)

• Integrating mental health requires health systems strengthening (e.g. effective referral system is part of quality service delivery yet many barriers to referral completion)

Maternal Mental Health in Ethiopia

• Population-based study assessed mental health among 1294 non-pregnant, postpartum women in Amhara region

• Results – 1 in 5 women experiencing mental distress (SRQ-20) – ~15% of surveyed women had had suicidal thoughts – Poor health of last delivered child and inequitable gender

attitudes associated with poor mental health – Social support from female friends was strongly protective

• Community mental health services could strengthen social

support between female friends with education and support group facilitation by health extension workers

Baumgartner et al., 2016; Baumgartner et al., 2014

Integrating mental health care into HIV services platform

• Integration is a priority strategy for providing mental health services

• Requires a health systems strengthening approach

• Referrals are key component of integrated service delivery; however referral follow-up is challenging across all health services

• Facilitated referrals are enhanced referrals that include components (e.g. escorting client) that support referral completion by strengthening linkages between two services or between community-based and facility-based services

• 7-step facilitated referral model for integrating family planning into HIV care and treatment services tested in Tanzania; model can be applied for other services integration

(Patel, et al. PLoS Med; 2013)

Facilitated Referrals to strengthen integrated mental health services

1. Screen 2. Counsel

3. Refer 4. Record 5. Accompany

6. Access 7. Monitor

PSYC

HIV

Screen clients for mental health problems Provide minimal psychoeducation

and/or counselling Refer clients with need to

clinic/service & Record referral Accompany clients to psychiatric

nurse, social worker, or trained lay counsellor

Clients with referrals access psychiatric clinic or social work services for follow-up Monitor reduction in symptoms,

disability, quality of life

Baumgartner et al., 2014

Facilitated referrals for integrating NCD services into HIV care and treatment in Zambia

• Quasi-experimental cohort study: 2 hospitals using facilitated referrals to support services for depression and diabetes among patients in HIV clinics

• Screening for depression and diabetes within routine HIV care and treatment service encounters – Depression care by HIV counselors/psychiatric nurses trained on group intervention

[8-week group counseling intervention for depression among PLWH by Petersen et al (2014) in South Africa]

– Diabetes care by clinical officers and nutritionists following MOH guidelines (additional training needed)

• Study objectives 1. To determine the feasibility of integrating NCD care into HIV care and treatment by

tracking service indicators, and 2. To assess the impact of mental health care on both depression symptoms and ART

adherence (pre/post-intervention; 3 month follow-up)

Zambia: Ongoing study update

• Existing government mental health services (on which we need to rely for referrals and supervision) need significant strengthening

• Data are still being collected but thus far we see about ~10% of HIV care and treatment clients are screening with high levels of depression symptoms indicative of severe depression and another ~10% with moderate depression

• Depression among both women and men, all ages, stresses of supporting families and food insecurity

Global mental health integration… Way forward

• Evidence-based and promising interventions developed for LMICs are becoming publicly available (e.g. Thinking Healthy Programme; Friendship Bench) and WHO’s mhGAP guidelines are increasingly being adapted for local contexts

• Integrating mental health care into other health services can also help advance those health services priorities (HIV medication adherence; maternal and child health outcomes, etc.)

• As MCH, HIV and other service platforms consider integrating and scaling up new and adapted mental health interventions, sufficient attention and resources must also be paid to strengthening health systems

– Task-shifting/sharing needs supportive supervision and monitoring – Functioning referral systems and training for non-specialists to screen/refer/follow-up – Incorporating mental health into HMIS – Sensitization of communities as well as health financing stakeholders that mental disorders are

treatable and a good MCH or HIV investment

Acknowledgements

FHI 360 Team & Advisors for Zambia Study • Namakau Nyambe • Earnest Muyunda • Pai Lien Chen • Rebecca Dirks • Mike Welsh • Tim Mastro

Funding • Zambia study: FHI Foundation • Ethiopia study: USAID