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CASE STUDY: BOSNIA AND HERZEGOVINA (BiH)

CASE STUDY: BOSNIA AND HERZEGOVINA (BiH). Harvard Program in Refugee Trauma (HPRT) Richard F. Mollica MD, MAR Michael P. Massagli, PhD James Lavelle, LICSW Aida Kapetanovi ć , MD. Major Objectives of World Bank-HPRT Project in BiH Middle Bosnian Canton (Travnik).

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CASE STUDY: BOSNIA AND HERZEGOVINA (BiH)

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  1. CASE STUDY: BOSNIA AND HERZEGOVINA (BiH) Harvard Program in Refugee Trauma (HPRT) Richard F. Mollica MD, MAR Michael P. Massagli, PhD James Lavelle, LICSW Aida Kapetanović, MD

  2. Major Objectives of World Bank-HPRT Project in BiH Middle Bosnian Canton (Travnik) • Mental health training and technical assistance to primary care providers (PCPs) • Create network of PCPs skilled in mental health and trauma-related disorders • Develop with cantonal MOH mental health services integrated at all levels, including CBRs • Integrate results into BiH health reform • Prepare Lessons Learned for dissemination throughout BiH

  3. ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND DISABILITY, BOSNIAN REFUGEES, 1996 (N=533) SOURCE: JAMA v282:437, 1999

  4. Persistence of Mental Health Symptoms Over 3 Years

  5. Change in Symptom Status 1996-1999

  6. Effect of Trauma, 1996

  7. Effect of Trauma, 1999

  8. THE MENTAL HEALTH COST OF MASS VIOLENCE SERIOUS MENTAL ILLNESS PSYCH. INCAPACITATION SERIOUS FAMIILY CONFLICT CLNICAL DEPRESSION/PTSD FEAR OF GOVERNMENT SEEKING JUSTICE/REVENGE PHYS, MENTAL EXHAUSTION DEMORALIZATION SOURCE: Scientific American, v282, June 2000:54-57

  9. Feeling No Trust in Others, Past Week

  10. 2001 Living Standards Measurement Survey (LSMS) in BiH (N=12,954) • 23% report depressive symptoms consistent with DSM-IV diagnosis of major depression • 6% report reexperiencing trauma symptoms • 15% report limitations in physical functioning • Women 2x more depression, PTSD, functional limitations than men

  11. Primary Health Care Patients: Middle Bosnian Canton, 2003 (N=184) • 32% psychiatric diagnosis (DSM-IV/SCID) • 16% major depression • 10% Generalized Anxiety Disorder • 3% PTSD only • 3% Dysthymia; other SCID = Structured Clinical Interview for DSM-IV

  12. Providers Needs Assessment: 2000 • 40% (30-80%) of patients have mental health problems • 65% of PCPs are not able to make DSM-IV (ICD-10) diagnoses • PCPs reported very low confidence in treatment of mental health crises • PCPs reported almost no confidence or very low confidence in treatment of different groups of traumatized patients

  13. Providers Needs Assessment: 2000 (cont’d) • 33% of PCPs didn’t know about CBRs • 54% of PCPs never referred patients to CBRs • 30% of those who did refer never received feedback from the CBR

  14. EDUCATION • 105 PCPs and psychiatrists trained • Curriculum completed: • Trauma Story • Psychosocial interviewing skills • Screening Instruments • Identification and management of the most common psychiatric disorders: mood disorders, neurotic stress-related and somatoform disorders, substance abuse, organic mental disorders, psychosis • Identification and management of disability • Management skills/health reform

  15. ON-SITE VISITS/SUPERVISION • Case-Oriented • Goals: • To sustain the knowledge • To improve relations between PCPs and mental health professionals • To prevent burnout

  16. Level of Trauma Experienced by PCPs and PCPs’ Families

  17. PCPs’ Confidence in Eliciting and Listening to Trauma Stories: Pre-training vs. Post-training Mean confidence

  18. PCPs’ Confidence in Diagnosing Certain Medical and Psychiatric Problems: Pre-training vs. Post-training Mean confidence

  19. MENTAL HEALTH SERVICES: OPTIMAL MODEL Community Police Emergency Room General Hospital Primary Health Care General Hospital In-patient Mental Hospital Criminally Insane

  20. MENTAL HEALTH SERVICES IN BOSNIA Community Community Rehabilitation Centers Primary Health Care Psychiatric Hospital

  21. MENTAL HEALTH SERVICES IN BOSNIA Community Primary Health Care Community Rehabilitation Centers General Hospital In-patient

  22. FRAMEWORK FOR MENTAL HEALTH RECOVERY I. Policy/Legislation RECOVERY VI. Linkage to Economic Development/ Human Rights II. Financing V. Role of International Agencies III. Science-Based Mental Health Services IV. Multi-Disciplinary Education

  23. BiH Mental Health (MH) Case Study I. Policy/Legislation • MH integrated into health reform • LSMS MH data integrated into BiH health statistics • Future role of CBRs

  24. BiH Mental Health (MH) Case Study II. Financing • Sustainable financing of MH in PHC • Psychiatry – PHC linkage • Job training and social services in PHC/CBRs • Cost-effective MH training and services

  25. BiH Mental Health (MH) Case Study III. Science-Based MH Services HPRT Model: • Needs assessment • Implementation of field-tested curriculum • On-site supervision • Monitoring assessment and feedback

  26. BiH Mental Health (MH) Case Study IV. Multi-Disciplinary Education • “Pedagogy of Trauma” in BiH medical schools • Integration into family medicine • CME

  27. BiH Mental Health (MH) Case Study V. Role of International Agencies • Coordination/collaboration among BiH MOH – UN – NGO – donors – universities

  28. BiH Mental Health (MH) Case Study VI. Linkage to Economic Development (ED) and Human Rights (HR) • Violence-induced trauma has negative impact on MH • Both provider and patient exposed to violence • MH has negative impact on social capital and physical functioning • Undiagnosed and untreated MH problems place significant burden on health care system

  29. Harvard Program in Refugee Trauma 22 Putnam Avenue Cambridge, MA 02139 http://www.hprt-cambridge.org

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