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  1. Photo: PMHP

  2. Lessons • Treatment gap • Preparing the ground • Teaching & Training • Routinise screening • The referral element • Intervention & Liaison • Supervision vs supervision • Monitoring and evaluation

  3. The extent of the problemBURDEN OF DISEASE WHO estimate mental illness will be one of 2 major illness burdens confronting the world by 2020

  4. The extent of the problemCommon perinatal mental disorders Global • HIC 13% (antenatal); 10% (postnatal) • LMIC 16% (antenatal); 20% (postnatal) Fisher et al 2012 Africa • Malawi 30.4% (MDE 13.9%) (SCID D at 9 mths PP) Stewart et al 2008 • Nigeria 18.6% (D) Abiodun 2006 • Ethiopia 21.9% (S) Servili et al 2010 (antenatal/postnatal) • Uganda 6.15% (D) Nakku et al 2006 • Zimbabwe 33% (D) Chibanda et al 2012 Other LMIC settings • Pakistan 25% (D) MDE Rahman et al . (2004). rural community • Chile 36% (S) Husain et al 2006 • India 16.2%-20.3% (PPD) (D) Chandran et al 2002; Patel et al 2002 • Nepal 12% (S) Regmi et al 2002 D: diagnostic S: screen

  5. South Africa • Neuropsychiatric conditions: 3rd highest contributor to burden of disease in SA Bradshaw et al 2007 • Prevalence common mental disorders (SASH study) Herman et al 2009 • 12-month prevalence = 16.5% • lifetime prevalence = 30%

  6. The extent of the problemperinatal mental illness South Africa • Antenatal depression • 40% (Khayelitsha – screening data) • 47% (KwaZulu Natal – diagnostic data) • Postnatal depression • 35% (Khayelitsha – diagnostic data) • Hanover Park (antenatal) PMHP 45% • 22% Major Depression • 22% Anxiety spectrum • 20% Alcohol and substance disorder • 13% medium/high suicide risk PMHP unpublished data 2013

  7. Mind the Gap • Treatment gap: >80% of SAs do not receive the mental health care they need Wolvaardt et al 2008, Seedat et al 2009

  8. Risk Factors Protective Factors having more education (RR 0.5; P = 0.03) having a permanent job (OR: 0.64; 95% CI: 0.4–1.0) being of the ethnic majority (OR: 0.2; 95% CI: 0.1–0.8) having a kind, trustworthy intimate partner (OR: 0.52; 95% CI: 0.3–0.9) • socioeconomic disadvantage (OR range: 2.1–13.2) • unintended pregnancy (1.6–8.8) • being younger (2.1–5.4) • being unmarried (3.4–5.8) • lacking intimate partner empathy and support (2.0–9.4) • having hostile in-laws (2.1–4.4) • Experiencing intimate partner violence (2.11–6.75) • having insufficient emotional and practical support (2.8–6.1) • in some settings, giving birth to a female (1.8–2.6) • having a history of mental health problems (5.1–5.6) Fisher et al, Systematic Review Bull World Health Organ 2012

  9. The intergenerational cycle • Interface with services • Antenatal care • PMTCT-HIV • Baby Clinics • = poor mental health • competency and capacity • Epidemic cluster • 20-40% Depression • 20% Anxiety • 15% Substance/Alcohol use • 35% Domestic violence • 15-20% Teens • Suicide Natural progression Distress during pregnancy – postnatal distress The abandonment of mothers The silence of mental illness - internal and external stigma Disrupt Mother Poverty-Mental Health cycle • Mental illness • Crying/irritability/inconsolability • Internalisingbehaviours - withdrawal • Externalisingbehaviours – aggression • Anxiety & Depression • Conduct Disorder • Substance Misuse • Unintended pregnancy • Suicidality • High risk behaviours Trans-placental Bonding/Attachment Obstetric complications • Physical development • Premature • Small for gestational age • Effects of substances • Impaired breastfeeding • Stunting/underweight • ‘Failure to Thrive’ • Increased diarrhoeal episodes • Increased admission to hosp/ICU • Non-completion immunisations • Infectious diseases • Neuro-cognitive development • Language delays • Motor delays • Recognition and memory • Attention deficit disorder and hyperactivity • Extreme casualties • Abuse • Abandonment • Neglect • Violence • Crime • Poverty • Poor education/drop-out • Unemployment • Unintended pregnancy • Substance Misuse • Infectious Diseases Society Infant/Child

  10. Cycle of healing and wellness • Services • Empathic care from primary care staff • Early identification & referral to quality counselling and follow-up • Accessible services • Optimal uptake of care • Antenatal • PMTCT and ARV • Child health • Social services • Family Planning • Specialist services Mother Human Capital Heckman’s investment Maintain Optimal foetal development Bonding/attachment/ breastfeeding Society Infant/Child • Quality of Life • Physical wellness • Social cohesion • Resilience • Compassion • Empowerment • Employment • Optimal child growth and physical development & wellness • Optimal child neurocognitive development • Optimal child educational achievement • Optimal child psychosocial development

  11. The work of the PMHP Clinical Services Incubator • Develop maternal mental health service interventions which are • Adaptable, responsive • Evidence-based • Cost-efficient Advocacy Research Teaching & Training Interventions to scale Vision All women have universal access to quality maternal mental health care, routinely integrated into maternity services.

  12. Preparing the ground • Relationship building – all levels • Identify and acknowledge staff mental health needs • Address staff mental health needs • “maternal mental health literacy” – join the dots…….. • Find champions • Buy-in from management • On-going

  13. Training and TeachingTo prepare and capacitate the public health environment to integrate maternal mental health services by building a critical mass of trained frontline health workers Key principles: • Address background trauma and abuse • Active participants - humour and affirmation • Acknowledge the mental health status and needs of participants ‘Care for the carer’ • Innate health worker skills – harnessed & optimised • Training packages (incl. train-the-trainer) • Training resources • Who • Cascade effect? 700-800 health workers trained/yr

  14. Training resources • PMHP manuals to support training are freely available for download on our website: www.pmhp.za.org/learn/useful-resources • Maternal mental health: a handbook for health workers • Service Development Guidelines • Counselling skills for primary health workers

  15. Routine screening • To screen or not to screen? • Do more harm? Labelling? • Adequate source for referral? • When to screen? – first antenatal visit • Who to screen? • Who to administer screening? • Screen with what • Valid • Brief • Easy to score • Culturally appropriate • Mood + risk

  16. The referral element • Location, location, location • Link with other ‘physical health appointments’ • Quality of referral • Explore, explain, demystify • Tracking for uptake • Open-door policy • Monitor declining and defaulting

  17. ScreeningMowbray Maternity Hospital (MMH)

  18. Interventionon-site and follow-up • On-site counselling – ‘one stop shop’ • Training • Dedicated • Space • Face-to-face and telephonic • Group • Different modalities (PST, CBT, IPT, Bereavement, MI, antenatal preparation, relaxation) • Liaison & referral • Takes time • Mapping • Relationship-building • Tracking • Poverty alleviation

  19. Counselling uptakeMMH ٭ ٭% of referred women never counselled

  20. Counselling outputsMMH

  21. Women seen by PMHP psychiatristMMH (3 years)

  22. Service changes over timeMMH

  23. 10 years’ service outputs • Screened: 17,991 • >80% of booking population • Counselled (on-site): 3,231 women; 7,061 sessions • Mean: 2.2 sessions/client • Psychiatry • >140 women received psychiatric intervention • Trained: approx 5,000

  24. Supervision, supervision, supervision • Not same as monitoring • Clinical supervision • Supportive; debriefing • Regular, scheduled • Senior and peer • Identify professional development/education needs • Identify personal support needs • Investment in retention, quality

  25. Monitoring and Evaluation • Balance • time invested vs improving/maintaining quality • Separate from supportive supervision • Regular, scheduled • Rationale • Feedback to stakeholders • Change, reflect, change

  26. Outcomes assessment2 sitesmid 2010 to mid 2012 • N= 821; 6-10 weeks postpartum • Telephone call by counsellor • Changes in presenting problems; worse, no change, some improvement, much improvement/resolved • Mother/infant matters

  27. Changes in presenting problems‘much improved’/ ‘resolved’2010-2012; 2 sitesn= 821

  28. Birth and Parenting outcomes2010-2012; 2 sitesn= 821

  29. ResearchTo address the knowledge gap pertaining to integrated maternal mental health care in low-resource service settings Capabilities Case Study - multiplicity of risk factors Psychiatry clients Utilisation patterns Evaluations and impact Hosting/supporting postgraduate multidisciplinary research: PhDs, MAs, post-doctoral research • 2012 PLoSMedicine Flagship paper on Stepped-Care Model • 2010 Journal of Child and Adolescent Mental Health • Screening tool development study • Consortia: • Programme for Improving Mental Health Care (PRIME) • Africa Focus on Intervention Research for Mental Health (AFFIRM)

  30. AdvocacyAdvance evidence-based policy development and implementation of maternal mental health services Film:Caring for Mothers Social media: Facebook Twitter and YouTube Policy & DoH collaboration: National Mental Health Policy for SA; National Strategic Plan for HIV/AIDS; Provincial Postnatal Care Plan; Task team for Patient-Centred Maternity Care • Website: www.pmhp.za.org • Articles in print media • Community newspapers • City newspapers – op-ed pieces • Radiointerviews • Coverage in digital media • Policy briefs • Issue briefs • Pamphlets and booklets for service users and public

  31. Lessons • Treatment gap • Preparing the ground • Teaching & Training • Routinise screening • The referral element • Intervention & Liaison • Supervision vs supervision • Monitoring and evaluation

  32. PMHP Hanover Park data • N= 404 • 1st antenatal visit • 1 in 3 systematic sampling • Mean 26 years; gest 17 wks • Race • African: 136 • “Coloured” 249 • Other 19 • Education • Some high school 94% • Completed high school 30% • Income • Less than $125/month • 53% food shortages • Relationships • Live with partner 41% • Married/stable relationship 90% • Abuse in last 6 months 11%

  33. Director Board of Advisors Ad hoc staff Perinatal Mental Health Project

  34. Poverty-Mental Illness cycle The cycle means that there is an increased risk of mental illness for those living in poverty and an increased likelihood that those living in poverty will drift into, or remain in, poverty. Lund et al., 2011

  35. Investment hypothesis Investing in Early Human Development: Timing and Economic Efficiency Orla Doyle, Colm P. Harmon, James J. Heckman,and Richard E. Tremblay  Econ Hum Biol. 2009 March; 7(1): 1–6.