CASE STUDY: BOSNIA AND CASE STUDY: BOSNIA AND HERZEGOVINA (BiH)HERZEGOVINA (BiH)

Harvard Program in Refugee Trauma (HPRT)Harvard Program in Refugee Trauma (HPRT)

Richard F. Mollica MD, MARRichard F. Mollica MD, MAR

Michael P. Massagli, PhDMichael P. Massagli, PhD

James Lavelle, LICSWJames Lavelle, LICSW

Aida KapetanoviAida Kapetanovićć, MD, MD

Social and Health Social and Health IndicatorsIndicators

19811981 19911991 20002000

Population 4,124,256 4,395,643 3,683,665

Refugees - - 643,250

Displaced Persons - - 501,000

Employed:

Unemployed

- 3.17:1 1:1

Monthly Income

in US$

190 299 174

Major Objectives of World Bank-HPRT Project in Major Objectives of World Bank-HPRT Project in BiH Middle Bosnian Canton (Travnik)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

ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND DISABILITY, BOSNIAN REFUGEES, 1996 (N=533)DISABILITY, BOSNIAN REFUGEES, 1996 (N=533)

SOURCE: JAMA v282:437, 1999

0

10

20

30

40

50

60

Per

cen

t

Asym PTSD Alone Dep Both

Total %Disabled %

Persistence of Mental Health Symptoms Persistence of Mental Health Symptoms Over 3 YearsOver 3 Years

Refugee cohort (n=378) - mental health status

0

10

20

30

40

50

60

70

1996 1999

Survey Year

Pe

rce

nt asymptomatic

depression

PTSD

depression and PTSD

Change in Symptom Status 1996-1999Change in Symptom Status 1996-1999

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

A (n=209) D (n=70) PTSD (n=20) D & PTSD(n=78)

1996 symptom status

Pe

rce

nt Asymptomatic - 1999

Depression

PTSD

Depression and PTSD

Effect of Trauma, 1996Effect of Trauma, 1996

Distribution of mental health symptoms - 1996

0

10

20

30

40

50

60

70

0-2 3-5 6 or more

Number of trauma events

Pe

rce

nt

asymptomatic

depression

PTSD

depression and PTSD

Effect of Trauma, 1999Effect of Trauma, 1999

Distribution of mental health symptoms - 1999

0

10

20

30

40

50

60

70

0-2 3-5 6 or more

Number of trauma events

Pe

rce

nt asymptomatic

depression

PTSD

depression and PTSD

THE MENTAL HEALTH COST THE MENTAL HEALTH COST OF MASS VIOLENCEOF MASS VIOLENCE

0 50 100

Percentage of General Population

SOURCE: Scientific American, v282, June 2000:54-57

SERIOUS MENTAL ILLNESS

PSYCH. INCAPACITATION

SERIOUS FAMIILY CONFLICT

CLNICAL DEPRESSION/PTSD

FEAR OF GOVERNMENT

SEEKING JUSTICE/REVENGE

PHYS, MENTAL EXHAUSTION

DEMORALIZATION

Feeling No Trust in Others, Past WeekFeeling No Trust in Others, Past Week

010

2030

4050

60

Symptom Status, 1999 (378 refugees)

Pe

rce

nt Not at all

A little

Quite a bit

Extremely Often

2001 Living Standards Measurement Survey 2001 Living Standards Measurement Survey (LSMS) in BiH (N=12,954)(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

Primary Health Care Patients: Middle Primary Health Care Patients: Middle Bosnian Canton, 2003 (N=184)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-IVSCID = Structured Clinical Interview for DSM-IV

Providers Needs Assessment: 2000Providers 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

Providers Needs Assessment: 2000 (cont’d)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

EDUCATIONEDUCATION105 PCPs and psychiatrists trained

Curriculum completed:

1) Trauma Story

2) Psychosocial interviewing skills

3) Screening Instruments

4) Identification and management of the most common psychiatric disorders: mood disorders, neurotic stress-related and somatoform disorders, substance abuse, organic mental disorders, psychosis

5) Identification and management of disability

6) Management skills/health reform

ON-SITE VISITS/SUPERVISIONON-SITE VISITS/SUPERVISION

Case-Oriented

Goals:

To sustain the knowledge

To improve relations between PCPs and mental health professionals

To prevent burnout

Level of Trauma Experienced by PCPs and Level of Trauma Experienced by PCPs and PCPs’ FamiliesPCPs’ Families

0%

10%

20%

30%

40%

50%

60%

70%

80%

None Mild WarTrauma

Moderate WarTrauma

Severe WarTrauma

Extreme WarTrauma

PCP

PCP's Family

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

0

1

2

3

4

5

6

Eliciting Trauma Story Listening to TraumaStory

Listening to EmotionalSuffering

Pre-training

Post-training

Mea

n co

nfid

ence

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

0

1

2

3

4

5

6

Somatic SymptomsCaused by Trauma

Mental HealthProblems

Depression PTSD

Pre-training

Post-training

Mea

n co

nfid

ence

Primary Health Care

Community

PoliceEmergency RoomGeneral Hospital

General HospitalIn-patient

MENTAL HEALTH SERVICES: OPTIMAL MODELMENTAL HEALTH SERVICES: OPTIMAL MODEL

Mental HospitalCriminally Insane

Primary Health Care

Community

Psychiatric Hospital

MENTAL HEALTH SERVICES IN BOSNIAMENTAL HEALTH SERVICES IN BOSNIA

Community Rehabilitation

Centers

Primary Health Care

Community

General HospitalIn-patient

MENTAL HEALTH SERVICES IN BOSNIAMENTAL HEALTH SERVICES IN BOSNIA

Community Rehabilitation

Centers

FRAMEWORK FOR MENTAL HEALTH RECOVERYFRAMEWORK FOR MENTAL HEALTH RECOVERY

RECOVERY

I. Policy/Legislation

V. Role ofInternational Agencies

III. Science-BasedMental Health Services

IV. Multi-Disciplinary Education

II. FinancingVI. Linkage to

Economic Development/ Human Rights

BiH Mental Health (MH) Case StudyBiH 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

BiH Mental Health (MH) Case StudyBiH 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

BiH Mental Health (MH) Case StudyBiH 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

BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study

IV. Multi-Disciplinary Education

• “Pedagogy of Trauma” in BiH medical schools

• Integration into family medicine

• CME

BiH Mental Health (MH) Case StudyBiH Mental Health (MH) Case Study

V. Role of International Agencies

• Coordination/collaboration among BiH MOH – UN – NGO – donors – universities

BiH Mental Health (MH) Case StudyBiH 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

Harvard Program in Refugee TraumaHarvard Program in Refugee Trauma

22 Putnam Avenue22 Putnam Avenue

Cambridge, MA 02139Cambridge, MA 02139

http://www.hprt-cambridge.org