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Transcript of Integrating traditional health practitioners in mental health: Is it possible? Results from a pilot...
Integrating traditional health practitioners in
mental health: Is it possible? Results from
a pilot project in KenyaThe 8th Pan-African PCAF Psychotrauma Conference
Christine Musyimi, BSc; MSc, PhD (c)
Africa Mental Health Foundation
13th-16th July, 2015
Trauma, PTSD and Depression
Continued stress long after trauma may lead to Post Traumatic Stress Disorder (PTSD) and consequently depression.
Depression one of the common long term mental disorders after trauma, comorbid with PTSD.
The trauma that caused PTSD also may cause depression.
PTSD and depression treatment similar.
Traditional Health Practitioners (THPs) Traditional Health Practitioners (THPs) do not all perform the same
functions.
They are categorized into diviners, herbalists, prophets, faith healers and traditional birth attendants (Pretorius, 1999).
THPs have been well known to provide holistic care (Mhame et al, 2010).
Kenya experiences a dearth of primary health care workers and abundance of THPs (Management Sciences for Health, 2012).
80% of people with health problems consult traditional healers (THs) as their first contact persons (World Health Organization (WHO), 2003).
Traditional Health Practitioners’ role
There are no rules and regulations in Kenya that guide the traditional healers and this places their patients at risk of sub standard care.
THPs seem to be the key to greater understanding of depression in rural communities (Johnson-Bashua, 2012).
There is need to include THPs in mental health service provision due to a high number of patients they receive and presence of priority mental illnesses (Ndetei et al, 2013; Havenaar et al, 2008).
Depression accounts for the greatest burden among mental disorders
Challenges of THPs in relation to conventional care
Lack of respect and mutual trust
Weak referral systems
Illiteracy and inadequacy of training opportunities
Solutions
Establish trust and mutual respect between formal and the informal sectors
Establish and strengthen collaboration and referral systems
Training opportunities for THPs especially on conventional methods of care in order to reduce sub standard care.
THPs integration in to the health care system
Current state: Solutions achieved through dialogue
Methodology
Training of 100 randomly selected THPs to screen and manage depression using mhGAP-IG.
In order to confirm THPs diagnosis, a sample of 100 patients (50 positive and 50 negative for depression) were randomly selected from a group of patients seen by THPs.
Referred to be screened for depression by a mental health professional using clinical judgment as per DSM-IV guidelines (reference standard).
Results
A total of 4081 patients were screened for depression over a period of three months by 78 THPs.
This translated to two patients per day.
Traditional healers and faith healers screened 1515 and 2566 patients respectively.
More than half of all screened patients (66.3%) were female.
Results The prevalence of depression among THP patients was found to
be 22.9% (95% CI 21.7-24.3).
Table 2: Prevalence of depression
Depression Prevalence
of
depression
n 95% CI
Overall depression
prevalence
22.9% 936 21.7-24.3
Traditional healers’ patients
with depression
22.4% 339 20.3-24.5
Faith healers’ patients with
depression
23.3% 597 21.7-24.9
Comorbidity and Correlates of depression The most frequently co morbid condition among patients with depression
was suicidal behavior (32.9%, OR=5.94, p=<0.0001), followed by presentation of at least one psychotic symptom (26.3%, OR=3.65, p=<0.0001).
Depression was significantly higher with increase in age (p<0.0001).
Females were 1.20 times likely to have depression.
The rate of depression was higher among single and separated or divorced persons as compared to those who were married.
Patients who were not employed or schooled reported higher levels of depression.
Measure of accuracy The ability of THPs to correctly identify a patient with depression, also
known as sensitivity is 46% while the likelihood that the patient will actually have depression (positive predictive value) is 79%.
Their ability to correctly exclude depression referred to as specificity from patients is 86% and the likelihood that the patient will have no depression (negative predictive value) is 57.8%.
Clinical judgement
True positive: 46%; True negative: 86%; False positive: 14%; False negative: 54%; specificity: 86.1%; sensitivity: 46%, Positive predictive value: 79%; Negative predictive value: 57.8%
POSITIVE NEGATIVE TOTAL
Traditional health practitioners’ mhGAP-
IG screening
POSITIVE 23 27 50NEGATIVE 6 37 43TOTAL 29 64 93
Baseline 6 weeks 12 weeks0
5
10
15
20
25
30
28.4
25.4
17.5
Time period
Est
imate
d M
ean s
core
sImprovement of depression post mhGAP-IG
intervention
Improvement of depression post mhGAP-IG intervention
12% resolution of symptoms 6 weeks post intervention
39% improvement in depression symptoms 3 months post intervention.
Similar improvement expected at primary health care level and 6-9 months without any intervention.
Therefore, THPs accelerated recovery of patients.
Recommendations Majority of THPs are the first contact persons for community
members in need of health care.
Inclusion of THPs in provision of mental health services particularly the priority conditions should be strengthened.
Community support networks particularly for more vulnerable groups such as women may aid in reducing the cycle of unemployment, poverty and depression and development of other mental disorders related to poverty.
Most of these traditional healers are illiterate, training opportunities using evidence based practices should be available at the community level.
Conclusion Acknowledge THPs role in mental health care and integrate
depression assessment in to their routine service provision.
Avoid performing parallel programmes.
Depression, a priority condition listed under the WHO mhGAP-IG can be psycho socially managed by THPs.
This same approach can be used for related conditions such as PTSD and mental disorders.
ReferencesHavenaar, J.M., Geerlings, M.I., Vivian, L. et al (2008) Common mental health problems in historically disadvantaged urban and rural communities in South Africa: prevalence and risk factors. Soc Psychiatry Psychiatr Epidemiol 43(3):209–15.
Johnson-Bashua, A. (2012) Yoruba traditional healers and mental illness: Causes, Diagnosis and Treatment. Philosophy, Religion and Politics in Africa, pp. 34–46.
Management Sciences for Health. (2012) Traditional and complementary medicine policy.
Mhame, P.P., Busia, K. and Kasilo, O.M. (2010) Clinical Practices of African Traditional Medicine. African Heal Monit, (14).
Ndetei, D.M., Mbwayo, A.W., Mutiso, V.N. et al (2013) Traditional healers and provision of mental health services in cosmopolitan informal settlements in. Afr J Psychiatry 16(2):134–40.
Pretorius, E. (1999) Traditional Healers. 249–56.
World Health Organization. (2003) Traditional Medicine. Fact sheet N°134. 2003. Available from: http://www.who.int/mediacentre/factsheets/2003/fs134/en/, accessed 5 April 2015.