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Towards the Evidence-Based Trauma-Informed Mental Health

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Towards the Evidence-Based Trauma-Informed Mental Health Ilia State University Tbilisi Georgia Towards the Evidence-based Trauma-Informed Mental Health Policy in Georgia PhD research degree student: Nino Makhashvili Mentor/Principal Supervisor: Tengiz Verulava Document submitted in support to upgrading to PhD in Public Health June 2015 Healthcare Policy and Management Program School of Business Ilia State University Tbilisi 2015 i Abstract Introduction Most people in the world who have mental illnesses receive no effective treatment. This phenomenon, described as the ‘treatment gap’, is increasingly acknowledged worldwide, and is seen as the difference between the true prevalence rate and the proportion that receive any kind of treatment. Prevalence of common mental disorders is particularly high among war-affected populations; war trauma can have long-term effects on their mental health. Mental healthcare field is under reform in Georgia and needs scientific evidence to inform mental health policies to close the treatment gap by developing services that are necessary for effective and continuous care. Objectives of the study My research seeks to address 3 main topics: - To identify the mental health disorders in 3 groups of war-affected populations: Older (the 90s’) & Newer (2008) Internally Displaced persons (IDPs) and Returnees in Georgia; - To collect experts’ opinions on the best effective models of service delivery meeting the identified needs; - To develop trauma-informed mental health policy recommendations. The overall aim is to examine patterns of common mental disorders among conflict- affected populations and to elaborate explicit mental health policy recommendations. Methodology The research consisted of two parts: 1. The study on common mental health disorders has been conducted among both Older, Newer IDPs, and Returnees (sample size 3600 persons); issues as prevalence of mental disorders among these groups, associated factors, disability impact, co-morbidity issues, utilization of existing health and mental health services were studied; 2. The experts’ survey has been conducted to explore experiences and opinions of prominent international and local mental health reformers and to capitalise on their vision i on relevant and most effective services applicable to conflict-affected big groups in Georgia. Results The study demonstrates that, several years after the end of military actions, prevalence rates of common mental disorders among conflict-affected populations are high. War experiences appear to be linked to PTSD, depression and anxiety disorders (23.3%, 14.0%, and 10.4% accordingly) and cause a substantial degree of disability among the survivors. Evidence on treatment gap in regard of service utilization was collected, i.e. only one third of those with mental disorders sought any assistance from health services. The experts survey provided the consensus-based evidence on priority services for our target groups. A set of services according to resourcefulness of regions across the country has been recognized. Five main themes have been identified and provided a foundation to policy recommendations concerning conflict-affected populations. Key words: Mental health Policy, War-affected populations, Common Mental Disorders and Comorbidity, Trauma-informed Care ii Acknowledgements I would like to express my gratitude to my mentor and principal supervisor prof. Tengiz Verulava (Ilia State University) - I enjoyed and benefited from his meaningful and rich collegiality, patience and encouragement. I am also thankful to prof. Bayard Roberts (London School of Tropical Medicine, UK) for his generous support in many aspects of this work. I was privileged to have a wonderful possibility of sharing my ideas with prof. Benedetto Saraceno (Lisbon and Geneva Universities) and prof. Graham Thornicroft (Institute of Psychiatry, King's College, London), who provided valuable suggestions at the early stage of the research. Special appreciations go to the research team members, especially to Dr. Ivdity Chiqovani (from Curatio International Foundation, Tbilisi), who were involved in big quantitative study lead by Bayard; to Dr. Mark van Omerren (from WHO, Geneva) and Mr. Emmanuel Streel for their comments on the experts’ survey questionnaire; and Ms. Keti Pilauri (GIP- Tbilisi) for her devoted work on the experts’ survey. Nato Kvavilashvili and Nino Agdgomelashvili also deserve my gratitude for their generous support in dealing with technical problems associated with the text. I do exceptionally acknowledge all persons who took part in the study and shared their experiences with us – Internally Displaced Persons, Returnees, and also foreign and Georgian experts (who are appreciated by names in this thesis). My gratefulness also goes to Academic Swiss Caucasian Net (ASCN) and to Mr. Denis Dafflon for giving me a chance to be engaged in the short-term visit program that truly enabled me to work on the thesis in a rich academic atmosphere of Fribourg University, Switzerland. I do owe particular and excessive “thank you” to my family members (remarkably to my mother), colleagues and friends who supported and encouraged me to accomplish this challenging task. By the work presented below I tried hard to bring together and link my two “love-stories” – a fascinating and heavy science of psychotraumatology and the challenging and stimulating field of mental health policy & reform. Do hope this study would contribute to further integration and synthesis of these areas in Georgia and beyond it. iii Contents Contents ............................................................................................................................... iv List of figures ......................................................................................................................... v List of tables .......................................................................................................................... vi Abbreviations ...................................................................................................................... vii Terminology ....................................................................................................................... viii I. Introduction ....................................................................................................................... 1 Rationale, aims and objectives of the study ........................................................................ 32 II. Literature Review ........................................................................................................... 34 III. Methodology ................................................................................................................. 69 IV. Overview of Findings .................................................................................................... 84 V. Interpretation/Discussion ............................................................................................. 118 VI. Conclusions/ Policy Recommendations ...................................................................... 139 Bibliography ...................................................................................................................... 144 Annexes ............................................................................................................................. 173 ANNEX 1 ................................................................................................................................ 173 ANNEX 2 Experts survay. ...................................................................................................... 200 iv List of figures Figure 1. Beds in Psychiatric Hospitals (selected countries)....................................................... 3 Figure 2.Mental Health Expenditure in 2006-2011 ..................................................................... 5 Figure 3: Internal displacement in Georgia ................................................................................ 18 Figure 4. Optimal Mix of Services (WHO, 2007) ....................................................................... 22 Figure 5. Mentalhealthservice components relevant to low,medium andhighresource settings .......................................................................................................................................... 31 Figure 6. Importance of MH strategic plan (WHO, 2004) ......................................................... 46 Figure 7. Multi-Layered Supports ............................................................................................... 63 Figure 8: proportion of respondents with single disorders and with co-morbidity (N = 3,025) ................................................................................................Error! Bookmark not defined. Figure 9: Reasons of not seeking health care in the presence of mental health, any emotional or behavioural problems during last 12 months (multiple answers allowed) ......... 97 List of tables Table 1. Budget and composition of State Program on Mental Health Care 2006-2013 (in GEL) ............................................................................................................................................ 6 Table 2. MH staff per 100,000 inhabitants (2011) .................................................................... 7 Table 3. Developing a mental health policy. WHO, 2005. .................................................... 45 Table 4: Sample Characteristics, by Population Group .........................................................
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