D R A F T WHO-AIMS REPORT ON MENTAL H EALTH SYSTEM IN MONTSERRAT MINISTRY OF HEALTH MONTSERRAT WHO-AIMS REPORT ON MENTAL HEALTH SYSTEM IN MONTSERRAT Report of the Assessment of the Mental Health System in Montserrat using the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS) Montserrat 2009 The data was collected in 2009 based on data for 2007 MINISTRY OF HEALTH MONTSERRAT PAHO/ECC Barbados office Pan American Health Organization (PAHO), WHO Regional Office for the Americas (AMRO) WHO Department of Mental Health and Substance Abuse (MSD) 2 This publication has been produced by the PAHO/ECC Barbados office, in collaboration with Pan American Health Organization (PAHO), WHO Regional Office for the Americas (AMRO) and WHO, Headquarters. At WHO Headquarters this work has been supported by the Evidence and Research Team of the Department of Mental Health and Substance Abuse, Cluster of Noncommunicable Diseases and Mental Health. For further information and feedback, please contact: 1) Linda Dias [email protected] 2) Shirley Alleyne Non-Communicable Diseases and Mental Health Advisor Barbados and the Eastern Caribbean Countries PAHO/WHO, Barbados [email protected] 3) Shekhar Saxena, WHO Headquarters [email protected] (ISBN) World Health Organization 2009 Suggested citation: WHO-AIMS Report on Mental Health System in Montserrat, WHO and Ministry of Health, Montserrat ,2009. (Copyright text as per rules of the Country Office) 3 4 Acknowledgement The World Health Organization Assessment Instrument for Mental Health (WHO-AIMS) was used to collect information and structure the report on the mental health system in Montserrat. The project in Montserrat was carried out by Dr. Margaret Hazlewood, PAHO/ECC consultant. This final document is the product of the Ministry of Health, Montserrat and the PAHO/ECC office’s efforts to collect, analyze, and disseminate information about the mental health system in Montserrat. Direct support for the project was received from: Mrs. Beverley Mendes, Permanent Secretary, Ministry of Health; Dr. Olufemi Dipeolu, Chief Medical Officer, Ministry of Health; Mrs. Desreen Silcott, Principal Nursing Officer, Glendon Hospital; Ms. Linda Dias, Community Mental Health Nurse, Ministry of Health; Miss Rona Greenaway, Senior Pharmacist, Ag., Glendon Hospital; and Mrs. Laura Taylor-Scotland, Director, Community Services Department. These persons played an essential role in the data collection, discussion, and review of this landmark assessment and to them sincere appreciated is awarded. In-country logistics and support were provided by Ms. Katrina Smith, Country Program Officer, PAHO/ECC office (Anguilla). Dr. Shirley Alleyne, Non-Communicable Diseases and Mental Health Adviser, PAHO/WHO Barbados Office, provided technical support for the review and final production of the report. The PAHO/ECC office and the national authorities in Montserrat wish to thank the World Health Organization for its remarkable foresight to design this instrument to assess the mental health systems in its Member States. The project received financial assistance and/or seconded personnel from: The National Institute of Mental Health (NIMH) (under the National Institutes of Health) and the Center for Mental Health Services (under the Substance Abuse and Mental Health Services Administration [SAMHSA]) of the United States; The Health Authority of Regione Lombardia, Italy; The Ministry of Public Health of Belgium and The Institute of Neurosciences Mental Health and Addiction, Canadian Institutes of Health Research. The WHO-AIMS team at WHO Headquarters includes: Benedetto Saraceno, Shekhar Saxena, Tom Barrett, Antonio Lora, Mark van Ommeren, Jodi Morris, Anna Maria Berrino and Grazia Motturi. Additional assistance has been provided by Monika Malo. The WHO-AIMS project is coordinated by Shekhar Saxena. 5 Executive summary The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS 2.2) was used to collect information on the mental health system in Montserrat. The goal of collecting this information is to improve the mental health system and to provide a baseline for monitoring change. This will enable Montserrat to finalize its mental health plan with clear baseline information and targets. It will be useful to assess gaps and monitor progress in implementing reform policies, providing community services, and involving users, families and other stakeholders in mental health promotion, prevention, care, and rehabilitation. Montserrat has a Mental Treatment Act (2006) and a draft mental health plan (2002). There is no mental health policy nor is there a well functioning national health information system to inform the formulation of policy options. Although there is no explicit human rights policy, the Act provides a legal framework to address the critical issue of ill-treatment of insane persons in institutions. There is no mental health unit in the Ministry of Health. No human rights review body exists and none of the mental health service delivery facilities has had an external human rights review. Financing is oriented towards community care and the mental health budget constituted around two percent of the total health expenditures. None of the mental health workers received training in human rights. There is no social insurance scheme and the entire population has free access to psychotropic drugs. There is no mental hospital. Mental health services are community-based and this involves diagnosing, treating, and follow-up of patients with mental illness. Access to mental health care is even across the island. The St. John’s health center is the main treatment facility. Forty-four persons were treated in an 11-month period in 2007, accounting for 667 outpatient contacts. Thirty-six percent of those seen were females. The overwhelming majority of mentally ill persons were diagnosed as having schizophrenia. Persons requiring hospitalization are admitted to the Glendon Hospital. Although there are no designated beds for psychiatric patients, the medical ward has a seclusion room (called a “strong room”) for such admissions. There are no trained mental health professionals assigned to the Glendon Hospital. Quantitative data on admission status (voluntary or involuntary) and use of restraints are not recorded. There are no forensic and other residential facilities. Inmates with mental illness are housed among the prison’s population. Treatment and follow-up care are managed by the community mental health nurses. Psychotropic medicines are available to address the symptoms of mental illness. These include antipsychotics, antidepressants, mood stabilizers, anxiolytics, and antiepileptics. Pharmacotherapy is the predominant treatment modality for the management of mental and behavioral disorders. The trusting relationship between the community mental health nurses and patients with chronic mental health conditions has a positive effect on compliance with treatment regimen. There is no risk-benefits assessment of the effects on long-term use of psychotropic medications. 6 Primary health care workers had at least two days of refresher training in essential skills of mental health care. The mental health nurses are not allowed to initiate a prescription for psychotropic drugs but are allowed to continue and/or adjust such prescriptions. Training in the application of psychosocial skills or behavioral interventions was non- existent. All primary health care centers are physician-based. None of the physicians in Montserrat has at least two days of refresher training in any aspect of mental health. There were 9 persons working in mental health in Montserrat which includes an internist, not specialized in psychiatry, and the visiting consultant psychiatrist from Dominica. There was no social worker, psychologist, or occupational therapist. Two community mental health nurses at St. John’s clinic form the nucleus of therapeutic and supportive care. There are no consumer and family associations. There is an ad hoc Mental Health Committee that participated in the drafting of the Mental Health Treatment Act. The Mentally Challenged Housing Social Impact Assessment (2006) created the framework for policy guidelines and action with respect to housing for the mentally challenged. The Red Cross and communities/villages play an active role in the care and protection of mentally challenged persons although there are no formal collaborative arrangements. Public education and awareness campaigns target the general population, adolescents, and professional groups linked to the health sector. The ad hoc Mental Health Committee serves as an advocacy group to address issues including stigma and discrimination against the mentally ill. The available health indicators are insufficient to provide timely, accurate, and relevant health information. There is no mental health information system to facilitate evidence- based decisions, program planning, monitoring, and evaluation of services. There are no reports or briefings to inform the prevalence, types, and effects of mental illness in Montserrat. There is no research on mental health published in indexed journals. The community-oriented approach to mental health includes a unique feature that addresses the nutritional and other needs of the mentally challenged patient. The Community Services Department enters into “good faith” agreements with supermarkets and cook shops in various communities where patients can collect groceries and receive daily meals. In some instances, patients