WHO-AIMS REPORT ON MENTAL HEALTH SYSTEM IN GUYANA 2008 MINISTRY OF HEALTH GUYANA WHO-AIMS REPORT ON MENTAL HEALTH SYSTEM IN GUYANA A report of the assessment of the mental health system in Guyana using the World Health Organization - Assessment Instrument for Mental Health Systems (WHO-AIMS). Georgetown, Guyana 2008 Ministry of Health Guyana WHO, Guyana 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 WHO, Country Office in Guyana 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) Dr. Krishnadat, Director Chronic Disease, Ministry of Health Guyan: [email protected] 2) Dr. Kathleen Israel, PAHO/WHO Representative, Guyana Country Office: [email protected] 3) Shekhar Saxena, WHO Headquarters: [email protected] (ISBN) World Health Organization 2006 Suggested citation: WHO-AIMS Report on Mental Health System in Guyana, WHO and Ministry of Health, Georgetown, Guyana, 2008. Copyright text as per rules of the Country Office 3 Acknowledgement The World Health Organization Assessment Instrument for Mental Health Systems (WHO- AIMS) was used to collect information on the mental health system of Guyana. The project in Guyana was implemented and carried out by Bhiro Harry, National Psychiatrist, Mayda Grajales, Chief Psychiatrist National Psychiatric Hospital, and Sonia Chehil, technical expert from the PAHO/WHO collaborating centre at Dalhousie University. Technical support was provided by Stan Kutcher Director of the PAHO/WHO collaborating centre at Dalhousie University, Hedwig Goede, PAHO Health System Advisor and Devora Kestel, PAHO Mental Health Regional Advisor. The preparation of this study would not have been possible without the collaboration of the Ministry of Health, Health Canada, PAHO Guyana and Dalhousie University. This project was funded by Health Canada as part of the PAHO Biannual Project Budget. The World Health Organization Assessment Instrument for Mental health Systems (WHO- AIMS) has been conceptualized and developed by the Mental Health Evidence and Research team (MER) of the Department of Mental Health and Substance Abuse (MSD), World Health Organization (WHO), Geneva, in collaboration with colleagues inside and outside of WHO. Please refer to WHO-AIMS (WHO, 2005) for full information on the development of WHO- AIMS at the following website. http://www.who.int/mental_health/evidence/WHO-AIMS/en/index.html 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 Maria Grazia Motturi. Additional assistance has been provided by Patricia Esparza and Liesbet Villé. The WHO-AIMS project is coordinated by Shekhar Saxena. 4 Executive Summary The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was used to collect information on the mental health system in Guyana. The goal of collecting this information is to improve the mental health system and to provide a baseline for monitoring the change. This will enable Guyana to develop information-based mental health plans with clear base-line information and targets. It will also be useful to monitor progress in implementing reform policies, providing community services, and involving users, families and other stakeholders in mental health promotion, prevention, care and rehabilitation. Although there is little epidemiologic data from Guyana upon which to base assessments of mental health service need, disease burden estimates have recognized the neuropsychiatric disorders as making a larger contribution to the burden of disease, measured in Disability Adjusted Life Years (DALYs), than other diseases such as HIV/AIDS, tuberculosis, and malaria combined. Unipolar depression alone has been identified as the fifth greatest contributor to disease burden in Guyana and suicide is estimated to be the third-leading cause of death among those 15 to 44 years of age, accounting for 13% of all deaths (PAHO; 2006, February 2003). Relevant studies in the Americas indicate there is likely a prevalence of 10 to 15% of the population with a mental disorder at any one time, with 3 to 5% of the population having a severe chronic mental disorder. Given a population estimate of 750,000, this would predict that 75,000 to 112,500 Guyanese suffer from mental disorders and require some level of mental health care services. Of these, approximately 22,500 to 37,500 would be expected to suffer from severe mental illness. These projections do not include the number of patients with epilepsy and mental retardation, which are not surveyed in typical psychiatric epidemiologic studies, but are included in the population serviced by mental health care services in Guyana. The current mental health system in Guyana is fragmented, poorly resourced, and not integrated into the general health-care system. Care of the mentally ill is provided under the legislative framework of the Mental Health Ordinance of 1930, which is antiquated and fails to make provisions for the protection of the rights of people with mental disorders. Persons with mental disorders are reported to suffer discrimination in their communities, the workplace, educational institutions, judicial services and the health-care system. Safeguards to protect individuals with mental illness from involuntary admission and treatment and mechanisms to oversee treatment practices within health facilities are lacking. There are no independent review bodies established to protect the human rights of users of mental health services. Stigma against the mentally ill is reported to be pervasive and considered by stakeholders to be expressed by the public as well as by many health professionals, the police, and policy makers and administrators alike. It is considered to be one of the greatest barriers to the development of modern mental health services in Guyana. Mental health services are inadequate and not available or accessible to the vast majority of the population. Although at least one medication from each class of psychotropic drug is available at all mental health facilities as well as most primary and secondary care facilities in Guyana, there are no guidelines or protocols for the use of psychotropic drugs, and few health or specialized mental health workers have received any training in the rational use of these medications. There are minimal 5 numbers of general health human resources with the necessary mental health competencies to provide mental health care services at any level of general health care services. In addition, few adequately trained specialized mental health professionals are available within mental health services. At the time of this assessment there were 3 psychiatrists in the public sector in Guyana, 2 based in Georgetown and one at the National Psychiatric Hospital. Besides these physicians, mental health staff has variable levels of training, and often lack the competencies required to provide adequate quality mental health care. Guyana’s total of 3 full-time equivalent psychiatrists translates into 0.5 psychiatrists per 100,000 population (equal to 5 per million) significantly below the world reference average of 4.2 per 100,000 (WHO, 2005). By these standards, Guyana’s mentally ill are markedly underserved. Available public mental health services are predominantly institution-based. Tertiary level services are provided by one 240-bed mental hospital - the National Psychiatric Hospital - which provides both inpatient and outpatient services. Care provided at the mental hospital is primarily custodial and heavily reliant on pharmacologic intervention. The majority of mental hospital beds are filled by long stay patients who do not necessarily require institutional care. There is one 4-bed short-stay community- based psychiatric unit in the country’s tertiary heath care facility, the Georgetown Public Hospital Corporation (GPHC), which provides emergency and acute care services. There are few community-based services and minimal services available at primary care level. There are no national or institutional standards for mental health care, facilities or human resources. The National Psychiatric Hospital (NPH) is in substantial disrepair and significantly below the standard of facilities that provide for physical health care, raising concern about equitable treatment of the mentally ill. There are no standards, protocols, policies or guidelines for the use of psychotropic medications; the assessment, treatment, monitoring, and ongoing evaluation of patients with mental disorders; the charting of patient information; or the maintenance