Impact of the Community Mental
Health System Sthrengthening
Project in Aceh, Indonesia
(2009-2011)
Hervita Diatri, Harry Minas
Disaster in Aceh
• Laboratory for better MH
system development in
Indonesia
• More than one hundred
local and international
MH and psychosocial
agencies arrived in Aceh
after the tsunami
• Training for primary
health professionals was
a key strategy
About Research Location
Bireuen
• Affected by both
disasters
• Bireuen District
8,7% of
population of
Aceh, >75%
living in rural
areas*
*Indonesia Statistics Center 2010
About Research
Items
Number
Number of Sub-districts
18
Number of Primary Health Care Centres (PHCs)
18
Number of GP1 participants
37
GP+2 : non GP+
24
Number of patient participants
With mental illness3 : with comorbidity4 :
without mental illness
556
460
(82,7%)
Number of treated patients5
Medication: Psychoeducation and or
counseling: Both
1Primary
care doctors
with additional mental health training
3According to MINI-ICD X
4Have more than one mental illness
5Medication and or psychosocial intervenstion (psychoeducation and counseling
2GPs
13
360
(64,7%)
96
(17,2%)
372 (80,9%)
279
(60,7%)
363
(78,9%)
343
(74,6%)
Mental Health Diagnosis
76
74
72
GPs who had received some additional mental health training (GP+)
70
are more likely to make a diagnosis of mentalPrevalence
disorderof in
Anypatients
Mental
who have a MINI diagnosis of mental disorder
than are non-GP+
68
Disorder
66
64
62
All of GP
GP+
non GP+
Mental Health Treatment
700
600
500
400GPs
who had received some additional mental health training
Treated by Non GP+
(GP+) are more likely to give treatment to people with mental
Treated by GP+
300
disorder than are non-GP+
Number of patients
200
100
0
Depression
Anxiety
Psychosis
PTSD
Manic
Mental Disorder and Disability
Research result:
The Multivariate regression
model
suggests
Mental
Health
Problems that the presence
Depression
of a mental disorder is associated with a substantially
increased risk (OR = 6.0) of having disability. Risk is a little
higher (OR = 6.2) if there is comorbidity.
Global Burden Study, 2010
Disability Recognition
500
450
78.6%
400
350
300
250
WHO-DASS
200
GP
150
22.7%
100
50
0
Disability
Severity 1
Severity 2
Severity 3
Psychosocial Support
Psychosocial support by GP
Psychosocial support (perceived by patients)
Disability
(WHO-DAS)
81,50%
(89,5% have MINI Diagnosis)
46,70%
• Different perceptions among GPs and patients related to psychosocial
support.
• More than 95% of the psychosocial support provided is psychoeducation
and counseling
• GP are more likely to give psychosocial support to patients with mental
disorder than patients without mental disorder
Mental Disorder – Disability - Poverty
• Being below the poverty line is associated
with a moderately increased risk (OR = 2,1) of
having disability
• One of the main forms of rehabilitation for
persons with mental disorder in Aceh has
been support with income generation
activities.
Opportunities and
Development Enablers
Mental Health Diagnosis
70
60
50
40
MINI
GP+
30
Non GP+
20
10
0
Depression
Anxiety
Psychosis
PTSD
Manic
Government Commitments
• Province and District Health Offices provide training
to PHC staff 2-3 times/year. There is an opportunity
to modify and enhance this training, and possibly to
introduce continuing supervision and mentoring.
• The Ministry of Health has prioritized PHC
development as the core of the national health
service in the 5 year strategic health plan (2015 –
2019)
Research Recommendations
GPs with some mental health training are more likely to
recognise and diagnose mental disorder, and to provide
treatment than are untrained GPs
There is a need to enhance disability recognition and
assessment, and referral to rehabilitation programs
GPs need to be able to develop appropriate rehabilitation plans
for persons with significant disability
There is a need to go beyond short-term clinical training, to
include training in disability, and to provide continuing skills
development, supervision and mentoring of GPs.
Research Recommendation
Past and Current Training Topics
%GP
Psychosis
Anxiety
Substance Abuse
PTSD
43,2%
40,5%
37,8%
37,8%
Depression
8,1%
Training specifically related to Depression, Anxiety,
PTSD, Disability and Psychosocial Rehabilitation still
need to be improved
Research Recommendations
• The majority (72,1%) of patients say they know about
mental disorder
• Knowing about mental disorders is associated with more
accurate self-identification of mental health problems
(79%, p = 0,049)
• More accurate self-identification of mental health
problems makes it more likely that the GP will recognise,
accurately diagnose and appropriately treat when
necessary.
• Community psychoeducation can empower people to
participate in an appropriate response to the presence of
mental health problems and response to disability.
Role of MH Clinic in PHC
120
100
80
60
40
PHC with MH clinic are more likely to make a diagnosis of mental
disorder in patients who have a MINI diagnosis of mental
GPdisorder
Prevalence
MINI Prevalence
than PHC without MH Clinic
20
PHC10
PHC9
PHC8
PHC7
PHC6
PHC5
PHC4
PHC3
PHC2
PHC1
PHC+8
PHC+7
PHC+6
PHC+5
PHC+4
PHC+3
PHC+2
PHC+1
0
Research Recommendation
• Nearly 99% of the patients believe that mental disorders
can be treated, and 96,2% among them believe that PHC
can effectively treat mental health problems
• The PHC is needed by the community to be more active
and capable in recognition of and response to mental
health problems in PHC attenders.
• The roles of PHC in mental disorder management has
been explicitly stated by the Indonesia’s New MH Law
(2014) to include MH promotion and illness prevention,
early diagnosis and treatment, and facilitating
rehabilitation in collaboration with other sectors
(especially the Social Affairs Office) and protection of the
rights of persons with mental disorder.
TERIMA KASIH