Edition 3

An electronic publication for

mental health in developing
countries - promoting fresh ideas
to reduce suffering worldwide.

Violence isnt mental illness

Mental health educa3on in Papua New Guinea

I used to have two patients round here, but then one of

them cut off the other ones leg so neither of them live
here any longer.
We were coming back from a singularly unsuccessful home visit. Working in the North of Scotland,
Im well aware that a hospital van causes comment in a village. The van was obviously the most
exciting thing all week - it having a white doctor was the months excitement: not least to the
psychiatric nurse, who proudly explained, Shes a doctor of sickness of thinking from Scotland.
I was mid-way through an unusual PRIME trip: eight weeks teaching and working in Papua New
Guinea. Over this time I discovered the reason for their pattern of cases - the community associates
mental illness with violence. Those who appear mentally ill but not at risk are periodically maltreated
but generally left alone. Those causing risk to themselves or others (women wanting to wander or
men who were violent) tend to be chained up inside a hut. Only those who couldnt be contained
this way got as far as the nearest clinic. This usually means young men; generally those who are
violent after taking drugs.

Teaching at various nursing schools, I found that the psychiatry curriculum was designed and taught
by staff with little formal mental health background or training. Persuading these staff that violence
did not equal psychosis was a struggle, though it was helped by teaching using the WHO mental
health GAP guide.
Teaching child development to a group of pastors, revealed culturally embedded ideas of what was
considered acceptable with regard to beating children. Although Unicef has a positive parenting
project, most people still struggle to conceptualise discipline without corporal punishment. There
are also many cases where young men regularly assault their parents and siblings. Once the young
man is stronger than his father, no one else will step in and help to control him.

So what can you actually do with so much need?

I trained the two regional psychiatric nurses in using the WHO mental health guide, especially the
diagnosis of psychosis versus substance misuse.
Concentrating on the well-women clinic (which had a domestic violence service), I gave teaching
about trauma, somatised depression and anxiety and medically unexplained symptoms. The service
had been given funding, but not training, to run a support group for women experiencing domestic
violence and I was able to explain the basic principles of this.
At one nursing school, nurses from
the psychiatric hospital were invited to
attend the mental health teaching. This
included role-plays on dealing with
patients who were agitated or
distressed. They revealed that they
often saw their role as stopping
escapes and giving medication - talking
to a patient who was distressed by
delusions or hallucinations was not
something they had ever seen done.

Nursing students practising listening skills

Final year students responded well to being helped to imagine what it might feel like to experience
psychosis and role-playing in groups to experiment with different approaches to the patient.
In future trips, hopefully a single session revising basic mental health will stop the atrophy of
confidence and knowledge. In general though, the biggest challenge is core PRIME teaching demonstrating by our attitudes and actions that people with mental illnesses matter just as much as
anybody else.
Dr Jenny Bryden

Teaching mental health

Does teaching mental health sound like a challenge?
Are you wondering:

How can I usefully teach whats needed in a short time?

What do primary care workers really need to know?

Where shall I get help?

Help is at hand. In 2009 WHO published mhGAP (Mental Health Gap Action Programme), aimed at
assisting primary care workers in diagnosing and treating mental health disorders. All evidenced-based and
prepared by leaders in their fields, mhGAP can be downloaded from the WHO website at WHO mhGAP
and it has been translated into different languages.
At first sight the manual looks daunting, with lots of diagrams and coloured boxes and pages, so some
training is helpful to make it useful. Most people then like to use the manual regularly and keep it with
them in the clinic. Experience shows that remembering the basic principles of care can be helped by the
mnemonic CATMAP.

communica*on

assessment

treatment

mobilising social support

a6en*on to overall wellbeing

protec*on of human rights

There are chapters on depression, psychosis, drug and alcohol abuse, children and adolescents problems,
dementia and epilepsy and the latest addition is on stress. All chapters have guidance on assessment and
various treatment, with emphasis on useful tools like psychoeducation, psychosocial support, problem
solving and guidance on appropriate medication with doses.
Although spiritual issues are not directly addressed, there are plenty of opportunities to include spiritual
care in the management of people with mental health difficulties, especially as the WHO has recently
published guidance on the importance of spiritual wellbeing as part of good care.
Unfortunately many people are still stigmatised if they have a mental illness and this adds to their distress
and can interfere with good care. Primary care workers are in an excellent position to challenge unhealthy
beliefs and role model treating people with mental illness well.
It may surprise some people to know that mental health is treatable and many people recover and go on
to lead productive lives. WHO says there is no health without mental health.

Anyone can learn to use the mhGAP manual - nurses, care workers, teachers, doctors, pastors, lay people
alike can be supported in their mission to improve the lives of people by learning from WHO mhGAP.

Dr Sophie Thompson teaching primary care workers using the mhGAP resource

The WHO mhCAP Intervention Guide

www.who.int/mental_health/mhgap

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h;p://www.who.int/mental_health/mhgap/newsle;er_july_2015.pdf?ua=1

DMH bite-size

The mhGAP newsle6er

www.who.int/mental_health/publications/mhgap_newsletters

Using mhGAP-IG on mobile phones for

frontline healthcare workers to manage
depression in Kenya.

The treatment gap in mental health in low and middle

income countries is es3mated at 80%, compared with less than 40% in high
income countries.
An area of increasing interest in delivering evidence based interven3ons across
medicine is that of using mobile phone technology.
One such project is Using mhGAP-IG on mobile phones for frontline
healthcare workers to manage depression in Kenya.
The project under the auspices of NGO African Mental Health Founda3on uses
specially designed soTware mounted on mobile phones to overcome barriers
of distance and travel, in order to train, supervise and support primary health
care workers to deliver WHO mental health treatment gap interven3on
guidelines (mhGAP-IG) at the Point of Care.
The project has yet to evaluate but is an interes3ng innova3on which promises
much in bridging the GAP.
Further details at h;p://goo.gl/H2nwZs

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