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Mental health, social justice – and a program that works

One of the more important health conferences has been underway in Sydney over the past two days. As you may have already seen, Pat Anderson delivered a powerful keynote to the third Coalition for Research to Improve Aboriginal Health (CRIAH) Conference.

CRIAH is a collaboration between the Aboriginal Health and Medical Research Council NSW and the Sax Institute.

Another of the keynote speakers yesterday was Professor Ezra Susser, Professor of Psychiatry and Epidemiology, Mailman School of Public Health, Columbia University, and associate editor of the International Journal of Epidemiology. He described the historic neglect of people with mental illness, as well as a program that has been shown to be useful in helping people transition from care.

***

Social justice and mental health

Anne Messenger reports:

As in most of the world’s metropolises, many people in New York City who are mentally ill and lacking community support find themselves in a cycle of recurrent incarceration or homelessness.

When Professor Ezra Susser and colleagues began working in New York’s homeless shelters they confronted the dilemma of how to create meaningful and sustainable supports in the community.

“You can’t just throw people out into the world and expect them to sink or swim because they usually sink if you throw them into a desolate situation where they’re all alone,” Professor Susser, an epidemiologist and psychiatrist from the Mailman School of Public Health Columbia University, told the audience of health researchers, academics and health professionals.

He said the fundamental problem facing mental health care was social inequality that pertains to, and has always pertained to, mental health care. Not only did the mentally ill face social exclusion, but mental health faced exclusion from health.

Photograph by Warren Clarke, and supplied by the Sax Institute

“So what do we mean by social exclusion of people with mental disorders? The World Health Organisation … documented people with mental disorders, just in the last year, on the following basis: they are excluded from civil and political rights, educational opportunities, and employment opportunities.

“They have less access to health and social services, to emergency relief services, a many-fold higher mortality rate in high income countries compared to the rest of the population, and they are frequently victims of violence and abuse. So for all these reasons they are a particularly vulnerable group that needs special attention.”

Professor Susser said an extreme example of the treatment of mentally ill patients was the Nazi gas chambers at Hartheim Castle Germany in 1940 – schizophrenics were the first group declared not fit to be part of the Aryan race and 80% of those in Germany were murdered, and unlike other mass murders it was not considered a war crime after the war.

“This was also a good example of not having an evidence base – they thought it was a simple genetic defect, but of course there’s the same rate of schizophrenia in Germany today as in other countries. This is only an extreme example of the long history of abuse of people with mental illness, which continues to this day.

“There has been quite a bit of progress since then…a report by the US Surgeon General in 1999 included a key message that mental health is fundamental to health and WHO has also said the same thing.”

However, Professor Susser said, compared to other kinds of defined health problems like cancer and cardiovascular disease there was very little investment in mental health care, treatment, prevention, promotion and wellbeing, or research.

“Everywhere mental health is not on parity with health but …for most of the world’s population there is less than one trained mental health professional of any kind per 100,000 people.”

To address the issue in his home city, Professor Susser and his colleagues, introduced a nine-month program for mentally ill people in New York’s homeless shelters who were transitioning from institutional shelter care, called Critical Time Intervention (CTI).

The intervention’s goals are to ensure its clients have supports for community living, dignity and meaningful life, and an active role in their recovery and social integration.

“We took people at the point of disequilibrium when they feel especially in need, when they can be engaged, everything is changing so they have a chance to restructure. CTI workers spent their time out in the field with people, rather than in the clinic, and because they mistrusted the clinic and the clinic didn’t really want them, the CTI worker had to find a way to make a connection between the client and the clinic.”

Two randomised controlled trials of the intervention have shown that people enrolled in CTI were doing much better after 18 months than the controls and were able to build durable supports. The intervention is adapted for other countries, and other contexts, including the UK, Netherlands, Brazil and Chile, where it is regionally led.

On the issue of local empowerment and commenting on a speech at the conference by his fellow keynote Pat Anderson, Professor Susser said it was inspiring that the Australian Aboriginal community was constructing a model “for what we should be doing in so many other places across the globe and in spite of setbacks which are inevitable like the NT Intervention, the way that people have formed a collective vision and emphasised the key point which is  involvement of community in their own health improvements.

“This is a fundamental point that is still lacking in most health services across the world.”

• Anne Messenger is Communications Director of the Sax Institute.

(For tweeters, @JulieLeask has been reporting on the conference).

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