Description and evaluation of a project to improve the identification and management of mood disorders in developing countries Ilse Blignault, Vijaya Manicavasagar, Odille Agnes Chang and Gordon Parker
Objective: This paper describes a training program in mood disorders for senior mental health clinicians in the Pacific region and presents the qualitative evaluation findings. Method: The program, which incorporated a 2-week intensive course in Sydney and follow-up in-country, was undertaken by 13 clinicians from the Ministries of Health in seven Pacific Island countries. Evaluation data were gathered throughout the program. Participating individuals and their respective Ministries also completed an activity completion report. Results: The evaluation was very positive. Individual and organizational reports documented immediate and expected ongoing benefits and expressed a desire for continuing collaboration. Conclusions: The program has resulted in a major boost to regional expertise and leadership in mood disorders. Furthermore, it has made an important contribution to the implementation of individual country mental health policies, one which strengthens the regional mental health network and builds new connections with Australian institutions. Success was based on a collaborative approach, high levels of institutional and individual commitment, and careful attention to both content and process issues. Sustainability will be enhanced through ongoing collaborative in-country and regional activities. Key words: evaluation, mood disorders, Pacific region, professional education and training.
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PSYCHIATRY IN XXX THE REGION
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lse Blignault Manager, Developing Countries Project, Black Dog Institute, Randwick, NSW, Australia. Vijaya Manicavasagar Director, Psychological Services, Black Dog Institute, Randwick, NSW, Australia. Odille Agnes Chang Senior Lecturer in Psychiatry, College of Medicine, Nursing and Health Sciences, Fiji National University, Fiji. Gordon Parker Executive Director, Black Dog Institute, Randwick, NSW, Australia. Correspondence: Dr Ilse Blignault, Manager, Developing Countries Project, Black Dog Institute, Hospital Road, Prince of Wales Hospital, Randwick, NSW 2031, Australia. Email:
[email protected]
T
he relationship between poverty, mental illness and disability is now well recognized, with the presence of any one factor increasing the likelihood of the others.1 In the Pacific region, mental health is receiving increasing attention. Several Pacific Island Countries (PICs) have recently developed, or are in the process of developing, national mental health policies and plans with support from development partners.1,2 In most PICs, the mental health workforce is very small and skills are limited,3 especially in identifying and managing mood disorders. Global Burden of Disease projections indicate that by 2030 depression will be the second leading cause of disability adjusted life years (DALYs) in middle-income countries and the third leading cause of DALYs in low-income countries.4 The Black Dog Institute (www.blackdog.org.au), a not-for-profit organization supported by the NSW Department of Health and the University of New South Wales, offers expertise in mood disorders via research, professional education and training, clinical services and community programs. In 2007, the Institute
doi: 10.3109/10398562.2010.498515 © 2010 The Royal Australian and New Zealand College of Psychiatrists
Following a successful pilot training program in 2008 involving 14 senior clinicians from Sri Lanka (8), Fiji (2), Papua New Guinea (2) and the Solomon Islands (2), further funding was obtained from the Australian Agency for International Development (AusAID) to repeat the training in 2009 with another group of clinicians from PICs only, with the goals of building leadership and expertise in mood disorders and contributing to mental health systems development in the Pacific region. Project partners for the 2009 training program included the Ministry/Department of Health in the Cook Islands, the Federated States of Micronesia, Fiji, Palau, Papua New Guinea, the Solomon Islands and Vanuatu, and the World Health Organization Pacific Islands Mental Health Network (PIMHnet). There were 13 trainees. This paper outlines the way in which the program was implemented and evaluated.
PROGRAM PREPARATION The core team assembled for the pilot program was reassembled. It consisted of Project Sponsor and Director (GP and VM), Project Manager (IB), Group Facilitator and Participant Liaison Officer, and was supported by the Institute’s education team and a psychology student volunteer. Information about the training program was circulated through PIMHnet. Trainee selection criteria emphasized leadership and capacity to transfer knowledge and skills to others. An employer letter of support was required with each nomination. With the exception of Fiji, each country was encouraged to send two participants. The final group included three psychiatrists, six doctors and four psychiatric nurses. Seven of the trainees were women and five held regional posts. Prior to their arrival in Sydney, email and fax were used to build links with and between the trainees, and to obtain their feedback on the planned course content. An orientation session was held for presenters to encourage tailoring of training materials to the geographical and socio-cultural context of the Pacific.
COURSE CONTENT AND FORMAT The training objectives were to increase knowledge and understanding of depression and bipolar disorder and
to build skills and confidence in their recognition and management. The 2-week course was organized into five streams designed to provide information about the diagnosis and treatment of mood disorders (‘Conceptual and Diagnostic Issues’ stream); training in the development and implementation of community information, engagement and destigmatization programs (‘Community’ stream); examples of train-the-trainer models for professional education (‘Training’ stream); practical suggestions for influencing public policy and advocacy (‘Public Policy’ stream); and experience in conducting clinical interviews with patients with mood disorders (‘Clinical’ stream). While a life-span approach was taken, in keeping with the demography of PICs, an additional 1-day workshop on dealing with mood disorders in adolescents was scheduled on the weekend. The majority of sessions were delivered by Institute staff and affiliates, with additional content experts involved as necessary. Content was delivered via a mix of lectures, demonstrations (including patient interviews) and practical activities, with most sessions of 1.5 hours duration. Trainees were encouraged to share their own country situations and experiences and, under the guidance of the group facilitator, to reflect on the content of each training day and its application to their own settings. On the first day, trainees were given comprehensive training folders and laptops for use during the course. Each trainee was also given a USB with copies of PowerPoint presentations and other resource material. Additional material was distributed, in hard copy and electronic form, as the course progressed. Trainees were introduced to the Institute’s website and other websites, as well as to a specially created private online forum which was used to post
Table 1:
Overall course evaluation
Item* Overall program informative Information relevant Confident about adaptation Materials appropriate Facilities suitable Program well organized Overall quality of program excellent Felt intellectually stimulated at BDI Travel arrangements well handled Accommodation suitable Social functions well organized Meals suitable Felt socially supported at BDI
Rating 4.9 4.5 4.2 4.7 4.9 4.9 4.9 4.9 5 4.9 5 4.7 4.9
*Rating scale: 1 ⫽ strongly disagree, 2 ⫽ disagree, 3 ⫽ neither
agree nor disagree, 4 ⫽ moderately agree, 5 ⫽ strongly agree.
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received funding through a bequest for a project that would enhance the treatment of mental illness in developing countries. The whole project incorporates two phases. The first involves developing and delivering an intensive educational course aimed at senior clinicians from developing countries at the Institute in Sydney, with continuing support provided via information and communication technology; while the second involves collaborating with those clinicians and their organizations to build awareness of mood disorders and train others in their own countries.
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messages and share files. Assistance was provided to those who were unfamiliar with the technology.
FOLLOW-UP ACTIVITIES During the formal follow-up period (extended from 3 to 4 months to allow for Christmas holidays), trainees were expected to work on mood disorders for the equivalent of 5 days with remote support and mentoring from the Institute. Clinical practice and professional development activities were discussed via email on a fortnightly basis, while new information and resources
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A train-the-trainer model was adopted, with trainees expected to share their new knowledge, skills and tools with others on their return. During the course, they worked on cultural and linguistic adaptations of Black Dog Institute resources. Most produced PowerPoint presentations for health worker training or community education, two adapted fact sheets for the community, and one developed a short drama for schools. These projects were shared with the whole group on the final day, when the trainees also presented their individual work plans for the follow-up period.
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(including those generated by the trainees) were shared via the online forum.
EVALUATION Feedback on individual sessions and activities was collected throughout the training, with a 2-page questionnaire assessing all aspects of the course, including any deficiencies, completed on the last day. As an AusAID requirement, each trainee and country partner organization also completed an activity completion report. Additional evaluation data were collected during the follow-up period. As shown in Table 1, the overall program content and organization were extremely positively evaluated. Participants felt stimulated and supported during their stay. Importantly, they considered the information presented very relevant to their own situations and felt confident about making the necessary adaptations. Hearing from those with personal experience of mood disorders (consumers and carers) was a revelation for many, and attending a book launch at the Institute by the NSW Governor, Her Excellency Professor Marie
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Applied training in clinical practice
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Established data base of clients with mood disorders to support monitoring of treatment outcomes
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Established a regular mental health clinic at provincial hospital (about one-third of patients have mood disorders)
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Fact sheet, “Helping someone with a mood disorder” [translated during course], used to educate family and friends
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Conducted and evaluated continuing medical education session, presenting the sub-typing model of depression
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Presented an overview of the training and the sub-typing model of depression at a grand round, attended by Ministry as well as hospital staff
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Delivered presentation on stigma at a grand round, and subsequently emailed copy of the PowerPoint file to all government health workers
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Delivered session on mood disorders as part of 2-week general training program on mental health [organized through PIMHnet]
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Delivered 4-day training course on mood disorders to registered nurses working in an outer island
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Gave short talk on mood disorders at a church meeting
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Play about mood disorders for high school students [written during course] performed
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Translated fact sheets
Figure 1:
Follow-up activities reported by trainees.
As a clinician from a developing country such as Fiji, with limited opportunities for psycho-education and training, being a participant in the Black Dog Institute’s training program was an extremely beneficial, timely and worthwhile experience. Being exposed to up to date research and knowledge in the field of mood disorders by premier experts was invaluable, as was the opportunity to put that information into perspective by sharing experiences from other countries with similar levels of mental health development, infrastructure and services. The availability of easily administered assessment tools and kits which we were free to adapt to our local settings was also noteworthy. From my personal perspective however, the most important feature of the training program was the willingness and eagerness of the trainers not only to impart their knowledge but to genuinely learn about and from the countries who participated. I believe it is this essential exchange of knowledge between the Institute and participating countries which is the mainstay of the program’s success. Country/Mental Health Service perspective The Institute’s training program has been instrumental for Fiji in further developing its Mental Health Clinical Services Network (MHCSN) and in supporting its efforts to expand and strengthen community mental health services. Fiji’s Ministry of Health has nominated three participants [two in 2008 and one in 2009] who are key members of the MHCSN representing each of the main divisions in the country. With Fiji’s limited human resources for health it is necessary to up-skill our medical and public health colleagues inmental health and psychiatry as they are the ones tasked to care for psychiatric patients in the outer areas. A focus on mood disorders is especially relevant given its poor identification rate in the country. Also, given Fiji’s high numbers of suicidal behaviour, it is timely and beneficial for the Ministry of Health and its National Committee for the Prevention of Suicide to collaborate with the Black Dog Institute in building awareness about mood disorders, especially depression and its relation to suicidal behaviour, which will be the focus of Fiji’s phase two project.
Figure 2:
Trainee and country perspectives by Dr Odille Chang.
Bashir, was inspiring. Written and verbal comments suggested that the trainees were, indeed, empowered by the training. Over the course, they became increasingly appreciative of their critical role in improving mental health services and mental health outcomes in their own countries. They also developed a sense of fellowship and a strong professional network, adding another layer to PIMHnet. All 13 trainees reported that the training program was consistent with their expectations, while four indicated that it exceeded their expectations. Nine of them indicated that they would have liked more on psychological intervention techniques, with seven specifically mentioning cognitive behavioural therapy. All but one were satisfied with the level of exchange and interaction with Fellows from other PICs. The following comments are illustrative: “Different perspectives and input”, “Felt comfortable to discuss relevant issues with them”, “Started to get to know them better and now I have everyone’s email to network”. During the follow-up period, all trainees made good progress on their individual work plans, most of which involved the application of newly acquired skills in their everyday clinical and community practice and disseminating information about mood disorders to their colleagues. Resource material adapted for local use during the
course itself was further refined through these processes. Figure 1 lists some of the follow-up activities. Feedback from the Ministries of Health highlighted the short- and long-term value of the training program from an organizational perspective. All expressed a desire for continuing collaboration with the Institute. Figure 2 presents benefits from the point of view of one trainee and Ministry. One of the authors, Dr Odille Chang, was farmerly a psychiatrist and senior manager in the Fiji Mental Health Service and a trainee in the 2008 pilot program. For the Black Dog Institute, the positive outcomes reaffirmed the importance of strong project management as well as broad institutional support. Providing everyone with laptops facilitated engagement with the material presented and enhanced both individual and group activities. Those less experienced at using computers learnt new skills and gained confidence. Providing internet and email access for an hour before and after the day’s program provided further opportunities for learning and allowed the trainees to keep in touch with work at home (especially important when sending staff for training leaves a large gap in services). Selection of trainees from different PICs contributed to the overall learning experience, while taking two trainees from each PIC meant they were able to support each other during the course and on return home. The
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Clinician/participant perspective
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Areas for improvement in future courses include adding 2 or 3 days and leaving the weekends free. Also, as the trainees were not accustomed to sitting for 8 hours, it would be useful to increase the level of physical activity (e.g. short walks during tea breaks and lunch).
CONCLUSION This training program has boosted expertise and leadership in mood disorders in the Pacific region. Furthermore, it has contributed to the implementation of individual country mental health policies, strengthening the regional mental health network and building new connections with Australian institutions. Success was based on a collaborative approach, high levels of institutional and individual commitment, and careful attention to both content and process issues. The second phase of the project, to be conducted in 2010, will involve a series of in-country activities that will build on the work to date and provide opportunities for
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holistic approach to conceptualizing and managing mood disorders and the importance attached to primary care as well as specialist care, consistent with the mental health policy frameworks in their home countries, was appreciated by all. An early presentation by the Institute’s Creative Director, demonstrating the value of pictures and stories in educating the public about mood disorders, was well-timed and particularly relevant to PICs.
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longer term evaluation of program impact. During this continuing contact with partner organizations and trai nees, we will explore options and potential funding sources for further collaborations that will improve identification and management of mood disorders in developing countries.
ACKNOWLEDGEMENTS This project was funded by AusAID’s Australian Leadership Awards – Fellowships program and The Christopher Molnar Bequest.
DISCLOSURE The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Minas H. International observatory on mental health systems: a mental health research and development network. International Journal of Mental Health Systems 2009; 3: doi:10.1186/1752-4458-3-2. 2. Hughes F. Mental health in the Pacific: the role of the Pacific Islands Mental Health Network. Pacific Health Dialog 2009; 15: 177–180. 3. Hughes F, Finlayson M, Firkin MP et al. Situational Analysis of Mental Health Needs and Resources in Pacific Island Countries. Geneva: Centre for Mental Health Research, Policy and Service Development, World Health Organization, January 2005. 4. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 3(11): e442. doi:10.1371/journal.pmed.0030442.
