Postgraduate training in psychiatry in Asia.

PURPOSE OF REVIEW: To understand the current situation, needs and challenges in the area of postgraduate training in psychiatry in Asia and identify implementable solutions.Leaders in psychiatric education from nine Asia Pacific countries prepared country reports, based on a suggested list of items and met for a day to discuss and identify implementable solutions to improve the current unsatisfactory status of postgraduate training in psychiatry. RECENT FINDINGS: Except Japan, all the other countries have a very low number of psychiatrists per 100 000 population - far lower than the global target of 10 psychiatrist per 100 000 population. The undergraduate teaching in psychiatry in majority of the countries is restricted to 20 h of lectures given during the 4-6 semester and 2-3 weeks of clinical ward placements. The duration as well as the overall quality of postgraduate training and methods of assessment and accreditation varies widely across and within countries. SUMMARY: Numerous gaps that need to be addressed to enhance the quality of psychiatrists trained in Asia were identified. There is a need to have uniform minimum standards of training and mechanisms of mutual support, for not only training but also academics and research activities in Asia.

Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective.

BACKGROUND: Major gaps remain - especially in low- and middle-income countries - in the realization of comprehensive, community-based mental health care. One potentially important yet overlooked opportunity for accelerating mental health reform lies within emergency situations, such as armed conflicts or natural disasters. Despite their adverse impacts on affected populations' mental health and well being, emergencies also draw attention and resources to these issues and provide openings for mental health service development. CASE DESCRIPTION: Cases were considered if they represented a low- or middle-income country or territory affected by an emergency, were initiated between 2000 and 2010, succeeded in making changes to the mental health system, and were able to be documented by an expert involved directly with the case. Based on these criteria, 10 case examples from diverse emergency-affected settings were included: Afghanistan, Burundi, Indonesia (Aceh Province), Iraq, Jordan, Kosovo, occupied Palestinian territory, Somalia, Sri Lanka, and Timor-Leste. DISCUSSION AND EVALUATION: These cases demonstrate generally that emergency contexts can be tapped to make substantial and sustainable improvements in mental health systems. From these experiences, 10 common lessons learnt were identified on how to make this happen. These lessons include the importance of adopting a longer-term perspective for mental health reform from the outset, and focusing on system-wide reform that addresses both new-onset and pre-existing mental disorders. CONCLUSIONS: Global progress in mental health care would happen more quickly if, in every crisis, strategic efforts were made to convert short-term interest in mental health problems into momentum for mental health reform.

Determinants of psychological morbidity in survivors of the earthquake and tsunami in Aceh and Nias.

BACKGROUND: The goal of this study was to collect information to inform the design of a mental health response following the massive December 2004 earthquake and tsunami in Aceh and North Sumatra, Indonesia. As well as exploring the effect on mental health of direct exposure to the tsunami the study was designed to examine the effect on mental health of immediate post-disaster changes in life circumstances (impact). METHODS: Information was collected from a sample of 783 people aged 15 years and over in earthquake and tsunami-affected areas of Aceh and Nias, 616 Internally Displaced Persons (IDPs) and 167 non-IDPs. The structured questionnaire that was designed for data collection consisted of demographic information, measures of disaster exposure and of changes in life circumstances (impact), the extended version of the Self-Reporting Questionnaire (SRQ), and a brief measure of resilience. Group comparisons, contrasting responses of IDPs and non-IDPs, were by chi-square for frequency data and t-tests for ordinal or continuous data. Hierarchical multiple linear regression analyses were performed to examine the relative contributions to psychopathology of demographic variables and measures of exposure, impact and resilience. RESULTS: High rates of psychopathology, including symptoms of anxiety and affective disorders and post-traumatic stress syndrome, were recorded in the overall sample, particularly in Internally Displaced Persons (IDPs) who experienced more substantial post-disaster changes in life circumstances (impact). The IDP group experienced significantly more SRQ symptoms than did the non-IDP group. Demographic factors alone accounted for less two percent of variance in SRQ-scores. Higher SRQ-20 scores were observed among women, those with lower education, those with diminished resilience beliefs, those experiencing high scores on disaster impact, those experiencing direct exposures to the disaster, and due to (unmeasured) conditions related to being an IDP. The greatest effect among these was due to disaster impacts. The pattern was similar when considering post-traumatic stress symptoms separately. CONCLUSIONS: Negative changes in a person's life circumstances following a disaster appear to have as important an effect on psychopathology as the direct experience of the disaster. Ameliorating the extent and duration of post-disaster negative changes in life circumstances may play an important role in prevention of post-disaster psychological morbidity.

Psychosocial responses to disaster: An Asian perspective.

The psychological and psychiatric impact of great natural disasters are beginning to be understood leading to new methods of prevention, intervention and mitigation. There is limited data from the Asian continent, however, which has been the location of some of the greatest disasters of recent times. In this paper, we outline the psychosocial intervention efforts from nine Asian nations when confronted with large-scale natural catastrophic events. These include reports from situations where local services have some capacity to respond as well as those where services are destroyed or overwhelmed. From this it is possible to draw some general principles of psychosocial disaster intervention: (1) Assessment of disaster, extant service systems and incoming resources. (2) Assessment of help-seeking pathways and cultural models of illness. (3) Facilitation and support for family reunion, identification of the dead and cultural and religious practices to address death and grief. (4) Foster and bolster community group activities where possible. (5) Psychosocial training of community, aid and health workers using a train the trainer model to promote case identification, psychoeducation and intervention, with specific emphasis on vulnerable groups, especially children. (6) Promote general community psychoeducation. (7) Train medical and health staff in basic psychiatric and psychological assessment and intervention for post-traumatic stress, mood and anxiety disorders. (8) Minimise risk factors for psychiatric morbidity such as displacement and loss of gainful activity. (9) Reshape mental health systems recognising the long-term psychiatric sequelae of disaster. The collective learnt experience from Asian natural disasters may be constructively used to plan strategies to respond appropriately to the psychosocial consequences of disaster both within Asia and in the rest of the world.

Mental health model of care programmes after the tsunami in Aceh, Indonesia.

Before the tsunami, there was no systematic training provided for General Practitioners (GPs) and nurses in issues related to mental health and psychosocial support in times of disasters. After the tsunami, the Department of Psychiatry, Faculty of Medicine, University of Indonesia in Jakarta was contracted to organize a special two-week intensive training programme on basic psychiatry for 13 GPs from Banda Aceh Mental Hospital. To improve the nursing practice, a Professional Nursing Practice Model (MPKP) has been piloted in two wards in Banda Aceh Mental Hospital. This is a model of best practice for nursing care and management in an open ward system developed by the School of Nursing group and implemented in several mental hospitals in Indonesia. Basic training of GPs located at the primary healthcare level is being carried out based on the existing Ministry of Health curriculum for GPs. It covers 14 conditions listed in the International Classification of Diseases (ICD) Primary Care classification and has been conducted in 11 tsunami-affected districts. Currently, a total of 169 GPs have been trained. In general, there is an increasing interest among primary care doctors in mental health. Currently, community mental healthcare is provided in 11 districts in Aceh and two districts in North Sumatra by 277 Community Mental Health Nurses (CMHN) who have received basic training. Two thousand six hundred and two cases of serious mental disorders (mostly chronic psychosis) have been detected and treated by the CMHN and the doctors in Primary Health Centres (PHC). CMHN can provide a vital link between patients in the community and doctors in PHC. Two years after the earthquake and tsunami in Aceh, psychosocial intervention should continue and mental healthcare should be made available not only at Banda Aceh Mental Hospital, but also general health services, including PHC services.