1. Global Mental Health A case study of Jordan: Introduction to Collaborative Care
Jo Ellen Patterson PhD, David Spees, MD,
Adi Khasawneh, MD
September 11, 2014

3. Activity Disclaimer ACTIVITY DISCLAIMER
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
Jo Ellen Patterson PhD, David Spees, MD,, Adi Khasawneh, MD have indicated they have no relevant financial relationships to disclose.

4. JORDAN

5. CONTEXT: JORDAN MENTAL HEALTH COMPETENCE AND QUALITY OF CARE
Primary health care is widely distributed, but mental health is not integrated.
PCPs failed to recognize psychiatric disorders in 76% of patients
limited interviewing skills required for psychiatric diagnoses
misinterpretation of symptoms (physical instead of psychiatric symptoms)
-W.H.O.
-Research shows that Primary health care system is widely distributed, but the mental health component is not integrated
Research confirms that PCPs are not trained in treating mental health conditions: a study showed that Study showed that PCPs failed to recognize psychiatric disorders in 76% of patients who reported having a significant level of psychiatric disorders; limited knowledge of psychiatry; limited interviewing skills required to elicit information relevant to psychiatric diagnoses; misinterpretation of symptoms ( physical instead of psychiatric symptoms)
When compared to GPs, family med physicians were shown to be better at detecting PDs
Conclusion: Increase training for PCPs for detecting and treating mental health conditions

6. WHO, WHEN & WHAT
GOAL: To introduce mental health assessment and primary care treatments to physicians
WHO:
4 USD therapy students and professor
WHAT:
One week at JUST
USD students train with UCSD Division of Family Medicine in Family Medicine Clinics
Lectures 2 x day
Shadowing
Informal conversations
USD and UCSD have cross teaching and share some faculty for over 10 years
One day and a half days at UNRWA
WHERE:
Department of Family Medicine,
Jordan University of Science and
Technology (JUST), Irbid, Jordan
Physicians at UNRWA (Refugee Health Clinics and Schools for Palestinians)

7. Program Content
Lectures and Activities Menu: Jordanian physicians voted on top choices
Options chosen: Screening for mental health, Basic Interviewing, Mental Health Resources (on the web), Assessing Children, Crisis Management, Behavioral Activation, Motivational Interviewing and others
NOT chosen: Global Mental Health, EBM, etc.

8. UNRWA & JUST

9. DATA: PROVIDER SURVEY and JUST, UNRWA & STUDENT EVALUATIONS
Provider Survey (N=12) (Beachan et al., 2012)
Program Evaluations
JUST (N=11)
UNRWA (N=20 )
Student Evaluations (N=4)

10. PROVIDER SURVEY
Survey with 38 questions for primary care providers (PCP) in Jordan - to assess mental health services.
Questions related to
PCP mental health competence
Quality of mental health care
Access
Stigma
Utilization
Reference: Journal of Clinical Psychology in Medical Settings: Primary Care Medical Provider Attitudes Regarding Mental Health and Behavioral Medicine in Integrated and Non-integrated Primary Care Practice Settings (Beacham et al., 2012) -
Published Data from Kentucky Physicians

11. PROVIDER SURVEY RESULTS (Beachan et al., 2012)
Overall similar responses from Jordanian and American Providers (Kentucky Community Clinics)
Differences found in:
access to mental and behavioral health care
competence of PCPs in treating mental health conditions
Q: “There are areas in working with psychiatric problems for which I would like to have more background and skills” (Jordan M= 5.5; Kentucky M= 4.51) (6= strongly agree)
Q: “ It is difficult to reach mental health colleagues for an informal consultation” (Jordan M= 5.0; Kentucky M= 0.2) (1= strongly disagree, 6= strongly agree)
Q: I am satisfied with the current referral process for mental health services (Jordan M= 3.7; Kentucky = 2.3) (1= strongly disagree, 6= strongly agree)

12. PROGRAM EVALUATION BY JORDANIAN RESPONDENTS: JUST
Self-created evaluation to measure program’s impact
Questions related to
Culture
Program strengths and weaknesses
Likelihood of using screening instruments available on the web
Interest in learning more about mental health and assessments
Responses:
90% would use websites or screening instruments in future clinical works
100% interested in learning more about mental health and behavioral health and incorporating mental health assessments in practice

13. PROGRAM EVALUATION BY JORDANIAN RESPONDENTS: UNRWA
Created tool used to evaluate program
Questions related to
Culture
Program strengths and weaknesses
Likelihood of using screening instruments available on the web
Interest in learning more about mental health and assessments
Responses:
80% would use websites or screening instruments in future clinical works
60% are interested in learning more about mental health and behavioral health and incorporating mental health assessments in practice

14. UNRWA & JUST PROVIDERS SUMMARY
Most popular seminars because they were “practical”
Assessment: Mental Health Screening Tools and Resources (PHQ-9, GAD-7, SIGECAPS)
Treatment: Behavioral Activation and Motivational Interviewing
Room for improvement?
More emphasis on demonstration of skills
Increased understanding of Jordanian Culture

15. STUDENT EXPERIENCE
Trip Objective: to influence and expose students to global mental health

16. PROGRAM EVALUATION BY STUDENTS
All 4 students indicated that they are “very interested” in learning more about Global Mental Health
Students were most influenced by
Gender issues
Stigma related to mental health
Role of Family in Treatment
“The work we did both at JUST and at the UN was some of the most meaningful and fun experiences not only that I have had in my life but also thus far in my career…entering a culture that I did not know much about and being able to talk about mental health on a cultural level is something that I have begun to grow passionate about.”

17. LESSONS LEARNED Training Cultural Competence and Power of Stigma
Sharing of resources, especially via web
Practical Skills for a rapid paced practice (not theory)
Time & patient load/day
USA 20-22
JUST 30-35
UNRWA 60-80
Cultural Competence and Power of Stigma
For providers and patients - also burden for families
Jordanian providers “uncomfortable telling patient about psychiatric condition”
Access to mental and behavioral healthcare

18. CONCLUSION: COLLABORATIVE CARE IN A NUTSHELL
Paradigm shift from mental health to behavioral health in primary care setting (soften stigma and include families)
PCPs should have the following skills and offer services in their practice
Mental Health Screening Tools
PHQ-9 (Depression)
GAD-7 (Anxiety)
Trauma Screening
Behavioral Activation (5 Minutes)
Motivational Interviewing (5 Minutes)
Eye Movement Desensitization and Reprocessing (EMDR)
Referral to Behavioral Health Provider

19. REFERENCES
Al-Jaddou, H., & Malkawi, A. (1997). Prevalence, recognition and management of mental disorders in primary health care in Northern Jordan. Acta Psychiatrica Scandinavica, 96,
Al-Krenawi, A., Graham, J. R., & Kandah, J. (2000, October). Gendered utilization differences of mental health services in Jordan. Community Mental Health Journal, 36(5),
Beachan, A., Herbst, A., Streitwieser, T. Scheu, E., & Sieber, W.. Primary Care Medical Provider Attitudes Regarding Mental Health and Behavioral Medicine in Integrated and Non-integrated Primary Care Practice Settings. Journal of Clinical Psychology in Medical Settings. Published online April 2012
Patel, Vikram, Minas, Harry, Cohen Alex & Prince, Martin J. (2014). Global Mental Health: Principles and Practice. New York: Oxford University Press
National Steering Committee for Mental Health (2011, January). National mental health policy. The Hashemite Kingdom of Jordan.

20. QUESTIONS & DISCUSSION