1. Impact of the Community Mental Health System Sthrengthening Project in Aceh, Indonesia (2009-2011) Hervita Diatri, Harry Minas

2. Disaster in Aceh Laboratory for better MH system development in Indonesia More than one hundred local and international MH and psychosocial agencies arrived in Aceh after the tsunami Training for primary health professionals was a key strategy Tsunami, 26 December 2004 30 years military conflict

3. About Research Location Bireuen Affected by both disasters Affected by both disasters Bireuen District 8,7% of population of Aceh, >75% living in rural areas* Bireuen District 8,7% of population of Aceh, >75% living in rural areas* *Indonesia Statistics Center 2010

4. About Research ItemsNumber Number of Sub-districts18 Number of Primary Health Care Centres (PHCs)18 Number of GP 1 participants37 GP+ 2 : non GP+2413 Number of patient participants556 With mental illness 3 : with comorbidity 4 : without mental illness 460 (82,7%) 360 (64,7%) 96 (17,2%) Number of treated patients 5 372 (80,9%) Medication: Psychoeducation and or counseling: Both 279 (60,7%) 363 (78,9%) 343 (74,6%) 1 Primary care doctors 2 GPs with additional mental health training 3 According to MINI-ICD X 4 Have more than one mental illness 5 Medication and or psychosocial intervenstion (psychoeducation and counseling

5. Mental Health Diagnosis GPs who had received some additional mental health training (GP+) are more likely to make a diagnosis of mental disorder in patients who have a MINI diagnosis of mental disorder than are non-GP+

6. Mental Health Treatment GPs who had received some additional mental health training (GP+) are more likely to give treatment to people with mental disorder than are non-GP+

7. Mental Disorder and Disability Mental Health Problems Depression Global Burden Study, 2010 Research result: The Multivariate regression model suggests that the presence of a mental disorder is associated with a substantially increased risk (OR = 6.0) of having disability. Risk is a little higher (OR = 6.2) if there is comorbidity.

8. Disability Recognition 22.7% 78.6%

9. Psychosocial Support Disability (WHO-DAS) Psychosocial support by GP 81,50% (89,5% have MINI Diagnosis) Psychosocial support (perceived by patients) 46,70% Different perceptions among GPs and patients related to psychosocial support. More than 95% of the psychosocial support provided is psychoeducation and counseling GP are more likely to give psychosocial support to patients with mental disorder than patients without mental disorder

10. Mental Disorder – Disability - Poverty Being below the poverty line is associated with a moderately increased risk (OR = 2,1) of having disability One of the main forms of rehabilitation for persons with mental disorder in Aceh has been support with income generation activities.

11. Opportunities and Development Enablers

12. Mental Health Diagnosis

13. Government Commitments Province and District Health Offices provide training to PHC staff 2-3 times/year. There is an opportunity to modify and enhance this training, and possibly to introduce continuing supervision and mentoring. The Ministry of Health has prioritized PHC development as the core of the national health service in the 5 year strategic health plan (2015 – 2019)

14. Research Recommendations GPs with some mental health training are more likely to recognise and diagnose mental disorder, and to provide treatment than are untrained GPs There is a need to enhance disability recognition and assessment, and referral to rehabilitation programs GPs need to be able to develop appropriate rehabilitation plans for persons with significant disability There is a need to go beyond short-term clinical training, to include training in disability, and to provide continuing skills development, supervision and mentoring of GPs.

15. Research Recommendation Past and Current Training Topics%GP Psychosis43,2% Anxiety40,5% Substance Abuse37,8% PTSD37,8% Depression8,1% Training specifically related to Depression, Anxiety, PTSD, Disability and Psychosocial Rehabilitation still need to be improved

16. Research Recommendations The majority (72,1%) of patients say they know about mental disorder Knowing about mental disorders is associated with more accurate self-identification of mental health problems (79%, p = 0,049) More accurate self-identification of mental health problems makes it more likely that the GP will recognise, accurately diagnose and appropriately treat when necessary. Community psychoeducation can empower people to participate in an appropriate response to the presence of mental health problems and response to disability.

17. Role of MH Clinic in PHC PHC with MH clinic are more likely to make a diagnosis of mental disorder in patients who have a MINI diagnosis of mental disorder than PHC without MH Clinic

18. Research Recommendation Nearly 99% of the patients believe that mental disorders can be treated, and 96,2% among them believe that PHC can effectively treat mental health problems The PHC is needed by the community to be more active and capable in recognition of and response to mental health problems in PHC attenders. The roles of PHC in mental disorder management has been explicitly stated by the Indonesia’s New MH Law (2014) to include MH promotion and illness prevention, early diagnosis and treatment, and facilitating rehabilitation in collaboration with other sectors (especially the Social Affairs Office) and protection of the rights of persons with mental disorder.

19. TERIMA KASIH