1. CASE STUDY: BOSNIA AND HERZEGOVINA (BiH) Harvard Program in Refugee Trauma (HPRT) Richard F. Mollica MD, MAR Michael P. Massagli, PhD James Lavelle, LICSW Aida Kapetanović, MD

2. Social and Health Indicators 198119912000 Population4,124,2564,395,6433,683,665 Refugees--643,250 Displaced Persons--501,000 Employed: Unemployed -3.17:11:1 Monthly Income in US$ 190299174

3. Major Objectives of World Bank-HPRT Project in BiH Middle Bosnian Canton (Travnik)  Mental health training and technical assistance to primary care providers (PCPs)  Create network of PCPs skilled in mental health and trauma-related disorders  Develop with cantonal MOH mental health services integrated at all levels, including CBRs  Integrate results into BiH health reform  Prepare Lessons Learned for dissemination throughout BiH

4. ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND DISABILITY, BOSNIAN REFUGEES, 1996 (N=533) SOURCE: JAMA v282:437, 1999

5. Persistence of Mental Health Symptoms Over 3 Years

6. Change in Symptom Status 1996-1999

7. Effect of Trauma, 1996

8. Effect of Trauma, 1999

9. THE MENTAL HEALTH COST OF MASS VIOLENCE SOURCE: Scientific American, v282, June 2000:54-57 SERIOUS MENTAL ILLNESS PSYCH. INCAPACITATION SERIOUS FAMIILY CONFLICT CLNICAL DEPRESSION/PTSD FEAR OF GOVERNMENT SEEKING JUSTICE/REVENGE PHYS, MENTAL EXHAUSTION DEMORALIZATION

10. Feeling No Trust in Others, Past Week

11. 2001 Living Standards Measurement Survey (LSMS) in BiH (N=12,954)  23% report depressive symptoms consistent with DSM-IV diagnosis of major depression  6% report reexperiencing trauma symptoms  15% report limitations in physical functioning  Women 2x more depression, PTSD, functional limitations than men

12. Primary Health Care Patients: Middle Bosnian Canton, 2003 (N=184)  32% psychiatric diagnosis (DSM- IV/SCID) 16% major depression 10% Generalized Anxiety Disorder 3% PTSD only 3% Dysthymia; other SCID = Structured Clinical Interview for DSM-IV

13. Providers Needs Assessment: 2000  40% (30-80%) of patients have mental health problems  65% of PCPs are not able to make DSM-IV (ICD-10) diagnoses  PCPs reported very low confidence in treatment of mental health crises  PCPs reported almost no confidence or very low confidence in treatment of different groups of traumatized patients

14. Providers Needs Assessment: 2000 (cont’d)  33% of PCPs didn’t know about CBRs  54% of PCPs never referred patients to CBRs  30% of those who did refer never received feedback from the CBR

15. EDUCATION 105 PCPs and psychiatrists trained Curriculum completed: 1)Trauma Story 2)Psychosocial interviewing skills 3)Screening Instruments 4)Identification and management of the most common psychiatric disorders: mood disorders, neurotic stress-related and somatoform disorders, substance abuse, organic mental disorders, psychosis 5)Identification and management of disability 6)Management skills/health reform

17. ON-SITE VISITS/SUPERVISION Case-Oriented Goals:  To sustain the knowledge  To improve relations between PCPs and mental health professionals  To prevent burnout

18. Level of Trauma Experienced by PCPs and PCPs’ Families

19. PCPs’ Confidence in Eliciting and Listening to Trauma Stories: Pre-training vs. Post-training Mean confidence

20. PCPs’ Confidence in Diagnosing Certain Medical and Psychiatric Problems: Pre-training vs. Post-training Mean confidence

21. Primary Health Care Community Police Emergency Room General Hospital In-patient MENTAL HEALTH SERVICES: OPTIMAL MODEL Mental Hospital Criminally Insane

22. Primary Health Care Community Psychiatric Hospital MENTAL HEALTH SERVICES IN BOSNIA Community Rehabilitation Centers

23. Primary Health Care Community General Hospital In-patient MENTAL HEALTH SERVICES IN BOSNIA Community Rehabilitation Centers

24. FRAMEWORK FOR MENTAL HEALTH RECOVERY RECOVERY I. Policy/Legislation V. Role of International Agencies III. Science-Based Mental Health Services IV. Multi-Disciplinary Education II. Financing VI. Linkage to Economic Development/ Human Rights

27. BiH Mental Health (MH) Case Study I.Policy/Legislation MH integrated into health reform LSMS MH data integrated into BiH health statistics Future role of CBRs

28. BiH Mental Health (MH) Case Study II.Financing Sustainable financing of MH in PHC Psychiatry – PHC linkage Job training and social services in PHC/CBRs Cost-effective MH training and services

29. BiH Mental Health (MH) Case Study III.Science-Based MH Services HPRT Model: Needs assessment Implementation of field-tested curriculum On-site supervision Monitoring assessment and feedback

30. BiH Mental Health (MH) Case Study IV.Multi-Disciplinary Education “Pedagogy of Trauma” in BiH medical schools Integration into family medicine CME

31. BiH Mental Health (MH) Case Study V.Role of International Agencies Coordination/collaboration among BiH MOH – UN – NGO – donors – universities

32. BiH Mental Health (MH) Case Study VI.Linkage to Economic Development (ED) and Human Rights (HR) Violence-induced trauma has negative impact on MH Both provider and patient exposed to violence MH has negative impact on social capital and physical functioning Undiagnosed and untreated MH problems place significant burden on health care system

33. Harvard Program in Refugee Trauma 22 Putnam Avenue Cambridge, MA 02139 http://www.hprt-cambridge.org