ARK Foundation in partnership with National Institute of Mental Health (NIMH) and with the technical support of Department of Health Science, University of York is implementing IMPACT SMI and IMPASS research study targeting people living with severe mental illness (SMI). As part of these research studies a stakeholder workshop was organized as on Monday, June 20, 2022, at NIMH. The workshop aimed to share and discuss overview of the IMPASS and IMPACT SMI study for raising awareness on the physical health of people living with severe mental illness (SMI) including effect of COVID-19 pandemic and its responses on SMI and their family members.

Workshop Participants

A diverse group of potential stakeholders attended the workshop from Government, Non-Government and Development Partner organizations.

From Government Organization:

Specifically, the following honorable dignitary stakeholders attended: Joint Secretary and Chief Coordinator of NDD (Neuro-developmental disorder) and Autism Cell under Health Services Division, Programme Manager – Mental health of Non-Communicable Disease Control (NCDC) Programme under Directorate General of Health Services, Chairman, Dept. of Psychiatry, BSMMU, Director, National Institute of Mental Health (NIMH), General Secretary Bangladesh Association of Psychiatry^[1], Former Director Primary Health Care, DGHS.

Other Stakeholders from Government Organization: Associate Professor, Registrar from NIMH, National Institute of Neuroscience Hospital, Programme Manager from Community Based Healthcare Programme, Assistant Health Officer and Programme Officer of Dhaka North City Corporation, Psychiatrists from NIMH.

From Development partner and Non-Government Organization: National Mental Health Consultant of WHO, representative from development partner Civil Society Organizations Sajida Foundation.

Presentation

Prof. Dr. Rumana Huque, Executive Director ARK Foundation and Dr. Helal Uddin, Associate Professor, National Institute of Mental Health (NIMH) gave an introduction to the workshop and shared overview including aims, methods, key findings and way forward of the IMPASS and IMPACT SMI study respectively.

Summary of IMPACT SMI study

People with SMI are vulnerable as, on average, they die earlier than the general population, primarily due to physical disorders. There is limited information on physical illnesses and health risk behaviours in people with SMI in low and middle-income South Asian countries and the IMPACT SMI study addressed this by conducting a survey to investigate the physical health and health risk behaviours of this population in Bangladesh, India and Pakistan. Randomly selected in and outpatients with an SMI  diagnosis (i.e. schizophrenia, bipolar disorder, major depressive disorder with psychotic feature) were interviewed (1500 SMI patients) followed by anthropometric measurements and blood sample collection among those who consented. Key findings from IMPACT SMI baseline survey are as follows:

• Nine percent had diabetes, 16.1% hypertension, 36.8% were overweight or obese, and 46% had hypercholesterolemia.
• Most participants (84%) with diabetes, hypertension and hypercholesterolemia were previously undiagnosed; of those diagnosed only around half were receiving treatment.
• Fifty percent of men and 19.1% of women used tobacco;
• 3% and 84.1% did not meet WHO recommendations for physical activity and fruit and vegetable intake respectively.
• Compared with the general population (data from the WHO STEPS survey), people with SMI were more likely to have diabetes (Odds ratio (OR)=1.7), hypercholesterolemia (OR=2.5) and to be overweight or obese (OR=2.0) in the country. They were less likely to receive tobacco cessation (OR=0.11), and weight management (OR=0.48) advice than the general population.

Summary of IMPASS study

The COVID-19 pandemic has adversely affected lives and challenged healthcare provision. Those with SMI are likely to be disproportionately affected. The IMPASS study explored the effect of COVID-19 and its response (e.g. lockdown) on people living with SMI majorly in terms of income earning, food security, financial management, access to healthcare, mental and physical health problem, vaccine uptake and hesitancy. Consented SMI patients who were recruited in IMPACT SMI survey were followed up through 5 rounds of telephone surveys (first three rounds were at the beginning of COVID-19 pandemic between May to October 2020 while fourth and fifth rounds were during June-Aug 2021 and Jan-Mar 2022 respectively when severity of pandemic quite reduced than beginning). Key findings from IMPASS survey are as follows:

• In round 1 survey, it was found that Television (80%), family and friends (77%), and religious leaders (38%) were the major source of information about COVID-19. Overall, participants reported good knowledge and that they were following government advice for limiting its spread.
• Finances (47.8%), employment (9%), and physical health (27.6%) were the most frequently mentioned concerns during COVID-19 pandemic.
• In round 1 survey, main earning member of the family of SMI patients generally were employed or running business (64%) pre-pandemic, but reported not currently working (43%) at the time of COVID-19 pandemic and related measures, this scenario was more evident at the beginning of COVID-19 pandemic which was gradually decreased (At round 5 survey 89% reported main earning member generally employed/running business and of them only 1.2% reported of not currently working) with the improvement from COVID-19 pandemic situation.
• Treatment for mental health was affected by COVID-19 pandemic and its response; this rate was also higher (54% in round 1) at the beginning of COVID-19 pandemic which was gradually reduced (5% in round 5 or round 6) with the improvement from COVID-19 pandemic situation.
• IMPASS survey (Jan-Mar 2022) findings revealed vaccine uptake rate as 64% among SMI people while Dr. Helal Uddin opined that at the time of conducting workshop, the rate increased to 72%.

Key points from discussion

The following are the key discussion points and suggestions from workshop participants:

Participants reflected that under IMPACT and IMPASS studies, two amazing research studies have been conducted, which investigated many issues and some of which can be of use for different types of research in future. Findings of these research studies will be of use as primary data for Bangladesh or International perspective.

Lack of screening at primary care and patient load at NIMH

National Institute of Mental Health (NIMH) was the study site in Bangladesh for the IMPACT SMI research study. Participants opined that even though NIMH is considered to be the tertiary level healthcare facility, in reality all types of patients from all over Bangladesh visit here as there is no screening process to identify mental health problem at primary health care facility. The ideal process should follow referral from primary or secondary health facilities to tertiary level.

Attitude of Government officials to work with mental health issues

Programme Manager, Mental health of Non-Communicable Disease Control (NCDC) Programme under Directorate General of Health Services mentioned in his speech about favorable attitude of NCDC office to work with mental health. He quoted “Office of Line Director, NCDC are very much cordial about the mental health issue. There is no problem from NCDC office side to work with this issue. If any planned activities from mental health act/strategic plan/policy are provided to NCDC office along with action plan then they will facilitate to implement this”.

Advocacy for ensuring mental health drugs at primary health care

Programme Manager, Mental health of NCDC informed that he raised the issue in drug list finalization meeting to include 6 essential drugs of mental health treatment in the revised list of drugs of Upazila Health Complex (UzHC) because if these are not included in the drug list of UzHC, procured and supplied, then UzHC personnel will not be able to provide those drugs to patients.

Neurodevelopmental disorders (NDD) and Autism cell and plans to achieve SDG3

Joint Secretary and Chief Coordinator NDD and Autism cell, Ministry of Health and Family Welfare stated that “Specific laws, acts, policies and strategic plans were developed to ensure rights and for protection of people living with NDD (e.g. schizophrenia, bipolar disorder) and Autism. NDD and Autism cell was formed to maintain coordination among Ministry of Health and Family Welfare which provide Diagnosis and treatment of people living with NDD and Autism and Social Welfare and other Ministries which do rehabilitation of such people. To achieve Sustainable Development Goals (SDG3) by 2030, we have added mental health and health insurance along with primary health care.’’

Lack of mental health professionals

• In Primary Healthcare facility (Upazila Health Complex) there is no psychiatrist, while in eight old Medical Colleges, the psychiatry units are not strong enough.
• According to earlier study findings, there are social stigma towards mental health issues, not only in community, but also among doctors.
• Lack of skilled human resources and crisis of mental health professionals is one of the challenges of implementation of mental health strategic plan.

Plans to address shortage of mental health professionals

Joint Secretary and Chief Coordinator NDD and Autism cell, Ministry of Health and Family Welfare informed that there are plans in implementation process to increase the number of psychiatrists through training and retraining option within psychiatry departments in Bangabandhu Sheikh Mujib Medical University (BSMMU), Pabna Mental health hospital, District Sadar Hospital and new medical colleges. Plans to address mental health are outlined in detail in the 8^th five year plan, the 4^th Health, Nutrition and Population Sector Programme (HNPSP), and the mental health policy. As a long term goal NDD and Autism cell have taken initiative to create large number of posts for Psychiatry considering to achieve the target of SDG3.

Strengthen Mental Health service in Primary Health Care

• It was suggested to strengthen mental health services in primary care: e.g. preliminary screening using the mhGAP (mental health gap action programme) tool in NCD corners to understand mental health conditions and then refer to specialist services (NIMH) based on severity found from preliminary diagnosis. This reduces pressure on NIMH to screen out patients who do not need mental health care.
• As a short term goal at union level 64,000 Para Counsellors are being prepared for mental health by training family welfare visitor who earlier advised pregnant mother for diet, antenatal care only. Those Para Counselors are doing para counseling for mental health also at village level.

Mental and physical comorbidities and service strategy

• Participants opined that through research, we may look into which medication or drug adjustment can be done for SMI patients with comorbidity (NCD or NCD risk factors).
• The participant concurred that, for complete management of psychiatric treatment, preventive measures should be given importance in strategic plan. Along with curative measures, this will help to prevent occurrence of new physical disease or aggravated physical condition (including NCD or NCD risk factors) due to antipsychotic medication and/or lifestyle health risk behavior through people’s and community participation. These are covered broadly in the mental health act/policy/strategic plan. This is now important to implement the plans to address physical health needs of SMI patients.
• It was mentioned that due to mental health problems, physical health is hampered, and also due to acute or chronic physical health problems mental health problems occur. Hence, mental and physical health are interrelated and cannot be separated from each other.
• It was suggested that it would be helpful to know segregated results of outcome variables regarding mental and physical comorbidity, lifestyle health risk behavior, lifestyle modification advice by gender and socio-economic group so that specific intervention/services can be designed for target population.

COVID-19 testing at mental health facility

Psychiatrists from NIMH opined that at the beginning of COVID-19 pandemic there was no testing facility of COVID-19 for patients. But with the change of time now COVID-19 testing facility is available for patients at NIMH.

COVID-19 vaccination at mental health facility

At NIMH there is COVID-19 vaccination centre from where any adult citizen irrespective of SMI people who did the registration and receive message for receiving vaccination can get vaccinated here. There is no priority option for getting COVID-19 vaccine among people living with SMI.

Health insurance for mental health

Joint Secretary and Chief Coordinator NDD and Autism cell informed that in Dhaka North and South City Corporation, Government health insurance scheme (known as Sasthyo Suroksha Karmasuchi-SSK) will be started within next two months. There will be a booth for SSK health insurance pilot programme at NIMH. All mental health treatment (medicine, tests) of SSK card holders will be borne by Government. If any required tests is/are to be done by SMI patients which are unavailable at NIMH then cost of those tests will be reimbursed.

Participants of Stakeholder Workshop agreed towards a consensus statement regarding vulnerability and needs of SMI patients which is as follows:

Findings from the workshop participants’ discussion and suggestions and insights of this research study will be helpful to design recovery-centric intervention programmes for SMI patients, increase capacity, quality of life, and develop skills on different activities. As there is limited information on physical illnesses and health risk behaviors in people with SMI in low and middle-income countries, these studies are very crucial to determine the actual scenario of physical health along with mental health within these countries and take measures accordingly.

Further Information:  

• “The IMPACT SMI research study is implemented in Bangladesh, Pakistan and India and was funded by the National Institute for Health Research (NIHR) (17/63/130) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government.”
• “The IMPASS research study is implemented in Bangladesh and Pakistan and was funded by the “Global effort on COVID-19 health research (GECO) UK Research and Innovation, Medical Research Council (UKRI-MRC) (Grant reference: R23204)” Co funders National Institute for Health Research (NIHR) (Grant reference: 17/63/130) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the UKRI-MRC or NIHR or the UK government.”

To know more information about the study please visit: https://www.impactsouthasia.com/

The Policy Brief is prepared by –

Prof. Rumana Huque, Asiful Haidar Chowdhury, Fariha Islam Munia on behalf of IMPASS study Research Team in Bangladesh