After four years, MSF is about to hand over mental health projects in Armenia

Michael Nielsen Click for large view The Gavar Day Center in the Gerhargunik Marz region established by MSF. The center, which was handed over to Mission Armenian in January 2006, is part of a network of day centers which gives those suffering from mental health problems a caring, therapeutic environment to visit daily. "Obviously MSF has not been able to change attitudes to mental health problems overnight," explained Krist Teirlinck, the project's Medical Co-ordinator. "But, through our experience over the years, we've realised that many of the patients locked away in in-patient psychiatric hospitals, or kept inside by their frightened families, could, with proper care and support, lead happy and productive lives in the community.

By the end of 2006 the MSF psycho-social program in Armenia will have been handed-over to a local NGO, 'Mission Armenia', and the Ministry of Health (MoH). So, what have been the successes of the project? What is the prevailing attitude to mental health problems in Armenia? And what are the challenges for the future?

Armenia is changing. While it remains a poor country, it has seen an explosion in international donor presence in the last two years. Much of their development work will focus on Gerhargunik Marz, the region where the mental health project is located. Local organisations, like Mission Armenia, are also developing the capacity to run projects.

"It is the right time for us to handover the mental health project, " said Cedric Roussel, head of mission. "We've already found an good partner in Mission Armenia, and the Ministry of Health (MOH), who will take over the mental health centre and regional cabinets (small outpatient mental health structures), is committed to continuing the model we've developed. It is sad for us to leave, but it marks a positive moment in the development of Armenia."

MSF first provided psychosocial care here to the survivors of the Spitak earthquake in 1988. In the following years, programs were also developed for patients being cared for in in-patient psychiatric institutions, and traumatised refugees from the war with Azerbaijan over Nagorno-Karabakh that began in 1989. Since 2002 MSF's mental health activities have been focused on outpatient care.

Those who suffer from mental illness in Armenia are all too often stigmatised. It is very common for families to hide relatives with mental health problems, scared that the relative will be excluded from the community if they ventured out in public. Those who are not able to care for their ill relatives at home resort to psychiatric hospitals.

Myths abound about the treatment of mental illness: a popular misconception is that, if you marry, your illness will vanish. And many problems, like depression or anxiety, are not seen as treatable maladies - patients too often suffer in isolation, visiting the wrong doctors (often a neurologist) only very late in their mental illness.

"Obviously MSF has not been able to change attitudes to mental health problems overnight," explained Krist Teirlinck, the project's Medical Co-ordinator. "But, through our experience over the years, we've realised that many of the patients locked away in in-patient psychiatric hospitals, or kept inside by their frightened families, could, with proper care and support, lead happy and productive lives in the community. And so, in 2002 we started to focus on establishing a workable model for outpatient mental health care, in one of the poorest and most vulnerable regions in Armenia, Gegharkunik Marz."

The program has included several inter-related components - an outpatient mental health centre in the lakeside town of Sevan, which offers supervision to regional cabinets in other towns in the region; a network of day centres, which have given those suffering from mental health problems a caring, therapeutic environment to visit daily; and an information campaign which raises awareness of the plight of those with mental illness.

"The core element of the model, which we've been trying to emphasise as it is new to Armenia, is a multi-disciplinary team which includes a psychiatrist, psychologist, social worker and nurse who work together in one place," said Teirlinck. "This approach is based on the recommendations of an international agreement on mental health care, that the Armenian Ministry of Health (MoH) has signed, called the Helsinki Agreement."

In addition to the emphasis on an integrated team of specialists, one of the project's goals has been to highlight the importance of social workers in assisting those with mental health problems. The social workers help beneficiaries negotiate the complex (and sometimes corrupt) Armenian social benefit system. They are also very involved in the day centres, where patients develop their self esteem and social skills by attending discussion groups, arts and crafts classes and receive support from a designated psychologist.

Three of the four day centres were handed over to a local NGO, Mission Armenia, at the end of January 2006.

Working alongside the medical part of the project, an Information, Education and Communication (IEC) campaign has attempted to address some of the population's prejudices about mental illness.

"We have used posters, outreach, television ads and a programme of special events - like a fun run for children on World Mental Health Day - to help to open up discussion of mental health problems in Armenia," explained Inga Sahakyan, the IEC manager.

A range of leaflets, free for visitors to local pharmacies, explores the characteristics of depression, psychosis and anxiety. And they are much in demand. The full impact of such education is hard to assess but, encouragingly, when compared to surveys conducted in 2003, many more survey respondents in 2005 showed a positive attitude towards mental health and were aware of the services available.

Many challenges, however, lie ahead.

"The MoH needs to show its commitment to the model we've developed, and move away from an old style response of 'isolation, drugs and stigmatisation'," said Roussel. "It will also be a challenge for them to continue to encourage health professionals to come and work in such isolated, poor areas.

"Unfortunately, there are very few young psychiatrists in Armenia, and these are the ones who could more easily accept, develop and promote the new approach MSF proposes. We also want to try and make sure that patients' rights are protected. Armenian law has recently been changed to guarantee consultations and treatment for free, so, theoretically, under-the-table fees should become a thing of the past."

It will also be a challenge for the MoH to ensure that they maintain a supply of good quality, new generation psychiatric drugs to the facilities.

In an attempt to make the handover as smooth as possible, the MSF team will spend the remainder of the year working with their MoH counterparts to familiarise them with the model and help them set realistic budgets and plans.