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Mental health in Indonesia’s Aceh province: Speaker series begins

Stephen Minas
Honorary Fellow, Centre for International Mental Health
A joint initiative of CIMH and the Nossal Institute for Global Health, the Aceh speaker series, part of a six-week Australian Leadership Award Fellowship program being undertaken by six mental health experts from Indonesia, began today with reports on two professions on the front line of mental health service delivery: nurses and general practitioners working in puskesmas – primary health care centres.
A/Prof Budi Anna Keliat, Ms Yulia Direzkia, Dr Rahmat Hidayat, Dr 
Hervita Diatri, Dr Hastha Yoga Bambang - the 'Dreaming Team' - 
undertaking a siz week Nosaal Institute for Global Health and Centre for
 International Mental Health program on strengthening mental health 
workforce in Aceh Province, Indonesia.

A/Prof Budi Anna Keliat, Ms Yulia Direzkia, Dr Rahmat Hidayat, Dr Hervita Diatri, Dr Hastha Yoga Bambang – the 'Dreaming Team' – undertaking a six week Nossal Institute for Global Health and Centre for International Mental Health program on strengthening mental health workforce in Aceh Province, Indonesia.
A/Prof Budi Anna Keliat, Team Leader of Community Mental Health Nursing in Aceh (CMHN), spoke on the challenges of service development from a nursing perspective. The CMHN programme has trained nurses in 23 districts across Aceh. The initial, basic stage of training has a focus on severe mental disorders. Two nurses are trained for each community mental health centre to allow for a sharing of responsibilities.
The training is crucial because the responsibilities are immense. According to Prof Keliat, each CMHN becomes responsible for the care of ten to twenty families. Among other things, nurses are trained to work with families in socially and economically difficult circumstances. For example, they must deal with the practice of pasung – the non-clinical confinement of persons with mental illness, often by their own family. A series of photographs illustrated the physical confinement that mentally ill people are sometimes subjected to, as well as their relative freedom after interventions by CMHNs. The leg of one man so pictured had been set in a heavy wooden stock – a not uncommon form of pasung.
The training of nurses is particularly important because of the low turnover rate for nurses working in Aceh. This is because nurses tend to be employed locally, unlike doctors who may work in the puskesmas for relatively short periods before moving on to other postings or to specialist training. This high turnover rate of doctors in primary care practice poses particular challenges for training of primary care doctors.
The CMHN programme developed for and commenced in Aceh has since been replicated in the Indonesian cities of Bantul, Bogor and Makasar. External evaluation of the CMHN programme has been carried out by Columbia University and by the University of Technology, Sydney.
Dr Hervita Diatri, Secretary of the National Taskforce on Mental Health System Development in Indonesia, spoke on the GP+ training programme for general practitioners in the Aceh districts of Pidie, Bireuen and North Aceh. The programme identified a number of challenges for mental health training to address. These include time-poor case identification, hesitancy in making physical and psychiatric diagnosis, the impact of clinicians’ own trauma experiences, reluctance to use medication and over-diagnosis of schizophrenia.
Dr Diatri outlined a number of recommendations to meet these challenges, including the introduction of a simple screening instrument for diagnosis, the use of standard operating procedures (SOPs) to increase practitioners’ confidence with medication, further research and a greater emphasis on multidisciplinary training (a point also made by Prof Keliat).
As helpful as SOPs can be, there is no substitute for individual initiative. Prof Keliat gave this example: One nursing cadre would visit a patient at the store where they sold goreng pisang (banana fritters). The cadre would buy goreng pisang and then check whether the amount of change the patient gave was correct. If it was, the cadre would ‘affirm’ the patient’s ‘rational’ behaviour. If not, a quiet word would be had with the responsible nurse.
Outside Jakarta, Aceh has the highest prevalence of mental disorder in Indonesia. According to figures cited by Dr Diatri, a survey of the three Aceh districts found that 78% of people have had traumatic experiences related to conflict. An estimated 65% of people in Aceh display symptoms of mental illness, compared to a national of approximately 10%. Dr Diatri appropriately referred to the group of colleagues from Indonesia who are at the University of Melbourne for six weeks as Australian Leadership Award Fellows as ‘the dreaming team’. While the challenges facing them are indeed immense they are not only ‘dreaming’ but working with great energy and creativity to find solutions for these challenges.
The series continues on 3 March at the University of Melbourne. Dr Rahmat Hidayat of Gadjah Mada University will discuss clinical psychology in community mental health, and Dr Sarifah Yessi of Aceh’s Provincial Health Office will look at mental healthcare from a government perspective.

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