Building on the strengths of Pacific mental health: Experience from Samoa

Let us consider two mental health services each attempting to meet the needs of a population of 200,000. One service has 240 registered patients (i.e. 120/100,000), the other has 2500 (1250/100,000). One has two acute beds and a total of around 100 bed nights/year, the other has 32 acute beds and around 10,000 bed nights/year (personal communication, Beveridge, 2014). You have probably guessed that one Mental Health Service is in a developing county – in this case Samoa, while the other is in a developed country – in this case Christchurch, New Zealand (adjusted for catchment area). What do these figures mean? The immediate response is to state that there is a large unmet need in Samoa which should attempt to upscale its services to match New Zealand. However, there is no specific evidence that the mental health of people living in Samoa is worse than that of people living in Christchurch despite this enormous disparity in the use of mental health services. There is no evidence one way or the other, since unfortunately there are, in fact, no data on the prevalence of mental disorders in Samoa. Our impression after visiting and working in Samoa for several years does not support the presence of a large unmet need. The reasons for this include the following.

Samoa is a collective tribal culture with strong family ties. Virtually everyone has family connections or is at least well known to others. There are individuals with serious mental disorders who choose, for whatever reasons, not to have contact with Mental Health Services. However, these individuals are well known to their community and their numbers appear to be small. We have visited all health centres on Upolu and Savai’i (the two main islands) and none report evidence of an unmet need for severe mental disorders. This apparent low prevalence is made more puzzling by the rates of severe mental disorders reported by Pacific people living in New Zealand. The New Zealand Mental Health Survey reported a 12-month prevalence rate of serious mental disorder of 5.9% in Pacific people (Foliaki et al., 2006). Obviously, this prevalence cannot be directly compared to our cursory survey, but it still seems reasonable to state that the prevalence of severe psychopathology is lower in Samoa than in New Zealand. Further support for this observation comes from data on the impact of migration on mental illness. The same New Zealand survey reports that New Zealand born pacific people have a rate of serious mental disorder of 6.7%, while those who migrated after the age of 18 have around half that rate at 3.7% (Foliaki et al., 2006). Migration to New Zealand may be good for many things but not ones mental health it would seem.

Pacific people may be less likely to use mental health services. Again using New Zealand data, it appears that only 25% of Pacific people with a serious mental disorder visit a health service for a mental health (Foliaki et al., 2006). If we transpose the New Zealand serious mental disorder prevalence figures onto Samoa then around 8000 people would have a serious mental disorder. If 25% of these individuals sought treatment this prevalence would suggest that over 2000 people (rather than 240) would be using mental health services, with ‘unmet need’ in a further 6000. On the face of it, it appears unlikely that around 6000 people in Samoa with a serious mental disorder are not in contact with health services, social services or the police. Alternatively, such individuals somehow function in a way which causes so little disability that they do not come into contact with nor require health services. Why advocate seeking out these individuals and treating them if they seem to be functioning reasonably?

This observation is consistent with evidence that individuals with serious mental disorders in developing countries have a better outcome than those in developed countries. The World Health Organization (WHO, 1979) International Study of Schizophrenia reported that living in a developing county was the single best predictor of good outcome in patients with schizophrenia. This unexpected finding was replicated in a larger WHO 10 country study (Jablensky et al., 1992). Despite methodological criticisms, these findings have never been convincingly refuted.

Clearly, there are ongoing mental health problems in Samoa and other Pacific Islands. (It would be unwise to push the tropical paradise paradigm yet again). Alcohol and drug disorders appear to be increasing although again there is only anecdotal data. Acutely unwell mental health patients sometimes end up in prison (in a similar way to New Zealand – (Evans et al., 2010)). Some patients with severe mental disorders are transferred to New Zealand mental health services. People with less severe mental illness such as anxiety disorders probably do not receive treatment (although again we have no idea of their prevalence). The poor availability of mental health services means people may not know where to get treatment. People with mental disorders may be better at minimising symptoms and this may be encouraged by their communities. However, there appear to be far fewer patients than we would expect in a similarly sized New Zealand catchment, their symptoms appear less severe – only requiring admission in a tiny minority of cases – and their outcome, at least functionally, appears to be better.

Overall, this data, weak though it is, suggests that we at least pause and reflect before telling Pacific countries what to do with their mental health services. While not ignoring the reality of mental illness in such countries we should not impose a mental health service which negates or reduces the inherent strengths which seem to reside in such societies. There is almost certainly a significant unmet need in Samoa, but scaling up Western mental health services to meet this may not be the most appropriate response. The exact factors and mechanisms subsumed under ‘culture’ that may influence the prevalence and outcome of serious mental disorder remain unknown – hypotheses include extended family support, informal non-stressful work, supernatural models of illness and less fostering of the sick role. Imposing services that are failing to deliver in developed countries does not seem a reasonable way forward. Service provision needs to build on the strengths of Pacific societies. An evidential base for mental health interventions is essential. We would argue that it is unethical to scale up treatment before doing pilot research to verify the effectiveness and acceptability of interventions and to ensure they are not undermining the strengths which appear to exist. Unfortunately, the financial and technical resources available for conducting research are very limited.

In conclusion, assisting Pacific Islands with mental health services is not simply imposing a developed world mental health system on the islands. There are clearly significant inherent strengths which appear to promote mental health in Pacific societies and may be associated with lower prevalence rates of serious mental disorders and a better outcome in the individuals who suffer from these disorders. Any changes should proceed cautiously with careful evaluation of their effects if we are not to inadvertently undo what appears to be working well. We may have as much to learn from pacific ways of managing mental health and illness as they have from us.