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

Australian & New Zealand Journal of Psychiatry, 50(5) 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 Building on the strengths of Pacific mental health: Experience from Samoa