Psychiatry in Papua New Guinea

Abstract

Papua New Guinea is an independent commonwealth in the South Pacific, lying just north of Australia and sharing its western border with Indonesia. The population of Papua New Guinea is 5.2 million, of whom 87% live in rural areas (2000 census) (National Statistics Office, 2003). The country has a very rich culture; for example, there are over 800 distinct language groups (although Papua New Guinea has less than 0.1% of the world’s population, it is home to over 10% of the world’s languages).

Although Papua New Guinea has less than 0.1% of the world’s population, it is home to over 10% of the world’s languages.

Administratively, Papua New Guinea is divided into four regions, which are further divided into a total of 20 provinces. The capital city is Port Moresby. Travel between the capital city and the provinces is generally by air, since Papua New Guinea’s limited road network does not connect all the provinces to one another.

The gross national income is US$580 per capita and the government spends 7% of its total budget on health (UNICEF, 2006). Only 0.7% of the total health budget is spent on mental health (World Health Organization, 2005).

Health indicators

Apart from clinical services, mental health services available to the public include mental health talks to schools as part of the ‘healthy schools programme’, radio broadcasts on mental health issues and a weekly mental health column in one of the daily newspapers.

The average national infant mortality rate is 82.2/1000 live births for males and 72.2/1000 for females, while the maternal mortality ratio is a horrific 370/100 000 live births (National Statistics Office, 2003). There are, however, wide provincial variations. Life expectancy at birth is 56 years (UNICEF, 2006). The doctor: population ratio is currently about 1:11 000, but disproportionately more doctors work in the urban areas than in the rural areas. The nurse:population ratio is 1:400.

Mental health resources and services

Public psychiatric services fall under the Social Change and Mental Health section of the Division of Curative Services within the National Department of Health. The resources in terms of facilities and manpower at the different care levels are summarised in Table 1. There are only five psychiatrists practising in the country, giving a national ratio of 1 per 1 000 000, but since all the psychiatrists are in the capital city, the true ratio is 1 psychiatrist for every 70 000 people in the city and zero for the rest of the country. The number of psychiatric nurses per 100 000 population is 0.09 and the number of social workers per 100 000 population is 0.04 (World Health Organization, 2005). The number of psychiatric beds per 10 000 population is 0.24, of which 0.17 per 10 000 are in the sole mental hospital and 0.07 per 10 000 are in the general hospitals (World Health Organization, 2005).

Table 1. Mental health facilities at different healthcare levels in Papua New Guinea.

Level	Facilities	Staffing	Services offered
Tertiary (capital city)	60-bed Laloki Psychiatric Hospital	2 psychiatristsa 12 psychiatric nurses 29 other general clinical health workers	Long-stay care Forensic services
	16-bed psychiatric ward within Port Moresby General Hospital, the national teaching and referral hospital	4 psychiatristsa 6 psychiatric nurses 7 other general clinical health workers	Acute in-patient care Occupational therapy Out-patient clinics
	Family Support Centre within Port Moresby General Hospital, the national teaching and referral hospital	Social workers 1 psychiatrista Other doctors and nurses Other non-medical agencies	One-stop centre for trauma counselling, child abuse counselling, crisis management, paralegal support and information, overnight emergency accommodation for victims of violence or abuse, liaison with other agencies
	Rehabilitation Centre	1 psychiatrista 2 psychiatric nurses 1 social worker	Day care Rehabilitation Occupational therapy Family support group
Secondary (provincial hospitals)	Psychiatric wards in only two provincial hospitals Most provincial hospitals have only psychiatric clinics	Psychiatric nursesb in some hospitals Community health workers Other general health workers Visits once or twice a year by psychiatrists Physicians responsible when psychiatrist is absent	In-patient care where there are units; otherwise, only out-patient clinics Referral to Laloki for admission
Primary (district health centres and below)	No psychiatric wards No psychiatric clinics	General nurses Other general health workers	Minimal out-patient care Referral to provincial hospitals

^aSome psychiatrists work in more than one place: the country has only five practising psychiatrists.

^bPsychiatric nurses are often deployed in non-psychiatric sections.

The commonest psychiatric conditions treated at out-patient level are depression and anxiety disorders. The commonest causes of admission are psychotic illnesses, mostly schizophrenia, bipolar disorder and cannabis-induced psychosis. Nearly all patients admitted with cannabis-induced psychosis are men under the age of 30 years. Papua New Guinea does not (at least as yet) have a problem with hard drugs such as heroin.

There are at present no private psychiatrists, no private psychiatric hospitals and no clinical psychologists in the country. Neither are there any neurologists, although there is one neurosurgeon.

There are no community-based services for people who are mentally ill. Patients in the community are looked after by their families.

Apart from clinical services, mental health services available to the public include mental health talks to schools as part of the ‘healthy schools programme’, radio broadcasts on mental health issues and a weekly mental health column in one of the daily newspapers. World Mental Health Day is celebrated publicly every year in several provinces; in addition to this, the mental health services are represented at the annual ‘Health Expo’ in the capital city. Posters and leaflets explaining mental health issues are distributed to the public free of charge at such venues. The public’s response to these services has always been very encouraging.

Mental health policy

The goal of the mental health programme is to improve access to mental health services at provincial and district levels and to improve the capacity at community level to support and maintain patient care and rehabilitation (Ministry of Health, 2000). This is to be achieved by 2010 through the following strategies (Ministry of Health, 2000):

• psychiatric patient care and treatment shall be free of charge

• Laloki Psychiatric Hospital shall remain the national referral centre

• four referral and supervising units shall be established at regional level

• psychiatric units shall be established at all provincial public hospitals

• all physicians caring for adult patients in public hospitals shall be responsible for hospital-based psychiatric units in the absence of psychiatrists

• community-based treatment and rehabilitation shall be established and supported.

Legislation

Mental health legislation in Papua New Guinea dates back to the Insanity Ordinance of 1912. This was superseded by the Mental Disorders and Treatment Ordinance of 1960. The latter was annulled in 1997 and replaced with a subsidiary chapter (no. 226) of the Public Health Act known as the Public Health (Mental Disorders) Regulation. This is the current mental health legislation in Papua New Guinea, but a review of the legislation is underway to make it more relevant to the mental health needs of 21st-century Papua New Guinea.

Training

Undergraduate medical students

There is one medical school in the country, the School of Medicine and Health Sciences of the University of Papua New Guinea, in Port Moresby. The undergraduate curriculum is based on the problem-based learning (PBL) approach and students are exposed to psychiatry from the second year to the final (fifth) year of their MBBS course. During the final year, students undergo a 4-week rotation in psychiatry.

Postgraduate specialisation

The medical school offers a 4-year degree course (Master of Medicine in Psychiatry, MMed), but psychiatry is a less popular career choice than other disciplines. All the students are required to write a research-based thesis. Students also spend several months of their third year attached to a psychiatric unit in Australia in order to gain exposure to psychiatry in a setting other than Papua New Guinea.

Students also spend several months of their third year attached to a psychiatric unit in Australia in order to gain exposure to psychiatry in a setting other than Papua New Guinea.

Psychiatric nurses

In order to specialise in psychiatry, nurses need to undergo a 1-year postgraduate degree course at the medical school.

Other health workers

Regular mental health workshops are held every 2 years to provide basic mental health training to non-specialists from all over the country to help them manage psychiatric patients. In addition to this, regular VHF radio sessions are broadcast live to all parts of the country, including remote health facilities. The facilitator teaches the topic for that session and health workers participate live and raise questions or seek advice about specific clinical cases. This has been found to be a very convenient and effective way of reaching health workers in remote areas.

Research

Earlier research in psychiatry, for example by the pioneering psychiatrist Burton-Bradley (1973), identified common forms of mental illness in the country and elicited the public’s views about the aetiology of mental illness (often attributed to sorcery). Later research confirmed the occurrence of substance misuse (Johnson, 1991), post-traumatic stress disorder (Johnson, 1989) and so on. However, despite the requirement for all MMed students to carry out research as part of their training, most make no attempt to get their work published after qualifying. As a result, there is still a dearth of research in psychiatry in Papua New Guinea.

Cannabis grows readily in the highlands of Papua New Guinea and the number of patients with cannabis-related psychosis has risen greatly over the past 15 years as the cultivation of the plant has increased, both for local consumption and as a cash crop to be smuggled into Australia in exchange for guns, which are then used in tribal fights.

Professional groups

The Papua New Guinea Psychiatric Association comprises all psychiatrists and psychiatric registrars in the country – a total of 11 members.

Non-governmental organisations

The Mental Health Foundation is a non-governmental organisation that provides support to people who are mentally ill, for example through donations.

The Family Support Group comprises carers of patients with a mental illness who are attending the Rehabilitation Centre. Their functions include education, mutual support, advocacy, fundraising and so on.

Challenges

The challenges include a shortage of trained staff, frequent shortages of basic psychiatric drugs, the absence of in-patient facilities at the provincial level and an increase in substance misuse, especially cannabis. Cannabis grows readily in the highlands of Papua New Guinea and the number of patients with cannabis-related psychosis has risen greatly over the past 15 years as the cultivation of the plant has increased, both for local consumption and as a cash crop to be smuggled into Australia in exchange for guns, which are then used in tribal fights.

Traditional beliefs about mental illness (e.g. sorcery) also hinder some patients from accessing services or adhering to the treatment prescribed.

An inadequate road network means that patients who need referral to the only psychiatric hospital but who are too disturbed to fly are frequently held not in general hospitals but in local police cells as the only available secure place. They are held until they are stable enough to be transferred by commercial aircraft without posing a risk to others on board.