1. MENTAL HEALTH Ahmed Mandil, Prof of Epidemiology Dr. Mohammad Afzal Mahmood College of Medicine, King Saud University

2. Headlines  General reflections  Magnitude of the problem  Classifications  Disorders  Etiology  Prevention and control  Integration into PHC

3. 3 Teaching and Learning Aims There is ignorance, superstition, stigma and fear around Mental Illness There is ignorance, superstition, stigma and fear around Mental Illness Etiology, pathogenesis diagnosis and treatment are imperfect. Etiology, pathogenesis diagnosis and treatment are imperfect. There is a different paradigm and a less rigorous epidemiology There is a different paradigm and a less rigorous epidemiology 8 September 2015Mental Health

4. 4 Often sad,sometimes mad,occasionally bad The medical model is: The medical model is: –Insufficient –Diagnosis is largely clinical and experiential 8 September 2015Mental Health

5. 5 More of an art than a science Treatment is pragmatic Treatment is pragmatic Prevention is about the politics of health Prevention is about the politics of health “populations, “populations, people pressures, poverty” 8 September 2015Mental Health

6. 6 Mental Health is a worldwide problem 8 September 2015Mental Health

7. 7 We are all vulnerable 8 September 2015Mental Health

8. Global Burden Mental & Substance Use disorders Study Harvey A Whiteford, et al: Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet: August 29, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61611-6 183·9 million DALYs (disability adjusted life years) 183·9 million DALYs (disability adjusted life years) 7·4% of all DALYs worldwide. 7·4% of all DALYs worldwide. 8·6 million YLLs (Years of life lost) 8·6 million YLLs (Years of life lost) 175∙3 million YLDs (22·9% of all YLDs) (Year of life lost to disability) 175∙3 million YLDs (22·9% of all YLDs) (Year of life lost to disability) Leading cause of YLDs worldwide. Leading cause of YLDs worldwide. Depressive disorders 40·5% of DALYs caused by mental and substance use disorders Depressive disorders 40·5% of DALYs caused by mental and substance use disorders Anxiety disorders 14·6% Anxiety disorders 14·6% 8 September 2015Mental Health 8

9. 8 September 2015Mental Health 9 Global Burden Mental & Substance Use disorders Study Harvey A Whiteford et al,: Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet: August 29, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61611-6

10. 8 September 2015Mental Health 10 Global Burden Mental & Substance Use disorders Study Harvey A Whiteford et al: Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet: August 29, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61611-6

11. KSA Estimates Riyadh: 30 – 40 % of PHC patients had mental disorders (mostly undiagnosed) Riyadh: 30 – 40 % of PHC patients had mental disorders (mostly undiagnosed) Al-Khobar: 22 % of health clinics patients had mental health disorders (8 % diagnosed) Al-Khobar: 22 % of health clinics patients had mental health disorders (8 % diagnosed) Central province: 18 % of adults with minor disorder, with rates higher among: Central province: 18 % of adults with minor disorder, with rates higher among: –Young: 15-29 years (23 %) –Divorced and widows (40 %) Suicidal rates: 1.1 per 100,000 mostly among: Suicidal rates: 1.1 per 100,000 mostly among: –Men –Age: 30-39 years –Immigrants 8 September 2015 11 Mental Health

12. 12 Classification of Mental Illness (I) The Neuroses: e.g. depression, anxiety, mania, obsessions and compulsions (usually the patient retains insight and orientation; they experience deep distress and may commit suicide) The Psychoses: e.g. schizophrenia, puerperal psychosis (the patient is disorientated, deluded, and lacking in insight) The Dementias: e.g. progressive deterioration with loss of recent memory and deterioration of a normal personality. They may be primary or more commonly secondary to another condition e.g. alcohol, cerebro- vacular stroke 8 September 2015Mental Health

13. 13 Classification of Mental Illness (II) Affective Disorders Affective Disorders Anxiety, depression, mania, obsessional disorders Schizophrenia Schizophrenia e.g. paranoid type, disorganized type Organic states Organic states e.g. dementia Personality Disorder Personality Disorder Abnormal personality Substance abuse Substance abuse Drugs, alcoholDrugs, alcohol Learning disorders Learning disordersSubnormality 8 September 2015Mental Health

14. 14 Classification of Mental Illness (III) Drug Problems Addictive drugs, (Heroin, Cocaine, Amphetamines,) alcohol nd drug related illness-psychosis, delirium and dementia Personality Disorders A personality and behaviour that is damaging to the individual and/or to society and which is not tolerated by the dominant culture Mental subnormality / learning disorders: Problems around intelligence and ability to learn on the basis of teaching and experience 8 September 2015Mental Health

15. 15 Mental Handicap/ learning disability The mind of a young child in the body of an adult 8 September 2015Mental Health

16. 16 Etiology of Mental Illness (I) Multiple factors (individual, family and community) Genetic factors Social / environmental factors (e.g. stress, deprivation) Physical factors (e.g. trauma, disease as: syphilis and pellagra) 8 September 2015Mental Health

17. 17 Etiology of Mental Illness (II) Inheritance-Genetics/Intra- uterine environment Schizophrenia,Huntington’s Infections- HIV,Syphilis,CJD Drug Abuse Alcohol,Heroin etc Trauma/head injuryBiochemistry/metabolic Porphyria,Diabetes Vascular-CVA Neurological diseases MS,Brain tumour Upbringing Mothering,education, parenting Nutrition/PCM 8 September 2015 Mental Health

18. PREVENTION AND CONTROL 8 September 2015 18 Mental Health

19. 19 Preventive Networks Mosque, Family, Home, Friends, Work 8 September 2015 Mental Health

20. Primary Prevention (Ref: WHO, Prevention & Promotion 2002 WHO, Prevention of Mental Disorders 2004) Universal prevention: targeting the general public or a whole population group. Selective prevention: targeting individuals or subgroups of the population whose risk of developing a mental disorder is significantly higher than that of the rest of the population. Indicated prevention: targeting persons at high-risk for mental disorders. 8 September 2015Mental Health 20

21. Primary Prevention Reducing/Eliminating Risk & Facilitating Protective Factors (Ref: WHO, Prevention & Promotion 2002 WHO, Prevention of Mental Disorders 2004) 8 September 2015Mental Health 21

22. 22 Prevention of Mental Illness Protection of the very young (promotion of family life) Prevention of social stress and insecurity Protection of the aged who may suffer from cerebral degeneration, depression and/or psychopathic states Prevention of brain damage Public education in mental health Premarital consultations and medical examination Provision of suitable institutions Legislation as regards drug abuse, compulsory admission to residential hospitals and guardianship Rehabilitation 8 September 2015Mental Health

23. 23 Treatment and Care Hospital Care Community Care 8 September 2015Mental Health

24. Integration of Mental Health into PHC The morbidity burden in great The morbidity burden in great Mental and physical health problems are interwoven Mental and physical health problems are interwoven Treatment gap is enormous Treatment gap is enormous PHC care for mental health PHC care for mental health –Enhances success –Promotes respect for human rights –Is affordable and cost-effective –Generates good health outcomes 8 September 2015 24 Mental Health

25. KSA Mental Healthcare Facilities BedsNumberFacility 30-120 each14MoH Psychiatric Hospitals 5701Al-Taif Hospital 165 totalMilitary, National Guards and University Hospitals 146 totalPrivate Hospitals 280 each3 Hospitals for Ʀ of Drug Dependence 20-30 each61Departments / Clinics attached to General Hospitals 8 September 2015 25 Mental Health

26. References (I) 1. WHO. Integrating mental health into primary care: A global perspective. Geneva: WHO, 2008 2. WHO. Saudi Arabia: Integrated primary care for mental health in the Eastern Province. In: Integrating mental health into primary care: A global perspective. Geneva: WHO, 2008 3. Sims P. Mental health and illness: An epidemiological perspective. University of Papua New Guinea 4. Al-Fares E, Al-Shammari S, Al-Hamed A. Prevalence of psychiatric disorders in an academic primary care department in Riyadh. Saudi Medical Journal 1992; 13: 49-53 8 September 2015 26 Mental Health

27. References (II) 5. Al-Khathmi A, Ogbeide D. Prevalence of mental illness among Saudi adult primary care patients in central Saudi Arabia. Saudi Medical Journal 2002; 23: 721-724 6. Elfawal M. Cultural influence on the incidence and choice of method of suicide in Saudi Arabia. American Journal of Forensic Medicine & Pathology 1999; 20: 163-168 7. Al-Khathami A. The implementation and evaluation of an educational program for PHC physicians to improve their recognition of mental illness in the Eastern Province of Saudi Arabia [dissertation]. Al- Khobar: King Faisal University, 2001 8 September 2015 27 Mental Health