1. Community Mental Health Awatif Alam /Ahmed Mandil, Prof of Epidemiology College of Medicine, KSU aalam@ksu.edu.sa

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

3. General Reflection: Community health service was concerned mainly with the control of communicable diseases. In the course of development, it has become increasingly concerned with every health aspect of life of individuals in the community. Psychiatry, has developed as a personal service to the mentally – ill individual, Only recently psychiatrists have attempted to contribute to preventive aspects of mental illness. However, preventive psychiatry remains in its infancy and needs much community efforts to be well developed.

4. Magnitude of Mental illness worldwide 20 November 2015Mental Health

5. We are all vulnerable 20 November 2015Mental Health

6. 20 November 2015Mental Health6 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

7. 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) 7·4% of all DALYs worldwide. 8·6 million YLLs (Years of life lost) 175∙3 million YLDs (22·9% of all YLDs) (Year of life lost to disability) Leading cause of YLDs worldwide. Depressive disorders 40·5% of DALYs caused by mental and substance use disorders Anxiety disorders 14·6%

8. Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, WHO An officially approved mental health policy exists since 2008. The mental health plan components include:  Timelines for the implementation of the mental health plan.  Funding allocation for the implementation of about half of the items in the mental health plan.  Shift of services and resources from mental hospitals to community mental health facilities.  Integration of mental health services into primary care. Legal provisions concerning mental health are also covered in other laws (e.g., welfare, disability, general health legislation etc.). Note: As of 2010, the Mental Health Act was under review and consideration in the Council of Ministers (Shoura Council).

9. Mental Health Burden in KSA: In Saudi Arabia, neuropsychiatric disorders are estimated to contribute to 14.% of the global burden of disease (WHO, 2008). Mental health expenditures by the government health department/ministry are 3.89% of the total health budget.

10. Etiology OF MENTAL ILLNESS The concept of multiple factors in the causation of psychogenic disorders has become generally accepted. The factors are considered to involve the individual, the family and the community.

11. genetic factors play a causative role in schizophrenia and in some manic depressive illnesses. social and environmental stress, social deprivation and other phenomena which characterize modern life. Physical causes, as disease or trauma, The roles of syphilis and advanced pellagra are well known to cause mental disturbances.

12. Etiology of Mental Illness (II) Inheritance- Genetics/Intra-uterine environment Schizophrenia,Huntington’s Infections- HIV,Syphilis,CJD Drug Abuse: Alcohol, Heroin etc Trauma/ head injury Biochemistry/metaboli c: Porphyria, Diabetes Vascular-CVA Neurological diseases: MS,Brain tumor Upbringing: Mothering, education parenting Nutrition/PCM

13. EXTENT OF MENTAL ILLNESS : It is estimated that one person in every ten, has some form of mental or emotional illness, from mild to severe, that could benefit from professional help or treatment. Estimates vary, however, depending on the criteria used for diagnosis and the kinds of mental conditions included. If only clearly disabling conditions are counted, the estimate of mental illness in the general population will be much lower than 10%. If milder emotional upsets, psychosomatic complaints and any of the various “problems of living” are included, a much larger proportion of the population will be found to have some form of emotional disorder.

14. EXTENT OF MENTAL ILLNESS : It is estimated that one person in every ten, has some form of mental or emotional illness, from mild to severe, that could benefit from professional help or treatment. Estimates vary, however, depending on the criteria used for diagnosis and the kinds of mental conditions included. If only clearly disabling conditions are counted, the estimate of mental illness in the general population will be much lower than 10%. If milder emotional upsets, psychosomatic complaints and any of the various “problems of living” are included, a much larger proportion of the population will be found to have some form of emotional disorder.

15. OBJECTIVES: Promote mental health in the community. Maintain – if possible – the mentally – ill within the community itself. Avoid un-necessary admission and restraint in special hospitals. Provide social therapy. “Community mental service is provided in hospitals, mental health centers, by general practitioners and health authorities (local and central) all working in harmony”.

16. BROAD CLASSIFICATION OF MENTAL ILLNESS : The psychoneurosis The psychosis Addictions, alcoholism, … etc. Mental retardation

17. psychoneurosis : Comprise a group of personality disorders, in which: Behavior traits, Thought processes, Emotional responses and Somatic functions occur in a repetitive pattern maladaptive and inappropriate to the ordinary stresses and demands of environment and living.

18. Psychoneurosis: Symptomatology has its origin outside conscious awareness and is traceable to modes of personality functioning which pre-existed in infancy and childhood. In general, the psychoneurotic reaction represents : Symbolic adaptation to anxiety involving only partially disturbed social functioning and reality testing. The psychoneurotic in contrast to the psychotic, maintains the capacity to perceive and adapt to environmental realities.

19. Psychoneurosis: Legally, the psychoneurotic is responsible for his actions. The onset of psychoneurosis occurs usually in early adult life. The course tends to be chronic. Appearance of these disorders, for the first time, after 45 years of age is unusual.

20. Psychoneurosis: Usually symptoms express themselves in the period of active sexual reproductivity and social responsibility. Psychoneurotic disturbances manifest themselves in the predisposed individual as a consequence of exposure to anxiety – arousing situations. The genetic and constitutional factors determine both the capacity of the personality to withstand stress and the determination of the organ systems which respond to stress.

21. The initial stage of personality development takes place during the early years of life, during which time the infant is wholly dependent upon his mother or a mother substitute. If the child is pushed and urged beyond his maturational limits, the beginning of self-doubt and shame are implanted. The child enters into the society of equals through various interactions (sibs),and their play is the introduction to the life of society in general. The child starts to learn to adjust to the needs and desires of others. He always strives for success.

22. Psychosis: Represents extreme form of breakdown in mental health, The individual no longer remains related to the reality situation, The patient is subjected to irrational and disordered emotional and intellectual process. Psychosis will lead to aberrant behavior recognizable by gross un-reality, e.g. schizophrenia, manic depressive psychosis, melancholia.

23. The psychotic who violates legal and social codes is placed under supervision or hospitalized.

24. Addictions, alcoholism, and other behavior disorders: The drugs that can affect mental processes and behavior are classified into three general groups: Depressants e.g. Valium, Librium, barbiturates. ( alcohol is the most commonly used and abused ). Stimulants include amphetamines, nicotine in tobacco. Hallucinogens include marijuana and lysergic acid diethylamide. “ Individuals must be fully informed of the possible hazard to health involved in alcohol and drug abuse.”

25. The governmental role in control of alcohol and drug abuse: Adopting certain legal regulations; for controlling the important and export of narcotic drugs, Regulating the production and distribution of drugs, Establishing penalties for illegal possession or sale of dangerous drugs. The provision of programs including: - treatment, - rehabilitation, - research and education (designed to prevent and combat the adverse personal and social consequences of drug abuse).

26. Mental Retardation: A person may be retarded in : intelligence level, in adaptive behavior, in academic achievement, in a combination of these elements. Mental retardation can be caused by any condition that interferes with development : - before birth,(gene incompatab., x-ray, infections) - during birth ( birth injury ) - in early childhood (meningitis, polio, lead poisoning)

27. PREVENTION AND CONTROL 20 November 2015Mental Health

28. Preventive Networks :Mosque, Family, Home, Friends, Work 20 November 2015

29. 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. 20 November 2015

30. Primary Prevention Reducing/Eliminating Risk & Facilitating Protective Factors (Ref: WHO, Prevention & Promotion 2002 WHO, Prevention of Mental Disorders 2004) 20 November 2015Mental Health30

31. The field of action for prevention encompasses: Protection of the very young, through 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 e.g. control of syphilis and alcoholism. Public education in mental health.

32. The field of action for prevention encompasses: Pre-marital consultations and medical examinations. Provision of suitable institutions for the care of the mentally ill. Legislation as regards drug abuse, compulsory admission to residential hospitals and guardianship. Rehabilitation.

33. 33 Treatment and Care Hospital Care Community Care 20 November 2015Mental Health

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

35. Availability of Mental health facilities in KSA:

36. Total number of facilities/beds Rate per 100,000 population Number of facilities/beds reserved for children and adolescents only Rate per 100,000 population Mental health outpatient facilities 940.36190.07 Day treatment facilities.. 30.01UN Psychiatric beds in general hospitals 1000.38UN Community residential facilities 20.0100 Beds/places in community residential facilities 2400.9100 Mental hospitals200.0800 Beds in mental hospitals300011.4300

37. Access to mental health care in KSA: Rates per 100,000 population) Females %Under age 18 % Persons treated in mental health outpatient facilities UN Persons treated in mental health day treatment facilities UN Admissions to psychiatric beds in general hospitals UN Persons staying in community residential facilities at the end of the year UN Admissions to mental hospitals76.53UN

38. KSA Mental Healthcare Facilities BedsNumberFacility 30-120 each14MoH Psychiatric Hospitals 5701Al-Taif Hospital 165 totalMilitary, National Guards and University Hospitals 146 totalPrivate Hospitals 280 each3Hospitals for treatment of Drug Dependence 20-30 each61Departments / Clinics attached to General Hospitals

39. References (I) 1. Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, World Health Organization. 1. WHO. Integrating mental health into primary care: A global perspective. Geneva: WHO, 2008. 1. 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. 1. Sims P. Mental health and illness: An epidemiological perspective. University of Papua New Guinea.2001 1. 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

40. References (II) 6. 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. 7. 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. 8. 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.