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MENTAL HEALTH Ahmed Mandil, Prof of Epidemiology Dr. Mohammad Afzal Mahmood College of Medicine, King Saud University Headlines General reflections Magnitude of the problem Classifications Disorders Etiology Prevention and control Integration into PHC Teaching and Learning Aims There is ignorance, superstition, stigma and fear around Mental Illness Etiology, pathogenesis diagnosis and treatment are imperfect. There is a different paradigm and a less rigorous epidemiology 23 May 2017 Mental Health 3 Often sad,sometimes mad,occasionally bad The medical model is: – Insufficient – Diagnosis is largely clinical and experiential 23 May 2017 Mental Health 4 More of an art than a science Treatment is pragmatic Prevention is about the politics of health “populations, people pressures, poverty” 23 May 2017 Mental Health 5 Mental Health is a worldwide problem 23 May 2017 Mental Health 6 We are all vulnerable 23 May 2017 Mental Health 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% 23 May 2017 Mental 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 23 May 2017 Mental 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 23 May 2017 Mental Health 10 KSA Estimates Riyadh: 30 – 40 % of PHC patients had mental disorders (mostly undiagnosed) 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: – Young: 15-29 years (23 %) – Divorced and widows (40 %) Suicidal rates: 1.1 per 100,000 mostly among: – Men – Age: 30-39 years – Immigrants 23 May 2017 Mental Health 11 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, cerebrovacular stroke 23 May 2017 Mental Health 12 Classification of Mental Illness (II) • Substance abuse Affective Disorders Anxiety, depression, mania, obsessional disorders • Learning disorders Schizophrenia e.g. paranoid type, disorganized type •Drugs, alcohol Subnormality Organic states e.g. dementia Personality Disorder Abnormal personality 23 May 2017 Mental Health 13 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 23 May 2017 Mental Health 14 Mental Handicap/ learning disability The mind of a young child in the body of an adult 23 May 2017 Mental Health 15 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) 23 May 2017 Mental Health 16 Etiology of Mental Illness (II) Inheritance-Genetics/Intrauterine environment Schizophrenia,Huntington’s Upbringing Drug Abuse Alcohol,Heroin etc Neurological diseases Mothering,education, parenting Trauma/head injury MS,Brain tumour Biochemistry/metabolic Porphyria,Diabetes InfectionsHIV,Syphilis,CJD Mental Health 23 May 2017 Nutrition/PCM Vascular-CVA 17 PREVENTION AND CONTROL 23 May 2017 Mental Health 18 Preventive Networks Mosque, Family, Home, Friends, Work 23 May 2017 Mental Health 19 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. 23 May 2017 Mental Health 20 Primary Prevention Reducing/Eliminating Risk & Facilitating Protective Factors (Ref: WHO, Prevention & Promotion 2002 WHO, Prevention of Mental Disorders 2004) 23 May 2017 Mental Health 21 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 23 May 2017 Mental Health 22 Treatment and Care Hospital Care Community Care 23 May 2017 Mental Health 23 Integration of Mental Health into PHC The morbidity burden in 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 23 May 2017 Mental Health 24 KSA Mental Healthcare Facilities Facility Number Beds MoH Psychiatric Hospitals 14 30-120 each Al-Taif Hospital 1 570 Military, National Guards and University Hospitals 165 total Private Hospitals 146 total Hospitals for Ʀ of Drug Dependence 3 280 each Departments / Clinics attached to General Hospitals 61 20-30 each 23 May 2017 Mental Health 25 References (I) 1. 2. 3. 4. WHO. Integrating mental health into primary care: A global perspective. Geneva: WHO, 2008 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 Sims P. Mental health and illness: An epidemiological perspective. University of Papua New Guinea 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 23 May 2017 Mental Health 26 References (II) 5. 6. 7. 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 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 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]. AlKhobar: King Faisal University, 2001 23 May 2017 Mental Health 27