Community Mental Health

Awatif Alam /Ahmed Mandil, Prof of Epidemiology

College of Medicine, KSU
aalam@ksu.edu.sa
Headlines:

 General reflections
 Magnitude of the problem
 Classifications
 Disorders
 Etiology
 Prevention and control
 Integration into PHC
 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.
 Magnitude of Mental illness
worldwide

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 We are all vulnerable

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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

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

Inheritance-Genetics/Intra-uterine :Drug Abuse

environment Schizophrenia,Huntingto
n’s Alcohol , Heroin etc

:Upbringing :Neurological diseases

Mothering , education MS ,Brain tumor
parenting
Biochemistry/
Trauma/head injury :metabolic
Porphyria , Diabetes

Infections- Vascular-CVA
HIV,Syphilis,CJD Nutrition/PCM
 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.
 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.
 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”.
BROAD CLASSIFICATION OF MENTAL
ILLNESS :

• The psychoneurosis

• The psychosis

• Addictions, alcoholism,
… etc.

• Mental retardation
 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.
 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.
 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.
 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.
• 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.
 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.
The psychotic who violates legal and social codes is placed under
supervision or hospitalized.
 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.”
 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).
 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)
 PREVENTION AND
CONTROL
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Preventive Networks : Family, Home, Friends, Work & Religion

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 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.

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Primary Prevention
Reducing/Eliminating Risk & Facilitating Protective Factors
(Ref: WHO, Prevention & Promotion 2002
WHO, Prevention of Mental Disorders 2004)

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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.
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.
Treatment and Care

Hospital Care

Community Care

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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
Availability of Mental health facilities in
KSA:
 Total number of Rate per 100,000 Number of Rate per 100,000
facilities/beds population facilities/beds population
reserved for children
and adolescents only

Mental health outpatient 94 0.36 19 0.07

facilities

Day treatment facilities. 3 0.01 UN UN

.

Psychiatric beds in general 100 0.38 UN UN

hospitals

Community residential 2 0.01 0 0

facilities

Beds/places in community 240 0.91 0 0

residential facilities

Mental hospitals 20 0.08 0 0

Beds in mental hospitals 3000 11.43 0 0

 Access to mental health care in KSA:

Rates per 100,000 Females % Under

population) age 18 %

Persons treated in mental health UN UN UN

outpatient facilities
Persons treated in mental health day UN UN
treatment facilities

Admissions to psychiatric beds in UN UN UN

general hospitals

Persons staying in community UN UN UN

residential facilities at the end of the
year

Admissions to mental hospitals 76.53 UN UN

KSA Mental Healthcare Facilities
Facility Number Beds
MoH Psychiatric Hospitals 14 30-120 each
Al-Taif Hospital 1 570
Military, National Guards and total 165
University Hospitals
Private Hospitals total 146
Hospitals for treatment of Drug 3 each 280
Dependence
Departments / Clinics attached 61 each 20-30
to General Hospitals
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
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.