Community Mental

Health CareThird Group Presentation

Group Members:1. Dr. M. Essa Ebrahemi2. Dr. Sayed Ahmad

Esmati3. Dr. Wazhma Hakimi4. Dr. Tuba Mahmood5. Dr. Farid Ahmad

Rahmani6. Dr. Zabihullah

Mahzoon

Government Islamic Republic of Afghanistan - GIRoAMinistry of Higher Education - MoHE

Kabul Medical University - KMUMaster of Public Health – MPH Program

Third Semester Behavioral Science Module

Facilitators:1. Dr. Wazhma Hakimi2. Dr. Farid Ahmad

Rahmani3. Dr. Zabihullah

Mahzoon

1. The Burden of Mental Health Problems2. Cost of mental health problems

Disability Mortality Economic impact Burden on families

3. Recognizing Mental Health Problems4. Promoting Mental Health 5. The structural Model of Mental Health6. Preventing Mental Health Problems7. Community Mental Health Care8. Healthcare system – the WHO pyramid9. Mental Health Legislation

Community Mental Health Care

Outlines

The Burden of Mental Health

Problems

First Section

Presented by: Dr. Wazhma Hakimi

For a long time, focus was only on diseases of greater mortality, but not on diseases which causes disability and suffering such as mental disorders.

Murry and Lopez, 1996: Combining mortality(YLL) and

morbidity(YLD)In addition to the number of deaths,

premature deaths and disability was also considered.

Mental disorders

The Burden of Mental Health

Problems

10 leading causes of health burdenRank Cause % DALYs lost1 Lower respiratory

diseases7.3

2 Diarrhoeal diseases 6.53 Perinatal conditions 6.14 Major Depressive

Disorders4.2

5 Ischaemic Heart Disease 4.06 HIV 3.47 Cerebrovascular disease 3.28 Road traffic accidents 3.09 Malaria 3.010 Tuberculosis 3.0

WHO: “There can be no health without mental health.”Loncar and Mathers, 2006:• 14% of the total burden of disease(2005)• 28% of NCD(2005)WHO, 2001:• Equal to cardiovascular disorders• More than the burden of cancer

Early age of onset (WHO, 2000) Treatment gap ( Kohn, et al, 2004)Reasons for existing treatment gaps for mental disorders:1. Not acknowledging the problem2. Perceiving that treatment is not effective3. Believing that the problem will go away by itself4. Deal with the problem without outside help5. Lack of knowledge about mental disorders6. Facing stigma as a major barrier7. Unavailable services8. Lack of accessibility to services

Why is the burden so huge?

1. Disability2. Mortality3. Economic impact4. Burden on families

Cost of mental health problems:

1.Physical2.SocialIn mental disorders, social disability can affect various areas:• Self care• Occupational performance• Functioning in relation to family and

household members• Functioning in a broader social context

Disability

Neuropsychiatric conditions cause 31.7% of YLD which are listed in the following box:

Major neuropsychiatric

conditions

YLD

Depression 11.8%Substance use disorder

3.3%

Schizophrenia 2.8%Bipolar disorder 2.4%Dementia 1.6%

Increased risk of premature death1-2 million deaths every yearA million people die by suicide every

year86% in LMIC> half between the ages of 15-44

Mortality

• Direct and indirect costs• In depressive disorders,Direct costs are:Medical ConsultationHospitalizationMedicationAnd indirect costs are:Being unable to workTime of family member

Economic Burden

Intangible costs_ pain and suffering Effects on quality of lifeVarious sources of stress include:1. Emotional reactions to the patient's illness2. The stress of coping with disturbed behavior3. Disruption of household routine4. Problems of coping with social withdrawal or

awkward interpersonal behavior5. Curtailment of social activities

Burden on families

Recognizing Mental Health Problems

Do emotional symptoms indicate mental disorders?

Presenting problems:• Inappropriate requests for urgent appointments• Multiple consultation or requests for tests• Unexpected outbursts during

consultation(tears, anger)• Excessive anxiety about a family memberRecurring problems:• Frequent consultation• Instability and breakdowns in relationships• Distressing/deteriorating social circumstances

Behaviors suggesting an underlying mental health problem:

Common symptoms which might suggest mental health problems:• Changes in behavior• Emotional disturbances• Disturbances in ways of thinking• Becoming dysfunctional

Changes that indicate mental health problems

• If an individual struggles to recover and the emotional difficulties persist beyond an expected period of recovery

• If the intensity of the symptoms cannot be explained by what has happened

• If there is no obvious cause• If the individual starts to suffer and cannot

function• If others are adversely affected

When should doctors suspect mental illness?

End – Section one

Promoting Mental Health

Second Section

Presented by: Dr. Farid Ahmad Rahmani

Mental health Vs. mental illness

What is mental health?“ A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”(WHO, 2001)

Promoting Mental Health

In order to achieve optimal mental health, there has to be equilibrium between individual experiences and those around an individual.Determinants of mental health:1. Individuals factors2. Social support and other social interactions3. Social structures and resources4. Cultural values

The influences between mental health and its determinants are reciprocal.

The structural Model of Mental Health:

The structural Model of Mental Health:

BecauseMental, physical and social well-being as well as mental health issues, physical ill health and social difficulties are linked.1. Mental health affects physical health2. Mental health affects social aspects3. Mental health affects spiritual health

Why promote mental health?

Many factors influence mental health, divided into three groups:1. The development and maintenance of healthy

communities2. Each person's ability to deal with the social world

through…3. Each person's ability to deal with thoughts and

feelings, the management of life and emotional resilience.

In theory, the aim of mental health promotion is to increase and enhance positive mental health.And the aim of mental ill-health prevention is to protect individuals from mental health problems.

How to promote mental health:

General principles of prevention

Definition of prevention(Caplan, 1964):1. Primary prevention: Reducing the incidence who

are normal but are at risk e.g., iodized salt2. Secondary prevention: Reducing prevalence of a

disorder by shorten its duration and limit its consequences through early treatment e.g., control of hypertension

3. Tertiary prevention: Reducing severity and disability e.g., rehabilitation

Preventing Mental Health Problems

1. The incidence, prevalence, and recurrence of mental disorders;

2. The time spent with symptoms; the risks for such mental illnesses;

3. The effects of illness on affected people, their families, and society.

Strategies to prevent mental health problems should aim to reduce(WHO, 2004):

1. Universal: Targeted at whole population e.g., good prenatal care

2. Selected: Targeted at subgroups e.g., family support for young, poor, first pregnancy mothers

3. Indicated: Targeted at high-risk individuals e.g., screening and early treatment for symptoms of depression and dementia.

Gorden (1983) classified preventive interventions as:

Some effective interventions to improve mental health for developing countries:1. Prenatal and neonatal intervention2. Interventions during infancy and childhood3. Interventions in adolescence and early

adult life4. Interventions in middle and late life

Primary prevention

Refers to early diagnosis and treatment to shorten the illness episode, to minimize the chances of transmission of the disorder and to limit disease consequences.

There are cost effective treatments in the context of mental health which reduce human suffering and the economic burden on society

E.g., Detecting depression promptly and treating it effectively

Prompt management of febrile convulsions Timely interventions for head injuries Early recognition and management of metabolic

disorders Proper treatment of epilepsy

Secondary prevention

Refers to measure which limit disability and handicap associated with disorders which may not be fully treatable.

E.g., educating and supporting the families, specific educational programs, opportunities for vocational training and social skills training for people with learning disability.

Rehabilitation of people with schizophrenia Interventions for people with dementia

Tertiary prevention

CommunityMental Health

Third Section

Presented by: Dr. Zabihullah Mahzoon

Presented by: Dr. Zabaiullah Mahzoom

Community Mental Health Care

Integration of mental health care into primary care:WHO(2001): • Primary mental health care services need to be

developed• Treatment and care for mental disorders should be

provided through primary care centers and other community-based settings.

• Doctors in primary care need to be trained and supported

Community Mental Health Care

Barriers to delivering an effective mental health service in primary care:• Lack of basic primary care infrastructure and

services• Overburdened and patient loads in services• Lack of doctor's time • Insufficient supervision and support of

doctors• Unavailability of essential psychotropic

medicines

1. The burden of mental disorders is great2. Mental and physical health problems are interwoven3. The treatment gap for mental disorders is enormous4. Primary care for mental health enhances access5. Primary care for mental health promotes respect of

human rights6. Primary care for mental health is affordable and cost

effective7. Primary care for mental health generates good

health outcomes

Reasons for integrating mental health into primary

care:

Healthcare system – the WHO pyramid

1. Detecting mental illnesses2. Providing basic medication3. Intervening in crises4. Referring to specialist mental health

services5. Managing co-morbidity6. Promotion of positive mental health and

prevention of mental disorders

Role of a doctor in primary care

Why do we need legislation for mental

health care?

Mental Health Legislation

1. Promotion of mental health and prevention of mental disorders

2. Access to basic mental health care3. Mental health assessments in accordance with internationally

accepted principles4. Provision of least restrictive type of mental health care5. Self-determination6. Right to be assisted in the exercise of self-determination7. Availability of review procedure8. Automatic periodic review mechanism9. Qualified decision-maker10. Respect for the rule of law

Mental Health Care LawTen basic principles of mental

health legislation

The noticeable features of the mental health ordinance are as follow:1. Access to mental health care2. Establish national standards and guidelines for

treatment3. Establish independent mechanisms for monitoring

care4. Promote positive mental health and prevent mental

illnesses5. Protect the rights of people with mental disorders

Mental Health Ordinance 2001