Community

Mental Health
Care
By: Dr. Wazhma Hakimi
 The Burden of Mental
Health Problems
 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
 10 leading causes of health burden
Rank Cause % DALYs lost
1 Lower respiratory diseases 7.3

2 Diarrhoeal diseases 6.5

3 Perinatal conditions 6.1

4 Major Depressive Disorders 4.2

5 Ischaemic Heart Disease 4.0

6 HIV 3.4

7 Cerebrovascular disease 3.2

8 Road traffic accidents 3.0

9 Malaria 3.0

10 Tuberculosis 3.0
WHO: “There can be no health without mental health.”
Loncer 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
 Why is the burden so huge?
 Early age of onset (WHO, 2000)
 Treatment gap ( Kohn, et al, 2004)
Reasons for existing treatment gaps for mental
disorders:
1. Not acknowledging the problem
2. Perceiving that treatment is not effective
3. Believing that the problem will go away by itself
4. Deal with the problem without outside help
5. Lack of knowledge about mental disorders
6. Facing stigma as a major barrier
7. Unavailable services
8. Lack of accessibility to services
Cost of mental health problems:

1. Disability
2. Mortality
3. Economic impact
4. Burden on families
 Disability
1. Physical
2. Social
In 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
Neuropsychiatric conditions cause 31.7% of
YLD which are listed in the following box:
Major neuropsychiatric YLD
conditions
Depression 11.8%
Substance use disorder 3.3%
Schizophrenia 2.8%
Bipolar disorder 2.4%
Dementia 1.6%
 Mortality

 Increased risk of premature death

 1-2 million deaths every year
 A million people die by suicide every year
 86% in LMIC
 > half between the ages of 15-44
 Economic Burden
• Direct and indirect costs
• In depressive disorders,
Direct costs are:
 Medical Consultation
 Hospitalization
 Medication
And indirect costs are:
 Being unable to work
 Claiming incapacity benefits
 Time of family member
 Burden on families

 Intangible costs_ pain and suffering

 Effects on quality of life
Various sources of stress include:
1. Emotional reactions to the patient's illness
2. The stress of coping with disturbed behavior
3. Disruption of household routine
4. Problems of coping with social withdrawal or awkward
interpersonal behavior
5. Curtailment of social activities
Recognizing Mental Health
Problems

Do emotional symptoms indicate

mental disorders?
Behaviors suggesting an underlying
mental health problem:
Presenting problems:
• Inappropriate requests for urgent appointments
• Multiple consultation or requests for tests
• Unexpected outbursts during consultation(tears,
anger)
• Excessive anxiety about a family member
Recurring problems:
• Frequent consultation
• Instability and breakdowns in relationships
• Distressing/deteriorating social circumstances
Changes that indicate mental
health problems

Common symptoms which might suggest mental

health problems:
• Changes in behavior
• Emotional disturbances
• Disturbances in ways of thinking
• Becoming dysfunctional
When should doctors suspect mental
illness?

• 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
Promoting Mental Health

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)
The structural Model of 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 factors
2. Social support and other social interactions
3. Social structures and resources
4. Cultural values

The influences between mental health and its

determinants are reciprocal.
 Why promote mental health?
Because
Mental, physical and social well-being as well as mental
health issues, physical ill health and social difficulties are
linked.
1. Mental health affects physical health
2. Mental health affects social aspects
3. Mental health affects spiritual health
How to promote mental health:
Many factors influence mental health, divided into three
groups:
1. The development and maintenance of healthy
communities
2. 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.
Preventing Mental Health
Problems
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 salt
2. 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
Strategies to prevent mental health problems
should aim to reduce(WHO, 2004):

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.
Gorden (1983) classified preventive
interventions as:

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.
 Primary prevention

Some effective interventions to improve mental health

for developing countries:
1. Prenatal and neonatal intervention
2. Interventions during infancy and childhood
3. Interventions in adolescence and early adult life
4. Interventions in middle and late life
 Secondary 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
 Tertiary 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
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
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
 Reasons for integrating mental
health into primary care:

1. The burden of mental disorders is great

2. Mental and physical health problems are interwoven
3. The treatment gap for mental disorders is enormous
4. Primary care for mental health enhances access
5. Primary care for mental health promotes respect of
human rights
6. Primary care for mental health is affordable and cost
effective
7. Primary care for mental health generates good health
outcomes
Healthcare system – the WHO
pyramid
Role of a doctor in primary care

1. Detecting mental illnesses

2. Providing basic medication
3. Intervening in crises
4. Referring to specialist mental health services
5. Managing co-morbidity
6. Promotion of positive mental health and prevention
of mental disorders
Mental Health Legislation

Why do we need legislation for

mental health care?
 Mental Health Care Law
Ten basic principles of mental health
legislation

1. Promotion of mental health and prevention of mental disorders

2. Access to basic mental health care
3. Mental health assessments in accordance with internationally
accepted principles
4. Provision of least restrictive type of mental health care
5. Self-determination
6. Right to be assisted in the exercise of self-determination
7. Availability of review procedure
8. Automatic periodic review mechanism
9. Qualified decision-maker
10. Respect for the rule of law
Mental Health Ordinance 2001

The noticeable features of the mental health ordinance are as

follow:
1. Access to mental health care
2. Establish national standards and guidelines for treatment
3. Establish independent mechanisms for monitoring care
4. Promote positive mental health and prevent mental
illnesses
5. Protect the rights of people with mental disorders