Mental health in the Eastern Mediterranean Region

Document technical information

Format pdf
Size 1.4 MB
First found May 22, 2018

Document content analysis

Category Also themed
Language
English
Type
not defined
Concepts
no text concepts found

Persons

David Hilbert
David Hilbert

wikipedia, lookup

Steve Crocker
Steve Crocker

wikipedia, lookup

Liu Huan
Liu Huan

wikipedia, lookup

Organizations

Places

Transcript

WHO Regional Publications, Eastern Mediterranean Series
In 2001 mental health was brought to the focus of international attention when the
World Health Organization devoted its World Health Day campaign and The world
health report to the subject. In many countries around the world, and particularly in
developing countries, mental health has long been a neglected area of health care,
more often than not considered in terms of institutions and exclusion, rather than the
care and needs of the human being. Current knowledge emphasizes early identification
and intervention, care in the community and the rights of mentally ill individuals.
The countries of the Eastern Mediterranean Region represent many challenges for the
organization of mental health care. Many countries are in a state of rapid social change,
some are in conflict or suffering the aftermath of conflict, while others are witnessing
the growing problem of substance abuse, with associated HIV/AIDS rapidly becoming
a public health priority.
This publication addresses three aspects: the planning of mental health services; the
current mental health situation in each of the countries of the Region, along with the
innovative approaches developed during the past two decades, and the challenges
and opportunities for addressing the mental health needs of the diverse populations.
Bringing together the experiences of the Region provides an opportunity to learn from
the past as well as for greater collaboration and cooperation in the future between
countries facing similar problems.
ISBN 92-9021-339-6
mhcover.indd 1
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health in the Eastern Mediterranean Region: reaching the unreached
29
Mental health in the
Eastern Mediterranean Region
Reaching the unreached
1
24/07/2006 14:00:17
WHO Regional Publications, Eastern Mediterranean Series 29
Mental health in the
Eastern Mediterranean Region
Reaching the unreached
WHO Regional Office for the Eastern Mediterranean
Mental health in the Eastern Mediterranean Region: reaching the unreached / WHO
Regional Office for the Eastern Mediterranean.
p. (WHO Regional Publications, Eastern Mediterranean Series; 29)
ISBN 978 92 9021 543 1
ISSN 1020-041X
1. Mental Health
2. Eastern Mediterranean Region
I. Title II. Series
[NLM Classification: WM 105]
The image used on the front cover incorporates the World Health Day 2001
logo, which was designed by Marc Bizet under the slogan
“Stop exclusion: Dare to care”
Permission to reproduce the logo is gratefully acknowledged
© World Health Organization 2006
All rights reserved.
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the World Health Organization in preference to others of
a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this
publication is complete and correct and shall not be liable for any damages incurred as a result
of its use.
Publications of the World Health Organization can be obtained from Distribution and Sales,
World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr
City, Cairo 11371, Egypt (tel: +202 670 2535, fax: +202 670 2492; email: [email protected]).
Requests for permission to reproduce WHO EMRO publications, in part or in whole, or to
translate them – whether for sale or for noncommercial distribution – should be addressed to the
Regional Adviser, Health and Biomedical Information, at the above address (fax: +202 276
5400; email [email protected]).
Printed by ESDUCK, Cairo
Contents
Foreword........................................................................................................7
Preface ..........................................................................................................9
Part 1. Strengthening mental health programmes
Chapter 1. Introduction ................................................................................17
Chapter 2. Historical aspects.......................................................................22
Activities of the Regional Office 1949–2000..........................................22
Country activities ...................................................................................24
Chapter 3. Overview of mental health in the countries of the Region .........26
Chapter 4. Developing programmes of mental health at country level........29
The need for national programmes of mental health.............................29
Steps for the development of national programmes of mental health ...29
Follow-up steps for finalizing a mental health national programme ......35
Adoption of the national programme of mental health by the
Ministry of Health...................................................................................36
Chapter 5. Development of services for treatment and rehabilitation in
primary health care......................................................................................38
Primary health care in the Region.........................................................38
The general principle of the primary health care approach...................38
Support mechanisms required for the provision of services for the
treatment of persons suffering from neuropsychiatric illnesses ............39
Chapter 6. The role of training in the context of national mental health
programmes ................................................................................................47
Integrating with primary health care ......................................................47
Training of primary care physicians .......................................................49
Evaluation and monitoring of training programmes...............................50
Constraints in the implementation of training programmes ...................51
Special aspects of training of auxiliaries and other health personnel
working at primary health care level......................................................52
Chapter 7. Developing programmes for the prevention of
mental disorders and the promotion of mental health .................................54
Strategies for prevention of mental, neurological and psychosocial
disorders in national mental health programmes ..................................54
Strategies for the promotion of mental health and healthy lifestyles
in the framework of national health programmes ..................................55
Role of psychology and the behavioural sciences in the
development of strategies..................................................................... 60
Involvement of university/academic centres in national mental health
programmes.......................................................................................... 61
Chapter 8. Needs assessment, research and evaluation ........................... 63
Importance of research......................................................................... 63
Promoting research .............................................................................. 64
Chapter 9. Advancing the global mental health agenda............................. 68
An increasing burden ............................................................................ 68
Mental health, mental disorders and the Millennium Development
Goals..................................................................................................... 70
Mental health, global development and the public health agenda........ 71
Mental health and WHO’s agenda ........................................................ 71
WHO’s strategic agenda ....................................................................... 73
Goals for 2016 ...................................................................................... 76
Main lines for mental health action in countries in the Eastern
Mediterranean Region .......................................................................... 77
Part 2. Country profiles
Afghanistan................................................................................................. 83
Bahrain........................................................................................................ 94
Djibouti ...................................................................................................... 102
Egypt......................................................................................................... 108
Islamic Republic of Iran ............................................................................ 124
Iraq............................................................................................................ 146
Jordan....................................................................................................... 157
Kuwait ....................................................................................................... 167
Lebanon.................................................................................................... 173
Libyan Arab Jamahiriya ............................................................................ 183
Morocco .................................................................................................... 190
Oman ........................................................................................................ 199
Pakistan .................................................................................................... 209
Occupied Palestinian Territory .................................................................. 224
Qatar ......................................................................................................... 236
Saudi Arabia ............................................................................................. 242
Somalia..................................................................................................... 255
Sudan ....................................................................................................... 263
Syrian Arab Republic ................................................................................ 274
Tunisia....................................................................................................... 280
United Arab Emirates................................................................................ 289
Yemen ....................................................................................................... 301
Part 3. Discussion and conclusions
Discussion and conclusions ......................................................................313
Global perspectives ...............................................................................313
Regional perspectives............................................................................316
Conclusions ...........................................................................................332
References ...............................................................................................334
Annexes....................................................................................................341
Annex 1. Joint statement on mental health by the Ministers of Health
of the Eastern Mediterranean Region ....................................................343
Annex 2. Questionnaire on country mental health information .................344
Annex 3. Principles for the protection of persons with mental illness
and the improvement of mental health care adopted by
United Nations General Assembly resolution 46/119 of
17 December 1991 ................................................................................356
Annex 4. Substance use and dependence: Technical paper
presented at the Fifty-second session of the Regional Committee
for the Eastern Mediterranean Region and resolution .......................... 374
Annex 5. Prevention of mental, neurological and psychosocial disorders 401
Annex 6. Regional meetings relating to mental health 1973–2005...........403
Annex 7. Suggested tasks for different categories of personnel ...............405
Annex 8. The list of essential neuropsychiatry drugs approved by
the Eastern Mediterranean Region .....................................................410
Annex 9. Training methods ........................................................................411
Annex 10. Evaluation and monitoring of training programmes..................417
Foreword
In the name of God, the Compassionate, the Merciful
The countries that now comprise the Eastern Mediterranean Region of
the World Health Organization were some of the earliest to recognize the
need for mental health care and to make provision for it: humane mental
hospitals were functioning in Baghdad, Cairo, Damascus, Fez and Rey many
centuries ago. Thereafter followed a period in which the intellectual vigour,
which for centuries had propelled the region to the forefront of humanitarian
pursuits, declined. Now, once again our region is on the threshold of a
revival, and the past few decades have seen promising developments in
innumerable spheres, particularly in the fields of health in general and in
mental health.
The same period has seen a sea change in our understanding of human
behaviour and mental health, making it possible to approach the subject in a
manner worthy of scientific inquiry. Now we are in a position where, using
the currently available knowledge and skills, we can prevent many mental
disorders, promote mental health and ameliorate the suffering of the
afflicted. What is necessary is to develop methods of making the knowledge
and skills available to everyone.
In the past 20 years, the countries of the Eastern Mediterranean
Region have adopted national programmes of mental health as a method of
meeting the needs of their peoples. This has brought in a new era in the
provision of mental health care using the primary health care approach. The
ultimate goal is to decrease both the stigma of mental illness and the reliance
on large institutions for their treatment through community-based care
programmes.
8
Reaching the unreached: strengthening mental health programmes in the EMR
This publication brings together the experiences of the 22 countries of
the Region in meeting the challenges posed by mental illness. These
experiences speak of the value of partnership between countries, between
professionals, and between professionals and the people they serve. In
addition to the country-level initiatives, a number of regional intercountry
activities have taken place with the help of the World Health Organization
Regional Office for the Eastern Mediterranean. These have provided an
opportunity to learn from each other and have generated know-how and a
number of instruments for tackling the issue. However, there is still a long
way ahead of us, and most of the needs of the people of the Region in the
area of mental health are unmet. Furthermore, these needs are on the rise as a
result of the many and often rapid social and economic changes that the
Region is going through. We need to plan ahead, and this is precisely the
purpose this monograph tries to serve by identifying the goals for the future.
This publication has been made possible by the valuable contributions
of many scholars in the field of mental health and the programme managers
for mental health in the ministries of health of the countries of the Region, to
all of whom I offer my special thanks. I would also like to thank the WHO
Department of Mental Health and Substance Abuse, which has contributed
both technically and financially to this publication. Thanks are also due to
WHO Representatives in the countries of the Region, who have helped in all
stages of the intellectual realization of this book, and to the Government of
Italy for its financial support to the publication.
In conclusion, I am delighted this publication has become a reality and
sincerely hope that it will become a vehicle for sharing, learning and
progress towards further realization of the goal of health for all.
Hussein A. Gezairy, MD, FRCS
WHO Regional Director for the Eastern Mediterranean
Preface
Mental health was selected in 2001 as the theme for World Health Day
and the subject of the World Health Report. The selection of mental health is
a reflection of the changes taking place around us at a rate unmatched in
human history. These changes serve to bring into focus the importance of
promoting positive mental health on the one hand and instituting measures
for prevention of ill health in its entirety on the other. The rapid rate of
urbanization in all the countries of the Region is not only putting tremendous
strain on physical infrastructures, as can be seen by the growth of sprawling
urban slums, but at the same time is placing stress on the social fabric of
society. Massive internal migration from the countryside to the city is
resulting in the break-up of the extended family system and social
institutions, giving way to nuclear families, separation and higher divorce
rates, single-parent families, children growing up without parent figure(s),
older members of families being left on their own, lack of social cohesion,
conflict of value systems, identity crises, increasing rates of unemployment,
violence and abuse. High rates of internal movement are matched by
similarly high rates of external migration in search of better economic
opportunities or for security reasons necessitated by strife and conflict in a
number of countries in the Region. This results not only in the social
consequences mentioned previously but has repercussions for the émigré
population, mostly young adults, and for the host country. Increasing
numbers of people in the Region are now entering the age of risk for
development of mental disorders—adolescence/early adulthood and old age;
and existing conditions of social and physical strife, underpinned by high
rates of poverty, provide fertile grounds for an upsurge in mental health
problems and their consequences, such as suicide, substance dependence,
10
Mental health in the Eastern Mediterranean Region: reaching the unreached
sexually transmitted diseases, AIDS and hepatitis. The World Bank report of
1993, the world mental health report presented to the United Nations in
1995, the global burden of disease report in 1996 and the US SurgeonGeneral’s report in 1999 have shown that mental ill health is responsible for
more than a tenth of the total burden of disease globally, projected to rise to
15% by 2020; suicide is among the top 10 causes of mortality-related burden
globally; five of the top ten causes of disability worldwide are mental health
problems; and depressive illness is projected be the second biggest cause of
disease burden by 2020. Numerous studies undertaken globally and in the
countries of the Eastern Mediterranean Region indicate that a high
percentage of all who seek help in any health facility suffer only from a
mental health related problem. These problems usually go undiagnosed, and
the result is unnecessary load on already overburdened general health
facilities.
At the same time, there are studies, experiences and programmes that
show mental health action is possible and proper systems of care can be
developed to successfully address many of mental health needs. Despite this,
the treatment gaps for mental illnesses in developing countries, including the
countries of the Region are truly horrifying: 95% for depression, 80% for
schizophrenia and 60%–98% for epilepsy. At the global level, the necessity
of attention to mental health is emphasized in the form of a number of
resolutions of the United Nations General Assembly and World Health
Assembly. In May 1995 the Secretary-General said “to secure mental health
for the people of the world must be one of the objectives of the United
Nations in its second half century…. Our objective is to promote the mental
health and well-being of all the inhabitants of the planet. Let us therefore
respond to this world mental health report not simply by blessing it; let us
take its recommendations and act upon them”.
At the regional level, in addition to a number of resolutions of the
Regional Committee over the years, a special ministerial declaration was
issued in Teheran in 1997 that pointed to the importance of taking concrete
steps to improve mental health (Annex 1). This was followed up by the
following 10-point programme for action for the Region.
1.
Comprehensive psychiatric services for early identification and care
2.
Integration of mental health within primary health care
Preface
3.
4.
5.
6.
7.
11
Provision of mental health skills for all professionals
Development of services for “crisis intervention” in the community
Development of “school mental health”
Development of “parenting skills training”
Programmes for urban populations such as adding a mental health
component to “healthy city” projects
8.
“Lifestyle” and “stress management” programmes
9.
Public mental health education
10. Using the resources of religion, culture and spiritual life
The past 20 years of commitment by health professionals, planners
and people of the Region towards improvement of mental health have been
unprecedented. This publication charts the progress made in the provision of
mental health care in the countries of the Eastern Mediterranean Region of
the World Health Organization. Its preparation has been a challenging and
fulfilling experience. We are not the first to advocate on behalf of “reaching
the unreached”. Mental health remains a neglected area of public health.
People who suffer from mental ill health are among the most vulnerable in
society, often from the poorest segments in society. They are the
“unreached”.
The methodology for preparing the material for each of the countries
was as follows. Information about each of the countries was available from
intercountry meetings held every two years. This information was then
supplemented with the reports of consultants and country focal points. In
addition a questionnaire (Annex 2) was circulated. Thus, the final
information is a product of multiple sources. Some of the data refer to
different time periods, pointing to the need for developing a mechanism at
regional and country levels to continuously update the available information
in a manner which could also remove some of the quantitative and
qualitative differences discernible in the section on individual countries;
however, some of the differences reflect the stages of development of
different mental health programmes. We hope this will serve as the first step
in this direction in the Region.
The general health and demographic statistics are taken from the last
available data provided to the Regional Office by the Member States. These
data may not be the most accurate but there is no basis for thinking that other
12
Mental health in the Eastern Mediterranean Region: reaching the unreached
sources of data are more accurate. The collection of data for this monograph
started before the global ATLAS project and the questionnaires used were
different. The Regional Office and WHO headquarters collaborated in data
collection from Member States of the Eastern Mediterranean Region for
ATLAS. The information from the WHO Mental Health Atlas, 2005 has
been given at the end of each country profile. This allows for an update of
the information along with the historical development of mental health in
each of the countries.
The monograph is organized into three sections. Part 1 covers the
philosophy and components of mental health programmes. The contribution
of the WHO programme Nations for Mental Health is also outlined in this
part. Part 2 covers the experiences of the countries of the Region; each
country has a section on general health and mental health. The overall
picture, though varied, shows the potential for bringing about a meaningful
change in making mental health services available and accessible for people
of the Region. A quantum shift from institutional to community-based care
and from mental illness to mental health is discernible. Part 3 discusses the
key issues in provision of mental health care today and tries to identify the
areas for future work, at the regional level. Annexes support the other
sections and the work as a whole.
We would like to extend our most sincere thanks to Dr Hussain A.
Gezairy, WHO Regional Director for the Eastern Mediterranean, for his
support for this work. His guidance, along with the advice and support of
Dr M.H. Khayat, Senior Policy Adviser, Dr Mohammad Abdi Jama, present
Deputy Regional Director and his predecessor Dr Abdulaziz Saleh, Dr
Ghada Hafez and Dr Anna Verster both former Directors of the Division of
Health Protection and Promotion, was instrumental in finishing this
important work. Also, this work would not have been possible without the
help of mental health professionals and the focal points of mental health
programmes of the countries of the Region. Our thanks to all of them.
Special thanks are due to the leaders of mental health in the Region,
Dr Kamal Fawal, Dr Amirah Seif el Din, Professor Malik. H. Mubbashar,
Professor Driss Moussaoui, Professor Ahmad Okasha, Professor Taha
Ba’ashar, Dr Davoud Shahmohammedi, Dr Yusef Abddel Ghani, Dr Shiva
Dolatabadi, Dr Mohammad Ghanem, and Dr Abdullah el Eryani who have
Preface
13
provided the impetus for this work through their innovative zeal. Last but not
the least we gratefully acknowledge the secretarial support of Ms Marianne
Orfali, Ms Ikbal Rizkallah, Ms Noha Khalil and Ms Marlene Fouad Ibrahim
who coordinated the correspondence, corrections and revisions.
Ahmad Mohit
R. Srinivasa Murthy
Benedetto Saraceno
Narendra N. Wig
Khalid Saeed
Vacat
Part 1
Strengthening mental health
programmes
vacat
Chapter 1
Introduction
There is a common misconception about the meaning of the term
“mental health care”. A large number of people, including many health
professionals, regard it as nothing more than a branch of medicine that deals
with the treatment of the seriously mentally ill or, in lay terms, a speciality
dealing only with “mad people”. This view of mental health is erroneous and
limiting. In fact a comprehensive mental health programme deals with
serious mental health problems as well as with problems of daily living
which affect health, such as tension, worry and stress, but it does not stop
there. It also seeks to protect and promote mental health in all its dimensions,
ranging across human emotions, attitudes, perceptions, thoughts and
behaviour. It is in this spirit that WHO’s Constitution conceives health as “a
state of complete physical, mental, and social well-being and not merely the
absence of disease or infirmity” [emphasis added] [1].
There are several popular misconceptions about neuropsychiatric
illnesses which need to be corrected:
•
neuropsychiatric illnesses are not common
•
neuropsychiatric illnesses do not form a significant burden on
individuals, the family or society
•
neuropsychiatric illnesses cannot be treated
•
interventions are expensive and require highly trained personnel
•
primary health care personnel do not have a role to play in the care of
the mentally ill.
In fact mental illnesses are as common in developing countries as in
the more developed countries and cause severe depletion of social capital.
18
Mental health in the Eastern Mediterranean Region: reaching the unreached
About 450 million people worldwide are believed to suffer from neurotic,
stress-related and somatoform disorders. A further 200 million suffer from
mood disorders, such as chronic depression and manic–depressive illness.
Mental retardation affects some 83 million people, epilepsy 30 million,
dementia 22 million and schizophrenia 16 million. An estimated one million
people committed suicide in 1999 and a further 10–20 million people
attempted suicide. Depressive disorders account for 20%–35% of all deaths
by suicide, There are few human conditions which cause more anguish to the
individual, to the family and the community than mental illness [2].
The portion of the global burden of disease attributable to
neuropsychiatric disorders is expected to rise from 10.5% in 1996 to 15% by
2020. The rise will be particularly sharp in developing countries, primarily
due to the projected increase in the number of individuals entering the age of
risk for the onset of these disorders [2].
In 1996 the United States of America spent more than US$ 99 billion
in direct costs for the treatment of mental illnesses, substance abuse and
dementias while the indirect costs imposed by mental illness in 1990 were
estimated to amount to US$ 79 billion [2].
Improving treatment rates will reduce disability and health care costs and
will improve economic and social productivity. At a global level it has been
estimated that the burden of disease attributable to major depression could be
reduced by more than 50% if all individuals with depression were treated.
Although many effective interventions exist, there is a wide gap between their
availability and widespread implementation. Even in best-case scenarios (in
established market economies with well developed health systems), it has been
estimated that only 35% of persons suffering from depression receive treatment.
In other countries, such as sub-Saharan Africa and China, treatment rates for
depression are as low as 5%. In India, treatment rates of 20% for schizophrenia
and epilepsy contrast with the 80% treatment rates for the same disorders in
countries with established market economies. Besides defined neuropsychiatric
illness, an additional burden is incurred because of psychosocial problems
experienced by vulnerable groups, such as indigenous peoples, those exposed to
disasters, displaced persons (there are more than 20 million displaced persons
worldwide), people living in absolute and relative poverty, and those in difficult
conditions as a result of chronic diseases such as HIV/AIDS [2].
Introduction
19
The impact of mental disorders on communities is large and
manifold. There is the cost of providing care, the loss of
productivity, and some legal problems (including violence)
associated with some mental disorders, though violence is caused
much more often by “normal” people than by individuals with
mental disorders. One specific variety of burdens is the health
burden. This has traditionally been measured in national and
international health statistics only in terms of incidence/prevalence
and mortality. While these indices are well suited to acute diseases
that either cause death or result in full recovery, their use for
chronic and disabling diseases poses serious limitations. This is
particularly true for mental and behavioural disorders, which more
often cause disability than premature death. One way to account
for the chronicity of disorders and the disability caused by them is
the Global Burden of Disease (GBD) methodology. In the original
estimates developed for 1990, mental and neurological disorders
accounted for 10.5% of the total DALYs lost due to all diseases
and injuries. This figure demonstrated for the first time the high
burden due to these disorders. The estimate for 2000 is 12.3% for
DALYs. Three neuropsychiatric conditions rank in the top twenty
leading causes of DALYs for all ages, and six in the age group 15–
44. In the calculation of DALYs, recent estimates from Australia
based on detailed methods and different data sources have
confirmed mental disorders as the leading cause of disability
burden. From an analysis of trends, it is evident that this burden
will increase rapidly in the future. Projections indicate that it will
increase to 15% in the year 2020 [3].
Source [2]
The essentials of mental health care are simple principles, many of
which have been taught by religions and enshrined in humanitarian and
ethical values all over the world throughout human history. For instance,
caring, showing concern, consoling and many similar attributes are helpful
in dealing with a human being in distress or suffering from a disease, yet
such basic mental health care strategies are not given prominence in the
training of health personnel. The most recent international guidelines are the
Principles for Policy on Mental Health (United Nations, December 1991,
Annex 3). Furthermore, modern medical advances have provided us with
medicaments, treatment modalities and techniques which make treatment of
20
Mental health in the Eastern Mediterranean Region: reaching the unreached
neuropsychiatric illnesses possible and practicable. Models of care that are
both inexpensive and effective are available. These models are employed at
the primary health care level for the treatment of common neuropsychiatric
illnesses, such as psychosis, epilepsy and depression in a number of
countries in the Eastern Mediterranean Region—Bahrain, Islamic Republic
of Iran, and Pakistan, for example [4,5,6].
But the case for adequate provision of mental health care does not rest
only on prevalence of or disability caused by neuropsychiatric illnesses.
There is a growing awareness that many health and social problems, for
example those related to alcohol and drug abuse, injuries, violence, suicide
and delinquency among youth, may be indicative of an underlying
psychosocial problem and thus are the concern of mental health
programmes. Many of the most serious health problems and common causes
of death in the world, such as heart disease, cancer, accidents and infections
including HIV/AIDS, could be considerably reduced if people could be
persuaded to adopt healthier lifestyles, for example by stopping or reducing
the consumption of alcohol and tobacco, ensuring safe sexual practices
compatible with the acceptable social and cultural norms or by engaging in
regular physical exercise.
It should also be noted that many failures in health care are not due to
any lack of technological solutions but to an inability to apply the available
solutions, often resulting from an insufficient understanding of sociocultural
factors impinging on human behaviour; for example, schistosomiasis and
diarrhoeal diseases can be prevented by changing people’s behaviour.
Similarly, we have the methods of family planning, yet we lack the means of
persuading people to use them. The current pandemic of acquired
immunodeficiency syndrome (AIDS) is a glaring example of how inadequate
our technological response can be when behavioural variables are not
factored in properly. One could easily list many similar examples. They all
show that without paying adequate attention to psychosocial and behavioural
factors, better health is unlikely to be achieved [2].
In summary, mental health care programmes are not limited to the
treatment of serious mental illnesses in an institutional setting. They deal
with the whole range of psychosocial and behavioural factors affecting both
health and disease. A mental health care programme must be incorporated
Introduction
21
into primary health care focusing on promotion of mental health and the
prevention of mental illnesses in harmony with local sociocultural conditions
and traditions. An integrated, well-structured mental health component can
play a vital role in the success of all health programmes. These are the
reasons behind the recommendation of the WHO Expert Committee on
Mental Health [7,8]: “Governments are urged to recognize mental disorders
as problems of high priority for the individual, for the community, and for
national development.”
Chapter 2
Historical aspects
Activities of the Regional Office 1949–2000
Mental health has been an important part of the understanding of
health from the beginnings of the World Health Organization (WHO). The
definition of health in the preamble to the Constitution of WHO recognizes
the important place of mental well-being: “Health is a state of complete
physical, mental and social well-being and not merely the absence of disease
or infirmity.” Further, the “extension to all peoples of the benefits of
medical, psychological, and related knowledge is essential to the fullest
attainment of health”. One of the functions of WHO is to “foster activities in
the field of mental health, especially those affecting the harmony of human
relations” [1].
The [First World Health] Assembly established a programme based
mainly on the recommendations of the Interim Commission, and, as
a first step towards future policy, it grouped the various subjects in
categories of importance. Malaria, maternal and child health,
tuberculosis, venereal diseases, nutrition and environmental
sanitation were assigned to a “top priority” class; second priority
was given to public health administration; third, to parasitic
diseases; fourth, to viral diseases; and fifth, to mental health
[emphasis added]. Sixth priority was accorded to a somewhat varied
group of other activities [9].
Historical aspects
23
Mental health care has been an important area of activity in the
Regional Office since its establishment in 1949. One of the earliest
references to mental health was in the Third Session of the Regional
Committee for the Eastern Mediterranean in September 1950, where the
Committee noted the “provisions made for activities related to typhus and
relapsing fever, bilharziasis, cholera, rabies, leprosy, nutrition, maternal and
child health and mental health” [emphasis added] [9].
In 1953, surveys about mental health problems were carried out in
Egypt, Iraq, Lebanon, Sudan, Syrian Arab Republic and Jordan. In the same
year, a mental health seminar was held in Beirut in which 20 participants
from eight countries participated [9].
In 1969, Dr A.H. Taba, then WHO Regional Director for the Eastern
Mediterranean, reviewing the 20 years of work of the Regional Office, noted
that the “Eastern Mediterranean Region is a tradition-bound area abruptly
thrust into the main stream of modern life resulting in a rising tide of organic
and mental stresses linked with overnight social changes” [9].
In his report at the Alma-Ata conference he further said:
Hospitals record a growing flow of psychiatric patients from
urbanized areas, and the emotional aspects and mental hazards
involved are increasingly being investigated along medico-social
lines. The traumatic encounter of youths with urban values and the
hasty settlement of nomads are already features of concern to
psychiatrists and public health planners. But psychiatric care
everywhere, whether at hospitals or at outpatient clinics is
handicapped by an acute shortage of well-trained workers, which adds
much to WHO commitments [10].
In the 1970s, activities in the mental health field focused on countrylevel evaluation of mental health services available in the countries of the
Region, by the then regional adviser on mental health, as well as by external
consultants to Ethiopia, Iran, Kuwait, Lebanon, Qatar, Saudi Arabia and
Sudan. An interregional seminar on the organization of mental health
services in developing countries was held in Addis Ababa, Ethiopia, in 1973,
which provided a good medium for discussing the organization of mental
health services and drawing up relevant recommendations [7,8].
24
Mental health in the Eastern Mediterranean Region: reaching the unreached
Country activities
A number of mental health activities that took place in the countries of
the Region between 1970 and 1980 were extremely important as they set in
motion the process of integration of mental health care within the primary
health care system during the 1980s.
In Iran, the founding of the Society for Rehabilitation of the Disabled,
planning for community mental health, the initiation of a nationwide mental
health epidemiological survey with designation of geographic areas for
provision of services (catchment areas), and the recommendation by a WHO
consultant for establishment of a central policy-making committee for more
effective planning, coordination and training in mental health (November
1973) set the scene for development of the Iranian national mental health
programme and integration of mental health care within primary health care
during the 1980s and 1990s.
In Lebanon, mental health care activities targeted improvement of the
organization and administration of mental health services, strengthening of
the psychiatric nurses training programme and drawing up of a programme
for an intercountry psychiatric nursing course for nursing tutors. A WHO
consultant in psychiatric nursing advised the establishment of a general
administrative department, including a nursing unit, for the effective
organization and coordination of psychiatric services in both general
hospitals and outpatient clinics (1973).
In Pakistan the 1970s marked the setting-up of psychiatric units in
general hospitals, development of postgraduate training programmes for
doctors and psychologists, and of community-based rehabilitative services
and halfway houses such as Fountain House, and the involvement of
nongovernmental organizations in mental health care.
This decade also was marked by a major WHO global initiative to
integrate mental health within primary health care, namely, the launching of
the WHO collaborative project on strategies for extending mental health
care. This seven-country project, spread over six years (1975–81), studied
the feasibility of integrating mental health care within the primary health
care system. Sudan (Senouris) was one of the four countries selected in the
first phase, and Egypt (Fayyum) was included in 1977 as part of a second
phase (three countries). The project developed epidemiological tools and
Historical aspects
25
training materials needed for achieving the objective of demonstrating the
need and feasibility of the primary mental health care approach.
All of the above developments prepared the ground for the
development of national programmes of mental health care in the 1980s. The
period 1980–98 could be called the era of national programmes of mental
health care. During this period significant progress was made in identifying
the goals of mental health care programmes, as well as in developing
strategic, indigenous approaches for realizing these goals. One striking
feature was intercountry cooperation fostered through regional intercountry
meetings, symposia, workshops and consultations at Amman (1983),
Damascus (1985), Isfahan (1989), Nicosia (1991), Islamabad (1993),
Casablanca (1995), Teheran (1997), Alexandria (1999) and Cairo (2003).
These were organized in order to review the progress of the programme as
well as to strengthen individual components of national programmes of
mental health. In the area of substance abuse the most important step was the
formation of the Regional Advisory Panel on Drug Abuse (RAPID). The
panel has had four meetings (Cairo 2002), Teheran (2003), Cairo (2004) and
Cairo (2005), and developed a comprehensive strategy, the principal
directions of which were approved by the Regional Committee for the
Eastern Mediterranean in 2005 (Annex 4). All these activities were
supported by visits of WHO consultants, fellowships and country activities.
The overall result of these efforts has been enhanced awareness of mental
health issues in the Region.
Chapter 3
Overview of mental health in
the countries of the Region
Recent years have seen significant changes in the field of mental
health in the countries of the Region. The stigma attached to
neuropsychiatric illnesses is diminishing, and people are more openly
coming for treatment to modern psychiatric services. Psychiatric services,
which were earlier totally confined to a few large mental hospitals, are now
gradually being replaced by psychiatric units with both inpatient and
outpatient facilities in general hospitals. In some countries, the process of
decentralization has been taken still further, and psychiatric services are
being provided at district hospitals and smaller peripheral units, along with
other general health services. In a number of countries, there is now a
separate senior officer in the ministry of health designated to look after the
mental health activities in the country. Many countries have developed
specific national mental health policies and programmes. Training
programmes in mental health for general practitioners, non-physicians and
health personnel working at primary health care level have started in a large
number of countries as a part of in-service skills enhancement programmes.
Although a majority of the countries of the Region have agreed in
principle to integrate mental health into the primary health care delivery
system, implementation so far has been limited. The reasons are manifold.
The shortage of qualified mental health professionals in almost all the
countries of the Region is well known, For example, facilities for training
leading to a postgraduate qualification in psychiatry are available only in a
Overview of mental health in the countries of the Region
27
small number of countries: Bahrain, Egypt, Islamic Republic of Iran, Iraq,
Jordan, Oman, Pakistan, Saudi Arabia and Sudan. Training facilities for
clinical psychology at different levels are at present limited only to Egypt,
Islamic Republic of Iran, Iraq and Pakistan, while psychiatric nursing
training is available only in Bahrain, Egypt, Pakistan and Islamic Republic
of Iran. While training programmes in mental health for in-service doctors
have started in many countries, the teaching of mental health and
behavioural sciences in the undergraduate medical curriculum continues to
be inadequate. The poor condition of medical records of the present mental
health services in some countries is also a serious shortcoming, hampering
the development of national programmes of mental health.
A negative attitude toward mental health is often encountered among
health planners and administrators, possibly stemming from a lack of
knowledge about recent developments in the field of mental health because
of little collaboration between university departments and ministries of
health. For example, a large number of health administrators are still not
aware that neuropsychiatric illnesses and psychosocial problems are
prevalent in their countries and contribute to a large proportion of disability
in the community and that it is possible now to adequately prevent, treat and
manage many of these conditions in a cost-effective manner (Annex 5).
Ambiguity over the roles of the members of the mental health care
team—the psychiatrist, the clinical psychologist, the psychiatric social
worker, the psychiatric nurse, and so on—is an additional problem faced by
many countries, possibly because many mental health professionals received
their initial training in the developed world and often transfer prejudices and
interprofessional rivalries from these countries to their own countries.
The committee recommends that mental health objectives should be
defined in each country. Taking into account the nature, extent and
consequences of mental disorders and the resources available. The
objectives should be realistic and should be formulated in terms of
health effect or service delivery to be achieved for a stated proportion
of the population in a defined area within a stated time [8].
28
Mental health in the Eastern Mediterranean Region: reaching the unreached
The provision of mental health services is further hampered by the
existence of old and outdated mental health laws in some countries of the
Region, which do not have adequate provisions for treatment, care and
rehabilitation of persons suffering from neuropsychiatric illnesses, at the
same time respecting human and civil rights.
In conclusion, it would appear that safeguarding mental health in
increasingly fractured societies, where many of the previous cultural and
social support systems (such as the family or organized religion) are
weakening, is an awesome challenge reaching far beyond the realm of health
care systems. However, the time is now ripe for integrating elements of
prevention and treatment of neuropsychiatric illnesses in primary health care
while incorporating promotion of mental health in the national development
policies as a logical step towards the goal of health for all .
Chapter 4
Developing programmes of
mental health at country level
The need for national programmes of mental health
All countries of the Region have developed national strategies to
translate the concept of health for all into reality. However, in most of these
national documents, mental health is not included, in spite of its recognized
importance. One way to redress this situation is to have a national
programme of mental health involving all the stakeholders at national and
sub-national levels integrated into the health and developmental strategies
and plans of each country [11–15]
With the emergence of specific plans of action for mental health at
country level opportunities for intracountry as well as intercountry technical
cooperation would greatly improve on the one hand, and the acquisition of
extrabudgetary resources to support country programmes would be
facilitated on the other.
Steps for the development of national programmes of
mental health
The initiative for a national mental health programme can come from
the political level, from health professionals and administrators or as a result
of strong public opinion. Mental health professionals can influence it at each
30
Mental health in the Eastern Mediterranean Region: reaching the unreached
level. They can help to start the process by promoting the need for a plan of
action; by lobbying political authority, health planners and administrators; by
mobilizing public opinion through the press, television and other media; and
by organizing national mental health groups incorporating members of all
related sectors.
Once enough momentum has been generated, a mental health action
group should be created, and entrusted with the task of formulating a
document on the proposed programme and plan of action. Such a document
needs to be reviewed at successive stages by mental health professionals,
health administrators and planners, and experts in other sectors such as
social services, education, law, nongovernmental organizations and
university research bodies, before final adoption by the ministry of health.
Development of national programmes of mental health means
formulating a policy and translating it into a plan of action. There are a
number of steps that are involved in this process [11,13].
Policy
A policy provides broad guidelines and the framework for a plan of
action. Policy stems from the basic principles governing a country as
contained in that country’s constitution, international agreements and
established codes of behaviour. A national policy can be developed out of a
number of sources such as:
•
legislation affecting the general public
•
previous activities to promote health
•
programmes of other social sectors
•
religious and other teachings relevant to health and well-being
•
current health practices
•
the harmony between existing policies and the programmes of the
various social sectors.
Formulation of a document on a national mental health
programme and preparing a plan of action
There is no one way to prepare a national programme of mental
health. Every country has its own historical background, set of health
priorities and constraints in resources. What follows is a broad consensus
Developing programmes of mental health at country level
31
statement on how this goal can be reached. This is based on discussions at
different intercountry meetings held during the past 23 years (Annex 6).
The current mental health situation in the country
Data on mental illnesses, including results of prevalence and incidence
surveys, if available, should be collected and annual statistics from mental
and general hospitals should be included. An assessment of existing
resources—hospital beds, mental health human resources (numbers of
psychiatrists, doctors, nurses, social workers, psychologists, etc.), existing
training facilities, including medical schools, health institutions and
specialist training facilities, should be reviewed. Current coverage by the
listed services, as well as gaps, and the needs in special areas, such as child
mental health, mental retardation, school health, drug dependence, mental
health of the elderly, mentally ill offenders and vagrants, should be surveyed.
Existence of any special activities on promotion of mental health and scope
for intersectoral collaboration in the country should be identified.
Barriers
While preparing a national programme of mental health, it is equally
important to identify main barriers, which can come in the way of
implementation, such as organizational, professional and developmental
barriers and barriers related to primary health care.
Organizational barriers include:
•
lack of appreciation by policy-makers and senior health administrators
of the nature and extent of mental health needs in the community
•
lack of a focal point responsible for mental health in the ministry of
health
•
no reference to mental health in national policies
•
absence of mental health in the list of national health priorities
•
lack of mechanisms for intersectoral collaboration.
Professional barriers include:
•
shortage of trained psychiatrists, clinical psychologists, psychiatric
social workers and psychiatric nurses
•
low prestige of psychiatry as a speciality
32
•
•
•
•
•
•
•
•
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
mental health professionals working predominantly in institutional
settings and not being supportive of the national programme
lack of public-health community-oriented mental health professionals.
Developmental barriers include:
resource constraints in terms of money and technical know-how
limited funds available for the general health sector
lack of supportive welfare structure for the total care of the mentally
ill.
Barriers at primary health care level include:
non-inclusion of mental health in the curricula of various categories of
health personnel
general lack of resources for the care of the mentally ill as reflected in
the non-availability of essential drugs
lack of database on mental health problems at primary health care
level
poor intersectoral coordination at the periphery.
Objectives of the programme
Some countries have chosen the provision of minimum mental health
care for all. Other countries have emphasized the need to enhance
community participation and self-help in mental health programmes or to
encourage a wider application of mental health knowledge and skills for
psychosocial problems.
A national mental health programme should include the following
broad objectives:
•
promotion of mental health
•
prevention of mental disorders
•
treatment and rehabilitation of the mentally ill and drug dependent
•
improvement of functioning of the general health services
•
contribution to overall socioeconomic development
•
enhancing quality of life.
Promotion of mental health means sensitizing the individual, the
community and society, as a whole about the role positive mental health can
play in every aspect of life be it economic, social or political.
Developing programmes of mental health at country level
33
Cost-effective preventive interventions for a significant number of
neuropsychiatric and psychosocial problems are now available (Annex 5). It
has been estimated that at least half of all such disorders in developing
countries could be prevented. Most of the preventive interventions however
would have to be undertaken by general health services and social sectors.
Similarly treatment of neuropsychiatric illnesses ill is possible and
practicable using models for providing mental health care through trained
primary health care personnel. These models have been developed and
evaluated in countries of the Region [4–6].
The current practice of medicine in many countries is becoming
overreliant on technology. Psychological skills, which could render health
care personnel more efficient and more satisfied with their work, are not
taught in most countries. As a result, the population’s satisfaction with health
care is decreasing, in spite of increased expenditure on provision of health
services. Mental health and behavioural sciences can provide the knowledge
and skills necessary to overcome these problems. It is the task of mental
health programmes to ensure that this occurs at all levels of health care,
involving all categories of health staff.
Similarly, but on a different plane, socioeconomic development often
leads to situations of major psychosocial impact. Untoward consequences of
developmental projects can often be avoided. Comprehensive mental health
programmes should involve those responsible for planning and economic
development and provide knowledge, which can render social change, and
development more harmonious with the expectations and psychological
needs of people; similarly, all these tasks require collaboration between
various social sectors and different professional disciplines. More important,
however, they require a change in the perception, motivation and attitude of
professionals dealing with the design and implementation of mental health
programmes.
General principles for organization of services
For the organization of mental health services at primary health care
level, general guiding principles should be to:
•
provide total coverage of the population
34
Mental health in the Eastern Mediterranean Region: reaching the unreached
Countries in the Region experience a multitude of psychosocial
stressers consequent to economic insecurity, poverty, internal troubles,
and armed conflict. Environmental catastrophes, such as earthquakes,
droughts or floods that lead to human displacement, add to the burden.
Social networks, e.g. those provided by family and friends and other
features of community life, which play an important protective role,
are in danger of disappearing in many countries. Recent trends
towards community disintegration and breakdown leave populations
more vulnerable. For example, in many countries where the father (or
both parents) migrates in search of labour or for other reasons, there is
an increasing tendency towards family breakdown. This affects the
upbringing of children and weakens ties between generations, thus
preparing the ground for other health problems.
High-risk behaviour of young people, such as experimenting with
drugs and alcohol, sexual promiscuity and reckless driving all tend to
become more frequent when family cohesion is weakened.
Furthermore, the presence in several countries of a sizeable expatriate
population, with a skewed age–sex composition and its own special
lifestyle, speaking a different language and with a different religious
and cultural background, all cause specific psychosocial problems in
recipient countries. [16]
•
•
•
•
•
integrate basic mental health services in the primary health care
setting and provide services by non-specialists who have appropriate
training in mental health in order to carry out appropriate tasks
provide essential drugs
provide an adequate referral system
strengthen specialist services
provide linkage with community development.
Activities
The draft document should specify both short-term and long-term
targets and especially list activities planned to be carried out in the first 3–5
years. The activities should be further divided into administration, services,
training, promotional and preventive activities, etc. A division of labour
between what will be primarily carried out by the health sector and what is
Developing programmes of mental health at country level
35
to be taken up by the other sectors can also be included. For activities in the
field of prevention of mental disorders and promotion of mental health,
perhaps the most important step is intersectoral collaboration.
Coordination
It is important to develop specific mechanisms for intersectoral
coordination. For example, it will be useful to have a focal point in the
ministry of health and a national committee (incorporating health
administrators and mental health specialists, with representatives from other
sectors, such as education and social services).
Monitoring and evaluation
Mechanisms for monitoring and evaluation should be built into the
programme.
Follow-up steps for finalizing a mental health national
programme
Preparation of a document on a proposed national mental health policy
and programme is a very important first step, but only one step on the road
to developing a comprehensive and reliable programme for mental health
care in a country. In many ways a mental health programme is a continuous
process of evolution, which keeps on growing and changing with the needs
of society. Experiences during the past 15 years in the countries of the
Eastern Mediterranean Region suggest that the following steps are very
helpful in taking the programme further once the initial document has been
prepared.
Obtaining a national consensus on the programme
This can be best achieved by organizing a multisectoral national
workshop to discuss and adopt the previously prepared document on the
national programme of mental health. Thirty to fifty participants should be
invited to this workshop, which would be normally organized by the
ministry of health. They should include the representatives from the
following sectors:
36
Mental health in the Eastern Mediterranean Region: reaching the unreached
•
leading mental health specialists in the country, such as psychiatrists,
clinical psychologists, psychiatric social workers, psychiatric nurses
and occupational therapists
•
representatives of the ministry of health, especially those dealing with
health planning, prevention of diseases, primary health care, and so
forth
•
other leading medical specialists, such as family physicians,
paediatricians and especially teachers from medical schools
•
representatives of the ministries of education, social welfare, law and
justice, police, youth affairs and religion
•
representatives of important nongovernmental organizations, religious
and community leaders, women’s organizations
•
press and other media.
Once such a multi-sectoral group has reached a consensus, the final
document and recommendations are submitted to the ministry of health with
copies to other involved ministries. Organization of such a workshop can
also generate public awareness enhancing the place of mental health in the
community.
Adoption of the national programme of mental health
by the Ministry of Health
In most of the countries of the Eastern Mediterranean Region, national
programmes of mental health have been adopted as follows:
•
approval of the plan of action and its inclusion in the national plan of
health
•
allotment of an adequate budget for activities of the programme
•
establishment of a separate section in the ministry of health to monitor
and implement the programme
•
establishment of a multisectoral (interministerial) national
coordination group.
Developing programmes of mental health at country level
Steps in developing a national mental health programme
•
•
•
•
•
Policy and situation analysis
Identification of programme components
Preparation of a draft document containing the Plan of action
with short and long-term goals and job description for each
level of personnel and sectors
Obtaining national consensus
Adoption by the ministry of health
37
Chapter 5
Development of services for
treatment and rehabilitation
in primary health care
Primary health care in the Region
Most of the countries in the Eastern Mediterranean Region have vast
rural populations, which have very little access to modern health services for
the treatment and rehabilitation of neuropsychiatric disorders. Almost all the
countries have adopted the primary health care approach to meet the health
needs of their populations. In recent years Afghanistan, Bahrain, Egypt,
Islamic Republic of Iran, Iraq, Jordan, Kuwait, Libyan Arab Republic,
Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Sudan, Syrian
Arab Republic, Tunisia, United Arab Emirates and Yemen have tried to
introduce mental health at the primary health care level. In this chapter,
organization of such services is discussed in further detail.
The general principle of the primary health care
approach
Primary health care is essentially health care made universally
accessible to individuals and families by means acceptable to them, through
their full participation and at a cost that the communities and country can
afford. It forms an integral part of a country’s health system, of which it is
Development of services for treatment and rehabilitation in primary health care
39
the nucleus, and part of the overall social and economic development of the
country [17]. The new approach, as an alternative to institutionalized care,
requires that mental health programmes be integrated within the primary
health care structure in its promotive, preventive and curative dimensions,
ensuring development of mental health services in harmony with the health
and social policies of the country [18].
Support mechanisms required for the provision of
services for the treatment of persons suffering from
neuropsychiatric illnesses
Experience has shown that the following support mechanisms are
essential for the success of the mental health services at primary health care
level:
•
adequate training in mental health care of doctors and all categories of
health personnel working in the primary health care team
•
mental health orientation of health administrators and planners
•
provision of regular supplies of essential neuropsychiatric drugs
•
adequate records and information system at primary health care and
referral levels
•
adequate referral system with support and supervision for the primary
health care team
•
involvement and support of the families and the community in which
mental health services are being established.
Mental health training of all health staff
The whole issue of mental health training is dealt with separately in
Chapters 6 and 7. Suggested tasks for different categories of personnel are
given in Annex 7.
Involvement of health administrators in mental health
programmes
The effective implementation of any health programme becomes
difficult if adequate management support is not available. Health
administrators in the field, being a government’s instruments for field
management, supervision and implementation of national health
40
Mental health in the Eastern Mediterranean Region: reaching the unreached
programmes, can play a pivotal role in the integration of mental health into
primary health care, providing very important leadership at the intermediate
level. They mediate between the community, the policy-maker and the
politician, coordinate the efforts of planners, professionals and the recipients
of services, namely the community. At present, many health administrators
have negative attitudes towards mental health. A very important aspect of a
national mental health programme is to bring about a change in
administrators’ opinion. They must be informed of the prevalence of mental
disorders, their burden on the family and community, the value of early
intervention and the cost–benefits of mental health care (appropriate to the
area, region or country). The broad shift has to be from mortality-oriented
epidemiology to morbidity and quality of life.
Lack of understanding and support from health administrators can
give rise to serious difficulties in the implementation of mental health
programmes, including the formulation of legislation for strengthening and
regulating mental health services; recruitment and effective use of qualified
human resources; establishment of national, regional and district mental
health services; equitable distribution of minimal mental health resources to
the urban and rural populations; and needs assessment, monitoring and
evaluation.
Thus, health administrators are key players in national mental health
programmes and they must be made aware of the value of mental health
services. If properly motivated, they can help to allocate resources at local
level, provide leadership and managerial support, and be key figures for
linkages between specialized resource centres and the health-care delivery
system. They can ensure incorporation of mental health care in the
educational activities of general health care and become agents for
intersectoral collaboration.
It must be explained to health administrators that a mental health
programme is not restricted to the treatment of neuropsychiatric illnesses—
knowledge of and skills in mental health can also improve the functioning of
general health services.
Active and continuous efforts should be made to develop regular
dialogue with health administrators at all levels. This should be done in
terms of sharing simple information about mental health and the overall
Development of services for treatment and rehabilitation in primary health care
41
effects of such a programme on health without excessive financial demands.
This can also be supported by holding orientation courses for them as has
been done in a number of countries (such as Islamic Republic of Iran and
Pakistan) [3–5,20].
The scope of such courses should include:
•
need and rationale for the integration of mental health into general
health services at the primary health care level
•
outline of an agreed national mental health programme
•
relevant epidemiological data regarding mental health, preferably
from the same country, with a description of the social and public
health consequences of mental illness
•
demonstration of simple technology for training of health staff,
including training materials such as manuals
•
inviting health administrators’ suggestions on already drawn-up plans
of action followed by active discussion on areas of collaboration
•
demonstration of an effective mental health care programme in a
primary health care setting using the existing health services.
Essential neuropsychiatric drugs for mental health services
Essential drugs are those that satisfy the health care needs of the
majority of the population. They should therefore be available at all times in
adequate amounts and in appropriate dosage forms. Provision of
neuropsychiatric drugs, which can be selected from the WHO list of essential
drugs for neuropsychiatric disorders appropriate to local needs, is an
essential requirement for the implementation of national mental health
programmes [19].
Before deciding on the essential neuropsychiatric drugs for a mental
health programme, it is important that:
•
priority mental disorders to be managed at primary health care level
and at referral centres are identified
•
the necessary tasks and training of personnel within the existing health
infrastructure are defined
•
a coordination, evaluation, and monitoring mechanism is developed.
There should be clear job/task descriptions for doctors and other
health personnel. It should also be explained that not all neuropsychiatric
42
Mental health in the Eastern Mediterranean Region: reaching the unreached
disorders require drugs in their management and the role of understanding,
support, counselling and psychosocial intervention must be emphasized in
the training programme. The range of non-pharmacological interventions
includes relaxation, problem-solving skills, developing and maintaining
social support networks, changing irrational thinking and lifestyles.
All health personnel concerned must be trained on the use of correct
standardized dosage of selected essential drugs for different age groups, as
well as duration of treatment, precautions, and possible side effects and their
management [18].
The selection of drugs for primary health care must be determined at
country level since the priorities; health infrastructure, training and
responsibilities of personnel and legal issues vary considerably in countries
of the Region. In some countries, such as Egypt, only a qualified medical
officer may prescribe psychotropic drugs. In other countries, such as
Pakistan and Yemen, the prescription of a limited range of drugs is accepted
policy at the level of medical assistant. These differences are a reflection of
the wider public health policies of those countries.
Experience globally and in the Eastern Mediterranean Region has
shown that it is possible to identify a limited range of drugs for use at
different levels of mental health care. Annex 8 contains a list of approved
essential neuropsychiatric drugs in primary health care.
Apart from their purely therapeutic benefits, an adequate and regular
supply of drugs increases the use of health services as a whole, enhances
motivation and morale of the staff and consequently improves the
functioning of health delivery system [20].
It is important that a coordinating committee on essential drugs at the
national or provincial level meet on a regular basis in order to review and
update, at regular intervals, the standard treatment schedules and guidelines
for clinical diagnosis, to assess the adequacy of clinical diagnosis and
management, to evaluate the system of supply, distribution and drug use, to
engage in curriculum development and training of primary health care
personnel in clinical diagnosis and patient management, to analyse the
standardized records, and to ensure that the service is effective and that
drugs are being used appropriately [21].
Development of services for treatment and rehabilitation in primary health care
43
Information and recording for mental health services in primary
health care
It is well recognized that for a programme of integration of mental
health services into primary health care to be successful, a simple and
appropriate recording and information system is vital. Such records should
be aimed towards clearly defined goals and regularly analysed, with
feedback provided to health staff. Similarly, for the monitoring of the
programme, development of suitable indicators is essential [18].
Need for an information system in mental health
Mental health professionals in countries of the Eastern Mediterranean
Region have the dual responsibility of initiating innovative mental health
care programmes and demonstrating their effectiveness and appropriateness.
In order to achieve this, reliable data have to be provided to answer the
following questions:
•
What are the diagnostic categories of patients benefiting from
provision of mental health services at primary health care level?
•
What are the pathways to care taken by people suffering from
neuropsychiatric illnesses?
•
What are the barriers to use of the available facilities?
•
What is the quality of care provided by non-specialist personnel?
•
What are the difficulties experienced by non-specialists in providing
care?
•
Are the referral channels working between the primary and specialist
care levels? And what is the density of their use?
•
What is the impact of the programme on the community?
•
What are the cost–benefits and the cost–effectiveness of the
programme?
In planning a records and information system, it is important to
generate data as part of routine care. This is important, as independent data
gathering is not always feasible. Additionally, all data should not be from
one level only and different types of information should be collected at
appropriate levels [22].
Information system at the primary health care level
After non-specialists (primary health care doctors or health worker)
have received mental health training, it is important that they keep a simple
44
Mental health in the Eastern Mediterranean Region: reaching the unreached
record system for recording their activities. Health personnel are often
reluctant to maintain such records. Many other programmes (such as growth
monitoring in children) have experienced similar difficulties. In view of this,
the record should be as simple as possible. The following schema is
proposed:
•
Each identified mentally ill person should have an individual record.
•
Each record should contain the following minimum information:
–
sociodemographic information such as age, sex, mailing
address, other contact information, next of kin
–
mode of referral
–
distance of patient’s dwelling from the health facility
–
clinical details such as presenting symptoms, duration of illness,
past treatment, disability
–
diagnosis
–
treatment advised, place of treatment and type
–
record of follow-up contacts and problems encountered in care
–
referral, if any advised.
This amount of detail can be reasonably obtained within about 5–10
minutes of interview. Recording can be simplified by providing multiplechoice responses, so that the recorder has only to tick the relevant items
It is important to have such records in the local language and prepared
either on cards (with a box to store them) or in a book of 30–40 sheets. A
ring file is suggested. These simple measures go a long way towards making
records effective.
If possible, it would be valuable for the primary health care worker to
record all referred cases in a separate notebook.
These data maintained by primary health care personnel are copied for
analysis by the supervisory team, leaving the original records for the local
clinic’s use. This simple system of recording would allow for periodic
review etc., and would form the focus of discussion by the supervisory team
during its visit.
Record system for the supervisory team
For the successful implementation of the mental health care
programme at primary health care level, regular support and supervision by a
specialist team is essential. This supervision is especially important during
Development of services for treatment and rehabilitation in primary health care
45
the first 12–24 months. These visits can help to clarify the functions of
health personnel at different levels of care and also maintain quality of care.
Specifically, during every visit by the professional team, a record of
activities should be maintained. Such a record would cover:
•
the clinical condition of patients necessitating referral
•
adequacy of the diagnosis of new cases seen in the preceding month(s)
•
adequacy and appropriateness of the treatment initiated
•
adequacy of record, drug availability, etc.
In addition, it is desirable to identify periodically from the total pool
of patients, a random 5%–10%, and call them for review. Such an analysis
can provide answers to key questions about the quality of care such as
accuracy of diagnosis, side effects and follow-up. As pointed out earlier, the
goal of this exercise is a positive one and can also form part of continuing inservice education.
In practice, supervisory team visits do not take place in an orderly
manner unless adequately planned. It is harmful for the programme to
convert a visit into a social occasion or for a demonstration of the
programme to visiting officials. If the need for the latter exists, such
demonstrations should not replace the review visits but should be planned as
additional visits.
It is often the case that primary health care programme data are not
linked with data collected by specialist centres. It is particularly important
for specialist centres to have this linkage as it provides a better picture of
disease prevalence, trends and service needs.
The following issues can be well addressed by linking these records:
•
the prevalence of neuropsychiatric illnesses in different catchment
areas
•
the duration of symptoms at different points of contact before help is
sought
•
diagnosis, distribution and changing patterns over time
•
treatment strategies employed at different levels of care
•
referral density from primary health care facilities and vice versa
•
comparison of the course and outcome of cases treated at primary
health care and specialist levels
46
•
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
These goals can be met by organizing the records as follows:
opening of a register in which all new patient contacts from the
catchment areas are entered (and duplications avoided)
collection of basic information at the time of registration with regard
to minimum demographic and clinical data.
Tertiary level information and analysis of the annual data for changing
trends in those seeking care
An information system as outlined above should form part of all
primary health care programmes. However, in those situations where
additional human resources are available, planned data gathering as outlined
below can assist the mental health programme:
•
comparison of different health facilities regarding use of services
•
study of a group of patients receiving regular help and their level of
social functioning as compared to those not receiving treatment
•
study of the general public’s attitudes towards mental disorder
•
pathways to care, or how patients reach mental health services
•
changing patterns of presenting complaints
•
cost–benefit analysis of care for persons in specific diagnostic
categories
•
indirect evidence of care in terms of suicide, homicide, divorce,
compulsory admission, and so on.
Chapter 6
The role of training in the
context of national mental
health programmes
Integrating with primary health care
A WHO intercountry meeting on mental health held in the Syrian Arab
Republic in 1985 highlighted the importance of developing comprehensive
national mental health programmes. These programmes should have clear
objectives, targets and plans of activities based on the principle of integration
of mental health into general health services at primary health care level. The
main strategy proposed for achieving these objectives was to provide
focused, goal-oriented mental health training for primary care in rural and
In the developing countries, trained mental health professionals are
very scarce indeed—often they number less than one per million of
the population. Clearly, if basic mental health care is to be brought
within reach of the mass of the population, this will have to be done
by non-specialized health workers—at all levels, from the primary
health worker to the nurse or doctor—working in collaboration with,
and supported by, more specialized personnel. This will require
changes in the roles and training of both general health workers and
mental health professionals [8].
48
Mental health in the Eastern Mediterranean Region: reaching the unreached
district centres [2,18,23,24]. It has been convincingly demonstrated in a
number of countries such as Islamic Republic of Iran, Pakistan and Saudi
Arabia during the past three decades that, with appropriate training, health
staff at primary care level can adequately look after a limited number of
common neuropsychiatric disorders with the aid of two or three essential
neuropsychiatric drugs and psychosocial intervention. Furthermore, such
training in psychosocial knowledge and skills has the potential to improve
the quality of general health services [20].
Providing mental health training for various categories of general
health staff working in primary health care is an enormous task. Ideally, such
mental health training should be provided at the point of entry for medical
doctors and other health personnel. Unfortunately, it is either not done at all
or done in such a way that mental health and behavioural sciences appear to
have no relevance to health care delivery. The approach is to provide short
courses of in-service training which are task-oriented and related to the dayto-day problems dealt with by health staff at primary health care level. To
carry forward such a large programme, a cascade model needs to be adopted
in all the countries concerned.
The shortage of senior mental health professionals in almost all the
countries of the Region continues to hamper progress, even though all
countries have almost doubled the number of professionals during the past
decade. Current training leading to a postgraduate qualification in psychiatry
is available in only half of the countries. Most of the remaining countries
continue to be dependent on overseas training and the importation of
expatriate professional staff for their mental health programmes. A number
of countries of the Region, however, are trying to enlarge the mental health
component of their medical undergraduate training programme, but face stiff
resistance from established disciplines.
The retraining of general physicians, general hospital residents and
family doctors is an important step towards extension of services to primary
health care. A number of countries have started special training programmes
for their general medical staff. The training covers essential aspects of more
common mental disorders, simple counselling skills and the use of essential
pharmacological interventions. The models for achieving this retraining vary
considerably between countries, depending on the organization of their
The role of training in the context of national mental health programmes
49
postgraduate facilities and the presence of established systems of release
from their service routines, to attend specific training courses.
Training of primary care physicians
The countries in the Eastern Mediterranean Region differ from each
other in terms of the availability of resources, the number of senior trainers
and the existing levels of knowledge and skills among their primary care
physicians. In spite of these differences, there are some objectives for
training that are important for all countries.
Objectives of training primary care physicians
Training should be relevant to the daily work of primary care
physicians. Emphasis should be on acquisition of skills rather than on
acquiring knowledge only. The training should affect the attitude of the
trainees by raising the awareness about the importance of psychosocial
factors and behaviour in health and disease. Training should enhance correct
management skills while avoiding unnecessary complexity or the use of
technical jargon. The range of interventions that can be undertaken by the
health personnel at each level should be specified for each country and
periodically revised (Annex 7). Training should have an impact on existing
services by decreasing the number of unnecessary secondary referrals,
laboratory tests and hospitalizations.
Primary care physicians can be trained through a number of methods
(Annex 9). The common methods used are:
•
case demonstration
•
case conference
•
criss-cross discussion
•
role-playing
•
use of audio tapes
•
use of television and videotapes
•
use of manuals.
50
Mental health in the Eastern Mediterranean Region: reaching the unreached
Evaluation and monitoring of training programmes
The development of a comprehensive training programme evolves
through progressive reinforcement by means of several training courses. Preand post-training evaluation of a trainee’s knowledge, skills and attitudes
about neuropsychiatric disorders and their treatment provide a measure of
the efficacy of the programme (Annex 10).
Trainees should be asked to comment freely on the content,
organization and delivery of the courses, indicating which elements of
training they found helpful and which may have been unhelpful or
confusing. This, together with the results of objective evaluation of trainee
skills/knowledge, provides the material necessary to refine the course for the
next batch of trainees.
All courses should include the following baseline measures, which are
important for evaluation:
•
a record of the trainees’ “psychiatric” diagnosis during the previous
month
•
a structured questionnaire to assess the knowledge, attitudes and
practices of trainees
•
a 10-minute history from a trained role-player portraying a common
neuropsychiatric illness in order to assess communication skills.
However, it is to be noted that all these measures may not be possible
for all centres to carry out because of logistic and/or resource constraints, in
which case the most feasible measure can be adopted initially.
All courses, in addition to repeating the above measures, should also
collect the rating of the relevance and quality of each component of the
course.
Optimally, one to three months after course completion, trainees
should be surveyed by postal questionnaire to ascertain the impact of
training on their practices.
In addition to these direct measures of the impact of training, it is
possible to use health service statistics to monitor the impact of newly
trained personnel on the existing services. Health administrators, in
particular, would find such data invaluable. The information that
administrators are looking for can be conveniently summarized as
educational evidence (evidence that the training has achieved the objectives
The role of training in the context of national mental health programmes
51
set for it); health service evaluation (evidence that training has had an impact
on services—for example, the number of referrals to secondary care before
and after training); and systematically collected information on the number
of cases identified by trained primary care physicians. If this last is collected
for the broad diagnostic groupings taught in the course, the administrators
would have the information they need to determine resource allocation.
Constraints in the implementation of training
programmes
Although techniques to meet the training needs of primary care
physicians and other personnel are widely available a number of constraints
still remain.
The first and most serious major constraint is a lack of enthusiasm
among mental health professionals as well as among senior administrators.
This can be rectified to some extent by adopting a mental health policy and
programme at national level.
The second major constraint is the lack of senior trainers in the
Eastern Mediterranean Region. Some countries have only a handful of
specialists with the basic skills to initiate training. The establishment of some
regional resource centres where potential trainers can gain skills and
experience through short-term fellowships would greatly assist the spread of
trainers.
Decentralization of mental health services implies that mental health
care should be made available at the community, district, and regional
levels through psychiatric inpatient and outpatient units linked to the
general medical facilities. The creation of large mental hospitals
should be discouraged but where they already exist the prime
consideration should be to ensure that the staff patient ratio allows
adequate treatment, care, and rehabilitation. A network of other
services as described in this report should support them.
Integration of mental health care into the general health service means
that the mental health component should be incorporated into the work
of the primary health worker, the community health centre, district and
regional health centres, and hospitals [8].
52
Mental health in the Eastern Mediterranean Region: reaching the unreached
Sometimes concern is expressed about the lack of quality audiovisual
equipment. Yet much can be achieved without resorting to sophisticated
audiovisual material. Lectures and case demonstration combined with crisscross discussion and role-playing can be substitutes for the television camera
and monitor. However, the value of television as a comparatively
inexpensive learning technology cannot be overestimated.
Special aspects of training of auxiliaries and other
health personnel working at primary health care level
Along with primary care physicians there is a large number of other
health personnel working at primary health care level. However, there is as
yet no standardized pattern of staffing of such health personnel across the
countries of the Eastern Mediterranean Region. Different categories of health
staff with varying duties and responsibilities have evolved in different
countries. Different names, such as health guides, health workers, birth
attendants, health technicians, sanitary patrols, vaccinators, dispensers,
nurses or health assistants, appear in the lists of health services of each
country.
In recent years, there has been a tendency in most countries to reduce
the categories of health staff in primary health care services and encourage
multiple functions for different categories. As yet there has been no
agreement on the mental health tasks which these health personnel should
perform; indeed, in most countries, there is at present no clearly defined
mental health role for these workers. Some countries have proposed
preventive and promotive roles while some others have suggested limited
curative roles for such staff. Decisions about mental health tasks to be
performed by these workers depend on many factors, such as the educational
background of workers and availability of other trained human resources. In
countries where the number of primary care doctors and specialists is
limited, health workers are bound to be given added responsibility. Recent
evidence in some countries of the Region, such as Islamic Republic of Iran,
Pakistan and Yemen, suggests that, with appropriate training, health workers
can adequately handle a limited number of neuropsychiatric conditions, such
as epilepsy, psychosis and severe depression, with one or two drugs and also
The role of training in the context of national mental health programmes
provide counselling
[4,6,20,23,24].
for
mental
retardation
and
substance
Principles of training auxiliaries
The following principles for training of auxiliaries or other health
personnel working at primary health care level are important.
•
The mental health training programme for auxiliaries should be
made simple (even simpler than that which has been proposed
for primary care physicians).
•
Greater emphasis should be placed on preventive and
promotive aspects focusing on a limited number of
neuropsychiatric disease conditions, such as epilepsy,
psychosis, depression, drug dependence and mental retardation.
•
Psychosocial skills, such as the art of listening, assessing
psychological or social stress, or giving emotional support to a
family in a time of crisis, should form an essential part of
training.
•
Techniques of working with the family and community should
be included in training.
•
Linkage of mental health training with other preventive and
curative tasks at primary health care level must be emphasized.
•
Short lectures, case demonstrations and group discussion can
be used for training. Audiovisual aids including videotapes
should be used where feasible.
•
Pre-assessment and post-assessment of knowledge, skills and
attitudes is an essential part of training.
•
Training should preferably be done at primary health care
centres or rural health centres, and the patients recruited for
training should be locals of the area. Simplified manuals and
other teaching aids should be specially prepared for primary
health care workers in local languages.
•
Psychiatrists from distant university centres should not conduct
training courses; physicians and administrative staff working in
the health centres should be involved in training.
53
abuse
Chapter 7
Developing programmes for
the prevention of mental
disorders and the promotion
of mental health
Strategies for prevention of mental, neurological and
psychosocial disorders in national mental health
programmes
A large proportion of neuropsychiatric disorders (and of the
subsequent disabilities) is preventable [2,25–27]. The implementation of
comprehensive programmes of prevention based on currently available
technologies could produce a substantial reduction of suffering to individuals
and their families, and of the socioeconomic losses, linked to these disorders.
In the countries of the Eastern Mediterranean Region, faced with numerous
public health problems and often suffering from scarce resources (which are
mainly used to provide treatment), proposals for preventive action against
neuropsychiatric illness have met with negative attitudes and responses from
both planners and mental health professionals. Many mental health
professionals feel that primary prevention of mental and neurological
disorders is difficult. This opinion is based on viewing “neuropsychiatric
illness” as a term exclusively reserved for the most serious disorders (such as
schizophrenia) and on the knowledge that certain mental disorders are linked
Developing programmes for prevention and promotion
55
with complex psychosocial issues, which are either hard to quantify or
impossible to alter (such as depression or drug dependence) Now that the
definition of tasks of mental health programmes is clearer and that it is
accepted that such programmes must deal with common neuropsychiatric
disorders, it should also become possible to convince the mental health
professionals of the possibility of preventive action.
In recent years, countries of the Region have included prevention in
national mental health programmes as a major aim of their plans of action. A
comprehensive list of effective measures for promotion of mental health and
prevention of mental illnesses that could be undertaken is given in Annex 5 [25].
The activities listed and the measures proposed must be applied
consistently and over a sufficiently long time. This can happen only if the
implementation of the programme is formally embedded in the national
health programme, appropriate training is provided for health workers and
others engaged in implementation of the programme and the exercise is
backed by ongoing evaluation in order to monitor the impact of these
measures.
Strategies for the promotion of mental health and
healthy lifestyles in the framework of national health
programmes
Advocating for mental health
The position of mental health on the scale of values of individuals and
communities is low in most communities. Many other aims, such as wealth
and physical beauty, are placed higher on the scale and receive precedence
when decisions are taken about spending money or investing effort. Even
when quick-wittedness, serenity or mathematical ability is considered
desirable, it is rare that these are seen as expressions of mental health and a
vigorous mental life. Societal efforts to improve or maintain mental life in
general are frequently half hearted, and mental health programmes lag
behind other programmes in priority and popularity.
It should also be noted that there is no universally acceptable
definition of mental health. However, most of the definitions produced over
the years in the literature include freedom from manifest psychopathology
and the potential to cope with the stresses of life and fully use one’s
56
Mental health in the Eastern Mediterranean Region: reaching the unreached
capacities. The field of promotion of mental health is chiefly concerned with
increasing the potential for leading a fulfilling life. Since all the definitions
of mental health are rooted in value judgements, and religion is such an
important contributor to the value systems prevalent in most of the countries
in the Eastern Mediterranean Region, religious concepts need to be seriously
considered when framing regional mental health promotion activities.
The movement towards national mental health programmes is
relatively new. It started in the mid 1970s, and in recent years has progressed
more rapidly in developing countries than in the industrially developed
countries. This is probably because in the established market economies of
Europe and north America, there were already well developed mental health
services existing both in the public and in the private sectors. In the
developing countries, human and material resources are scarce and in order
to meet the mental health needs of their populations the emphasis has to be
on a primary health care approach, multi-sectoral collaboration and use of
human resources in the existing health infrastructure. A WHO expert
committee meeting in 1974 on the organization of mental health services in
developing countries provided the broad framework for the developments of
the past three decades [8].
It is clear that the promotion of mental health cannot be done by the
mental health services alone. In fact, mental health specialists will have a
rather limited—albeit very important—role in the promotion of mental
health. Their tasks will be those of advocacy and of technical support to
programmes for which other social sectors will have to carry principal
responsibility. These will include in particular the schools, community
organizations, religious institutions and political bodies likely to influence
public opinion. However, many others—such as the entertainment
industry—will also have to be engaged in this effort. For this reason it will
Collaboration with non-medical community agencies means that the
contribution of community agents such as religious leaders, teachers,
development workers, the police, and the various associations should
be sought and that mental health professionals should devote part of
their time to the mental health education of such workers in the
community in order to make such a broad approach possible [8].
Developing programmes for prevention and promotion
57
be of great importance that the national coordinating bodies dealing with
mental health exert their role in promotional activities.
The promotion of health lifestyles was the topic of a discussion by the
WHO Regional Committee for the Eastern Mediterranean [28]. The
promotion of mental health is a concept that is akin to the promotion of
healthy lifestyles but covers a broader area. Both efforts can however be
undertaken in conjunction and using similar approaches. .
Success in efforts to promote mental health will depend on the clarity
with which programme proposals are formulated and on their immediate
applicability. In view of the specificity of the situations in the countries of
the Region, it will be important that the proposals and materials are tailored
accordingly, ensuring that the different disciplines and sectors involved are
represented.
The following areas of mental health promotion are particularly
stressed for inclusion in the activities in national programmes.
School mental health programmes
As nations have moved towards a commitment to universal education,
schools are finding it necessary to expand their role by providing health
services, including mental health services, to deal with factors interfering
with schooling [29–34].
Schools, with the full support of families and the community, are
currently the best place to develop a comprehensive mental health
programme for children for the following reasons:
•
almost all children attend school at some time during their lives
•
schools are often the strongest social and educational institutions
available for intervention
•
schools have a profound influence on children, their families and the
community
•
young people’s ability and motivation to stay in school, to learn and to
use what they learn is affected by their mental well-being
•
schools can act as a safety net, protecting children from hazards that
affect their learning, development and psychosocial well-being
•
schools are crucial in building self-esteem and a sense of competence
in addition to the family
58
Mental health in the Eastern Mediterranean Region: reaching the unreached
•
school mental health programmes are effective in improving learning
and mental well-being
•
when teachers are actively involved in mental health programmes, the
interventions can reach generations of children.
Teachers have often received some training in developmental
principles. This makes them potentially well qualified to identify and remedy
mental health difficulties in school-aged children.
A comprehensive mental health programme should be part of a
comprehensive school health programme, aimed at providing experience that
will strengthen the children’s coping abilities to counter environmental stress
and disadvantages with which they may have to cope while growing up.
Comprehensive school health initiatives are available that result in higher
school attendance rates, enhanced academic success, less school drop-out
and reduced criminal behaviour. Mental health and life skills education has
been demonstrated to reduce drug use, alcohol consumption and cigarette
smoking in children and adolescents. School-based mental health
interventions may be environment-centred or child-centred and changes in
one can affect the other.
Children in schools offer an excellent opportunity to promote sound
principles of mental health and healthy lifestyles. Already a number of
countries of the Region, such as Bahrain, Egypt, Islamic Republic of Iran
and Pakistan, have started such programmes in school and these need to be
further developed and extended (see details in country profiles, Part 2).
Collaboration with religious leaders in the promotion of mental
health
Religion often provides a broad framework for choice of lifestyle,
interpersonal relationships, family life and values. Good progress has already
been made in some countries for collaboration with religious leaders and
institutions in activities related to mental health programmes, such as using
religious leaders to campaign against drug abuse in Egypt or use of centres
of religious healing for extension of mental health services in Pakistan and
Sudan. There is need to further develop and extend such activities [39].
Developing programmes for prevention and promotion
59
Use of the press, television and other media
The mass media are important agents of social change and help shape
individual choice. As yet, mental health professionals have made a very
limited contribution to the promotion of mental health through the media.
Those efforts that have been made, such as in Egypt, Pakistan, Islamic
Republic of Iran and Tunisia, have been well received and the need for
greater dialogue and collaboration between mental health professionals and
media professionals is being felt in a world where the media play an
increasingly important role in determining values, lifestyles and attitudes
[28]. Mental health week has become the focal point for many groups of
individuals in order to increase awareness in the community. The media have
also taken up seriously the challenge of educating the public. The number of
national celebrations across the Region has increased from tens to hundreds.
Collaboration with nongovernmental organizations
Many nongovernmental organizations are doing excellent work in the
field, partly because of the advantages they have over governments in microlevel planning and implementation with a great amount of operational
flexibility. They are especially active with respect to the care of the mentally
handicapped and the elderly and management of substance abuse. Mental
health professionals must collaborate with them to further propagate national
programmes.
Families and mental health
The family occupies a central position in the promotion of mental
health as it is the crucible in which the personality of an individual develops
and the framework of values is formed. Changes in recent decades,
especially those resulting from urbanization, have led to the joint family
system breaking down. Schools and the mass media have taken over some of
the traditional roles of parenting. The nuclear family places heavy stress on
parents to fulfil the multiple needs of children. Single-parent families, due to
migration, divorce or death, are recognized as having a negative impact on
child development.
Mental health professionals must understand the changes in family
structure and functioning. It is not possible to go back to the past family
60
Mental health in the Eastern Mediterranean Region: reaching the unreached
system but it should be possible to build the strengths of the family to meet
the needs of the family members. Specifically, training in parenting skills,
setting up of day-care facilities, crisis support, formation of self-help groups,
and psycho-educational programmes for families with specific problems are
examples by which negative impact can be minimized [2]. Furthermore
mental health professionals can also influence laws and policies affecting the
family structure and dynamics.
Role of psychology and the behavioural sciences in
the development of strategies
Recent advances in clinical psychology and other branches of the
behavioural sciences have led to the development of a large body of
knowledge of direct relevance to the promotion of mental health and the
prevention of disorders [25–27]. Some of the areas that are particularly
relevant are:
•
social and developmental influences on mental health, such as factors
affecting the intellectual and emotional growth of children
•
factors affecting motivation to change high-risk behaviour
•
methods of preventing “burn-out syndrome”
•
psychological aspects of “vulnerability”, the importance of cognitive
variables, such as self-esteem and of social, cognitive and emotionmodifying skills
•
secondary and tertiary prevention of mental disorders, such as
effective psychological treatments for conduct and learning disorders
in children and of anxiety, depression and sleep disorders in adults and
functional problems associated with sensory loss in the elderly, as well
as the psychological component of rehabilitation programmes for
persons with schizophrenia or head injury
•
the prevention of physical disorders, such as reduction of risk factors
in coronary heart disease, and psychological treatment of pain,
including headache.
Developing programmes for prevention and promotion
61
Involvement of university/academic centres in national
mental health programmes
Most of the countries in the Region have well established mental health
institutes and departments of psychiatry. Similarly, most of the universities and
major academic institutions have departments of psychology, sociology and
other behavioural sciences. There is a need for these departments to be more
involved in the activities of the newly emerging national mental health
programmes. Traditionally, the university centres have limited their role to
teaching undergraduate and postgraduate students, with some additional
involvement in research. In general, university centres have kept themselves
aloof from the activities of the public health sector, the responsibility for
which has been left largely to the ministries of health. Universities and other
academic centres need to play a more active role in the national programmes.
Governments in countries of the Region are generally supportive of
the development of national mental health programmes. However, good
models of intersectoral collaboration and mental health services in primary
health care suitable for developing countries are limited at present and
unfortunately, in most of the countries of the Eastern Mediterranean Region,
the priority accorded to mental health programmes is also not very high.
Therefore a crucial question is who should provide the technical expertise to
develop and sustain these newly emerging national programmes?
In these circumstances, the role of mental health professionals, who
understand and value the progress of these mental health programmes better
than others, becomes critical and as traditional leaders of mental health
professionals work in the universities and academic centres, their
involvement in these programmes is vital.
In the Eastern Mediterranean Region, a number of university departments
in Egypt, Islamic Republic of Iran, Iraq, Morocco, Pakistan, Tunisia and Yemen
have developed active collaboration with their respective ministries of health to
develop national mental health programmes in their countries. For example,
since 1985 there has been a significant development in the Islamic Republic of
Iran where the newly created universities of medical sciences now combine the
role of teaching along with the health care responsibility for the province in
which the university is situated. This system has contributed to the progress of
the mental health programme in the country (see country profiles, Part 2).
62
Mental health in the Eastern Mediterranean Region: reaching the unreached
Areas in which mental health professionals, working in the
university centres, can play a role in the national programmes of
mental health
•
Academic centres’ role in national mental health programmes
•
Technical advice and assistance in formulating the document
on national mental health policy and programme
•
Representation on national and provincial multisectoral groups
to monitor and coordinate the progress of the programme
•
Leadership role in the activities of the national programme,
which can include:
−
organization of sections of community psychiatry in the
existing departments of psychiatry
−
activities related to the extension of mental health care
services in the rural and urban areas (responsibility of
providing care to specific catchment areas)
−
development of suitable teaching/learning materials in
local languages for the training of general physicians
and other staff working in primary health care, and
organization of workshops for training of trainers, in
collaboration with the ministry of health
•
Orientation of the general public and nongovernmental
organizations to the programmes on promotion of mental
health through meetings and lectures on radio and television
and writings in the press, etc.
•
Reorientation of teaching of all health personnel, such as
psychiatrists, doctors, nurses, social workers and psychologists,
with special emphasis on:
•
−
inclusion of behavioural and psychosocial sciences in
the curricula
−
inclusion of principles and activities of national mental
health policy and programme as a regular part of
teaching
−
practical training in community mental health linked
with extension of services in the rural/urban areas
Involvement in needs-based research to support the national
programme and evaluation of the innovative approaches
developed as part of the national programme
Chapter 8
Needs assessment, research
and evaluation
Importance of research
At present, there is very limited mental health research from the
countries of the Region. However, it is recognized that research has to be an
important part of the development of mental health programmes. There are
many reasons for the emphasis on country level mental health research.
Firstly, there are differing risk factors in the countries of the Region which
requires that epidemiological studies are carried out in individual countries.
Secondly, mental disorders differ in expression modified by factors like
education, social norms and since diagnostic systems are developed for use
in international situations, there is need for local knowledge to influence the
development of diagnostic systems. Thirdly, the beliefs and traditional
practices have a greater role in seeking help in countries of the Region and
services have to be developed based on these factors. Fourthly, religion is an
important part of the lives of the people and this area can contribute to better
understanding of mental health.
The priorities for research have been regularly discussed in the many
intercountry reports (Annex 6). The section on research in chapter 4 of The
world health report 2001 [2] provides a good framework for planning
research studies in Member countries.
64
Mental health in the Eastern Mediterranean Region: reaching the unreached
Promoting research
Note. This section is taken from The world health report 2001 Mental health: new understanding, new
hope, Geneva, World Health Organization, 2001, 104–106
Although knowledge of mental and behavioural disorders has
increased over the years, there still remain many unknown variables which
contribute to the development of mental disorders, their course and their
effective treatment. Alliances between public health agencies and research
institutions in different countries will facilitate the generation of knowledge
to help in understanding better the epidemiology of mental disorders, and the
efficacy, effectiveness and cost-effectiveness of treatments, services and
policies.
Epidemiological research
Epidemiological data are essential for setting priorities within health
and within mental health, and for designing and evaluating public health
interventions. Yet there is a paucity of information on prevalence and the
burden of major mental and behavioural disorders in all countries,
particularly in developing countries. Similarly, longitudinal studies
examining the course of major mental and behavioural disorders and their
relationship with psychosocial, genetic, economic and other environmental
determinants are lacking. Epidemiology, amongst other things, is also an
important tool for advocacy, but the fact remains that many countries lack
data to support advocacy for mental health.
Treatment, prevention and promotion outcome research
The burden of mental and behavioural disorders will only be reduced
if effective interventions are developed and disseminated. Research is
needed to develop more effective drugs which are specific in their action and
which have fewer adverse side-effects, more effective psychological and
behavioural treatments, and more effective prevention and promotion
programmes. Research is also needed on their cost-effectiveness. More
knowledge is required to understand what treatment, either singly or in
combination, works best and for whom. Adherence to a treatment,
prevention or promotion programme can directly affect outcomes, and
research is also needed to help understand those factors affecting adherence.
Needs assessment, research and evaluation
65
This would include examination of factors related to: the beliefs, attitudes
and behaviours of patients and providers; the mental and behavioural
disorder itself; the complexity of the treatment regime; the service delivery
system, including access and treatment affordability; and some of the broad
determinants of mental health and ill-health, for example, poverty.
There remains a knowledge gap concerning the efficacy and
effectiveness of a range of pharmacological, psychological and psychosocial
interventions. While efficacy research refers to the examination of an
intervention’s effect under highly controlled experimental conditions,
effectiveness research examines the effects of interventions in those settings
or conditions in which the intervention will ultimately be delivered. Where
there is an established knowledge base concerning the efficacy of treatments,
as is the case for a number of psychotropic drugs, there needs to be a shift in
research emphasis towards the conduct of effectiveness research. In addition,
there is an urgent need to carry out implementation or dissemination research
into those factors likely to enhance the uptake and utilization of effective
interventions in the community.
Policy and service research
Mental health systems are undergoing major reforms in many
countries, including de-institutionalization, the development of communitybased services, and integration into the overall health system. Interestingly,
these reforms were initially stimulated by ideology, the development of new
pharmacological and psychotherapeutic treatment models, and the belief that
alternative forms of community treatment would be more cost-effective.
Fortunately there is now an evidence base, derived from a number of
controlled studies, demonstrating the effectiveness of these policy objectives.
Most of the research to date has, however, been generated in industrialized
countries and it is questionable whether results can be generalized to
developing countries. Research is therefore needed to guide reform activities
in developing countries.
Given the critical importance of human resources for administering
treatments and delivering services, research needs to examine the training
requirements for mental health providers. In particular, there is a need for
controlled research on the longer term impact of training strategies, and the
66
Mental health in the Eastern Mediterranean Region: reaching the unreached
differential effectiveness of training strategies for different health providers
working at different levels of the health system.
Research is also needed to understand better the important role played
by the informal sector and if, how and in what ways the involvement of the
traditional healers can either enhance or adversely affect treatment outcomes.
For example, how can primary health care staff better collaborate with
traditional healers in order to improve access, identification and successful
treatment of persons suffering from mental and behavioural disorders? More
research is required to understand better the effects of different types of
policy decisions on access, equity and treatment outcomes, both overall and
for the most disadvantaged groups. Examples of research areas include the
type of contracting arrangement between purchasers and providers that
would lead to better mental health service delivery and patient outcomes, the
impact of different methods of provider reimbursement schemes on access
and use of mental health services, and the impact of integrating budgets for
mental health into general health financing systems.
Economic research
Economic evaluations of treatment, prevention and promotion
strategies will provide useful information to support rational planning and
choice of interventions. Although there have been some economic
evaluations of interventions for mental and behavioural disorders (for
example, schizophrenia, depressive disorders and dementia), economic
evaluations of interventions in general tend to be scarce. Again the
overwhelming majority come from industrialized countries.
In all countries, there is a need for more research on the costs of
mental illness and for economic evaluations of treatment, prevention and
promotion programmes.
Research in developing countries and cross-cultural
comparisons
In many developing countries there is a notable lack of scientific
research on mental health epidemiology, services, treatment, prevention and
promotion, and policy. Without such research, there is no rational basis to
guide advocacy, planning and intervention [40].
Needs assessment, research and evaluation
67
Despite many similarities of mental problems and services across
countries, the cultural context in which they occur can differ substantially.
Just as programmes need to be culturally informed, so does research.
Research tools and methods should not be imported from one country to
another without careful analysis of the influence and effect of cultural factors
on their reliability and validity.
WHO has developed a number of transcultural research tools and
methods including the Present State Examination (PSE), Schedule for
Comprehensive Assessment in Neuropsychiatry (SCAN), Composite
International Diagnostic Interview (CIDI), Self Reporting Questionnaire
(SRQ), International Personality Disorder Examination (IPDE), Diagnostic
Criteria for Research (ICD-10DCR), World Health Organization Quality of
Life Instrument (WHOQOL), and World Health Organization Disability
Assessment Schedule (WHODAS) [41].These and other scientific tools need
to be further developed to allow valid international comparisons that will
help in understanding the commonalities and differences in the nature of
mental disorders and their management across different cultures.
One lesson of the past 50 years is that tackling mental disorders
involves not only public health but also science and politics. What can be
achieved by good public health policy and science can be destroyed by
politics. If the political environment is supportive of mental health, science is
still needed to advance understanding of the complex causes of mental
disorders, and to improve their treatment.
Chapter 9
Advancing the global mental
health agenda
An increasing burden
The 20th century witnessed significant improvements in somatic
health in most countries. A number of key public health threats were
eradicated or brought under control under the leadership of WHO. Priority
was given to communicable diseases in view of their inherent potential for
spread. A focus on noncommunicable diseases and mental health would now
appear to be the next natural step in public health priorities. In the case of
mental health, this is due to the inherent potential of mental health disorders
to proliferate, not only as a result of complex and multiple biological,
psychological, but also social determinants. However, the mental component
of health has reached a plateau and, in many instances, has deteriorated
seriously.
During the course of the past century, increased life expectancy was
made possible by improved physical health. However, this has meant that a
larger proportion of the population now reaches an age which carries higher
risks of morbidity attributable to mental disorders.
WHO estimates that at any one time, as many as one in four of the
world's population suffer from different forms of mental, behavioural and
neurological disorders, including affective disorders, alcohol and drug abuse,
epilepsy, dementias, mental retardation, schizophrenia and stress-related
Advancing the global mental health agenda
69
disorders. Mental, neurological and substance use disorders cause a large
amount of burden (13% of overall disability-adjusted life years) and
disability (33% of overall years lived with disability) [2]. However, behind
these often repeated figures lies an enormous amount of human suffering.
More than 150 million persons suffer from depression at any point in time.
Nearly 1 million commit suicide every year. About 25 million suffer from
schizophrenia, 38 million from epilepsy and more than 90 million from an
alcohol or drug use disorder. A large proportion of these individuals do not
receive any health care for their condition.
The treatment gap for most mental disorders is high. According to a
recent review by WHO from published sources, originating from the United
States of America, Europe, Brazil, Chile, China, India, Zimbabwe and others
[42], the percentages of people in need of treatment and not receiving it are
as follows:
Schizophrenia
Depression
Bipolar disorder
Panic disorder
Obsessive compulsive disorder
Alcohol abuse and dependence
32.2%
56.3%
50.2%
55.9%
57.3%
78.1%
The reasons for this are twofold. First, the mental health infrastructure
and services in most countries is grossly insufficient for the large and
growing needs. Forty per cent of all countries have no policy for mental
health care and 25% assign no budget for it. Even where a budget exists, it is
very small with 36% of countries devoting less than 1% of the total health
budget to mental health care. Although community-based services are
recognized to be most effective, 65% of all psychiatric beds are still in
mental hospitals, eating away at the already meagre budgets while providing
largely custodial care in an environment that violates basic human rights
[43]. Second, widely prevalent stigma and discrimination prevent those in
need from seeking help [2].
Beyond the figures, which relate exclusively to mental and
neurological disorders, far too many people, many of whom belong to
70
Mental health in the Eastern Mediterranean Region: reaching the unreached
vulnerable groups such as women, children, the elderly, refugees and
indigenous populations, suffer from the effects of violence, dislocation,
poverty, isolation, stress and deprivation. These people and those suffering
from acute or chronic mental illness that is inadequately managed, form a
broad nation living dispersed within the many nations of the world.
Mental health, mental disorders and the Millennium
Development Goals
1. Poverty and hunger. Mental disorders are much more common among
the poor and they, in turn, increase poverty. A substantial proportion of
homeless poor people have mental and substance use disorders. People
who are refugees or displaced suffer from a broad range of mental
disorders. Children who do not receive enough iodine through salt
develop mental retardation. People exposed to major economic
transitions are at risk for alcohol, substance use and suicide [44,45]. The
stresses imposed by absolute poverty are powerful determinants of
mental disorders such as depression and substance abuse. The
psychological impact of relative poverty is the result of both the indirect
(increased exposure to behavioural risk factors due to psychosocial
stress) and direct (physiological circumstances associated with social
position). One of the most consistent predictors of mental disorders in
low income countries is lack of education. Linkages between poverty
and depression have been clearly shown in studies of suicide among
poor farmers in India, of maternal depression in women from
impoverished peri-urban settlements in South Africa, and of severe
depression among people who are less educated and unemployed in
Chile.
2. HIV/AIDS, tuberculosis, malaria and other diseases. Mental and
behavioural factors and disorders such as depression are important for
adherence and compliance to treatment of these diseases. Substance use
is an important risk factor for HIV.
3. Maternal health. Mental health care for depression and substance use
disorders is important for decreasing the morbidity and mortality among
Advancing the global mental health agenda
71
mothers, as well as to prevent short-term and long-term adverse effects
on neonates and children.
Mental health, global development and the public
health agenda
Recent developments, including experience related to the development
of The world health report 2001, indicate why the case for advancing the
interests of mental health has now become so compelling. Mental health
problems already account for more than one-eighth of the global burden of
disease and this is likely to increase in future. Decades of neglect of this area
combined with current needs and emerging opportunities make urgent action
a singular priority.
The proportion of the global burden of disease attributable to mental,
neurological and substance use disorders is expected to rise from 12.3% in
2000 to 16.4% by 2020. Alcohol consumption alone is responsible for 4% of
the global burden. More than 150 million persons suffer from depression at
any point in time and nearly one million commit suicide every year. The
population of injecting drug users comprises approximately 10 million
people worldwide and 4%–12% of all HIV cases in the world are due to
injecting drug use which is a driving force behind the HIV/AIDS epidemic
in many parts of the world. The rise in the burden of mental, neurological
and substance use disorders will be particularly sharp in developing
countries, primarily because of the projected increase in the number of
individuals entering the age of risk for the onset of disorders. These
problems pose a greater burden on vulnerable groups such as people living
in absolute and relative poverty, those coping with chronic diseases and
those exposed to emergencies.
Mental health and WHO’s agenda
In 2002 the Executive Board adopted a resolution (EB109.R8) on
strengthening mental health and the World Health Assembly affirmed its
provisions (WHA55.10). Similar resolutions on mental health were adopted by
the African, Americas, European and Western Pacific regions between 1999
72
Mental health in the Eastern Mediterranean Region: reaching the unreached
and 2003. Due to this focused effort, governments are now more aware of the
negative impact of mental, neurological and substance use disorders not only of
individuals but also of families and communities. However, governments need
to make a more determined effort to put mental health in their agenda. In
addition, in spite of the availability of cost-effective treatment for most of those
disorders, a huge gap still exists between their implementation and the needs
worldwide. Reducing this gap and improving treatment rates will not only
reduce the burden of disease and disability and health care costs, but will also
increase economic and social productivity. The burden attributed to depression
or the mortality due to suicide, for instance, could be reduced by a half and one
fourth, respectively, if all individuals concerned received appropriate care.
Finally, to address this gap, it is vital that innovative mental health policies and
legislation be designed and become a harmonious part of health systems.
Promoting mental health, preventing mental disorders, mainstreaming costeffective interventions in primary health care and engaging with local
communities will be key components of such innovative policies.
The WHO mental health and substance abuse programme addresses a
broad spectrum of issues and problems ranging from the promotion of
mental health to the prevention and management of the most disabling
mental, neurological and substance use disorders. Work carried out by WHO
in recent years has clearly demonstrated the presence of three groups within
people having mental, neurological or substance use disorders (roughly
about 450 million people).
a)
Those that are at present not served by any mental health services.
This group is as large as about 200 million people.
b)
Those who are at present served by inadequate and often inappropriate
services, including long term hospitalization in mental hospitals where
human rights violation is the norm, or in outpatient services with poor
resources. This group is again about 200 million people.
c)
Those who are receiving adequate and appropriate services in settings
with good resources and protection of human rights. This group is
only about 50 million people; a vast majority of them live in
developed countries.
Most academic, teaching and research efforts in the world are focused
on the third group. WHO has a clear mandate to focus its attention and
Advancing the global mental health agenda
73
efforts on the first two groups. The objectives of WHO’s work are thus to
extend services to those who at present have none and to improve quality of
care and respect for dignity and rights to those who are at present
inadequately and inappropriately served. For WHO, the present poor state of
mental health services constitutes a global emergency.
WHO’s strategic agenda
The successful mental health awareness activities promoted by WHO in
2001 (World Health Day, World Health Report, Ministerial Round Table in the
54th World Health Assembly) clearly created a solid ground for action. The
WHO Mental Health Global Action Programme endorsed by the World Health
Assembly in 2002 identified clear strategies for concrete action. These include
information for decision-making and technology transfer, advocacy against
exclusion and for human rights, development of comprehensive and effective
mental health policies and services and promotion of public mental health
research. These strategies are implemented at three levels, global, national and
local.
Global level
Advocacy and global partnership on human rights of the mentally ill
A global movement is needed to turn the tide in favour of restoring
basic human rights to the mentally ill and to decrease stigma and
discrimination against them. Advocacy at higher levels is also required to
strengthen the political commitment required to support mental health
planning and its integration in the broader framework of general health and
development. A global partnership with service users, families, professionals
and social advocates needs to be built to achieve this [46].
Global information system
Basic information on epidemiology of mental disorders and on mental
health resources within countries needs to be available as a baseline and for
monitoring trends over time. The information should be comparable across
regions and countries.
74
Mental health in the Eastern Mediterranean Region: reaching the unreached
Guidance on policy and service organization for prevention and treatment of
mental, neurological and substance use disorders
Given the early stage of development of these fields, standards,
guidelines and training packages for policy, services and cost-effective
preventive and curative interventions are needed for adaptation and use
within countries [47,48].
National level
Mental health policy and legislation
A comprehensive mental health policy and legislation are essential
requirements for taking forward the mental health agenda within any
country. About 40% of countries do not have a comprehensive national
mental health policy and progressive legislation incorporating protection of
human rights of the mentally ill. WHO provides technical cooperation in
developing mental health and substance use policies and legislation which
are coherent components of the broader health system development [48].
Promoting life style conducive to mental health and to prevent mental
disorders
Promotion and prevention are long term objectives in mental health.
Evidence is accumulating regarding effective public health interventions
towards these objectives. These include skills-based and information-based
programmes for specifically targeted groups that are vulnerable or at a
vulnerable phase of life. Programmes within schools and the workplace are
included.
Reorganization and expansion of mental health services
Two-thirds of all mental health beds in the world are still in large
mental institutions. Community mental health services are still in their
infancy in most countries. Primary health care is still unable to provide even
basic mental health care. WHO provides technical cooperation in
reorganizing and expanding their mental health services. This involves
collecting baseline data, developing achievable targets with timelines and
providing technical assistance to achieve these.
Advancing the global mental health agenda
75
Disease-specific programmes
Disease-specific programmes and initiatives can help in focusing
attention and attracting resources to the most important mental health
problems within the country. These include community care for severe
mental disorders, campaigns against epilepsy, stress reduction and suicide
prevention programmes, prevention of alcohol-related problems and
prevention of mental retardation. WHO provides technical cooperation to
establish and scale up these programmes.
Capacity development in monitoring and research
Countries need to develop capacity to undertake monitoring of their
mental health services and to conduct relevant research in public health
aspects of mental health. WHO provides technical cooperation in evaluating
the research infrastructure, in developing an appropriate research agenda and
in enhancing the capacity to conduct research as well as to disseminate and
use the research findings.
Local level
Integration of mental health with other priority programmes
Links and synergies between mental health and other priority
programmes can be mutually beneficial. This needs to be systematically
done at the local level. WHO provides technical cooperation to facilitate
links between mental health and priority programmes like antenatal care,
maternal and child health, prevention of violence, treatment of chronic
diseases and treatment of HIV/AIDS and other infectious diseases.
Early identification and management of mental disorders, involvement
of service users and families in treatment and maintenance treatment for
substance dependence have been demonstrated to be effective. WHO
provides technical cooperation to scale up these interventions.
Training to health and other sector personnel
Mental health professionals are neither available in adequate numbers
in low and middle income countries nor necessary for providing all mental
health care. It is vital that primary care health professionals and personnel
from other sectors (e.g. education, social welfare, justice, and human
resources) be trained in identification and management (including referral)
76
Mental health in the Eastern Mediterranean Region: reaching the unreached
of common mental health problems and in prevention and promotion
activities.
Empowerment of communities
It is important, especially in the area of mental health, that
communities become involved in service provision as well as in prevention
of mental disorders and promotion of mental health. WHO provides
technical cooperation to empower community-based organizations, including
services users and family groups, in playing a significant role in decisions
related to planning that affects mental health.
Goals for 2016
WHO can and must play a key role in assisting Member States in
implementing the above described three-level agenda. Some clearly defined
goals drive WHO’s effort.
1. Strengthening of mental health systems. At least 40% of all low and
middle income countries should have systematically assessed their
mental health systems using the WHO instrument. At least 20% of such
countries should have taken concrete steps towards strengthening their
mental health system using the WHO model.
2. Legislation and human rights for individuals with mental disorders. At
least 40% of countries should have enacted or revised their mental health
legislation within the previous ten years.
3. Suicide prevention initiative. At least 10 countries with the highest rates
of suicide should have taken specific steps for reducing suicides (e.g.
availability of lethal pesticides, guns).
4. Community care for severe mental disorders. The number of long stay
(more than 2 years) patients in mental hospitals should have decreased
by 50% with corresponding development of adequate community
services.
5. Treatment of depression co-morbid with physical diseases. Evidencebased guidance for identification and treatment of co-morbid depression
with common physical diseases (e.g. hypertension, obesity, diabetes,
Advancing the global mental health agenda
77
HIV, tuberculosis, malignancies) should be available for health care
professionals in primary and specialist care [49].
6. Involvement of families in care of mental disorders. Systematic training
for families in caring for severe mental disorders and intellectual
deficiency should be available in at least 20% of all countries.
7. Treatment of alcohol-related problems in primary health care. At least
20% of primary health care professionals in low and middle-income
countries should be trained in identification and treatment of alcoholrelated disorders.
8. Policy for alcohol-related problems. At least 20% of countries should
have taken specific policy steps (e.g. increased taxes on alcoholic
beverages, implemented drink-driving laws, curbed marketing to
minors) to decrease alcohol-related problems.
9. Treatment of injecting drug use disorders and its consequences. At least
50% of affected countries should be using maintenance drug treatment
routinely. At least 50% of affected countries should be integrating
prevention and treatment of injecting drug use with those for HIV and
AIDS.
10. Mental health in emergencies. At least 20% of low and middle-income
countries should have developed a comprehensive plan and trained
professionals for mental health care in face of serious emergencies.
Main lines for mental health action in countries in the
Eastern Mediterranean Region
As indicated in The world health report 2001 the minimum actions
required for mental health care refer to the same basic recommendations,
which apply to countries in all WHO regions. The difference from country to
country lies in the degree or intensity of the action, depending on the
country’s resources [50]. At the same time, it is considered there is enough
evidence to justify several priorities for action in the Eastern Mediterranean
Region.
78
Mental health in the Eastern Mediterranean Region: reaching the unreached
1. Respect of human rights in people admitted to mental hospitals, and the
gradual transfer of their care to the community level. It is difficult to
imagine a place where human rights are so blatantly violated as in
mental hospitals. Initially conceived as a place of refuge and protection
for the “beloved brothers of the Prophet”, they gradually became not
only un-therapeutic but also deleterious to many people, reinforcing
disease chronicity and dependence of patients. In order to overcome this
unwanted situation, there are two lines of action, one short-term and the
other medium to long-term. The first refers to the immediate
improvement of the living conditions in existing mental hospitals and the
enforcement of respect for human rights, as spelled out in the UN
Principles for the Protection of Persons with Mental Illness and the
Improvement of Mental Health Care. The second concerns the gradual
transfer of the focus of care from large mental hospitals to communitybased facilities, and the predominant use of psychiatric beds in general
hospitals for those unavoidable situations in which a psychiatric
admission is necessary.
There is now evidence that community care results in better outcomes
and quality of life, limits the stigma of receiving treatment, and leads to
earlier treatment, in addition to complying with the UN principles.
According to data recently published by WHO, the Region as a whole is
below the world average in terms of a) presence of treatment facilities for
severe mental disorders in primary care (50% versus 59.1% in the
world); b) presence of three essential psychiatric drugs at primary health
care level (78.9% versus 80.6%); and c) presence of mental health in
community care (54.5% versus 63.4%). In spite of the fact that countries
in the Region are above the world average in both the presence of a
national mental health programme (6.4% versus 69.7% in the world) and
a budget specified for mental health (80% versus 72%), these are clear
indications of the need for a reorientation of mental health services in the
Region. The information that almost three-quarters (74.7%) of all
psychiatric beds in the Region are in psychiatric hospitals and only
11.2% are in general hospitals only reinforces this opinion.
Advancing the global mental health agenda
79
2. Action on the growing use of illicit drugs, particularly of injecting drugs,
and the devastating dissemination of HIV/AIDS. Although Islamic
societies have always forbidden the use of substances that cloud the
mind and impair consciousness, and in spite of a supposed revival of
religiousness among youth, there is evidence of a worrying growing use
of illicit drugs in countries of the Region. In addition to the
socioeconomic problems associated with drugs, and the specific
psychiatric problems consequent to the use of these substances, the use
of injecting drugs also contributes to the dissemination of HIV/AIDS.
Governments and societies must awake quickly to this growing problem
and take appropriate action, ranging from limiting the access to these
harmful substances and preventing their use, to the establishment of
services for early identification of users, detoxification and long-term
follow-up. A multisectoral approach is needed to achieve efficient
results. The present successful WHO project in the Islamic Republic of
Iran on drug dependence treatment and HIV/AIDS needs to be extended
to other countries of the Region.
3. Reconstruction of the health care system of Afghanistan and Iraq,
without which no mental health care is possible. Prolonged civil war and
in Afghanistan and conflict in Iraq, as well as in other places in the
Region, have practically destroyed the health care delivery system.
Without the reconstruction of the basic health care delivery network no
mental health care is possible. Rebuilding the mental health systems of
Afghanistan and Iraq represents an excellent opportunity to demonstrate
the advantages of mental health care integrated into general health care,
as well as to demonstrate the feasibility of a sound mental health care
system without the mistakes and disadvantages of large, centralized
mental hospitals.
4. Technical cooperation with mental health services in the occupied
Palestinian territory. The existing project has two main components: a
mental health policy and five-year implementation plan, and the
development of community mental health services including two in the
psychiatric hospitals of Bethlehem and Gaza. The third important
component of the project is the development of human resources which
80
Mental health in the Eastern Mediterranean Region: reaching the unreached
includes training of health workers in the territory but also abroad
(France, Italy and United Kingdom). The project also addresses the
general public through the development of anti-stigma initiatives and
campaigns and the establishment of family associations and service users
groups. It is quite innovative that not only the family component was
promoted (groups have been established in Bethlehem, Ramallah and
Hebron) but also the service users’ component through the support of the
groups of “Hearing voices”; these groups have played a very important
role in steering the situation in the psychiatric hospital in Bethlehem.
Such a complex project, which encompasses policy, organizational,
infrastructure and education issues, needs to be assessed. This is the
reason why WHO initiated in the territory the WHO Assessment
Instrument for Mental Health Systems (WHO-AIMS) to ensure the
monitoring and evaluation of the mental health project on the ground.
5. The Darfur humanitarian emergency. The dramatic situation in Darfur
will obviously represent a major challenge for health and mental health
in the future. A sustained effort has already been initiated by WHO but it
will require substantial international support for many years.
6. The increasing need for better information about mental health policy,
service organizations, resources available, integration with primary
health care and other key information, which are vital to better planning
and rational investing. WHO is developing a systematic assessment of
mental health systems in Afghanistan, Egypt, Iraq, Islamic Republic of
Iran, Tunisia and the occupied Palestinian territory.
Part 2
Country profiles
Afghanistan
Overview
Afghanistan has a land area of 652 225 km2. Large areas of the
country, particularly in the north and the east, are mountainous with altitudes
reaching 8000 metres. Many roads and tracks become impassable during the
winter months. The most recent population estimates place it at 23 million
(2004). The urban and nomadic populations constitute 25% and 3.6% of the
population, respectively; more than half of the urban population lives in the
major cities: Kabul, Jalalabad, Kandahar, Mazar-i-Sharif and Herat. The
proportion of the population below 15 years and above 65 years of age is
45.5% and 2.4%, respectively (2000).
Afghanistan is designated by the United Nations as one of the world’s
least developed countries with an estimated infant mortality rate of 147 per
1000 live births (2002) and life expectancy of 44.7 years (2003). The overall
literacy rate and adult female literacy rate are 16% and 5%, respectively
(1997). The crude birth rate and the crude death rate are estimated at 48 and
17.2 per 1000 population, respectively (2002). Maternal mortality ratio is
estimated at 160 per 10 000 live births (2003). Under-5 mortality rate is
estimated at 257 per 1000 live births (2004). In 2001, the rates per 10 000
population for physicians, dentists, nurses/midwives and hospital beds were
1.9, 0.3, 2.2 and 3.9, respectively. The per capita income is US$ 158 (2004),
the Ministry of Public Health budget represents 6.3% of gross domestic
product and per capita expenditure on health by the Ministry of Public
Health was estimated in 2005 at US$ 3.69 as opposed to the national average
84
Mental health in the Eastern Mediterranean Region: reaching the unreached
of US$ 10 per capita. Dari and Pushtu are the two national official
languages.
The primary health care strategy was endorsed in 1979. The strategy
sets the following objectives:
•
increase accessibility and efficiency of the health care delivery system
•
strengthen the functional integration of preventive and curative
services
•
adopt the team approach and strengthen the district health system
•
improve public awareness about health and healthy lifestyles
•
improve the development of human resources as regards planning,
production and use by more equitable distribution of qualified
personnel
•
reallocate resources more favourably towards primary health care.
The health system infrastructure is a pyramid of referral institutions
from health posts in the village, to basic health centres, on to provincial,
regional and central hospitals. The health care system has five levels, from
village, district, provincial and regional up to central level. At village level,
there are the village health workers and traditional birth attendants, with a
feldscher [male nurse] at the sub-centre or health post.
These are linked to basic health centres, at the district level, headed by
a physician, and some districts have a district hospital with 10–20 beds.
There are limited maternal and child health services and some family
planning services in the sub-centres and basic health centres. In 1987, there
were 13 sub-centres, 107 basic health centres and 172 hospitals. Not all
health centres and hospitals are functional; and of those that are, some are
operating with reduced capacity.
With a view to improving the operational efficiency of primary health
care services, the Ministry of Public Health has begun to implement the
district health system based on primary health care in many districts. In
1994, a policy of decentralization and delegation of financial and
management responsibilities to regions and provinces was introduced.
Operationally, the country is divided into seven regions—northern, northeastern, central, southern, south-eastern, eastern, and western.
Due to these efforts, before the protracted period of conflict, 280
districts out of a total 330 district were covered with some components of
Afghanistan
85
primary health care. Health personnel were state-employed; a few had
private practices in addition to their public employment. Private practice
concentrated mainly on running pharmacies; 92% of pharmacies and 30% of
laboratories were privately owned. Nearly two-thirds of physicians’ private
clinics were situated in Kabul and the provincial capitals. Unfortunately, all
of this information belongs to the past, and reliable information regarding
today’s situation is hard to come by and of course harder to quote.
The provincial health profiles presented by the regions during a health
sector planning workshop, organized by the Regional Office in 1998,
demonstrated wide variations in the levels of organization and management
of health services; human resources and their distribution; number of health
facilities, the package of services they provide; and accessibility of primary
health care services.
The education sector is taking part in health education in schools;
primary-level and secondary-level curricula have been revised to incorporate
information on health matters. The Ministries of Agriculture, Information
and Broadcasting, and Planning contribute to promoting people’s health, and
the Ministry of Planning ensures that health goals are incorporated into
socioeconomic development plans. However, no adequate mechanism exists
to ensure the accuracy of this information and systemic analysis and
monitoring to show the impact of these actions on health.
Mental health
Overview
Any description and discussion of mental health care in Afghanistan
must keep in view the sociopolitical realities of the country. More than two
decades of fighting ravaged the whole country; death, disability, destruction
and disease have affected all aspects of health. External and internal
migration of millions of Afghans has affected the whole social and family
structures.
86
Mental health in the Eastern Mediterranean Region: reaching the unreached
Up until about 1995 the treatment facilities in the country consisted of
the following.
•
•
•
•
•
•
•
Kabul province
Kabul Psychiatric Hospital. This is a 50-bed short-stay hospital, with
provision for 30 male and 20 female patients. It is located in an old
building about 5 km from the city centre. Annual admission to the
hospital is around 650 patients. Yearly outpatient attendance is
estimated at 800, and the number of psychiatrists working in the
hospital is 11, one of whom is a lady doctor.
Marastoom Asylum. This is a 20-bed hospital, supported by the
Afghan Red Crescent Society, which provides care for chronically ill
persons, including the mentally retarded and those suffering from
substance-related psychiatric disorders.
Substance-dependent Rehabilitation Facility. This was started in 1990
in Kabul. Currently, there are 10 beds, of which two are for female
patients. The annual admission is estimated at around 700 patients.
Community mental health centres. The four centres at Wazir Akbar
Khan, Katre Parwan, Khosal Miria and Alandin in Kabul province are
presently not functional.
Ali-Abad Hospital. There are only 5 beds for psychiatry in this general
hospital of 60 beds. Annual admission is estimated at 420 patients.
Jalalabad province
There are two centres for mental health care. The university hospital
has 10 beds, and there are 25 beds in the general hospital. The total
outpatient load is around 5000 cases per year, while admissions are
estimated at 650 per year.
Mazar-i-Sharif province
There is one mental health centre in the general hospital. The
outpatients register showed 2119 cases in 1998, while 69 patients were
admitted. Four beds are available for male patients only. There are
three doctors working in this centre.
Afghanistan
87
Mental health human resources
There is extreme shortage of all categories of trained mental health
professional. There are only a handful of fully trained psychiatrists with a
postgraduate degree/diploma qualification. Doctors working as psychiatrists
have been trained for short periods abroad (Poland, Sudan, India) or have
had in-service training within Afghanistan. Those serving as psychologists
have a bachelor’s degree in psychology from Kabul University. In 1990–91,
a one-year in-service training programme for psychologists in learning
difficulties was carried out. In 1996, a three-month diploma on mental health
was conducted in Mazar-i-Sharif with the assistance of WHO.
Mental health training
Undergraduate medical education includes 18 lectures in each of the
first and second semesters in the first year on behavioural sciences, 18
lectures in each of psychiatry and neurology during the fifth year, two weeks
of clinical attachment each in psychiatry and neurology, and one month
internship in psychiatry.
Postgraduate mental health training is not available in Afghanistan for
any category of mental health professional.
National mental health programme and related policies
A committee set up by the Ministry of Public Health drew up a
national mental health programme for Afghanistan. The programme was
discussed and adopted at a national workshop for mental health held in
Kabul in 1987. Policies for therapeutic and essential drugs were adopted in
1996 while narcotics and substance-abuse policy has been in place since
1988.
The national mental health programme has the following objectives:
provision of mental health care to all the population; integration of mental
health with primary health care; community participation; and services for
special groups, especially those affected by war. The programme document
outlines services, training, administrative strategies and approaches for
promotion of mental health and provision of services for the war-affected
population.
88
Mental health in the Eastern Mediterranean Region: reaching the unreached
Community mental health programmes
A large number of doctors and other health personnel have undergone
short-term training in basic mental health care. Many workshops, seminars
and group educational activities have been carried out for various categories
of personnel on mental health and substance-abuse related topics. Training
programmes for non-health personnel, such as teachers, school principals,
youth leaders, volunteers and community leaders have also been organized
from time to time.
Two mental health manuals were prepared in Dari for primary health
care doctors and other staff in 1998.
Current situation
The mental health services in Afghanistan are in a poor state. Despite
neuropsychiatric disorders being recognized as a major public health
problem during the health sector planning workshop in 1998 and a number
of recent psychiatric epidemiological studies in the general population, only
a few regions have outpatient services, supplemented by nongovernmental
organizations supporting some centres around the country. WHO provides
some neuropsychiatric drugs to the Ministry of Public Health but the
capacity of the Ministry of Public Health is very limited because, despite
setting up some new facilities in the 1980s, it does not have the trained staff
available to operate these and consequently their services have been
deteriorating year after year. In terms of health planning, as part of the Basic
Package of Health Services (BPHS) mental health is included as one of the
priorities from the village level onwards. In 2005, a 5-year mental health
strategic plan of action was developed to address the needs of the population.
Limitations
The severe shortage of trained key mental health professionals, the
extremely limited facilities, poor equipment and drug supplies and the
prevailing socioeconomic circumstances and continuing insecurity are the
major hindrances to the development of mental health services.
Afghanistan
89
Summary update (Mental health atlas, 2005)
Epidemiology
Some studies on refugees are available. Mukhamadiev (2003) studied
the prevalence of depression in 908 Tadjik refugee women in Afghanistan
and found a high prevalence of endogenous depression (28.6%). A 1.5 year
follow-up showed good prognosis in subjects who had sub-syndromal
depression, but not in those with endogenous depression. Rasekh et al (1999)
found that symptoms that met the diagnostic criteria for anxiety, depression
and post-traumatic stress disorder were common in 160 Afghan women
(including 80 women currently living in Kabul and 80 Afghan women who
had recently migrated to Pakistan) during the Taliban regime. Mghir et al
(1995) used the Structured Clinical Interview for DSM-III-R to detect mental
illness among 38 children and young adults and identified depression and
PTSD in more than one-third of the subjects.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1986. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation. The new Afghan Government has identified
mental health as one of five health priorities. Since 1986, there has been no
new government policy regarding mental health and the old mental health
policy is still followed. The policy outlines prevention, treatment and
rehabilitative facilities for mentally ill patients.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1988. A new policy on drug demand reduction was formulated
in 2002.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1988. The national mental health programme has the following
objectives: provision of mental health care to all, integration of mental health
90
Mental health in the Eastern Mediterranean Region: reaching the unreached
with primary care and community care, services for special populations,
especially the war-affected. It also outlines services, training, administrative
strategies and approaches for promotion of mental health and provision of
services for the war-affected. It advocates the development of a nucleus of
trained mental health professionals to act as ‘master trainers’ for primary
health care physicians and health workers in their respective provinces in
order to ensure at least a minimum provision of mental health services.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1996.
Mental health legislation
There is mental health legislation. The latest legislation was enacted in
1997.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary source of mental
health financing is out-of-pocket expenditure by the patient or family. The
country has disability benefits for persons with mental disorders. Disability
support services are provided for persons with physical, psychiatric,
intellectual, sensory or age-related disabilities (or a combination of these),
which are likely to continue for a minimum of six months and reduce
independent functioning to the extent that ongoing support is required.
Mental health facilities
Mental health is not a part of the primary health care system. Actual
treatment of severe mental disorders is not available at the primary level.
Community level workers from the local population (villages) have been
involved in providing integrated health care for the last 8 years.
Regular training of primary care professionals is not carried out in the
field of mental health. Two mental health manuals were prepared in Dari for
primary health care doctors and other staff in 1998. WHO has organized
mental health training for primary health care physicians. Nongovernmental
organizations are running training courses for primary health care doctors,
Afghanistan
91
nurses and midwifes, village health volunteers and traditional birth
attendants.
There are community care facilities for patients with mental disorders.
Mental Health is included in the Basic Package of Health Services (BPHS)
which covers health service delivery up to district level. New treatment
guidelines for common mental health disorders are being formulated (draft is
ready). Four Community Mental Health Centres have been established in the
capital, but further expansion is required. There are two general psychiatric
rehabilitation centres with 160 beds.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
0.055
0.031
0.024
0
0.036
0.034
0.07
0.07
0.09
0
Currently, there are no social workers, and there are only a very few
trained psychiatrists. Most doctors working as psychiatrists have either had
in-service training or have attended short courses abroad. A three-month
diploma course was held in 1996 to train some doctors in psychiatry.
Postgraduate training in psychiatry is not present. Psychologists get their
training from Kabul University. Much of the qualified human resources and
technical expertise has left the country.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in treatment. The Afghan Government
collaborates with nongovernmental organizations to rapidly expand basic
(mental) health services to underserved populations.
92
Mental health in the Eastern Mediterranean Region: reaching the unreached
Information gathering system
There is no mental health reporting system in the country. Each
hospital maintains registry books on their inpatient and outpatient
information. Quarterly reports are submitted by the mental hospital to the
Ministry of Public Health. The country has no data collection system or
epidemiological study on mental health.
Programmes for special populations
The country has specific programmes for mental health for the
disaster-affected population. There is a regular programme for traumatized
children (trauma and grief programme) which is supported by UNICEF.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, amitriptyline,
chlorpromazine, diazepam, haloperidol. The cost of medicines keeps
fluctuating as the local currency is unstable due to the war. Over-the-counter
sales of psychotropics occur.
Other information
There is a shortage of staff due to the war and more international
support is needed. A new Mental Health Unit under the Primary Care
Directorate was established in 2003 (it is not functional as yet). Since mental
health is a component of the Basic Package of Health Services, guidelines
and a treatment protocol for common mental disorders in primary health care
have been developed. Treatment guidelines for substance use have also been
almost finalized. A strategy for integration of mental health services into
primary care was finalized in 2004.
Additional sources of information
Mghir R et al. Depression and posttraumatic stress disorder among a
community sample of adolescent and young adult Afghan refugees. The
journal of nervous and mental disease, 1995, 183:24–30.
Mohit A et al. Mental health manpower development in Afghanistan: a report
on a training course for primary health care physicians. Eastern
Mediterranean health journal, 1999, 5:373–377.
Afghanistan
93
Mukhamadiev DM. Aspects of depressive states in repatriated female
refugees. Zhurnal Nevrologii i Psikhiatrii Imeni S.S. Korsakova, 2003,
103:21–23.
Rasekh Z et al. Women’s health and human rights in Afghanistan. JAMA,
1999, 280:249–255.
van de Put W. Addressing mental health in Afghanistan. Lancet, 2002,
360:41–42.
Ventevogel P et al. Mental health care reform in Afghanistan. Journal of
Ayub medical college, 2002, 14:1–3.
Bahrain
Overview
Bahrain consists of 33 islands, of which Bahrain island is the largest
and contains the capital Manama. Over half the population lives in Manama
and in Muharraq, the second island, which is linked, to Manama by a
causeway. The surface area of the country is 718 km2. The total population is
estimated at 0.78 million in 1996 with an average population growth of 2.7%
per year (2003). The urban population constitutes 100% of the total (2004).
The people of Bahrain are largely Arab Muslims. About 66% of the
population is local; the rest are expatriates, mainly from Bangladesh, India,
Islamic Republic of Iran, Oman, Pakistan, Sri Lanka and eastern Asia. The
proportion of the population below 15 and above 65 years of age is 27.6%
and 2.57%, respectively (2002). Of adults (15 years and over), 88% are
literate, and the adult female literacy rate is 83%. The infant mortality rate is
is estimated at 7.3 per 1000 live births, maternal mortality ratio 2.0 per
10 000 live births, crude birth rate 21.3 per 1000 population, total life
expectancy at birth 73.8 years and under-5 mortality rate 9.4 per 1000 live
births (2003). The per capita income is US$ 11 872 (2003) and the budget
allocated to the Ministry of Health represents 4% of the total. The Ministry
of Health spends US$ 232 compared to the US$ 517 national per capita
expenditure on health (2002). The rates for physicians, dentists,
nurses/midwives and hospital beds per 10 000 of the population are 18.5,
2.7, 45.7 and 28.1, respectively (2003). There are 0.3 health centres per
10 000 persons (2003).
Bahrain
95
Development of health systems
The country’s constitution upholds the people’s right to health. Both
the private sector and the community contribute to providing health care
services, but the main burden rests with the government. Sectors that have an
impact on health frequently interact in planning, implementation and
evaluation.
Mechanisms for involving the community in the implementation of
health strategies are not well established, the main hurdle being the lack of
public awareness of health issues and problems. To overcome this,
nongovernmental organizations receive full encouragement and financial
support from the Ministry of Health and the Ministry of Social Affairs in
order to promote health education at all levels. For example, youth clubs,
together with the primary health care centres, conduct health education
campaigns; the Bahrain Family Planning Society is actively engaged in
workshops, seminars and lectures on family planning; and the Bahrain Red
Crescent Society has been providing courses on first aid for several years. In
addition, there are joint committees representing health centres and youth
clubs in each area.
The Salmaniya Medical Centre is the main health centre in Bahrain. It
is allocated a large percentage of the Ministry of Health’s budget and
provides most secondary and tertiary health care. There are 19 other health
centres on Bahrain island as well as five rural maternity hospitals, one
psychiatric hospital and one geriatric hospital for the Bahrain Defence Force,
and three private hospitals. The College of Health Sciences provides training
to students in nursing and allied health sciences.
The entire population is now covered with health care, safe drinkingwater and adequate sanitary facilities. Moreover, maternal and child health
care services cover the targeted population, with immunization coverage
reaching almost 100%. Essential drugs are available in all health centres and
community involvement, as mentioned previously, is becoming stronger.
Mental health
The Ibn Sina Psychiatric Hospital was founded in 1932, and the first
qualified psychiatrist was appointed in 1967. This hospital is the nucleus of
96
Mental health in the Eastern Mediterranean Region: reaching the unreached
mental health services. It has 201 inpatient beds (with a 20-bed alcohol and
drug dependence unit, 25 beds for acute patients, 40 for short-stay patients,
42 for long-stay patients and 20 beds for the mentally retarded). There is a
day hospital with a capacity of 40 patients. There are an average of 1000
admissions per year and about 20 000 attendants every year to the outpatient
department. There are 22 psychiatrists, 3 clinical psychologists, 6 psychiatric
social workers, and 79 psychiatric nurses in the country.
A diploma programme in psychological medicine has been available
since 1991. This is organized in collaboration with the Royal College of
Physicians of Ireland. The psychiatry department is involved in the training
of the family physicians as part of a one-year diploma course offered by the
college of health sciences.
The psychiatric community service was started in 1979 with the aim
of extending psychiatric care to all those who need it in their own
environment. Primary health care is well advanced in Bahrain. There are 19
health centres and each of these is within 5 km of its catchment area.
Essential psychotropic drugs are available at all the health centres, and any
new requirement can be met within 24 hours. A recent development is
budget decentralization so that each health centre will handle it at its own
level.
National programme for development of mental health and
related policies
The policies for therapeutic and essential drugs and for narcotics and
substance abuse were formulated in 1975and 1983, respectively. The
national mental health programme was developed in 1988 with the help of
WHO. Its short-term objectives were:
•
prevention and treatment of mental disorders and their subsequent
disabilities by making mental health care available and accessible to
all the population with special emphasis on the most vulnerable and
underserved
•
enhancement of the use of mental health knowledge in general health
care, social development and improvement of quality of life by the
extension of mental health care to primary health level
Bahrain
•
•
•
•
•
97
public mental health education in order to increase the detection of
illness and encourage community participation in the development of
mental health services
legislative measures for protection of the rights of mentally ill
persons.
The long-term objectives are:
planning and programming for special psychiatric services, e.g.
substance abuse, abnormal mental offenders, mental impairment,
psychogeriatrics and liaison psychiatry
improving information systems and statistical data
research to improve the state of mental health care, identification of
needs, and setting of priorities for future plan of action.
Initiatives
There have been a number of initiatives towards using community
resources for mental health work, notably:
•
mental health training of expatriate child carers about normal
psychological and social development of children during the first five
years of life
•
mental health training on how to cope with the daily routines of
children in a positive way
•
introduction to behavioural problems of children and how to approach
them
•
strengthening of the relationship between mother and child
•
working with the Bahrain Women’s Organization for advocacy,
promotion of positive mental health and prevention of
neuropsychiatric illnesses
•
initiation of school mental health programmes.
Research
Research has been carried out on medical education; use of services;
drug abuse; electroconvulsive therapy; attempted suicide; and child mental
health, and some clinical drug trials have been conducted.
98
Mental health in the Eastern Mediterranean Region: reaching the unreached
Summary update (Mental health atlas, 2005)
Epidemiology
There is substantial epidemiological data on mental illnesses in
Bahrain in internationally accessible literature. No attempt was made to
include this information here.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1993. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1983.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1989.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1975.
Mental health legislation
The latest mental health legislation is Decree 3. The latest legislation
was enacted in 1975.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are tax-based and out-of-pocket
expenditure by the patient or family. The country has disability benefits for
persons with mental disorders.
Bahrain
99
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is available at the primary level.
Primary care is provided only after stabilization of the case. There are 23
primary care centres, each within 5 km of the catchment area, and all have
psychiatric drugs. Any new drugs can be procured within a day.
Regular training of primary care professionals is carried out in the
field of mental health. The psychiatry department is involved in the training
of family physicians. Child care workers have been trained on issues related
to mental health and behavioural disorders.
There are community care facilities for patients with mental disorders.
There are regular home visits through outreach programmes of the hospital.
The psychiatric community care was started in 1979 and forms an important
aspect of mental health delivery system along with primary care. During
community visits, family members are encouraged to participate in the
treatment. Patients are given information on treatment, management and
other educational items related to their illness. A day care centre that can
provide services for 40 clients exists.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
3.3
3.3
0
0
5
0.3
23
1
0.8
1.5
Psychiatric training is undertaken in the country with licensing from
the Arab Board of Psychiatry. Beds have been earmarked for treatment of
drug abusers and management of mentally retarded individuals.
100
Mental health in the Eastern Mediterranean Region: reaching the unreached
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention and
rehabilitation.
Information gathering system
There is mental health reporting system in the country. Data are
available from the Bahrain Health Statistics, 1999. The country has a data
collection system or epidemiological study on mental health. Data collection
is hospital-based.
Programmes for special populations
The country has specific programmes for mental health for elderly and
children.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenytoin sodium, sodium
valproate, amitriptyline, chlorpromazine, diazepam, fluphenazine,
haloperidol, lithium, biperiden. All drugs available at the psychiatric hospital
can be made available to health centres on request and according to needs of
known patients.
Additional sources of information
Al Haddad, Community psychiatry in Bahrain. World health forum. 1989,
10:432.
Okasha A, Seif el Dawla A. Reliability of ICD-10 research criteria: an Arab
perspective. Acta psychiatrica Scandinavica, 1992, 86:484–8.
El Hefny F, Al Haddad MK, Mathur V. Utilisation of psychotropic drugs in
patients of the long stay ward. Pharmacoeconomics. 1992, 1:203–6.
Abdel-Mawgoud M, Al-Haddad MK. Heroin addiction in Bahrain: 15 years
experience. Addiction. 1996, 91:1859–64.
Al Hamadeh RR et al. Overdose among youth in Bahrain: psycho-social
characteristics, contact with helping agencies and problems. Journal of the
Royal Society of Health. 1997, 117:366–71.
Bahrain
101
Al Haddad MK, Baig BZ, Ebrahim RA. Epidemiology of HIV and AIDS in
Bahrain. Journal of communicable diseases. 1997, 29:321–8.
Shooka A, al-Haddad MK, Raees A, OCD in Bahrain: a phenomenological
profile. International journal of social psychiatry, 1998, 44:147–54.
Al-Musawi NM. Psychometric properties of the Beck depression inventoryII with university students in Bahrain. Journal of personal assessment. 2001,
77:568–79.
Derbas AN, al-Haddad MK. Factors associated with immediate relapse
among Bahraini heroin abusers. Eastern Mediterranean health journal,
2001, 7:473–80.
Al-Haddad MK et al. HIV antibodies among intravenous drug users in
Bahrain. Journal of communicable disease. 1994, 26:127–32.
Djibouti
Overview
Djibouti, which lies on the Horn of Africa at the southern entrance to
the Red Sea, has a coastline of 370 km and an area of 23 000 km2. According
to estimates the population was 817 000 in 2004, and the annual population
growth rate is 4.3% (2003); the percentage of the population below 15 years
of age and above 65 years of age is 37.6% and 2.1%, respectively (2002).
The total adult literacy rate and the adult female literacy rate in 2003 were
49% and 38%, respectively. According to the most recent statistics, the infant
mortality rate is 102 per 1000 live births (2002) and the maternal mortality
ratio is 54.6 per 10 000 live births (2002). The crude birth rate in 1996 was
42 per 1000 population. The total life expectancy at birth was 44.1 years in
2000. In 2002, the under-5 mortality rate was estimated at 94.6 per 1000 live
births. The gross national product per capita is US$ 854 (2002). The health
budget of the government constitutes 6.3% of the national budget. The
Ministry of Health expenditure per capita is US$ 28.4 while the national per
capita expenditure on health is US$ 54 (2002). There are 2.2, 1.93, 8.0 and
16.1 physicians, dentists, nurses/midwives and hospital beds per 10 000 of
the population (2004).
Administratively, the country is divided into five districts. Health
activities in the public sector are fragmented and divided among several
ministries, with the Ministry of Public Health and Social Affairs bearing the
major responsibility. The Ministry of Public Health and Social Affairs has
defined its health policy for developing health systems (1995). The general
objectives of this plan are as follows:
Djibouti
•
•
•
•
•
•
103
training of human resources
strengthening preventive programmes
improving hospitals
ensuring the stability of the Djibouti family
developing community involvement
recognizing the importance and promotion of urban health services
and adopting a national drug policy.
At the first level of contact with the health services, the system
comprises small units which provide health care to remote or nomadic
communities. They also offer some maternal and child health care. The
middle tier of the pyramid consists of district hospitals, which provide nonspecialized inpatient or outpatient care and supervise the activities of the
rural health units under their jurisdiction. There is a tuberculosis service
attached to each district health centre. In 1998, there were 24 primary health
care centres all over the country, although the functioning of those located in
northern districts of Tadjourah and Obock was severely impaired during the
civil war of 1991–93. At the apex of the pyramid is the Hôpital Générale
Peltier, the general hospital in Djibouti city, which has 610 beds and which
provides specialized inpatient and outpatient services. There is, in addition, a
small childcare hospital with 25 beds and a maternity hospital with 50 beds.
Besides the public health sector, there are three small private hospitals (or
clinics) with 61 beds. In addition, national and foreign nongovernmental
organizations are involved in the health service delivery programmes. These
include Catholic Relief Services, the Red Sea Mission, Organization of
Volunteers for Progress (AFVP), Médecins Sans Frontières, and at the local
level, the National Union of Djibouti Women.
In 1990, with the collaboration of WHO, a continuing education unit
was set up in the ministry to take charge of training of personnel in the
management of services. This programme aims to:
•
improve the qualifications of health personnel
•
increase the number of students in medicine, dentistry and pharmacy
•
increase the number of trained paramedical workers
•
assume responsibility for progressive replacement of the expatriate
technical staff serving under cooperative agreements
104
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
develop the national centre for the training of health personnel and
organize a national programme for continuing education.
Mental health
Present mental health situation in Djibouti
Mental health problems are on the rise due to rapid and profound
changes of lifestyle in Djibouti. However, there is decreasing tolerance of
patients suffering from neuropsychiatric problems. These facts are
particularly noticeable in urban areas, where patients are increasingly
referred to public health staff who are not trained to deal with them. Thus,
comprehensive mental health services are urgently needed. Although no
study has been done on the role of khat in mental disorders in Djibouti, there
is anecdotal evidence that its use is widespread.
Mental health facilities
Currently, the system of psychiatric assistance is limited to the
department of psychiatry of the Peltier Hospital in Djibouti. The department
has 50 beds, and its dilapidated condition does not make it an ideal place to
treat patients with dignity.
More than 2000 people seek consultations at the department of
psychiatry at the Peltier Hospital every year. These consultations relate to
acute and chronic diseases. Annual admission is 500 patients. The period of
hospitalization is one month on average. Ambulatory treatments follow
hospitalization. This solution, which yields good results, involves great
difficulties for the patients who live far from Djibouti city. The hospitalized
patients thus represent only a segment of the people who could benefit from
psychiatric care.
Mental health human resources
There are at present in Djibouti one psychiatrist, one chief nurse and
six nurses or assistant nurses. All psychiatric assistance and care given is
centralized in Djibouti city. There is no community-based psychiatric care.
Djibouti
105
Future plans
In order to cover the whole country effectively, a national mental
health programme will have to use both the existing health infrastructure and
the medical and paramedical personnel available. The problem that should
be solved urgently is that of personnel training. This may be done efficiently,
with limited means, by short-term courses at the department of psychiatry,
Peltier Hospital. In addition to the training of psychiatrists, it is necessary to
provide general practitioners with sufficient information on some aspects of
psychiatry. This type of training may be conducted in short-term courses at
the department of psychiatry.
Summary update (Mental health atlas, 2005)
Epidemiology
There is a paucity of epidemiological data on mental illnesses in
Djibouti in internationally accessible literature. Mion and Oberti (1998)
found that the prevalence of khat use among 100 army recruits was 84%
with a mean consumption of 400 grams per chew. Khat abuse is believed to
be common and associated also with other mental disorders (Mohamed,
2004).
Mental health resources
Mental health policy
A mental health policy is absent.
Substance abuse policy
A substance abuse policy is absent.
National mental health programme
A national mental health programme is absent. A national mental
health programme is being formulated. This is expected to lead to the
development of primary mental health care services, treatment facilities and
human resources.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1997.
106
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health legislation
An old French legislation forms the basis of legal action. New
legislation needs to be formulated. Details about the year of enactment of the
mental health legislation are not available.
Mental health financing
There are no budget allocations for mental health. Details about
expenditure on mental health are not available. The primary source of mental
health financing is grants. The country does not have disability benefits for
persons with mental disorders.
Mental health facilities
Mental health is not part of the primary health care system. Actual
treatment of severe mental disorders is not available at the primary level.
Mental health will be included with primary care in the new national mental
health programme. Regular training of primary care professionals is not
carried out in the field of mental health. There are no community care
facilities for patients with mental disorders. Ambulatory care is available
following hospitalization and for those for whom hospitalization is not
deemed necessary.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
0.7
0
0.7
0
0
0
0.16
0
0
0
There are 4 nursing attendants. A Chinese psychiatrist is providing
services temporarily. Psychiatric assistance is concentrated at the psychiatry
department of Peltier Hospital. Besides that, psychiatric services are nonexistent.
Djibouti
107
Nongovernmental organizations
Nongovernmental organizations are not involved with mental health in
the country.
Information gathering system
There is a mental health reporting system in the country. Data up to
1999 are available. The country has no data collection system or
epidemiological study on mental health.
Programmes for special populations
No specialized services exist. International organizations like the
UNHCR provide help for refugees.
Therapeutic Drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam,
haloperidol. These drugs are available only at the general hospital and not at
primary care level. None of the anti-Parkinsonian drugs are available.
Other information
Magico-religious treatment is present to a great extent. General
knowledge about mental disorders is very limited.
Additional sources of information
Mion G, Oberti M. Epidemiologic study of khat use in the National Army of
Djibouti. Médecine tropicale, 1998, 58:161–164.
Mohamed AK. (Focal point for mental health, Djibouti, Personal
communication), 2004.
Egypt
Overview
The total area of Egypt is about 1 001 450 km2, and the total
population is 69.323 million (2004). In 2004, 42% of the population lived in
urban areas. The population below 15 years of age and above 65 years of age
is estimated at 37.8% and 3.4%, respectively (2003). The total adult literacy
rate and the adult female literacy rate, is estimated at 61% and 50%,
respectively (2003). The crude birth rate and the crude death rate are
estimated at 25.8 and 6.4 per 1000 population, respectively (2004). Infant
mortality is estimated at 23.2 per 1000 live births and under-5 mortality rate
29.6% per 1000 live births (2003). Total life expectancy is estimated at 70.6
years (2004). The maternal mortality ratio is 6.8 per 10 000 live births
(2003). The per capita income is US$ 1193 (2003) and the budgetary
allocation for health represents 4.9% of the total and the per capita
expenditure on health by Ministry of Health and Population is US$ 21.5 as
compared to the national per capita expenditure of US$ 59 (2003). The rates
per 10 000 population for physicians, dentists, nurses/midwives and hospital
beds are 22.2, 3, 26.5 and 21.7, respectively (2003).
The health system is based on primary health care, which is provided
through various health establishments such as maternal and child health
centres, school health units and health offices, as well as rural and urban
health centres. The Ministry of Health and Population has also tried to
strengthen primary health care through establishing various training centres
for primary health care health teams. Attention has been focused on
renovating and developing health centres and re-equipping them with new
Egypt
109
facilities. A new policy also dictates that all schools with 1000 pupils or
more shall be provided with school health clinics; 80 of these clinics have
already been established and 50 more are in the process of being set up.
Health planning in Egypt takes place through the planning department
in the Ministry of Health and Population, in conjunction with the various
technical units in the Ministry. Similar planning units also exist in the
provincial health directorates. Local communities are involved through
people’s local councils at rural, urban and governorate levels. Since health
plan drafts are initially prepared locally, the communities are involved in
planning and finalizing these initial plans. They are also involved in the
delivery and monitoring of services. The community also contributes to the
financing of certain local health projects, as in the provision of land space
for construction of health centres, or by paying minimal fees for services
provided. Three bodies are responsible for coordinating and encouraging
research: these are the health councils, and the Information Centre and the
central department of research and development in the Ministry of Health
and Population.
Mental health
Historical aspects
Egypt was one of the centres for the WHO project “Strategies for
extending mental health care” (1975–81), which developed the initial
programme to integrate mental health into primary health care. The national
mental health programme of Egypt was developed in October 1986. A
revised national mental health programme was prepared, following a review
workshop in 1991.
Mental health facilities
Total facilities in the 27 governorates are as follows:
110
Mental health in the Eastern Mediterranean Region: reaching the unreached
Facility
Total capacity
(beds)
Abbassiya/Cairo
3000
Helwan
400
Heliopolis
120
Khanka
3000
Banha
225
Tanta
120
Shobra Kass
15
Azazi
160
Harbit
40
Maamoura
800
El Tel El Kebir
40
Assiut
50
Aswan
36
High Dam
160
Bani Soueif
100
Total
8266
•
•
Working
capacity
2300
400
120
2000
225
120
15
160
--800
40
--36
106
90
6412
Number of
patients
1992
225
80
980
150
120
12
140
--740
20
--6
86
86
4571
There are psychiatric departments and outpatient clinics in the general
hospitals in 19 governorates with a total of 621 beds.
The psychiatric departments and outpatient clinics in the nine
university teaching hospitals have a bed capacity of 10–30 beds each:
Cairo University
30
Ayn Shams University 20
Al Azhar University
20
Alexandria University 30
Tanta University
10
Mansoura University
30
Assiut University
10
Zagazig University
20
Banha University
10
Total
190
•
Psychiatric departments and clinics for schools and university students
are available in four centres in Cairo and one each in Alexandria,
Qaliubiya, Tanta, Giza and Assiut. In governorates where no similar
Egypt
•
•
•
111
facilities are available, two days are allotted to students in the
psychiatric clinics.
Special schools for education and rehabilitation of mentally retarded
children (belonging to the Ministry of Social Welfare) are available in
the following cities:
–
Cairo: four for boys and one for girls
–
Alexandria: one for boys
–
Tanta: one for boys
–
Minya: one for boys.
There are seven private psychiatric hospitals in Cairo with a total
capacity of about 760 beds.
The number of psychiatrists in Egypt is about 600 and most of them
are in Cairo, Alexandria or other big cities. There are 1355 psychiatric
nurses, 241 clinical psychologists and 61 psychiatric social workers.
National mental health programme, legislation and related
policies
Of the health budget, 9% is allocated to mental health activities. The
national policy on substance abuse was formulated in 1986 as was the
mental health programme. The mental health act dates back to the 1940s
while the essential drugs list was updated in 1994.
The objectives of the national mental health programme are to make
essential mental health care available and accessible for all in Egypt with
special emphasis on the most vulnerable and inappropriately served
populations; to enhance the use of mental health knowledge and skills to
improve general health care; to enhance the use of mental health principles
to promote social health and related functions including socioeconomic
development and productivity as well as general quality of life; and to
emphasize community participation as a goal as well as a means for
achieving these objectives.
The strategies and approaches identified for the programme were
establishment of a national coordination group for mental health; integration
of essential mental health care into community health services starting with
primary health care; extension of mental health care services involving
active participation of all health personnel at all levels from specialists to
primary health teams; strengthening of adequate referral services and
112
Mental health in the Eastern Mediterranean Region: reaching the unreached
provision of relevant modalities of treatment, as seems appropriate;
promotion of appropriate use of established health record (health card) and
information system; provision of essential drugs for neuropsychiatric
disorders; training in mental health for health personnel at different levels for
better management of mental health problems; and integration of mental
health care with social services and collaboration with other related sectors
in the ministries of education, social welfare, religious affairs, justice and
interior, as well as with private services and nongovernmental organizations.
Progress of national mental health programme
The mental health programme was revised in 1991 by a national
committee. In more recent years, five hospitals were established with a total
capacity of 651 beds were:
•
Banha Mental Hospital, Qaliubiya governorate (225 beds)
•
Azazi Mental Hospital, Sharqiya governorate (140 beds)
•
High Dam Mental Hospital, Aswan governorate (106 beds)
•
El Tel El Kebir Mental Hospital, Ismailiya governorate (40 beds)
(since closed)
•
Heliopolis Mental Hospital, Cairo governorate (120 beds).
Abassiya, Helwan and Khanka mental hospitals have recently been
renovated. There has been an increase and expansion in mental health
departments in the faculties of medicine.
Training courses have been organized on mental health for general
practitioners and nursing staff working at basic health care units. In 1986–
87, training was provided for 250 physicians and 250 nurses in the
governorates of Assiut, Minya, Gharbiya and Suez.
In 1989, training was provided for 20 trainers in Ismailiya, so that they
could later train general practitioners and basic health care unit staff in their
governorates In 1987, a mental health care manual for primary health care
physicians was published, and in 1991, an integrated manual for basic health
care units, which included a section on mental health, was published. During
1997, as part of the Nations for Mental Health programme, the Alexandria
project was initiated, covering a population of about half a million.
Two districts in the governorate of Alexandria were chosen as test and
control areas. In the test area, all general practitioners and nurses in primary
Egypt
113
health care centres were trained, and selected responsibilities in mental
health assigned to them. A referral and back-referral system was also
established between these trained personnel and Ma’amoura psychiatric
hospital. Pre-training knowledge and attitude tests were given. The aim was
to integrate mental health with the activities of primary health care centres in
the test area. Five courses of training covering 170 general practitioners have
been given and the project is continuing. Over 300 personnel have been
trained.
An integrated plan is being developed by the Ministry of Health and
Population in order to reduce demand for drugs through intensive
sensitization, treatment, follow-up and rehabilitation activities. Eighteen new
laboratories for detection of addictive substances in biological secretions
have been established, covering most governorates, and training was
provided for the staff of these laboratories. The therapeutic services offered
to addicts were expanded, and special departments were established for them
within psychiatric hospitals. Legislation for drug control has been
promulgated, such as the law on drugs passed by the People’s Assembly
(1989), the President’s Decree establishing the National Fund for the Control
of Drug Addiction and Abuse, and the joint decisions of the ministers of
justice, social affairs and health establishing sanitaria and departments for
the treatment of drug abuse and addiction. Along with these activities,
information campaigns have been intensified in the media to upgrade
awareness regarding drug hazards.
In 1989, mental health activities in schools were initiated in
Alexandria. Manuals, teaching aids and health education materials have been
developed to support the programme. Systematic research has focused on the
impact of the training programmes in a pre- and post-training format, study
of long-term sustenance of attitudes and skills and the impact of training on
attendance in school health clinics. All these studies have shown the
programme’s usefulness.
Between 1989 and 1997, the following training programmes were
organized:
•
31 one-week training courses for 1451 school health physicians
•
24 one-week training programmes for 800 maternal child health
physicians
114
Mental health in the Eastern Mediterranean Region: reaching the unreached
•
7 training programmes for 160 social workers at maternal and child
health centres
•
60 training programmes for 3055 school social workers and teachers
•
2 training programmes for 160 school psychologists
•
4 advanced seven-week training programmes for physicians.
Currently, in Alexandria governorate, there are 23 guidance and
counselling centres, 11 centres at maternal and child health facilities and two
in paediatric hospitals.
In addition, there are two centres in Kafr El Dawar, one centre in
Damanhour and one centre in Marsa Matrouh governorate. The High
Institute of Public Health, University of Alexandria, has initiated mental
health studies leading to a diploma, and masters and doctoral degrees.
Recent developments
A recent development in the mental health programme in Egypt is the
long-term bilateral development programme between the Government of
Egypt and the Government of Finland, which addresses the key problems of
mental health care/mental welfare in Egypt. This programme includes
curative aspects and prevention of mental diseases, as well as promotion of
mental health. Based on the identified causes of problems, five components
of interventions were outlined including: human resources development,
functional development, structural development, community development,
mental health promotion and prevention. The Government sees the mental
health programme as an individual project but as part of the overall health
sector reform. The overall objective of the programme is to improve mental
welfare in Egypt.
The achievements of the programme so far are as follows.
•
A human resource strategy for mental health was developed, training
needs assessed and a resource base established.
•
An activity to integrate mental health activities within the family
health system was started by integrating mental health activities as
part of the basic benefits package (BBP) in health reform and also
integrating psychotropic drugs in the essential drugs list for primary
health care. Guidelines and training curricula on mental health in
primary health care were developed for physicians, nurses and social
Egypt
115
workers/health educators. Training was conducted in five governorates
with continuous follow-up and support. For the sustainability of the
activities, a training-of-trainers programme was established.
•
Activities for improving training in mental health in the undergraduate
physician and nurse education curricula are in process.
•
A continuing medical education programme was developed to cover
mental health professionals. A capacity-building programme in mental
health for nurses and for psychologists was developed, along with
training of trainers in different mental health aspects for sustainability.
•
Case management protocols and treatment guidelines were developed
for schizophrenic and depressive patients.
•
Improved management systems and practices in mental health care/
services, e.g. medical record, nursing management and quality
management systems, were instituted.
•
A master plan for the provision of mental health services was
developed, which is considered as a strategy for mental health in
Egypt. The master plan includes levels of care, scope of services for
each level of care, referral system, human resource requirements and
physical infrastructure requirements.
•
Development of intermediate services/facilities and other alternative
approaches for psychiatric care, based on cost-benefit analysis, was
planned.
•
A programme to support the development/improvement of child
psychiatric services in Abbassiya, Khanka and Maamoura hospitals,
along with the establishment of the first day care centre for child
psychiatry in Abbassiya hospital, was initiated.
•
Two community-based mental health pilot programmes were started
based on social marketing strategy and KAP study.
Implementation of the programme is based on the strategic principles
of participatory approach, ownership, sustainable development, horizontal
partnership, reflectivity, networking, collaboration with other programmes
overlapping the mental health programme and continuous quality
improvement.
116
Mental health in the Eastern Mediterranean Region: reaching the unreached
Summary update (Mental health atlas, 2005)
Epidemiology
Ghanem et al (2004) conducted a national household survey of
prevalence of mental disorders in 5 governorates, using the Mini
International Neuropsychiatric Interview-Plus (MINI-Plus). Almost 17%
(11% to 25.4% in different governorates) of adults had mental disorders,
with the common ones being mood disorders (6.4%), anxiety disorders
(4.9%) and somatoform disorders (0.6%). Psychoses were seen in 0.3% of
the population. Mental disorders were associated with gender (female),
marital status (widow, divorced), occupation (housewife, unemployed),
education (illiteracy), housing (overcrowding) and physical illnesses. Okasha
et al (2001) assessed a sample of students, selected through multistage
stratified random sampling with the General Health Questionnaire, the
Arabic Obsessive Scale for obsessive traits and the Yale Brown Obsessive
Compulsive Scale. They found that psychiatric morbidity was present in
51.7% and obsessive compulsive disorder (ICD 10) in 19.6%. Girls, younger
adolescents and first-borns were likely to be affected to a greater extent. In a
study of university students, Okasha et al (1985) found that almost 14% of
students faced academic difficulties. Psychiatric disorders were diagnosed in
42% of male students with academic problems, compared to 9% of students
with no such problems, with neuroses accounting for nearly half of the cases
and schizophrenia for a quarter. Farrag et al (1998) examined 2000 elderly
(above 60 years) subjects from a region in a 3-phase population-based study
using a modified version of the MMSE and a standardized protocol for those
who screened positive (MMSE score of 21 or below). The prevalence of
dementia was 4.5% with Alzheimer in 2.2%, multi-infarct dementia in 0.9%,
dementia of mixed type in 0.55% and secondary dementia in 0.45%. Agespecific prevalence tended to double every 5 years. Soueif et al (1982, 1990)
reported on psychoactive drug use in a nationally representative sample
(n = 14 656) of male secondary school students, using standardized
questionnaires. They found that between 8% (for alcohol) and 21.4% (for
synthetic drugs) of experimenters continued their drug use and that the age
of onset was 12–16 years. A greater proportion of urban students used
tobacco, alcohol and cannabis, and delinquency was associated with drug
use. In another sample (n = 5530), they noted that consistently more arts
Egypt
117
stream students in comparison to science stream students were immersed in
the drug culture. In similar studies, Soueif et al (1986, 1987) examined the
non-medical use of drugs among university students (n = 2711), using
standardized tools. They found that university students were more likely to
use stimulants and continue with drug use (10%–31% for different drugs)
compared to male secondary school students, but the age of starting drug use
was later in this sample. In comparison to male university students using
drugs, female university student (n = 2366) who used drugs came from a
higher socioeconomic background. They were less likely to use stimulants
and narcotics or to smoke, and they started drug use later (usually after 16
years). Their preferred drugs were hypnotics, tranquilizers and alcohol.
Nasser (1986, 1994) found lower rates of abnormal eating attitudes in
college students in Cairo (12%) in comparison to those in London (22%). In
the earlier study, no Arab student fulfilled criteria for an eating disorder, but
in the later studies he found a prevalence rate of 1.2% for bulimia and 3.4%
for partial syndrome of bulimia (Russel's criteria). Okasha and Lotaif (1979)
estimated the rate of suicide attempts in Cairo to be 38.5/100 000 population
based on their assessment of admissions for attempted suicide in one
hospital. Among suicide attempters, those in the age group of 15-44 years
and students were overrepresented. Depression, hysterical reactions and
situational reactions were common psychiatric conditions associated with
suicide. Overdosing was the commonest method (80%) used. Temtamy et al
(1994) administered the Stanford-Binet test to 3000 randomly selected
community subjects. The prevalence of mental retardation was 3.9% (higher
rates were reported in rural areas). Parental consanguinity was established in
65%. Farrag et al (1988) assessed 2878 children from the 2nd and 3rd grades
in elementary schools for their reading ability by means of standardized tests
for linguistic ability and rate of letter identification. The 84 children (3%)
with IQ 90 or more and no evidence of sensory or motor impairment
identified as backward in their reading ability at this stage were reassessed
after 3 years. Thirty-seven (1%) children, who did not attain satisfactory
reading skills even at this stage, were diagnosed to have specific reading
disability. The male to female ratio was 2.7 to 1. Abou et al (1991)
administered the Arabic version of the Children’s Depression Inventory to
1561 preparatory school children selected through stratified random
118
Mental health in the Eastern Mediterranean Region: reaching the unreached
sampling and found the rate of depression to be 10.3%. Further testing in
sub-samples revealed that depression scores were predicted by neuroticism,
introversion, relationship with fathers, sibs and peers, scholastic performance
and mothers’ depression scores.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1978. The components of the policy are promotion, prevention and
treatment. The objectives of the policy are to provide a basis for improving
mental health and well-being of the population through provision of services
to the population at risk, community care and family support.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1986. A President's Decree has established a National Fund for
the Control of Drug Addiction and Abuse. The Supreme Council for the
Control of Drug Addiction and Abuse is chaired by the Prime Minister.
Laboratories for detection of addictive substances in biological secretions
have been established in most regions. The policy direction is towards harm
reduction.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1986. A new mental health programme was adopted in 2002.
The programme aims to integrate mental health into community care,
develop health recording and information gathering system, provide essential
drugs and develop human resources. The other areas earmarked for
development are quality assurance, development of intermediate and
alternative systems of proving mental health care, developing child and
adolescent psychiatry services, analysing the role of nongovernmental
organizations, increasing awareness about mental health problems among the
population and promoting mental health and preventing mental disorders.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present.
Details about the year of formulation are not available.
Egypt
119
Mental health legislation
There is a Mental Health Act from the 1940s that is being revised.
There is also a more recent law on narcotics which was formulated in 1989.
Currently, efforts are being made to upgrade the law. The latest legislation
was enacted in 1944. A code of practice was established in 2005.
Mental health financing
There are budget allocations for mental health. The country spends
9% of the total health budget on mental health. The primary sources of
mental health financing in descending order are tax-based, out-of-pocket
expenditure by the patient or family, social insurance and private insurances.
The country has disability benefits for persons with mental disorders.
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is not available at the primary level.
Psychiatry has been integrated in the primary health care services in line
with the Health Reform adopted by the Ministry of Health. A system for
referral between the different levels of care has been established.
Regular training of primary care professionals is carried out in the
field of mental health. In the past two years, about 639 personnel were
trained. Manuals for mental health care for primary care physicians and
basic health care units are available. Training facilities are present. Training
courses have been organized for general practitioners, maternal child health
physicians, social workers and nursing staff working at basic health units.
Training courses have also been held for trainers. Evaluation of training
programmes for general practitioners showed significant improvement in
attitudes, knowledge and skills regarding mental disorders and drug misuse
and their management.
There are community care facilities for patients with mental disorders.
Intermediate services were started for both patients with chronic mental
disorders and drug use disorders. Large mental hospitals are trying to place
long-stay patients in and follow them up in the community.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
1.3
1.1
120
Mental health in the Eastern Mediterranean Region: reaching the unreached
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
0.1
0.1
0.9
0.2
2
0.5
0.4
0.1
There are few occupational therapists. Almost four-fifths of
psychiatric beds are in Cairo. Beds for treatment of drug abusers and
forensic patients are available. Specific allocations of beds have not been
made for child and adolescent mental health. In an effort to provide quality
assurance in big mental hospitals, standards have been developed and quality
assurance teams have been deployed. Most psychiatrists have their own
private clinics. There is a permanent training centre for continuous inservice training of mental health professionals, particularly nurses,
psychologist and social workers employed in mental health facilities.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention and
rehabilitation. The Child Mental Health Prevention Association, a
nongovernmental organization, was established in 1995, to spread the
concept of mental health among families. There are also guidance and
counselling centres at different governorates.
Information gathering system
There is a mental health reporting system in the country. The country
has no data collection system or epidemiological study on mental health. A
new National Health Information System for Mental Health was developed
by the Ministry of Health and Population. The General Secretariat of Mental
Health is piloting a data collection system.
Programmes for special populations
The country has specific programmes for mental health for disaster
affected populations, elderly and children. Outpatient clinics and day care
centres for children and adolescents are present in some mental hospitals.
Egypt
121
Clinics for school and university students are available in four centres. Eight
special schools for education and rehabilitation of mentally retarded children
are available. Of these, one caters to girls. Under the aegis of the school
mental health programme, training programmes for school teachers, school
physicians and school supervisors are undertaken, orientation courses for
adolescents are held and special clinics at district levels are conducted in the
area of mental health and drug misuse.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: phenobarbital, amitriptyline, diazepam.
Imipramine is available in primary health care centres (commonest strength:
25 mg, approximate cost for 100 tablets: US$ 9.45).
Other information
Finland has provided support to the mental health programme in
Egypt since 2002. The programme addresses five main components: human
resource development, functional development, structural development,
community development and mental health prevention and promotion.
UNODC supports some activities for improving treatment services and
rehabilitation of drug abusers.
Additional sources of information
Abou Nazel MW et al. A study of depression among Alexandria preparatory
school adolescents. Journal of the Egyptian Public Health Association, 1991,
66:649–674.
Daoud R, Atallah S, Loza N. Psychiatric services in Egypt - an update.
International psychiatry, 2002, 2:12–14.
Farrag AF, el Behary AA, Kandil MR. Prevalence of specific reading
disability in Egypt. Lancet, 1988, 2:837–839.
Farrag A et al. Prevalence of Alzheimer’s disease and other dementing
disorders: Assiut-Upper Egypt study. Dementia and geriatric cognitive
disorders, 1998, 9:323–328.
Ghanem M, Gadallah M, Mourad S et al. National survey of prevalence of
mental disorders in Egypt, 2004, WHO sponsored study (under publication).
122
Mental health in the Eastern Mediterranean Region: reaching the unreached
Country profile for mental health services. Cairo, Mental Health Programme
in Egypt, 2003. ([email protected])
Master plan for provision of mental health services in Egypt. Mental Health
Programme in Egypt, 2003. ([email protected])
Nasser M. Comparative study of the prevalence of abnormal eating attitudes
among Arab female students of both London and Cairo universities.
Psychological medicine, 1986, 16:621–625.
Nasser M. Screening for abnormal eating attitudes in a population of
Egyptian secondary school girls. Social psychiatry and psychiatric
epidemiology, 1994, 29:25–30.
Okasha A. Mental health in the Middle East: an Egyptian perspective.
Clinical psychology review, 1999, 19:917–33.
Okasha A et al. A psychiatric training programme for general practitioners in
primary health care in Egypt. Primary care psychiatry, 2002, 8: 9–16.
Okasha A et al. Academic difficulty among male Egyptian university
students. I. Association with psychiatric morbidity. British journal of
psychiatry, 1985, 146: 140–144.
Okasha A, Lotaif F. Attempted suicide. An Egyptian investigation. Acta
psychiatrica Scandinavica, 1979, 60: 69–75.
Okasha A et al. Prevalence of obsessive compulsive symptoms (OCS) in a
sample of Egyptian adolescents. Encephale, 2001, 27: 8–14.
Soueif MI et al. The extent of drug use among Egyptian male university
students. Drug and alcohol dependence, 1986, 18: 389–403.
Soueif MI et al. The extent of nonmedical use of psychoactive substances
among secondary school students in Greater Cairo. Drug and alcohol
dependence, 1982, 9: 15–41.
Soueif MI et al. The use of psychoactive substances by female Egyptian
university students, compared with their male colleagues on selected items.
Drug and alcohol dependence, 1987, 19: 233–247.
Soueif MI et al. Use of psychoactive substances among male secondary
school pupils in Egypt: a study on a nationwide representative sample. Drug
and alcohol dependence, 1990, 26: 63–79.
Egypt
123
Temtamy SA et al. An epidemiological/genetic study of mental subnormality
in Assiut Governorate, Egypt. Clinical genetics, 1994, 46: 347–351.
Report on the intercountry meeting on the evaluation of the progress of
national mental health programmes in the Eastern Mediterranean Region,
Casablanca, Morocco, 22–26 May 1995. Alexandria, World Health
Organization, Regional Office for the Eastern Mediterranean, 1996.
Report on the intercountry consultation on mental health legislation in
different law traditions, Kuwait, 29 September–2 October 1997. Alexandria,
World Health Organization, Regional Office for the Eastern Mediterranean,
1999.
Report on the intercountry meeting on the mental health needs assessment at
the community, health services and policy levels, Teheran, Islamic Republic
of Iran, 7–10 September 1997. Alexandria, World Health Organization,
Regional Office for the Eastern Mediterranean, 1998.
Islamic Republic of Iran
Overview
The Islamic Republic of Iran, with a surface area of 1 648 000 km2,
has a population of 66.775 million (2004). Of this, 28.4% is below the age of
15 years and 5% above 65 years (2003). About 61% of the population reside
in urban areas (2004). Life expectancy at birth is 69 years (2000). The
literacy rate for the adult population is 79% and the female literacy rate is
73% (2002). The crude birth rate is estimated at 18.1 per 1000 population,
crude death rate 4.4 per 1000 population, infant mortality rate 36 per 1000
live births (2002), and under-5 mortality rate 36 per 1000 live births (2000).
Life expectancy at birth is 69 years and maternal mortality is estimated at 3.7
per 10 000 live births. The per capita income in 2002 was US$ 1745. The
budget of the Ministry of Health and Medical Education is 8% of the
national budget and 6% of gross national product. The Ministry of Health
and Medical Education’s per capita expenditure is US$ 104, compared to the
US$ 171.4 spent per capita on health. In 2001, there were 11.1 physicians,
2.1 dentists, 16.1 nursing/midwifery personnel and 16.3 hospital beds per
10 000 population. Available health facilities by January 1999 comprised
14 936 health houses, 2332 rural health centres, 2007 urban health centres,
271 district health centres and 422 health posts, which are the equivalent of
health houses in urban areas.
Development of health system
Since 1979 the country’s health policy has been based on primary
health care, with particular emphasis on expansion of health networks and
Islamic Republic of Iran
125
programmes in rural areas and with priority allotted to preventive rather than
curative services.
More attention has been given to reduction of population growth by
use of family planning; control of diarrhoeal, respiratory and iodine
deficiency diseases; integration of mental health, tuberculosis, leprosy,
diabetes and malaria programmes into the primary health care system;
community-oriented medical education; increase of immunization coverage;
reduction of maternal and infant mortality; increase of community
participation; increase of basic environmental sanitation and adequate safe
water in rural communities; and expansion of health networks, including the
construction of district hospitals where needed. There is also a policy of
vaccination of women, which requires that all women of childbearing age,
not only pregnant women, be immunized against tetanus.
In both towns and villages, the first point of contact between the
public and the health system is the health centre. However, in the villages,
the health centre performs its functions with the help of a large number of
health houses, which effectively become the first point of contact. The
responsibility of the rural health centre is to supervise, support and accept
referrals from the health houses.
District hospitals in towns offer services to referred cases from rural as
well as urban health centres. District hospitals are responsible for
specialized, inpatient and outpatient curative services. The activities of the
district health centres, as well as those of the district hospitals, are
coordinated by the manager of the health network who administers the
district health activities. Although, formally, this referral follow-up chain
exists, it is somewhat weak, especially between the second and specialist
level.
National health policies are decided at meetings of the Council of the
Undersecretary of the Ministry of Health and Medical Education, headed by
the Minister of Health and Medical Education. In each district, there is a
district planning council, to which each sector submits its planning needs in
priority order. The plans approved by this council are referred for formal
consideration to the provincial council, which, with due consideration of
provincial priorities, coordinates the plans and ultimately sends them to the
planning councils at the national level. In each province of the country, there
126
Mental health in the Eastern Mediterranean Region: reaching the unreached
is at least one university of medical sciences and health services. The
chancellor of this university is in charge of all health affairs in the province,
executing his or her duties through deputies for health, treatment, and so on.
He or she also works with the deans of different health-related schools.
The health network has been decentralized to district level so that
implementation of programmes is independent of central administrative and
financial control. The communities are actively involved in the planning and
implementation of health services, mainly through the health councils in
rural areas. Public health and primary health care now account for 13% of
the medical curriculum.
Mental health
The history of development of mental health services in the country
can be divided into four periods.
The period of asylum care, covering most of the early decades of this
century. Asylums of different sizes existed in Teheran, Hamadan, Shiraz and
Isfahan. The condition of these facilities were very poor, and most of them
were either part of or extensions of areas where beggars congregated for
alms. Teheran’s municipality opened the first government-supported asylum
in the 1930s.
The second phase involved the introduction of psychiatry as a part of
medical education and the formation of new university hospitals. This period
started in the late 1940s. Residency training in psychiatry started during the
early 1960s in Teheran University’s Roozbeh Hospital. It was than followed
by similar programmes in Shiraz, Isfahan, Tabriz and Mashhad universities.
Community mental health programmes started in the 1970s. The
Society for the Rehabilitation of the Disabled headed by a senior deputy of
the Ministry of Health and Welfare was established and planning for
community mental health started. This organization introduced the concept
of comprehensive mental health care. It initiated the building of new
hospitals and centres in the provinces, started a wide range of
epidemiological research, and established specialized level training
programmes for psychiatry and psychiatric nursing. After 1979, training and
research programmes of this society were integrated to form the Teheran
Psychiatric Institute.
Islamic Republic of Iran
127
The period of integration of mental health services into the primary
health care system started in the mid 1980s. The first pilot projects were
started in 1987 in Shahr-e-Kord and Shahreza followed by integration
throughout the country. This programme was evaluated by an independent
expert group from WHO in 1995.
Mental health facilities
•
Number of psychiatric beds:
–
public (Ministry of Health and Medical Education and
universities of medical sciences): 6575
–
public sector psychiatric wards in general hospitals: 796
–
private: 310
–
welfare: 2000
–
other (military, etc.): 571
–
total: 9456.
•
Number of psychiatric hospitals: 23
•
Number of private psychiatric clinics: 485
•
Number of private clinical psychology offices: 255.
Mental health human resources
•
Number of psychiatrists: 800
•
Number of registered psychiatry residents (under training) every year:
55–63
•
Number of PhD clinical psychologists: 60
•
Number of MSc clinical psychologists: 400
•
Number of BSc psychologists in health services: 600
•
Number of MSc psychiatric nurses: 35
•
Number of psychiatric social workers: 175
Mental health training
There are 39 medical schools in the country, most of which are
affiliated with regional universities and function directly under the Ministry
of Health and Medical Education. There are also a number of medical
schools that are affiliated with the Islamic Azad University, which is a
tuition-dependent, semigovernmental higher education system with schools
128
Mental health in the Eastern Mediterranean Region: reaching the unreached
throughout the country. Only one or two schools belong to other sectors,
such as the military. All these medical schools have undergraduate training in
behavioural sciences and psychiatry. Ten medical schools, all belonging to
the government sector, offer psychiatry residency programmes for 55–65
candidates a year. The certification process is done through Iranian Board of
Medical Specialities, which is a national body functioning under the
supervision of the deputy minister of health and medical education for
educational affairs. The examiners come from all the universities that have
psychiatric training. Only the ones who are certified by the board can
become faculty members of medical schools. In 1997, board certification in
child psychiatry with a two-year training period after basic certification was
started.
One centre in the country offers postgraduate psychiatric nursing
training towards an MSc degree. Three centres offer the same degree in
clinical psychology. There are 6–10 psychiatric nursing graduates a year.
There are about 25 clinical psychology graduates a year, and almost all of
them continue to work in mental-health-related areas.
National programme of mental health, legislation and related
policies
Of the health budget, 3% is used for mental health activities. The
national programme of mental health was formulated in October 1986 by a
multidisciplinary team of professionals and was consequently adopted by the
Ministry of Health and Medical Education. The implementation of this
programme started in 1987. The narcotics and substance abuse policy was
formulated in 1987, while the therapeutic and essential drugs policy was
formulated in 1988.
The objectives of the mental health programme are:
•
to make essential mental health care available and accessible to all in
the Islamic Republic of Iran in the near future, with special emphasis
on the most vulnerable, unserved and underserved rural population as
well as the unprivileged, inappropriately served population in
deprived urban areas and in remote parts of the country
Islamic Republic of Iran
•
129
to develop mental health care models in keeping with the culture and
social structure of Iranian society and to encourage community
participation in the development of mental health care services
•
to enhance mental health knowledge and skills in general health care
and to encourage the wider application of mental health principles to
promote social health, socioeconomic development as well as
improving the quality of life
•
to develop suitable programmes for the mental health care of those
affected by war (such as immigrants, homeless, disabled, bereaved,
mentally ill) as well as to have a long-term plan for post-war mental
health problems.
The strategies identified include service strategies, training strategies,
administrative strategies and promotion of mental health and war-related
services. The national mental health programme document also identifies
clear objectives for implementation. The period 1987–97 can be divided into
two periods namely, the period of pilot programmes (1987–90) and the
period of expansion (1990 to date).
The first pilot programmes were implemented in 1987 in Shahr-eKord district in Chahar Mahal-e-Bakhtiari province and Shahreza district in
Isfahan province in the central part of the country. Later on, a third pilot
programme started in Hashtgerd, Teheran province. These pilot projects
provided both the experience as well as the practical details of integration of
mental health into primary health care. Following the pilot projects, a
number of developments occurred in the country that led to the expansion of
the programme rapidly in the rural areas. These were:
•
creation of a mental health unit within the Ministry of Health and
Medical Education
•
formation of a national mental health advisory group
•
involvement of the medical universities in the national mental health
programme
•
declaration of mental health as the ninth component of primary health
care
•
preparation of a manual for behvarz (rural health worker), a manual
for doctors and an information system, and training for all health
personnel
130
Mental health in the Eastern Mediterranean Region: reaching the unreached
•
•
celebration of a mental health week every year in October
review of workshops on the national programme (1991) and research
methodology (1993)
•
international independent evaluation (1995)
•
seminars and conferences
•
public mental health education through the mass media and other
sectors
•
establishment of general hospital psychiatric wards
•
urban mental health and school mental health programmes.
As a result of all these efforts, there was a rapid expansion of the
mental health programme. As of January 2000, about 15.6 million (23%) of
the total population were covered. Of this, 12 million are in the rural areas,
which constitutes over 50% of the rural population. The programme covers
8494 health houses, 1554 health centres and 199 districts. The total number
of patients seen is 128 425, of which 13 900 are psychotic or what is
characterized in the programme as major mental illness, 23 500 epileptics,
28 800 mentally retarded, 47 900 neurotic or what is categorized in the
programme as minor mental illness and 14 200 miscellaneous. Over 20 000
personnel have been trained. The current nationwide coverage is about 23%.
Prevention of mental disorders
Special programmes for the war-affected population, school mental
health and urban mental health have been developed in the country. In
addition, mental health professionals have contributed to the overall
development of rehabilitation services.
Research
During the past 10 years, an impressive amount and wide range of
research has been undertaken by professionals. The most important of these
was the evaluation of the community mental health programmes at Shahr-eKord, Shahreza and Hashtgerd.
Independent evaluation
In November 1995, an independent evaluation was undertaken of the
national mental health programme by an international group of five
Islamic Republic of Iran
131
consultants. This evaluation included special studies, field visits and a
national workshop.
The special studies provided information about mental health care and
the way the programme is perceived by the personnel. The salient findings
are as follows.
•
Behvarz. A total of 266 behvarz were studied. The results show that
more than half of the behvarz scored above 50% in the total
knowledge and attitude scores. On average, about 15 patients were
identified by each behvarz as suffering from mental health problems at
health houses covering an average population of 1500. A majority of
the patients were provided care at the health houses by the visiting
general practitioner and the behvarz of the area.
•
Rural health centres. The rural health centre is the health care level
where diagnosis and treatment are provided by general practitioners.
Of the psychiatric patients seen at rural health centres, most were
referred from health houses. There were more direct referrals of
persons with “minor psychiatric morbidity” as compared to other
diagnostic groups. The doctors provided care for a number of
psychiatric emergencies. The most common difficulties reported by
the doctors in providing mental health care were follow-up of cases,
diagnosis, duration of treatment, and side effects and dosage of
medicine. A one-day census showed that rapid turnover of doctors at
the primary health care level, with an average stay of only 3–6 months
for each doctor, often led to many of them not having specific mental
health training and becoming fully involved in the programme.
•
District health centres. These centres are staffed by psychiatrists or
general practitioners trained in psychiatry and one psychologist. About
25% of the mentally ill persons seen at the district health centre are
patients with psychoses and about 20% each with neuroses, mental
retardation and epilepsy. There is a regular process of referrals and
back-referrals at different levels of health care. The need for referrals
to specialized psychiatric centres is relatively small.
•
More than 40 professionals and planners from different disciplines and
departments reviewed the evaluation findings and outlined the
132
Mental health in the Eastern Mediterranean Region: reaching the unreached
programme for the next phase of the national mental health
programme for the period 1996–2001.
Programmes for the mental health care of those affected by war
Four foundations are responsible for the care of different aspects
related to post-war conditions. Mental health care is an important aspect,
which is the point of attention concerning the affected individuals in warrelated psychiatric conditions, as well as primary health care for their
families.
Counselling centres
In the 1990s more than 80 counselling centres were developed and
established in medical and other universities, 20 by welfare organizations; 10
private counselling centres were also established. Twenty centres offer
telephone counselling, and a hotline is also operational for clients.
Religious affairs and mental health
Many activities have been done to use religious resources in the field
of mental health. Research units in this area exist in the Iran, Tabriz, Isfahan,
Kerman and Mashhad universities of medical sciences and many studies,
conferences and researches have been done.
Healthy city initiative in Teheran
The need for provision of services in urban areas has been felt for a
long time, and innovative activities have been initiated in urban areas. One
such activity has been the introduction of a mental health component to
“healthy city” projects, which are basically environmental projects. The
main objective is to provide necessary mental health services to urban,
suburban and slum dwellers using the vehicle of healthy city projects,
including neighbourhood health volunteers. Attitudes and knowledge tests of
the community and volunteers were done by mental health experts working
with the project managers. The same team performed a prevalence study for
case findings for the initiation of this project. The project is active in
prevention activities and the promotion of mental health. Patients are
referred to general practitioners or, when need exists, specialists.
Islamic Republic of Iran
133
Child mental health
In Teheran, Iran, Shahid Beheshti and Teheran universities of medical
sciences are involved with child psychiatry and mental health services for
children. Child mental health facilities include 30 beds in Imam Hossein
Hospital (Shahid Beheshti University), with an outpatient clinic three days
every week, an inpatient and outpatient family therapy unit, and a speech
therapy unit. There are 20 beds in Navab Hospital (Iran University), with an
outpatient clinic two days every week. There are also outpatient clinic
services and a family therapy unit in Roozbeh Hospital (Teheran University).
There are three child psychiatrists in Imam Hossein Hospital, one in
Navab Hospital and three in Teheran University. Child psychiatry services
are starting in Isfahan University of Medical Sciences as well.
Child mental health training programmes consist of education for
medical students and internships, specialized child psychiatry courses (about
three months), hands-on training in outpatient clinics, and two-year child
psychiatry courses in Shahid Beheshti University.
One of the programmes in child psychiatry that is proceeding is the
pilot special project in school mental health in the Damavand area in
northeast Teheran.
Mental health week
Mental health week has been celebrated in the third week of October
since 1985. Mental health week seminars are held in nearly all district and
provincial health centres. The goal of this programme is to change the
prevalent, popular attitudes, and to attract popular attention and support for
mental health promotion in the country.
Recent developments
Expansion of urban coverage
Since most of the progress in integrating mental health in primary
health care happened in rural areas, despite the expansion of urban
population, in recent years more stress has been put on urban mental health.
The coverage in urban areas by health volunteers almost doubled during the
past five years. Health volunteers, mostly ordinary housewives, having
received training by the health system, provide basic health training and
134
Mental health in the Eastern Mediterranean Region: reaching the unreached
services. Another urban project has been initiation of demonstration projects
of home care for mentally ill patients. These projects were initiated in 2004,
some within the universities and some with the collaboration of
nongovernmental organizations. Another achievement was the issuing of a
decree by the Ministry of Health and Medical Education that provincial
mental health experts who work under the supervision of the mental health
unit are allowed to inspect the mental hospitals. They have recently
developed a checklist to make an objective evaluation possible.
Suicide prevention
Interventions started in four cities in 2001. The main component of the
package was training of general practitioners. Suicide rates were reduced in
all four cities, and the programme has been expanded to 10 cities.
Mental health promotion
A life skills training programme, which was first piloted in Shahid
Beheshti Medical University and the State Welfare organization in the late
1990s, was developed into a national initiative in the Ministry of Health and
Medical Education starting in 2003. A national programme was developed
and training manuals and video CDs prepared for all levels. All provincial
mental health focal points were trained as trainers in 2003. The long term
plan is to cover all 16.5 million students in 5 years. A very serious
intersectoral coordination is under way. Capacity-building has also started
for parenting skills training, and all mental health focal points have been
trained in all 40 medical universities.
Disaster mental health
Seven years ago, in Shahid Beheshti Medical University with the
collaboration of the mental health unit of the Ministry of Health and Medical
Education, the Iranian disaster mental health programme started with a needs
assessment of survivors of two earthquakes in Birjand and Ardabil. This
highlighted the need for psychosocial intervention in natural disasters. Based
on these studies, a national plan was developed. Human resource
development was started and integration of the new plan with the ongoing
national mental health infrastructure was initiated. Red Crescent relief
workers and psychologists and psychiatrists from all disaster prone
Islamic Republic of Iran
135
provinces were trained in training-for-trainers workshops and the programme
was implemented after the Qazvin earthquake as a pilot.
After the Bam earthquake in which about 30 000 people died, a
comprehensive psychosocial intervention was started for survivors. In the
immediate post-phase (the first 2 weeks) information dissemination and
tracing was done. During the next phase, which lasted for about one year,
tent visits, initial psychosocial support, screening was were carried out and
more professional psychosocial support was provided. Over 80 000
survivors in more than 20 000 tents or temporary settlements received initial
psychosocial support, and over 40 000 received more professional group
trauma counselling and other comprehensive services. There were also
activities in schools and recreation centres for children, public meetings and
activities aimed at special groups. Health volunteers were trained for
psychosocial empowerment of the people. They started rebuilding the social
networks and providing social support to the services. The Iranian
experience has been unique in terms of being comprehensive and providing
satisfactory coverage.
At present in every province trained people are prepared for
interventions on disaster mental health and there is a “future package”
including all the material needed for such interventions in the mental health
unit of the Ministry of Health. Such preparations were shown to be effective
when, one year after the Bam earthquake, another earthquake in Zarand was
managed even more efficiently.
Other recent activities have been advocacy for mental health which
led to a 10-fold increase in the budget of the unit in 2004, child abuse
prevention and prevention of violence against women.
Harm reduction
Injecting drug use has been a major area of public health concern,
characterized by concentrated HIV epidemics among injecting drug users
and prisoners in certain provinces. Injecting drug users accounted for 60.8%
of all HIV cases reported to the Ministry of Health and Medical Education,
and 94.8% of the reported cases are among men. Recognizing the potential
magnitude of the problem, a comprehensive prevention and care response
has been started targeting drug users both in the community and in prisons.
136
Mental health in the Eastern Mediterranean Region: reaching the unreached
The National AIDS Committee was formed in 2001. In order to reduce
the harms related to injecting drug use and to prevent the spread of
HIV/AIDS among injecting drug users, the National Harm Reduction
Committee was formed as a sub-committee in 2002. Currently, the Director
of the Office for AIDS and Hepatitis at the Centre for Disease Control at the
Ministry serves as its secretary. The Substance Abuse Prevention and
Treatment Office in the Ministry plays a crucial role in the committee. There
is multi-sectoral collaboration between various sectors, notably the Ministry
of Health and Medical Education, Drug Control Headquarters Secretariat,
National Welfare Organization, National Prisons Organization and law
enforcement representatives as well as Iranian Red Crescent Society.
Nongovernmental organizations in harm reduction for drug-using
populations have played a major role as well. All this has led to a better
coordination of harm reduction activities throughout the country. A five-year
plan (2002–2007) for substance use-related harm reduction interventions
was prepared. The objectives of the plan include establishing, consolidating,
strengthening and coordinating multisectoral, multilateral harm reduction
interventions; and reducing drug injecting related harms such as bacterial
infections, crime, injecting-related mortality, HIV, hepatitis and other bloodborne virus infection.
More recently, protocols and guidelines for establishing government
and private methadone maintenance treatment clinics and guidelines for
establishing and operating outreach programmes, drop-in centres and
shelters for drug users have been prepared. In addition, the Substance Abuse
Prevention and Treatment Office created the Iranian National Centre on
Addiction Studies at Tehran University of Medical Sciences in 2003 to carry
out a range of tasks, including ongoing research into the effectiveness of
harm reduction interventions. All this has created an evidence-based
framework for prevention, care and support for injecting drug users.
Key among important accomplishments in HIV/AIDS prevention and
care implementation are:
•
Establishment of a large number of Triangular Clinics, providing
services related to drug users, STI services and care and support for
people living with HIV/AIDS with the Ministry delivering a sound
Islamic Republic of Iran
137
infrastructure for providing care and support for people living with
HIV/AIDS
•
Acceptance of methadone maintenance treatment as an important drug
treatment and HIV prevention component for opiate-using
populations, and plans for enhanced delivery at a variety of settings,
including closed settings such as prisons
•
The establishment of Triangular Clinics in the prison system for
providing care and support to HIV-positive prisoners
•
HIV information, safe sex education, and health education related to
HIV targeting all prisoners in Iranian prisons.
The health sector of the Iranian Prisons Organization must be
commended for its harm reduction efforts within prisons and drug
rehabilitation centres. Harm reduction services in prisons include individual
and group health education, risk reduction information, risk reduction
counselling, provision of condoms, and voluntary HIV counselling and
testing, with methadone maintenance treatment available in certain prisons.
Harm reduction is proceeding alongside other preventive and promotional
activities including life skills training and parenting skills training run by the
Mental Health Office of the Ministry, Ministry of Social Welfare, Ministry of
Education, the media and many other public sectors and nongovernmental
organizations.
Summary update (Mental health atlas, 2005)
Epidemiology
According to the most recent epidemiologic survey (Noorbala et al,
2004) which used the General Health Questionnaire (GHQ-28) (n = 35 014),
21% of the population (25.9% of the women and 14.9% of the men) were
identified as likely to be suffering from mental illness. Interview of families
by general practitioners revealed that the rates of mental retardation, epilepsy
and psychosis were 1.4%, 1.2% and 0.6%, respectively. Bash and colleagues
(Bash and Bash-Liecht, 1978; Bash 1984) reported on psychiatricepidemiological surveys (based partly on census studies, partly on random
samples) that sampled rural, urban, tribal subjects above 6 years. The
surveys employed questionnaires and tests in the screening phase and
individual psychiatric examinations of all possible cases in the confirmation
138
Mental health in the Eastern Mediterranean Region: reaching the unreached
phase. Prevalence in various settings for any psychiatric disorder was: rural
(14.9%), urban (16.6%), tribal (2.1%); for all psychoreactive cases (included
in the foregoing): rural (8.7%), urban (9.8%), tribal (1.2%); for all
psychosomatic cases (included in the psychoreactive): rural (1.7%), urban
(2.3%), tribal (0.9%). Significant sex differences were found only in the poor
strata. Alemi (1978) found the prevalence of opium use disorders in a survey
of randomly chosen households from a rural community to be 6.9% in
comparison to the rate of 1.1% estimated for the population based on registry
of patients. Merchant et al (1976) found that 24% of university students
(n = 607) reported life time use of drugs with 11% reporting use more than
three times in their lives. The majority of drug users had used marijuana
(54%). Use of drugs was significantly associated with sex, age, number of
years of university attended and father's education. In another study of
university students (n = 501), Ahmadi and Yazdanfur (2002) reported that the
prevalence of regular current use of various substances was: cigarettes
(36.1%), alcohol (21.4%), opium (7.6%) and cannabis (3.0%). Substance use
was significantly higher among males. Ahmadi and Javadpour (2001) found
that among randomly selected health care students (n = 346), 34.7% used
substances at some point in time. Almost 6.9% of the students were current
regular users of substances (cigarettes: 5.5%, alcohol: 1.7%, opium: 1.4%,
cannabis: 1.2%, heroin: 0.3% and LSD: 0.3%). Use of substances was
significantly related to gender (11.3% of males and 1.4% of females were
current regular users). Agahi and Spencer (1982) found that among 712
students aged 14–18 years, 11% had used some drugs of which opium was
the commonest, followed by marijuana and heroin. Thornicroft and Sartorius
(1993) reported the ten-year follow-up data of the WHO Collaborative Study
on Depression (n = 439). Almost 18% had very poor clinical outcome, 24%
had severe social impairment for more than half of the follow-up period and
21% had no full remissions. The best clinical course (one or two reasonably
short episodes of depression with complete remission between episodes) was
more common in endogenous depression (65%) in comparison to
psychogenic depression (29%). A fifth (22%) had at least one episode lasting
for more than 1 year, and 10% had an episode lasting over 2 years during
follow-up. Death by suicide occurred in 11% of patients, with a further 14%
making unsuccessful suicide attempts. Shokrollahi et al (1999) administered
Islamic Republic of Iran
139
a sexual function questionnaire to 300 healthy married women (16–53 years
old) attending a family planning centre. Approximately 38% of the women
had at least one sexual dysfunction; the common ones were inhibited desire
(15%), inhibited orgasm (26%), lack of lubrication (15%), vaginismus (8%)
and dyspareunia (10%). There were significant correlations between sexual
dysfunction in women and their knowledge (low) and attitude (conservative)
towards sexuality and their husbands' sexual dysfunction. Nobakht and
Dezhkam (2000) conducted a two-stage study to assess eating disorders in
3100 schoolgirls in the age group of 15-18 years using the Farsi translation
of the Eating Attitudes Test (EAT-26), the Eating Disorder Diagnostic
Inventory and a supplementary clinical interview. The lifetime prevalence of
anorexia nervosa, bulimia nervosa and partial syndrome was 0.9%, 3.2% and
6.6%, respectively. Zarghami and Khalilian (2002) conducted interviews
and/or psychological autopsies on 318 cases of self-burning. Selfimmolation was associated with young age (average: 27 years), female
gender (83%), housewife status, high school education, psychiatric (95%,
mostly adjustment disorder) and chronic physical illnesses (30%) and high
mortality (79%).
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1986. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation. Community education is a component of the
policy.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1987. Alcohol is prohibited by both religion and legislation.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1986. The national mental health programme was evaluated in
1995 and 1997 and changes were made based on suggestions. In 1995, it was
evaluated jointly by the WHO and the Teheran Psychiatric Institute.
Recently, different sub-programmes on service delivery in urban areas,
140
Mental health in the Eastern Mediterranean Region: reaching the unreached
prevention and promotion have been added to the main body in accordance
with the population shift and change of priorities. Other related programmes
are Integration of Substance Abuse Prevention within the Primary Health
Care and a Harm Reduction Programme.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1988. The essential drugs list was last updated in 2001.
Mental health legislation
Although there are different laws regarding the mentally ill, there is no
modern mental health legislation. Since last year, a team has been working
on a draft for a new legislation. A mandate by the Minister of Health was
issued in 1997 to allocate 10% of all general hospitals to psychiatry beds.
The Mental Health Department has recently started a nationwide advocacy
campaign to implement this mandate. Details about the year of enactment of
the mental health legislation are not available.
Mental health financing
There are budget allocations for mental health. The country spends 3%
of the total health budget on mental health. The primary sources of mental
health financing in descending order are tax-based, out-of-pocket
expenditure by the patient or family, social insurance and private insurances.
The National Health Service in Iran is funded by the Government and
health insurance. If covered by health insurance, patients pay 25% of the fee
for outpatient and 10% of the fee for inpatient treatment (consultation,
laboratory investigations or medicines). Fees do not vary across age ranges.
All emergencies are treated immediately without prior payment. The private
sector can accept patients without insurance but it provides a limited range
of services and the fees are high. Psychologists cannot send bills to insurance
companies directly.
The country has disability benefits for persons with mental disorders.
Since 2001, disabled mentally ill patients are entitled to a stipend of about
US$ 30 per month if they do not receive other free services. Already, about
10 000 disabled patients are receiving disability benefits and the number is
increasing. Institutional care is free of charge for the disabled mentally ill.
Islamic Republic of Iran
141
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level. Mental health
delivery for severe illnesses is one of the objectives in rural and deprived
areas.
Regular training of primary care professionals is carried out in the
field of mental health. In the last two years, about 20 185 personnel were
trained. Mental health services at the primary care level are available to more
than one-fifth of urban and more than four-fifths of the rural population.
Behvarz (multipurpose health workers), who are selected from the target
community, have a pivotal role in the country’s primary health care network.
Their training lasts two years and equips them for active case finding,
appropriate referral to the general practitioner and active follow-up of the
patients. Psychologists are playing a vital role at the level of primary health
care and supervision of health houses. Postgraduate training facilities for
medical and nursing graduates are available. Training facilities for general
physicians and mental health workers (or behvarz) is also present. Manuals
for the training of medical doctors and behvarz are available. A difficulty
noted in the provision of primary mental health care was the rapid turnover
of doctors at this level (average stay of 3-6 months), which often led to many
of the posted doctors not having specific mental health training. To keep up
with the urban shift in population, neighbourhood health volunteers are
being trained for preventive and promotive activities and appropriate
referral.
There are community care facilities for patients with mental disorders.
Mental health is integrated into the primary care system whose basis is
community care. Community participation is sought through involvement of
nongovernmental organizations and religious establishments in mental health
care and public education (e.g. during mental health week).
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
1.6
1.4
0.2
0.04
1.19
142
Mental health in the Eastern Mediterranean Region: reaching the unreached
Number of neurosurgeons per 100 000 population
0.4
Number of psychiatric nurses per 100 000 population
0.5
Number of neurologists per 100 000 population
0.6
Number of psychologists per 100 000 population
2
Number of social workers per 100 000 population
0.6
Among the other 325 professionals are occupational therapists and
medical assistants. Facilities for treatment of drug abusers (300 beds) and reorientation centres for drug abusers with criminal and social problems are
available. At least 100 beds are available for children with behavioural
disorders. Board certification in child psychiatry with a two-year additional
training period is available. There is no requirement for licensure or
certification of clinical psychologists and they do not have prescription
privileges. There are numerous psychologists working outside the mental
health sector. Guidelines have been developed and refresher/training
workshops have been held for physicians, nurses and social workers on
demand-reduction issues.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy and promotion. In 2004,
many joint activities between the Department of Mental Health and
Nongovernmental organizations were started on prevention, promotion and
homecare for mentally ill patients.
Information gathering system
There is mental health reporting system in the country. There is a
simple information system for mental disorders like psychosis, depression,
epilepsy, mental retardation, etc.
The country has no data collection system or epidemiological study on
mental health. The Department of Mental Health recently started collecting
national data on mental health with collaboration of the National Health
Research Center. A national epidemiological study on mental health was
done in 1999 (Noorbala, 2004) as an adjunct to the periodic National Health
Survey.
Islamic Republic of Iran
143
Programmes for special populations
The country has specific programmes for mental health for disaster
affected populations and children. Although the mental health programme
caters to all populations, since 2003, children and adolescents have been
receiving more attention.
There are special facilities for child and adolescent psychiatry in the
form of special departments, training facilities, school mental health
programmes. Special projects on school mental health and on prevention of
child abuse and violence against women (in collaboration with UNICEF and
WHO) are under way. Life skills training has gained impetus and cascade
training of main focal points in all provinces was accomplished in 2003.
Four foundations provide special services ranging from consultation to
rehabilitation to populations affected by war. Under the national programme
on mental health interventions in natural disasters, more than 70 000
survivors received planned interventions during the 8 months after Bam
earthquake and over 400 psychiatrists/psychologists and 1500 teachers were
trained. Pilot projects on suicide prevention, under way in four cities have
shown promising results. Integration of substance abuse prevention within
primary health care and harm reduction activities including methadone
maintenance and outreach activities for street drug users has been launched
with collaboration of the Ministry of Health and Higher Education and
Nongovernmental organizations.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, chlorpromazine, diazepam, fluphenazine,
haloperidol, lithium, biperiden. In 2003, the list was amended to include 32
medications, e.g. nortryptiline, fluoxetine, trihexiphenedyl, risperidone, etc.
Additional sources of information
Agahi C, Spencer C. Patterns of drug use among secondary school children
in post-revolutionary Iran. Drug and alcohol dependence, 1982, 9:235–242.
Ahmadi J, Benrazavi L. Substance use among Iranian nephrologic patients.
American journal of nephrology, 2002, 22:11–13.
144
Mental health in the Eastern Mediterranean Region: reaching the unreached
Ahmadi J, Javadpour A. Assessing substance use among Iranian healthcare
students. Journal of substance use, 2001, 6:196–198.
Ahmadi J, Yazdanfar F. Current substance abuse among Iranian university
students. Addictive disorders and their treatment, 2002 1:61–64.
Alemi AA. The iceberg of opium addiction. An epidemiological survey of
opium addiction in a rural community. Drug and alcohol dependence, 1978,
3:107–112.
Bash KW. Epidemiology of psychosomatic disorders in Iran. Psychotherapy
and psychosomatics, 1984, 42:182–186.
Bash KW, Bash-Liechti J. Psychiatric resurvey of a central Iranian village
thirteen years later. Nervenarzt, 1978, 49:713–719.
Ghobari B, Bolhari J. The current state of medical psychology in Iran.
Journal of clinical psychology in medical settings, 2001, 8:39–43.
Hashemi N, London M. Psychiatric practice in the Islamic Republic of Iran
and the United Kingdom. Psychiatric bulletin, 2003, 27:190–191.
Merchant NM, et al. Factors related to drug abuse among Iranian university
students. Pahlavi medical journal, 1976, 7:516–528.
Nobakht M, Dezhkam M. An epidemiological study of eating disorders in
the Islamic Republic of Iran. International journal of eating disorders, 2000,
28:265–271.
Noorbala AA, Bagheri Yazdi SA, Yasamy MT et al. Mental health survey of
the adult population in the Islamic Republic of Iran. British journal of
psychiatry, 2004, 184, 70-73.
Shadpour K. Primary health care networks in the Islamic Republic of Iran.
Eastern Mediterranean health journal, 2000, 6: 822–825.
Shokrollahi P et al. Prevalence of sexual dysfunction in women seeking
services at family planning centres in Tehran. Journal of sex and marital
therapy, 1999, 25: 211–215.
Thornicroft G., Sartorius N. The course and outcome of depression in
different cultures: 10-year follow-up of the WHO Collaborative Study on the
Assessment of Depressive Disorders. Psychological medicine, 1993 23:
1023–1032.
Islamic Republic of Iran
145
Yasamy MT et al. Mental health in the Islamic Republic of Iran:
achievements and the areas of need. Eastern Mediterranean health journal,
2001, 7: 381–391.
Yasamy MT et al. Disaster mental health in Iran. In: Disaster mental health
in Asia. New Delhi, Indian Red Cross (in press).
Zarghami M, Khalilian A. Deliberate self-burning in Mazandaran, Islamic
Republic of Iran. Burns, 2002, 28:115–119.
Iraq
Overview
The surface area of Iraq is about 435 052 km2. The population is
estimated at 26.563 million, of whom 75% live in urban areas (2004). The
majority of Iraqis are Muslims (95%) with a small minority of Christians and
others. The percentage of the population below 15 years of age and above 65
years is 46.3% and 3.0%, respectively (2003). The total adult literacy rate
and the female adult literacy rate in 1995 were estimated at 56% and 43%,
respectively (2000). Infant mortality rate in 2003 was estimated to be 107
per 1000 live births, maternal mortality ratio 29.4 per 10 000 and under-5
mortality rate 130 per 1000 live births. In 2003, the life expectancy at birth
was estimated to be 63.2 years for the total population.
Iraq’s per capita gross national product in 2003 was US$ 721, and
1.5% of gross national product was allocated for health. There are 6.2, 1.2,
12.1 and 13.3 physicians, dentists, nurses/midwives and hospital beds
respectively per 10 000 of the population (2003).
Iraq’s health policy focuses on reducing infant, child and maternal
mortality through the following strategies: providing maternal and child
health services in all health centres; decreasing mortality from diarrhoeal
disease through the use of oral rehydration therapy; decreasing infant
mortality through ameliorating obstetric and postnatal services; decreasing
child mortality due to respiratory diseases; increasing safe water and
sanitation coverage; and increasing immunization coverage. The primary
health care approach has been strengthened in the community and in the
Iraq
147
various professional cadres through primary health care councils at different
levels.
The primary health care councils, which are made up of
representatives from the health authorities and other government and
nongovernmental organizations (with community support), supervise and
monitor the activities of primary health care. A primary health care council
also exists at the central level, headed by the Minister of Health and
comprising senior officials from the Ministry of Health, other ministries, the
Central Population Council, the General Federation of Iraqi Women, the
Farmers’ Union and the Labour Union.
Mental health
A brief historical note
One of the earliest facilities for the care of the people afflicted with
mental illnesses was established in Baghdad during the middle ages.
Ironically, in a country with such a tradition of care, since 1990, mental
health care, like many other aspects of the care for the population has been
badly affected by war and embargo.
Mental health facilities
Psychiatric hospitals and units in general hospitals form part of the
specialized services that represent the third level of mental health care. There
are 23 psychiatric facilities in the country, 16 in Baghdad. Six are universitybased departments, and the Ministry of Health runs all facilities.
Al Rashad Mental Hospital, established in 1956 in Baghdad, is a longstay institution with a forensic psychiatry unit. It has bed strength of 1300, of
which 300 are forensic psychiatry beds.
Ibn Rushd Psychiatric Hospital is a short-stay hospital with 74 beds
(established in 1968). It is located in Baghdad. There is also an attached drug
dependence centre with 15 beds, established in 1979.
The psychiatric units in general hospitals have bed strengths of 20
beds. These units are located at the Baghdad Teaching Hospital (30–40
beds), Al Yarmouk Teaching Hospital (12 beds), Al-Kademia Nahrain
Medical College (20 beds), Mosul General Hospital (30 beds), Basra
General Hospital (30 beds) and Al Najaf General Hospital (30 beds).
148
Mental health in the Eastern Mediterranean Region: reaching the unreached
There are 12 schools and institutes for the mentally retarded, under the
supervision of the Ministry of Labour and Social Affairs.
There are outpatient psychiatric clinics in all the general hospitals. In
addition, the mental health component of the general medical services is
being developed, and general practitioners and medical assistants are
receiving specialized mental health training.
There are a few community care facilities such as the homes for the
elderly in Baghdad and Mosul and institutes for homeless children and
orphans.
Mental health human resources
There were 160 consultant psychiatrists, 10 psychiatric social workers
and 20–30 psychiatric nurses, approximately half in Baghdad. Most
psychiatrists in Iraq have private clinics, through which supportive
psychotherapy, medication and electroconvulsive therapy services are
available.
Mental health training
A postgraduate programme leading towards a full qualification in
psychiatry (Iraqi Board in Psychiatry and Arab Board in Psychiatry) is
available with 10 positions per year at five centres. A new two-year MSc
course in clinical psychology started in 1994 in Baghdad. There are two
courses of training for psychiatric social workers conducted annually.
As far as the teaching of paramedical personnel is concerned,
graduates from the University Nursing College in Baghdad have good
theoretical and practical training in psychiatry, but all other health workers
(nurses from the nursing schools, medical assistants and auxiliaries) receive
only theoretical training in psychiatry.
All medical schools provide undergraduate teaching in mental health
care during the two years of basic sciences. There are about 15 hours of
lectures in psychology. During the three years of clinical teaching, there are
about 30 hours of lectures in psychiatry. During the fifth and sixth years,
some 60 hours of clinical training is given on the wards to groups of eight to
ten medical students at a time. During the internship period (2 years),
Iraq
149
rotation in psychiatry is obligatory for one month, while another 3 months in
psychiatry are optional.
National mental health programme, legislation and
related policies
The narcotics and substance abuse policy was formulated in 1965
while the therapeutic and essential drugs policy was formed in 1986. The
national mental health programme was formulated in1989 and is based upon
the following principles: mental health care and promotion are components
of primary health care; mental health care and promotion should be
delegated from the specialist to the general health worker, mental health care
and promotion activities need stronger decentralization; and mental health
care and promotion must be integrated with other health care and social
services.
The overall objective of the national programme is integration of
mental health care and promotion with general health care in order to
improve the mental health of the whole population of Iraq. The more specific
approaches towards this goal are: strengthening central coordination of
mental health care and promotion and bringing together the resources of
various sectors of Iraqi society; decentralization of mental health care and its
integration with general health care; renovation and reinforcement of the
existing mental health services; develop an information system to facilitate
collection of reliable information on mental health problems and services
being offered; and promotion of mental health research.
Coordination of mental health care
The Iraqi Committee for Mental Health Promotion is an advisory body
to the Minister of Health. It consists of five consultant psychiatrists; one of
them chairs the Committee.
Mental health legislation
Fragments of mental health legislation exist in the civil and criminal
codes of Iraq. These have been consolidated and expanded into a draft
150
Mental health in the Eastern Mediterranean Region: reaching the unreached
mental health act. This draft was reviewed and updated recently, and it is in
the final stage of legislation. Currently the public health act 89/1981 governs
mental health-related issues.
Progress
A wide range of training programmes were undertaken as part of the
national mental health programme during 1996 and 1997: 648 primary
health care physicians, 462 nurses and 625 educational administrators and
school teachers were trained in mental health. In addition, courses for
training for teachers and social workers working in special schools and
institutions for mentally handicapped children, hostels for the elderly and
reform schools were conducted. Also, two or three courses per year were
conducted in Baghdad and in every governorate for physicians working at
primary health care, along with training in mental health for nursing,
education, literature, arts and medical technology institutes.
Research
The Ministry of Higher Education and Scientific Research has a
research body for medical research. During the past few years, studies have
been completed on prevalence of child psychiatric disorders; prevalence of
psychiatric disorders in medical, surgical wards and outpatients; problems of
drug and alcohol abuse; clinical and epidemiological aspects of mental
disorders.
Recent developments
The two years (2004–2005) of mental health initiatives by the
Ministry of Health, Iraq and WHO have demonstrated both the need for
mental health care as well as viable and practical approaches to meet the
needs. The achievements are:
•
establishing a National Council for Mental Health to guide the mental
health and substance abuse programmes
•
mental health needs assessment using the WHO-AIMS; this provides
baseline data as well as the basis for the identification of priorities
Iraq
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
151
10 psychiatrists trained for 3 months in psychiatric specialties in the
United Kingdom
rebuilding of seven psychiatric facilities
building of a new psychiatric facility in Erbil
construction of two 8-bed facilities in Najaf and Nasiriya
20 medical officers trained in psychiatry for work in governorate
hospitals
20 male psychiatrists trained in research methodology
17 research projects providing information about the magnitude of the
mental health problems in specific population groups and the impact
of mental disorders in terms of quality of life of ill persons
40 psychiatric nurses trained in psychiatry for 6 weeks
20 nurses to be trained in psychiatry for 3 months
25 professionals provided one week psychiatry update training
improving the skills of teachers of undergraduate medical education
in psychiatry
initiatives for addressing substance abuse problems
public awareness campaign material on mental health for use with the
general population
psychological first aid services to the general population and school
children
integration of mental health care with general health services
involvement of voluntary organizations in mental health care
revised mental health act and substance abuse legislation.
Summary update (Mental health atlas, 2005)
Epidemiology
Ahmad et al (1998, 2000a) developed the Iraqi version of the
Posttraumatic Stress Symptoms in Children (PTSS-C) screening instrument
and applied it to a group of children affected by a mass-escape tragedy in
Kurdistan; they found the prevalence rate of PTSD to be 20% according to
DSM-III-R criteria. PTSD symptoms reduced at 4 month follow-up but were
again high at 14 and 26 month follow-up. Dyregrov et al (2002) interviewed
a group of 94 children, who had been exposed to a bombing that killed more
than 750 people, at 6 months, 1 year and 2 year intervals with the help of
152
Mental health in the Eastern Mediterranean Region: reaching the unreached
selected items from different inventories, including the Impact of Event
Scale (IES). The children continued to experience sadness and remained
afraid of losing their family. Although there was no significant decline in
intrusive and avoidance reactions as measured by the IES from 6 months to 1
year following the war, reactions were reduced 2 years after the war.
However, the scores were still high, indicating that symptoms persist, with
somewhat diminished intensity over time. Ahmed et al (2000b) interviewed
randomly selected 45 pairs of children and their caregivers (mostly mothers)
in two displacement camps in Kurdistan with the help of PTSS-C and the
Harvard Trauma Questionnaire (HTQ). PTSD was reported in 87% of
children and 60% of their caregivers. Childhood PTSD was significantly
predicted by child trauma score and the duration of captivity, but was
unaffected by maternal PTSD. It did not disappear after the reunion with the
PTSD-free father. In a 1-year follow-up study, Ahmad and Mohamad (1996)
found that children in orphanages showed greater behavioural symptoms and
PTSD compared to children in foster care. Yasseen and Al-Musawi (2001)
and Hamamy et al (1990) performed karyotypic analyses on children
suffering from severe mental retardation and Down syndrome. The former
study showed that while two-thirds of patients had chromosomal
abnormalities, only 10% had recognizable syndromes. In the latter study,
81.9% of children with Down's syndrome were shown to have trisomy 21
and 18.1% to have 46/47 + G type of mosaic. Examination for parental
consanguinity revealed that 77.9%, 16.2% and 5.9% of the trisomy 21 cases
and 53.3%, 26.7% and 20.0% of the mosaic cases were from nonconsanguineous, first-cousin and second-cousin marriages, respectively.
Amin-Zaki et al (1978, 1979) studied 32 infants exposed to methylmercury
exposure over a 5 year period. In nine cases of cerebral palsy,
methylmercury exposure occurred only during the last trimester or postnatally via suckling. Whereas the mother's symptoms usually improved, the
damage to the fetal nervous system appears to be permanent. Milder cases
(minimal brain damage syndrome) previously not identified in other studies
were also reported. The syndrome consists of varying degrees of
developmental retardation in addition to exaggerated tendon reflexes and the
pathologic extensor plantar reflex.
Iraq
153
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1981. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1965.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1987. The national mental health programme was started in
1989 and is concerned primarily with the integration of mental health with
primary care leading to improvement of the mental health status of the
country. Promotion of proper research facilities and information gathering
systems are also a part of the programme. Coordination of mental health is
done by the Iraqi Committee for Mental Health Promotion, an advisory body
to the Minister of Health. In 2004, an advisory body called the National
Council for Mental Health was established in the Ministry of Health, which
is working to formulate/implement a mental health policy, a mental health
legislation, a substance abuse policy and a national mental health
programme.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1986.
Mental health legislation
There is a Public Health Act (No. 89/1981). This includes mental
health issues. A draft of new mental health legislation was approved by
Cabinet in October 2004 and has been submitted to the Government for
approval. The last legislation was enacted in 1981.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
154
Mental health in the Eastern Mediterranean Region: reaching the unreached
mental health financing in descending order are tax-based and out-of-pocket
expenditure by the patient or family.
The country has disability benefits for persons with mental disorders.
The services provided by the Government are free, though payment has to be
made for private services.
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is available at the primary level. Drugs
are supplied to needy patients at the primary care level after confirmation of
the diagnosis by specialists.
Regular training of primary care professionals is carried out in the
field of mental health. Postgraduation in psychology and training for
paramedical staff is also present. Training is also provided to teachers, social
workers employed in special schools, primary care physicians and nurses.
General practitioners in the primary health centres are being trained in
psychiatry in order to deliver better psychiatric services at the primary level.
Short training courses for orientation are provided.
There are community care facilities for patients with mental disorders.
Care is provided through the facilities of the Ministry of Social Welfare.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
0.63
0.55
0.06
0.02
0.7
0.09
0.1
0.04
0.05
0.2
There are approximately 300 beds for forensic psychiatry and 15 beds
for treatment of drug dependence. Approximately half of mental health
professionals are based in Baghdad. Most psychiatrists have private clinics.
Iraq
155
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, prevention, treatment and
rehabilitation. Training facilities are also provided by nongovernmental
organizations. The Iraqi Society of Psychiatrists, which is a
nongovernmental organization, is actively involved in the promotion of
mental health. The Iraqi Mental Health Foundation UK focuses on training
and academic liaison in the post-war situation. The Red Cross helped in the
rehabilitation of Al-Rashad Mental Hospital in Baghdad, which was
seriously damaged by mobs during the regime change period in 2003.
Information gathering system
There is a mental health reporting system in the country. The country
has no data collection system or epidemiological study on mental health.
There is a lack of proper information gathering system and monitoring of
existing mental health services is not possible due to lack of operational data
and other information.
Programmes for special populations
The country has specific programmes for mental health for refugees,
disaster affected population, elderly and children. Special services are
limited in scope. There are 12 schools for the mentally handicapped. In
addition, some homes for the elderly and institutes for homeless children and
orphans are available.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam,
fluphenazine, haloperidol, levodopa. The drug supply is erratic and new
generation drugs are lacking.
Additional sources of information
Ahmad A, Mohamad K. The socioemotional development of orphans in
orphanages and traditional foster care in Iraqi Kurdistan. Child abuse and
neglect, 1996, 20:1161–1173.
156
Mental health in the Eastern Mediterranean Region: reaching the unreached
Ahmad A, Mohamed HT, Ameen NM. A 26-month follow-up of
posttraumatic stress symptoms in children after the mass-escape tragedy in
Iraqi Kurdistan. Nordic journal of psychiatry, 1998, 52:357–366.
Ahmad A et al. Reliability and validity of a child-specific cross-cultural
instrument for assessing posttraumatic stress disorder. European child and
adolescent psychiatry, 2000a, 9:285–294.
Ahmad A et al. Posttraumatic stress disorder in children after the military
operation ‘Anfal’ in Iraqi Kurdistan. European child and adolescent
psychiatry, 2000b, 9:235–243.
Amin-Zaki L et al. Methylmercury poisoning in Iraqi children: clinical
observations over two years. British medical journal, 1978, 1:613–616.
Amin-Zaki L et al. Prenatal methylmercury poisoning. Clinical observations
over five years. American journal of diseases of children, 1979, 133:172–
177.
Dyer O. British Iraqi doctors set up charity to support Iraq's mental health
services. British medical journal, 2003, 327:832–833.
Dyregrov A, Gjestad R, Raundalen M. Children exposed to warfare: a
longitudinal study. Journal of traumatic stress, 2002, 15:59–68.
Hamamy HA, Al Hakkak ZS, Al Taha S. Consanguinity and the genetic
control of Down syndrome. Clinical genetics, 1990, 37:24–29.
Yasseen AA, Al-Musawi TA. Cytogenetics study in severely mentally
retarded patients. Saudi medical journal, 2001, 22:444–449.
Jordan
Overview
Jordan, with a land area of 89 440 km2, lies east of the River Jordan.
About 80% of the land area of Jordan is desert. The population is
concentrated in the northern and central highlands where the rainfall is
sufficient to support cultivation. The population is estimated at 5 617 000
and the proportion of the population below 15 years and above 65 years of
age is 37.1% and 3.5%, respectively. The adult literacy rate and the female
adult literacy rate are estimated to be 90% and 85%, respectively. Infant
mortality rate is estimated at 22.1 per 1000 live births and under-5 mortality
rate 27 per 1000 live births (2002). Life expectancy at birth is 71.5 years
(2003). The crude birth rate per 1000 population is 29. Maternal mortality
ratio is estimated at 4.0 per 10 000 live births (2004). The per capita gross
national product is US$ 1773 (2004). The Ministry of Health budget
represents 6% of the national budget, comprising 2.6% of gross national
product. The per capita expenditure by the Ministry of Health is US$ 165
(2004) There are 22.4 7.3, 32.5, and 17 physicians, dentists, nurses/midwives
and hospital beds per 10 000 of the population, respectively (2004).
The constitution of Jordan states that it is the responsibility of the
government to make health available to all citizens. There is political
commitment at the highest level to achieving the goal for health for all. The
Higher Health Council was established by law and is headed by the Prime
Minister; its membership comprises representatives of the various health
sectors. This council plays a major role in health planning and in adopting
new health strategies.
158
Mental health in the Eastern Mediterranean Region: reaching the unreached
Three sectors remain the main providers of health in the country,
namely the public, the private and the international donor agencies. The
public sector is composed of the Ministry of Health (which is the principal
provider), the Royal Medical Services (for armed forces), the University of
Jordan and the social security organization. The private sector provides
services through 29 hospitals with 1563 beds in addition to private outpatient
clinics and the facilities run by the nongovernmental organizations. The
international sector includes the United Nations Relief and Works Agency
for Palestine Refugees in the Near East (UNRWA) and other UN bodies, as
well as foreign charity organizations.
The Ministry of Health provides services through a series of primary
health care centres and district hospitals. Each of the districts is selfsufficient in services, and referrals to the capital and other large cities are
made only for cases needing specialized tertiary care.
Monitoring and evaluation are conducted at the national level. A
standard format for monitoring and evaluating the activities of primary
health care exists and is used for assessment purposes. Various training
courses, including the leadership development programme organized by
WHO, have been made available for the purpose of increasing the
managerial capabilities of staff working at the Ministry of Health.
Primary health care committees have been formed at the level of the
health centre and are composed of members of the community. These
committees meet regularly in order to identify needs and problems and find
solutions. Representatives from these primary health care committees are
also members of the Higher Health Council and other councils concerned
with health. Communities are also involved in the provision of resources
through donation of buildings or plots of land for health centres.
Health education is included in school educational curricula in order
to increase awareness of health problems. In addition, health education as a
separate subject has been included in the curricula of nursing and
paramedical staff. Moreover, the time allocated to the various health
education programmes in the mass media has been increased.
Nongovernmental organizations also contribute to the implementation of
health strategies by coordinating with the Ministry of Health on various
projects.
Jordan
159
When extensive development projects are initiated, a committee is
formed made up of representatives from the health and other sectors to
determine the effect of such projects on health; for example, the effect of
major irrigation projects on the spread of schistosomiasis, or that of various
industrial projects on environmental pollution.
The national health plan is part of the socioeconomic development
plan and is implemented through a health system based mainly on primary
health care. Efforts have been made to orient the private sector towards
primary health care by drawing up contracts with physicians in the private
sector, making them responsible for performing primary health care duties
such as immunization, maternal and child care services, and registration of
vital statistics, with occasional referral to health centres for diagnostic
purposes. The physicians’ contracts also bind them to work in any
geographic or medical catchment area specified by the Ministry of Health.
Existing health centres offer primary health care to 95.5% of the
community, and 86.1% of the population can reach these centres in less than
30 minutes.
Mental health
Historical aspects
Mental health services in Jordan reflect the various changes in the
history of the country. Until 1966, mental health services in Jordan were
delivered through only one mental hospital in Bethlehem, covering both East
and West Banks. After the 1967 war, patients on the East Bank had no access
to the services of this hospital. Hence, the Ministry of Health established a
60-bed mental hospital at Fuhais, just outside Amman, with a specialized
clinic three days a week. In 1987, the National Centre for Mental Health was
opened in Amman to provide mental health services. In 1987, a national
committee was formed for the development and implementation of the
national programme of mental health.
Mental health facilities
The mental health services in Jordan consist of the National Centre for
Mental Health, with 200 beds, and two public mental hospitals with 390
beds, at Fuhais and Na’our, south of Amman. The National Centre for
160
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental Health has the additional role of promoting training of hospital
residents, nurses, social workers, psychologists and medical students. In
addition, the Royal Medical Services mental health unit offers 40 beds, and
there is one day-care centre and one rehabilitation centre. There are 31
psychiatric clinics in cities and towns all over the country, 22 of which are in
the private sector. Establishment of psychiatric units in general hospitals has
yet to be implemented. There are two private hospitals with a total of 118
beds and two geriatric homes with a total of 200 beds.
Mental health human resources
There are 70 psychiatrists in the country. Of these, 12 work under the
health ministry, 3 in the academic departments, 22 in the private sector and
the rest in other sectors. There are 13 psychologists working for the mental
health services. Of these, 8 have BS degrees, 3 have MS degrees, and 2 have
PhDs. There are only eight psychiatric nurses. There are 26 social workers in
the mental health services. In addition, there are over 300 educational
psychologists working in the Ministry of Education. There is a psychiatry
residency programme with two positions in the University of Jordan Medical
School.
Medical undergraduates receive 120 hours devoted to psychiatry, and
the clinical training consists of clinical work and internship.
National mental health programme, legislation and related
policies
A national programme of mental health was formulated by a national
committee and discussed in a national workshop in Amman in July 1988 but
was adopted in 1994. A policy on therapeutic and essential drugs was
formulated in 1988 while a narcotics and substance abuse policy was
adopted in 2000. A psychiatric special committee is reviewing the Jordan
Mental Health Act. There is also a special committee of the Ministry of
Justice planning the amendments to the sectors relevant to mental health in
Jordanian criminal law, Jordanian civil law and the Jordanian law of correct
procedures. Currently chapters 49, 50 and 51 of the common law deal with
mental health.
Jordan
161
The mental health programme objectives are integrating mental health
services therein; preventing mental disorders and promoting public
awareness in this respect; and treating mental cases in a more efficient and
less costly way. The national mental health programme also outlined the
service strategies, training strategies, management strategies and strategies
for mental health promotion.
It was envisaged that by 1995 the national mental health programme
would provide diagnostic aids in at least 50% of the health centres in the
country; establish mental health sections in 50% of public hospitals;
establish mental guidance centres in 50% of schools; initiate a programme
for mental health promotion; include psychosocial components in the health
curricula of educational institutions; and provide rehabilitation centres for at
least 50% of the mentally handicapped in the country. Some progress has
been made in implementation of these goals. At present, the mental health
programme is integrated to the work of some primary health care centres. Of
course, as it is true for all the countries of the Region, further attempts are
needed.
Progress of the national mental health programme
Since the formulation of the national mental health programme, 105
general physicians and 70 nurses have been trained in mental health care. A
school mental health programme has been initiated. Preventive activities
have been implemented through primary health care centres, schools and the
mass media. Mental health has been promoted through disseminating
information to the public, primary health care physicians and leading health
administrators.
The problem of drug abuse and dependence is an important priority
and it is being tackled in collaboration with other sectors as a national
strategy.
A major problem has been the limited human resources. Many
professionals seek vacancies with better salaries in neighbouring countries
while others move to the private sector. Therefore, there is a shortage of
qualified psychiatrists in the Ministry of Health. The problems in
implementing rehabilitation and occupational therapy efficiently stem from a
lack of continuous financial support as well as a lack of experts in this field.
162
Mental health in the Eastern Mediterranean Region: reaching the unreached
Summary update (Mental health atlas, 2005)
Epidemiology
Al Jaddou and Malkawi (1997) administered an Arabic version of the
General Health Questionnaire (GHQ-28) to 794 primary care patients and
found the prevalence of psychiatric morbidity to be 61%. Multiple logistic
regression analysis revealed that unemployment and perceived severity of
physical illness were positively correlated with psychiatric disorders.
Haddad and Malak (2002) interviewed randomly selected cluster samples
drawn from medical and engineering colleges (n = 650) using the modified
Arabic version of the WHO Smoking Questionnaire and the Attitudes
towards Smoking Questionnaire. The prevalence of smoking was 28.6%
(50.2% among males and 6.5% among females). Smoking commenced after
15 years of age in four-fifths of the cases. Warren et al (2000), who
conducted the Global Youth Tobacco Survey, reported that tobacco use in the
surveyed age group ranged from 10% to 33% in various countries. Oweis
(2001) interviewed about 280 primiparous women with no previous history
of psychiatric illness and complicated pregnancy and child birth using a
number of standardized and locally validated tools including the Edinburgh
Postnatal Depression Scale (EPDS). They found high rate of postpartum
depression. The prevalence of postpartum depression was associated with
perceived stress of childbirth, having a girl child, years of education and
income and giving birth in a public or military hospital (as against a private
hospital, which was perceived as less stressful). Shuriquie et al (1999)
assessed 201 female nursing students (17–21 years) with the Arabic version
of the Abnormal Eating Attitude Scale. They found abnormal eating attitudes
and over-concern with food and body image in 12.4%. Abnormal attitudes
were inversely correlated with socioeconomic status. Daradkeh (1989) found
that the annual suicide rate during 1985-1990 was 2.1 per 100 000. The peak
suicide rate was in the age group 15–34 years. The majority of males who
committed suicide were single and either unemployed or unskilled manual
workers. Over two-thirds of females who committed suicide were either
housewives or students. Nearly two-thirds of the total population that
committed suicide had previous psychiatric treatment. Violent methods of
suicide were most frequently used. Abu al-Ragheb and Salhab (1989)
reported that during the 13-year period (1973-1985) at least 329 deaths in
Jordan
163
Jordan resulted from poisoning by pesticides (organophosphates: 93.6%) of
which 61% were due to self-ingestion. Three fifths of the suicides were in
the 15–24 year age group. Significantly fewer parasuicides were reported
during Ramadan than the month preceding it and the month that follows
Ramadan (Daradkeh, 1992). Kharabsheh et al (2001) reported on a mass
psychogenic illness involving more than 800 young people who believed
they had suffered from the side-effects of DPT vaccine administered at
school; 122 of them were admitted to hospital. The media, the children’s
parents and the medical profession played a role in the escalation of this
mass reaction. Janson and Dawani (1994) examined 2528 children aged 0–7
years representing 95% of a catchment area. Almost 7.8% had a disability or
a chronic disease. Severe mental retardation was one of the commonest
disabilities.
Mental health resources
Mental health policy
A mental health policy is absent. A draft for the mental health policy
had been prepared in 1986, but is still to be implemented.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 2000.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1994. The national mental health programme aims to integrate
mental health into public health and to promote mental health awareness. It
also outlines service strategies, training strategies and management and
promotion strategies.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1988.
164
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health legislation
Chapter 49/50/51 from the Law of Common Health is regarding the
compulsory admission to psychiatric hospitals. The latest legislation was
enacted in 2003.
Mental health financing
There are no budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are tax-based and out-of-pocket
expenditure by the patient or family.
The country has disability benefits for persons with mental disorders.
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is available at the primary level. There
have been initiatives to train general physicians and nurses on aspects of
mental health care.
Regular training of primary care professionals is carried out in the
field of mental health. In 2003–2004 about 160 personnel were trained.
There are no community care facilities for patients with mental
disorders. Psychiatrists now cover health centres in 5 regions. Psychological
counselling centres have been established in the main schools.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
1.57
1.4
0.08
0.07
1
0.2
2
0.3
0.6
2
Prior to 1966, there was only one mental hospital in Bethlehem. After
the 1967 war, patients on the East Bank did not have access to the services of
the hospital and so a new 60-bed mental hospital was constructed and in
Jordan
165
1987 the National Centre for Mental Health was opened. A day care centre
and a rehabilitation centre are there. Recently, a 46 bedded centre for
treatment of drug abuse was created. Although there are 3000 psychologists
and 2000 social workers only a few work in the field of mental health. Many
professionals seek vacancies with better salaries in neighbouring countries,
while others move to private sectors. Among military psychiatrists, two have
a diploma in forensic psychiatry and one in child psychiatry (they were
trained in the UK). Clinical psychologists have to obtain a licence from the
Ministry to practice.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in promotion and rehabilitation.
Information gathering system
There is a mental health reporting system in the country. The country
has no data collection system or epidemiological study on mental health.
Programmes for special populations
The country has specific programmes for mental health for elderly and
children. Two homes for the elderly with a capacity for 200 elderly
individuals are under construction. As a part of the national mental health
programme, an initiative has been taken to start a school mental health
programme.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam,
fluphenazine, haloperidol, lithium, biperiden. Sinemet is available instead of
carbidopa and levodopa (it combines 25 mg of the former and 250 mg of the
latter). The cost per 100 tablets is US$ 0.47.
Additional sources of information
Abu al-Ragheb SY, Salhab AS. Pesticide mortality. A Jordanian experience.
American journal of forensic medicine and pathology, 1989, 10:221–225.
166
Mental health in the Eastern Mediterranean Region: reaching the unreached
Al Jaddou H, Malkawi A. Prevalence, recognition and management of
mental disorders in primary health care in northern Jordan. Acta psychiatrica
Scandinavica, 1997, 96:31–35.
Daradkeh TK. Suicide in Jordan 1980-1985. Acta psychiatrica Scandinavica,
1989, 79:241–244.
Daradkeh TK. Parasuicide during Ramadan in Jordan. Acta psychiatrica
Scandinavica, 1992, 86:253–254.
Haddad LG., Malak MZ. Smoking habits and attitudes towards smoking
among university students in Jordan. International journal of nursing
studies, 2002, 39:793–802.
Janson S, Dawani H. Chronic illness in preschool Jordanian children. Annals
of tropical paediatrics, 1994, 14:137–144.
Kharabsheh S, Al-Otoum H, Clements J et al. Mass psychogenic illness
following tetanus-diphtheria toxoid vaccination in Jordan. Bulletin of the
World Health Organization, 2001, 79:764–770.
Oweis AI. Relationships among the situational variables of perceived stress
of the childbirth experience, perceived length and perceived difficulty of
labor, selected personal variables, perceived nursing support and postpartum
depression in primiparous Jordanian women living in Jordan. Widener
University School of Nursing, 2001.
Shuriquie N. Military psychiatry–a Jordanian experience. Psychiatric
bulletin, 2003, 27:386–388.
Shuriquie N, Elias T, Abdulhamid M. A study of abnormal eating attitude
among Jordanian female college students. Bahrain medical bulletin, 1999,
21: 88–90.
Takriti A. Psychiatry in Jordan. International psychiatry, 2004, 5:9–11.
Warren CW, Riley L, Asma S et al. Tobacco use by youth: a surveillance
report from the Global Youth Tobacco Survey project. Bulletin of the World
Health Organization, 2000, 78:868–876.
Kuwait
Overview
Kuwait has a surface area of 17 818 km2. Kuwait’s population is
estimated at 2.64 million of whom 41% are Kuwaiti citizens. Of these,
22.8% are under the age of 15 years, while the corresponding figure among
non-Kuwaitis is 16%. The population of people above 65 years of age is
estimated at 1.6%. Life expectancy at birth is 78.7 years. About 92% of the
adult population and about 90% of the female adult population are literate.
The crude birth rate is estimated at 17 per 1000 population, crude death rate
1.8 per 1000 population (2004), infant mortality rate 9.4 per 1000 live births,
maternal mortality ratio 0.9 per 10 000 live births, and under-5 mortality rate
11.4 per 1000 (2003). The leading causes of mortality in the total population,
in 1997, were: diseases of the circulatory system (38.4%), accidents (16.1%),
neoplasms (10.7%) and diseases of the respiratory system (5%). The per
capita gross national product in 2002 was US$ 14400. Of the total budget,
6.9% goes to the Ministry of Public Health. Annual per capita expenditure
by the Ministry of Public Health is US$ 547 (2002). The rates per 10 000
population for physicians, dentists, nurses/midwives and hospital beds are
19, 3, 40 and 21, respectively. Non-Kuwaiti nurses represent 86% of all
nurses (2003).
Articles 9, 10, 11, and 15 of the Constitution clearly affirm the
responsibility of the state for provision of health care to all sectors of the
population, with special emphasis on vulnerable groups such as the
handicapped, the deprived, children, mothers and the elderly. The health
plan, as part of the total socioeconomic development plan and health policy,
168
Mental health in the Eastern Mediterranean Region: reaching the unreached
is based on three principles: maintenance and promotion of health;
improvement of the physical, mental and social well-being of the people;
and reducing morbidity, disability and mortality as much as possible. In this
framework, health goals have been defined as long-term and medium- or
short-term.
The health system is based on three levels of health care delivery:
primary, secondary and tertiary health care. Primary health care is delivered
through a series of health centres. Family health clinics, mother and
childcare clinics, diabetic clinics, dental clinics, and preventive care clinics;
school health services, ambulance services and police health services are
also available.
Secondary health care is provided through six general hospitals, each
serving about 300 000 people. Tertiary health care is provided through a
number of national specialized hospitals and clinics.
The regional organization of the health care delivery system is now
complete so that each of the six general hospitals, along with a number of
health centres which refer to it, constitutes a health region. Regional
directors of health are involved in the planning process as well as in
itemization of the budget and recruiting of human resources. They are
responsible for annually reporting on the activities of their regions.
Mental health
Historical aspects
Mental health care in Kuwait can be considered to fall into three
distinct phases. Until the late 1980s mental health care was strongly
institutionalized in the form of a large psychiatric hospital in Kuwait city.
This situation existed until alternatives were considered as part of
developing a national programme of mental health. Iraqi occupation defined
the next phase as it brought to the forefront a new set of needs due to the
period of occupation. The third phase relates to the period of reorganization
of mental health care in the country.
Mental health infrastructure
The major centre of psychiatric care is the Psychiatric Hospital in
Kuwait city, with 480 beds. The hospital facility has 24 wards, 3 of which
Kuwait
169
are for treatment of addiction, separate from the main hospital building, with
58 beds, of which 14 are for detoxification, 24 for rehabilitation and 20 for
long stay. This unit admits male patients only.
The rest of the wards cater for acute, short-term, long-term, geriatric
and forensic patients in addition to an occupational therapy centre and a day
centre. There is a new hospital under construction with additional 260 beds
along with a day centre for 150 clients. There are also plans to open a pilot
halfway house to cater for 30 patients, in one of the regions. Outpatient
clinics are conducted both at the Psychiatric Hospital as well as at the five
regional hospitals (Adan, Amiri, Farwaniyya, Jahra and Mubarak Al Kabir).
Psychiatric clinics are also conducted at various other centres such as
prisons, special schools and centres where psychiatric assistance is required
(14 centres).
Child psychiatric clinics are carried out in the paediatric departments
in Sabah, Amiri and Mubarak hospitals and the Rigae centre.
At present, there are no community mental health facilities such as
halfway houses, group homes, day centres or sheltered workshops.
For occupational activities in the psychiatric hospital there is a
workshop which offers art, woodwork, sewing, embroidery and domestic
science. A social, leisure and recreational programme also exists, with
outings and visits to various facilities in the country. The available facilities
however are not adequate.
A very important outpatient psychiatric service is the Rigae centre,
which opened in 1993. This is for care of those suffering from post-traumatic
stress disorder and provides services for those affected by occupation during
the events prior to the Gulf War, such as prisoners of war, the injured and
families of those killed, injured or missing. This centre also carries out
public education and research activities.
Mental health human resources
There are 51 psychiatrists, 17 psychologists, 8 social workers, 294
psychiatric nurses and 182 non-medical staff working in the Psychiatric
Hospital. About 45% of the psychiatrists and 80% of the rest of the staff are
expatriates.
170
Mental health in the Eastern Mediterranean Region: reaching the unreached
Undergraduate medical education in psychiatry consists of 130 hours,
of which 100 hours are for practical training.
The official mental health policy and the national programme for
mental health formulated in 1997 advocates the regionalization of services
and the integration of mental health into primary health care. Training of
primary health care workers in mental health issues is a recognized priority.
At present, training includes a 5-week clinical attachment for medical
students and appropriate courses for nurses. To improve detection, referral
practice and treatment of common neuropsychiatric disorders primary care
physicians are attached to specialist mental health services for a four-week
period. Each course is attended by between two and four physicians
depending on interest, background and availability. Family doctors are
attached for 8 weeks of postgraduate training. Over 40 personnel have been
trained. The policies for essential drugs and narcotics and substance abuse
were formulated in 1983 and 1980, respectively.
Summary update (Mental health atlas, 2005)
Epidemiology
There is substantial epidemiological data on mental illnesses in
Kuwait in internationally accessible literature. No attempt was made to
include this information here.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1957. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1983.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1997.
Kuwait
171
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1980.
Mental health legislation
There is no written legislation. However, efforts had been made to
formalize a legislation, though it has not been successful. Details about the
year of enactment of the mental health legislation are not available.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are social insurance, private
insurance and out-of-pocket expenditure by the patient or family. The
country has disability benefits for persons with mental disorders. Treatment
is provided by the Government and social benefits by the Ministry of Social
Affairs.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level. Primary care is
provided by the family doctor. Facilities should be developed further.
Regular training of primary care professionals is carried out in the
field of mental health. In 2003–2004, about 40 personnel were trained.
Primary care physicians and family physicians are attached to specialist
mental health services for a 4 and 8 weeks period, respectively.
There are community care facilities for patients with mental disorders.
Community care is provided through district and general hospitals and
family doctors. Community care facilities are not well developed. However,
there are 2 day care centres which cater to more than 30 clients and one halfway house that caters to 30 clients.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
3.4
3.4
0
0
3.1
172
Mental health in the Eastern Mediterranean Region: reaching the unreached
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
22.5
1.4
0.4
There are 19 occupational therapists. There is a plan to increase the
bed strength in mental hospitals from the current level of 3.4 per 10 000 to
4.58 per 10 000 population in 2005. Some beds have been earmarked for the
management of drug abusers (260), geriatric and forensic patients. There is a
specialized unit for treating PTSD patients. Although there are more than
1000 psychologists and social workers, only a few work in the field of
mental health; 31 of them are employed by the psychiatric hospital which
serves as the main psychiatric set-up for Kuwait.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention,
treatment and rehabilitation.
Information gathering system
There is a mental health reporting system in the country. Only data
from the psychiatric hospital are available. The country has a data collection
system on mental health.
Programmes for special populations
The country has specific programmes for mental health for disaster
affected population, elderly and children.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, ethosuximide,
phenobarbital, phenytoin sodium, sodium valproate, amitriptyline,
chlorpromazine, diazepam, fluphenazine, haloperidol, lithium, biperiden,
carbidopa, levodopa.
Additional sources of information
Bale R. A project to develop quality improvements in the Kuwait mental
health service. Journal of psychiatric practice, 2000, 24:112–12.
Lebanon
Overview
Lebanon has a surface area of 10 454 km2, with a Mediterranean
coastline of 211 km. Beirut, the capital, stands in the centre of this coastal
strip. The Lebanese terrain is a mixture of coast, mountain and inland plain.
The total population is estimated to be 4.37 million, 85% of whom are living
in urban areas (2004). The percentage of the population below 15 years and
above 65 years of age is 28.4% and 6.6%, respectively (2000). Of females,
84% above the age of 15 years are literate and the total adult literacy rate is
88% (2000). The crude death rate is estimated at 4.1 per 1000 population and
the crude birth rate 16.9 per 1000 population (2004), infant mortality rate 26
per 1000 live births (2001), maternal mortality ratio 10.4 per 10 000 live
births, total life expectancy at birth 71.3 years, and under-5 mortality rate 33
per 1000 live births (2001). The per capita gross national product in 2004
was US$ 4951. The Ministry of Public Health budget is 3.7% of the national
budget. The rates for physicians, dentists, nurses/midwives and hospital beds
per 10 000 of the population are 23.6, 8.81, 30 and 30, respectively (2004)
The fifteen years of civil war which ended in the early 1990s caused
massive destruction to the country’s infrastructure, electricity, water and
telecommunication systems, and the road network was severely damaged. As
a result, the quality of life of the people had deteriorated, in the areas
affected in particular and in the whole of Lebanon in general.
174
Mental health in the Eastern Mediterranean Region: reaching the unreached
Development of health systems
The national health policy is based on health being a constitutional
right of every citizen and an integral component of human rights. The health
policy emphasizes the primary health care approach and the concept of
“centralized control and decentralized implementation”.
The district health system, which has been implemented in seven
districts, is made up of three components: the community health workers, the
health centres and the district hospital. The community health worker is
chosen by the village committee and performs home visits and a variety of
duties encompassing aspects of primary health care; he or she also refers
patients to the health centre when necessary. The health centre has at least
one physician and one nurse and provides service for maternal and child
health, family planning, health education, school health, laboratory and
radiological investigations, provision of necessary drugs, promotion of good
nutrition, vaccination, and provision of supervision for community health
workers, as well as collection of data and compilation of statistics. Each
health centre is linked to a district hospital in a referral chain.
The district hospital, which is staffed with a surgeon, an internal
medicine specialist, a paediatrician and a gynaecologist, is the final point in
the referral chain of the district health system. The district hospital can refer
the more complicated cases to a regional or central hospital. A district health
committee supervises the district. These committees consist of
representatives of all health outlets and facilities in the district as well as
local representatives from the Ministry of Education and the municipalities.
The governor of the district chairs the committee.
As the public sector became progressively marginalized as a result of
the war, numerous nongovernmental, private, voluntary and religious
organizations emerged to fill the gap. The Red Crescent and the Red Cross
play a major part in health care delivery. They are charged with certain
services such as immunization and blood bank services. However, many of
the services provided by private and nongovernmental organizations are not
affordable and the Ministry of Public Health and Social Affairs subsidize
private hospitals for treatment of patients who cannot afford to pay.
Lebanon
175
Mental health
The health system in general and mental health in particular are very
much dependent on nongovernmental and religious organizations. Such
organizations get support from different Christian, Druze and Muslim
communities, but usually serve the whole population.
On the outskirts of Beirut, the Lebanese Hospital for Mental and
Nervous Disorders was established in 1898, run first by English psychiatrists
and later on by Lebanese specialists. There is only one functioning
psychiatric hospital, the 1500-bed Psychiatric Hospital of the Cross (Hôpital
Psychiatrique de la Croix) founded in the early 1950s and run by Maronite
nuns. Psychoses account for 60% of the admissions. Male schizophrenic
patients outnumber females in a proportion of 2 to 1. The Ministry of Public
Health subsidizes the care of the majority of hospitalized patients.
As mentioned, there are other facilities supported by other
communities. An example is the Muslim Old People’s Asylum, which is
located in western Beirut.
It is estimated that there are 45 psychiatrists in Lebanon. Some of
them are attached to the mental hospital, where they work part-time. The
others are working in private clinics. The current emphasis on training
includes sensitizing medical students to mental health problems by a twomonth training course in the fourth year. Postgraduate training includes four
years of intensive theoretical and clinical training at the Psychiatric Hospital
of the Cross. In 1987, the Psychiatric Hospital of the Cross signed an
agreement with a French university to enable Lebanese physicians to be
trained in psychiatry in Beirut and take the final examination for the Special
Studies Certificate in Paris. General practitioners and general nurses receive
two to three months’ training. Community involvement includes the
activities of the church in response to the major national problem of drug
dependency. There were an estimated 24 000 young substance dependants in
the country during the years of conflict; however, this figure dropped
significantly after the war to an estimated 8000–10 000 with heroin the main
substance of dependence, inhaled or injected. There are 60 clinical
psychologists and they work mainly in schools, 20 psychiatric social workers
and 30 psychiatric nurses.
176
Mental health in the Eastern Mediterranean Region: reaching the unreached
The national mental health programme and essential drugs policy
were prepared in December 1987. The objectives of the mental health
programme are to make mental health care available for everybody in
Lebanon, in a decentralized manner); to adapt models of care to the social
and cultural patterns of the rural communities which, up to now, have
received little attention; to enhance mental health knowledge of the
community in order to counter the stigma attached to neuropsychiatric
disorders; to develop suitable programmes to assist the large number of
persons affected by the war; and to ensure provision of essential
neuropsychiatric drugs.
The progress of the national mental health programme has not been
satisfactory due to the war and its disruption.
Currently, the Ministry of Public Health of Lebanon, in an effort to
improve mental health services is focusing on two priority areas.
The first area is provision of ambulatory mental health services within
primary health care centres. This is conceived with the aim of promoting
prevention of neuropsychiatric disorders, providing care for those suffering
from such disorders in their own milieu and decreasing stigma. Furthermore,
the availability of these centres all over the country facilitates
implementation and reduces costs. Each mental health team will comprise a
psychiatrist, a social worker, a psychologist and a psychiatric nurse who will
work in close collaboration with the other physicians of the centre and
paramedical staff. A prevalence and service fact-finding survey for
psychiatric morbidity is now being conducted to try and quantify the
problems that the war has created in the psychosocial domains. At primary
health care centres, a complete human resources reorganization is under way
with the introduction of quality assurance, on-site training of paramedical
staff and the formation of psychiatric teams.
The second area is the setting up of a psychogeriatric care system
within a comprehensive geriatric service. The need for such a system is
becoming obvious in Lebanon as the population is ageing. Although there
are several old people’s homes, none has a psychogeriatric care system with
standardized procedures. In a second phase, a community-based care system
will be developed for the care of the elderly.
Lebanon
177
Already two centres for outpatient primary health care and three
centres for geriatric custodial care have been identified for this work, the
medical, paramedical and nursing teams have been formed, and on-site
training of existing staff is being conducted. In addition, the senior physician
visited the United Kingdom on a WHO fellowship in geriatric medicine
during 1996. In the area of quality assurance, an extensive database has been
developed with a computer link-up.
Summary update (Mental health atlas, 2005)
Epidemiology
Weissman et al (1996, 1997) conducted a study in 10 countries
including Lebanon to estimate the rates and patterns of major depression,
bipolar disorder and panic disorder based on cross-national epidemiologic
surveys (n = 40 000). The lifetime rates for major depression ranged from
1.5% in Taiwan to 19% in Beirut. The annual rates ranged from 0.8% in
Taiwan to 5.8% in New Zealand. The mean age at onset showed less
variation, and the rates of major depression were higher for women than men
at all sites. Major depression was also associated with increased risk for
comorbidity with substance abuse and anxiety disorders at all sites. The
lifetime rates of bipolar disorder were more consistent across countries
(0.3% in Taiwan to 1.5% in New Zealand). The sex ratios were nearly equal
and the age at first onset was on an average 6 years earlier than the onset of
major depression. The lifetime prevalence rates for panic disorder ranged
from 0.4% in Taiwan to 2.9% in Italy. The mean age at first onset was
usually in early to middle adulthood, and females were affected more than
males. Panic disorder was associated with an increased risk of agoraphobia
and major depression in all countries. Karam et al (2000) conducted a study
on a stratified cluster sample of 1851 students from two major universities
using the Diagnostic Interview Schedule (DIS) and DSM-III criteria. They
found that the prevalence of alcohol, nicotine, tranquillizer and heroin use
was 49.4%, 18.3%, 10.2% and 0.4%, respectively. Alcohol abuse was
present in 2.1% and alcohol dependence in 2.4%. Abuse and dependence of
other substances besides nicotine and alcohol ranged between 0.1 to 0.8%.
Naja et al (2000) found that in a randomly selected community sample of
1000 people, the prevalence of benzodiazepine use during the past month
178
Mental health in the Eastern Mediterranean Region: reaching the unreached
was 9.6%, with half being dependent on the drug. Current use was associated
with age greater than 45 years, female gender, cigarette smoking and recent
life events. Karam et al (1998) interviewed randomly selected 658 subjects,
aged 18–65 years, from four Lebanese communities with the Arabic version
of the DIS (DSM-III-R criteria) and the War Events Questionnaire. The
lifetime prevalence of major depression across the four communities varied
from 16.3% to 41.9%. Level of exposure to war and a history of pre-war
depression predicted the development of depression during war. Chaaya et al
(2002) interviewed about 400 postpartum women at two points in time, 24
hours and 3-5 months after delivery. During the latter visit, subjects were
screened using the Edinburgh Postnatal Depression Scale. The overall
prevalence of postpartum depression was 21%, but it was significantly lower
in urban (16%) compared to the rural (26%) area. Lack of social support and
prenatal and lifetime depression, stressful life events, vaginal delivery, poor
education, unemployment and chronic health problems were significantly
related to postpartum depression. El Khoury et al (1999) used the DIS to
interview a group of women (n = 150) at two points in time of pregnancy,
the first on the second post-delivery day and the second, one year later. The
prevalence of major depression was 31.3% during lifetime, 10% during
pregnancy and 10.9% during one year follow-up. Lifetime depression was
associated with the number of children in the household. Depression during
pregnancy was inversely related to economic and educational level.
Weissman et al (1999) assessed over 40 000 subjects in nine countries
including Lebanon, using the DIS. The lifetime prevalence of suicide
ideation ranged from 2.1% (Lebanon) to 18.5% (New Zealand) and for
suicide attempts from 0.7% (Lebanon) to 5.9% (Puerto Rico). Women had a
2–3 fold higher rate of suicide attempts than men in most countries. Suicide
ideation and attempts were associated with being divorced/separated.
Chiementi et al (1989) used a questionnaire to interview mothers of more
than 1000 children aged 3 to 9 years. Children who had experienced death of
a family member, forced displacement of family or destruction of home or
had witnessed death were 1.7 times more likely to exhibit nervous,
regressive, aggressive and depressive behaviour than those who had not
experienced trauma. Macksoud and Aber (1996) interviewed 224 Lebanese
children (10–16 years old) and found that PTSD varied according to the
Lebanon
179
number and level of stressful exposure. Various types of war traumas were
differentially related to PTSD, mental health symptoms and adaptational
outcomes.
Mental health resources
Mental health policy
A mental health policy is absent.
Substance abuse policy
A substance abuse policy is absent.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1987. Although a national mental health programme was
initiated in 1987, its progress was not satisfactory due to the war.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1987.
Mental health legislation
Details about mental health legislation are not available.
Mental health financing
There are no budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are tax-based, out-of-pocket
expenditure by the patient or family and social insurance. Lebanon depends
mainly on the private sector for the provision of health services. The
Ministry of Health has contracts with the private sector and needy patients
receive free treatment. The country does not have disability benefits for
persons with mental disorders. There is no disability funding for mental
health.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is not available at the primary level. In order to
improve mental health services the Government is shifting from
comprehensive care to areas of importance. The two areas of importance
180
Mental health in the Eastern Mediterranean Region: reaching the unreached
have been ambulatory mental health service within the primary care centres
and a psychogeriatric care system within a comprehensive geriatric service
with emphasis on a community-oriented programme.
Regular training of primary care professionals is not carried out in the
field of mental health. A training programme was supposed to have started in
2001. General practitioners and general nurses receive 2-3 months training.
Training is also under way on psychogeriatric issues.
There are no community care facilities for patients with mental
disorders.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
7.5
7.4
0.1
2
1
5.3
3
0.6
1.5
The figures for personnel are approximations. The number of
psychologists working in mental health is around 10% of the total number of
psychologists. There is only one psychiatric hospital run by the nuns. This
centre also runs schools, medical clinics and hospice centres. All
psychiatrists have private clinics.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in prevention, treatment and
rehabilitation.
Information gathering system
There is a mental health reporting system in the country. The country
has no data collection system or epidemiological study on mental health.
Lebanon
181
Programmes for special populations
The country has specific programmes for mental health for children. A
comprehensive system of care has been developed for management of some
child psychiatric disorders like attention-deficit/hyperactivity disorder.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam,
fluphenazine, haloperidol, lithium, biperiden, carbidopa, levodopa. All drugs
(including second and third generation anti-psychotics, anti-depressants,
anti-convulsants and non-conventional medication) can be prescribed by
primary care physicians and are available free of cost for poor patients
through the Ministry of Health.
Additional sources of information
Aboujaoude E. The psychiatric hospital of the cross: a sane asylum in the
Middle East. American journal of psychiatry, 1982, 159:1982.
Chaaya M, Campbell OM, El Kak F et al. Postpartum depression: prevalence
and determinants in Lebanon. Archives of women's mental health, 2002,
5:65–72.
Chimienti G., Nasr JA, Khalifeh I. Children’s reactions to war-related stress.
Affective symptoms and behaviour problems. Social psychiatry and
psychiatric epidemiology, 1989, 24:282–287.
El Khoury N, Karam EG., Melhem NM. Depression and pregnancy. Journal
médical Libanais, 1999, 47:169–174.
Fayyad JA, Jahshan CS, Karam EG. Systems development of child mental
health services in developing countries. Child and adolescent psychiatric
clinics of North America, 2001, 10:745–762.
Karam EG., Howard DB, Karam AN et al. Major depression and external
stressors: The Lebanon wars. European archives of psychiatry and clinical
neuroscience, 1998, 248:225–230.
Karam E, Melhema N, Mansour C et al. Use and abuse of licit and illicit
substances: prevalence and risk factors among students in Lebanon.
European addiction research, 2000, 6:189–197.
182
Mental health in the Eastern Mediterranean Region: reaching the unreached
Macksoud MS, Aber JL. The war experiences and psychosocial development
of children in Lebanon. Child development, 1996, 67:70–88.
Mohit A. Mental health and psychiatry in the Middle East: historical
development. Eastern Mediterranean health journal, 2001, 7:336–347.
Naja WJ, Pelissolo A, Haddad RS et al. A general population survey on
patterns of benzodiazepine use and dependence in Lebanon. Acta
psychiatrica Scandinavica, 2000, 102:429–431.
Weissman MM, Bland RC, Canino GJ et al. Cross-national epidemiology of
major depression and bipolar disorder. Journal of the American medical
association, 1996, 276:293–299.
Weissman MM, Bland RC, Canino GJ et al. The cross-national epidemiology
of panic disorder. Archives of general psychiatry, 1997, 54: 305–309.
Weissman MM, Bland, RC, Canino GJ et al. Prevalence of suicide ideation
and suicide attempts in nine countries. Psychological medicine, 1999, 29: 9–
17.
Libyan Arab Jamahiriya
Overview
The Libyan Arab Jamahiriya has an estimated area of 1 775 500 km2
with a population of 5.84 million (2004). Most of the population is
concentrated in the main cities on the coastal plains, namely Tripoli,
Benghazi, Misurata and Zuwarah. About 85% of the population is urban. The
population growth rate is 2.9% (2002), the percentage of the population
below 15 years of age and above 65 years of age is 32.6% and 4%,
respectively (2002). It is estimated that 82% of the total adult population and
74% of the female adult population are literate (1996). The crude death rate
is estimated at 7 per 1000 population in 2002, and the crude birth rate is
estimated at 36 per 1000 population. Life expectancy is 69.5 years (2001). In
2001, infant mortality was estimated at 24.4 per 1000 live births, maternal
mortality 4.0 per 10 000 live births, and under-5 mortality 30.1 per 1000 live
births.
The main causes of hospital mortality in 1987 were as follows: injury
and poisoning (15.5%); diseases of the circulatory system (11.6%); perinatal
mortality (11.4%); diseases of the respiratory system (7%); and neoplasm
(4.4%). The per capita gross national product was US$ 3690. The Ministry
of Health’s budget is 3.3% of the national budget, comprising 12% of the
gross national product, and its per capita expenditure is US$ 121. The rates
per 10 000 population for physicians, dentists and nurses are 12.1, 0.9 and
50, respectively and there are 39 beds per 10 000 population (2002). The
geographic distribution of beds is more or less equitable, with the highest
rate per 10 000 population being less than twice the lowest rate.
184
Mental health in the Eastern Mediterranean Region: reaching the unreached
The motto of Libyan health policy is “health for all by all”. The goal
of this policy is to create a society in which every member can play an active
role, both socially and economically, and in which services are equally
distributed among the whole population. The strategy involves:
•
enhancing medical and paramedical human resources through
redistribution and training of necessary cadres
•
improving, updating and developing health facilities
•
improving the management of hospitals
•
focusing on public health programmes: the four main pillars which
support primary health care are health education; maternal, child and
school health services; nutrition and environmental protection
programmes; and programmes on control and prevention of
communicable diseases.
•
supporting the health infrastructure to meet the needs of the increasing
population.
The health system operates on several levels. The first level consists
of the basic health care units, each providing curative and preventive
services for 5000 to 10 000 citizens. The second level comprises the basic
health care centres, which serve from 10 000 to 26 000 citizens. The third
level consists of the polyclinics, which play an important role in cities.
Staffed by specialized physicians and containing laboratory as well as
radiological services and a pharmacy, these polyclinics serve approximately
50 000 to 60 000 citizens, and there are 18 of them throughout the country.
At the fourth level, are the hospitals in rural areas and the central hospitals in
urban areas. The fifth level comprises the specialized hospitals.
Mental health
Historical developments
Mental health care in the Libyan Arab Jamahiriya is rooted in a
centralized and institution-based system. The first psychiatric facility in the
country was a traditional hospital at Al Marj Al Qadim. It was active during
the Italian occupation before the Second World War and was destroyed by an
earthquake in the 1960s, leaving only the Serganish Mental Hospital, in
Tripoli, with a capacity of 1200 beds. This hospital accepts patients from all
Libyan Arab Jamahiriya
185
over the country. Because of lack of staff it caters to only 350 inpatients. In
1974, a psychiatric hospital of 200 beds was established at Dar Al Shifa. A
new hospital of 250 beds was built in the early 1980s. This includes a
mosque and a farm for the rehabilitation of patients.
Benghazi Psychiatric Hospital, has 350 beds. There is a rehabilitation
department and provision for recreational and occupational therapy.
There are outpatient psychiatric units in general hospitals across the
country such as Al Marj (20 beds), Al Bayda (20 beds), Denna (40 beds),
Al Korfa (geriatric outpatient department) and Homs (10 beds). These are
psychiatric clinics connected to general health facilities.
Care for the mentally retarded is provided in three institutions. In
Tripoli, there is Al Swani Sanatorium with 450 beds; at Benghazi, there are
235 beds; and at Al Jabal Al Akhdar, there are 76 beds.
Al Amal Sanatorium in Tripoli has 130 beds for geriatric services.
There is a department of child psychiatry in the Paediatric Hospital at
Benghazi.
Drug abuse is becoming a major health, social and economic problem.
Many drug abusers are injecting heroin. In the mental health facility of
Tripoli, there is a 50-bed detoxification unit. It is voluntary. No substitution
medication is given. Patients are accepted only once and in case of relapse,
they are not readmitted.
Mental health human resources
There are eight qualified psychiatrists: four in Tripoli and four in
Benghazi. There are also residents from other countries working in the two
hospitals. There are nine social workers and eight psychologists in Tripoli
and similar numbers in Benghazi.
Students undergoing undergraduate training in psychology at
Garyounis University receive training in clinical psychology. Social workers
graduate from the High Institute for Social Study. There is a school for
psychiatric nurses at Tripoli Mental Hospital. It gives a degree equivalent to
a high school diploma. There is an acute shortage of occupational therapists.
The undergraduate medical students receive psychiatric theory
teaching (30 hours) in the fourth year of study. They are also given practical
training at Benghazi and Tripoli Mental Hospitals.
186
Mental health in the Eastern Mediterranean Region: reaching the unreached
National programme of mental health
Official recognition for mental health was demonstrated in the form of
ministerial resolution 654 in 1975, which regulated the treatment of the
mentally ill in mental hospitals. A national mental health programme was put
forward in November 1988. Ministerial Resolution 172 of 1989 formulated a
board to look after the national mental health care programme.
The objectives of the national mental health programme are to provide
essential mental health care for all in the Libyan Arab Jamahiriya and to
foster application of mental health principles in other spheres of life such as
work, family, community participation and national growth. The national
mental health programme identified the strategies and the administrative
mechanisms. The goals for 1990–95 were: starting of postgraduate training
in psychiatry and clinical psychology; short courses for training of social
workers; training of primary care physicians; establishment of day hospitals
and occupational therapy units; a general hospital psychiatry unit with 25
beds; and research.
The current mental health legislation was introduced in 1975.
Summary update (Mental health atlas, 2005)
Epidemiology
There is a paucity of epidemiological data on mental illnesses in
Libyan Arab Jamahiriya in internationally accessible literature. Avasthi et al
(1991) conducted a study on 1009 psychiatric in-patients. Using ICD-9
descriptions, they found schizophrenic psychosis in 39%, affective psychosis
in 17%, neurotic disorders in 12%, organic psychosis in 8% and acute
psychosis in 7%. Neurotic depression was the commonest type of neurotic
disorder, and anti-social personality was the commonest among personality
disorders. Pu et al (1986) did a sociodemographic study on 100 patients
suffering from hysteria in one particular area. Verma (1990) conducted a
cytogenetic analysis of cases of Down syndrome and found the prevalence to
be 1 in 516 live births. 82% of the mothers of cases of Down syndrome were
over 30 years of age as compared to 36% of the mothers of controls.
Cytogenetically 96% of the cases were that of trisomy 21.
Libyan Arab Jamahiriya
187
Mental health resources
Mental health policy
A mental health policy is absent. Mental health policy is part of the
general health policy.
Substance abuse policy
A substance abuse policy is absent.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1988. The national mental health programme was put forward
with the objective of providing essential mental health care for all in all
spheres of life, like work, family, community and national growth.
National therapeutic drug policy/essential list of drugs
Details about the national therapeutic drug policy/essential list of
drugs are not available.
Mental health legislation
A ministerial resolution No. 654 in 1975 regulates the treatment of
mentally ill in mental hospitals. It needs to be revised. There is a national
committee looking into the aspect of a new legislation. The latest legislation
was enacted in 1975.
Mental health financing
There are no budget allocations for mental health. Details about
expenditure on mental health are not available. Details about sources of
financing are not available. The country has disability benefits for persons
with mental disorders. A monthly stipend of 90 Libyan dinars is provided to
the mentally disabled.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level.
Regular training of primary care professionals is carried out in the
field of mental health. Psychiatric services are integrated in the primary care
system. Training programmes for social workers, primary care physicians
and clinical psychologists are components of the mental health programme.
188
Mental health in the Eastern Mediterranean Region: reaching the unreached
However, the facilities are poor and manuals for doctors and workers are not
available.
There are community care facilities for patients with mental disorders.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
1
1
0
0
0.18
0.18
0.5
0.15
5
1.5
Most psychologists are social psychologists. There are beds for the
mentally retarded (500), elderly (130), drug abusers (50) and children.
Patients with drug abuse are admitted only once. There is an acute shortage
of occupational therapists.
Nongovernmental organizations
Details about nongovernmental organization facilities in mental health
are not available.
Information gathering system
Details about mental health reporting systems are not available.
Details about the data collection system or epidemiological studies on
mental health are not available. Hospital data collection is done.
Programmes for special populations
The country has specific programmes for mental health for elderly and
children. There are services for children and elderly and also forensic
psychiatry services.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: unknown.
Libyan Arab Jamahiriya
189
Additional sources of information
Avasthi A et al. Inpatient sociodemographic and diagnostic study from a
psychiatric hospital in Libya. International journal of social psychiatry,
1991, 37:267–279.
Pu T et al. One hundred cases of hysteria in eastern Libya. A sociodemographic study. British journal of psychiatry, 1986, 148:606–609.
Verma IC et al. Cytogenetic analysis of Down syndrome in Libya. Indian
journal of pediatrics, 1990, 57:245–248.
Morocco
Overview
Morocco covers an area of 710 850 km2 and is located in north-west
Africa, between the Mediterranean Sea, the Atlantic Ocean and the Sahara
Desert.
Morocco is a constitutional monarchy. The official religion is Islam.
Administratively, the country is divided into regions which are subdivided
into states, provinces and prefectures. In total, there are 16 large regions and
68 provinces. The regions currently have autonomous management (local
governments).
The population of Morocco is about 30.9 million, and the average
population density is 38.4 per km2. Of these, 29.6% are under 15 years old
and 5.2% are above 65 years of age (2004). The urban population amounted
to 55% of the total population in 2004. The total adult literacy rate and the
female adult literacy rate are 52% and 38%, respectively (2002). The infant
mortality rate is estimated at 40 per 1000 live births, maternal mortality ratio
22.7 per 10 000 live births and under-5 mortality rate 47 per 1000 live births
The total life expectancy at birth is 70.3 years (2002), the crude birth rate is
estimated to be 20.1 and crude death rate 5.5 per 1000 population (2004).
The per capita gross national product is US$ 1200. The Ministry of
Public Health budget is 5.3% of the government budget. At present there are
72 general hospitals and 34 specialized hospitals, with a total bed strength of
25 715, coming to 11 beds per 10 000 population. The corresponding rates
for physicians, dentists and nurses/midwives are 5.4, 1 and 8.7 respectively
(2003). There are 1949 primary health care institutions are (563 in rural
Morocco
191
areas and 1386 in urban areas), corresponding to 0.8 establishment per
10 000 inhabitants (1999).
Health system infrastructure
The national health system is organized in three main sectors, public,
private for-profit and private non-profit.
The public sector comprises the Royal Armed Forces Health Service
and the Ministry of Public Health. It aims to implement prevention,
promotion of health and treatment strategies through two networks.
The primary health care network consists of:
•
the rural dispensary
•
the community health centre
•
the local hospital
•
the urban health centre.
The hospital network comprises general hospitals and specialized
hospitals and is organized on three intervention levels:
•
public health polyclinics and provincial hospitals
•
regional hospitals
•
academic hospitals.
The private non-profit sector includes national funds of social security
institutions and mutual fund institutions.
Mental health
Introduction of modern psychiatry
In Morocco many psychiatric institutions were built between 1920 and
1995. Berrechid Hospital (near Casablanca) was the first to be operational. It
has an asylum structure with a large capacity (2000 beds). Next was Til
Mellil Psychiatric Hospital (in the Casablanca region). Regional psychiatric
hospitals, with smaller capacities (80 to 100 beds), were founded in
Marrakech, Oujda, Fès, Tangiers, Tétouan and Meknès. Since the 1960s,
psychiatric services began to be integrated into general hospitals (10 to 30
beds) and development of ambulatory psychiatry services in the public and
private sectors started. The national mental health programme was adopted
192
Mental health in the Eastern Mediterranean Region: reaching the unreached
in 1992 while the policies for narcotics/substance abuse and essential drugs
were formulated in 1972.
Legislative measures
The principal law is the 1959 dahir (Royal decree). It specifies
manner of patient placement and discharge and sets forth protective
measures for mentally sick people and for their property.
Administration and planning
The Central Service for Mental Health and Degenerative Diseases was
created in 1959. The service develops plans and programmes for the
prevention and treatment of mental illnesses as well as the protection of the
mentally ill, supervises medical care institutions (public and private), health
centres and psychiatric institutions, coordinates different sectors involved in
mental health care and with national and international nongovernmental
organizations, oversees continuing education of health professionals, furthers
the goal of mental health, participates in the fight against drug addiction in
coordination with other sectors.
The Mental Health Committee, which organizes and supervises mental
institutions and rehabilitation centres, is operated by all sectors on a national
level.
Mental health care facilities
Psychiatric institutions are in four main sectors—public health,
academic, military and private. There are also institutes for helping mentally
handicapped children.
Academic centres
Collège Polytechnique Universitaire de Salé, Al Razi: 200 beds
Collège Polytechnique Universitaire de Casablanca: 120 beds
Public health
Marrakech: 220 beds
Berrechid: 650 beds
Til Mellil: 160 beds
Tangiers: 100 beds
Tétouan: 200 beds
Morocco
193
Fès: 130 beds
Oujda: 130 beds.
Psychiatric services integrated into general hospitals
This started at a faster pace after the development of the national
programme for mental health. Currently most of the provincial hospitals
offer psychiatric services and the break-up of their bed strength is as follows:
Agadir: 60 beds
Laâyoune: 15 beds
Taroudannt: 40 beds
Beni Mellal: 30 beds
Khouribga: 30 beds
Khenifra: 10 beds
Meknès: 80 beds
Mohammedia: 30 beds
Safi: 26 beds
Taza: 4 beds
El Jadida: 20 beds
Al Hoceima: 60 beds.
Military hospitals
Muhammad V Military Hospital of Rabat: 40 beds
Muhammad V Military Hospital of Meknès: 20 beds
Muhammad V Military Hospital of Oujda: 10 beds
Private sector
Sixty-three private surgeries, which are concentrated in urban areas of
Morocco.
Ambulatory care facilities
The development of ambulatory psychiatry within the primary health
care system has allowed people who previously avoided mental hospitals to
have easier access to medical care. This policy has allowed psychiatry to be
demystified on the one hand and on the other reduced the average length of
time spent in the hospital. There are 200 health centres spread over the
country offer mental health services integrated within primary health care.
194
Mental health in the Eastern Mediterranean Region: reaching the unreached
Summary update (Mental health atlas, 2005)
Epidemiology
A WHO assisted study on prevalence of mental disorders was
conducted on representative samples (n = 6000) from many regions of the
country using the Mini International Neuropsychiatry Interview (MINI), and
the results are being compiled. Data are regularly collected from public
psychiatric institutions. In 2002, among outpatients (n = 1 504 508), 34%
had schizophrenia, 25.1% had mood disorders, 16.7% had neuroses and
1.8% had alcohol and drug use disorders. Among inpatients (n = 15 398)
65.2% had schizophrenia, 11.9% had mood disorders, 2.5% had neuroses
and 5.1% had alcohol and drug use disorders (Ministry of Health, 2004).
Kadri et al (2002) used DSM-IV criteria to assess sexual dysfunction in a
representative sample of the population of women aged 20 and older in one
city (n = 728). The 6-month prevalence was 26.6% with dysfunctions of
sexual arousal as the commonest disorder. Age, financial dependency,
number of children and sexual harassment were positively associated with
presence of sexual disorder. Ghazal et al (2001) evaluated a randomly
selected and representative sample of students attending six secondary
schools (n = 1887) and a second group composed of students of the French
secondary school (n = 157). Subjects completed a sociodemographic
questionnaire and the Bulimic Investigatory Test of Edinburgh (BITE). In the
first group, 15.3% of subjects took at least one substance, 12.7% were
dependent on tobacco and 5.7% consumed alcohol occasionally. Almost a
sixth of students reported a familial history of disturbed eating behaviour.
The overall prevalence of bulimia in this group was 0.8% (1.2% in female
and 0.1% in male subjects). The mean age of bulimic subjects was 18.6
years. In the group from the French school, the prevalence of bulimia was
1.9% in the whole sample (3.4% among girls and no case among boys).
Bulimic subjects did not differ from the non bulimic subjects with regard to
sociodemographic characteristics. Kadri et al (2000) assessed 100 adult
males for two consecutive years over a 6-week period during Ramadan with
clinical interviews, visual analog scales and the Hamilton Anxiety Scale.
Smokers were significantly more irritable than non-smokers before the
beginning of Ramadan. An increase in irritability was noted in both groups
during Ramadan, but irritability increased more in smokers than in non-
Morocco
195
smokers. Taoudi Benchekroun et al (1999) reported that during Ramadan the
sleep chronotype as evaluated by the Horne and Ostberg scale changed
significantly with an increase of the evening type and a decrease in the
morning type. Daytime sleepiness as evaluated by the Epworth Sleepiness
Scale was significantly increased.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1972. The components of the policy are promotion, prevention, treatment
and rehabilitation. Decentralization is also a component of the policy. Since
1972, the mental health policy has been reviewed several times with the help
of the Moroccan Society of Psychiatry. The legislation on mental health,
which was formulated in 1959 by dahir, is the highest legislation form in the
country.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1972.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1973. The mental health programme was revised in 1992 and
1995. The programme was formulated according to the dahir. The
programme has been reviewed several times.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1972. The last review was in 2000. New as well as old
drugs (neuroleptics, anti-depressants, mood-regulators) are on the list.
Mental health legislation
The dahir 1-58-295 relating to the prevention of mental illnesses and
protection of the patients is the latest mental health legislation. Though it is
old, its articles are well formulated and were examined by WHO experts in
1998. Reviews may be done in the future. The main aim is to guarantee the
medical characteristics of mental institutions by entrusting them with the
196
Mental health in the Eastern Mediterranean Region: reaching the unreached
prime mission of treating the sick while protecting their rights and their
property during their period of illness. The Law created the Central Service
for Mental Health and Degenerative Diseases and the Mental Health
Committee, organized mental institutions and other psychiatric set-ups and
specified different manners of patient admission and discharge among its
many other laws, as well as the modalities of protection of the sick.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are tax-based, social insurance,
out-of-pocket expenditure by the patient or family and private insurance.
Each state has its own budget line specified for equipment and investment
work in hospitals at regional levels.
The country has disability benefits for persons with mental disorders.
Those who become handicapped or lose their autonomy benefit from the
system in the form of paid sick leave plus disability card if the disability is
definite. Common diseases are supported like other illnesses.
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is available at the primary level.
Outpatient clinics are integrated to some extent into the primary health care
system. Two hundred health centres spread over the country offer mental
health services within primary health care.
Regular training of primary care professionals is carried out in the
field of mental health. Training on primary mental health care is integrated in
basic academic courses of general physicians, in faculties of medicine and in
the health professional training institutes (Instituts de formation en carrières
de santé: IFCS).
There are community care facilities for patients with mental disorders.
The community programme includes the family which plays an important
role in the therapeutic programme.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
0.783
0.52
Morocco
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
197
0.17
0.1
0.4
0.12
2.2
0.3
0.03
0.007
The situation is unsatisfactory, especially in the public sector.
Nongovernmental organizations (NGOs)
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention,
treatment and rehabilitation.
Information gathering system
There is a mental health reporting system in the country. The country
has a data collection system or epidemiological study on mental health.
Several specific studies were conducted by the main psychiatric university
centres like Ibn Rushd (Casablanca) and Ar-Razi (Rabat-Salé). An
exhaustive list of studies and results is available from the Ministry of Health.
Programmes for special populations
The country has specific programmes for mental health for children.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam,
fluphenazine, haloperidol, lithium, levodopa. Other drugs are available in the
primary health centres.
Other information
There has been a psychiatric tradition in Morocco since the Middle
ages; The moristanes (health care places for the mentally ill) were precursors
of public sector psychiatric hospitals. Then, two psychiatric university
centres were established in Salé in the 1960s and in Casblanca in the 1970s.
Recently, two university centres were created in Marrakesh and in Fès.
198
Mental health in the Eastern Mediterranean Region: reaching the unreached
According to mental health policy of the Ministry of Health, several mental
health services are being created each year in the general hospitals. The goal
is to have sectorized coverage of mental needs of the population in the entire
country.
Additional sources of information
Des organismes chargés de la prevention et du traitment des maladies
mentales et de la protection des malades mentaux (Government document).
Ghazal N et al. Prevalence of bulimia nervosa among secondary school
students in Casablanca. Encephale, 2001, 27:338–342.
Kadri N et al. Irritability during the month of Ramadan. Psychosomatic
medicine, 2000, 62:280–285.
Kadri N, McHichi Alami KH, McHakra Tahiri S. Sexual dysfunction in
women: population based epidemiological study. Archives of women’s
mental health, 2002, 5:59–63.
Moussaoui D. Creating a department of psychiatry in a developing country.
World psychiatry, 2002, 1:57–58.
Taoudi Benchekroun M et al. Epidemiological study: chronotype and
daytime sleepiness before and during Ramadan. Therapie, 2002, 54:567–
572.
Oman
Overview
Oman, with a surface area of 309 500 km2, occupies the south-eastern
corner of the Arabian Peninsula. Most of Oman consists of desert, semi-arid
plains and mountains. Northern Oman, which contains most of the resources
and population, is separated from the southern province of Dhofar by
700 km of desert. The total population is 2.65 million (2004), with about
73% locals. About 71% of the population lives in urban areas. The
proportion of the population below 15 years of age and above 60 years of
age is 33.7% and 3.2 %, respectively (2002). In 2003, 81% of the total adult
population was literate and in the same year, the percentage of adult literate
females was estimated at 74%. Estimated total life expectancy at birth is
74.2 years, infant mortality rate 10.3 per 1000 live births, under-5 mortality
rate 11.1 per 1000 live birth and maternal mortality ratio 2.3 per 10 000 live
births (2003). The per capita gross domestic product is US$ 7337 (2003),
and the Ministry of Health is allocated 5.4% of the budget, which is 2.2% of
the gross national product. The Ministry of Health’s per capita expenditure is
US$ 201 as compared to the national per capita expenditure of US$ 246 on
health. The rates for physicians, dentists, nurses and hospital beds per 10 000
population are 16.3, 1.8, 37 and 22, respectively (2004). The majority of the
population is Muslim.
Health for all has been endorsed as national policy. The principal
thrust of the national health policies is that health care is the right of every
individual; The Ministry of Health is the main provider of health care in the
country. There are three other governmental organizations concerned,
200
Mental health in the Eastern Mediterranean Region: reaching the unreached
namely the Ministry of Defence, the Royal Oman Police, and Petroleum
Development of Oman, which provide medical care only to their employees
and dependants. Only two private hospitals exist in Oman. During 1989, the
health system was regionalized, and the provision of health services in each
of the eight health regions became the responsibility of the regional
directorates general.
Health services, at the first-contact level, are provided through health
centres, each headed by a resident physician. The services provided by these
facilities are basically curative, with a number of preventive and promotive
services such as maternal and child health services. The outpatient
departments of small local hospitals (with 4–49 beds) are also accessible to
the people as a first line of contact and thus contribute, to a large extent, in
the delivery of primary health care. Attached to both health centres and
hospitals are 66 public health units manned either by one or more physicians
or, in the case of the smaller ones, by sanitarians. In rural areas, health
services are based on a combination of static as well as mobile health units
to serve both the rural and the nomadic populations. At the local and regional
levels, the curative services are provided by local hospitals with 50 to 60
beds and regional hospitals with 200 or more beds. These hospitals have
extensive inpatient and outpatient services including specialized services in
medicine; surgery; paediatrics; gynaecology; ear, nose and throat;
ophthalmology; dental surgery; dermatology; and psychiatry. At the central
level, three major hospitals in Muscat provide tertiary care and act as
national referral hospitals. In addition, there is one psychiatric hospital.
Nongovernmental organizations, such as the Oman Women’s
Association, cooperate in the Ministry of Health’s expanded programme on
immunization, maternal and child health services, and health education
programmes.
The Faculty of Medicine at Sultan Qaboos University started
functioning in 1986. Total enrolment in 1989–90 was 238 medical students
(in addition to 99 studying medicine overseas). The Institute of Health
Sciences has increased its training facilities for paramedical staff and is now
producing
nursing
personnel,
medical
laboratory
technicians,
physiotherapists and radiography technicians. In addition, regional training
Oman
201
centres are being established to train secondary school graduates as health
workers.
Mental health
Historical aspects
The first psychiatric facility for the care of mentally ill patients in
Oman was started with one psychiatrist at Al Rahma Hospital, Muscat, in
1975. Initially, the Psychiatric Unit consisted of an outpatient clinic in a
makeshift three-room block and a small ward having five beds. Almost at the
same time, the psychiatrist at Al Rahma Hospital started monthly visits to
Sultan Qaboos Hospital in Salalah, where he would conduct an outpatient
clinic for three days. In April 1976, a 30-bed ward was started for male
patients, initially to accommodate 16 patients from Jalali Fort. In January
1979, a psychiatrist was permanently posted at Sultan Qaboos Hospital,
Salalah, in charge of the outpatient clinic and five beds for acute psychiatric
cases. In view of the progressive increase in the number of patients seeking
psychiatric care (in 1980, there were 656 new cases, 6209 total registered
attendance) a 60-bed facility named Ibn Sina Hospital was inaugurated in
November 1983.
Mental health facilities and personnel
Facilities
The mental health care facilities consist of the Ibn Sina Hospital, near
Muscat, regional referral hospitals and the Department of Behavioural
Sciences at Sultan Qaboos University Medical School.
Ibn Sina Hospital is the only inpatient psychiatric facility. It is located
25 km west of Muscat. It is a 60-bed facility with two male wards and one
female ward that house acute as well as chronic psychiatric patients and
severely mentally retarded children and adolescents. Two senior consultants,
two specialists, two junior specialists, five medical officers, nursing staff and
three social workers staff it. The hospital is equipped with an
electroencephalogram, X-ray, laboratory and two small occupational therapy
units for male and female patients.
202
Mental health in the Eastern Mediterranean Region: reaching the unreached
Psychiatrists are stationed in seven regional referral hospitals in
Salalah, Sohar, Nizwa, Ibri, Rustaq, Ibra, Sur, Musandam and Buraimi. Each
of these psychiatrists has access to four beds in the local general hospital for
their patients, except in Salalah, where 10 beds are available.
The Sultan Qaboos University Medical School has a Department of
Behavioural Sciences with about 15 psychiatric beds in the university
hospital. These are exclusively training beds, and the facility functions
outside the regular health system.
There is a small 15-bed facility for the mentally retarded managed by
the Ministry of Social Affairs.
A referral system exists between the first, second and third levels of
care.
There has been a growing awareness of the drug abuse problem since
1972. The main drug of abuse, initially, was charas (cannabis). Between
1974 and 1980, the use of opiates, alcohol and psychotropic drugs was also
seen. From 1982, there have been some cases of heroin dependence. Cases
of cologne drinking, glue sniffing and shoe polish sniffing have been
reported.
Training programmes
Fifty students every year graduate from Sultan Qaboos University
Medical School. Students are taught behavioural sciences in the first year of
training and subsequently receive clinical training in psychiatry.
Nursing training has only theoretical classes and very little practical
training.
A joint postgraduate psychiatric residency programme (Sultan Qaboos
University and Ibn Sina) is also available for the training of doctors.
National mental health programme and related policies
Objectives and strategies
The national mental health programme of Oman was discussed and
finalized in a national workshop in March 1990 with participation of
professionals and planners from a wide range of disciplines and sectors. The
essential drugs policy has been in operation since 1975 and the narcotics and
substance abuse policy has been formulated in 1999. The objectives of the
Oman
203
national mental health programme are: provision of mental health care for
all; prevention, treatment, rehabilitation and promotion of mental health and
quality of life by adopting culturally sound and relevant psychosocial and
behavioural principles at work, in family life and in the community.
The main strategies identified are: integration of mental health
services in general health care; development of an administrative structure
for mental health; a school mental health programme; involvement of
religious teachers; services for the mentally retarded; programmes for
substance abusers; training of professionals; mental health education for the
community; and operational research.
Progress
The national mental health programme has been actively implemented
in Oman. The integration of mental health with general health care has been
achieved by the following steps: preparation of a manual for medical officers
on mental health care; standard operating procedures for the management of
psychiatric cases (in print); biannual training programmes for primary health
physicians—these three-week training programmes emphasize knowledge,
skills and positive attitudes; a review workshop in October every year in
order to assess the progress of the national mental health programme and
development of community-based psychiatric care in Oman; development of
a referral system linking the different levels of care; regional workshops in
psychiatry, which are regularly held for the training of primary health care
staff from every region of the country for primary management of
psychiatric cases. Over 150 personnel have been trained.
School mental health programme
Education administrators, schoolteachers and schoolchildren
constitute a large portion of the literate population, particularly in the rural
areas, and hence, exert tremendous influence on community attitudes and
behaviour patterns, including popular ideas and beliefs on health and
disease. This resource can be exploited in school mental health programmes,
by inculcating a positive attitude towards mental health and illness among
the community by using the school system as a social tool of change. School
health workers, selected teachers and students are given special training in
204
Mental health in the Eastern Mediterranean Region: reaching the unreached
workshops to attain skills so that they can recognize and help those in need
of special education and parents and teachers who need counselling in
dealing with children. Children are taught simple slogans aimed at
modifying their attitude. Such slogans are also propagated among the
community through banners, posters, advertisements in newspapers and
magazines, stickers and stamps printed on school homework notebooks.
Research
Research studies using routine hospital data have been carried out. A
study conducted in 1995 showed that poor compliance and irregularity in
taking medicines were the main causes of relapses of chronic psychiatric
cases in Oman. Distance from hospitals also contributed to poor attendance
record and poor compliance with treatment. The conclusion of this study was
that strengthening of the primary health care services near patients’ homes
was essential.
Legislation
Royal decree 17/99 was issued in 1999 for control of narcotics and
psychotropic substances.
Summary update (Mental health atlas, 2005)
Epidemiology
Chand et al (2001) conducted an 8-year retrospective analysis of
hospital records of cases with dissociative disorder. These disorders were
common, and female predominance was not marked. The most common
presentations were dissociative convulsions, dissociative motor and
dissociative trance disorders. Zaidan et al (2002) reviewed Accident and
Emergency records over a 6-year period and found 123 cases of deliberate
self-harm. Most patients with deliberate self-harm were women, students and
unemployed. Analgesic (paracetamol) use was the preferred method
followed by other non-pharmaceutical chemicals. Al Adawi et al (2002) used
the Eating Attitude Test and the Bulimic Investigatory Test to assess eating
disorders in Omani teenagers, non-Omani teenagers and Omani adults. On
the Eating Attitude Test, 33% of Omani teenagers (29.4% females and 36.4%
males) and 9% of non-Omani teenagers (7.5% of males and 10.6% females)
Oman
205
showed anorexia-like behaviour. On the Bulimic Investigatory Test, 12.3%
of Omani teenagers (13.7% females and 10.9% males) showed a propensity
for binge eating or bulimia. Among the non-Omani teenagers, 18.4% showed
bulimic tendencies with females outnumbering males. Only 2% of Omani
adults showed any problems related to eating behaviours. Kenue et al (1995)
assessed 492 children (<15 years of age) and found that 2% had disabilities
related to chromosomal abnormality, genetic, perinatal and infectious
factors. Down syndrome was present in 31% of children with chromosomal
abnormalities.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1992. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1999. The Royal Decree 17/99, Law on Control of Narcotics
and Psychotropics was formulated in 1999. The components of the policy are
prevention, treatment, rehabilitation and advocacy.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1990. The national mental health programme was revised in
1992. It envisages to provide mental health care for all through the primary,
secondary and tertiary level, taking into account measures for prevention,
treatment, promotion and rehabilitation and keeping in view the culture,
family and community. The aim was to involve the whole community along
with religious teachers, incorporate programmes for the mentally retarded
and substance abusers and train professionals. A review workshop is held
every year to assess the progress of the national mental health programme.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1975.
206
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health legislation
There is no specific mental health legislation. The provision of mental
health care is an essential component of the National Health Policy as
contained in the policy statement issued by the Ministry of Health in 1992.
The Royal Decree 17/99, Law on Control of Narcotics and Psychotropics
was formulated in 1999.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are tax-based, private insurance
and out-of-pocket expenditure by the patient or family. Psychiatric services
are provided free of charge to most Omani patients.
The country has disability benefits for persons with mental disorders.
Disability benefits are provided by the Ministry of Social Affairs to all
Omani nationals who have physical or mental disorders.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is not available at the primary level. Primary care
and referral services are available. Patients with severe psychiatric disorders
are referred to secondary and tertiary levels and managed at primary level
only after they are stabilized.
Regular training of primary care professionals is carried out in the
field of mental health. In 2003–2004, about 250 personnel were trained.
Besides training during residency, there are some training facilities for
nursing graduates and some for primary care doctors. The training
programme for primary care doctors is held on a regular basis along with
regional workshops. The Ministry of Health has published a manual for
primary health care professionals, which lays down the standard operating
policy for primary management of psychiatric problems.
There are community care facilities for patients with mental disorders.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
0.49
0.28
0.21
Oman
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
207
0
1.4
0.4
5
0.25
0.25
0.5
There are 15 other mental health professionals. Besides the central
psychiatric hospital near Muscat, there are psychiatrists at the nine regional
hospitals, eight of which have four beds for psychiatry. There are also beds
allotted to other major hospitals and universities. There is a 15-bed facility
for the mentally retarded under the Ministry of Social Affairs with training
schools for the handicapped. Some beds are earmarked for female patients.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion and
rehabilitation.
Information gathering system
There is a mental health reporting system in the country. The country
has a data collection system on mental health.
Programmes for special populations
The country has specific programmes for mental health for minorities,
elderly and children.
There is a school mental health programme that involves participation
of administrators, school teachers, school children. The programmes are
mainly concentrated in rural areas and they are educated through lectures,
debates, essay competitions, posters, etc. School health workers and teachers
are given some training in order to pick up certain behavioural problems and
learning disorders.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital,
chlorpromazine, diazepam, haloperidol. Procyclidine and maprotiline are
208
Mental health in the Eastern Mediterranean Region: reaching the unreached
available through the primary health care system. Other psychotropics,
except atypical anti-psychotics, are also available through primary health
care centres if they are prescribed by secondary and tertiary centres.
Additional sources of information
Al Adawi S et al. Presence and severity of anorexia and bulimia among male
and female Omani and non-Omani adolescents. Journal of the American
Academy of Child and Adolescent Psychiatry, 2002, 41:1124–1130.
Chand SP, Koul R, Al Hussaini AA. Conversion and dissociative disorders in
the Sultanate of Oman. Journal of the American Academy of Child and
Adolescent Psychiatry, 2001, 40:869–870.
Kenue RK et al. Cytogenetic analysis of children suspected of chromosomal
abnormalities. Journal of tropical pediatrics, 1995, 41:77–80.
Zaidan ZAJ et al. Deliberate self-poisoning in Oman. Tropical medicine and
international health, 2002, 7:549–556.
Pakistan
Overview
Pakistan comprises four provinces: Baluchistan, North-west Frontier
Province, Punjab and Sind, in addition to the federally administered tribal
areas and federal capital territory of Islamabad. It is bordered by China,
Afghanistan, Islamic Republic of Iran and India, having a population of
151.8 million (excluding an estimated 3–4 million Afghan and Bangladeshi
immigrants) and an area of 796 095 km2.
Population growth rate is 1.9%, 43.4% of the population is under 15
years of age and 3.5% above 65 years of age (2001). Total adult literacy rate
is estimated at 53%, and adult female literacy rate is estimated at 42%
(2001). The crude birth rate is estimated at 27.3 per 1000 population and the
total life expectancy at birth is estimated at 63 years (2002). The infant
mortality rate is estimated at 80 per 1000 live births (2002), maternal
mortality ratio 35.0 per 10 000 live births, and under-5 mortality rate 103 per
1000 live births (2001). The per capita gross national product is US$ 495 and
the Ministry of Health budget is 3.5% of the national budget (1999). The per
capita expenditure on health by the Ministry of Health is US$ 4 as compared
to the national expenditure of US$ 15. The rates for physicians, dentists,
nurses/midwives and beds per 10 000 population are 7.3, 0.4, 4.7 and 6.8,
respectively (2003).
The National Ninth Five-Year Development Plan (1998–2003) and
prospective plan for 2003–13 emphasized the qualitative improvement of
primary health care services, developing public–private–nongovernmental
organization partnerships, community involvement in planning,
210
Mental health in the Eastern Mediterranean Region: reaching the unreached
implementation and monitoring of services while following the principles of
equity, efficiency and effectiveness.
Health network
The existing network of health services in the public sector consists of
865 hospitals, 4523 dispensaries, 4484 basic health units, 513 rural health
centres and 262 tuberculosis centres. There were 89 929 hospital beds and
78 470 registered doctors, 3159 dentists, 28 661 nurses, 4589 lady health
visitors, 42 000 lady health workers and 21 840 midwives (December, 1996).
Mental health
At the time of Pakistan’s creation in 1947, there were only three
mental hospitals, at Lahore, Hyderabad and Peshawar, and a psychiatric unit
at the Military Hospital in Rawalpindi. It was during the 1960s and 1970s,
with the development of effective methods of treatment, biological and
psychosocial, that psychiatric units were gradually established in all the
medical colleges of the country. Provision of mental health services is
currently reliant on 320 psychiatrists based in major urban centres.
Departments of psychiatry have been established in all the 18 public medical
colleges and four of the 19 private medical colleges in the country.
At the undergraduate level, behavioural sciences have been
incorporated into the curricula of all the medical schools in Pakistan. An
indigenous behavioural sciences teaching module has been developed for
medical students, and a demonstration project of community-oriented
medical education with a significant stress on behavioural sciences was
initiated in 1998 in four of the public sector medical colleges, one in each
province of the country.
The College of Physicians and Surgeons, Pakistan is the main
certifying body for postgraduate training in psychiatry, having a four year
training programme leading to fellowship in psychiatry. In addition
universities also offer MDs and diploma training courses for shorter
durations.
There are two centres at Lahore and Karachi for training of clinical
psychologists, and they train about 20 clinical psychologists every year.
Currently about 400 clinical psychologists are available in the country.
Pakistan
211
Psychiatric nursing is being offered as a separate subject at all the
nursing institutions in the country, and a curriculum for psychiatric nursing
has been developed, At the undergraduate level psychiatry is taught during
second, third and fourth years of training along with practical training. A
two-year postgraduate diploma for psychiatric nursing has been initiated in
nurses training colleges in the country, and so far 52 psychiatric nurses have
qualified. In addition, 287 nurses have been trained at the Institute of
Psychiatry, Rawalpindi, in community psychiatric nursing.
There is no provision for training of psychiatric social workers at the
university departments. Thirty social welfare officers have received training
at the Institute of Psychiatry, Rawalpindi, as part of the human resources
development initiative.
Epidemiological studies carried out in Pakistan have shown that 10%–
66% of the general population suffers from mild to moderate psychiatric
illnesses in addition to the 0.1% suffering from severe mental illnesses.
Prevalence of severe mental retardation in children between 3 and 9
years of age has been estimated at 16–22 per 1000.
According to recent estimates, there are 4 million substance abusers in
Pakistan (2000). The most common substance of abuse is heroine (49.7%),
and 71.5% of the abusers are below 35 years of age. There are about 232
facilities for drug detoxification all over the country.
In the light of the above facts it is evident that it will not be possible in
the foreseeable future to realize the objective of the national programme of
mental health if reliance is placed exclusively on specialized human
resources.
The national mental health programme of Pakistan was the first one in
Eastern Mediterranean Region to be developed, in 1986 at a
multidisciplinary workshop, and incorporated in the seventh, eighth and
ninth five-year national development plans. It aims at universal provision of
mental health and substance abuse services by their incorporation in primary
health care. The strategies for realizing this aim are:
•
teaching and training of personnel at all tiers of primary health care
and incorporation of mental health and behavioural sciences in the
curricula of health, education, social sciences and law enforcement
institutions
212
•
•
•
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
strengthening of existing centres and establishment of new psychiatric
centres
streamlining adequate referral services and provision of essential
drugs
a multidisciplinary approach, intersectional collaboration (with social
services, nongovernmental organizations and the private sector) and
linkage with community development.
rapid expansion and development of specialized human resources
base.
Progress of work
In order to realize the aims of the national mental health programme, a
national coordinating group comprising psychiatrists, psychologists,
economists, public health experts and policy-makers has been set up. The
priority areas for action were identified as follows.
Development of a model of mental health care delivery integrated within
primary health care
This model was initially developed in two subdistricts of Rawalpindi,
and is being replicated in parts of all provinces of the Pakistan. Most of the
policy-level and field-level administrators have been provided with
orientation in the field of mental health, including those from the armed
forces, which has resulted in the setting-up of mental health training
programmes as part of the ongoing in-service training programme of district
health development centres. These centres have been set up to build the
capacity of primary care personnel to handle common health problems by
organizing on-the-job training for them. Mental health has been included in
the regular programmes of training being run by these centres in Punjab and
over the coming years it will be expanded to the other provinces. More than
2000 primary care physicians have so far been trained in mental health.
Similarly training manuals have been prepared for local health volunteers,
local health workers and multipurpose health workers, and so far more than
40 000 have received training all over the country, in a decentralized manner,
under the District health development centres initiative. So far, more than 65
junior psychiatrists have been trained in community mental health in order to
act as resource persons in development of community mental health
Pakistan
213
programmes in their areas and to provide the training, referral and evaluation
support to integration of mental health in primary health care. In addition to
psychiatrists from Pakistan, mental health professionals from Egypt, Islamic
Republic of Iran, Morocco, Nepal, Palestine, Sudan, Tunisia and Yemenhave
been trained in community mental health, to act as resource persons in their
respective countries.
A national essential drugs list has also been formulated which includes
all the essential neuropsychiatric drugs included in the WHO list.
Another major development has been the acceptance in principle to
include indicators for mental illnesses as part of the national health
management information system. This is a crucial development for
integrating mental health into primary health care.
The government of Pakistan has now agreed to fund the integration of
mental health in primary health care on a national scale and a separate
budget has been allocated for this purpose.
Human resources development
See the above sections.
Intersectoral collaboration for promotion of mental health and prevention of
neuropsychiatric illnesses
Development of a school mental health programme. During the
demonstration phase it was realized that schools can play an effective role in
stimulating community efforts for mental health care provision. This
realization led to the development of a school mental health programme. The
programme is both child- and environment-centred and works through a
series of four phases: familiarization, training, reinforcement and evaluation
to achieve its objectives.
During 2000, a mental health component was included in teachertraining programmes at national level. So far more than 150 education
administrators from all provinces have been provided with orientation
training.
Training of master trainers from all provinces (batches of 40 for four
months each) would start from January 2001. Text book boards of all
provinces are being approached for inclusion of mental health issues in the
school curricula being prepared by them.
214
Mental health in the Eastern Mediterranean Region: reaching the unreached
Activities with faith healers. Faith healers and religious leaders are the
first port of call for the majority of the mentally ill patients. Thus the
potential benefits of involving the faith healers, rather than antagonizing
them, in the provision of mental health services are manifold, foremost being
the perception by the community that services are in line with their health
belief system. After the initial reservations were overcome, a relationship
beneficial to the mentally ill in the community was forged. One particular
research project in this regard is worth mentioning which shows that about
25% of the patients presenting to faith healers in a subdistrict of 0.5 million
were given “medical diagnoses” and referred to the nearest health facility, a
significant departure from past practices.
Activities with nongovernmental organizations. Nongovernmental
organizations are taking on an increasingly important role in developmental
activities. The National Rural Support Programme is an organization active
in the field of income generation, education, agriculture, forestry, tourism
and health, having access to about 20 000 village-level organizations. The
programme and its sister organizations have agreed to include mental health
among all its activities and about 20 000 community activists will be trained
each year through this initiative, highlighting the role of mental health in
national development activities.
Research and publications
Lack of indigenous research has been a major hindrance in rational
planning and allocation of resources, however over the last few years a
number of research papers have been published. The major areas of research
activity include: mental health policy research, epidemiological research,
health systems research, economic evaluation of models of mental health
care delivery, development and validation of research instruments,
evaluation of intersectoral linkages, and clinical research.
Legislation
The government of Pakistan has repealed the mental health act of
1912–26. A new mental health law embodying the modern concept of mental
illnesses, treatment, rehabilitation, and civil and human rights was
promulgated on 20 February 2001.
Pakistan
215
It can be safely concluded that in Pakistan mental health is making
progress towards its goal of integration of primary health care.
Summary update (Mental health atlas, 2005)
Epidemiology
Mumford et al (1996, 1997) used the Bradford Somatic Inventory to
screen a general population sample in two rural areas. Further interviews
were conducted using ICD-10 research diagnostic criteria. About 46% and
66% of women and 15% and 25% of men suffered from anxiety and
depressive disorders. Emotional distress was associated with age, social
disadvantage (in both genders), living in unitary households (in women) and
lower education (in younger subjects). Ahmad et al (2001) used the Bradford
Somatic Inventory (BSI) and Self-Reporting Questionnaire (SRQ) in another
rural sample (n = 664) and found that 72% of women and 44% of men were
suffering from anxiety and depressive disorders. BSI and SRQ scores had
negative correlations with socioeconomic factors. In contrast, in an urban
slum sample only 25% of women and 10% of men had depression and
anxiety (Mumford et al, 2000). Emotional distress was associated with age
(in both genders), less education (in younger women) and low financial
status (in women) as in the previous study, but in the urban setting women
living in joint households reported more distress than those living in unitary
families. Husain et al (2000) conducted a two-phase survey of a rural general
population sample, employing the Personal Health Questionnaire and the
Self-Rating Questionnaire for screening (n = 259) and the Psychiatric
Assessment Schedule and Life Events and Difficulties Schedule for detailed
assessment. The adjusted prevalence of depressive disorders was 44.4%
(25.5% in males and 57.5% in females). Nearly all cases had lasted longer
than 1 year. In comparison to non-cases, the affected individuals were less
well educated, had more children and experienced more marked,
independent chronic difficulties. Rabbani and Raja (2000) interviewed 260
mothers in an urban squatter settlement with the Aga Khan University
Anxiety and Depression Scale (AKUADS) and found probable mental
disorder in 28.8%. Psychiatric morbidity was associated with older age
group, longer duration of marriage, interpersonal conflicts with husband or
in-laws, husband’s unemployment, lacking permanent source of income and
216
Mental health in the Eastern Mediterranean Region: reaching the unreached
lack of autonomy in making decisions. Khan and Reza (2000) conducted a 2year analysis of reports related to suicide in a major newspaper in Pakistan
(n = 306 suicides reported from 35 cities). Prevalence of suicide was
associated with gender (male), age (under 30 years) and marital status
(unmarried for men and married for women). More than half the subjects
used organophosphate insecticides. Khalid (2001) analysed the pattern of
suicide in a region based on newspaper reports (n = 1230 news-items) and
found a similar profile. Males adopted more violent methods (61.20%) while
females more often ingested chemicals (35.20%). Khan and Reza (1998)
reviewed records of 262 female and 185 male suicidal inpatients. Three
quarters of the suicidal persons were under the age of 30 years. Compared to
men, women were younger and more often married. Benzodiazepines were
the commonest drugs used for self-poisoning among both genders, but
women used organophosphorus insecticides more often than men. Javed et al
(1992) used the Rutter Scale and found emotional and behavioural disorders
in 9.3% of children. Yaqoob et al (1995) assessed a stratified sample
(n = 1303) of urban children from 2 to 24 months of age for serious mental
retardation (DQ<50). The incidence per 1000 live births was 22 in the periurban slums, 9 in the urban slums, 7 in a village and 4 in an upper middle
class group. Down syndrome was the most common cause of severe mental
retardation (36%). Durkin et al (1998) conducted a two-stage survey of 2–9
year-old children obtained via cluster sampling (n = 6365) using the Ten
Questions screen for disabilities and structured medical and psychological
assessments. Prevalence of mental retardation was 1.9% for serious
retardation and 6.5% for mild retardation. Lack of maternal education,
perinatal difficulties, neonatal infections, postnatal brain infections and
injury and malnourishment were associated with mental retardation. Bashir
et al (2002) identified mild mental retardation in 6.2% of children in a
community sample of 6–10 year olds by a two stage method using the Ten
Questions as a screening tool (n = 649 families), psychometric tests (WISCR and Griffiths) and clinical interviews. The distribution of mild mental
retardation was uneven, the prevalence being 1.2% among children from the
upper-middle class, 4.8% in the rural setting, 6.1% in urban slums and
10.5% in the poor peri-urban slums. Additional impairments were found in
Pakistan
217
three quarters of the children with mental retardation, of which speech
impairment was the most common.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1997. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation. Intersectoral collaboration is also a component
of the policy. The mental health policy envisages to train primary care
providers, to establish resource centres at teaching hospitals and psychiatric
and detoxification centres, to set up monitoring and evaluation systems and
to prepare training and teaching modules. Special facilities would be
established for mentally handicapped. Crisis intervention and counselling
services for special groups of population would be started. Large mental
hospitals would be reorganized and upgraded.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1997. It includes interventions for both reduction of supply
and demand. The policy is being implemented by the Planning Commission
of the Government of Pakistan.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1986. The national mental health programme is a part of the
general health policy of the country and is aimed at incorporating mental
health in primary care, removing stigma, caring for mental health and
substance abuse patients across the country and maintaining principles of
equity and justice in the provision of mental health and substance abuse
services. It was fully implemented in 2001. It does not have a specific
suicide reduction plan.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1997.
218
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health legislation
In February 2001, a new mental health ordinance 2001 was enacted.
The new ordinance puts emphasis on promotion of mental health and
prevention of mental illness. It provides encouragement to community care
and proposes the establishment of powerful federal mental health authority
by the Government. It provides protection of the rights of the mentally ill
and promotion of the mental health literacy. It also provides the guidelines
for the development and establishment of new national standards for the care
and the treatment of patients. Informed consent for treatment and
investigations can be obtained from the patient or his/her relatives.
Mental health financing
There are budget allocations for mental health. The country spends
0.4% of the total health budget on mental health. The primary sources of
mental health financing in descending order are out of pocket expenditure by
the patient or family, tax-based, social insurance and private insurance.
The country has disability benefits for persons with mental disorders.
Disability benefit is paid to individuals who are not able to work due to
mental illness.
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is available at the primary level. The
programme has initially started in Punjab, the largest province, in 1985 and
is being extended to others over the years. There are many residential and
day-care facilities, especially for people with learning disabilities providing
social, vocational and educational activities.
Regular training of primary care professionals is carried out in the
field of mental health. Training programmes have started in the province of
Punjab as a part of in-service training for primary care personnel. Till now,
approximately 2000 primary care physicians and 42 000 primary care
workers have been trained. Community activists from nongovernmental
organizations (e.g. National Rural Support Programme (NRSP) are also
being trained. Although there are training programmes for physicians, nurses
and psychologists, there are no such facilities for social workers. Mental
health training has been included in the programme of the District Health
Development Centres. The Institute of Psychiatry Rawalpindi Medical
Pakistan
219
College was the first WHO collaborating Centre for mental health in the
Eastern Mediterranean Region and is acting as a resource centre at national
and regional level for training, services information system and research.
Multiple training manuals for primary health care physicians, paramedics,
community workers and teachers have been developed. In an additional
training package on counselling skills for health professionals, a package for
rehabilitation of the mentally ill has been developed. Personnel from
Afghanistan, Egypt, Islamic Republic of Iran, Morocco, Nepal, Palestine,
Sudan, Tunisia and Yemen have been trained in the Institute of Psychiatry.
The National Steering Committee evaluates the quality of care delivery on a
regular basis.
There are community care facilities for patients with mental disorders.
The community mental health programme was planned in a phased manner.
The first phase included collection of data pertaining to demographics,
knowledge, attitudes and beliefs about mental health and sensitization of the
community towards mental health. The second phase involved training of
personnel in mental health. The third phase involved stimulation of
community activities through advocacy campaigns using religious leaders
and developing a workable referral system. In the final phase, qualitative
changes were incorporated in the services and steps were taken to improve
the knowledge of the population about mental health. The programmes have
been initiated in all provinces but have not been generalized to the whole
population. More than 78 junior psychiatrists have been trained in
community mental health to act as resource persons in the development of
programmes in their areas.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
0.24
0.06
0.148
0.02
0.2
0.2
0.08
0.14
0.2
220
Mental health in the Eastern Mediterranean Region: reaching the unreached
Number of social workers per 100 000 population
0.4
There are about 2000 other mental health personnel. There are four
mental health hospitals in the country. All medical colleges have psychiatric
units. Psychiatric units are also present in allied hospitals in both public and
private sector. Some psychiatric care facilities are available at the tehsil
level. Beds for the treatment of drug abusers are available at most hospital
facilities (232 centres). Forensic beds are available at a few centres. There
are two child psychiatrists in the country. Mental health professionals are
concentrated in big urban centres. Most psychiatrists have private clinics.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention,
treatment and rehabilitation. Some of the nongovernmental organizations
like the Fountain House have done exemplary work in order to build the
foundation of rehabilitation psychiatry in Pakistan. A concept of agrotherapy
for the rural population has evolved. Recently, the organization the National
Rural Support Programme decided to include mental health among their
activities.
Information gathering system
There is no mental health reporting system in the country. A mental
health reporting system has been initiated in the National Health
Management Information System (HMIS). The country has a data collection
system or epidemiological study on mental health. An information system
for using in tertiary facilities has been developed at the WHO Collaborating
Centre at Rawalpindi. It has been agreed that the HMIS will collect
information from primary care centres on depressive illness, substance abuse
and epilepsy.
Programmes for special populations
The country has specific programmes for mental health for refugees
and children. Nongovernmental organizations are involved in service
provision and advocacy for the above groups. Afghan refugees are being
provided with services by international organizations. There are also
facilities for women and victims of torture.
Pakistan
221
There are some facilities for children in the larger hospitals and
regional hospitals, but the most parts of the country have no facilities for
child and adolescent psychiatry. There are many residential and day care
facilities for people with learning disabilities, especially in big cities. There
is a school mental health programme and it aims to develop awareness of
mental health among schoolchildren, schoolteachers and the community; to
provide essential knowledge about mental health to teachers so that they are
able to impart that to the students and are able to recognize and provide
some counselling to the students for basic psychological problems. Its
positive impact has been evaluated and published in international journals.
Mental health issues have been incorporated in the teacher training
programme at the national level. Text book boards have been approached for
inclusion of mental health topics in school curricula.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital,
chlorpromazine, diazepam, haloperidol. Imipramine is supplied instead of
amitriptyline. Procyclidine is supplied.
Other information
Active community research has been conducted regarding mental
health in the last few years which has been published. The innovative
community mental health programme included the faith healers. Human
resources development at national and international level has been carried
out. Print as well as electronic media have been utilized to spread mental
health education. Collaboration with schools and nongovernmental
organizations like the National Rural Support Programme has been
established. Public educational material on sleep disturbance, anxiety
disorder, phobias, drug dependence, depression and psychosis is available.
Pakistan is actively involved in developing guidelines for economic analysis
of community mental health care programmes in low-income countries.
Additional sources of information
Ahmad I, Saeed K, Mubbashar MH et al. Minor psychiatric morbidity and
socio-economic factors. Medical forum monthly, 2001, 12:5–8.
222
Mental health in the Eastern Mediterranean Region: reaching the unreached
Bashir A, Yaqoob M, Ferngren H et al. Prevalence and associated
impairments of mild mental retardation in six- to ten-year old children in
Pakistan: a prospective study. Acta paediatrica, 2002, 91:833–837.
Durkin MS, Hasan ZM, Hasan KZ. Prevalence and correlates of mental
retardation among children in Karachi, Pakistan. American journal of
epidemiology, 1998, 147:281–288.
Monograph on mental health institute of psychiatry and WHO collaborating
centre for mental health research and training, Cairo, Regional Office for the
Eastern Mediterranean, 2000.
Gadit AA, Khalid N. State of mental health in Pakistan. Hamdard University.
Karachi, 2002.
Gater R, Rehman ChU. Mental health and service developments in the
Rawalpindi district of Pakistan. Journal of college of physicians and
surgeons Pakistan, 2001, 11:210–214.
Husain N, Creed F, Tomenson B. Depression and social stress in Pakistan.
Psychological medicine, 2000, 30:395–402.
Javed MA, Kundi MZ, Khan PA. Emotional and behavioural problems
among school children in Pakistan. Journal of the Pakistan Medical
Association, 1992, 42:181–183.
Karim S, Saeed K, Rana MH. Pakistan mental health profile. International
review of psychiatry, 2004, 16:83–92.
Khalid N. Pattern of suicide: causes and methods employed. Medical forum
monthly, 2001. 12:27–29.
Khan MM, Reza H. Gender differences in nonfatal suicidal behaviour in
Pakistan: significance of sociocultural factors. Suicide and life-threatening
behavior, 1998, 28:62–68.
Khan MM, Reza H. The pattern of suicide in Pakistan. Crisis. Journal of
crisis intervention and suicide, 2000, 21:31–35.
Mental Health Programme Country Report of Pakistan for Regional
Consultation on World Health Report, 2000.
Ministry of Health report of the sub-committee on health and substance
abuse. Planning Commission. Government of Pakistan, 1998.
Pakistan
223
Ministry of Health Mental Health Policy. Ministry of Health Government of
Pakistan,1997.
Mubbashar MH, Saeed K. Developing models of balanced mental health
care: the case of Pakistan. World psychiatry, 2002, 1:100–101.
Mubasshar MH. Development of mental health services in Pakistan.
International psychiatry, 2003, 1:11–13.
Mumford DB. Stress and psychiatric disorder in rural Punjab - A community
survey. British journal of psychiatry, 1997, 170:473–78.
Mumford DB, Minhas FA, Akhtar I et al. Stress and psychiatric disorder in
urban Rawalpindi. Community survey. British journal of psychiatry, 2000,
177:557–562.
Mumford DB, Nazir M, Jilani F-U-M et al. Stress and psychiatric disorder in
the Hindu Kush. A community survey of mountain villages in Chitral,
Pakistan. British journal of psychiatry, 1996, 168:299–307.
Mumford DB, Saeed K, Ahmad I et al. Stress and psychiatric disorder in
rural Punjab: a community survey. British journal of psychiatry, 1997, 170:
473–478.
Rabbani F, Raja FF. The minds of mothers: maternal mental health in an
urban squatter settlement of Karachi. Journal of the Pakistan medical
association, 2000, 50:306–312.
Yaqoob M, Bashir A, Tareen K et al. Severe mental retardation in 2 to 24month-old children in Lahore, Pakistan: a prospective cohort study. Acta
paediatrica, 1995, 84:267–272.
Yousaf F. Psychiatry in Pakistan. International journal of social psychiatry,
1997, 43: 298–302.
Occupied Palestinian
Territory
Overview
There are an estimated 3.82 million Palestinians living in the Gaza
Strip and West Bank, (in addition 3 million reside abroad) which together
cover an area of 6162 km2, 49% of whom are urban residents. By age, 46%
of the population is below 15 years and 3.1% above 65 years (2003). The
registered refugee population is distributed in the “fields of operation”, as
follows: Lebanon, 319 000; Syrian Arab Republic, 299 000; Jordan,
1 011 000; West Bank 459 000; and Gaza Strip 560 000.
In 2002, the adult literacy rate and the female adult literacy rate were
estimated at 91% and 86%, respectively. Infant mortality rate is estimated to
be 24 per 1000 live births, under-5 mortality rate 28.5 per 1000 live births,
maternal mortality ratio 2.1 per 10 000 live births, crude birth rate 27.2 per
1000 population, and total life expectancy at birth 72.3 years (2003).
Respiratory diseases are still the leading causes of morbidity and mortality
among children and infants (health status indicators for registered refugees
are generally worse with higher infant mortality rates, and crude birth rates,
i.e. 30–40 per 1000 and 44.4 per 1000, respectively but maternal mortality
rates and under-5 mortality are lower—2.5 per 10 000 and 28.1 per 1000,
respectively while literacy rates are about the same according to UNRWA
data). Per capita gross national product in Palestinian Authority areas is
US$ 1784, and the Authority allocates 5% of its total budget for health,
which comes to 2.5% of gross national product. Per capita expenditure on
health by the Ministry of Health is US$ 39 while nationally it is US$ 143.
Occupied Palestinian territory
225
The rates for physicians, dentists, nurses/midwives and hospital beds per
10 000 population are 8.3, 0.8, 13.1, and 12.5, respectively (2003).
Coupled with an increased level of tension and unrest, the adverse
effects of the continuing conflict situation, loss of employment opportunities
due to mass immigration of Russians to Israel, restrictions on movement of
the population and extended curfews, the unemployment (and
underemployment) rate is estimated to be 30%–40% in the Gaza Strip and in
the inner parts of the West Bank (1997).
Because of the dispersal of the Palestinian people across different
areas and as a result of the lack of a unified political authority, there is no
unified health policy or strategy; rather, the various bodies providing
services have their own characteristics. In addition to the public health
services available in the countries of residence and those provided by the
Palestinian Authority, the main providers of health care for the Palestinian
population are the Palestinian Red Crescent Society and the United Nations
Relief and Works Agency for Palestine Refugees in the Near East
(UNRWA).
UNRWA’s health system is organized at three levels. At the primary
level, outpatient services are provided, where protective/promotive services
are combined with curative medical services and are supplemented by
activities to ensure proper nutrition and improved environmental health in
the refugee camps.
At the secondary level, referral and support services comprise
inpatient care at subsidized hospitals, as well as specialist and rehabilitative
care and other basic support services through contractual arrangements or
individual patient subsidies. At this level, UNRWA also provides partial
subsidy towards the cost of prosthetic devices required to improve the
capacity of disabled persons. There is a small UNRWA-operated cottage
hospital in Qalqilia, West Bank, inherited from the Red Cross in 1950, which
has lately been extended with the addition of an operating theatre and is in
the course of being upgraded.
The Palestinian Red Crescent Society established in 1986 and adopted
in 1990 a national health plan for the Palestinian population, in coordination
with responsible officials in health centres inside the occupied territories as
well as with other Palestinian health institutions beyond their borders.
226
Mental health in the Eastern Mediterranean Region: reaching the unreached
This plan is based on the development of:
•
infrastructure and management of the various Palestinian health
institutions
•
primary health care facilities through the expansion of existing ones,
as well as training of required human resources and purchase of
necessary equipment
•
a mental health programme
•
rehabilitation centres
•
a health human resources plan
•
a drug policy (together with preparation of a list of essential drugs)
•
construction and administrative organization of hospitals
•
encouraging international societies as well as local organizations to be
more involved in health matters.
The Palestinian Red Crescent Society runs 16 hospitals (with a total of
1500 beds), 45 field hospitals, 200 clinics, 15 maternal and child health
centres, 20 dental clinics, 10 rehabilitation centres, 3 nursing schools, 15
blood banks and 28 laboratories. Health staff associated with the Palestinian
Red Crescent, at present, number 364 physicians, 41 dentists and 280 nurses,
in addition to 405 health technicians serving the Palestinian population
outside the occupied territories. A growing number of behavioural disorders
have been observed, especially among young people, who account for 69%
of those wounded during civil disobedience. Moreover, the present situation
of continued pressure, occupation and military action against civilians
which, has been going on for decades and has become much worse recently,
is expected to bring much harm to the psychosocial and behavioural
development of the population, especially children.
According to a special committee of experts that reported to the World
Health Assembly in 1989, the health situation of the Palestinian population
has remained disturbing, despite the praiseworthy efforts made by the health
workers concerned. The committee found that this situation was largely
associated with the lack of a structured health system designed to provide
appropriate primary, secondary and tertiary care. This, in turn, is largely due
to the fact that the health system is not specific to the territories, nor is it
independent, but is regarded as an extension of the Israeli system. This
dependency is at the root of the non-existence of long-term health planning,
Occupied Palestinian territory
227
which can be undertaken only within the framework of an economic and
social development plan, and in the present situation, this can only be the
Israeli plan.
Since the start of the intifada, many people’s committees have been
formed in villages, towns and refugee camps to help the implementation of
health programmes. These committees are concerned with health and social,
emergency and ambulatory services. Furthermore, syndicates, unions,
religious groups and charitable and voluntary organizations contribute to the
implementation of health programmes such as those for safe drinking water,
sanitation, environmental health, health education, immunization and
maternal and child health activities and campaigns. In addition, intifada
committees have played a vital role in combating drug trafficking and
addiction and in distribution of food rations during curfew periods.
Mental health
Epidemiological data on mental illness among the Palestinian
population are not available. However, reports by psychiatrists working in
some of the field areas, reports of brief visits by child mental health
consultants and results of an exploratory study confirm that there is a high
frequency of mental health problems in the refugee population. The Director
of Mental Health Services, Gaza, reported in 1989 that there was a high
incidence of hysteria, anxiety, depression and psychosocial problems
presenting with somatic complaints. Discussing the increasing incidence of
mental health problems, the report says that:
… scattered throughout the world, the Palestinians do not feel at home
anywhere. They are unwanted everywhere and are regarded as a
source of potential trouble. Their anger and fear are turned into
aggression. Daily life is a continuous story of fighting. Violent
demonstrations are common occurrences in the life of Gaza and the
West Bank. Cases of anxiety, depression and psychotic reactions are
frequently seen following confrontations. Children’s problems like
outbursts of temper and aggressive behaviour, sleep disturbances and
anxiety are also on the increase.
228
Mental health in the Eastern Mediterranean Region: reaching the unreached
In 1989 UNRWA in collaboration with Rädda Barnen (Save the
Children, Sweden) carried out a research study of psychosocial problems in
children (health centre interviews, home interviews and child observation) in
Jabal al Hussein and Marka refugee camps in Amman, Jordan, which also
confirmed the high frequency of psychosocial disturbances among the
children. These disturbances were noted to be partly due to lack of
stimulation.
Against this background, in June–July 1989, a WHO short-term
consultant reviewed the situation and developed a draft mental health
programme for UNRWA in 1989. It has the following objectives: to provide
essential mental health care, which includes not only treatment and
prevention of mental disorders, but also promotion of mental health, for all
the refugee population; to enhance the use of mental health knowledge, skills
and attitudes in general health care and in social development; to add mental
health inputs into education and the school health services for amelioration
and prevention of social, behavioural and learning problems among children,
and to promote healthy psychosocial development of every refugee child;
and to encourage community participation in the development of mental
health services and generate self-help in the community.
Strategies and approaches identified were integration of mental health
with existing services; training of personnel; mental health tasks for different
categories of personnel; strengthening of the mental health infrastructure and
building of a referral system; provision of essential drugs for mental health
care; development of an information system; services for special groups such
as mentally retarded children, preschool children, schoolchildren;
rehabilitation care for drug-dependent persons; and administrative support.
The essential first step envisaged for the mental health programme
implementation was the appointment of a core officer/group responsible for
mental health at UNRWA headquarters. This core officer/committee would
assess priorities in mental health as part of general health and welfare
programmes, facilitate provision of know-how for the mental health
programme and allocate resources and monitor the programme. Similarly, at
the field operations level, a mental health programme coordination
committee could be constituted with representation from the curative and
preventive medical care, nursing, education and relief services sections of
Occupied Palestinian territory
229
UNRWA and other related sectors. The implementation of the mental health
programme in each field area was to be the responsibility of this committee.
Progress
The recognition of the mental health needs of the refugee population
outlined above has resulted in a number of positive developments. The Gaza
community mental health programme was established in 1990 in order to
meet the most immediate needs by providing effective psychosocial therapy
for affected children and their families; devise training programmes for
mental health workers and other community workers (teachers, social
workers, health workers and others) in mental health; conduct research to
document and contribute to the understanding of the psychological,
psychosocial, psychopolitical and psychiatric problems in Gaza; establish a
multidisciplinary team of professionals and paraprofessionals to form the
basis for the comprehensive ongoing mental health programme; provide
preventive, curative and rehabilitative services for the population of the Gaza
Strip; develop a focal point in the Eastern Mediterranean Region for the
exchange of information, staff and students from other centres around the
world for increasing the understanding of mental health and psychosocial
issues of displaced populations; and through a programme of public
education, raise the general public’s awareness of mental health issues.
Community mental health programmes have trained 28 psychiatric social
workers, 24 psychiatric nurses, 24 primary care doctors, 24 teachers, 144
child care workers and 25 nongovernmental organization staff in mental
health. A manual has been developed in country for physicians, primary care
workers and schoolteachers. Innovative approaches developed are in the
areas of school mental health, nongovernmental organization initiatives and
the formation of self-help groups.
Mental health facilities
There are two psychiatric hospitals, in Gaza with 34 beds (started in
1979) and in the West Bank with 320 beds (started in 1960). There are two
general hospital psychiatric units at Nablus and Tulkarm with four inpatient
beds each (established in 1980). There are no private psychiatric hospitals.
There is a child mental health clinic and the Gaza Community Mental Health
230
Mental health in the Eastern Mediterranean Region: reaching the unreached
Centre. There are no specialized drug dependence treatment centres.
Nongovernmental organizations such as the Swedish International Relief
Association run facilities for the mentally retarded.
Mental health human resources
There are 18 psychiatrists, of whom 15 are in government service and
3 in private practice. There are 40 clinical psychologists—13 in government
service and 27 in the private sector. There are 17 trained social workers and
72 trained psychiatric nurses are working in the country. An important
development has been the deputation of four medical officers of UNRWA for
specially planned mental health training at WHO collaborating centres in
Manchester, UK, and Bangalore, India. These four medical officers
completed their training in 1992 and returned to work with the Palestinian
population.
The training of undergraduate medical students consists of 20 hours of
lectures, 20 hours of clinical work and posting during internship. Psychiatry
is included as an examination topic as part of general medicine practices.
There is no mental health specialist training facility in the country. In
September 1995, a research methodology workshop on priorities of mental
health services was conducted. The future priorities identified were
epidemiological studies of mental health problems in adults and children;
drug dependence and trauma-related disorders.
Recent developments
During the past decade a large number of studies have reported high
levels of psychosocial problems among children and adolescents, women,
refugees and prisoners. A study conducted by the Gaza Community Mental
Health Programme on the prevalence of post-trauma stress disorders (PTSD)
among children 10–19 years of age revealed that 32.7% suffered from a high
level of PTSD needing psychological intervention, 49.2% suffered from
moderate PTSD symptoms, 15.6% suffered from a low level of PTSD and
only 2.5% had no symptoms. Boys had higher rates (58%) than girls (42%)
and children living in camps suffered more than children living in towns
(84.1% and 15.8% respectively).
Occupied Palestinian territory
231
In a report from the University of Geneva on Palestinian perceptions
of their living conditions during the second intifada, it was observed that
46% of parents reported aggressive behaviour among their children, 38%
noted bad school results, 27% reported bedwetting, while 39% stated that
their children suffered from nightmares. The study also revealed that more
refugee children (53%) than non-refugee children (41%) behave
aggressively: 38% of the respondents said that shooting was the main
influence, 34% stated that it was violence on television, 7% cited
confinement at home and 11% specified that it was the arrest and beating of
relatives and neighbours; 70% of refugees and non-refugees stated that they
had not received any psychological support for the problems of their
children.
Save the Children (United States) and the Secretariat of the National
Plan of Action for Palestinian Children in collaboration with Save the
Children (Sweden) conducted an assessment of the state of well being of
Palestinian children in the occupied Palestinian territory. The majority of
sampled children (93%) reported feeling unsafe and exposed to attack. They
feared not only for themselves but also of their family and friends. Almost
half of the children (48%) had personally experienced violence. One out of
five children (21%) had moved out of their homes. Children in the Gaza
Strip were generally more affected than children in the West Bank. Children
in urban and refugee camp settings were also more affected than children in
rural areas. More than half the children (52%), especially the somewhat
older children in the sample (59%), felt that their parents can no longer fully
meet their needs for care and protection. Care givers (mainly parents and
teachers) themselves were stressed and frustrated, having less emotional and
mental energy to provide the necessary psychosocial support to their
children. 65% of parents reported significant interaction with their children
through dialogue, 12% reported some interaction, while 23% of parents did
not have any meaningful interaction. Nine out of ten parents reported
symptomatic traumatic behaviour among their children, ranging from
nightmares and bedwetting, to increased aggressiveness and hyperactivity, as
well as a decrease in attention span and concentration capacity.
In a series of studies over the past 10 years by the Gaza Community
Mental Health Centre, the following findings are reported:
232
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
the more traumatic experiences children had, the more they
participated in the intifada, and the more there were concentration,
attention and memory problems, as well as increased neuroticism and
risk-taking behaviour along with decreased self-esteem;
•
greater exposure to traumatic events was associated with children
perceiving their parents as disciplinarian, rejecting and hostile, with
boys perceiving their parents more negatively than girls;
•
the more traumatic events children experienced, the more political
activity they were involved in, and the more they suffered from
psychological adjustment problems, althrough good parenting was
protective to children;
•
the level of neuroticism was significantly lower after the peace treaty
of 1993, and the more creative children were, the more their neurotic
symptoms decreased because of the peace treaty;
•
adults exposed to house demolition showed higher levels of anxiety,
depression and paranoic symptoms than those only witnessing
demolition and the control group, while women suffered more
symptoms than men and the findings were similar in children;
•
the most prevalent types of trauma exposure for children were
witnessing funerals (95%), witnessing shooting (83%), seeing injured
or dead strangers (67%) and having a family member injured or killed
(62%);
•
among children living in the area of bombardment, 54% suffered from
severe PTSD, 33.5% moderate levels and 11% mild and doubtful
levels, with girls being more vulnerable;
•
men experienced more traumatic events, but exposure was associated
with more severe psychiatric disorders among women, while
peritraumatic dissociation as an acute response to trauma constituted a
risk for mental health symptoms in both men and women.
Among studies of general medical practitioners, focused on attitudes
to mental illness, the ability to detect mental disorders among primary care
patients and the characteristics of PTSD among patients attending primary
health care facilities in the Gaza Strip, older doctors had significantly more
traditional attitudes than the younger doctors. General practitioners detected
only 12% of patients with mental disorders, while those with postgraduate
Occupied Palestinian territory
233
training, female doctors and those over 40 years old had better detection
rates. The overall prevalence of PTSD symptoms in primary health care
patients was 29%, and was higher among females and those exposed to
traumatic events.
The current situation regarding the mental health needs of the
population of the occupied Palestinian territory can best be described as an
area of high recognition and need with limited care programmes. Over the
past few years there has been high recognition of the need for
psychosocial/mental health care of the Palestinian population living in the
West Bank and the Gaza Strip. A large number of initiatives have been
undertaken by UNRWA, the Ministry of Health of the Palestinian Authority
and a large number of nongovernmental organizations. Coordination of the
mental health activities of the Ministry of Health and UNRWA has been
initiated. There has been increasing utilization of mental health services by
the population from 2000 onwards, with an average increase of 20%
annually, despite the stigma about mental disorders. Evaluation has been
done of the work of psychosocial counsellors and mid-course correction
made of the UNRWA psychosocial programme.
The mental health needs of the Palestine refugees can be considered
under three broad groups. The first is the need for services related to the
psychiatric illnesses (schizophrenia, manic depressive psychosis, depression,
substance abuse, epilepsy, mental retardation, etc.) which are known to be
prevalent in about 5% of the population. These conditions are important as
they contribute to the global burden of diseases (about 12% in 2001) and
effective interventions are available to provide care to this group of persons.
Early interventions can reduce disability and promote recovery. Care of
persons with these disorders can be undertaken both by the mental health
specialists and for some, e.g. epilepsy, by primary health care personnel.
The second is the need for services to address behavioural changes
and the common mental disorders that are present among those seeking
primary health care. Most studies have shown this to range between 10% and
20% of the general medical clinic population. Most of these disorders are
related to psychosocial stress factors in the lives of patients. This group of
patients most frequently present with somatic complaints and are not
recognized as having nonphysical problems by general medical personnel. In
234
Mental health in the Eastern Mediterranean Region: reaching the unreached
one study in the Gaza Strip, the recognition rate was only 12%.
Nonrecognition often leads to unnecessary investigations and use of
nonspecific medicines, such as analgesics and vitamins, without benefit to
the patients. In addition, this group is known to utilize primary health care
more than those with physical disorders. There is another group of patients,
including those with diabetes, hypertension and cancer, in which
psychosocial factors play an important role. In both these groups of patients
coming to primary health care, a number of interventions are known to be
effective. The interventions can range from patient education about the link
of physical complaints to life situation (reinterpretation), teaching of
relaxation, providing opportunities for sharing of feelings and problems,
counselling, problem-solving skills, group-work and use of
tranquillisers/antidepressants for limited periods of time. All of these
interventions can be undertaken by both the medical officers and other staff,
such as nurses, at primary health care facilities.
The third group of mental health needs is for services to address the
psychological reactions in the general population (especially children and
youth), that are a result of living with the wide variety of stresses associated
with being a refugee and living in a situation of occupation. There are studies
showing that this is an important area for mental health intervention.
Interventions for this large group of people are more focused on preventive
and promotive activities. These can be undertaken at the general population
level through community-level interventions, at the family level and at the
individual level in settings such as schools and health facilities.
Additional sources of information
Qouta S, El-Saraj E. Community mental health as practiced by the Gaza
community mental health programme. In: Jong JD. Trauma, war, and
violence: public mental health in sociocultural context, Kluever
Academic/Plenum Publishers, New York, 2002.
Thabet AA, Vostanis P. Social adversities and anxiety disorders in the Gaza
Strip, Archives of disease in childhood, 1998, 78:439–442.
Zakrison TL et al. The prevalence of psychological morbidity in West Bank
Palestinian Children, Canadian journal of psychiatry, 2004, 49:60–63.
Occupied Palestinian territory
235
Thabet AA, Vostanis P. Post-traumatic stress reactions in children of war,
2000. www.gcmhp.net/research/Post_traumatic.html
Qouta S, Punamaki RL, El Saraj E. Prevalence and determinants of PTSD
among Palestinian children exposed to military violence, European Journal
of child and adolescent psychiatry, 2003, 12:265–272.
Thabet AA, Vostanis P. Effect of trauma on the mental health of Palestinian
children and mothers in the Gaza Strip, Eastern Mediterranean health
journal, 2001, 7:413–421.
Qatar
Overview
Qatar has a surface area of 11 493 km2. The country is flat except for
some hills and high ground to the northwest. The population is 656 000 and
the entire population resides in urban areas (2004). The proportion of the
population below 15 years of age and above 65 years of age is 26.6% and
1.3%, respectively (2002). In 1997, the total adult literacy rate and the
female adult literacy rate were estimated at 83% and 81%, respectively. The
infant mortality rate is estimated at 8.7 per 1000 live births, under-5
mortality rate 10.2 per 1000 live births, average life expectancy at birth 74.7
years, crude birth rate 19.8 per 1000 population and maternal mortality ratio
0.0 per 10 000 live births (2002). The per capita gross domestic product in
2003 was US$ 29753.
The per capita Ministry of Health expenditure is US$ 731.4 as
compared to the national expenditure of US$ 935 (2003). The Ministry’s
expenditure represents 7% of the government total expenditures (2003).
There are an estimated 23.5 physicians, 3.6 dentists, 54.8 nurses/midwives
and 23.6 hospital beds, respectively per 10 000 population (2002). Of the
physicians employed by the Ministry of Health, 46% are working in primary
health care delivery. Similarly, 30% of nurses are working in primary health
care services. A nursing college has recently been established in Qatar.
Almost all hospital services in Qatar are controlled by a private
medical corporation—the Hamad Medical Corporation. Recently, a planning
committee, comprising representatives of the various departments of the
Ministry of Health, as well as of hospitals, was established as a nucleus for a
Qatar
237
national planning committee for health development. The licensing
commission for private clinics has been reorganized in such a way that it
enables the public sector to play a supervisory role over private sector
activities, especially where primary health care services are delivered.
The primary health care services and peripheral health clinics are run
by the Ministry of Health. In recent years, in addition to establishing new
health centres, the following steps have been taken to reorient services
towards primary health care:
•
school health services have become the responsibility of the Ministry
of Health and form part of the activities of the Directorate of Primary
Health Care
•
a new Division for Childhood Immunization has been established in
the Ministry of Health to cover immunization against the six diseases
of childhood targeted by the expanded programme on vaccination:
diphtheria, measles, mumps, pertussis, poliomyelitis and tetanus
•
health education has become part of health centres’ activities; the
necessary health promotion leaflets have been prepared for their use.
Mental health
Background
A psychiatric service was first established in Qatar in 1971, soon after
the country’s independence. In 1983, the Department of Psychiatry having
18 beds for male patients and 12 for female patients moved to Rumaillah
Hospital as a part of Hamad Medical Corporation. At that time, most of the
treatment activities were centred on general psychiatry and liaison
psychiatry. Now the central psychiatric facility located at the Rumaillah
Hospital has 220 beds. This facility houses the Departments of Psychiatry,
Rehabilitation, Mental Retardation, Special Education and Geriatric
Medicine. The Department of Psychiatry, besides providing mental health
care to the whole country, also works with three other psychiatric services,
those of school health, the armed forces and the police force. The armed
forces polyclinic has a consultant psychiatrist. The police force polyclinic
has a consultant psychiatrist.
238
Mental health in the Eastern Mediterranean Region: reaching the unreached
There are 5 psychiatrists, 7 residents in psychiatry, 10 social workers,
8 psychologists, 43 nurses and one counsellor as part of the mental health
care system at the central psychiatric facility.
At present, all inpatient admissions are informal; and a 24-hour
telephone line for patients and families, is planned.
National mental health programme and policy
The substance abuse policy was formulated in 1986, and the
therapeutic and essential drugs policy has been in operation since 1980. The
national mental health programme was introduced in 1990 and stresses those
areas related to the community care system in mental health. This will
include action plans to be implemented in the following areas.
•
upgrading of family health physicians’ knowledge and skills through
ongoing periodical courses on mental health
•
establishment of legislation where not available and amendment if
needed
•
family involvement in patient care, early detection of morbidity and
reducing stigma through raising public awareness
•
counselling programmes in school health with the aim of dealing with
psychosocial problems and scholastic failures; special education and
teacher training is also included.
Progress
The Department of Psychiatry at Rumaillah Hospital has been
accredited to the Arab Board Training Programme since 1993. Seven
physicians are enrolled in this active training programme, and four of them
recently obtained their qualification after passing the final exam. Besides the
Arab Board Training Programme, the Department also receives trainees from
the University of Qatar who are studying for the diploma in psychological
counselling. The Department also takes physicians from the primary health
care and dermatology department as part of their internship training
programme. Over 15 personnel have been trained.
Qatar
239
Database
A computerized database information system covering all psychiatric
clinical services is available.
Legislation
There is no formal mental health act in Qatar as yet. It is therefore left
to the discretion of the civil or religious courts to arbitrate in consultation
with psychiatrists when controversy arises. Psychiatry, in turn, plays only an
advisory role with recommendations on the matter. It is planned to establish
a mental health act for Qatar.
Summary update (Mental health atlas, 2005)
Epidemiology
There is substantial epidemiological data on mental illnesses in Qatar
in internationally accessible literature. No attempt was made to include this
information here.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1980. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1986.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1990. The national mental health programme stresses
legislation, family involvement, primary health care and counselling
programmes.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1980.
240
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health legislation
Details about the mental health legislation are not available.
Mental health financing
There are budget allocations for mental health. The country spends 1%
of the total health budget on mental health. The primary source of mental
health financing is tax-based. The country has disability benefits for persons
with mental disorders.
Mental health facilities
Mental health is a part of the primary health care system. Actual
treatment of severe mental disorders is not available at the primary level.
Primary care is provided to a small number of centres. All psychiatric drugs
are dispensed except for controlled drugs. Drug abuse patients are referred to
the psychiatric clinics and only referrals from the catchment areas are seen.
Generally, psychologists attend and handle referrals on-site.
Regular training of primary care professionals is carried out in the
field of mental health. In the last two years, about 15 personnel were trained.
Training courses for physicians from primary health care and dermatology
are held.
There are community care facilities for patients with mental disorders.
A community nursing service was started in 1993 and domiciliary visits for
assessments and home management of patients in liaison with their families
have started. There are also day-care centres at certain hospitals which
impart stress control, assertive training, job training, family education,
increase self knowledge, rehabilitate institutionalized chronic patients and
carry out family-oriented educational programmes.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
0.97
0.97
0
0
3.4
0.8
10
1
Qatar
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
241
1.2
10
There are three other mental health professionals of different
categories. Beds have been earmarked for women patients and for services
related to rehabilitation, mental retardation, special education and
psychogeriatrics.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in treatment.
Information gathering system
There is mental health reporting system in the country. The country
has data collection system or epidemiological study on mental health. A
computerized database information system covering all psychiatric clinical
services includes modern diagnostic criteria and information on treatment
and referral outcomes are possible, but only in the capital city.
Programmes for special populations
The country has specific programmes for mental health for elderly and
children. There are facilities for imparting mental health services to schools.
There are also ambulatory child psychiatry facilities. Psychogeriatric
services consist of an inpatient service with follow-up protocol.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, ethosuximide,
phenobarbital, phenytoin sodium, sodium valproate, amitriptyline,
chlorpromazine, diazepam, fluphenazine, haloperidol, lithium, carbidopa,
levodopa.
Other information
Qatar’s psychiatric service was established in 1971. Almost all
hospital services are controlled by the Hamad Medical Corporation, which is
a government corporation.
Additional sources of information
El-Islam MF. Psychiatry in Qatar. Psychiatric bulletin, 1995, 19:779–781.
Saudi Arabia
Overview
Saudi Arabia has an area of 2 250 000 km2 and a population of 22.68
million (2004). The population of people below 15 years of age and above
65 years of age is estimated at 40.8% and 3.1%, respectively; the total adult
literacy rate and the female adult literacy rate were 80% and 72%,
respectively (1999).
The crude birth rate is 31 per 1000 population (2003). The total life
expectancy is estimated at 71.4 years (2001). The infant mortality rate is
estimated at 19.1 per 1000 live births, under-5 mortality rate 30 per 1000 live
births and maternal mortality ratio 1.8 per 10 000 live births (2000). The per
capita gross national product is US$ 8014 (2002). In 2001, the government
allocation for the Ministry of Health was 7.1% of the budget and 3% of the
gross national product. The per capita spending on health by the Ministry of
Health is US$ 266 (2002). There are an estimated 15.3 physicians, 1.9
dentists, 32.3 nurses/midwives and 22.4 beds per 10 000 population (2001).
Mental health
Historical aspects
The development of mental health care in Saudi Arabia can be seen to
fall into two clear phases. Until 1983, mental health care in the country was
mainly provided by the Taif Mental Hospital. This was a hospital meant for
250 patients, but serving a larger number (for example, in 1978, there were
1800 patients). This also meant that patients had to travel long distances to
Saudi Arabia
243
obtain mental health care. This often resulted in delays in seeking care and,
problems of discharge into the community.
After 1983, a shift occurred in the form of setting-up of smaller-sized
(20–120 beds) psychiatric hospitals all over the country along with
outpatient clinics. The next phase envisages further integration of mental
health with primary health care.
Mental health facilities
Taif Hospital has 570 beds. There are 14 other mental hospitals with a
bed capacity of 30–120 beds in other parts of the country, isolated from the
general hospitals and working independently. Psychiatric departments and
clinics attached to general hospitals total 61 in number, having 20–30 beds
each.
There are three Amal Hospitals with 280 beds each under the joint
administration of the Ministries of Health and Interior for treatment of
persons with alcohol and drug dependence. In 1996, a unit attached to the
general hospital in Qassim, was opened for treatment of substance abuse
with a bed capacity of 20 beds. There are, in addition, 165 beds for
psychiatric inpatients in other governmental health sectors, such as military,
national guard and university hospitals. There are many private units and 146
beds in general private hospitals for psychiatric care, as well as outpatient
services. Six school health units provide some psychiatric services in
Riyadh, and other such units are planned in other regions after training of the
staff in the School Health Unit of the Ministry of Health.
Rehabilitation services for persons with mental disorders are planned
but are currently concentrated in the private and nongovernmental
organization sector.
The services for the mentally retarded consist of beds in Taif and other
mental hospitals. There are secure sections for the treatment of mentally ill
offenders in Taif and some other mental hospitals.
At present, child psychiatric services are delivered mainly on an
outpatient basis, and emergency cases can be admitted to paediatric
departments or to general hospitals under the supervision of the nearest
psychiatrist.
244
Mental health in the Eastern Mediterranean Region: reaching the unreached
Integrated data are available for services in all mental hospitals,
general hospitals, psychiatric units and outpatient clinics. These data are
compiled from returns by the psychiatrists from each centre. Between 1991
and 1996, there was an increase of about 26% in outpatient attendance,
including new contacts. Similarly, there was an equal increase in both first
admissions and readmissions to inpatient care. This indicates that for a
number of reasons that need to be more deeply studied, the services are
being increasingly used by the population.
Mental health human resources
There are about 458 psychiatrists in the country. Of these, 286 are
working in Ministry of Health facilities, 108 in other governmental sectors
and 64 in the private sector. There are a disproportionate number of
expatriates: there are only 78 Saudi psychiatrists. There are 183 social
workers working in mental hospitals. There are 108 psychologists working
in Ministry of Health facilities, and 1271 nurses. All the psychologists and
social workers are Saudi nationals, but the majority of nurses are not.
Mental health training
There are four universities with medical schools—King Saud
University, Riyadh; Jeddah; Abha; and King Faisal University, Dammam.
There are approximately 270 new medical graduates per year.
There are two postgraduate programmes in psychiatry, one at King
Faisal University and the other at King Saud University. Gradually, more
Saudi nationals are taking up psychiatry. There are also training programmes
in the psychiatric units in military hospitals, national guard hospitals and
King Faisal Specialist Hospital in Riyadh.
National mental health programme
The Saudi national mental health programme was developed in 1989.
The objectives of the programme are:
•
to make essential mental health services available to all citizens and
residents in the country, paying more attention to those who are more
in need of these services and to underserved areas
Saudi Arabia
•
•
•
•
•
•
•
•
•
•
•
245
to develop a mental health care model in keeping with the social,
cultural and religious values of the country
to encourage community participation in the development of mental
health care services
to use mental health knowledge and skills in order to help solve
psychosocial problems, and to encourage the application of mental
health principles for promotion of social health and enhancing
socioeconomic development of society, as well as improving the
quality of life
to decrease the untoward impact of social and economic development
on society such as drug abuse, smoking, delinquency and crime.
Strategies for the programme are:
integration of mental health services with general health services
supporting the present mental health services and making these
services available in all areas and providing mental health services to
the more vulnerable groups
incorporating mental health services into primary health care through
existing health staff by suitable additional training
linking the primary health care centres to mental health services and to
teaching centres through a series of referral systems
training and supervising by mental health professionals of the medical
personnel who will form the treatment teams at primary health care
level
providing the essential neuropsychiatric drugs at primary health care
level
cooperating with non-health sectors (community leaders,
nongovernmental organizations, religious establishments, and so on)
in planning and implementation of the programme.
Progress
A Directorate of Mental and Social Health has been created in the
Ministry of Health. It is clear the primary health care level is the principal
avenue through which mental health services can reach those in the
community most in need of them
246
Mental health in the Eastern Mediterranean Region: reaching the unreached
The Directorate has set up a training programme for the mental health
component of primary health care. The programme has been undertaken as
follows. First, a training manual was prepared and sent to all centres that are
staffed by Ministry psychiatrists. Second, a series of workshops has been set
up to train psychiatrists in how to improve the skills of primary health care
physicians in the recognition and management of common mental disorders.
A third initiative has been taken jointly by the Directorates of Primary
Health Care and of Mental and Social Health. They require all medical staff
in primary health care centres throughout the country to attend a training
programme on the recognition and management of common mental
disorders. The details of such training courses vary between regions. A
common pattern is to have the doctors meet the psychiatrists, either at the
primary health care centre or a hospital, for a few hours a week for two
months and all must attend at some stage; Most primary health care
physicians and nurses are not Arabic speakers, but all other staff are Saudi,
which makes communication with the psychiatric patients possible. All
antidepressants and neuroleptics and some anti-epileptics are exempt from
the controlled drug list, and only minor tranquillizers (benzodiazepines
included) and hypnotics remain controlled. Primary health care physicians
are allowed to prescribe only non-controlled drugs.
Liaison with agencies outside the health field
There have been encouraging efforts made through the Directorate of
Mental and Social Health to develop educational programmes with schools,
the police and other sectors. The impression is that more activity should be
considered with the police, who are an indisputably important pathway to
care. Similarly, consideration might be given to increasing dialogue and
collaboration with religious leaders, teachers and local authorities.
Community education
Advocacy and public awareness campaigns and programmes are
carried out during the events like World Mental Health Day in October every
year and this will be continued. Health education is mainly the responsibility
of a special department in the Ministry of Health, which carries out all health
educational programmes, including mental health educational programmes.
Saudi Arabia
247
Traditional healers
Traditional healers or sheikhs (respected persons) continue to play a
large part in mental health care, and this includes the treatment of some
common neurotic disorders. Some psychiatrists working in the provinces
work in close contact with traditional and religious healers and sometimes a
great deal of useful collaboration between them exists.
Legislation
A mental health act, already prepared, is awaiting formal approval
from the legislation. It has been formulated after consideration of similar
legislation in many countries and recommendations from the United Nations
and the World Health Organization. This document contains the basic
regulations for admission and discharge in mental hospitals, beside the main
human rights of the psychiatric patient. The Directorate has developed and is
using a manual of processes and regulations for all mental health institutions
in the country until the mental health act is approved.
Drug dependence
Saudi Arabia is fortunate that its culture, religion and policies have, up
to the present, ensured a low level of drug- and alcohol-dependence
problems. The Amal Hospitals concentrate more on prevention, early
recognition and family counselling programmes.
Future plans
•
To continue establishing outpatient clinics in the general hospitals and
to upgrade some of these clinics to psychiatric units with a limited
number of beds (20–30).
•
To revise and update the national mental health programme according
to progress and experiences gained since 1989.
•
To collaborate with the Directorate of Health Centres of the Ministry
of Health for the integration of mental health care into primary health
care services by training of trainers and primary health care physicians
in the regions and also to prepare another manual for training of the
non-medical staff in the primary health care centres (60 master
trainers have been trained so far and 2000 primary health care
248
•
•
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
physicians have been trained by them until 1998 using an
indigenously developed manual).
To provide more psychological counselling and guidance centres in
the general hospitals in other regions after the successes achieved in
the Riyadh region.
To foster coordination and collaboration between the Directorate of
Mental and Social Health and other institutions and agencies for the
implementation of the primary mental health care programme,
especially with the Ministry of Education and General Presidency of
Girls for training in school health units.
To organize training programmes for psychiatrists, psychologists and
social workers in collaboration with the universities, health institutes
and some big mental health hospitals
Summary update (Mental health atlas, 2005)
Epidemiology
Al-Khatami and Ogbeide (2002) evaluated 609 adults, selected
randomly from a family and community clinic at an Armed Forces hospital,
using the Rahim Anxiety-Depression Scale. The prevalence of minor mental
morbidity was 18.2% (women: 22.2%, men: 13.7%). Rates were higher
among the young (15–29 years: 23.2%), divorcees and widows (more than
40%) and among those suffering from bronchial asthma (28.3%). El Rufaie
et al (1999) estimated the prevalence of somatized mental disorder (SMD)
and psychologized mental disorder (PMD) in a sample of primary health
care patients using the 12-item General Health Questionnaire and the
Clinical Interview Schedule. SMD and PMD constituted 48% and 42% of
those identified with a psychiatric disorder, respectively. The estimated
prevalence rate of SMD was 12% and it was associated with less education
and less severe disorders. The most common ICD-10 psychiatric diagnoses
among both the groups were mixed anxiety and depressive disorder,
generalized anxiety disorder and mood and adjustment disorders. Recurrent
depressive disorder and dysthymia were significantly more prevalent in the
PMD group. El-Rufaie et al (1988) used the Arabic version of the Hospital
Anxiety and Depression Scale (HAD) in primary care patients and found the
prevalence rate of depression and anxiety to be 26% (17% had depression
Saudi Arabia
249
and 16% had anxiety). The rate of depression was higher among females and
that of anxiety among males. Al-Shammari and Al-Subaie (1999) assessed
7970 elderly (above 60 years) subjects who were selected from primary
health care in five administrative regions by a stratified two-stage sampling
procedure using the Geriatric Depression Scale (GDS) and clinical
evaluation. Depressive symptoms were reported by 39%, with 8.4% having
severe depression. Depression was associated with gender (female),
education (low), unemployment, marital status (divorced or widowed),
locality (rural), housing arrangements (poor), isolation, financial constraints,
life events (loss), participation in recreational activities (limited), medical
illness (especially faecal or urinary incontinence), medication, perception of
poor health and dependence on others for daily activities. Elfawal (1999)
reviewed hospital data on suicides and estimated its prevalence to be
1.1/100 000 population. It was associated with gender (male:female ratio
was 4.5:1), age (30 to 39 years: 44.3%), ethnicity (all immigrants: 77%,
Indians: 43%). The most common means of suicide were hanging (63%).
Malik et al (1996) found that more than four fifths of drug overdose cases
(n = 57) were self-inflicted (parasuicide). Parasuicide was associated with
age (more than 95% were below 40 years), ethnicity (Saudi: 89%) and
gender (females: 78%). Psychiatric illnesses were diagnosed in 74.4% of
cases, with depression (39.5%) and personality disorders (34.9%) being
common. Abolfotouh (1997) assessed 305 schoolboys aged 8–12 years using
the Rutter Children’s Behaviour Questionnaire. The prevalence of behaviour
disorders was 13.4% and it was associated with family size, crowding index,
parents’ education, birth order, parental death, social class and poor
academic performance of index child. These factors jointly contributed to
12.8% of the variance in total behaviour score. However, mother's illiteracy
was the only significant predictor of maladjusted children. Al-Subaie et al
(1996) validated the Arabic version of the Eating Attitude Test (EAT-26) and
assessed a representative stratified random sample of grade 7–12 urban
female students (n = 129). Twenty-five were identified by EAT-26 as having
abnormal eating attitudes. One case was identified as having anorexia
nervosa and no cases of bulimia were found. Milaat et al (2001) assessed
children (below 15 years) selected through a multistage sampling of
households (n = 875) using the ten questions survey. The point prevalence of
250
Mental health in the Eastern Mediterranean Region: reaching the unreached
any disability was 3.7%. Three-fifths of cases had a single disability, onefifth had two conditions and one-fifth had three or more conditions. Speech,
motor and mental disabilities were the commonest disabilities identified.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1989. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 2000.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1989. The national mental health programme aims at
integrating mental health into primary and community care, developing a
model keeping in view the social, cultural and religious values of the country
in perspective, using mental health principles in promoting social health,
decreasing untoward impact of social and economic development on society
like drug abuse, smoking, delinquency and crime.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1988.
Mental health legislation
A mental health act is awaiting approval. The General Directorate for
Mental Health has developed a manual of procedures and regulations for
mental health institutions in the country until the mental health act is
approved.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary source of mental
health financing is tax-based. Development of psychiatric services is
Saudi Arabia
251
incorporated in the budget of general health services. The country has
disability benefits for persons with mental disorders.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level. All antidepressants and neuroleptics and some anti-epileptics are exempt from
control and so all primary care physicians can prescribe most of the drugs.
Regular training of primary care professionals is carried out in the
field of mental health. The General Directorate for Mental Health has a well
designed training programme for the mental health component of primary
health care. There are training manuals and workshops for psychiatrists on
methods how to train primary care personnel. All medical staff of primary
care services is required to attend training programmes on the recognition
and management of common mental disorders. The immediate and posttraining evaluations of the trainees show favourable changes in their attitude
and knowledge and enhanced motivation to practice psychiatry at primary
health care centres. A system of ongoing training is needed because the
majority of primary care doctors are expatriates (predominantly from
neighbouring Arab states).
There are community care facilities for patients with mental disorders.
Rehabilitative services were planned following a Royal decree in 1988 but it
mainly concentrated among private organizations and self help groups like
the Patients' Friends Committee, etc.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
1.18
0.8
0.04
0.34
1.1
0.5
6.4
0.07
0.97
2.4
252
Mental health in the Eastern Mediterranean Region: reaching the unreached
There are 22 other mental health staff belonging to different
categories. There are three Amal hospitals which take care of patients with
problems with drug abuse. They collectively have 840 beds. Some beds have
been earmarked for mentally retarded individuals and mentally ill offenders.
About three fourths of the psychiatrists and a majority of nurses are
expatriates. Traditional healers and religious healers play an important part
in mental health care.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention,
treatment and rehabilitation.
Information gathering system
There is mental health reporting system in the country. The country
has data collection system or epidemiological study on mental health. There
are no epidemiological studies, but data are available for all services.
Programmes for special populations
The country has specific programmes for mental health for children.
Child psychiatric services are mainly provided as out-patient care and
emergency cases are admitted in paediatric hospitals or general hospitals. Six
school units are operational in Riyadh.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, ethosuximide,
phenobarbital, phenytoin sodium, sodium valproate, amitriptyline,
chlorpromazine, diazepam, fluphenazine, haloperidol, lithium, biperiden,
carbidopa, levodopa.
Other information
Until 1983, mental health care was mainly provided by the Taif mental
hospital, but since then smaller hospitals and outpatient clinics have been set
up. The next phase would involve integration of mental health into primary
care.
Saudi Arabia
253
Additional sources of information
Abolfotouh MA. Behaviour disorders among urban schoolboys in southwestern Saudi Arabia. Eastern Mediterranean health journal, 1997, 3:274–
283.
Al-Faris E, Al-Subaie A, Khoja T et al. Training primary health care
physicians in Saudi Arabia to recognize psychiatric illness. Acta psychiatrica
Scandinavica, 1997, 96:439–444.
Al-Khathami AD, Ogbeide DO. Prevalence of mental illness among Saudi
adult primary-care patients in central Saudi Arabia. Saudi medical journal,
2002, 23:721–724.
Al-Shammari SA, Al-Subaie A. Prevalence and correlates of depression
among Saudi elderly. International journal of geriatric psychiatry, 1999,
14:739-747.
Al-Subaie A, Al-Shammari S, Bamgboye E et al. Validity of the Arabic
version of the Eating Attitude Test. International journal of eating disorders,
1996, 20:321–324.
Elfawal MA. Cultural influence on the incidence and choice of method of
suicide in Saudi Arabia. American journal of forensic medicine and
pathology, 1999, 20:163–168.
El-Rufaie OE, Albar AA, Al-Dabal BK. Identifying anxiety and depressive
disorders among primary care patients: a pilot study. Acta psychiatrica
Scandinavica, 1988, 77: 280–282.
El-Rufaie OEF, Al Sabosy MMA, Bener A et al. Somatized mental disorder
among primary care Arab patients: I. Prevalence and clinical and
sociodemographic characteristics. Journal of psychosomatic research, 1990,
46:549–555.
Malik GM, Bilal A, Mekki TE et al. Drug overdose in the Asir region of
Saudi Arabia. Annals of Saudi medicine, 1996, 16:33–36.
Milaat WA, Ghabrah TM, Al-Bar HMS et al. Population-based survey of
childhood disability in eastern Jeddah using the ten questions tool. Disability
and rehabilitation, 2001, 23:199–203.
254
Mental health in the Eastern Mediterranean Region: reaching the unreached
Qureshi NA, Al-Ghamady S, Al-Haddad NS et al. Integration of mental
health care into primary care. Saudi medical journal, 2001, 22:899–906.
The national scientific committee of mental health in primary health care.
National manual for primary mental health care, 1996.
Somalia
Overview
Somalia has a surface area of 637 657 km2. The topography of the
country varies from mountainous in the north, calcareous highlands in the
west, and arid plateaus in the east. Population estimates show a population
density barely in excess of one person per km2 at 8.3 million (2004). The
population is relatively young, with 44.8% below the age of 15 years and
2.7% above the age of 65 (2000). The urban population makes up 25% of the
total. The total adult literacy rate and the female adult literacy rate, in 2002,
were 19% and 13%, respectively. United Nations sources estimated the crude
birth and crude death rates to be 46.4 and 17.6 per 1000 population,
respectively, for 2003. Somalia has the world’s second highest infant
mortality rate and the second highest ratio of maternal mortality. These are
estimated at 120 per 1000 live births (2003) and 160 per 10 000 live births
(2000), respectively. The under-5 mortality rate was estimated at 224 per
1000 live births in 2000. Total life expectancy at birth is 49 years (1998), one
of the lowest in the world.
The major health problems are communicable diseases (tuberculosis,
measles, malaria, sexually transmitted diseases), diarrhoeal diseases,
schistosomiasis, tetanus, respiratory infections, obstetrical problems,
anaemia and leprosy. The per capita gross national product is US$ 192.
Somalia is designated by the United Nations as a least developed country.
The first point of contact for health care, at the village level, is the primary
health care post, staffed by one locally recruited community health worker
and one traditional birth attendant. Next in line is the primary health care
256
Mental health in the Eastern Mediterranean Region: reaching the unreached
unit, which serves from 10 000 to 15 000 persons and is staffed by one
public health nurse, one nurse midwife and one sanitarian.
The district health centre, which is staffed by one senior physician
among others, is responsible for four primary health care units and covers
from 40 000 to 60 000 persons. The regional health centre is in effect the
district health centre of the regional capital. Governmental health curative
services are offered at district and regional hospitals. Regional hospitals vary
in size, from 50 to 200-bed capacity. Each of the 18 regions has one regional
hospital and there are two public hospitals in the Banadir Region. The
specialized hospitals number 17, comprising 10 tuberculosis hospitals, three
mental hospitals, two leprosy hospitals and one paediatric and obstetric
hospital. The district hospitals follow more or less the administrative map of
the country. The usual capacity ranges from 10 to 20 beds. In addition to
hospitals, there are 411 primary health care posts, 50 primary health care
units and 94 maternal and child health centres (reported at the end of 1990).
In 1997, Somalia had a reported ratio of 0.4 physicians, 2 nurses and 4.2
beds per 10 000 population.
Until 1990, the primary health care programme was working in nine
regions, with an additional seven regions receiving partial coverage. Because
of security-related deterioration in various regions few of the urban hospitals
are now functioning and virtually none of the rural ones is operational.
Financial as well as human resources are inadequate, and Somalia
depends almost entirely on external sources for health financing.
Mental health
There is one mental hospital in the country, in Berbera on the northern
coast. This hospital has patients living in cells 1 metre × 2 metres with iron
bars and chains. There is no provision of medicines, clothes or even food.
Whatever food the patients get is through public charity, which can be very
erratic. There is no provision for any kind of activity by the patients, the
basic hygiene is deficient, psychotropic drugs are almost non-existent and
often, the only treatment available is electroconvulsive therapy. The nursing
staff is inadequate and poorly trained. Opportunities for recreation and
occupational therapy are practically non-existent. The criminal patients are
mixed along with other patients.
Somalia
257
The psychiatric section at Forlinini Hospital, Mogadishu, is part of a
chronic diseases set-up, which includes tuberculosis and leprosy.
The mental section of Hargesia Hospital, like the other hospitals, is
deficient in basic amenities but is a part of a general hospital and has
therefore a potential for becoming a model for a modern general hospital
psychiatric unit.
There are five trained psychiatrists in the country. Four of them work
in Forlinini Hospital in Mogadishu. There is no psychiatrist at Berbera
mental hospital. Three psychiatric nurses have been trained but only one
works for the Ministry of Health and even he has no clinical responsibility.
There is no clinical psychologist or psychiatrist social worker in the country.
Except for the three hospitals mentioned above and the private
practices set up by the psychiatrists working there, modern psychiatric care
is non-existent elsewhere in the country. The major referral hospital (Digfer,
Mogadishu), which has major specialities, including neurology and
neurosurgery, has no psychiatric presence, even at outpatient level, and the
services of the psychiatrists available in Mogadishu are not used, either at
this hospital or other outpatient facilities in the capital. There is no tradition
of liaison services in other facilities.
The whole structure of primary health care being set up in the country
has no psychiatric input, though such input has been agreed in principle.
Currently, the majority of the psychiatric patients are either unattended—
living with their families—or receiving attention of the traditional healers. A
local nongovernmental organization called the General Assistance and
Volunteers Organization (GAVO) and an Italian nongovernmental
organization called GRU-UNA are active in provision of mental health
services.
The country has made an important advance by banning the use of
khat, but there is a concern that there might be a growing misuse of other
psychoactive substances such as alcohol, opiates, psychotropic drugs and
tobacco. There is no provision for prevention and treatment of drug abuse in
the country.
The knowledge and understanding of the general public regarding the
causes and management of psychiatric disorders is rudimentary and in
general, quite archaic and false. Most people believe mental illness to be due
258
Mental health in the Eastern Mediterranean Region: reaching the unreached
to demons and spirits, and there is hardly any consolidated attempt at
educating the public with the correct information and changing their
attitudes.
Mental health training
Psychiatry is part of the medical curriculum at the University Medical
School in Mogadishu. The teaching is, however, carried out by a visiting
Italian psychiatrist who comes once a year for two to three months and
imparts rudimentary theoretical knowledge. One of the Somali psychiatrists
has a quasi involvement in the teaching programme, but his efforts are
poorly coordinated with that of the visiting psychiatrist, and clinical training
is inadequate. A rudimentary theoretical knowledge is imparted to nurses at
the nursing school.
Against this background, in 1983 and 1986, WHO short-term
consultants visited Somalia. They reviewed the situation and formulated a
national mental health programme in consultation with the mental health
professionals of Somalia.
Objectives of the national mental health programme
•
To provide minimal mental health care for all, taking into account not
only the treatment and prevention of mental disorders, but also the
promotion of mental health.
•
To provide mental health principles in other spheres of life in work,
family interaction, community participation, for national growth and
international participation.
Strategies for the proposed national mental health programme
Strategies for the proposed national mental health programme were to
provide mental health care for all by integration of mental health into the
general health programme, to provide graded training to various categories
of workers at all these levels so that they can recognize mental disorders and
epilepsy; encourage early rehabilitation of the mentally ill and epileptics;
provide mental health education to the community; and refer all such cases
that cannot be managed by them to regional hospitals.
Somalia
259
Integration at the administrative level
Prior to the current years of unrest, it was planned to create a mental
health unit in the Ministry of Health. A trained psychiatrist and work in the
context of a national coordination committee will head this unit for mental
health. The national mental health programme also envisaged activities in
the areas of mental retardation, upgrading of mental hospitals, drug
dependence care, involvement of nongovernmental organizations, nursing
training and research. The civil strife and lack of resources have resulted in a
lack of progress in any of the areas outlined above.
Recent developments
During 2004–2005, a major step was taken in improving the human
resources for mental health care. A group of two dozen nurses and social
workers were trained in essentials of psychiatry care at Bassao, Somalia over
a period of 3 months. This was a residential training programme. The
trainees were members of the different mental health care facilities,
voluntary organizations. The 3-month training consisted of lectures, case
demonstrations and clinical work at the psychiatric unit in the general
hospital and active community level mental health activities. At the end of
the training, each of the participants made a plan for organizing psychiatric
care in their areas of work.
Summary update (Mental health atlas, 2005)
Epidemiology
There is a paucity of epidemiological data on mental illnesses in
Somalia in internationally accessible literature. Elmi (1983) conducted an
epidemiological research study on khat chewing in a random sample of
about 7500 people. He suggested that the prevalence of the khat chewing has
continuously increased in all social groups and that the excessive use of khat
may create considerable problems of social, health and economic nature.
260
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health resources
Mental health policy
A mental health policy is absent. There is no unified health policy.
Substance abuse policy
A substance abuse policy is absent.
National mental health programme
A national mental health programme is absent.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is absent.
Mental health legislation
Details about the mental health legislation are not available.
Mental health financing
There are no budget allocations for mental health. Details about
expenditure on mental health are not available. The primary source of mental
health financing is grants. The financing of mental health services is almost
entirely dependent on grants from WHO and nongovernmental
organizations. The country does not have disability benefits for persons with
mental disorders.
Mental health facilities
Mental health is not a part of the primary health care system. Actual
treatment of severe mental disorders is not available at the primary level.
Recently, a Mental Health Coordinator was appointed for North-West
Somalia to initiate integration of mental health care into primary health care
and training of primary health care personnel.
Regular training of primary care professionals is not carried out in the
field of mental health. The voluntary workers of GAVO have been trained in
the principles of psychiatric interview, introduced to DSM-IV, given training
on psychopharmacology, psychosocial rehabilitation and hospital
management. The training lasted for 2 years.
There are no community care facilities for patients with mental
disorders. Limited community care through nongovernmental organizations
and WHO are available in very limited areas of one region in northwest
Somalia. A psychosocial centre was established in Berbera in 1990.
Somalia
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
261
0.398
0.06
0.03
0
0.19
There are only three centres for psychiatry, the mental hospital in
Berbera and the general psychiatric wards in Hargesia and Mogadishu. Until
the arrival of the nongovernmental organization from Italy, the condition of
the mental hospital was appalling. Patients were kept in chains, and supply
of food was largely dependent on charity. UNDP is supporting the
psychiatric ward in Hargesia in terms of structural facilities and supplies.
There is no private psychiatric inpatient facility though there are a few
private clinics in Mogadishu and Hargesia. There is no specialized drug
abuse treatment centre and there is no mental health training facility in the
country. Only limited data about one area of Somalia, Somaliland is
available. Psychiatrists have private clinics.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in advocacy, promotion, prevention,
treatment and rehabilitation. The whole mental health set-up of Somalia is
based on the efforts of nongovernmental organizations - GRT-UNA of Italy
and General Assistance and Volunteer Association (GAVO), a local Somali
nongovernmental organization. They help in the provision of services to
mental patients and street children and provide training for primary health
care personnel.
Information gathering system
There is no mental health reporting system in the country. The country
has no data collection system or epidemiological study on mental health.
262
Mental health in the Eastern Mediterranean Region: reaching the unreached
Programmes for special populations
No programmes for special population groups exist. UNDP and
nongovernmental organizations are supporting the Government’s plans for
reintegration of the militia personnel including those that are mentally ill,
into the mainstream through projects involving occupation.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: unknown.
Additional sources of information
Elmi AS. The chewing of khat in Somalia. Journal of ethnopharmacology,
1983, 8:163–176.
Mental health in Somaliland. (Government document).
Omar MA. Developments in mental health services in Somalia. NIMHANS
journal, 1986, 4:131–132.
Sudan
Overview
With an area of 2 506 000 km2, Sudan is the largest country in Africa.
The heart of the country, in terms of population, lies at the confluence of the
Blue and White Niles. The conurbation of the three towns, Khartoum,
Khartoum North and Omdurman, is situated there and contains almost 20%
of the population. The total population of Sudan is estimated to be 34.5
million (2004). The urban population is 36%. About 2.2 million are still
entirely nomadic. There are about 19 major ethnic groups and a further 597
subgroups. Of the population 42% are below 15 years, and 4% are above the
age of 65 years (2001). In 2000, the total adult literacy rate and the female
adult literacy rate were estimated at 50% and 49%, respectively. The crude
death rate is 11.5 per 1000 population and the crude birth rate is 37.8 per
1000 population (2004). The infant mortality rate is estimated at 68 per 1000
live births, and under-5 mortality rate 104 per 1000 live births. Total life
expectancy at birth was 56.6 years in 2000. Maternal mortality ratio is
estimated at 50.9 per 10 000 live births (2000).
The per capita gross national product in 2001 was US$ 430. The per
capita Ministry of Health expenditure was US$ 8.7 in 2004. The Ministry of
Health expenditure represented 2.4% of the country’s budget. In 2003 there
were 1.8, 0.07, 5.1 and 7.1 physicians, dentists, nurses/midwives and
hospital beds per 10 000 of the population, respectively.
Health has been declared the first national priority after security. The
health policies give priority to family health and reduction in morbidity and
mortality rates among mothers and children; encourage community
264
Mental health in the Eastern Mediterranean Region: reaching the unreached
involvement in the planning, implementation and supervision of the health
services; reinforce primary health care and the delivery of its integrated
components through the area health system; encourage scientific research
into the more pressing health problems, including environmental pollution,
endemic and epidemic diseases and malnutrition; seek improvement of the
managerial skills of personnel at all levels; and emphasise coordination
between health-related ministries and departments.
The design of the health care system in Sudan is based on primary
health care and the “health area” concept, which is conceived as a
decentralized health care system able to integrate, at district level, the
existing vertical programmes, including preventive, curative and promotive
activities. At village level, primary health care units represent the first level
of contact between the community and the health services. Secondary health
care is available in small towns through rural hospitals and urban health
centres. Tertiary health care services comprise provincial, regional,
university and specialist hospitals.
Committees for health have been established at both village and
national levels. These committees are involved in planning, execution,
resource finding and allocation as well as supervision of health services in
their localities. The committees are supported by national laws and
regulations and are effective, powerful bodies.
Nongovernmental organizations play a recognized role in the delivery
of health care. The Ministry of Health has invited them to participate in
planning sessions and meeting at national and local levels.
The health services suffer from acute shortages in trained personnel.
There are no health human resources plans, and universities and other
training institutions work in isolation from the Ministry of Health. Training
and education are thus not directed toward meeting national needs.
Mental health
Historical aspects
Prior to the Second World War, there were hardly any organized
psychiatric services for the care of mental patients. In the 1950s the Clinic
for Nervous Disorders, Khartoum North, was established, and the Kober
Institution was built to cater for 120 forensic psychiatric patients. This was
Sudan
265
followed by the establishment of four psychiatric units in provincial capitals,
at Wad Medani, Port Sudan, El Obeid and Atbara. In 1964, a 30-bed
psychiatric ward was built in Khartoum General Hospital. Finally, in 1971,
plans were laid to start work on Omdurman Psychiatric Hospital, the first of
its kind in Sudan. The underlying policy was first to establish psychiatric
units with close links with medical institutions and broad connections with
community agencies. Other mental health developments include establishing
a school for psychiatric medical assistants and organizing training courses
for social workers and psychologists, for Sudan and other countries. Sudan
was one of the countries selected to participate in a WHO project on
strategies for extending mental health into primary health care, which paved
the way for present day developments in the field of mental health in the
region (1975–81).
The narcotics and substance abuse policy was formulated in 1995.
Operationally, a national mental health programme formulated in 1986 and
revised in 1998 includes short-term and long-term targets with emphasis on
human resources development and extension of the mental health services to
peripheral parts of the country. The guiding principles were close integration
of essential mental health care with the general health system at the primary
health care setting; development of training programmes for health personnel
at all levels of the health service; development of an appropriate referral
system with comprehensive recording of information; provision of essential
drugs; and community involvement and close collaboration with other social
sectors, agencies and organizations.
Progress
In 1990, a mental health unit in the Ministry of Health was
established. There is now a mental health board, supported by the Sudanese
Psychiatric Association, which acts as an advisory body to the Minister of
Health. Integration of mental health services has occurred to an extent in the
north of the country at the level of district general hospitals, and is being
extended to the primary health care level. In existing mental health services,
attention has been given to special groups such as migrants, vagrants, the
elderly, refugees and the displaced, and street children. School mental health
has been introduced into the mental health programme. A list of essential
266
Mental health in the Eastern Mediterranean Region: reaching the unreached
drugs, which contains neuropsychiatric drugs at different levels, has been
formulated while the policy has been operational since 1970.
A four-year postgraduate course leading to an MD in psychological
medicine was initiated in 1989. Training courses are also available for
medical officers and other health care staff. Forty-eight doctors who work at
primary health care level have been trained in mental health for two weeks,
and a one-week course was held for police and prison officers. The medical
curriculum now incorporates community psychiatry at the University of
Al Gezira. Four psychologists and four social workers have undergone
postgraduate training. Intensive community involvement includes use of the
mosque and input from religious healers as well as the Sudanese National
Society for Mental Health and the Sudanese Institute of Traditional
Medicine.
Substance dependence represents a serious problem. Measures to
combat this are directed by the multidisciplinary Sudanese National Narcotic
Control Board, with support from WHO.
Legislation
Mental health legislation forms a chapter of the Public Health Act of
1973. This was reviewed by the Sudanese Psychiatric Association in 1985. A
mental health law was enacted in 1998.
Recent developments
Sudan was a pioneer country in mental health services during the
1970s. Some innovative approaches, like starting of general hospital
psychiatric units and integration of mental health with primary health care,
were introduced during this period, earlier than other countries of the
Region. However, currently, mental health services are inadequate. The
national mental health programme was first formulated in 1986 and revised
in 1998.
There were four developments in the past years. First, there is
evidence of high mental health morbidity among the internally displaced
population in Darfur region. Second, the Gezira mental health project has
demonstrated both the feasibility and the effectiveness of the integration of
mental health with general health care. Third, a number of psychosocial
interventions have been developed to address the needs of traumatized
Sudan
267
populations. Fourth, efforts have been directed to develop a national mental
health policy and a strategic 6-year mental health plan of action.
El-Ghaili et al (2002) reported on the impact of the community-based
mental health services. The Gezira Mental Health Programme represents a
collaborative work involving the university, the community and the
government. Its aims were to modify community concepts, attitudes and
practices concerning mental health; to ensure community involvement and
participation; to extend mental health services; to train primary health care
staff; and to encourage research. The programme was implemented in three
phases: preparatory, implementation, and evaluation. In the evaluation of the
impact of the programme on changing community attitudes, on training of
staff, on extension of mental health services and on research, qualitative
assessment, through interviews, focus group discussion, supervision visits
and review of reports were used. There was overall agreement that the
programme helped in raising public awareness regarding the concept of
mental health, the care of the mentally ill and community participation.
Members of the health team who received training as part of the programme
reported a better understanding of mental health problems and an
improvement in their handling of the mentally disturbed patients. Teachers
reported an increased awareness of mental health problems in schoolchildren
and a better collaboration with those involved in the handling of such
problems. Social workers and psychologists updated their knowledge and
skills and were well prepared to participate in the programme. Members of
the different sectors involved reported a better standard of collaboration
regarding mental health activities. These findings indicate that this
programme, by providing a new model for health services in this field, has
induced a large policy change within Sudan. The community-based activities
have resulted in a major change in the delivery of mental health services in
Gezira State. The programme has resulted in a major shift in mental health
services being provided by central hospitals to PHC settings. In addition it
stimulated research, thereby providing much original information that will
help in preparing for future plans.
268
Mental health in the Eastern Mediterranean Region: reaching the unreached
Summary update (Mental health atlas, 2005)
Epidemiology
Rahim and Cederblad (1989) evaluated a sample of 204 subjects aged
22-35 years using the Self-Rating Questionnaire, the Eysenck Personality
Inventory and a Sudanese rating scale of anxiety and depression, a
psychiatric interview and a medical examination. Results showed that 16.6%
of the subjects had at least one disorder as per DSM-III. The most common
were depression (8.4%) and generalized anxiety (3.4%). Alcohol abuse was
rare (0.4%). There was no sex difference in the prevalence of mental
disorders. Cederblad and Rahim (1989) re-interviewed 104 randomly chosen
subjects in 1983 (from the original pool of 197 children examined in 1964–
1965). The overall psychiatric impairment was 14% (males 18%; females
8%). In an earlier study they evaluated the psychological effect of
urbanization on children aged 3–15 years living in a sub-urban community
that transformed from a rural to urban economy between 1965 and 1980.
Interviews done in 1965 and 1980 showed an increase in behaviour problems
in boys aged 7–15, while there was an improvement in physical health and
nutrition. Behaviour problems were associated with factors related to parents
(blue-collar workers, maternal anxiety/depression, harsh corporal
punishment) and children (dropping out of school, poor somatic health)
(Rahim & Cederblad, 1986). Cederblad (1988) assessed behaviour disorders
in children of different ages in Sweden, Sudan and Nigeria. The similarities
of frequencies of behaviourally disturbed children were more striking than
the differences. Rural children generally had less behaviour problems than
urban ones. However, in another multi-country study, carried out in a
primary care setting (n = 925), that employed a two-stage screening process,
Giel et al (1981) found the prevalence of mental disorders among children to
range from 12% to 29%. Rahim and Cederblad (1986) and Cederblad et al
(1986) evaluated the prevalence of enuresis in 8462 children aged 3–15
living in the suburban area. 88% wetted their beds at least several times per
week. The prevalence of enuresis was higher in boys than in girls. Only 5%
of the children above 7 years of age had secondary enuresis. An intensive
study of 245 children selected through stratified sampling did not reveal any
association between enuresis and somatic, developmental, behavioural,
socio-economic or child rearing (including bladder-training) factors.
Sudan
269
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1998. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1995.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1998. The national mental health programme aims to integrate
with general health facilities along with promotion of comprehensive mental
health care, train mental health personnel and establish a national
organizational body for systematic coordination of related activities and the
promotion of mental health.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1970.
Mental health legislation
The most recent legislation is the state law, Gezira Mental Health Law
of 1998. The mental health legislation forms chapter of the Public Health Act
of 1973, which was revised in 1985. The Mental Health Act has been drafted
and has gone to the parliament for approval. The latest legislation was
enacted in 1998.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary source of mental
health financing is tax-based. The country has disability benefits for persons
with mental disorders.
Mental health facilities
Mental health is not a part of primary health care system. Actual
treatment of severe mental disorders is not available at the primary level.
270
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health has not been integrated with the primary care, and there is also
a lack of personnel.
Regular training of primary care professionals is carried out in the
field of mental health. In the last two years, about 40 personnel were
provided training. Training facilities are present for primary care physicians,
police and prison officers. The Gezira Mental Health Programme was aimed
at modifying community concepts, attitudes and practices concerning mental
health, ensuring community involvement and participation and extending
mental health services by training primary health care staff. The evaluation
of the programme showed that it helped in raising public awareness and
community participation. Members of the health team and teachers who
received training reported a better understanding of mental health problems
and an improvement in their handling of the mental problems. Sudan has the
experience of using traditional healers for provision of mental health
services.
There are no community care facilities for patients with mental
disorders. Community care is absent due to the lack of proper transportation,
lack of social workers and poor health education.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
0.2
0.18
0.02
0
0.09
0.007
0.2
0.014
0.17
0.1
Many mental health professionals including most psychiatrists have
left for other countries.
Sudan
271
Nongovernmental organizations
Nongovernmental organizations are not involved with mental health in
the country. Special attention has been given to migrants, elderly, refugees,
displaced and homeless and children.
Information gathering system
There is no mental health reporting system in the country. Some
mental health information particularly numbers related to admissions for
major disorders are collected from a few hospitals in the general health data
collection system, but the system has many limitations.
The country has no data collection system or epidemiological study on
mental health. There are no funds or personnel to carry out epidemiological
studies.
Programmes for special populations
These groups are supported by nongovernmental organizations and
UNICEF. A school mental health programme is present.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: phenobarbital, phenytoin sodium. Since
mental health is not integrated in primary care level, most of the drugs are
not available at primary care level. A list of essential neuropsychiatric drugs
for all levels has been formulated.
Additional sources of information
Cederblad M. Behavioural disorders in children from different cultures. Acta
psychiatrica Scandinavica, supplementum, 1988, 344:85–92.
Cederblad M, Rahim SI. Epidemiology of nocturnal enuresis in a part of
Khartoum, Sudan. II. The intensive study. Acta paediatrica Scandinavica,
1986, 75:1021–1027.
Cederblad M, Rahim SI. A longitudinal study of mental health problems in a
suburban population in Sudan. Acta psychiatrica Scandinavica, 1989,
79:537–543.
El Gaili DE, Magzoub M, Schmidt HG. The impact of a community-oriented
medical school on mental health services. Education for health, 2002,
15:149–157.
272
Mental health in the Eastern Mediterranean Region: reaching the unreached
Giel R, de Arango MV, Climent CE et al. Childhood mental disorders in
primary health care: results of observations in four developing countries. A
report from the WHO collaborative study on strategies for extending mental
health care, Pediatrics, 1981, 68:677–683.
Mohit A. Mental health and psychiatry in the Middle East: historical
development. Eastern Mediterranean health journal, 2001, 7:336–347.
Rahim SI, Cederblad M. Epidemiology of nocturnal enuresis in a part of
Khartoum, Sudan. I. The extensive study. Acta paediatrica Scandinavica,
1986, 75:1017–1020.
Rahim SI, Cederblad M. Effects of rapid urbanization on child behaviour
and health in a part of Khartoum, Sudan--II. Psycho-social influences on
behaviour. Social science and medicine, 1986, 22:723–730.
Rahim SI, Cederblad M. Epidemiology of mental disorders in young adults
of a newly urbanized area in Khartoum, Sudan. British journal of psychiatry,
1989, 155:44–47.
El-Ghaili DE, Magzoub MM, Schmidt HG. The impact of a communityoriented medical school on mental health services, Education for health,
2002, 15:149–57.
Shaaban KM, Baashar TA. A community study of depression in adolescent
girls: prevalence and its relation to age, Medical principles and practice,
2003, 12:256–9.
Bolea PS, Grant G Jr, Burgess M, Plasa O. Trauma of children of the Sudan:
a constructivist exploration, Child welfare, 2003, 82:219–33.
Karunakara UK, et al. Traumatic events and symptoms of post-traumatic
stress disorder amongst Sudanese nationals, refugees and Ugandans in the
West Nile, African health sciences, 2004, 4:83–93.
Neuner F, et al. A comparison of narrative exposure therapy, supportive
counseling, and psychoeducation for treating posttraumatic stress disorder in
an African refugee settlement, Journal of consulting and clinical psychology,
2004, 72:579–87.
Eisenbruch M, de Jong JT, van de Put W. Bringing order out of chaos: a
culturally competent approach to managing the problems of refugees and
victims of organized violence, Journal of trauma stress, 2004, 17:123–31.
Sudan
273
Goodman JH. Coping with trauma and hardship among unaccompanied
refugee youths from Sudan, Qualitative health research, 2004, 14:1177–96.
Lustig SL, Weine SM, Saxe GN, Beardslee WR Testimonial psychotherapy
for adolescent refugees: a case series, Transcultural psychiatry, 2004, 41:3145.
Coker EM Traveling pains: embodied metaphors of suffering among
Southern Sudanese refugees in Cairo, Culture, medicine and psychiatry,
2004, 28:15-39.
Coker, EM. Dislocated identity and the fragmented body: discourses of
resistance among Southern Sudanese refugees in Cairo, Journal of refugee
studies, 2004b 17:
Awadalla AW et al. Subjective quality of life of family caregivers of
community living Sudanese psychiatric patients. Social psychiatry and
psychiatric epidemiology, 2005, 40: 755–763.
Awadalla AW et al. Subjective quality of life of community living Sudanese
psychiatric patients: comparison with family caregivers’ impressions and
control group, Qualitative life research, 2005, 14:1855–67.
Geltman PL et al. The “lost boys of Sudan”: functional and behavioral health
of unaccompanied refugee minors re-settled in the United States, Archives of
pediatric adolescent medicine, 2005, 159:585–91.
International Medical Corps. Basic needs, mental health, women's health
among the internally displaced persons in Nyala District, South Darfur,
Sudan. www.imcworldwide.org, 2005.
Syrian Arab Republic
Overview
The Syrian Arab Republic has a total area of 185 180 km2 of which
approximately 80 000 km2 is cultivable land; the remainder is desert and
barren mountains. The country’s population is estimated at 18.2 million
(2004). The population growth rate is 2.5% (2003); 40.2% of the population
is below 15 years while 3.6% of the population is above 65 years of age
(2002), 50% of whom are living in urban areas. The total adult literacy rate
and the adult female literacy rates are estimated at 86% and 78%,
respectively (2003). In 2002, the crude death rate was estimated to be 4.9 per
1000 population, and the crude birth rate 30 per 1000 population. The infant
mortality rate is 18.1 per 1000 live births, under-5 mortality rate 20.2 per
1000 live births, maternal mortality ratio 6.5 per 10 000 live births and total
life expectancy at birth 71.5 years (2003).
The per capita gross national product in 2003 was US$ 1150. In 2002,
3.8% of government budget was given to ministry of health, comprising
1.5% of the gross national product. The per capita Ministry of Health
expenditure, in 2002, US$ 18.6. As regards human and material resources
the overall rates per 10 000 population of physicians, dentists,
nursing/midwifery personnel and hospital beds are 14.3, 8.7, 18.8 and 14.9,
respectively (2003).
Within the framework of national development, the health objectives
are to increase the quantity and quality of health services provided, achieve
more equitable coverage of health services between urban and rural areas,
decrease morbidity and mortality due to infectious diseases and
Syrian Arab Republic
275
environmental pollution, and decrease the infant morality rate to the lowest
possible, use existing resources more efficiently by improving performance
of health human resources and updating equipment as well as improving
management, increasing availability of drugs and concentrating on local
manufacture of essential drugs.
The health system is based on primary health care and is delivered at
three levels: village, district and provincial. At village level, there are rural
health centres and health units. At district level, there are larger health
centres including training facilities and specialized physicians. District
health centres are staffed with at least one physician, one nurse, and one
public health technician. Some larger centres are additionally staffed with
dentists, paediatricians, obstetricians, pharmacy technicians, laboratory
technicians, midwives and health visitors. On average, there are 9.8 health
workers per district health centre. A small district general hospital also exists
in each district. The health centres belonging to each of the country’s 14
provinces report to one main health centre. Each is allocated its own budget,
and each director of health is given authority and flexibility to implement
programmes within the present development strategy
At provincial level, there are urban health centres staffed with
specialized physicians and dentists in addition to various technicians. Among
the services provided in health centres are immunization, maternal and child
health, family planning, control and prevention of communicable diseases,
environmental control, preventive care for chronic noncommunicable
diseases, and health education. At the provincial level, there are also large
general hospitals and specialized hospitals. At the national level, there is a
network of ambulance, blood bank and drug distribution services.
Mental health
Background and developments
The project profile for the national mental health programme was
prepared by WHO and a national committee in Damascus in November 1987
(it was submitted for approval in 2001). The objectives were to extend
mental health services throughout the country at the primary health care
level, in full coordination with the general health system; to provide training
to basic and auxiliary medical cadres in order to equip them with the
276
Mental health in the Eastern Mediterranean Region: reaching the unreached
necessary information and suitable skills in the field of mental health care; to
strengthen specialized mental health services, and to promote mental health
education in the community and stimulate community participation, so as to
achieve the objectives of the national mental health programme.
Under the overall general objective, the services objectives included
establishment of four treatment units in the four provinces where such
services were not available; establishment of four psychiatric outpatient
clinics in four selected hospitals; establishment of a referral system to
specialized hospitals from these centres; preparation of an information
system; preparation of a list of essential neuropsychiatric drugs; and
preparation of a manual on mental health services in the country.
A national committee was formed to review mental health services.
The committee was chaired by the director of the national mental health
programme, and had as members psychiatrists working in the mental health
sector, such as the director of Ibn Sina Hospital; the head of the Department
of Psychiatry, University of Damascus; the head of the Department of
Psychiatry, Military Medical Services; and a representative from the
Ministry of Work and Social Affairs (Social Insurance Foundation). A
Mental Health Department was established in Ministry of Health and within
the framework of the sixth five-year plan, ending in 1990, was the allotment
of a special budget for restructuring of mental health services—initiation of
psychosocial clinics in Damascus and Aleppo in order to serve as centres for
mental health studies; incorporation of psychiatric clinics within polyclinics,
and ensuring the availability of at least one such clinic in each province;
initiation of two centres for the treatment of addiction in Damascus and
Aleppo; and initiation of intensive courses in the field of psychiatry in
Damascus and Aleppo for qualifying general practitioners and nurses.
Legislation
The rules governing mental health and psychiatric treatment in the
Syrian Arab Republic are derived from the health legislation issued in 1981
by the Ministry of Health. The essential drugs policy was formulated in
1990.
Syrian Arab Republic
277
Mental health facilities
There are 800 beds at Ibn Sina Psychiatric Hospital in Damascus
distributed over 18 wards, allotted for the treatment of 600 male patients and
200 female patients—of whom 100 are under legal confinement. Treatment
of such patients is mainly conducted through the use of psychoactive drugs
and rehabilitation through work and other social and artistic activities.
Ibn Khaldoun Psychiatric Hospital, in Aleppo, has 400 beds, 250 of
which are for male patients and 150 for female patients, receiving more or
less the same type of medical treatment used at Ibn Sina Hospital in
Damascus.
In addition a psychiatric department providing therapeutic psychiatric
services at the Ministry of Health Hospital of Ibn Al-Nafees; a teaching
psychiatric department which provides similar services at Al-Moassat
Hospital of Damascus University; as well as two more mental health
departments providing such services at two military hospitals affiliated to
military medical services are operating in Damascus.
In addition to these hospitals, there are special foundations attached to
the Ministry of Work and Social Affairs, which provide treatment and
rehabilitation to the mentally handicapped and delinquents, under the
supervision of licensed psychiatrists. Over 60 primary care personnel have
been trained in mental health.
Summary update (Mental health atlas, 2005)
Epidemiology
There is a paucity of epidemiological data on mental illnesses in
Syrian Arab Republic in internationally accessible literature. Maziak et al
(2002) recruited a sample of 412 women from 8 randomly selected primary
care centres in one area. A special questionnaire was prepared for the study
purpose consisting of SRQ-20 non-psychotic items and questions about
background information considered relevant to the mental health of women
in the studied population. Direct individual interviews were also conducted.
The prevalence of psychiatric distress was 55.6%. The following factors
were found to predict women's mental health on logistic regression: physical
abuse, education (illiteracy), polygamy, residence, age and age of marriage.
Among those predictors, women's illiteracy, polygamy and physical abuse
278
Mental health in the Eastern Mediterranean Region: reaching the unreached
were the strongest determinants of mental distress leading to the worse
outcomes.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 2001.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1993.
National mental health programme
A national mental health programme is present. The programme was
formulated in 2001.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1990.
Mental health legislation
The legislation concerns the organizing the admission and discharge
of patients in government psychiatric hospitals. The latest legislation was
enacted in 1965.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. Details about sources of
financing are not available. The country has disability benefits for persons
with mental disorders.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level.
Regular training of primary care professionals is carried out in the
field of mental health. About 110 nurses and general physicians have been
trained in the last 10 years.
There are no community care facilities for patients with mental
disorders.
Syrian Arab Republic
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
279
0.8
0.78
0.02
0
0.5
0.6
0.5
0.9
0
0
Beds have been earmarked for female patients. Forensic beds are
available.
Nongovernmental organizations
Nongovernmental organizations are not involved with mental health in
the country.
Information gathering system
There is no mental health reporting system in the country. Only
statistical admission data of psychiatric hospitals are reported. The country
has no data collection system or epidemiological study on mental health.
Programmes for special populations
The country has specific programmes for mental health for refugees
and elderly. Services for mentally retarded are available.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, phenytoin
sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam,
fluphenazine, haloperidol, carbidopa, levodopa.
Additional sources of information
Maziak W et al. Sociodemographic correlates of psychiatric morbidity
among low-income women in Aleppo, Syrian Arab Republic. Social science
and medicine, 2002, 54:1419–1427.
Tunisia
Overview
Tunisia has a land area of 154 630 km2. It has a population of 9.91
million (2004), 65% of whom are resident in urban areas. The Tunisian
population is young, 26.7% being under 15 while those over 65 years of age
represent only 6.8% of the population (2002). In 2003, the total adult literacy
rate and the adult female literacy rates were estimated at 78% and 69%,
respectively. The infant mortality rate was estimated at 22.8 per 1000 live
births in 2001. In 1999, the under-5 mortality rate was estimated at 24.2 per
1000 live births and the maternal mortality ratio 4.5 per 10 000 live births. In
2002, the total life expectancy at birth was estimated at 73 years of age. The
crude birth rate was 16.7 per 1000 population in 2002.
Administratively, the country is divided into 23 governorates, which
are further subdivided into districts (délégations) and subdistricts. The gross
national product per capita was US$ 2161 in 2004. The Ministry of Public
Health budget was 8.3% of the total budget comprising 2.0% of the gross
national product. The per capita expenditure on health was US$ 119, while
the Ministry of Public Health spent US$ 67.(2002) In 2003 there were 9
physicians, 1.67 dentists, 36.4 nurses/midwives and 20.5 hospital beds per
10 000 of the population.
The health infrastructure can be divided into three main sectors: the
public, the social security and the private sectors. The greater part of the
population is served by the public sector. The services of government
departments, such as the army, the police and the Ministry of Education are
responsible for relatively limited populations.
Tunisia
281
Since 1990, the pyramid of health infrastructure has had four levels in
the governorates: an extensive network of 1471 basic health centres
(including maternal and child health centres, dispensaries and health posts)
forms its base. At the secondary level are the 102 district hospitals, which
provide primary health care and maternity and general inpatient and
outpatient care. These two levels of the public health pyramid cover most of
the health needs of the local communities. The third level—second-referral
level—is made up of 23 regional hospitals. At the top of the pyramid are 12
teaching hospitals, nine specialized institutes and 15 national specialized
centres.
Community involvement in the field of health is carried out within the
framework of local health councils (or committees) in each health district.
Chaired and organized by the local political and administrative authority,
these councils comprise locally elected representatives as well as the officers
in charge of health-related sectors. It is also quite common that the
community intervenes more directly in setting up a health centre managed
directly by the people, in organizing health education, hygiene and first aid
campaigns with nongovernmental organizations (for example, the Tunisian
Youth Organization, the Red Crescent Society and the Tunisian Organization
for Road Safety).
Mental health
Mental health facilities
The mental health facilities and human resources are largely
centralized and institution-based in Tunisia. There is a concentration of
psychiatrists in the capital city, which has about two-thirds of the specialists.
Mental health infrastructure
The chief components of mental health care are the psychiatric
hospitals. The total number of psychiatric beds in the country is 902. These
are distributed as follows:
Razi Hospital: 640 beds
Military Hospital, Tunis: 48 beds
Fattima Bourghiba Hospital, Monastir: 25 beds
Aedi Shaker Hospital, Sfax: 189 beds
282
Mental health in the Eastern Mediterranean Region: reaching the unreached
There is a total lack of facilities in the interior of the country,
particularly in the governorates of the west, the centre and the north, except
in Kairouan, where there is one psychiatrist to provide services for a
population of 450 000.
Specialized health care for children and adolescents are almost nonexistent, with the exception of the day hospital of Habib Thameur, in Tunis,
the consultancy in Sfax, at Monastir Hospital, and the school centres in
Tunis and Sousse.
There are other institutions in which mentally ill persons are housed
and receive care. These institutions include asylums for the elderly (under
the auspices of the Ministry of Social Welfare), homes for the handicapped
without families, private hospitals and traditional healers’ wards that use
traditional methods in the setting of modern facilities. There are also
nongovernmental organizations which participate in the care of the mentally
ill and for the retarded (e.g. the League for the Care of the Mentally
Retarded).
Mental health human resources
There are 81 psychiatrists in the country. Of these, 19 are in the public
psychiatric institutions, 20 in academic departments and 42 in private
sectors. There are 10 psychologists in the country and no social workers.
There are 310 nurses working in psychiatric institutions, of whom 40 have
received specialized training in psychiatry.
There are four medical colleges, and the undergraduate medical
students receive limited training in mental health amounting to 28 hours.
National mental health programme
The draft programme was developed in 1990 against a background of
rapid social change and urbanization with a resultant greater recognition of
the need for mental health care for the general population. The focus of the
national mental health programme is to provide appropriate care for
psychiatric patients and to prevent mental disorders, especially those caused
as a result of industrialization and modernization. The programme aims at
integration of mental health with general health and primary health care,
Tunisia
283
intersectoral coordination, training of personnel and information, education
and communication to the general population.
A ministerial decree issued in May 1992 established a technical
committee for mental health. The committee consists of leading psychiatrists
and representatives of other ministries. There are five subcommittees: on
training, on health education and information, on the treatment of the
mentally ill and care for groups at high risk, on judicial issues, and for
coordination among social sectors.
The subcommittees have initiated several activities, such as training of
personnel, preparation of a manual for physicians at the primary health care
level, visits of specialists to outpatient departments on a periodic basis,
review of the drug lists at the primary health care level, radio and television
programmes and research. The narcotics/substance abuse policy was
formulated in 2000 and the essential drugs policy has been in place since
1979.
Community mental health programmes
There is very good primary health care in the country. However no
systematic effort to integrate mental health care with primary health care has
been made. The activities carried out include the preparation of a doctor’s
manual and training of 60 health workers, 120 nurses and about 500 general
physicians. Over 280 personnel have been trained in mental health.
The school health programme in the country is very well developed,
consisting of about 500 public health physicians and 700 nurses. Currently,
only one centre carries out mental health work.
Research
Currently, a general population epidemiological survey of depression
and schizophrenia in the Ariana area is in progress. Similarly, other studies
about the prevalence of mental illness in homes for the elderly and in the
divorced have been completed.
284
Mental health in the Eastern Mediterranean Region: reaching the unreached
Summary update (Mental health atlas, 2005)
Epidemiology
A community epidemiological study carried out on a representative
sample of 5000 adults in one region reported a life time prevalence of about
9% for major depression and 0.6% for schizophrenia (Hachmi et al, 1995).
Fakhfakh et al (2000) assessed the use of tobacco (smoking) in Tunisia since
1970 using different sources. Cigarette smoking increased from 1981 to
1993 but decreased slightly after that. The prevalence of current tobacco
smoking was 30.4% (52% for males and 6% for females). In young people,
the prevalence was 29.2% (50% for males and 3.9% for females). Young
people who attended school smoked less than those who did not (18.1%
versus 38.4%). Most started smoking between 14 years and 18 years. Gassab
et al (2002) conducted a retrospective study of depression in a clinical
sample (n = 155) of bipolar (n = 86) and recurrent depressive disorder
(n = 59) patients, diagnosed according to the DSM-IV criteria. The following
factors were correlated with bipolarity: separation/divorce, family history of
psychiatric disorders (especially bipolar disorders), early onset, number of
affective episodes, sudden onset of depressive episodes and psychotic
features, catatonic features, hypersomnia and psychomotor inhibition.
Somatic comorbidity (diabetes, hypertension, rheumatic diseases) and
dysthymic disorders were predictors of non-bipolar depression. The bipolar
family history criterion had the highest positive predictive validity, while the
psychotic characteristics criterion had the lowest positive predictive validity.
Moalla et al (2001) found that organic (somatic illnesses, epilepsy) and
environmental (parental quarrels, poor family support) factors were
associated with onset of mental disorders in a sample of more than 1400
child psychiatry out-patients. Ayadi et al (2002) found divorce to be
associated with mental disorders in children (personality disorders,
functional disturbance and depressive disturbance). Karoui and Karoui
(1993) compared children with pica with children without pica in a day care
centre and found that pica was associated with gender (male), family history
of pica (positive in 57% of the cases), socioeconomic status (low) and
locality (urban). The onset was between 12 and 18 months in most cases.
Children of divorced parents had worse short- and medium-term outcomes in
Tunisia
285
comparison to children of parents who were staying together, but the longterm outcome was similar.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1986. The components of the policy are advocacy, promotion, prevention,
treatment and rehabilitation. There are committees and sub-committees
looking into the training of personnel, preparation of manuals for physicians
at the primary care level, visits of specialists to outpatient departments on a
periodic basis, review of drug list, radio and television programmes and
research. The main thrust of the policy are integration of mental health into
primary care, training of non-psychiatric medical professionals in psychiatric
care, creation of psychiatric services in general hospitals and sectorization of
services.
Substance abuse policy
A substance abuse policy is present. The policy was initially
formulated in 1969. The substance abuse policy was revised in 1969 and
2000.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1990. The goals of the programme are to promote and protect
mental health and to prevent, detect and treat mental disorders.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1979. The national therapeutic drug policy/essential drugs
list was re-evaluated in 1993 and in 2000.
Mental health legislation
Law No. 92-83 of 1992 on mental health and conditions of
hospitalization of individuals with mental disorders was the first law in the
field of mental health. The latest legislation was enacted in 2003.
286
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health financing
There are no budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are tax-based, out-of-pocket
expenditure by the patient or family, private insurances and social insurance.
The country has disability benefits for persons with mental disorders.
Mental health patients are provided financial, treatment and transportation
benefits.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level. The general
practitioners diagnose severe disorders and refer patients almost
systematically to the second/third level of care (a second level of care is only
available in a few regions) for treatment and monitoring.
Regular training of primary care professionals is carried out in the
field of mental health. In the last two years, about 280 personnel were
trained. Although training has been provided to some primary care
personnel, a system of follow-up has not been developed yet. A manual for
training of physicians has been prepared.
There are community care facilities for patients with mental disorders.
Some nongovernmental organizations provide community-based care for
children under the aegis of the Social Affairs Ministry.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
1.13
0.85
0.27
0
1.6
0.2
0.2
0.4
0.6
Tunisia
287
Two thirds of the specialists are based in the capital and along the
coastline.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in promotion, prevention and
rehabilitation. Some nongovernmental organizations are involved in the care
and training of the mentally retarded children.
Information gathering system
There is no mental health reporting system in the country. Preparations
are going on to include some indicators in the annual health reporting
system.
Programmes for special populations
The country has specific programmes for mental health for indigenous
population, elderly and children. There are services for delinquents,
abandoned children, prostitutes and patients affected by HIV.
There are some facilities for children and adolescents in the form of
day care hospitals, consultancy clinics and medico-school centres. There is
also a school health programme. There are homes for the elderly and
mentally retarded individuals.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, sodium valproate,
amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, lithium.
Drugs like cloimipramine form a part of the essential drug list.
Other information
Additional sources of information
Ayadi H et al. Parental divorce and psychopathologic unrests at the child and
the teenager. Tunisian comparative study. Neuropsychiatrie de l'enfance et de
l'adolescence, 2002, 50:121–127.
Fakhfakh R et al. Trends in tobacco consumption in Tunisia. Eastern
Mediterranean health journal, 2000, 6:678–686.
288
Mental health in the Eastern Mediterranean Region: reaching the unreached
Gassab L, Mechri A, Gaha L et al. Bipolarity correlated factors in major
depression: about 155 Tunisian inpatients. Encephale, 2002, 28:283–289.
Karoui A, Karoui H. Pica in Tunisian children. Results of a survey
performed in a polyclinic of the Tunisian social security national
administration. Pediatrie, 1993, 48:565–569.
Moalla Y, Ayedi H, Laaribi H et al What etiologic factors at the Tunisian
children? Timely an epidemiologic investigation. Neuropsychiatrie de
l'enfance et de l'adolescence, 2001, 49:343–351.
Hachmi et al. Epidémiologie des troubles dépressifs et de la schizophrénie
dans le gouvernorat de l'ARIANA. Mémoire de psychiatrie. Library of the
Faculty of Medicine of Tunis: Srairi LYES, 1995.
Republique Tunisienne Ministerè de la santé. Programme National de Santé
Mentale, 1998.
United Arab Emirates
Overview
There are seven member states of the United Arab Emirates: Abu
Dhabi, Dubai, Sharjah, Ajman, Umm Al-Quwain, Ras Al-Khaimah and
Fujairah. They lie mostly on the southern shore of the Persian Gulf but also
extend to the Gulf of Oman shore. The total area of this seven-state
federation is 83 600 km2. The Emirates’ population is dominated by
expatriate males as a result of a massive influx of immigrant workers after
the oil boom.
The political commitment to national health and the right of all
citizens and residents to comprehensive health care is strongly confirmed by
the constitution of the country, which dictates that health services are to be
provided to all the people free of charge. The strategies of the Ministry of
Health for the promotion and development of the health of the people in the
United Arab Emirates are well defined and explained in three national
documents published in 1986, the national five-year development plan for
the United Arab Emirates (1986–1990), the health strategy to attain the goal
of health for all by the year 2000, and Primary health care in the United
Arab Emirates (1986–1990).
The third five-year development plan (1986-90) provides broad
objectives and guidelines to translate primary health care policy into
strategies for implementation as detailed in the document. The priority areas
defined by the strategy are as follows: control and prevention of childhood
communicable diseases, control and prevention of tuberculosis control and
prevention of diarrhoeal diseases control of diseases related to pregnancy,
290
Mental health in the Eastern Mediterranean Region: reaching the unreached
malaria control, control of accidents and their complications, care of
diabetics care of hypertensive patients, care of cancer patients, prevention of
AIDS, control of parasitic intestinal diseases, strengthening of occupational
health development of health human resources, and development of health
systems.
The population was 4.21 million in 2004 of which about 61% were
male. Of the population aged 15 years and over, 66% are male. In 2002, the
populations below 15 years of age and above 65 years of age were estimated
to be 25.5% and 1.0% respectively. In 2002, the total adult literacy rate and
the adult female literacy rate were estimated to be 86% and 91%
respectively. Unofficial estimates suggest that non-national respectively.
Unofficial estimates suggest that non-nationals may account for some 70%
of the total population. The per capita gross national product in 2001 was
US$ 256 141.
The crude birth rate was 15.5 per 1000 population in 2002, the infant
mortality rate was estimated at 8.1 per 1000 live births and the under-5
mortality rate 10.2 per 1000 live births. Also in 2002, the maternal mortality
ratio was 0 per 10 000 live births. The total life expectancy at birth was
estimated to be 72.6 years of age in 2002. The rates for physicians, dentists,
nurses/midwives and hospital beds per 10 000 population are 16.9, 2.9, 35.2
and 21.9, respectively (2002).
Mental health
During the past 25 years, the United Arab Emirates has seen rapid
developments in all spheres of life, including health services. The effort has
been to provide modern health services for all the population. However, the
general development of hospital services has not included adequate
provisions for psychiatric care. During the past 15 years, a national mental
health programme was formulated and initiatives made to implement the
same. Practically, out of the 15 objectives set out in the national mental
health programme in 1991, 90% has been implemented and the rest of the
objectives remain under way.
United Arab Emirates
291
Abu Dhabi psychiatric hospital
Introduction
The psychiatric hospital in Abu Dhabi was built on instructions of the
President, His Highness Sheikh Zayed Bin Sultan Al Nahayan, in 1985
following a heroin epidemic in the area and followed by the establishment of
federal law No.6 on control of narcotic and like substances (1986). The
hospital opened in 1995.
The hospital is located within a medical city. Psychiatric patients can
use all the ancillary services within the medical city (such as radiology and
laboratory services), thus giving patients and their families the motivation
for treatment, hope for socialization and the sense of belonging to the
community.
The psychiatric hospital functions as a national resource centre for
clinical work, teaching and research, with special emphasis on the
integration of mental health services with other health services and
multidisciplinary practice and teaching. This promotes liaison psychiatrycooperation between general medical departments and the hospital. The
hospital has formal academic links with the Department of Psychiatry and
Behavioral Sciences of the Faculty of Medicine and Health Services at
United Arab Emirates University in Al-Ain with full commitment to
multidisciplinary teaching aimed at improving the standard of mental health
care in all the emirates. Teaching programmes are provided for
undergraduates and postgraduates, nurses, social workers, psychologists and
technical staff. Also, the hospital offers scientific lectures for medical staff
and regular lectures for patients’ relatives in the day centre and hosts
scientific meetings such as those held by the psychiatric division of the
Emirates Medical Association.
A central psychiatric register has been established by the Ministry of
Health for collection of data and research statistics regarding mental health
service. This system is being currently installed into the psychiatric hospital
in Abu Dhabi. Data from all emirates, regional and international centers
would be pooled into this information system.
The hospital is intended to be the leading model for a modern
community-based acute psychiatric unit within the Gulf Cooperation
Council states and is the equal of many units in developed countries.
292
Mental health in the Eastern Mediterranean Region: reaching the unreached
A manual defining the operational strategy of the agreed policies,
procedures and guidelines is available containing: policies for different
disciplines-doctors, clinical psychologists, social workers, occupational
therapists and nursing specialists; and job descriptions for all specialties.
The hospital contains adult general unit, psychiatric intensive unit, day
treatment centre, chemical dependency unit, rehabilitation unit, child and
adolescent unit. Liason and community psychiatry unit and teaching centres.
There are at present six consultants with internationally recognized
qualifications, six senior registers (specialist grade), 10 general practitioners
with three psychiatric qualifications, 15 social workers, 14 clinical
psychologists (three PhD Psych), seven occupational therapists (only one
with a recognized qualification) and 134 nurses.
Al-Ain
Following an accident that led to the demolition of the 30 bedded unit
housing the psychiatric patients, there is now a psychiatric unit in the
General Hospital with two consultants and hospital registers. Another
consultant psychiatrist will join the group soon. This unit is run jointly by the
medical staff of the Department of Psychiatry and Behavioural Sciences of
the Faculty of Medicine and Health Services at United Arab Emirates
University in Al-Ain.
There is a psychiatry unit in Tawam General Hospital with a
consultant psychiatrist, who runs an emergency outpatient clinic as well.
Another psychiatrist will be appointed soon.
Dubai
Al Amal Hospital is a purpose-built psychiatric hospital built in 1981
isolated from the main hospital complex. Because of shortage of staff, only
50 beds are being used for acute general psychiatry and drug-dependent
persons. There is only one consultant, specialist and several psychologist and
social workers. Currently, a rehabilitation facility is being arranged.
A link with the primary health care centre and General Hospital for
liaison is being considered. The load of police cases and patients from the
northern emirates make any attempt for reform difficult at present. Although
there are prison services, there is no close coordination to make use of the
United Arab Emirates
293
Khor Al Anz Detention Centre for criminally mentally ill patients as a
rehabilitation centre, and the influx of patients greatly undermines the efforts
of the Ministry of Health at further development.
Ras Al-Khaima
A psychiatrist provides treatment for patients in the general medical
ward of the General Hospital. A new female psychiatrist has been appointed
and attempts are under way to build a general psychiatric ward for a regular
outpatient clinic.
Sharjah
A consultant psychiatrist has been appointed to Al-Qasimi General
Hospital, which has an outpatient clinic and admission beds in the general
medical ward.
Fujairah
A psychiatrist is being appointed to Fujairah Hospital on the east coast
to replace the resigned one who was running a psychiatric unit in the General
Hospital.
Services for the mentally handicapped and geriatric
Services for the mentally handicapped and geriatric need more
coordination because the medical care of this group of patients is divided not
only between different ministries, but also between local and federal
departments.
Philanthropists and charity groups have built many centres for the
physically and mentally handicapped. Many of these centres are now
occupied by both groups. The same is true for elderly people. What started as
a service for the elderly turns out to be an institution for psychogeriatrics run
either by the Ministry of Labour and Social Affairs or the Ministry of Health,
sometimes with no joint coordination and concomitant waste of human and
financial resources.
A recent survey has shown that practically, there is a centre for the
mentally handicapped in each emirate run by the Ministry of Labour and
Social Affairs and probably another one for the elderly. While this is
294
Mental health in the Eastern Mediterranean Region: reaching the unreached
considered federal, there could be a “local” one sponsored by “private”
authority.
The existing centres at present are as follows:
•
Abu Dhabi Rehabilitation Centre, which caters for a mixture of
mentally retarded and psychogeriatric patients with a 100-bed
capacity, run by the Ministry of Health.
•
Sharjah Centre for Humanitarian Services, which is a local or private
institution that caters mainly for young mentally retarded, with a good
standard of care.
•
Abu Dhabi Centre for the Mentally Retarded, run under the auspices
of the Ministry of Labour and Social Affairs, is a day centre where
children come early during the day and are transported back home at
the end of the day.
There are also schools for the educationally subnormal which cater
for mentally retarded children. They are under no direct supervision by the
Ministry of Health, but do have a liaison with the Ministry of Education.
Child and adolescent mental health services
There is a psychiatric clinic at the School Health Center in Abu Dhabi,
which deals with early detection of and intervention for psychological
problems in schoolchildren. Those who need further help, crisis intervention
or further treatment are sent to a specialized centre at the child psychiatry
unit, which is run by a general psychiatrist with special experience in child
psychiatry. Until a child psychiatrist joins the department, consultant opinion
can be taken from a consultant child psychiatrist at department of Psychiatry
and Behavioural Sciences of the Faculty of Medicine and Health Services at
United Arab Emirates University, where two child psychiatrists are
employed. In Rashid Hospital, there is a child psychiatry service in a 10bedded unit with an outpatient clinic.
Residential centre for delinquent children
As is the case with mentally retarded children and psychogeriatrics,
delinquent children and substance abusers receive greater attention from
society and nongovernmental organizations than the mentally ill. So, a Social
Residential Centre for delinquent children and a Rehabilitation Centre for
United Arab Emirates
295
substance abusers under either the Ministry of Labour and Social Affairs or
the Ministry of Interior would be found; such patients are only brought to
medical services for admission during crisis.
This problem is being addressed now by the Central Psychiatric
Register, which is designed to coordinate the efforts of different ministries
towards a common policy, procedure and guidelines for mental health
services for those patients.
Department of Psychiatry and Behavioral Sciences, Faculty of
Medicine and Health Services, United Arab Emirate University,
Al-Ain
The Department of Psychiatry and Behavioural Sciences, Faculty of
Medicine and Health Services, United Arab Emirates University, Al-Ain, has
a small inpatient unit and good teaching staff to cover undergraduates in
coordination with Al-Jimi Psychiatric Unit. Medical Students are sent for
practical training to the psychiatric hospital in AbuDhabi, which has more
comprehensive facilities; and a good spirit of cooperation between the two
facilities for internship training has developed.
Human resources
The number of psychiatric staff in the United Arab Emirates has
increased approximately five times over the past few years in all categories
of multidisciplinary team. In the Abu Dhabi psychiatric hospital, there are 22
doctors with psychiatric qualifications ranging from M.R.C. Psych. to a
masters degree in psychiatry, as well as PhDs in clinical psychology and
special grade psychiatric nurses from Europe. There are 15 social workers.
Occupational therapists that did not exist 5 years ago are officially
recognized by the Ministry of Health and have a formal job description.
Western region-Abu Dhabi: A new psychiatrist is being appointed in
the new General Hospital thus covering the geographical distribution of
mental health service in the seven Emirates.
Progress in national mental health programme implementation
The national mental health programme was formulated in August
1991 with 15 objectives outlined in the programme. As part of the initiative
296
Mental health in the Eastern Mediterranean Region: reaching the unreached
to integrate mental health with primary health care, a WHO training course
on psychiatry in primary health care is conducted in coordination with
primary health care doctors in Abu Dhabi, Al-Ain and Dubai on a regular
basis, in addition to training for primary health care physicians in early
detection and treatment of mental illnesses. Psychiatric consultancy clinics
have been opened in some of the larger primary health care centres, run by
psychiatrists in conjunction with the primary health care doctors. Through
the liaison and community psychiatric unit, arrange for follow-up and
appointment either through the social worker in the hospital-based crisis
intervention team or domiciliary service or hot-line service run by nonmedical staff in the hospital. In addition, a workshop was conducted with the
administrators and WHO experts and it was agreed that primary health care
doctors can prescribe psychotropic drugs according to the WHO list and this
procedure is being organized with the responsible agencies.
The same course is being organized for school health doctors on a
regular basis in the different Emirates with the consent and permission of the
Ministry of Health and certificates of attendance are being issued to
encourage promotion in this field.
These continuing medical education courses are conducted
simultaneously in Abu Dhabi, Al-Ain and Dubai, and occasionally in other
emirates.
Public awareness programmes
The liaison and community psychiatry unit organizes a public
education programme with the mass media and lectures for police who work
with hospital staff in the chemical dependency unit and forensic psychiatry
unit, as well as for schoolchildren who come for regular orientation visits,
and school social workers and university students who come for summer
training courses. There is also an intensive training programme in the day
centre for patients and relatives. They are given brochures, pamphlets and
posters.
Central mental health committee
A central mental health committee works directly under the Minister
of Health under the chairmanship of the Undersecretary for Health and
United Arab Emirates
297
Director of Curative Medicine as well as Heads of Psychiatric Departments
and representatives from the Faculty of Medicine and Health Services,
United Arab Emirates University, Al-Ain, and the legal adviser of the
Minister of Health. This procedure has greatly strengthened the decisions of
the committee and facilitated the meetings and decision-taking. A great deal
of development has happened since then. The central mental health
committee has working parties comprising medical and paramedical staff to
advise on subjects pertinent to their specialties. This has facilitated
recruitment, establishment of new clinics and amendment of current
legislations.
Recruitment of forensic psychiatrists
Two psychiatrists, with special experience in forensic psychiatry, have
been appointed by the police for prisons and medico-legal cases. They work
in close cooperation with the forensic psychiatry team in the hospital. It has
reduced the workload and the medico-legal complications of police cases. A
common policy is being drawn up for long-stay prisoners in psychiatric
wards, mentally ill offenders admission and disposal.
Mental health training for general nurses, social workers and
clinical psychologists
A continuing medical education programme has been designed for
regular training of general nurses, social workers and clinical psychologists,
and certificates of recognition have been designed to encourage these
academic activities.
An in-service training unit has been issued for the establishment of a
Central Psychiatric register fully equipped with a computerized system, staff
and ancillary equipment to coordinate natural mental health services with
other ministries at local, regional and international levels.
Summary update (Mental health atlas, 2005)
Epidemiology
There is substantial epidemiological data on mental illnesses in the
United Arab Emirates in internationally accessible literature. No attempt was
made to include this information here.
298
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health resources
Mental health policy
A mental health policy is absent.
Substance abuse policy
A substance abuse policy is present. Details about the year of
formulation are not available.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1991. It aims at the universal provision of mental health and
substance abuse services by their incorporation in primary health care. The
strategies for realizing this aim are through training of personnel in mental
health at all primary care levels, strengthening existing centres and opening
new ones, streamlining referral services and providing essential drugs,
linking community and other sectoral services to it and developing human
resources.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present.
Details about the year of formulation are not available.
Mental health legislation
There is a Federal Mental Health Act. It contains sections on
definition of mental disorders, the role of authorities and police and on some
details on detention and psychoses. The law needs to be reviewed. There is
no specific mental health law on mentally abnormal offenders. The Sharia
Islamic law addresses such issues. A national forensic psychiatric committee
is being set up in collaboration with the ministries of health and justice.
Attempted suicide is a crime. The latest legislation was enacted in 1981.
Mental health financing
Details about disability benefits for mental health are not available.
Details about expenditure on mental health are not available. Details about
sources of financing are not available. Details about disability benefits for
mental health are not available.
United Arab Emirates
299
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level. There are
extensive primary care services which cater to all kinds of mental disorders.
Regular training of primary care professionals is carried out in the
field of mental health.
There are community care facilities for patients with mental disorders.
Facilities for rehabilitation are available through the community-based
rehabilitation approach. Community care services are not well developed
and this is compensated for by the primary care services.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
1.4
2
11
1
1.2
There are seven occupational therapists. A psychiatric hospital opened
in Abu Dhabi in 1995 with facilities for general psychiatry, forensic
psychiatry, addiction, emergency, child and adolescent psychiatry,
consultation-liaison and community care. It has an attached day treatment
centre. There are other psychiatric facilities in different cities. The private
sector is well established. Most professionals work in the hospital in Abu
Dhabi. In the other parts of the Emirates the number of personnel is limited,
and most have 1 or 2 psychiatrists only.
Nongovernmental organizations
Details about nongovernmental organization facilities in mental health
are not available.
300
Mental health in the Eastern Mediterranean Region: reaching the unreached
Information gathering system
Details about mental health reporting systems are not available. The
country has a data collection system or epidemiological study on mental
health. A central psychiatric register has been established by the Ministry of
Health for collection of data and research statistics regarding mental health,
and data from all over the Emirates would be pooled into this information
system.
Programmes for special populations
The country has specific programmes for mental health for elderly and
children. There are services for the mentally retarded and delinquents.
There are also school health centres in some areas which deal with
early detection and intervention of psychological problems in schoolchildren. Residential centres for delinquents are also present in some areas.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: unknown.
Other information
Psychiatric services are based on the public health system which is
organized on an emirate by emirate basis. A federal ministry has a
coordinating role. Abu Dhabi has the most extensive services followed by
Dubai. A special committee was established to advise on planning and
development of psychiatric services nation-wide.
Additional sources of information
Kraya N. Thirty years on: psychiatric services in the United Arab Emirates.
Australasian psychiatry, 2002, 10:168–171.
Kronfol NM. Perspectives on the health care system of the United Arab
Emirates. Eastern Mediterranean health journal, 1999, 5:149–167.
Yemen
Overview
The total area of Yemen is 460 000 km2. The estimated population is
21 million, with 46.2% under the age of 15 years, 2.9% above the age of 65
(2002). The total fertility rate per woman is 6.5 and 27% of the population
lives in urban areas (2002). The total adult literacy rate is about 47% and
adult female literacy rate is 31% (2003). The crude death rate is estimated at
11.4 per 1000 population, crude birth rate 39.2 per 1000 population, and total
life expectancy at birth 62.9 years (2003). The infant mortality rate is
estimated at 67.4 per 1000 live births (2000), maternal mortality ratio 36.6
per 10 000 live births (2003) and under-5 mortality rate 94.8 per 1000 live
births (2001).
Per capita gross national product is US$ 614 (2003). The Ministry of
Public Health budget is 4.5% of the national budget, and the per capita
expenditure by the Ministry of Public Health US$ 6.2 as compared to
national per capita expenditure of US$ 23 on health (2001). The rates per
10 000 population for doctors, dentists, nurses/midwives and hospital beds
available are of 2.2, 0.12, 4.5 and 5.9, respectively (2003). Administratively,
the country is divided into 17 governorates and 238 directorates.
Development of health systems
Following unification between Democratic Yemen and Yemen Arab
Republic in 1990, the entire organizational set-up of the health system went
into a stage of transition. A new organizational management structure was
established after unification focused on decentralization of decision-making
302
Mental health in the Eastern Mediterranean Region: reaching the unreached
to district level and has defined new responsibilities of governorate and
district health authorities.
The national primary health care strategy includes the following
priority areas:
•
development of a nationwide health care infrastructure for primary
health care backed by referral care
•
improvement in maternal and child health and family planning
•
strengthening the control of communicable diseases
•
improvement of supervision and management of public health
services, including development of a programme to strengthen
hospital management and health care administration
•
development of an appropriate combination of public and private
sectors
•
development and training of health personnel including retraining,
reorientation and continuous education
•
community participation and decentralization of health management
through defining responsibilities of governorates and district health
authorities
•
improvement in the quality, effectiveness and level of services of the
existing health care system.
The primary health care units each serve a population of about 2000
persons and are staffed with two primary health care workers and one trained
birth attendant, who are recruited locally. The primary health care centres,
which serve 10 000 persons on average, are staffed with one or two
physicians and between three and six nurses and a few technicians. Some
centres also have 5 to 20 beds, a laboratory and X-ray section. District
hospitals and a governorate hospital in the respective governorate capital
area provide specialist care facilities. Specialized and university hospitals in
Sana’a and Aden are the main referral centres for the country.
Nongovernmental organizations such as the Yemeni Women’s
Association, Yemeni Youth Association and Yemeni Red Crescent are also
involved in health care delivery.
Yemen
303
Mental health
Historical aspects
The development of mental health care in the Yemen can be divided
into four periods: prior to 1966, 1966–86, 1986–90 and since 1990. In South
Yemen before 1966, psychiatric patients were kept in prison, and no formal
mental health services were available. In the Yemen Arab Republic (North
Yemen) hundreds of psychiatric patients were kept in Al Shabaka prison,
Taiz, a custodial centre in Hudaydah and in other prisons in the governorates
of Dhamar and Hajjah.
At this point, there were over 500 psychiatric patients in Sana’a
central prison without care and among the other general prisoners. There
were 89 patients at Al Shabaka prison in cramped conditions with limited
ventilation. The Dar Al Salaam prison was a little better due to the
involvement of Catholic nuns caring for the inmates.
Organized mental health services started in Aden in 1966 in an
isolated place in Sheikh Othman under the name of Al Salaam clinic.
Following independence of the then South Yemen in 1967, outpatient
services were started in this clinic. A convalescent ward followed this for
recovered patients. In the 1970s, an outpatient clinic was opened in
Al Jumhurriyya hospital, Sana’a, on a twice-weekly basis. Later on, a
modern psychiatric hospital for 208 patients was built in Aden, funded by the
Kuwaiti government.
Mental health facilities and personnel
•
Sana’a: psychiatric unit at Al Thawra Hospital with daily outpatient
and inpatient facilities for 20 patients; psychiatric ward in the prison
with 170 patients; psychiatric hospital for females having 35 beds and
daily outpatient services, which is run by a religious nongovernmental
organization called Islah.
•
Hudaydah: Dar Al Salaam Mental Hospital, housing 150–200 patients;
outpatient clinics at Al Olofi Hospital and Al Thawra General
Hospital;
•
Taiz: Psychiatric unit with 20 beds at Al Thawra General Hospital;
prison psychiatric ward with 130 patients; daily outpatient services in
Al Thawra General Hospital.
304
Mental health in the Eastern Mediterranean Region: reaching the unreached
•
Aden: neuropsychiatric hospital with 208 beds and daily outpatient
clinic; outpatient clinics at Al Jumhuriyya General Hospital and the
central prison.
•
Lahej: weekly outpatient clinic in general hospital since 1986.
•
Abhyan: weekly outpatient clinic in general hospital since 1990.
•
Mukallah: daily outpatient clinic.
•
Seyun: weekly outpatient clinic.
There are 20 psychiatrists and 55 psychologists (of whom only 10 are
qualified) in the country. Some of the nurses have been trained in psychiatric
nursing in India and Egypt. There are three psychiatric social workers.
Programmes for postgraduate training of psychiatrists have been operational
since 2000.
There are two medical colleges in the country at Sana’a and Aden.
Both of them have full departments of psychiatry. The current teaching of
psychiatry and behavioural sciences at Sana’a University is as follows: 25
hours in the pre-clinical period, 4 weeks in clinical work during clinical
training and 4 weeks of training during internship.
National mental health programme
Against the background of strongly institutional care in the country
and extremely limited trained personnel, the Yemens formulated a national
mental health programme with the assistance of the WHO in December
1986.
Objectives
•
Development of mental health services for all in the near future with
extension to rural areas to serve the ones in need particularly those
improperly served, under-served and deprived within the existing
services integrated with primary health care services.
•
Enhanced use of modern knowledge of psychological, social and
behavioural sciences and modern technology for improvement of
health in general and social development.
•
Encouragement of the community, represented by official and social
organizations and societies, to participate in the development of the
mental health programme and support it.
Yemen
•
305
Reducing the harmful caused to mental health by broken homes,
internal and external migration and behavioural disorders, delinquency
and drug abuse, alcohol abuse and dependency and against the sequel
of sociocultural and economic changes taking place in the country
affecting the community, family and individual.
Strategies
The strategies identified were to develop an administrative support
system; integration of mental health within primary health care at all levels
of health care; provision of essential drugs; training of personnel; special
programmes for children, mentally retarded; drug dependent persons and for
rehabilitation; development of a mental health information system; revision
of mental health legislation and research. The period 1980–86 was a period
of innovation and extension of the programmes to the community. Following
the formulation of the national mental health programme, there was
organizational support and extension of the pilot programmes to integrate
mental health service delivery in primary health care with supervisory
support from the specialist services besides training of 1784 medical officers
and health personnel from distant rural health facilities and district hospitals.
Outreach services were started in the governorates of Mukallah, Seyun,
Abhyan and Lahej (on an average 500 patients are seen once in the twoweek-visits). This was a very effective period. In some ways, the rapid
progress of 1986–90 has been checked in the period prior to the start of the
Nations for Mental Health programme in 1997. This is one of the reasons
why, in 1997, the Yemen was selected as the site of one of WHO’s
demonstration programmes for its Nations for Mental Health initiative.
Some of the achievements can be summarized as follows.
•
The psychiatric ward for female patients in the central prison of
Sana’a has been closed. The patients were shifted to a new hospital,
which has 35 beds with all basic facilities, and also daily outpatient
services where both men and women get free consultation. Psychiatric
male patients are separated from other inmates in the prison and are
treated by psychiatrists. Their number has fallen from 500 to 170. The
admission of patients to the psychiatric ward in the prison and
306
•
•
•
•
•
•
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
discharge are decided by the psychiatrist and not by law-enforcing
authorities in Sana’a.
The department of psychiatry at Al–Thawra Hospital, Sana’a, the
outpatient clinics at the general hospitals of Taiz, Hudaydah, and Aden
and the extension clinics at Lahej, Mukallah, Seyun and Abhyan are
being more openly accepted by the community and by other medical
disciplines. They are serving to remove the fear and stigma of mental
disorders in the community.
The rehabilitation and vocational training centre in Sana’a offers
education and training for moderately retarded adolescents. The
rehabilitation and physiotherapy centre in Sana’a helps severely
mentally retarded children with motor disabilities.
The new psychiatric unit of Al Thawra hospital at Taiz is an open
system. Every patient is admitted along with a relative who takes part
in patient care. The relatives provide food and drugs to their patients.
The average stay is 2 to 3 weeks only.
The first drafts of the Arabic translation of a doctor’s manual and
health workers’ manual are available.
Regular in-service training programmes are being organized for the
nurses in the neuropsychiatric hospital in Aden. Lectures on mental
health are given to all the trainees of the Institute of Human Resources
Development in Health, in Aden.
Nongovernmental organizations and the public are being encouraged
to donate space, buildings and funds for the treatment of the mentally
ill. The Charitable Society for Social Reform is supervising the
hospital for psychiatric female patients in Sana’a.
Talk shows, interviews and discussions on various aspects of mental
health are periodically given on radio and television by professional
people. Articles on mental health appear in local newspapers and
periodicals.
Yemen
307
Summary update (Mental health atlas, 2005)
Epidemiology
There is a paucity of epidemiological data on mental illnesses in
Yemen in internationally accessible literature. Hassan et al (2002) assessed
the effect of khat chewing on mood symptoms in 200 healthy volunteers in a
hospital. They used the Hospital Anxiety and Depression Scale to assess
symptoms in khat chewing and abstinent individuals. More mood symptoms
were reported by the group that continued to chew khat.
Mental health resources
Mental health policy
A mental health policy is present. The policy was initially formulated
in 1986. The components of the policy are promotion, prevention, treatment
and rehabilitation.
Substance abuse policy
A substance abuse policy is absent.
National mental health programme
A national mental health programme is present. The programme was
formulated in 1983. The goals of the programme are integration of mental
health services into primary care, initiating a school health programme,
increasing the number of psychiatric beds in hospitals and providing training
facilities.
National therapeutic drug policy/essential list of drugs
A national therapeutic drug policy/essential list of drugs is present. It
was formulated in 1986.
Mental health legislation
There is no mental health legislation. Islamic laws are used for people
with mental illness.
Mental health financing
There are budget allocations for mental health. Details about
expenditure on mental health are not available. The primary sources of
mental health financing in descending order are out-of-pocket expenditure
308
Mental health in the Eastern Mediterranean Region: reaching the unreached
by the patient or family and tax-based. The country has disability benefits for
persons with mental disorders. Monthly social benefits may be given to
some mentally ill patients.
Mental health facilities
Mental health is a part of primary health care system. Actual treatment
of severe mental disorders is available at the primary level. Primary care is
available in some areas only.
Regular training of primary care professionals is carried out in the
field of mental health. In 2003–2004, about 150 personnel were trained.
Medical officers and health workers from rural health facilities and district
hospitals and general physicians were trained. Regular in-service training is
being provided to nurses.
There are no community care facilities for patients with mental
disorders. A community psychiatric care demonstration project has been set
up with the help of WHO.
Psychiatric beds and professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
1.85
1.1
0.4
0.35
0.5
0.06
0.09
0.08
1.2
0.04
Some beds have been earmarked for women. The number of beds in
prison psychiatric wards has been reduced by two-thirds and psychiatric
patients are separated from other inmates in the prison.
Nongovernmental organizations
Nongovernmental organizations are involved with mental health in the
country. They are mainly involved in treatment and rehabilitation. The
Yemen
309
International Committee of the Red Cross has helped in the provision of
services and reform in prison psychiatric wards.
Information gathering system
There is a mental health reporting system in the country. It is included
in the 5-year plan of health reporting. The country has no data collection
system or epidemiological study on mental health. Rehabilitation centres for
mentally challenged individuals are available.
Programmes for special populations
The country has specific programmes for mental health for refugees.
There is a mental hospital for women in Sanaa.
Therapeutic drugs
The following therapeutic drugs are generally available at the primary
health care level of the country: carbamazepine, phenobarbital, sodium
valproate, amitriptyline, chlorpromazine, diazepam, haloperidol. Yemen
follows the WHO Essential Drugs List.
Other information
Mental health services were practically non-existent before 1966 and
patients used to be kept in prisons. Since then, a lot of improvement has
occurred. Hospitals have been built, training provided to different personnel
at all levels of care and the administration has been educated about
psychiatric illnesses. Different nongovernmental organizations and WHO
helped in building the infrastructure. However, there are some difficulties in
the form of inadequate financial support or poor follow-up facilities that
have slowed down the implementation of the mental health programme.
Additional sources of information
Hassan NA et al. The effect of chewing khat leaves on human mood. Saudi
medical journal, 2002, 23:850–853.
310
vacat
Mental health in the Eastern Mediterranean Region: reaching the unreached
Part 3
Discussion and conclusions
vacat
Discussion and conclusions
Global perspectives
Introduction
WHO has pioneered the development of mental health services and
programmes, particularly in the developing countries. Beginning with the
document Organization of mental health services in developing countries
[7], a large number of initiatives have been taken to address the various
issues in this area. Notable among these have been the development of:
policies and strategies for global action for the improvement of mental health
care [46-48]; guidelines of the promotion of human rights of persons with
mental disorders [48,51]; checklists and glossaries on quality assurance in
mental health care [52]; a consensus statement on psychosocial rehabilitation
of the elderly [53,54]; basic principles of mental health care law [55];
guidelines for the elaboration and management of national programmes of
mental health [11–13]; behavioural science learning modules; programmes
for improving the psychosocial development of children [56]; life skills
education in schools [29–34]; guidelines for the primary prevention of
mental neurological and psychosocial disorders (25,26); mental health for
primary care personnel on common mental disorders [57]; support materials
for families with schizophrenia [58] and Alzheimer disease [59]; the Nations
for Mental Health programme [60–62]; behavioural interventions in general
health care [63–70]; and prevention of suicide [71–76]. All these
developments provided a window of opportunity for new initiatives. One
such initiative took the form of declaring mental health a WHO priority and
314
Mental health in the Eastern Mediterranean Region: reaching the unreached
developing a global agenda for mental health, setting into motion the global
WHO strategy for mental health, which was endorsed in November 1999 by
the Director-General and the WHO cabinet.
The four themes underpinning the WHO strategy are:
•
raising the level of awareness about the importance of mental health
globally
•
empowering policy-makers to develop effective mental health policies
•
enabling mental health professionals to provide better treatment and
care
•
empowering people suffering from mental disorders.
The strategy was conceived as a concrete and well-focused response
to the burden attributable to neuropsychiatric disorders. It is based on three
interlocking initiatives, each taking into account all ages and both sexes:
advocacy, policy and effective intervention.
Advocacy
•
To raise the profile of mental health, particularly that of vulnerable
groups, including women (Resolution of the Commission on the
Status of Women 43/3, on women and mental health with emphasis on
special groups), and to place it on the political, health and
development agendas of governments and other organizations
(international and national) with the potential to promote mental
health and prevent mental illnesses.
•
To check human rights violations, reduce the burden of stigma and
discrimination, facilitating access to care, improved quality of care,
recovery from illness, and equal participation in society.
To achieve this, WHO will mobilize a unified international advocacy
agenda for the incorporation of mental health issues into the human rights
legislation of countries (drawing on UN General Assembly Resolution
46/119 on the protection of persons with mental illness and the improvement
of mental health care (1991) (Annex 3).
Policy
•
To integrate mental health into the primary health sector at national
and local levels, focusing on issues of organization and management,
Discussions and conclusions
315
financing, legislation, human resources development and training,
private/public sector roles, procurement and regulation of
psychotropic drugs, quality assurance for treatment and care, linkages
to sectors outside health (such as housing and employment), and
overcoming barriers to the implementation of effective interventions
at all levels of the health system.
•
To promote the adoption of a life-span perspective in order to
appropriately address mental health needs that change with age; for
example, the importance of early stimulation programmes and skillsbuilding for the promotion of mental health of children and
adolescents, and home care programmes for elderly patients, affected
by dementia and other forms of disability, and their family caregivers.
•
To promote social cohesion of communities’ (for example, through
institutions such as health-promoting schools and workplaces,
community support and counselling networks and families).
To achieve this, WHO has developed a joint WHO/World Bank mental
health reform initiative which brings together the best evidence for policy
development and implementation in the context of the mental health sector
and places it in the broader context of varied social, economic, political and
environmental situations of countries, around the globe.
Effective intervention
•
To document and disseminate the evidence base for specific costeffective, culturally relevant treatment, prevention and promotion
interventions for neuropsychiatric disorders (focusing on psychosis,
depression, epilepsy, suicide prevention and vulnerable groups).
•
To provide recommendations on how best to involve all the sectors
concerned in promotive and preventive activities for which evidence
is available.
•
To provide recommendations on how best to integrate the mental
health component into primary health care through training,
monitoring and supervision of primary care workers by specialists,
and the creation of systems of referral and back-referral between
primary care and specialist services.
316
Mental health in the Eastern Mediterranean Region: reaching the unreached
To achieve this WHO is supporting the launch of global campaigns
targeting depression/suicide prevention schizophrenia and epilepsy, which
reach out to key international and national nongovernmental organizations,
professional organizations, academic institutions and civil society.
Despite the global movement towards a world more caring of its
vulnerable members, there is a dramatic lack of implementation of the
existing cost–effective interventions owing to a number of barriers:
•
the low priority of mental health on the international and national
agendas
•
mental health services usually having a vertical administrative and
management structure separate from that of the general health sector
•
inequitable financing and health insurance that does not incorporate
mental health treatment and illness prevention as a benefit
•
the centralization of services, for example in large and potentially
harmful psychiatric institutions, which leaves few resources for more
effective community-based services
•
poor or limited application of cost-effective mental health
interventions because of lack of rational care guidelines, scarcity of
skilled health professionals and policy-makers, inadequate monitoring
of treatment and care, and restricted availability of psychotropic
drugs, particularly at lower levels of the health system (poor planning
of needs, distribution problems, poor regulation of prices)
•
stigma and discrimination, which limit the access of patients to
treatment, the degree to which doctors and health workers have been
trained adequately and their willingness to intervene.
Regional perspectives
Progress in mental health
The past two decades have seen significant progress in the field of
mental health. Three areas—diagnosis, treatment and prevention—are
relevant for the current review of mental health programmes in the Region.
Sartorius identified at the global level these developments as follows [77]:
Acceptance of psychiatry as a medical discipline rests on three
premises: that its practitioners can reach a reliable diagnosis using
tools that other branches of medicine use; and second, that treatment
Discussions and conclusions
317
of psychiatric disorders is possible and effective and that it can be
evaluated, using criteria valid for the assessment of medical treatment;
and third, that psychiatry can contribute to the improvement of public
health by providing specific suggestions concerning the prevention
(and the organization of treatment) of mental illness and the
rehabilitation of those with it.
The progress of countries of the Eastern Mediterranean Region in the
above three areas, namely understanding of mental disorders, care of
mentally ill persons and prevention of mental disorders and promotion of
mental health has been impressive. The situation regarding care of the
mentally ill 25 years ago was largely institutionalized and centralized.
On 15 March 1979, when the “pavilion” of Ibn Rushd Hospital
became the University Psychiatric Centre of Casablanca, there was only one
trained psychiatrist and one resident to be in charge of three provinces and
four cities namely Casablanca, Mohamedia, El Gidida and Benshimane. The
building was in a terrible condition: with almost no electricity, no water
supply, no doors (except some metallic ones which did not close), no glass in
windows and almost no medication. The ceiling was falling on the heads of
the patients and staff, and rats were usual guests of the pavilion. The image
of psychiatry was terrible in the community, and the authorities decided to
close the ward in the teaching hospital and to transfer the patients to a
psychiatric hospital 25 km outside Casablanca. Now the same centre is
recognized as a teaching and research hospital providing wide range of
services and functions as a referral hospital. It also trains different categories
of caregivers for Morocco and other countries.
In southern Yemen, before 1966, patients were kept in the prison, and
no formal mental health services were available. The beginnings of
organized mental health services were made in Aden in 1966 in an isolated
place in Sheikh Othman under the name of Al Salam clinic. Initiatives have
now been taken to integrate mental health with primary health care in
Yemen.
The available facilities in the Region varied from large mental
hospitals to prisons. The stigma attached to the mentally ill, mental hospitals
and the mental health profession was high. From such a position, mental
health in the Region has changed.
318
Mental health in the Eastern Mediterranean Region: reaching the unreached
The most impressive of the developments is the recognition of the
mental health needs of the people of the countries of the Region as indicated
by formulation of national mental health programmes in most of the
countries. In many countries, care has moved from the centralized
institutions (prisons, mental hospitals) to general hospitals and primary
health care facilities, and there has been a significant increase in the
available professional training programmes and support and supervision of
primary health care personnel work. Programmes for the prevention of
neuropsychiatric disorders and promotion of mental health are taking root,
for example, school mental health programmes, public mental health
education, involvement of religious centres in mental health programmes
and rehabilitation.
Involvement of universities and academic departments of psychiatry
has enriched the programmes by providing leadership, quality assurance,
training, support and evaluation. The changing mental health legislation
highlighting the rights of the mentally ill is providing the framework for
these efforts.
National mental health programmes
Beginning with the formulation of a national mental health
programme by Pakistan in March 1986, currently 20 of the 22 countries of
the Region have developed or formulated national mental health
programmes. All of them focus on provision of mental health care for all,
integration of mental health care with primary health care and community
participation. Some countries have included care of war victims, prevention,
information system, development of mental health infrastructure and
research.
In all of the countries, the national mental health programme has come
to be a rallying point for re-examination of the mental health needs and
stimulus for innovative approaches to mental health care. One of the
professionals of the Region expressed this as follows. “The development of a
national programme of mental health has provided the much needed sense of
direction to the efforts of the mental health professionals in the country”. Of
the many activities of the national mental health programme, the integration
of mental health care with general health care is the most common activity.
Discussions and conclusions
319
The chief reason for this is the time period in which the mental health
programmes are being implemented. The Alma-Ata Declaration of 1978 has
had an impact in all countries of the Region. The shift from care for a few to
care for all has brought into the health systems a recognition of the needs of
marginalized groups, such as the mentally ill. The second reason is
international movement towards non-institutional care both in rich and poor
countries. Third, the availability of models of care such as integration with
primary health care has made it possible to take up these programmes with
limited resources. Fourth, the leadership of WHO to provide information,
bringing together professionals and administrators towards an identifiable
goal and over a time period of two decades, has been important. Lastly, the
special sociopolitical situation has brought to public attention the mental
health needs of the population. Some examples will illustrate this.
•
In the Palestinian population, even before the start of the mental health
programme in 1990, studies had shown a growing number of
behavioural disorders, especially among the young people who
account for 69% of the wounded. The present situation is expected to
produce disturbances harmful to the psychosocial and behavioural
development of the population, especially children. Among school
teachers, there was an appreciation of psychosocial and behavioural
problems among children.
•
In Kuwait, following the Gulf War, a special mental health treatment
facility called the Rigae centre was started to provide care for persons
with post-traumatic stress disorder.
•
In Lebanon, narcotic production tripled during the years of conflict,
and there were an estimated 240 000 young drug addicts. These came
under control with specific interventions.
The above selective review of the awareness of mental health issues
indicates a major role for mental health programmes. Mental health
programmes have to cater for the persons suffering from neuropsychiatric
illnesses, the usual emphasis till recent times, and move on towards
prevention and activities for mental health promotion.
At the regional level, the situation has implications for the future of
mental health programmes—mental health programmes should develop
collaborative programmes with other programmes (such as healthy lifestyle
320
Mental health in the Eastern Mediterranean Region: reaching the unreached
promotion, community-based initiatives, parenting skills training, cancer,
diabetes, and health education programmes). Primary health care personnel
must be sensitized and trained in psychosocial skills for interventions. New
studies have to be directed towards understanding the nature of psychosocial
stresses and the pathways from stress to deviant behaviour and disease
states.
This overview would be incomplete without reference to the
limitations of the progress of the last two decades. National mental health
programmes, however valuable in planning, have not received adequate
financial and administrative support. The innovative approaches to mental
health care have largely remained at the pilot project level or at the local
level and have not spread to become national programmes. Programmes for
mental health promotion and prevention of mental disorders have been seen
in only some countries. All of the initiatives have depended on strong and
charismatic leadership, which at times has led to the collapse of programmes
with change of leadership. A number of innovative programmes have
received setbacks through political change and war. These setbacks have
turned the clock of progress backwards or diverted the activities of
development to more immediate needs.
Evaluation and research activities to support the implementation of
national programmes have been limited and not built into strategies for
programme implementation. In almost all the countries, the initial goals
outlined for the short term and longer term periods were very ambitious.
Looking back, they were unrealistic. However they do serve as rallying
points for re-examination of mental health needs and stimuli for innovations
in mental health care.
The varied degrees of progress of the national mental health
programmes leads us to identify the following components for success of
such programmes.
Discussions and conclusions
321
Components for success of national mental health programmes
1.
Formulation of a national mental health programme is valuable as a
planning process at country level.
2.
The creation of a mental health unit in the ministry(ies) of health is
central for implementation of a national mental health programme.
3.
The formation of a supportive advisory committee is needed to
support the programme.
4.
Planners and professionals accept the programmes more easily if they
follow upon well planned and evaluated pilot programmes.
5.
The stage of implementation and effectiveness of the primary health
care programme are determining factors for the level of integration of
mental health services.
6.
Professionals, especially, those in academic departments, have to be
active partners in the national mental health programme at the levels
of training, support and evaluation.
7.
The primary health care programme needs to be supported by a
number of other activities such as use of media for raising the
awareness of the public about mental health issues, development of
school mental health programmes, formation and collaboration with
nongovernmental organizations, self-help groups of families, and
religious leaders.
8.
In each country it is essential to develop viable models of care at the
administrative unit level (governorate, district, wilayat, province) so
that the essential mental health team is defined for the country based
on the national health care situation.
9.
Evaluation of the programme is important to continuously identify the
levels of care, limits of care and the administrative supports needed
for the care to be satisfactory.
Mental health professionals need to share their concerns for the
mentally ill and seek support from planners and public by a process of
dialogue and continuous updating of advances in the understanding of
causation, availability of effective treatments, economics of care (benefits
and costs) and rights of the mentally ill.
322
Mental health in the Eastern Mediterranean Region: reaching the unreached
Future directions for national mental health programmes
Review of the progress of national mental health programmes
indicates gradual changes over the past 20 years in the level of enthusiasm
and involvement of health administrators and mental health professionals.
The stimulus initiated by WHO from the mid 1980s of “reaching the
unreached” and extending services needs to be strengthened by advocacy
and addressing new realities.
A two-pronged strategy needs to be adopted to rekindle this waning
enthusiasm. Evidence-based decision-making must be promoted right from
the stage of policy-making to service delivery, by bringing together the
currently seemingly divergent strands of development taking place in the
disciplines concerned with study of human behaviour. Equity-based
decision-making must be promoted at all levels through public education
campaigns involving collaboration of all stakeholders. This two-pronged
strategy has to have a strong base of robust research studies to have a chance
to succeed. These will have to be both longitudinal population-based studies
and focus group-based needs assessment studies. The former type of study is
expensive and human resources-intensive and in the majority of the
countries of the Region would be technically difficult, while the latter can be
carried out more easily. We do not have the luxury of choice, but we can
determine our priorities for the immediate and medium-term future which
may involve focusing on studies to:
•
determine the burden of common neuropsychiatric illnesses on
families/caregivers;
•
evaluate the efficacy, cost–effectiveness and cost–utility of biological,
psychological and social interventions and models of mental health
care delivery;
•
assess the quality of life of individuals and families with members
suffering from neuropsychiatric illnesses;
•
delineate the effect of educational and behavioural modification
programmes on the quality life of populations.
The mental health of the population of the countries of the Region
presents a complex picture of high need and recognition of the importance of
mental health as well as extremely limited resources for providing mental
health care and promoting mental health. However, the limited infrastructure
Discussions and conclusions
323
offers unique opportunities to organize activities utilizing the best of the
known information and models of care.
There are five major directions for the countries of the Region,
namely, organization of mental health care as part of general health care;
developing mental health human resources using innovative approaches;
providing support to mental health programmes through legislation and
research efforts; involvement of voluntary organizations and other sectors for
mental health initiatives; and focusing on special areas like child mental
health and urban mental health.
Integration of mental health with primary health care
The World Health Report 2001 recommended the organization of
mental health care by integration of mental health with primary health care.
The advantages of such integration is at many levels, from the practicality of
implementation within a short period to fighting stigma of mental disorders.
The majority of the countries of the Region have initiated programmes for
integration of mental health care with general health services. In some
countries the efforts have moved from pilot programmes to cover large
population groups. In one country mental health is fully integrated in the
primary health care system throughout the country. However, in many
countries the effort to date has been mainly to carry out training programmes
or take up pilot programmes for such integration. Some countries have
developed training manuals for primary health care personnel.
This approach to the organization of services has great significance for
the countries of the Region. However, in the future development of this area,
there are some specific areas that need greater attention in the countries of
the Region. One of these is the extension of pilot programmes to the whole
country. The issue of evaluation of the programmes is vital for the future
extension of the pilot programmes. Evaluation should include: the impact of
training programmes through pre-post training evaluation for changes in the
knowledge, attitudes and skills. The other levels of evaluation could include
the level of care provided by trained medical officers in their clinical settings
after a period of time from the training, the quality of psychiatric care
provided, the impact of care on the patients and their families and lastly the
324
Mental health in the Eastern Mediterranean Region: reaching the unreached
level and type of support required by medical officers from specialist
professionals in order to undertake the care programme.
There is also need to develop training programmes that are easy and
can be used in different settings in a standardized manner. The programmes
should have in-built mechanisms for periodic revision, in order to make
them suitable to changing social, demographic and economic contexts, such
as increased urbanization.
Human resource development
The greatest barrier to mental health care programmes in the countries
of the Region is the limited availability of specialist human resources.
Almost all of the countries have a very limited number of mental health
professionals. In some countries the number of professionals is grossly
inadequate even to provide minimal psychiatric care.
The World Health Report 2003, recognized the importance of human
resources as follows [78]:
The most critical issue facing health care systems is the shortage of
the people who make them work. Although this crisis is greatest in
developing countries, particularly in sub-Saharan Africa, it affects all
nations... Furthermore, all countries are now part of the global
marketplace for health professionals, and the effects of the demand–
supply imbalance will only increase as trade in health services
increases. Accordingly, new models for health workforce
strengthening must be developed and evaluated.
There are four approaches to address this need. The first of these is to
enhance training in psychiatry within undergraduate medical education.
Currently the amount of training (a few hours of lectures and a few clinical
sessions) does not reflect the amount of mental health work a general
medical doctor has to provide, and the skills required to meet service needs
are not provided as part of the training. It is also observed that, as psychiatry
is not an examination topic, students often neglect this area against other
competing demands. By bringing the training in psychiatry to the appropriate
level, new generations of students will be fully trained in psychiatry to take
up the integration of mental health with primary health care. In some
countries of the Region, major changes have already been made in the
Discussions and conclusions
325
undergraduate training of psychiatry. There is need for other countries to
take up similar curricular reform.
Similarly, all countries of the Region have undergraduate and
postgraduate training programmes for the training of psychologists, social
workers, nurses and other therapists. Most of these courses are largely
academic and do not provide the trainees with opportunities to acquire
knowledge and skills relevant to working in mental health care. Most such
training programmes do not have practical training in clinical settings. By
suitably modifying the curriculum and developing a more practical approach
to training, there offers the possibility of increasing human resources for
mental health care. This can be specially achieved by linking the training to
the developing national programmes and the emerging roles of the voluntary
organizations.
The second approach is to develop short training for non-specialists
like medical officers, general psychologists and general social workers and
nurses. These training programmes can be shorter than the traditional fulltime courses of 2–3 years. The usual period of training is 3–6 months. The
training can emphasize the clinical and practical aspects to suit the specific
situation of the country or region or a programme like school mental health
or rehabilitation. It is envisaged that in the course of the work, most of these
short-term trained personnel will take up fuller professional training and join
the professional teams as full professionals.
The third approach, specifically relevant to mental health care, is the
use of a wide variety of non-professionals. Mental health programmes have
pioneered the use of volunteers in suicide prevention, of patients as
therapists in substance dependence programmes like Alcoholics Anonymous,
and of family members as therapists to other family members. The principle
here is the limited role individuals play in a specific situation, especially
based on their own personal life experiences. The strength of these personnel
is in their focused expertise and their acceptance by other help seekers.
The fourth approach refers to the involvement of staff of other sectors.
As part of deprofessionalization, the use of personnel working with different
sectors, like health, education, police, etc., has been a frequently used
resource for mental health care. In this approach, the health worker,
preschool teacher, schoolteacher, police etc, take on a certain component of
326
Mental health in the Eastern Mediterranean Region: reaching the unreached
mental health care in addition to their other regular activities. These
additions can be at the level of identification of persons needing care,
referral, first aid, care of a particular level, etc. depending on the country and
the type of programme. This approach not only increases the human
resources available, but also destigmatizes the use of mental health care by
the community as services are seen as part of the larger system of care.
Mental health education of the public
Community mental health programmes aim to provide care in the
community by using the resources of the community. This is an important
shift in emphasis from people being passive agents to their becoming active
partners. This approach was the central message of the concept of primary
health care and the Alma-Ata Declaration of 1978. It is interesting that in the
Eastern Mediterranean Region, the important role of the people was
recognized, nearly 30 years before Alma-Ata, by Dr Aly Tawfik Shousha, the
first WHO Regional Director for the Eastern Mediterranean, in 1949 as
follows. “Health is not something that can be done to people; it must be done
for themselves by themselves [4].”
This approach assumes great importance in mental health. Individuals
and communities are the central forces towards prevention of mental
disorders and promotion of mental health. This recognition of the centrality
of the community is reflected in the objectives of national mental health
programmes in the countries of the Region.
WHO has rich experience in this area from its many public health
programmes (such as tuberculosis, maternal health and family planning) and
mental health professionals can benefit from them.
Substance abuse
Substance abuse is more than a health problem; it is a formidable
moral, social and economic challenge with pandemic dimensions. Not a
single country in the world can be called “drug free”. The Eastern
Mediterranean Region is an important centre for the production of illicit
drugs (more than 75% of all world opium is grown in Afghanistan) and a
transit area of the world for illicit drugs. The people of the Region are
increasingly vulnerable to drug-related health, social and economic
Discussions and conclusions
327
problems. First, substance abuse in general is not showing a decreasing trend
but an increasing trend. Second, the mode of use of the drugs is shifting from
oral use and inhalation to the injecting route, which is more harmful. Third,
younger and younger age groups are becoming victims to drug dependence,
and fourth, the increasing number of women who use drugs is likely to cause
greater harm to the families and community. There is a need for a strategic
plan to address the issues of drug use in a multi-sectoral and multi-pronged
manner.
There is a need to continue to work on substance abuse in a realistic
way and in active coordination with other concerned health programmes,
such as HIV/AIDS, healthy lifestyles and other sectors like law and order,
justice, education and labour. Specific areas for action are the need to:
improve knowledge about the regional substance abuse situation and related
services; identify measures to support comprehensive country planning of
substance abuse activities which in the health and social sectors would be
capable of addressing primary prevention, demand reduction and harm
reduction; create and/or support centres for longitudinal study of substance
abuse in the countries; and collect evidence-based, region-specific models of
effective drug abuse prevention, treatment and rehabilitation and encourage
collaboration and intersectoral coordination of activities.
In order to address the whole range of issues caused by substance
abuse, the Regional Director invited a number of experts to form a Regional
Advisory Panel on Drug Abuse (RAPID) in 2002. This advisory panel
developed a comprehensive strategy which combines elements for supply,
demand and harm reduction. The strategy was approved by the Fifty-second
Session of the Regional Committee in September 2005 (Annex 4).
Children’s mental health
The proportion of the population below 15 years is more than a third
of the population of the Region, and longitudinal studies carried out in
countries of the Region show that the prevalence of mental health problems
has increased significantly even though standards of living and the physical
health of children have improved [79,80]. However, children’s mental health
remains a neglected area of mental health services. There are no or very few
328
Mental health in the Eastern Mediterranean Region: reaching the unreached
child mental health personnel or services, even in some countries with well
developed mental health services.
In the area of children’s mental health, the most impressive
programmes in the Region are the school mental health programmes. Egypt
and Pakistan have provided models of intervention, and WHO has developed
a wide range of educational materials on school mental health, life skills
education in schools and the improvement of the psychosocial development
of children (see References). There is need for enhancing the scope,
coverage and evaluation of the initiatives in this area.
Future studies in the field of children’s mental health and learning
difficulties might include:
•
study of the impact of school mental health programmes on academic
performance and prevalence of emotional problems;
•
focused studies of at-risk children such as migrant populations,
children in single parent families and families under stress to
understand the pathogenesis of problems;
•
identification of practices in the school system having positive and
negative effects on mental health;
•
evaluation of different models of school mental health.
Mental health of survivors of disasters and those living in
conflict situations
Addressing the needs of populations suffering from mental health
problems as a result of disasters and conflict in the Eastern Mediterranean
Region is a stated goal of WHO. This is highlighted by World Health
Assembly resolution WHA55.10 [81], which urged Member States “to
strengthen action to protect children from and in armed conflict” and
resolution EB109.R8 of the Executive Board of WHO [82] which urged,
“support for [the] implementation of programmes to repair the psychological
damage of war, conflict and natural disasters” Several countries in the
Eastern Mediterranean Region are currently in a state of conflict. A number
of countries experience a wide variety of disasters, the earthquakes in the
Islamic Republic of Iran and Pakistan in 2005, floods in Djibouti and the
tsunami effect in Somalia being recent examples.
Discussions and conclusions
329
There is evidence that the prolonged and extensive history of suffering
due to disasters and conflicts in the Eastern Mediterranean Region has
resulted in a high prevalence of mental disorders. The most prevalent
disorders in the general population are major depression (mean = 64%,
range = 38.5% – 97%), post-traumatic stress disorder (mean = 43%,
range = 20.4% – 72.8%) and anxiety (mean = 58%, range = 21.5% – 86%)
[83]. The most vulnerable groups are women, children, refugees, those who
are unable to receive treatment and those who suffer from torture and intense
stress. The high rates of mental disorders in the general population have been
addressed by professionals in a number of ways. Unfortunately for the
population, disasters and conflict situations have been associated with
limited mental health services, either due to migration of professionals or
because the country concerned had very limited mental health infrastructure.
There is a need for countries of the Region to develop national plans
for disaster mental health care, along with contingency planning, human
resource development at all administrative levels. Some countries like
Islamic Republic of Iran has developed such plans and programmes.
As a result, to address the situation of massive needs and limited
professional resources, many innovative approaches have been adopted.
These have ranged from training alternative professionals, use of community
resources like teachers and volunteers or empowering the population using
culturally acceptable forms of coping (Bam earthquake, Pakistan
earthquake). The broad approach to addressing the needs of the survivors
with higher levels of psychiatric problems, should be to view the emotional
reactions, not in disease terms but as “normal” reactions to an abnormal
situation. There is also need to develop a community-oriented approach to
cover all of the populations.
There are six levels of intervention to address the mental health needs.
First, there is a need to increase the resilience of populations. All the people
must be given increased knowledge and skills on the handling of stressful
life situations by promoting healthy lifestyles. This help should be available
to all at the population level rather than at hospital level. Second, as there is
evidence of a correlation between mother’s distress and that of the child, the
whole family should become the focus for effective support. Interventions
must be developed to help rebuild the family by increasing communication
330
Mental health in the Eastern Mediterranean Region: reaching the unreached
among family members, strengthening family rituals and sharing of
emotions. Third, community solidarity and traditional methods of support
should be encouraged, as often, during times of disasters and conflicts,
communities become fragmented through the massive loss of life and largescale displacement that takes place. The rebuilding of community support
networks is in reality a way of promoting mental health of the population.
Fourth, the media can be an important positive influence in spreading mental
health promotion messages to the general population. Fifth, mental health
skills of caring for the population should be integrated with the general
services, through teachers in the education system and through volunteers
working in the voluntary organizations. Last, in the rebuilding of society,
there is a temptation to implement short-term measures to alleviate suffering.
In each situation a long-term plan to rebuild the essential mental health
services at the primary, secondary and tertiary levels should become part of
rebuilding of the country. [83]
Urban mental health
The progress of mental health to date has been to some extent
successful in covering the rural areas using the primary health care network.
However, the urban sector remains largely neglected. Currently, 15 countries
of the Region have an urban population of more than 50%. In five of these it
is above 80% and in another five it is between 60% and 80%.
Epidemiological studies generally point to a higher prevalence of mental
health problems in urban populations. Therefore it is imperative that models
of mental health care, delivery, prevention of mental disorders and
promotion of mental health for urban areas should receive priority. A
beginning in this direction has been made, and as of 1997, 35 cities in the
Region had healthy cities projects. For example, in Teheran the healthy city
project has a strong mental health component. This project includes work
with volunteers, school mental health and rehabilitation of war widows,
along with other physical health and environmental activities. In other
countries of the Region (such as Bahrain and Tunisia) community level
support is provided for the chronically mentally ill and their families by
visiting community psychiatric nurses. In some countries, such as Egypt,
Discussions and conclusions
331
suicide prevention is tackled through crisis centres that are being set up, and
they are proving to be valuable.
Initiatives for urban mental health which may be undertaken include
setting up of community-level mental health facilities such as day-care
centres, half-way houses, parental skills training, crisis intervention centres,
help lines, stress management programmes for working women, self-help
groups of at-risk individuals, support and networking of elderly persons,
decentralized services for marginalized persons (such as street children).
Legislation
The 1990s saw major changes in the approach to mental health law,
significant among which is the UN Principles for the Protection of Persons
with Mental Illness and for Improvement of Mental Health Care (Annex 3).
Nearly half of the countries of the Region do not have mental health
legislation, although a few countries have revised their mental health
legislation in recent years [84]. In a number of countries, the laws relating to
mental health are antiquated, and emphasis is on admission and discharge
procedures. As part of their national mental health programmes, many
countries are revising the laws relating to the mentally ill. In a few countries
draft legislation is awaiting acceptance. The WHO Regional Office for the
Eastern Mediterranean is working towards bringing laws in line with the
current understanding of mental health and the rights of the mentally ill.
Legislation, though only a guiding force in mental health programmes, can
often lead to positive attitudes and remove the stigma of mental illness and
mental health care.
The first consultation on mental health legislation was held in
Alexandria, Egypt, on 1–2 May 1996. This meeting exchanged views on
comparative mental health legislation in Islamic, civil and common law, and
developed an agenda for an intercountry meeting. The second meeting was
held in Kuwait on 2–6 October 1997. The reports of these consultations were
made available to the Member States.
Research
Developments in the understanding of mental disorders and mental
health have emphasized the close interaction of biological and psychosocial
332
Mental health in the Eastern Mediterranean Region: reaching the unreached
factors. This shift emphasizes the need for developing country level and
community level databases for action. The research needs of the Region have
been repeatedly discussed in WHO intercountry meetings. There has been
also a growth in mental health research in the Region. Research
methodology workshops have also been organized in a number of countries.
There is need for greater support [2]. This area also can enhance the role of
academic departments and universities in the mental health programmes.
Conclusions
National mental health programmes have been a positive initiative of
the WHO Regional Office for the Eastern Mediterranean in order to meet the
mental health needs of the population of the countries of the Region. The
approaches identified in 1985 and implemented during the past 20 years
have set the tone for the future.
The integration of mental health into primary health care, though far
from being complete in countries of the Region, has shown that services can
be delivered through the existing staff, if supervisory, referral, monitoring
and administrative support is provided by the specialist services. The
implementation has varied across the countries, and future work should
focus on model development for a geographical unit (catchment area);
evaluation of impact on individuals, families and community; and
development of information and quality assurance systems.
The collaboration within the health sector and other sectors is essential
for preventive and promotive activities. Education and media are two of the
sectors which can play a pivotal role in bringing about a lasting change in
the attitudes of the community towards mental health, thereby reducing the
stigmatization and discrimination endured by the mentally ill and their
families on the one hand, and paving the way for incorporating principles of
positive mental health in their daily life on the other. This change in attitudes
can be translated into active involvement of community institutions in
planning for services, their efficient delivery and monitoring of its impact on
the community’s well-being.
Urban populations are growing in the Region. Current programmes
have not adequately covered this group. Appropriate programmes should be
Discussions and conclusions
333
developed for urban mental health care provision, prevention of mental
disorders and promotion of mental health.
Research should become an important component of activities of the
country mental health programmes. These should be linked to the goals of
national mental health programmes. This will require training for
professionals in research methodology, initiation of pilot collaborative
projects and intercountry sharing of experiences and mutual support.
Legislation is an important support mechanism towards the rights of
the mentally ill. Outdated legislation should be revised to bring it in harmony
with the modern understanding of mental health and concepts of care.
References
1. Constitution of the World Health Organization. Geneva, Official records of
WHO, No. 2:100.
2. The world health report 2001. Mental health: new understanding, new
hope. Geneva, World Health Organization, 2001.
3. Murray CJ, Lopez AD, eds. The global burden of disease: a comprehensive
assessment of mortality and disability from disease, injuries and risk factors
in 1990 and projected to 2020. Cambridge, Massachusettes, Harvard
University Press, 1996.
4. Mubbashar MH et al. Community-based rural mental health programme.
Report of an experiment in Pakistan. EMR health services journal, 1986,
1:14–20.
5. A new era in mental health. In: EMRO: partner in health in the Eastern
Mediterranean 1949–1989. Alexandria, Egypt, WHO Regional Office
for the Eastern Mediterranean, 1991.
6. Mohit A et al. Mental health manpower development in Afghanistan:
report of a training course for primary health care physicians. Eastern
Mediterranean health journal, 1999, 5(2):215–9.
7. WHO/EMRO Interregional seminar on the organization of mental health
services, Addis Ababa, Ethiopia. Alexandria, Egypt, WHO Regional
Office for the Eastern Mediterranean, 1973.
8. Organization of mental health services in developing countries, Geneva,
World Health Organization, 1975 (WHO Technical Report Series, No.
564).
9. The first ten years of the World Health Organization, 1948–1957,
Geneva, World Health Organization, 1956.
References
335
10. Taba AH. The Eastern Mediterranean Region and its people, In: Report
of the Regional Director of the Eastern Mediterranean Region to the
Alma Ata Conference. Geneva, World Health Organization,
1978.(IC/PHC/78.6)
11. Public mental health—guidelines for the elaboration and management of
national mental health programmes. Geneva, World Health
Organization, 1996 (WHO/MNH/MND/96.19).
12. Mental health programmes: concepts and principles. Geneva, World
Health Organization, 1992 (WHO/MNH/92.11).
13. National mental health programmes.
Organization, 1987 (MNH/POL/87.8).
Geneva,
World
Health
14. Care for the mentally ill: components of mental health policies governing
the provision of psychiatric service. Geneva, World Health
Organization/Montreal,
Douglas
Hospital
Center,
1987
(WHO/POL/87.10).
15. Global action for the improvement of mental health care: policies and
strategies.
Geneva,
World
Health
Organization,
1996
(WHO/MNH/MND/96.4).
16. The work of WHO in the Eastern Mediterranean Region, Annual report
of the Regional Director, 1 January-31 December, 1995. Alexandria,
Egypt, WHO Regional Office for the Eastern Mediterranean, 1996.
17. Primary health care. Report of the international conference on primary
health care, Alma Ata, USSR. Geneva, World Health
Organization/UNICEF, 1978 (Health for All Series, No. 1).
18. The introduction of a mental health component into primary health care.
Geneva, World Health Organization, 1990.
19. Essential treatments in psychiatry. Geneva, World Health Organization,
1993 (WHO/MNH/MND/93.26).
20. Mubbashar SS, Saeed K, Gater R. Reaching the unreached. Evaluation of
training of primary health care physicians. Journal of College of
Physicians and Surgeons, Pakistan, 2001, 11(4):219–23.
21. Harding TW, Chrusciel TL. The use of psychotropic drugs in developing
countries. Bulletin of the World Health Organization, 1975, 52:357-367.
22. Wig NN. Rational treatment in psychiatry. Perspectives on psychiatric
treatment by level of care. In: Sartorius N et al., eds. Treatment of mental
336
Mental health in the Eastern Mediterranean Region: reaching the unreached
disorders: a review of effectiveness. Washington DC, World Health
Organization/American Psychology Association, 1993:423–41.
23. Mohit A. Mental health in Teheran in the context of the Iranian national
mental health program. In: Goldberg D, Thornicroft G, eds. Mental
health in our future cities. Psychology Press, 1998:217–38.
24. Chisholm D et al. Integration of mental health care into primary care
demonstration cost–outcome study in India and Pakistan. British journal
of psychiatry, 2000, 176:581–8.
25. Prevention of mental, neurological and psychosocial disorders, Geneva,
World Health Organization, 1986.
26. Guidelines for the primary prevention of mental, neurological and
psychosocial disorders (5 volumes). Geneva, World Health Organization,
1994 (WHO/MNH/MND/93.21–93.24).
27. Sartorius N. Universal strategies for the prevention of mental illness and
the promotion of mental health. In: Jenkins R, Ustun TB, eds. Preventing
mental illness: mental health promotion in primary care. Chichester,
John Wiley and Sons, 1998:61–67.
28. Healthy lifestyles. Resolution adopted at the Thirty sixth session the
Regional Committee for the Eastern Mediterranean. Alexandria, Egypt,
WHO Regional Office for the Eastern Mediterranean, 1989
(EM/RC36/R.7).
29. Mental health programmes in schools. Geneva, World Health
Organization, 1994 (WHO/MNH/PSF/93.3).
30. Life skills education in schools. Geneva, World Health Organization,
1994 (WHO/MNH/PSF/93.7A Rev. 1).
31. Training workshops for the development and implementation of life skills
programmes. Life skills evaluation in schools, part 3. Geneva, World
Health Organization, 1994 (WHO/MNH/PSF/93.7 B Rev. 1).
32. The development and dissemination of life skills education: an overview.
Geneva, World Health Organization, 1994 (WHO/MNH/PSF/94.7).
33. Research to improve implementation and effectiveness of school health
programmes,
Geneva,
World
Health
Organization,
1996
(WHO/HPR/HEP/96.3)
34. Life skills education. Planning for research. Geneva, World Health
Organization, 1996.
References
337
35. Mubbashar MH. Promotion of mental health through school health
programme, EMR health services journal, 1989, (6):14–9.
36. Rahman A et al. Randomised trial of the impact of school health
programmes in rural Rawalpindi, Pakistan. Lancet, 1998, 352:1022–25.
37. Saeed K et al. Detection of disabilities by school children: a pilot study
in rural Pakistan. Tropical doctor, 1999, 29:151–5.
38. Seif El Din AG. Evaluation of an educational training programme for the
development of trainers in child mental health in Alexandria. Eastern
Mediterranean health journal, 1996, 2(3):482.
39. Saeed K et al. The prevalence, classification and treatment of mental
disorders among attenders of native faith healers in rural Pakistan. Social
psychiatry and psychiatric epidemiology, 2000, 35:480–5.
40. Okasha A. Karam E. Mental health services and research in the Arab
world. Acta psychiatrica Scandinavica, 98:406–413.
41. Sartorius N. Janca A. Psychiatric assessment instruments developed by
the World Health Organization. Social psychiatry and psychiatric
epidemiology, 31: 55–69.
42. Kohn R, Saxena S, Levav I et al. Treatment gap in mental health care.
WHO Bulletin, 2004, 82: 858–866.
43. Atlas: country profiles on mental health resources 2001. Geneva, World
Health Organization, 2001.
44. Saraceno B, Barbui C. Poverty and mental illness. Canadian journal of
psychiatry, 1997, 42:285–290
45. Patel V et al. Poverty, psychological disorder and disability in primary
care attenders in Goa, India. British Journal of psychiatry, 1998,
172:533–53
46. Mental health. A call for action by world health ministers. Geneva,
World Health Organization, 2001.
47. WHO mental health policy and service guidance package: organization
of services for mental health. Geneva, World Health Organization, 2003.
48. WHO mental health policy and service guidance package: mental health,
human rights and legislation. Geneva, World Health Organization, 2003.
49. Chisholm D, Sanderson K, Ayuso-Mateos JL et al. Reducing the global
burden of depression: population-level analysis of intervention cost-
338
Mental health in the Eastern Mediterranean Region: reaching the unreached
effectiveness in 14 world regions. British journal of psychiatry, 2004,
184:393–403.
50. Saraceno B. Mental health: scarce resources need new paradigms. World
Psychiatry. 2004, 3:3–5.
51. Guidelines for the promotion of human rights of persons with mental
disorders.
Geneva,
World
Health
Organization,
1996
(WHO/MNH/MND/95.4).
52. Quality assurance in mental health care: checklists and glossaries. Vol.
1. Geneva, World Health Organization, 1994 (WHO/MNH/MND/94.17).
53. Lausanne technical consensus statements on psychiatry of the elderly.
Geneva, World Health Organization, 1999.
54. Psychosocial rehabilitation: a consensus statement. Geneva, World Health
Organization, 1996 (WHO/MNH/MND/96.2).
55. Mental health care law: ten basic principles. Geneva, World Health
Organization, 1996 (WHO/MNH/MND/96.9).
56. Learning to be parents. An annotated bibliography of programmes for
young people. Geneva, World Health Organization, 1985
(WHO/MNH/PRO.88.1).
57. Diagnosis and management of common mental disorders in primary
care.
Geneva,
World
Health
Organization,
1998
(WHO/MSA/MNH/EAC/98.1).
58. Schizophrenia information for families. Geneva, World
Organization, 1992 (WHO/MNH/MND/92.8).
Health
59. Alzheimer disease: help for caregivers. Geneva, World Health
Organization, 1994 (WHO/MNH/MND/94.8)
60. Nations for mental health: a special programme for mental health in
underserved populations. Geneva, World Health Organization, 1996
(WHO/MSA/MNH/96.5).
61. Nations for mental health: an overview of the strategy to improve the
mental health of underserved populations. Geneva, World Health
Organization, 1997 (WHO/MSA/NAM/97.3).
62. Nations for mental health: recommendations for evaluation. Geneva,
World Health Organization, 1998 (WHO/MSA/NAM/98.1).
References
339
63. Preparing patients for invasive medical and surgical procedures:
behavioural and cognitive aspects. Geneva, World Health Organization,
1993 (WHO/MNH/PSF/93.2A).
64. Communicating bad news. Geneva, World Health Organization, 1993
(WHO/MNH/PSF/93.2B).
65. Introducing parents to their abnormal baby. Geneva, World Health
Organization, 1993 (WHO/MNH/PSF/93.2D).
66. Promoting non-pharmacological interventions to treat elevated blood
pressure.
Geneva,
World
Health
Organization,
1993
(WHO/MNH/PSF/93.2C).
67. Psychological interventions for patients with chronic back pain. Geneva,
World Health Organization, 1993 (WHO/MNH/PSF/93.2E).
68. Self-management of recurrent headache. Geneva, World Health
Organization, 1993 (WHO/MNH/PSF/93.2F).
69. Improving adherence behaviour with treatment regimens. Geneva, World
Health Organization, 1993 (WHO/MNH/PSF/93.2G).
70. Insomnia: behavioural and cognitive interventions. Geneva, World
Health Organization, 1993 (WHO/MNH/PSF/93.2G).
71. Preventing suicide: a resource for general physicians. Geneva, World
Health Organization, 2000 (WHO/MNH/MBD/00.1).
72. Preventing suicide: a resource for media professionals. Geneva, World
Health Organization, 2000 (WHO/MNH/MBD/00.2).
73. Preventing suicide: a resource for teachers and school staff. Geneva,
World Health Organization, 2000 (WHO/MNH/MBD/00.3).
74. Preventing suicide: a resource for prison officers. Geneva, World Health
Organization, 2000 (WHO/MNH/MBD/00.4).
75. Preventing suicide: a resource for primary health care workers. Geneva,
World Health Organization, 2000 (WHO/MNH/MBD/00.5).
76. Preventing suicide: how to start a survivor group. Geneva, World Health
Organization, 2000 (WHO/MNH/MBD/00.6).
77. Sartorius N. Introduction. In: Sartorius N et al, eds. Treatment of mental
disorders: a review of effectiveness. Washington DC, World Health
Organization/American Psychological Association, 1993:xv–xx.
340
Mental health in the Eastern Mediterranean Region: reaching the unreached
78. The world health report 2003. Shaping the future. Geneva, World Health
Organization, 2003:110.
79. Rahim SIA, Cederbald M. Effects of rapid urbanization of child
behaviour in a part of Khartoum, Sudan. Journal of child psychology and
psychiatry, 1984, 25(4):629–41.
80. Giel R et al. Childhood mental disorders in primary health care: results
of observations in four developing countries. Pediatrics, 1981, 68: 677–
683.
81. World Health Organization, Mental health: responding to the call for
action, WHA55.10, 18 May 2002.
82. World Health Organization, Strengthening mental health, EB109.R8, 17
January 2002.
83. Ghosh N, Mohit A, Murthy RS, Mental health in countries of the Eastern
Mediterranean Region in conflict situations. Journal of the Royal Society
for Promotion of Health, 2004, 124:268–270.
84. Mental health ordinance 2001. Gazette of Pakistan, extra, 20 February
2001 [part1].
Annexes
Annex 1
Annex 2
Questionnaire on country
mental health information
Name of country------------------------------
Year of report--------------
1.
Country’s population based on the last official census divided to men, women
and groups, rural/urban, population shifts rural/urban.
1.1 Total population……………….
1.2 Sex distribution: Males………..Females…………..
1.3 Urban population………….Rural……………..Nomadic……….
1.4 Age distribution: <15 years…..> 60 years…………..
1.5 Literacy rate: Males…………Females………Total Pop………..
2.
The structure of health sector (primary health care system).
(Describe basic unit, different levels of care and health facilities and personnel
available in the country).
3.
Main health indicators
3.1 Life expectancy at birth…………………
3.2 Birth rate……………………………..
3.3 Death rate……………………………
3.4 Infant mortality rate…………………
3.5 Under-5 mortality rate…………………
3.6 Maternal mortality rate…………………
3.7 Low-birth-weight babies (<2500 g at birth)……………….
3.8 Safe water supply coverage…………………………………..
Annex 2
345
3.9 Sanitary facilities coverage……………………………………..
3.10 Immunization coverage………………………………
3.11 Population covered by health care………………………..
4.
5.
Health facilities and health personnel:
Total
4.1 Hospital beds per 10,000 pop………………
……
4.2 Physicians per 10,000 pop…………………..
……
4.3 Dentists per 10,000 pop……………………..
…….
4.4 Nurses and midwives per 10,000 pop………
…….
4.5 Primary health care unit per 10,000 pop……
…….
Leading causes of death (in hospitals)
Mental health infrastructure
6.
Hospital facilities
6.1 Mental hospitals
Location
No. of beds
Year of starting
1.
2.
3.
4.
5.
6.2 General hospital psychiatric units
Location
No. of beds
Year of starting
1.
2.
3.
4.
5.
6.3 Private psychiatric hospitals
Location
1.
2.
3.
No. of beds
Year of starting
346
Mental health in the Eastern Mediterranean Region: reaching the unreached
4.
5.
6.4 Specialized facilities (use additional page, if needed)
6.4.1 Child mental health
6.4.2 Geriatric psychiatric units
6.4.3 Drug dependence units
Location
No. of beds
Year of starting
1.
2.
3.
4.
5.
(use additional space if needed)
6.4.4 Community care facilities (half-way homes, hostels, long-stay
homes)
6.4.5 Mental retardation facilities
7.
Human resources
7.1 Psychiatrists
Total……………
Year……
7.1.1 Government ……
7.1.2 Private psychiatrists……….
7.1.3 Academic service………….
7.1.4 Child psychiatry……………
7.1.5 Drug abuse…………………..
7.1.6 Geriatric psychiatry…………
7.1.7 Military sector
7.1.8 Others
7.2 Trained clinical psychologists
7.2.1 Government service………………………
7.2.2 Private sector……………………………..
7.2.3 Specialist areas
7.2.3.1 Child mental health………………..
7.2.3.2 Drug abuse………………………..
7.2.3.3 Mental retardation………………..
Total……………
Annex 2
347
7.2.3.4 Others…………………………..
7.3 Trained psychiatric social workers……………
7.4 Trained psychiatric nurses…………………….
7.5 Neurologists……………………………………
8.
Training programmes
8.1 Undergraduate medical training in mental health
8.1.1 Hours of teaching (lectures)………………….
8.1.2 Hours of clinical work………………………..
8.1.3 Posting during internship………………………Yes/No
8.1.4 Examination subject……………………………Yes/No
8.1.4.1 Separate paper……………………….Yes/No
8.1.4.2 Part of medicine paper………………. Yes/No
Describe the training and recent changes in training
8.2 Training of psychiatrists
8.2.1 M.D. programme
Yes/No/Not available.
No of positions/year……………………..
8.2.2 Diploma in psychological medicine
Yes/No/Not available
No. of positions/year…………………
8.2.3 Specialized training (e.g. child psychiatry, etc.)
8.2.4 Total No. of training centres………………
8.3 Training of clinical psychologists
8.4 Training of psychiatric social workers
8.5 Training of psychiatric nurses
8.6 Any other training
9.
National Programme of Mental Health
9.1 Does the country have a National Programme
of Mental Health (NPMH)?
Yes/No
If yes, year of formulation……………….
If no, are there plans for formulation of
a NPMH when is it likely to occur?
10. Support for the NPMH (If yes to 9.1)
10.1 Approved by the parliament or equivalent
legislative body
Yes/No
Yes/No
348
Mental health in the Eastern Mediterranean Region: reaching the unreached
10.2 Approved by the cabinet of ministers
Yes/No
10.3 Signed by the Minister of Health
10.4 Formation of a National Mental Health
Advisory Committee.
10.5 Identification of a mental health office/
unit in the Ministry of Health
Yes/No
Yes/No
10.6 Availability of NPMH as a document
11. What are the essential components of NPMH?
11.1 Universal coverage of basic mental health
services
Yes/No
Yes/No
Yes/No
11.2 Integration with general health care
Yes/No
11.3 Identification of levels of mental health care
Yes/No
11.4 Dissemination of mental health skills to periphery
Yes/No
11.5 Task distribution for mental health care
Yes/No
11.6 Integration with education system
Yes/No
11.7 Human resources development: undergraduate
11.8 Human resources development: mental health
professionals
Yes/No
Yes/No
11.9 Legislation
Yes/No
11.10 Rehabilitation
Yes/No
11.11 Welfare benefits
Yes/No
11.12 NGO involvement
Yes/No
11.13 Public education
Yes/No
11.14 Prevention of mental disorders
Yes/No
11.15 Promotion of mental heath
Yes/No
11.16 Improvement of mental hospitals
Yes/No
11.17 Information system
Yes/No
11.18 Community involvement
Yes/No
11.19 Drug abuse programmes
Yes/No
11.20 Geriatric services
Yes/No
11.21 Child mental health
Yes/No
11.22 Parental skills training programme
11.23 Mental health skills for private
sector health personnel
Yes/No
Yes/No
11.24 Self-help groups for families
Yes/No
11.25 Urban mental health
Yes/No
11.26 Disaster care
Yes/No
Annex 2
349
11.27 Others
12. Implementation of the NPMH:………………to………………….
Activity
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Nationwide
Region
Pilot
programme
Not
applicable
Other
comments
Universal coverage
Integration into PHC
Levels of MNH care
Dissemination of
mental health skills
Task distribution
Integration into
education system
Human resources: UG
Human resources: PG
Legislation
Rehabilitation
Welfare benefits
NGO involvement
Public education
Prevention
Promotion
Mental hospitals
Information system
Community
involvement
Drug abuse
Geriatric service
Child mental health
Parental skills
Private sector
Self-help groups
Urban mental health
Disaster care
Others
13. Training programmes undertaken as part of NPMH
Year
Approx. No.
13.1 Medical administrators
………
………
13.2 Politicians
………
………
13.3 Psychiatrists
………
……...
13.4 Clinical psychologists
………
………
13.5 Psychiatric social workers
………
………
13.6 Psychiatric nurses
………
………
350
Mental health in the Eastern Mediterranean Region: reaching the unreached
13.7 Primary care doctors
……… .………
13.8 Primary care workers
……… ………
13.9 Prison staff
………
.………
13.10 Educational administrators
………
….……
13.11 Teachers
……… ………
13.12 Welfare administrators
……… ………
13.15 Child care workers
……… …….…
13.16 NGO staff
……… ………
13.17 Others
……… ………
14. Training materials developed in the country
Year
14.1 Manual for primary care physicians
Yes/No
………
14.2 Manual for primary care workers
Yes/No
………
14.3 Manual for schoolteachers
Yes/No
………
14.4 Manual for NGO staff
Yes/No
………
14.5 Pamphlets for general public
Yes/No
………
14.6 Posters on mental health
Yes/No
………
14.7 Videos for general public
Yes/No
………
14.8 Videos for training non-specialists
Yes/No
………
14.9 TV programmes
Yes/No
………
14.10 Radio plays/programmes
Yes/No
………
14.11 Others (specify)
Yes/No
……….
15. Innovative approaches to mental health care
15.1 School mental health
Yes/No
15.2 Volunteers in urban areas
Yes/No
15.3 Involvement of traditional healers
Yes/No
15.4 NGO initiatives
Yes/No
15.5 Self help groups
Yes/No
15.6 Others
(Please describe each of these in detail using additional sheets under the following
headings)
•
Year of starting
•
Reason for starting
•
Choice of intervention
Annex 2
•
•
•
•
•
•
•
351
Choice of personnel
Choice of tasks
Monitoring of work
Extension from pilot phase to larger areas
Impact of the programme
Outcome of the programme
Acceptance by professionals, policy-makers and people
16. What additional assistance is required for fuller implementation of NPMH in your
country?
16.1 Trained human resources
16.2 Technical information
16.3 Funds
16.4 Intersectoral collaboration
16.5 Others (Specify)….
17. What are the limitations of the NPMH as it applies to your country?
17.1 Incompatibility of the programme with the health sector
17.2 Incompatibility of the programme with sociocultural
values of people
17.3 Mental health professional attitudes
17.4 Financial inputs
17.5 Other
(NB: Please give specific example for each item)
Treatment system
18. Essential psychiatric drugs
18.1 Primary care level
18.1.1
18.1.2
18.1.3
18.1.4
18.1.5
18.2 Secondary care level
18.2.1
18.2.2
18.2.3
18.2.4
18.2.5
Yes/No
352
Mental health in the Eastern Mediterranean Region: reaching the unreached
18.2.6
18.2.7
18.2.8
18.3 Tertiary care level
18.4 Availability of essential drugs at all times
18.4.1 Primary care level
Yes/No/Variable
18.4.2 Secondary care level
Yes/No/Variable
18.4.3 Tertiary care level
Yes/No/Variable
18.5 Production of essential psychiatric drugs within the country?
18.5.1 Chlorpromazine
Adequate/Not adequate / Not produced
18.5.2 Amitryptyline/Impramine
Adequate/Not adequate/Not produced
18.5.3 Phenobarbitone
Adequate/Not adequate/Not produced
18.5.4 Inj. Anatensol
Adequate/Not adequate/Not produced
18.5.5 Trihexyphenidyl
Adequate/Not adequate/Not produced
18.5.6 Lithium carbonate
Adequate/Not adequate/Not produced
18.5.7 Haloperidol
Adequate/Not adequate/Not produced
18.5.8 Fluoxetine
Adequate/Not adequate/Not produced
18.5.9 Sodium penthothal
Adequate/Not adequate/Not produced
18.5.10 Diazepam
Adequate/Not adequate/Not produced
18.5.11 Alprazolam
Adequate/Not adequate/Not produced
18.5.12 Antabuse
Adequate/Not adequate/Not produced
19. Information system
19.1 Is there a mental health information system concerning the
country?
19.2 If yes, what are the components?
19.2.1 Admissions/discharges
19.2.2 OPD attendance
19.2.3 Duration of stay
19.2.4 Legal admissions
19.2.5 Other
Yes/No
Annex 2
353
20. Evaluation of NPMH
20.1 What is the current evaluation mechanism for the mental health programme?
20.2 What are the indicators used for monitoring?
20.2.1
20.2.2
20.2.3
20.2.4
20.2.5
20.2.6
20.3 Has there been an independent evaluation of any of the mental health
programme activities?
Yes/No
Please give details….
21. Mental health research
21.1 Does a national level research body for medical research exist?
Yes/No
If yes, please give name and details.
21.2 Sources of funding for mental health research
21.2.1 National research body
Yes/No
21.2.2 Ministry of Health
Yes/No
21.2.3 WHO
Yes/No
21.2.4 UNICEF
Yes/No
21.2.5 NGO
Yes/No
21.2.6 Others
21.3 Has there been any research methodology workshop on mental
health?
Yes/No
If yes, please give details……………..
21.4 What were the projects identified as priority for mental health research
relevant to your country?
21.4.1
21.4.2
21.4.3
21.4.4
21.4.5
21.4.6
354
Mental health in the Eastern Mediterranean Region: reaching the unreached
21.4.7
21.4.8
21.4.9
21.4.10
21.5 What are the major research projects completed in the country
(during the last ten years)
Please use additional pages, if required.
21.6 What are the constraints for mental health research?
21.6.1
21.6.2
21.6.3
21.6.4
21.6.5
21.7 What are the priority topics for research in:
• the next two years?
• the next five years?
21.8 List the mental health publications from your country
22. Legislation
22.1 What is the current law relating to mental health care in the
country?
22.2 What are the limitations of the law?
22.3 What have been the efforts to revise the law?
22.4 What is the current phase of revision of the mental health
legislation?
23. Mental health related indicators (Add)
23.1 Suicide rate
23.2 Homicide rate
23.3 Divorce rate
23.4 Prison population (10 000 population)
23.5 Homeless persons
23.6 Street children
23.7 Refugees
23.8 Children in institutions
23.9 Involuntary admissions to mental hospitals
Annex 2
355
23.10 New long stay patients- (more than one year admission)
23.11 Custodial care patients (>5 years)
24. Please describe in one page the highlights of the country mental health profile
during the past 20 years (in your own words)
25. Please describe in one page what you would like to see happening in the area of
mental health in your country in the next 10 years?
26. Any other information…………..
Annex 3
Principles for the protection
of persons with mental
illness and the improvement
of mental health care
adopted by United Nations General
Assembly resolution 46/119 of 17
December 1991
Application
These Principles shall be applied without discrimination of any kind
such as on grounds of disability, race, colour, sex, language, religion,
political or other opinion, national, ethnic or social origin, legal or social
status, age, property or birth.
Definitions
In these Principles:
“Counsel” means a legal or other qualified representative;
“Independent authority” means a competent and independent authority
prescribed by domestic law;
“Mental health care” includes analysis and diagnosis of a person's
mental condition, and treatment, care and rehabilitation for a mental illness
or suspected mental illness;
Annex 3
357
“Mental health facility” means any establishment, or any unit of an
establishment, which as its primary function provides mental health care;
“Mental health practitioner” means a medical doctor, clinical
psychologist, nurse, social worker or other appropriately trained and
qualified person with specific skills relevant to mental health care;
“Patient” means a person receiving mental health care and includes all
persons who are admitted to a mental health facility;
“Personal representative” means a person charged by law with the
duty of representing a patient's interests in any specified respect or of
exercising specified rights on the patient's behalf, and includes the parent or
legal guardian of a minor unless otherwise provided by domestic law;
“The review body” means the body established in accordance with
Principle 17 to review the involuntary admission or retention of a patient in a
mental health facility.
General limitation clause
The exercise of the rights set forth in these Principles may be subject
only to such limitations as are prescribed by law and are necessary to protect
the health or safety of the person concerned or of others, or otherwise to
protect public safety, order, health or morals or the fundamental rights and
freedoms of others.
Principle 1
Fundamental freedoms and basic rights
1.
All persons have the right to the best available mental health care,
which shall be part of the health and social care system.
2.
All persons with a mental illness, or who are being treated as such
persons, shall be treated with humanity and respect for the inherent
dignity of the human person.
3.
All persons with a mental illness, or who are being treated as such
persons, have the right to protection from economic, sexual and other
forms of exploitation, physical or other abuse and degrading
treatment.
4.
There shall be no discrimination on the grounds of mental illness.
“Discrimination” means any distinction, exclusion or preference that
358
Mental health in the Eastern Mediterranean Region: reaching the unreached
has the effect of nullifying or impairing equal enjoyment of rights.
Special measures solely to protect the rights, or secure the
advancement, of persons with mental illness shall not be deemed to be
discriminatory. Discrimination does not include any distinction,
exclusion or preference undertaken in accordance with the provisions
of these Principles and necessary to protect the human rights of a
person with a mental illness or of other individuals.
5.
Every person with a mental illness shall have the right to exercise all
civil, political, economic, social and cultural rights as recognized in
the Universal Declaration of Human Rights, the International
Covenant on Economic, Social and Cultural Rights, the International
Covenant on Civil and Political Rights, and in other relevant
instruments, such as the Declaration on the Rights of Disabled
Persons and the Body of Principles for the Protection of All Persons
under Any Form of Detention or Imprisonment.
6.
Any decision that, by reason of his or her mental illness, a person
lacks legal capacity, and any decision that, in consequence of such
incapacity, a personal representative shall be appointed, shall be made
only after a fair hearing by an independent and impartial tribunal
established by domestic law. The person whose capacity is at issue
shall be entitled to be represented by a counsel. If the person whose
capacity is at issue does not himself or herself secure such
representation, it shall be made available without payment by that
person to the extent that he or she does not have sufficient means to
pay for it. The counsel shall not in the same proceedings represent a
mental health facility or its personnel and shall not also represent a
member of the family of the person whose capacity is at issue unless
the tribunal is satisfied that there is no conflict of interest. Decisions
regarding capacity and the need for a personal representative shall be
reviewed at reasonable intervals prescribed by domestic law. The
person whose capacity is at issue, his or her personal representative, if
any, and any other interested person shall have the right to appeal to a
higher court against any such decision.
Annex 3
7.
359
Where a court or other competent tribunal finds that a person with
mental illness is unable to manage his or her own affairs, measures
shall be taken, so far as is necessary and appropriate to that person's
condition, to ensure the protection of his or her interest.
Principle 2
Protection of minors
Special care should be given within the purposes of these Principles
and within the context of domestic law relating to the protection of minors to
protect the rights of minors, including, if necessary, the appointment of a
personal representative other than a family member.
Principle 3
Life in the community
Every person with a mental illness shall have the right to live and
work, as far as possible, in the community.
Principle 4
Determination of mental illness
1.
A determination that a person has a mental illness shall be made in
accordance with internationally accepted medical standards.
2.
A determination of mental illness shall never be made on the basis of
political, economic or social status, or membership of a cultural, racial
or religious group, or any other reason not directly relevant to mental
health status.
3.
Family or professional conflict, or non-conformity with moral, social,
cultural or political values or religious beliefs prevailing in a person's
community, shall never be a determining factor in diagnosing mental
illness.
4.
A background of past treatment or hospitalization as a patient shall not
of itself justify any present or future determination of mental illness.
5.
No person or authority shall classify a person as having, or otherwise
indicate that a person has, a mental illness except for purposes directly
relating to mental illness or the consequences of mental illness.
360
Mental health in the Eastern Mediterranean Region: reaching the unreached
Principle 5
Medical examination
No person shall be compelled to undergo medical examination with a
view to determining whether or not he or she has a mental illness except in
accordance with a procedure authorized by domestic law.
Principle 6
Confidentiality
The right of confidentiality of information concerning all persons to
whom these Principles apply shall be respected.
Principle 7
Role of community and culture
1.
Every patient shall have the right to be treated and cared for, as far as
possible, in the community in which he or she lives.
2.
Where treatment takes place in a mental health facility, a patient shall
have the right, whenever possible, to be treated near his or her home or
the home of his or her relatives or friends and shall have the right to
return to the community as soon as possible.
3.
Every patient shall have the right to treatment suited to his or her
cultural background.
Principle 8
Standards of care
1.
Every patient shall have the right to receive such health and social
care as is appropriate to his or her health needs, and is entitled to care
and treatment in accordance with the same standards as other ill
persons.
2.
Every patient shall be protected from harm, including unjustified
medication, abuse by other patients, staff or others or other acts
causing mental distress or physical discomfort.
Annex 3
361
Principle 9
Treatment
1.
Every patient shall have the right to be treated in the least restrictive
environment and with the least restrictive or intrusive treatment
appropriate to the patient’s health needs and the need to protect the
physical safety of others.
2.
The treatment and care of every patient shall be based on an
individually prescribed plan, discussed with the patient, reviewed
regularly, revised as necessary and provided by qualified professional
staff.
3.
Mental health care shall always be provided in accordance with
applicable standards of ethics for mental health practitioners, including
internationally accepted standards such as the Principles of Medical
Ethics adopted by the United Nations General Assembly. Mental health
knowledge and skills shall never be abused.
4.
The treatment of every patient shall be directed towards preserving and
enhancing personal autonomy.
Principle 10
Medication
1.
Medication shall meet the best health needs of the patient, shall be
given to a patient only for therapeutic or diagnostic purposes and shall
never be administered as a punishment or for the convenience of
others. Subject to the provisions of paragraph 15 of Principle 11,
mental health practitioners shall only administer medication of known
or demonstrated efficacy.
2.
All medication shall be prescribed by a mental health practitioner
authorized by law and shall be recorded in the patient's records.
362
Mental health in the Eastern Mediterranean Region: reaching the unreached
Principle 11
Consent to treatment
1.
No treatment shall be given to a patient without his or her informed
consent, except as provided for in paragraphs 6, 7, 8, 13 and 15 below.
2.
Informed consent is consent obtained freely, without threats or
improper inducements, after appropriate disclosure to the patient of
adequate and understandable information in a form and language
understood by the patient on:
(a)
The diagnostic assessment;
(b)
The purpose, method, likely duration and expected benefit of
the proposed treatment;
(c)
Alternative modes of treatment, including those less intrusive;
and
(d)
Possible pain or discomfort, risks and side-effects of the
proposed treatment.
3.
A patient may request the presence of a person or persons of the
patient’s choosing during the procedure for granting consent.
4.
A patient has the right to refuse or stop treatment, except as provided
for in paragraphs 6, 7, 8, 13 and 15 below. The consequences of
refusing or stopping treatment must be explained to the patient.
5.
A patient shall never be invited or induced to waive the right to
informed consent. If the patient should seek to do so, it shall be
explained to the patient that the treatment cannot be given without
informed consent.
6.
Except as provided in paragraphs 7, 8, 12, 13, 14 and 15 below, a
proposed plan of treatment may be given to a patient without a
patient's informed consent if the following conditions are satisfied:
(a) The patient is, at the relevant time, held as an involuntary patient;
(b) An independent authority, having in its possession all relevant
information, including the information specified in paragraph 2
Annex 3
363
above, is satisfied that, at the relevant time, the patient lacks the capacity to
give or withhold informed consent to the proposed plan of treatment or, if
domestic legislation so provides, that, having regard to the patient’s own
safety or the safety of others, the patient unreasonably withholds such
consent; and
(c) The independent authority is satisfied that the proposed plan of
treatment is in the best interest of the patient’s health needs.
1.
Paragraph 6 above does not apply to a patient with a personal
representative empowered by law to consent to treatment for the
patient; but, except as provided in paragraphs 12, 13, 14 and 15 below,
treatment may be given to such a patient without his or her informed
consent if the personal representative, having been given the
information described in paragraph 2 above, consents on the patient's
behalf.
2.
Except as provided in paragraphs 12, 13, 14 and 15 below, treatment
may also be given to any patient without the patient's informed consent
if a qualified mental health practitioner authorized by law determines
that it is urgently necessary in order to prevent immediate or imminent
harm to the patient or to other persons. Such treatment shall not be
prolonged beyond the period that is strictly necessary for this purpose.
3.
Where any treatment is authorized without the patient's informed
consent, every effort shall nevertheless be made to inform the patient
about the nature of the treatment and any possible alternatives and to
involve the patient as far as practicable in the development of the
treatment plan.
4.
All treatment shall be immediately recorded in the patient’s medical
records, with an indication of whether involuntary or voluntary.
5.
Physical restraint or involuntary seclusion of a patient shall not be
employed except in accordance with the officially approved
procedures of the mental health facility and only when it is the only
means available to prevent immediate or imminent harm to the patient
or others. It shall not be prolonged beyond the period which is strictly
necessary for this purpose. All instances of physical restraint or
364
Mental health in the Eastern Mediterranean Region: reaching the unreached
involuntary seclusion, the reasons for them and their nature and extent
shall be recorded in the patient's medical record. A patient who is
restrained or secluded shall be kept under humane conditions and be
under the care and close and regular supervision of qualified members
of the staff. A personal representative, if any and if relevant, shall be
given prompt notice of any physical restraint or involuntary seclusion
of the patient.
6.
Sterilization shall never be carried out as a treatment for mental illness.
7.
A major medical or surgical procedure may be carried out on a person
with mental illness only where it is permitted by domestic law, where
it is considered that it would best serve the health needs of the patient
and where the patient gives informed consent, except that, where the
patient is unable to give informed consent, the procedure shall be
authorized only after independent review.
8.
Psychosurgery and other intrusive and irreversible treatments for
mental illness shall never be carried out on a patient who is an
involuntary patient in a mental health facility and, to the extent that
domestic law permits them to be carried out, they may be carried out
on any other patient only where the patient has given informed consent
and an independent external body has satisfied itself that there is
genuine informed consent and that the treatment best serves the health
needs of the patient.
9.
Clinical trials and experimental treatment shall never be carried out on
any patient without informed consent, except that a patient who is
unable to give informed consent may be admitted to a clinical trial or
given experimental treatment, but only with the approval of a
competent, independent review body specifically constituted for this
purpose.
10.
In the cases specified in paragraphs 6, 7, 8, 13, 14 and 15 above, the
patient or his or her personal representative, or any interested person,
shall have the right to appeal to a judicial or other independent
authority concerning any treatment given to him or her.
Annex 3
365
Principle 12
Notice of rights
1.
A patient in a mental health facility shall be informed as soon as
possible after admission, in a form and a language which the patient
understands, of all his or her rights in accordance with these Principles
and under domestic law, which information shall include an
explanation of those rights and how to exercise them.
2.
If and for so long as a patient is unable to understand such
information, the rights of the patient shall be communicated to the
personal representative, if any and if appropriate, and to the person or
persons best able to represent the patient's interests and willing to do
so.
3.
A patient who has the necessary capacity has the right to nominate a
person who should be informed on his or her behalf, as well as a
person to represent his or her interests to the authorities of the facility.
Principle 13
Rights and conditions in mental health facilities
1.
Every patient in a mental health facility shall, in particular, have the
right to full respect for his or her:
(a)
Recognition everywhere as a person before the law;
(b)
Privacy;
(c)
Freedom of communication, which includes freedom to
communicate with other persons in the facility; freedom to
send and receive uncensored private communications; freedom
to receive, in private, visits from a counsel or personal
representative and, at all reasonable times, from other visitors;
and freedom of access to postal and telephone services and to
newspapers, radio and television;
(d)
Freedom of religion or belief.
366
2.
Mental health in the Eastern Mediterranean Region: reaching the unreached
The environment and living conditions in mental health facilities
shall be as close as possible to those of the normal life of persons of
similar age and in particular shall include:
(a)
Facilities for recreational and leisure activities;
(b)
Facilities for education;
(c)
Facilities to purchase or receive items for daily living,
recreation and communication;
(d)
Facilities, and encouragement to use such facilities, for a
patient's engagement in active occupation suited to his or her
social and cultural background, and for appropriate vocational
rehabilitation measures to promote reintegration in the
community. These measures should include vocational
guidance, vocational training and placement services to enable
patients to secure or retain employment in the community.
3.
In no circumstances shall a patient be subject to forced labour. Within
the limits compatible with the needs of the patient and with the
requirements of institutional administration, a patient shall be able to
choose the type of work he or she wishes to perform.
4.
The labour of a patient in a mental health facility shall not be
exploited. Every such patient shall have the right to receive the same
remuneration for any work which he or she does as would, according
to domestic law or custom, be paid for such work to a non-patient.
Every such patient shall, in any event, have the right to receive a fair
share of any remuneration which is paid to the mental health facility
for his or her work.
Principle 14
Resources for mental health facilities
1.
A mental health facility shall have access to the same level of
resources as any other health establishment, and in particular:
Annex 3
367
(a) Qualified medical and other appropriate professional staff in
sufficient numbers and with adequate space to provide each
patient with privacy and a programme of appropriate and active
therapy;
(b) Diagnostic and therapeutic equipment for the patient;
(c) Appropriate professional care; and
2.
(d) Adequate, regular and comprehensive treatment, including
supplies of medication.
Every mental health facility shall be inspected by the competent
authorities with sufficient frequency to ensure that the conditions,
treatment and care of patients comply with these Principles.
Principle 15
Admission principles
1.
Where a person needs treatment in a mental health facility, every
effort shall be made to avoid involuntary admission.
2.
Access to a mental health facility shall be administered in the same
way as access to any other facility for any other illness.
3.
Every patient not admitted involuntarily shall have the right to leave
the mental health facility at any time unless the criteria for his or her
retention as an involuntary patient, as set forth in Principle 16, apply,
and he or she shall be informed of that right.
Principle 16
Involuntary admission
1.
A person may (a) be admitted involuntarily to a mental health facility
as a patient; or (b) having already been admitted voluntarily as a
patient, be retained as an involuntary patient in the mental health
facility if, and only if, a qualified mental health practitioner authorized
by law for that purpose determines, in accordance with Principle 4,
that person has a mental illness and considers:
368
Mental health in the Eastern Mediterranean Region: reaching the unreached
(a)
That, because of that mental illness, there is a serious likelihood
of immediate or imminent harm to that person or to other
persons; or
(b)
That, in the case of a person whose mental illness is severe and
whose judgement is impaired, failure to admit or retain that
person is likely to lead to a serious deterioration in his or her
condition or will prevent the giving of appropriate treatment that
can only be given by admission to a mental health facility in
accordance with the principle of the least restrictive alternative.
In the case referred to in subparagraph (b), a second such mental
health practitioner, independent of the first, should be consulted where
possible. If such consultation takes place, the involuntary admission or
retention may not take place unless the second mental health practitioner
concurs.
2.
Involuntary admission or retention shall initially be for a short period
as specified by domestic law for observation and preliminary
treatment pending review of the admission or retention by the review
body. The grounds of the admission shall be communicated to the
patient without delay and the fact of the admission and the grounds
for it shall also be communicated promptly and in detail to the review
body, to the patient’s personal representative, if any, and, unless the
patient objects, to the patient's family.
3.
A mental health facility may receive involuntarily admitted patients
only if the facility has been designated to do so by a competent
authority prescribed by domestic law.
Principle 17
Review body
1.
The review body shall be a judicial or other independent and impartial
body established by domestic law and functioning in accordance with
procedures laid down by domestic law. It shall, in formulating its
decisions, have the assistance of one or more qualified and
Annex 3
369
independent mental health practitioners and take their advice into
account.
2.
The review body’s initial review, as required by paragraph 2 of
Principle 16, of a decision to admit or retain a person as an
involuntary patient shall take place as soon as possible after that
decision and shall be conducted in accordance with simple and
expeditious procedures as specified by domestic law.
3.
The review body shall periodically review the cases of involuntary
patients at reasonable intervals as specified by domestic law.
4.
An involuntary patient may apply to the review body for release or
voluntary status, at reasonable intervals as specified by domestic law.
5.
At each review, the review body shall consider whether the criteria for
involuntary admission set out in paragraph 1 of Principle 16 are still
satisfied, and, if not, the patient shall be discharged as an involuntary
patient.
6.
If at any time the mental health practitioner responsible for the case is
satisfied that the conditions for the retention of a person as an
involuntary patient are no longer satisfied, he or she shall order the
discharge of that person as such a patient.
7.
A patient or his personal representative or any interested person shall
have the right to appeal to a higher court against a decision that the
patient be admitted to, or be retained in, a mental health facility.
Principle 18
Procedural safeguards
1.
The patient shall be entitled to choose and appoint a counsel to
represent the patient as such, including representation in any
complaint procedure or appeal. If the patient does not secure such
services, a counsel shall be made available without payment by the
patient to the extent that the patient lacks sufficient means to pay.
2.
The patient shall also be entitled to the assistance, if necessary, of the
services of an interpreter. Where such services are necessary and the
patient does not secure them, they shall be made available without
370
Mental health in the Eastern Mediterranean Region: reaching the unreached
payment by the patient to the extent that the patient lacks sufficient
means to pay.
3.
The patient and the patient’s counsel may request and produce at any
hearing an independent mental health report and any other reports and
oral, written and other evidence that are relevant and admissible.
4.
Copies of the patient’s records and any reports and documents to be
submitted shall be given to the patient and to the patient’s counsel,
except in special cases where it is determined that a specific
disclosure to the patient would cause serious harm to the patient's
health or put at risk the safety of others. As domestic law may
provide, any document not given to the patient should, when this can
be done in confidence, be given to the patient's personal representative
and counsel. When any part of a document is withheld from a patient,
the patient or the patient's counsel, if any, shall receive notice of the
withholding and the reasons for it and shall be subject to judicial
review.
5.
The patient and the patient's personal representative and counsel shall
be entitled to attend, participate and be heard personally in any
hearing.
6.
If the patient or the patient’s personal representative or counsel
requests that a particular person be present at a hearing, that person
shall be admitted unless it is determined that the person's presence
could cause serious harm to the patient's health or put at risk the safety
of others.
7.
Any decision whether the hearing or any part of it shall be in public or
in private and may be publicly reported shall give full consideration to
the patient's own wishes, to the need to respect the privacy of the
patient and of other persons and to the need to prevent serious harm to
the patient's health or to avoid putting at risk the safety of others.
8.
The decision arising out of the hearing and the reasons for it shall be
expressed in writing. Copies shall be given to the patient and his or
her personal representative and counsel. In deciding whether the
decision shall be published in whole or in part, full consideration shall
Annex 3
371
be given to the patient’s own wishes, to the need to respect his or her
privacy and that of other persons, to the public interest in the open
administration of justice and to the need to prevent serious harm to the
patient's health or to avoid putting at risk the safety of others.
Principle 19
Access to information
1.
A patient (which term in this Principle includes a former patient)
shall be entitled to have access to the information concerning the
patient in his or her health and personal records maintained by a
mental health facility. This right may be subject to restrictions in
order to prevent serious harm to the patient's health and avoid
putting at risk the safety of others. As domestic law may provide,
any such information not given to the patient should, when this can
be done in confidence, be given to the patient’s personal
representative and counsel. When any of the information is withheld
from a patient, the patient or the patient's counsel, if any, shall
receive notice of the withholding and the reasons for it and it shall
be subject to judicial review.
2.
Any written comments by the patient or the patient’s personal
representative or counsel shall, on request, be inserted in the
patient’s file.
Principle 20
Criminal offenders
1.
This Principle applies to persons serving sentences of imprisonment
for criminal offences, or who are otherwise detained in the course of
criminal proceedings or investigations against them, and who are
determined to have a mental illness or who it is believed may have
such an illness.
2.
All such persons should receive the best available mental health care
as provided in Principle 1. These Principles shall apply to them to
the fullest extent possible, with only such limited modifications and
exceptions as are necessary in the circumstances. No such
372
Mental health in the Eastern Mediterranean Region: reaching the unreached
modifications and exceptions shall prejudice the persons’ rights
under the instruments noted in paragraph 5 of Principle 1.
3.
Domestic law may authorize a court or other competent authority,
acting on the basis of competent and independent medical advice, to
order that such persons be admitted to a mental health facility.
4.
Treatment of persons determined to have a mental illness shall in all
circumstances be consistent with Principle 11.
Principle 21
Complaints
Every patient and former patient shall have the right to make a
complaint through procedures as specified by domestic law.
Principle 22
Monitoring and remedies
States shall ensure that appropriate mechanisms are in force to
promote compliance with these Principles, for the inspection of mental
health facilities, for the submission, investigation and resolution of
complaints and for the institution of appropriate disciplinary or judicial
proceedings for professional misconduct or violation of the rights of a
patient.
Principle 23
Implementation
1.
States should implement these Principles through appropriate
legislative, judicial, administrative, educational and other measures,
which they shall review periodically.
2.
States shall make these Principles widely known by appropriate and
active means.
Annex 3
373
Principle 24
Scope of principles relating to mental health facilities
These Principles apply to all persons who are admitted to a mental
health facility.
Principle 25
Saving of existing rights
There shall be no restriction upon or derogation from any existing
rights of patients, including rights recognized in applicable international or
domestic law, on the pretext that these Principles do not recognize such
rights or that they recognize them to a lesser extent.
Annex 4
Substance use and
dependence
Technical paper presented at the
Fifty-second session of the Regional
Committee for the Eastern
Mediterranean and resolution
Executive summary
The public health importance of substance use and dependence is
growing from year to year as it is more than a health problem; it is a
formidable moral, social and economic challenge with pandemic
dimensions. Not a country or place in the world can be certified as “drug
free”. As part of one of the most important transit areas of the world for
illicit drugs, with many countries experiencing rapid social change and
conflict situations, the countries of the Eastern Mediterranean Region are
increasingly vulnerable to health, social and economic problems related to
substance use and dependence. The trend in substance use among youth (15–
24 years) and women is rising. The commonest substances of dependence
are cannabis, sedatives, opiates and stimulants. Injecting drug use is a new
development with significant public health implications, specifically related
to spread of bloodborne infections. The most frequently injected drugs are
Annex 4
375
opiates. The rate of HIV positive status among injecting drug users increased
from 0.16% in 1999 to 3.26% in 2003. Similarly HIV transmission through
injecting drug use increased from 2% in 1999 to 13% in 2003.
There is an urgent need to recognize the health impact of substance
use and dependence. A number of measures at the level of the individuals,
family, community and the health system can be initiated to address the
problem. During the past two years, the Regional Office with the advice of
the members of the Regional Advisory Panel on the Impact of Drugs
(RAPID) has made good progress in formulating a regional response to
address this problem. A draft regional strategy to address substance use and
dependence has been developed with the following strategic directions:
development of national policy with focus on multisectoral actions and
networking; increasing understanding of and knowledge about substance use
and dependence, especially the extent of the problem, underlying factors,
consequences and interventions; development of human resources;
increasing accessibility to a wide range of services for psychosocial wellbeing, prevention, early detection, treatment, rehabilitation and harm
reduction integrated within general health system facilities; communitycentred actions in all these areas relying on culturally acceptable
interventions using religious forums and educational settings and
nongovernmental organizations. Member States are recommended to
develop national strategies addressing prevention, treatment and harm
reduction; ensure access for those affected to health and social support
systems; build appropriate capacities in ministries of health; and introduce
primary prevention programmes, such as life skills education in schools.
1.
Introduction
The public health importance of substance use and dependence is
growing from year to year as it is more than a health problem; it is a
formidable moral, social and economic challenge with pandemic
dimensions. Not a country or place in the world can be certified as “drug
free”. As part of one of the most important transit areas of the world for
illicit drugs, with many countries experiencing rapid social change and
conflict situations, the countries of the Eastern Mediterranean Region are
376
Mental health in the Eastern Mediterranean Region: reaching the unreached
increasingly vulnerable to health, social and economic problems related to
substance use and dependence.
Throughout history, people have used different substances to alter
their state of mind. The brewing of alcohol was generally popular among
pre-Islamic communities living in Egypt, Iran and the Arabian peninsula [1].
Use of opium was part of traditional culture in a number of countries of the
Region. Until recently, most drug use was limited to specific settings
according to specific traditions. What is new in recent times is the wider
range of drugs abused, the higher potency of the drugs, the more active
routes of administration (such as injecting drug use), the lack of social
controls against abuse and, consequently, the larger proportion of the
population using and becoming dependent on drugs with attendant health
and social consequences. In this connection
The purpose of this paper is to:
•
review the substance use and dependence situation globally and in the
Region with emphasis on a number of alarming trends, such as the
increase in the absolute number of drug users, decreasing average age
of drug users, increasing number of women drug users and tendency
towards more injecting drug use.
•
present the recent understanding and the approaches to care and
identify areas for countries to take action to address the issue. Such
actions include developing national policies, organizing preventive
programmes, integrating substance-dependence care programmes into
general health care and minimizing the health harms caused by
substance use and dependence.
2.
2.1
Global situation
Prevalence [2]
Use of alcohol, tobacco, and other controlled substances is increasing,
and contributing significantly to the global burden of disease. Tobacco use is
growing in developing countries and among women. Currently, 50% of men
and 9% of women in developing countries smoke, as compared with 35% of
men and 22% of women in industrialized countries. China, in particular,
contributes significantly to the epidemic in developing countries. Indeed, the
Annex 4
377
per capita consumption of cigarettes in Asia is higher than in other parts of
the world, with the Americas and eastern Europe following closely behind.
Whereas the level of consumption of alcohol has declined in the past
20 years in industrialized countries, it is increasing in developing countries,
especially in the WHO Western Pacific Region, where the annual per capita
consumption among adults ranges from 5 to 9 litres of pure alcohol, and also
in countries of the former Soviet Union. To a great extent the rise in the rate
of alcohol consumption in developing countries is driven by rates in Asian
countries. The level of consumption of alcohol is much lower in the WHO
African, Eastern Mediterranean and South-East Asia Regions.
According to estimates of the United Nations Office on Drugs and
Crime (UNODC), about 200 million people use one type of illicit substance.
Cannabis is the most common illicit substance used, followed by
amphetamines, cocaine and opioids. Illicit substance use is a predominantly
male activity, much more so than cigarette smoking and alcohol
consumption. Substance use is also more prevalent among young people
than in older age groups. 2.7% of the total global population and 3.9% of
people 15 years and above had used cannabis at least once between 2000 and
2001. In many industrialized countries, for example Canada, European
countries and the United States of America, more than 2% of youths reported
heroin use and almost 5% reported smoking cocaine in their lifetime. Indeed,
8% of youths in western Europe and more than 20% of those in the United
States of America have reported using at least one type of illicit substance
other than cannabis. Injecting substance use is also a growing phenomenon,
with implications for the spread of HIV infection in an increasing number of
countries [3].
The global burden of substance use is substantial, accounting for 8.9%
of productive life lost annually due to disability and premature mortality, as
measured in disability-adjusted life-years (DALYs). The main health burden
is due to licit rather than banned substances. Among the ten leading risk
factors in terms of avoidable disease burden, tobacco was fourth and alcohol
fifth in 2000, and both remain high on the list in the 2010 and 2020
projections. Tobacco and alcohol contributed 4.1% and 4.0%, respectively, to
the burden of ill health in 2000, while illicit substances contributed 0.8% [4].
The burdens attributable to tobacco and alcohol are particularly high among
378
Mental health in the Eastern Mediterranean Region: reaching the unreached
males in industrialized countries (mainly Europe and North America). This is
because men in industrialized countries have a long history of significant
involvement with tobacco and alcohol and because people in these countries
live long enough for substance-related health problems to develop.
2.2
Adverse effects
People use psychoactive substances because they expect a benefit,
whether pleasure or the avoidance of pain. But use of psychoactive
substances also carries the potential for harm, whether in the short-term or
long-term. Harmful effects due to substance use can be divided into four
categories: chronic health effects; acute or short-term health effects; acute
social problems; and chronic social problems. Examples of chronic health
effects include liver cirrhosis (alcohol consumption), lung cancer and
emphysema (smoking) and HIV infection (injecting drug use). Acute or
short-term biological health effects of drugs such as opioids and alcohol
include those caused by overdose, as well as casualties due to the substance’s
effects on physical coordination, concentration and judgement, in
circumstances where these qualities are demanded. Casualties resulting from
driving after drinking alcohol or after other drug use feature prominently in
this category, but other accidents, suicide and (at least for alcohol) assaults
are also included. The third and fourth categories of harmful effects
comprise the adverse social consequences of the substance use: acute social
problems, such as a sudden break in a relationship or an arrest; and chronic
social problems, such as defaults in working life or in family roles [2].
The World Drug Reports published by UNODC provide reliable
information about the production, distribution and economic aspects of the
drugs of abuse in the Region. The reports highlight the importance of several
countries of the Region as major producers of drugs. About 87% of the
worldwide opium production is in Afghanistan. Four of the top five cannabis
sources are in the Region: Morocco (22%), Pakistan (15%), Afghanistan
(13%), Lebanon (8%) [3,5]. Increase in production is complemented by
increases in seizures of illicit drugs and violence associated with the illegal
traffic of drugs. According to the most recent report of UNODC, the extent
of land used for opium cultivation in Afghanistan has decreased in 2005.
However, the actual amount of opium produced has not decreased
substantially.
Annex 4
379
2.3
New understanding
A very important development of the past two decades is the greater
understanding of the biological, psychological and social origins of drug use
and dependence. A WHO publication released in 2004, Neuroscience of
psychoactive substance use and dependence, provides many answers with
evidence from a number of scientific disciplines [2]. It is significant that the
newer understanding of the functioning of the brain can now guide substance
abuse prevention and treatment programmes.
The book makes a number of important observations summarized
below.
•
All psychoactive substances can be harmful to health, depending on
how they are taken, in which amounts and how frequently.
•
•
•
•
•
Use of psychoactive substances is to be expected because of their
pleasurable effects as well as peer pressure and the social context of
their use.
Harm to society is not only caused by individuals with substance
dependence. Significant harm also comes from nondependent
individuals, stemming from acute intoxication and overdose, and from
the form of administration (e.g. through unsafe injections);
Substance dependence is a complex disorder with biological
mechanisms affecting the brain and its capacity to control substance
use. It is not only determined by biological and genetic factors, but
psychological, social, cultural and environmental factors as well
(Box 1).
Treatment for substance dependence is not only aimed at stopping
drug use. It is a therapeutic process that involves behaviour changes,
psychosocial interventions and often, the use of substitute
psychotropic drugs. Dependence can be treated and managed costeffectively, saving lives, improving the health of affected individuals
and their families, and reducing costs to society.
One of the main barriers to treatment and care of people with
substance dependence and related problems is the stigma and
discrimination against them.
380
Mental health in the Eastern Mediterranean Region: reaching the unreached
Box 1. Risk and protective factors for substance use
Risk factors
Protective factors
Environmental
Environmental
•
•
•
•
•
•
•
•
•
•
•
•
availability of drugs
poverty
social change
peer culture
occupation
cultural norms, attitudes
policies on drugs, tobacco and alcohol
economic situation
situational control
social support
social integration
positive life events
Individual
Individual
•
•
•
•
•
•
•
•
•
•
•
•
•
•
genetic disposition
victim of child abuse
personality disorders
family disruption and dependence problems
poor performance at school
social deprivation
depression and suicidal behaviour
good coping skills
self-efficacy
risk perception
optimism
health-related behaviour
ability to resist social pressure
general health behaviour
Source: [2]
Studies in countries of the Region have shown that people with drug
dependence have the highest stigma among a list of physical and mental
health conditions [5,6]. This stigma prevents the affected persons from
getting care. In a recent study from greater Cairo, only 12% of those
dependent on drugs had received treatment at any time [5].
3.
3.1
Regional situation
Overview
In 2003–2004, the Regional Office undertook a situation analysis of
the substance use and dependence in countries of the Region. A detailed
questionnaire on aspects of substance use and dependence was sent to all
countries, and responses were received from 19 countries (Afghanistan,
Bahrain, Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon,
Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Palestine, Saudi Arabia,
Somalia, Sudan, Syrian Arab Republic, United Arab Emirates and Yemen).
In 13 countries there is an official estimate of the extent of the substance
dependence problem in the country. The trend of substance use among youth
(15–24 years) is rising in 13 countries, stable in 5 countries and decreasing
Annex 4
381
in one country. The estimated age of initiating substance use by youth is
around 15–18 years in most countries. In 11 countries there is an official
estimate of the extent of substance dependence in women. The commonest
substances of dependence among women are sedatives, opiates and
stimulants.
The average age of persons with substance dependence is 33–44
years. In three countries it is between 20 and 30 years. Policy-makers and the
general public are aware of and giving attention to substance dependence
relating to opiates (14 countries), cannabis (9 countries), stimulants (6
countries) and sedatives (4 countries). Injecting drug use was reported as a
considerable problem in 3 countries, moderate in 7 countries and rare in 5
countries. In 16 countries there is an estimate of the number of injecting drug
users, with the numbers ranging from 200 to 137 000. The trend of injecting
drug use is rising in 10 countries, stable in 4 countries and decreasing in 4
countries. The most frequently injected drug is opiates in 13 countries.
3.2
Spiritual, social and cultural dimensions and assets
Analysis of the true condition of this Region cannot be complete
without consideration of the strong cultural, religious and social assets of the
Region. Islam is the religion of 90% of the people of this Region.
Christianity is the second religion. Both these religions promote strong
family ties, helping those in need and moral and spiritual codes that promote
healthy lifestyles. Islam in particular takes a strong stand against use of
khamr. They ask you about intoxicants (khamr) and games of chance. Say,
“In both of them there lies serious harmfulness (ithm) as well as some
benefits to mankind. Yet, their harmfulness outweighs their usefulness.
[2:219]. God has prohibited sins which means harm for the individual and
the society: My lord has only forbidden indecencies, the inward and the
outward, and sin [7:33].
Contrary to what some people believe, and according to many
authentic Islamic narrators, khamr refers not only to alcohol but to any
substance that clouds or veils the mind and consciousness. The Prophet 
said: “Everything that intoxicates is wine and all kinds of wine are
prohibited,”1 and the Prophet  also said: “Every intoxicant is forbidden and
1
Narrated by Muslim and Ibn Majeh on behalf of Ibn Umar.
382
Mental health in the Eastern Mediterranean Region: reaching the unreached
every narcotic is forbidden and anything that causes drunkedness when taken
in quantity is completely forbidden, as is anything that dims reason”.2
Islamic teachings also emphasize the development of a human
personality. As the person resorts to alcohol and drugs to escape from
problems, while Islam refuses passiveness and escaping challenges. Islam
urges individuals to act positively and try to change the bad reality. An ideal
Muslim is a responsible human being who always urges decency and
opposes what is detestable. The strength of her/his personality is based on
two strong characteristics that Islam encourages: patience and belief in
predestination:
Surely we will try you with fear and hunger, and loss of property, lives
and crops; but [prophet], give good news to those who are steadfast, those
who, when afflicted with a calamity say: “surely we belong to God, and to
Him we shall return”. These will be given blessings and mercy from their
Lord, and it is they who are rightly guided. [2: 155-157]
Another aspect of Islamic teachings which can be used in planning for
prevention of substance abuse and care of the substance-dependent rests on
the activation of the role played by individuals and the community in
providing mental, spiritual and social support to those dependent on
substances. Community participation and each individual’s responsibility to
assist when another member of the community is in distress are important
assets that can be used in the development of programmes. Awareness of
this great religious heritage and finding ways of using it in the best way for
prevention, care and reduction of harms related to drugs is of great
importance in this Region.
In the Eastern Mediterranean Region, as well as many other areas of
the world, the breakdown of extended family, unplanned urbanization,
internal migration and the appearance of an underclass nouveaux poor are
among major social causes of substance abuse. However, the fact that the
foundation of the family is still strong is an asset. In this respect, any
programme for substance abuse treatment and control should have a
component of working with and through families, particularly families
affected.
2
Narrated by Abu Naem in “Ma’refat al sahaba” on behalf of Anas ibn Huthayfah.
Annex 4
383
3.3
Tobacco use [7]
Tobacco consumption increased by 24% in the Middle East from 1990
to 1997. In fact, the Middle East and Asia are the only two regions in the
world where cigarette sales increased during that time period. Half of adult
males in the Middle East are smokers. Egypt has the highest number of
people that use tobacco, while the highest consumption rate is in Tunisia.
This rate rose from 12 billion sticks in 1970 to 52 billion in 1997. The
countries of the Gulf Cooperation Council (GCC) as a whole spend US$ 800
million per year on tobacco.
The number of tobacco shops in Morocco increased from 9600 in
1969 to 20 000 in 2003. In Egypt, the direct annual cost of treating diseases
caused by tobacco use is estimated at US$ 545.5 million. The percentage of
cancer deaths among men attributable to tobacco increased from 8.9% in
1974 to 14.85% in 1987. Smoking causes 90% of lung cancer cases in
Egypt. There are 30 000 smoking-related deaths per year in countries of the
GCC. With lung cancer topping the list of the region’s ailments, 15% of the
total medical costs in countries of the GCC, where health care is free, go
towards the treatment of smoking-related illnesses.
The longer a person has smoked, the higher the risks to health. Those
who start to smoke in their teens face the biggest risks. In fact, a person’s
risk of developing lung cancer is affected more by the length of time as a
smoker than by the number of cigarettes smoked daily. Compounding the
problem, 85% of smokers in Egypt also smoke sweetened tobacco (shisha)
in water pipes, a practice that is also very prevalent in the GCC. In the GCC
50% of students aged 14 to 18 years smoke. Around 25% of them started
between the ages of 10 and 15 years [8].
3.4
Alcohol consumption
Alcoholic beverages and the problems they engender have been
familiar fixtures in human societies since the beginning of recorded history
[9]. The brewing of alcohol from dates, grapes, honey and sorghum (doura)
was generally popular among pre-Islamic communities living in the Arabian
peninsula [1]. Temples from ancient Egypt show scenes of wine-making and
intoxicated people. Around 200 years ago a major increase in the potential
for harmful effects occurred with the discovery of the distillation process,
384
Mental health in the Eastern Mediterranean Region: reaching the unreached
which increases concentrations of alcohol. At the very beginning of the
Islamic era, the drinking of wine was clearly identified as a disruptive social
evil and was effectively dealt with. Baasher in 1981 noted “after 14
centuries, the successful Islamic model of alcohol abstention and prohibition
still stands out as exceptional, indeed, almost unique in human history”[1].
However, in the past two decades there have been increasing reports of
people with alcohol-related health problems seeking health and mental
health care from a number of countries of the Region [10]. In 2005, some
countries reported a general increase in the use of alcohol and persons
dependent on alcohol.
At the global level, increasing number of studies are being published
regarding the harmful effects of alcohol, increasing death related to
intoxication and the fact that many of the outlets for alcohol consumption are
in the deprived neighbourhoods and increasingly more deprived population
groups are specifically harmed by alcohol consumption. A series of articles
in a recent issue of International Journal of Epidemiology are just examples.
Other reports strongly dispute the previous publications that attribute useful
effects to moderate drinking.[11, 12, 13]
Harmful consumption was discussed at the World Health Assembly in
May 2005 and addressed in resolution WHA58.26 on “Public health
problems caused by harmful use of alcohol”. In the resolution, the Health
Assembly recognized that the patterns, context and overall level of alcohol
consumption influence the health of the population as a whole, and that
harmful drinking is among the foremost underlying causes of disease, injury,
violence, disability, social problems and premature deaths.
Proven strategies to reduce the alcohol-related burden of disease
include: institution of a minimum legal age to buy alcohol; government
monopoly of retail sales; restrictions on hours/days of sale; restrictions on
the density of sales outlets; taxes on alcohol; sobriety checks; lower limits
for blood alcohol concentration for drivers; and interventions in health care
settings.
WHO is undertaking work in several areas relating to alcohol use and
health, including: collecting, compiling and disseminating scientific
information on alcohol consumption; preparing global and regional research
and policy initiatives on alcohol; and providing support to countries in
Annex 4
385
promoting identification and management of alcohol use disorders in
primary health care.
The fact is that although the magnitude of alcohol-related problems is
less in this Region than in others, the trend is upwards and more proactive,
comprehensive programmes are needed to deal with this issue. The
following can be regarded as necessary first steps:
• development of a reliable data collection and reporting system for
provision of more accurate information; such a system should provide
better data on manufacturing, import, smuggling and home production
of alcohol as well as patterns of consumption and more accurate
statistics on the number of alcohol abusers. The experiences of other
regions, such as the European Region, can help in this regard.
•
regional level consultations to discuss the development of
comprehensive, multisectoral programmes addressing particularly the
most vulnerable groups and youth;
•
inclusion of alcohol abuse on the agenda of the future work of the
Regional Advisory Panel on Drug Abuse (RAPID) in order to develop a
regional strategy on alcohol abuse.
3.5 Khat use
Khat use is prevalent in three countries of the Region, namely
Djibouti, Somalia and Yemen. It is variously estimated that in these
countries, about 60%–80% of the adults consume khat on a daily basis. Its
use is growing in popularity, with wide-ranging social and economic effects
such as shifting of crop patterns in favour of khat growth. A recent study in
Hargeisa, Somalia, showed an association between psychotic illness and
regular khat chewing. Other negative effects include neglect of children and
increased poverty, as families spend a disproportionate amount income on
buying khat [14].
Public health approaches to khat use must consider the wide cultural
and social acceptance of khat in certain countries and harmonize
interventions with prevailing social attitudes and practices [15]. At present,
systematic studies are needed on the effect of chronic use on health and
disease, including among family members of regular users; the association
386
Mental health in the Eastern Mediterranean Region: reaching the unreached
between khat use and patients in psychiatric facilities; and identification of
vulnerable groups among users.
3.6
Abuse of medicinal drugs
Among the general population, especially among urban populations,
the abuse of licit drugs such as tranquilizers is becoming a public health
problem. In contrast to illicit drugs like heroin, abuse of licit drugs is more
common among women. Currently, the regulation of drug dispensing is
inadequate, and widespread misuse of licit drugs could become a problem in
the future. Methods for monitoring the trends in this area need to be
developed. An attempt has been initiated in the greater Cairo area in
association with UNODC.
3.7
Injecting drug use
Of the many health impacts of the use of illicit drugs, the most
important health problem is the spread of HIV/AIDS among injecting drug
users. The proportion of AIDS cases attributable to injecting drug use in the
Region has increased, from 2.4% of all reported AIDS cases in 1999 to
approximately 13% in 2003. This increase reflects a shifting trend from
heterosexual transmission to transmission by injecting drug use. In 1999 less
than 0.2% of the injecting drug users tested for HIV in the Region were
positive. In 2003, the rate of HIV positive tests among injecting drug users
reached 7.7%. This is a very worrying public health problem. The issue of
the specific harm from injecting drug use in spreading HIV/AIDS needs
special attention. Similarly the problem of substance use and dependence in
prisons is a matter of concern. A recent study of 611 drug users visiting
treatment centres in Teheran found that the prevalence of HIV-1 was 15%
[16]. The rates were higher among those who had shared needles in prison.
Lack of condom use during sex was also significantly associated with the
infection.
The development of needle exchange programmes, such as in the
Islamic Republic of Iran, and the activism of former substance users as
leaders to bring about change, as in Oman, are positive developments
[17,18]. There is a need for closer cooperation between the programmes for
control and prevention of AIDS and sexually transmitted diseases and for
Annex 4
387
mental health to make antiretroviral drugs available to injecting drug users
and to develop outreach and public education programmes to reduce social
stigma.
Two studies completed in 2004 in Egypt and Libyan Arab Jamahiriya
illustrate the dramatic aspects of this problem. In a study of 431 HIV riskbehaviours of problem drug users in greater Cairo, only 98 respondents
(23%) had ever been in treatment for drug use [19]. Of these 98, only 11%
were currently in therapy. In addition there was a very low rate of HIV
testing among the group. In the Libyan Arab Jamahiriya, in the past few
years, there has been dramatic increase in injecting drug use related HIV
infections as a result of a change is the form of the heroin available and
restrictions on availability of needles [20]. These studies highlight the need
to monitor the situation on a continuous basis, as changes may occur
suddenly due to a variety of factors.
Needle exchange programmes are particularly important in the light of
findings that HIV is able to survive in used needles for several days and
hepatitis C for several weeks (depending on temperature, humidity and other
factors). A public health approach must therefore emphasize the importance
of collecting used needles and syringes. The effectiveness of this approach in
breaking the chain of transmission of HIV and other bloodborne viruses such
as hepatitis is well established [21].
The basis of substitution therapy is harm reduction in the areas of
health, family life, occupational status and in decreased crime and legal
consequences. For example, once HIV has been introduced into a local
community of injecting drug users, there is the possibility of extremely rapid
spread. Provision of substitution maintenance of opioid dependence is an
effective HIV/AIDS prevention strategy that should be considered for
implementation, as soon as possible, for injecting drug users with opioid
dependence in communities at risk of HIV/AIDS epidemics. It is for these
reasons, provision of substitution maintenance therapy should be integrated
with other HIV preventive interventions and services, as well as with those
for treatment and care of people living with HIV/AIDS [22-25].
One of the earliest indications of the spread of injecting drug use
among drug users was from prisons. In many countries, large numbers of
drug users are imprisoned for varying periods of time. In prison, the use of
388
Mental health in the Eastern Mediterranean Region: reaching the unreached
illicit drugs often continues and becomes the source of spread of blood-borne
diseases. It is only recently that prison-based programmes for drug abuse in
terms of treatment and harm reduction have been introduced. This is a
important area for future work. A recent study from Teheran, Islamic
Republic of Iran showed a relationship between HIV-1 infection and the
length of incarceration among participants who used injecting drugs [16].
The prevalence of HIV infection was 5% among those never in prison, 15%
among those with less than 6 months in prison, and 31% among those with
more than 6 months of prison stay. Prisons are extremely high-risk
environments for HIV transmission because of overcrowding, poor nutrition,
limited access to health care, illicit drug use and unsafe injecting practices,
unprotected sex and tattooing. Many of the people in prisons come from
marginalized populations, such as injecting drug users, who are already at
elevated risk of HIV infection. In most cases, high rates of HIV infection in
prisons are linked to the sharing of injecting equipment and to unprotected
sex in prison. Syringe sharing rates are invariably higher in prisons than
among injecting drug users outside prison.
Evidence is increasing that HIV transmission can be reduced in
prisons [23]. Since the early 1990s, various countries have introduced
prevention programmes in prisons. Such programmes usually include:
information, education and communication on HIV/AIDS; voluntary
counselling and testing; distribution of condoms; use of bleach or other
disinfectants; exchange of needles and syringes; and substitution therapy.
Additional components of a harm reduction programme with a significant
potential to reduce individual risk behaviour associated with drug injection
and other risk behaviour are treatment and care related to HIV/AIDS,
hepatitis and tuberculosis, including access to highly active antiretroviral
therapy.
There are strong reasons for prison services to consider introducing
substitution therapy. These include: problems in managing regimens and
difficulties for staff that arise during withdrawal, including drug smuggling
and acts of violence toward staff and other prisoners; the growing problem of
suicide and self-harm during the period of withdrawal among imprisoned
drug users and drug dependent people; the importance of equity in provision
between prisons and communities; the drive to provide clinical services at a
Annex 4
389
standard equivalent to internationally agreed best practice; the risk of a fatal
overdose in the first few days following release from prison, especially for
short-term prisoners. Substitution therapy programmes report several
valuable benefits, including decreased use of other drugs, decreased crime,
decreased mortality, less HIV transmission, less hepatitis C transmission and
marked improvements in the health of drug users. This treatment has been
shown to work and to be cost-effective [24,25].
4.
Regional efforts to address substance use
In 1999, an intercountry consultation was organized for development
of guidelines for demand reduction in substance abuse with special emphasis
in injecting drug use. Experts recommended a balance between supply
reduction and demand reduction and prevention of drug abuse. Recognizing
the growing problem of injecting drug users, the Regional Office set up the
Regional Advisory Panel on Impact of Drugs (RAPID) in September 2002
to: perform an in-depth study of different available data on substance abuse,
with particular emphasis on injecting drug use and its related health
consequences including HIV/AIDS; support and advise on creating a unified
data collection system for the Region; and advise on the development of a
regional strategy on all health-related aspects of substance abuse, including
demand and harm reduction interventions.
During the past two years, the Regional Office with the advice of the
members of RAPID, has made progress in understanding the regional
situation regarding substance use and dependence. Following the first
meeting of RAPID, a survey of the substance use situation in Member States
was undertaken.
Innovative approaches to prevention, treatment and rehabilitation of
individuals with substance dependence have been initiated by a number of
countries. In Pakistan, the school mental health programme started in the
1980s had an anti-drug message “smoking is injurious to health”. In recent
years comprehensive HIV/AIDS prevention and care programme for
injecting drug users was developed in Kermansah province, Islamic
Republic of Iran under the name “triangular clinic”, to signify the synthesis
of treatment, reduction of harm and care [18]. The initial success of this
approach led to the extension of the clinics to prisons and to 21 other
390
Mental health in the Eastern Mediterranean Region: reaching the unreached
provinces. The effort has resulted in a significant reduction of new HIV
infections. The key elements are the political commitment, coordinated
activities of a number of organizations and a dedicated and skilled team of
carers.
In the area of prevention of drug abuse in school students, Egypt is
conducting a major initiative. The National Project for Drug Abuse Demand
Reduction among youth has been in operation since April 2001. The strength
of the project is the active participation of the youth in school settings and
out of school settings. The project is under implementation of 100
preparatory and secondary schools and 30 youth centres and clubs and
includes a media campaign and the strengthening the capacity of 30
nongovernmental organizations to address the problem. In 2005, the
programme was further extended to cover an additional 150 schools. As part
of another initiative, a National Trust Fund provides support for delivery of
services, including a hot-line for drug abuse with linkages to the different
treatment and rehabilitation centres. In Morocco, there are active
programmes with preventive interventions for street children.
A number of countries have set up national committees on drug
abuse, such as the National Commission on Drugs in Morocco, National
Project for Drug Abuse Demand Reduction in Egypt and National Harm
Reduction Committee in the Islamic Republic of Iran. Several countries have
recently opened new modern specialized treatment and rehabilitation centres
(Bahrain, Kuwait, Saudi Arabia).
5.
Strategic issues
There are a few questions that often come to mind when considering
substance use and dependence. What is it that drives people to seek solace
from substances of abuse? How is it that the substance of abuse becomes so
much a part of the user that it dominates the user’s life? Why are young
people more at risk? Why is relapse so frequent after periods of abstinence?
How is it that women use substances of abuse less frequently then men?
What are the environmental /social risk factors? How can we increase the
resilience of individuals to avoid seeking solace from substances of abuse in
times of crisis? How do we balance the ethical aspects of harmonizing the
Annex 4
391
rights of the individual with that the needs of the society in choosing options
to address substance use and dependence?
One very striking aspect of substance use and dependence is the
importance of youth. Efforts must be focused on reducing the demand
among young people. Work with young people is in progress in a number of
countries such as Egypt and the Islamic Republic of Iran. There are many
reasons that working with this age group is important. First, providing
education and skills to cope with the developmental needs of young people
can reduce the demand for substance use and, thus, dependence. Second, the
involvement of young people can have a larger effect on society, as they
bring fresh ideas and energy to the community. Third, the skills that are
shared with young people to address substance use also have beneficial
effects in reducing other behaviour-related problems such as suicide,
violence and risk taking behaviour. It is well known that school-based
programmes, especially life-skills education programmes, are effective in
preventing substance use and promoting mental health. There is an urgent
need for life-skills education to become a regular part of the school
curriculum.
Religion and spirituality have an important role in matters of health
[26]. A recent report from Beirut on the inverse association between
spirituality and smoking behaviour among new students at the university, has
important implications [27]. Religion and spirituality have a special place in
the hearts and minds of the people of the Region. It is important to find ways
and means of maximally utilizing the religious beliefs and practices both to
help prevent the problem of substance use and in the treatment and
rehabilitation of people dependent on substances.
Transcending belief systems, such as religious conviction, can
strengthen the personality and enable people to liberate themselves from the
need to passively escape into the artificial and deluding world of intoxicants
like alcohol or drugs. This is particularly true for Islam which opposes using
any substance which can cloud the consciousness. Religious, and particularly
Islamic, practices, and situations that unite a people in a conviction,
strengthen self control, emotional awareness and stability and a general antidrug attitude. For example, the statistics of drug abuse at different periods in
Palestine show a decline during the peak of resistance (intifadah). A recent
392
Mental health in the Eastern Mediterranean Region: reaching the unreached
study on protective factors against substance abuse has shown that two
factors have a clear effect on decreasing the monthly use of alcohol,
marijuana and cigarettes in adolescents: promoting the place of health in
individuals’ value systems and spirituality [28].
There is an urgent need to recognize the health consequences of
substance use and dependence. Substance use and dependence cannot be
seen only as a law and order problem. Supply reduction alone has not been
successful in any of the countries. Legal efforts must be continued with
medical interventions. The health interventions have to be directed at many
levels. The needs of the vulnerable group of youth, especially during
adolescence, should be given priority. More efforts must be directed at early
identification, treatment and rehabilitation. Harm reduction strategies are
needed to reduce the impact of substance use on the individual and
community. There is also need for addressing the larger social situations like
poverty, social deprivation, marginalization and conflict situations to reduce
the use of substances. Programmes to address substance use must be
multisectoral in nature, with the key sectors being health, education,
agriculture, labour, police and social welfare. There is also urgent need for
monitoring the trends of substance use in the different populations.
The recent regional survey brought forth two important points. The
first point, which is positive, is that a high level of recognition is now being
given by most countries to the problem, evident in the creation of
professional units, passing of legislation and development of different
interventions. The second point is that there is very little factual information
about the nature, magnitude, consequences, outcome of interventions and
cost of the problem in the countries. This type of information is crucial for
proper planning.
6.
Strategic directions
A regional strategy on substance use and dependence has been under
development by the Regional Advisory Panel on the Impact of Drugs
(RAPID) during the past three years. During 2003–2004, the substance use
situation in the Region was reviewed through a questionnaire sent to all
countries. Based on the findings, a draft regional strategy was finalized in
June 2005. The strategic directions identified in the strategy are:
Annex 4
393
•
Developing national policies on substance use and dependence;
•
Developing effective coordination mechanisms for implementation of
national policies;
•
Developing mechanisms to increase understanding and knowledge of
the substance use and dependence situation within each country and the
underlying factors, the harmful consequences and interventions
currently provided;
•
Development of a wide variety of human resources;
•
Increasing access to a range of health and social care services in the
community for the provision of treatment, rehabilitation, aftercare and
harm reduction, along with integration of services with general health
care;
•
Promoting psychosocial well-being and prevention of substance use and
dependence;
•
Promoting multisectoral action and networking.
WHO has an important role to play in the development of substance
use and dependence policies, programmes and services in countries. This
role includes advocacy and policy support; monitoring and surveillance;
capacity building through training, developing guidelines and establishing
collaborating centres and expert networks; research, documentation and
dissemination of information; development of indicators for monitoring
substance use and dependence in the countries; partnership establishment
(United Nations agencies, nongovernmental organizations, community-level
organizations) and fundraising; and development of a code of ethics related
to this field.
7.
Conclusions
The dynamics of substance use and dependence include social,
economic, environmental, political, cultural and religious dimensions. The
growing problem both in terms of the numbers of people involved as well as
the impact on the health of the individuals and communities makes substance
use a public health priority.
394
Mental health in the Eastern Mediterranean Region: reaching the unreached
Interventions have to address––at the level of health promotion in
general and mental health in particular––prevention in the groups at risk
(such as adolescents), early recognition, and care and rehabilitation of people
dependent on substances. The interventions cannot be restricted to the health
system only; the other sectors like the education sector, the legal system, the
media all are important.
In the countries of the Region, one of the most important needs is to
document the changing pattern of substance use and dependence and the
public health consequences. In addition, there is need to review the many
social attitudes, practices and positions to recognize the changing aspects of
substance use and dependence. The problem has to be seen from a
multisectoral perspective and the solutions have to be also from a number of
sectors. Health interventions are an important part of the effort to prevent
substance use and dependence and treatment/rehabilitation. There is an
added urgency in the countries of the Region due to the large numbers of
injecting drug users and increasing spread of HIV/AIDS. There are a number
of initiatives that can be taken up for effective action.
8.
Recommendations
Member States
1. Develop national strategic plans addressing prevention, treatment and
harm reduction in relation to substance use, along with a mechanism to
monitor trends and associated consequences of substance use.
2. Ensure access for the affected population to health and social support
systems in order to enhance early identification, treatment, harm
reduction and rehabilitation, and promote quality of life and social
function.
3. Build appropriate capacities in ministries of health and provide support
for development of “centres of excellence” in the fields of training,
research, and service provision for substance use and dependence.
4. Introduce primary prevention programmes, such as life-skills education
in schools.
Annex 4
395
WHO
5. Enhance collaboration and coordination with other international
organizations to harmonize messages about substance use and its harms
and to avoid duplication of efforts.
6. Actively support the efforts of Member States to formulate and
implement programmes to control substance use and dependence, and
establish or strengthen mechanisms for exchange of experience between
countries.
7. Continue to develop indicators and systems for monitoring and initiate
the development of an information system and focused research to
monitor the changing trends in substance use.
References
1. Baasher T. The use of drugs in the Islamic world. British journal of
addiction, 1981, 26:233–43.
2. Neuroscience of psychoactive substance use and dependence. Geneva,
World Health Organization, 2004.
3. World drug report 2005. New York, United Nations Office on Drugs and
Crime, 2005.
4. World health report 2002: Reducing risks, promoting healthy life.
Geneva, World Health Organization, 2002.
5. World drug report 2004. New York, United Nations Office on Drugs and
Crime, 2004.
6. Room R et al. Cross-cultural views on stigma, valuation, parity and
societal values towards disability. In: Üstün TB et al, eds. Disability and
culture: universalism and diversity. Seattle, WA, Hogrefe and Huber,
2001.
7. Tobacco control country profiles for the Eastern Mediterranean Region,
Cairo, WHO Regional Office for the Eastern Mediterranean Region,
2003.
8. Al-Badah A. Controlling the tobacco epidemic in the Gulf Cooperation
Council (Arabic). Kuwait, GCC States Publications, 2001.
396
Mental health in the Eastern Mediterranean Region: reaching the unreached
9. Room R, Babor T, Rehm J. Alcohol and public health. The Lancet, 2005,
365:519–30.
10. Global status report on alcohol. Geneva, World Health Organization,
1999.
11. Mäkelä P et al. Temporal variation in deaths related to alcohol
intoxication and drinking. International Journal of Epidemiology, 2005,
34:765–771.
12. Pollack CE et al. Neighbourhood deprivation and alcohol consumption:
does the availability of alcohol play a role? International Journal of
Epidemiology, 2005, 34:772–780.
13. Nilssen O et al. Alcohol consumption and its relation to risk factors for
cardiovascular disease in the north-west of Russia: the Arkhanglesk
study. International Journal of Epidemiology, 2005, 34:781–788.
14. Odenwald M et al. Khat use as risk factor for psychotic disorders: a
cross-sectional and case control study in Somalia. BMC medicine, 2005,
3:1–10.
15. Baasher T. The use of khat: a stimulant with regional distribution. In:
Edwards G, Arif A, eds. Drug problems in the socio-cultural context: A
basis for policies and programme planning. Geneva, World Health
Organization, 1980.
16. Zamami S et al. Prevalence of and factors associated with HIV-1
infection among drug users visiting treatment centers in Teheran, Islamic
Republic of Iran. AIDS, 2005, 19 (7):709–16.
17. Effectiveness of community based outreach in preventing HIV/AIDS
among injecting drug users, Geneva, World Health Organization, 2004.
18. Best practice in HIV/AIDS prevention and care for injecting drug users.
The Triangular Clinic in Kermanshah, Islamic Republic of Iran. Cairo,
WHO Regional Office for the Eastern Mediterranean, 2004 (WHOEM/STD/052/E).
19. HIV risk-behaviours of problem drug users in Greater Cairo. Cairo,
United Nations Office on Drugs and Crime, 2004.
20. UNODC. Drug use and HIV/AIDS in Libya: a multi-method study.
Presentation to the third meeting of the WHO Regional Advisory Panel
on Impacts of Drug Abuse, Cairo, Egypt, 20–23 September 2004.
Annex 4
397
21. Effectiveness of sterile needle and syringe programming in reducing
HIV/AIDS among injecting drug users. Geneva, World Health
Organization, 2004.
22. Kerr T et al. Opioid substitution and HIV/AIDS treatment and
prevention. The Lancet, 2004, 364:1918–9.
23. Policy brief: Reduction of HIV transmission in prisons, Geneva, World
Health Organization, 2004 (WHO/HIV/2004.05).
24. Substitution maintenance therapy in the management of opioid
dependence and HIV/AIDS prevention. Geneva, World Health
Organization, 2004 (WHO/UNODC/UNAIDS position paper).
25. Effectiveness of drug dependence treatment in preventing HIV among
injecting drug users. Geneva, World Health Organization, 2005.
26. Chatters LM. Religion and health: Public health research and practice.
Annual review of public health, 2000, 21:335–67.
27. Affifi R, Khawaja M, Salem MT. Religious identity and smoking
behaviour among adolescents: evidence from entering students at the
American University of Beirut (Unpublished document, 2004).
28. Ritt-Olson A et al. The protective influence of spirituality and “health-asa-value” against monthly substance use among adolescents varying in
risk. Journal of adolescent health, 2004, 34:192–199.
398
Mental health in the Eastern Mediterranean Region: reaching the unreached
Resolution EM/RC52/R.5: Substance use and
dependence
The Regional Committee,
Having reviewed the technical paper on substance use and
dependence;3
Recalling resolutions WHA 32.40 on the development of the WHO
programme on alcohol-related problems, WHA36.12 on alcohol
consumption and alcohol-related problems: development of national policies
and programmes, WHA42.20 on prevention and control of drug and alcohol
abuse, WHA58.26 on public health problems caused by harmful use of
alcohol, and EM/RC40/R.9 on abuse of narcotics and psychoactive drugs;
Recalling also The World Health Reports of 2001 and 2002, which
indicate that the disease burden and health consequences of substance abuse
and dependence are significant;4 5
Alarmed by the new trends and extent of the public health problems
associated with substance use and dependence, particularly among young
people and women, in Member States of the Region;
Concerned at the rise in injecting drug use in the Region, especially
for its serious health consequences that threaten to spread human
immunodeficiency virus (HIV) and other blood-borne infections;
Concerned also at the economic loss to society resulting from
substance use and dependence;
Noting the growing evidence of the effectiveness of strategies and
measures to treat and reduce harm among substance users;
Recognizing that a number of countries in the Region are major
producers of opium, cannabis and khat;
Stressing the value that all religions, and, with particular reference to
this region, Islam attach to saving lives through prohibiting the use and
abuse of alcohol and other mind-altering substances;
3
Document No. EM/RC52/5
The world health report 2001. Mental health: new understanding, new hope. Geneva, World
Health Organization, 2001.
5
The world health report 2002. Reducing risks, promoting healthy life. Geneva, World Health
Organization, 2002
4
Annex 4
399
1.
URGES Member States to:
1.1
Establish or strengthen a functional multisectoral national
coordinating body to address all issues related to substance use and
dependence;
1.2
Make a wide range of approaches and interventions available to
address different aspects of primary prevention, through
programmes like life skills education, and different levels of care,
rehabilitation and harm reduction, with major reliance on
community-based mechanisms and not only hospital-based services;
1.3
Establish an information system and undertake focused research to
monitor the changing trends in substance use and dependence and
alcohol consumption, and foster the building of an evidence base;
1.4
Address alcohol consumption as a potentially major public health
issue and develop mechanisms for monitoring production, import
and smuggling and ways to control consumption and deal with the
health hazards of alcohol;
1.5
Enact national legislation that considers the substance-dependent as
patients not criminals and toughens the punishment of drug dealers;
1.6
Stimulate the religious self-deterrent through explaining the
religious ruling against alcohol and drug use, and applying religious
teachings in control and prevention;
2.
REQUESTS the Regional Director to:
2.1
Support the efforts of Member States to formulate national policies
and strategies and implement sustainable programmes to control
substance use and dependence including alcohol;
2.2
Develop programmatic linkages with the global programmes dealing
with these matters across the United Nations system (UNODC,
UNAIDS), with other organizations, and between Member States;
2.3
Convene a regional consultation to consider the magnitude of the
problem of use of khat in the Region, conduct an evidence-based
400
Mental health in the Eastern Mediterranean Region: reaching the unreached
study of its impact on the individual and the community, and
propose suitable solutions to remedy this problem;
2.4
Report to the Regional Committee on progress in implementation of
this resolution at its meeting in 2007.
Annex 5
Prevention of mental,
neurological and
psychosocial disorders
List of interventions that can be directed against each
problem area
Problem
Mental retardation
Acquired lesions of the central
nervous system
Peripheral neuropathy
Intervention
Prenatal and perinatal care
Immunization
Family planning
Epilepsy control
Nutrition
Day care
Accident prevention
Family support
Teaching of parenting skills
Better long-term care institutions
Recognition and care of sensory and motor handicaps
Treatment of hypertension and infection
Epilepsy control
Control of abuse of certain substances
Accident prevention
Accident prevention
Recognition and care of sensory and motor handicaps
Health education
Control of abuse of certain substances
402
Mental health in the Eastern Mediterranean Region: reaching the unreached
List of interventions that can be directed against each
problem area
Psychoses
Epilepsy
Emotional and conduct disorders
Abuse of certain substances
Conditions of life that lead to
disease
Violence
Excessive risk-taking behaviour in
young people
Family breakdown
Treatment of depression and schizophrenia
Family support
Better long-term care institutions
Dementia control
Treatment of anxiety, depression, and infection
Support services
Prenatal and perinatal care
Immunization
Treatment
Accident prevention
Health education
Family planning
Health education
Role of teacher
Teaching of parenting skills
Day care
Primary health care
Primary health care
Prevention of iatrogeny
Health education
Psychosocial care
Crisis intervention
Control of abuse of certain substances
Health education
Teaching of parenting skills
Accident prevention
Control of abuse of certain substances
Health education
Teaching of parenting skills
Health education
Support services
Teaching of parenting skills
Crisis intervention
Accident prevention
Day care
Teaching of parenting skills
Support services
The role of the media, cultural and religious influences, nongovernmental organizations and intersectoral collaboration and government
action apply in greater or lesser degree to all patients.
Source: Prevention of mental, neurological and psychosocial disorders. Geneva,
WHO, 1988.
Annex 6
Regional meetings relating to
mental health 1973–2005
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Interregional seminar on the organisation of mental health services,
Addis Ababa, Ethiopia, 27 November – 4 December 1973.
Group meeting on mental health legislation, Cairo, Egypt, June
1976.
Third Coordination Group for the WHO mental health programme,
Alexandria, Egypt, 10-14 September 1979.
Scientific working group meeting on mental health research,
Karachi, Pakistan, June 1981.
Research in behavioural sciences – EM/Advisory Committee
meeting, Limassol, Cyprus, 18-20 April 1983.
Regional intercountry group meeting on the development of mental
health programme, Amman, Jordan, 24-28 September 1983.
Intercountry meeting on the health, social and economic aspects of
Khat, Mogadishu, Somalia, October 1983.
Regional intercountry meeting on national programmes of mental
health, Damascus, Syrian Arab Republic, 2-6 November 1985.
Consultation group meeting on application of behavioural sciences
in health services, Alexandria, Egypt, September 1985.
Intercountry workshop on training in mental health in primary health
care, Islamabad, Pakistan, 7-12 March 1987.
Regional intercountry meeting on the progress of national
programmes of mental health, Isfahan, Islamic Republic of Iran, 1216 March 1989.
404
Mental health in the Eastern Mediterranean Region: reaching the unreached
12.
The second intercountry meeting on progress achieved in national
mental health programmes, Nicosia, Cyprus, 16-20 July 1990.
Consultation on school mental health programmes, Islamabad,
Pakistan, 14-17 November 1993.
Intercountry meeting on the progress of the national mental health
programmes in the Eastern Mediterranean Region, Casablanca,
Morocco, May 1995.
Consultation on Mental Health Legislation, Alexandria,Egypt,1-2
May 1996.
Intercountry meeting on needs assessment, Tehran, Islamic Republic
of Iran, September 1997.
Mental Health Legislation in different Law traditions including
Islamic Law, Kuwait, October 1997 ( In collaboration with Islamic
Association for Medical Sciences).
Intercountry consultation for development of guidelines for demand
reduction in substance abuse with special emphasis in injecting drug
use, Beirut, Lebanon, 25-27,November 1999.
Intercountry meeting on evaluation of the National Mental Health
Programmes, Alexandria, Egypt, December 2000.
First meeting of the Regional Advisory Panel on impacts of drug
abuse(RAPID), Cairo, Egypt, 23-26 September 2002.
Consultation on mental health and rehabilitation of psychiatric
services in post-conflict and complex emergency countries, Cairo,
Egypt, 28-30 July 2003.
Second meeting of the Regional Advisory Panel on impacts of drug
abuse(RAPID), Tehran, I. R. Iran, 1-4 2003 December 2003.
Third meeting of the Regional Advisory Panel on impacts of drug
abuse(RAPID), Cairo, Egypt, 20-23 September 2004.
Meeting on the role of religion and spirituality for the prevention of
substance abuse and rehabilitation of drug users, Cairo, Egypt 15
December 2004.
Consultation on Life Skills Education, Cairo, Egypt, 19-20 June
2005.
Fourth meeting of the Regional Advisory Panel on impacts of drug
abuse (RAPID), Cairo, Egypt, 27-28 June 2005.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
Annex 7
Suggested tasks for different
categories of personnel
The following are the different categories of personnel from the health
and related sectors and the mental health activities that they can carry out.
1.
Health guide
•
•
•
Mental health education to community using different means like
lectures in mosques, schools and village community gatherings.
Educating and supporting the family and community care of mentally
ill patients, helping to remove the stigma of mental illnesses and the
importance of regular medication.
Identification of patients with major mental health problems like
psychosis, fits, and mental retardation.
Referral of patients to health unit/centre, district centre and keeping
records of old and new patients.
First aid for acute psychiatric problems.
Prevention of mental disorders and promotion of mental health.
2.
Medical assistant
•
•
Advising health team about traditions and beliefs in the community.
Facilitating the role of the community health guide, e.g. by organising
village meetings.
Identification of people in need of mental health care.
•
•
•
•
406
•
•
Mental health in the Eastern Mediterranean Region: reaching the unreached
Assistance in the re-integration of the mentally ill in the community,
and
Collaboration with health personnel to promote mental health and
psychosocial development.
3.
Preschool child workers
•
•
•
Early recognition of preschool children with problems.
Provide first aid in emergencies.
Use mental health promotion activities in the day care facility by plan
and stimulation.
Guidance to parents about parenting skills and referral of problem
children.
•
4.
School teacher
•
Early identification of childhood problems and referral to health
facility.
First aid in emergencies.
Provide mental health education to children regarding accident
prevention, risk-taking behaviour and drug abuse, along with methods
to increase self-esteem.
Parental counseling about adolescence and its management.
Early detection of sensorial defects and referral for help.
Contributing by educational activities, to the promotion of positive
attitude towards the mentally ill.
•
•
•
•
•
5.
Police
•
Recognition of acute mental disorders and undertaking of necessary
action to protect the mentally ill, his family and his fellow citizens.
Provision of first aid in specified problems. (e.g. an epileptic fit, acute
excitement, threatened suicide)
•
Annex 7
6.
•
•
•
•
•
•
7.
•
•
•
•
•
•
•
•
407
General practitioner/Medical graduate
(Trained for two weeks in mental health and working at district centre)
Recognition, diagnosis and treatment of commonly occurring
psychiatric problems in the clinics and community.
Referral to governorate or central hospital difficult cases with
information and treatment details.
Maintenance of records of all treatment and patients of the area.
Provide in-service training to medical assistants and health guides.
Supervision and support of medical assistants and health guides.
Recognition of the health policy in the country and the national
programme of mental health.
General practitioner
(Trained for two months in mental health and working at governorate
hospitals)
Recognition, diagnosis and treatment of all mental disorders
(outpatient and inpatient).
Management of cases with treatment with drugs, electroconvulsive
therapy (ECT) and supportive psychotherapy.
Maintenance of proper records of all receiving care.
Support of all cases referred by the district and health centres and
feedback for follow-up.
Referral of difficult cases to central hospital with adequate details.
Organisation of training regularly for the new medical doctors,
medical assistants and health guides.
To initiate preventive programmes of primary level involving teachers,
murabbias and community leaders.
Supervision and support of health guides, medical assistants, and
medical officers of the area by periodic field visits.
408
Mental health in the Eastern Mediterranean Region: reaching the unreached
8.
Clinical psychologist
•
•
•
Development of psychological tests.
Knowledge about public health principles in mental health.
Activities to promote mental health through health workers, voluntary
agencies, teachers, police and village leaders.
Mental health research of public health priority mental disorders.
Development of teaching and training materials and assessment
methods.
•
•
9.
Specialist social workers
•
Supportive activities and vocational help to the patients and their
families.
Development of teaching and training materials for different
categories of personnel.
Activities to promote mental health through health workers, voluntary
agencies, teachers, police and village leaders.
Knowledge of public health principles in mental health care.
Social assessment of outpatients and inpatients and visits to homes
and workplaces.
•
•
•
•
10. Psychiatric nurse
•
•
•
Training of health personnel in task-oriented mental health care.
Strengthening of the family supports and acceptance of the mentally
ill by the families.
Supervision and support to health and personnel of the other sectors in
mental health care.
Annex 7
409
11. Psychiatrist at central hospital
•
•
•
•
•
•
•
•
Correct diagnosis and treatment of mental disorders attending the
outpatient department and those referred by the peripheral units.
Inpatient treatment of patients requiring intensive care and observation
for short periods of time (prolonged and custodial care will be
discouraged).
Annual maintenance and analysis of the records and feedback to the
peripheral units and the Ministry of Health.
Initiation of preventive techniques and develop mechanisms for
mental health promotion.
Training to general practitioners, medical assistants, health guides and
develop manuals and other teaching aids.
Initiate research into problems of relevance to programme
implementation.
Evaluation of effectiveness of the different training programmes.
Support and supervision of the different personnel.
Annex 8
Essential neuropsychiatric
drugs for general health care1
Conditions
Level of medical personnel required to prescribe drugs
Psychiatric
specialist
Neurotic disorders
Anxiety
Depression
Psychotic disorders
Schizophrenia
Other
Epilepsy
Grand mal
Other
Emergencies
Acute psychosis
More than 6
years’ training
e.g. general
physician
2-3 years
training,
e.g. medical
assistant
IMI
IMI
CPZ
FPZ
BP
TPZ4
LC
HAL
HAL inj
CPZ
FPZ
BP
TPZ
CPZ
FPZ
BP
CPZ3
PB
PHT
CBZ
ESM
VA
PB
PHT
PB
(PB)
CPZ
CPZ
DZP inj
CPZ
CPZ inj
DZP inj
CPZ
CPZ inj
DZP1
IMI 2
AMI
<1 year training
e.g. village health
worker
Acute alcohol
withdrawal
DZP inj
DZP inj
Status epilepticus
Other disorders
Drug/alcohol withdrawal
CPZ
CPZ
Insomnia
DZP
DZP
1
Diazepam is often overprescribed and careful training in its rational use is mandatory.
2
Imipramine and amitriptyline are nearly equivalent. Although the latter is included in the WHO Model List of
Essential Drugs, imipramine is recommended because of its lower cost and more general availability.
3
In several countries programmes, village health workers have been trained to follow up on treatment with
chlorpromazine initiated at a higher level.
4
It is recommended that trifluoperazine, although not on the WHO Model List of Essential Drugs, should also
be available.
Key: AMI Amitriptyline
ESM Ethosuximide
PB Phenobarbital
BP Biperiden
FPZ Fluphenazine
PHT Phenytoin
CBZ Carbamazepine
HAL Haloperidol
TPZ Trifluoperazine
CPZ Chlorpromazine
IMI Imipramine VA
Valproic acid
DZP Diazepam
LC Lithium carbonate
inj injection
1
Source: Appropriate neuropsychiatric drugs for primary health care, Alexandria, WHO Regional
Office for the Eastern Mediterranean, 1995 (EMRO Technical Publications Series 21).
Annex 9
Training methods
The various methods which have been tried and whose efficacy in
imparting the required skills are given below.
1.
The lecture
The lecture is a time-honoured method of teaching. In spite of all its
faults, it is still an economical and useful method in the hands of a good
teacher. For the training of primary care physicians (PCPs), the following
points should be conveyed to the trainers:
•
PCPs should not be treated as undergraduate students and are expected
to listen and make notes during long didactic lectures. Nor should they
be treated as postgraduate students of psychiatry preparing for their
final examination who are to be told all about the latest theories of the
aetiology of mental disorders and the newest drugs in the market.
Such lectures may be easy to deliver by psychiatrists but they are
largely a waste of time for PCPS.
•
Each lecture should be prepared carefully, keeping in view the need of
the PCP, linking it with the tasks which are required of him in his
daily practice.
•
It is always useful before the start of the lecture to ask a few general
questions from the PCPs, related to the topic of the lecture, to assess
their existing knowledge, and their general style of handling such
problems in their practice.
412
•
•
2.
Mental health in the Eastern Mediterranean Region: reaching the unreached
The lecture should not be long – almost never beyond 40 minutes. At
the end of the lecture, sufficient time should be left for a question-andanswer session, which is often the most important part of the exercise.
Appropriate teaching aids, like a blackboard, chart or overhead
projector, should be used to illustrate the important points of the
lecture. Slides or transparencies, if used, should be specially prepared
for PCPs (and not simply taken from the pool of slides for medical
students). It should be remembered that too many slides in a lecture,
with lights going on and off, reduce communication, which is essential
for a good lecture.
Case demonstration
Next to the lecture, perhaps the most common method of teaching is
case demonstration. It is an extremely useful and important method. Here
again, the essential part is that patients should be selected very carefully.
Patents with gross psychotic symptoms are easy to find in psychiatric
services but these are not the best patients to teach PCPs. As far as possible,
patients who are commonly seen by PCPs in their daily practice should be
selected. At the same time, symptoms and psychopathology should be
sufficiently clear and obvious for demonstration.
3.
Training in interview methods
Perhaps the most important new skill which PCPs should acquire
during these training courses is the technique of psychiatric interview: in
short, how to listen and how to talk to the patient in day-to-day practice. A
good interview with a patient can be utilized for various purposes – for
obtaining history, for assessing mental state or for providing counseling. All
these three elements often exist together in the average doctor-patient
encounter in general practice.
Interview training can be provided in various ways. In the absence of
a television or other audio-visual facility, one simple technique is to conduct
a live interview in a group setting. In a small group, a patient (or a role
player) is invited and interviewed by one physician in his usual style. The
teacher and other participants listen attentively, observe the behaviour of the
Annex 9
413
interviewing doctor and patients, and take notes, but do not interrupt in any
way. After about 10-15 minutes, the patient withdraws. After the interview,
participants make observations on what they have just witnessed, e.g.
“doctor was too dominant and did not let the patient talk” or “after
mentioning chest pain, patient referred to work problems; this was not
followed up by interviewing doctor” and so on. If necessary, the patient is
called back to demonstrate the points which were missed by the interviewing
doctor. Such an exercise is usually followed by a demonstration in which the
teacher interviews another patient, in front of the group, and which is again
followed by analysis and discussion by the group.
More important than the content of the interview, the trainees should
learn the art of interviewing – how to make people comfortable, how to
make them relax and talk about their personal problems, how to pick up
hints about underlying psychological and social problems, etc.
In some psychiatric centres, a one-way mirror-screen is used for
interview training, especially for psychotherapy. However, for brief
interview training for PCPs, there is generally not much difficulty in a live
interview in a small group setting. It is one of the simplest and best
techniques of mental health training.
4.
Case conference
In this classical teaching exercise, the patient is examined by one or
two students and then presented to the teacher in a group. It is a useful
exercise but, since the teacher does not watch the student taking history and
conducting examinations, many of the deficiencies in interview skills remain
unexposed. It should be combined with the exercise of interview training as
mentioned above.
5.
Criss-cross discussion
This is a very useful low-cost technology in which the PCPs present
their problem-patient’s history in a group setting with a trainer acting as a
resource person. They are encouraged to describe patients they have seen
with problems similar to those about which they have been taught. The
teacher is passive, but provides information to the group on request, and
414
Mental health in the Eastern Mediterranean Region: reaching the unreached
corrects errors if necessary. Other members of the group interact by citing
their experiences and difficulties with similar problems. Such discussions
become very animated and the method has been called “criss-cross fire” by
those experienced in it.
6.
Role-playing
As is well known, psychiatric patients are often difficult to have when
needed for teaching, e.g. they have already recovered from their illness, they
are too disturbed to be shown in a group, they do not speak the right
language or simply cannot keep the appointment. A good alternative
technique, which has become quite popular in recent years, is “role-playing”.
In this training method, another person, e.g. a staff member (a doctor, nurse
or social worker) acts or plays the role of a patient. The advantage is
obvious. The “role player” can be tutored to present specific symptoms and
history, which heightens the effect of a short training interview. With a little
practice, role-playing can be made into a very useful addition to training of
PCPs and it can be used in almost all settings.
7.
Use of audiotapes
Audiotapes are now available in every country. These can be useful
employed in training, especially for demonstrating a sample of patient’s talk
or conversation between patient and doctor. Their use is particularly helpful
when the patient’s symptoms and improvement are being demonstrated over
a length of time. The PCP can also make a recording of his own interview of
his selected patients in his practice which can be brought for group
discussion.
8.
Use of television and videotapes
The use of television and videotapes has revolutionized modern
teaching and training techniques. In recent years, television sets, videorecording and projecting machines have become widely available in many
countries of the Region. Many universities and teaching centres have
Annex 9
415
developed special studios and have trained technicians to prepare technical
video films for teaching.
Video films and television are very well suited for training of PCPs.
With a simple videocamera, interviews of patient by PCPs can be recorded in
their own clinic settings. These videotapes can be replayed later in the group
sessions. The great advantage of the videotape is that it can be stopped at any
point or a sequence repeated when required, till the teacher has clarified the
essential message. This technique is particularly useful for training in
interviewing skills, especially if the PCP can see the film of himself
interviewing in his own setting. It is also a great learning exercise for the
teacher who is faced with the reality of the actual primary health care setting
which is considerably different from the specialist clinics.
Another interesting technique found useful is a common psychological
test administered to all patients who are later interviewed on videotape.
Information about high scores on this test enables the teacher to pick up
interviews where patients are more likely to have psychological problems in
their presentations. The general format of training in these sessions is that
the teacher begins showing the interview which is to be discussed, then stops
the machine. The physician who has conducted the actual interview briefly
gives information about the patient. The recording is started and stopped
whenever the teacher or audience wants to make an observation or ask a
question. If the patient was not handled well, the physician is asked how else
he could have handled the situation. The teacher makes constructive
suggestions when required but remains in general non-judgemental and
helpful.
9.
Use of manuals
Manuals have become an integral part of short-term training
programmes in health in many countries all over the world. A list of
manuals, which are available and have been commonly used in the Eastern
Mediterranean Region during recent years to organize mental health training
programmes for primary care physicians and other health personnel.
Manuals differ from standard textbooks in that they are smaller and
briefer. They can be easily carried around and consulted in day-to-day work
both during and after training, but more important than their size is their
416
Mental health in the Eastern Mediterranean Region: reaching the unreached
emphasis on practical training. The focus is more on acquisition of skills
rather than on only acquiring knowledge. For example, whereas a standard
textbook of psychiatry, while describing a mental disorder, would use the
conventional medical format of aetiology, signs and symptom, differential
diagnosis, treatment, etc., a manual would directly describe the specific
mental health tasks which a primary health care physician or worker is to
perform during his/her duties, i.e. how to recognize and manage epilepsy or
acute psychosis with a limited number of drugs or when to refer a case to a
specialist centre, etc. The second essential feature of a manual is that it must
be in simple language without excessive use of technical jargon. It is also
important that it should be available in the local language in which the health
staff have been educated.
The contents of a manual vary according to the objectives of the
training programmes. For short training courses of one to two weeks
duration, it is obvious that only a limited number of topics and clinical
conditions can be included. Hence, priorities must be carefully chosen.
From the public health point of view, priority must be given to those clinical
conditions which are common, cause serious personal distress and social
disability, and for which management is relatively simple, cost-effective and
can be delivered at the community level. In mental health programmes, it is
important that the training is not only confined to recognition and
management of diseases, but also in factors in history, simple counseling
measures such as reassurance and emotional support, etc. These skills can
help the trainees in many situations of mental as well as general health
problems. It is useful to have a summary of points to remember at the end of
each chapter. Flowcharts have also proved very useful in many training
programmes but they should be prepared carefully, keeping in mind the
general educational background of the trainees and their familiarity with
such methods.
Depending on whether a manual is to be used only by trainees or is
planned for the use of trainers also, it should provide information on how to
organise such training programmes including advice about pre- and posttraining assessment of knowledge, attitudes and skills of the trainees.
Annex 10
Evaluation and monitoring of
training programmes
The development of a comprehensive training programme is never
achieved at the first attempt but evolves through progressive reinforcement
by means of several courses. Measurements of improvement in the trainee’s
knowledge, skills and attitudes to mental disorders at the beginning and end
of each course provide the only certain measure of checking the efficacy of
the programme.
Trainees should be asked to comment freely on the content,
organization and delivery of the course, indicating which elements of
training they found helpful and which may have been unhelpful or
confusing. This, together with the results of objective evaluation of trainee
skills/knowledge, provides all the material necessary to refine the course for
the next batch of trainees.
1.
All courses could include the following baseline observations:
•
•
•
Trainees should provide a record of their “psychiatric” diagnoses
during the previous month.
Their attitude to mental illness should be assessed, using specially
constituted multiple choice questions.’
If the acquisition of interview skills is to be measured, each PCP
should take a 10-minute history from a trained role-player who
portrays a straightforward mental illness. Measures of the number of
items of information extracted and interview behaviour are taken.
418
Mental health in the Eastern Mediterranean Region: reaching the unreached
However, it is to be noted that this procedure is time-consuming and is
not recommended for all centres.
2.
All courses should collect observations at the end of training (e.g. on
the last day):
•
Repeat measures of attitudes to mental illness.
•
Repeat measures of knowledge of psychiatry.
•
Let each trainer rate the relevance and quality of each component of
the training course.
3.
Optimally, at least one month after course completion, trainees can be
surveyed by postal questionnaire to ascertain the impact of training on
their practice.
In addition to these direct measures of the impact of training, it is
possible to use health services statistics to monitor the impact of newly
trained personnel on the existing services. Health administrators, in
particular, would find such data invaluable. The information administrators
are looking for can be conveniently summarized as: educational research
evidence (evidence that the training has achieved the objectives set for it),
health service evaluation (evidence that training has had and impact on
services, e.g. number of referrals to secondary care) and systematically
collected information on the number of cases identified by trained PCPs. If
this last is collected for the broad diagnostic groupings taught in the course,
the administrators would have the information they need to determine
resource allocation.
WHO Regional Publications, Eastern Mediterranean Series
In 2001 mental health was brought to the focus of international attention when the
World Health Organization devoted its World Health Day campaign and The world
health report to the subject. In many countries around the world, and particularly in
developing countries, mental health has long been a neglected area of health care,
more often than not considered in terms of institutions and exclusion, rather than the
care and needs of the human being. Current knowledge emphasizes early identification
and intervention, care in the community and the rights of mentally ill individuals.
The countries of the Eastern Mediterranean Region represent many challenges for the
organization of mental health care. Many countries are in a state of rapid social change,
some are in conflict or suffering the aftermath of conflict, while others are witnessing
the growing problem of substance abuse, with associated HIV/AIDS rapidly becoming
a public health priority.
This publication addresses three aspects: the planning of mental health services; the
current mental health situation in each of the countries of the Region, along with the
innovative approaches developed during the past two decades, and the challenges
and opportunities for addressing the mental health needs of the diverse populations.
Bringing together the experiences of the Region provides an opportunity to learn from
the past as well as for greater collaboration and cooperation in the future between
countries facing similar problems.
ISBN 92-9021-339-6
mhcover.indd 1
Mental health in the Eastern Mediterranean Region: reaching the unreached
Mental health in the Eastern Mediterranean Region: reaching the unreached
29
Mental health in the
Eastern Mediterranean Region
Reaching the unreached
1
24/07/2006 14:00:17

Similar documents

×

Report this document