Community Mental

Health

Awatif Alam /Ahmed Mandil,

Prof of Epidemiology
College of Medicine, KSU
aalam@ksu.edu.sa
Headlines:
 General reflections
 Magnitude of the problem
 Classifications
 Disorders

 Etiology

 Prevention and control

 Integration into PHC
 General Reflection:
 Community health service was concerned mainly with the
control of communicable diseases.
 In the course of development, it has become increasingly
concerned with every health aspect of life of individuals in
the community.
 Psychiatry, has developed as a personal service to the
mentally – ill individual,
 Only recently psychiatrists have attempted to contribute
to preventive aspects of mental illness.
 However, preventive psychiatry remains in its infancy
and needs much community efforts to be well developed.
 Magnitude of Mental illness
worldwide

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 We are all vulnerable

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Global Burden Mental & Substance Use disorders Study
Harvey A Whiteford et al: Global burden of disease attributable to mental and
substance use disorders: findings from the Global Burden of
Disease Study 2010. Lancet: August 29, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61611-6

November 29, 2023 Mental Health 6

Global Burden Mental & Substance Use disorders
Study
Harvey A Whiteford, et al: Global burden of disease attributable to mental and
substance use disorders: findings from the Global Burden of
Disease Study 2010. Lancet: August 29, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61611-6

 183·9 million DALYs (disability adjusted life years)

 7·4% of all DALYs worldwide.
 8·6 million YLLs (Years of life lost)
 175∙3 million YLDs (22·9% of all YLDs)
(Year of life lost to disability)

 Leading cause of YLDs worldwide.

 Depressive disorders 40·5% of DALYs
caused by mental and substance use
disorders
 Anxiety disorders 14·6%
Mental Health Atlas 2011 - Department of
Mental Health and Substance Abuse, WHO
 An officially approved mental health policy exists since 2008.
 The mental health plan components include:
 Timelines for the implementation of the mental health plan.
 Funding allocation for the implementation of about half
of the items in the mental health plan.
 Shift of services and resources from mental hospitals to
community mental health facilities.
 Integration of mental health services into primary care.
 Legal provisions concerning mental health are also covered in other
laws (e.g., welfare, disability, general health legislation etc.).
 Note: As of 2010, the Mental Health Act was under review and consideration in the
Council of Ministers (Shoura Council).
 Mental Health Burden in KSA:
 In Saudi Arabia, neuropsychiatric disorders are
estimated to contribute to 14.% of the global burden of
disease (WHO, 2008).

 Mental health expenditures by the government health

department/ministry are 3.89% of the total health budget.
Etiology OF MENTAL ILLNESS

The concept of multiple

factors in the
causation of
psychogenic
disorders has become
generally accepted.
 The factors are
considered to involve
the individual,
 the family
 and the community.
 genetic factors play a causative role in
schizophrenia and in some manic depressive
illnesses.

• social and environmental stress,

• social deprivation and other phenomena
which characterize modern life.

• Physical causes, as disease or trauma,

•The roles of syphilis and advanced pellagra are
well known to cause mental disturbances.
Etiology of Mental Illness (II)
Inheritance-Genetics/Intra-uterine :Drug Abuse
environment Schizophrenia,Huntingto
n’s Alcohol , Heroin etc

:Upbringing :Neurological diseases

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

Infections- Vascular-CVA
HIV,Syphilis,CJD Nutrition/PCM
 EXTENT OF MENTAL ILLNESS :
• It is estimated that one person in every ten, has some form
of mental or emotional illness, from mild to severe, that could
benefit from professional help or treatment.

• Estimates vary, however, depending on the criteria used

for diagnosis and the kinds of mental conditions included.
• If only clearly disabling conditions are counted, the
estimate of mental illness in the general population will be
much lower than 10%.
• If milder emotional upsets, psychosomatic complaints
and any of the various “problems of living” are included, a
much larger proportion of the population will be found to
have some form of emotional disorder.
 EXTENT OF MENTAL ILLNESS :
• It is estimated that one person in every ten, has some
form of mental or emotional illness, from mild to severe,
that could benefit from professional help or treatment.
• Estimates vary, however, depending on the criteria
used
for diagnosis and the kinds of mental conditions included.
• If only clearly disabling conditions are counted, the
estimate of mental illness in the general population will be
much lower than 10%.
• If milder emotional upsets, psychosomatic complaints
and any of the various “problems of living” are included, a
much larger proportion of the population will be found to
have some form of emotional disorder.
OBJECTIVES:
 Promote mental health in the
community.
 Maintain – if possible – the
mentally – ill within the
community itself.
 Avoid un-necessary
admission and restraint in
special hospitals.
 Provide social therapy.

“Community mental service is provided in hospitals,

mental health centers, by general practitioners and
health authorities (local and central) all working in
harmony”.
BROAD CLASSIFICATION OF
MENTAL ILLNESS :
 The psychoneurosis

 The psychosis

 Addictions,
alcoholism, … etc.

 Mental retardation
 psychoneurosis :
Comprise a group of personality disorders, in
which:
 Behavior traits,
 Thought processes,
 Emotional responses and
 Somatic functions

occur in a repetitive pattern maladaptive and

inappropriate to the ordinary stresses and
demands of environment and living.
 Psychoneurosis:
 Symptomatology has its origin outside conscious
awareness and is traceable to modes of personality
functioning which pre-existed in infancy and childhood.
In general, the psychoneurotic reaction
represents :

• Symbolic adaptation to anxiety involving only partially

disturbed social functioning and reality testing.

• The psychoneurotic in contrast to the psychotic,

maintains the capacity to perceive and adapt to
environmental realities.
 Psychoneurosis:
• Legally, the psychoneurotic is responsible
for his actions.
• The onset of psychoneurosis occurs
usually in early adult life.
• The course tends to be chronic.
• Appearance of these disorders, for the
first time, after 45 years of age is unusual.
 Psychoneurosis:
 Usually symptoms express themselves in the
period of active sexual reproductivity and social
responsibility.
 Psychoneurotic disturbances manifest
themselves in the predisposed individual as a
consequence of exposure to anxiety – arousing
situations.
 The genetic and constitutional factors determine
both the capacity of the personality to withstand
stress and the determination of the organ
systems which respond to stress.
• The initial stage of personality development takes
place during the early years of life, during which time
the infant is wholly dependent upon his mother or a
mother substitute.
• If the child is pushed and urged beyond his
maturational limits, the beginning of self-doubt
and shame are implanted .
• The child enters into the society of equals through
various interactions (sibs),and their play is the
introduction to the life of society in general.

• The child starts to learn to adjust to the needs

and desires of others.
• He always strives for success.
Psychosis:
 Represents extreme form of breakdown
in mental health,
 The individual no longer remains related
to the reality situation ,
 The patient is subjected to irrational and
disordered emotional and intellectual
process.
 Psychosis will lead to aberrant behavior
recognizable by gross un-reality,
e.g. schizophrenia, manic depressive
psychosis, melancholia.
 The psychotic who violates legal and
social codes is placed under supervision
or hospitalized.
 Addictions, alcoholism, and other
behavior disorders:
The drugs that can affect mental processes and behavior
are classified into three general groups:
• Depressants e.g. Valium, Librium, barbiturates.
( alcohol is the most commonly used and abused ).
• Stimulants include amphetamines, nicotine in tobacco .

• Hallucinogens include marijuana and lysergic acid

diethylamide.

“ Individuals must be fully informed of the possible hazard

to health involved in alcohol and drug abuse.”
 The governmental role in control of
alcohol and drug abuse:
 Adopting certain legal regulations; for controlling the
important and export of narcotic drugs,

 Regulating the production and distribution of

drugs,

 Establishing penalties for illegal possession

or sale of dangerous drugs.

 The provision of programs including:

- treatment,
- rehabilitation,
- research and education
(designed to prevent and combat the adverse personal
and social consequences of drug abuse).
 Mental Retardation:
A person may be
retarded in :
 intelligence level,
 in adaptive behavior,
 in academic achievement ,
 in a combination of these
elements.
Mental retardation can be caused by any condition
that interferes with development :
- before birth,(gene incompatab., x-ray, infections)
- during birth ( birth injury )
- in early childhood (meningitis, polio, lead poisoning)
 PREVENTION AND CONTROL

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Preventive Networks :Mosque, Family,
Home, Friends, Work

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 Primary Prevention
(Ref: WHO, Prevention & Promotion 2002 WHO, Prevention of Mental Disorders 2004)

 Universal prevention: targeting the general public or a

whole population group.

 Selective prevention: targeting individuals or subgroups

of the population whose risk of developing a mental disorder is
significantly higher than that of the rest of the population.

 Indicated prevention: targeting persons at high-risk for

mental disorders.

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

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The field of action for prevention
encompasses:
 Protection of the very young,
through promotion of family life.
 Prevention of social stress and
insecurity.
 Protection of the aged; who may
suffer from cerebral degeneration,
depression and/or psychopathic
states.
 Prevention of brain damage e.g.
control of syphilis and alcoholism.
 Public education in mental health.
The field of action for prevention
encompasses:

 Pre-marital consultations and

medical examinations.
 Provision of suitable
institutions for the care of the
mentally ill.
 Legislation as regards drug
abuse, compulsory
admission to residential
hospitals and guardianship.
 Rehabilitation.
Treatment and Care

Hospital Care

Community Care

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Integration of Mental Health
into PHC
 The morbidity burden is great
 Mental and physical health problems are
interwoven
 Treatment gap is enormous
 PHC care for mental health
 Enhances success
 Promotes respect for human rights
 Is affordable and cost-effective
 Generates good health outcomes
Availability of Mental health
facilities in KSA:
 Total number of Rate per 100,000 Number of Rate per 100,000
facilities/beds population facilities/beds population
reserved for children
and adolescents only

Mental health outpatient 94 0.36 19 0.07

facilities

Day treatment facilities. 3 0.01 UN UN

.

Psychiatric beds in general 100 0.38 UN UN

hospitals

Community residential 2 0.01 0 0

facilities

Beds/places in community 240 0.91 0 0

residential facilities

Mental hospitals 20 0.08 0 0

Beds in mental hospitals 3000 11.43 0 0

 Access to mental health care in KSA:
Rates per 100,000 Females % Under
population) age 18
%
Persons treated in mental health UN UN UN
outpatient facilities
Persons treated in mental health UN UN
day treatment facilities

Admissions to psychiatric beds in UN UN UN

general hospitals

Persons staying in community UN UN UN

residential facilities at the end of the
year

Admissions to mental hospitals 76.53 UN UN

KSA Mental Healthcare Facilities
Facility Number Beds
MoH Psychiatric Hospitals 14 30-120 each
Al-Taif Hospital 1 570
Military, National Guards and total 165
University Hospitals
Private Hospitals total 146
Hospitals for treatment of Drug 3 each 280
Dependence
Departments / Clinics attached 61 each 20-30
to General Hospitals
References (I)
1. Mental Health Atlas 2011 - Department of Mental Health and
Substance Abuse, World Health Organization.

1. WHO. Integrating mental health into primary care: A global

perspective. Geneva: WHO, 2008.

1. WHO. Saudi Arabia: Integrated primary care for mental health

in the Eastern Province. In: Integrating mental health into
primary care: A global perspective. Geneva: WHO, 2008.

1. Sims P. Mental health and illness: An epidemiological

perspective. University of Papua New Guinea.2001

1. Al-Fares E, Al-Shammari S, Al-Hamed A. Prevalence of

psychiatric disorders in an academic primary care department
in Riyadh. Saudi Medical Journal 1992; 13: 49-53
References (II)
6. Al-Khathmi A, Ogbeide D. Prevalence of mental illness among
Saudi adult primary care patients in central Saudi Arabia . Saudi
Medical Journal 2002; 23: 721-724.

7. Elfawal M. Cultural influence on the incidence and choice of

method of suicide in Saudi Arabia. American Journal of Forensic
Medicine & Pathology 1999; 20: 163-168.

8. Al-Khathami A. The implementation and evaluation of an

educational program for PHC physicians to improve their
recognition of mental illness in the Eastern Province of Saudi
Arabia [dissertation]. Al-Khobar: King Faisal University, 2001.