Mental Health Strategy: How to lessen the psychiatric morbidity?

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Written by:

Dr. S. Abdullah Al-Farooq

FCP, Asst. Professor, Psychiatric Department

Jahurul Islam Medical College & Hospital, Bajitpur, Kishoregonj

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What is mental or emotional health?

Mental or emotional health refers to once overall psychological well being.

- The way feels about himself

- Quality of relationship

- Ability to manage feelings and dealt with difficulties.

People who are mentally and emotionally healthy have

- Sense of contentment

- Zest for living

- Ability to dealt with stress

- Flexibility to learn new things and adapt to change

- Balance between work and rest

- Ability to build and maintain relationship

- Self confidence and high self-esteem

What is Resilience?

An ability to bounce back from adversity, trauma and stress.

Building resilience

Letting strong emotions.

And also releasing when needed.

Actions to deal with problems

Meet demands of daily living.

Spend time with love one.

Rely on others and also rely on self.

Physical Health is connected to mental and emotional health.
  -    Get enough rest

-      Good nutrition

- Exercise

 

-          Avoid cigarettes and other substances

Improve mental and emotional health by taking care oneself.

-          Practice self discipline

-          Learn or discover new things

-          To think that positively impacts others

-          Enjoy the beauty of nature

-          Engaging meaningful creative works

-          Meet leisure time a priority

-          Appeal your senses, e.g. listen to music

-          Meditation prayer

-          Limit unhealthy mental habits, like worrying

-          Manage stress, avoid alter, adopt or accept

Supportive relationship: the foundation of emotional health

-          Spend time face to face with close one or friends

-          Get out from behind TV or Computer screen

-          Do something that helps others

-          Be a joiner of social action, special interest group

Risk factors that can compromise mental and emotional health

-          Poor early attachment to parents

-          Traumas or serious loss early in life

-          Learned helplessness

-          Illness

-          Poor socio-economic condition

-          Side effect of medication

-          Substance abuse

Red flag symptoms that require immediate attention

-          Inability to sleep

-          Feeling down hopeless or helpless most of the time

-          Concentration problem interfering work or personal life

-          Smoking, over-eating drugs or alcohol to cope with difficulties

-          Negative or self-destructive thoughts or fears

-          Thoughts of death or suicide

If red flag symptoms identified make an appointment with mental health personal.

Theme of the mental health strategy

-          Improve the mental health and well being of the population and keep population well

-          Improve outcome for people with mental health problems through high quality services that are equally accessible to all.

Mental health is as important to people as their physical health.

Objectives:

-          More people will have good mental health

-          More people with mental health problem with recover

-          More people with mental health problem will have good physical health

-          More people will have a positive experience of care and support

-          Fewer people will suffer avoidable harm

-          Fewer people will experience stigma and discrimination

Strategy should be:

-          Participant driven

-          Prevention focused

-          Community based

-          Recovery and/or self-determination outcome oriented

-          Reflects best treatment support practice

-          Cost effective

Consumer principles

-          Consumer involvement in planning and management of the system

-          Prevention of consumer’s right

-          Recovery of self-determination

-          Choice and self-direction of the service

System Principles

-          Continuity of care

-          Description of core services (mental health, developmental disabilities, substance abuse)

-          Implementation of uniform portal

-          Target population and criteria for identifying them

-          Integration and best usages of state facilities with community system of care

-          Attention to and involvement of the provider to the system

-          Inter-system collaboration

-          Workforce development

-          Cultural competence and cultural relevance

-          A planning management and performance evaluation

Consumers Outcome

-          Increased percentage of consumers receiving timely adequate care

-          Increased percentage of consumers given a choice of providers

-          Increased percentage of consumers participating in the development of their persons centered plan

-          Increased percentage of consumers with crisis present to the provider

-          Decreased re-hospitalization

-          Decreased rate of preventable death

-          Decreased rate of disability

-          Decreased rate of drop out

-          Increased job placement

-          Increased functioning

System Performance

-          Increased public access to the provider

-          Increased portion of public resources spent on evidence based and best practice

-          Increased number of providers

-          Increased ability to local crisis service

-          Decreased percentage of hospital admission

-          Increased continuity of care

-          Decreased disability

-          Reduced rate of drop out

-          Increased employment opportunities for consumers

Historical background of mental Health services

Three periods

-          1) Rise of the asylum

-          2) Decline of the asylum

-          3) Balancing mental health

The Rise of Asylum

-          The asylum emerged as the main societal institutions for care of mentally ill and by the end of nineteenth century, became merely custodial hospital

-          Placed remote from community

-          Strong evidence of overall poor standard of treatment and care

The Decline of the asylum

Asylum care resulted

-          Progressive loss of life skills

-          Deficit symptoms

Concerns included:

-          Ill treatment of patients

-          Professional isolation of the institution

-          Poor reporting

-          Weak staff training

-          Failure of management and leadership

In response to these deinstitutionalization proceeded

Deinstitutionalization:

-          Prevention of inappropriate mental hospital admission

-          Provision of community facilities

-          Discharge to the community of long term institutional patients

-          Establishment and maintenance of community support system for non-institutionalized patients

Balancing Mental Health care

With following characteristics:

-          Services close to home including modern hospital care for acute admission and long term facilities in the communities

-          Interventions related to disabilities

-          Treatment and care specific to the need

-          Services consistent with human rights

-          Services which reflect the priorities of the users

-          Coordination between mental health professionals and other agencies

Basic Psychiatric Services

-          Inpatient care

-          Emergency services

-          Outpatient care

-          Day Care (Partial hospitalization, halfway home, after care service)

-          Community consultation

-          Research and education

Mental health service Components

Relevant for countries with low level of resources:

-          Primary care mental health with specialist backup

-          Screening and assessment by primary care staff

-          Talking treatment including counseling and advice

-          Pharmacological treatment

-          Liaison and training with mental health specialist staff when available

-          Limited specialist backup available for:

-             Training

-             Consultation for the complex cases

-             In patients assessment and treatment

World Health Organization view

Community mental health service is the recommended form of health care by WHO specially for developing countries. WHO proposed the following recommendations for effective community psychiatric approach:

-          Provide treatment in primary care

-          Make psychotropic drugs available

-          Give care in the community

-          Educate the public

-          Involve communities, families and consumers

-          Establish national policies, programs and legislation

-          Develop human resources

-          Link with other sectors

-          Monitor community mental health

-          Support more research

A step-wise approach to delivering mental health service

-          Establishing the service principles

-          Setting the boundary conditions

-          Assessing the population need

-          Assessing current provision

-          Formulating a strategic plan

-          Implementing the service components at the local level

-          A monitoring and review cycle

Psychiatric Morbidity: Diagnoses of the Patients attending Psychiatry Outpatient Department of a Hospital

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Psychiatry Outpatient Department, Jahurul Islam Medical College Hospital
Year of Study: 2010
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Asst. Prof. S. Abdullah Al-Farooq^a, Dr. Nitai Chandra Ray^b

INTRODUCTION

Psychiatric morbidity is one of the major health problems all over the world. Bangladesh is a densely populated country, where prevalence of Psychiatric illness is similar to other countries of the world. According to a report of World Health Organization about 10% of the general population suffer from minor psychiatric illness and 1% from major psychiatric disorders.¹ Recently conducted national survey of mental health is Bangladesh showed that 16.05% of the adult population were suffering from psychiatric illness. The prevalence of neurotic disorder, in the study was 8.4%, major depressive disorder and psychosis were 4.6% and 1% respectively. The study also explored that among the psychiatric patients 52.3% were detected suffering from neurosis, 28.7% major depressive disorder and 6.7% psychosis.²

Photo collected from: http://farm4.static.flickr.com

The greater number of population of our country mainly resides in the rural areas. Availability of the mental health services is inadequate in comparison to the need and it is almost unavailable in the rural areas. Previously in our country there were some studies among limited population groups regarding mental illness. In one study 29.% of the patients attending general practice were suffering from functional disorders and 6% from both functional and organic disorders. Among the sufferers 47% patients were neurotic, 37% psychosomatic, 10% were suffering from mood disorder, 1.44% schizophrenia, 2.88% alcohol and other substance related disorders, 2% organic psychiatric syndrome.³

Another rural based study in Dasherkandi, a village nearby Dhaka found that 6.52% of the population had been suffering from psychiatric illness.⁴

Among the patients attending the outpatient department of National Institute of Mental Health, Dhaka 37.46% were suffering from schizophrenia and other psychiatric disorders, 16.14% anxiety disorder, 7.66% substance related disorders, 6.6% somatoform disorders, 4.12% mental retardation and 7.88% other disorders.⁵

A study carried out in private clinic in Dhaka city demonstrated that among their admitted patients, 39.4% were suffering from schizophrenia and other psychotic disorders, 18.75% mood disorders, 3.6% borderline personality disorder, 1.6% somatoform disorders and 0.7% anxiety disorder.⁶

Jahurul Islam Medical College Hospital is one of the few tertiary hospitals situated in the rural area of Bangladesh. The aim of the study was to evaluate the pattern of psychiatric diseases of the patients attending in the psychiatric outpatient department of private medical college hospital situated in a village of the Kishoregonj district of Bangladesh.

METHODS

The patients consulted by the doctors at the psychiatry outpatient department of the Jahurul Islam Medical College and Hospital (JIMCH) Bhagolpur, Bajitpur, Kishorgonj during the period of January to December 2010 were included in the study. Information regarding the patients were documented in the outpatient register book. This was retrospective study. Data regarding specific diagnosis and the patients’ socio-demographic criteria were collected from the register book of the patients from the period of January to December 2010. Diagnosis of the patients attending the psychiatry outpatient department done following the Diagnostic and Statistical Manual for Mental Disorder 4^th Edition (DSM-IV) criteria of the mental disorder and confirmed with assistance of consultant psychiatrist. Only new cases were included in the study. Data were presented in the tabular form and statistical analyses were done as required. The precaution was taken not to harm the physical and mental condition of the patient and confidentiality of the personal data was strictly maintained.

RESULT

During the period of January to December 2010, 1033 new cases were treated in the psychiatry outpatient department of JIMCH, were included in the study. Out of 1033 cases 585 (56.63%) were male and 448 (43.37% were female from 4 years to 90 years age group. 668 (64.67%) patients were married , 339 (32.82%) were unmarried, 21 (2.03%) were widow and only 5 (0.48%) were divorced/separated. 964 (93.22%) patients were Muslim and 69 (6.68%) were Hindus. A s the study were carried out in the rural area, most of the patients 319 (30.88%) were illiterate, followed by secondary education 281 (27.2%), primary education 199 (19.27%), passed secondary and higher secondary examination 181 (17.52%) and 53 (5.13%) patients were graduate. Most of the patients 929 (89.94%) resided in the rural area and 104 (10.06%) were urban. Regarding occupational status among the patients 387 (37.46%) were housewife, followed by students 167 (16.17%), unemployed 139 (13.46%), businessman 99 (9.58%), 90 (8.71%) patients were depend on agriculture. 317 (30.69%) patients from 18-27 years age groups had more psychiatric disorder followed by 28-37 years age group 269 (26.04%) cases.

Out of 1033 patients 109 (16.36%) were suffering from generalized anxiety disorder in which male suffer more than female. 164 (15.88%) were diagnosed suffering from major depressive disorder in which female suffered more than male. Among the patients 85 (8.23%) diagnosed Bipolar Mood Disorder.  83 (8.03%) cases were schizophrenia, 87 (8.42%) brief psychotic disorder or schizophreniform psychosis, 24 (2.32%) substance related disorder, men affected more than women. There were 24 (2.32%) cases of conversion disorder and 44 (4.26%) somatoform disorders, most of them were female. Regarding other disorders, 26 (2.52%) cases were obsessive compulsive disorders, 7.16% suffered from other anxiety disorders, 56 (5.42%) tension headache and migraine, 56 (5.42%) erectile dysfunction and premature ejaculation, 20 (1.94%) epilepsy and 6 (0.58%) Dementia. There were 20 (1.94%) Attention-deficit hyperactivity disorder, 6 (0.58%) mental retardation, 3 (0.29%) autistic disorders. 203 (19.65%) cases were referred from other outpatient departments of the hospital. 219 (21.20%) patients showed positive family history of psychiatric illness, 235 (22.75%) were smokers and 47 (4.55%) used illicit substances.

Table-1: Distribution of Patients by Sex, Age Group, Habitat, Religion and Marital Status

Particulars	Number	Percentage
Sex
Male	585	56.63%
Female	448	43.37%
Age Group
<18 years	145	14.04%
18-27 years	317	30.69%
28-37 years	269	26.04%
38-47 years	156	15.10%
48-57 years	85	8.23%
58 and above years	61	5.90%
Habitat
Rural	929	89.94%
Urban	104	10.06%
Religion
Islam	964	93.32%
Hinduism	69	6.68%
Others
Marital Status
Married	668	64.67%
Unmarried	339	32.82%
Widow	21	2.03%
Divorced / Separated	5	0.48%

Table-2: Distribution of Patients by Educational Status.

Particulars	Number	Percentage
Illiterate	319	30.88%
Primary	199	19.27%
Secondary	281	27.20%
SSC / HSC	181	17.52%
Graduation & above	53	5.10%

Table-3: Distribution of Patients by Occupation

Particulars	Number	Percentage
Agriculture	90	8.71%
Service	54	5.23%
Business	99	9.58%
Teacher	21	2.03%
Student	167	16.17%
Day Labor	13	1.26%
Works Abroad	15	1.45%
Unemployed	139	13.46%
Housewife	387	37.46%
Others (Technicians / Shoe makers/Plumbers /Weavers/Carpenters/Imam/etc.)	48	4.65%

Table-4: Distribution of Patients by Family History of Psychiatric illness, History of Smoking, Substance use and Referred from other departments.

Particulars	Number	Percentage
Family History of Psychiatric Illness	219	21.20%
History of Smoking	235	22.75%
History of Substance Use	47	4.55%
Referred from other Departments	208	20.14%

Table-5: Types of Psychiatric Disorder among the Psychiatry Outpatients

Sl.#	Disease	Male	Female	Total	%
1	Generalized anxiety Disorders	103	66	169	16.36%
2	Other Anxiety Disorders	40	34	74	7.16%
3	Obsessive Compulsive Disorders	13	13	26	2.52%
4	Major Depressive Disorders	68	96	164	15.88%
5	Bipolar Mood Disorders	57	28	85	8.23%
6	Schizophrenia	43	40	83	8.04%
7	Brief Psychotic Disorders / Schizophreniform Disorders	44	43	87	8.42%
8	Acute Stress Disorders	2	6	8	0.77%
9	Post Traumatic Stress Disorder	1	0	1	0.10%
10	Somatoform Disorders	11	33	44	4.26%
11	Conversion Disorders	3	12	15	1.45%
12	Insomnia	11	0	11	1.06%
13	Psychosexual Disorders	56	0	56	5.42%
14	Extra-pyramidal Syndrome	6	2	8	0.77%
15	Adjustment Disorders	1	2	3	0.29%
16	Mental Retardation	4	2	6	0.58%
17	Epilepsy	18	2	20	1.94%
18	Attention Deficit Hyperactivity Disorders	3	4	7	0.68%
19	Autistic Disorders	2	1	3	0.29%
20	Conduct Disorders	4	4	8	0.77%
21	Hyperventilation	1	1	2	0.19%
22	Tension Headache	15	13	28	2.72%
23	Migraine	11	17	28	2.72%
24	Post Partum Psychosis	-	1	1	0.10%
25	Delusional Disorders	-	2	2	0.19%
26	Personality Disorders	-	2	2	0.19%
27	Substance related Disorders	22	2	24	2.33%
28	Abnormal Grief	3	3	6	0.58%
29	Deliberate Self Harm – poisoning	2	1	3	0.29%
30	Dementia	6	0	6	0.58%
31	Head Trauma	1	1	2	0.19%
32	Post Coital Headache	2	0	2	0.19%
33	Others (Neurological / Physical illness undiagnosed/ etc.)	32	17	49	4.74%
	TOTAL	585	448	1033	100.00%

DISCUSSION

Most patients were between 18-37 years age group 56.75%, literate 69.12%, married 64.67%, housewife 37.46%, the finding is consistent with national study carried out by National Institute of Mental Health.² Table-1 shows number of male patients (56.63%) is higher than female (43.37%). In our country females usually do not seat health case as readily as male.⁷ This reflects the attitude of society towards female. Anxiety disorders 23.52% and major depressive disorders 15.88% were the common disorders requiring treatment in the psychiatry outpatient department in a tertiary hospital situated in the rural area which is similar to the psychiatric co-morbidity among Bangladeshi rural population.⁸ Most of the cases male suffered more than female though in few cases of major depressive disorder with conversion disorder 1.45% female suffered more than male. Next to depressive illness bipolar mood disorder 8.23%, schizophrenia 8.03%, brief psychotic disorder and schizophreniform disorder 8.42% are psychotic disorder requiring admission in the hospital.⁹ Schizophrenia is a disorder which causes significant impairment of both social and occupational functioning, if managed properly will be able to lead a productive life in the society. Patients with depressive disorder, bipolar mood disorder, substance related disorders 2.32% are serious burden to family and society and threat to national economy, therefore their management is important.

Study revealed that major depressive disorder, somatoform disorders (4.26%) and conversion disorder (1.45%) were more among female probably because of stressful life events, the effect of child birth and learned helplessness (5.8). The number of patients with somatoform disorders, conversion disorder, tension headache (2.71%), migraine (2.71%) found less among the total number of patients. This correlates with the false belief of the patients regarding their symptoms as being physical rather than psychological.⁹ These patients also seek health care from other outpatient departments of this hospital. The child psychiatric disorders like attention-deficit hyperactive disorder 0.68%, autistic disorders 0.58%, mental retardation 0.58%, early diagnosis and proper management is essential to improve the quality of life of these children.⁹ Epilepsy 1.94% also being treated by different outpatient department of this hospital, early management reduces suffering and disability of the patients, helps to lead normal life. Patients with psychosexual disorders 5.42% also seek care from dermatology outpatient department. Only 6 cases of dementias were being treated throughout the year, probably due to lack of awareness regarding the problem and its management among the rural people.

Psychiatric morbidity was highest among housewife 37.46% because of stressful life event, child rearing, housekeeping and learned helplessness.⁹ Students 16.17% who were mostly adolescent and of early adultness and therefore vulnerable for psychiatric disorders. Next to student, psychiatric morbidity were frequent among unemployed 13.46%, because these people are facing daily life stresses.⁶ 21.2% patients had positive family history of psychiatric illness, indicating major psychiatric disorders have substantial contribution of genetic heritability.

CONCLUSION

This study though gives a pattern of different psychiatric disorders among the rural people in Bangladesh, a community based study is essential to delineate the exact picture. Only hospital based study can not reflect the exact picture, because some of the patients do not seek hospital based treatment because of stigma, some cannot afford such treatment, some are unaware about the availability of the treatment and probably a good number of patients seek alternative treatment for psychiatric morbidity. Psychiatric problem is at present a national issue, awareness about the illness is gradually increasing. So number of patients seeking psychiatric treatment is also increasing. To meet this need facility of the mental health services should be available for all.

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a. Assistant Professor, Psychiatry. Jahurul Islam Medical College & Hospital, Bajitpur, Kishoregonj

b. Registrar, Medicine. Jahurul Islam Medical College & Hospital, Bajitpur, Kishoregonj

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Corresponding Author: S. Abdullah Al-Farooq, Assistant Professor, Department of Psychiatry, Jahurul Islam Medical College & Hospital, Bhagolpur,  Bajitpur, Kishoregonj. E-mail: farooq.jimch@gmail.com

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