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Trauma and Mental Health: lessons from Iraq

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1 Trauma and Mental Health: lessons from Iraq
A University Teaching Trust Trauma and Mental Health: lessons from Iraq Dr Mohammed Al-Uzri Consultant Psychiatrist & Honorary Senior Lecturer

2 Contents Background IMHS IASC Guidlines Support from UK Conclusion


4 Background Population: estimated 30 million
nearly half of the population of Iraq are under the age of 18. Breaking of social fabric Deterioration of education system Deterioration of health system

5 Iraq Mental Health Survey
“It is against the background of ongoing insecurity situation in Iraq and the recognised need for the organisation of mental health services , the Iraq Mental Health survey was undertaken in order to insure policies and strategies are based on an evidence to support the development of services for persons with mental and psychosocial needs“ World Psychiatry8:2- June 2009

6 Iraq Mental Health Survey
The methodology of the Iraq Mental Health Survey is the same as the WHO World Mental Health Survey (WMH) In all South/Centre governorates except Anbar governorate, fieldwork began on the 1st of August 2006, and completed on the 8th of September The fieldwork in Anbar governorate was delayed until the 1st of October 2006, due to the security problems, and was completed on the 17th of November In Kurdistan region, the survey began on the 1st of February 2007 and completed on the 11th of March 2007. The data collection tool was Composite International Diagnostic Interview (CIDI). Sample size: 4332

7 Composite International Diagnostic Interview (CIDI)
CIDI is a fully structured lay administered interview that generates both the ICD-10 and DSM-IV diagnoses. The disorders included: anxiety disorder( panic disorder, agoraphobia without panic disorder, specific phobia, social phobia, generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD), mood disorders ( major depressive disorder (MDD), moderate depressive disorder, minor depressive disorder, dysthymic disorder, bipolar disorder I and II ) substance use disorders (alcohol and drug abuse with or without dependence).

8 Objectives of the Iraq Mental Health Survey
to identify the prevalence (life time, 12 month and 30 day) of mental disorders among 18 years and older; to find out the relationship between prevalence of mental disorders with trauma exposure and socio-demographic characteristics (age , gender, education… etc); to identify the impact of mental disorders in the adult population 18 years and older ; to assess the treatment utilisation by the persons with mental disorders; to provide policy-and decision-makers and researchers with reliable, accurate and relevant data for the development of mental health care policies.

9 SUMMARY FINDINGS Overall 12 month prevalence rate is 13.6%
Prevalence rate in females is more than in males Anxiety disorders is the most common mental disorder group followed by mood disorders No sex difference in the prevalence rate of PTSD Higher prevalence rates in those 65 years and above Some mental disorders have higher prevalence rates in urban areas Any disorders is higher in the Kurdistan region (14.13%) than in the south/centre (10.51%)

10 SUMMARY FINDINGS High rates of exposure to trauma in the population (56%) Males (65%) are more exposed to trauma than females (46%). Higher rates of exposure to trauma among mentally ill persons Higher the exposure to trauma, greater the chance of having mental disorder Commonest trauma exposure, in order of frequency in the total population was search buy police/army(18.18%); shooting (17.19%); internal displacement(17.08%); witness to killing (16.14%); exposure to bomb blast( 15.16%); death of dear one (13.63%); combat exposure( 13.43%) and refugee experience (8.57%).

11 SUMMARY FINDINGS 2 out of 5 persons with mental disorders express suicidal ideas Prevalence of suicidal ideas are higher in females(53.80%) as compared to males(29.16%) 10.8% of respondents with one or more 12-month DSM-IV/CIDI disorders reported receiving treatment for emotional problems at any time in the 12 months before their interview

12 Rates of mental disorders-Comparison with other surveys in developing countries
12 month prevalence Iraq Lebanon China Nigeria Affective Disorder 4.1 6.6 2.2 1.3 Any Anxiety disorder PTSD 10.4 1.1 11.2 2.0 2.7 0.2 0.0 Any Substance Disorder 1.6 0.8 Any Disorder 13.6 17.0 7.0 5.8

13 However, Stress and trauma are related concepts and experiences at basic biological and psychosocial levels Stress responses are normal reactions to abnormal situations and are not necessarily pathological. Not everyone who experiences a stressful situation/ trauma develops PTSD or any other mental disorder. There are numerous factors of resilience, most notably supportive families and communities and, by extension, international communities, which enable people to cope and even prevail in the face of adversity.

14 Posttraumatic Stress Disorder
(PTSD) Complex PTSD (Herman) Ongoing Traumatic Stress Disorder (OTSD) A: Stressor (experienced or witnessed) Reaction of fear, helplessness, or horror B: Anxiety C: Dissociation D: Hyperarousal E: Nightmares F: Flashbacks Multiple traumas and stressors in childhood Severe relationship impairments Disturbances of mood regulation (e.g., outbursts of anger) Stress endures in time Person experiences psychological symptoms plus • physiological correlates • changes in vital signs: Temperature, Blood pressure, Heart rate, Respiratory rate, pain • endocrine/metabolic changes • difficulty maintaining internal milieu From Dyer & Bhadra 2012

15 IASC Guidelines for mental health and psychosocial support in emergencies
IASC = Inter-Agency Standing Committee, established (1992) by UN General Assembly Forum to coordinate humanitarian responses to emergencies Focus on community-based psychosocial support rather than a primary focus on treating individuals community-level workers (CLW) trained in basic psychosocial aspects of care, with ongoing support of social workers, and medical professionals trained in disaster mental health to support those with more significant mental health needs. IASC Bodies Individual NGOs ICVA IFRC InterAction IOM OCHA UNFPA UNHCR UNICEF WFP WHO ACF MdM-E American Red Cross Mercy Corps Action Aid Int MSF-H CARE Austria Oxfam GB CCF RET HealthNet TPO SC-UK IMC SC-US ICMC ACT Int. INEE IRC

16 non-specialised supports
services Focused, non-specialised supports Community and family supports Provide basic overview of the pyramid Basic services and security 16 16

17 Layer 1 Basic services and security
The well-being of all people should be protected through the provision of basic needs in a way that is participatory, safe and socially appropriate No specific psychosocial or mental health activities, but of those basic activities that are necessary for any psychosocial wellbeing such as - Basic information Legal position Primary health care services Work, Nutrition Shelter Advocacy to decision makers to protect displaced population Coordination with other sectors

18 Layer 2 Community and family supports
Smaller number of people who are able to maintain their mental health and psychosocial well being if they receive help in accessing key community and family supports. Support and mobilize the community in re-establishing daily life and community activities. Train and support community members in psychosocial support, including effective coping mechanisms and discouraging harmful practices. Provide information to the population on the situation, assistance and effective coping mechanisms Train and supervise community workers Concentrate the above mentioned activities in multifunctional social centers or safe spaces, and ensure that the activities are run by both Iraqis, and by members of the host community

19 Layer 3: Focused, non-specialised supports
Support structures for people who require more individual, family or group interventions by trained and supervised workers who are not specialists in the domain of mental health and psychosocial support. Basic mental health and first aid psychosocial interventions in primary health care centres Psychosocial care for humanitarian workers Organize a system of caseworkers who are able to give psychosocial support to families and individuals. (training and supervision!) Referral

20 Layer 4: Specialised services.
Required for a small percentage of the population with complaints and symptoms are intolerable and causes severe dysfunction. Organising multidisciplinary mental health services in general health care where the population have easy access Organisation of psychological support for people with severe psychological reaction to current or past situations traumatic reactions that disrupt social functioning of family and or individual. Avoid programming that focuses solely on one single diagnosis (e.g. PTSD) or one single category beneficiaries. Integrate or attach such support to existing health, social or educational services

21 Role of UK’s Diaspora Relocate to Iraq Formation of IMHF
Establishing Iraq Sub Committee, RCPsych (

22 Input of Diaspora Building Capacity (CPD/CME, ToT, supervision)
Training Curriculum development Integrating mental health into primary care services Introduction and development of Psychological Interventions Service Development Al-Uzri, Abed & Abbas , International Psychiatry 2012

23 IMHS conclusion “the findings of the Iraq Mental Health Survey showing significant prevalence of mental disorders, their association with trauma, their impact on the health status of the population and the currently very low level of medical treatment received by the ill individuals, calls for a concerted effort to develop community based mental health services in Iraq on a priority basis. “

24 Conclusions Strong association between stress/ trauma and mental health problems Expect an increase in mental health problems with reduction in violence Expect different type of mental health problems Tailor intervention to hierarchy of needs Need to collaborate with relevant organisations

25 Personal lessons Protect yourself! Manage your expectation
Work in teams Work with local partner Collaborate with others Professional neutrality

26 Thank you

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