4Background Population: estimated 30 million nearly half of the population of Iraq are under the age of 18.Breaking of social fabricDeterioration of education systemDeterioration of health system
5Iraq 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
6Iraq 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
7Composite 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).
8Objectives 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.
9SUMMARY FINDINGS Overall 12 month prevalence rate is 13.6% Prevalence rate in females is more than in malesAnxiety disorders is the most common mental disorder group followed by mood disordersNo sex difference in the prevalence rate of PTSDHigher prevalence rates in those 65 years and aboveSome mental disorders have higher prevalence rates in urban areasAny disorders is higher in the Kurdistan region (14.13%) than in the south/centre (10.51%)
10SUMMARY FINDINGSHigh 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 personsHigher the exposure to trauma, greater the chance of having mental disorderCommonest 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%).
11SUMMARY FINDINGS2 out of 5 persons with mental disorders express suicidal ideasPrevalence 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
12Rates of mental disorders-Comparison with other surveys in developing countries 12 month prevalenceIraqLebanonChinaNigeriaAffective Disorder220.127.116.11.3Any Anxiety disorderPTSD10.41.111.22.02.70.20.0Any Substance Disorder1.60.8Any Disorder13.617.07.05.8
13However,Stress and trauma are related concepts and experiences at basic biological and psychosocial levelsStress 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.
14Posttraumatic Stress Disorder (PTSD)Complex PTSD(Herman)Ongoing Traumatic Stress Disorder(OTSD)A: Stressor (experiencedor witnessed)Reaction of fear,helplessness,or horrorB: AnxietyC: DissociationD: HyperarousalE: NightmaresF: FlashbacksMultiple traumas and stressors in childhoodSevere relationship impairmentsDisturbances of mood regulation(e.g., outbursts of anger)Stress endures in timePerson experiences psychologicalsymptoms plus• physiological correlates• changes in vital signs:Temperature,Blood pressure,Heart rate,Respiratory rate, pain• endocrine/metabolicchanges• difficulty maintaininginternal milieuFrom Dyer & Bhadra 2012
15IASC 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 emergenciesFocus on community-based psychosocial support rather than a primary focus on treating individualscommunity-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 BodiesIndividual NGOsICVAIFRCInterActionIOMOCHAUNFPAUNHCRUNICEFWFPWHOACF MdM-EAmerican Red Cross Mercy CorpsAction Aid Int MSF-HCARE Austria Oxfam GBCCF RETHealthNet TPOSC-UKIMC SC-USICMC ACT Int.INEEIRC
16non-specialised supports servicesFocused,non-specialised supportsCommunity and family supportsProvide basic overview of the pyramidBasic services and security1616
17Layer 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 appropriateNo specific psychosocial or mental health activities, but of those basic activities that are necessary for any psychosocial wellbeing such as- Basic informationLegal positionPrimary health care servicesWork,NutritionShelterAdvocacy to decision makers to protect displaced populationCoordination with other sectors
18Layer 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 mechanismsTrain and supervise community workersConcentrate 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
19Layer 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 centresPsychosocial care for humanitarian workersOrganize a system of caseworkers who are able to give psychosocial support to families and individuals. (training and supervision!)Referral
20Layer 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 accessOrganisation 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
21Role of UK’s Diaspora Relocate to Iraq Formation of IMHF Establishing Iraq Sub Committee, RCPsych (http://www.rcpsych.ac.uk/college/internationalaffairsunit/iraqsubcom.aspx)
22Input of Diaspora Building Capacity (CPD/CME, ToT, supervision) Training Curriculum developmentIntegrating mental health into primary care servicesIntroduction and development of Psychological InterventionsService DevelopmentAl-Uzri, Abed & Abbas , International Psychiatry 2012
23IMHS 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. “
24ConclusionsStrong association between stress/ trauma and mental health problemsExpect an increase in mental health problems with reduction in violenceExpect different type of mental health problemsTailor intervention to hierarchy of needsNeed to collaborate with relevant organisations
25Personal lessons Protect yourself! Manage your expectation Work in teamsWork with local partnerCollaborate with othersProfessional neutrality