Overview on Mental Health services in Egypt

1. Nasser Loza , FRCPsych Secretary General for Mental Health Ministry of Health Egypt Overview on Mental Health services in Egypt

3. Egypt • Hospital Based Mental Health system ( 17 Psychiatric Hospitals in 14 out of the 29 Governorates ) • 2 large Hospitals at Cairo represents 60 % of available psychiatric Beds ( each is approx. 1800 Beds) • 2% of Health expenditure devoted to MH, 59 % is directed to MH Hospitals • Length of stay of long stay patients in older institutions ; > 50 % stayed longer than 5 years • 1.44 Psychiatrist, 1.806 Psychiatric Nurse, 0.11 psychologist, 0.27 Social worker /100,000 population

4. 1 2 3 New Mental Health Act 2009 Establishing a national mental health commission &Updating organizational structure for the mental health secretariat Raised awareness on patients rights among mental health staff MAIN STRENGTHENS OF EGYPT MENTAL HEALTH SYSTEM

5. 4 5 Evidence Based decision making ; establishing the MHIS and research unit Upgrading the Forensic Psychiatric services MAIN STRENGTHENS OF EGYPT MENTAL HEALTH SYSTEM

6. MAIN WEAKNESSES OF THE COUNTRY MENTAL HEALTH SYSTEM 1-Long stay patients 2-Stigma 3-Abuse Large number of long stay psychiatric Patients staying in old Psychiatric institutions Stigma of Psychiatric illness is deeply rooted in the Community Perception Abuse of the patient rights in the, community ;Media , work, family members & institutions

7. New Mental Health Legislation • 2009Act Replacing 1944 Act Introducing : • Rules for involuntary and voluntary admission • independent assessment • National commission for mental health as a national review body involuntary treatment • emergency treatment • community treatment orders • ECT • sanctions • forensic assessment • funding resources for mental health

8. Mental Health Act, 1944 • No single amendments has been done since 1944. • Single supervisory board for the entire country that should review all cases of compulsory admissions. • Its jurisdiction is optional to hospitals that opt to abide by its rules

9. Application of 1944 act • Forcing patients to sign voluntary admission forms. • Involuntary admission to ineligible hospitals using voluntary forms. • Admission on moral basis. • Denying voluntary patients their rights for discharge upon their request. • Mental health act had been practically declared dead.

10. Cross tabulation for length of stay in years at Abbassia and Khanka hospitals classified by gender

13. Involuntary admissions January 2007-August 2009

14. New Mental Health Legislation • 2009Act Replacing 1944 Act • Introducing :Rules for involuntary and voluntary admission, independent assessment ,National commission for mental health ,involuntary treatment , community treatment orders , least restrictive alternative principles, ECT , sanctions , forensic assessment ,funding resources • Patient’s rights Vs. Community worries • Debates on :Family role Vs. individual informed decision making

15. PARTS of the law • 1) Part One: jurisdiction of the Law & Definitions.   • 2) Part Two: Councils of Mental Health.   • A. First Section: National Council for Mental Health.   • B. Second Section: Local Council for Mental Health.   • 3) Part Three: The Patient's Admission.   • A. First Section: Voluntary Admission.   • B. Second Section: Compulsory Admission.   • C. Third Section: Lodging by virtue of Decisions or Judicial Court rulings.   • 4) Part Four: Treatment of a Psychiatric Patient.   • 5) Part Five: Psychiatric Patients' Rights.   • 6) Part Six: Mental Health Fund.   • 7) Part Seven: Penalties.

16. Examples of new tasks of Mental Health Councils • Setting up registers for entry of names of The Psychiatrists, duly permitted from the part of the Council for applying Decisions of Admissions, as well as involuntary treatment and treatment Injunctions, and independent evaluation pursuant to provisions of the Executive Regulation of this law.

17. Patients’ Rights • Charter for patients’ rights • Provisions to empower these rights • Committee for patients’ rights

18. Legislation alone cannot provide such protection What can else help? Reducing stigma and discrimination. Enhancing awareness within society. Ensuring an adequate and well trained workforce and access to a range of psychological and medical treatment.

19. Percentage of Discharged Patients whose length of stay is within 3 monthsModifying length of stay policies October 2006-March 2007 note : how helwan hospital changes policy in one month once data was analyzed and discussed in Nov , and remained on same policy

21. How the media responded …

23. 2006-2010 “One Community Campaign “National Campaign for raising awareness on mental illness and rights of mentally ill persons Aims : Raising awareness of the community Changing attitude Collaborating Partners: Ministry of Health Government of Finland World Health Organization Faculty of Mass Media Pharmaceutical Companies Advertisement agencies , Film Production companies , Graphic Design Agencies

24. Campaign tools : TV Advertisements Short Films Radio Audio clips Website Billboards Posters Brochures

26. Main messages of the TV clips Five messages were narrated as the clip rolled on: These messages were 1- Among the causes of mental illness is daily stressors 2- Invitation to critically appraise the following sentence: “This is a psychiatric patients, stay away” 3- Mental illness is recognizable, diagnosable and treatable 4- Mental illness is like any other illness: potentially curable 5- Invitation to critically appraise the following sentence: “This was a psychiatric patient, stay away under all circumstances: in sickness or health”: Once mentally ill, always mentally ill”

27. Study designed in collaboration between Ministry of Health and Cairo University for assessment of the Impact of the antistigma campaign and perception of the community to mentally ill persons N.Khairy,E Hamdy,F.Bahgat

28. Systems Approach to Community Survey on Impact of Antistigma Campaign Assessment of Impact of anti stigma campaign : Through assessment of those who exposed to campaign TV clips compared to those not exposed by exposure to main themes of the clips in questionnaire Questionnaire and Image stimulus card to assess perception of mentally ill

29. Participants Total number of participants: 3000 Representative of the nationally recognized representative numbers of age groups, literacy groups and gender (according to the 2007 census) Completed along 5 weeks Area covered: greater Cairo and other dispersed areas Individually administered: one to one: in case of illiteracy, questionnaire would be read without explanation in order not to influence choice. Time of administration lasting between 10 and 20 minutes according to age and literacy

30. Results Both males and females equally represented Age: mean= 34 yrs Marital status: 50% married, 38% single Employment: 70% Education

31. Results: Beliefs about cause of mental illness 77% of participants would take a sick relative to a psychiatrist

32. Did viewing the clips make a difference?17% of the sample reported that they were exposed to the clips less than one year ago

33. ResultsDoes society reject the mentally ill? Total participants: average 38% rejection

34. ResultsIs society inclined to be inclusive of the mentally ill? Total Participants: average exclusion rate: 34%

35. National Mental Health Survey: One-year Prevalence of Psychiatric Disorders inUpper Egypt (Emad Hamdi et al 2009) Method • cross-sectional survey of adults residing in a randomized household sample from Upper Egypt using standardized assessments. • Short Arabic version of PSE-10 (WHO , 2000) • Socioeconomic Status questionnaire (Fahmy and Sherbini, 1977) • Sheehan Disability Scale • Global Assessment of Functioning , GAF • one-stage design aimed at detecting discrete mental disorders and sub-clinical conditions.

36. Sample Design • Target sample is 5000 respondents. With a non-response rate of around 20%, this led to a sample size of around 6000 households (one respondent per household). • The study utilized the Egypt Demographic and Health Survey 2005 (EDHS 2005) sample frame, which is the most recent updated sample frame available. • It guarantees a proper multistage randomization procedure.

37. Pearson chi square test p=0.000 Provisional data from National Mental Health Survey 2006-2008

39. Psychiatric Morbidity (Caseness) in Upper Egypt by age- group * some data are missing

41. Relation between Employment and Psychiatric Morbidity in Upper Egypt ** statistically significant difference

42. Relation between Education and Psychiatric Morbidity Caseness in Upper Egypt ** statistically significant difference

43. Thank You Mental Health Secretariat -EGYPT www.mentalhealthegypt.com