Introduction to psychiatry

Fikirte Girma (M.D, Psychiatrist)

Department of Psychiatry
AAU
November 2014

1
 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

2
 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

3
 Basic concepts and terms

• Psychiatry
• Normality
• Mental health
• Mental disorder
• Illness and disease

4
 Basic concepts and terms cont’

• Psychiatry (psych-soul or mind, iatros-healer)

• a medical discipline that deals with mental and
behavioral disorders
• Normality and mental health are central issues in
psychiatry, but there are no clear-cut definitions
of these terms

5
 Basic concepts and terms cont’

• Normality
• a state of complete social, mental and physical
well-being (WHO)
• patterns of behavior or personality traits that are
typical or that conform to some standard of
proper and acceptable ways of behaving and
being.

6
 Basic concepts and terms cont’

• Mental health
• the successful performance of mental functions, in
terms of thought, mood, and behavior that results
in productive activities, fulfilling relationships with
others, and the ability to adapt to change and to
cope with adversity (A Report of the US Surgeon
General)

7
 Basic concepts and terms cont’

• Mental disorder
• behavioral or psychological syndrome or pattern
that is associated with distress (e.g. a painful
symptom) or disability (Impairment in one or more
areas of functioning) (DSM IV)

8
 Basic concepts and terms cont’
• Disease is the pathological process, deviation
from a biological norm
• Illness is the patient's experience of ill health,
sometimes when no disease can be found
• A person can have a disease with out being ill
• e.g. hypertension
• A person can be ill without having a disease
• e.g. MUS

9
Common confusions within psychiatry

• Psychology
• a science that investigates behavior,
experience, and normal functioning of the mind
• Psychotherapy
• the treatment of psychological issues by non-
physical/pharmacological means
• Psychoanalysis
• a particular sort of psychotherapy, or means of
exploring the unconscious mind

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 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

11
 Why study Psychiatry?
• As a doctor you have to promote health
• Subject of medicine is human being- biopsychosocial
• High burden of the disease
• Psychiatric disorders are prevalent and often go
untreated
• Most Psychiatric disorders respond well to
treatment
• Associated stigma and discrimination
• Consideration of the psychological aspects of the
doctor-patient relationship
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 Myths and facts - 1

Mental illnesses are a luxury and not important in Ethiopia

NO: Mental illnesses have a high burden in Ethiopia

Traditional healers provide the best care for mental illness

NO: There is no evidence to support this in the case of

severe mental illness. Medication is almost always
necessary, together with psychosocial support

13
 Myths and facts - 2

A person who has had mental illness can never lead a normal
life, so why bother?

NO: Most people with mental illnesses can recover and

resume normal activities.

Mentally ill people are too dangerous to treat in health centres

NO: People with mental illness are much more likely to be the
victims of violence than to be violent

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Leading causes of years of life lived with
disability
1 Unipolar depressive disorders 10.9%
2 Hearing loss, adult onset 4.6%
3 Refractory errors 4.6%
4 Alcohol use disorders 3.7%
5 Cataracts 3.0%
6 Schizophrenia 2.7%
7 Osteoarthritis 2.6%
8 Bipolar affective disorder 2.4%
9 Iron-deficiency anemia 2.2%
10 Birth asphyxia and birth trauma 2.2%
(Both sexes, all ages)
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Predictions for the leading causes
of disability and mortality in 2030
World 1 HIV/AIDS
2 Unipolar depressive disorder
3 Ischaemic heart dis.
High-income countries 1 Unipolar depressive disorder
2 Ischaemic heart disease
3 Alzheimer
Middle-income countries 1 HIV/AIDS
2 Unipolar depressive disorder
3 Cerebrovascular
Low-income countries 1 HIV/AIDS
2 Perinatal disorder
3 Unipolar depressive disorder
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Serious cases receiving no treatment
during the last 12 months
80 85%

70
76%

60

50

50%
40

30 35%

20

10

Lower range Upper range

Lower range Upper range
Developed countries Developing countries
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 Stigma & Discrimination

• Many individuals with mental disorders are

perceived by the community as weak,
inhuman, dangerous or inferior because of
their symptoms.
• As a result of stigma, these people are
excluded or they exclude themselves
• Stigma and discrimination from health care
system…

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Effects of stigma & discrimination
• Affects sense of self-worth
• Contributes to shortened life expectancy
• Slows recovery
• Limits access and quality of health care
• Can lead to abuse
• Disrupts relationships

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As students and health care providers

• Changeyour own perception and attitude

towards people with mental disorders, its
cause and treatment

• Respectand advocate for the Rights of Persons

with Disabilities

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 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

21
Mental health service in Ethiopia

• For the most part, through the ages, most

people with mental health problems were
simply cared for in the community
• It is like that even currently
• People with active psychosis could well have
lived in the wilderness, or become beggars

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Mental health service in Ethiopia
cont’

• Illness, including mental illness were thought

to be related to certain agents outside our
bodies & environment (spiritual phenomena)
• Labelled witches or possessed

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Mental health service in Ethiopia cont’

• Even in our time, for most people,

understanding of mental illness is not far from
the past
• Treatment were based on supernatural beliefs
• Holy water, prayer, witchcrafts, traditional healers
etc…

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 Beginning of modern care

• Amanuel Hospital is a pioneer of modern

mental health service in Ethiopia
• Established in 1930EC by the Italians
• It was built in the outskirts of the city to serve the
local people (Ethiopians) as a general hospital
• Five years later it became a center for receiving
the mentally ill ( like a shelter or an asylum)

25
 Beginning of modern care-cont’
• In 1948, officially recognized as a mental
hospital under the Ministry of health
• General practitioners, nurses and other low-
level health workers used to give service in
the hospital
• In the 1960s and 1970s Psychiatrists from
different European countries entered
Ethiopia to provide service in Amanuel
hospital
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 Beginning of modern care-cont’
• The number of beds was only 360
• Some patients had to share beds
• The average duration of hospital stay was
close to 18 years
• Most patients were restrained
• A number of patients received a cocktail of
high dose antipsychotics

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 Beginning of modern care-cont’
• Around 250 patients received ECT in one
week

• A psychiatric out patient clinic was started at

St Paul hospital

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 Beginning of modern care-cont’
• In 1978, director of WHO, professor Mahler,
visited the country and later sent his vice
director, the Nigerian Professor Adewoy
Lambo to Ethiopia
• Professor Adewoy Lambo was a psychiatrist,
he visited the hospital and decided to
support in improving the service

29
 Beginning of modern care-cont’
• In 1979, training of Psychiatric nurses was
started at Amanuel Hospital, in collaboration
with WHO
• The psychiatric nurses were then sent back to
their respective regions to start the first out
patient psychiatric clinics
• more than 400 psychiatric nurses have graduated
from this program
• around 57 psychiatric clinics run by psychiatric
nurses through out the country
30
 Beginning of modern care-cont’
• In 1975, another large center that received
the mentally ill known as “Dikuman”
• intended to shelter people who were disabled,
mentally ill, displaced by war and drought, etc…
• Progressively, became more and more filled
with mentally ill people
• In 1978, Amanuel hospital started providing
free mental health service to the mentally ill
in Dikuman

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 Beginning of modern care-cont’
• The support from Amanuel continued up
until 2003 when the center was rebuilt and
transformed in to a rehabilitation center
under the leadership of Brothers of Charity

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Ethiopian psychiatrists by the Ethiopian
department of psychiatry at AAU
• In 1995E.C
• Department of Psychiatry at AAU started a psychiatry
residency program (and also sub-speciality) in
collaboration with university of Toronto
• Psychiatrists began establishing clinics in General
hospitals
• Zewditu Memorial Hospital, Yekatit 12 Hospital, Tikur
Anbessa Hospital, Army Hospital and many private
clinics
• Adama, Mekelle, Hawassa, Harar, Jijiga, Jimma…

33
 Integrating mental health in to
primary health care

• In 2003
• WHO in collaboration with the Ministry of Health
• mhGAP

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 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

35
 Common terms in psychiatric
classification
• Organic brain disorders Vs Functional mental
illnesses
• Organic conditions - caused by identifiable physical
pathology affecting the brain, directly or indirectly
e.g. dementias, delirium
• Functional conditions - attributed to some kind of
psychological stress
• in many cases it would be more honest to say that their
cause is not known
• As knowledge advances, some ‘functional’ conditions
are likely to be reclassified as ‘organic’ 36
 Common terms in psychiatric
classification
• Psychosis Vs neurosis
• Psychosis
• Severe illness
• Symptoms outside normal experience, such as delusions
and hallucinations
• Loss of insight; subjective experience mistaken for
external reality
• Neurosis
• Anxiety
• Often less severe
• Symptoms possibly understandable as an exaggeration
of the normal response to stress
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 Purposes
• To distinguish one psychiatric diagnosis from
another, so that clinicians can offer the most
effective treatment
• To provide a common language among
health care professionals
• To explore the still unknown causes of many
mental disorders

38
 Classification of mental illness

• International Classification of diseases (ICD)

• Diagnostic and Statistical Manual of mental

disorders (DSM)

39
 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

40
 Causes of mental illness

• Unknown/incompletely understood
• Can not find a single cause for most mental
disorders in most cases
• Biopsychosocial

41
 Causes of mental illness cont’

•Predisposing factors: are those that render the

personality susceptible or vulnerable and are
present over a long period of time
•Precipitating factors: events that precede
clinical onset
•Perpetuating factors: Factors that prolong the
course of a disorder after it has been provoked

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 Etiologic formulation
Biological Psychological Social-
cultural-
spiritual
Predisposing

Precipitating

perpetuating

protective
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 Outline

• Basic concepts and terms

• Why study Psychiatry
• Mental health service in Ethiopia
• Classification of mental illness
• Causes of mental illness
• Treatment in Psychiatry

44
 Treatment in Psychiatry
• In the past, psychiatric patients were often
hospitalized for many years
• Today, most psychiatric patients are
managed as outpatients
• Average hospital stay is around 6 weeks (with
only a small number of cases involving long-
term hospitalization)

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 Inpatient care

• admitted to a hospital, sometimes involuntarily

• criteria for involuntary admission vary with
jurisdiction
• patients are assessed, monitored, and often
given medication and receive care
• physicians, nurses, psychologists, occupational
therapists, social workers, and other medical
professionals

46
 Outpatient care
• Periodically clinic visit for consultation,
usually 30-60 mins
• Psychiatric practitioner assesses the patient's
condition
• Provide treatment and follow-up
• Frequency varies widely
• depending on the type, severity and stability of
each patient's condition, and on what the
clinician and patient decide would be best

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 Treatment type
• Pharmacotherapy
• Electroconvulsive therapy
• Psychological treatments
• Social interventions
• Rehabilitation

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 Summary of treatment

• Multi-disciplinary

• Bio-Psycho-Social model

• Follow-up

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