(FINAL2018)COMMUNITY MENTAL HEALTH LECTURE.ppt

Profesor Dr Sherina Mohd Sidik
MBBS (Malaya), MMED (Fam Med) (UKM), PHD (ComM Health) (Auckland)
Department of Psychiatry
Faculty of Medicine & Health Sciences
Universiti Putra Malaysia
DISEASE BURDEN OF
MENTAL HEALTH IN
MALAYSIA

LECTURE CONTENT
• Definition of mental health
• Types of mental illnesses
• Epidemiology of mental health
worldwide
• Disease burden of mental health in
Malaysia
• Determinants of mental health

INTRODUCTION
World Health Organization defines HEALTH as:
“A state of complete physical, mental
and social well-being and not merely the
absence of disease”.
(WHO, 2001)

DEFINITION OF MENTAL HEALTH
A state of well-being in which the individual
realizes his or her own abilities, can cope with
the normal stresses of life, can work
productively, and is able to make a contribution
to his or her community.
(WHO, 2001)

Mental health is more than the absence
of mental illness.
Mental, physical and social functioning
are interdependent.
Mental health is the foundation for
individual well-being and the effective
functioning of a community.

MENTAL DISORDERS
“ Health conditions characterized by alterations
in thinking, mood or behavior (or some
combination thereof) associated with distress
and/or impaired functioning.”
(US Department of Health and Human Services, 1999)

MENTAL ILLNESS
“A term that refers collectively to all diagnosable
mental disorders”.
(US Department of Health and Human Services, 1999)

TYPES OF MENTAL ILLNESS
There are many types of mental illnesses. The common types include:
a) Anxiety disorders
b) Depressive disorders
c) Bipolar disorders
d) Psychotic disorders
e) Eating disorders
http://www.webmd.com/mental-health/mental-health-types-illness

TYPES OF MENTAL ILLNESS
a) Anxiety disorders
• Characterized by feelings of fear, worry, nervousness, rapid
heartbeat and sweating.
• Examples are:
i. Generalized anxiety disorder (GAD)
ii. Post-traumatic stress disorder (PTSD)
iii. Obsessive compulsive disorder (OCD)
iv. Panic disorder
v. Social anxiety disorder

b) Depressive disorders
• Characterized by persistent depressed mood and loss
of interest or pleasure.
• Examples are:
i. Major depressive disorder
ii. Dysthymia
iii. Premenstrual dysphoric disorder

Major depressive disorder DSM-5 diagnostic criteria
A. Five (or more) of the following symptoms have been present during the same two week period and represent a change from
previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of interest or pleasure
1. Depressed mood most of the day, nearly everyday
2. Marked diminished interest and pleasure in all, or almost all, activities most of the day, nearly everyday
3. Significant weight loss (not dieting) or weight gain (more than 5% body weight in a month), or decrease or increase in
appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
9. Recurrent thoughts of suicide or death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
D. The occurrence of the MDE is not better explained by schizoaffective disorder, schizophrenia etc.
E. There has never been a manic episode or a hypomanic episode.
(American Psychiatric Association, 2013)

c) Bipolar disorders
• Characterized by feelings of overly happy,
fluctuations from extreme happiness to extreme
sadness.
• Example: Manic disorder

d) Psychotic disorders
• Involve distorted cognitive and thinking
• Delusions (false fixed beliefs)
• Hallucinations (eg. hearing voices)
• Example: Schizophrenia

e) Eating disorders
• Involve extreme emotions, behaviors and attitudes
towards weight and food.
• Examples are:
i. Anorexia nervosa
ii. Bulimia nervosa
iii. Binge eating disorder

DEFINITION OF TERMS
• DALY : Disability Adjusted Life Years
: The sum of years of productive life lost due to
disability
• YLD: Years lived with disability
: It is the number of years that a person lives with disease

PREVALENCE OF MENTAL HEALTH
PROBLEMS WORLDWIDE

World Health Organization
• The World Health Organization (WHO) reported in 2001 that
mental health disorders account for 24% of all health-related
disability (WH0, 2001).
• These disorders are of significant public health importance and
accounted for 10.5% of all disabilities (WHO, 2001).
• Major depression was found to be the fourth disorder
worldwide in terms of disease burden, and was expected to be
the second highest disorder by the year 2030 (Mathers C.D.
et.al, 2006) (Table 5)
• Globally, estimated 350 million people are affected by
depression (mostly are women); 60 million bipolar
affective disorder; 21 million schizophrenia; 47.5
million dementia (WHO, 2015).

(Mathers CD and Loncar D, 2006)

• Unipolar depressive disorder is projected to
be the highest burden of disease in high
income countries.
• Whereas, in middle income countries and
worldwide it is projected to be the second
highest disorder only to HIV/AIDS (Table 6)
(Mathers CD and Loncar D, 2006)

Global burden of disease 2004
 Mental health disorders were the most important
causes of disability, accounting for around one third
of years lived with disability (YLD) among adults aged
15 years and over.
 The disabling burden of mental health disorders
ranked highest compared to other disorders for both
genders. The percentage was higher among females
compared to males (next slide).
(Global burden of disease, 2004)

Leading global causes of YDL, by sex, 2004

The burden of mental health disorders
also ranked highest in low and high
income countries (next slide).

Leading global causes of YDL, high-income and low-and middle income countries, 2004

• Anxiety disorders:
 Most prevalent class of mental disorders in the
general population.
 Lifetime prevalence of any anxiety disorder was
14.3%.
 12-month prevalence of anxiety disorder of 8.3%.
 Prevalence was higher in Western developed
countries than in developing countries.

• Depressive disorders:
 Next most prevalent class of mental disorders in the
community.
 Lifetime prevalence of any depressive disorder was
10.6%.
 12-month prevalence was 5.1%.
 Prevalence was generally higher in Western developed
countries than in developing countries.
Kessler RC, 2009
IQR: Inter quartile range

• Mental health problems and illnesses such as dementia,
schizophrenia, depression, bipolar, attention deficit disorder
and autism affect 26.2% of Americans aged 18 years or older.
• About 6% of the population (1 in 17) suffer from a serious
mental illness.
• 45% of those with any mental disorder met criteria for 2 or
more disorders, with severity strongly related to comorbidity.
(Kessler RC, 2005 & National Institute of Mental Health, 2008)

PREVALENCE IN US
In US, 22.1% of Americans aged 18 years and above suffer from a diagnosable
psychiatric disorder (American Nurses Association, 2007).
Estimates of psychiatry disorders among American adults aged 18 years and
above:
Type of psychiatry disorder Prevalence
% (Million)
Mood disorder 9.5% (20.9)
Major depressive disorder 6.7% (14.8)
Dysthymic disorder 1.5%
Bipolar disorder 2.6% (5.7)
Schizophrenia 1.1% (2.4)
Post Stress Traumatic Disorder 3.5% (7.7)
Obsessive Compulsive Disorder 1.0% (2.2)
Generalized anxiety disorder 3.1% (6.8)
(Kessler RC 2005)

• Approximately 40 million American adults (18.1%) in a given
year, have an anxiety disorder.
• Most people with one anxiety disorder also have another
anxiety disorder.
• Approximately 6 million of them (2.7%) suffer from panic
disorder.
(Kessler RC 2005)

PREVALENCE IN EUROPE
Of the 870 million people living in the European
Region, at any one time about:
 100 Million people are estimated to suffer from anxiety
and depression
 21 M suffer from alcohol use disorders
 7 M suffer from Alzheimer’s disease and other dementias
 4 M suffer from schizophrenia
 4 M suffer from bipolar affective disorder
 4 M from panic disorders.
(WHO, 2005)

 Neuropsychiatric disorders are the second greatest cause of
the burden of disease on the Europe Region after
cardiovascular diseases.
 They account for 19.5% of all disability-adjusted life-years
(DALY).
 Depression alone is the third greatest cause, accounting for
6.2% of all DALYs.
(WHO, 2005)

PROBLEMS IN ASIAN COUNTRIES

PREVALENCE IN SINGAPORE
• In a household survey that was carried out among
6616 adults in Singapore, the 12-month prevalence
of MDD was 5.8% (Chong SA et al 2012a).
• The lifetime prevalence of mental disorders was
12.0% (Chong SA et al 2012b).

PROBLEMS IN MALAYSIA

National Health and
Morbidity Surveys (NHMS)
• Important platforms for monitoring the health of
the Malaysian population, and provide community-
based data on the pattern of common health
problems, health service utilisation and health
expenditure in the community (Nor Ani A, 2016)
• NHMS II (1996): The prevalence of mental
problems in Malaysian households among people
aged 16 years and above was 10.7% and increased
to 11.2% (NHMS III, 2006) using the General
Health Questionnaire (GHQ-12 and GHQ-28,
respectively)

National Health Morbidity
Surveys (NHMS)
• NHMS IV (2011-2014): The MINI International
Neuropsychiatric Interview (MINI); a short, structured
structured diagnostic interview compatible with the
the Diagnostic and Statistical Manual of Mental
Disorders-IV (DSM-IV). Prevalence for diagnosed
diagnosed lifetime and current Depression was 2.4%
and 1.8% respectively.
• NHMS V (2016): The GHQ-12; same screening
questionnaire for mental health in the NHMS II was
was used to compare the current findings with the
previous ones. The prevalence of mental health
problems had increased to 29.2% (almost 3-fold
increment from NHMS II findings).

PREVALENCE IN MALAYSIA
Risk factors based on National Health
Morbidity Surveys
 Depression was higher in urban areas, among
16-24 age group, among females, widowed
and adults with lower education.
 Generalized anxiety (GAD) was higher in
urban areas, among 16-24 age group, among
females, widowed and adults with tertiary
education.

High risk groups
• Women, elderly, adolescents (NHMS II)
• Women, single, widowed, divorced (NHMS III)
• Women, urban residence, age 16-24 years old, primary
education, widowed / divorced, income RM1000-1999 (NHMS
IV)
• Women are 1.5 – 2.0 times more at risk than men (WHO,
MAGPIE, NHMS II, MBODI, NHMS III)
• Children and adolescents are 13.0% (NHMS II), increased to
20.3% (NHMS III), 20.0% (NHMS IV)
• Suicidal ideation 6.4% (highest among 16-24 years old,
unmarried, unemployed) (NHMS III)
• Suicidal ideation 1.7% (highest among 16-24 years old,
females, Indian, no formal education, widowed and single)
(NHMS IV)

PREVALENCE IN MALAYSIA…cont
Recent Studies
• NHMS 2012: 8.1% of the students felt lonely most of the time
or always (significant among female); approximately 5.4%
were unable to sleep at night due to worry; 7.9% have suicidal
ideation (significant among female); 6.8% attempted suicide;
approximately 3.1% not having close friends.
• Community from three districts in Selangor: 10.3% depression
(Siti Fatimah et al, 2014) and anxiety 8.2% (Siti Fatimah et al,
2015).
• 7.0% of undergraduate medical students in a Malaysian public
university have suicidal behaviour risk (Tan et al, 2014).

Malaysian Burden of Disease & Injury Study
2004
 Study done by MBODI with collaboration with WHO
shown that one-fifth of the non-fatal burden was
contributed by mental disorders (MBODI, 2004).
 8.6% of DALY is contributed by mental disorders, and
currently ranked as 4th leading cause of disease
burden.

PREVALENCE IN PRIMARY CARE
• In 70 primary care clinics in New Zealand, the prevalence
for anxiety was 20.7% & depression 18.1% for patients
aged 18 years and above (MAGPIE, 2003).
• In Malaysia, a study in a semi-urban primary care centre
found 24.7% patients had mental health problems;
depression (14.4%), somatoform disorder (12.2%), panic
and anxiety disorders (6.5%), binge eating disorder
(3.4%) and alcohol abuse (2.3%) (Ruzana et al, 2009).
• Women attending a Malaysia primary care clinic: 12.1%
depression (Sherina et al, 2012a) and 7.8% anxiety (Sherina et al,
2012b)

SUMMARY
• Prevalence of lifetime depression:
• Prevalence of current depression:
Country Prevalence
Malaysia 2.4%
Japan 3.2%
China 3.6%
South Korea 4.3%
USA 16.9%
Country Prevalence
Malaysia 1.8%
Singapore 5.5%
Thailand 4.4%
South Korea 1.7%
Australia 4.1%

HOW ARE CASES OF DEPRESSION & OTHER
MENTAL HEALTH DISORDERS DETECTED IN
PRIMARY CARE & COMMUNITY?
Questionnaires:
Screening, Case-finding & / or Diagnostic

WHAT NEEDS TO BE DONE AFTER DETECTING
MENTAL HEALTH DISORDERS IN PRIMARY
CARE?

DISCUSSION 1
1. What are the determinants of mental health?
2. Give some examples of causes / predictors of
mental health.

DISCUSSION 2
1. Discuss issues related to mental health
problems.
2. Share yours/families/friends stories of
suffering from mental health problems.
3. How do they cope up with their problems?
Can they discuss their problems freely? How
does the society accept this?

Profesor Dr Sherina Mohd Sidik
MBBS (Malaya), MMED (Fam Med) (UKM), PHD (ComM Health) (Auckland)
Department of Psychiatry
Faculty of Medicine & Health Sciences
Universiti Putra Malaysia
MEASUREMENT OF
DEPRESSION, ANXIETY
& STRESS

HOW ARE CASES OF DEPRESSION &
OTHER MENTAL HEALTH DISORDERS
DETECTED IN PRIMARY CARE &
COMMUNITY?
Questionnaires:
Screening, Case-finding & / or Diagnostic

Types of Questionnaires
Questionnaires commonly used in primary
care & community settings in Malaysia:
• General Health Questionnaire (GHQ-12, GHQ-28,
GHQ-30)
• Depression Anxiety Stress Scale (DASS)
• Patient Health Questionnaire (PHQ-9)
• Generalized Anxiety Questionnaire (GAD-7)

Multiple factors determine the level of mental
health of a person at any point of time:
• Social
• Psychological
• Biological

SOCIAL FACTORS
• Poverty
• Low level of education
• Rapid social change and social disorganization
• Stressful work conditions
http://www.who.int/mediacentre/factsheets/fs220/en/

• Gender discrimination
• Risks of violence
• Physical ill-health
• Human rights violations
SOCIAL FACTORS

PSYCHOLOGICAL FACTORS
• Personality factors
• Stressful life events
• Level of perceived stress
• Low self-esteem

BIOLOGICAL FACTORS
• Genetic:
o Family members with mental illness have higher risk of
developing mental illness.
o Siblings of an affected person have 4-12 times likelihood to
develop disorder than the general population
o First degree relatives are at a 10-fold increased risk of illness as
compared to second degree relatives
• Heritability:
o Heritability of mental disorders vary widely, from high
heritability (90%) for autism to low heritability (0%) for
dysthymia.
o Environmental factor make strong contribution to the overall
risk, even for the most heritable mental disorders.
Faraone SV et al 2008

BIOLOGICAL FACTORS
• Specific chromosomal loci and genes:
o Autism: linkage to chromosome 7q
o Bipolar disorder: linkage to chromosome 13q
and 22q.
Faraone SV et al 2008

BIOLOGICAL FACTORS
Imbalances of biochemicals in the brain
• A variety of biochemical called
neurotransmitter exists in brain. They are
important to ensure the brain function
properly.
• Disturbance of certain biochemicals in the
brain have been associated with mental
illness.
http://www.myhealth.gov.my/v2/index.php/en/mental-
health/mental-health-for-prime-years/mental-illness

BIOLOGICAL FACTORS
• Schizophrenia:
– High concentration of dopamine.
• Depression:
– Lower concentration of serotonin
• Anxiety:
– Lower concentration of serotonin
http://www.myhealth.gov.my/v2/index.php/en/mental-
health/mental-health-for-prime-years/mental-illness

INTERACTION OF BIOLOGICAL,
PSYCHOLOGICAL AND SOCIAL FACTORS
WHO, 2001

Determinants of health, operating at a
population or community level, translate into
risk and protective factors that influence the
physical and mental health of individuals.

RISK FACTORS OF MENTAL HEALTH
& ILLNESS
• Risk factors increase the likelihood that a disorder
develops and can exacerbate the burden of existing
disorders.
• Risk factors have negative effect on mental health.
• Factors such as poverty, discrimination and high rates
of crime and violence reduces mental health and
increases mental illness.
• Some of other risk factors that affects mental health
are shown in next slide.
Ritter Lois A and Lampkin SM 2012

RISK FACTORS OF MENTAL HEALTH
& ILLNESS

PREVENTIVE /PROTECTIVE FACTORS OF
MENTAL HEALTH & ILLNESS
• Protective factors reduce the likelihood that a
disorder will develop. It also moderates the impact of
stress and transient symptoms on social and
emotional wellbeing, thereby reducing the likelihood
of disorders.
• Protective factors have positive effect on mental
health.
• Feelings of safety, security and healthy physical
environment increases ones mental health status.
• Some of other protective factors that affects mental
health are shown in next slide.

PREVENTIVE / PROTECTIVE FACTORS OF
MENTAL HEALTH & ILLNESS

MANAGEMENT OF
MENTAL ILLNESS
• Medication
• Cognitive behavioral therapy
• Mindfulness
• Interpersonal therapy
• Problem solving therapy
• Psycho-education
• Stress management technique
• Relaxation and breathing technique

Mental Health Care at Primary
Care Clinics

Level People
responsible
Focus of Disease Action
Level
1
Primary care
Assistant medical
officer
Nurses
Medical Officer
Recognition Screening
Level
2
Primary Care
Family Medicine
Specialist
Medical Officer
Mild Depressive Episode Psychological Intervention-
(counselling , problem solving
and supportive
psychotherapy)
± Medication
Level
3
Primary Care
Family Medicine
Specialist
Moderate Depressive
Episode
Medication
Psychological Intervention
Referral to secondary care if
indicated including for
cognitive behaviour therapy
(CBT)

Level 4 Secondary Care
Outpatient
psychiatric
services
Moderate to Severe
Episode
Medication
Psychological intervention
including CBT
Level 5
Secondary Care
In-patient
setting
Risk to self/others
Severe self neglect
Psychotic symptoms
Lack of impulse control
Medication
Psychological intervention
including CBT
ECT
Level People
responsible
Focus of Disease Action

WHAT NEEDS TO BE DONE AFTER
DETECTING MENTAL HEALTH
DISORDERS IN PRIMARY CARE?

Major Depressive Disorder DSM-V diagnostic criteria
A. Five (or more) of the following symptoms have been present during the same two week period and represent a change from
previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of interest or pleasure
1. Depressed mood most of the day, nearly everyday
2. Marked diminished interest and pleasure in all, or almost all, activities most of the day, nearly everyday
3. Significant weight loss (not dieting) or weight gain (more than 5% body weight in a month), or decrease or increase in
appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
9. Recurrent thoughts of suicide or death (not just fear of dying)
B. The symptoms do not meet criteria for a Mixed Episode
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning
D. The symptoms are not due to medical illness, alcohol, medication, or drug abuse
E. The symptoms are not due to normal bereavement
In children and adolescents, depressed mood may manifest as irritable mood
Note: Symptoms that are clearly due to general medical condition or mood-incongruent delusions or hallucinations are not included.
Adapted from APA (2000) DSM-IV-TR

Always assess for Suicide Risk

The following are risk factors for suicide:
1. Active suicidal ideas / plans
2. Past suicide attempt
3. Family history of suicide
4. Severity of depression
5. Hopelessness
6. Psychomotor agitation
7. Loss of relationship
8. Financial or occupational difficulties
9. Poor social support
10. Alcohol abuse/dependence
11. Low self-esteem
12. Other co-morbidities
**Patients with suicide risk must be referred immediately to a Psychiatrist

Other Indications for Referral to Psychiatric
Services
• Unsure of diagnosis
• Failure to respond to treatment
• Advice on further treatment
• Clinical deterioration
• Recurrent episode within 1 year
• Psychotic symptoms
• Severe agitation
• Self neglect

TREATMENT AVAILABLE
1. Supportive therapy:
➨patient education on
mental health
2. Medication :
➨if necessary

Patient Version Guide Major Depressive
Disorder

Medication
• Medication for depression in primary care clinics are
only started after consulting the visiting psychiatrist
to the clinic
• Once medication has been started, the patients can
be on follow-up by the FMS and MOs

Moderate-severe depressive
episode
• Offer antidepressants
• Drug of first choice is an SSRI (Selective Serotonin
Reuptake Inhibitors)
– Fluoxetine
– Fluvoxamine
– Sertraline
– Escitalopram
– Paroxetine
– Citalopram

Quick Reference Management Guide for
Medical & Health Personnel

ACTIVITIES
• Day care centre for patients with mental illness
(Psycho Social Rehab / PSR)
• Education material / modules on mental health
(patients / primary health care personnel)
• Training of primary health care personnel at
psychiatric units
• Seminars and exhibitions on mental health
• “HELPLINE” by NGOs

PREVENTIVE MEASURES
• Health Education and Health Promotion
• Healthy Lifestyle Activities
• Early Detection
• Early intervention and treatment
• Support from the family, community and
government

ISSUES RELATED TO
MENTAL HEALTH PROBLEMS

CONCLUSION
• Mental health problems are of significant public health concern.
• It is our responsibility to educate people surrounding us that mental
health problems are disorders which are similar to diseases such as heart
disease, diabetes and other diseases.
• Anyone may develop a mental health disorder at some point of their life
and there are various treatments available for the management of these
disorders.
• Do not stigmatize people suffering from these disorders. Instead offer
them our moral support.

REFERENCES
• American Psychiatric Association (2013). The Diagnostic and Statistic
Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric
Publishing.
• American Nurses Association (2007). Psychiatric mental health nursing
scope & standards. Washington, DC: Author.
• Chong Saa, Janhavi V, Edimansyah A and Mythily S (2012). The prevalence
and impact of major depressive disorder among Chinese, Malays and
Indians in an Asian multi-racial population. Journal of Affective
Disorders.138:128–136.
• Chong SAb, Edimansyah A, Luo Nan, Janhavi V and Mythily S (2012).
Prevalence and impact of mental and physical comorbidity in the adult
singapore population. Annal Academy Medicine Singapore. 41:105-14.
• Faraone SV, Glatt SJ and Tsuang MT (2008). Mental health etiology:
Biological and Genetic Determinants (book section).

• http://www.webmd.com/mental-health/mental-health-types-illness.
• Institute for Public Health (IPH) 2011. National Health and Morbidity
Survey 2011 (NHMS 2011). Vol. II: Non-Communicable Diseases, 2011: 188
pages.
• Institute of Public Health (2008). The Third National Health and Morbidity
Survey (NHMS III) 2006. Vol 1. Kuala Lumpur: Ministry of Health Malaysia.

REFERENCES
• Kessler RC, Chiu WT, Demler O, Walters EE (2005). Prevalence, severity, and comorbidity of
twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-
R). Archives of General Psychiatry. 62(6):617-27.
• Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, Ustun TB and Wang S
(2009). The global burden of mental disorders: An update from the WHO World Mental
Health (WMH) Surveys. Epidemiology Psichiatry Sociology: 18(1): 23–33.
• Lois A.Ritter and Shirley Manly Lampkin (2012). Community Mental Health (book).
• Malaysian burden of disease and injury study (MBODI), 2004.Institute of Public Health.
Health prioritization: burden of disease approach. Kuala Lumpur: Ministry of Health Malaysia.
• Mathers CD and Loncar D (2006). Projections of global mortality and burden of disease from
2002 to 2030. Plos Medicine 3(11):e442.
• Mental health : facing the challenges, building solutions : report from the WHO European
Ministerial Conference (2005).
• Ustun TB, Ayuso-mateos JL, Chatterji S, Mathers C and Murray CJL (2004). Global burden of
depressive disorders in the year 2000. British Journal of Psychiatry. 184: 386-392.
• US Department of Health and Human Services [DHHS] (1999). Mental health: A report of the
surgeon general.
• The global burden of disease (2008): 2004 update.
• World Health Organization (2001). The world health report 2001. Mental health: New
understanding, New Hope.

References
• Economy Planning Unit Malaysia. Ninth Malaysia Plan 2006-2010. Vol
Chapter 13: Women and development. Putrajaya: Prime Minister's
Department; 2006.
• Institute of Public Health. The Second National Health and Morbidity
Survey 1996 (NHMS II). Vol 6. Kuala Lumpur: Ministry of Health Malaysia;
1999.
• Institute of Public Health. The Third National Health and Morbidity Survey
(NHMS III) 2006. Vol 1. Kuala Lumpur: Ministry of Health Malaysia; 2008.
• Institute of Public Health. Malaysian burden of disease and injury study
(MBODI). Health prioritization: burden of disease approach. Kuala Lumpur:
Ministry of Health Malaysia; 2004.
• Institute for Public Health (IPH) 2011. National Health and Morbidity
Survey 2011 (NHMS 2011). Vol. II: Non-Communicable Diseases, 2011: 188
pages.

References
• MaGPIe. The nature and prevalence of psychological problems in New
Zealand primary healthcare: a report on Mental Health and General
Practice Investigation (MaGPIe). New Zealand Medical Journal.
2003;116(1171).
• MOH Malaysia. Management of Major Depressive Disorder. Clinical
Practice Guidelines, 2007. http://www.moh.gov.my (last accessed 15 July
2011)
• MS Sherina, B Arroll, F Goodyear-Smith. Prevalence of anxiety among
women attending a primary care clinic in Malaysia. British Journal of
General Practice 2011;61:389-390
• World Health Organization. The World Health Report 2001. Mental Health:
New Understanding New Hope. Geneva: World Health Organization; 2001.
• World Health Organization. Women's mental health: an evidence based
review. Geneva: World Health Organization; 2000.

References
• World Health Organization. Research capacity for mental health in low-
and middle-income countries: results of a mapping project. Geneva: World
Health Organization; 2007.
• World Health Organization. Integrating mental health into primary care : a
global perspective. Geneva: World Health Organization; 2008
• ZZ Ruzanna, T Maniam, M Marhani, O Khairani, K Pervesh. Psychiatric
morbidity among adult patients in a semi-urban primary care setting in
Malaysia. International Journal of Mental Health Systems 2009;3:13.

EXTRA NOTES
DSM 5 CRITERIA – ANXIETY DISORDERS
• Generalized Anxiety Disorder
• Post Traumatic Stress Disorder
• Obsessive Compulsive Disorder
• Panic Disorder
• Social Anxiety Disorder

Generalized anxiety disorder DSM-5 diagnostic criteria
A. Excessive anxiety and worry, occurring more days than not for at least 6 months,
about a number of events or activities (such as work or school performance).
B. The individuals finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days than not
for the past 6 months):
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbances (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
E. The disturbances is not attributable to the physiological effects of a substance (e.g.
drug abuse, a medication) or another medical conditions(e.g. hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g. anxiety
about having panic attacks in panic disorder, negative evaluation in social anxiety
disorder and etc).

Post traumatic stress disorder DSM-5 diagnostic criteria
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person the event(s) as it occurs to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend.
In cases of actual or threatened death of a family member or friend, the event(s) must
have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s).
2. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic events occurred:
1. Recurrent, involuntary and intrusive distressing memories of the traumatic event(s).
2. Recurrent distressing dreams in which the content and/or affect of the dream are related
to the traumatic event(s).
3. Dissociative reactions (e.g. flashbacks) in which the individuals feels or acts as if the
traumatic events were recurring.
4. Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).

(continue)
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic events occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
2. Avoidance or efforts to avoid external reminders (people, places, conversations, activities,
objects, situations) that arouse distressing memories, thoughts or feelings about or closely
associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more)
of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the
world ( e.g. I’m bad, No one can be trusted).
3. Persistent distorted cognitions about the cause or consequences of the traumatic events that
lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g. fear, horror, anger, guilt or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g. inability to experience happiness).

(continue)
E. Marked alterations in arousal and reactivity associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as
verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hyper vigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbances (e.g. difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of substance (e.g. medication,
alcohol) or another medical condition.

Obsessive compulsive disorder DSM-5 diagnostic criteria
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by 1 and 2.
1. Recurrent and persistent thoughts, urges or images that experienced at some time during the
disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety or
distress.
2. The individual attempts to ignore or suppress such thoughts, urges or images, or to neutralize
them with some other thought or action.
Compulsions are defined as 1 and 2.
1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying,
counting and repeating words)that the individuals feel driven to perform in response to an
obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or
prevent some dreaded event or situation.
B. The obsessions or compulsions are time-consuming (e.g. take more than 1 hour a day) or
cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
C. The symptoms are not attributable to the physiological effects of a substance (e.g. drug
abuse, medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g.
excessive worries in GAD, preoccupation with appearance as in body dysmorphic disorder,
etc) (American Psychiatric Association, 2013)

Panic disorder DSM-5 diagnostic criteria
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or
intense discomfort that reaches a peak within minutes, and during which time four (or
more) of the following symptoms occur:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization or depersonalization
12. Fear of losing control or going crazy
13. Fear of dying

Panic disorder DSM-5 diagnostic criteria (continue)
B. At least one of the attacks has been followed by 1month (or more) of one of the following:
1. Persistent concern or worry about additional panic attacks or their consequences ( e.g. losing
control, having heart attack).
2. A significant maladaptive change in behavior related to the attacks (e.g. behaviors designed
to avoid having panic attacks).
C. The disturbance is not attributable to the physiological effects of a substance (e.g. drug
abuse, medication) or another medical condition(e.g. hyperthyroidism, cardiopulmonary
disorders).
D. The disturbance is not better explained by the symptoms of another mental disorder.

Social anxiety disorder DSM-5 diagnostic criteria
A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possibly scrutiny by others. Examples include social interactions (e.g. having
conversation, meeting unfamiliar people), being observed ( eating or drinking).
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be
negatively evaluated (e.g. will be humiliating, lead to rejections).
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured with intense fear of anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation.
F. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety or avoidance causes clinically significant distress or impairment in social,
occupational or other important areas of functioning.
H. The fear, anxiety or avoidance is not attributable to the physiological effects of a substance.
I. The fear, anxiety or avoidance is not better explained by the symptoms of another mental
disorder.
J. If another medical condition (e.g. Parkinson’s disease, obesity, disfigurement from burns or
injury) is present, the fear, anxiety or avoidance is clearly unrelated or is excessive.

EXTRA NOTES
DSM 5 CRITERIA – DEPRESSIVE DISORDERS
• Dysthymia
• Pre-menstrual Dysphoric Disorder
• Schizophrenia
• Anorexia Nervosa
• Bullimia Nervosa
• Binge eating disorder

Dysthymia DSM-5 diagnostic criteria
A. Depressed mood fro most of the day, for more days than not, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
C. During the 2 year period of the disturbance, the individual has never been without the
symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for MDD may continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode and criteria have never been
met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizo-affective disorder,
schizophrenia, delusional disorder end etc.
G. The symptoms are not attributable to the physiological effects of a substance or another
medical condition.
H. The symptoms cause clinically significant distress or impairment in social, occupational or
other important areas of functioning. (American Psychiatric Association, 2013)

Prementrual dysphoric disorder DSM-5 diagnostic criteria
A. In the majority of menstrual cycles, at least 5 symptoms must be present in the final week
before the onset of menses, start to improve within a few days after the onset of menses,
and become minimal or absent in the week of postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (e.g. mood swings, feeling suddenly sad or tearful)
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness or self-deprecating thoughts.
4. Marked anxiety, tension and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must additionally be present, to reach a total of 5
symptoms when combined with symptoms from Criterion B.
1. Decreased interest in usual activities (e.g. work, school, friends, hobbies)
2. Subjective difficulty in concentration
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating or specific food craving.
5. Hypersomnia or insomnia
6. A sense of being overwhelmed or out of control
7. Physical symptoms such as breast tenderness, or swelling, joint or muscle pain, a sensation of
bloating or weight gain. (American Psychiatric Association, 2013)

D. The symptoms are associated with clinically significant distress or interference with work,
school, usual social activities, or relationship with others (e.g. avoidance of social
activities).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such
as MDD, panic disorder, dysthymia etc).
F. Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic
cycles.
G. The symptoms are not attributable to the physiological effects of a substance (e.g. drug
abuse or medication) or another medical condition.
Prementrual dysphoric disorder DSM-5 diagnostic criteria
(continue)

Schizophernia DSM-5 diagnostic criteria
A. Two (or more) of the following, each present for a significant portion of time during 1-
month period (or less if successfully treated). At least 1 of these must be (1), (2) or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g. frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (e.g. diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in
one or more major areas, such as work, interpersonal relations, or self-care is markedly
below the level achieved prior to the onset.
C. Continuous signs of the disturbances persist for at least 6 months. This 6-months period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A
and may include periods of prodromal or residuals symptoms.
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been
ruled out.
E. The disturbance is not attributable to the physiological effects of a substance (e.g. drug abuse
or medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made.

Anorexia nervosa DSM-5 diagnostic criteria
A. Restriction of energy intake related to requirements leading to a significantly low body
weight in the context of age, sex, developmental trajectory and physical health. Significantly
low weight is defined as a weight that is less than minimally normal.
B. Intense fear of gaining weight or of becoming fat, or persistent behaviors that interferes with
weight gain, even tough a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence
of body weight or shape on self-evaluation or persistent lack of recognition of the
seriousness of the current low body weight.

Bulimia nervosa DSM-5 diagnostic criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
1. Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is
definitely larger than what most individuals would eat in a similar period of time under
similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop
eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or
excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur on average at least
once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Binge-eating disorder DSM-5 diagnostic criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
1. Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is
definitely larger than what most individuals would eat in a similar period of time under
similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop
eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating too much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory
behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia
nervosa or anorexia nervosa.

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