Mental health / primary health care

‫الرحمن‬ ‫ا‬ ‫بسم‬‫الرحمن‬ ‫ا‬ ‫بسم‬
‫الرحيم‬‫الرحيم‬
Mental healthMental health
‫والصلة‬ ‫العالمين‬ ‫رب‬ ‫لله‬ ‫الحمد‬‫والصلة‬ ‫العالمين‬ ‫رب‬ ‫لله‬ ‫الحمد‬
‫خاتم‬ ‫محمد‬ ‫نبينا‬ ‫على‬ ‫والسلم‬‫خاتم‬ ‫محمد‬ ‫نبينا‬ ‫على‬ ‫والسلم‬
‫آله‬ ‫وعلى‬ ‫المرسلين‬ ‫وسيد‬ ‫النبياء‬‫آله‬ ‫وعلى‬ ‫المرسلين‬ ‫وسيد‬ ‫النبياء‬
‫وبعد‬ ‫أجمعين‬ ‫وصحبه‬‫وبعد‬ ‫أجمعين‬ ‫وصحبه‬

Mental health as part of primaryMental health as part of primary
health carehealth care
 Mental health care is a basic and essentialMental health care is a basic and essential
building block for ensuring life-long goodbuilding block for ensuring life-long good
health. Multipurpose health workers,health. Multipurpose health workers,
family doctors and general practitionersfamily doctors and general practitioners
need to become increasingly better able toneed to become increasingly better able to
recognize any potential mental impairmentrecognize any potential mental impairment
or brain disorder in order to provide qualityor brain disorder in order to provide quality
carecare..

 To ensure that basic mental healthTo ensure that basic mental health
services are available to all people, evenservices are available to all people, even
the most vulnerable and deprived groups,the most vulnerable and deprived groups,
in the past two decades the WHOin the past two decades the WHO
Regional Office for theRegional Office for the EasternEastern
Mediterranean collaborated with almost allMediterranean collaborated with almost all
countries of the Region to preparecountries of the Region to prepare
national mental health programmesnational mental health programmes..

The implementation ofThe implementation of
these programs have beenthese programs have been
carried out in differentcarried out in different
degrees in the countries ofdegrees in the countries of
the Regionthe Region..

 Depression, a mental illness in which aDepression, a mental illness in which a
person experiences deep, unshakableperson experiences deep, unshakable
sadness and diminished interest insadness and diminished interest in
nearly all activities.nearly all activities.
People also use the term depression toPeople also use the term depression to
describe the temporary sadness,describe the temporary sadness,
loneliness, or blues that everyone feelsloneliness, or blues that everyone feels
from time to time.from time to time.

 In contrast to normal sadness, severeIn contrast to normal sadness, severe
depression, also called majordepression, also called major
depression, can dramatically impair adepression, can dramatically impair a
person's ability to function inperson's ability to function in
social situations and at work. Peoplesocial situations and at work. People
with major depression often havewith major depression often have
feelings of despair, hopelessness, andfeelings of despair, hopelessness, and
worthlessness, as well as thoughts ofworthlessness, as well as thoughts of
committing suicidecommitting suicide

 Surveys indicate that people commonlySurveys indicate that people commonly
view depression as a sign of personalview depression as a sign of personal
weakness, but psychiatrists andweakness, but psychiatrists and
psychologists view it as a realpsychologists view it as a real
illness. In the United States, the Nationalillness. In the United States, the National
Institute of Mental Health has estimatedInstitute of Mental Health has estimated
that depression costs society many billionsthat depression costs society many billions
of dollars each year, mostly in lost workof dollars each year, mostly in lost work
time.time.

Why is depression important?Why is depression important?
 Projections are that by 2020, depressionProjections are that by 2020, depression
will be second only to heart disease in itswill be second only to heart disease in its
contribution to the global burden ofcontribution to the global burden of
disease as measured disability-adjusteddisease as measured disability-adjusted
life yearslife years

PREVALENCEPREVALENCE

Depression is one of the mostDepression is one of the most
common mental illnesses. At leastcommon mental illnesses. At least
8 percent of adults in the United8 percent of adults in the United
States experience seriousStates experience serious
depression at some point duringdepression at some point during
their lives, and estimates rangetheir lives, and estimates range
as high as 17 percent.as high as 17 percent.

Epidemiology of DepressionEpidemiology of Depression
Among WomenAmong Women In U.S. twice as many women (12.3%) asIn U.S. twice as many women (12.3%) as
men (6.7%) are affected each yearmen (6.7%) are affected each year

12.4M women and 6.4M men12.4M women and 6.4M men
 For low-income women, the estimatedFor low-income women, the estimated
prevalence doubles to 25%prevalence doubles to 25%
 Most prevalent among women of child-Most prevalent among women of child-
bearing and child-rearing age (16 to 53)bearing and child-rearing age (16 to 53)

Epidemiology of DepressionEpidemiology of Depression
Among MothersAmong Mothers
 Estimated rates of depression amongEstimated rates of depression among
pregnant and postpartum women rangepregnant and postpartum women range
from 8 to 20%.from 8 to 20%.
 For low-income women with youngFor low-income women with young
children, prevalence rates are commonlychildren, prevalence rates are commonly
estimated at approximately 40%.estimated at approximately 40%.

PREVALENCEPREVALENCE
 Primary Health Care Physicians are the
diagnosticians at the front line of the
health services, and untreated depression
has come to be viewed as a major public
health problem.

In Arab worldIn Arab world
Communities in Arab world show
depression ranging from 13% to 32%.
Highest rate 32% was recorded in
Lebanese women after the civil war.
Urban population in Dubai and Cairo
showed lower rates 12% and 16%
respectively.

 The illness affects all people, regardless ofThe illness affects all people, regardless of
sex, race, ethnicity, or socioeconomicsex, race, ethnicity, or socioeconomic
standing. However, women are two tostanding. However, women are two to
three times more likely than men to sufferthree times more likely than men to suffer
from depression. Experts disagree on thefrom depression. Experts disagree on the
reason for this difference. Some citereason for this difference. Some cite
differences in hormones, and others pointdifferences in hormones, and others point
to the stress caused by society'sto the stress caused by society's
expectations of women.expectations of women.

PrevalencePrevalence
 Depression occurs in all parts of the world,Depression occurs in all parts of the world,
although the pattern of symptoms canalthough the pattern of symptoms can
vary. The prevalence of depression invary. The prevalence of depression in
other countries varies widely, fromother countries varies widely, from 1.51.5
percent of people in Taiwan to 19percent of people in Taiwan to 19
percent of people in Lebanonpercent of people in Lebanon. Some. Some
researchers believe methods of gatheringresearchers believe methods of gathering
data on depression account for differentdata on depression account for different
rates.rates.

A number of large-scale studiesA number of large-scale studies
indicate that depression ratesindicate that depression rates
have increased worldwide overhave increased worldwide over
the past several decades.the past several decades.
Furthermore, younger generationsFurthermore, younger generations
are experiencing depression at anare experiencing depression at an
earlier age than did previousearlier age than did previous
generations.generations...

Social scientists have proposedSocial scientists have proposed
many explanations, includingmany explanations, including
changes in family structure,changes in family structure,
urbanization, and reduced culturalurbanization, and reduced cultural
andand religious influencesreligious influences

Prevalence of DepressionPrevalence of Depression
 In JordanIn Jordan
• A study published last year, doneA study published last year, done
on Jordanian women reviewingon Jordanian women reviewing
PHC centers for different reasonsPHC centers for different reasons
showed a rate of 37% scoredshowed a rate of 37% scored
positively.positively.

OnsetOnset
 Although it may appear anytime fromAlthough it may appear anytime from
childhood to old age, depressionchildhood to old age, depression
usually begins during a person's 20susually begins during a person's 20s
or 30s. The illness may come onor 30s. The illness may come on
slowly, then deepen gradually overslowly, then deepen gradually over
months or years.months or years.

Symptoms.Symptoms.
 A) Appetite and Sleep ChangesA) Appetite and Sleep Changes
B) Changes in Energy LevelB) Changes in Energy Level
C) Poor Self-EsteemC) Poor Self-Esteem

CAUSES/Risk FactorsCAUSES/Risk Factors

Some depressions seem toSome depressions seem to
come out of the bluecome out of the blue, even when, even when
things are going well. Othersthings are going well. Others
seem to have an obvious cause:seem to have an obvious cause:
a marital conflict, financiala marital conflict, financial
difficulty, or some personaldifficulty, or some personal
failure.failure.

 Yet many people with these problems doYet many people with these problems do
not become deeply depressed. Mostnot become deeply depressed. Most
psychologists believe depression resultspsychologists believe depression results
from an interaction between stressful lifefrom an interaction between stressful life
events and a person's biological andevents and a person's biological and
psychological vulnerabilities.psychological vulnerabilities.

A) Biological/Genetic FactorsA) Biological/Genetic Factors
 ..
Depression runs in families. By studying twins,Depression runs in families. By studying twins,
researchers have found evidence of a strongresearchers have found evidence of a strong
genetic influence in depression. Geneticallygenetic influence in depression. Genetically
identical twins raised in the same environmentidentical twins raised in the same environment
are three times more likely to have depression inare three times more likely to have depression in
common than fraternal twins, who have onlycommon than fraternal twins, who have only
about half of their genes in common. In addition,about half of their genes in common. In addition,
identical twins are five times more likely to haveidentical twins are five times more likely to have
bipolar disorder in common.bipolar disorder in common.

 These findings suggest that vulnerability toThese findings suggest that vulnerability to
depression and bipolar disorder can bedepression and bipolar disorder can be
inherited. Adoption studies have providedinherited. Adoption studies have provided
more evidence of a genetic role inmore evidence of a genetic role in
depression. These studies show thatdepression. These studies show that
children of depressed people arechildren of depressed people are
vulnerable to depression even whenvulnerable to depression even when
raised by adoptive parents.raised by adoptive parents.

Genetic/Biochemical FactorsGenetic/Biochemical Factors
 Genes may influence depression byGenes may influence depression by
causing abnormal activity in the brain.causing abnormal activity in the brain.
Studies have shown that certain brainStudies have shown that certain brain
chemicals called neurotransmitters playchemicals called neurotransmitters play
an important role in regulating moods andan important role in regulating moods and
emotions.emotions.

 Neurotransmitters involved in depressionNeurotransmitters involved in depression
include norepinephrine, dopamine, andinclude norepinephrine, dopamine, and
serotonin. Research in the 1960sserotonin. Research in the 1960s
suggested that depression results fromsuggested that depression results from
lower than normal levels of theselower than normal levels of these
neurotransmitters in parts of the brain.neurotransmitters in parts of the brain.

 Support for this theory came from theSupport for this theory came from the
effects of antidepressant drugs, whicheffects of antidepressant drugs, which
work by increasing the levels ofwork by increasing the levels of
neurotransmitters involved in depression.neurotransmitters involved in depression.
However, later studies have discreditedHowever, later studies have discredited
this simple explanation and havethis simple explanation and have
suggested a more complex relationshipsuggested a more complex relationship
between neurotransmitter levels andbetween neurotransmitter levels and
depression.depression.

 An imbalance of hormones may also playAn imbalance of hormones may also play
a role in depression. Many depresseda role in depression. Many depressed
people have higher than normal levels ofpeople have higher than normal levels of
hydrocortisone (cortisol), a hormonehydrocortisone (cortisol), a hormone
secreted by the adrenal gland in responsesecreted by the adrenal gland in response
to stress. In addition, an under active orto stress. In addition, an under active or
overactive thyroid gland can lead tooveractive thyroid gland can lead to
depression.depression.

Medical causesMedical causes

A variety of medical conditions can causeA variety of medical conditions can cause
depression. These include dietary deficiencies indepression. These include dietary deficiencies in
vitamin B6, vitamin B12, and folic acid (seevitamin B6, vitamin B12, and folic acid (see
Vitamin); degenerative neurological disorders,Vitamin); degenerative neurological disorders,
such as Alzheimer's disease and Parkinson'ssuch as Alzheimer's disease and Parkinson's
disease ; strokes in the frontal part of the brain;disease ; strokes in the frontal part of the brain;
and certain viral infections, such as hepatitis andand certain viral infections, such as hepatitis and
mononucleosis.mononucleosis.

 Many chronic diseases:Many chronic diseases:
 CardiovascularCardiovascular
 DiabetesDiabetes
 EpilepsyEpilepsy
 Multiple SclerosesMultiple Scleroses
 Rheumatoid Arthritis and othersRheumatoid Arthritis and others

B) Psychological FactorsB) Psychological Factors
 As a secondary to psychiatric illnessAs a secondary to psychiatric illness
especially Neurotic (Obsessiveespecially Neurotic (Obsessive
Compulsive Neurosis), or AffectiveCompulsive Neurosis), or Affective
Schizophrenia.Schizophrenia.

C) StressfulC) Stressful
Events/EnvironmentalEvents/Environmental

Psychologists agree that stressfulPsychologists agree that stressful
experiences can trigger depression inexperiences can trigger depression in
people who are predisposed to the illness.people who are predisposed to the illness.
For example, the death of a loved oneFor example, the death of a loved one
may trigger depression. Psychologistsmay trigger depression. Psychologists
usually distinguish true depression fromusually distinguish true depression from
grief, a normal process of mourning agrief, a normal process of mourning a
loved one who has died (Reactiveloved one who has died (Reactive
Depression).Depression).

GenderGender
 In the United States, women are about as twiceIn the United States, women are about as twice
as likely as men to be diagnosed and treated foras likely as men to be diagnosed and treated for
major depression. Approximately 20-25% ofmajor depression. Approximately 20-25% of
women and 12% of men will experience awomen and 12% of men will experience a
serious depression at least once in theirserious depression at least once in their
lifetimes. Among children, depression appearslifetimes. Among children, depression appears
to occur in equal numbers of girls and boys.to occur in equal numbers of girls and boys.
However, as girls reach adolescence, they tendHowever, as girls reach adolescence, they tend
to become more depressed than boys do. Thisto become more depressed than boys do. This
gender difference continues into older age.gender difference continues into older age.

 Other stressful experiences may includeOther stressful experiences may include
divorce, pregnancy, the loss of a job, anddivorce, pregnancy, the loss of a job, and
even childbirth. About 20% of womeneven childbirth. About 20% of women
experience an episode of depression,experience an episode of depression,
known as postpartum depression, afterknown as postpartum depression, after
having a baby. In addition, people withhaving a baby. In addition, people with
serious physical illnesses or disabilitiesserious physical illnesses or disabilities
often develop depressionoften develop depression

TREATMENTTREATMENT
 Depression typically cannot be shaken orDepression typically cannot be shaken or
willed away. An episode must thereforewilled away. An episode must therefore
run its course until it weakens either on itsrun its course until it weakens either on its
own or with treatment. Depression can beown or with treatment. Depression can be
treated effectively withtreated effectively with antidepressantantidepressant
drugs, psychotherapy, or adrugs, psychotherapy, or a
combination of both.combination of both.

Other TreatmentsOther Treatments

Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT) can oftencan often
relieve severe depression in people who fail torelieve severe depression in people who fail to
respond to antidepressant medication andrespond to antidepressant medication and
psychotherapy. Regular aerobic exercise maypsychotherapy. Regular aerobic exercise may
improve mood as effectively as psychotherapyimprove mood as effectively as psychotherapy
or medication. In addition, some researchor medication. In addition, some research
indicates that dietary modifications can influenceindicates that dietary modifications can influence
one's mood by changing the level of serotonin inone's mood by changing the level of serotonin in
the brain.the brain.

 Despite the availability of effectiveDespite the availability of effective
treatment, most depressive disorders gotreatment, most depressive disorders go
untreated and undiagnosed. Studiesuntreated and undiagnosed. Studies
indicate that general physicians fail toindicate that general physicians fail to
recognize depression in their patients atrecognize depression in their patients at
least half of the time. In addition, manyleast half of the time. In addition, many
doctors and patients view depression indoctors and patients view depression in
elderly people as a normal part of aging,elderly people as a normal part of aging,
even though treatment for depression ineven though treatment for depression in
older people is usually very effective.older people is usually very effective.

ConclusionConclusion
 Of the estimated 17.5 million AmericansOf the estimated 17.5 million Americans
who are affected by some form ofwho are affected by some form of
depression, 9.2 million have major ordepression, 9.2 million have major or
clinical depressionclinical depression
 Two thirds of people suffering fromTwo thirds of people suffering from
depression do not seek necessarydepression do not seek necessary
treatment.treatment.

 80%80% Of all people with clinical depressionOf all people with clinical depression
who have received treatment significantlywho have received treatment significantly
improve their lives.improve their lives.
 The economic cost of depression isThe economic cost of depression is
estimated at $30.4 billion a year but theestimated at $30.4 billion a year but the
cost in human suffering cannot becost in human suffering cannot be
estimatedestimated

 Women experience depression aboutWomen experience depression about
twice as often as mentwice as often as men
 By the year 2020, the World HealthBy the year 2020, the World Health
Organization (WHO) estimates thatOrganization (WHO) estimates that
depression will be the number two causedepression will be the number two cause
of "lost years of healthy life" worldwideof "lost years of healthy life" worldwide


 According to the U.S. Centers for DiseaseAccording to the U.S. Centers for Disease
Control and Prevention (CDC) suicide wasControl and Prevention (CDC) suicide was
the ninth leading cause of death in thethe ninth leading cause of death in the
United States in 1996United States in 1996


Key Take Home Messages:Key Take Home Messages:
Maternal Depression & ParentingMaternal Depression & Parenting
 Maternal depression often co-exists withMaternal depression often co-exists with
prior or concurrent traumaprior or concurrent trauma
 Maternal depression is a caregivers’Maternal depression is a caregivers’
disease, thus a two-generation conditiondisease, thus a two-generation condition
 Depression interferes with parentingDepression interferes with parenting

 Impact on child may be serious, of longImpact on child may be serious, of long
durationduration
 Structural barriers such as lack ofStructural barriers such as lack of
insurance and racism leave many familiesinsurance and racism leave many families
outside treatmentoutside treatment
 Depression is treatableDepression is treatable

RecommendationsRecommendations
 Public education.Public education.
 Provision of relevant posters and leafletsProvision of relevant posters and leaflets
in waiting rooms at PHC centers helps inin waiting rooms at PHC centers helps in
destigmatization of the disease.destigmatization of the disease.
 Improvements in depression screeningImprovements in depression screening
have paralleled improvements inhave paralleled improvements in
depression treatment and reduced stigmadepression treatment and reduced stigma

 Encourage patients to talk about theirEncourage patients to talk about their
symptoms with their Family doctors.symptoms with their Family doctors.
 Recognition of depression by the patientRecognition of depression by the patient
and his or her family.and his or her family.

 PCPs have embraced responsibility forPCPs have embraced responsibility for
screening ,recognition, and treatingscreening ,recognition, and treating
depressiondepression
 For additional efficiencies, we will needFor additional efficiencies, we will need
 Advances in technology (e.g,computerizedAdvances in technology (e.g,computerized
screening and scoring)screening and scoring)
 Improved Rx outcomesImproved Rx outcomes

Training courses for Primary Health
physicians to improve their diagnostic
skills in depression to improve the
recognition rate of depression in
Primary Health Care Settings in Jordan
is also recommended

Dementia is defined asDementia is defined as
global impairment ofglobal impairment of
cognitive function whichcognitive function which
interferes with normalinterferes with normal
activities.activities.

 Impaired short and long-termImpaired short and long-term
memory and other cognitivememory and other cognitive
functions (abstract thinking,functions (abstract thinking,
judgment, speech,judgment, speech,
coordination, planning orcoordination, planning or
organizationorganization

 Alzheimer's accounts for most cases ofAlzheimer's accounts for most cases of
dementia.dementia.
 10-20% cases are attributed to vascular10-20% cases are attributed to vascular
(multi-infarct) dementia(multi-infarct) dementia
 Other causes-alcoholism, Parkinson, vitOther causes-alcoholism, Parkinson, vit
B12 deficiency, hypothyroidism, CNSB12 deficiency, hypothyroidism, CNS
infections, intracranial lesionsinfections, intracranial lesions

Prevalence of DementiaPrevalence of Dementia
 Increases steadily with age, roughlyIncreases steadily with age, roughly
doubling every 5 yearsdoubling every 5 years
 Common among institutionalized elderlyCommon among institutionalized elderly
 Present in ½ to 2/3 of nursing homePresent in ½ to 2/3 of nursing home
residentsresidents
 Family history associated with anFamily history associated with an
increased risk of Alzheimerincreased risk of Alzheimer

Prevalence of DementiaPrevalence of Dementia
 disease progresses over a period of 2-20disease progresses over a period of 2-20
years, causing increasing functionalyears, causing increasing functional
impairment and disabilityimpairment and disability
 Care of the demented patient imposes anCare of the demented patient imposes an
enormous psychosocial and economicalenormous psychosocial and economical
factors.factors.
• Alzheimer’s burden on the familyAlzheimer’s burden on the family

Risk factorsRisk factors
 Age: Strongest risk factor particularly forAge: Strongest risk factor particularly for
ALZ dALZ d
 annual incidence 0.6% for age 65-69annual incidence 0.6% for age 65-69
 1% for age 70-741% for age 70-74
 2% for age 75-792% for age 75-79
 3.3 % for age 80-84 and 8.4% for above3.3 % for age 80-84 and 8.4% for above
8585
 1/2-2/3 of nursing home residents1/2-2/3 of nursing home residents

 Family history : Especially in relation toFamily history : Especially in relation to
ALZ DALZ D
 First degree relatives have 10-30%First degree relatives have 10-30%
increased risk for the diseaseincreased risk for the disease
 Apolipoprotein E epsilon 4 genotypeApolipoprotein E epsilon 4 genotype
predisposes to development of ALZDpredisposes to development of ALZD

 History of head trauma especially withHistory of head trauma especially with
the epsilon 4 allelethe epsilon 4 allele
 History of low educational achievementHistory of low educational achievement
 Organic solvent exposureOrganic solvent exposure
 Female gender 16%/6%Female gender 16%/6%
 Relationship to blood pressure : a URelationship to blood pressure : a U
shape associationshape association
 Hypercholesterolemia /role of statinsHypercholesterolemia /role of statins

DiabetesDiabetes

Screening TestsScreening Tests
 Dementia is easily recognized inDementia is easily recognized in
advanced stages, often overlooked inadvanced stages, often overlooked in
early stageearly stage
 Clinicians fail to detect 21-72% of patientsClinicians fail to detect 21-72% of patients
with dementia esp. in early stageswith dementia esp. in early stages

 Routing physical examination and patientRouting physical examination and patient
history not sensitive for dementia,history not sensitive for dementia,
especially if family members not present toespecially if family members not present to
corroborate patient self-reportcorroborate patient self-report

Alzheimer Warning SignsAlzheimer Warning Signs
Top TenTop Ten
Alzheimer AssociationAlzheimer Association
1. Recent memory loss affecting job1. Recent memory loss affecting job
2. Difficulty performing familiar tasks2. Difficulty performing familiar tasks
3. Problems with language3. Problems with language
4. Disorientation to time or place4. Disorientation to time or place
5. Poor or decreased judgment5. Poor or decreased judgment
6. Problems with abstract thinking6. Problems with abstract thinking
7. Misplacing things7. Misplacing things
8. Changes in mood or behavior8. Changes in mood or behavior
9. Changes in personality9. Changes in personality
10. Loss of initiative10. Loss of initiative

Dementia Type—TotalDementia Type—Total
PopulationPopulation
Distribution of Dementia Types
Mild cognitive impairment
Dementia with Lewy bodies
Vascular
Mixed
Other
Alzheimer’s—mild
Alzheimer’s—moderate
Alzheimer’s—severe
Overall, Alzheimer’s disease accounts for just over half of all dementia—
significantly more than any other form. About two fifths of all patients
are in each of the mild and moderate stages, and the remaining fifth are
in the severe stage
Source: Icon and Landis, Fall 2000
Alzheimer’s disease
15%
2%
14%
13%
1%
22%
55%
11%
22%

AD Is Often MisdiagnosedAD Is Often Misdiagnosed
urce: Consumer Health Sciences, LLC. Alzheimer’s Caregiver Project. 1999.
Patient initially diagnosedPatient initially diagnosed
with ADwith AD
Patient’s first
diagnosis other than
AD
Yes
28%
NoNo
72%72%
21%
7%
9%
14%
14%
35%
Normal aging
Depression No diagnosis
Dementia (not AD) Stroke
Other

AD is Under-diagnosedAD is Under-diagnosed
 Early Alzheimer’s disease is subtle, the diagnosisEarly Alzheimer’s disease is subtle, the diagnosis
continues to be missedcontinues to be missed

it is easy for family members to avoid the problemit is easy for family members to avoid the problem
and compensate for the patientand compensate for the patient

physicians tend to miss the initial signs andphysicians tend to miss the initial signs and
symptomssymptoms
 Less than half of AD patients are diagnosedLess than half of AD patients are diagnosed

Estimates are that 25% to 50% of cases remainEstimates are that 25% to 50% of cases remain
undiagnosedundiagnosed

Diagnoses are missed at all levels of severity: mild,Diagnoses are missed at all levels of severity: mild,
moderate, severemoderate, severe
Evans DA. Milbank Quarterly. 1990; 68:267-289

 Undiagnosed AD patients often face avoidable social,Undiagnosed AD patients often face avoidable social,
financial, and medical problemsfinancial, and medical problems
 Early diagnosis and appropriate intervention may lessenEarly diagnosis and appropriate intervention may lessen
disease burdendisease burden

Early treatment may improve overall courseEarly treatment may improve overall course
substantiallysubstantially
 No definitive laboratory test for diagnosing AD existsNo definitive laboratory test for diagnosing AD exists

Efforts to develop biomarkers, early recognition byEfforts to develop biomarkers, early recognition by
brain scanbrain scan

Prevalence of AlzheimerPrevalence of Alzheimer
 Alzheimer’s disease (AD) is the mostAlzheimer’s disease (AD) is the most
common form of dementia. It represents acommon form of dementia. It represents a
worldwide medical challenge affectingworldwide medical challenge affecting
more than 18 million people; estimated tomore than 18 million people; estimated to
reach 34 million by the year 2025reach 34 million by the year 2025..

PREVALENCE of ADPREVALENCE of AD
 Estimated 4 million cases in US (2000)Estimated 4 million cases in US (2000)
• (2000 - 46 million individuals over 60 y/o)(2000 - 46 million individuals over 60 y/o)
 Estimated 500,000 new cases per yearEstimated 500,000 new cases per year

 Increase with age (prevalence)Increase with age (prevalence)

1% of 60 - 65 (10.7m) = 107,0001% of 60 - 65 (10.7m) = 107,000

2% of 65 - 70 ( 9.4m) = 188,0002% of 65 - 70 ( 9.4m) = 188,000

4% of 70 - 75 ( 8.7m) = 350,0004% of 70 - 75 ( 8.7m) = 350,000

8% of 75 - 80 ( 7.4m) = 595,0008% of 75 - 80 ( 7.4m) = 595,000
• 16% of 80 - 85 ( 5.0m) = 800,00016% of 80 - 85 ( 5.0m) = 800,000

Estimated Number of New AD Cases, in Thousands
377 411 454 491
615
820
959
0
200
400
600
800
1000
1200
1995 2000 2010 2020 2030 2040 2050
1000

Reprinted with permission from Brumback, RA, Leech RW, J. Ohio State Med Assoc.
1994: 87, 103-111

ECONOMIC IMPACT OF ADECONOMIC IMPACT OF AD
 2 million AD patients in nursing homes2 million AD patients in nursing homes

Projection to California – 240,000Projection to California – 240,000
 Nursing homes cost - $120 to $160 per dayNursing homes cost - $120 to $160 per day
 Annualized cost of nursing homes rangesAnnualized cost of nursing homes ranges

from $40,000 to $70,000 per yearfrom $40,000 to $70,000 per year
 Nursing Home Care of AD patients costs $80 billion perNursing Home Care of AD patients costs $80 billion per
yearyear

for life-time cost – about $175,000 per patientfor life-time cost – about $175,000 per patient
 The majority of patients live at home andThe majority of patients live at home and
are cared for by family and friendsare cared for by family and friends
 With lost wages of patients and families plus costs forWith lost wages of patients and families plus costs for
non-nursing home patients:non-nursing home patients:

Total costs: $Total costs: $120 billion annually120 billion annually ((Am J Publ HlthAm J Publ Hlth))

Projection to California – $14.5 billion annually!Projection to California – $14.5 billion annually!

 With over 1.5 million cases in the ArabWith over 1.5 million cases in the Arab
world.world.
Alzheimer’s disease is a devastatingAlzheimer’s disease is a devastating
illness which can affect all members ofillness which can affect all members of
societysociety

Conclusions andConclusions and
 Next to Cancer and AIDS, the highestNext to Cancer and AIDS, the highest
medical budgets are allocated tomedical budgets are allocated to
Alzheimer’s research. The ArabAlzheimer’s research. The Arab
Conference on AD 2005 seeks to developConference on AD 2005 seeks to develop
a regional and national plan to raise thea regional and national plan to raise the
level of awareness on AD and reachlevel of awareness on AD and reach
patients, caregivers, specialists, doctors,patients, caregivers, specialists, doctors,
nurses, specialized international agenciesnurses, specialized international agencies
and governmental and non-governmentaland governmental and non-governmental
organizationsorganizations

Multiple Sclerosis Multiple Sclerosis
Epidemiology and Epidemiology and
PrevalencePrevalence
OnsetOnsetGeographic DistributionGeographic Distribution
Population StudiesPopulation StudiesGenetic FactorsGenetic Factors

Who Has MSWho Has MS
 In the United States, about 400,000In the United States, about 400,000
people have the disease, which is twice aspeople have the disease, which is twice as
common in women as men.common in women as men.
 Approximately 2.5 million people mayApproximately 2.5 million people may
have MS worldwide.have MS worldwide.
 Most people with MS are diagnosedMost people with MS are diagnosed
between the ages of 20 and 40.between the ages of 20 and 40.

 OnsetOnset
 Geographic DistributionGeographic Distribution
 Population StudiesPopulation Studies

Genetic FactorsGenetic Factors

OnsetOnset
 There are about 300,000 patients suffering fromThere are about 300,000 patients suffering from
Multiple Sclerosis in the North America today.Multiple Sclerosis in the North America today.
The age of onset peaks between 20 and 30The age of onset peaks between 20 and 30
years. Almost 70% of patients manifestyears. Almost 70% of patients manifest
symptoms between ages 21 and 40. Diseasesymptoms between ages 21 and 40. Disease
rarely occurs prior to 10 or after 60 years of age.rarely occurs prior to 10 or after 60 years of age.
However, patients as young as 3 and as old asHowever, patients as young as 3 and as old as
67 years of age have been described.67 years of age have been described.

 Like other immuno- mediated diseases,Like other immuno- mediated diseases,
females are affected more frequently thanfemales are affected more frequently than
males (1.4 to 3.1 times as many womenmales (1.4 to 3.1 times as many women
than men affected.)than men affected.)

Geographic DistributionGeographic Distribution
 There is a very specific geographicThere is a very specific geographic
distribution of this disease around thedistribution of this disease around the
world. A significantly higher incidence ofworld. A significantly higher incidence of
the disease is found in the northernmostthe disease is found in the northernmost
latitudes of the northern and the southernlatitudes of the northern and the southern
hemispheres compared to southernmosthemispheres compared to southernmost
latitudes.latitudes.

 This observation is based on theThis observation is based on the
incidence of the disease in Scandinavia,incidence of the disease in Scandinavia,
northern United States and Canada, asnorthern United States and Canada, as
well as Australia and New Zealand. Thewell as Australia and New Zealand. The
data from migration studies shows that ifdata from migration studies shows that if
the exposure to a higher risk environmentthe exposure to a higher risk environment
occurs during adolescence (before 15occurs during adolescence (before 15
years of age,) the migrant assumes theyears of age,) the migrant assumes the
higher risk of the environment..higher risk of the environment..

What Is MS?What Is MS?
 Multiple sclerosis (MS) is a disease thatMultiple sclerosis (MS) is a disease that
attacks the central nervous system—theattacks the central nervous system—the
brain and the spinal cord. Depending onbrain and the spinal cord. Depending on
which nerves are damaged, people withwhich nerves are damaged, people with
MS may experience problems withMS may experience problems with
balance, muscle coordination, vision,balance, muscle coordination, vision,
speech, thinking, or other physical andspeech, thinking, or other physical and
mental abilities.mental abilities.

Population StudiesPopulation Studies
 There are also population studies thatThere are also population studies that
show difference in susceptibility to MSshow difference in susceptibility to MS
between different populations. Lapps inbetween different populations. Lapps in
Scandinavia appear to be resistant to theScandinavia appear to be resistant to the
disease, contrary to the expectationsdisease, contrary to the expectations
based on their geographic distribution.based on their geographic distribution.
Native Americans and Hutterites veryNative Americans and Hutterites very
infrequently suffer from MS, as opposed toinfrequently suffer from MS, as opposed to
other residents of the North America. MSother residents of the North America. MS
is uncommon in Japan, China and Southis uncommon in Japan, China and South
America.America.

 It is practically unknown among theIt is practically unknown among the
indigenous people of equatorial Africa andindigenous people of equatorial Africa and
among native Inuit in Alaska. When theamong native Inuit in Alaska. When the
racial differences are correlated, Whiteracial differences are correlated, White
populations are at greater risk than Asianpopulations are at greater risk than Asian
or African populations. We can not yetor African populations. We can not yet
explain these obvious inconsistencies inexplain these obvious inconsistencies in
disease distribution, but the knowledge ofdisease distribution, but the knowledge of
them may be helpful in assessing specificthem may be helpful in assessing specific
patients.patients.

Prevalence of MSPrevalence of MS
Prevalence data imply that racial andPrevalence data imply that racial and
ethnic differences are important inethnic differences are important in
influencing the worldwide distribution ofinfluencing the worldwide distribution of
MS and that its geography must beMS and that its geography must be
interpreted in terms of the probableinterpreted in terms of the probable
discontinuous distribution of geneticdiscontinuous distribution of genetic
susceptibility alleles. Racially andsusceptibility alleles. Racially and
ethnically influenced differences in the riskethnically influenced differences in the risk
of MS, however, can be modified byof MS, however, can be modified by
environment.environment.

Genetic FactorsGenetic Factors
 The incidence of MS in first degree relatives isThe incidence of MS in first degree relatives is
20 times higher than in general population,20 times higher than in general population,
suggesting the influence of genetic factors onsuggesting the influence of genetic factors on
the disease. Monozygotic twin studies show thethe disease. Monozygotic twin studies show the
concordance rate of 30%. Dizygotic twins showconcordance rate of 30%. Dizygotic twins show
concordance rate of less than 5%. These resultsconcordance rate of less than 5%. These results
suggest that both the genetic factors andsuggest that both the genetic factors and
environmental exposure are important inenvironmental exposure are important in
disease expression.disease expression.

SymptomsSymptoms
 Symptoms associated with MS varySymptoms associated with MS vary
widely. There is not yet a way to predictwidely. There is not yet a way to predict
what symptoms people with MS maywhat symptoms people with MS may
experience. MS symptoms are divided intoexperience. MS symptoms are divided into
three types:three types:
 ..

 Primary symptomsPrimary symptoms are those causedare those caused
directly by the disease process includingdirectly by the disease process including
immune system activity, destruction ofimmune system activity, destruction of
myelin or the ensuing nerve damage.myelin or the ensuing nerve damage.

The most common includeThe most common include
 problems with walking or maintainingproblems with walking or maintaining
balance, visual impairment (balance, visual impairment (optic neuritisoptic neuritis),),
 lapses in memory,lapses in memory,
 inability to solve problems or pay attentioninability to solve problems or pay attention
for long periods of time,for long periods of time,
 pain,pain,

 sexual dysfunction,sexual dysfunction,
 dizziness,dizziness,
 depression or mood swings,depression or mood swings,
 and disturbances in bladder or boweland disturbances in bladder or bowel
function.function.
 Less common symptoms include speechLess common symptoms include speech
and swallowing disorders, tremors andand swallowing disorders, tremors and
seizuresseizures

 Secondary symptomsSecondary symptoms are complicationsare complications
that occur as a result of primarythat occur as a result of primary
symptoms. For instance, a person with MSsymptoms. For instance, a person with MS
may have urinary burning, which could bemay have urinary burning, which could be
a sign of a urinary tract infection, resultinga sign of a urinary tract infection, resulting
from lack of bladder control caused byfrom lack of bladder control caused by
nerve damage.nerve damage.

 Tertiary symptomsTertiary symptoms may include loweredmay include lowered
self-esteem, which could affect a person'sself-esteem, which could affect a person's
family or social life.family or social life.

Multiple sclerosis in Arabs inMultiple sclerosis in Arabs in
JordanJordan
..
 Department of Biochemistry andDepartment of Biochemistry and
Microbiology, Faculty of Medicine, JordanMicrobiology, Faculty of Medicine, Jordan
University, Amman.University, Amman.
 In a 2-year hospital-based study (1992In a 2-year hospital-based study (1992
and 1993), there were 131 multipleand 1993), there were 131 multiple
sclerosis patients attending 2 large referralsclerosis patients attending 2 large referral
hospitals in Jordan. There were 126 Arabshospitals in Jordan. There were 126 Arabs
of whom 84 were Palestinians and 36of whom 84 were Palestinians and 36
indigenous Jordanians.indigenous Jordanians.

 Comparison of these subgroups, which had aComparison of these subgroups, which had a
similar age distribution revealed that the diseasesimilar age distribution revealed that the disease
was twice as frequent in Palestinians (estimatedwas twice as frequent in Palestinians (estimated
42.0/100,000) among Jordanians (estimated42.0/100,000) among Jordanians (estimated
20.0/100,000). Clinical presentation, pattern of20.0/100,000). Clinical presentation, pattern of
disease, disability associated with the diseasedisease, disability associated with the disease
were similar to that in the disease reported inwere similar to that in the disease reported in
Caucasians in the West. All investigationsCaucasians in the West. All investigations
including neurophysiology and imaging wereincluding neurophysiology and imaging were
also very similar to Western reportsalso very similar to Western reports

 More research and surveys about MSMore research and surveys about MS
should be done in the Arab world.should be done in the Arab world.
 Researchers must consider the availableResearchers must consider the available
evidence and direct their efforts towardsevidence and direct their efforts towards
multicenter studies of similar ethnicmulticenter studies of similar ethnic
groups living under different environmentalgroups living under different environmental
conditions. Such an approach mayconditions. Such an approach may
provide significant clues for bothprovide significant clues for both
pathogenetic and triggering mechanismspathogenetic and triggering mechanisms
of MS.of MS.

‫ال‬ ‫بحمد‬ ‫تم‬‫ال‬ ‫بحمد‬ ‫تم‬

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