EPDEMOLOGY OF HYPERTANSON

Prof.Dr.Selma KARABEYEpidemiology of Mental Disorders

Mental Health Definition-WHOIt is conceptualized as 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 fruitfully, and is able to make a contribution to his or her community. With respect to children, an emphasis is placed on the developmental aspects, for instance, having a positive sense of identity, the ability to manage thoughts, emotions, as well as to build social relationships,and the aptitude to learn and to acquire an education, ultimately enabling their full active participation in society.

A human rights perspective is essential!Widespread human rights violations and discrimination the need for services, policies, legislation, plans, strategies and programmes to protect, promote and respect the rights of persons with mental disorders in line with the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Childand other relevant international and regional human rights instruments.4Mental health and disorders: determinants and consequencesinclude not only individual attributes such as the ability to manage one's thoughts, emotions, behaviours and interactions with others, but also social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions, and community social supports.Exposure to adversity at a young age is an established preventable risk factor for mental disorders.Vulnerability Certain individuals and groups in society may be placed at a significantly higher risk of experiencing mental health problems: members of households living in poverty, people with chronic health conditions, infants and children exposed to maltreatment and neglect, adolescents first exposed to substance use, minority groups, indigenous populations, older people, people experiencing discrimination and human rights violations, lesbian, gay, bisexual, and transgender persons, prisoners, people exposed to conflict, natural disasters or other humanitarian emergencies. The current global financial crisis provides a powerful example of a macroeconomic factor leading to cuts in funding despite a concomitant need for more mental health and social services because of higher rates of mental disorders and suicide as well as the emergence of new vulnerable groups [for example, the young unemployed). In many societies, mental disorders related to marginalization and impoverishment, domestic violence and abuse, and overwork and stress are of growing concern, especially for women's health.

6Higher Rates of Disability and MortalityPeople with mental disorders experience disproportionately higher rates of disability and mortality. For example, persons with major depression and schizophrenia have a 40% to 60% greater chance of dying prematurely than the general population,Owing to physical health problems that are often left unattended [such as cancers, cardiovascular diseases, diabetes and HIV infection) and suicide. Suicide is the second most common cause of death among young people worldwide.Burden of Mental DisordersMental disorders often affect, and are affected by, other diseases such as cancer, cardiovascular disease and HIV infection/AIDS, For example, there is evidence that depression predisposes people to myocardial infarction and diabetes, both of which conversely increase the likelihood of depression. Many risk factors such as low socioeconomic status, alcohol use and stress are common to both mental disorders and other noncommunicable diseases. There is also substantial concurrence of mental disorders and substance use disorders.Taken together, mental, neurological and substance use disorders exact a high toll, accounting for 13% of the total global burdenBurden of Mental DisordersIn a sample representing the general population, consisting of 60.559 adults from 14 countries, as six of the less developed and eight developed, from different regions of the world indicates that lifetime prevalance of any psychiatric disorder, according to DSM-IV critera was between 8.6% (Shanghai) and 47.3% (U.S.).

Lifetime prevalance of mental disorders is about 18% in Turkey

Concordance rate in individuals with a psychiatric disorder( a second psychiatric disease in the same period) has been found between 52% and 75%.

Dnyann deiik blgelerinden alts daha az gelimi, sekizi gelimi olmak zere 14 lkede genel poplasyonu temsil eden 60559 bireylik erikin rnekleminde ruhsal hastalklarn yk ve ruh sal hizmetleri de btnlkl bir biimde ele alnmtr. DSM-IV ltlerine gre, herhangi bir ruhsal bozukluun yaam boyu yaygnl %8.6 (angay) ile %47.3 (ABD) arasnda deien oranlarda grld bulunmutur. Trkiye Ruh Sal Profili almas (1998), Trkiyede ruhsal hastalklarn yaam boyu yaygnlnn %18 olduu bulunmutur. Toplumun sosyal yapsnn deimesi ve sosyal destek sistemlerinin giderek azalmas nedeniyle bu orann daha ykselmi olmas olaslk dahilindedir. Bir psikiyatrik bozukluu olan bireyde ehastalanma (ayn dnemde ikinci bir psikiyatrik hastalk olma) oran yaplan eitli aratrmalarda %52-75 arasnda bulunmutur.

9Social and Humanitarian AspectMental disorders frequently lead individuals and families into poverty.Homelessness and inappropriate incarceration are far more common for people with mental disorders than for the general population, and exacerbate their marginalization and vulnerability. Human rights violation because of stigmatization and discriminationrestrictions on the rights to work and education, reproductive rights and the right to the highest attainable standard of health. unhygienic and inhuman living conditions, physical and sexual abuse, neglect, and harmful and degrading treatment practices in health facilities. They are often denied civil and political rights such as the right to marry and found a family, personal liberty, Mental disorders frequently lead individuals and families into poverty. Homelessness and inappropriate incarceration arefar more common for people with mental disorders than for the general population, and exacerbate their marginalization andvulnerability. Because of stigmatization and discrimination, persons with mental disorders often have their human rightsviolated and many are denied economic, social and cultural rights, with restrictions on the rights to work and education, as wellas reproductive rights and the right to the highest attainable standard of health. They may also be subject to unhygienic andinhuman living conditions, physical and sexual abuse, neglect, and harmful and degrading treatment practices in healthfacilities. They are often denied civil and political rights such as the right to marry and found a family, personal liberty, the rightto vote and to participate effectively and fully in public life, and the right to exercise their legal capacity on other issues affectingthem, including their treatment and care. As such, persons with mental disorders often live in vulnerable situations and maybe excluded and marginalized from society, which constitutes a significant impediment to the achievement of national andinternational development goals. The Convention on the Rights of Persons with Disabilities, which is binding on States Partiesthat have ratified or acceded to it, protects and promotes the rights of all persons with disabilities, including persons withmental and intellectual impairments, and also promotes their full inclusion in international cooperation including internationaldevelopment programmes.10Treatment GapFor non-affective psychotic disorders (mainly schizophrenia) 32.2%,depression 56.3% ,disthymia 56.0%,bipolar disorder 50.2%, panic disorder 55.9%, common anxiety disorders 57.5%, obsessive-compulsive disorder 57.3%, and alcohol abuse or dependence 78.1% rates were reported.Psikiyatrik bozukluu olduu halde tedavi grmeyenlerin oranlarn tanmlayan tedavi a oranlarna bakldnda nemli oranda hastann tedavi alamad grlmektedir. Dnya Salk rgt blgeleri dikkate alnarak yaplan bir almada, tedavi a oranlarnn dikkat ekici dzeylerde yksek olduu bildirilmektedir. Affektif olmayan psikotik bozukluklar (bata izofreni) iin % 32.2, depresyon iin % 56.3, distimi iin % 56.0 bipolar bozukluk iin %50.2, panik bozukluu iin % 55.9, yaygn anksiyete bozukluu iin % 57.5, obsesif-kompulsif bozukluk iin % 57.3, ve alkol ktye kullanm-bamll iin % 78.1 oranlarnda bildirilmitir. Blgelere gre deiiklik gsterse de, psikiyatrik bozukluklarda tedavi a tm dnyada olduu gibi lkemizde de ok yksektir.

Health systems have not yet adequately responded to the burden of mental disorders; as a consequence, the gap betweenthe need for treatment and its provision is large allover the world. Between 76% and 85% of people with severe mental disordersreceive no treatment for their disorder in low-income and middle-income countries; the corresponding range for highincomecountries is also high: between 35% and 50%. A further compounding problem is the poor quality of care for thosereceiving treatment. WHO's Mental Health Atlas 2011 provides data that demonstrate the scarcity of resources within countriesto meet mental health needs, and underlines the inequitable distribution and inefficient use of such resources. Globally, forinstance, annual spending on mental health is less than US$ 2 per person and less than US$ 0.25 per person in low-incomecountries, with 67% of these financial resources allocated to stand-alone mental hospitals, despite their association with poorhealth outcomes and human rights violations. Redirecting this funding towards community-based services, including theintegration of mental health into general health care settings, and through maternal, sexual, reproductive and child health,HIV/AIDS and chronic noncommunicable disease programmes, would allow access to better and more cost-effective interventionsfor many more people.11Psychotic Disorders and Lifetime PrevalancesSchizophrenia (1%), Schizoaffective disorder (0.5-0.8%),Paranoid disorder (0.05-0.1%),Brief psychotic disorder, shared psychotic disorder, bipolar disorder (1.2%),Manic episodes and psychotic depression (seen less)Psikotik bozukluklar genellikle kroniklemekte, yeti yitimine neden olmakta ve hasta bireyin kendi bana yaamn srdrmesini engellemektedir. Bu tr ar ruhsal bozukluu olan bireyler hastaln oluturduu bata bilisel, duygusal ve davransal kayp ve sorunlardan dolay hem tedavi/izlem sreci hem kiisel bakm ve hem de sosyal ve mesleki ilevselliklerini srdrebilmek iin yardm ve destee ihtiya duymaktadrlar. Bu nedenlerle bu grup hastaya zel tedavi, rehabilitasyon ve bakm yntemleri gelitirilmektedir.

12Mood DisordersBipolar disorder type-1 and type-2Major depression (lifetime prevalence of 10-25% women, men 5-12%)Dysthymic disorder (6%)Cyclothymic disorder (0.4-1%)Other depressive disorders (minor depressive disorder, recurrent brief depressive disorder 2%, , premenstrual dysphoric disorder 3-8% in women aged 14-44)Anxiety DisordersSpecific phobias 11%,Panic disorder 3%, Social anxiety disorder 13%, Obsessive-compulsive disorder 2%, Post-traumatic stress disorder 3%, Generalized anxiety disorder 5% ,In total, lifetime prevalence of all of the anxiety disorders are considered as 25%.Yalnzca bu yaygnlk oran bile anksiyete bozukluklarnn bir halk sal sorunu olduunu gstermektedir. Ayrca hastaneye yatrlan hastalarda yaklak % 23 oranlarnda anksiyete grlebildii gz nnde tutulursa tbbi bir duruma bal anksiyete bozukluunun yaygn ve nemli bir durum olduu sylenebilir.Son yllarda bireysel ve toplumsal krizler, kazalar ve eitli afetler nedeniyle akut stres bozukluu ve travma sonras stres bozukluunda acil ve hzl mdahaleler ile uzun sreli terapi gereksinimleri hzla artmaya devam etmektedir.

14Mental Disorders Connected to a General Medical ConditionDeliriumThe point prevalence of 10-30% in general hospitalsIn general population 0.4%, In Cancer patients 25-40%, In post-operative patients 5-75%, In ICU patients 12-50%, In people remaining in nursing home 60%, In dementia patients 22-89%.Mental Disorders Connected to a General Medical ConditionDementiaDementia, can occur for many reasons, including particularly Alzheimer's type dementia.The onset of dementia is usually 65 years of age,Advancing age, having a rising prevalence of dementia; 4% in the population above 65 years of age, while 40% frequency in the population above 85 years of ageAlcohol and Substance Use DisordersRapid changes in the social structure, the effects of globalization, population mobility and other changes due to an increase in the use of alcohol and other substances that increase with each passing year, and have been used at younger ages.

Therefore, as the prevention of the spread of alcohol and substance abuse, a sufficient number of treatment and rehabilitation centers are the need of community. OtherSomatoform Disorders Dissociative Disorders Sexual Dysfunction Personality Disorders

Dnyann farkl blgeleri, lkeleri ve kltrlerinde yaplan aratrmalar cinsel sorunlarn genel olarak sk rastlandn ortaya koymaktadr. Yaplan ok sayda almann deerlendirilmesinde yaklak olarak her kiiden birinin cinsel yaamnn herhangi bir dneminde en az bir cinsel ilev bozukluu yaadn ortaya koymaktadr.eitli toplum ve kltrlerde yaplan almalar, cinsel ilev bozukluklarnn rastlanma skl konusunda birbirine benzer sonular vermektedir. Ancak, kltrel ve toplumsal etkenlerle ortaya kan baz farkllklar da vardr. rnein, bizim gibi muhafazakar toplumlarda cinselliin yasaklanmas, formal bir cinsel eitimin olmamas, cinselliin bir tabu olarak alglanmas ve bekaretin nemsenmesi gibi etkenler kadnlarda vaginismus ve cinsel istek bozukluklarnn, erkeklerde ise cinsel istek ve boalma bozukluklarnn, cinsel liberalizmin egemen toplumlara gre daha yksek oranlarda rastlanmasna yol amaktadr. Yine cinsel deneyimin yetersiz olduu toplumsal kesim ya da genlerde, erkeklerde erken boalma, kadnlarda ise eitli orgazm glklerinin dier kesimlere oranla daha sk rastland gzlenmektedir.Hekime bavuran olgularn ya dalmlar asndan da farkllklar gzlenmektedir. Gelimi bat lkelerinde daha ok ileri yalardaki kiiler bavururken, gelimekte olan lkelerde ve dou toplumlarnda daha ok gen-orta ya kuan hekime bavurduu gzlenmektedir. Bu nedenle, bat toplumlarndaki bavurularda menopoz, diabetesmellitus, hipertansiyon, ila kullanmlar vb. kaynakl erektildisfonksiyon, cinsel isteksizlik ve disparoni gibi hastalklar daha n plana karken, dierlerinde vag-jinismus, cinsel birleme kuramama, erken boalma gibi psikojenik kkenli cinsel ilev bozukluklar ilk sralarda yer almaktadr.lkemizdeki cinsel tedavi merkezlerine bavurularda da gen erikinlik dnemi ba ekmektedir. lkemizdeki cinsel tedavi merkezleri, poliklinikleri ve uzmanlar son yllarda hzla art gstermesine karn hasta bavurularndaki art bunun nne gemitir. Bu artn nedenleri arasnda toplumda bu alanda artan bilin, medyann yaygnlamas ve bu konuda oynad rol, cinsel tedavi olanaklarnda son yllardaki vb. saylabilir. Tm bu gelimeler, tbbn ve tm hekimlerin bu alanda daha donanml ve hazrlkl olmasn zorunlu klmaktadr. Tm hekimlerin ve zellikle psikiyatristlerin, jinekologlarn ve rologlarn cinsel sorunlar ve tedavileri konusunda bilgi ve yeti sahibi olmalar, temel bilgilendirme ve danmanlk ile uygun ynlendirmeleri yapabilecek durumda olmalar gerekmektedir. Her hekim ya da psikiyatrist cinsel terapi ya da tedavi yapmak durumunda deildir, ancak birok vakada basit bir bilgilendirme bile kiinin kafasndaki yanl bilgi ve koullanmalar dzelterek sorunun zmn salayabilir. Ya da daha balang aamasnda bulunan bir performans anksiyetesini ya da cinsel inhibisyonu ortadan kaldrabilir.

18Mental Health Profile of TurkeyA representative sample of the population of Turkey 3889 households 7479 adults were interviewed Interviews were conducted with GPs(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: materialsComposite International Diagnostic Interview (CIDI)

General Health Questionnaire

Brief Disability Questionnaire

Health Services Utilization Survey

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: educational status

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: the mean age

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: prevalance of ICD-10 groups

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: application-sex relationship for mental problems

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: admission rates due to mental health problems

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)Mental Health Profile of Turkey: first consulted person due to mental health problems

(Kaynak: Kl C. Trkiye Ruh Sal Profili: Erikin nfusla ilgili sonular. Ankara: Salk Bakanl Temel Salk Hizmetleri Genel Mdrl Yaynlar, 1998)TK Salk Aratrmas,2012

TK Salk Aratrmas,2012

TK Salk Aratrmas,2012

TK Salk Aratrmas,2012

Burden of Mental Disorders in Turkey

Proportional Burden of Mental Disorders in Total.

almay yrten aratrmaclar, Trkiyede hem kentsel hem de krsal alanda ruhsalbozukluklarn nemli hastalk yk oluturduu yorumunu getirmektedirler.33Human Resources in Mental Health

DS 2008 verilerine gre Avrupa blgesinde her 100 bin kiiye 8 akut psikiyatriyata den talyadan sonra 100 bin kiiye 10 psikiyatri yata ile (adli ve kronik bakm vebamllk tedavisi iin kullanlan yataklar dahil) Trkiye ikinci en az yatak saysna sahiplkedir. (Grafik.3.). Ancak talyada bakm yataklar da dahil edildiinde tm psikiyatri yataksays 100 bin kiiye 33 yatak olmaktadr.35Distribution of the Psychiatrists

Trkiyede Mart 2011 itibariyle aktif olarak alan 1625 ruh sal ve hastalklaruzman bulunmaktadr. Bu kiilerin 862si Salk Bakanl, 277si niversitelerde alrken486 ruh sal ve hastalklar uzman zel sektrde hizmet vermektedir. lkemizde 100 binkiiye den ruh sal ve hastalklar uzman says 2,20dir.36WHO-European Region: Number of the Psychiatrists

Avrupa Birliinin 15 lkesinde 100 bin kiiye ortalama 12,9 ruh sal vehastalklar uzman dmektedir. DS Avrupa blge lkeleri iinde en az ruh sal vehastalklar uzman oranna sahip olan lke Trkiyedir (Grafik.4.).37Distribution of the Child and Adolescent Psychiatrists

Salk Bakanl verilerine gre Trkiyede Mart 2011 itibariyle aktif olarak alan206 ocuk ve ergen ruh sal ve hastalklar uzman bulunmaktadr. Bu kiilerin 82si SalkBakanl, 87si niversitelerde alrken 37 ocuk ve ergen ruh sal ve hastalklaruzman zel sektrde hizmet vermektedir. lkemizde 100 bin kiiye den aktif alan ocukve ergen ruh sal ve hastalklar uzman says 0.28dir. Ekim 2010 tarihinde lkedekiocuk ve ergen ruh sal ve hastalklar uzman dalmn gsteren ekil.5.de 45 ilimizdeocuk ve ergen ruh sal ve hastalklar uzman olmad grlmektedir.38

DS Avrupa Blgesinde 100 bin kiiye den ocuk ve ergen ruh sal uzmanortalamas 1,5dir. Grafik.5.de Avrupa ortalamasyla kyaslandnda Trkiyede st ihtisasgerektirmeyen branlarda en az uzmann psikiyatri (1/5,9) ve ocuk ve ergen ruh sal vehastalklar (1/5,4) branlarnda olduu grlmektedir.39

lkemizde ylda ortalama 170 ruh sal ve hastalklar uzmannn sisteme eklendiigz nne alnrsa Avrupa lkelerindeki ruh sal ve hastalklar uzman oranna yetimekok uzun zaman alacaktr. Grafik.7.de ylda 170 psikiyatri asistan alnmaya devam edildiitakdirde 2050 ylna kadar olan projeksiyon grlmektedir. Ayn grafikte kontenjanlarn %50ve %100 artrlmas halinde beklenen projeksiyonlar da gsterilmitir. Avrupada 100 binkiiye den ruh sal ve hastalklar uzman saysnn 15 lke ortalamasnn gnmzde12,9 olduu dnlrse, kontenjan %100 artrldnda bile 2050 ylnda 100 bin kiiyeancak 10,2 uzman saysna ulalmaktadr.Mevcut durum incelendiinde; niversitelerde yatak bana den asistan saysdoygunluk dzeyinde olduundan kontenjan artrm yapmak mmkn grnmemektedir.Eitim aratrma hastanelerindeki durum da farkl deildir. Yeni almas planlanan kampushastanelerde psikiyatri eitim klinii olmayan illerde yeni klinikler aarak kontenjannarttrlabilecei dnlmektedir.40Psychologist

In Turkey 1.85 /100.000Salk Bakanl verilerine gre Trkiyede salk alannda aktif olarak alan 1370psikolog bulunmaktadr (Mart 2011). Bu kiilerin 918i Salk Bakanlnda, 183niversitelerde, 269u ise zel sektrde hizmet vermektedir. 2010-11 eitim yl itibariylelkemizde 40 niversitede 2632 psikoloji rencisi kontenjan vardr. lkemizde 100 binkiiye den salk alannda aktif alan psikolog says 1,85dir.41Social WorkerThere are 613 social workers working actively in the field of health in Turkey (March 2011).529 of these individuals in Ministry of Health, while 71 of them working in the universities and 13 of in the private sector.As of the 2010-11 academic year, in 10 universities in our country social services has a quota of 678.The number of active working social workers in our country is 0,92 per 100 thousand people. Ministry of Health Medical Social Work Practice Directive was published in February 2011.Salk Bakanl verilerine gre Trkiyede salk alannda aktif olarak alan 613sosyal almac bulunmaktadr (Mart 2011). Bu kiilerin 529u Salk Bakanlnda, 71iniversitelerde alrken 13 sosyal almac zel sektrde hizmet vermektedir. 2010-11eitim yl itibariyle lkemizde 10 niversitede 678 sosyal hizmetler kontenjan vardr.lkemizde 100 bin kiiye den aktif alan sosyal almac says 0,92dir.

Salk Bakanl Tbbi Sosyal Hizmet Uygulama Ynergesini ubat 2011deyaynlanmtr. Bu ynerge ile Bakanla bal alan sosyal almaclarn grev tanmlarve alma prosedrleri detayl tanmlanmtr.42Nurse

Trkiyede 2010 yl itibariyle ruh sal alannda alan hemire says ise 1.677dir.Ancak ruh sal alannda alanlarn sertifikasyon ve srekliliini salamada sorunlaryaanmaktadr. lkemizde 12 niversitede hemirelere psikiyatri yksek lisans eitimiverilmektedir. Ruh sal alannda yksek lisans yapm 179 hemire varken 47 hemire deyksek lisans eitimine devam etmektedir (Mart 2010). eitli lkelerde ruh sal alanndaalan hemire saylar Grafik.6.da verilmitir. Trkiyede toplam 150.649 ebe ve hemireolduunu gz nne alrsak bunlarn yaklak %1,1 i ruh sal alannda grev yapmaktadrdenebilir.43Institutions in Mental HealthMINISTRY OF HEALTHMental Health DepartmentRegional Psychiatry Hospitals and Psychiatry ClinicsPsychiatry PoliclinicsProvincial Health Directorates and 112 Emergency servicesCommunity Mental Health Centers

UNIVERSITIESPsychiatry clinics and policlinicsMINISTRY OF JUSTICEInstitute of Forensic Medicine Probation and help branch offices Other topics of concerningthe Ministry of JusticePrisoners patients Safeguard Patients Patients under treatment Deprivation of liberty in order to protect Guardianship of children ...MINISTRY OF FAMILY AND SOCIAL POLICY MINISTRY OF LABOUR AND SOCIAL SECURITY MINISTRY OF EDUCATION General Directorate of Special Education, Guidance and Counseling Services Department of Counseling and Guidance Services Department of Special EducationGuidance and Research Centers Guidance and Counseling Services in Educational Institutions Guidance and Counseling Services Staff Involved in Special Education Services Schools and InstitutionsAdvisory ServicesMINISTRY OF INTERNAL AFFAIRSThe Police organizationDistrict GovernorsOther topics concerning the Ministry of Internal Affairs Suicide prevention Crisis prevention The intervention in exciter patients Dependence control programsMINISTRY OF TRANSPORTRTUK(Radio and Television Supreme Council)Other Municipalities Recruitment office GendarmeMental Health SystemsThere are three different types of mental health systems in the worlda. Hospital based modelb. Community based modelc. Community-Hospital balanced modelTrkiyede ruh sal hizmetleri arlkl olarak kamu sektr tarafndan hastanetemelli model ile verilmektedir. Salk Bakanlna bal toplam 8 blge RSHH geni corafiblge ve byk nfus esasna dayal olarak hizmet vermektedir. rnein ekil.1.degrld gibi Elaz RSHHsi 18 il ve 9.411.745 kiilik bir nfusa hizmet verirken BakrkyRSHHsi 6 il ve 12.797.601 milyon nfusa hizmet vermektedir.

49Hospital Based ModelThe oldest and traditional model that is used between the years of 1800s and 1960s.Many large psychiatry hospitals are founded in this periodThese hospitals are outside the city and have on average 2.000 beds (For instance in England there are 120.000 beds in this way)This model is left at 1960 because hospitals were very crowded, hygiene conditions were bad, violations of patients rights were very commonHospital Based ModelPolyclinic services, Hospitalization during an exacerbation / attack,Lonely patients or patients who are not cared by someone admitted into the hospitals providing care for periods ranging up to 50-60 years.Sunulan hizmet, ar ruhsal hastalklarnsadece alevlenme/atak dnemlerine odaklanmakta, hastaln alevlenmesine zeminhazrlayan biyopsikososyal etmenlere mdahale olana tamamakta, hastann sosyal vemesleki ilevselliine katkda bulunmay hedeflememektedir. ounlukla hastala igrsolmayan ar ruhsal bozukluu olan hastalarn hastaneden ayrldktan sonra ila kullanm vekontrole gelmeleri bazen sadece kendi inisiyatiflerinde bazen de bu konuda hibirbilinlendirme yaplmayan ailelerinin sorumluluunda olmaktadr. Sonuta, hastalar hastanednda hastalklaryla ba baa kalmakta ve alevlenmeyi hazrlayc ve hzlandrc etmenlerleba edememekte ve hastalnn yeniden alevlenmesi ve hastaneye yat kanlmazolmaktadr. Hastalar hem sk ve iddetli atak geirmekte hem de toplumda akl hastalar iinvar olan damgalama davran pekimektedir. Aileler ounlukla hasta ve hastalkla ilgili bireitim veya kurum destei alamamakta bu da tkenmilikle sonulanmaktadr. Dnerkapfenomeni olarak adlandrlan bu gidi, hastane yatak saylarnn ihtiyaca cevap verememesineve yeni yatak ihtiyacna, bu youn talebe yetimek zorunda kalan meslek profesyonellerininmedikal tedaviye ek olarak psikososyal mdahalelerde bulunmak iin zaman ve enerjiayramamalarna, dolup taan hastanelerde insani ihtiyalarn karlanamamasna, en iyikoullarda bile asgari dzeyle yetinilmesine sebep olmaktadr.51Community Based ModelCommunity-based mental health model based on the target of patient groups who have severe mental disorders or who are admitted in the hospital for a long timeIn hospital-based model, only treatment needs of the patient can be met; but numerous other problem areas can not be interfered with. The "problem" is a public health problem; the hospital-based model, which only cares the patients admitted to hospital during an exacerbation and then left them alone, should be changed and there should be transition to the community-based psychiatric model. Avrupa Birliinin 2009 Trkiye lerleme Raporunda Kurumsallamaya alternatifolarak toplum temelli hizmetlerin oluturulmas ok nemlidir. Bu konuda ocuklarn vegenlerin salklarnn korunmas ynnde zel aba gsterilmesi ihtiyac bulunmaktadreklinde nerdii toplum temelli model, 1960larda ncelikle talyada, ezamanl olarakngiltere, Fransa, Almanyada balayan ve Tablo.6.da gsterildii gibi tm dnyada hzlageilen, DSnn de tavsiye ettii bir modelidir.52Community-Hospital Balance ModelCommunity-based model costs are very high, especially in terms of human resourcesConsidering our country's health care system, socio-economic conditions and calculating that it will take decades to correct the deficiencies in the terms of human resources, it seen that the ideal model will be the community-hospital balance model.Still in community-hospital balance model applied in the UK, psychiatric hospitals have been reduced under 200 beds and protected; also community psychiatry system is well established.Community based mental health servicesCommunity based mental health system are based upon the main elements below:Configuration of services in accordance with geographic areaMultidimensional/comprehensive services by a teamFor every identified area:One responsible community mental health center,Care institutionsPreventive housesPrevented workplacesPsychiatry beds in the general hospitalsToplum temelli ruh sal modeli talyada ruh sal reformuyla 1961 ylndabalam ve Tablo.6.da gsterildii gibi son 30 ylda Avrupa lkelerinin hemen hepsindeuygulamaya geilmitir. talyada balayan deiim, dier Bat Avrupa lkelerinde de ksasre sonra balam ve tamamlanmtr. En son Yunanistan Avrupa Birliine giri srecinderuh sal sistemini deitirmitir. Bulgaristan ve Romanya gibi Dou Avrupa lkelerinde dedeiim programlar yrtlmektedir. Ayn deiim sreci randa da yrtlmekte, DSAfganistana da ayn sistemi nermektedir. Tm bu lkelerde yaanan deiim, hastanetemelli ruh sal sisteminden toplum temelli ruh sal sistemine geilmesi eklindedir.Toplum temelli ruh sal modeli, modern bat lkelerinin salk hizmetlerindeki temelunsurlardan biridir.54Community Mental Health CenterOne center for any geographic area that has 100-300 thousand populationMental Health TeamPsychiatry specialist,Psychologist, Psychiatry Nurse, Social Worker, Ergotherapist, occupational therapist and other assistant staffThe center where the team serve is outside the hospital buildingTeam is mobile, when needed they go to patient

Bu modelde lke 100-300 bin nfustan oluan corafi alanlara blnr ve her alan iinbir toplum ruh sal merkezi planlanr. Merkezde alan ruh sal ekibi psikiyatri uzman,psikolog, psikiyatri hemiresi, sosyal almac, ergoterapist, ura terapisti ve dier yardmcpersonelden oluur. Ekip hareketlidir, hizmeti gerektiinde hastann yaad alana gtrr.Ekibin hizmet verdii merkez genellikle ana hastanenin dndadr. Ekip grev ve sorumlulukasndan yaplandrlm, yaplacak iler ise planlanmtr. Her hasta iin kayt vardr ve ohasta iin yaplacaklar bireysel olarak yazl planlanmtr. Ama kronik ar ruhsalrahatszl olan hastalarn yaadklar ortamda takip ve tedavilerinin yaplmasdr. Bu sayedehastalarn toplumun dna atlmadan ve dlanmadan toplumla birlikte yaamalar hedeflenir.Bakanlmz tarafndan 2006 ylnda hazrlatlan ulusal ruh sal politika metnindetoplum temelli modele gei tavsiye edilmi ve Bakanlmz ruh sal politikasnda hastanetemelli modelden toplum temelli modele geme karar almtr. Bu modelin ilk basamaolarak da Toplum Ruh Sal Merkezleri (TRSM) ama karar Salk Bakanl tarafndanNisan 2009da alnm ve pilot almalarn sonular deerlendirilerek ilgili ynerge ubat2011de yaynlanm ve uygulamas balamtr.55

Community Mental Health CenterA center;where severe psychiatric patients and their families are instructed and informedwhere rehabilitation, psychoeducation, occupational therapies, group or individual therapies are administrated to increase the life skills of patientswhere patients are followed strictly, (even at an emergency, patients are visited by mobile groups) This centers cooperate with psychiatry clinicsCare of the people who have severe psychiatric disease10% of them need care in the long termWhile 50% of the schizophrenia patients live with their families in Europe, this rate is estimated to be 95% in TurkeyWith the modernization process it is estimated that living with family would decrease and care bed need would increasePrivate institutions has been established to care disabled people (150)Ruhsal zrllerin bakmnda ada yaklam, toplum iinde apartman dairelerindekk gruplar halinde yaamalardr. Bu nedenle oluturulacak bakm yataklar toplum iindekk gruplar barndran evler veya ev topluluklar eklinde olmaldr.58Care of the people who have severe psychiatric diseaseAccording to NIMH (National Institute of Mental Health) Data, severe mental disorder has been identified in the one third and one fourth of homeless peopleAccording to a study carried out on homeless people in Istanbul, 85.7% of them has a psychiatric disease, 43,1% of them has psychotic disorder.Development and Promotion of Mental HealthRaising awareness of stigmatization and discriminationPrevention of violence against womanPrevention of child abusePrevention of suicidesPrevention of the psychological results of the disasters and traumas

Damgalanma ruhsal rahatszl olan bireylerin karlatklar en nemli sorunlardanbiridir. Hastalarn kendilerine saygsn azaltan, aile ve evreyle ilikisini bozan,sosyallemelerini engelleyen, zgrce yaama ve alma haklarn ellerinden alan birtutumdur. Sonuta hastalar hastalklar sebebiyle her vatandan sahip olduu sradan birinsan gibi yaamak hakkna sahip olamamaktadrlar.Toplumda ok yaygn olan ruh sal bozuk olan kiiler daha ok iddet gsterirlerve tehlikelidirler, ruhsal hastalk kiisel zayflktan dolay oluur, ruhsal hastalar tedaviedilemezler gibi yanl bilgi ve nyarglar sebebiyle oluan damgalama ve ayrmclklamcadele etmek gerekir. Damgalama ve ayrmclkla mcadelenin etkili olabilmesi iin hastave hasta yaknlarnn kurduklar dernekler, salk alanlar, sivil toplum kurulular, medya,meslek kurulular ve resmi organlar hep birlikte hareket etmelidirler. DS bu mcadeleninbelirli bir program dahilinde yaplmasn ve eylem plannn oluturulmasn nermektedir.

Kadna Ynelik iddetin nlenmesiKadnlara ynelik aile ii iddet, kadnlarla erkekler arasnda eit olmayan gilikilerinin sonucu meydana gelen ve zel yaam iinde olduundan dolay genellikle gizlitutulan, tespit edilmesi zor bir sorundur. Birlemi Milletler Kadna Ynelik iddetinnlenmesi Bildirgesinde kadna ynelik iddet, ister kamusal isterse zel yaamda meydanagelsin, kadnlara fiziksel, cinsel, psikolojik ac veya strap veren ya da verebilecek olancinsiyete dayal bir eylem uygulama ya da bu tr eylemlerle tehdit etme, zorlama veya keyfiolarak zgrlkten yoksun brakma eklinde tanmlanmaktadr.Aile ii iddet organ travmalarna, geici veya kalc sakatlklara, yetersiz beslenmeye,kronik hastalklarn artmasna, madde bamllna, kronik arya, korunmasz cinsel ilikiyegirmeye, pelvik enflamatuar hastalklara, jinekolojik problemlere, dklere, dk arlktaocuk doumlarna, anne lmlerine, intiharlara neden olabilen nemli bir halk salsorunudur. iddet maduru ve risk altndaki kadnlarda depresif belirtiler, organik nedenlerleaklanamayan bedensel yaknmalar, uykusuzluk, youn korku ve kayg duyma sk rastlananbelirtiler olarak bildirilmektedir.

ocuk stismarnn nlenmesilkemizde mevcut sistemde, istismara urayan, ihmal edilen ocuklarn tan, tedavi,bildirim, izlem ve adli ilem srelerinde eitli aksaklklar yaanmakta, bunun sonucunda daistismara etkin bir biimde mdahale edilememektedir. Tbbi ve adli ilemler srasndaocuklarn yaantlarn uygunsuz koullarda defalarca dile getirmesine neden olunmakta, buda ocuun urad travmay iddetlendirmekte ve bazen yeni bir travma yaamasna sebepolmaktadr. Bu kurumlarda ocukla grme yapan kiiler, ou zaman ocuun ruhsaldurumunu gzetebilecek grme yapma eitimi almam kiiler olmaktadr. Zaten madurolan bu ocuklarn bu konuda zellemi kurumlarda deerlendirilmesi bu sreci daha azrselenme ile geirmeleri iin gereklidir. Bu zellemi kurumlarn istismara urayanocuklarla grme yapmak iin eitim alm kiileri istihdam etmesi gereklidir. Konu ileilgili kolluk kuvvetleri, adli merciler, sosyal hizmetler gibi kamu kurum temsilcilerinin istismara urayan ocukla mkerrer grmelerden kanmas, ocukla uzman kiilerinyapt grmeyi izlemeleri, kendi kurum ileyileri iin gerekli olan raporlar bu izlemsonucu oluturmalar, mahkemeler ve ilgili dier tm kurumlarn mmkn olduu lde bugrme ve raporlar esas kabul etmesi nemlidir. Bu amala, 2009 ylnda Adalet Bakanl,ileri Bakanl, MEB, Salk Bakanl, SHEK, Yargtay, Adli Tp Kurumu, EmniyetGenel Mdrl, Jandarma Genel Komutanl, Diyanet leri Bakanl ve Baronunkatlmlar ile bir alma balatlm ve yaplan bir dizi toplantdan sonra alnan kararlarnilerliini grmek amacyla Ankarada ilk pilot ocuk zlem Merkezi (M) 2010 ylndaalmtr. Yaplan gzlemlerde uygulamann ocuklar asndan olduka faydal olduu tespitedilmi ve ilgili kurumlarn ortak kararyla ocuk izlem merkezi saysnn yakn zamanda12ye karlmasna karar verilmitir. Bu arada ilgili kurumlar tarafndan bu konuyla ilgiliyasal mevzuatta ihtiya duyulan yeni dzenleme almalarna balanmtr.

Afet ve Travmalarn Ruhsal Sonularnn nlenmesilkemiz deprem kua zerinde olduu iin bazlar ok iddetli olabilen depremlerile sel, dmesi, toprak kaymas gibi doal afetler ska yaanmaktadr. Ayrca lkemizdeyangn, i kazas, doal gaz patlamas gibi olaylar da seyrek deildir. Tm bunlara maruzkalan, bazen geni kitleler bazen de bireyler olay annda, hemen sonrasnda veya uzun yllarboyunca psikolojik olarak etkilenebilmekte ve bazen psikiyatrik mdahale gerekmektedir.Afet veya travma sonras oluan stresi en aza indirmek ve ileri dnemlerderahatszlklarn ortaya kmasn engellemek iin proaktif mdahalede bulunmak gerekir. Afetyada travma an ve hemen sonras kaotik bir sretir. htiyalarn en yksek, kaynaklarn enaz olduu bu dnemde insanlar zamana kar bir yar yapmak zorundadr. Fizyolojik vemaddi ihtiyalarn n planda olduu bu dnemde olayn oku psikolojik ihtiyalar glgeler.Ancak barnma, yemek, gvenlik gibi temel fizyolojik ihtiyalarn belirli bir dzeydekarlanmaya baland ve kaotik ortamn biraz getii dnemde psikolojik ihtiyalar nsray alr. Psikolojik sorunlar fizyolojik ihtiyalarn artmasna sebep olduu gibi karlanmasve ba edilmesi her zaman mmkn olmayan problemlere de sebep olabilirler. Bu dnemdekitlelere veya bireye salkl mdahalede bulunulmazsa ileride yaanabilecek sorunlarn dahaok bymesi muhtemeldir.zellikle geni kitleleri etkileyen afetler kiinin yaralanmas veya sakatlanmas,yaknlarn lm veya sakat kalmas, kiinin bunlar kt artlarda grmesi ve yaamas,aresizlik, imkanszlk, bir ey yapamama, ie yaramama duygularnn youn yaanmas,olaylardan veya sonularndan bir ekilde sorumlu olduunu dnme, bakalarn sulama veintikam alma dnceleri, z saygy kaybetme, intihar dnceleri, temel fizyolojikihtiyalarn karlamamas sebebiyle regrese olma veya sululuk duyma gibi youn psikolojiksreler yaanabilir. Bu sreleri yaayanlarn ou akut stres bozukluu semptomlargsterse de ok az post-travmatik stres bozukluu tans alr. Ancak bu zorlu sreleremutlaka mdahale edilmeli ve kitleler veya birey desteklenmelidir. Bu mdahale veyadestein nasl yapld ok nemlidir. zellikle byk afetlerde bazen psikolojik destekverenler de post-travmatik stres bozukluu yaabilmektedir.

60Prevention of suicidePrevalance: 3-45/100.000.There are biological, genetic, psychological, sociological and environmental factorsAmong the top 5 causes of young deaths in 15-19 aged)Many have mental disorderATTENTION: 40-60 % of them consult a physican in the month before suicideMany prefer GP, not psychiatrist

Studies for adolescents and children

Eitim sistemi;ocuk ve ergen ruh salnda eitim sistemi ok nemlidir. Tm eitim kurumlarndarehberlik ve psikolojik danma hizmetleri kapsamnda yrtlen psikososyal destek venleme almalar, hem ocuk ve ergenlerin salkl geliiminde hem de salkl bir toplumolumasnda nemli bir yere sahiptir. Bu konuda yrtlen faaliyetler, ruhsal sorunlarn erkenfark edilmesi asndan da kritik bir neme sahiptir. Bu nedenle okul alanlarnn ocuk veergen ruh sal konusunda bilgilendirilmeleri ocuklarn hem salkl geliimleri ve hem desorunlarnn erken dnemde tedavi edilebilmesini salayan bir adm olmaktadr. ocuk veergen ruhsal sorunlarnn tedavi aamasnda nemli yeri olan zel eitim merkezlerilkemizde Milli Eitim Bakanlna balanmsa da, bu kurumlarn eitim ilevlerinin ieriigzden geirilmeli ve toplum temelli modele entegre edilmelidir.Adalet ve gvenlik sistemi;Adalet sisteminin hem ocuklarn gvenliinin ve bakma muhta olanlarn korumaaltna alnmasnn salanmas gibi ilevleri ve hem de ok nemli bir ocuk ve ergen ruhsal koruma sistemi olan ocuk haklarnn takibi ykmll vardr. zellikle ergenlikdneminde sua eilimli ve su ileyen genler konusunda adalet ve emniyet tekilatylatedavi kliniklerinin ibirlii iinde olmas gerekmektedir. Krize mdahale konusunda bubirimlere srekli hizmet ii eitim planlanmaldr.62Estimated cost of mental health action plan

Plann 6 yllk toplam maliyeti yaklak 1.67 milyar TL olarak tahmin edilmektedir.Bina inaat ve tadilatna btenin %68i ayrlm olsa da (Tablo.17.) 2016 ylndan sonrakidnemde bu alandaki ihtiyacn ok azalaca; 2017-2023 yllarn kapsayan dnmedekaynaklarn tamamnn toplum temelli ruh sal sistemine kaydrlaca dnlmektedir.63 References and Web SourcesT.C. Salk Bakanl Ulusal Ruh Sal Eylem Plan (2011-2023). T.C. Salk Bakanl Yayn No; 847. Anl Reklam Matbaaclk Ltd.ti. Kzlay Ankara. 2011.World Health Organization. Mental health action plan 2013-2020.TUK, Salk Aratrmas, 2012.Kaplan &SadocksComprehensiveTextbook of Psychiatry(ev. Editrleri: Aydn H, Bozkurt A.) Ankara / Trkiye: Gne Kitabevi Ltd.ti.,Lippincott Williams &Wilkins. 2007.Krolu E, Gle C. (Editrler) Psikiyatri Temel Kitab, 2. bask, Ankara: Hekimler yayn birlii. 2007.