بسم الله الرحمن بسم الله الرحمن الرحيمالرحيم

Mental healthMental health

الحمد لله رب العالمين والصالة الحمد لله رب العالمين والصالة والسالم على نبينا محمد خاتم والسالم على نبينا محمد خاتم األنبياء وسيد المرسلين وعلى األنبياء وسيد المرسلين وعلى

آله وصحبه أجمعين وبعدآله وصحبه أجمعين وبعد

Mental health as part of primary Mental health as part of primary health carehealth care

Mental health care is a basic and essential Mental health care is a basic and essential building block for ensuring life-long good building block for ensuring life-long good health. Multipurpose health workers, family health. Multipurpose health workers, family doctors and general practitioners need to doctors and general practitioners need to become increasingly better able to become increasingly better able to recognize any potential mental impairment recognize any potential mental impairment or brain disorder in order to provide quality or brain disorder in order to provide quality carecare. .

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

The implementation of The implementation of these programs have been these programs have been carried out in different carried out in different degrees in the countries of degrees in the countries of the Regionthe Region. .

DepressionDepression

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

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

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

Why is depression important?Why is depression important?

Projections are that by 2020, depression Projections are that by 2020, depression will be second only to heart disease in its will be second only to heart disease in its contribution to the global burden of contribution to the global burden of disease as measured disability-adjusted disease as measured disability-adjusted life yearslife years

PREVALENCEPREVALENCE

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

Epidemiology of Depression Epidemiology of Depression Among Women Among Women

In U.S. twice as many women (12.3%) as In U.S. twice as many women (12.3%) as men (6.7%) are affected each year men (6.7%) are affected each year 12.4M women and 6.4M men12.4M women and 6.4M men

For low-income women, the estimated For 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 Depression Epidemiology of Depression Among MothersAmong Mothers

Estimated rates of depression among Estimated rates of depression among pregnant and postpartum women range pregnant and postpartum women range from 8 to 20%.from 8 to 20%.

For low-income women with young For low-income women with young children, prevalence rates are commonly children, 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 of The illness affects all people, regardless of sex, race, ethnicity, or socioeconomic sex, race, ethnicity, or socioeconomic standing. However, women are two to standing. However, women are two to three times more likely than men to suffer three times more likely than men to suffer from depression. Experts disagree on the from depression. Experts disagree on the reason for this difference. Some cite reason for this difference. Some cite differences in hormones, and others point differences in hormones, and others point to the stress caused by society's to 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 can vary. although the pattern of symptoms can vary. The prevalence of depression in other The prevalence of depression in other countries varies widely, from countries varies widely, from 1.5 percent 1.5 percent of people in Taiwan to 19 percent of of people in Taiwan to 19 percent of people in Lebanonpeople in Lebanon. Some researchers . Some researchers believe methods of gathering data on believe methods of gathering data on depression account for different rates.depression account for different rates.

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

Social scientists have proposed Social scientists have proposed many explanations, including many explanations, including changes in family structure, changes in family structure, urbanization, and reduced cultural urbanization, and reduced cultural and and religious influencesreligious influences

Prevalence of DepressionPrevalence of Depression In JordanIn Jordan

• A study published last year, done A study published last year, done on Jordanian women reviewing on Jordanian women reviewing PHC centers for different reasons PHC centers for different reasons showed a rate of 37% scored showed a rate of 37% scored positively. positively.

OnsetOnset

Although it may appear anytime from Although it may appear anytime from childhood to old age, depression childhood to old age, depression usually begins during a person's 20s usually begins during a person's 20s or 30s. The illness may come on or 30s. The illness may come on slowly, then deepen gradually over slowly, 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 to Some depressions seem to come out of the bluecome out of the blue, even when , even when things are going well. Others seem things are going well. Others seem to have an obvious cause: a to have an obvious cause: a marital conflict, financial difficulty, marital conflict, financial difficulty, or some personal failure.or some personal failure.

Yet many people with these problems do Yet many people with these problems do not become deeply depressed. Most not become deeply depressed. Most psychologists believe depression results psychologists believe depression results from an interaction between stressful life from an interaction between stressful life events and a person's biological and events 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 strong researchers have found evidence of a strong genetic influence in depression. Genetically genetic influence in depression. Genetically identical twins raised in the same environment identical twins raised in the same environment are three times more likely to have depression in are three times more likely to have depression in common than fraternal twins, who have only common 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 have identical twins are five times more likely to have bipolar disorder in common.bipolar disorder in common.

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

Genetic/Biochemical FactorsGenetic/Biochemical Factors

Genes may influence depression by Genes may influence depression by causing abnormal activity in the brain. causing abnormal activity in the brain. Studies have shown that certain brain Studies have shown that certain brain chemicals called neurotransmitters play an chemicals called neurotransmitters play an important role in regulating moods and important role in regulating moods and emotions. emotions.

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

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

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

Medical causesMedical causes

A variety of medical conditions can cause A variety of medical conditions can cause depression. These include dietary deficiencies in depression. These include dietary deficiencies in vitamin B6, vitamin B12, and folic acid (see vitamin B6, vitamin B12, and folic acid (see Vitamin); degenerative neurological disorders, Vitamin); degenerative neurological disorders, such as Alzheimer's disease and Parkinson's such 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 and and 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 illness As a secondary to psychiatric illness especially Neurotic (Obsessive especially Neurotic (Obsessive Compulsive Neurosis), or Affective Compulsive Neurosis), or Affective Schizophrenia. Schizophrenia.

C) Stressful C) Stressful Events/EnvironmentalEvents/Environmental

Psychologists agree that stressful Psychologists agree that stressful experiences can trigger depression in experiences 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 one For example, the death of a loved one may trigger depression. Psychologists may trigger depression. Psychologists usually distinguish true depression from usually distinguish true depression from grief, a normal process of mourning a grief, a normal process of mourning a loved one who has died (Reactive loved one who has died (Reactive Depression).Depression).

GenderGender In the United States, women are about as twice In the United States, women are about as twice

as likely as men to be diagnosed and treated for as likely as men to be diagnosed and treated for major depression. Approximately 20-25% of major depression. Approximately 20-25% of women and 12% of men will experience a women and 12% of men will experience a serious depression at least once in their serious depression at least once in their lifetimes. Among children, depression appears to lifetimes. Among children, depression appears to occur in equal numbers of girls and boys. occur in equal numbers of girls and boys. However, as girls reach adolescence, they tend However, as girls reach adolescence, they tend to become more depressed than boys do. This to become more depressed than boys do. This gender difference continues into older age.gender difference continues into older age.

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

TREATMENTTREATMENT

Depression typically cannot be shaken or Depression typically cannot be shaken or willed away. An episode must therefore willed away. An episode must therefore run its course until it weakens either on its run its course until it weakens either on its own or with treatment. Depression can be own or with treatment. Depression can be treated effectively with treated effectively with antidepressant antidepressant drugs, psychotherapy, or a drugs, psychotherapy, or a combination of both.combination of both.

Other TreatmentsOther Treatments

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

Despite the availability of effective Despite the availability of effective treatment, most depressive disorders go treatment, most depressive disorders go untreated and undiagnosed. Studies untreated and undiagnosed. Studies indicate that general physicians fail to indicate that general physicians fail to recognize depression in their patients at recognize depression in their patients at least half of the time. In addition, many least half of the time. In addition, many doctors and patients view depression in doctors 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 in even though treatment for depression in older people is usually very effective.older people is usually very effective.

ConclusionConclusion

Of the estimated 17.5 million Americans Of the estimated 17.5 million Americans who are affected by some form of who are affected by some form of depression, 9.2 million have major or depression, 9.2 million have major or clinical depressionclinical depression

Two thirds of people suffering from Two thirds of people suffering from depression do not seek necessary depression do not seek necessary treatment. treatment.

80%80% Of all people with clinical depression Of all people with clinical depression who have received treatment significantly who have received treatment significantly improve their lives.improve their lives.

The economic cost of depression is The economic cost of depression is estimated at $30.4 billion a year but the estimated at $30.4 billion a year but the cost in human suffering cannot be cost in human suffering cannot be estimatedestimated

Women experience depression about Women experience depression about twice as often as mentwice as often as men

By the year 2020, the World Health By the year 2020, the World Health Organization (WHO) estimates that Organization (WHO) estimates that depression will be the number two cause depression 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 Disease According to the U.S. Centers for Disease Control and Prevention (CDC) suicide was Control and Prevention (CDC) suicide was the ninth leading cause of death in the the 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 with Maternal 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 parenting Depression interferes with parenting

Impact on child may be serious, of long Impact on child may be serious, of long durationduration

Structural barriers such as lack of Structural barriers such as lack of insurance and racism leave many families insurance and racism leave many families outside treatmentoutside treatment

Depression is treatableDepression is treatable

RecommendationsRecommendations

Public education.Public education. Provision of relevant posters and leaflets Provision of relevant posters and leaflets

in waiting rooms at PHC centers helps in in waiting rooms at PHC centers helps in destigmatization of the disease.destigmatization of the disease.

Improvements in depression screening Improvements in depression screening have paralleled improvements in have paralleled improvements in depression treatment and reduced stigmadepression treatment and reduced stigma

Encourage patients to talk about their Encourage patients to talk about their symptoms with their Family doctors.symptoms with their Family doctors.

Recognition of depression by the patient Recognition of depression by the patient and his or her family.and his or her family.

PCPs have embraced responsibility for PCPs have embraced responsibility for screening ,recognition, and treating screening ,recognition, and treating depressiondepression

For additional efficiencies, we will needFor additional efficiencies, we will need Advances in technology (e.g,computerized Advances 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

DementiaDementia

Dementia is defined as Dementia is defined as global impairment of global impairment of cognitive function which cognitive function which interferes with normal interferes with normal activities.activities.

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

Alzheimer's accounts for most cases of Alzheimer's accounts for most cases of dementia.dementia.

10-20% cases are attributed to vascular 10-20% cases are attributed to vascular (multi-infarct) dementia (multi-infarct) dementia

Other causes-alcoholism, Parkinson, vit Other causes-alcoholism, Parkinson, vit B12 deficiency, hypothyroidism, CNS B12 deficiency, hypothyroidism, CNS infections, intracranial lesionsinfections, intracranial lesions

Prevalence of DementiaPrevalence of Dementia

Increases steadily with age, roughly Increases steadily with age, roughly doubling every 5 years doubling every 5 years

Common among institutionalized elderly Common among institutionalized elderly Present in ½ to 2/3 of nursing home Present in ½ to 2/3 of nursing home

residents residents Family history associated with an Family history associated with an

increased risk of Alzheimerincreased risk of Alzheimer

Prevalence of DementiaPrevalence of Dementia disease progresses over a period of 2-20 disease progresses over a period of 2-20

years, causing increasing functional years, causing increasing functional impairment and disability impairment and disability

Care of the demented patient imposes an Care of the demented patient imposes an enormous psychosocial and economical enormous psychosocial and economical factors.factors.

• Alzheimer’s burden on the familyAlzheimer’s burden on the family

Risk factorsRisk factors Age: Strongest risk factor particularly for Age: 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 above 3.3 % 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

Risk factorsRisk factors Family history : Especially in relation to Family 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 genotype Apolipoprotein E epsilon 4 genotype

predisposes to development of ALZDpredisposes to development of ALZD

Risk factorsRisk factors History of head trauma especially with the epsilon 4 History of head trauma especially with the epsilon 4

alleleallele History of low educational achievementHistory of low educational achievement Organic solvent exposureOrganic solvent exposure Female genderFemale gender 16%/6% 16%/6% Relationship to blood pressure : a U shape Relationship to blood pressure : a U shape

associationassociation Hypercholesterolemia /role of statinsHypercholesterolemia /role of statins

DiabetesDiabetes

Screening TestsScreening Tests

Dementia is easily recognized in advanced Dementia is easily recognized in advanced stages, often overlooked in early stagestages, often overlooked in early stage

Clinicians fail to detect 21-72% of patients Clinicians fail to detect 21-72% of patients with dementia esp. in early stageswith dementia esp. in early stages

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

Alzheimer Warning SignsAlzheimer Warning SignsTop 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 personality 9. Changes in personality 10. Loss of initiative10. Loss of initiative

Dementia Type—Total Dementia Type—Total PopulationPopulation

Distribution of Dementia Types

Mild cognitive impairmentDementia with Lewy bodiesVascularMixedOther

Alzheimer’s—mildAlzheimer’s—moderateAlzheimer’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

Source: Consumer Health Sciences, LLC. Alzheimer’s Caregiver Project. 1999.

Patient initially diagnosed Patient initially diagnosed with ADwith AD

Patient’s first diagnosis other than AD

Yes 28%

NoNo 72% 72%

21%7%9%

14%

14%

35%

Normal agingDepression No diagnosis

Dementia (not AD) Stroke

Other

AD is Under-diagnosedAD is Under-diagnosed Early Alzheimer’s disease is subtle, the diagnosis Early Alzheimer’s disease is subtle, the diagnosis

continues to be missed continues to be missed it is easy for family members to avoid the problem it is easy for family members to avoid the problem

and compensate for the patient and compensate for the patient physicians tend to miss the initial signs and physicians 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 remain Estimates 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 lessen Early diagnosis and appropriate intervention may lessen disease burdendisease burden Early treatment may improve overall course Early 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 by Efforts to develop biomarkers, early recognition by brain scanbrain scan

Prevalence of AlzheimerPrevalence of Alzheimer Alzheimer’s disease (AD) is the most Alzheimer’s disease (AD) is the most

common form of dementia. It represents a common form of dementia. It represents a worldwide medical challenge affecting worldwide medical challenge affecting more than 18 million people; estimated to more than 18 million people; estimated to reach 34 million by the year 2025reach 34 million by the year 2025. .

PREVALENCE of AD PREVALENCE 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) = 107,000 1% 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 491615

820959

0200400600800

10001200

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 per Nursing 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 and The 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 for With 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 Arab With over 1.5 million cases in the Arab world.world.Alzheimer’s disease is a devastating Alzheimer’s disease is a devastating illness which can affect all members of illness which can affect all members of societysociety

Conclusions and Conclusions and RecommendationsRecommendations

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

      

Multiple Sclerosis Multiple Sclerosis Epidemiology and Epidemiology and

PrevalencePrevalenceOnsetGeographic Distribution

Population StudiesGenetic Factors

Who Has MSWho Has MS

In the United States, about 400,000 In the United States, about 400,000 people have the disease, which is twice as people have the disease, which is twice as common in women as men. common in women as men.

Approximately 2.5 million people may Approximately 2.5 million people may have MS worldwide. have MS worldwide.

Most people with MS are diagnosed Most people with MS are diagnosed between the ages of 20 and 40. between the ages of 20 and 40.

Onset Geographic Distribution Population Studies

Genetic Factors

OnsetOnset

There are about 300,000 patients suffering from There 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 30 The age of onset peaks between 20 and 30 years. Almost 70% of patients manifest years. Almost 70% of patients manifest symptoms between ages 21 and 40. Disease symptoms 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 as However, 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 than females are affected more frequently than males (1.4 to 3.1 times as many women males (1.4 to 3.1 times as many women than men affected.)than men affected.)

Geographic DistributionGeographic Distribution

There is a very specific geographic There is a very specific geographic distribution of this disease around the distribution of this disease around the world. A significantly higher incidence of world. A significantly higher incidence of the disease is found in the northernmost the disease is found in the northernmost latitudes of the northern and the southern latitudes of the northern and the southern hemispheres compared to southernmost hemispheres compared to southernmost latitudes. latitudes.

This observation is based on the incidence This observation is based on the incidence of the disease in Scandinavia, northern of the disease in Scandinavia, northern United States and Canada, as well as United States and Canada, as well as Australia and New Zealand. The data from Australia and New Zealand. The data from migration studies shows that if the migration studies shows that if the exposure to a higher risk environment exposure to a higher risk environment occurs during adolescence (before 15 occurs during adolescence (before 15 years of age,) the migrant assumes the years 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 that Multiple sclerosis (MS) is a disease that attacks the central nervous system—the attacks the central nervous system—the brain and the spinal cord. Depending on brain and the spinal cord. Depending on which nerves are damaged, people with which nerves are damaged, people with MS may experience problems with balance, MS may experience problems with balance, muscle coordination, vision, speech, muscle coordination, vision, speech, thinking, or other physical and mental thinking, or other physical and mental abilities. abilities.

Population StudiesPopulation Studies

There are also population studies that show There are also population studies that show difference in susceptibility to MS between difference in susceptibility to MS between different populations. Lapps in Scandinavia different populations. Lapps in Scandinavia appear to be resistant to the disease, contrary appear to be resistant to the disease, contrary to the expectations based on their geographic to the expectations based on their geographic distribution. Native Americans and Hutterites distribution. Native Americans and Hutterites very infrequently suffer from MS, as opposed to very infrequently suffer from MS, as opposed to other residents of the North America. MS is other residents of the North America. MS is uncommon in Japan, China and South uncommon in Japan, China and South America. America.

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

Prevalence of MSPrevalence of MS

Prevalence data imply that racial and ethnic Prevalence data imply that racial and ethnic differences are important in influencing the differences are important in influencing the worldwide distribution of MS and that its worldwide distribution of MS and that its geography must be interpreted in terms of geography must be interpreted in terms of the probable discontinuous distribution of the probable discontinuous distribution of genetic susceptibility alleles. Racially and genetic susceptibility alleles. Racially and ethnically influenced differences in the risk ethnically influenced differences in the risk of MS, however, can be modified by of MS, however, can be modified by environment. environment.

Genetic FactorsGenetic Factors

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

SymptomsSymptoms

Symptoms associated with MS vary Symptoms associated with MS vary

widely. There is not yet a way to predict widely. There is not yet a way to predict what symptoms people with MS may what symptoms people with MS may experience. MS symptoms are divided into experience. MS symptoms are divided into three types: three types:

. .

Primary symptomsPrimary symptoms are those caused are those caused directly by the disease process including directly by the disease process including immune system activity, destruction of immune 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 maintaining problems with walking or maintaining balance, visual impairment (balance, visual impairment (optic neuritis), ),

lapses in memory,lapses in memory, inability to solve problems or pay attention inability 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 bowel and disturbances in bladder or bowel

function. function. Less common symptoms include speech Less common symptoms include speech

and swallowing disorders, tremors and and swallowing disorders, tremors and seizuresseizures

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

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

Multiple sclerosis in Arabs in Multiple sclerosis in Arabs in JordanJordan

. . Department of Biochemistry and Department of Biochemistry and

Microbiology, Faculty of Medicine, Jordan Microbiology, Faculty of Medicine, Jordan University, Amman.University, Amman.

In a 2-year hospital-based study (1992 In a 2-year hospital-based study (1992 and 1993), there were 131 multiple and 1993), there were 131 multiple sclerosis patients attending 2 large referral sclerosis patients attending 2 large referral hospitals in Jordan. There were 126 Arabs hospitals in Jordan. There were 126 Arabs of whom 84 were Palestinians and 36 of whom 84 were Palestinians and 36 indigenous Jordanians.indigenous Jordanians.

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

RecommendationsRecommendations More research and surveys about MS More research and surveys about MS

should be done in the Arab world.should be done in the Arab world. Researchers must consider the available Researchers must consider the available

evidence and direct their efforts towards evidence and direct their efforts towards multicenter studies of similar ethnic groups multicenter studies of similar ethnic groups living under different environmental living under different environmental conditions. Such an approach may provide conditions. Such an approach may provide significant clues for both pathogenetic and significant clues for both pathogenetic and triggering mechanisms of MS.triggering mechanisms of MS.

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