Infant Mental HealthInfant Mental Healthin Israelin Israel
Sam Tyano, MDSam Tyano, MDMiri Keren, MDMiri Keren, MD
Acco, Sep. 2009Acco, Sep. 2009
IsraelIsrael
• Total population: 7.28 million
• Ethnic distribution: 80.1% - Jewish; 19.9%- Non Jewish:– Arabs: 14.65% (1,066,520)– Bedouins: 2.74% (200,000)– Druze: 1.64% (120,000) – Armenian: 0.068 (5000)
• Land surface area: 22,770 Km2
• Neighboring countries: Lebanon, Syria, Jordan, Egypt
ReligionReligion
Jewish
Muslims
Christians
Druze
others
76%16%
4.5%1.8%1.8%
• Languages spoken:Languages spoken:– Official: Hebrew, Arabic– More 17 languages
• Literacy rates:Literacy rates:– Total population: 95.4%– Male: 97.3%– Female: 93.6%
• Between 1993 and 2006, post-secondary education increased by 45% among Jewish women and doubled among Arab women. However, the educational disadvantage of Arab women remains: in 2006, 19% of Arab women, as compared with 46% of Jewish women, had post-secondary education
GNPGNP
• GNP- 128.67 Billion $
• Per capita-18,624 $
• By the end of 2006, the number of Israeli children and adolescents below the age of 18 totaled 2,365,800.
• Of these, 69.1% were Jews; 24% Muslims; 1.9% Christians; 2% Druze; and 3% did not have a registered religion
• % of total budget dedicated
to health: 7.9%
• % of total health budget dedicated to mental health: 5.8%
Health & mental health policies and ways of Health & mental health policies and ways of enforcing them including patients' rightsenforcing them including patients' rights
Under Israeli law, all citizens and de jure residents are medically insured. Medical services are delivered primarily by four public health funds (HMO-like organizations) except for mental health services, which until now have been delivered mainly by the Ministry of Health.
Ctd.Ctd.
Mental health care is facing a major reform effort, including a proposed shift in responsibility for the provision of mental health services from the Ministry of Health to the four public HMOs. When responsibility for mental health services shift from the ministry to public insurers, the role of the primary care physician as a “gatekeeper” and guide is likely to become even more prominent.
National Expenditure on Health, by National Expenditure on Health, by financing sector, 2007financing sector, 2007
Government budget
Households
Health tax
37%
36%
27%
Specialty mental health clinics by providers, Specialty mental health clinics by providers, target age group and districttarget age group and district
ChildrenChildren
and youth-n and youth-n All ageAll age
groups ngroups nAdults only Adults only
nnTotal NTotal N
Government & Government & municipalitiesmunicipalities
21 37 43 101
Private and Private and NGOsNGOs
2 5 0 7
Public Public hospitalshospitals
2 10 2 14
HMOsHMOs 10 34 30 74
TotalTotal 35 86 75 196
Infant Mental Health Project in Infant Mental Health Project in IsraelIsrael
• Stage 1 ( 1997-2005 )- The creation of 7 units of Infant Psychiatry all around the country
• Stage 2 ( 2006-2009 )- The creation of one satellite to each one of the sites
Safed
kineret
Dead sea
Mediterranean sea
Stage 1Stage 1 1. Petah Tikvah
2. Haifa
3. Safed
4. Jerusalem Eitanim
5. Jerusalem Hadassa
6. Beer Shaeva
7. Ashdod
Safed
kineret
Dead sea
Mediterranean sea
Stage 2 SatellitesStage 2 Satellites.11 .Rosh Haayin
2 .Bnei Braq
3 .Kafer Kassem
4 .Nazareth
5 .Tirat Hacarmel
6 .Beitar Ilit
7 .Eilat
Collaborative Regional projectsCollaborative Regional projects• Geha Mental Health Center was the first mental health
center that initiated sharing of professional knowledge between Palestinian and Israeli Adult and Child Psychiatrists:
- A two-year training course in Adult Psychiatry for professionals from Gaza Mental Health Center took place at Geha Hospital (once a month).
- Geha Child and Adolescent teams went to Gaza strip, to meet local community professionals and implement workshops, frontal lectures and group supervision in Child Psychiatry. Five meetings actually took place.
CTD -The Israeli-Palestinian Infant CTD -The Israeli-Palestinian Infant Mental Health Training Course ProjectMental Health Training Course Project
• Setting: Three overnight week-ends at a hotel in East Jerusalem for a 48 (16 x 3) hours of training.
• Participants: 14 Palestinians from Bethlehem, Ramallah, Naplus, and East Jerusalem, with 14 Israelis from West Jerusalem. All of them are community child mental health professionals.
• Goal: To increase basic knowledge on core concepts of psychopathology in infancy, early detection, diagnosis, assessment and therapeutic principles, and specific diagnostic entities.
CTD -To summarize the processCTD -To summarize the process……
• Mental Health professionals from both sides of the conflict first meet in a neutral country, far from societal pressures, just to “feel” if the encounter is possible; then share knowledge.
• Sharing knowledge about mental processes in itself triggers affects, because of our basic identity as therapists.
• Mutual affective recognition leads to a change of perception of the Enemy, first in the professionals’ minds and then back in their own society through them.
Some data about the Some data about the Mother UnitMother Unit
• 1996: 50
• 2008: 263
0
50
100
150
200
250
300
New cases
1996
2008
Petah Tikvah dataPetah Tikvah data
Number of Number of sessions per sessions per month:month:
• 2004 : 220
• 2008 : 470
0
50
100
150
200
250
300
350
400
450
5002004
2008
0
10
20
30
40
50
60
Boys
Girls
Gender distributionGender distribution
60%
40%
Age distributionAge distribution
Number of casesNumber of cases AgeAge
61 0 - 1years
101 1 - 2 years
92 2 - 3 years
Sources of referralSources of referral (2008)(2008)
Nb of casesNb of cases SourceSource90 Self referred
58 Well-Baby Centers
56 Pediatricians
15 Social welfare
6 Adult psychiatrist
1 Day care
1 Child psychiatrist
Who is referred to the infant mental Who is referred to the infant mental health clinic ?health clinic ?
Nb of casesNb of cases ReasonsReasons
385
Infant (sleep, feeding, behavior, anxiety, development…)
34
Mother (depression, anxiety, difficult relationship with infant, divorce…)
11
Father (depression, anxiety, difficult relationship with infant, divorce…)
Range of change following treatmentRange of change following treatment
Full change- 32.65 %
Partial change - 63%
No change - 4%
0
10
20
30
40
50
60
70
Range of change
Domains of changeDomains of change
0
10
20
30
40
50
60
70
80
Infant’s symptoms
Parent-Infant Relationship
Perception of the infant
75%
14.58%10.42
%
The Unit involvement in Petah Tiqva The Unit involvement in Petah Tiqva communitycommunity
• Consultations to Day nursery for high risk infants
• Training and Supervision of “Support Security” groups run by Community Nurse and Social worker.
• Supervision of Ethiopian community workers
• Consultations and Supervision in Residential nursery for waiting-for-adoption infants
The three pivots of the ProjectThe three pivots of the Project
Clinic
Research Teaching
Creating an academic structure aimed at Creating an academic structure aimed at training Infant Mental Health Units training Infant Mental Health Units
professionals:professionals:• Authorization from the Post Graduate School of
Medicine to open a 2 years program on Infant Psychiatry. • The students are Multidisciplinary Senior professionals .• Structure of the 6 hours a week course:
– lectures on clinical infant psychiatry
– pediatrics, general, legal, ethical, economical and other community issues
– Small groups clinical discussion of videotaped normal infants (first year of the course) and supervision on cases
presented by the students (second year of the course).
One more step: A computerized chart One more step: A computerized chart for all the Unitsfor all the Units
The aim:The aim:
To develop a common clinical, research and epidemiological conceptualization
of our work.
Integrating research into clinical Integrating research into clinical routine work at the Unitroutine work at the Unit
• It is crucial for - Continuously showing the need and the impact of work
with infants.
- Increasing the team’s level of knowledge.- Understanding better the field we are in…- Defining our own identity by combining our theoretical
definition with what we actually do.
• Two types of research: - Descriptive and comparative. - Longitudinal (videotaped) follow-ups.
Projects for the near futureProjects for the near future
• To consolidate the existing satellites and expand them in accordance with local needs.
• To create centers for intensive care where parents and infants can come three to four times a week and get a therapeutic accompaniment ,a parental education and support.
• To establish a national-based preventive program, based on professionals’ home visits, aimed at reducing the percentage of infants at risk for later psychopathology, and improving parents’ coping with challenging infants.
• To enlarge the collaboration with Palestinian IMH professionals
Vision for futureVision for future
• Planning actions for fighting the stigma around Infant Psychiatry. ( See WPA awareness Project on Child Psychiatry 2007 )
• Improving the collaboration between Social welfare, Ministry of Health, Pediatricians, Psychologists and Child Psychiatrists working with Infants .