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 .