07. Tunis.jpg
Tunisia is a country with an approximate area of 164 thousand sq. km. (UNO, 2001). Its population is 9.937 million, and the sexratio (men per hundred women) is 101 (UNO, 2004). The proportion of population under the age of 15 years is 27% (UNO, 2004),and the proportion of population above the age of 60 years is 8% (WHO, 2004). The literacy rate is 83.1% for men and 63.1% forwomen (UNESCO/MoH, 2004).The country is a lower middle income group country (based on World Bank 2004 criteria). The proportion of health budget to GDPis 6.4%. The per capita total expenditure on health is 463 international $, and the per capita government expenditure on health is350 international $ (WHO, 2004).The main language(s) used in the country is (are) Arabic and French. The largest ethnic group(s) is (are) Arab. The largest religiousgroup(s) is (are) Muslim.The life expectancy at birth is 69.5 years for males and 73.9 years for females (WHO, 2004). The healthy life expectancy at birth is 61 years for males and 64 years for females (WHO, 2004).

EPIDEMIOLOGY

A community epidemiological study carried out on a representative sample of 5000 adults in one region reported a life time prevalence of about 9% for major depression and 0.6% for schizophrenia (Hachmi et al, 1995). Fakhfakh et al (2000) assessed the use of tobacco (smoking) in Tunisia since 1970 using different sources. Cigarette smoking increased from 1981 to 1993 but decreased slightly after that. The prevalence of current tobacco smoking was 30.4% (52% for males and 6% for females). In young people, the prevalence was 29.2% (50% for males and 3.9% for females). Young people who attended school smoked less than those who did not (18.1% versus 38.4%). Most started smoking between 14 years and 18 years. Gassab et al (2002) conducted a retrospective study of depression in a clinical sample (n=155) of bipolar (n=86) and recurrent depressive disorder (n=59) patients, diagnosed according to the DSM-IV criteria. The following factors were correlated with bipolarity: separation/divorce, family history of psychiatric disorders (especially bipolar disorders), early onset, number of affective episodes, sudden onset of depressive episodes and psychotic features, catatonic features, hypersomnia and psychomotor inhibition. Somatic comorbidity (diabetes, hypertension, rheumatic diseases) and dysthymic disorders were predictors of non-bipolar depression. The bipolar family history criterion had the highest positive predictive validity, while the psychotic characteristics criterion had the lowest positive predictive validity. Moalla et al (2001) found that organic (somatic illnesses, epilepsy) and environmental (parental quarrels, poor family support) factors were associated with onset of mental disorders in a sample of more than 1400 child psychiatry out-patients. Ayadi et al (2002) found divorce to be associated with mental disorders in children (personality disorders, functional disturbance and depressive disturbance). Karoui and Karoui (1993) compared children with pica with children without pica in a day care centre and found that pica was associated with gender (male), family history of pica (positive in 57% of the cases), socioeconomic status (low) and locality (urban). The onset was between 12 and 18 months in most cases. Children of divorced parents had worse short- and medium-term outcomes in comparison to children of parents who were staying together, but the long-term outcome was similar.

MENTAL HEALTH RESOURCES

Mental Health Policy A mental health policy is present. The policy was initially formulated in 1986. The components of the policy are advocacy, promotion, prevention, treatment and rehabilitation. There are committees and subcommittees
looking into the training of personnel, preparation of manuals for physicians at the primary care level, visits of specialists to outpatient departments on a periodic basis, review of drug list, radio and television programmes and research. The main thrust
of the policy are integration of mental health into primary care, training of non-psychiatric medical professionals in psychiatric care, creation of psychiatric services in general hospitals and sectorization of services.
Substance Abuse Policy A substance abuse policy is present. The policy was initially formulated in 1969. The substance abuse policy was revised in 1969 and 2000.
National Mental Health Programme A national mental health programme is present. The programme was formulated in 1990. The goals of the programme are to promote and protect mental health and to prevent, detect and treat mental disorders.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1979. The national therapeutic drug policy/essential drugs list has been re-evaluated in 1993 and in 2000. Mental Health Legislation Law No. 92-83 of 1992 on mental health and conditions of hospitalization of individuals with mental disorders was the first law in the field of mental health. The latest legislation was enacted in 2003.
Mental Health Financing There are no budget allocations for mental health. Details about expenditure on mental health are not available. The primary sources of mental health financing in descending order are tax based, out of pocket expenditure by the patient or family, private insurances and social insurance. The country has disability benefits for persons with mental disorders. Mental health patients are provided financial, treatment and transportation benefits.
Mental Health Facilities Mental health is a part of primary health care system. Actual treatment of severe mental disorders is available at the primary level. The general practitioners diagnose severe disorders and refer patients almost systematically to the second/third level care (a second level care is only available in a few regions) for treatment and monitoring. Regular training of primary care professionals is carried out in the field of mental health. In the last two years, about 280 personnel were provided training. Though training has been provided to some primary care personnel, a system of follow-up has not been developed yet. A manual for training of physicians has been prepared. There are community care facilities for patients with mental disorders. Some NGOs provide community based care for children under the aegis of the Social Affairs Ministry.

Psychiatric Beds and Professionals

Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population

  • 1.13
  • 0.85
  • 0.27
  • 0.0
  • 1.6
  • 0.2
  • 0.2
  • 0.4
  • 0.6
  • 0.0

Programmes for Special Population The country has specific programmes for mental health for indigenous population, elderly and children. There are services for delinquents, abandoned children, prostitutes and patients affected by HIV.

There are some facilities for children and adolescents in the form of day care hospitals, consultancy clinics and medico-school centres. There is also a school health programme. There are homes for the elderly and mentally challenged individuals.

Therapeutic Drugs

The following therapeutic drugs are generally available at the primary health care level of the country: carbamazepine, sodium valproate, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, lithium. Drugs like cloimipramine form a part of the essential drug list.


Source: World Health Organization Mental Health Atlas