PSYCHIATRYINvIEmm I

n November 1996 a collaborative workshop organised by the Vietnam National Institute of Mental Health and the Section of Social and Cultural Psychiatry of the Royal Australian and New Zealand College of Psychiatrists was held in Hanoi. Approximately 45 participants from Australia and New Zealand and 90 psychiatrists and psychiatric trainees from throughout Vietnam attended the workshop. This was the first major psychiatric scientific meeting held in Vietnam and was a valuable opportunity for colleagues from the three countries to meet and get to know each other, and to discuss recent developments in mental health and opportunities for collaboration. The meeting was very successful. It was certainly a most enjoyable experience. A number of collaborative possibilities that were discussed are now being actively pursued. The abstracts from the papers presented by the Vietnamese participants are reprinted below from the conference proceedings [l]. (Allabstracts of papers presented by Vietnamese, Australian and New Zealand participants were also printed in a separate volume in Vietnamese.) These abstracts give a very good overview of psychiatric research, psychiatric training and mental health services in Vietnam. Harry Minas Chairman, RANZCP Section of Social and Cultural Psychiatry

Figure I: West Lake, Hanoi

Figure 2: Associate Professors Harry Minas and Tim Lambert and Professors Peter Yellowlees and Bruce Singh

SOME FEATURES OF EPIDEMIOLOGY OF MENTAL DISORDERS IN VIETNAM

The prevalence of some mental disorders is shown below:

IVguyen Dang D w

Table I: Prevalence of some mental

Central Psychiatric Hospital and National Institute of Mental Health Since 1964 more than 30 epidemiological studies of mental disorders have been carried out in Vietnam in communes or quarterswith populations of between 3,000-50,000, USING screening instruments and mental health interviews. Diagnoses have been made in the 1970s and 1980s using ICD-8 and ICD-9 criteria and, since 1992, ICD-10 has been used, together with Korbicov’s Classification and DSM-111.

disorders SchEophrenia Bipolar mood disorder Epilepsy Traumatic psychosis Neurosis Phychopathy Alcoholism Drug addiction Bahaviouraldisorders in adolescents aged 10-17 yean

0.3- I .O%

0.03406% 0.3-.O% 0.15-0.2% 3-5% 0.245% 0.2-3.0% 0.1545%

0.37%

In relation to prevalence of the ‘endogenous

Australasian Psychiatry Vol5, No 1 February 1997 3

psychoses’, there is no daerence in different study areas. The prevalence of neurosis is higher in urban areas than in rural areas.Drug abuse prevalence is higher in the highland regions where poppies are grown. Other basic measures are not mentioned. The epidemiologicalindices are helpful to health authorities in the design of mental health service strategies.

RESEARCH STUDIES ON MENTAL HEALTH IN Tran Thi Binh An The author presents research works on Mental Health during recent years. They are as follows: Epidemiological surveys of mental disorder Mental handicaps Mental health protection at community level Mental retardation Behavioural disorders in adolescence Head injury due to H i c accidents Drug abuse and treatment methods Stress-related disorders 0 Clinical epidemiologicalresearch on alcohol abuse The above-mentioned research work was under the guidance of the National Institute of Mental Health and the leaders of Mental Health Services, so they aimed at common objectives, had suitable samples and reasonable criteria for assessment. These research projects had synchronised structure from the South to the North, from urban to rural regions, and from the highlands to the coastal areas. All the studies focused on emerging problems of the society and their relation to the mental health of the community. The studies produced very meaninghrl data and figures which prompted the Government and the authorities to develop better solutionsfor mental health problems and for the protection of mental h&. Dif€icdtiesin mental health research include the lack of specialists,with one psychiatrist per 15O,O00 population, and an i d e q w ~ budget. e These problems make it very difficult for Vietnamese psychiatrists to deal with mental health problems of the society. Some main orientations for mental health research in the comingyears will be referred to. The author hopes that Vietnamese psychiatry will take advantage of the cooperation with Australia and New Zealand in community mental health research.

EPIDEMIOLOGICALRESEARCH AND SCHIZOPBRENlAINvlETNAM Nguyen Van Siem N a t w d Institute OfMental Health & Central Psychiatric Hospital Psychiatric epidemiologicalresearch and psychiatry have developed together in Vietnam. Up till now, more than 30 epidemiologicalsurveys have been published and can be classified in three categories: The first category comprises surveys carried out in communes or quarters of about 3,000-5,OOO inhabitants each. People suspected to be mentally ill are revealed by key persons in community. When the diagnosis of schizophrenia has been based on the four A’s (Bleulerian symptoms), the prevalence has been underestimated (0.15423%of the general population). The second category includes surveys carried out in communes or quarters of about 4,000-10,000 inhabitants each, 4 Australasian Psychiatry

Vol5, No 1 February 1997

and from household to household. Schizophrenia has been diagnosed according to the presence of negative symptoms and the prevalences given have been 0.3-0.37%. The Lhird category includes surveys carried out in a commune or quarter of about 4,5oO-l2,000inhabitants each, using screening instruments that might contribute to the early identification of those with possible schizophrenic disorders (interviewcarried out at home, from house to house). When the diagnosis has been made according to ICD-10 diagnostic criteria for schizophrenia, the prevalence reported has ranged from 0.52461%.Other basic epidemiological measures will also be discussed. Known and found cases have all been registered and treated at community level. Follow-up studies and epidemiological evaluation have been carried out in two study areas.

EPIDEMIOLOGICAL SURVEYS OF ALCOHOL ABUSE

Tran Viet N& Director, National Institute OfMental Health, Hanoi In 1W,epidemiological surveys were carried out at seven rural areas and eight urban areas including 80,892 inhabitants. Morbidity rates of alcohol abuse were higher in mountainous areas (7.047%) than in urban areas (6.3-10.4%).In rural areas, these rates were 0.57-1.2% The rate of alcoholism w a s high in urban areas (1.17-3.61%).In mountainous and rural areas, these rates were respectively 0.2-2.34%and 0.14-0.42% of the general population. Alcohol abuse was markedly higher in males, who constituted 98%of abusers. The quantity of alcoholic beverage consumed every day was 100-500 mL. In rural and mountainous areas, rice alcohol was consumed. In urban areas, various alcohol beverages were used by 3643.8%of abusers. Persons that started drinking at the ages 21 to 30 years represented 43.840% of abusers. Alcohol abuse in drivers was found in 4.4492%.Neurological symptoms (plyneuritis, headaches, trembling, hypoaesthesia) were found in 7.1-72% of abusers. Medical conditions (alcoholic cirrhosis, gastritis, acute pancreatitis) in 0.7-34%. Alcoholic psychosis (delirium tremens; Korsakov’s psychosis; psychotic disorder predominantly delusional or hallucinatory; personality or behaviour disorder): 0.31-6.91%of inpatients. Social harms: Fighting in 10-80%of abusers, delinquency in 5-52%, responsibility for accidents 5.20%,loss of job in 10-32%, broken family in 8-18%, collapsed familial economy in 1548%. The control of alcohol abuse requires a multisectoral participation.

MENTAL DISORDERS IN VIETNAMESE CHILDREN Hoang Cam Tu Department of Psychiatry and Epilepsy, Institutefor the Protection of Child Health, Hanoi The Vietnamese population is approximately 75 million, with children under 16 years making up 50%. The Mental Health Care system for adults has been developed over more than 30 years, and its network extends to the communal level of the Primary Health Care system. However, the system of Mental Health Care is very young and weak, raising recent concerns. Public knowledge concerning mental health care for children is still poor, there is a small number of staff working in the system and there is a lack of necessary skills.

There is, as yet, little basic epidemiologicaldata concerning mental disorders in Vietnamese children. Some surveys conducted by the Institute for the Protection of Child Health showed that among children with mental disorders, neurosis made up 16.7-25.5%; pain without organic cause made up 32.3%;mental retardation 1%;behavioural disorders (including criminal behaviours) 2.4-3.7%. Drug abuse is rapidly increasing, with adolescents constituting 70%of the total number of drug addicts. Among cases of suicide, 10%are in the age group 1&17 years. In some institutions for Child Mental Disonlers, statistics show high rates of neurosis (2-12%), mental retardation (16-17%), tic (7.3-16.7%), post-encephalitis mental disorders (12.8%),other acute psychotic disorders (5.2-23.6%), attention deficit-hyperkineticsyndrome (2.44.7%),depression (2.6%). In addition epilepsy made up a considerable rate. Vietnamese child psychiatry is not yet sufficiently developed. We would like to propose: It is necessary to perfom epidemiological surveys according to a unified method in order to have better data on child psychiatry in Vietnam. Training in the mental health of children is needed for psychiatrists, nurses, psychologists and social workers. Community information and education concerning mental health care for children is also very important.

management of depression in young people. These guidelines are presented, and considered in terms of their applicability within an Australian and Vietnamese context.

TRAINING OF PSYCHIATRISTS IN VIETNAM Nguyen Viet Thiem National Institute of Mental Health

IDENTIFICATION AND MANAGEMENT OF DEPRESSION IN YOUNG PEOPLE: VIETNAMESE AND AUSTRALWIJ PERSPECTIVES Marie R B a s h and Hoang Cam Tu Depression in adolescents and young adults has become a public health problem in a number of developed countries including Australia and New Zealand. It is estimated that at any one time, between 1 and 3 per cent of adolescents could experience a major depressive disorder. Consequences such as prolonged psychological distress, disruption of family relationships, deterioration in scholastic and work performance may occur. In response to this problem, the leading health advisory body in Australia, The National Health and Medical Research Council has developed best practice guidelines for the identification,assessment, diagnosis, prevention and

Figure 3: Professor Marie Bashir

Figure 4: Professor Nguyen VLet Thiem, National Institute of Mental Health Even though Vietnam has to ovemome so much economic difficulty after the war, psychiatry has established and maintained a mental health care network including 19 psychiatric hospitals at provincial level, 38 psychiatric wards in 33 general hospitals in numerous provinces and cities and 375 psychiatric dispensaries at districts and communes. Working according to this system, Vietnamese psychiatry has more than 500 preliminary psychiatrists, 70 Grade I psychiatrists, 20 Grade II psychiatrists, six psychiatric PhDs and four Professors of Psychiatry. Our psychiav is much younger than a lot of other medical specialties, but we have an effective network and a contingent of medical sta€f cooperating from the central level down to the commune level throughout the country. However, to respond to the increasing demand for quality of treatment and the target of health care for all by the year 2O00, mental health is an important part of human beings' health according to its full meaning and we still have to make a lot of effort in training 90 that we can perform our duties effectively. In order to increase the quantity and competence of psychiatrists, we have adopted the following training strategy: To teach general practitioners some basic knowledge of psychiatry so that they can integrate with others in their clinics at districts and communes. Currently, we have about 600 general practitioners (trained in this way) working in the mental health care system. Prelirnimwyp s y c h i : Preliminary psychiatrists are trained in the following manner: General practitioners who have specialised in psychiatry for one year. Preliminary psychiatrists are the main component of the psychiatric team, working in psychiatric hospitals in provinces and cities. Up to now, there are more than 500 preliminary psychiatrists trained in this way. Grade Ipsychiutrists: Preliminary psychiatrists (who have

Australasian Psychiatry Vol5, No 1 February 1997 5

had enough practical experience) specialise for two years in psychiatry to become Grade 1 psychiatrists. General practitioners may specialise for three years with a special training program in the National Institute of Mental Health and Hanoi Medical College. Nowadays, we have 70 Grade I psychiatrists throughout the country. Gude Upsychiatrists:They are experts experienced in psychiatric practice and capable of designing mental health care strategies appropriate to their area. Most Grade I1 psychiatrists work in central psychiatric hospitals and the psychiatric departments of medical colleges. Training of Grade II psychiatrists: Grade I psychiatrists with some years experience in clinical psychiatry undergo further specialisation in psychiatry for two years at NIMH and the psychiatric depaTtment of Hanoi Medical College. MaJten cud PhB in Psychiatry: Masters and PhD in Psychiatry are trained to become the experts working in scientific research and teaching units. They are the main component of the psychiatric team working in NIMH and the psychiatric d e p t m e n t s of medical colleges. A masters and PhD training pragram has been planned and we are preparing to carry it out. Up to now, we have two Masters and six PhDs. All were trained abroad, in Russia and other countries. In the h, because of a lack of facilities, we would like help and experience from other countries, especially from Australia and New zealand, in the training of postgraduates. Apart from these activities, in order to accomplish the Mental Health care system all over the country, we need assistance (materials as well as experience) from other countries to complete our training pmgrams for social workem, psychiatric nurses and psychologists.

the South (Bien Hoa) and a couple of small ones in the Noah

(Hanoi and Bacgiang). All three institutions were places where patients with chronic, severe psychoses were confined. Stage 2: From 1954 to 1975: Formal Vietnamese psychiatry was born with the establishment of the Hanoi Medical College Department of Psychiatry in 1957. Subsequently, some other Departments of Psychiatry were founded in Thai Binh, Bac Thai and Hai Phong. These Psychiatry Departments trained psychiatrists who were later distributed to the Noahem provinces to form the psychiatric hospitals, mental health centew, and psychiatric clinics in general hospitals at provincial level. The Mental Health Network was gradually developed in the North and integrated into the primary health care system. Stage 3: From 1975 until m:There was further consolidation and strengthening of the mental health network in the North as well as step by step development of the same model of mental health senices in the newly liberated provinces in the South. The country now has six Departments of Psychiatry in medical colleges (where S20 psychiatrists have been trained), 20 psychiatric hospitals at National and provincial levels, and 33 mental health clinics in General Hospitals. The total number of psychiatric beds is 5,300. The Mental Health Network also consists of 375 district mental health clinics, with 30% of communal health centers taking part in provision of mental health services. This network is now providing treatment and management for approximately 150,000patients with schizophrenia and epilepsy. These institutions and the whole network of mental health services of the country are now working under the unified guidance and direction of the National Institute of Mental Health on aspects of prevention, treatment. training, research and international cooperation.

MENTAL HEALTH SERVICES IN VIETNAM Nguyen Viet Former Director, Naiionul Instituie of Mental Health

This paper describes the development of Mental Health Services in Vietnam through 3 stages. Stage 1: Befoore 1954: With no formal psychiatry throughout the Country, there was only one large psychiatric institution in

THE ROLE OF WHO IN THE DEVELOPMENT OF PSYCHIATRY IN VIETNAM Ngo Thanh Hoi National Institute of Mental Health Over the past 10 years, WHO project MNH.OO1 has developed greatly and has become the most important international cooperative project of the Mental Health sector in Vietnam. It is recognized that the project has supported Vietnamese Mental Health services and psychiatry through the development of a modem psychiatry following advanced orientations of WHO. Some import research projects have been supported, such as:

Figure 5 : Dr Michael Epsteln, Secretary of the RANZCP, presenting a College plaque t o Professor Nguyen Viet, Director, National Institute of Mental Health

6 .4ustralasian Psvrhiaw Vol5, No 1 February 1997

Trial of ICD-10 application in diagnosis of mental disorders in Vietnam, and Clinical-Epidemiological survey on Alcohol abme in Vietnam. WHO has also supported a series of training courses, seminars and workshops on the most i m p o m emerging problems for Mental Health care in Vietnam. These have included: Workshop on behavioural disorders in Children and Adolescents, 1991. Workshop on upgrading the quality of diagnosis and treatment of mental disorders, 1992. Training courses on Methodology of treatment for Drug Abuse, 1994. Meeting on prevention of drug abuse and HIV infection in Vietnam, 1995. Other workshops and training courses have been held on: Community-based Mental Health care. Clinical psyrhopharmacology.

Five-year application of ICD-10 criteria in Diagnosis of mental disorder in Vietnam. Alcohol abuse in Vietnam. Stress related disorders: diagnosis and treatment. Experts and consultants have been sent to Vietnam by WHO to assist Vietnamese psychiatrists in upgrading their knowledge and practical skills in almost all fields of modem psychiatry. With WHO fellowships, ten Vietnamese psychiatrists have travelled overseas to gain experience, knowledge and skills from countries within the region and world-wide. WHO has supplied some essential medicaments and equipment which have played an important part in consolidating and strengthening the quality as well as the capacity of Mental Health institutions in Vietnam. Overall, the cooperation with WHO has formed one of the principal dynamic forces contributing to the development of Vietnamese psychiatq and Mental Health services in response to increasing requirements for Mental Health care for Vietnamese people at present and in the future. 0

PRIMARY MENTAL HEALTH CARE IN HANOI Nguyen Minh Hai Hanoi Psychiutric Hospital Hanoi is the Capital of S.R. Vietnam. Area 922.8 km2 Population 2,219,400with a growth rate of 2.2% per Ye=

Mental Health Network 43 psychiatrists, 10 pharmacists Since 1970, Mental Health services in Hanoi has been developed following the direction of integrating into the developnrent of t h t z Primary Health Care network of the Metropolitan Health Service. The Hanoi Mental Health Center (under the authorisation of the Hanoi psychiatric Hospital) is responsible for: Organising the treatment for outpatients downward to the communal level Directing Psychiatric consultations in Health Centers of the districts Implementing basic surveys on Mental Health Medicament distribution Propagandising Psychiatric hygiene and prevention of mental disorders Information, training and retraining for the st& of network Mental Health counselling Psychiatric consultations in District Wealth Centres are responsible for: Management of patients within the district, including:

.

.

I

Hanoi Psychiatric Hospital: 300 beds

I

Hanoi Mental Health Center

~

I

I

1

I0 District Health Centers. each includes: A psychiatric clinic with I psychiatrist, I pharmacisf 2 nurses

Communal Health service One nurse responsible for mental health

diagnostic examination, prescription, direction for treatment and care at home or at Communal Health Centers. Examine new patients, send them to mental Health Center or Hospital if necessary. Take part in mental health surveys or scientific research. Communal nurses who are responsible for mental health: Keep and distribute medicines to patients according to the prescriptions of the doctors. Follow up outpatients, find new cases or relapses of mental disorder, refer cases when appropriate to the Mental Health Centre or Psychiatric Clinic in the District health Centre. Guide families and patients to follow long term treatment. At present 5,000 outpatients with schizophrenia or epilepsy are under treatment and management by this Mental Health Network. Various activities are being carried out to support patients, and to promote mental Health for the people of Hanoi.

.

. .

SCHIZOPHRENIA IN FORENSIC PSYCHIATRY AT THE CENTRAL PSYCHIATRIC HOSPITAL Tran Van Cuong National Institue $Mental Health Of the total number of individuals (n = 119) with mental disorders and being under forensic psychiatry unit at the Central Psychiatric Hospital (Thuong Tin) during the period 1990-19!95 because of delinquency, those with schizophrenia represented 42%.Among them 94%were male. In 98%of cases, age at onset of illness ranged from 15 to 34 years. 28% of patients had at least one first-degre biological relative that suffered from schizophrenia. The paranoid type was related to delinquency in 60% of cases. Psychosocial factors played a mle in provoking illegal actions in 40% of acute cases and in 60% of stabilised cases. The length of illness prior to the time of infraction was one to five years in 74% of cases. The means the patients used to cany out illegal actions were various, with the most common means being knives (54% of cases). The patients were responsible for 36 caws of death and 20 cases of severe injury. The majority of victims were family members. One of the difficulties in practising Forensic Psychiatry is that the diagnosis has to be made retrospectively and it is not always easy to determine the relationship between the patient’s mental state at the time of illegal action and his aggressive acts. Forensic Psychiatiy is very recent in our institution. We would like help Gom Australian and New Zealand colleagues by exchange of experience and providing literature.

COMMUNITY BASED PSYCHO-SOCIAL REHABILITATION OF PERSONS WITH

SCHIZOPHRENIA Nguyen Dang Dung

Central Psychiatric Hospital and National Institute of Mental Health Schizophrenia is a common chronic mental illness (prevalence of 0.3-1% of population). It is also a disabling and relapsing illness with many bad outcomes individually and socially. If well treated and rehabilitated in primary health care services, patients can be well integrated in the community. A pilot-study for this purpose was carried out in five communes/quarters with 5,000-10,000 inhabitants each. The program includes the following activities: Providing the necessary information about schizophrenia to lay persons in community, such as family members, Red Cross

Australasian Psychiatry Vol5, No 1 February 1997 7

members. teachers and other volunteers. Individual therapy, readaption therapy, and family therapy are used. The evaluation is made after one year implementation. Relapse in 8oo/o of cases. Very good remission in 20-30%; good remission in 44-50%, mean remission in l2-190/0, increase in functioning at school and at work in 3040%. The community potential has been mobilised. Staff members at Primary Health Care (PHC) services, Red Cross members. volunteers and especially family m e n h w have played an important role in the patients' rehabilitation. The community attitude towards persons with schizophrenia has been improved in terms of tolerance, care taking and providing social supports for normal life for patients with schizophrenia. One year experience showed that the integration of community based psycho-social rehabilitation for those with schizophrenia into PHC services is feasible. The program could be developed in a large scale manner at communedquarters if state funding were available.

PSYCHIATRIC CLINICS ITY GENERAL HOSPITAL Nguyen Van Ngan The treatment of mental patients has recently been making gmat impmvements. During the past decades, the building of psychiiatric hospitals designed for several thousand patients seemed to be a marvellous achievement. The long duration of stay of mental patients in the hospital used to be an index of the civilization of the country. Yet it is no longer suitable. Nowadays many nations and international organisations have been concerned with treatment of mental patients in families and in the community. Therefore the issue of the organisation of psychiatric clinics in general hospitals is worth paying attention to.

In this report, some aspects of a psychiatric clinic in a general 600 bed hospital will be discussed. Although the number of beds in the clinic for mental patients is only a small part of the total beds (5-7%) it is very important, because this clinic receives the mental patients in the acute stage of illness. The rate of psychiatric emergencies is high (38%), including patients who have attempted suicide or other dangerous behaviors (19.8%). The rate of patients with mental disorders due to such diseases as encephalitis, vascular diseases, brain tumors, toxicosis, etc., is 17-1Wc. Those patients needed help from other disciplines, such as intensive cam! and emergency, neurology, neurosurgery, toxicology, infectious pathology, etc. The help is mow sdEcient when the psychiatric rlinic is in a general hospital. Cm the other hand, the psychiatrists are able to recognise concomitant mental disorderr early in patients with somatic diseases. In the general hospital, mental patients can have all advantages of available medical technical expertise as do other patients. Generally, mental patients can be given more complete care. A psychological survey showed that 82% of questioned patients and 98%of their relatives agreed with the idea to organive the psychiatric rlinic in a general hospital. Most of the patients and their relatives did not like treatment in a psychiatric hospital. It might be related to negative attitude of the .society lo psychotic patients. That social complex has even had influence on the staff working in psychiatric hospitals. Regarding the arrhiterture and organisation of a psyrhiatric clinic. we think the open-door system is suitable. It allows not only the patients, but also the medical staff to feel comfortable. Generally speaking, following the trend of treating mental patients in the community and families, the organisation of psychiatnc clinics in general hospitals is necessary. We think, thereforr, that besides provincial psychiatric hospitals, such 8 Australasian Psychiatry Vol5, No 1 February 1997

psychiatric clinics with 20-25 beds should also be organised in provincial general hospitals.

DRUG PROGRAMS IN VIETNAM Nguyen Minh Tuan and Ngo Thanh Hoi National Institute of Mental Health

There are approximately 185,000 drug abusers throughout the country (c. 0.3%of the population). About 50,000 are injecting drug users and the rest (135,000)are drug-smokers. The main drugs being abused now are opium and opioid substances. 6080% of injecting drug users share non-sterilised syringes and needles. Up to the date of 16th August 1996, there have been 4.109 HIV positive cases, 3% AIDS patients, with 1% deaths. Injecting drug users made up 72.7% and sex-workers made up 6.3%of the total n u d e r of HIV positive persons found in Vietnam. Vietnam has developed a national drug control program (VNDCP) according to government resolution W/CP - January, 1993. The VNDCP - Master plan of activities to the year 2000 involved 18 Ministries and Sectors of the whole country, including the Ministry of Health. The main tasks are as follows: Information and preventive education. Demand reduction: 'Long-term community based treatment and rehabilitation of drug abuse' is now applied in Vietnam with some promising results. A pilot study of methadone maintenance treatment is carried out by NIMH. Other harm reduction programs have started by integrating the activities of drug prevention and HIV/AID prevention programs. Supply reduction: Law enforcement on prevention of drug tra3icking and drug trading. Eradication of opium poppy cultivation in the mountain areas by developing substitution planting and raising living standards of minor ethnic population. Enhancement of the forces fighting against illicit trading and &cking in drugs. The Vietnamese people and the Government have made great efforts to develop the programs on both demand and supply reduction of drugs, reinforcement of the legal system, cooperation with other countries and international organizations. Although there are many difficulties, especially in aspects of the economy, we believe that Vietnam will gain increasing success in the drug programs, that need effective support from international community.

CLINICAL ASSESSMENT IN CHILD BND ADOLESCENTPSYCHIATRY IN NllMH DinhDangHoe In August 1992, under the leadership of Prof. Nguyen Viet, director of NIMH, the unit for Paediatric Psychiatry was founded in response to the requirement for mental health care for children and adolescents in Vietnam. From August 1992 to October 1996,770 examinations and treatment courses have been undertaken for 300 children. Male: 177 (59%); female: 123 (41%); from Hanoi: 161(54.7%),fmm provinces: 139 (45.3%),Age from 6 to 15years: 269 (81.7%); age from 11to lS years: 168 (56%) The diagnoses were as follows:

Diagnosis Epilepsy Psychotic disorders Mental retardation Somatic-formed disorders (including 30 cases with headache [lo%]) Behavioural disorders Tic Depression Other: various diagnoses such as dmrsion disorder, anxiety, learning disorders, sleep disorders, etc.

No. of cases

Sample (%)

67

50 47

22.3 16.7 15.7

34 25 23 10

11.3 8.3 7.7 3.3

44

14.7

Clinical examination: Observation and interview of the child, interview of members of the family or the child’s teachers. Psychometric tests: A number of tests have been applied to assess intelligence (Raven, Gille, Denver), personality (MMPI), depression (Beck), anxiety (Zung) and some Painting tests. Diagnoses have been made in accordance with ICD-10 criteria. Suitable methods of treatment were selected for each particular case including, as appropriate, pharmacotherapy and psychotherapy, with close cooperation between the psychiatrist, the family and the school. The unit of Paediatric Psychiatry faces a number of difficulties. It is a small institution, which lacks necessary equipment and sta€f,and lacks experience, 60 it is very difficult to set up examination, treatment and staff training. Some considerable advantages are the support of Bach Mai Hospital, a big general hospital with many specialized sectors that consistently offer useful cooperation.The support of foreign experts has included occasional lectures, and the presentation of books, journals, documents, etc. Now we need more investment and support to develop mental health care for children and adolescents.

RELAXATION TRAINING IN VIETNAM Nguyen Viet National Institute of Mema1 Health

Before 1957, psychotherapies used to be carried out by general doctors and traditional medical practitioners. They were mostly promotion, reasonable explaining and indirect psychotherapies. In 1957, with the establishment of the Psychiatric Department of the Hanoi Medical College, specific psychotherapieshave been developed. Trials of psychoanalysis had been carried out but with obviously limited results, and the main direct psychotherapies that have been broadly applied were persuasive therapy and suggestive therapy. Hypnotherapy has been applied since 1966, with some early remarkable results, but with many disadvantages revealed over time. In order to overcome those disadvantages, research on Relaxation Training started since 1970 in the NIMH. This method is the combination of amended Schultz’s method of Relaxation and Hathayoga method of Training (Asana positions and abdominal breathing). From 1979 Relaxation Training has been taught in Hanoi Medical College and applied nation-wide. The method has undergone the practice of treatment and has shown its effectiveness in neurosis and somatopsychogenic disorders. The first steps of a research program on behaviour therapy were taken in 1984. Some good results have been gained but this method required a well-trained process which is difficult to popularize. Therefore Relaxation Training still remains the principal method of direct psychotherapy in Vietnam today.

THE USE OF PSYCHOTROPIC DRUGS IN PRACTICAL PSYCHIATRY Nguyen Viet Thiem N a t w d Institute OfMental Health In Vietnam, although the range of available psychotropic drugs is insufficient, pharmacological treatments have enabled us to take care of mental patients in hospitals organised according to an open door system, and also to provide treatment to large numbers through Primary Health Care services, with an emphasis on social rehabilitation. The essential psychotropic drugs in common usage in state health services are chlorpromazine, haloperidol, levomepromazine, methophenazine, sulpiride, diazepam, amitriptyline and c a r h e p i n e . Also used are the long-acting neuroleptics, such as piportil L.4,haldol decanoate, fluphenazine decanoate and flupenthixol decanoate. As well as lithium salts, depamide, selleril, neuleptil, solian, anafranil, clozapine and MA01 are not used in Vietnam. The rational use of drug treatments enables reduction in the length of patients’ stay in hospital and also reduction of ECT indications to a necessary minimum. Unwanted effects and pharmacodependence are common.

ECT APPLICATION IN THE NATIONAL INSTITUTE OFMENTLHEALTH Nguyen Thi Mai ECT was initiated by Cerletti and Bini in 1937. Although it seemed to be apparently invasive, ECT has good effectiveness in many cases. Since the 1950s, with the availability of the new neuroleptics and antidepressants, the use of ECT has gradually diminished. When drug-resistance increased in psychiatric treatment, ECT began again to be applied in many countries. In Vietnam, in the National Institute of Mental Health, the indications for ECT are the following: Severe depression with suicidal ideas or behaviours Catatonic immobility or excitement Hebephrenic excitement with poor results of long-term treatment The contra-indications are: Organic brain disease Heart and vascular diseases Respiratory insufficiency Severe infectious diseases Diseases of bones, muscles and joints a Old age, premancy or menstrual period Due to the anti-psychiatry campaigns in the decades of the 1960s and 197Os, many countries abolished ECT without anaesthesia. ECT has been applied in NIMH for several years with sigdcant effectiveness,rare complications (except for some cases of joint displacement - jaw, shoulder) and mild disorder of memory during the first one to two weeks after ECT. Now in Vietnam, we lack ECT equipment, especially in provinces, where equipment is oft& old and in poor condition. Therefore we need support to acquire a number of new, modern ECT machines.

TREATMENT OF USUAL NEUROLEPTIC RESISTANT CASES OF SCHIZOPHRENIA IN THE CENTRAL PSYCHIATRIC HOSPITAL pham h c T M The Central Psychiatric Hospital is a high level specialised Australasian Psychiatry Vol5, No 1 February 1997 9

institution which receive people with schizophreniafrom northern provinces and mainly from districts near the Hospital. Annually, there are about 1,500 admissions and mcst admissions are cases of chronic schizophrenia(appmximately W%) with many relapses and hospitalisations. 15%of patients are &tory to usual neuroleptics. The patients in this study are those who meet one ofthe two following criteria: Patients who do not respond at all after at least 6 weeks of treatment with two or more usual nemleptics from two a e r e n t classes. Patients unable to tohate treatment with usual neuroleptic drugs because of severe and untreatable side effects and extrapyramidal m t i o n s . Over many years, several treatments have been used without satisfactory success. In recent years, three treatments have been on trial: use of Leponex alone, use of ECT alone, and use of neuroleptics intermittently. The number of patients included in the study are still relatively small in nurnber and it is too early to report results.

THE USE OF DEPAMIDE AND LITHIUM SALTS IN THE 'lWATMF,NT AND PREVENTION OF AFfk%VE PSYCHOSIS La Thi Buoi N a t w d Institute o f h i e d Health In recent years, the thymo-regulators have been more and more in common usage. Lithium carbonate has a n m w safety

10 Australasian Psychiatry Vol5, No 1 February 1997

spectrum and its use requires careful control of lithium blood level. There have been serious cases of allergic reactions to

cahamazepine. A study using depamide in the treatment of affective disorders has been carried out in NIMH in the years 1%%. Three series of patients with the same diagnosis have been treated, the first series of 31 patients by depamide, the second of 30 patients by lithium carbonate and the third of 30 patients by neuroleptics. The results obtained are as follows: Effectiveness has been obtained later in the series using depamide than in the series using lithium salt, but the side effects in the first are rare and tolerance is better. Depamide combined with nemleptics has stabiLised affective disordem more rapidly than neuroleptics used alone. Unwanted effects, such as parkinsonian symptoms, have been rare because the neumleptic is prescribed in reduced dose. As for the preventive action of lithium salt compared with depamide, there is no significantmerenee. Therefore, depamide has been used in the prevention of relapse of affective psychosis and schizo-affective disorder. The cases in study are still small in number because of a lack of depamide in Vietnam. We would like, dear Australian and New Zealander colleagues, your help and cooperation in further developing the study of relapse-prevention of affective disorder using depamide. Reference 1. Minas IH. (ed.1 Reeeni Developments in Mental Health: Proceedings of a Colhboratiw~Workshop Betuwn'Victnam Australia and New Zealuta. Melbourne, Centre for Cultural Studies in Health, 1996.