1. Introduction

Currently many children and adolescents in Armenia are not receiving treatment for mental health (MH) problems due to lack of awareness of the problem, fear of stigma or lack of access to appropriate services [7]: Child and adolescent mental health during the Soviet era, approaches to psychiatry ignored the social and psychological elements of mental illness and were biased towards those that were biomedical in origin. Interventions such as family therapy and psychotherapy were consequently undervalued, with great store being set on the provisibin of drug therapy. There was lack of understanding new concept and approaches: no sufficient continuous medical education; no prevention related systematic interventions were available in Armenia.

2. Content

10-20 % of children and adolescents at some point in their life may have MH related issues and half of the MH problems are starting around age of 14, as well as ¾ of the problems - before 20 years old [1,2].

According to official general child health (0-14 y.o.) statistics of 2018 [3] child illness per 100,000 population were 49787.1, among which and mental health related disorders are 295.4.

Comparison of the statistics with the year of 2015 indicates that there is an insignificant difference (50105.5 cases in 2015), in terms of child mental ill health the number of disorders is 260.4 in 2015 and 295.4 in 2018, which is showing that there is an increase of about 13% in mental health disorders [3]. In case of morbidity the total number of hospitalization per 100,000 population aged 0-14 was 60146.7 and particularly mental disorders 559.8 in 2015, but in 2018 total hospitalization is decreasing: number is 58808.3, but in case of children there is an increasing 9 % with total number of 611.8.

Armenia is not an exception when looking at the list of issues indicated in WHO report: “Children with mental disorders face major challenges with stigma, isolation and discrimination, as well as lack of access to health care and education facilities, in violation of their fundamental human rights” [2].

The study among patient’s family members shows that the majority (60%) think that other people can think negatively about personssuffering from mental illness or can associate mental health patients’ problems with their families, and think negatively about their families as well. Almost all (80%) respondents that mental health problems can bring to lower quality of life and worsen their families’ quality of life even more than mental health patients’ quality of life [4].

3. Psychiatric Services and CAMH Services as well

In Armenia it is implemented within the framework of a state order, the state is obliged to cover all necessary expenses.

Psychiatric care and services, including Child and Adolescent Psychiatry is free of charge and is part of the state order, the state is obliged to compensate all costs. There are no in-patient CAMH services available in Armenia, except five beds for chronically ill psychiatric patients provided in the Adult Psychiatric hospital in Armash village of Ararat province [8].

All out-patient child psychiatry is provided free of charge by “Saint Grigory the Illuminator” medical centre in Yerevan, except the Gyumri MH centre of Shirak region.

In general mental illness in the family can be a crisis for family members. Those children in Armenia with MH or developmental problems quite often do not live with their families for various reasons, such as financial, lack of appropriate home care services, no accommodation or a very small flats for large families, everyday problems, but they still need 24 hours 7 days care. When they are abandoned by family they receive their care by different agencies related to Ministry of Labor Social Affairs.

There are very few publications on CAMH in Armenia. According to the Institute of Child and Adolescent Health, thirty percent of adolescents, especially females, reported feeling sad quite often orvery often during the last week; 7.5% of surveyed boys and 10.1% of girls had thought about attempting suicide during the past 12 months [5]. Overall, the concept of mental health care for children is not well developed; many interventions are fragmented and controversial.

It is indicated in the joint report three CAMH institutions, including UNICEF Armenian office that great efforts have been made to encourage the adoption of internationally recognized approaches to therapy, “old-fashioned” and outmoded practices which reflect only biological considerations remain popular. Implementing new concepts and mechanisms on mental health care in a country in transition such as Armenia is strongly dependent upon public perceptions [7].

WHO-AIMS REPORT ON MENTAL HEALTH SYSTEM IN Armenia (2009) stating that there are 1311.5 users per 100,000 general population treated true mental health outpatient facilities. Among those patients treated through outpatient services 29% are female and 2% are children and adolescents. There are 3 mental health facilities that provide day treatment care in Armenia, all of them are for adults only. There are no day treatment facilities for children and adolescents.

Same report is also positioning that only 5% of the training for medical doctors is devoted to mental health. Yet the training is even less for nurses and takes only 1% of their undergraduate curriculum. The majority (51-80%) of physician-based primary health care doctors make on average at least one referral per month to a mental health professional. The majority (51-80%) of non-physician based primary health care clinics make a referral to a higher level of care [6].

In another UNICEF and Arabkir charity joint report (Bruce Dick, et al, 2010), discussing about strengthening health services for school-age children and adolescents in Armenia, they are concluding that it will be important to have consensus around the content of the minimum package of services for school-age children and adolescents, in terms of the priority health issues that it should be possible to respond to at primary care level (acute illness, chronic illness, physical and mental health, prevention and identification of high risk behaviours).

In parallel with all mentioned before there are also various nongovernmental organizations are functioning and they are mostly implementing projects in the field of CAMH, besides there are very few private organizations that are providing paid CAMH services, the overall size of which is much smaller than the state.

4. Conclusion

The issue of human resources and training of professionals is still remaining unresolved. The co-authors can consider the personnel issue as the Achilles heel not only child and adolescent Psychiatry, but also Psychiatry in general. Most of skilled child psychiatrists are concentrated in Yerevan, and there are no child psychiatrists working in regions of Armenia. As the co-authors already mentioned, currently concentrated in Yerevan, and there are no child psychiatrists working (January- February 2020) by state order only eight child psychiatrists in Yerevan are involved in the field of outpatient psychiatric care and a specialist in Gyumri the second in its size city of Armenia.

The current state is far from satisfactory and there is a huge demand for intensive intervention for solving the problem: to postgraduate more child psychiatrists, to other professionals’ allayed mental health and according to statistical data and prevalence of mental disorders among child and adolescents create network of child and adolescents mental health services.

There is a huge need for interventions: work out strategic frame work and preventative policy, data-driven and/or decision-making tools aimed to improve Public and Ministry of Health, Ministry of Social affairs resources allocation for care and Prevention. Identification and early detection of MH difficulties among children and adolescents is mainly related to family members, teachers and other school staff, however it is essential that parents and teachers are equipped with MH literacy and basic knowledge to stimulate recognition and further process of professional intervention. The co-authors are also thinking that there is a recommendation for future research in the field to identify specific focus areas that are vulnerable and need attention from Preventative point of view.

In terms of education, there is need to review educational syllabuses and programs of the higher institutions for all MH and education related professionals in accordance with principals mentioned above. Part of their education must be devoted to early recognition and prevention measurements in Child and Adolescent MH field and to home based awareness and treatment programs for children and adolescents with mental disorders to face the multiple challenges of living with these children.

To conclude: New mental health concepts, treatment and other approaches, the ongoing improvement of information, scientific knowledge and communication is required, and the sustainable support of all responsible stakeholders to address the alarming treatment gap in Armenia.

Competing Interests

The authors declare that they have no competing interests.

Acknowledgments

The co-authors acknowledged the efforts and support of Prof. Dr. Sabine Bährer-Kohler.