MENTAL HEALTH A Call for Action by World Health Ministers - World Health Organization

 
M I N I S T E R I A L    R O U N D       T A B L E S      2 0 0 1

                                                                           5 4 T H   W O R L D     H E A L T H         A S S E M B L Y
M E N T A L H E A L T H : A Call for Act on by World Health M n sters

                                                                           M E N TA L H E A LT H
                                                                                  A Call for Action by
                                                                                 World Health Ministers

                                                                                           World Health Organization
                                                                                                   Geneva
M I N I S T E R I A L     R O U N D         T A B L E S       2 0 0 1

        5 4 T H   W O R L D   H E A L T H   A S S E M B L Y

   M E N TA L H E A LT H
           A Call for Action by
          World Health Ministers

                              Geneva
© World Health Organization, 2001
This document is not a formal publication of the World Health
Organization (WHO) and all rights are reserved by the
Organization. The document may, however, be freely reviewed,
abstracted, reproduced and translated, in part or in whole, but not
for sale or for use in conjunction with commercial purposes.
The views expressed in this document are solely the responsibility
of the authors.
Table of
contents
 5    Preface by Gro Harlem Brundtland, Director General
         WHO and ministers of health forge an alliance on mental health

 9    Introduction by the coordinators of the round tables
         Mental health:World health ministers call for action

15    Background document

23    The state of the evidence: review papers
23       Mental health services and barriers to implementation
39       Socioeconomic factors and mental health
57       Stigmatization and human rights violations
73       Gender disparities in mental health

93    The discussions: summary records of statements by ministers

135   Report by the secretariat

141   Speech to the plenary
         A new beginning

145   Regional statements: renewing commitment to mental health
         Regional office for Africa
         Regional office for the Americas
         Regional office for the Eastern Mediterranean
         Regional office for Europe
         Regional office for South-East Asia
         Regional office for the Western Pacific

155   Epilogue by Benedetto Saraceno, Director,
         Department of mental health and substance dependance
         WHO’s response to the ministers call for action

159   Annex
         List of participants of the round tables
Preface
                             WHO and ministers
                        of health forge an alliance
                                 on mental health

Gro Harlem Brundtland
Director General
World Health Organization
Geneva
M E N TA L H E A LT H : A C A L L F O R A C T I O N

       I have great pleasure in presenting this publi-        stigmatization both of which represent a substantial
       cation which reflects our determined efforts           hidden burden of mental illness.WHO and
       to put mental health right at the core of the          Ministers of Health have concluded that this lack of
global health and development agendas.We are in               investment in mental health is now unacceptable.
the process of building a significant movement for
                                                              Over the years, we have followed the evolution of
mental health which will allow us to make a lasting
                                                              new knowledge and evidence.We now have a clear
difference for the millions of people who expect
                                                              picture of the burden of disease arising from men-
that societies and policy makers devote as much
                                                              tal disorders. In the World Health Report 2001
attention to mental problems as to physical illness-
                                                              that we devote to mental health, we bring updated
es.This has not been the case until now. In contrast
                                                              figures which show that four of the ten leading
to the dramatic improvements in physical health in
                                                              causes of disability worldwide are neuropsychiatric
most countries over the course of the past century
                                                              disorders, accounting for 30.8% of total disability
– in particular, unprecedented improvements in
                                                              and 12.3% of the total burden of disease.This lat-
mortality rates – the mental component of health
                                                              ter figure is expected to rise to 15% by the year
has in many places not improved. As many as 450
                                                              2020.The rise will be particularly sharp in devel-
million people worldwide are estimated to be suf-
                                                              oping countries primarily due to the projected
fering at any given time from some kind of mental
                                                              increase in the number of individuals entering the
or brain disorder, including behavioural and sub-
                                                              age of risk for these disorders and as a result of
stance abuse disorders.This is an overwhelming
                                                              social problems and unrest, including the rising
figure considering that mental health is not only
                                                              number of persons affected by violent conflicts,
essential for individual well-being, but also essen-
                                                              civil wars, displacements and disasters. If we take
tial for enhancing human development including
                                                              the example of depression which is currently
economic growth and poverty reduction.
                                                              ranked fourth among the 10 leading causes of the
Unsurprisingly, it is this statement that was echoed
                                                              global burden of disease, it is predicted that by the
by many Ministers of Health during the Round
                                                              year 2020, it will have jumped to second place.
Tables. “There is no development without health
                                                              Major depression is linked to suicide. Most people
and no health without mental health.”
                                                              who commit suicide are also clinically depressed. If
                                                              we take suicide into account, then the already huge
We know that one out of every four persons who
                                                              burden associated with depression increases much
turn to the health services for help is troubled by
                                                              more.
mental or behavioural disorders, which are not
often correctly diagnosed and/or treated. And                 But there is good news also.Today we are in a bet-
mental health care has simply not received until              ter position to make use of the accumulated wealth
now the level of visibility, commitment and                   of knowledge and the technologies that allow us
resources that is warranted by the magnitude of               more effectively to manage, treat and prevent a
the mental health burden. Only a very small per-              wide range of mental and neurological problems.
centage of national health budgets in most coun-              We have made huge strides in developing effective
tries go to mental health. One consequence of this            treatments for most of the mental disorders and
inadequate attention is the “treatment gap” – the             further improvements in treatments are likely
gulf between the huge numbers who need treat-                 thanks to advances in the understanding of brain
ment and the small minority who actually receive              functioning and psychosocial factors.With the cur-
it. More than 40% of countries have no mental                 rent treatments, most persons with mental, brain
health policy and over 30% have no mental health              or behavioural disorders can become functioning
programme. Even countries that do have mental                 and productive members of the community and
health policies often disappointingly neglect some            live normal lives.We also have some effective pre-
of the more vulnerable populations. For example,              ventive approaches based on a better understand-
over 90% of countries have no mental health poli-             ing of the interrelation between the complex bio-
cy that includes children and adolescents. In most            logical, psychological and social determinants of
countries, stigma and human rights violations of              mental disorders. A number of demonstration pro-
persons with mental illness are rampant. Few                  grammes in countries have provided evidence
efforts are in place to address discrimination and            based interventions for improved access and quali-

                                                          6
PREFACE

ty of mental health care.This means ensuring that           Political instability, violence especially against
mental health services are incorporated in all levels       women, natural disasters, armed conflicts, and the
of health services, ranging from primary health             HIV/AIDS crisis are seriously challenging the cop-
care to support for families and other social servic-       ing capacity of the affected populations. Managerial
es.                                                         weakness in health systems persist. Most impor-
                                                            tantly, the serious shortage of mental health
WHO has a critical role to play in turning this
                                                            resources, especially service providers, was noted
knowledge into reality. Accordingly, I have made
                                                            in many countries.There were large technical gaps
mental health a priority programme of WHO.
                                                            in countries regarding prevalence, diagnosis and
This programme has set the stage for global mental
                                                            treatment issues compounded by lack of knowl-
health action through a combination of special
                                                            edge about financing schemes, anti-stigma and leg-
events taking place throughout 2001.These events
                                                            islation issues as well as intersectoral collaboration
aim to raise awareness of the nature and scope of
                                                            in mental health. Ministers explored and clarified
mental problems and the life circumstances of peo-
                                                            the critical issues in these areas and outlined the
ple suffering from them (World Health Day), gen-
                                                            strategic steps required in resolving them.They
erate political will for national action (World
                                                            also identified what needs to be done by the inter-
Health Assembly Ministerial Round Tables), and
                                                            national community.
disseminate the evidence and science related to
prevention and care. (World Health Report 2001              All the messages and statements of Ministers are
on Mental Health).These activities have been                contained in various sections of this publication.
instrumental in mobilizing interest and commit-             They are reflections of a promise for a brighter
ment for global and national action to redress the          future for all the millions of people suffering from
mental health status of populations around the              mental disorders and the attendant discrimination.
world.                                                      We look forward to working more intensely with
                                                            countries, forging wholesome and sustainable part-
The publication of this document is particularly
                                                            nerships that will do justice to the Ministers call
important because it brings together the back-
                                                            for action.We will continue our efforts to become
ground, the proceedings as well as the outcomes of
                                                            more effective in providing technical support to
the World Health Assembly’s Ministerial Round
                                                            countries at a time when they seek to restructure
Tables on Mental Health.The Round Tables were a
                                                            and reform their mental health systems, generate
historic occasion for Health Ministers from coun-
                                                            policies and improve the provision of services and
tries around the world to come together and
                                                            treatment for all those who need them.That I
review with their peers the major challenges they
                                                            believe is not only our responsibility but also an
face in the prevention, treatment and care of men-
                                                            opportunity for reducing suffering, disability,
tal problems.They engaged in open discussions on
                                                            poverty, and premature death.
the progress that had been made in dealing with
the priority mental health problems in their coun-          The time for action is now. I therefore invite politi-
tries and acknowledged that this was not sufficient-        cians, scientists, technicians, humanitarians, social
ly consistent or widespread. A high level of politi-        activists and programme managers in health to
cal will was apparent along with growing aware-             read this publication and build upon its messages
ness of the need for change in policies and health          for the improvement of mental health and well-
systems. In some countries impressive efforts have          being of all peoples.
been made to expand mental health services
through intersectoral partnerships. Some innova-
tive approaches to reach vulnerable and under-
served populations and to strengthen community-
based care were noted. A number of factors how-
ever restrain the implementation of national strate-
gies. Rapid economic reforms and social change                                 Gro Harlem Brundtland
including economic transitions are bringing about                              Director General
alarming rates of unemployment, family break-                                  World Health Organization
down, personal insecurity and income inequality.

                                                        7
Introduction
                                    Mental health:
                             World health ministers
                                     call for action
Coordinators of the round tables:

Meena Cabral de Mello
Scientist
Department of Mental Health and Substance Dependence
World Health Organization
Geneva

Thomas Bornemann
Senior Adviser
Department of Mental Health and Substance Dependence
World Health Organization
Geneva

Itzhak Levav
Senior Adviser
Ministry of Health
Jerusalem, Israel
M E N TA L H E A LT H : A C A L L F O R A C T I O N

Background                                                    The discussions
       The sheer magnitude of the mental disorders                  The Executive Board of WHO in January
       and the huge social and economic burden                      2001 approved the theme of mental health
       they place on families and communities war-                  for the Round Table Discussions at the 54th
rant an urgent call for global and national mental            World Health Assembly.Thus, four Ministerial
health initiatives.This is doubly so since cost effec-        Round Tables took place concurrently on May 15,
tive interventions for the treatment and care of              2001 to discuss the broad perspectives on mental
almost all people with mental disorders exist and             health with special attention to four sub-themes
can be implemented by all countries. A major chal-            namely: Mental health services and barriers to
lenge facing policy makers, however, is how to                implementation; Mental health and socioeconomic
increase access to quality mental health care that is         factors; Stigmatization and human rights violations;
anchored in the communities where people with                 and Gender disparities in mental health.
mental illness live.
Many countries have initiated and/or are undergo-
                                                              The purpose and objectives
ing reforms of their mental health care systems,
moving from traditional institutional care or sim-                   The Round Tables provided a forum for
ply frank neglect, to care which is local, humane,                   health ministers to review jointly the major
and unrestricted.Through an analysis of such coun-                   challenges they face in addressing mental
try processes, precious lessons can be drawn to               health problems in their countries and to engage in
better inform policy and programme develop-                   a dialogue through which they shared information,
ment. It is timely therefore that countries have the          approaches, and opportunities for redressing the
opportunity to examine together the evidence for              situation.The objectives were to raise awareness of
prevention, treatment and care so that they are in            the urgent need to address the mental health bur-
better position to develop effective action plans for         den; to place mental health firmly on the national
addressing the mental health problems in their                and international health and development agendas;
countries.                                                    and to generate political commitment for increas-
                                                              ing support to mental health policies, legislation,
The cumulative experience of developing mental
                                                              programmes and services in all countries.
health care across countries at various resource
levels coupled with the new evidence emerging
from scientific research, shows that actions to
                                                              The participants
address the mental health of populations have mul-
tiple benefits.These include direct benefits of serv-               Over 30 Ministers of Health participated in
ices in decreasing the symptoms associated with                     each Round Table. (In a few cases senior
mental disorders, reducing the overall burden of                    members of delegations were specifically
these diseases by lowering mortality and disability,          designated to represent the Ministers.) A balanced
and, improving the functioning, productivity and              mix of low, middle and high income countries with
quality of life of affected people.                           different political and health systems, priorities and
                                                              level of resources for mental health was achieved
At the global level, the benefits of mental health
                                                              in each group. Four Ministers elected by the World
interventions for decreasing the burden are sub-
                                                              Health Assembly served as Chairpersons.They
stantial. Mental disorders account for about 160
                                                              were: Mr Phillip Goddard of Barbados; Mr Lyonpo
million lost years of healthy life. Of this at least
                                                              Sangay Ngedup of Bhutan; Mrs Annette King of
30% can be easily averted with existing interven-
                                                              New Zealand; and Prof. M. Eyad Chatty of the
tions. For example, the disability associated with
                                                              Syrian Arab Republic (see annex for a complete list
depressive disorders in a community could be
                                                              of participants by round table).
reduced to half with adequate care.

                                                         10
INTRODUCTION

                                                              ■ Ms Ana Paula de Almeida G.C. Ferrao Mogne
The facilitators
                                                              Co-ordinator of the National Mental Health
      Eight external experts with extensive inter-            Program of Mozambique.
      national and national experience in mental
      health assisted the Chairpersons in facilitating        ■ Dr Vikram Patel
discussion and triggering debate.They brought a               Senior Lecturer at the Department of Infectious
broad range of scientific, clinical, policy and pro-          and Tropical Diseases and the Department of
gramme expertise to the round tables from differ-             Epidemiology and Population Health of the
ent regions of the world.They also contributed                London School of Hygiene and Tropical Medicine
state-of-the-art review papers on the four sub-               in London, UK. Dr Patel is also Director of
themes of the discussions.These facilitators were:            Sangath Society in Goa, India.
■ Dr Jill Astbury

Associate Professor and Director of the                       Documentation
Postgraduate Teaching Programs of the Key Centre                    Two sets of background documents were
for Women’s Health in Society,World Health                          prepared for the Round Tables.The first was
Organization Collaborating Centre in Women’s                        the official Background Document reproduced
Health at the University of Melbourne.                        in Section 3 of this publication. It contains a general
                                                              discussion on the status of mental health around
■ Dr Lourdes L. Ignacio
                                                              the world and brief discussions of the four sub-
Chair of the Department of Psychiatry and                     theme topics.The document highlights the lack of
Professor of Psychiatry in charge of the Social and           community-based mental health services, the
Community Psychiatry Program of the University                widespread stigmatization of people with mental
of Philippines, Manila.                                       disorders, and the roles of poverty and gender
                                                              inequality on mental health. All these factors are
■ Dr Sylvia Kaaya                                             known to be linked o poor mental health outcomes
                                                              but the role of the health sector in dealing with
Head of the Department of Psychiatry at
                                                              them is not always sufficiently defined. Each sec-
Muhimbili University College of Health Sciences
                                                              tion of the document is followed by a set of discus-
in Dar-es-Salaam,Tanzania.
                                                              sion points aimed at stimulating reflection, aware-
                                                              ness and dialogue around the issues and what needs
■ Dr Arthur Kleinman
                                                              to be done to address them.
Professor of Social Anthropology at the
                                                              A second set of documents, distributed in site, was
Department of Anthropology of Harvard
                                                              prepared in the form of review papers.These
University; and Maude and Lillian Presley
                                                              papers present in considerable detail the latest sci-
Professor of Medical Anthropology and Professor
                                                              entific and research evidence related to each of the
of Psychiatry at Harvard Medical School in
                                                              sub-theme topics, model policies, programmes and
Cambridge, USA.
                                                              service examples from different countries, as well
■ Dr Julian Paul Leff
                                                              as illustrations and consumers/carers testimonies.
                                                              The reviews reflect not only the current status of
Professor of Social and Cultural Psychiatry and               knowledge on the issues but they also provide
Head of the Section of Social Psychiatry at the               guidance on policy and programmatic implications,
Institute of Psychiatry, University of London,                as well as future research.The four documents are
London, UK.                                                   contained in Section 4 entitled The State of the
                                                              Evidence.
■ Dr Juan José Lopez-Ibor

President of the World Psychiatric Association and
Director of the WHO Research and Training
Centre for Spain in Madrid, Spain.

                                                         11
M E N TA L H E A LT H : A C A L L F O R A C T I O N

                                                                  ble standards of care in the face of other health
The process                                                       priorities and limited resources?
      To catalyse attention on Mental Health in               ■   What are the key mental health concerns in
      2001, the invited speakers of the Director                  countries and through which strategies and
      General at the opening Plenary of the World                 approaches are they being addressed? What are
Health Assembly were two family members name-                     the main technical and policy obstacles that must
ly: Ms Noreine Kaleeba, (widowed by AIDS)                         be overcome to improve mental health pro-
Community mobilization adviser of UNAIDS and                      grammes and service provision?
founder of The AIDS Support Organization of                   Midway through the sessions, presentations were
Uganda, and Ms. Diane Froggart, mother of a son               made by the second facilitator in each of the round
affected by schizophrenia and Executive Director              tables to trigger more focused discussion on the
of the World Fellowship for Schizophrenia and                 selected sub-theme topics. Discussion points high-
Allied Disorders. Both speakers highlighted key               lighted in the background document (see Section 3)
mental health concerns such as the need to over-              were used to guide the debate.
come fear, silence and stigma; raise community
awareness and stimulate involvement; decrease the             Through a process of sharing experiences and ideas
burden of care on families and encourage partner-             openly and frankly, Ministers of each Round Table
ships between families and professionals.Their tes-           build a clearer picture of the global mental health
timonies were powerful reminders of the human                 status, the social context within which mental
dimension of mental illness and its huge socioeco-            problems were occurring, the mental health priori-
nomic impact on families and communities.                     ties in each region, what could be done, and how
                                                              best it could be achieved. Strategies and approach-
The Discussions were opened by the Chairpersons               es that were being implemented with success in
and followed by general presentations made by one             selected projects within countries were discussed.
of the two facilitators assigned to each round table.         Similarly the shortfalls in extending these to cover
The presentations highlighted the following issues:           entire countries were highlighted. Ministers spoke
■ the epidemiology, disease burden and socioeco-              of the policy, technical and managerial difficulties
  nomic impact of mental disorders including                  in providing equitable and humane care to all those
  future trends;                                              in need, especially the most vulnerable groups in
■ the interdependence of bio-psycho-social deter-             their countries.They were spontaneous in request-
  minants of mental disorders;                                ing intensified support from the international com-
■ the effects of social factors such as poverty,
                                                              munity and WHO in regards to certain crucial
  stigmatization and human rights violations, and             areas.
  gender discrimination on the onset, course and
  outcome of mental disorders;
■ the availability of cost effective treatments and           Reporting
  the vast treatment gap; and
                                                                   Summary records of each Minister's inter-
■ the barriers to the development of mental health
                                                                   ventions during the discussions are contained
  policies and programmes, intersectoral collabo-                  in Section 5 of this publication. A single
  ration, and comprehensive community-based                   report of the event prepared by the secretariat,
  mental health services.                                     compiling and collapsing the reports of the four
Ministers were invited to discuss the general issues          round tables, is provided in Section 6.
in the light of the following questions:                      On behalf of all the participants, the integrated
■ What can be done to increase awareness, com-                conclusions of the four Round Tables were present-
  mitment and resources for addressing the burden             ed to the final plenary of the World Health
  of mental disorders?                                        Assembly on 18 May 2001 by Mr Phillip Goddard,
■ What is the level of responsibility of the public           Minister of Health of Barbados.The text of this
  sector in addressing mental health issues (preven-          speech, which was adopted by the Assembly, is
  tion and care) and maintaining the highest possi-           reproduced in full in Section 7:A New Beginning

                                                         12
INTRODUCTION

The outcomes
       The Ministerial Round Tables were successful
       in creating greater global co-operation and
       dialogue on mental health issues.Three fea-
tures are prominent for follow-up action.The first
is the consensus on the primordial importance of
Mental Health for the health and development of
societies.This provides a useful policy basis for pri-
oritizing mental health at international, regional
and national levels.The second refers to the com-
mitment expressed by governments to intensify
action in pursuit of evidence-based solutions to
mental health policy development, appropriate leg-
islation, access to treatment and care, and promo-
tion and prevention.The third involves the strate-
gic areas identified by the Ministers for strengthen-
ing technical support between the international
community and countries.
The World Health Organization, including its head-
quarters, regional and country offices, is building
on these features to better support countries in
their quest for equitable and humane care for peo-
ple with mental problems. It is in consideration of
the concerns raised by the Ministers that WHO’s
Regional Directors and Advisers in Mental Health
have issued statements reaffirming their strong
commitment to support countries in addressing
their mental health priorities.These statements are
provided in Section 8.
Finally, the Epilogue of this publication (Section 9)
is a statement by Dr Benedetto Saraceno, Director
of WHO’s Department of Mental Health and
Substance Dependence, which outlines the new
strategic orientation of the Programme.This is
intended to better respond to the requests by
Ministers for intense technical support in achieving
national mental health goals.
In the words of Dr Gro Harlem Brundtland,
Director General of WHO, “The message we can
bring to the world is one of optimism. Effective
treatments are there. Prevention and early detec-
tion can drastically reduce the burden.” And hence
the social and human suffering.

                                                         13
Background
Document
         Mental health
M E N TA L H E A LT H : A C A L L F O R A C T I O N

       The historical marginalization of mental               Future increases in the prevalence of mental prob-
       health from mainstream health and welfare              lems will pose serious social and economic handi-
       services in many countries has contributed to          caps to global development unless substantive
endemic stigmatization and discrimination of men-             action is taken now.
tally ill people. It has also meant that mental health
                                                              At present, the mental health budget in most coun-
has received low priority in most public health
                                                              tries constitutes less than 1% of total (public sec-
agendas with consequences on budget, policy plan-
                                                              tor) health expenditure. Moreover, mental health
ning and service development. Estimation of the
                                                              problems are frequently not covered by health
global burden of disease with disability adjusted
                                                              plans at the same level as other illnesses, creating a
life years (DALYs) shows that mental and neuro-
                                                              significant, often overwhelming, economic burden
logical conditions are among the most important
                                                              for patients and their families, ranging from loss of
contributors; for instance, in 1999 they accounted
                                                              income to disruptions in household routine,
for 11% of the DALYs lost due to all diseases and
                                                              restriction of social activities and lost opportuni-
injuries. Among all the mental and neurological
                                                              ties. Recently collected data show that more than
disorders, depression accounts for the largest pro-
                                                              40% of Member States have no clear mental health
portion of the burden. Almost everywhere, the
                                                              policy and more than 30% have no national mental
prevalence of depression is twice as high among
                                                              health programme. Although almost 140 of the
women as among men. Four other mental disor-
                                                              191 Member States have an updated list of essen-
ders figure in the top 10 causes of disability in the
                                                              tial drugs, including psychotropic drugs, one third
world, namely alcohol abuse, bipolar disorder,
                                                              of the global population has no access to the latter.
schizophrenia and obsessive compulsive disorder.
                                                              In rural areas of developing countries psychotropic
The number of people with mental and neurologi-               drugs are rarely available in adequate or regular
cal disorders will grow – with the burden rising to           supplies.
15% of DALYs lost by the year 2020.The rise will
                                                              Research has shown that general health care
be particularly sharp in developing countries pri-
                                                              providers can manage many mental and neurologi-
marily owing to the projected increase in the num-
                                                              cal problems both in terms of prevention as well as
ber of individuals entering the age of risk for the
                                                              diagnosis and treatment.Yet, less than half of those
onset of these disorders. Groups at higher risk of
                                                              patients whose condition meets diagnostic criteria
developing mental disorders include people with
                                                              for mental and neurological disorders are identi-
serious or chronic physical illnesses, children and
                                                              fied by doctors. Patients, too, are reluctant to seek
adolescents, whose upbringing has been disrupted,
                                                              professional help. Globally, less than 40% of people
people living in poverty or in difficult conditions,
                                                              experiencing a mood, anxiety or substance use dis-
the unemployed, female victims of violence and
                                                              order seek assistance in the first year of its onset.
abuse, and neglected elderly persons.
                                                              Stigmatization complicates access to those who
The economic impact of mental disorders is wide-              need help, treatment and care; it is responsible for
ranging, long-lasting and large. Measurable causes            a huge hidden burden of mental problems.
of economic burden include health and social serv-
                                                              In most cases, a complex interaction between bio-
ice needs, impact on families and care givers (indi-
                                                              logical, psychological and social factors contributes
rect costs) lost employment and lost productivity,
                                                              to the emergence of mental health and neurologi-
crime and public safety, and premature death.
                                                              cal problems. Strong links have been made
Studies from countries with established economies
                                                              between mental health problems with a biological
have shown that mental disorders consume more
                                                              base, such as depression, and adverse social condi-
than 20% of all health service costs.The aggregate
                                                              tions such as unemployment, limited education,
yearly cost of mental disorders in 1990 for the
                                                              discrimination on the basis of sex, human rights
United States of America was estimated at US$
                                                              violations and poverty.
148 000 million. Estimates for other regions of the
world are not yet available, but even in countries            Recent advances in neurosciences, genetics, psy-
where the direct treatment costs are low it is likely         chosocial therapy, pharmacotherapy, and sociocul-
that the indirect costs due to “productivity loss”            tural disciplines have led to the elaboration of
account for a large proportion of the overall costs.          effective interventions for a wide range of mental

                                                         16
BACKGROUND DOCUMENT

health problems, offering an opportunity for peo-            In order to deal with the burden of mental and
ple with mental and behavioural disorders and                neurological disorders in countries and reduce the
their families to lead full and productive lives.            psychosocial vulnerabilities of individuals, atten-
Clinical trials have demonstrated the effectiveness          tion needs urgently to be paid to the determinants
of pharmacological treatments for the major men-             that can be modified of the development, onset,
tal, neurological and substance use disorders: neu-          progression and outcome of mental problems.
roleptics for schizophrenia, mood stabilizers for            Critical areas include: the organization of mental
bipolar disorder, antidepressants for depressive ill-        health services, which influences access, effective-
ness, anxiolytics for anxiety disorders, opioid sub-         ness and quality of prevention, treatment and care;
stitutions for substance dependence, and anticon-            stigmatization and discrimination, which detrimen-
vulsants for epilepsy. Specific psychological and            tally affect access to care, quality of care, recovery
social interventions, including family intervention,         from illness, and equal participation in society;
cognitive-behavioural therapy, social skills training        socioeconomic factors, which show a clear associa-
and vocational training, have been shown to be effi-         tion with frequency and outcome of mental prob-
cacious for severe mental illness. Rehabilitation is         lems; and gender roles, which determine the dif-
possible for most people with mental illness.There           ferential power and control that men and women
is evidence for the effectiveness of primary preven-         have over the determinants of their mental health,
tion strategies, especially for mental retardation,          and their susceptibility and exposure to specific
epilepsy, vascular dementia and some behavioural             mental health risks.
problems. Models of service delivery in primary
care settings have been implemented around the
world, and are being evaluated.Training of family            Mental health services and
members, community agents and consumers/users                barriers to implementation
offer great scope to extend the capacity for servic-
                                                             “I was a resident or rather an inmate of the psychiatric
es. Special mention needs to be made of the poten-
                                                             hospital. My husband and children receded. I saw no one.
tial of staffing schools with mental health workers
                                                             The mental health workers were the only ones who could
who have basic skills in detecting and treating
                                                             open the locked door. I left my hope on the other side of
developmental and emotional disorders in chil-
                                                             the locked door. It was a frightening experience.There was
dren.Training mothers to provide infants with psy-
                                                             an air of unreality there.” Female patient, United
chosocial care, has demonstrated in many pro-
                                                             States of America
grammes around the world the feasibility and suc-
cess of such an approach. Meeting the needs of                      Some countries have reduced the burden of
children and adolescents who are most exposed to                    mental problems through national reform
the psychiatric consequences of poverty, famine                     strategies that have shifted the emphasis of
and loss of parents is critical in developing coun-          the mental health budget from out-dated mental
tries.                                                       asylums to community-based services and the inte-
                                                             gration of mental health care into primary health
A large gap separates the availability of effective          care. Cost-effective, community-based services can
mental health interventions from their widespread            now be delivered in numerous ways that meet
implementation. Even in established market                   many individual and community needs, and princi-
economies with well developed health systems,                ples for successful implementation of such services
less than half those suffering from depression               have been identified. Similarly, on the basis of
receive treatment. In other countries, treatment             country experiences, the requirements for success-
rates for depression are as low as 5%. In areas              ful integration of mental health into primary health
stricken by disaster or war, the situation is even           care have been defined; they include strategies for
worse. In low-income countries, most patients suf-           ensuring sufficient numbers of adequately trained
fering from severe mental and neurological prob-             specialist and primary health care staff, regular
lems such as schizophrenia and epilepsy do not get           supplies of essential psychotropic drugs, estab-
treatment even when it is available at low cost              lished linkages with specialist care services, refer-
(anticonvulsant therapy for epilepsy can cost US$ 5          ral criteria, information and communications sys-
per patient per year).                                       tems, and appropriate links with other community

                                                        17
M E N TA L H E A LT H : A C A L L F O R A C T I O N

and social services. Several models of nongovern-              ■   What mechanisms can governments put in place
mental activity in a wide range of areas, from serv-               to ensure an adequate supply of psychotropic
ice delivery and training to political advocacy, have              drugs?
proven to be successful.The participation of the               ■   How can nongovernmental and other communi-
nongovernmental sector, an irreplaceable source of                 ty-based organizations, including traditional heal-
support for mental health programmes, remains to                   ers and religious agencies, be engaged in a
be expanded in much of the world.                                  national mental health programme?
Establishing effective mental health systems faces
many challenges. A common issue is ensuring the
transfer of care from mental hospitals to the com-
                                                               Stigmatization and
munity; the many obstacles include political con-
                                                               human rights violations
siderations, stigmatization and the absence of com-
munity services. How to organize and finance                   “Given the number of families in every society who are
mental health services is also an issue for most               affected by mental illness, it is amazing that there has
countries. Because of the significant disruption to            not been an outcry to do more. Shame and fear have built
social functioning caused by mental illnesses, coop-           walls of silence.” Caregiver, Belize
eration is essential between private and public sec-
                                                                      Stigmatization and violations of human rights
tors such as education, housing, employment,
                                                                      represent a sizeable, albeit hidden, burden of
criminal justice, media, social welfare and women’s
                                                                      mental illness. Around the world, many men-
affairs.
                                                               tal health patients still receive outmoded and inhu-
Securing an adequate and affordable supply of psy-             mane care in large psychiatric hospitals or asylums,
chotropic drugs is a major concern for many men-               which are often in poor condition. Besides con-
tal health systems. Similarly, most parts of the               tributing to endemic stigmatization and discrimina-
world are experiencing a critical shortage of                  tion of the mentally ill, these failings have led to a
trained professionals. Services are lacking for peo-           wide range of human rights violations. Mental ill-
ple with specialized needs, such as children,                  ness has often been seen as untreatable, and men-
refugees and older persons, as well as those who               tally ill individuals are labelled as violent and dan-
have substance use disorders, particularly in rural            gerous. People with alcohol and substance depend-
areas. Services for linguistic and cultural minorities         ence are considered morally and psychologically
and indigenous people in many societies are often              weak.The media perpetuate these negative charac-
inadequate or inappropriate.                                   terizations. Stigmatization often leaves persons suf-
                                                               fering from mental illness rejected by friends, rela-
Most people who need and could potentially bene-
                                                               tives, neighbours and employers, leading to aggra-
fit greatly from services are not getting them. Even
                                                               vated feelings of rejection, loneliness and demoral-
in developed countries with well resourced health
                                                               ization.
services, less than half those people who need
treatment and care receive it. Although we know a              Stigmatization also leads to discrimination; thus it
great deal about how to solve the many and varied              becomes socially acceptable to deprive stigmatized
problems, the challenge is to remove the barriers.             individuals of legally granted entitlements. Health
The potential return to society is substantial.                insurance companies discriminate between mental
                                                               and physical disorders and provide inadequate cov-
Discussion points                                              erage for mental health care. Labour and housing
                                                               policies are less open to people with a history of
■   What are some of the critical barriers to the pro-         mental disorders than people with physical disabili-
    vision of community-based mental health servic-            ties.
    es in your country and what efforts are being              Surveys have shown that negative social attitudes
    made to overcome them?                                     toward the mentally ill constitute barriers to rein-
■   What are the obstacles to providing services and           tegration and acceptability, and adversely affect
    psychotropic drugs in rural areas and how are              social and family relationships, employment, hous-
    they being tackled?                                        ing, community inclusion and self-esteem. Equally,

                                                          18
BACKGROUND DOCUMENT

they create barriers to parity of treatment oppor-            ■   What is the level of responsibility and the role of
tunities, restrict the quality of treatment options               the public health sector in tackling such stigmati-
and limit accessibility to best treatment practices               zation and discrimination?
and alternatives. Unfortunately, negative attitudes           ■   How can other sectors contribute to stopping the
towards the mentally ill and stigmatizing stereo-                 denial, through discrimination, to mentally ill
types may also be shared by medical and hospital                  people of equitable access to services and consid-
personnel; patients frequently complain that they                 eration?
feel most stigmatized by doctors and nurses.
                                                              ■   Given that mental health legislation requires a
The myths and negative stereotypes about mental                   balance between the right to individual liberty,
illness, although strongly held by the community,                 the right to treatment and the legitimate expec-
can be overcome – as communities recognize the                    tation of community safety, what are the critical
importance of both good mental and physical                       issues in formulating, implementing and enforc-
health care; as advocacy renders people with men-                 ing balanced legislation?
tal disorders and their families more visible; as
effective treatments are made available at the com-
munity level; and, as society acknowledges the                Socioeconomic factors
prevalence and burden of mental disorders.
                                                              “Poverty is pain; it feels like a disease. It attacks a person
Introducing legislative reforms that protect the              not only materially but also morally. It eats away at one’s
civil, political, social, economic, and cultural enti-        dignity and drives one into total despair ”A woman,
tlements and rights of the mentally ill is also cru-          Republic of Moldova
cial. However, this step alone will not bear the
                                                                     Socioeconomic factors, especially poverty,
fruits expected by legislators without a concerted
                                                                     influence mental health in powerful and
effort to erase stigmatization as one of the major
                                                                     complex ways.They are highly correlated
obstacles to successful treatment and social reinte-
                                                              with an increase in the prevalence of serious dis-
gration of the mentally ill in communities.The
                                                              orders such as schizophrenia, major depression,
public needs to be engaged in a dialogue about the
                                                              antisocial personality disorders and substance use.
true nature of mental illnesses, their devastating
                                                              Most of these disorders are about twice as com-
individual, family and societal impacts, and the
                                                              mon among the poorest sections of society as in
prospects of better treatment and rehabilitation
                                                              the richer ones. In addition, malnutrition, infec-
alternatives. At the same time, stigmatizing atti-
                                                              tious diseases and lack of access to education can
tudes need to be tackled frontally through cam-
                                                              be risk factors for mental disorders and can wors-
paigns and programmes aimed at professionals and
                                                              en existing mental problems.These findings are
the public at large. Public information campaigns
                                                              consistent in countries across income levels.They
using mass media in its various forms; involvement
                                                              illustrate the broader concept of poverty, which
of the community in the design and monitoring of
                                                              includes not only economic deprivation but also
mental health services; provision of support to
                                                              the associated lack of opportunities for accessing
nongovernmental organizations and for self-help
                                                              information and services.
and mutual-aid ventures, families and consumer
groups; and education of personnel in the health              The relationship between poverty and high preva-
and judicial systems and employers – all are critical         lence rates of psychiatric disorders can be
strategies to start dispelling the indelible mark, the        explained in two ways, which are not mutually
stigma caused by mental illness.                              exclusive and which appear to be operative for dif-
                                                              ferent disorders. First, poor people in most soci-
                                                              eties, even among the wealthiest countries, are
Discussion points                                             exposed to greater levels (quality and quantity) of
                                                              environmental and psychological adversity, which
■   What measures has your country put (or does it            produces high levels of stress and psychological
    plan to put) in place to fight discrimination and         distress.They have major difficulties accessing
    stigmatization of mentally ill people and their           information and mental health services. In most
    families?                                                 developing countries these services are so limited

                                                         19
M E N TA L H E A LT H : A C A L L F O R A C T I O N

that they remain out of reach for the poor: infor-             ■   Do individuals and families with mental and neu-
mation is often not available to illiterate popula-                rological disorders get social support or benefits
tions; transport is difficult and costly; and respon-              under poverty-alleviation schemes or social-wel-
siveness of the health services is low. Not only do                fare measures in your country?
these factors contribute to chronicity and more                ■   What are the barriers faced by the poor in
disability, but they may also trigger non-psychotic                accessing mental health information and care in
forms of mental illness, especially depression and                 your country? What are your country’s plans to
anxiety disorders. Considerable evidence points to                 make mental health services more equitable?
the social origins of psychological distress and
depression in women, both of which conditions
affect them disproportionately.
                                                               Gender disparities
The second explanation for the relationship
                                                               “It is not the physical abuse which is the worst but the
between poverty and high prevalence rates of psy-
                                                               terror which follows – the emotional abuse. I am still
chiatric disorders refers to “downward drift” with
                                                               angry and terrified.” Battered woman, Australia
people with a mental illness incurring much
greater risks for homelessness, unemployment and                     Gender roles are critical determinants of
social isolation.While families remain the key                       mental health that need to be considered in
providers of care in most parts of the world, the                    policies and programmes.They govern the
strain of providing care over time can lead to peo-            unequal power relationship between men and
ple with severe mental illness being rejected by               women and the consequences of that inequality.
their families.This estrangement enhances the risk             They affect the control men and women have over
for poverty. In all events, socioeconomic factors              socioeconomic determinants of their mental
and mental health are inextricably linked.The                  health, their social position, status and treatment in
treatment gap for most mental disorders is large               society.They also determine the susceptibility and
but for the poor segments of populations in all                exposure of men and women to specific mental
countries it is seemingly unbridgeable.                        health risks.
Mental disabilities result in substantial societal bur-        Sex differences are seen most graphically in the
dens of lost productivity and added costs for sup-             prevalence of common mental disorders – depres-
port, not to mention the high cost of the loss of              sion, anxiety and somatic complaints.These disor-
potential contributions to society of people or                ders, most prevalent in women, represent the most
families who care for the mentally ill. Hence, the             common diagnoses within primary health care set-
cumulative costs significantly drain the economies             tings and constitute serious public health prob-
of poor countries. National policies to reduce                 lems. In particular, depression, predicted to be the
poverty focus on stabilizing and improving income,             second leading cause of global disability burden by
strengthening education, and meeting basic human               2020, is twice as common in women as in men,
needs such as housing and employment.With the                  across most societies and social contexts; it may
health of a nation increasingly being seen as a criti-         also be more persistent in women than men.
cal component of development, mental health, as a              Reducing the disproportionate number of women
key aspect of public health, needs to be acknowl-              who are depressed would significantly lessen the
edged as a priority for overall social development.            global burden of disability caused by mental and
                                                               behavioural disorders.
Discussion points                                              The lifetime prevalence rate for alcohol depend-
■   What information on the magnitude and burden               ence, another common disorder, is more than
    of mental and neurological disorders among the             twice as high for men as for women. Men are also
    poor is available in your country? Are there any           more than three times more likely to have antiso-
    plans to collect further information?                      cial personality disorder than women.
■   Is health, in particular mental health, a part of          Although the prevalence rates of severe mental dis-
    poverty reduction strategies and programmes in             orders such as schizophrenia and bipolar disorder
    your country?                                              (together affecting less than 2% of the population)

                                                          20
BACKGROUND DOCUMENT

are much the same between the sexes, differences              problems in women and to alcohol problems in
have been reported in age of onset of symptoms,               men seem to reinforce social stigmatization and to
frequency of psychotic symptoms, course of these              constrain help-seeking behaviour.They impede the
disorders, social adjustment and long-term out-               accurate identification and treatment of psycholog-
come for men and women.The disability associat-               ical disorders.
ed with mental illness falls most heavily on those
                                                              Mental health problems related to violence are also
who experience three or more concomitant disor-
                                                              poorly identified. Among victims, women are
ders – again, mainly women.
                                                              reluctant to disclose information unless asked
Gender-specific risk factors                                  about it directly.When undetected, violence-relat-
                                                              ed health problems increase and result in high and
Depression, anxiety, somatic symptoms and high                costly use of the health and mental health care sys-
rates of comorbidity are significantly related to risk        tem.
factors that can be related to gender, such as vio-
lence, socioeconomic disadvantage, income                     Discussion points
inequality, low or subordinate social status and              ■   To what extent is your country’s mental health
rank, and unremitting responsibility for the care of              policy gender-sensitive and does it identify and
others. For instance, the frequency and severity of               address the gender-specific risk factors necessary
mental problems in women, are directly related to                 for prevention?
the frequency and severity of such factors.
                                                              ■   What needs to be done to enable primary health
Economic restructuring has had gender-specific                    care providers to gain and use the skills necessary
consequences for mental health. Economic and                      to identify gender-related violence and for the
social policies that cause sudden, disruptive and                 management and care of the ensuing mental
severe changes in income, employment and social                   problems?
capital that cannot be controlled or avoided can              ■   How can the health sector improve intersectoral
significantly increase inequality between men and                 collaboration between government departments
women and the prevalence rate of common mental                    in order to remove gender bias and discrimina-
disorders.                                                        tion, and to modify social structural factors such
Violence against women is a public health concern                 as child care responsibilities, transport, cost, and
in all countries, an estimated 20% to 50% of                      lack of health insurance that constrain women’s
women have suffered domestic violence. Surveys in                 access to mental health care?
many countries reveal that 10% to 15% of women
report that they are forced to have sex with their
intimate partner.The high prevalence of sexual
violence to which women of all ages are exposed,
with the consequent high rate of post-traumatic
stress disorder explains why women are most
affected by this disorder.

Gender bias

Gender bias is seen in the diagnosis and treatment
of psychological disorders. Doctors are more likely
to diagnose depression in women than in men,
even when patients have similar scores on stan-
dardized measures of depression or present with
identical symptoms.Women are significantly more
likely than men to be prescribed mood-altering
psychotropic drugs. Also, alcohol problems in
women are rarely recognized by health providers.
Such gender stereotypes as proneness to emotional

                                                         21
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