Mental Health: a Call for Action by World Health Ministers

MINISTERIAL ROUND TABLES 2001

54TH WORLD HEALTH ASSEMBLY

Call for Act Health M on by World n sters MENTAL HEALTH A Call for Action by World Health Ministers MENTAL HEALTH: A A HEALTH: MENTAL

World Health Organization Geneva MINISTERIAL ROUND TABLES 2001

54TH WORLD HEALTH ASSEMBLY

MENTAL HEALTH

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 MENTAL HEALTH: A CALL FOR ACTION

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 however restrain the implementation of national strategies. 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.

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 MENTAL HEALTH: A CALL FOR ACTION

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, awareness 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 MENTAL HEALTH: A CALL FOR ACTION

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 features 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 commitment expressed by governments to intensify action in pursuit of evidence-based solutions to mental health policy development, appropriate legislation, access to treatment and care, and promo- tion and prevention.The third involves the strategic areas identified by the Ministers for strengthening 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 people 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.

Background Document

Mental health MENTAL HEALTH: A CALL FOR ACTION

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, effectiveness, 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 success 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 integration 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 MENTAL HEALTH: A CALL FOR ACTION 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 community 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 suffering 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 community 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 different disorders. First, poor people in most societies, 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 MENTAL HEALTH: A CALL FOR ACTION 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-related 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 violence, 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