WHO MENTAL HEALTH

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 Action by World Health Ministers

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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 Action by World Health Ministers

G e n e v a

© World Health Organization, 2001

This document is not a formal publication of the World HealthOrganization (WHO) and all rights are reserved by theOrganization. The document may, however, be freely reviewed,abstracted, reproduced and translated, in part or in whole, but notfor sale or for use in conjunction with commercial purposes.

The views expressed in this document are solely the responsibilityof the authors.

Table of contents

Preface by Gro Harlem Brundtland, Director General

WHO and ministers of health forge an alliance on mental health

Introduction by the coordinators of the round tables

Mental health:World health ministers call for action

Background document

The state of the evidence: review papersMental health services and barriers to implementationSocioeconomic factors and mental healthStigmatization and human rights violationsGender disparities in mental health

The discussions: summary records of statements by ministers

Report by the secretariat

Speech to the plenaryA new beginning

Regional statements: renewing commitment to mental healthRegional office for AfricaRegional office for the AmericasRegional office for the Eastern MediterraneanRegional office for EuropeRegional office for South-East AsiaRegional office for the Western Pacific

Epilogue by Benedetto Saraceno, Director,Department of mental health and substance dependance

WHO’s response to the ministers call for action

AnnexList of participants of the round tables

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WHO and ministers of health forge an alliance

on mental health

Gro Harlem Brundtland

Director General World Health OrganizationGeneva

Preface

I have great pleasure in presenting this publi-cation which reflects our determined effortsto put mental health right at the core of the

global health and development agendas.We are inthe process of building a significant movement formental health which will allow us to make a lastingdifference for the millions of people who expectthat societies and policy makers devote as muchattention to mental problems as to physical illness-es.This has not been the case until now. In contrastto the dramatic improvements in physical health inmost countries over the course of the past century– in particular, unprecedented improvements inmortality rates – the mental component of healthhas in many places not improved. As many as 450million people worldwide are estimated to be suf-fering at any given time from some kind of mentalor brain disorder, including behavioural and sub-stance abuse disorders.This is an overwhelmingfigure considering that mental health is not onlyessential for individual well-being, but also essen-tial for enhancing human development includingeconomic growth and poverty reduction.Unsurprisingly, it is this statement that was echoedby many Ministers of Health during the RoundTables. “There is no development without healthand no health without mental health.”

We know that one out of every four persons whoturn to the health services for help is troubled bymental or behavioural disorders, which are notoften correctly diagnosed and/or treated. Andmental health care has simply not received untilnow the level of visibility, commitment andresources that is warranted by the magnitude ofthe mental health burden. Only a very small per-centage of national health budgets in most coun-tries go to mental health. One consequence of thisinadequate attention is the “treatment gap” – thegulf between the huge numbers who need treat-ment and the small minority who actually receiveit. More than 40% of countries have no mentalhealth policy and over 30% have no mental healthprogramme. Even countries that do have mentalhealth policies often disappointingly neglect someof the more vulnerable populations. For example,over 90% of countries have no mental health poli-cy that includes children and adolescents. In mostcountries, stigma and human rights violations ofpersons with mental illness are rampant. Fewefforts are in place to address discrimination and

stigmatization both of which represent a substantialhidden burden of mental illness.WHO andMinisters of Health have concluded that this lack ofinvestment in mental health is now unacceptable.

Over the years, we have followed the evolution ofnew knowledge and evidence.We now have a clearpicture of the burden of disease arising from men-tal disorders. In the World Health Report 2001that we devote to mental health, we bring updatedfigures which show that four of the ten leadingcauses of disability worldwide are neuropsychiatricdisorders, accounting for 30.8% of total disabilityand 12.3% of the total burden of disease.This lat-ter figure is expected to rise to 15% by the year2020.The rise will be particularly sharp in devel-oping countries primarily due to the projectedincrease in the number of individuals entering theage of risk for these disorders and as a result ofsocial problems and unrest, including the risingnumber of persons affected by violent conflicts,civil wars, displacements and disasters. If we takethe example of depression which is currentlyranked fourth among the 10 leading causes of theglobal burden of disease, it is predicted that by theyear 2020, it will have jumped to second place.Major depression is linked to suicide. Most peoplewho commit suicide are also clinically depressed. Ifwe take suicide into account, then the already hugeburden associated with depression increases muchmore.

But there is good news also.Today we are in a bet-ter position to make use of the accumulated wealthof knowledge and the technologies that allow usmore effectively to manage, treat and prevent awide range of mental and neurological problems.We have made huge strides in developing effectivetreatments for most of the mental disorders andfurther improvements in treatments are likelythanks to advances in the understanding of brainfunctioning and psychosocial factors.With the cur-rent treatments, most persons with mental, brainor behavioural disorders can become functioningand productive members of the community andlive normal lives.We also have some effective pre-ventive approaches based on a better understand-ing of the interrelation between the complex bio-logical, psychological and social determinants ofmental disorders. A number of demonstration pro-grammes in countries have provided evidencebased interventions for improved access and quali-

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ty of mental health care.This means ensuring thatmental health services are incorporated in all levelsof health services, ranging from primary healthcare to support for families and other social servic-es.

WHO has a critical role to play in turning thisknowledge into reality. Accordingly, I have mademental health a priority programme of WHO.This programme has set the stage for global mentalhealth action through a combination of specialevents taking place throughout 2001.These eventsaim to raise awareness of the nature and scope ofmental problems and the life circumstances of peo-ple suffering from them (World Health Day), gen-erate political will for national action (WorldHealth Assembly Ministerial Round Tables), anddisseminate the evidence and science related toprevention and care. (World Health Report 2001on Mental Health).These activities have beeninstrumental in mobilizing interest and commit-ment for global and national action to redress themental health status of populations around theworld.

The publication of this document is particularlyimportant because it brings together the back-ground, the proceedings as well as the outcomes ofthe World Health Assembly’s Ministerial RoundTables on Mental Health.The Round Tables were ahistoric occasion for Health Ministers from coun-tries around the world to come together andreview with their peers the major challenges theyface in the prevention, treatment and care of men-tal problems.They engaged in open discussions onthe progress that had been made in dealing withthe priority mental health problems in their coun-tries and acknowledged that this was not sufficient-ly consistent or widespread. A high level of politi-cal will was apparent along with growing aware-ness of the need for change in policies and healthsystems. In some countries impressive efforts havebeen made to expand mental health servicesthrough 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 changeincluding economic transitions are bringing aboutalarming rates of unemployment, family break-down, personal insecurity and income inequality.

Political instability, violence especially againstwomen, natural disasters, armed conflicts, and theHIV/AIDS crisis are seriously challenging the cop-ing capacity of the affected populations. Managerialweakness in health systems persist. Most impor-tantly, the serious shortage of mental healthresources, especially service providers, was notedin many countries.There were large technical gapsin countries regarding prevalence, diagnosis andtreatment issues compounded by lack of knowl-edge about financing schemes, anti-stigma and leg-islation issues as well as intersectoral collaborationin mental health. Ministers explored and clarifiedthe critical issues in these areas and outlined thestrategic steps required in resolving them.Theyalso identified what needs to be done by the inter-national community.

All the messages and statements of Ministers arecontained in various sections of this publication.They are reflections of a promise for a brighterfuture for all the millions of people suffering frommental disorders and the attendant discrimination.We look forward to working more intensely withcountries, forging wholesome and sustainable part-nerships that will do justice to the Ministers callfor action.We will continue our efforts to becomemore effective in providing technical support tocountries at a time when they seek to restructureand reform their mental health systems, generatepolicies and improve the provision of services andtreatment for all those who need them.That Ibelieve is not only our responsibility but also anopportunity for reducing suffering, disability,poverty, and premature death.

The time for action is now. I therefore invite politi-cians, scientists, technicians, humanitarians, socialactivists and programme managers in health toread this publication and build upon its messagesfor the improvement of mental health and well-being of all peoples.

Gro Harlem BrundtlandDirector General World Health Organization

P R E FA C E

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Mental health:World health ministers

call for action

Coordinators of the round tables:

Meena Cabral de Mello

ScientistDepartment of Mental Health and Substance DependenceWorld Health OrganizationGeneva

Thomas Bornemann

Senior AdviserDepartment of Mental Health and Substance DependenceWorld Health OrganizationGeneva

Itzhak Levav

Senior Adviser Ministry of HealthJerusalem, Israel

Introduction

Background

The sheer magnitude of the mental disordersand the huge social and economic burdenthey place on families and communities war-

rant an urgent call for global and national mentalhealth initiatives.This is doubly so since cost effec-tive interventions for the treatment and care ofalmost all people with mental disorders exist andcan be implemented by all countries. A major chal-lenge facing policy makers, however, is how toincrease access to quality mental health care that isanchored in the communities where people withmental illness live.

Many countries have initiated and/or are undergo-ing reforms of their mental health care systems,moving from traditional institutional care or sim-ply frank neglect, to care which is local, humane,and unrestricted.Through an analysis of such coun-try processes, precious lessons can be drawn tobetter inform policy and programme develop-ment. It is timely therefore that countries have theopportunity to examine together the evidence forprevention, treatment and care so that they are inbetter position to develop effective action plans foraddressing the mental health problems in theircountries.

The cumulative experience of developing mentalhealth care across countries at various resourcelevels coupled with the new evidence emergingfrom scientific research, shows that actions toaddress the mental health of populations have mul-tiple benefits.These include direct benefits of serv-ices in decreasing the symptoms associated withmental disorders, reducing the overall burden ofthese diseases by lowering mortality and disability,and, improving the functioning, productivity andquality of life of affected people.

At the global level, the benefits of mental healthinterventions for decreasing the burden are sub-stantial. Mental disorders account for about 160million lost years of healthy life. Of this at least30% can be easily averted with existing interven-tions. For example, the disability associated withdepressive disorders in a community could bereduced to half with adequate care.

The discussions

The Executive Board of WHO in January2001 approved the theme of mental healthfor the Round Table Discussions at the 54th

World Health Assembly.Thus, four MinisterialRound Tables took place concurrently on May 15,2001 to discuss the broad perspectives on mentalhealth with special attention to four sub-themesnamely: Mental health services and barriers toimplementation; Mental health and socioeconomicfactors; Stigmatization and human rights violations;and Gender disparities in mental health.

The purpose and objectives

The Round Tables provided a forum forhealth ministers to review jointly the majorchallenges they face in addressing mental

health problems in their countries and to engage ina dialogue through which they shared information,approaches, and opportunities for redressing thesituation.The objectives were to raise awareness ofthe urgent need to address the mental health bur-den; to place mental health firmly on the nationaland international health and development agendas;and to generate political commitment for increas-ing support to mental health policies, legislation,programmes and services in all countries.

The participants

Over 30 Ministers of Health participated ineach Round Table. (In a few cases seniormembers of delegations were specifically

designated to represent the Ministers.) A balancedmix of low, middle and high income countries withdifferent political and health systems, priorities andlevel of resources for mental health was achievedin each group. Four Ministers elected by the WorldHealth Assembly served as Chairpersons.Theywere: Mr Phillip Goddard of Barbados; Mr LyonpoSangay Ngedup of Bhutan; Mrs Annette King ofNew Zealand; and Prof. M. Eyad Chatty of theSyrian Arab Republic (see annex for a complete listof participants by round table).


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The facilitators

Eight external experts with extensive inter-national and national experience in mentalhealth assisted the Chairpersons in facilitating

discussion and triggering debate.They brought abroad range of scientific, clinical, policy and pro-gramme expertise to the round tables from differ-ent regions of the world.They also contributedstate-of-the-art review papers on the four sub-themes of the discussions.These facilitators were:

■ Dr Jill Astbury

Associate Professor and Director of thePostgraduate Teaching Programs of the Key Centrefor Women’s Health in Society,World HealthOrganization Collaborating Centre in Women’sHealth at the University of Melbourne.

■ Dr Lourdes L. Ignacio

Chair of the Department of Psychiatry andProfessor of Psychiatry in charge of the Social andCommunity Psychiatry Program of the Universityof Philippines, Manila.

■ Dr Sylvia Kaaya

Head of the Department of Psychiatry atMuhimbili University College of Health Sciencesin Dar-es-Salaam,Tanzania.

■ Dr Arthur Kleinman

Professor of Social Anthropology at theDepartment of Anthropology of HarvardUniversity; and Maude and Lillian PresleyProfessor of Medical Anthropology and Professorof Psychiatry at Harvard Medical School inCambridge, USA.

■ Dr Julian Paul Leff

Professor of Social and Cultural Psychiatry andHead of the Section of Social Psychiatry at theInstitute of Psychiatry, University of London,London, UK.

■ Dr Juan José Lopez-Ibor

President of the World Psychiatric Association andDirector of the WHO Research and TrainingCentre for Spain in Madrid, Spain.

■ Ms Ana Paula de Almeida G.C. Ferrao Mogne

Co-ordinator of the National Mental HealthProgram of Mozambique.

■ Dr Vikram Patel

Senior Lecturer at the Department of Infectiousand Tropical Diseases and the Department ofEpidemiology and Population Health of theLondon School of Hygiene and Tropical Medicinein London, UK. Dr Patel is also Director ofSangath Society in Goa, India.

Documentation

Two sets of background documents wereprepared for the Round Tables.The first wasthe official Background Document reproduced

in Section 3 of this publication. It contains a generaldiscussion on the status of mental health aroundthe world and brief discussions of the four sub-theme topics.The document highlights the lack ofcommunity-based mental health services, thewidespread stigmatization of people with mentaldisorders, and the roles of poverty and genderinequality on mental health. All these factors areknown to be linked o poor mental health outcomesbut the role of the health sector in dealing withthem is not always sufficiently defined. Each sec-tion of the document is followed by a set of discus-sion points aimed at stimulating reflection, aware-ness and dialogue around the issues and what needsto be done to address them.

A second set of documents, distributed in site, wasprepared in the form of review papers.Thesepapers present in considerable detail the latest sci-entific and research evidence related to each of thesub-theme topics, model policies, programmes andservice examples from different countries, as wellas illustrations and consumers/carers testimonies.The reviews reflect not only the current status ofknowledge on the issues but they also provideguidance on policy and programmatic implications,as well as future research.The four documents arecontained in Section 4 entitled The State of theEvidence.

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The process

To catalyse attention on Mental Health in2001, the invited speakers of the DirectorGeneral at the opening Plenary of the World

Health Assembly were two family members name-ly: Ms Noreine Kaleeba, (widowed by AIDS)Community mobilization adviser of UNAIDS andfounder of The AIDS Support Organization ofUganda, and Ms. Diane Froggart, mother of a sonaffected by schizophrenia and Executive Directorof the World Fellowship for Schizophrenia andAllied Disorders. Both speakers highlighted keymental health concerns such as the need to over-come fear, silence and stigma; raise communityawareness and stimulate involvement; decrease theburden of care on families and encourage partner-ships between families and professionals.Their tes-timonies were powerful reminders of the humandimension of mental illness and its huge socioeco-nomic impact on families and communities.

The Discussions were opened by the Chairpersonsand followed by general presentations made by oneof the two facilitators assigned to each round table.The presentations highlighted the following issues:

■ the epidemiology, disease burden and socioeco-nomic impact of mental disorders includingfuture trends;

■ the interdependence of bio-psycho-social deter-minants of mental disorders;

■ the effects of social factors such as poverty,stigmatization and human rights violations, andgender discrimination on the onset, course andoutcome of mental disorders;

■ the availability of cost effective treatments andthe vast treatment gap; and

■ the barriers to the development of mental healthpolicies and programmes, intersectoral collabo-ration, and comprehensive community-basedmental health services.

Ministers were invited to discuss the general issuesin the light of the following questions:

■ What can be done to increase awareness, com-mitment and resources for addressing the burdenof mental disorders?

■ What is the level of responsibility of the publicsector in addressing mental health issues (preven-tion and care) and maintaining the highest possi-

ble standards of care in the face of other healthpriorities and limited resources?

■ What are the key mental health concerns incountries and through which strategies andapproaches are they being addressed? What arethe main technical and policy obstacles that mustbe overcome to improve mental health pro-grammes and service provision?

Midway through the sessions, presentations weremade by the second facilitator in each of the roundtables to trigger more focused discussion on theselected sub-theme topics. Discussion points high-lighted in the background document (see Section 3)were used to guide the debate.

Through a process of sharing experiences and ideasopenly and frankly, Ministers of each Round Tablebuild a clearer picture of the global mental healthstatus, the social context within which mentalproblems were occurring, the mental health priori-ties in each region, what could be done, and howbest it could be achieved. Strategies and approach-es that were being implemented with success inselected projects within countries were discussed.Similarly the shortfalls in extending these to coverentire countries were highlighted. Ministers spokeof the policy, technical and managerial difficultiesin providing equitable and humane care to all thosein need, especially the most vulnerable groups intheir countries.They were spontaneous in request-ing intensified support from the international com-munity and WHO in regards to certain crucialareas.

Reporting

Summary records of each Minister's inter-ventions during the discussions are containedin Section 5 of this publication. A single

report of the event prepared by the secretariat,compiling and collapsing the reports of the fourround tables, is provided in Section 6.

On behalf of all the participants, the integratedconclusions of the four Round Tables were present-ed to the final plenary of the World HealthAssembly on 18 May 2001 by Mr Phillip Goddard,Minister of Health of Barbados.The text of thisspeech, which was adopted by the Assembly, isreproduced in full in Section 7:A New Beginning


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The outcomes

The Ministerial Round Tables were successfulin creating greater global co-operation anddialogue on mental health issues.Three fea-

tures are prominent for follow-up action.The firstis the consensus on the primordial importance ofMental Health for the health and development ofsocieties.This provides a useful policy basis for pri-oritizing mental health at international, regionaland national levels.The second refers to the com-mitment expressed by governments to intensifyaction in pursuit of evidence-based solutions tomental 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 internationalcommunity and countries.

The World Health Organization, including its head-quarters, regional and country offices, is buildingon these features to better support countries intheir quest for equitable and humane care for peo-ple with mental problems. It is in consideration ofthe concerns raised by the Ministers that WHO’sRegional Directors and Advisers in Mental Healthhave issued statements reaffirming their strongcommitment to support countries in addressingtheir mental health priorities.These statements areprovided in Section 8.

Finally, the Epilogue of this publication (Section 9)is a statement by Dr Benedetto Saraceno, Directorof WHO’s Department of Mental Health andSubstance Dependence, which outlines the newstrategic orientation of the Programme.This isintended to better respond to the requests byMinisters for intense technical support in achievingnational mental health goals.

In the words of Dr Gro Harlem Brundtland,Director General of WHO, “The message we canbring to the world is one of optimism. Effectivetreatments are there. Prevention and early detec-tion can drastically reduce the burden.” And hencethe social and human suffering.

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Mental health

BackgroundDocument

The historical marginalization of mentalhealth from mainstream health and welfareservices in many countries has contributed to

endemic stigmatization and discrimination of men-tally ill people. It has also meant that mental healthhas received low priority in most public healthagendas with consequences on budget, policy plan-ning and service development. Estimation of theglobal burden of disease with disability adjustedlife years (DALYs) shows that mental and neuro-logical conditions are among the most importantcontributors; for instance, in 1999 they accountedfor 11% of the DALYs lost due to all diseases andinjuries. Among all the mental and neurologicaldisorders, depression accounts for the largest pro-portion of the burden. Almost everywhere, theprevalence of depression is twice as high amongwomen as among men. Four other mental disor-ders figure in the top 10 causes of disability in theworld, namely alcohol abuse, bipolar disorder,schizophrenia and obsessive compulsive disorder.

The number of people with mental and neurologi-cal disorders will grow – with the burden rising to15% of DALYs lost by the year 2020.The rise willbe particularly sharp in developing countries pri-marily owing to the projected increase in the num-ber of individuals entering the age of risk for theonset of these disorders. Groups at higher risk ofdeveloping mental disorders include people withserious or chronic physical illnesses, children andadolescents, whose upbringing has been disrupted,people living in poverty or in difficult conditions,the unemployed, female victims of violence andabuse, and neglected elderly persons.

The economic impact of mental disorders is wide-ranging, long-lasting and large. Measurable causesof economic burden include health and social serv-ice needs, impact on families and care givers (indi-rect costs) lost employment and lost productivity,crime and public safety, and premature death.Studies from countries with established economieshave shown that mental disorders consume morethan 20% of all health service costs.The aggregateyearly cost of mental disorders in 1990 for theUnited States of America was estimated at US$148 000 million. Estimates for other regions of theworld are not yet available, but even in countrieswhere the direct treatment costs are low it is likelythat the indirect costs due to “productivity loss”account for a large proportion of the overall costs.

Future increases in the prevalence of mental prob-lems will pose serious social and economic handi-caps to global development unless substantiveaction is taken now.

At present, the mental health budget in most coun-tries constitutes less than 1% of total (public sec-tor) health expenditure. Moreover, mental healthproblems are frequently not covered by healthplans at the same level as other illnesses, creating asignificant, often overwhelming, economic burdenfor patients and their families, ranging from loss ofincome to disruptions in household routine,restriction of social activities and lost opportuni-ties. Recently collected data show that more than40% of Member States have no clear mental healthpolicy and more than 30% have no national mentalhealth programme. Although almost 140 of the191 Member States have an updated list of essen-tial drugs, including psychotropic drugs, one thirdof the global population has no access to the latter.In rural areas of developing countries psychotropicdrugs are rarely available in adequate or regularsupplies.

Research has shown that general health careproviders can manage many mental and neurologi-cal problems both in terms of prevention as well asdiagnosis and treatment.Yet, less than half of thosepatients whose condition meets diagnostic criteriafor mental and neurological disorders are identi-fied by doctors. Patients, too, are reluctant to seekprofessional help. Globally, less than 40% of peopleexperiencing a mood, anxiety or substance use dis-order seek assistance in the first year of its onset.Stigmatization complicates access to those whoneed help, treatment and care; it is responsible fora huge hidden burden of mental problems.

In most cases, a complex interaction between bio-logical, psychological and social factors contributesto the emergence of mental health and neurologi-cal problems. Strong links have been madebetween mental health problems with a biologicalbase, such as depression, and adverse social condi-tions such as unemployment, limited education,discrimination on the basis of sex, human rightsviolations and poverty.

Recent advances in neurosciences, genetics, psy-chosocial therapy, pharmacotherapy, and sociocul-tural disciplines have led to the elaboration ofeffective interventions for a wide range of mental


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health problems, offering an opportunity for peo-ple with mental and behavioural disorders andtheir families to lead full and productive lives.Clinical trials have demonstrated the effectivenessof pharmacological treatments for the major men-tal, neurological and substance use disorders: neu-roleptics for schizophrenia, mood stabilizers forbipolar disorder, antidepressants for depressive ill-ness, anxiolytics for anxiety disorders, opioid sub-stitutions for substance dependence, and anticon-vulsants for epilepsy. Specific psychological andsocial interventions, including family intervention,cognitive-behavioural therapy, social skills trainingand vocational training, have been shown to be effi-cacious for severe mental illness. Rehabilitation ispossible for most people with mental illness.Thereis evidence for the effectiveness of primary preven-tion strategies, especially for mental retardation,epilepsy, vascular dementia and some behaviouralproblems. Models of service delivery in primarycare settings have been implemented around theworld, and are being evaluated.Training of familymembers, community agents and consumers/usersoffer great scope to extend the capacity for servic-es. Special mention needs to be made of the poten-tial of staffing schools with mental health workerswho have basic skills in detecting and treatingdevelopmental and emotional disorders in chil-dren.Training mothers to provide infants with psy-chosocial care, has demonstrated in many pro-grammes around the world the feasibility and suc-cess of such an approach. Meeting the needs ofchildren and adolescents who are most exposed tothe psychiatric consequences of poverty, famineand loss of parents is critical in developing coun-tries.

A large gap separates the availability of effectivemental health interventions from their widespreadimplementation. Even in established marketeconomies with well developed health systems,less than half those suffering from depressionreceive treatment. In other countries, treatmentrates for depression are as low as 5%. In areasstricken by disaster or war, the situation is evenworse. In low-income countries, most patients suf-fering from severe mental and neurological prob-lems such as schizophrenia and epilepsy do not gettreatment even when it is available at low cost(anticonvulsant therapy for epilepsy can cost US$ 5per patient per year).

In order to deal with the burden of mental andneurological disorders in countries and reduce thepsychosocial vulnerabilities of individuals, atten-tion needs urgently to be paid to the determinantsthat can be modified of the development, onset,progression and outcome of mental problems.Critical areas include: the organization of mentalhealth services, which influences access, effective-ness and quality of prevention, treatment and care;stigmatization and discrimination, which detrimen-tally affect access to care, quality of care, recoveryfrom illness, and equal participation in society;socioeconomic factors, which show a clear associa-tion with frequency and outcome of mental prob-lems; and gender roles, which determine the dif-ferential power and control that men and womenhave over the determinants of their mental health,and their susceptibility and exposure to specificmental health risks.

Mental health services andbarriers to implementation

“I was a resident or rather an inmate of the psychiatrichospital. My husband and children receded. I saw no one.The mental health workers were the only ones who couldopen the locked door. I left my hope on the other side ofthe locked door. It was a frightening experience.There wasan air of unreality there.” Female patient, UnitedStates of America

Some countries have reduced the burden ofmental problems through national reformstrategies that have shifted the emphasis of

the mental health budget from out-dated mentalasylums to community-based services and the inte-gration of mental health care into primary healthcare. Cost-effective, community-based services cannow be delivered in numerous ways that meetmany individual and community needs, and princi-ples for successful implementation of such serviceshave been identified. Similarly, on the basis ofcountry experiences, the requirements for success-ful integration of mental health into primary healthcare have been defined; they include strategies forensuring sufficient numbers of adequately trainedspecialist and primary health care staff, regularsupplies of essential psychotropic drugs, estab-lished linkages with specialist care services, refer-ral criteria, information and communications sys-tems, and appropriate links with other community

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and social services. Several models of nongovern-mental activity in a wide range of areas, from serv-ice delivery and training to political advocacy, haveproven to be successful.The participation of thenongovernmental sector, an irreplaceable source ofsupport for mental health programmes, remains tobe expanded in much of the world.

Establishing effective mental health systems facesmany challenges. A common issue is ensuring thetransfer of care from mental hospitals to the com-munity; the many obstacles include political con-siderations, stigmatization and the absence of com-munity services. How to organize and financemental health services is also an issue for mostcountries. Because of the significant disruption tosocial functioning caused by mental illnesses, coop-eration is essential between private and public sec-tors such as education, housing, employment,criminal justice, media, social welfare and women’saffairs.

Securing an adequate and affordable supply of psy-chotropic drugs is a major concern for many men-tal health systems. Similarly, most parts of theworld are experiencing a critical shortage oftrained professionals. Services are lacking for peo-ple with specialized needs, such as children,refugees and older persons, as well as those whohave substance use disorders, particularly in ruralareas. Services for linguistic and cultural minoritiesand indigenous people in many societies are ofteninadequate or inappropriate.

Most people who need and could potentially bene-fit greatly from services are not getting them. Evenin developed countries with well resourced healthservices, less than half those people who needtreatment and care receive it. Although we know agreat deal about how to solve the many and variedproblems, the challenge is to remove the barriers.The potential return to society is substantial.

Discussion points

■ What are some of the critical barriers to the pro-vision of community-based mental health servic-es in your country and what efforts are beingmade to overcome them?

■ What are the obstacles to providing services andpsychotropic drugs in rural areas and how arethey being tackled?

■ What mechanisms can governments put in placeto ensure an adequate supply of psychotropicdrugs?

■ How can nongovernmental and other communi-ty-based organizations, including traditional heal-ers and religious agencies, be engaged in anational mental health programme?

Stigmatization and human rights violations

“Given the number of families in every society who areaffected by mental illness, it is amazing that there hasnot been an outcry to do more. Shame and fear have builtwalls of silence.” Caregiver, Belize

Stigmatization and violations of human rightsrepresent a sizeable, albeit hidden, burden ofmental illness. Around the world, many men-

tal health patients still receive outmoded and inhu-mane care in large psychiatric hospitals or asylums,which are often in poor condition. Besides con-tributing to endemic stigmatization and discrimina-tion of the mentally ill, these failings have led to awide range of human rights violations. Mental ill-ness has often been seen as untreatable, and men-tally ill individuals are labelled as violent and dan-gerous. People with alcohol and substance depend-ence are considered morally and psychologicallyweak.The media perpetuate these negative charac-terizations. Stigmatization often leaves persons suf-fering from mental illness rejected by friends, rela-tives, neighbours and employers, leading to aggra-vated feelings of rejection, loneliness and demoral-ization.

Stigmatization also leads to discrimination; thus itbecomes socially acceptable to deprive stigmatizedindividuals of legally granted entitlements. Healthinsurance companies discriminate between mentaland physical disorders and provide inadequate cov-erage for mental health care. Labour and housingpolicies are less open to people with a history ofmental disorders than people with physical disabili-ties.

Surveys have shown that negative social attitudestoward the mentally ill constitute barriers to rein-tegration and acceptability, and adversely affectsocial and family relationships, employment, hous-ing, community inclusion and self-esteem. Equally,


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they create barriers to parity of treatment oppor-tunities, restrict the quality of treatment optionsand limit accessibility to best treatment practicesand alternatives. Unfortunately, negative attitudestowards the mentally ill and stigmatizing stereo-types may also be shared by medical and hospitalpersonnel; patients frequently complain that theyfeel most stigmatized by doctors and nurses.

The myths and negative stereotypes about mentalillness, although strongly held by the community,can be overcome – as communities recognize theimportance of both good mental and physicalhealth care; as advocacy renders people with men-tal disorders and their families more visible; aseffective treatments are made available at the com-munity level; and, as society acknowledges theprevalence and burden of mental disorders.

Introducing legislative reforms that protect thecivil, political, social, economic, and cultural enti-tlements and rights of the mentally ill is also cru-cial. However, this step alone will not bear thefruits expected by legislators without a concertedeffort to erase stigmatization as one of the majorobstacles to successful treatment and social reinte-gration of the mentally ill in communities.Thepublic needs to be engaged in a dialogue about thetrue nature of mental illnesses, their devastatingindividual, family and societal impacts, and theprospects of better treatment and rehabilitationalternatives. At the same time, stigmatizing atti-tudes need to be tackled frontally through cam-paigns and programmes aimed at professionals andthe public at large. Public information campaignsusing mass media in its various forms; involvementof the community in the design and monitoring ofmental health services; provision of support tonongovernmental organizations and for self-helpand mutual-aid ventures, families and consumergroups; and education of personnel in the healthand judicial systems and employers – all are criticalstrategies to start dispelling the indelible mark, thestigma caused by mental illness.

Discussion points

■ What measures has your country put (or does itplan to put) in place to fight discrimination andstigmatization of mentally ill people and theirfamilies?

■ What is the level of responsibility and the role ofthe public health sector in tackling such stigmati-zation and discrimination?

■ How can other sectors contribute to stopping thedenial, through discrimination, to mentally illpeople of equitable access to services and consid-eration?

■ Given that mental health legislation requires abalance between the right to individual liberty,the right to treatment and the legitimate expec-tation of community safety, what are the criticalissues in formulating, implementing and enforc-ing balanced legislation?

Socioeconomic factors

“Poverty is pain; it feels like a disease. It attacks a personnot only materially but also morally. It eats away at one’sdignity and drives one into total despair ”A woman,Republic of Moldova

Socioeconomic factors, especially poverty,influence mental health in powerful andcomplex ways.They are highly correlated

with an increase in the prevalence of serious dis-orders such as schizophrenia, major depression,antisocial personality disorders and substance use.Most of these disorders are about twice as com-mon among the poorest sections of society as inthe richer ones. In addition, malnutrition, infec-tious diseases and lack of access to education canbe risk factors for mental disorders and can wors-en existing mental problems.These findings areconsistent in countries across income levels.Theyillustrate the broader concept of poverty, whichincludes not only economic deprivation but alsothe associated lack of opportunities for accessinginformation and services.

The relationship between poverty and high preva-lence rates of psychiatric disorders can beexplained in two ways, which are not mutuallyexclusive and which appear to be operative for dif-ferent disorders. First, poor people in most soci-eties, even among the wealthiest countries, areexposed to greater levels (quality and quantity) ofenvironmental and psychological adversity, whichproduces high levels of stress and psychologicaldistress.They have major difficulties accessinginformation and mental health services. In mostdeveloping countries these services are so limited


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that they remain out of reach for the poor: infor-mation is often not available to illiterate popula-tions; transport is difficult and costly; and respon-siveness of the health services is low. Not only dothese factors contribute to chronicity and moredisability, but they may also trigger non-psychoticforms of mental illness, especially depression andanxiety disorders. Considerable evidence points tothe social origins of psychological distress anddepression in women, both of which conditionsaffect them disproportionately.

The second explanation for the relationshipbetween poverty and high prevalence rates of psy-chiatric disorders refers to “downward drift” withpeople with a mental illness incurring muchgreater risks for homelessness, unemployment andsocial isolation.While families remain the keyproviders of care in most parts of the world, thestrain of providing care over time can lead to peo-ple with severe mental illness being rejected bytheir families.This estrangement enhances the riskfor poverty. In all events, socioeconomic factorsand mental health are inextricably linked.Thetreatment gap for most mental disorders is largebut for the poor segments of populations in allcountries it is seemingly unbridgeable.

Mental disabilities result in substantial societal bur-dens of lost productivity and added costs for sup-port, not to mention the high cost of the loss ofpotential contributions to society of people orfamilies who care for the mentally ill. Hence, thecumulative costs significantly drain the economiesof poor countries. National policies to reducepoverty focus on stabilizing and improving income,strengthening education, and meeting basic humanneeds such as housing and employment.With thehealth of a nation increasingly being seen as a criti-cal component of development, mental health, as akey aspect of public health, needs to be acknowl-edged as a priority for overall social development.

Discussion points

■ What information on the magnitude and burdenof mental and neurological disorders among thepoor is available in your country? Are there anyplans to collect further information?

■ Is health, in particular mental health, a part ofpoverty reduction strategies and programmes inyour country?

■ Do individuals and families with mental and neu-rological disorders get social support or benefitsunder poverty-alleviation schemes or social-wel-fare measures in your country?

■ What are the barriers faced by the poor inaccessing mental health information and care inyour country? What are your country’s plans tomake mental health services more equitable?

Gender disparities

“It is not the physical abuse which is the worst but theterror which follows – the emotional abuse. I am stillangry and terrified.” Battered woman, Australia

Gender roles are critical determinants ofmental health that need to be considered inpolicies and programmes.They govern the

unequal power relationship between men andwomen and the consequences of that inequality.They affect the control men and women have oversocioeconomic determinants of their mentalhealth, their social position, status and treatment insociety.They also determine the susceptibility andexposure of men and women to specific mentalhealth risks.

Sex differences are seen most graphically in theprevalence of common mental disorders – depres-sion, anxiety and somatic complaints.These disor-ders, most prevalent in women, represent the mostcommon diagnoses within primary health care set-tings and constitute serious public health prob-lems. In particular, depression, predicted to be thesecond leading cause of global disability burden by2020, is twice as common in women as in men,across most societies and social contexts; it mayalso be more persistent in women than men.Reducing the disproportionate number of womenwho are depressed would significantly lessen theglobal burden of disability caused by mental andbehavioural disorders.

The lifetime prevalence rate for alcohol depend-ence, another common disorder, is more thantwice as high for men as for women. Men are alsomore than three times more likely to have antiso-cial personality disorder than women.

Although the prevalence rates of severe mental dis-orders such as schizophrenia and bipolar disorder(together affecting less than 2% of the population)


20

are much the same between the sexes, differenceshave been reported in age of onset of symptoms,frequency of psychotic symptoms, course of thesedisorders, social adjustment and long-term out-come for men and women.The disability associat-ed with mental illness falls most heavily on thosewho experience three or more concomitant disor-ders – again, mainly women.

Gender-specific risk factors

Depression, anxiety, somatic symptoms and highrates of comorbidity are significantly related to riskfactors that can be related to gender, such as vio-lence, socioeconomic disadvantage, incomeinequality, low or subordinate social status andrank, and unremitting responsibility for the care ofothers. For instance, the frequency and severity ofmental problems in women, are directly related tothe frequency and severity of such factors.

Economic restructuring has had gender-specificconsequences for mental health. Economic andsocial policies that cause sudden, disruptive andsevere changes in income, employment and socialcapital that cannot be controlled or avoided cansignificantly increase inequality between men andwomen and the prevalence rate of common mentaldisorders.

Violence against women is a public health concernin all countries, an estimated 20% to 50% ofwomen have suffered domestic violence. Surveys inmany countries reveal that 10% to 15% of womenreport that they are forced to have sex with theirintimate partner.The high prevalence of sexualviolence to which women of all ages are exposed,with the consequent high rate of post-traumaticstress disorder explains why women are mostaffected by this disorder.

Gender bias

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

problems in women and to alcohol problems inmen seem to reinforce social stigmatization and toconstrain help-seeking behaviour.They impede theaccurate identification and treatment of psycholog-ical disorders.

Mental health problems related to violence are alsopoorly identified. Among victims, women arereluctant to disclose information unless askedabout it directly.When undetected, violence-relat-ed health problems increase and result in high andcostly use of the health and mental health care sys-tem.

Discussion points

■ To what extent is your country’s mental healthpolicy gender-sensitive and does it identify andaddress the gender-specific risk factors necessaryfor prevention?

■ What needs to be done to enable primary healthcare providers to gain and use the skills necessaryto identify gender-related violence and for themanagement and care of the ensuing mentalproblems?

■ How can the health sector improve intersectoralcollaboration between government departmentsin order to remove gender bias and discrimina-tion, and to modify social structural factors suchas child care responsibilities, transport, cost, andlack of health insurance that constrain women’saccess to mental health care?


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Julian Leff

Professor of Social and Cultural PsychiatryHead of the Section of Social PsychiatryInstitute of PsychiatryLondon, U.K.

The state of the evidence

Mental health services andbarriers to implementation

Executive summary

The move to community-based mentalhealth care

Psychiatric services in developed countrieswere highly centralized as a result of the mas-sive programme of building psychiatric hos-

pitals.The process of running down and closingthese hospitals has resulted in decentralization,with the establishment of community-based servic-es. In many developing countries, the great majori-ty of people with psychiatric conditions are man-aged in the community, but with very few special-ized professionals. In many of these countries, thedevelopment of psychiatric services continues tohave a low priority despite the high level of chron-ic disability caused by psychiatric illnesses.

Individuals and their families must have access toaffordable psychiatric services and to sufficientlytrained health workers to correctly diagnose andtreat the problems. An optimal balance betweenspecialist and primary health care services is need-ed. Mental health legislation also requires a balancebetween the right to individual liberty, the right totreatment, and protection of the public. In thosecountries which lack a mental health law, it is ofhigh priority that one be enacted.

New interventions

In the last two decades there have been majoradvances in both drug and social treatments for awide range of psychiatric conditions. New types ofantipsychotic drugs and antidepressants have beenintroduced which have fewer side effects than theolder drugs, but are more expensive. Cognitive-behavioural therapies, which aim to alter faultythinking patterns and equip patients with helpfulstrategies to combat symptoms, have been intro-duced both for neuroses and for schizophrenia andmanic-depression. Involving families in treatmenthas been shown to improve the outcome for alco-holism, eating disorders, depression, schizophre-nia, and childhood neuroses and behavioural prob-lems.These innovative developments greatlyextend the range of effective psychiatric interven-tions, but are available to very few patients, even indeveloped countries.

Making drug and psychosocialtreatments available to allwho could benefit

Disseminating effective psychosocial treatments isa major challenge in all countries. In developingcountries in which psychiatric services need to beestablished in primary care facilities, the costs ofproviding appropriate psychiatric training to thestaff and of ensuring an uninterrupted supply ofessential drugs must be budgeted for nationally.Some drugs may be purchased under genericnames from non-profit organizations.There aregood examples of training paramedical staff to pre-scribe a limited range of psychotropic medication.In addition, with minimal training, they can useflow-charts for diagnosis, assessment, managementand referral.

In the absence of specialized professionals, para-medical staff and family members can be trained tohelp other families cope better with a mentally illmember. Although the responsibility for the care ofpeople with psychiatric illness falls almost entirelyon the family in developing countries, a genuinecollaboration between professionals and familymembers is rare.

The therapeutic value of work

Work is a crucial factor in the social reintegrationof psychiatric patients. However, in developedcountries it is very difficult to find a job if you havea history of mental illness.The recent developmentof social firms or co-operatives has provided ananswer to this problem. In order to improve thequality of life of people with mental illness livingin the community, it is essential to forge stronglinks between mental health services and depart-ments of employment, welfare and housing.

The growth of users and relativesorganizations

Non-governmental organizations for users and rel-atives have grown to become national advocacygroups, as well as providers of services, in manydeveloped countries.They are still embryonic inmost developing countries.The recognition thatusers have a legitimate voice is empowering andalso has the effect of reducing the stigma of mentalillness.


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Special groups and their needs

Children and Adolescents: In most countries in theworld, the development of psychiatric services forchildren has lagged behind those for adults.Children and adolescents are more exposed to thepsychiatric consequences of poverty, famine andloss of parents in developing countries, preciselywhere child psychiatric services are least in evi-dence.With the spread of universal education,schools are becoming the most appropriate venuefor health related interventions for children.Primary care workers need to be based in schoolsand to be equipped with skills to identify emotion-al and behavioural problems in children, and totreat and manage them.The possibility also existsof training mothers in the better care of infants toprevent later problems in psychological develop-ment.

Substance Misuse: The scale of misuse of psychoac-tive substances, including multiple substance use,has grown dramatically worldwide in the past threedecades. A wide range of effective treatments isavailable for alcohol and drug problems, includingpsychosocial, medical and educational interven-tions.These are best located in primary care serv-ices, which should collaborate with available com-munity agencies, including self-help groups. Equalattention should be given to measures to reducethe demand for psychoactive substances and toreduce the supply.

The Elderly: Older people are at high risk for sui-cide (particularly men), depression and dementia.The psychiatric problems of the elderly areincreasing yearly as the proportion of older peoplerises steadily worldwide. At the same time, the dis-solution of the extended family under the pres-sures of urbanization and industrialization is slowlyremoving the natural support networks that sustainthe elderly.Therefore there is a pressing need tosupport and improve the care already provided tothe elderly by their families, including the provi-sion of respite care, and the incorporation of men-tal health assessment and management into generalhealth services for the elderly.

M E N TA L H E A LT H S E R V I C E S A N D B A R R I E R S T O I M P L E M E N TAT I O N

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Mental health care in developedand developing countries

Introduction

The development of psychiatric services hasdiverged markedly in developed and develop-ing countries. In the former, services became

strongly centralized through a massive programmeof building psychiatric hospitals in the nineteenthand early twentieth centuries.These were usuallysited outside towns and cities.These hospitals wereenclosed worlds, isolated from the rest of society,and patients, once admitted, were likely to remainfor the rest of their life.

In developing countries a few psychiatric hospitalswere built by the colonial powers, but these wereoften designated for their own personnel to theexclusion of the local population.With the endingof colonial rule, the psychiatric hospitals weretaken over by the new governments, but they havenever catered to more than a tiny proportion ofthe population. In India, for example, there areonly about 25,000 psychiatric beds for a popula-tion exceeding one billion (Wig, 1997).Consequently, in developing countries familiescontinue to be the main source of care and supportfor people with psychiatric disorders, includingthose of the greatest severity.

Following the end of the Second World War, thefocus of care in developed countries began to shiftfrom the psychiatric hospitals to communitybased services.This was in response to changes inthe attitudes of staff, increasing public awarenessof abusive practices in the hospitals, and the intro-duction in 1955 of chlorpromazine, a drug withspecific antipsychotic action. In North America,Europe and Australia the process of deinstitution-alization (transferring services from psychiatrichospitals to community facilities) has proceededsteadily, resulting in the closure of many psychi-atric hospitals. In Italy, Law 180 was enacted in1978 preventing the admission of patients to psy-chiatric hospitals, though psychiatric beds in gen-eral hospitals remain available. In England andWales, by 2000 only 14 of the 130 psychiatrichospitals were still open. In Valencia, Spain, thelast of the 8 psychiatric hospitals was closed in2001.The neglect of mental hospitals continues

to date in both developed and developing coun-tries.

The old psychiatric hospitals represent a largeinvestment of capital in both the buildings and thegrounds, and of revenue in the staff.The land onwhich they stand has become quite valuable ascities have expanded to incorporate the once-dis-tant asylums. In many countries the sites of thepsychiatric hospitals have been sold to developersand the funds raised have been invested in commu-nity services. Staff in the psychiatric hospitals havebeen redeployed to work in the community.Thedominant model in the organization of comprehen-sive psychiatric care in many European countrieshas been the creation of geographically definedareas, known as sectors; this concept was developedin France in the mid-20th century. From the 1960son, the organizing principle of sectorization hasbeen widely applied to many areas in almost allcountries in Western Europe, with sector sizeranging form 25,000 to 30,000 population.

Deinstitutionalization has not however been anunqualified success and community care still facesmany operational problems. Among the reasons forthe lack of better results are that some govern-ments have not allocated resources saved by closinghospitals to community care, and that professionalshave not been adequately prepared to fully under-stand and accept the changing place of care androles. Critics of the community based approachclaim that it has led to many more mentally ill peo-ple becoming homeless or being imprisoned(Lamb, 1976). However, follow-up studies ofcohorts of long-stay patients discharged from psy-chiatric hospitals have shown that if communityservices are well organized and adequately funded,these negative outcomes can be avoided, withimprovement in the patients’ quality of life(Trieman et al, 1999; Leff et al, 2000; Rothbard etal, 1999).

In many developing countries on the other hand,care programmes for the individuals with mentaland behavioural problems continue to have a lowpriority.There is no psychiatric care for the major-ity of the population: care is still mostly limited toa small number of institutions – usually over-crowded, understaffed and inefficient – and servic-es do not reflect the needs of the ill individuals orthe range of approaches available for treatment and


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care.The public seeks help in these centres as a lastresort. Many hospitals continue to operate underlegislation that is more penal than therapeutic. Forexample, in 15% of countries around the world,(WHO Project ATLAS. Preliminary analysis ofinformation collected during an initial study, fromOctober 2000 to March 2001, from 181 coun-tries) the laws governing admission and dischargeare more than 60 years old; these laws place barri-ers to admission and discharge. Also, since thereare few specialized professionals, the communityresorts to the available traditional healers. Most ofthese countries do not have adequate national leveltraining programmes for psychiatrists, psychiatricnurses, clinical psychologists, psychiatric socialworkers and occupational therapists.

A result of all these factors is a negative institu-tional image of the mentally ill which is added tothe stigma of being mentally ill. Even now, theseinstitutions continue to be out of step with thedevelopments and human rights of persons withmental illness as seen from reports on mental hos-pitals in several countries. However, stimulated bythe accumulating evidence of the inadequacies andfailures of the psychiatric hospital coupled with theappearance of “institutionalism”, (the developmentof disabilities as a consequence of social isolationand institutional care in remote asylums) manydeveloping countries have initiated the process ofde-institutionalization.

Community-based mental health care

De-institutionalization can be defined as abasic precondition of any serious mentalhealth care reform. De-institutionalization is

not synonymous with de-hospitalization.This hasto be seen as a complex process leading to theimplementation of a solid network of communityalternatives. Closing mental hospitals, withoutcommunity alternatives is as dangerous as creatingcommunity alternatives without closing the mentalhospitals. Both have to occur at the same time.

To prevent and treat mental disorders a spectrumof services is needed, including mental health pro-motion, illness prevention, early intervention,treatment and rehabilitation (Jenkins and Üstün,1998; Rahman et al, 1998).The complexity of

delivering these services to meet community needsis a challenge. For example, community education,school and workplace mental heath promotionrequire collaboration between different govern-ment departments and other stakeholders. Chronicmental disorders require integrated treatment andsupport services to reduce disability, increasesocial functioning and improve quality of life(Katschnig et al, 1997).

For other more prevalent conditions, cost effec-tive treatments are now available to removeactive symptoms and disability (Nathan andGorman, 1998) and can often be applied by pri-mary health care providers (Saraceno et al, 1995;Abas et al, 1995; Üstün and Sartorius, 1995). Forthis, individuals and/or their families or othermembers of the community must recognize theproblem, have accessible and affordable profes-sional services and sufficiently trained healthworkers to correctly diagnose and treat the prob-lems. An optimal balance and collaborationbetween specialist and primary health care serv-ices and between hospital and community care isneeded. Mental health legislation also requires abalance, between the right to individual liberty,the right to treatment and the legitimate expec-tation of community safety.

In most countries where deinstitutionalization hasoccurred, the process began with local initiativesand was only officially endorsed as governmentpolicy at a later stage.The exceptions are somecountries in Europe and Latin America where thelaw was altered to start the process of change. Forthe transition to community care to be successfullyachieved, it is essential to have the full backing ofthe government so that there is equity of servicesnationally, and so that mental health legislation isamended to meet new standards of caring forpatients.The process of formulating new laws mustbe carried out in collaboration with representativesof the criminal justice system. In those countrieswhere there is no existing mental health law, it isof high priority that one should be enacted.

In some countries, even when decisions have beenmade to deliver a balanced spectrum of servicesnationally, the outcome has often fallen short of itsfull potential because insufficient attention wasgiven to structural, functional and financial issuesthat are principal barriers to successful policy


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implementation. Examples that demonstrate theimportance of those issues include:

■ The deinstitutionalization of patients with severemental illness needs to be linked to an upgradingof the health care system within the communitythat will have to receive the patients (Lamb,1992).

■ The utilization of primary health and social serv-ices to deliver care to people with mental illnessrequires that these services have sufficient train-ing and structural linkages to specialist mentalhealth service providers (Strathdee and Jenkins,1996).

■ Training mental health professionals as a meansof expanding access to care requires that suffi-cient attention is given to issues of distributionand specific role based skills through certificationand other means (Jenkins, 1999).

■ The dependence on families and community sup-port systems, including self-help groups, publichousing etc, requires that sufficient structuraland financial linkages be established to the men-tal health services (Whiteford, 1994).

Good quality care in the community is no cheaperthan psychiatric hospital care (Hallam et al, 1994),and there are transitional costs which need to bemet before the new service is fully established.Hence mental health budgets need to reflect this.Furthermore, in developing countries in whichpsychiatric services need to be established in pri-mary care facilities, the costs of providing primarycare workers with appropriate psychiatric training,and of ensuring an uninterrupted supply of essen-tial drugs, must be budgeted for nationally. Healthbudgets are under constant pressure to expandfrom all medical and surgical specialties. In view ofthe heavy burden of disability produced by psychi-atric disorders budgets for mental health need tobe protected. (WHO, 1997)

In conclusion, community based mental health careis about empowerment of people with mental andbehavioural disorders and refers to the stage inwhich the main goal is to develop a wide range ofservices within local settings. In this process,which has not yet begun in many regions andcountries, it is aimed to ensure that some of theprotective functions of the asylum are fully provid-ed, and the negative aspects of the institutions arenot perpetuated.The care in the community

approach aims to provide services which offertreatment and care with the following characteris-tics:

■ services which are close to home through pri-mary health care, including general hospital-carefor acute admissions, and long-term residentialfacilities in the community;

■ interventions related to disabilities as well assymptoms;

■ treatment and care specific to the diagnosis andneeds of each individual;

■ wide range of services which address the needsof service users themselves and of other ill per-sons;

■ services which are co-ordinated between mentalhealth professionals and community agencies;

■ mobile rather than static services, includingthose which can offer home treatment;

■ partnership with carers and meeting their needs;

■ legislation to support the above aspects of care.

The advent of new treatments forpsychiatric conditions

In the last two decades there have been majoradvances in both drug and social interventions fora wide range of psychiatric conditions:

Drug therapies

New types of drugs have been introducedfor treating the symptoms of psychosis.Following the introduction of chlorpro-

mazine in 1955, a number of related antipsychoticdrugs came on the market.These all had the disad-vantage of causing severe neuromuscular sideeffects at therapeutic doses, which deterred manypatients from taking them regularly. Clozapine, adrug which was free of these side effects, becameavailable, but had the dangerous propensity of sup-pressing white cells in 1-2 percent of patients.Since 1973 four or five novel antipsychotic drugshave been introduced which lack the neuromuscu-lar side effects of the older drugs and do not affectthe white cells. Hence they are more acceptable topatients. However they are much more costly: forexample, in the United Kingdom, the monthlycost of haloperidol is £5, while clozapine costs£241.


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New types of antidepressant drugs have beendeveloped which are considerably safer than theolder types when taken as an overdose, but are alsomore expensive.

Psychosocial therapies

Cognitive-behavioural therapies, which aim to alterfaulty thinking patterns and equip patients withhelpful strategies to combat symptoms, have beenintroduced for depression (Beck et al, 1979), anxi-ety states, phobias (Marks, 1987), and obsessive-compulsive disorders (Marks et al, 1975). For eachof these conditions the psychological treatment isas effective as drug treatments or better. Patientsare generally reluctant to take drugs for long peri-ods and greatly prefer non-drug treatments.Recently a cognitive-behavioural approach to psy-chotic symptoms (delusions and hallucinations) hasbeen shown to be of benefit, particularly forpatients who have responded poorly to antipsy-chotic drugs (Kuipers et al, 1998;Tarrier et al,1999).

Family therapy improves the outcome for adultswith alcoholism, eating disorders, and depression,and for children with neuroses and behaviouralproblems.Working with families of people withschizophrenia adds a significant advantage to main-tenance drug treatment in reducing the relapserate (Leff, 2001) and has been endorsed by aCochrane Review as evidence based (Pharoah et al,1999).

These innovative developments greatly extend therange of effective psychiatric treatments, but areavailable to very few patients, even in developedcountries with well-resourced national health serv-ices.The difficulty in disseminating these treat-ments is partly due to the lack of training in thenecessary skills, and partly to the fact that there isno commercial organization with an interest inpromoting the product.

Integrating psychiatric carewithin primary health care

Despite the major differences between men-tal health care in developing and developedcountries, they share a common problem: the

poor utilization of available psychiatric services.Even in countries with well established services,fewer than half of those individuals needing themmake use of them This is related to the stigmaattached to the individuals with mental and behav-ioural disorders and the inadequacy of servicesprovided.

This stigma issue was also highlighted in the USSurgeon General’s Report of December 1999.Thereport noted: “Despite the efficacy of treatmentoptions and the many possible ways of obtaining atreatment of choice, nearly half of all Americanswho have a severe mental illness do not seek treat-ment. Most often, reluctance to seek care is anunfortunate outcome of very real barriers.Foremost among these is the stigma that many inour society attach to mental illness and to peoplewho have a mental illness.”

Integrating psychiatric care within general healthcare – which includes the opening of psychiatricadmission wards in general hospitals – has theadded advantage of reducing the stigma of anadmission for psychiatric illness. In developedcountries it is rare nowadays for patients with non-psychotic disorders to be admitted, and admissionwards are almost exclusively occupied by patientswith psychoses.The great majority of patients withnon-psychotic disorders are treated by primarycare physicians, only 5% of them being referred tosecondary care (Goldberg & Huxley, 1980).However, up to one half of patients consulting pri-mary care physicians with psychological disordersare incorrectly perceived as suffering from physicalillnesses (Docherty, 1997; Goldberg & Huxley,1992) leading to a waste of money on physicaltests and delay in their receiving appropriate treat-ment, or its absence.This is partly because manypatients present to their doctors with bodily ratherthan psychiatric complaints (Üstün & Sartorius,1995).The problem is very serious because depres-sion accounted for more than 10 per cent of yearsof life lived with a disability worldwide in 1990.Many episodes of depression become chronic, par-


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ticularly if untreated: persistent symptoms werefound in 32 per cent of 60 patients 12 to 15months after remission (Paykel et al, 1995).Improvements in training of primary health careproviders for assessment and management of men-tal disorders is a priority for both developing anddeveloped countries.

The organization of mental services as part of pri-mary health care is a general approach in develop-ing countries. At one level it can be seen as neces-sity in the face of lack of trained professionals andresources to provide specialized services. At anoth-er level it is a reflection of the opportunity toorganize mental health services in a manner that isdevoid of isolation, stigma and discrimination.Theapproach of utilizing all the available communityresources has an attraction of empowering individ-uals, families and communities to make mentalhealth an agenda of people rather than profession-als. However, currently mental health care is notreceiving the attention that is needed. Even incountries where pilot programmes have shown thevalue of integrating mental health care within pri-mary health care (e.g. Brazil, Colombia, India,Sudan) the expansion to cover the whole countryhas not occurred.

Treatment interventions throughprimary health care

Drug treatments

Psychiatric drug treatments can be delivered byprimary care physicians in developed countries,although they are not always as skilled in their useas psychiatrists.This is particularly the case withantidepressant drugs which tend to be prescribedin too low a dosage. In developing countries eventhe cheapest, most basic drugs may be availableonly sporadically, or not at all.This problem stemsfrom a combination of insufficient central fundsand an inadequate infrastructure for distribution. Ithas been tackled successfully in Sichuan Province,China, by training village medical auxiliaries in theuse of three low cost psychiatric drugs: an antide-pressant, an antipsychotic, and carbamazepine,which is effective both for stabilizing mood disor-ders and controlling epilepsy. In a similar initiativein Belize, Central America, well trained psychiatricnurse practitioners have been prescribing psy-chotropic medication for some years, a service

which has been positively evaluated (Kohn et al,2000).This exemplifies the approach recommend-ed by the Expert Committee on the Use ofEssential Drugs (WHO, 1988).

Continuous maintenance medication is oftenrequired for the psychoses (schizophrenia andmanic-depressive illness) and sometimes fordepressive disorders. An interruption in the supplyof drugs can lead to relapse of these conditions. Incertain circumstances, drugs may be purchasedunder generic names from non-profit organizationssuch as ECHO (Equipment for CharitableHospitals Overseas) and UNIPAC (UNICEFProcurement and Assembly Centre), which supplydrugs of good quality at economic prices (WorldHealth Organization, 1990).

Even with a very limited range of psychotropicdrugs to prescribe, the health worker will need todecide which are indicated for particular clients.Flow-charts have been developed for psychiatricconditions that incorporate decisions about diagno-sis, assessment, management and referral.Theiradvantage is that they can be used with minimaltraining (World Health Organization, 1990).

Psychosocial treatments

In developed countries there is usually a cadre ofpsychiatric staff based in the community whocould deliver these effective new treatments.However there is a logistic problem in training asufficient number of them in the requisite skills.Training in psychosocial interventions that havebeen proven efficacious is time-consuming, andduring training the staff member is absent from thework site and has to be replaced. Funds need to bemade available both for the training and forreplacement staff. Managers are often reluctant tocommit funds to the short term investment, eventhough there are long term economic gains interms of reduced hospitalization rates (Cardin etal, 1985; Zhang et al, 1994). Even when staff aretrained, they are not always able to utilise theirskills efficiently.This is partly due to the pressureof their case load, and partly to the lack of ade-quate supervision and support for work that isemotionally demanding. In order to integrate psy-chosocial interventions into a clinical service it isnecessary to achieve a culture change in the wholeservice by educating all the staff, including man-


30

agers, in the value of the interventions, and train-ing a core group of workers who can providemutual support (Fadden, 1998).

A cascade model of training in family work, cogni-tive-behavioural approaches for schizophrenia, andassertive community treatment has been estab-lished in Britain for psychiatric personnel (theThorn Initiative) (Lancashire et al, 1997).Twonational training centres accept trainees from any-where in Britain, and provide training both in thenecessary skills and, for selected individuals, tobecome trainers themselves. Six satellite trainingcentres are now operating and a further six arebeing established. However, even after severalyears of operation of this programme only a smallproportion of families who could benefit from thisintervention are receiving it.This technologicalinnovation is not available for most of the world,although training in family work is becoming estab-lished in certain centres in Europe and the US.

A model of this kind is inappropriate for a devel-oping country due to lack of sufficient psychiatri-cally trained personnel available to work at thecommunity level. Furthermore, even whenproviders exist, there is often maldistribution, dueto their commitment to private patients and areluctance to practice in rural communities.Thestrategy of training health workers in the use of alimited range of drugs cannot be applied to psy-chosocial treatments, since the effective compo-nents in these complex interventions have yet tobe identified. A different approach has beenattempted in Britain which may be applicable todeveloping countries. A voluntary organization forpatients with schizophrenia and their families (theNational Schizophrenia Fellowship) has introduceda novel programme which uses family members astrainers for other families (Carers Education andSupport Project).The training programme for tento twelve carers is delivered in ten three hour ses-sions. It aims to improve carers’ understanding ofsevere mental illness, to reduce stress and ease theburden of caring, and to improve communicationskills (Shore & Holmshaw, 1998). Although not yetfully evaluated, this strategy is promising. However,the approach to working with families will need tobe modified to be sensitive to local cultures, as hasbeen achieved successfully in Malaysia (Razali et al,2000) and China (Xiong et al, 1994; Zhang et al,1994). In all these endeavours it is crucial to rec-

ognize that the family is not the target of treatmentbut is a partner in the treatment process. Effectiveworking relationships between families and mentalhealth staff depend upon consultation, co-opera-tion, mutual respect, equality, sharing of comple-mentary resources and skills, and clarity of expec-tations (Community Liaison Committee of theRoyal Australian and New Zealand College ofPsychiatrists, 2000).

Although the responsibility for the care of peoplewith psychiatric illness falls almost entirely on thefamily in developing countries, a genuine collabo-ration between professionals and families remainsin its infancy. For example, in India there are a fewplaces where family interventions have been deliv-ered (Shankar & Menon, 1993;Verghese et al,1991), but these are specialized facilities and suchapproaches are not available in routine service set-tings.The importance of the family’s commitmentto the caring role cannot be overemphasized, par-ticularly since there is evidence that the manifestlybetter outcome for patients with schizophrenia indeveloping countries (Jablensky, 1992) is partlydue to a greater tolerance by relatives for symp-toms and disturbed behaviour (Wig et al, 1987;Whyte, 1991)

Combating social exclusion

Work as a therapeutic activity

Long-term care in a psychiatric hospitalexcluded patients from participation in socie-ty. Since these institutions provided a total

environment (Goffman, 1961) including shelter,work and recreation, there was no reason forpatients to step outside the gate, even if they wereallowed to do so.Transferring patients to homes inthe community does not automatically ensure rein-tegration into society.There are a number of barri-ers to social integration including stigmatizing atti-tudes of the public, patients’ lack of social skills,and the difficulty in obtaining a job in openemployment.Work is a crucial ingredient in thereintegration of psychiatric patients since it canprovide them with social contact with ordinary cit-izens, it can give them a sense of worth throughcontributing to society, it can alleviate the povertythat many endure (see Socioeconomic Factors andMental Health), and it can help to reduce delusions


31

and hallucinations. Patients discharged from psy-chiatric hospital who have a job are much less like-ly to be rehospitalized than those who are unem-ployed, regardless of their level of symptoms(Jacobs et al, 1992).The provision of shelteredworkshops in the community maintains the socialisolation of patients from mainstream society, andusually requires them to undertake repetitive,unsatisfying packing or assembly tasks. A preferablealternative is the recent development of socialfirms or co-operatives (Saraceno, 1997), which area particular feature of the community psychiatrymovement in Italy. A comparison of patients withschizophrenia in Bologna, Italy, and Boulder,Colorado, USA, found that 30% of the Italianpatients worked more than 30 hours per weekcompared with 8% of the American patients, andthe Italian patients earned two and a half times asmuch and enjoyed a better quality of life (Warneret al, 1998). Social firms for people with psychi-atric disabilities are now reasonably well estab-lished in Europe, with Germany having by far thelargest number (Grove et al, 1997).

In developing countries, in which families providevirtually all the care for people with psychotic ill-nesses, they are often able to find tasks within afamily enterprise which their relative is able toperform. In this event, mentally ill family memberscan feel they are contributing to the family’s wel-fare and are included in a social unit. However, thespread of urbanization and industrializationinevitably curtails these opportunities for employ-ment.Therefore social firms represent a way for-ward in both developed and developing countries.Their development could be encouraged by taxincentives from the government and by theinvolvement of local businessmen as advisors.

In order to improve the quality of life of peoplewith mental illness living in the community, it isessential to forge strong links between mentalhealth services and departments of employment,welfare, and housing.

The user movement

The growth of users and relativesorganizations

The past two decades have seen the rise ofthe user movement. Non-governmentalorganizations for users and relatives have

grown to become national advocacy groups inmany developed countries, for example, theNational Alliance for the Mentally Ill in the USA,ENOSH in Israel, MIND in Britain.Through pro-viding information about mental illness and raisingpublic consciousness about the issues, these organi-zations play a vital role in combating stigma (seeStigmatization and Human Rights Violations).Theyhave also become active players in policy develop-ment.

In Great Britain, MIND, receives a substantialgrant from the government.Through such mecha-nisms, users are able to express their views of thekinds of services they would like to receive, andact as a pressure group on providers of mentalhealth services, including the government. Indeveloped countries, users are increasingly beingincluded on bodies that make decisions about thedevelopment of psychiatric services.This recogni-tion that users have a legitimate voice is empower-ing and also has the effect of decreasing stigma.

In developing countries they are currently small inmembership or non-existent, though they arebecoming established in Latin America in countriessuch as Argentina and Brazil. However, they areoften locally based without a national identity,which inhibits them from acting as a pressuregroup for the improvement of services, and fromproviding adequate support to all users and rela-tives who need it.

In some countries there is a growing self-helpmovement organized by and for users.


32

Services needs of some specialgroups

Psychiatric problems in children andadolescents

In most countries in the world, the develop-ment of psychiatric services for children haslagged behind those for adults, with the defi-

ciencies being greatest in low income countries.

Between 10 and 20 per cent of children and ado-lescents are affected annually, their psychiatricmorbidity accounting for five of the top ten lead-ing causes of disability for those aged 5 and above(Murray & Lopez, 1996). In Latin America and theCaribbean alone, 17 million children suffer frommoderate to severe psychiatric disorders in need ofcare (Presentation, PAHO/WHO DirectiveCouncil, 1997). In many developing countriesthere is a paucity of adequately trained child andadolescent mental health professionals.Adolescents, a group at high risk for psychiatricdisturbances, often have to be treated in facilitiesfor adults. Substance abuse in children and adoles-cents also is a worldwide problem (Belfer &Heggenhougen, 1995) and has severe consequencesin terms of morbidity and mortality

Children and adolescents are more exposed to thepsychiatric consequences of poverty, famine andloss of parents in developing countries, wherechild psychiatric services are least in evidence. Inthe absence of a cadre of adequately trained childand adolescent mental health professionals, it isunrealistic to plan for the institution of these serv-ices in developing countries in the near future.Instead the focus should be on equipping mentalhealth workers with basic skills in the detectionand treatment of child psychiatric disorders, as inAlexandria, Egypt, where child counsellors havebeen trained to work in schools (El-Din, 1993).With the spread of universal education, schools arebecoming the most appropriate primary venue forhealth related interventions for children. Sincechild mental health symptoms do not differ signifi-cantly across cultures, it is feasible to use expertisefrom child psychiatry services in developed coun-tries to compile training packages for primary careworkers in developing countries (Nikapota, 1993),(Thabet & Vostanis, 1998).These training materials

should be adapted so that they are culturally appro-priate.These workers need to be based in schoolsand to be equipped with skills to identify emotion-al and behavioural problems in children and totreat and manage them.They should also be able toidentify vulnerable children and to employ preven-tive strategies. Other forms of outreach are neededto work with children and adolescents who resistcoming to conventional settings for care. Multi-function health clinics, after-school programmes,and activities programmes can be venues for coun-selling activities.

The possibility exists of training mothers in bettercare of infants in an attempt to prevent later prob-lems in psychological development. A pilot projectin one of the deprived townships in Cape Town hasdemonstrated the feasibility of this approach(Cooper et al, in press). Mothers of older childrenhave been successfully trained to befriend postna-tally depressed mothers in Ireland, with the aim ofimproving mother-infant interaction.

Children and adolescents with diagnosable seriousmental illness require treatments analogous toadult treatments. However, caution must be usedin the consideration of the use of psychopharmaco-logic agents that are not approved for use withchildren and adolescents.Though most care cannow be done on an outpatient basis, for childrenand adolescents with the most serious problemsand marginal support from families, appropriateinpatient care is indicated. Inpatient care shouldalways be considered for suicidality and psychoticconditions.

Children continue to be traumatized in great num-bers by armed conflict, by epidemics such asHIV/AIDS, and by natural disasters.Wars directlyaffect children by violence inflicted on them andtheir families, and indirectly by the emotional trau-ma caused to their carers. Eighty percent of thevictims of war are children and women (Lee,1991). Displacement due to war resulted inapproximately 21.5 million refugees in 1999. AIDSis now a pandemic in sub-Saharan Africa, Russiaand parts of Asia. Over one quarter of the youthpopulation in sub-Saharan Africa is infected.Themental health consequences are both direct,including dementia and depression, and indirect,through loss of parental figures and stigmatization.For children not raised in situations of armed con-


33

flict or disaster, there is increasing awareness of thehigh prevalence of physical and sexual abuse, neg-lect and poor parenting, and the serious andenduring effects of these experiences on mentalhealth.

Substance misuse

The scale of misuse of psychoactive substances hasgrown dramatically world wide in the past threedecades. In many countries there has also been arising prevalence of multiple substance use.Thoseat high risk include indigenous peoples, prisoners,young people, and refugees. A particularly vulnera-ble group are people with severe psychiatric ill-ness, whose treatment and management is serious-ly compromized by concomitant substance misuse.While these problems are most prevalent inWestern countries, they exist everywhere.

A wide range of effective treatments is available foralcohol and drug problems, including psychosocial,medical and educational interventions. Such inter-ventions are best located in primary care services,particularly in developing countries, where special-ized services may be absent. All available commu-nity agencies, including self-help groups, should beenlisted to assist substance users in recovery andrehabilitation.

Equal attention should be given to measures toreduce demand for psychoactive substances and toreduce supply.This obviously requires collabora-tion between health and other governmentaldepartments. Given that elimination of substancemisuse is unlikely in the foreseeable future, there isgrowing interest in harm reduction strategies.(World Health Organization, 1998).This includesproviding oral opioids such as methadone as main-tenance therapy for injecting opioid users, and set-ting up syringe exchange facilities or makingsyringes legally available for drug injectors who areunwilling to abstain from injecting drugs.Thesestrategies not only reduce mortality and morbidityamong injecting drug users, but reduce the spreadof infectious diseases such as hepatitis and HIVinfection.

The service needs of multiple substance users andpeople with psychoses who also misuse substancesshould be considered.The latter require care frompsychiatric services and drug abuse services, sothat inputs from both need to be co-ordinated.

The Elderly

At the other end of life, the elderly are at high riskfor suicide (particularly men), for depression, andfor dementia. Rates of suicide are proportionatelyhigher in older people in virtually all countries inwhich they have been measured reliably. Men overthe age of 75 are the group with the highest inci-dence of all (De Leo, 1997). Some 70 per cent ofolder suicide victims are considered to have beensuffering from a mental illness, most frequently amajor depressive disorder (Conwell, 1997). In theUnited Kingdom, depression severe enough towarrant treatment is found in between 11 and 16per cent of elderly people living at home(Copeland et al, 1987).This high rate is attributa-ble to the existence of physical health problems(Robert et al, 1997). Presence of depression fur-ther increases the disability among this population.Depressive disorders among the elderly goes unde-tected even more often than among younger adultsbecause it is often mistakenly considered a part ofthe ageing process.

The main causes of dementia are Alzheimer’s dis-ease and cerebrovascular disease, their relativeimportance varying from country to country(Jorm, 1991).The incidence rises approximatelyexponentially with age, but is lower in Asian coun-tries than in Europe or North America (Jorm &Jolley, 1998).The prevalence of dementia reachesnearly 40% in people aged 90 years.

The mental problems of the elderly are increasingyearly as the proportion of older people in thepopulation rises steadily worldwide. At the sametime, the dissolution of the extended family underthe pressures of urbanization and industrializationis slowly removing the natural support networksthat used to sustain the elderly.

Special policy and service issues regarding the eld-erly include therefore the need to support andimprove the care already provided to the elderly bytheir families, incorporating mental health assess-ment and management into general health servicesfor the elderly, and providing respite care to familymembers who are still often the carers.


34

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Socioeconomic factorsand mental health

Vikram Patel,

Senior LecturerLondon School of Hygiene and Tropical Medicine and Sangath SocietyGoa, India

Ricardo Araya,

Senior Lecturer in PsychiatryUniversity of Wales College of MedicineFormerly Associate Professor of Epidemiological PsychiatryUniversidad de Chile, Chile

Glyn Lewis,

Srofessor of Epidemiological PsychiatryUniversity of Wales College of Medicine, UK

Leslie Swartz,

Professor of PsychologyUniversity of Stellenbosch, South Africa


Executive summary

This paper presents some of the current evi-dence that shows the links between socioeco-nomic determinants and mental disorders.

The authors have chosen to focus on depressiveand anxiety disorders for several reasons. First,these are the commonest of all mental disorders.Second, these disorders account for the largestproportion of the aggregate burden attributed tomental disorders, mainly because of their high fre-quency.Third, these disorders are typically seen inthe general health care settings and can be man-aged effectively by general health workers withbasic skills and training. Finally, there is good evi-dence of an association with socioeconomic deter-minants and depressive and anxiety disorders.

However, it needs to be recognized that severe, butfar less common, mental disorders such as schizo-phrenia also cause a significant burden to society,for instance consuming most of the resourcesdevoted to specialist mental health services. It isalso evident that socioeconomic determinants playan important influence on other mental disorders,notably alcohol and substance abuse.Thus, policies,which are geared to reducing the impact of socioe-conomic determinants on depressive and anxietydisorders, are likely to have a beneficial effect onthe risk and outcome of other mental disorders aswell.

This working paper has used research and pro-gramme evidence from across the world todemonstrate the following issues:

The burden of depression and anxiety

■ The prevalence rates of depressive and anxietydisorders varies between settings. Clinically sig-nificant disorder occurs in up to 20% of adultsliving in the community.The prevalence rate ishigher in health settings, between 15% and 40%of adults attending primary care and generalmedical clinics. Depression and anxiety typicallyoccur together and the term depression is usedin this document to refer to both types of emo-tional disorders.

■ Depressive and anxiety disorders are not tran-sient disorders; about half of all sufferers have achronic or recurrent course.

■ Women are significantly more vulnerable to suf-fer these disorders than men. Some of the factorsresponsible for this increased risk may lie in theunequal status of women in most societies acrossthe world.

Socioeconomic factors and depression

■ Socioeconomic disadvantage is strongly associat-ed with the presence of depressive and anxietydisorders.This disadvantage can take many formsfrom obvious material deprivation to more sub-tle ways reflecting lack of opportunities due topoorer education, greater risk of adverse lifeevents or other forms of covert or overt socialdiscrimination.

■ Irrespective of the average per capita income of asociety, persons who are at the bottom end ofthe social hierarchy are at a greater risk to sufferthese disorders than those who are at the upperend, an effect which seems to be more pro-nounced in more unequal as well as poorer soci-eties.Thus overcoming poverty might contributeto improve mental health but it is unlikely to beenough; a more equitable distribution ofresources remains important.

■ A variety of social phenomena associated withrapid urbanization by globalization may be detri-mental to mental health through increasing stressor reducing natural protective factors. Examplesof such phenomena include squalid living condi-tions in urban areas for migrants, and the break-down of families as sources of social support.

■ Depressive and anxiety disorders are disablingand can prevent sufferers from carrying out theirtasks at home and in employment. Depressiveand anxiety disorders have adverse economicimplications for the individual, their families andsociety.

Implications for interventions andpolicy

■ The vast majority of persons with depressive andanxiety disorders never receive treatment. Fewconsult mental health professionals. If they doseek health care at all, they do so from generalhealth care professionals and traditional medicalpractitioners.

■ There is evidence, mostly from developed coun-tries, that some forms of treatments are effica-


40

cious and cost-effective for common mentalhealth conditions such as depression and anxiety.These interventions can be easily delivered bygeneral health care workers. Improved treatmentis a priority though that alone would not lead toa reduction of the prevalence in the community.

■ Social and economic policies may impose anunacknowledged burden on society by influenc-ing the prevalence of depressive and anxiety dis-orders. Policies aimed at reducing poverty andimproving economic equity are likely to have theunanticipated benefit of improving mental healthand reducing the burden of depression.

■ Some intervention programmes may help toreduce the impact of poverty on mental health.Poverty reduction and full employment policiesshould have benefits in reducing prevalence.Provision of micro-credit as a means of reducingdependence on informal moneylenders may alsoreduce financial strain. Investing in mainstreameducation and school completion should improvethe individual’s long-term opportunities andimprove mental health, especially in the develop-ing world.

■ General practitioners and community healthworkers must be involved in mental health poli-cies and programmes.The emphasis in healthpolicy must be to achieve adequate skills for thediagnosis and treatment of depressive and anxietydisorders in general health care settings.Treatment with antidepressant medication andinexpensive psychosocial interventions should beavailable everywhere.These programmes can beimplemented at little additional cost, becausethey use existing human and infra-structuralresources.

■ Research is badly needed, especially from the lessdeveloped world, to strengthen the evidencebase. Longitudinal research into the causes ofdepressive and anxiety disorders, and identifyingthe links between socioeconomic inequalities anddepressive and anxiety disorders is required.Thisresearch should be designed so as to inform andevaluate changes in social and economic policy.

S O C I O E C O N O M I C FA C T O R S A N D M E N TA L H E A LT H

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Introduction

As the nations of the world come closer toeach other in this era of globalization, it isimportant to consider what relationship

exists between socioeconomic factors and mentalhealth within and between countries. It would befair to say that, till recently, the relationshipbetween poverty and mental health was a topicwhich was rarely taken seriously by health, social,or economic policies. Amidst various health priori-ties and concerns about economic inequality andpoverty, where does mental health fit in? Can wereally be mentally well when our bodies are sickand our stomachs empty? Can cash-strapped healthservices divert resources to mental illness with itsvague, fuzzy boundaries and connotations of asy-lums, shock therapy and madness? Isn’t mental ill-ness largely due to consumerism and materialismrather than lack of essential things? Is mental ill-ness a consequence of the material deprivation thatsome of the poorest members of our global villagehave to endure? These are just some of the clichésand challenges one faces in a discourse on impov-erishment and mental health.This paper presentsevidence to demonstrate that, far from being a lux-ury item or a matter of concern only for richnations, mental illness is closely associated withpoverty and inequality and may impede someaspects of economic development.The relationshipbetween socioeconomic status and mental disorderhas important implications for all the nations of theworld.

In presenting the evidence and implications ofsocioeconomic determinants of mental health, thispaper will focus on depressive and anxiety disor-ders.The reasons for this focus are that depressionis the commonest of all mental disorders and,arguably, poses the greatest public health burden.However, other mental health problems such asschizophrenia, dementia and alcohol and drugdependence are major sources of disability in theirown right. For speciality mental health services,the costs of health and social care for schizophreniaand other functional psychoses are the main bur-den. Dementia will become an ever increasingissue within the developed and developing world asthe population ages. Alcohol problems are a com-mon source of work absence in all areas of theworld. Nevertheless, it has become apparent that

depression leads to more disability in aggregatethan these other mental health problems and posesa special burden on primary health care services.The paper tackles the issue in three parts. First, itpresents the global evidence to justify that depres-sion is a serious global public health issue. Second,it presents evidence to demonstrate that there is arelationship between poverty, socioeconomicinequality and depression.Third, it considers poli-cies and programmes, which may reduce the publichealth and individual burden posed by depression.

Depressive & anxiety disorders

What is depression and anxiety?

The symptoms of depression and anxiety arecommon and reported in all populations ofthe world1.There needs to be a distinction

drawn between the ups and downs of emotionallife that everyone experiences and the moresevere depressions and anxiety disorders seen in aclinical setting. Clinically significant depressiveand anxiety disorders are largely a matter ofjudgement on behalf of the clinician and patientand the precise case definition used in a study cantherefore markedly influence the prevalence.Over the past 30 years there has been a consider-able amount of progress in measuring the symp-toms of depression and anxiety in a reliable way.Relatively brief, standardised interviews exist thatcan be used in all the countries of the world.Though some methodological issues remain, theseare relatively minor.

Symptoms of depression and anxiety

There is now a professional consensus about themajor symptoms of depression and anxiety. Forexample, depression is characterised by a numberof symptoms, in addition to a lowering of mood.These are loss of interest, poor concentration andforgetfulness, lack of motivation, tiredness, irri-tability, poor sleep and changes in appetite.Thehallmark “negative” attitudes of depressed individu-als is perhaps the most disabling aspect of the ill-ness. Anxiety is associated with a fearful feeling,worrying thoughts and physical symptoms such aspalpitations, tingling sensations, headaches andchest pain.The symptoms of depression and anxi-ety are universal and occur in all societies that have


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been studied2. Furthermore, depression and anxi-ety in the primary or general health care settingtypically occur together. In this document, theterm “depression” is used to denote the clinicalpresentation of both depression and anxiety.Thepresentation of symptoms, however, does appear tovary between different countries. In many develop-ing countries, subjects with depression complain todoctors mainly of their physical symptoms (such astiredness).The psychological symptoms are pres-ent when they are directly asked3, 4. Similarly, thereis also some variation in how these symptoms arelabelled around the world. For example, inZimbabwe, the idiom of kufungisisa or “thinkingtoo much” is used to describe psychological symp-toms5.

The burden of depression

The evidence of high prevalence of depression hasbeen building up over the past 20 odd years from arange of settings in high-, middle- and low-incomecountries from all regions of the world6-12.Thesestudies reveal community prevalence figures thatvary between different countries but can be up to20% in some studies. For example, the prevalencein the UK psychiatric morbidity survey was about14%.The case definition used in this study reflect-ed a severity appropriate for treatment in primaryhealth care. Just over 2% of the UK population hadthe more severe depressions that are familiar topsychiatric specialists. Prevalence estimates inattendees at primary health care, the sector cater-ing for the poorest members of some societies,show levels that can be as high as 40%13-15.Depression often runs a chronic or recurrentcourse with nearly half of patients in treatment set-tings remaining ill for 12 months or more16, 17.

There is now a large body of evidence demonstrat-ing the considerable disabling effects of depressionboth in the community and primary health sector(see below)13, 18, 19. In addition to disability, there isevidence that depression can also lead to increasedmortality.The risk of death by suicide in personswith depression or substance abuse is well-described20.There is growing concern of the risingrates of suicide in many developing countries, par-ticularly amongst adolescents and young adults inwhom suicide is one of the three leading causes ofdeath. In India, for example, the suicide rateincreased by 6.2% per annum between 1980 and

1990, during which period the population growthrate was 2.1%; the highest growth in suicide rateswas for young adults21. Deliberate self-harm (i.e.self-harm which does not lead to death) is far com-moner than completed suicide and is fast becomingthe commonest reason for emergency medicaltreatment in some developing countries such as SriLanka22.

Depression is also associated with poor physicalhealth. Even after excluding suicide, recent cohortstudies from the UK and USA have demonstrated ahigher mortality rate in patients with depres-sion20, 23.There is also an increased risk ofischaemic heart disease in those with depression23.It has been suggested that the impact of socioeco-nomic inequalities on physical health may be medi-ated by an effect on psychological health24.

Primary care is regarded as the cornerstone ofhealth care in both the developed and developingworld. Most treatment of depression occurs in pri-mary health care rather than in specialist settings.However, despite the considerable evidence of theeffectiveness of drug and psychological treatmentsfor depression, albeit largely from the developedworld25, the vast majority of patients in developingcountries do not receive these treatments. Instead,they are prescribed a cocktail of medicines aimedat various symptoms, such as painkillers, vitaminsand sleeping medicines13, 26.Thus, policies whichstrengthen the treatment services in primary careand improve the availability of antidepressants andbrief and effective psychological interventions areneeded to help reduce the burden of illness foraffected persons.

Depression & Disability

Depression and anxiety are exceptionally disablingconditions and the disability is often not widelyacknowledged, in part because of the stigma asso-ciated with these illnesses. In the MedicalOutcomes Study in the US the disability associatedwith a variety of chronic medical conditions suchas diabetes, arthritis and depression were com-pared. Depression was the most disabling condi-tion of all those investigated27. Depression is dis-abling for a variety of reasons.The symptoms ofdepression such as poor concentration and lack ofmotivation impair the ability to carry out everydaytasks. Irritability combined with these can affect


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the relationships with other family members andfellow workers.The “negative” attitudes of depres-sion can impair judgement and reduce problem-solving abilities. It is perhaps this latter aspect ofdepression that is especially worrying in relation tosocioeconomic inequalities. It is likely that depres-sion impairs the ability of poor people to deal withthe difficult circumstances they experience.Arguably, for the poorest people in the world,problem-solving abilities are essential in order todeal with their circumstances. One particular areawith adverse consequences is the impact of depres-sion in women on their children. Postnatal depres-sion is common and it can have adverse effects onthe intellectual and emotional development of chil-dren28, 29 leading to cycles of disadvantage.

The relationship between the severity of disorderand disability is an important concern from a pub-lic health perspective. Depression can be thoughtof along a single continuum of severity. Disabilityincreases in line with the increase in severity. Inaggregate, mild depressive conditions may lead tomore disability in the population than that attribut-able to the less common, more severe disorders30.This paradoxical situation, in which less severecases of a disorder are more important, is commonin public health. It has important implications, nev-ertheless, for public policy and research as indicat-ed below.

Public health and depression

The Global Burden of Disease (GBD) estimatesdeveloped by WHO, the World Bank and theHarvard School of Public Health31a, revealed thatmental and neurological disorders accounted for11% of the total Disability Adjusted Life Years(DALYs) lost due to all diseases and injuries in199931b. Based on the analysis of trends, projec-tions indicate that the burden due to mental andneurological disorders will increase to 15% by theyear 2020.

The GBD study ranked depression as the 4th lead-ing cause of burden among all disease, accountingfor 4.1% of total burden. It will rise from 4th to2nd leading cause of DALYs by 2020. It will thenbe second only to ischaemic heart disease forDALYS among both sexes. It is notable that for thedeveloping regions it will be the highest rankingcause of burden.These estimates have demonstrat-

ed that depression causes an enormous burden onsociety.

Taking the example of ischaemic heart disease, riskfactors such as smoking and high blood pressurehave been identified, and public health interven-tions target those risk factors and try to reducetheir frequency in the population.We need suchpublic health oriented research into depression thatwill then lead on to primary preventive pro-grammes and to improved access to efficacioustreatment for people with depression.

Summary■ Depression and anxiety disorders are two of a

range of mental health disorder problems butthey are the most common and thus importantfrom a public health perspective.

■ In primary or general health care settings,depression and anxiety typically occur togetherand the term depression is used in this documentto reflect both types of emotional states.

■ Depression exists in all countries of the world,even if there is variation in how patients presenttheir complaints to health workers.

■ Depression is one of the most disabling condi-tions seen in medical practice. An importantsource of disability is the impairment in problemsolving ability.

■ Most treatment of depression occurs in primaryhealth care, not in specialist care. Even thougheffective pharmacological and brief psychologicaltreatments have been developed, most patientsdo not seek nor receive appropriate treatment.

■ Depression leads to as much burden as ischaemicheart disease; a public health approach isrequired.

Socioeconomic inequalities anddepression

The definitions and use of terms in the areaof socioeconomic inequalities can be especial-ly confusing. From an epidemiological per-

spective it is useful to think of a variety of measur-able indicators of socioeconomic inequalities.Occupational status is used by many governmentsas an indicator, which reflects the status or skill


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level within the employed population.Unemployment, those without work who areactively seeking employment, can also be includedunder this heading.There is relatively little thatgovernments can do to change the distribution ofoccupational status in a country, but unemploymentis potentially more amenable to government eco-nomic policies. Low income and poverty are otherimportant indicators of socioeconomic status thatare also possible to influence.There are broadlytwo approaches to defining poverty – one based onincome and the other on resources available to ahousehold (deprivation).Though these measuresare associated with each other there is, surprisingly,a little overlap between occupational status, lowincome and deprivation.These can therefore bestudied separately and their relative importanceinvestigated. Finally, educational attainment is also acommonly used measure of socioeconomic status.

The evidence of an associationbetween poverty and depression

Poverty

There is now a substantial body of evidence,which demonstrates the relationship betweenpoverty and socioeconomic inequalities with

depression. In the United Kingdom there is goodevidence showing an association between low stan-dard of living (not owning a car and/or a house)and the prevalence of depression32, 33. British dataalso suggest that socioeconomic measures appearto delay recovery rather than increase the onset ofnew episodes33. However it is also possible thatthose with poor mental health have a reducedcapacity to earn, and this might account for someor all of the observed socioeconomic gradient.Thisexplanation has been called social selection.Thereis some evidence for social selection34-36 but it doesnot appear to be able to explain the whole socioe-conomic gradient.There is evidence from a longi-tudinal study in the USA that low income is associ-ated with depression37.

Evidence is beginning to accumulate demonstratinga similar association between economic disadvan-tage and the presence of depression in developingcountries too. For instance, a community studyfrom Indonesia found strong associations betweendepression and the presence of household ameni-

ties such as electricity, and ownership of a televi-sion38. In this study, the rates of depression in theleast developed villages were twice those in themost developed villages. A recent community sur-vey of 3,870 persons in Chile found that depres-sion was associated with several socioeconomicadversities. On multivariate analyses, acute finan-cial strain, described as a recent drop in income,and lower educational level remained significantlyassociated with the prevalence of depression11.Similar results have been reported from NorthernBrazil, Pakistan, Lesotho, and Zimbabwe4, 12, 39, 40.There is also evidence, from prospective longitudi-nal studies in less developed countries, that eco-nomic deprivation is associated with incidence andpersistence of depression. A study from Zimbabweshowed that economic variables, such as being indebt and having cash savings, were associated withthe incidence of depression41. Impoverishment wasalso associated with the persistence of morbidity;thus, individuals with depression whose economicdifficulty resolved over a period of a one-yearstudy, had much higher recovery rates than thosewho developed fresh economic difficulties17.

Unemployment in men

There is good evidence from the UK that unem-ployment in men increases the risk of depression42.The association between unemployment in womenand the disorder is more complex. Many womenwithout work, especially with children, do notregard themselves as unemployed.There is also thepossibility that loss of job to a woman is regardedas less of a threat to self-esteem, at least in womenwith a partner.

Poor educational achievement

Education, which is strongly correlated withpoverty, emerges as a factor strongly associatedwith the prevalence of depression in many devel-oping countries43.The mechanism through whicheducation might protect persons from depressionis unclear. However, it is plausible that education isan important determinant of present and futurelife opportunities which promote mental health inlater life. In any case, it is important to realize thatthe socioeconomic variables beloved by epidemiol-ogists might have different meanings and signifi-cance in different societies.


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Gender inequality and depression

Women have been shown to be 2 to 3 times atgreater risk to suffer from depression in most soci-eties. It is likely that the severe adversities faced bywomen, in part as a result of gender inequalityincreases their vulnerability44. Gender inequalityoperates within households unlike other types ofinequality, which operate between households.Thus, gender inequality is superimposed onincome and other inequalities. Factors associatedwith gender inequality include domestic violenceand restriction of opportunities for education,employment and adequate health care. Further, theunique reproductive roles played by women mayalso predispose them to depression in differentstages of the reproductive cycle, for exampledepression after childbirth45. [See paper on GenderDisparities and Mental Health for a fuller discus-sion on this subject]

Causal pathways betweensocioeconomic factors anddepression

Do socioeconomic factors causedepression?

Poverty was defined many years ago as “themother of all diseases”. However there maybe more explicit links between poverty and

depression than many other conditions.We alsoneed to understand more about the links andmechanisms if we are to plan preventive policies ina sensible way. At present, there is little real under-standing about the mechanisms or mediating fac-tors between low socioeconomic status anddepression.The following section gives some plau-sible ideas about the importance of various factors.

Social supports

There is evidence that lack of social supports mayincrease the risk of depression. Low socioeconomicstatus might decrease a person’s ability to engagein social activities.

■ Unplanned urbanisation has and is posing greatstrains on traditional social support systemsacross the developing world46.The lack of socialsupport and the breakdown of kinship structuresis probably the key stressor for the millions of

migrant labourers to the urban centres of Asia,Africa and South America, leaving behind mil-lions of dependants in the rural areas whose onlyhope of survival are the remittances their rela-tives will send from distant cities.

■ In developed countries, increased mobility oflabour has reduced family ties and also led to thedecline of the extended family.

■ Brown and Harris, identified factors such as hav-ing no one to confide in as one of the vulnerabili-ty factors for depression47. For young womenwho are married far from their parental homesand live for most of the year without their hus-bands, it is not hard to imagine why they may bemore likely to be depressed.

Lack of control on resources

■ There are the obvious material stresses, whichaccompany poverty.The daily worries about pay-ing essential bills and being able to afford food inthe face of inflationary pressures and insecureemployment could be expected to wear even thestrongest mind down. It is not surprising thenthat those individuals who experienced anincome drop, mostly poor people, have a higherprevalence of depression11.

■ The ability to deal with new difficulties is harderfor those with less money. A car that has brokendown or a leaking roof requires money, and forthe poor these will be much greater stresses.

■ One of the most consistent predictors of mentaldisorder in developing country studies is lack ofeducation. Education might provide a means ofescape from poverty or access to knowledge andother ways to resolve problems11, 38, 43.The lackof opportunity in a society where there is hugeincome inequality, high unemployment, andunderemployment, and no social welfare provi-sion can be expected to lead to feelings of hope-lessness, anger and despair.

■ There is the well-recognized association betweenpoverty and a higher burden of physical illhealth, particularly infectious diseases, and inade-quate access to good, affordable health care.Thismay mean that many poor persons with mentalhealth problems go untreated, or treated inap-propriately and suffer for long periods as hasbeen already described earlier.


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Social comparison

The potential stresses imposed by absolute povertymay be considerably different from those of rela-tive poverty. It is suggested that the psychologicalimpact of “relative” poverty is the result of both theindirect (e.g. increased exposure to behaviouralrisk factors due to psychosocial stress) and direct(e.g. physiological effects of chronic mental andemotional stress) effects of psychosocial circum-stances associated with social position. One pro-posed mechanism is that of “cognitive compari-son”, whereby people are made aware of the vastdifferences in socioeconomic status that prevail.The knowledge of how the richer “other half live”affects psychosocial well being and thus, overallhealth status48.

Does depression worsen poverty?

There is a reason to support this possibility withevidence for two major mechanisms. First, the evi-dence that mental disorders lead to disabilitywhich has been described earlier. A range of stud-ies has conclusively demonstrated that depressionis profoundly disabling leading to a range of social

and occupational disabilities19. For example, studiesof primary care attendees in India and Zimbabweshowed that subjects with depression spent morethan twice the number of days in the previousmonth in bed or being unable to do their dailyactivities as compared to others13, 49.

Second, there is evidence that persons with depres-sion receive more health care especially in primarycare. Most people with depression consult forphysical symptoms and in many health systems,both in developing and developed countries, thiscan lead to numerous costly consultations, investi-gations and polypharmacy15. Often governmentsare not capable or willing to finance treatment andthe costs are then transferred to the sufferers whoresort to the private sector. No matter who paysthe bill, depression drains away precious resources.There are no reliable economic estimates fromdeveloping countries but there is substantial evi-dence of the enormous economic burden ofdepression in developed countries50.


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The vicious cycle of impoverishment and mental disorder:

Ill-healthe.g. Depression and anxiety,

Stress related physical ill health,Alcohol abuse, Chronic ill-health

Economic deprivationMalnutrition, Low education,

Income inequality, Indebtedness,Inadequate health care, Overcrowding,

Lack of social networks

Economic impactReduced productivity,

Increased health expenditure

Cycle of impoverishment and mental disorder

Thus, the nature of the relationship betweenimpoverishment and mental illness is complex, bi-directional and dynamic, leading to a vicious cycleof impoverishment and mental illness (Figure 1).An example of such a vicious cycle could be as fol-lows: an episode of depression is triggered bymaterial deprivation and domestic violence,depression in turn robs the woman of the neces-sary coping skills and energy to overcome herproblems and leads her to spend money and timeseeking relief from various health practitioners,often without any benefit.

Illustrative narrativesdemonstrating linkages

The following are some narratives from vari-ous countries, which demonstrate theresearch linkages between socioeconomic

factors and depression.

Suicides of farmers in India

Since the mid-1990s, the seasonal monsoon hasconsistently failed in some central regions of Indialeading to low harvests and, subsequently, lowerincomes for farmers.The ones who have sufferedthe most have been the poorest subsistence farm-ers, those who were not credit-worthy enough toget bank loans and had to borrow money fromloan-sharks at exorbitant rates of interest to tideover the financial crisis.With their crops failing,the farmers were faced with the stark choice ofselling whatever few assets they still had orbecome bonded labor to the moneylender until thedebt was repaid. It is not surprising, then, thatthese circumstances led to suicide.There have beenmore than 200 reported suicides by farmers inrecent years, and these figures only reflect the gov-ernment statistics. Although these figures mayappear small, they must be seen in the context ofrepresenting an occupational group of subsistencefarmers in a geographically defined region of India.There is evidence that farmers from the backwardcastes were disproportionately more affected.

Poverty and maternal depression in South Africa

In an informal settlement in Khayelitsha, SouthAfrica, the prevalence of depression amongstwomen who have recently given birth has beenfound to be 35% – roughly three times the expect-ed rate based on studies in other countries28.Thewomen in this community are largely migrantsfrom rural areas who come to an impoverishedperi-urban settlement in search of employmentand access to resources such as health care, espe-cially at key times such as during pregnancy.Circular migration patterns between the country-side and the city may have an effect on social sup-port and networks. Most of these women enjoyvery little support from male partners, and manyrelationships do not last through the pregnancy.The women’s own mothers, a traditional source ofsupport and assistance through pregnancy andearly parenthood, are often far away in rural areas.Both maternal depression and economic hardshiphave been found to impact on children’s develop-ment.There is an association between maternaldepression and impaired mother-infant interaction.This impairment has in other contexts been foundto be a key predictor of poor social, emotional,and cognitive development in children.This couldpotentially lead a cycle of deprivation and demor-alisation.

Poverty, income inequalities and depression in Chile

Chile shows the lowest proportion of people livingbelow US$1/day among the ten most incomeunequal countries in the world51. General morbidi-ty and mortality indicators are in line with thoseencountered in most developed countries.However, the prevalence of depressive disorders ishigher than in other countries with morepoverty11. Depression tends to concentrate on themost socially disadvantaged sectors of society.Thepoorest, especially under financial strain, the lesseducated, the unemployed, and the socially isolatedshow the highest prevalence of depression.Thesefindings support the hypothesis that markedinequalities can act as risk factors for depression.


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Depression and ageing in developingcountries

The mental health of elders is even less wellunderstood or acknowledged either by the com-munity or the medical profession in developingcountries. A major reason for this is that the elder-ly comprise less than 10% of the population inmost developing countries.This is bound to changein the future with the falling birth rates and risinglongevity leading to predictions that over the next20 years this oldest sector of the population willexceed 100 million in India alone.The implicationsof this demographic ageing are grave, for fewdeveloping countries have systematic social wel-fare, pension or health care systems sensitive to theneeds of the elderly. Further, all developing coun-tries are facing dramatic socioeconomic changeswhich are accompanied by the gradual breakdownof traditional extended family systems which haveformed the bulwark for the care of the disabledand chronically ill52.

Summary■ There are strong cross-sectional associations

between low income, low education and otherindicators of poverty and depression

■ There is evidence that depression impairs eco-nomic performance

■ The evidence available cannot definitively pointto whether depression is caused by deprivedsocioeconomic conditions or if these disorderslead to deprivation. It is likely that a combinationof both is the best answer to this etiological puz-zle.

Implications for health policiesand programmes

The implication of the evidence we havereviewed is that policies and programmesaimed to reduce poverty, provide education

and reduce socioeconomic inequalities are highlylikely to help reduce the prevalence of depression.Reducing the prevalence should also have someeconomic benefits, in addition to health benefitsfor individuals and a reduction of the burden onhealth services. However, the present economicdevelopment policies adopted by many countries,

particularly in the developing world, are fuellingsocioeconomic inequalities51. From a public healthperspective, the evidence on socioeconomic deter-minants and depression can be used to consider anumber of primary and secondary preventivestrategies.

Primary prevention

Primary prevention is used to describe policies thataim to reduce the prevalence of incidence.The evi-dence to support the efficacy of interventions inthis field is weak, mainly because few if any inter-ventions have been tried and/or evaluated in termsof their impact on depression. It is difficult to per-suade governments or international agencies toinvest in these programmes compared to primaryprevention programmes for malnutrition or infec-tious diseases. Based on the earlier discussions, wenow consider examples of primary preventivestrategies:

■ Investing in education

The key factor may not be whether 100% of chil-dren are in primary school, but rather the propor-tion of children who fail to complete the minimumyears needed to obtain a secondary school certifi-cate [10-12 years in most countries].This is a farmore significant landmark in society for without it,the number of years of schooling is irrelevant toprospective higher educational institutions oremployers.Thus, even though there are impressivegains in increasing school enrolment, there mayneed to be further emphasis on reducing schooldrop-out rates; in many developing countries, lessthan half the children who are in primary schoolgo on to complete their 10 years of secondary edu-cation. Several reasons may account for highdropout rates, such as the need to earn moneyvery early in life and childhood mental healthproblems53. Because education permits greaterchoices in life decisions and influences aspirations,self-image and opportunities54, it is likely thatinvestment in education will lead to improvedmental health of the population. In many develop-ing countries, this investment will need to focus onwomen who may be less likely to access adequateeducation.


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■ Micro-credit: safe loans to the poorest

In many developing countries, indebtedness toloan-sharks is a consistent source of stress andworry.This was best demonstrated by the narrativeon farmers and suicide from India. Indeed, it is notuncommon for the children of a family to spendtheir lives toiling to repay the interest of relativelysmall loans taken out by their parents. It is clearthat here lies another potential preventive strategyin that local banks could step in and review theirprocess of assessing credit-worthiness for personswho belong to the poorest sectors of society.Radical community banks and loan facilities such asthose run by SEWA in India and the GrameenBank in Bangladesh could be involved in setting upsuch loan facilities in areas where they do notexist. Provision of such loans may reduce mentalillness by removing the key cause of stress: thethreat posed by the informal moneylender.

■ Working towards healthier families

In Khayelitsha, South Africa, a community-basedintervention to improve mother-infant interactionis currently underway.Women from the communi-ty, all mothers themselves, were recruited andgiven training based partly on the World HealthOrganization’s PEIMAC programme. Most womenhave not completed high school.Treatment focuseson emotional support for the mother as well as aneducational component, which teaches mothersabout infants’ interactivity and the importance andvalue of child-focussed interaction from birthonwards.The intervention is being run as a con-trolled trial, and impacts on both mother andinfant are being assessed by a team blind towhether the intervention has been delivered to aparticular mother. An important feature of theintervention is that it is low cost and is of such anature that if it proves successful it should be pos-sible to integrate the programme into the existingprimary health care system.This programme maylead to evidence for the effectiveness of preventionof maternal depression, and possibly, the adverseeffects of maternal depression on infant develop-ment.

■ Health promotion

Most public health campaigns such as the DefeatDepression Campaign in the UK have generallyaimed to increase awareness of depression, and

increase knowledge about the effectiveness ofinterventions available in health services.There isalso the potential to use health promotion to publi-cise “stress reduction” techniques that could beused more widely. Similarly, changing the charac-teristics of the workplace and working practicescould have benefit on mental health. At present,these ideas are necessarily speculative but deservefurther development and evaluation.

Secondary prevention

The key to secondary prevention, is to strengthenthe treatment of depression in primary health care.There needs to be much greater cooperation andcollaboration between mental health and primarycare health workers.There would need to begreater emphasis on training general health work-ers on common mental health problems. Individualclinicians need training to recognize and effectivelytreat depression.The message is clear: patientswith depression and anxiety are already in yourclinic.These disorders are amongst the commonestof all health problems; they are profoundly dis-abling and prone to chronicity and there are cheapand effective pharmacological and psychosocialremedies for them. Just as clinicians must treattuberculosis even if they cannot get rid of the over-crowding, so must we challenge the mental despairof clinicians who argue that if their patients arepoor they must be depressed and there is little theycan do about it.The greatest evidence that thisbelief is untrue is evidenced by the fact that themajority of the poor do not get depressed, they areonly at greater risk than the rich.

■ Integration of mental health in primary health care

The integration of primary mental health into pri-mary health care has been the mantra of the WHOfor over a decade.The models for such integrationare likely to vary considerably between differenthealth systems. In areas such as theKwaZulu/Natal province in South Africa whichexperiences severe adversities such as poverty, highlevels of violence and high rates of HIV/AIDS,there is enormous pressure on primary health careservices to deal with physical illness. In this con-text of scarce resources, a programme was able totrain primary health care nurses in KwaZulu/Natalto provide a comprehensive care approach which


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took account of psychosocial and emotional factorsamongst their clients55. However, structural factorsin the Organization of health care may inhibitproviders’ capacity to deliver appropriate compre-hensive care. Any focussed intervention to dealwith depression and other morbidity at primaryhealth care level must be supported by a commit-ment on the part of health system management atall levels to viewing these issues as important andworthy of professional attention. Research frommore developed countries has suggested that someresource intensive models such as those whichemploy formal psychotherapy and care managersto ensure compliance could be more cost-effectivefor the treatment of depression.Thus simpler andaffordable interventions need to be implementedpossibly focusing on those at higher risk. Someinteresting and innovative programmes were devel-oped and used many years ago. For instance in theabsence of health professionals, lay communityleaders and other health workers were trained todeal with mental disorders in Cali, Colombia56

with good results. In Chile, work is underway totest the cost-effectiveness of a simple, stepped caretreatment package for depressed women fromimpoverished backgrounds in Santiago, ChileA.Early results are promising and suggest that effec-tive interventions can be delivered by people withminimal training, at a low cost and, most impor-tantly, are well accepted by the local population. Arandomized controlled trial for the treatment ofdepression in general health care has also beenrecently completed in Goa, India; the trial willprovide data on efficacy and cost-effectiveness ofanti-depressant and psychological treatmentB.

■ Medical pluralism in mental health care

Mental health manpower cannot meet the needs ofall persons with depression, especially in develop-ing countries. On average, there is about one psy-chiatrist for every million people in large areas ofsub-Saharan Africa.The population of India, nowexceeding 1 billion people, has less than 4,000 psy-chiatrists.The vast majority of psychiatrists indeveloping countries work in large mental hospi-tals or in private practice.The vast majority ofthose with depression are treated, if at all, by gen-eral health care providers, traditional and religioushealers, Non-Governmental and voluntary organi-zations and families57. NGOs support sufferers and

families in ways, which are often ignored by formalmental health services, such as advocacy for therights of the mentally ill and provision of commu-nity-based interventions.Traditional medical prac-titioners are often consulted for depression andmay provide psycho-spiritual interventions whichare consonant with the cultural attributions thatsufferers have about their illness60.The privatemedical sector is a major provider of generalhealth care in many developing countries59. Itsinvolvement in the implementation of mentalhealth programmes would be imperative.

■ Integration of mental health into existing health promotion programmes

Depression typically occurs in situations ofextreme stress.There are several examples ofexisting public health priorities in which depres-sion are of great relevance such as maternal andchild health, reproductive and sexual health, ado-lescent health and violence prevention. Attachingmental health interventions onto these programswould imply using existing resources and manpow-er and providing more comprehensive care, whichreflects the broad concerns of health. Such integra-tion can be implemented with minimal additionalcost and would have the advantage of greateraccess to sufferers as a result of the lesser stigmathan would be attached to seeking help from men-tal health services.

■ Intersectoral cooperation

In Pakistan, the Gujarkhan demonstration projectinvolves community leaders, schoolteachers, andprimary health care workers. For instance masseducational campaigns were launched and mentalhealth issues were introduced into the school cur-riculum as a form of reducing stigma as well aseducating families on how best to protect theirmental health60. Similar projects have also beendeveloped in Latin America and other parts of theworld but the evaluation of these initiatives is lesswell known.These initiatives can help to increasethe involvement of communities in deciding andimplementing solutions for their own problems.Local participation is a fundamental requisite forthe success of any of these programmes.


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Summary■ Policies aimed at reducing poverty and inequality

will have an effect in reducing the burden ofdepression.

■ Primary prevention of depression could includepoverty reduction programmes, full employmentpolicies, investment in education, micro-creditarrangements and pubic health promotion cam-paigns.

■ Secondary prevention would require integrationof mental health care in primary health care byproviding training and support to health careproviders and improving collaboration with pri-vate, traditional and non-governmental healthsectors.

Conclusions

This working paper has presented evidence,which demonstrates the public health impor-tance of depressive and anxiety disorders for

all countries independent of their level of develop-ment.We have argued for a close associationbetween socioeconomic adversity and depression,an association that is present in most societies,again irrespective of the stage of economic devel-opment.This association is in both directions.Though there is still some uncertainty, all the evi-dence suggests that poor socioeconomic conditionscan cause depression and that depression canreduce socioeconomic functioning. In the long runwe need further research and evaluation of thekind of primary prevention programmes we haveproposed as these are probably among the mostsuitable ways of dealing with the burden of depres-sion in the community.There is also a need toaddress the burden of depression by strengtheningprimary care assessment and treatment.The paperhas highlighted policies and programmes, whichcould work towards primary and secondary pre-vention of depression.

Despite the compelling evidence of an associationbetween depression and economic deprivation, it isimportant to recognize that the majority of peopleliving even in squalid poverty remain well, copewith the daily grind of existence and do not suc-cumb to the stressors they face in their lives.Indeed, this is the real challenge for public health

researchers; to identify the protective qualities inthose who do not become depressed when facedwith awful economic circumstances for therein liesa potential to help and prevent mental health prob-lems. Could informal local community social net-works protect some from depression? Could reli-gious or spiritual involvement limit alcohol abusein some men and help prevent suicide in womenand teenagers? Could micro-credit schemes whichare challenging the existing notions on who knowshow to handle money properly help prevent somefrom succumbing to despair? Could being close toone’s family provide the necessary confidante andsupport? Could a caring local councillor’s effortsto clean up a slum help reduce the suicide rate?These are the practical research questions arisingfrom the relationship between poverty and mentalillness.

In societies where mental health services are poor-ly developed, it may be argued that preventivestrategies aimed at strengthening protective factorsin local communities may be a more sensibleinvestment of scarce resources than duplicating theextensive mental health care systems of the devel-oped world (whose existence has not led to anysignificant reduction in the prevalence of mentaldisorders).Thus, funding research on depressionwith a local significance should be an importantconsideration in allocation of research funds indeveloping countries. Future longitudinal researchis needed in order to establish causal directions,and the mechanisms linking depression with lowsocioeconomic status.


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A. Araya,R., Rojas, G., Fritsch,R.,Simon,G. Cost-effective primary care program for depressedpoor women in Santiago Chile (NIMH GrantRO1 MH59368-01)

B. Patel,V., Chisholm,D., Mann,A. A randomizedcontrolled trial of pharmacological and psycho-logical treatment for common mental disordersin general health care settings in Goa, India(Wellcome Trust Tropical Health ServicesProject Grant)

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S U M M A R Y R E C O R D S O F S TAT E M E N T S B Y M I N I S T E R S

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J. Arboleda-Flórez

Professor and HeadDepartment of PsychiatryQueen’s UniversityKingston, Ontario, Canada


Executive summary

General theoretical considerations

Stizein, to tattoo or to brand, was a distin-guishing physical mark placed during Greektimes on slaves who were thus branded so

that others would know that they were inferior orless valued members of society.Through Latin, theword has moved to modern languages as Stigma, aform of social construction to indicate a distin-guishing mark of social disgrace that, at the sametime, conveys a social identity. Stigma consists oftwo fundamental components: (1) the recognitionof the differentiating “mark” and (2) the subsequentdevaluation of the person. Stigmatizing conditionscould develop from bodily physical deformities,group identifications such as race, sex, or religion,or assumed blemishes of individual characterunderlying cultural beliefs about the nature ofmental disorders or unemployment. Stigma devel-ops in the context of social relationships and inter-actions, and its strength and resilience depend onthree dimensions: visibility, controllability, and ori-gin.The more visible the mark, the more theblemish is perceived as being under the “control” ofthe bearer, and the more feared the impact such asconveying a sense of danger, the more the stigma.Cultural beliefs have led to the fear of mental ill-ness and mental patients, hence the stigma.Stigmatizing attitudes are held by many, includinghealth professionals and mental health personnel.

Effects of stigma

Stigmatization is closely related to prejudice in thatthe stigmatized person or group becomes the tar-get of negative or prejudicial attitudes, but unlikeprejudice, stigma involves definitions of characterand class identification, hence, it has larger impli-cations than mere prejudice. Negative attitudesinclude painting all mental patients as deranged,violent, homicidal, incompetent and incurable,morally flawed, unmotivated or inadequate anddepicting them in the media as unpredictable andviolent. Stigma and prejudice about persons withmental illness lead to discrimination and the denialof lawful legal entitlements. Surveys have shownthat negative social attitudes toward persons withmental illness constitute barriers to reintegrationand acceptability .These attitudinal barriers impact

negatively on social and family relationships,employment, housing, community inclusion, self-esteem, and prompt access to treatment opportu-nities.

Changing policies anddeinstitutionalization

Mental illnesses and disabilities are highly prevalentworldwide.They have major economical impactsbeyond merely those directly related to healthbudgets.The recognition of their negative impactshas led many countries to implement legislativerevisions and to modify health plans and mentalhealth systems such as community alternatives,deinstitutionalization, and proper budgetary alloca-tions.

Research on stigma

Research findings have led to the identification ofstrategies and best models for combating stigmatiz-ing attitudes in populations such as choosing thebest content for public campaigns and the targetingof specific subpopulations.

Efforts to combat stigma

A number of national and international pro-grammes, campaigns, and reform efforts have beendescribed to reflect the variety of initiatives beingundertaken to combat the stigma of mental illness.Strategies most frequently used by different groupsaround the world are listed based on a review ofwhat worked in different settings.


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Objectives and purpose

Despite their relatively high frequency, sadly,the most frequent contact the general publichas with mental illness is through the media

where, often, mental patients are depicted asunpredictable, violent and dangerous (Steadmanand Cocozza, 1978). Such depictions stem fromsensational reporting of crimes purportedly com-mitted by a person with a mental illness, or frommovies in which a popular plot, long exploited bythe cinematographic industry, is that of the “psy-cho-killer” (Byrne, 1998).The association betweenmental illness and violence is only one of the manynegative stereotypes and prejudicial attitudes heldby the public about persons with a mental illnessthat help perpetuate stigmatizing and discriminato-ry practices against them.

The objectives of this document include a reviewof the theoretical elements that lie at the founda-tions of stigma as a social construct and its negativeconsequences on persons with mental illness andtheir families, and to describe programs andresearch initiatives geared at managing, or erasing,the stigma about mental illness.The purpose is tohelp mental health planners and governments toadopt more comprehensive mental health policies.Such policies should address not only the legisla-tive and budgetary aspects of mental health pro-grams, but also the education of the public onmental heath issues, the promotion of good mentalheath practices, and the prevention of mental con-ditions in the population.

Historical elements

Stizein, to tattoo or to brand in Greek, was adistinguishing mark burned or cut into theflesh of slaves or criminals by the ancient

Greek, so that others would know who they wereand that they were less valued members of society.Although the Greek did not use the term stigma inrelation to mental illness, stigmatizing attitudesabout the illnesses were already apparent in thesense that mental illness was associated with con-cepts of shame, loss of face, and humiliation(Simon, 1992) as in Sophocles’ Ajax, or Euripedes’The Madness of Heracles.

Later, and throughout the Christian world, theword stigmata became associated with peculiarmarks on individuals re-enacting the wounds ofChrist on their bodies, mostly on their palms andsoles (Paul, Gal 6: 17).This religious connotationis not the same as the other derivative of the Greekword, stigma, which is a form of social construc-tion to indicate a distinguishing mark of social dis-grace that, at the same time, conveys a social iden-tity.The Inquisitorial attitude toward witches, asdictated in the Malleus Maleficarum (The Hammer ofthe Witches 1486/1971), apart from being highlymisogynous, also represents a negative and con-demning attitude toward mental illness.This atti-tude might have been the origin of the stigmatizingattitudes toward persons with mental illness fromthe rise of rationalism in the 17th century to ourdays in Christian cultures (Mora, 1992). “Madness”has long been held among Christians as being aform of punishment inflicted by God on sinners(Neaman, 1975).

Theoretical considerations

Goffman (1963) thought of stigma as anattribute that is “deeply discrediting” so thatstigmatized persons are regarded as being of

less value and “spoiled” by the stigmatizing condi-tion. He classified these conditions in three groups:“abominations” of the body, such as physical defor-mities, “tribal identities” such as race, sex, or reli-gion, and “blemishes of individual character” suchas mental disorders, or unemployment. Stigma,however, is not a static concept, but a social con-struction that is linked to values placed on socialidentities. It is a process consisting of two funda-mental components: the recognition of the differ-entiating “mark”, and the subsequent devaluation ofthe bearer (Dovidio, Major and Crocker, 2000).These authors conceive of stigma as a relationalconstruct that is based on attributes, so that, stig-matizing conditions may change with time andfrom a culture to another. Stigma, then, woulddevelop within a social matrix of relationships andinteractions and will have to be understood withina three-dimensional axis involving perspective,identity, and reactions.

Perspectives pertain to the way the stigma is per-ceived. Stigma is different, whether it is perceivedby the person who does the stigmatizing (perceiv-

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er) or by the person who is being stigmatized (tar-get). Identities relate to group belongingness, andthey lie in a continuum from entirely personal togroup-based identifications. Finally, Reactions arethe ways the stigmatizer and the stigmatized reactto the stigma and its consequences; reactions couldbe measured at the cognitive (knowledge), affec-tive (feelings, tones and attitudes), and behaviourallevels.

Along with these three dimensions it is alsoimportant to distinguish three major characteris-tics of the stigmatizing mark: “visibility”, or howobvious the mark is, “controllability” which relatesto the origin or reason for the mark and whetherit is under the control of the bearer, and “impact”or how much those who do the stigmatizing fearthe stigmatized (Crocker, Major and Steele, 1998).The more visible the mark, the more it might beperceived to be under the control of the bearer,and the more feared the impact such as conveyingan element of danger, the more pronounced thestigma.

Mental patients who show visible signs of theirconditions because their symptoms or the sideeffects to medications make them appear abnor-mal, who are socially construed as being weak ofcharacter or lazy, and who display threateningbehaviours, usually score high on any of these threedimensions. By a process of association and classidentity, all mental patients are equally stigmatized;the individual patient, regardless of level of impair-ment or disability, is lumped together into a class;class belongingness reinforces the stigma againstthe individual.

The description of the characteristics of stigma, orwhat it is, and how it develops begets the questionof why it develops. Unfortunately, there is little lit-erature on the subject, but Stangor and Crandall(2000) while indicating that very little is knownabout the development of stigma, advance the the-ory that three major components will be required:function, perception, and social sharing.They theo-rize that an original “functional impetus” is accen-tuated through “perception”, and subsequently con-solidated through social “sharing” of information.The sharing of stigma becomes part of a societythat creates, condones, and maintains the stigma-

tizing attitudes and behaviours.These authors fur-ther indicate that the most likely candidate for theinitial “functional impetus” is the goal of avoidingthreat to the self.

Initial perception of tangible or symbolic threat

Perceptual distortions that amplify group differences

Consensual sharing of threats and perceptions1

Tangible threats are “instrumental” in the sense thatthey threaten a material or concrete good, whilethose that are symbolic threaten beliefs, values,ideology, or the way in which the group ordains itssocial, political or spiritual domains.

In relation to mental illness, cultural perceptionsseem to indicate that it poses a tangible threat tothe health of society because it engenders twokinds of fear: the fear of potential immediate physi-cal threat of attack and the fear that we may allshare of losing our own sanity. In addition, to theextent that mental ill persons are stereotyped aslazy, unable to contribute, and hence, a burden tothe system, then, mental illness may be also seen asposing a symbolic threat to the beliefs and valuesystem shared by members of the group.

More specifically, the stigma associated with men-tal illness can also be attributed to the traditionaldivision of venues for treatment and health caresystems.The division between the two systemsmeant that persons with mental illness were sentaway to mental institutions or asylums consequent-ly segregating them from those who were physical-ly ill and who were cared and treated for in generalhospitals in their own communities.The decisionto send persons with mental illness to far awaymental hospitals, although well intentioned in itsorigins, contributed to their dislocation from theircommunities, and the loss of their community ties,friendships and families. At a more systemic andacademic level, the segregation between the twosystems of health also meant the banishment ofmental illness and of psychiatry from the generalstream of medicine. At a different level, the lack ofeffective therapies that influenced most of psychi-atric work for centuries also contributed to theasylum mentality.The few therapeutic successes,such as the cure for pellagra or for syphilis, onlyhelped to reinforce the idea that the patients thatremained in the mental hospitals suffering fromother mental illnesses were incurable.


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1. Adapted from Stangor and Crandall, p. 73

Myths and stigma

Stigma, or the feeling of being negatively dif-ferentiated because of being affected by aparticular condition or state, is related to

negative stereotyping and prejudicial attitudes.These in turn, lead to discriminatory practices thatdeprive the stigmatized person from legally recog-nized entitlements. Stigma, prejudice, and discrim-ination are, therefore, inextricably related. Unlikeprejudice, however, stigma involves definitions ofcharacter and class identification, so it has largerimplications and impacts. Often, prejudice stemsfrom ignorance, or unwillingness to find the truth.For example, a study conducted by the CanadianMental Health Association, Ontario Division(Ontario, Canada), in 1993-1994, found that themost prevalent misconceptions about mental ill-ness included that mental patients were dangerousand violent (88%), that they had a low IQ or weredevelopmentally handicapped (40%), that theycould not function, hold a job, or had anything tocontribute (32%), that they lacked will power orwere weak or lazy (24%), that they were unpre-dictable (20%), and, finally, that they were to beblamed for their own condition and should justshape up (20%).

In a survey among first year university students inthe United States, it was found that almost two-thirds believed that “multiple personalities” were acommon symptom of schizophrenia (Torrey,1995).The same author reports on a different pollconducted among the general public in which55% of respondents did not believe that mentalillness existed and only 1% acknowledged thatmental illness was a major health problem. Someof these myths also surfaced in a study conductedin Calgary, Alberta, Canada, during the pilot studyfor the World Psychiatric Association (WPA)Programme “Open the Doors” (Stuart andArboleda-F1orez, 2001). In this study, it wasfound that respondents believed that persons withschizophrenia could not work in regular jobs(72%), had a split personality (47%), or weredangerous to the public because of violent behav-iour (14%). In Africa, people’s thoughts aboutmental illness are strongly influenced by tradition-al beliefs in supernatural causes and remedies.Even policy makers frequently hold the opinionthat mental illness is often incurable and unre-

sponsive to accepted medical practices (Gurejeand Alem, 2000).

Unfortunately, high levels of knowledge couldcoexist with high levels of prejudice and negativestereotypes. For while most of the myths aboutmental illness could be traced down to prejudiceand ignorance of these conditions, enlightenedknowledge does not necessarily translate into lessstigma unless the tangible and symbolic threats thatit poses are also eradicated.This could only bedone through better education of the public andconsumers about the facts of mental illness andviolence, and through the provision of consistentappropriate treatment to prevent violent reactions.Good medication management should also aim atdecreasing the visibility of symptoms amongpatients (consumers), and at providing better pub-lic educational programs on mental health promo-tion and prevention.

Human Rights infringements

Outright discriminatory policies ending inabuses of human rights and denial of legalentitlements can often be traced to stigmatiz-

ing attitudes, plain ignorance about the facts ofmental illness, or lack of appreciation of the needsof persons with mental illness.These policies andabuses are not the preserve of developing countriesonly.

In countries with established economies, healthinsurance companies openly discriminate againstpersons who acknowledge that they have had amental problem. Life insurance companies, as wellas income protection insurance policies make averitable ordeal out of collecting payments due totemporary disability caused by mental conditionssuch as anxiety or depression. Many patients seetheir payments denied or their policies discontin-ued. Government policies sometime demand thatmental patients be registered in special files beforepharmacies could dispense needed psychiatricmedications. At a larger level, many developedcountries provide only a modicum of funds fromtheir national research budgets for research inmental conditions. In Canada, for example, mentalhealth research commands less than 5% of all thehealth research budgets, yet mental illness affectsdirectly 20% of Canadians (CAMIMH, 2000)


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In developing countries, beliefs about the nature ofmental conditions, sometimes enmeshed with reli-gious beliefs and cultural determinants, tend todelay needed treatment by penalizing and stigma-tizing not only the patients, but also their families,even when they are entitled to access treatmentopportunities (Gureje and Alem, 2000).Within theChinese culture, mental illness is highly stigmaticfor the whole family not just the individual afflict-ed.The emphasis on collective responsibility leadsto the belief that mental illness is a family prob-lem.Thus, Chinese caregivers may prefer to copewith mental illness within the context of the familyas long as possible.The downside to this approachis the subsequent delay in treatment that mayresult (Ryder, Bean and Dion, 2000).

In general, illness and disability due to mental dis-orders have received little attention from govern-ments in developing countries including Africangovernments. Mental health services have beenpoorly funded and most countries lack formalmental health policies, programmes, and actionplans. In 1988 and 1990 two resolutions designedto improve mental health were adopted amongAfrican countries. A survey conducted two yearslater to follow-up on what progress had resultedfrom these resolutions unfortunately showed disap-pointing findings (Gureje, Alem, 2000).

In Uganda, per capita yearly expenditures for men-tal illness is only US$ 4.00, well below the US$10.00 recommended by the World Bank (TheMonitor, 1998). In Nigeria, excessive workloads,frequent transfers, responsibility without authority,and other inherently poor management practicesare blamed for the poor mental health conditionsof employees and the consequences if they hap-pened to complain about their difficulties(Vanguard Daily, 2000).

Consequences of stigma

Sartorius (1999) sustains that the stigma ofmental illness affects the requirements forcare of good quality in mental health. In his

view, stigma attitudes compromize access to carethrough perceptions among policy makers and thepublic that persons with mental illness are danger-ous, lazy, unreliable and unemployable. Eventually,these attitudes impact on the willingness of author-

ities to provide proper financial resources for theircare.

Some researchers argue that persons with mentalillness are not stigmatized.They base their conclu-sions on measurements of social distance that showacceptance of mental patients, findings showingthat what is stigmatizing is the behaviour and notthe label, and the fact that mental patients them-selves are rarely able to report concrete instancesof rejection.These findings, however, are contraryto multiple other reports among patients and theirfamilies, and even among mental health personnelwho feel that their work is less appreciated andremunerated than similar intense work with otherpatient populations. Link et al (1992) refute find-ings denying the pernicious effects of stigma on thebasis that these studies have been flawed by thetypes of questions they have asked and, conse-quently, by the types of replies that they haveobtained. Real life perceptions and patients’ testi-monials tell a different story about how it feels tohave a mental illness.

Michelle, a vivacious 25 year-old office worker, tellsabout her major disappointment with her family andfamily friends who simply expected her to have an abor-tion when she announced that she was pregnant.Theyassumed that her schizophrenia would incapacitate her todeliver and to care for her baby.They were also afraidthat her medications could have teratogenic effects on thebaby. She carried her baby to term and is taking care ofit despite the opposition of family and friends.

Michelle’s experience is not uncommon. For manypersons with mental illness, the stigma of their ill-ness is worse than the disease and it spreads acloud over every aspect of their lives. and even thelives of other members of the family.

John, a 19-year-old university student, had to accept thetermination of a relationship he had just started with agirl from his neighbourhood. Her parents objected to therelationship and decided to send her to another city forher education, in part in an attempt to break up the rela-tionship, once they knew that John’s mother’s frequenthospitalizations for the past several years were not due to“diabetes”, but to a manic depressive illness. Johndescribed the experience with some resignation,“it seemsas if I have to carry the sins of my parents”.

In the study by the Canadian Mental HealthAssociation, Ontario Division, in 1993-1994 quot-


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ed above, mental patients felt that social and familylife (84%), along with employment (78%) andhousing (48%), were the areas most commonlyaffected by stigma. In that survey respondents alsofelt excluded from the community (22%) andcomplained that stigma has a negative impact ontheir self-esteem (20%).

In a survey conducted among members of theirown support organization by “survivors” of mentalillness in Thunder Bay, Ontario, Canada (P.A.C.E.Report, 1996), they identified housing, employ-ment, and transportation in public buses as degrad-ing and outright discriminatory.

“I have to lie to my landlord to get a place to live, liketell him you are on disability, if it is not visible or physi-cal, they don’t take you. Even slumlords won’t take youbecause they don’t want psychiatrically ill people livingin their buildings.”

In this Report, “survivors” found that “mentalhealth barriers” among the public often lead tostigmatization, prejudice and stereotyping and thatthey were not listened to, or understood.They alsofelt ignored, avoided, or treated without respectand sensitivity.They reported that these attitudescould also be found during their interactions withsocial assistance personnel and with clinical staff.

“At the agency the staff talk about patients and howcrazy they are. No wonder there is such stigma in thecommunity.”

And another patient commented poignantly abouthealth staff:

“At the hospital, they take your clothes away.They putyou in pyjamas ...it strips away your identity.You know,we are not all crazy.We don’t all see the boogiemanaround the corner. Some of us have legitimate complaints.But if you are always told ‘oh, you are overreacting’ youknow, you don’t know what you are talking about or stufflike that, after a while you start to believe that yeah,maybe I am.There are some doctors who don’t know, youknow, an oesophagus from an asshole.”

In The Last Taboo (Simmie and Nunes, 2001), one ofthe authors, Scott Simmie, describes his feelingsafter a bout of major depression:

“Stigma was, for me, the most agonizing aspect of my dis-order. It cost friendships, career opportunities, and – mostimportantly – my self-esteem. It wasn’t long before Ibegan internalizing the attitudes of others, viewing

myself as a lesser person. Many of those long days in bedduring the depression were spent thinking,‘I’m mentallyill. I’m a manic-depressive. I’m not the same anymore’. Iwondered, desperately, if I would ever again work, everagain be ‘normal’ It was a godawful feeling that con-tributed immensely to the suicidal yearnings that invadedmy thoughts.”

Violence and mental illness

Few popular notions and misconceptions areso pervasive and stigmatizing as is the beliefthat persons with mental illness are danger-

ous and violent.This could be hardly surprisingwhen practically no month goes by without themedia reporting on the sad story of yet anotherhorrendous crime committed by an alleged mentalpatient. At times, the story also mentions that theculprit is suspected to be “psycho”, “paranoid”,“depressed”, or “schizophrenic”.This type of news,even when reported conscientiously and accurate-ly, arouses fear and apprehension and pushes thepublic to demand measures to prevent furthercrimes. Persons with mental illness in general bearthe brunt of impact because of the actions of thefew.

The grotesque and sensationalistic portrayal of per-sons with mental illness in the media (Rovner,1993) pales in comparison to how they have beenportrayed in movies right from the beginning ofthis industry in the early 1900s.Wahl and Harman(1989) found that 85.6% of relatives of personswith mental illness identified movies about “men-tally ill killers” as the most important contributorto the stigma of the illness. Movies have not onlystigmatized those with mental illness, their nega-tive stereotypes have extended also to psychiatristswho are often portrayed as libidinous lechers,eccentric buffoons, vindictive, repressive agents ofsociety, or evil minded, and in the case of femalepsychiatrists, as loveless and unfulfilled women(Gabbard and Gabbard, 1992).

Media accounts of crimes allegedly committed bymental patients reinforce the association betweenviolence and schizophrenia in the public mind.Such association has been traced to be directlyrelated to how mental illness and persons withmental illness are portrayed in the media (Philo,1997). Unfortunately, the media do not inform the


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public that only a very small minority of mentalpatients commits serious crimes, or that the per-centage of violence that could be attributed tomental illness as a portion of the general violencein the community is also small (Monahan, 1997).

The association between mental illness and vio-lence, specifically schizophrenia, although con-firmed epidemiologically (Arboleda-F1orez,1998), remains still unclear and seems to flow notso much through direct links of causality, butthrough a series of confounders and covariatingpotential causes. Studies that purport to demon-strate an association between mental illness andviolence still need to concentrate on severalaspects of the relationship:

■ they need to demonstrate that the association isone of causality;

■ they need to tease out the contextual elements inwhich the violence occurs;

■ they need to measure the risk of violence from apublic health perspective; and

■ they need to identify measures that could helpmanage the risk among those patients who couldbecome violent.

Fear, as already indicated above, is the primaryimpulse to the development of stigma.The fear ofmental illness, and the subsequent stigmatization ofthose with mental illness, is largely based on fearsthat they are unpredictable and dangerous.Unfortunately, one single case of violence is usuallysufficient to counteract whatever gains mentalpatients have made to be accepted back into thecommunity.

Changing policies anddeinstitutionalization

The recognition worldwide that the largeprevalence of mental conditions and theirassociated disabilities have major impacts not

only on health budgets, but on the total economy,has spurred national governments to face the chal-lenges and develop strategies to cope with mentalillness in their respective countries. In the UnitedStates, the 1999 Report of the Surgeon Generalurged the nation to rally the national will to findbetter ways to fight mental conditions including

among others, a fight against stigma (SurgeonGeneral Report, 1999).

Government initiatives worldwide include a wholerevamping of mental health systems to integratethe care of persons with mental illness in the main-stream of the health system, reorganization ofbudgetary allocations to protect access to mentalhealth treatment, restructuring of mental healthfacilities, and introduction of legislation to protectthe rights of persons with mental illness and theirlegal entitlements that tend to get eroded by dis-crimination.

Many of these initiatives are known generically as“deinstitutionalization policies”, because they havein common characteristics such as the divestmentof mental hospitals, the treatment of mentalpatients in general hospitals, and their reintegra-tion in their communities of origin. Important andenlightened as these initiatives have been, manyhave not met with the success expected simplybecause it is not enough to just transfer thepatients to the community, or to deny beds tonewly diagnosed patients. An integrated and seam-less mental health system should cover the wholespectrum of needs for early diagnosis, treatment,and psychosocial rehabilitation, as well as initiativesfor public education on the recognition and pre-vention of mental conditions and the promotion ofmental health in the population.

Specifically, deinstitutionalization initiatives have tobe implemented together with the development ofadequate community systems to house those withmental illness and to provide for their successfulreintegration into the community. Often, the lackof these community systems worsens the stigmaheld against persons with mental illness when theyare observed walking aimlessly in the downtownareas of large cities, loitering in town squares,shopping centres or markets, or being destituteand homeless. In addition, mental health legislationhas to be made more flexible and responsive tocontemporary mental health policies and the reali-ties of the mental health system.


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Recent research on stigma ofmental illness

Although there does not seem to be a one-to-one relationship between exposure toenvironmental stressors such as stigma and

discrimination, and adaptational outcomes,research on stigma has demonstrated that it hasnegative outcomes on physical health and on self-esteem (Miller and Major, 2000). Persons withmental illness often experience prejudice similar tothose who suffer racial or ethnic discrimination,but the practical effects are complex and affectedby a number of factors such as age, sex, the degreeof stigma felt by the patient, and the degree of self-stigmatization (Hayward and Bright, 1997).

Stigmatization and prejudice have often been con-firmed in research studies as one of the reasonswhy many persons do not seek, or postpone untiltoo late, seeking assistance (Wills, 1983). Recentresearch has also demonstrated that the fear ofmental illness is not just related to the behavioursometimes demonstrated by persons with mentalillness, but to the label itself and the consequencesthat flow from the illness.Thus, in the pilot site ofthe WPA Programme “Open the Doors”, Edmonton,Canada, respondents rated “loss of mind” as moredisabling than any other handicapping condition(Thompson et al, under review). In the same study,the Calgary group found that greater knowledgewas associated with less distancing attitudes, butthat exposure to persons with mental illness wasnot correlated with knowledge or attitudes (Stuartand Arboleda-Florez, 2001). Link et al (1999)came to a similar conclusion regarding the splitbetween knowledge and attitude among the gener-al public.The Alberta, Canada, groups concludedthat broad approaches to increase mental health lit-eracy (Jorm, 2000) may not be as effective amongalready highly educated population groups aswould specifically focused interventions amongsmall groups such as high school students, or clini-cal workers. Corrigan and Penn (1999) have cometo the same conclusion in regard to the specificgroup targeting approach, which they extend tothe targeting of specific beliefs about mental illnessamong ethnic minorities.

Efforts to combat the stigma ofmental illness

National and international organizations andassociations as well as national and local gov-ernments have come to appreciate the need

to change attitudes toward persons with mental ill-ness and to sensitize the public to the notion thatmental conditions are no different than other con-ditions in their origin and that diagnosis and treat-ments are available and effective. Campaigns like“Changing Minds” organized by the Royal College ofPsychiatrists in the UK (www.changingminds,2001) are based on providing information to thepublic so as to dispel myths and stereotypes aboutthose with mental illness.The campaign has usedleaflets, pamphlets, films and other ways of masscommunication. In one well-known film, “1 in 4”,the message is direct and pithy as it emphasizesthat mental health problems can touch anyone:

1 in 4, the film proclaims, could be your Brother, yourSister. Could be your Wife, your Girlfriend...] in 4 couldbe your Daughter...] in 4 could be me...it could be you

Pamphlets produced for the campaign emphasizemessages indicating that social despair and isolationhave replaced old methods of physical isolation:

For centuries people with mental illness were kept awayfrom the rest of society, sometimes locked up, often in poorconditions, with little or no say in running their lives.

Today, negative attitudes lock them out of society moresubtly but just as effectively.

One of the major goals of the Australian NationalMental Health Promotion and Prevention ActionPlan (1999) has been improving mental health lit-eracy in the population.With this in mind, a seriesof campaigns like the Australian NationalCommunity Awareness Program (CAP) and theAustralasian “Psychiatric Stigma Group ” have beenaimed at increasing mental health literacy amongthe general population.The former, CAP, was afour-year program liberally funded to increasecommunity awareness of all mental conditions.Specifically, it had three goals: to position mentalhealth on the public agenda, to promote a greaterunderstanding and acceptance of those experienc-ing mental illness, and to dispel myths and miscon-ceptions about mental illness.The program had abuilt-in evaluation based on benchmark survey and


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pre-post tracking design.The most significantresults include, that while tolerant attitudes wereconsolidated, they did not increase; that there wasa slight increase in the awareness of services; andthat there was no clear evidence of behaviourchange (Rosen, 2000).

The Australasian Psychiatric Stigma Group hasmore modest goals mostly by linking consumers,providers, and many other interested groups in apublic evaluation of the impact of stereotyping andstigma on the lives of psychiatric service-users,their carers, and the lives of providers (Rosen,2000).

SANE Australia is a national charity that helps peo-ple affected by mental conditions. One major andfamous feature of this group is the popular TV soapopera “Home and Away” in which a storyline is abouta young character that develops schizophrenia(SANE, 1999). SANE has a function similar toNAMI (National Alliance for the Mentally Ill) inthe United States and CAMIMH (CanadianAlliance on Mental Illness and Mental Health,2000); they are all umbrella family groups thatlobby for better education, more research funding,and more accessible treatment opportunities forpersons with mental illness.

In New Zealand, a National Plan (1998) has beendevised as part of the Blueprint for Mental HealthServices to combat stigma and discrimination asso-ciated with mental illness. An important compo-nent of this plan is the involvement of aboriginalcommunities. A similar program has been envi-sioned in Canada with the aboriginal communitiesthat seek to empower them to organize their owncultural resources to develop programs and servic-es that meet their own physical, mental and spiri-tual needs (Nishnawbe Aski-Nation, 1990).

In the United States of America, the NationalInstitute of Mental Health (NIMH) has an exten-sive educational campaign available in pamphlets,booklets and on the internet.The information pro-vided covers a wide variety of topics ranging fromspecific mental conditions to issues such as suicideor youth and violence.The web site(www.nimh.nih.gov/practitioners/patinfo.cfm#top) provides updated information on research top-ics, treatment, new medications and programs, andlegislative initiatives.The site also has a Spanishportal.The U.S. Center for Mental Health Services

Knowledge Exchange Network (KEN) providesonline information (www.mentalhealth.org) onstigma.

Although not written anywhere yet as publications,but only as internal government documents, themental health programmes presently devised in ElSalvador (2000) are worth mentioning as initiativesfrom developing countries. In El Salvador, anextremely active advocate for better mental healthpolicies, the present First Lady of the Nation, inher capacity as Director of the Secretaría Nationalde la Familia (National Family Secretariat) hadstarted to set up a National Mental Health Council(Consejo Nacional de Salud Mental) in October ofthe year 2000, that would encompass the gamut ofcitizens and organizations that might have a func-tion on issues pertaining to mental health in thecountry. Organigrams, plans and sets of functionsand activities for the Council were thrown in disar-ray, however, and the development work delayed,by the earthquakes that have devastated the coun-try since the beginning of this year, 2001.Yet, thegroundwork already done in the organization ofthe Council gave impetus for a massive mobiliza-tion of national forces to set up community grass-roots activities bent on immunizing the populationagainst the deleterious mental health effects andimpacts of the catastrophe, the prevention of panicreactions especially among young children, and theimmediate treatment of those already affected bypost-traumatic stress reactions.

Mental health and professional organizations havejoined forces with government bureaucracies andeducational establishments all over the country todevelop on-the-field training for nurses, teachers,and other local community human resources per-sonnel through sessions on training-for-trainersmental health counsellors and for the delivery ofgroup therapy initiatives and individual counselling.Many of these activities are being carried out fromsemi-destroyed schools and government buildings,in the fields below half – uprooted trees, or in theplazas or street comers of little towns, right in themiddle of the debris and rubble that is still beingshaken by ongoing milder tremors.The experienceof El Salvador on emergency mental health action,and the impact that it has had on demystifyingmental illness and emotional problems and, hence,decreasing stigma, is one of those untold stories ofhow humans can mobilize and rise to the circum-


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stances as long as they are given a few tools andthe empowerment to act.

In Tajikistan, where the population has a hostile andfearful attitude toward psychiatric illness, stigma isa problem. In 1998, the Union of Mental HealthSupport, a national NGO, was created to preventstigma related to psychiatric disorders and to pro-vide appropriate measures and assistance to psychi-atric institutions. A draft law, approved by theMinisters of Health, Justice, Social Welfare,Economics, and Labour, will be submitted toParliament.The new law is needed because theexisting laws allow for the abuse of psychiatry forpolitical purposes. If the new law passes, it will beone of the most modern psychiatric laws in thearea. Also encouraging is that within the last year asurvey was conducted to assess community atti-tudes toward mental illness and psychosocial dis-tress.The survey results will be used in the designof a community education and awareness campaign(Baibabayev, Cunningham and de Jong, 2000).

The Republic of Slovakia is another country that,since 1991, is struggling to reform its mentalhealth care system to address better issues such asstigma.While some progress has been made in thepast 10 years, the speed of reform has been slow.Factors contributing to morbidity from mental ill-ness in Slovakia include the fact that the high hopesthat blossomed immediately following the changein political power have remained mostly unreal-ized.This has resulted in a sense of hopelessness inthe population. How to destigmatize persons withmental illness remains one of the three major men-tal health concerns in Slovakia. Reform effortshowever are currently being intensified and thereis an increased interest in the field of psychiatryamong young physicians (Breier, 2000).

At an international level, two programmes, onefrom the World Psychiatric Association (WPA) andthe other from the World Health Organization(WHO), merit a more extensive review.The WPAinitiated in 1998 its Global Programme AgainstStigma and Discrimination Because ofSchizophrenia. Although the “Open the Doors”(www.openthedoors.com) programme is circum-scribed to schizophrenia, its results in the differentcountries where it has been implemented areequally applicable to any other mental condition.The Programme was first pilot-tested in Calgary

and Alberta, Canada in 1998, and has now movedto Spain, Austria, Germany, Israel, Italy, Greece,Egypt, India, and China.The Programme has tar-geted different audiences according to locations,but depends heavily on local action groups thatorganize themselves to plan and initiate projectsthat mobilize local resources into action to combatthe stigma associated with this disease.

The WPA Programme (2000) has produced fourvolumes containing how-to guidelines and infor-mation on schizophrenia.Volume One is a step-by-step how-to guide to develop local programmes;Volume Two is a compendium of the latest knowl-edge on the diagnosis and treatment of schizophre-nia including psychosocial reintegration strategies;Volume Three includes reports from differentcountries; and Volume Four is a collection ofreports from other countries where similar initia-tives are on-going or being planned. A final volumeis being planned with an annotated bibliography ofpractical materials. All these materials are down-loadable from the WPA Programme web site.

The World Health Organization (2001) haslaunched its initiative, “Stop exclusion. Dare tocare” aimed at combating stigma and at rallyingsupport for more enlightened and equitable struc-tures for the care of those with mental illness andthe acceptance of mental health as a major topic ofconcern among member-states.This initiativebrings timely information to correct the mythssurrounding mental conditions such as the beliefsthat they affect only adults in rich countries, thatthey are not real illnesses but incurable blemishesof character, or that the only alternative would beto lock mental patients in institutions.

“Stop exclusion. Dare to care” provides a soberingreminder of the extent of mental conditionsthroughout the world with about 45 million per-sons worldwide suffering from schizophreniaalone, not to mention the many million of personswho suffer from depression, dementia, alcoholismor other mental problems. Sadly, it also shows howthe majority of these persons are deprived of eventhe most basic treatments, such as, for example,persons suffering from alcohol dependency ofwhom only 22% receive treatment, or personsaffected by epilepsy of whom, in some countries,less than 10% have access to treatment.The WHOMental Health Programme makes the point that


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mental health should be made part of the generalhealth care services in countries and that it is theethical responsibility of nations to be inclusive ofall citizens and respect their human rights.

This WHO Mental Health Programme invites indi-viduals, families, communities, professionals, scien-tists, policy makers, the media, and NGOs to joinforces and to share a vision where individuals rec-ognize the importance of their own mental health;patients, families and communities feel sufficientlyempowered to act on their own mental healthneeds; professionals will not only treat those withmental illness, but will also engage actively inmental health promotion and preventative activi-ties; and policy makers will plan and devise poli-cies that are more responsive to the needs of theentire population.

“Stop exclusion. Dare to care” has so far used asmethodologies the distribution of pamphlets,posters, booklets, and stickers, and through themany collateral organizations and distributionchannels open to WHO, it aims at providing incen-tives to national governments and health careorganizations to change policies and to becomeactively involved in the reorganization of servicesand in the development of appropriate mentalhealth policies.

The conceptual elements of all these programs fol-low cognitive methodologies for behaviouralchange.Their three major goals are similar:

■ to increase awareness and knowledge of thenature of mental illness;

■ to improve public attitudes toward those whosuffer from mental illness and their families; and

■ to generate action to prevent and to eliminatestigma and discrimination.

Strategies to combat stigma

Sartorius (1999) recommends that breakingthe cycle of disadvantage resulting from stig-ma should be made a priority .He describes

several steps leading to disadvantage such as dis-ease, impairment, the stigma linked to these two,discrimination, reduction of opportunities for reha-bilitation and role malfunctioning, and places thecorresponding interventions at each one of thesesteps. Apart from recovery with proper treatment

and therapeutic efforts to reduce disability, severalstrategies to combat stigma and discriminationbecause of mental illness have been found successfulby different groups around the world. Usually,these include the participation of all those who careand who treat those with mental illness, as well asthe patients, or consumers themselves.The follow-ing are the strategies most frequently used:

■ Speakers’ bureaux that train and organize indi-vidual consumers, or patients, and their familiesto provide talks to specialized groups such as stu-dents, nurses, or business people, about theirmental illness and how they are coping and man-aging their lives.

■ Plays and other artistic expressions offered byconsumers that highlight the importance of theillness and its debilitating effects as well as theimpact of stigma and discrimination.

■ Organization of special mental health curricula inpublic schools according to level of maturity,age, and grade of the students.

■ Targeting particular groups that consumers con-sider tend to stigmatize them with some regular-ity such as emergency room personnel, the cler-gy, or bureaucrats, and offer them information,talks, or presentations about mental illness.

■ One size does not fit all. Differentiate anti-stig-ma campaigns according to specific target groupsrather than mounting massive generic publicefforts.

■ Work closely with the media and prepare “infok-its” that provide timely information when issuespertaining to mental conditions break out in thenews.

■ Participate actively in organized activities such asWorld Mental Health Day sponsored by theWorld Federation for Mental Health (October 10each year), or Mental Health Awareness Week.

■ Become a “stigma-buster” by being aware and beready to denounce local or national news, adver-tisements, or movies that stigmatize, ridicule, ordemonize people with mental illness as violent,unpredictable or dangerous.

■ Advise decision-makers on the difficulties thatpersons with mental illness face in securingproper housing and employment, and in access-ing treatment, or using public facilities.


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■ Help consumers and families organize themselveslocally and join nationally in “consumer move-ments”.

■ Organize local groups and help amalgamate theminto single national conglomerates or Alliancesfor Mental Health. For example, help form aNational Association for Mental Health thatworks in close association with professionalgroups such as the National Psychiatric,Psychological, Nurses, or Social WorkersAssociations, that could speak with authority tonational governments on behalf of persons withmental illness.

■ Stimulate national groups or mental health con-glomerates to lobby the government to introducelegislation that combats stigma and that outlawsdiscrimination whether based on group character-istics or individual physical or mental disabilities.

■ Stand up and be ready to clear out prejudice andmisconceptions about the persons with mentalillness.

Conclusion

Empowerment is intrinsic to the mentalhealth of communities.The support andinvolvement of communities in the develop-

ment, implementation, and organization of theirown health structures and programs lead to therealization at the community level of the impactand the ramifications to health of social scourgessuch as drug and alcohol abuse, family and socialviolence, suicide and homicide, and mental illnessthemselves.

Centuries of prejudice, discrimination and stigma,however, cannot be changed solely through govern-ment pronouncements and legislative fiats, impor-tant as they are.The successful treatment and com-munity management of mental illness relies heavilyon the involvement of many levels of government,social institutions, clinicians, caregivers, the publicat large, the patients or consumers themselves, andtheir families. Successful community reintegrationof mental patients and the acceptance of mental ill-ness as an inescapable fact of our social fabrics canonly be achieved when communities take controland become masters of their own mental healthstructures, programmes, services and organization-al arrangements.

There is a need, therefore, to engage the public ina dialogue about the true nature of mental illness,their devastating effects on individuals, their fami-lies, and society in general, and the promises ofbetter treatment and rehabilitation alternatives. Anenlightened public working in unison with profes-sional associations and with lobby groups on behalfof persons with mental illness can leverage nationalgovernments and health care organizations to pro-vide equitable access to treatment and to developlegislation against discrimination.With these tools,communities could then enter into a candidexchange of ideas about what causes stigma andwhat are the consequences of stigmatizing attitudesin their midst. Only these concerted efforts will,eventually, dispel the indelible mark. the stigmacaused by mental illness.

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Gender disparities in mental health

Jill Astbury

Associate Professor and DirectorWHO Collaborating Centre in Women’s HealthKey Centre for Women’s Health in SocietySchool of Population HealthUniversity of Melbourne, Australia


Executive summary

This paper examines current evidenceregarding rates, risk factors, correlates andconsequences of gender disparities in mental

health. Gender is conceptualized as a structuraldeterminant of mental health and mental illnessthat runs like a fault line, interconnecting with anddeepening the disparities associated with otherimportant socioeconomic determinants such asincome, employment and social position.

Gender differentially affects the power and controlmen and women have over these socioeconomicdeterminants, their access to resources, and theirstatus, roles, options and treatment in society.Gender has significant explanatory power regard-ing differential susceptibility and exposure to men-tal health risks and differences in mental healthoutcomes. Gender differences in rates of overallmental disorder, including rare disorders such asschizophrenia and bipolar disorders, are negligible.However, highly significant gender differences existfor depression, anxiety and somatic complaints thataffect more than 20% of the population in estab-lished economies. Depression accounts for thelargest proportion of the burden associated with allthe mental and neurological disorders and is a par-ticular focus of this paper. It is predicted to be thesecond leading cause of global burden of disease by2020.

To address this mounting problem, a muchimproved understanding of the gender dimensionsof mental health is mandatory. Evidence is availableon some aspects of the problem but serious gapsremain. It is known that:

■ Rates of depression vary markedly betweencountries suggesting the importance of macroso-cial factors. Nevertheless, depression is almostalways reported to be twice as common inwomen compared with men across diverse soci-eties and social contexts.

■ Despite its high prevalence, less than half thepatients with depression disorder are likely to beidentified by their doctors in primary care set-tings. Gender differences in patterns of helpseeking and gender stereotyping in diagnosiscompound difficulties with identification andtreatment. Female gender predicts being pre-scribed psychotropic drugs. Even when present-

ing with identical symptoms, women are morelikely to be diagnosed as depressed than men andless likely to be diagnosed as having problemswith alcohol.

■ Men predominate in diagnoses of alcoholdependence with lifetime prevalence rates of20% compared with 8% for women, reported inpopulation based studies in establishedeconomies. However, depression and anxiety arealso common comorbid diagnoses, highlightingthe need for gender awareness training to over-come gender stereotypes and promote accuratediagnosis of both depression and alcohol depend-ence in men and women if they are present.

■ Comorbidity is associated with mental illness ofincreased severity, higher levels of disability andhigher utilization of services.Women have higherprevalence rates than men of both lifetime and12 month comorbidity involving three or moredisorders. Depression and anxiety are the mostcommon comorbid disorders but concurrent dis-orders include many of those in which womenpredominate such as agoraphobia, panic disorder,somatoform disorders and post traumatic stressdisorder.

■ Reducing the overrepresentation of women whoare depressed must be tackled as a matter ofurgency in order to lessen the global burdencaused by mental and behavioural disorders by2020.This requires a multi-level, intersectoralapproach, gendered mental health policy with apublic health focus and gender-specific risk fac-tor reduction strategies, as well as gender sensi-tive services and equitable access to them.

■ Gender acquired risks are multiple and intercon-nected. Many arise from women’s greater expo-sure to poverty, discrimination and socioeco-nomic disadvantage.The social gradient in healthis heavily gendered, as women constitute around70% of the world’s poor and earn significantlyless than men when in paid work.

■ Low rank is a powerful predictor of depression.Women’s subordinate social status is reinforcedin the workplace as they are more likely to occu-py insecure, low status jobs with no decisionmaking authority.Those in such jobs experiencehigher levels of negative life events, insecurehousing tenure, more chronic stressors andreduced social support.Traditional gender roles


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further increase susceptibility by stressing passiv-ity, submission and dependence and impose aduty to take on the unremitting care of othersand unpaid domestic and agricultural labour.Conversely, gains in gender development thatimprove women’s status are likely to bring withthem improvements in women’s mental health.

■ Globalization has overseen a dramatic wideningof inequality within and between countriesincluding gender-based income disparities. Forpoor women in developing countries undergoingrestructuring, rates of depression and anxietyhave increased significantly. Increased sexual traf-ficking of girls and women is another mental,physical, sexual health and human rights issue.The mental health costs of economic reformsneed to be carefully monitored.

■ Finally, the epidemic of gender based violencemust be arrested.The severity and the durationof exposure to violence are highly predictive ofthe severity of mental health outcomes. Rates ofdepression in adult life are 3 to 4 fold higher inwomen exposed to childhood sexual abuse orphysical partner violence in adult life. Followingrape, nearly 1 in 3 women will develop PTSDcompared with 1 in 20 non victims. Current lev-els of detection of violent victimization are poorand primary health care providers require bettertraining to intervene successfully to arrest thecompounding of mental health problems.

■ Rates of psychiatric comorbidity and multi soma-tization are high, but neither well identified nortreated.The gendered nature of comorbidityposes complex therapeutic challenges regardingdetection and appropriate models of care.

■ Research needs to be conducted into the rela-tionship of violence to comorbidity.Women areat significantly increased risk of violence from anintimate and are over represented amongst thepopulation of highly comorbid people who carrythe major burden of psychiatric disorder.Equally, research is needed to understand betterthe sources of resilience and capacity for goodmental health that the majority of women main-tain, despite the experience of violence in theirlives.

■ Access to safe affordable housing is essential ifwomen and children are to escape violent vic-timization and the cessation of violence is highly

therapeutic in reducing depression. Improvedbalance in gender roles and obligations, pay equi-ty, poverty reduction and renewed attention tothe maintenance of social capital would furtherredress the gender disparities in mental health.

G E N D E R D I S PA R I T I E S I N M E N TA L H E A LT H

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Background

Data on the size of the global burden of men-tal disorders reveal a significant and growingpublic health problem (Murray & Lopez,

1996). Mental illness is associated with a signifi-cant burden of morbidity and disability and life-time prevalence rates for any kind of psychologicaldisorder are higher than previously thought. Ratesare increasing in recent cohorts and affect nearlyhalf the population (Kessler, McGonagle, Zhao etal, 1994;WHO & ICPE, 2000).

Despite being common, mental illnesses are underdiagnosed by doctors. Less than half of those whomeet diagnostic criteria for psychological disordersare identified by their primary care providers(Üstün & Sartorius, 1995). Patients, too, appearreluctant to seek professional help. Only 2 in every5 people experiencing a mood, anxiety or sub-stance use disorder report seeking assistance in theyear of the onset of the disorder (WHO & ICPE,2000).

Other factors besides patient reluctance determinemental health care service utilization. Of increas-ing importance is the way mental health care isfinanced and organized including the shift to “userpays” health policies. Income level and medicalinsurance status can significantly predict access,particularly to specialist care (McAlpine &Mechanic, 2000; Alegria, Bijl, Lin et al, 2000)

Overall rates of mental disorder are almost identi-cal for men and women (Kessler, McGonagle,Zhao et al, 1994) but striking gender differences inthe patterns of mental illness.

Gender, human rights and theglobal burden of disease

Gender is a critical determinant of health,including mental health. It influences thepower and control men and women have

over the determinants of their mental health,including their socioeconomic position, roles, rankand social status, access to resources and treatmentin society. As such, gender is important in definingsusceptibility and exposure to a number of mentalhealth risks.

If it is accepted that both women and men have afundamental right to mental health, it becomesimpossible to examine the impact of gender onmental health without considering gender-baseddiscrimination and gender-based violence.Consequently, a human rights framework is neededto interpret gender differences in mental healthand to identify and redress the injustices that leadto poor mental health. Many of the negative expe-riences and exposures to mental health risk factorsthat lead to and maintain the psychological disor-ders in which women predominate involve seriousviolations of their rights as human beings includingtheir sexual and reproductive rights.The 1999Human Development Report, referring to theincrease in organized crime related to globaliza-tion, noted an escalation in the trafficking ofwomen and girls for sexual exploitation – some500,000 girls and women trafficked to WesternEurope alone – and described trafficking as one ofthe “most heinous violations of human rights”.Themultiple, severe mental health consequences ofsexual violence and abuse are discussed below.

Gender and patterns of mental disorder

In examining the role of gender in mental ill-ness a distinction needs to be made betweenthe low-prevalence and severe mental disor-

ders such as schizophrenia and bipolar disorder,where no consistent gender differences in preva-lence rates have been found, and the high-preva-lence disorders of depression and anxiety wherelarge gender differences in rates have been consis-tently reported. Depression and anxiety, oftenassociated with somatic complaints, are known toaffect around 1 in 5 people in the general commu-nity and more than 2 in 5 primary care attendersin a variety of countries (Üstün & Sartorius, 1995;Patel, 1999).

General population studies indicate that lifetimeprevalence rates for schizophrenia and bipolar dis-order range from 0.1% to 3% for schizophreniaand from 0.2% to 1.6% for bipolar disorders(Piccinelli & Homen 1997) and no significant gen-der differences have been reported.

Differences in rates of disorder are only onedimension of the role played by gender in mental


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health and illness. Beyond rates, gender is relatedto differences in risk and susceptibility, the timingof onset and course of disorders, diagnosis, treat-ment and adjustment to mental disorder.

A comprehensive review of schizophrenia researchfound frequent reports of gender differences in ageof onset of symptoms. Men typically had an earlieronset of symptoms than women and poorer pre-morbid psychosocial development and functioning(Piccinelli & Homen, 1997). Despite later onset,some studies report that women experience ahigher frequency of hallucinations or more positivepsychotic symptoms than men (Lindamer et al.1999). Similarly, while the population prevalencerates of bipolar disorder appear not to differ, gen-der differences occur in the course of the illness.Women are more likely to develop the rapidcycling form of the illness, exhibit more comor-bidity (Leibenluft,1997) and have a greater likeli-hood of being hospitalized during the manic phaseof the disorder (Hendrick, Altschuler, Gitlin et al.2000).

A number of studies report that women withschizophrenia have higher quality social relation-ships than men. However, a cross national surveydrawn from Canada, Cuba and the USA (Vandiver,1998) found that this was only true for Canadianwomen; Cuban men reported higher quality of lifethan Cuban women. A Finnish study on gender dif-ferences in living skills, involving self care andshopping, cooking and cleaning for oneself, foundthat half the men but only a third of the womenlacked these skills that are so important for inde-pendent living (Hintikka et al., 1999).Thus skillsinculcated through gender socialization can affectlong term adjustment to and outcome of a severemental disorder.

Gender specific exposure to risk also complicatesthe type and range of adverse outcomes associatedwith severe mental disorder.When schizophreniacoexists with homelessness, women experiencehigher rates of sexual and physical victimization,and more comorbid anxiety, depression and med-ical illness than men (Brunette & Drake, 1998).

Gender and Depression

Depression contributes most significantly to theglobal burden of disease and it is the most fre-quently encountered women’s mental health prob-lem (Piccinelli & Homen, 1997). Unipolar ormajor depression occurs approximately twice asoften in women as in men and is predicted to bethe second leading cause of global disease burdenby 2020 (Murray & Lopez 1996). Any significantreduction in the overrepresentation of women whoare depressed would make a significant contribu-tion to reducing the global burden of disease anddisability. Depression and anxiety are the mostcommon comorbid disorders and a significant gen-der difference exists in the rate of comorbidity(Linzer et al., 1996). Comorbidity contributes sig-nificantly to the burden of disability caused by psy-chological disorders (Kessler et al, 1994; Üstün &Sartorius 1995,WHO & ICPE, 2000).

The gender difference in depression is one of themost robust findings in psychiatric epidemiology. Acomprehensive review of almost all general popu-lation studies conducted to date in the UnitedStates of America, Puerto Rico, Canada, France,Iceland,Taiwan, Korea, Germany and Hong Kong,reported that women predominated over men inlifetime prevalence rates of major depression(Piccinelli & Homen, 1997).This difference is doc-umented in clinical and community samples and


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Mental Disorders Lifetime Lifetime 12 Month 12 MonthPrevalence Prevalence Prevalence PrevalenceFemale Male Female Male

Major depressive episode 21.3% 12.7% 12.9% 7.7%

Alcohol dependence 8.2% 20.1% 3.7% 10.7%

Antisocial personality disorder 1.2% 5.8% NA NA

National Comorbidity Survey: Prevalence rates of selected disorders

Source: Kessler et al., 1994

across racial groups (Kessler et al., 1994; Gater etal., 1998,WHO & ICPE, 2000). Depression mayalso be more persistent in women (Bracke, 2000)and female gender is a significant predictor ofrelapse (Kuehner, 1999).

The US National Comordbidity Survey (Kessler etal.,1994), like many other studies before and since(Üstün & Sartorius 1995; Linzer et al., 1996;Brown, 1998), found women had a higher preva-lence of most affective disorders and non affectivepsychosis and men had higher rates of substanceuse disorders and antisocial personality disorder.

The most common disorders were major depres-sion and alcohol dependence and these disordersare often co-morbid for men with alcohol depend-ence. Both showed large gender differences inprevalence, as seen in the following table.

In addition, while completed suicide rates are high-er in men, a nine country study reported thatwomen had consistently higher rates for suicideattempts (Weissman, Bland, Canino et al, 1999).Gender-based violence is a significant predictor ofsuicidality in women, with more than 20% ofwomen who have experienced violence attemptingsuicide (Stark & Flitcraft, 1996). Rates of both sui-cide ideation and suicide attempts vary widelybetween countries (Weissman, Bland, Canino et al,1999).

Women also have significantly higher rates of posttraumatic stress disorder (PTSD) than men(Kessler et al, 1995). General population surveyshave reported that around 1 in every 12 adultsexperiences PTSD at some time in their lives andwomen’s risk of developing PTSD following expo-sure to trauma is approximately twofold higherthan men’s (Breslau et al, 1998), and thus paral-lelling the difference found in rates of depression.

Gender and Comorbidity

Depression and anxiety are common comorbiddiagnoses and women have higher prevalence thanmen of both lifetime and 12 month comorbidity ofthree or more disorders (Kessler et. al., 1994,WHO & ICPE, 2000). Almost half of patients withat least one psychiatric disorder have a disorderfrom at least one other cluster of psychiatric disor-ders (Üstün & Sartorius, 1995).These clustersincluded most disorders, apart from alcohol

dependence, in which women have already beenfound to predominate (Russo, 1990), includingdepressive episode, agoraphobia, panic disorderand generalized anxiety; somatization, hypochon-driasis and somatoform pain. Psychiatric comor-bidity, with depression as a common factor, is acharacteristic finding of many studies on women’smental health (Brown et al. 1996; Linzer, Spitzer,Kroenke et al, 1996) and a repeated finding fromstudies on the mental health effects of violencefrom an intimate (Resnick et al., 1997).

Recent research findings have pointed to the needfor improved recognition of the presence and sig-nificance of comorbid conditions. Comorbidity isassociated with increased severity, higher levels ofdisability and higher utilization of services and isconcentrated in a small group of people. Highlycomorbid people, who as a group represent aboutone sixth of the population between 15 and 54years in the US, have been found to carry themajor burden of psychiatric disorder (Kessler et al,1994).When all lifetime disorders were examinedin the National Comorbidity Survey only 21%occurred in people who over their lifetime hadexperienced only one disorder, while 79% of life-time disorders, in this sample, were comorbid dis-orders. For 12 month disorders, the findings wereeven stronger. It is therefore of considerableimportance that women had significantly higherlifetime and 12 month comorbidity of three ormore disorders than men in this and other studies(Üstün & Sartorius 1995,WHO ICPE, 2000).

Subsequent analysis of data from the NationalComorbidity Survey reported strong associationsbetween panic attacks and panic disorder andmajor depression, with panic attacks being predic-tive of the first onset of major depression and pri-mary depression predicting a first onset of subse-quent panic attacks. Of gender significance was thefinding that this relationship was weaker when theinfluence of prior traumatic experiences and histo-ries of other mental disorders were statisticallycontrolled in the analysis (Kessler, Stang,Wittchenet al, 1998).

The multi-country WHO study on PsychologicalProblems in General Health Care also found thatcurrent panic attacks and a diagnosis of panic dis-order were frequently associated with the presenceof a depressive disorder.Women predominate in all


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three disorders – panic attacks, panic disorder anddepressive disorder.The combination of these dis-orders resulted in a long lasting and severe disor-der that was linked to a higher rate of suicidality.(Lecrubier & Üstün, 1998).

Comorbidity and compounding over time

It is not only the co presence of multiple disordersat one point in time that needs urgent attention.Clinicians, policy makers and researchers alsorequire a better understanding of why psychologi-cal disorders compound and proliferate over thelife course of a sub group of highly comorbid peo-ple, women in particular, in order to devise effec-tive interventions.

For example, patients who are initially free fromdisability, but then experience a depressive illness,can experience a change in their disability statuswhich may gather momentum over time. Ormel,Vonkorff, Oldehinkel et al. (1999) found that therisk of onset of physical disability, even after con-trolling for the severity of the physical disease,increased 1.5 fold three months after the onset of adepressive illness and 1.8 fold at 12 months.Therisk of onset of social disability increased evenmore significantly from a 2.2 fold risk at 3 monthsto a 23 fold risk at 12 months.

Of particular importance is the need to identifywomen who have a history of and/or are currentlyexperiencing violent victimization.Violence relatedhealth outcomes including higher rates of depres-sion and post traumatic stress disorder increase andcompound when victimization goes undetected.This results in increased and more costly utilizationof the health and mental health care system (AMA,1992; Koss, 1994; Acierno, Resnick andKilpatrick, 1998).

Gender bias

Research

Gender bias has skewed the research agenda.The relationship of women’s reproductivefunctioning to their mental health has

received protracted and intense scrutiny over manyyears while other areas of women’s health havebeen neglected. Recent research suggests that the

impact of biological and reproductive factors onwomen’s mental health is strongly mediated and, inmany cases disappears, when psychosocial factorsare taken into account. For example, research onmenopause has revealed that emotional well beingin middle aged women is positively associated withtheir current general health status, psychosocialand lifestyle variables, but not with theirmenopausal status nor their hormone levels(Dennerstein, Dudley and Burger, 1997).

By contrast, the contribution of men’s reproduc-tive functioning to their mental health has beenvirtually ignored.The few studies that have beenconducted reveal that men are emotionally respon-sive to many of the same events as women. Forexample, men as well as women experiencedepression following the birth of a child and thereis a high level of correlation between parentsregarding depressive symptoms (Soliday,McCluskey-Fawcett and O’Brien, 1999).

Health programmes directed towards women havetypically had a narrow focus on reproductive healthand fertility control, especially in developing coun-tries.The preoccupations of health planners, aidagencies and researchers are not necessarily sharedby the women towards whom these programmesare directed. In a study conducted in the Voltaregion of Ghana, nearly three quarters of thewomen, when asked to identify their most impor-tant health concerns, nominated psychosocialhealth problems such as “thinking too much” and“worrying too much”, not reproductive health con-cerns (Avotri & Walters, 1999).The explanationswomen gave of their health problems stressedheavy workloads, the gendered division of labour,financial insecurity and unremitting responsibilityfor the care of children.

Treatment

Gender bias and stereotyping in the treatment offemale patients and the diagnosis of psychologicaldisorders has been reported since the 1970’s(Broverman,Vogel, Broverman et al., 1972).Recent research findings are less consistent. Somehave found that doctors are more likely to diagnosedepression in women compared with men, evenwhen they have similar scores on standardizedmeasures of depression or present with identicalsymptoms (Callahan, Bertakis, Azari et al, 1997;


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Stoppe, Sandholzer, Huppertz et al, 1999).However, no gender difference in the detection ofdepression and anxiety disorders by doctors wasfound in the multi country WHO study of psycho-logical problems in general health care (Gater etal, 1998). Detection or identification of psycholog-ical disorder is an important first step in improvingthe quality of care, but one which must be fol-lowed by effective treatment to have a positiveeffect on outcome.

Female gender is a significant predictor of beingprescribed psychotropic drugs. It has also beenreported that women are 48% more likely thanmen to use any psychotropic medication after sta-tistically controlling for demographics, health sta-tus, economic status and diagnosis (Simoni-Wastila, 2000).

Gender differences exist in patterns of help seek-ing for psychological disorder.Women are morelikely to seek help from and disclose mental healthproblems to their primary health care physicianwhile men are more likely to seek specialist mentalhealth care and are the principal users of inpatientcare. Men are also more likely than women to dis-close problems with alcohol use to their healthcare provider (Allen, Nelson, Rouhbakhsh et al,1998).This suggests that gender based expectationsregarding proneness to emotional problems inwomen and proneness to alcohol problems in men,as well as a reluctance in men to disclose symp-toms of depression, reinforce social stigma andconstrain help seeking along stereotypical lines.

Despite these gender differences, most women andmen experiencing emotional distress and/or psy-chological disorder are neither identified or treatedby their doctor (Üstün & Sartorius, 1995). Anadditional problem is that many people with psy-chological disorders do not go to their doctors. Ina recent US study, almost three fifths of those withsevere mental illness received no speciality careover a 12 month period (McAlpine & Mechanic,2000). If help is not sought in the year of onset ofa disorder, delays in help seeking of more than 10years are common in many countries (WHO &ICPE, 2000). If there is significant unmet need, aswell as poor identification of disorder in peoplewho do go to primary care providers in relativelywell-resourced developed countries, the situationis likely to be much worse in developing countries.

Funding, organization and insurance

The organization and financing of mental healthcare makes an important contribution to socialcapital, and is an indicator of access and equity inmental health care.

To reduce gender disparities in health care in rela-tion to the disorders in which women predomi-nate, requires that barriers to accessing care arelowered and patient preferences are heeded.Women’s overrepresentation amongst those livingin poverty, means that cost will be a significantbarrier to mental health care. A “user pays” systemwhere consumers either pay directly out of theirown pockets for services or to cover the cost ofhealth insurance, will further disadvantage poorwomen who are over represented amongst thoseexperiencing depression, anxiety, panic disorder,somatization disorder and posttraumatic stress dis-order.

Depending on the way mental health care is fund-ed, medical insurance status can significantly pre-dict access to speciality care. One US study report-ed that those with insurance were six times morelikely to have access to care than those without(McAlpine & Mechanic, 2000). Lack of insuranceinteracts with other aspects of the socioeconomicdisadvantage experienced by the severely mentallyill, in comparison with those with no identifiablemental disorder.

Both income level and the organization and financ-ing of mental health can exert an influence on thelikelihood of mental health services being utilizedand the particular sector of service provision likelyto be accessible. A three country study, using datafrom the 1990-1992 National Comorbidity Survey,the 1990-1991 Mental Health Supplement to theOntario Health Survey and the 1996 NetherlandsMental health Survey and Incidence study, exam-ined interrelationships between income, organiza-tion and financing of mental health care and differ-ential use of mental health treatment.The threesectors of mental health care provision examinedwere the general medical, speciality and humanservices sectors. Ontario was the only place whereincome was unrelated to the sector of care forpatients, indicating equity of access. In relation tohuman development, it is perhaps no coincidencethat Canada also ranks first on the HumanDevelopment Index and the Gender Development


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Index (UNDP, 2000). In the US, income was posi-tively related to speciality sector treatment andnegatively related to treatment in the human serv-ices sector. In the Netherlands, patients in the mid-dle income group were less likely to receive spe-ciality care and those in the high income group lesslikely to receive care from the human service sec-tor (Alegria, Bijl, Lin et al, 2000).

If access to care is not blocked by cost considera-tions, those in greatest need are likely to seektreatment. Another Canadian study revealed thatsingle motherhood status was the strongest inde-pendent predictor of mental health morbidity andutilization of mental health services. Low incomewas the next strongest predictor and of course,recall here too, that low income is interrelatedwith single motherhood status (Lipman, Offordand Boyle, 1997).

The trend to managed care in some countries,when associated with reductions in the intensityand duration of treatment, is likely to impact moston those with chronic disorders who are also mostlikely to be experiencing social disadvantage.

Gender sensitive services

To reduce gender disparities in mental health treat-ment, gender sensitive services are essential. Ifwomen are to be able to access treatment at alllevels from primary to specialist care and inpatientas well as outpatient facilities, services must be tai-lored to meet their needs.

To ensure that the assistance available is also mean-ingful to those seeking treatment, the full range ofpatients’ psychosocial and mental health needsmust be addressed.This involves services adoptinga life course approach, by acknowledging currentand past gender specific exposures to stressors andrisks and by responding sensitively to life circum-stances and ongoing gender based roles andresponsibilities.

Gender sensitivity will not improve unless clientbased preferences inform models of treatment andthe provision of care. For women generally, butespecially low income ones, services have to bemade genuinely accessible.This includes havingaccess to services during the weekend or eveninghours, short waiting times and locating servicesclose to public transport routes.With regard to the

doctor patient relationship, preferred health careproviders are those who show a sense of concernand respect and are willing to talk and spend timewith patients. Integrated services where social andclinical services are available on one site are alsopreferred by women (O’Malley, Forrest andO’Malley 2000).

Some women with mental illness or substance usedisorders are also parents and carers. Services needto be aware of the impact of this role on women’slives and their willingness to seek help, includingfears that their children will be taken from them, ifthey do seek treatment (Mowbray et al., 1995).For women experiencing postnatal psychologicaldisorder such as postnatal depression and postpar-tum psychosis, but also for women experiencingemotional distress, exhaustion and parenting diffi-culties, mother-baby units that allow joint admis-sion can be useful.To reduce stigma, such unitsshould operate as part of general maternity hospi-tals and services. Mothers and babies should not besent to psychiatric hospitals.

Services that attempt to assist women with severemental illness need to move beyond stereotypicalassumptions and roles regarding women and notonly provide access to living and social skills butalso to vocational training and employment sup-port.

Violence and severe mental illness

Violence-related mental health problems are poor-ly identified, victimization histories are not rou-tinely taken and women are reluctant to disclose ahistory of violent victimization unless physiciansask about it directly (Mazza & Dennerstein, 1996).

At the same time, violent victimization, especiallysevere childhood sexual abuse (CSA), significantlypredicts admission as an inpatient to a psychiatricfacility during adulthood. A New Zealand study(Mullen, 1993) found women whose childhoodsexual abuse involved penetrative sex, were sixteentimes more likely to report psychiatric admissionsthan those who had been subjected to lesser formsof abuse. Given the significance of CSA as a predic-tor of inpatient admission, it is important thatinpatient and residential services provide womenwith adequate safety and privacy. Even after con-trolling for the effect of coming from an unstablefamily home where one or both parents were


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absent, had mental health problems or were inconflict, CSA remained a significant predictor oflater psychopathology.

Gender and risk

Emerging evidence indicates that the impactof gender in mental health is compounded byits interrelationships with other social, struc-

tural determinants of mental health status, includ-ing education, income and employment as well associal roles and rank.There are strong, albeit vary-ing, links between gender inequality, human pover-ty and socioeconomic differentials in all countries.Gender differences in material well being andhuman development are widely acknowledged.According to the 1998 World Health Report :

Women’s health is inextricably linked to their status insociety. It benefits from equality, and suffers from discrim-ination.Today, the status and well being of countless mil-lions of women world-wide remain tragically low (WHO,1998: 6).

In every country, gender development continues tolag behind human development (UNDP, 2000) oras an earlier Human Development Report (UNDP,1997) put it: “no society treats its women as wellas its men”.Women constitute more than 70% ofthe world’s poor (UNDP 1995) and carry thetriple burden of productive, reproductive and car-ing work. Even in developed countries, lone moth-ers with children are the largest group of peopleliving in poverty (Belle 1990) and are at especiallyhigh risk for poor physical and mental health(Macran et al., 1996; Lipman, Offord and Boyle,1997). Clearly, gender must be taken into accountin looking at the way income disparities, inequali-ties and poverty impacts on mental health.

Gender and rank

There is a strong social gradient in health.Adverse mental health outcomes are 2 to 2 _times higher amongst those experiencing

greatest social disadvantage compared with thoseexperiencing least disadvantage (Dohrenwend1990; Kessler et al., 1994; Kunst et al., 1995;Bartley & Owen, 1996; Macran et al., 1996;Stansfeld et al., 1998). Environmental stressors,including increased numbers of negative life

events, experiences and chronic difficulties, arehighly significant in accounting for the lower socialclass predominance of non-psychotic psychiatricdisorders like depression and anxiety. Less controlover decision making, the structural determinantsof health and less access to supportive social net-works correlate with higher levels of morbidityand mortality (Kessler et al., 1994;Turner &Marino, 1994; Brown, 1998).

While there is a large amount of evidence thatconfirms a strong relationship between socioeco-nomic status, position in the social hierarchy andmental health, most research has lacked a genderperspective.

Analyses of the social gradient in health have con-centrated on the material indicators of inequalityand social disadvantage. However, the social gradi-ent in physical and mental health also operates on asymbolic and subjective level. Social position car-ries with it an awareness of social rank and a clearunderstanding of where one stands in the scale ofthings.The link between a sense of loss and defeat,entrapment, and humiliation denoting devaluationand marginalization, is strengthened by relatedresearch on social rank (Gilbert & Allan 1998).Depression is strongly related to several interrelat-ed factors:

■ Perceptions of the self as inferior or in anunwanted subordinate position, with low selfconfidence.

■ Behaving in submissive or in non assertive ways.

■ Experiencing a sense of defeat in relation toimportant battles, and wanting to escape butbeing trapped.

The very same qualities that characterize depres-sion and low social rank, have been regarded asnormal and desirable qualities of “femininity” andencouraged if not enforced through socialization,“tradition” and outright discrimination. By con-trast, psychosocial resources, the wherewithal toexercise choice, having a confidant, social activitiesand a sense of control over one’s life, form criticalbulwarks against depression regardless of awoman’s age (Zunzunegui et al., 1998). Feelings ofautonomy and control significantly lessen the riskof depression occurring in the context of whatmight otherwise be considered as an importantloss. Brown, Harris and Hepworth (1995) found


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that when marital separation was initiated by thewoman, only about 10% of such women subse-quently developed depression.When the separa-tion was almost entirely initiated by her partner,around half the women developed depression.Interestingly, the rate of depression increasedagain, if infidelity was discovered and not followedby separation.

Gender and work

Women in paid work receive significantlylower wages than their male counterparts.Relative income inequality penalizing

women and favouring men is structurally embed-ded as women typically earn around two thirds ofthe average male wage and this disparity has per-sisted over time.The level of gender developmentin a country is strongly related to rates of pay.Between 1993-1995, less than 10% of womenwere in low paid work in Sweden, where theranking for gender development is higher than forhuman development. In contrast, in Japan and theUS where gender development rankings are lowerthan human development rankings, more than30% of women were in low paid jobs (UNDP,1997).

The weakening of worker protection laws toattract foreign investment and the employment ofgirls and women as “outworkers” or sweated labourin garment and footwear industries and in exportprocessing zones (EPZ), as well as their overrepre-sentation amongst sex workers, represent signifi-cant threats to mental and physical health and vio-lations of women’s human rights.

The workplace itself is another area where rank ispredictive of depression and linked to gender.Work characteristics, especially skill discretion anddecision making authority are closely allied toemployment grade and make the largest contribu-tion to explaining differences in well being anddepression.The highest levels of well being and theleast depression are found in the highest employ-ment grade; the reverse is true for those in thelowest grades who have a higher prevalence of neg-ative life events, chronic stressors and less socialsupport.Women are more likely to occupy lowerstatus jobs with little decision-making discretion(Stansfeld, Head and Marmot, 1998).

Research on the subjective correlates of eventsrelated to subordinate status or lower rank, com-plements earlier work that documented the rela-tionship between various objective measures ofrank and the increased likelihood of poor health,depression and anxiety. Rank related variables arefound in clusters, rarely in isolation and combinestructural, material determinants, rank and sym-bolic indicators of social standing and gender roles.The resultant mix is strongly predictive of thecommon mental disorders. It includes low educa-tional status, unemployment, low employment sta-tus and pay, insecure, “casual” employment, singleparent status, homelessness and insecure housingtenure and inadequate income, poor social supportand diminished social capital (Belle, 1990; Macran,Clarke and Joshi; 1996, Brown et al, 1996;Kawachi et al., 1999).

Gender roles

Gender socialization, which stresses passivi-ty, submission and lower rank, are not onlyreinforced for women by their structural

position in paid employment – lower status, more“casual”, part-time and insecure jobs and lowerrates of pay – but by their much larger contribu-tion to unpaid domestic and caring work in thehome.Women of reproductive age may carry thetriple burden of productive, reproductive and car-ing work. Not surprisingly, gender differences inrates of depression are strongly age related.Thelargest differences occur in adult life, no differ-ences are found in childhood and few in the elderly(Vazquez-Barquero et al., 1992; Beekman et al.,1995; Zunzunegui et al., 1998).

Gender differences in mental health cannot beexplained by relying solely on role analysis toexamine women’s mental health and structuralanalysis to examine men’s mental health. Even so,when social role variables such as marital status,children and occupational status were matchedbetween women and men who participated in themulti country WHO study on PsychologicalProblems in Primary Care, the female excess indepression was reduced by 50% across all centresin the study (Maier, Gansicke, Gater et al, 1999).

To fully understand gender differences in mentalhealth, there is a need to integrate a gender role


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analysis with a structural analysis of the determi-nants of health because gender roles intersect withcritical structural determinants of health includingsocial position, income, education and occupationaland health insurance status. Role patterns ofwomen are not evenly distributed across incomelevels. A French study found that housewives andlone mothers are more common at the bottom andmiddle of the income scale and working womenwithout children, married or not, are more com-mon at the top (Khlat, Sermet and Le Pape, 2000).In addition, the measurement of women’s incomeis problematic. A significant amount of income datais missing for women in many large scale surveys(Macran et al., 1996).The substitution of “familyincome” or “total household income”, as a proxymeasure of socioeconomic status has inherentproblems.This proxy measure may bear little rela-tionship to the way income is distributed withinthe household, especially in households wherewomen are subjected to violence and experiencehigh levels of coercive control over all aspects oftheir lives including the spending of money.Toaccurately assess women’s income, information isnecessary on their levels of access to and controlover income within the household. Assuming equi-table access to and distribution of “family income”is unwarranted, but continues to be widely prac-ticed (WHO & ICPE, 2000)

Numerous studies have reported that low incomemothers, especially lone mothers, have significant-ly higher levels of depression than the generalpopulation (Macran & Joshi, 1996; Salsberry,Nickel, Polivka et al., 1999). Compared with thegeneral population, poor women are exposed tomore frequent, more threatening and moreuncontrollable life events, such as the illness anddeath of children and the imprisonment or deathof husbands.They face more dangerous neighbour-hoods, hazardous workplaces, greater job insecuri-ty, violence and discrimination, especially if theybelong to minority groups (Belle 1990, Brown1998; Patel et al. 1999). Other gender basedexperiences, such as having two or more abor-tions, or experiencing sexual abuse or other formsof violence and adversity in childhood or adult lifealso contribute significantly to poorer mentalhealth (Bifulco et al. 1991; Fellitti et al., 1998).These factors, separately and together, work toreduce the degree of autonomy, control and deci-

sion making latitude possible for women on lowincomes.

Economic policies

Current evidence on the consequences ofglobalization and restructuring indicates thatsocioeconomic deprivation is increasing and

income inequality is widening within and betweenmany countries (UNDP, 2000). Considerable evi-dence links rising income inequality to increasingrates of common mental disorders, like depres-sion, anxiety and somatic symptoms (Patel et al,1999), increased rates of mortality from physicalconditions (Lynch, Smith, Kaplan, House, 2000)and increased mental health related mortality asso-ciated with substance use disorders and suicide(Lorant, 2000). In Russia, the predictors of signifi-cant falls in life expectancy include fast paced eco-nomic change, high turnover of the labour force,increased levels of crime, alcoholism, inequalityand decreasing social cohesion (Walberg, McKee,Shkolnikov et al, 1998).

The impact of globalization and structural adjust-ment programmes is especially severe in the poor-est nations. Moreover, it occurs in gender distinctways because of the separate roles men and womenplay and the different constraints they face inresponding to policy changes and shifts in relativeprices (Kirmani & Munyakho, 1996). Cutbacks inpublic sector employment and social welfarespending can cause the costs of health care, educa-tion and basic foodstuffs to become unaffordable,especially to the poor, the majority of whom arewomen (Bandarage, 1997).

Evidence on the gender specific effect of restruc-turing on mental health is persuasive. Dataobtained from primary care attenders in Goa(India), Harare (Zimbabwe), Santiago (Chile) andfrom community samples in Pelotas and Olinda(Brazil) showed significant associations betweenhigh rates of depression, anxiety and somaticsymptoms and female gender, low education andpoverty (Patel et al., 1999).This study reveals howgender inequality accompanies but is also wors-ened by economic inequality and rising incomedisparity.The result of this interaction is a steeprise in the very mental disorders in which womenalready predominate.


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Economic policies that cause sudden, disruptiveand severe changes to the income, employmentand living conditions of large numbers of peoplewho are powerless to resist them, pose over-whelming threats to mental health. Disruptive,negative life events that cannot be controlled orevaded are most strongly related to the onset ofdepressive symptoms. An increase in the numberof such events is paralleled by an increase in thenumbers of women becoming depressed.The sizeof the contribution made by these events to com-mon mental disorders is evident from a number ofstudies on women’s mental health carried out overrecent years in a range of countries.

Based on research carried out in Great Britain,Brown, Harris and Hepworth (1995) calculate that85% of women from the community (as opposedto a patient group) who developed “caseness” fordepression in a 2 year study period experienced asevere event in the 6 months before onset.Depression was particularly likely to occur when asevere event (or events) was accompanied by vul-nerability factors, especially those associated withlow self-esteem and inadequate support.Thematching of a current severe event with a pro-nounced ongoing difficulty was also critical to theonset of depression (Brown et al., 1990; Brown,1998).

Severe, disruptive negative events could involveloss or danger but other features were moreimportant in initiating depression. Most importantof all was the experience of humiliation, defeat anda sense of entrapment, often in relation to a corerelationship. Almost three-quarters of the severeevents occurring in the six months prior to theonset of depression involved entrapment or humil-iation whereas just over one fifth involved lossalone and only 5% concerned danger alone (Brownet al., 1995). Studies conducted in Zimbabwe attwo different time points offer further insight intothe strength of the relationship between the natureand frequency of severe events and associated ratesof depression. In the first study , the annual inci-dence of depression was 18%, double that found ininner London (Abas & Broadhead, 1997).Thisincreased to 30.8% in the second study (Broadhead& Abas, 1998).The excess of onset cases in thesecond study was primarily due to the increasednumbers of severe and disruptive events and diffi-culties occurring in the intervening time period.

The severe events reflected, “the high levels ofphysical illness and premature death in familymembers, the predicaments associated with sea-sonal migration between rural and urban homes,problems associated with infertility and the largenumber of marital and other relationship crises”(Broadhead & Abas, 1998: 37).

Population based studies of women in Zimbabwe,London, Bilbao, the Outer Hebrides, rural Spainand rural Basque Country, Spain, found thatwomen meeting the criteria for depression variedfrom a low of 2.4% in the Basque Country to ahigh of 30% in Zimbabwe. Negative, irregular, dis-ruptive life events were found to trigger depres-sion in all six sites.Taken together, these findingsindicate that a strong linear relationship existsbetween the number and severity of events and theprevalence of depression (Brown, 1998).

Impact of gender-based violenceon mental health

Where women lack autonomy, decision mak-ing power and access to income, many otheraspects of their lives and health will necessar-

ily be outside their control. In particular, genderdifferentiated levels of susceptibility and exposureto the risk of violence place stringent limitationson women’s ability to exercise control over thedeterminants of their mental health.

Social research indicates that depression in womenis triggered by situations that are characterized byhumiliation and entrapment and that this occurs inrelation to “atypical events” (Brown, Harris andHepworth, 1995).This view is challenged by evi-dence about the chronic nature of much genderbased violence and its direct link to increased ratesof depression.

The prevalence of violence against women (VAW)is alarmingly high (WHO, 1998).Women com-pared to men are at greatly increased risk of beingassaulted by an intimate (Kessler, Sonnega, Brometet al., 1995).Violence in the home tends to berepetitive and escalate in severity over time (AMA1992) and encapsulates all three features identifiedin social research on depression in women: humili-ation, enforced inferior ranking and subordination,and blocked escape or entrapment.


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Violence – physical, sexual and psychological – isrelated to high rates of depression and co morbidpsychopathology, including posttraumatic stressdisorder (PTSD), dissociative disorders, phobiasand substance use and suicidality (Roberts et al1998). Moreover, psychological disorders areaccompanied by multi somatization, altered healthbehaviours, changed patterns of health care utiliza-tion and health problems affecting many body sys-tems (Resnick et al., 1997; Roberts et al. 1998;Felitti et al., 1998). Being subjected to the exerciseof coercive control leads to diminished self esteemand coping ability.

Violent victimization increases women’s risk forunemployment, reduced income and divorce(Byrne et al, 1999). For this reason, gender basedviolence is a particularly important cause of poormental health because it further weakens women’ssocial position by operating on the structuraldeterminants of health at the same time as itincreases vulnerability to depression and other psy-chological disorders.

The high incidence of sexual violence against girlsand women has prompted researchers to suggestthat female victims make up the single largestgroup of those suffering from post traumatic stressdisorder (Calhoun & Resick, 1993). A nationwidesurvey of rape in the US, found 31% of rape vic-tims developed PTSD at some point in their livescompared with 5% of non victims (Kilpatrick,Edmunds & Seymour, 1992). PTSD also persistslonger in women than in men (Breslau et al,1998).

The mental health impact on the millions ofwomen who are caught up in sexual trafficking hasnot been assessed.The trauma of repeated abuseand denial of any human rights is severe and ongo-ing. Mental health effects are likely to include allthose previously identified in research on VAW andto parallel those experienced by other victims oftorture.The likely causal role of violence indepression, anxiety and other disorders such asposttraumatic stress disorder is suggested by:

■ Three to four fold increases in rates of depres-sion and anxiety in large community samplesamongst those exposed to violence comparedwith those not exposed (Mullen et al. 1998;Saunders et al. 1993).

■ Severity and duration of violence predicts severi-ty and number of adverse psychological out-comes, even when other potentially significantfactors have been statistically controlled in dataanalysis.This has been found in studies on themental health impact of domestic violence(Campbell & Lewandowski, 1997; Roberts et al.1998) and childhood sexual abuse (Mullen et al.,1993).

■ Marked reductions in the level of depression andanxiety once women stop experiencing violenceand feel safe (Campbell et al., 1996) comparedwith increases in depression and anxiety whenviolence continues (Sutherland et al., 1998).

The evidence presented here indicates that thefemale excess in depression and other disordersreflects women’s greater exposure to a range ofstressors and risks to their mental health, ratherthan an increased, biologically based vulnerabilityto psychological disorder.

Implications for policies andprogrammes

To reduce gender disparities in mental healthinvolves looking beyond mental illness as adisease of the brain.This is not to deny that

distress and disorder exist and require compassion-ate and scientifically based treatment nor that thestigma associated with all forms of mental illnessmust be eradicated. However, clinicians,researchers and policy makers also need to sociallycontextualize the mental disorders affecting indi-viduals and the risk factors associated with them.

There is strong evidence that globalization andlarge scale restructuring have increased incomeinequalities and adverse life events and difficulties,with particularly severe impacts on women.Moreover this increase in gender based income dis-parities is associated with increasing rates of com-mon mental disorders amongst women in a num-ber of countries (Patel et al, 1999; Broadhead andAbas, 1998).

Governments need to monitor the mental healtheffects of their economic reforms and take urgentaction to bring about a more gender equitable dis-tribution of the benefits of globalization. Activemeasures need to be taken to protect social capital,


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as this too, is powerfully related to how peoplerate their health (Kawachi et al, 1999). If genderbased income inequalities are not reduced, thenumbers of girls and women who are forced torely on harmful and/or illegal activities forincome, such as work in the sex industry, will con-tinue to escalate.

Budgets for mental health will become rapidlydepleted if funding is focussed on curative treat-ment and care. Medical treatment that is confinedto the alleviation of presenting symptoms is at besta partial response. Such a response fails to addressongoing high levels of exposure to mental healthrisks or to reduce gender based levels of suscepti-bility. In other words, while improving identifica-tion and treatment of mental disorders is certainlynecessary, it is clearly not sufficient to reduce theirincidence.

Currently, the rates of detection, treatment andappropriate referral of psychological disorders inprimary health care settings are unacceptably low.The high rates of depression in women and alcoholdependence in men strongly indicate a large unmetneed for improved access, at a community level, tolow or preferably no cost gender sensitive coun-selling services. Psychologists and social workersworking in community based health services thatare responsive to the psychosocial issues of thosethey serve, are well placed to provide cost effectivemental health services.

All health care providers need to be better trainedso that they are able to recognize and treat not justsingle disorders such as depression and alcoholdependence, but also their co occurrence.Clinicians need to be equipped to assess andrespond to gender specific, structurally deter-mined risk factors and to become proficient inproviding much needed advocacy for their patientswith other sectors of the health and social welfaresystem.Without these skills, rates of comorbidityamong patients will compound. Skill in traumafocussed counselling is a priority for clinicians inall health sectors who encounter women (Acierno,Resnick and Kilpatrick, 1997).

Women’s overrepresentation amongst those withpsychiatric comorbidity (Kessler et al., 1994)together with the heightened burden of disabilityassociated with comorbidity indicates the need toclearly identify gender specific risk factors for

comorbidity. In particular, the complex linkagesbetween depression in women, multi somatizationand psychiatric comorbidity in the context of a his-tory of violent victimization need to be clarified.

Mental health care funding, too, must be respon-sive to the issue of psychiatric comorbidity.Clinicians need to have adequate consultation timewith their patients to permit accurate diagnosis.Time and cost pressures on “throughput” mayappear economic and efficient in the short termbut are incompatible with providing patients gen-der sensitive, meaningful assistance with theirmental health problems. Repeated utilization of themental health care system consequent on the fail-ure to accurately diagnose and treat is a far moreexpensive outcome in the long term.

The concept of “meaningful assistance” in mentalhealth care needs to be promoted. Meaningfulassistance implies a patient centred approach.Gender disparities in mental health will not bereduced until women’s own mental health con-cerns and life priorities are taken into account inprogramme design and implementation (Avotri &Walters, 1999). Currently under diagnosed andpoorly treated conditions, especially the combina-tion of depression, violence related health condi-tions and significant psychosocial problems urgent-ly require meaningful assistance.

Gender based barriers to mental health care, espe-cially cost and access, bias and discrimination mustbe removed. Intersectoral collaboration across gov-ernment departments and gender sensitive policymaking in education, housing, transport andemployment are required to ensure that the multi-ple structural determinants of mental health arefacilitated to work in positive synergy, maintainsocial capital and support social networks (Kawachiet al, 1999). A free, universal medical insurancescheme is the only way to ensure mental healthcare will be accessible to the most socioeconomi-cally disadvantaged group (Lipman, Offord andBoyle, 1997).

A public health approach to improve primary pre-vention and address gender specific risk factors fordepression and anxiety disorders is indicated by alarge body of evidence. Social safety nets andincome security are especially important forwomen and their mental health. A public healthapproach necessarily broadens the notion of effec-


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tive treatment.The most obvious way of reducingviolence related mental health problems is toreduce women’s exposure to violence.Womenwho have been but are no longer being batteredshow significant reductions in their level of depres-sive symptoms, while those who continue to expe-rience violence do not (Campbell et al, 1993).Providing access to refuges and alternative formsof safe housing is thus a powerful mental health“treatment”.

Better quality evidence needs to be collected thatis informed by a gendered, social determinants, lifecourse approach. Cross sectional research hasrevealed significant factors in the onset of depres-sion but much more longitudinal research isrequired to understand how changes in social andhousehold conditions mediate the course ofdepression and its chronicity (Bracke, 2000). Ifpersistence in adversity is neither accurately meas-ured nor disentangled from persistence in depres-sive symptoms, its role in the chronicity of depres-sive symptoms cannot be ascertained.

A priority for mental health promotion and inter-vention programmes is to incorporate a mentalhealth focus in all programmes related to childhealth.The level of exposure to adverse childhoodevents has a strong graded relationship with all themajor causes of adult morbidity and mortality andthe behavioural risk factors associated with them(Felitti et al, 1999). Childhood sexual abuse, inparticular, is predictive of multiple negative healthoutcomes including high rates of psychiatric mor-bidity as well as homelessness, prostitution, sub-stance use disorders and suicidality.The earliestpossible identification and protection of thoseexposed to adverse childhood events, and ideallythe elimination of these events, is necessary to pre-vent re-victimization and arrest the progressionand compounding of poor mental, physical, sexualand social health outcomes. Consequently, the goalof preventing childhood neglect and exposure toall forms of trauma and adversity must inform thedesign and implementation of maternal and childhealth, family violence services and social welfareand social security services.

At the same time, “zero tolerance” health educationand promotion campaigns to reduce violenceagainst women and children need to be designedusing culturally appropriate formats in order to

counter traditional beliefs and attitudes that con-done and perpetuate violence.

Conclusion

To address gender disparities in mental healthrequires action at many levels. In particular,national mental health policies must be

developed that are based on an explicit analysis ofgender disparities in risk and outcome.

Effective strategies for risk factor reduction in rela-tion to mental health cannot be gender neutralwhile the risks themselves are gender specific andwomen’s status and life opportunities remain “trag-ically low” worldwide (WHO, 1998). Low status isa potent mental health risk. For too many women,experiences of self worth, competence, autonomy,adequate income and a sense of physical, sexualand psychological safety and security, so essentialto good mental health, are systematically denied.The pervasive violation of women’s rights, includ-ing their reproductive rights, contributes directlyto the growing burden of disability caused by poormental health.

Consequently, a rights framework needs to beadopted to improve the ethical and interpretativedimensions of research, mental health care practiceand policy. Mental health research has scarcelybegun to address the impact of patient and humanrights violations on mental health.These includethe psychological effect of failure to gain informedconsent, denial of patient privacy and dignity, andthe use of treatments that may successfully altermood but neglect ongoing exposure to experiencesthat grossly violate the right to mental health suchas living in safety and freedom from fear.Thisomission needs to be rectified.


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Summary records of statements by Ministers

The discussions

This section contains summaries of the state-ments made by the Ministers of Health par-ticipating in the round table discussions.The

statements appear in alphabetical order accordingto country and regroup the participants of all fourround tables.

Angola

Dr Hamukwaya described how the mental healthsituation in her country had been aggravated byinternal conflict and its consequences. Political,social and economic stability and prosperity wereessential to bring about improvements. She empha-sized the importance of promoting healthylifestyles and adopting psychosocial rehabilitationmeasures as part of a national policy to improvethe mental and physical health of the Angolan peo-ple. She also reaffirmed her country’s intention tofight marginalization and social exclusion by associ-ating its efforts with initiatives taken by WHO topromote mental health.

Argentina

Dr Lombardo traced the history of mental healthcare in his country from its origins in the 19th cen-tury, including the establishment in 1957 of theNational Mental Health Institute, which hadendorsed the approach of treating mental healthdisorders as health problems and not diseases.Nevertheless, developments in lifestyles, includingthe emergence of “modern” problems such as stresshad led to the increased incidence of serious men-tal disorders.The treatment of such disorders haddeveloped in parallel on an interdisciplinary andintersectoral basis, with recognition of the funda-mental importance of community participation inhealth matters. Argentina currently had a highnumber of mental health specialists, comparable tothe numbers in the most developed countries.Progress had also been made in the treatment ofmental disorders with the emergence of new drugsin the second half of the twentieth century, whilethe development of new outpatient services hadhelped persons with mental disorders to avoidsocial marginalization and stigmatization. In thatrespect, he emphasized that the isolation of manyadults in modern society was a basic reason for thedevelopment of mental health disorders.

Legislation placing emphasis on promotion andprevention was currently being adopted at variouslevels in Argentina. A National Primary MentalHealth Care Act, the principal focus of which wason prevention, had recently been adopted and hadbeen accompanied by legislation covering thetreatment of various conditions related to mentalhealth disorders. Similar legislative measures werealso being adopted by the provinces.The mentalhealth policy had been incorporated into thenational health policy emphasizing the promotionof healthy lifestyles and including the prevention ofsubstance abuse, and the development of a nationalprogramme to prevent depression and detect pos-sible cases of suicide at an early date.The basic ele-ments of the treatment of mental health disorderswere: the elimination of stigmatization; the organi-zation of multidisciplinary health services coveringprevention, health promotion, care and rehabilita-tion; and the social reintegration of patients.Gender was another fundamental aspect of mentalhealth problems, since more women than men suf-fered from mental health disorders. Attentiontherefore needed to be paid to problems of genderdiscrimination in modern societies. Finally, it wasnecessary to identify the socioeconomic elementsthat led to the development of mental disorders,including poverty and marginalization. Mentalhealth patients needed immediate reintegrationand assistance to promote their participation in thelife of the community. He welcomed the initiativetaken by WHO on one of the major health prob-lems of the coming years.

Australia

Professor Mathews said that the rapid pace ofsocial change, economic pressures, war and popu-lation movements and other factors had con-tributed to difficulties in recognizing and providingadequate support for mental health problems.Thatsocial change had also been accompanied by theloss of traditional family support in many coun-tries.Transitional societies, such as indigenousAustralians, were having difficulty with socialadjustment, and they and other vulnerable groupswere likely to suffer from drug and alcohol prob-lems, and problems related to violence and suicide,which Australia, like other countries, was takingvery seriously.


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Stigmatization was still a problem, and newapproaches to the philosophy of care and treatmentwere needed.The Australian National MentalHealth Strategy sought to promote the mentalhealth of the Australian community and to preventthe development of mental health problems andmental disorders; to reduce the impact upon indi-viduals, the family, and the community; and to pro-tect the rights of people with mental illness.

Particular emphasis had been placed on reducingstigmatization through programmes targeted atschools to increase awareness and understanding ofmental health problems, engaging with the mediato promote community understanding, and work-ing with community groups, as well as the profes-sional health sector, to promote acceptance.Australia had underpinned its work with legislativeprotection of the rights of people with mental ill-ness and had developed community plans for men-tal health support involving specialist care and aninterdisciplinary focus. Australia’s commitment topromotion and prevention had engaged theCommonwealth and state Governments and com-munity organizations, as well as stakeholdergroups, patient groups, and also the private sector.Australia fully supported the WHO mental healthinitiative and was committed to an interdiscipli-nary focus with a view to reducing stigmatizationand recognizing co-morbidities, emphasizing men-tal health promotion and prevention and rehabilita-tion.

Austria

Professor Waneck said that WHO had successfullydrawn public attention to mental health problems,which were often underestimated and misunder-stood. Great progress had recently been made inthe field of psychiatry and yet psychiatric disordersin the industrialized countries were increasing. Anew consciousness had emerged, evidenced by theburgeoning number of self-help groups, as a resultof which most people with mental illnesses wereliving within the community, able to make theirown life choices. At the global level, however,much remained to be done.The Austrian healthauthorities vigorously pursued the WHO-advocat-ed policy aimed at ending the exclusion of thementally ill, particularly in the field of hospitalpsychiatric services, which had been decentralized

and integrated, thus representing an importantstep forward in destigmatizing psychiatric disor-ders and those suffering from them. Self-helpgroups also played an instrumental role in theefforts to destigmatize psychiatric illness, as theyprovided vital back-up to the policy already inplace.

To strengthen the Austrian mental health policy, acountrywide survey of mental health provision hadbeen commissioned, bringing together, for the firsttime, data on psychiatric and psychosocial care forthe benefit of the mentally ill, their families andthose professionally concerned. Projects would beanalysed and additional measures adopted in thelight of the data produced by the survey, the sec-ond part of which was due at the end of 2001.Other important future objectives included thesatisfaction of needs, the integration of basic care,quality assurance and the participation of patientsand their relatives, care professionals, administra-tors and politicians. In conclusion, he hoped thatthe national and international efforts undertakenwould improve the information available in thefield of psychiatric care and that the stigmaattached to psychiatric illness would diminish tothe point where such health problems could beopenly discussed without taboo.

Bahamas

Dr Knowles said that he had taken comfort fromthe realization that most countries had problemssimilar to those in his own country but was sad tohear that solutions were hard to come by, regard-less of the size of a country’s gross domesticproduct.

The Bahamas, was a country of scattered popula-tions, which hindered service delivery. In additionto the country’s usual array of mental health prob-lems, it had suffered from being directly situatedbetween the major cocaine-producing LatinAmerican countries and the United States ofAmerica.The crack and cocaine epidemic of the1980s had been closely followed by the AIDS epi-demic and an upsurge in violent crime.

The Bahamas had recently reviewed its mentalhealth services and was revising its mental healthplan correspondingly. His country would welcomedirection in its efforts to provide sufficient num-


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bers of mental health workers, especially psychia-trists.That was not seen as a glamorous profession,nor did graduate nurses want to specialize in psy-chiatric care. He also asked for advice on the careof mentally ill patients in prisons, where the neces-sary psychiatric services were not available, and onthe multidisciplinary care of mentally ill adoles-cents.

Belarus

Dr Zelenkevich said that it was time to bring theproblem of mental illness out into the open. Oneof the principal challenges was how to ensure thatsuch illness was allocated its proper share of thescarce resources available, and to that end, it wasimportant to include mental health in all healthplans and policies and to involve general practi-tioners.The change-over from institutionalizedforms of care to care in the community, as well asthe increase in the number of specialists in mentalhealth being trained in medical schools, wouldcontribute to a more efficient use of resources.Greater efficiencies could also be achieved bymobilizing other sectors to assist the health sectorand by pooling resources. Nongovernmentalorganizations also had an important contributionto make.

Belgium

Mrs Aelvoet said that in her country, as in others,there had been an increasing demand for mentalhealth treatment, despite a substantial economicupsurge, which indicated that wealth per se was nosolution. Furthermore, stigmatization was stillwidespread; people with mental disorders weretreated differently from those with physical illness-es and tended to be regarded as abnormal. Duringthe past 25 years, there had been a trend towardsencouraging patients to stay in their home environ-ment, thereby enabling them to continue to workand function as usual.That had been achieved bythe development of first-level care, home supportservices and home visits by doctors, in addition tooutpatient and institutional care.

In 2001, a 10% increase in the health budget hadbeen agreed, constituting the largest increase forany government department.The concept had

been accepted that chronically ill patients, includ-ing those with mental disorders, should receivefinancial and institutional support. A system hadalso been developed to place a ceiling on theamount each patient should pay in any one year,anything over and above that amount being coveredby a reimbursement system, taking into accountpersonal socioeconomic circumstances.

In connection with gender specificity, it had beenestablished that women were more dependent onlegal drugs, whereas men tended to be dependenton alcohol. For issues of national importance, ithad been stipulated that at least one-third of themembers of all national committees should bewomen, including those concerning health.

Benin

Professor Ahyi observed that his country, likemany others, had been slow in responding to men-tal illnesses, in part because of the belief, commonin Africa, that they could be treated by traditionalmedicine.The recognition that many conditionsdid not respond to such treatment had forced anew approach and helped to raise mental health toone of the six top health priorities for Benin.Withsupport from WHO the country had begun coop-eration with Ghana and Mozambique on issues ofhealth promotion, but that concept had rapidly ledto issues of well-being and quality of life. A smallnational coordinating team had soon discoveredthat “health problems” were viewed in a prejudiciallight, there being a major general confusion aboutillness and health: as soon as one talked abouthealth promotion, that raised images of illness.Similarly, health centres and dispensaries were seenas focused on disease rather than on health. A con-clusion was that, in Benin, the training of healthcare workers needed to be revised to correct thosemisperceptions. In the past two years there hadbeen a move to educate the public at communitylevel, for example by encouraging communicationbetween generations. For instance, in one village abench had been placed by a communal path,enabling older people to come out of their homesand be more integrated into community life.People stopped and talked, and perceptions andattitudes soon changed.


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With regard to medicines, even generic drugswere rare in Benin. Moreover, those psychotropicdrugs that featured on the essential drugs list werenot ordered because the population was poor andthe demand for such drugs was considered to besmall. Further, the Bamako Initiative encouragedcost recovery. After the introduction of the healthpromotion policy, there had been a reduction inthe number of patients and the rate of cost recov-ery had also declined. A contradiction becameapparent: people preferred to have more patientsso that there would be sufficient funds to maintainthe existing system of health rather than reducingthe number of patients. Health promotion hadmeant social mobilization in order to reduce costs.A further important point was the culture ofhealth, not disease – and mental health was a casein point.The conclusion reached was that therewas no development without health and no healthwithout mental health. Mental health was the por-tal of entry for the development of developingcountries.With democratization came decentral-ization, but that had posed various problems. Forexample, social mobilization had resulted in themultiplication of demands for the expansion ofservices based on the successes of pilot projectswith the incorporation of mental health into pri-mary health care.

Bolivia

Dr Cuentas-Yáñez observed that mental healthprogrammes, whether against familial violence oralcoholism or for the administration of psychiatrichospitals, were based on a predominantly clinicalvision. He advocated a more cultural approach tomental health, and recalled that Bolivia had beenpart of the Inca empire. At that time, some 400years ago, itinerant “doctors” (cayaguayos) had dis-pensed basic mental health care. He argued thatevery mental health programme should take cog-nizance of the cultural heritage as well as of theepidemiological profile and the impact of poverty.The prevalence and incidence of mental illnesseswere known to be associated with social groups;alcoholism was closely linked with intrafamilialviolence, both of which were synonymous with themechanisms of desperation during economic diffi-culties. Culture differentiated mental health fromother health programmes, and people’s perceptions

and cultural background needed to be accommo-dated.

Bosnia and Herzegovina

Mr Misanovic said that stigmatization was animportant issue in Bosnia and Herzegovina.Thestigma arose from the subconscious fear that any-one could fall victim, permanently or temporarily,to mental ill-health. Bosnia and Herzegovina was apost-traumatic society in transition. Half the popu-lation suffered from war or stress-related psychi-atric disorders; the other half had dealt with theproblem by referring to the sufferers as “broken”people, partly out of fear that psychological traumacould be passed on to the next generation. It wasdifficult to fight stigmatization in post-traumaticsocieties because stigma was used to deny people’srights. Bosnia and Herzegovina needed a very dif-ferent procedure for eradicating the problem ofstigmatization. It needed extremely clear recom-mendations not only on how to eliminate stigma,but also on how to promote mental health and pre-vent mental disorders.

Botswana

Ms Phumaphi said that steps similar to thosedescribed by other speakers had been taken byBotswana in relation to patient integration, the set-ting up of community hospitals, and campaigns toreduce the stigma associated with mental illness.Two issues were of particular importance. First, itwas essential to recognize that mental illness was ahuman problem as well as a medical problem, andto develop programmes aimed at particular socialand economic groups.The power of peer groupscould be harnessed to promote mental well-being.Secondly, her country attached importance to earlyintervention, which was a critical element inimplementing mental health policies. She agreedthat there was a need for research into mental ill-ness and into the links between mental and physi-cal health.

In Botswana, stigmatization corresponded to fearof those with mental illnesses.That was perhapsbecause their loss of control of their lives was asso-ciated in the minds of others with disruption totheir lives.The response to the four questions


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´

^

raised by their Chairman could be summed up inthree words: information, education, communica-tion. Botswana had medical-aid societies that didnot provide adequate care for the mentally illbecause of stigma; there was a high unemploymentrate among the mentally ill because employers didnot want to hire them; and insurance payments hadbeen denied to the families of mentally ill patientswho had committed suicide.

Consideration also had to be given to the plight ofthose who already had special needs in addition tosuffering from the stigma of mental ill-health, forexample, children in difficult circumstances,women, refugees and migrants, the elderly, conflictsurvivors, prisoners, and young people engaged insubstance abuse.Those groups’ needs should beaccommodated in appropriate legislation. It wasalso vital that patients be properly managed; to doso entailed removing stigma among health careworkers. Consideration should be given to ways ofcountering the results of stigmatization by legisla-tive means, such as regulations governing patientmanagement that would help to eliminate stigmati-zation among health care workers.

Brazil

Dr Yunes said that mental health was one of hisGovernment’s main priorities. Historically, it hadbeen given a low priority despite the fact thatmental disorders represented a heavy burden onthe quality of life of patients and their families, aswell as on the economy. In Brazil, as in many othercountries, hospital-based care was still predomi-nant, swallowing up most of the financial, technicaland human resources available and limiting accessto treatment.There was a need for strategies toenhance primary and community-based care.

A reform had been launched in the early 1990saiming to decentralize the mental health care sys-tem and to redistribute resources from hospitals tocommunity-based services; to disseminate infor-mation on the effectiveness of new models oftreatment on patient rights and on the importanceof combating stigma and discrimination; and todesign and implement broad-based programmesfor the social reintegration of long-term patients.The obstacles to the implementation of communi-ty-based mental health services in Brazil were the

lack of trained health professionals, including gen-eral practitioners who could act as psychiatrists inremote areas, and the insufficient availability ofdrugs. His Government had introduced a pro-gramme to finance basic kits of psychiatric drugsfor distribution, free of charge, at outpatient clin-ics, but since outpatient services were still insuffi-cient the drugs were not yet reaching all thosewho needed them.

It had also addressed stigmatization and humanrights problems by conducting regular inspectionsof psychiatric hospitals. Legislation had beenadopted to protect the rights of mental patientsand to promote their social integration, and servic-es had been introduced to support women living inviolent domestic environments.

Brunei Darussalam

Mr Matnor noted that WHO had not paid mentalhealth the same attention as it had to other issues,and therefore needed to organize activities to pro-mote awareness. In many countries, developmentsin the approach to mental health were guided bythe outcome of discussions on the issue at interna-tional and regional forums. In his country, closedmental clinics within hospitals had been replaced in1982 by a single specialist hospital providing out-patient care and counselling, and steps had beentaken to decentralize primary health care so that itcould be provided at community level. Brunei wasable to provide free medical care and drugsbecause of its small population and land area.

One of the country’s approaches to the problem ofstigmatization of mental illness had been to changecertain names. For example, the term “ward 5”commonly associated with mental problems, andhence “bad” people, had been replaced by “psychi-atric ward”, and the new hospital had comfortablerooms instead of the cages and bars formerly usedto hold mentally ill patients.The Lunatic Law hadbeen renamed the Psychiatric Act.The word “men-tal” was no longer used; the terms “stress” or “lightdepression” were more acceptable to young peopleand made them more willing to come forward fortreatment. Because those identified as having men-tal problems often lost their jobs, the Governmentprovided allowances to encourage them to undergotreatment. Brunei’s main problem was how to


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encourage the formation of a nongovernmentalorganization to care for the mentally ill.The stigmaattached to mental disease was apparently still toohigh for that to come about.

Burkina Faso

Mr Tapsoba described the evolution of mentalhealth care in his country, which included decen-tralizing the health system and incorporating men-tal health care into the responsibilities of districtlevel structures. Lack of coordination had resultedin a lack of adequate supervision, insufficient epi-demiological data, lack of enough properly trainedstaff, insufficient financial and material resourcesfor mental health services, and inequitable accessto medicines owing to the slow introduction ofcheaper generic psychotropic drugs. A nationalmental health programme had been formulated tomeet the main areas of concern and would beimplemented, despite financing problems, as partof the national development plan which extendedto 2010.

In regard to gender issues, he drew attention to aparticular problem in Burkina Faso, that of a cate-gory of woman known as the “devourer of souls”.These women, because they lived alone, were wid-ows or had no resources, were often driven out oftheir villages although healthy in mind and bodybecause they were alleged to be the cause of mys-terious deaths. Eventually they either committedsuicide, disappeared into the bush or suffered men-tal health problems. Only women – never men –were so accused.The public authorities and reli-gious associations were aware of the problem butdid not have enough resources to provide adequatesupport. He appealed for help from WHO.

Canada

Mr Rock, welcoming the exchange of views oncommon problems, said that his country’s experi-ence was similar to that described by previousspeakers.The Canadian Government had recog-nized the importance of integrating mental healthinto primary health care systems and had recentlyfunded a pilot project to make mental health serv-ices available within the community. As almost20% of primary health care patients presented

with mental health problems, it had been consid-ered important to ensure that the training of healthprofessionals included the identification, recogni-tion and treatment of such problems.The impor-tance of early intervention in children to preventmore complex difficulties later on could not beoveremphasized. Disease prevention was given highpriority in Canada, and the development of anational approach towards early childhood devel-opment was encouraged.Thus, a “children’s agen-da” had been created, covering prenatal nutritionfor young mothers, programmes focusing on thecrucial years of brain development between birthand the age of three years, early identification ofsigns of emotional maladjustment, and emphasis onthe prevention of foetal alcohol syndrome anddefects that limited personal development and ledto social cost and disruption in later life.

Many of Canada’s communities, especially those ofindigenous peoples, were rural and remote andexperienced harsh winter weather. Increasing andsuccessful use had been made there of moderninformation and communication techniques, suchas telemedicine, teleradiology and telepsychiatry.Rather than being a barrier to the personal rela-tionship between therapist and patient, the tele-vised connection appeared to facilitate full partici-pation in the consultation.

A new approach to the organization, coordinationand financing of health research, including mentalhealth, had been adopted with the creation of vir-tual mental health research institutes consisting ofnetworks of researchers. One such institute wasdevoted to mental health and involved researchersin clinical and biomedical fields, the provision ofservices, and population health and health determi-nants. By bringing those four perspectives togetherand substantially increasing the level of financing,Canada’s research enterprise was more effectiveand better use was made of its research funds.Investment in mental health was being increased toreflect more appropriately the importance attachedto that area in the health system. Canada would behosting the World Assembly for Mental Health inJuly 2001, bringing together people from aroundthe world with valuable perspectives and insightsinto the ways in which national health systemscould better organize, coordinate and deliver serv-ices for mental health, and he encouraged theinvolvement of all Ministers present.


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Chad

Mrs Kimto recalled that her country had sufferedmany years of civil war. Added to that was a diffi-cult economic situation and the fact that healthcoverage reached only 11% of the population.Theneed for mental health care was enormous, forinstance, for children, people with HIV/AIDS, warwidows, alcoholics, prisoners and refugees.Furthermore, mental disorders were traditionallyconsidered as deriving from evil spirits or curses.At the time of independence in 1970 the countryhad one asylum in the capital, where patients wereshut away and made the objects of curiosity andmockery.The building had been destroyed in thecivil war. Currently the psychiatric unit of themain national hospital acted as a referral centreand provided an open service with care and treat-ment.The Government accorded mental health atop priority.The national programme of mentalhealth had organized a consensus workshop in1999 which had helped to identify the current situ-ation, priority areas, strategies, interventions,funding and the main actors.To achieve socialmobilization in favour of mental health issues, theMinistry of Public Health had involved traditionaland religious authorities in the programme.Thenumber of associations concerned with mentalhealth had grown and were linked in a network.Every year a mental health day was celebrated on10 October in order to mobilize public opinionand to raise awareness of the need to prioritizemental health, particularly as Chad was in a post-war situation.WHO’s World Health Day offered agood opportunity to undertake additional activi-ties, for instance in communities and schools,including the use of mass media. A community,multidisciplinary approach was considered to bethe most logical.Within the ministry an intersec-toral, interministerial committee for mental healthhad been created, charged with the task of creatinga coordinated mental health programme coveringcare, social reinsertion, awareness and informa-tion, and advocacy at the highest levels.The majorrole of traditional medicine in Chad justified coop-eration with relevant structures and bodies.

Legislation enacted on mental health had beeneffective, but practical difficulties remained.Qualified staff, psychotropic drugs, infrastructureand funds were all lacking.The Government aimed

to strengthen the national programmes for thepromotion of mental health, to formulate a nation-al plan for the distribution of drugs and to createreferral centres. A new centre was being built inN’Djamena.The Government was also integratingmental health into the health activities of districthealth authorities.

Chile

Dr López stressed that close alliances between allthose involved in treating and caring for peoplewith mental illness, including their families, wereneeded in order to raise the profile of mentalhealth and attract more resources. For the past 10years, Chile had therefore been promoting theestablishment of such groups at national andregional levels.The initiative had been accompa-nied by efforts to raise general awareness of thepublic health implications of mental health disor-ders and to improve the ability of local health serv-ices to respond to the problem. Chile had benefit-ed from access to national and international epi-demiological research studies that had enabled thescientific community and health professionals todevelop better treatment and prevention strate-gies. As a result of its greater visibility, mentalhealth was now regarded as an important compo-nent in Chile’s health reform programme.

The public sector had an important role to play inensuring that psychiatric treatment was made avail-able at the primary health care level to people withfew resources. Indeed, the population should haveaccess to the specialized services they requiredregardless of their ability to pay.

In addition to the type of mental health disordersprevalent in developing countries, Chile also hadto contend with those associated with more devel-oped countries, such as schizophrenia and bipolardisorders.Treating them was proving to be a con-siderable challenge and had led to the establish-ment of outpatient clinics and specialist units ingeneral hospitals.

Depression was a major cause for concern, partic-ularly among women. A programme designed todetect and treat depression was being developed atthe primary health care level and 40% of generalmedical practices currently provided access to apsychologist. In addition, the new generation of


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safer antidepressants was being made more widelyavailable. Alcohol and drug dependence constitutedanother serious mental health problem which Chilewas confronting through the development of a sys-tem to provide treatment to those in need withsupport from non-profit organizations. Othermajor areas of concern, about which more infor-mation was urgently required, included the mentalhealth of schoolchildren and indigenous people,and work-related mental health problems.

In 2000, Chile had launched a national mentalhealth plan, and additional resources had beenmade available that would increase the proportionof the total health budget allocated to mentalhealth by between 1% and 1.4% in the first year.

China

Dr Peng Yu described how the transition to a mar-ket economy in China had been accompanied by anupsurge in mental health problems; for instance,mental disorders were the single most importantfactor in university student drop-out rates.Whilerecognizing the need to adapt its policies and activ-ities to reflect the new health situation, theGovernment had insufficient numbers of healthprofessionals with adequate training in the diagno-sis and treatment of mental disease. AlthoughChina had sufficient supplies of domestic andimported psychotropic medicines, limited funds inremote areas restricted the access of farmers andagricultural workers to the drugs they needed.TheGovernment was focusing its efforts on providingbasic and community-based training, delivered, inthe case of remote areas, through the use oftelecommunications.

In the 1990s, China had launched a programmeaimed at assuring the rehabilitation of some 200million persons and providing training in mentalhealth for primary health care physicians. Its cur-rent goal was to reach as many as 400 million peo-ple nationwide, drawing on the help of WHO,among others, in order to launch pilot projects andhonour its commitment to promoting mentalhealth.

Croatia

Dr Gilic recalled that, more than 50 years previous-ly, his countryman Dr Andrija Tampar, one of thefounders of WHO, had proposed the inclusion ofmental health among other components in the def-inition of health for the WHO Constitution.

Socioeconomic conditions were a prerequisite formental health and welfare, as the example ofCroatia illustrated. One in six of Croatia’s popula-tion had been displaced during the recent war.Wardamage had also had a dramatic effect upon pro-ductivity and unemployment, and had causedpoverty and related mental health disorders.Although the new Government was addressing theongoing effects of the war, in 1999, three out ofevery five cases of illness were associated withmental disorders, such as schizophrenia, alco-holism, and reaction to stress.The Croatian healthauthorities were giving effect to WHO recommen-dations such as the transfer of patients sufferingmental disorders from hospitals to primary healthcare, the focus on community-based mental healthcare, emphasis upon training of mental health careworkers, and seeking to prevent stigmatization anddiscrimination against mental health patients, so asto enable them to participate to the fullest possibleextent in the life of the community.

In conclusion, with improving social and economicconditions in Croatia, a reduction in mental disor-ders was to be expected in the near future.

Cuba

Dr Dotres Martínez stressed the importance ofproviding adequate care to all patients with mentaldisorders and of considering mental health fromthe point of view of both health services and suchsocial factors as poverty, inequity, violence andother risk factors.

In Cuba, where health care was universally provid-ed free of charge, priority was given to mentalhealth.The trends since 1995 had been towardscommunity-based care mediated through trainingand education of families to enable them to livewith sufferers.Thus, 137 municipalities had estab-lished community mental health centres.Work wasunder way to restructure psychiatric hospitals and


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redefine their mission and functions both from theviewpoint of increasing primary health care cover-age and of focusing attention on mental health.

Improvements had been made in information sys-tems and in the identification of indicators to eval-uate the impact of mental health measures.Theidentification of risk factors played a fundamentalrole in community-based care of patients withmental disorders and should be addressed as partof a preventive strategy that included family mem-bers and the community. In Cuba, the shift towardsmental health had been carried out by trainingdoctors, nurses and specialists at all levels.Thecountry had a large number of psychiatrists provid-ing care to adults and children, while mental healthconcepts had been incorporated into training ofprimary health care physicians and family healthspecialists.

The participation of communities and of communi-ty organizations in providing services and rehabili-tation to patients was vital for the management ofrisk factors, and ensuring that the goals set couldbe achieved in a sustainable manner.

Legislation was important: public health law, thefamily code and even the criminal code shouldinclude provisions to protect psychiatric patientsand all disabled persons.Those persons should beguaranteed social benefits, opportunities to partici-pate in society and to gain access to employmentand education, and thus to avail themselves of anintegrated system of care. In that regard, one ofCuba’s greatest difficulties was that the economicembargo imposed on it by the United States ofAmerica restricted access by patients to the psy-chotropic drugs they needed. In spite of the diffi-culties, Cuba remained committed to communityparticipation and health education as the bestmeans of reducing the incidence of mental disor-ders.

Cyprus

Mr Savvides said that since the 1980s Cyprus hadshifted the emphasis of its national policy awayfrom outmoded mental asylums, characterized bystigmatization of the disease and violation ofpatients’ human rights, to community-based serv-ices and the integration of mental health care intoprimary health care. Most patients were now

released into half-way houses or hostels and totheir families, and only the oldest and most institu-tionalized of patients remained in the old-styleinstitutions.

Among the measures introduced in the context ofcare in the community were the retraining of psy-chiatric nurses and establishment of communitypsychiatric services; the deployment of multidisci-plinary teams at the community level; and collabo-ration with nongovernmental organizations andlocal authorities in setting up various centres, clin-ics, and types of accommodation. Although muchhad been achieved, significant problems remained,including a shortage of trained personnel, poorcoordination with social services, inadequate cov-erage in rural areas, inadequate training of primaryhealth care workers and poor information andcommunication systems.

Among the most important actions taken byCyprus to counter stigmatization and human rightsviolations was the enactment of a law in 1997 forthe provision of psychiatric treatment, whichincorporated the 10 principles recommended byWHO.The media had been enlisted to draw atten-tion to mental health issues, making patients morevisible, emphasizing the availability of successfultreatment and providing information and educationto professionals and the public at large.The factthat World Health Day 2001 had been devoted tomental health had offered an opportunity to inten-sify efforts in that domain.

Since knowledge of the extent of mental illnessand neurological problems in Cyprus was poor, anepidemiological study would be conducted in 2002and the results would be used to direct policy.Future measures would include more training ofprofessionals, greater multisectoral cooperation,public education, research and the removal of allbarriers that prevented the full reintegration ofpatients into society.

Czech Republic

Professor Fise welcomed the round-table discus-sion, particularly since psychological and psychi-atric disorders were increasing in importance in hiscountry.The highest prevalence rates were for neu-rotic disorders, affective disorders and schizophre-nia.The number of suicides of men in the Czech


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Republic was also increasing, while the suicide rateof women was decreasing. Although higher thanthe average in the European Union, the suicide rateof 15.5 per 100 000 population in his country wassignificantly lower than, for example, the countriesof the former Soviet Union.

One of the most serious problems faced by hiscountry in the field of mental health was the short-age of specialists in psychiatry; more were beingtrained in psychiatry, psychology and psychothera-py, although problems persisted in financing thattraining, and that of general practitioners and nurs-es in modern aspects of psychology and psy-chotherapy. Psychiatric patients were traditionallylocated in specialized institutions, which were veryfrequently isolated and oriented towards the long-term, and sometimes lifelong hospitalization ofpatients, thus underlining the segregation of thementally ill and contributing to discriminationagainst both the discipline of psychiatry and againstthe patients themselves. In recent years, the num-ber of places in institutions for the mentally ill hadbeen increased by one-third. It was planned toorganize psychiatry departments as sections oflarge hospitals, with modern equipment, designedfor short stays with intensive diagnostics and treat-ment, to be followed by outpatient care. It wouldalso be necessary to organize a system of care forchronic alcoholics and persons affected by otherkinds of addiction. However, the necessary meas-ures would require substantial funding.

Finally, he welcomed the possibility of cooperating,through his country’s Research Institute ofPsychiatry and the Society of Psychiatry, withWHO and its office for Europe in the field ofmental health.

Democratic Republic of the Congo

Professor Mashako Mamba said that mentalhealth problems in his country had been neglectedbecause of the prevalence of major factors affectingphysical health, notably infectious and parasitic dis-eases. Such neglect also stemmed from the Africanbelief that more emphasis should be given to con-crete than to abstract health problems.The warthat his country was experiencing, which had dis-placed and killed many people and split up fami-

lies, had resulted in various kinds of depression andstress caused by psychological trauma. Anothermajor problem was the abuse of psychoactive sub-stances, particularly cannabis.

Faced with a lack of mental health institutions andspecialized human resources, his Government haddecided to integrate mental health into primaryhealth care, although such integration raised theproblem of adequate training.The community-based health care system reduced the risk ofpatient rejection or stigmatization, but treatmentoften required the prescription of psychotropicdrugs, whose high cost placed them beyond thereach of most patients. In that respect, he appealedfor a North-South partnership so that his country’srequirements for such drugs could be met.

Denmark

Mr Rolighed said that, in his country, all personshad free and equitable access to the health systemirrespective of sex, age, social status and the prob-lem from which they suffered. It was important toensure that mentally ill patients were given appro-priate treatment, and to that end the Danish med-ical authorities worked closely with research, edu-cation and quality assurance programmes.

Dominican Republic

Mrs Caba described how the traditional barriers toimproving mental health in her country, such asattitudes of health workers and managers towardspeople with mental disorders, remainedunchanged.The formulation of mental health serv-ices was thus restricted, particularly in generalhospitals. Integration of mental health into primaryhealth care needed money and time, the high costof drugs forming part of the problem. As part ofhealth sector reform, the Government was work-ing on a subsystem of mental health care withcommunity and nongovernmental organizations inorder to strengthen the provision of services at dif-ferent levels.

The theme of World Health Day 2001 had provid-ed a unique opportunity to enlist allies in theprocess of improving mental health care. A cam-paign had been launched to strengthen the humanrights of people with mental disorders, and to try


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to improve the way they were treated. Its targetsincluded people in the business sector and theworkplace, where issues such as alcohol abuse andstress needed to be addressed. In addition hercountry was working to improve its present inade-quate system of monitoring and record-keeping.Coverage of primary mental health care needed tobe improved, too. Although for some 22 yearsthere had been good results with community-basedmental health care, the network was concentratedin the capital. Crisis care centres were urgentlyneeded in hospitals, but that development had beenthwarted by the resistance of health care person-nel, often hospital administrators.The lack of a cri-sis intervention unit for children and young peoplepresented a serious gap in the system.Rehabilitation and social reinsertion programmeswere also needed.

With regard to gender issues, progress had beenmade through work with nongovernmental organi-zations, other ministries such as those for women’saffairs, the judiciary, and in particular the police.Campaigns had been run on prevention of anddealing with violence in the family, and “solidaritynetworks” for women had been establishedthroughout the capital and in some other cities.The Government was trying to re-educate healthpersonnel to have a more positive attitude to men-tal health care. In the education sector, consider-able support in the early detection of the effects ofdomestic violence came from teachers.The currentfocus was on violence against women, children andyoung people, together with ensuring routinescreening for risk factors of domestic violence.Refuges for the victims of such violence wereplanned.

Ecuador

Dr Jandriska drew attention to four issues associ-ated with mental health problems in his country:the fact that Ecuador was located in a high-risk dis-aster area; the number of persons displaced as aresult of the “Plan Colombia” strategy; the highlevels of migration away from families in order tofind work; and the level of political instability. Itwas important to analyse mental health in relationto society.To that end, his Ministry had set up aseries of mobile units in poor areas from whichwage earners were often forced to migrate and a

psychologist had been attached to each unit toanalyse the resulting community problems.

Since 1994, there had been greater awareness ofmental health in Ecuador, and it was hoped that thedraft legislation developed in that regard wouldenter into force as soon as possible. Ecuador faceda wide range of mental health disorders withprevalence of alcohol misuse particularly high inyoung people. A multifaceted approach was neededto ascertain the causes of substance misuse and vio-lence, in particular violence directed at women.Ecuador and a neighbouring country planned todevelop joint legislation on psychotropic sub-stances.

Affirming the need to pay attention to indigenouspopulations, he said that his Government was tak-ing steps to provide those in Ecuador with healthcare services of good quality based on local needs.

Egypt

Professor Sallam emphasized the importance ofdifferentiating between mental health and addic-tion and between mental illness in children andcriminals. Prevention of mental illness and rehabil-itation were not high priorities in developing coun-tries. Egypt had undertaken a major reform in thatregard, and a Presidential Decree had been issuedto the effect that, while psychiatric hospitals werestill needed, the system should be reformed. Manyspeakers had advocated incorporating mentalhealth care into primary health care; could WHOestablish an agenda for that, according to the dif-ferent countries’ needs?

There was an urgent need in developing countriesto act promptly against early addiction.Waysshould be sought of “immunizing” children againstaddiction with a service set up for people at highrisk and for first-time users. Countries like hiswould greatly benefit from assistance from interna-tional donors for prevention of addiction and reha-bilitation.Therapeutic measures such as music andagriculture could be helpful in transforming psy-chiatric hospitals into rehabilitation centres.Similar treatments could be applied to violentbehaviours.That problem, linked to psychologicaldepression, was affecting the entire world. Hewould welcome the introduction of a social com-ponent into mental health strategies. As things


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stood, sufferers were often ignored by their rela-tives and friends; a change in attitude was the firststep towards improvement.

Fiji

Mr Nacuva noted the need to consider mentalhealth problems in the specific context of each par-ticular country, taking into account changes such asthe moves from colonial status to independenceand from traditional societies to cash economies. InFiji, the health budget was small and it was difficultto find the funds for mental health services.However, the sense of responsibility for caring forothers was strong and it had therefore been possi-ble to build on community involvement.TheMinistry of Health had opted for a multisectoralapproach involving all aspects of civil society in thepromotion of mental health and the prevention ofmental disorders. Fiji had one specialized psychi-atric hospital.The emphasis on community-basedservices and vigorous clinical management had ledto a dramatic decrease in the bed occupancy rateand length of stay despite an increase in the num-ber of new cases. Relevant legislation was alsobeing reviewed. It was vital to change social atti-tudes to mental health care and Fiji was addressingthe problem in its own particular context and inspite of budgetary constraints.

Finland

Dr Eskola noted that WHO had been active in themental health area since the 1970s. Although men-tal health had received a lower priority in the1980s, it was a cause for satisfaction that greateremphasis was now being placed on it. As theFinnish approach to mental health was very similarto that described for Sweden, he focused on thereduction of the specific problems of suicide anddepression in his country, areas in which consider-able success had been achieved.

The rates of suicide in Finland had increased rapid-ly from the 1950s through the 1980s, rising from26.5 to 41 per 100 000 for men, with a figuredouble that for women. A 10-year, nationwide sui-cide prevention strategy had been launched in the1980s and had achieved a reduction of suicide ratesof nearly 20% in relation to the peak period. An

evaluation of the project had shown that thestigmatization of mental health disorders had beengreatly reduced and on that basis a programme toaddress the problem of depression had beenlaunched.

During its presidency of the European Union twoyears previously, Finland had identified mentalhealth as the number one health problem. Fromthat experience, his Government had concludedthat clear changes were needed in mental healthpolicies. First, mental health should be brought outof its political isolation into the broader sphere ofpublic health. Second, instead of concentrating onmental health at the individual level, there was aneed to strengthen the approach to mental healthfor the population as a whole, in particular as ameans of promoting the integration of mentalhealth into public health policies, strategies, andprogrammes.Third, emphasis must be shifted fromthe negative concept of mental disorders to a morepositive mental health model.The key importanceof mental health was encapsulated in Finland’s slo-gan: “There is no health without mental health.”

France

Dr Kouchner said that mental health was a conceptwith wider social ramifications than traditionalpsychiatry. Although the drugs developed over thepast 20-30 years had allowed some progress in thetreatment of mental disorders, they had also cam-ouflaged the difficulties. People with mental healthproblems were always stigmatized. Furthermore,psychiatrists, psychologists and social workers didnot agree on their practices or general objectives.The general medical community and psychiatristsdisagreed about the extent of the mental healthsector.Was social work a marginal component ofthe sector or was it fully integrated? Psychiatristswere unwilling to become involved in what theyconsidered to be social problems, such as depres-sion and suicides among young people.There waspoor follow-up on the part of hospital emergencyservices and society in general of young peoplewho attempted suicide. It was known that one intwo succeeded on a second attempt and that half ofthose who had committed suicide had consulted ageneral practitioner the week previously. Generalpractitioners did not have the training to deal withsuch problems.


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There was insufficient communication betweenpsychiatrists and social workers in developed coun-tries. In France, the problem of drug addiction hadinitially been viewed as a psychiatric illness,whereas it was now considered a social problem. Itappeared that 30% of prisoners suffered frommental illness, and 20% had been imprisoned forthat reason.Was their mental health dealt withadequately? Were domestic violence and alcoholabuse psychiatric problems? Those problemsremained unsolved because of a lack of under-standing between social workers, general practi-tioners and psychiatrists.

Efforts had been made to close down psychiatrichospitals and provide care in small communitystructures in general hospitals, close to thepatients’ families and to patients’ associations.However, some psychiatrists complained that theywere swamped by social problems and that closureof the large psychiatric hospitals meant that nobeds were available for patients with severe psychi-atric conditions such as schizophrenia or manicdepression.

Georgia

Dr Gamkrelidze said that the significant social,political and economic changes that had occurredin Georgia at the beginning of the 1990s had had anegative effect on the country’s medical care sys-tem and particularly on psychiatric care. Owing tomajor shortages of psychotropic medicines and adrastic deterioration of the conditions in hospitals,patients had left, and the mortality rate in theinstitutions had increased. In March 1995, theGeorgian Parliament had passed a law on psychi-atric care which had become the legal basis for theState programme. Hospital and outpatient care wasprovided by a network of hospitals, regional clin-ics, psycho-neurological clinics and consultingunits.The State covered the treatment costs ofabout 30 000 patients registered as suffering fromschizophrenia, affective disorders, organic andsymptomatic psychoses, post-traumatic psychosesand other psychiatric disorders. However, morethan 70 000 patients registered in psychiatric insti-tutions outside the public programme requiredprofessional psychiatric care.The budget of theprogramme was greatly in deficit. In order to func-

tion optimally, it would require US$ 4.5 million,whereas the actual allocation was about US$ 1.5million.

Nevertheless, the Government had managed toextend its programme. Regional psychiatric clinicshad been opened, and a programme of psychoso-cial rehabilitation for children and young peoplehad begun functioning in 2000. A service forurgent psychiatric care was planned for 2002. In2000, a national health policy had been developedin the Ministry of Health, in cooperation with theEuropean Regional Office of WHO and theGeorgian Society of Psychiatrists, with a strategicplan for implementation during the comingdecade.The main strategic goals for developmentand reform of the psychiatric care system were:

■ extension of the public programme of psychiatriccare and a gradual increase in free medical care;

■ creation of a system of social rehabilitation andsocial assistance to patients with mental disor-ders;

■ creation of a system of psychiatric care for chil-dren and young people;

■ a reduction of the suicide rate in the generalpopulation; and

■ reduction of the incidence of psychiatric diseasesdue to social stress.

The plan envisaged the creation of five centres forthe psychosocial rehabilitation of patients by theyear 2009, in addition to the centre functioning inthe capital; nine psychosocial assistance units hadbeen opened in various regions of the country.Theprolonged economic crisis did not permit full, reg-ular financing of the state mental health care pro-gramme and made it difficult to ensure optimalfunctioning of the system of psychiatric care in hiscountry.

Ghana

Dr Anane welcomed the choice of mental health asthe theme for World Health Day 2001. In Ghanamental ill-health was typically regarded as aggres-sive or strange behaviour; general society did notconsider the milder but distressing forms such asdepression and anxiety as mental disorders. Mentalhealth programmes had begun in 1888, with theenactment of the Lunatic Asylum Ordinance.That


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Act had been improved in 1972 with a mentalhealth decree, followed by upgrading of facilities,strengthening of personnel and an expansion ofinstitutional care, with a decentralization policyleading to the setting up of mental health units ingeneral hospitals. However, progress in that areahad slowed sharply with the economic decline inrecent years. Owing to financial constraints, insti-tutions were not giving the required attention tothe subject, professional development programmeswere constrained and many trained staff werelured abroad to better paid jobs – the proportionhad reached 30% of mental health care providers,nurses in particular, in the previous year.Currently, the country had one psychiatrist for 1.5million population. Low pay and the stigmatizationassociated with mental illness did not encouragerecruitment. Although the Ministry of Health hadimplemented a motivational programme for allhealth professionals, that step had been limited byfinancial constraints and offset by the increasingincidence of mental illness, especially depression,which might underlie the fatalism engendered byspreading poverty. Ghana therefore supported theview that coordinated global efforts to mitigate theravages of poverty would be a major step to count-er mental illness.

Ghana had set its priorities.The Government’smental health policies stressed decentralization ofmental health services, not only through the estab-lishment of units in tertiary and regional hospitalsbut also through the integration of mental healthinto primary health care. Also, even with the cur-rent meager resources, model programmes fortraining of both medical and non-medical staff inprevention, identification and treatment of mentaldisorders had been drawn up. Major focuses wereattitudinal change, particularly for senior healthworkers and policy-makers, and the need to ensurethat all health professionals were knowledgeableabout mental health. Finally, the focus should be ona biophysical model for mental health care, whichrecognized the biological, psychological and socialroots of mental disorders. A purely medicalapproach would be bound to fail; a sector-wideapproach including communities was needed foreffective care. Prevention must be seen to be asimportant for mental health as for general health.Effective communication, including parentingskills, crisis management and the use of non-pro-

fessionals in the community would be vital for pre-vention of mental health problems. Since 1978Ghana had had a three-monthly training pro-gramme for community psychiatric nurses, whowere subsequently placed in all districts.

He noted that gender issues might often be seen asmental health problems. Societal attitudes aboutexpected gender roles, including the childbearingrole of women, often caused intense stress: femaleinfertility was an instance. As in other countries,more women reported depression than men.

In order to achieve success, mental health workerswere needed to take the lead, but they were inshort supply. He urged support for disadvantagedcountries in training and retaining personnel.

Greece

Professor Spyraki said that the mental health sys-tem in Greece had significantly changed in thepast two decades, including the introduction of amodernizing legislative framework.With assis-tance from WHO and with financial support fromthe European Union, Greece had reformed itssystem of mental health care, thereby graduallybringing about significant qualitative and quanti-tative changes. Legislation passed in 1999 hadgiven priority to primary care, outpatient care,de-institutionalization, pyschosocial rehabilita-tion, community care and the provision of infor-mation to the community; mental health serviceswere to be decentralized and divided into sectors;social enterprises were being set up for personswith mental health disorders, and a committeehad been established for the protection of theirrights.

Within the framework of psychiatric reform, anaction programme to develop mental health servic-es throughout the country had been launched in1997, which was reviewed and updated every fiveyears.The recent creation of a large number ofpermanent government posts related to the pro-gramme, at a time of relative economic austerity,had been a measure of the priority assigned to themental health care system by the Government. Inthe current year, a committee of persons workingin the media had been set up for the purpose ofincreasing awareness of mental health issuesthrough television, radio and other means.


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Greece

Professor Spyraki said that fighting stigmatizationwas important not only to overcome mental illnessbut also to improve society. In response to theChairman’s first question, about the measures putin place to fight stigma, he said that Greece hadoffered services for the mentally ill in psychiatricunits in general hospitals and mental health cen-tres; that had changed perceptions for both thepatient and the relatives. Secondly, campaigns wereimportant to teach children tolerance at an earlyage. Children had to realize that while mental ill-ness had biological and genetic determinants,social disparities were also crucial factors.Everyone should ask themselves to what extentthey were responsible for the mental illness of oth-ers and what they could do to help.

Grenada

Dr Modeste-Curwen said that her country hadtried to fight stigmatization by shifting the empha-sis from institutionalization of patients to the startof treatment in the community. However, becausemany of the mentally ill had never had a job orwere unable to hold one, they returned to theinstitution shortly after being sent out to the com-munity. Grenada had therefore started on a policyof industrial therapy to develop or teach skills,essentially in agriculture. She had recently touredan agricultural area in the presence of media repre-sentatives so that they would show mental healthpatients as productive rather than nonproductiveor destructive persons. A multisectoral organiza-tion (involving health sector representatives andthe community) was helping those with mentaldisorders by organizing activities such as sportsmeetings in which healthy members of the com-munity participated alongside the patients.Recently, a long-term institutionalized patient hadbeen helped to launch a book of poetry.The mediahad been extremely supportive throughout in pro-moting understanding of the productivity of thementally ill.

Guinea

Dr Saliou Diallo said that his country had earlierintroduced a mental health policy and programmewith a strategy of decentralizing all the healthstructures that would facilitate referrals.Thatmeant the integration of mental health into thebasic minimum package of health activities, partic-ularly in primary health care.That requiredchanges in attitude and culture with regard tomental disorders by decision-makers, health carepersonnel and the general population, with promo-tion of healthy lifestyles. Unfortunately manyobstacles were being met, such as the great gapbetween supply and demand, the paucity of trainedstaff, the high cost of drugs, the civil disturbancesin Liberia and Sierra Leone with the resultinginflux of refugees and incursion of rebels, all ontop of poverty and exclusion.With a calming oftensions and the implementation of decentraliza-tion, Guinea looked forward to an improved situa-tion.

Honduras

Dr Castellanos said that the prevalence of hurri-canes on the Caribbean and Atlantic coasts and thePacific Rim Fault, which gave rise to frequentearthquakes, were special factors affecting mentalhealth in his country.They precipitated both eco-nomic difficulties for the country and mental dis-orders among the people.The most frequentlydiagnosed problems in Honduras included violence(30%), depressive illnesses (27%), epilepsy (11%),psychological disorders (6%), and behaviouralproblems beginning in childhood (5%). In 1975,the Ministry of Health had established a mentalhealth department to deal specifically with suchproblems. Intensive work throughout the countryhad formed the basis for the mental health pro-gramme.

In 1998 Hurricane Mitch had killed three thousandpeople and wreaked extensive infrastructural andagricultural damage with lingering effects on thepopulation. Following a detailed analysis of thegeneral health situation, a poverty-reduction strat-egy had been devised that included a major pri-mary mental health care component.Workingdirectly with the victims of Hurricane Mitch, spe-


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cific attempts had been made to enhance commu-nity participation through decentralization. Astrong response had been received from both thepeople of Honduras and from such organizations asPAHO,WHO, and other friendly institutions andgovernments which had provided support.Currently under development was a strategy onmental health in disaster situations.

Gender issues figured largely in the efforts beingmade to bring about change in the country. Manywomen had been participating, particularly youngsingle mothers from rural areas who were suffer-ing mental disorders. In that connection, much hadbeen done to enact laws against family violenceand a special national institute for women’s issueshad been established.The Ministry of Health haddevised a national sexual and reproductive healthprogramme, and work was proceeding on a speciallaw on HIV/AIDS. Destructive as it had been,Hurricane Mitch had strengthened the unity of thepeople of Honduras and had provided an incentiveto confront mental health problems.

Hungary

Mr Pulay said that awareness-raising campaignshad targeted various groups, the first being deci-sion-makers, including the Minister of Health.With a view to a better allocation of resources, itwas important to convince ministers of finance ofthe significance of mental health problems. Forexample, in Hungary, it had been decided that newantidepressant drugs should be made available ataffordable prices, since the chronically mentally illwere among the poorest members of society.Hence national insurance now covered 90% of thecosts for such drugs. A second target group con-sisted of the patients themselves. Although theywere insured, lack of objective information andfear of stigmatization prevented them from comingforward for treatment. Other targets had includedprimary health care workers, who were crucial incombating gender discrimination, and detectingviolence and mental illness in the family andschools. As the Director-General had stated in heraddress to the current Health Assembly, it wasessential to act now to create a better future forthe children of the world.

Iceland

Mr Gunnarsson, noting that mental health wasvitally important to the well-being of nations andto human, social and economic status, said that ithad been included as one of seven target areas inIceland’s new health plan. In that connection, thespecific objectives of his Government included thereduction, within the next 10 years, of suicides by25% and of mental disorders by 10%.The actionplanned to attain those objectives included: betterregistration of mental disorders; better training forhealth care personnel; provision of better informa-tion to the public, in particular by enlisting thecooperation of the media; improvement of accessto mental health care; the offering of more treat-ment options; and improvement of coordinationbetween schools and the mental health services.The focus was on children, young people and theelderly, especially those in rural areas. It was hopedthat the health plan would help to reduce thestigmatization of those suffering from mentalhealth disorders and discrimination against themand their families.

Studies had shown that those suffering from mentaldisorders tended to be from the less well-off sec-tors of society and, despite the fact that Icelandhad a strong social welfare infrastructure, stepswere being taken to strengthen the system still fur-ther. Efforts were also being made to reduce gen-der disparity: the longevity of women as comparedto men, together with other factors such as theirgreater exposure to stress, made it necessary todistinguish between the health needs of womenand those of men and to take such factors intoaccount when planning mental health care. In con-clusion, he recalled that most mental illness couldbe treated and that many mental illnesses werepreventable.

India

Dr Thakur said that mental health disorders hadbeen treated in India by yoga since ancient times.India had launched a mental health programme in1982.The integration of mental health in the pub-lic health programme had aroused criticism at first,but was currently recognized as having been cor-rect. Efforts were being made to improve services


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in mental hospitals in order to make them morepatient-friendly.While he agreed with ProfessorLadrigo-Ignacio that problems such as natural dis-asters and wars caused mental disorders, therewere also area-specific problems. For instance,men from Kerala often worked in neighbouringcountries, and their absence led to family prob-lems, even suicide, while in poorer states such asBihar the suicide rate was much lower.

With the development of genomic research, itwould be possible to investigate whether somemental disorders were of genetic origin.The roundtable might identify the need for such a study, asgene therapy could then be used in treatment.

Mental disorders should not be considered as dis-eases but as part of life. It was his day-to-day expe-rience in medical practice that many persons suf-fered from slight depression. Addressing theirmental health would help them to function better.Efforts should be made to combat the stigmaattached to mental deterioration.

Indonesia

Dr Sujudi said that, as a result of legislation passedin 1960, Indonesia had adopted a social approachtowards mental health care offering more open andcomprehensive facilities and services. In 1974,mental health care had been integrated into select-ed district hospitals and health centres. Inadequateresults in the identification and care of patients hadled to the introduction in 1993 of training in thediagnosis and treatment of psychiatric patients forsubstantial numbers of personnel in such hospitalsand health centres. Subsequently, the detection ofmental health disorders among outpatients hadincreased from 0.47% to 2.15%. Communitymental health activities had been promoted on anationwide scale; they would support the develop-ment of relevant policies and strategies forimprovements at provincial and district levels.Much remained to be done, as indicated by theunsafe environmental conditions and unhealthybehaviour which prevailed, but Indonesia was seek-ing to adopt strategies that emphasized welfare-oriented and community-based mental health care,as well as the inpatient services, and promotionand prevention, activities which were important toenhancing the overall development of health.

Iran, Islamic Republic of

Dr Farhadi observed that the problem of theincreasing gap between physical and mental healthservices was particularly acute in developing coun-tries, owing largely to lack of awareness, low polit-ical commitment, an acute shortage of trained pro-fessionals, weak intersectoral collaboration and theabsence of community services. All too often,mental health services were neither affordable noraccessible.The only way forward was to integratemental health services into general and primaryhealth care systems, thus ensuring the provision ofthe most basic level of services for the seriously ill.

Iran had taken that initiative following a pilot proj-ect in 1987, aimed at promoting awareness ofmental health issues and making essential mentalhealth care available to all. Following wide-rangingtraining programmes for medical personnel andcommunity workers and the establishment of alarge number of rural and urban mental healthcentres, mental health care was now available to6% of the rural population and 12% of the urbanpopulation. In addition, innovative programmeshad been developed, such as an urban mentalhealth programme, the integration of a preventiveprogramme for substance abuse disorders, withinthe primary health care system, a school pro-gramme and integration of mental health into the“Healthy Cities” project.

With a view to expanding mental health services in2001 and beyond, Iran’s national mental healthprogramme was being revised, a new mentalhealth act was in preparation, and efforts werebeing made to increase inpatient and outpatientmental health facilities and counselling services.

Iraq

Dr Mubarak recalled that his country was experi-encing a difficult situation in view of the sanctionsimposed and almost daily bombardments. Cases ofmental ill-health had increased, caused by the fearof air raids and the constant trauma of bombingattacks, which particularly affected children,women and the elderly.Those difficulties were wellknown; the lengthy duration of such problems wasanother source of trauma.The current situationmeant that it was very difficult to measure the


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social consequences of mental health problems, asit was impossible to obtain research data. Despitethe signature of a memorandum of understanding,the measures taken under the pretext of protectinghuman rights, and particularly the positions takenby certain representatives on the United NationsSecurity Council Committee established byResolution 661, made it difficult to achieve anyprogress in the health situation in Iraq. Close coop-eration was required with WHO to develop betterapproaches to mental health disorders, particularlythrough hospital treatment.

It was difficult to persuade trained practitioners towork in the field of mental health. HisGovernment did not have the capacity to providethem with scholarships to study abroad, and it wasdifficult to bring in qualified personnel to trainhealth practitioners in Iraq. Measures adopted toencourage newly graduated health professionals towork in the field of mental health included the cre-ation of training programmes and rotation systemsfor new graduates, including incentives for them tospend two years working in mental health.Thesanctions meant that the drugs required to treatmental disorders were classified as non-urgent andwere in very short supply.

Iraq’s situation was having a severe impact on soci-ety, and particularly on women. Frustration wascoming to the surface and confrontations weredeveloping between family members. Childrenexperienced frustration when they saw toys adver-tised to which their access was restricted or pro-hibited, and women, confined to their houses,were experiencing depression.To relieve the situa-tion, legislation had been adopted and other meas-ures devised, including soft loans, to enablewomen to work from home.The Government wascooperating with nongovernmental and otherorganizations in civil society to deal with mentalhealth disorders. Heavy penalties were imposed oninstitutions and enterprises discriminating againstpersons with mental disorders.

The treatment of mental health should be a subjectof close cooperation between countries at regionaland international levels and should not be treatedas a political issue. Although there could not beone standard approach to mental health whichwould fit all countries,WHO should lead in devel-oping action in that field.

Israel

Dr Leventhal said that the future of mental healthlay not in hospitals, but in the community; it wasthe concern of society as a whole, not just of men-tal health professionals.

Israel had taken the opportunity provided by WorldHealth Day 2001 to extend the event to a week ofawareness-raising on mental health. He thankedWHO for providing excellent supporting material.

Mental health affected the whole community sincevirtually everyone experienced some form of men-tal health disorder at some point in their lives,although mostly to a very minor degree.The prob-lems associated with mental ill-health were part ofliving in a modern society. Prevention of thoseproblems and mental health promotion wereimportant at all levels. He regretted the shortageof material available for preventive activities andasked WHO to provide leadership in that field;such material would have the added advantage ofensuring that the public was well informed.

In conclusion, he commended the admission of aformer prime minister of Norway that he too hadsuffered from depression, thus highlighting the factthat such issues affected privileged as well as disad-vantaged members of society.

Israel

Dr Leventhal considered that the present roundtable and the World Health Day campaign werepart of the fight against stigmatization. Societycould only fight stigmatization if the health sectorplayed a leading role.The health sector should bereoriented to incorporate consideration of mentalhealth issues in physical health. It had to set a goodexample. However, the fight against stigmatizationconcerned not just the health system but also theeducation and welfare systems. All should con-tribute to the fight against stigmatization.

In answer to the Chairman’s fourth question, vio-lence had in the past been associated with mentalillness because mental health institutions had oncebeen considered prisons.To avoid that, patientsshould now be given access to health servicesbefore their illness reached the point where theyrequired institutionalization. In Israel’s experience,


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only the courts could strike the balance betweenrespect for human rights and enforced admissionto a mental health institution. Since Israel hadadopted the policy of using the courts, more peo-ple were reflecting on the question. Health profes-sionals were in effect asking society as a whole toshare in taking such decisions, which resulted in abetter balance.

Italy

Dr Oleari said that the Italian experience in thearea of mental health dated from the 1978 law toreform psychiatric services and specifically toeliminate institutionalization. However, institution-alization could continue as a problem, even in theabsence of psychiatric hospitals, just as stigmatiza-tion and marginalization could still occur, unlessthe patient was treated as a full citizen.What wasneeded was a network that included health, socialand community services.

Many problems had been encountered after theadoption of the 1978 law, in particular in connec-tion with specific mental health programmesinvolving the participation of associations of thefamilies of psychiatric patients, which was consid-ered to be essential.Treatment necessarily involvedinpatient mental health centres, care for acutepatients in general hospitals, and residential struc-tures that were conducive to the reintegration ofthe patient into society.

Many national health services had encountered theproblem of how to finance social and health servic-es. Such economic difficulties had not yet beenfully surmounted in Italy also. Mental health fund-ing was not related to expected outcomes, and aneffort was being made to weight the per capitacontributions through which health services werefunded, by taking into account such sex-relatedfactors as neonatal mortality and infant mortality,rather than purely socioeconomic criteria. Muchmore remained to be done along those lines. InItaly, 5% of the health service budget was current-ly allocated to mental health.

All psychiatric hospitals had been closed, and gen-eral hospitals had been given responsibility fortreating acute patients. He considered that theItalian approach was both positive and in line withthe experience of other countries, and expected

future efforts to place emphasis on the rights ofmental health patients as citizens and on the pre-vention of mental health problems.

Japan

Mr Kondo said that the competition inherent in afree-market economy had resulted in rising inci-dences of stress, distress and mental disorders inhis country, underlining the importance of placingmental health high on the agenda. He welcomedthe decision to devote World Health Day 2001 tothat problem.

Until recently, Japan had placed considerableemphasis on the hospitalization of psychiatricpatients.The results were too many long-termpatients, and the raising of several human rightsconcerns. Currently, efforts were being made toensure that patients acquired greater autonomy aspart of their reintegration into society.TheMinistry of Health, Labour and Welfare nowfocused on community-based care, and adequatesupport mechanisms were being set up, includingemployment opportunities for patients with men-tal disorders. Suicide was a significant social prob-lem in Japan, often caused by financial difficulties.Adequate services to improve the social environ-ment should be provided at the regional and work-place levels to prevent such difficulties. It wouldalso be important to conduct research into thecauses of depression.

As in other countries, stigmatization of patientswith mental disorders was a major problem.Measures were being taken to eliminate prejudiceand achieve social integration of sufferers througheducation and information campaigns, such asthose carried out by and through WHO.

Jordan

Dr Kharabseh explained that his country faced twoobstacles to the improvement of mental health careprovision: lack of resources and a shortage of spe-cialized workers in the mental health sector.Thosetwo barriers were the result of war, human rightsviolations and other injustices.


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He emphasized the importance of integrating men-tal health and general health programmes, and ofmaking treatment affordable in order to care forthe poor properly.

Lao People’s DemocraticRepublic

Dr Boupha congratulated WHO for highlightingmental health and bringing that important topic tothe attention of Member States.

Among its strategies for addressing mental health,her country had promoted a series of activitiesusing video productions and school contests withina community-based approach, as part of a deliber-ate strategy to tackle mental health issues.

She stressed that mental health factors relating towomen had generally been overlooked.There weresome 75 million unwanted pregnancies in theworld each year. Unwanted pregnancies could havetragic consequences for the women, their familiesand society as a whole.The issue was one ofempowerment: women should be allowed todecide when and whether they wished to becomepregnant. A great deal of distress and depressioncould thus be avoided. She urged WHO and theauthorities in each country responsible for mentalhealth programmes to take into consideration theproblems related to women’s health.

Lesotho

Mr Mabote said that, historically, mental healthservices in Lesotho had been marginalized, as wasreflected in both legislation and budget allocations,with stigmatization and discrimination rife. Mentalill-health accounted for a significant proportion ofDALYs lost, with the largest proportion of the bur-den due to epilepsy and depression, the latterbeing more common in women than in men.Substance abuse, especially of alcohol, was risingand his country recognized the need for vigilancein that area. For many years, mental health serviceshad failed to pay sufficient attention to emerginggender-related issues and violence.TheGovernment was now giving serious attention togender-sensitive policies and a specific ministrywas dealing with the question. Moreover, an asso-ciation of women lawyers was playing a leading

role in raising private and public awareness of gen-der issues in many areas. Mental health policy wasbeing revised to incorporate contemporary gen-der-related issues, such as the effects of unemploy-ment, and to encourage disclosures concerningviolence and emotional abuse. In addition, publicawareness campaigns, seminars and workshopswere providing a strong foundation for policy for-mulation concerning effective prevention of gen-der-related mental health problems. Preventivemeasures included poverty-reduction strategiesinvolving income-generation projects.Training wasneeded to sensitize health care workers and others,such as the police, to the mental health conse-quences of gender-related violence, and to theneed to provide tactful counselling and support.

Madagascar

Professor Ratsimbazafimahefa observed thatmental health was an integral part of WHO’s defi-nition of health, although it had long been over-looked in the developing countries because of thepriority given to control of communicable dis-eases. At Madagascar’s present stage of epidemio-logical transition, the number of mental disordersand disabilities, the legal battles concerning peoplewith mental problems, the increasing number ofsuicides and of patients who remained hiddenaway, unable to face the difficulties of adapting tolife in society, all served to highlight mental healthas a top priority.

The celebration of World Health Day 2001 had fur-ther widened the country’s understanding of theissue by seeking to redefine mental health and itsimplications for quality of life. It had also under-lined that mental health was a means and an indica-tor of economic, social and cultural developmentso that failings in mental health led to poverty atevery level.Thus her country had attached particu-lar importance to the management of mental ill-ness, which was handled chiefly by the publichealth system. Severe cases could be referred toprovincial psychiatric centres, but otherwise men-tal health was part of primary health care.However, deficiencies both in number and qualityof personnel had led to the appointment of a men-tal health coordinator to review the national men-tal health policy.That policy would include preven-tion and treatment of mental illness with social


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reintegration, and would especially emphasize thedevelopment of human resources with training formental health nurses and psychiatrists. Doctorsworking in primary health care had training guidesto teach them about mental health.The lack ofinternational solidarity on mental health issues wasto be deplored. She asked WHO to seek ways ofdeveloping partnerships to give fresh impetus tothat new world priority.

Malaysia

Mr Chua Jui Meng recounted a visit to a mentalinstitution that had a clock tower with no clock;that had brought to his mind the thought that, onentering the place, there was no time, no realityand, for many inmates, no hope – they had beenmarginalized and stigmatized by society and, worstof all, by their own families. For the whole of theprevious year, the Government had run a healthylifestyle campaign in the mass media on the themeof mental health, including prevention. He echoedthe description by the delegate of Trinidad andTobago of the mass media as allies; every year,Malaysia, had given awards to journalists for thebest writing on HIV/AIDS, as well as to the news-papers they worked for. As poor or unbalancedreporting about mental health issues could sparkfear and discrimination, he proposed that similarawards be given to the journalists and the massmedia which projected a more positive picture ofwhat mental illness meant; that would be a start.

Maldives

Mr Abdullah welcomed WHO’s initiative to placemental health actively on the global agenda.Awareness-raising on behalf of the complex andforgotten issue of mental illness could be just assuccessful as that on behalf of HIV/AIDS.WHOshould vigorously persuade Member States to dedi-cate a significant part of their national health budg-ets to improving treatment and facilities for thementally ill, thereby enabling a large number ofpeople to return as productive contributors to themainstream of society. He called upon his fellowministers to attach greater importance to mentalhealth and to step up their contributions to it.

Maldives

Mr Abdullah said that the biggest stumbling blockin the fight against mental ill-health was the stigmaattached to it. He endorsed the view that informa-tion, education and communication provided a wayforward. He was gravely concerned by the break-down of family values and strongly believed thatspending more time with family and childrenwould help to solve the problems. Research hadproved that time spent with one’s family removedfear and prevented the development of mentalafflictions. People were being killed by the hecticlives they led, which gave rise to social problemsfor their families, including mental illness.Thehealth sector could not tackle the growing prob-lems on its own. An integrated approach wasrequired, involving the education sector, the com-munity and nongovernmental organizations.

Mauritius

Mr Jugnauth, speaking as a lawyer rather than as amedical doctor, asked why it had taken so long forgovernments and international organizations torecognize the issue of mental health.What werethe problems, and the related solutions, in the fieldof mental health? In response to those questions,he said that the key words were: recognition, iden-tification, and treatment. Because those sufferingfrom mental illness often attempted to hide theirproblem, such illness was both denied by theaffected person and unrecognized as a real illnessby their families. Accordingly, those who neededhelp were excluded from treatment.

Barriers to implementation of mental health serv-ices included public attitudes, resulting in a fearamong individuals which prevented them fromcoming forward with their problems. A centrally-based institution in Mauritius had been constructedin a remote area as a high-security hospital for dis-ruptive psychiatric and acute psychiatric patients,with different rules and regulations from thoseapplied to general hospitals.Those admitted to thatinstitution could not receive relatives or closefriends.

The main barrier had been the failure to recognizemental illness, which was essential if the necessarytreatment were to be provided.To achieve such


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goals and overcome such barriers, he suggestedthat countries might follow the example ofMauritius in adopting a mental health act thatclearly identified the fundamental freedoms andbasic rights of those affected by mental illness, andprovided for the protection of minors sufferingfrom mental illness, life in the community andtheir rehabilitation in society. Other provisions ofthe act included the determination of mental ill-ness, medical examination, confidentiality, the roleof the community and culture, standards of careand treatment on a basis of equality with otherpatients, conditions in mental health facilities,resources for those facilities, admission principles,review bodies, procedural safeguards, access toinformation and equal treatment of criminaloffenders.

Decentralization of mental treatment had beenmoving forward but with acute patients remainingin the psychiatric hospital.Wards for psychiatricpatients in the regional hospitals were situated soas not to affect the rest of the patients.

Although Mauritius had eradicated malaria,poliomyelitis and tuberculosis, about 30% of thepopulation still suffered from some kind of mentalillness. Decentralization had been essential to reachthose people and to make mental health servicesmore available; to assure cost-effectiveness of serv-ices; to promote greater awareness in the commu-nity; and to suppress stigmatization of mental andpsychiatric problems.

The main problems were societal, but there werealso financial constraints, particularly in Africanand other developing countries, which made it dif-ficult to decentralize. Another problem involvedshortages of medical personnel, owing particularlyto the emigration of trained medical personnel.

Mexico

Dr Frenk Mora underlined the double burden ofdisease that was afflicting developing countries.They faced mental health problems linked to back-wardness and poor hygiene, such as epilepsy andmental retardation, as well as new types of mentaldisorder more commonly associated with devel-oped countries, such as depression and psychosis.Moreover, current epidemiological and demo-graphic trends, such as population ageing, indicat-

ed that the burden of mental disease was set toincrease in the future in all countries.

Mental health problems served to magnify existingdeficiencies in the overall health care system inrespect of quality of treatment and care, respectfor the human rights of people with mental healthdisorders, and fairness in financing, including thelack of health insurance cover for the mentally ill.Consequently, mental health should be treated as apriority in efforts to reform health systems. Animportant first step in increasing awareness of theproblems associated with mental disorders was todocument the scope of the problem. In thatrespect, Mexico had carried out several surveyswhich, in conjunction with WHO’s ATLAS project,should provide scientific evidence for treatingmental health as a priority area.

The public sector had a vital, proactive governancerole to play in articulating the importance of men-tal health, protecting the human rights of thosesuffering from mental disorders and combating thestigma attached to mental illness. In Mexico, prior-ity had been given to devising new mental healthprogrammes, in particular to tackle alcohol anddrug dependence, depression, schizophrenia,dementia, psychological disorders in children, andepilepsy. New pilot projects were under way tointroduce innovative approaches that included theintegration of prevention and treatment of mentalhealth disorders in general health care systems;early detection of learning disabilities and socialrehabilitation of patients in half-way houses, shel-tered workshops and residential accommodation tofacilitate their gradual reintegration into the com-munity.

He agreed with Dr López on the need to focusspecial attention on the mental health of indige-nous people, taking into account their particularcultural circumstances.

Mongolia

Professor Nymadawa observed that, while mentaldisorders were increasing in all Member States,they were a particular problem for countries intransition. In the previous 10 years, Mongolia hadundergone drastic socioeconomic changes in itsefforts to build up a multiparty democracy and amarket economy.That difficult task had rendered


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social problems more acute, resulting in increasedprevalence of depression, alcoholism, accidents,suicide and crime, especially among the poor.According to a recent study, 51% of the adult pop-ulation used alcohol and the suicide rate had risenfive-fold between 1989 and 2000.TheGovernment had introduced several measures topromote stabilization and provide social protec-tion. Since 1990, cost-sharing mechanisms hadbeen introduced into the previously universallyfree health service and a social health insurancescheme had been set up in 1994. However, thecosts of treatment for chronic mental health condi-tions continued to be met by the State in the sameway as some other priority health services such asimmunization programmes and pregnancy andchildbirth care.

He expressed appreciation for WHO’s support incoping with the mental health problems arisingfrom economic transition. Mongolia faced a severechallenge from increasing mental health disorders,especially alcoholism and depression, and hoped tolearn from the experience of other countries withdifferent conditions and structures.

Morocco

Mr El Khyari observed that lack of knowledge washampering efforts to tackle mental health prob-lems, many of which were influenced by complexsocial factors. Moreover, the financial and humanresource costs of long-term treatment and supportfor those with mental disorders were beyond thereach of many developing countries. Many wereexperiencing economic transition and its conse-quences, such as the splitting of families anddecreasing belief in traditional medicine, at thesame time as undergoing as severe resource con-straints. Mental health disorders required theinvolvement of several different ministries andmany different aspects of civil society; they calledfor solutions that went beyond the conventionalhealth care framework. He therefore welcomedthe interest being shown by the international com-munity through WHO.

Mozambique

Dr Ferreira Songane described the developmentof his country’s mental health programme in 1990,based on prevention, training and partnership, in amultisectoral approach. Although Mozambique’spsychiatric hospitals had largely become redun-dant, it lacked the resources to eliminate thestigmatization of the mentally ill. In practice, manysufferers were simply left on the streets to die.

Since it had insufficient specialists and wanted todecentralize services, Mozambique was providingpsychiatry training for doctors at the middle level ofthe system, including a significant public and socialhealth component.The physicians worked closelywith traditional practitioners who also had expertisein the use of drugs, and who thus could help over-come social resistance to seeking treatment.

The streets of Mozambique revealed children asyoung as five years of age who were forced out towork or to seek food and were deprived of theeducation and care they needed to enjoy mentalhealth in later years. His Government hoped that,with the help of WHO and through its highly effec-tive Regional Office for Africa, such phenomenacould be effectively eradicated.

Myanmar

Mr Ket Sein described how the launch of hisGovernment’s mental health programme in 1998had started to break down the misconceptions pre-viously attached to mental health disorders.Awareness had been enhanced by the activities ofhealth education teams and projects. Communityparticipation in activities designed to provide moralsupport for sufferers had also been important inimproving acceptance by the community and inencouraging community-based care.The engage-ment of well-known artists and cartoonists to openand promote exhibitions of paintings and drawingsby people with mental disorders had contributedgreatly to the change in people’s perception ofmental illness and to minimizing discrimination.

The community-based approach to mental disor-ders covered the training of basic health care work-ers. New care guidelines had been issued, and thesupply of basic psychotropic drugs had improved.


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Nongovernmental organizations were encouragedto promote mental health activities, including theprevention of substance abuse among young peo-ple. Health education activities had been intro-duced in schools and in the community. A maternaland child welfare association had started to pro-mote health and well-being, including programmesfor education and income generation. Nationalcommittees for women’s affairs had sponsored theestablishment of counselling centres for victims ofviolence.

At the national level, a concerted effort was beingmade as a result of the mental health theme forWorld Health Day 2001 to secure adequate sup-plies of affordable, good quality psychotropicdrugs. Meditation, which was already part ofMyanmar’s culture, continued to be encouragedfor the harmonious mental state that it promoted.

Namibia

Dr Amathila, noting that the stigma of mental ill-ness had been eclipsed in Namibia by that associat-ed with HIV/AIDS, said that gender disparities hadbeen actively addressed in her country, and that nohealth service excluded women. As far as mentalhealth was concerned, women in Namibiaappeared to be stronger than men; however, thelevel of violence against women was increasing.The health authorities had set up centres forwomen and children who had been abused, and inthe previous year, an organization entitled “Menagainst violence against women” had been set up bymen to provide counselling to abusive men.

Unemployment, poverty, alcoholism andHIV/AIDS were important factors in the rise inmental instability in Namibia, especially amongyoung people.The refugees from neighbouringwar-torn Angola also experienced mental healthproblems. It would therefore be important to cre-ate employment opportunities where possible, andto improve the country’s economy. HIV/AIDS hadresulted in an increased incidence of depressionand suicides; counselling services were not alwaysaccessible to the young, and immediate, confiden-tial support, which should also cover mental healthissues, should be provided.Traditional healers werenow based at rural clinics to deal primarily withmental illness. Pensions for persons aged 60 years

and over had helped to reduce depression amongthe elderly. However, the elderly were having totake care of an increasing number of AIDSorphans, and additional steps should be taken tosupport them in that regard.

Namibia currently had only one psychiatrist, andthere was a clear need for additional investment inhuman resources and training to improve care forthose with mental illness. Some 15% of the grossdomestic product was devoted to health services,and it was important to ensure that due attentionwas given to mental health.

Nepal

Mr Tamrakar observed that further study wasneeded in order to determine whether certainbehaviours and lifestyles might be conducive tomental illness, and to investigate the mitigatinginfluence of spiritual aspects of individuals’ lives,such as meditation. His country had adopted anational mental health policy. In the past, the sizeof the problem had not been recognized, owing tothe stigma attached to mental disease, as well as tothe shortage of trained personnel. A community-based pilot project was gradually being introduced,involving traditional healers and civil society as awhole in an awareness-raising campaign. However,it was difficult to allocate adequate resources inthat area, and Nepal would welcome support fromWHO to find funding for mental health projectsand to provide drugs for a limited period.

Netherlands

Dr Borst-Eilers said that her country had also seena growing demand over the past 10 years for helpfor mental disorders, due to the increasing inci-dence of such problems and to the fact that helpwas being sought at an earlier stage, largely as aresult of de-stigmatization.The change hadundoubtedly been promoted by well-known per-sonalities who had openly admitted to sufferingfrom certain disorders.The availability of effectivetreatment for mental health problems such as anxi-ety and depression in primary health care centres,by family doctors, psychiatric nurses, social work-ers or primary care psychologists, was also respon-sible for the growing demand.


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Like France, the Netherlands had also begun toshift from institutional to community care, wherepatients received support and various kinds ofambulatory treatment. In order for the shift to besuccessful, budget cuts were inadvisable, as com-munity care was not necessarily cheaper than insti-tutional care in view of the personal supportrequired. It was also important not to push theconcept further than the community could toler-ate. Some vulnerable patients with chronic psy-chotic conditions and those who posed a threat toothers needed the protected environment of aninstitution and should not be exposed to life in acommunity. One of the most important aspects ofcommunity care was the building up of broad pub-lic support by making it clear to the local commu-nity that professional help was readily available inthe event of a disturbance. Community care hadbeen introduced into a number of cities in theNetherlands with great success.

Niger

Mr Adamou said that, since the independence ofhis country, mental health care had been providedat the national hospital in the capital and at threehospitals that had psychiatric units; however, withwaning funds and resources, their performance haddeteriorated. On the occasion of World Health Day2001,WHO had provided certain psychotropicdrugs, which had enabled the country to resumeits activities in that field. Clearly, in a country asvast as Niger, three hospitals were insufficient tocover all mental health care needs.The mentallyill, whether hospitalized or not, were rejected bytheir families and were looked after by the State. Inhis country, traditional medicine existed side-by-side with modern medicine.The traditional healerswere not witch doctors and did cure some mental-ly ill people.The intention of the authorities was topromote primary health care for mental disordersand to decentralize that care through personneltraining and the provision of sufficient drugs.Niger’s mental health programme was new, andthere was need still to formulate policy, coordinatethe activities of all those involved in mental healthcare and to raise awareness. All that was neededwas financing. He had found the round table usefuland would make good use of some of the sugges-tions that had been made.

Nigeria

Professor Nwosu commented that in Nigeria men-tal health care had initially been the responsibilityof families and communities, and had then beentransferred to hospitals before being restored tothe community.The disintegration of the extendedfamily system in Africa had placed an enormousburden on the community for the management ofmental health care. In that regard, poverty allevia-tion was a crucial instrument for integrating men-tally ill patients into society and giving them ade-quate care.While traditional healers played a majorrole in treatment, the community also needed edu-cation and awareness programmes so that tradi-tional care would be effectively integrated into theorthodox health care system.

She asked that WHO devise a special programmeon postpartum psychosis, a neglected area of men-tal illness.

Norway

Mr Tønne said that as a result of a study conduct-ed a few years earlier, which had led to someshocking conclusions about the state of the mentalhealth care system in Norway, his Governmentwas working on a long-term plan to bring the sys-tem up to acceptable standards. In reply to thethird question put by the Chairman, he said thatopenness and inclusion were two of the key issuesbeing addressed.The history of mental health carein Norway, as in many other countries, had beenone of non-information, lack of openness, closedinstitutions, stigmatization, exclusion, shame andfear.The reform of that situation had been a longprocess which had required changes in culture,attitude and behaviour amounting to a completere-education of society.The second key issue,inclusion of those afflicted and affected, was close-ly connected to the first, because it could not beattained without the active participation ofpatients and their families.That implied participa-tion in the development of the mental health caresystem and treatment offered, participation in thedesign and performance of information and educa-tion programmes, and, perhaps most importantly,individual participation in self-help and self-treat-ment.


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Research in Norway indicated that 20% of thepopulation suffered from mental illness at leastonce during their lifetime, and that mental illnesswas a growing factor in causing school drop-outs,unemployment and absenteeism. In the debate onmental health some difficult and controversialquestions had arisen, for example the question ofwhether a general recognition of mental healthproblems as illness might not entail the risk oflowering the threshold of illnesses requiring treat-ment, thereby reducing the capacity of individualsto cope with their own problems.

Norway

Mr Tønne said that the broad answer to theChairman’s four questions was that information, inthe sense of education of society as a whole, wasthe best remedy. All efforts to fight stigma hadactively to involve everyone who suffered frommental health problems and stigmatization.

With regard to the comments made by the dele-gate of Israel, it was important to distinguishbetween mental illness and the mental problemsthat arose in normal society. Care had to be takenthat efforts to promote mental health did not pro-duce stigma by turning normal problems into ill-nesses and disorders.Thresholds should not belowered; rather, work should continue on educa-tion and information.

Pakistan

Dr Kasi said that the debate had shown that theprevalence of mental ill-health was high in all soci-eties, particularly among women. Governmentswere obviously keen to adopt preventive as well ascurative measures to eradicate mental health prob-lems, to reduce stigmatization of people withmental disorders, and promote their social reha-bilitation. However, efforts in developing coun-tries were hindered by lack of financial resourcesand technical capacity. He urged WHO and thedeveloped countries to assist the developing coun-tries in that regard. It was also essential to deter-mine the scale of the problem and how it affectedcountries’ societies and economies.The currentdiscussion would contribute to that process andPakistan looked to the international community

for further support, while following a consistentpolicy.

An area not so far discussed was the collection ofdata on mental health problems in areas of conflictand occupation by foreign forces, in particularamong refugee populations, as for example inKashmir and Palestine.There was a danger thattheir concerns might be marginalized in the gener-al debate.

Pakistan

Dr Kasi related that recent studies carried out inrural areas and urban slums in Pakistan had showna high prevalence of neuropsychiatric disorders.Mental health had also been identified as a mainpriority area in the national health policy.TheLunacy Act of 1902 had recently been replaced bythe National Mental Health Ordinance 2001 whichprovided a balanced framework for protecting thehuman rights of mentally ill people and their fami-lies.The national mental health programme hadestablished pilot projects at local level to providemental health care as a component of primaryhealth care.The media and nongovernmentalorganizations were supporting efforts to promotepublic awareness and understanding of mental ill-ness by tackling traditional myths and supersti-tions. Other public sectors, in particular theDepartment of Education, were actively involvedin the mental health programme, and mentalhealth education was being introduced in privateand state-run medical schools. Psychiatric nursingcourses were also being offered by nursing schools.Mentally ill people and their families were eligibleto receive grants, as well as social and disabilitypensions. Most health care services for the mental-ly ill were provided by the public sector, althoughthe private sector was rapidly emerging as a newplayer in that area. As yet, no policy existed to reg-ulate private sector providers and health insurancewas not available, although the Government hadrecently submitted an ordinance on the regulationof private hospitals, including mental health insti-tutions.


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Panama

Dr Gracia García said that he had found the roundtable highly instructive. It would be important todetermine to what extent mental health systemshad been affected by the economic and social poli-cies and crises imposed by the current develop-ment model. Panama resembled other LatinAmerican countries in experiencing increasedpoverty, greater unemployment and a resultant risein disease in general and in mental illness in partic-ular. One immediate effect of an unstable economywas decreased spending on health and education.

In 2000, Panama had made mental health a priorityand had implemented four programmes.The firsthad focused on obtaining accurate epidemiologicaldata on the real impact of mental illness on society.The second had ensured early diagnosis and treat-ment of mental illness in a national care systemthrough promotion campaigns and education pro-grammes for patients, their families and generalpractitioners. Joint public-private sector supportgroups for patients and their relatives had beenestablished to eradicate stigmatization of mentallyill patients by their families and society, so that thepatients could be reintegrated into society as rapid-ly as possible. A community pharmacy programmehad been established that gave patients access tohigh-quality drugs at reasonable prices.The possi-bility of State subsidies for drugs in the event ofeconomic necessity was being studied.

Papua New Guinea

Mr Mond described his country’s 10-year actionplan for social change and mental health.The mainchallenges were: the need to increase public aware-ness and involvement; the limited financialresources; poor service coverage; inadequate train-ing of staff, community, and home care providers;a lack of psychiatrists and psychiatric nurses; aneglect of forensic psychiatry; poor intersectoralcollaboration; and, finally, insufficiently developeddata and evaluation indicators.To respond to thoseproblems, month-long awareness campaigns andtraining seminars were held for skills development,and a community-based psychosocial health carecentre had been established. Pocket-sized standardtreatment manuals were being prepared for gener-

al practitioners, nurses and other health care pro-fessionals, to help them deal with mentally illpatients in the hospital setting.

The Government’s mental health policies werelinked to social change, and included free psychi-atric care and rehabilitation as an integral part ofthe public hospital system and the establishmentand support of community-based treatment andpsychosocial rehabilitation, carried out in collabo-ration with nongovernmental organizations andother such groups.

Peru

Dr Pretell Zarate said that developing countries,with their many priorities and scant resources,needed more information on mental health inorder to raise awareness of the problem.The firststep should be to carry out national epidemiologi-cal studies. He appealed to WHO to support coun-tries in carrying out surveys on mental health atcountry level, in order to provide more accuratedata on the prevalence and epidemiological profileof mental disease. Such surveys would permit anassessment of requirements in terms of human,professional, and family resources, and of mentalhealth care provision.They would also support thedevelopment of appropriate models for developingcountries to deal with mental health problems. Heapplauded the pragmatic efforts of many countriesin providing psychiatric training for health careworkers, but he wondered what results had beenobtained from such training in terms of quality ofcare, prevention, diagnosis and referral to otherlevels. Secondly, he enquired what experience hadbeen gained in mobilizing families and communi-ties, particularly in rural areas, to avoid isolation,discrimination and stigmatization in respect of thementally ill. Lack of resources and failure to prior-itize mental health were problems shared by alldeveloping countries, and it was therefore of vitalimportance to conduct a global survey on mentalhealth.

Peru

Dr Pretell Zarate said that a significant cause ofstigmatization and segregation was the pessimisticview of mental health patients as lost causes or as a


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source of great expense to the State. It wouldtherefore be very useful to wage a major educa-tional campaign showing the scientific progressmade with regard to the causes of many of thoseproblems and the existence of new and more effec-tive methods of treatment and rehabilitation. Forexample, the World Summit for Children’s globalcampaign to iodize salt was an effective, cheap andeasy means of preventing damage to the brain andmental disease.

Poland

Professor Opala said that the Polish Ministry ofHealth and Social Welfare had approved a newmental health programme in 1994 with the aim ofensuring improved access to appropriate healthcare and support for those with mental disorders.The implementation of the programme and themental health of the population were being moni-tored. A recent study of mental health had revealedthat the number of people with a positive assess-ment of their lives had increased but feelings ofhappiness and satisfaction had declined. Highermental well-being was associated with broadersocial support, increased income, participation inreligious practices and marriage, whereas a lowersense of mental well-being affected in particularthe elderly, the unemployed, those with a lowerincome and those suffering from loneliness.Thehighest risk for mental disorder was found in per-sons over 65 years old, 51% of whom (88% inwomen) admitted to feeling sad and depressed.The Council for Mental Health Promotion haddrawn attention to some of the risk factors formental disorder and measures had been introducedto monitor and promote mental health, includingthe identification of risk groups, the introductionof educational programmes for families, the imple-mentation of school curricula to develop skills inproblem-solving and coping and the establishmentof various forms of psychological counselling andintervention for people in emotional crisis. Suchmeasures would be included in the national mentalhealth programme.

Portugal

Mr Boquinhas said that his Government hadapproved a national mental health plan in 1996 and

in the last five years had ratified a new mentalhealth act and organized new mental health servic-es around hospital and community care.Intersectoral cooperation was being promoted.

Other legislation, concerning collaborationbetween the health sector, social services and non-governmental organizations in the development ofpsychosocial rehabilitation programmes had alsobeen approved. For example, the national councilfor mental health and a number of regional coun-cils had been established, and a hospital referralnetwork put in place.The integration of mentalhealth services into the national health serviceensured their greater accessibility and adequacy.In-patient treatment was now provided in generalhospitals. Local services had been developed toreplace psychiatric hospitals, and new psychiatricservices were being funded at the communitylevel, including services for children. Drugs for thetreatment of severe mental illness were partly sub-sidized.

There was nevertheless a marked lack of progressin some areas. Stigmatization persisted, little atten-tion was paid to preventive programmes and therewas a lack of community-based facilities to bridgethe gap between hospital and home care.There wasalso a lack of epidemiological data on psychiatricmorbidity and mortality and use of the availablefacilities.There was a particular need for monitor-ing and assessment of the national mental healthpolicy, its implementation and the quality of care.Efforts were being made to promote mental healthby investing in community-based facilities for long-term patients, developing a national plan to createother facilities such as day care and continuity ofcare on medium-term and long-term bases.Epidemiological and economic studies were beingplanned at the local and national levels, and anongoing monitoring and assessment programmehad been established to ensure quality of service.

Republic of Korea

Dr Lee said that, until the mid-1990s, hisGovernment’s policy had been geared to long-termhospitalization of mentally ill patients. However,with the enactment of the Mental Health Act in1995, there had been a trend towards a communi-ty-oriented approach, concentrating on early


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detection, early treatment, rehabilitation and inte-gration in the community. Considerable improve-ments had been achieved. About one million per-sons were currently receiving treatment, repre-senting 2.7% of the total population. A large-scaleepidemiological study on mental illness was underway. Measures had been put in place to providesupport for families, appropriate jobs for thoseable to work, and entitlements to disablement ben-efits.The Government was committed to combat-ing social stigma related to mental illness throughpublic campaigns and community-based projects.Mental Health Day 2001 had been celebrated withthe design of a special emblem to draw attention tothe importance of mental health and the organiza-tion of academic seminars and rallies for mentallyill patients.

Romania

Dr Bartos explained how she had learned early inher medical career the true importance of ade-quate mental health services.The lack of such serv-ices allowed many persons with mental disordersto hide behind real or virtual barriers, some ofwhich were presented by prejudice and intoler-ance. In her country, despite the important socialchanges that had occurred, violence, unemploy-ment and a rapid deterioration in economic condi-tions and living standards were all affecting themental health of the population.The Governmentbelieved that health care was a collective socialgood to which everyone should have free and equi-table access. Better health in Romania would beachieved through a strategy of correcting theexcessive orientation towards hospital serviceswhich was detrimental to outpatient and commu-nity care.

The Ministry of Health and the Family had sub-mitted a bill to promote mental health and theprotection of persons with psychological disor-ders, to ensure that they were treated in a man-ner that fully respected their dignity, without dis-crimination and, in so far as possible, in the com-munity.WHO had supported the preparation ofthat bill and had also contributed to the evalua-tion of mental health at the national level.Romania needed a national mental health planbased on: the determination and evaluation of thereal dimension of the problem; the reform and

effectiveness of the system of mental health serv-ices; and integrated, interdisciplinary and inter-sectoral programmes to promote mental health.Family doctors needed to be involved to a greaterextent as “gatekeepers” and special assistancewould have to be provided to vulnerable andhigh-risk groups.The Ministry was also coordi-nating a project financed by the World Bank forthe establishment of a mental health centre. Shewelcomed the support provided by WHO and itsinitiatives to raise awareness of mental healthproblems, which had prompted several new activ-ities, which she hoped, would reduce certainobstacles to mental health service reform, includ-ing traditional attitudes and inertia. In transitioncountries, such as her own, one of the most diffi-cult reforms had concerned hospitals, in whichmost mental health services were located and thecall for emphasis to be given to outpatient andcommunity services. Such a course of action washard, given the lack of information on the realdimension of the problem. She therefore wel-comed the round table which, even if it did notknock down existing barriers, would neverthelessweaken them.

Russian Federation

Professor Krasnov stressed that the rise andspread of mental health problems were characteris-tic of all societies, rich, poor, or in transition. Itwas wrongly assumed that poverty eradication wasthe prerequisite to the reduction of prevalence ofmental health problems; however, those problemswere themselves factors of social and economicdevelopment.

Any long-term strategy of care and preventionrequired greater integration of psychiatric servicesinto the general health system, with families andeven former patients contributing their uniqueexperience, skills and advice on how to overcomecertain problems.The task could not be left to spe-cialists alone; it required the participation of allmembers of society, and of primary health careworkers in the first instance. Although his countryhad limited experience in that domain, it hadorganized local polyclinics facilitating early inter-vention through offering access to services thatcommunities would otherwise shun if provided bylarge institutions.


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He suggested that a global appraisal be made ofexperience in mental health care in different coun-tries in order to develop effective health care mod-els.WHO was uniquely positioned for such a task.

Many participants had described community-basedmental health care policies, but there were as manyinterpretations of the term “community” as therewere regions, countries or towns.Whereas mostvillagers knew one another, in large urban apart-ment blocks people rarely knew their neighbours.Effective community-based care should be predi-cated by a definition of “community”.

Rwanda

Dr Rwabuhihi noticed that the date for WorldHealth Day, devoted to mental health, had been 7 April. However, that day was one of mourning inRwanda to commemorate the tragedy of 1994,where in the space of only 100 days one millionRwandans had been killed by other Rwandans.Thesignificance of that date would prevent Rwandafrom celebrating World Health Day for many yearsto come. Mental health programmes in Rwandawere being decentralized in order to help to copewith the healing of an entire society. It was not aquestion of healing a few groups on the marginsbut of instituting a mental health programme forthe whole population.The need was more readilyunderstood when set against the backdrop of themore-than 120 000 persons still in prison on suspi-cion of having participated in the massacre of theircompatriots. One survey of 3000 children in 12provinces had revealed that over 90% had been indanger of being killed and more than 95% believedthat they were dead, even though they were living.Those factors gave an indication of the enormity ofthe task being faced with very few resources.Rwanda had chosen a participatory form of justicein which people who had witnessed the massacresfor three months would be able to tell the truthabout what had happened.That was the reason toask everyone to participate, including the tradi-tional health systems, the district hospitals and thehealth centres, in order to seek the truth and assistin the healing process.The traditional healers wereneeded because there was a desperate shortage ofso-called modern medical personnel.There werefewer than 200 doctors in Rwanda as comparedwith more than 10 000 traditional healers. He

thanked all those who had helped Rwanda, espe-cially in training. He expressed his particularappreciation to Switzerland for its cooperation intraining doctors and mental health specialists.

Rwanda

Dr Rwabuhihi said that mental health institutionsshould not remain in isolation but should be locat-ed in city centres. Rwanda had recently opened acentre for psychological and social consultations inthe middle of town, next to the main bus station,and had been surprised to find how many people ithad attracted. It might help to make that approachmore widespread.

San Marino

Mr Morri said that mental disorders should receivegreater attention. Since 1955, patients in SanMarino had enjoyed free, direct access to medicalcare, including care for mental and neurologicaldisorders. As San Marino had no psychiatric hospi-tals, patients requiring admission were referred toinstitutions in other countries. In addition, relevantlegislation was being reviewed to respond to newneeds, including support to care providers.

San Marino had always attached importance to car-ing for patients with mental disorders throughsocial and community-based services, and strate-gies had been improved to enhance quality of life.Rehabilitation was individually tailored, andincluded access to half-way houses for reintegra-tion into the community, occupational rehabilita-tion workshops and special training contracts.Private companies could enjoy reductions in theirsocial contributions if they employed certified dis-abled persons and were required by law to employone disabled person for every 20 employees.Thoseand other administrative and social measures wereeffective in preventing the stigmatization of per-sons with mental disorders.

Voluntary assistance contributed significantly to theservices provided by the State, and some voluntaryassociations were actively promoting informationon mental disorders, supporting rehabilitation, andencouraging the involvement of the mentally andphysically disabled in sport.


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Current commitments would need to be sustained,through, inter alia, investment in human resourcesand the implementation of preventive programmestargeted at all social groups, and the provision ofeffective and individually tailored care. It wouldalso be essential to improve understandingbetween patients with mental disorders and doc-tors.

Senegal

Mr Diop, describing the experiences in his coun-try, said that particular stress was being laid onraising public awareness of mental health matters.Through the national health education system,mental health experts were promoting a pro-gramme in the mass media, using all theSenegalese languages. In 2001, particular emphasiswas being given to epilepsy, prevalence of whichwas 8% to 11%. An information programme wasbeing developed to induce traditional practitionersto refer patients with mental disorders to special-ized care services. So far, participation by the Statein care for patients with mental diseases was stillvery low, although the Ministry of Health was cur-rently developing a national programme in thatregard.The strategies were aimed at reducingstigmatization and exclusion and encouraging fami-ly participation in caring for patients with mentalhealth problems. Some patients were cared for inpsychiatric villages, staffed by carers from the sameregion. Elsewhere specialized teams were being setup to visit patients in their own environment. Anattempt was being made to integrate mental healthcare into the basic health care programme, whichinvolved training health workers at all levels andimproving prevention, screening and treatment.Traditional practitioners were also becomingincreasingly involved in mental health care along-side professional health workers.

Sierra Leone

Dr Jalloh welcomed the decision to focus on men-tal health for World Health Day 2001 and toinclude the subject on the agenda of the currentHealth Assembly.

The Ministers of Health of Uganda and theDemocratic Republic of the Congo had raised the

issue of civil strife as a factor in mental health prob-lems. It was important for countries that had under-gone war to share their experience of the relation-ship between war and mental health. On 6 January1999, rebels had invaded his country’s capital,Freetown, and had carried out widespread and bar-baric attacks on the civilian population, includingarbitrary executions, abductions, single and gangrapes, amputations, arson and looting. At least 10000 people were alleged to have died and at presentsome 150 000 were displaced from their homes.

While most medical personnel acknowledged thatgross atrocities had been committed, they knewlittle or nothing about post-traumatic stress disor-der, which was difficult to define both conceptuallyand operationally. It was a unique diagnosis, in thatan exposure or criterion stressor was an integralpart of the disease.The criterion stressor requiredthat a person had experienced an event that wasoutside the range of usual human experience.Although specific criterion stressors might be diffi-cult to define, participation in war was generallydeemed to be such an experience.

The concept of post-traumatic stress disordershould be considered with care, as not all disordersarising after traumatic events fell into that catego-ry.To overcome mass traumatization, as in the caseof Sierra Leone, the healing capacity of familycommunity systems should support people in cop-ing with severe stress and with more severe mentalhealth problems.The number of traumatic experi-ences and their duration were important risk fac-tors in the development of post-traumatic stressdisorder. Sufferers from traumatic stress often hadphysical complaints, the so-called psychosomaticstress symptoms, although they were often misdi-agnosed by medical practitioners who were notpsychiatrists. It was important to consider not onlyconventional forms of depression and schizophre-nia, but also the stress disorders that arose as aresult of war.

Singapore

Professor Ee Heok Kua said that it was importantto convey a positive message indicating that manypeople did recover from mental health problems.To that end, Singapore’s health authorities workedclosely with nongovernmental organizations, held


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public forums every two months on common men-tal illnesses including depression and anxiety, andcollaborated with the mass media to destigmatizemental illness and to ensure that correct informa-tion was provided.

It was important for governments to ascertain theextent of mental health illnesses in order to planservice. Following a national survey in Singapore,action had been taken in three areas: teachers andcounsellors had been trained to recognize andmanage mental health problems in schoolchildren;personnel and managerial staff had also beentaught to recognize the common signs of mentalillnesses in the workforce, as well as counsellingtechniques; and retired professionals had beentrained to provide counselling support to the eld-erly. In all cases, if a problem could not be man-aged, the individual concerned was referred to aspecialist.

He hoped that mental health would remain a focusof attention for WHO, and that, in the future, theOrganization would coordinate programmes andmake sure of their effectiveness.

Slovakia

Mr Hlavacka said that because mental health carewas dominated by medical specialists the relatedstrategies did not involve other professionals, suchas social carers, patients and families.The role ofthe family was crucial, not only in terms of diagno-sis (as the family was often the first to identify theproblem), but also in enhancing access.The familycould bring the patient for treatment and assist inreintegration.Thought should be given to a socialenvironment that optimized the ability of the fami-ly to care for the patient. Often, the problem wasnot one of education or understanding, but of theeconomic ability to care.

Like other countries, Slovakia had formulated amental health strategy.The difficulties lay in moni-toring implementation and in establishing indica-tors of performance. Evaluation of treatmentstended to be based on costs, the number of drugsused and the number of treatment centres avail-able. However, there were few indicators to meas-ure responsiveness of care.The views of the caregivers, the families and the individual patientsshould be sought on how to improve the service.

There was also a place for the type of benchmark-ing that WHO was carrying out. Finally, as to therole of WHO and other international organiza-tions, the causes of mental illness, such as povertyand stress, must also be tackled.

Slovenia

Mr Marusic said that alcohol consumption and sui-cide each accounted for 30 deaths per year per 100000 population.The current national health pro-gramme contained little on the subject of mentalhealth, so a national mental health programme andnational legislation on alcohol and tobacco con-sumption were currently in preparation. Primaryprevention had already been introduced into thework of general practitioners, who were requiredto put questions to their patients concerning theirmental well-being.Those with the highest risk fac-tors were then involved in group therapy. A pro-gramme to encourage healthy schools and work-places had also been launched. In order to reducestigmatization, a patient advocacy act that stressedthe need to protect the human rights of those withmental disorders was under discussion.The thirdand final reading of that act was to take place inthe near future.

South Africa

Dr Tshabalala-Msimang said that one of herGovernment’s objectives was to promote an inte-grated approach to health care. Health care wasnot regarded as being the responsibility of theDepartment of Health alone and it had been possi-ble to achieve an increase in social spending inrecent years. A mental health bill, to be submittedto Parliament in the near future, would provide aframework for the delivery of care at all levels ofthe health system and would promote rights forthose disabled by mental illness. South Africa wasalso finalizing a special training instrument toimprove the skills of staff. An important challengewas the provision of appropriate services for peo-ple emotionally traumatized as a result of, forinstance, rape, child abuse and family break-up.Prevention of mental disorders was crucial andoften involved intersectoral collaboration. SouthAfrica had initiated a programme aimed at theprevention of violence in schools and projects


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along the lines of the WHO parent-child bondingprogramme.The next step was to improve pri-mary mental health care. One-stop centres hadbeen established for abused women, and healthworkers were being trained to deal with basicproblems, to counsel on victim empowerment,and to recognize the need for referral. Futureactivities should include expansion of the networkof referral centres and attention to the needs ofhealth workers who took care of people withmental disorders.

Recent research had indicated that high blood alco-hol levels were associated with well over half of allnon-natural deaths including homicides and trafficaccidents. Greater emphasis should be given toreduction of demand and supply of alcohol; pre-vention work in that area would have many humanand financial advantages.The spread of HIV/AIDSamong psychiatric patients was also a serious con-cern. A project aimed at developing comprehensivelife skills in schools, which covered HIV/AIDS andsubstance abuse prevention, had been introducedunder the WHO/UNDCP Global Initiative onPrimary Prevention of Substance Abuse. Lastly, shedrew attention to the need to develop appropriatecommunity services and to shift budget resourcesaccordingly.

Sri Lanka

Mr Seneviratne said that, although his country hadachieved high levels of health with a relativelysmall financial investment, developments in mentalhealth had lagged behind other aspects. Sri Lankawas facing high suicide rates and psychosocial dis-abilities related to stress, in connection with thesocioeconomic effects of the war in the northernand eastern areas of the country. Lack of awarenessof mental disorders, social stigma and the low pri-ority attached to mental health continued toobstruct the development of mental health servic-es. A series of measures had been taken in recentyears to develop mental health services and todecentralize mental health care.The greatest prob-lems faced by Sri Lanka were the lack of qualifiedpsychiatrists, which he hoped would be alleviatedby the training of medical officers; and the highrate of suicide among the young, which he hopedcould be addressed through research conducted incooperation with other countries.

Sweden

Mr Engqvist said that, in 1995, Sweden had chal-lenged the traditional views of mental health serv-ices, shifting from large-scale institutional psychi-atric care towards municipality-based rehabilita-tion and integration programmes.The aim was toensure that people with mental health problemswere closer to the main stream of health services.Despite major investment and a positive responseto the structural changes introduced, however, theprofessional and other available resources had notmet the required high standards of care. A nationalcentre had therefore been established to providesupport for individuals suffering mental or func-tional impairment and to ensure maintenance oftheir dignity and respect, in which connectionpersonnel training was important. Moreover, anational action plan presented in 2000 would sub-stantially increase health care funding and focusefforts on improving primary health care and carefor the elderly and the mentally ill.The importantrole and the responsibilities of general practition-ers in prevention and early intervention wereequally underlined. Under Swedish legislation(compliance with which was annually monitored)patients had the right of access to information, aswell as the right to a second opinion and a voice intheir care and treatment. Special attention wasdevoted to patient empowerment and the valuableassistance of patient organizations was recognized,both in the development of legislation and guide-lines and in the evaluation of reform and otherchanges.

Although mental health conditions had generallyimproved in Sweden, mental ill-health hadincreased at an alarming rate, particularly amongteenagers and young women. Special measureswould therefore be taken. Mental illness wasstrongly connected to poverty and substance abuse.Notwithstanding the significance of genetic factorsin many conditions, social support systems werecrucial in diminishing the consequences of mentalillness, in which context he highlighted the advan-tage of multiprofessional approaches and theimportance of cooperation between the differentactors, including nongovernmental organizations.

Together with a well-developed preventive healthsystem, a proper education system was the key to


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providing the basic conditions needed to ensurethat young people developed self-esteem andadopted healthy lifestyles. In that context, encour-aging progress had been recorded in Sweden’sefforts to tackle domestic violence, including thedevelopment of a new training programme forprofessionals in the fields of health, social servicesand law enforcement. Sweden had also investigatedgender differences in the provision of health careand was endeavouring to eliminate conditionsattributable to gender discrimination.

Switzerland

Ms Dreifuss, responding to the Chairman’s secondand third questions, suggested that the primeresponsibility of the public sector was to ensurethat everyone had access to care. In Switzerland,that meant that mental health was covered byhealth insurance on an equal footing with physicalhealth. However, access to mental health care washampered by the public’s poor level of knowledgeof mental disorders. A second responsibility of thepublic sector was therefore to promote under-standing of how mental disorders evolved in orderto allow early intervention.Whereas certain issuessuch as drug dependence, because of their effecton public order, were well known and tackled,such disorders as depression quietly took holdbefore treatment could be delivered and before thecommunity or the family became aware of theirexistence.

It was also the State’s responsibility to develop andto ensure good quality mental health care, to con-duct epidemiological studies, research and train-ing, and to safeguard the human rights of patientswith mental illnesses as persons fully integratedinto society.

The approach to mental health problems shouldtarget different segments of society.Young people’sproblems, as manifested in drug abuse, suicidesand depression, differed from the problems of thevery old, characterized by serious depressions, andthe problems of work-related stress and the work-place in general.Those approaches needed to beadjusted to take account of differences betweenmen and women. Switzerland had had to developspecific responses to the problems of migrants anddisplacement. Caring for refugees and the particu-

lar traumas they brought with them required a dif-ferent perspective on diagnosis. In summary, shestressed the need for widespread information, butalso a targeted approach according to populationgroups, in order to promote understanding ofmental health.

Thailand

Dr Winai Wiriyakitjar remarked that his countryhad experienced two major crises in the pastdecade: HIV/AIDS and the economic recession.There was an increasing number of mental healthproblems, including suicide: the annual rate hadincreased from 7.2 to 8.6 per 100 000 populationover the past five years.The Government had triednot to cut health expenditure but to use the eco-nomic crisis as an opportunity to review its healthstrategies.

The World Health Day theme and related activi-ties showed that discrimination and access tomental health care were major concerns in mostcountries.Thailand’s experience with psychotrop-ic drugs was that side-effects increased stigmatiza-tion and reduced compliance. Newer drugs hadfewer side-effects but were more expensive. Forthat reason he proposed that access to such drugsshould be given high priority in the WHO revisedmedicine strategy. Also, he wanted WHO to con-sider recommending that Member States ensurethat such drugs were appropriately representedon essential drug lists. He concluded by express-ing the hope that the output of the round tableswould be more than a report; he expected a con-crete result that would improve mental health andalleviate the suffering of those with mental disor-ders.

The former Yugoslav Republic of Macedonia

Dr Nedzipi said that mental health care in hiscountry was inadequate, and lack of resources forhospital and community care deprived many men-tally ill persons of their basic human rights.WithWHO’s support, however, the Ministry of Healthhad elaborated a master plan to improve humanresources and had proposed new legislation toenhance patients’ rights and combat stigmatization.


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Community mental health services had been set upin three pilot areas in partnership with threeEuropean municipalities. Day-care centres, protect-ed homes, social enterprises and social clubs weresupported by the public service and by nongovern-mental organizations, in a multisectoral approach.Mechanisms were in place to ensure the sustainabil-ity of the community-based approach, and initia-tives had been taken to increase the resources ofthe project and replicate it in other pilot areas.

Trinidad and Tobago

Dr Parasram said that, after a long period of neg-lect, mental health had become an integral part ofhis country’s health sector reform programme.Thenew mental health plan currently being imple-mented took into account the relationship betweenmental health, social pathology and other exacer-bating conditions and sought to provide a range ofintegrated services, with the emphasis on primarycare of the individual within the community. It alsocomprised activities such as a legislative review,restructuring, an assessment of health needs andhuman resources, training, health promotion andthe development of regional plans in associationwith provider agencies. Approval had been givenfor the establishment of a suicide-prevention taskforce; the current system of drug procurement anddistribution was under review; and new genera-tions of drugs were available at public mentalhealth care institutions. Such policies and reviews,however, were insufficient in themselves to reversethe stigma of mental illness and related problems, aprocess which demanded continuous efforts. In hiscountry, fruitful forums had been held with themedia.That group could serve as an important allyin overcoming the challenges entailed in movingthe mental health care agenda forward. On thatscore, he looked forward to the continuation ofnational, regional and international action aimed atimproving the quality of mental health for theworld’s citizens.

Tunisia

Dr Abdessalem said that mental health had longbeen neglected for a number of reasons. Onceindependent,Tunisia had immediately tackled suchscourges as infant mortality and had embarked on a

countrywide immunization campaign. Since 1990,it had included mental health in its general healthstrategy, with emphasis on legislation, organizationand human resources.

The first major component of that strategy hadbeen the integration of the mental health pro-gramme into existing structures dispersedthroughout the country, to take those services clos-er to the users.The second component, still beingfinalized, was the establishment of the structuresnecessary for the various categories of mentalhealth care. Counselling units had been set up insecondary schools, higher education establish-ments, and in some small hospitals. A decision hadyet to be taken with regard to voluntary and invol-untary hospitalization. A third important measurewas to attack the myriad risk factors for mentaldisorders through education, affording all childrenthe opportunity to continue their studies and thefight against poverty with the creation of jobs foryoung people. Action was being taken to protectvulnerable groups, particularly children and theelderly, especially with respect to violence againstwomen and children.The authorities were alsoendeavouring to ensure that persons who were orhad been mentally ill were reintegrated into thecountry’s social and economic systems.

He endorsed the view expressed by many speakersthat legislation on its own did not provide effectivemental health care. A change of mentality wasrequired among all persons involved in mentalhealth care, including psychiatrists, who weresometimes unwilling to share their power andknowledge. It was equally important to train socialworkers, specialized nurses, psychologists and psy-chiatrists, and to provide psychiatric training forgeneral practitioners. In short,Tunisia’s strategyfocused on prevention and reduction of risk andaffording its citizens better access to proper care indecentralized clinics, sponsored by university fac-ulties of medicine and psychiatry.

Uganda

Dr Kiyonga had seen evidence in his country thatstigmatization could be overcome.When he hadbeen a medical student in the late 1970s, no stu-dent would have dared to admit to being near amental hospital, yet when a psychiatric clinic had


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recently been closed in town and mental healthpatients had been asked on radio to go to an out-of-town hospital for treatment, the reaction hadbeen good. Furthermore, people were now con-tacting physicians about mental illness. In two fur-ther major developments, former sufferers fromschizophrenia had formed an advocacy group toeliminate stigmatization of the disease, and the par-ents of epileptic children had created an associationto seek care for their children and to promote themessage that epilepsy was a manageable condition.In order to give people confidence, the health sec-tor had to demonstrate that treatment worked andthat people got better. Sufficient confidence had tobe generated in the population that people couldbe treated before legislation was adopted. Suchlegislation should be timed to coincide with animprovement in care and not be rushed through.

Lastly, was there any evidence that the extendedfamily structure prevailing in most African Statesoffered an advantage in mental health care? Could itbe shown, all other things being equal, that coun-tries with an extended family structure stood a bet-ter chance of dealing with mental illness than devel-oped countries that did not have such a structure?

Uganda

Dr Kiyonga, noting the trust placed in traditionalhealers by the general population in his country,expressed interest in views on the role that tradi-tional medicine could play in mental health care.His country gave a high priority to the treatmentof mental illness as the HIV/AIDS pandemic andprotracted civil strife had increased the incidenceof such illnesses. Uganda, in common with othersub-Saharan countries, suffered from high rates ofunemployment and poverty.The public sector wastherefore seen as the key to tackling mental healthproblems and to raising public awareness so as toreduce stigmatization and to encourage the mental-ly ill to seek help. A loan recently granted by theAfrican Development Bank would be used toreform national institutions responsible for healthcare delivery and to integrate the delivery of men-tal health and general health care.The training ofhealth workers was currently being reviewed, inorder to facilitate recognition at primary healthcare level of conditions likely to affect mentalhealth and to avoid over-specialization.

United Arab Emirates

Mr Al-Madfaa, concurred with previous speakerson the importance of eliminating discriminationand stigmatization in regard to the mentally ill. Hiscountry took account of the psychiatric causes ofcertain illnesses, and was making efforts to raiseawareness of mental health issues among studentsin universities and training institutes.The need forinteraction between various ministries was recog-nized, and the ministries of health and education inhis country were working together to combat psy-chological disorders among schoolchildren. Heemphasized the importance of awareness-building,of the role of the family, of research, and of the useof the media in order to target areas for mentalhealth action more successfully.

United Kingdom of Great Britainand Northern Ireland

Ms Hutt said that the National Assembly for Waleswas aware that all the policy areas for which it wasresponsible, namely health and social services,housing, environment, economic development andeducation, were relevant to the improvement ofhealth and well-being and to tackling mental healthproblems. It had also become clear to thatAssembly in the two years of its existence that anational strategy for mental health was essential,with priority funding. Such a strategy would pro-vide for local delivery and local management ofservices through primary care and communityhealth development.

Every effort was being made in Wales to ensurethat people who had used mental health services orwere suffering from mental health problems wereinvolved in policy development, both in their localcommunities and in the National Assembly.

In developing community services, it was essentialto have plans and funds in place before closingexisting institutions. It was equally important, withone in four people likely to experience mental dis-tress at some time, either in their families or intheir communities, to ensure that the communitywas able to address their needs.


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United Republic of Tanzania

Ms Abdallah observed that some 85% of the pop-ulation of her country lived in rural areas wherethere were practically no mental health servicesapart from traditional healers. In most cases men-tal illness was associated with curses or supernatu-ral causes. Her Government had developed a men-tal health policy, but traditional practices stillneeded to be integrated into modern medicine.She requested assistance from WHO in that area.

Specific causes of mental disorders in her countryincluded the rapid breakdown of traditional psy-chological support systems and social norms,poverty and rural-urban migration in the absenceof social skills and strategies to adapt. A secondcause was the long-term presence of refugees,whose settlements were breeding grounds formental disorders. In surrounding areas there hadbeen increases in crime, resulting in insecurityamong the indigenous population. Mental healthservices thus needed to serve local populations aswell as refugees.

United States of America

Mr Thompson, responding to the second questionput by the Chairman, said that it was the responsi-bility of governments to disseminate informationon mental health as widely as possible in order tocombat the suspicion and scepticism that surround-ed the subject. In the United States, one seventh ofgross national product was spent on mental andphysical health combined, and in all countries men-tal illness was among the five leading factors con-tributing to low productivity, absenteeism and sui-cide.The United States was spending more thanUS$ 1000 million on research into mental health,as a result of which great progress was being made.

Two of the most difficult problems in the field weresuicides among young people and discriminationagainst women. More needed to be done to reachout to young people and to try, through the educa-tion system, to reduce the number of suicides andeventually to prevent them.There was no doubtthat certain mental illnesses were more prevalentamong women than men, a difference that shouldbe reflected in research and in expenditure on serv-ices. His Government intended to give mental ill-

ness a higher priority than in the past, and toensure that it was treated on a par with physical ill-ness.

Uruguay

Dr Touyá said that a process of de-institutionaliza-tion of mental health care had begun in 1986, withmuch of the responsibility passing to the communi-ty.That had resulted in fewer and shorter hospitalstays, thereby improving patients’ quality of life intheir family environment. Psychiatric care couldnot fail to improve with increasing knowledgeabout brain function. Nevertheless, the risks formental disorders were increased in a civilizationthat pushed people increasingly towards self-destruction.The most positive approaches wereprevention and protection, to which end WHOshould firmly support countries that set examplesof strong family bonds, which were known toreduce poverty and violence.The media should beused to raise awareness.

Venezuela

Dr Urbaneja Durant reported her country’s expe-rience in carrying out extensive political and insti-tutional changes that had enabled progress byensuring that universal rights such as the right tohealth were met.That right must include the rightto mental health, and health must be seen as anintegral part of well-being and development.Obstacles to those goals were often related topoverty and inequality.Venezuela had worked outthree strategies to try to overcome those obstacles:incorporating guarantees for rights in the country’sconstitution; ensuring application of the constitu-tional provisions through governmental policies;and health system reform.

Venezuela’s constitution enshrined health as a basicright, without any discrimination on grounds suchas mental ability or gender. It included respect fordiversity and differences between individuals,which demanded a major change in attitudes.

Promoting health was essential for guaranteeingoverall rights.That meant intersectoral approaches,improved access to more effective and appropriateservices, tackling discrimination, and provision of


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decent living conditions for health. Gender differ-ences were recognized, for instance in access tohealth services, discrimination and quality of life.The National Women’s Institute had designed spe-cific policies and strategies together with nationalplans in that regard. A council for the protection ofchildren and young people had been established toensure shelter, proper nutrition and feeding, andaccess to education, especially for street children.For disabled people there was a national commit-tee for disabled persons and legislation forimproved protection was being enacted. Stepswere being taken to improve the living conditionsfor indigenous people whose rights were guaran-teed in the constitution. Laws were in place toguarantee individual rights in times of emergencyand disasters.

Her country had changed its model of health care,emphasizing health, rather than disease, as thestarting point. Prevention and health promotionformed critical strategic elements for health careworkers; they needed to understand that in inte-grated health care, health must be promoted inplaces regularly frequented by people, such asschools, sports venues, and outpatient clinics. Inparallel, the profile of a health worker was beingchanged in favour of that integrated health careapproach.That would help to remove the stigmasthat blocked access to the mental health care whichpeople needed; otherwise mental health problemsand stigmatization would be exacerbated.

Specifically with regard to psychiatric care, she wasconvinced of the need to care for both acute andchronic cases, with involvement not only ofpatients but also of their families and communities.That would ensure proper treatment, both in hos-pitals and in communities, with rapid reintegrationinto society.

Viet Nam

Professor Pham Manh Hung informed the meet-ing that, like many developing countries,Viet Namhad seen an increase in the incidence of mental andbrain disorders.The Government was dedicated topoverty reduction and had made considerableprogress in the past five years. Priority had beengiven to programmes with a strong commitmentto the provision of equitable health care services

for the poor, including priority allocation ofexpenditure for health in poor areas. Health work-ers in the mental health field were encouraged byadditional allowances equivalent to 20% of theirsalaries, a seven-hour working day and early retire-ment.

Improvements had also been made in hospital care,and the number of mental health departments incities and provinces had been increased, as had thenumber of psychiatrists. More recently, mentalhealth care had been integrated into the generalhealth service, with emphasis on community-basedservices. Most districts currently had a mentalhealth consultancy, responsible for the care and fol-low-up of patients.

Community awareness of mental health problemshad increased. Nevertheless, and despite the con-siderable progress made in providing mental healthcare, poor people continued to suffer. Limited gov-ernment expenditure on health and the lack ofwell-trained psychiatrists on the one hand, andpoverty, social discrimination and prejudice, a lackof information and superstition on the other, weremajor obstacles to the provision of mental healthcare and information on preventive treatment.

To counteract that situation, the Government hadapproved a five-year plan for development of thehealth sector with the aims, inter alia, of expand-ing health care centres to a further 50 communes,expanding community-based mental health servic-es to other provinces, providing community-basedmanagement and improving cure and rehabilitationrates. A notable result was that 50% of the coun-try’s community health centres now had at leastone medical doctor.

Yemen

Dr Al-Munibari agreed with earlier speakers thatwarfare and violence were among the major causesof mental illness. He also pointed out that smokinghad a deleterious effect on mental health, andemphasized the importance of sporting activities inovercoming mental health problems. It was essen-tial that the subject of mental health should remainon the agenda of future round tables.


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Yugoslavia

Dr Kovac said that in the past 10 years the popula-tion of his country had experienced the traumas ofwar, sanctions, and consequent impoverishment.That had occurred at both family and communitylevels, and materially as well as spiritually, throughthe collapse of traditional social and cultural val-ues, and the loss of hope. Mental health wasimpaired as never before.The incidence of classicalmental disorders had increased, as had conditionssuch as post-traumatic stress syndrome, anxiety,neurosis, substance misuse and marked depressionswith psychosomatic symptoms.Those were reac-tive pathologies to which people were not suscep-tible in normal conditions.The consequences wereincreased social pathologies, evidenced as greaterdelinquency, crime and violence.The presence oflarge numbers of refugees, with associated mentaldisorders, posed an additional problem. Children,many orphaned or living in collective centres, con-stituted the most vulnerable population. Some hadexperienced traumas at an early age.

The past 12 months had seen considerableimprovement in mental health.The Ministry ofHealth and Social Policy was finalizing a multidisci-plinary project to reduce and eliminate sufferingand to facilitate treatment.The support of WHO inthose efforts would be welcomed.

Zambia

Mr Mumba observed that mental health problemscontinued to have a considerable negative impacton his country’s health status.While Zambia haddone a great deal to upgrade the quality of mentalhealth care in recent years, there had been a signif-icant erosion of the human resource base, in par-ticular, front-line mental health workers. Healthinfrastructures and equipment were in a deplorablestate, and essential psychotropic drugs were onlyintermittently available. Zambia had established apost of mental health specialist, and some progresshad been made. A mental health situation analysishad been undertaken; a draft bill had been submit-ted to the Ministry of Legal Affairs; mental healthhad been integrated into the essential health carepackage at community level, with the possibility of

referrals; and mental health had been accorded itsplace among public health priorities.

Zambia’s participation in international forums andprojects had led to the establishment of key linkswith a broad spectrum of mental health experts. Asa member of the International Consortium forMental Health Policy and Services of the GlobalForum for Health Research, Zambia was pursuingways of securing WHO support, and was partici-pating in the WHO/UNDCP Global Initiative onPrimary Prevention of Substance Abuse. At thelocal level, partnerships had been established withcommunities, giving them a central role in realiz-ing improvements in mental health care. HisGovernment was committed to developing a men-tal health policy, providing human resources formental health, reviewing relevant legislation andupgrading health infrastructure and equipment.New international networks would also be devel-oped that would benefit the local mental healthprogramme. Zambia viewed the stigmatization andmarginalization of people with mental health prob-lems as an inappropriate legacy from the past.Mental health services were a crucial componentof primary health care that would enable people towork productively and fruitfully.The inclusion ofmental health in WHO’s public health agendaunderscored the commitment of governments tothe development and improvement of nationalmental health services in line with relevant resolu-tions adopted by the World Health Assembly, theWHO Regional Committee for Africa, the UnitedNations General Assembly and UNDCP.

Zimbabwe

Dr Stamps said that, after achieving independence,his country had totally recast its Mental HealthAct, so that it was currently dedicated to the needsof the patient rather than to the needs of societyfor protection.The Government had formulated itspolicy on mental illness, on the basis that psychi-atric events were never due to a deliberate act onthe part of the patient, so that all treatment,including the provision of drugs, was free.Therewas, however, a severe staffing problem. Nurseswere being trained but, on qualifying, often wentto more attractive posts abroad.The lack of trainedstaff meant that passive disorders were diagnosed along time after the first symptoms appeared.


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He drew attention to the increasing use of drugs intreating mental disorders, including the adminis-tration of stimulants and sedatives to children agedbetween two and four years.

The use of psychedelic substances to ensnareyouth, for the purpose of commercial gain, was amatter of great concern. Although the worst prob-lem was that of alcohol, dangerous drugs werereadily available to young patrons of night clubs.The involvement of community leaders had beenvery effective in confronting such trends. Heappealed to all to work together to bring about amore spiritual approach to living, in order toreduce temporary or permanent mental disability.


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Report by thesecretariat

This section contains a synthesis of the main issuesraised by the Ministers during the four roundtables.

World health ministers call for action

Ministers unanimously agreed that it is time tofeature mental health on the world healthagenda and to consider the huge burden of

mental health problems as priorities for nationalaction.The fact that countries have to face otherhealth problems and that their health budgets arelimited can no longer be deterrents to action.Mental health problems are significant contributorsto the global disease burden, have huge economicand social costs, and cause human suffering. Newdevelopments persuasively indicate that cost-effec-tive solutions are possible in all contexts. Manystrategies, approaches and interventions have beenidentified and are being used in numerous smallprojects around the world.These need to be evaluat-ed and the results disseminated widely to includethem in national mental health programmes.TheMinisters expressed their commitment to addressingthe pressing mental health needs of their populationsand called for international support and action.

The current social context ofmental health

Ministers expressed the importance of con-textualizing mental health since it is deter-mined by a variety of challenges faced by

their countries. Much of the world is facing rapideconomic reforms and social change, includingeconomic transitions that are linked to alarmingrates of unemployment, family breakdown, per-sonal insecurity and income inequality. Povertyremains a reality for much of the world, withwomen constituting a majority of those affected.Many countries experience political instability,social unrest and war.There are large populationsof traumatized refugees and internally displacedpersons who must be resettled, often in countrieswith limited resources to do so.The spread of HIVand AIDS has had a major social and economicimpact on many countries, leaving large numbersof survivors in need of care and support.Womenface great pressures with a range of gender-based

disadvantages and huge numbers experience physi-cal and sexual violence resulting in high rates ofdepression and anxiety disorders.Young people,particularly street children and those exposed toviolence, are at high risk for substance misuseincluding alcohol. Indigenous people and othergroups are undergoing social upheaval that isaccompanied by climbing suicide rates. In manyparts of the world, mental health systems are poor-ly funded and organized.

Taken together the above concerns cast a broadframework for discussing mental health problemssince they are squarely placed at the heart of thesocial changes of our era. Ministers also broughtup some of the more positive effects of changewhich include a steady increase in awareness,weakening of stigma, and the development of glob-al approaches to mental health problems and pre-vention.They referred to the enthusiastic engage-ment of governments and communities alike in thecelebrations of World Health Day 2001 dedicatedto mental health.

Overcoming stigma and humanrights violations

The ministers repeatedly made urgent callsfor action to further reduce stigma, discrimi-nation and the violations of rights of persons

with mental illness since these affect the wholecontinuum of care. It was noted that the discrimi-nation between coverage of mental and physical ill-ness by health insurance schemas is fed by stigma.There is need to address the institutionalizedstigmatization of persons with mental illness, aprocess exacerbated by the placement of psychi-atric hospitals in far out places away from publicscrutiny. Shifting mental health services to generalhospitals and community clinics has helped inmainstreaming mental health problems; this mustbe pursued. Efficiency can be gained by recyclingthe infrastructure of mental hospitals to serve gen-eral health care purposes. Enforcing minimumstandards in infrastructure, and in the provision ofhigh quality care, coupled by the support of updat-ed legislation, is a critical step in protecting therights of persons with mental illness. Most impor-tantly, addressing stigma amongst all health profes-sions, including mental health workers, was con-sidered necessary.


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Since much of the stigma related to people withmental illness results from lack of information onthe causes, the frequency and treatment possibili-ties, accurate information and education should beprovided to politicians, decision makers, serviceproviders, the general public and the media as aprimary means to reduce stigma.The media caneither reinforce or reduce stigma powerfully. Itneeds to be involved in campaigns designed toeradicate negative stereotypes and promote attitu-dinal change.The role of consumers, families andtheir organizations as well as visible role models instigma reduction efforts was considered pivotal.Educational campaigns must be accompanied bythe development and upgrading of services.

Sensitization on mental health issues, removingignorance, superstitions and false traditionalbeliefs, requires multisectoral approaches andshould include, among others, schools, criminaland judiciary systems, employment agencies, andhousing and welfare systems.

Improving mental health policies and services

Shifting to community-based care and integrating mental health within Primary Health Care

Ministers discussed strategies to advancemental health care beyond the recognitionthat there must be parity between care for

physical and mental disorders.There was agree-ment that mental health care should be intimatelyintegrated into the general health care system. Itwas repeatedly noted that Primary Health Care(PHC) has a significant role to play in mentalhealth services delivery, including in countries withhighly specialised care. Integration into PHC is inline with the global movement in which manynations are engaged in the provision of mentalhealth care shifting it from psychiatric hospitals tothe community. For this shift to occur, budgetsmust be maintained or even increased; mentalhealth teams, with multidisciplinary representa-tion, must be developed; the needs of especiallyvulnerable groups must be met through supervisedcare; communities must have access to crisis cen-tres for the management of acute conditions; andbroad public support for community care must be

secured. Shifting the location of care also facilitatescollaboration with non-governmental organiza-tions, social services, and other community agents,many of which are motivated to fill some of theservice gaps.

Treatment costs

Mental health treatments should be affordable forall those in need. Given that poverty is a risk factorfor mental disorders, the principle of equitabletreatment for the poor must be preserved.Concern was expressed that access to basic psy-chotropic drugs, especially in rural areas, was acrosscutting problem and that strategies to reducecosts should be considered by regions and bygroups of countries, amongst them the bulk pur-chase of essential psychotropic drugs.

Financing of care

Financing community-based mental health care is achallenge for all nations, especially the provision ofcomprehensive care to all those in need. Sincemental health problems have intersectoral ramifica-tions, it was suggested that financing of servicesshould be intersectoral as well; ways to overcomethe barriers in this regard ought to be devised.

Human resources

Many ministers noted that the human resourcebase for mental health care is limited partly due tothe brain drain.Therefore, attention has to begiven to sustainable training programmes in mentalhealth care at various levels of service provision.However, there are unsolved issues in this regardsuch as who should be trained and what should bethe content of that training. Identifying categoriesof health workers who can be trained in the deliv-ery of psychotropic drugs and psychosocial inter-ventions with reasonable quality of care standards,is critical. Protecting mental health professionalsworking under adverse conditions was consideredimportant to prevent the high rates of staffburnout. Special mention was made of the need tobuild capacity in research training in developingcountries.

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Traditional and faith healers

The reality in many countries is that traditional andfaith healers provide much of the mental healthcare in communities because of traditional beliefsand because these practitioners outnumber thosewithin formal health systems.There is a lack ofadequate information on the practices of faith andtraditional healers, and few programmes that artic-ulate collaborative linkages between traditional andmodern medicine systems. Research into theseaspects is urgently needed along with inquiry intothe effectiveness of traditional practices. In themeantime there is need to inform traditional heal-ers and co-ordinate them with the general healthcare system through some form of regulation forconsumer protection.

Consumer and family involvement

To help families in their role as primary caregivers, they must have full access to systems ofsupport including education and training.Consumers/users and their organizations can bemost valuable in providing patient education, peersupport and policy input.

Services for the special needs of women

All agreed that gender issues are pertinent in men-tal health care. Service provision has to take intoaccount women’s health and mental health needsresulting from widespread discrimination. In par-ticular, the mental health needs of victims ofdomestic and sexual violence requires specialinterventions.To properly address this problem,special training must be provided to health work-ers.The reduction of two frequent factors, alcoholand drugs, that facilitate violent behaviour amongmen, demands preventive interventions.

Country strategies

Ministers reported recent developments andapproaches in mental health care in their countries.These included:

Decentralization of mental health services:

■ Downsizing of mental hospitals and establish-ment of community mental health servicesincluding beds in general hospitals.

■ Establishing proper funding for community serv-ices.

Integration of mental health care in primaryhealth care:

■ Training health care professionals and paraprofes-sional workers.

■ Training traditional healers in mental health care.

Improvement of mental health services:

■ Incorporating a gender approach in mental healthpolicies.

■ Using mobile mental health units to serveremote and rural areas.

■ Integrating a mental health component in essen-tial packages of care.

■ Using telepsychiatry to train and consult withmental health workers in rural areas and wherepopulations are dispersed.

■ Monitoring quality of care and human rights vio-lations.

Legal provisions for mental health care:

■ Revising legal provisions for care of persons withmental illness.

■ Decreasing stigma around persons with mentalillness.

■ Involving the mass media.

■ Encouraging self-help, consumer/family groups,and NGOs in mental health advocacy.

■ Replacing stigma-generating labels with stigma-free denominations.

Implementation of multisectoral approaches for mental health:

■ Collaborating with education, employment,social welfare, and other sectors.

■ Building partnership with private enterprises andlabour unions.


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■ Creating employment opportunities for womento empower them economically and reduce stresslevels.

■ Integrating mental health programmes withviolence prevention initiatives.

Meeting the needs of specialgroups

The following population groups were espe-cially mentioned by many ministers sincethey require immediate mental health action

in their countries:

Rural, remote and dispersedpopulations

The unmet needs and difficulties in providing ade-quate health services to rural and dispersed popu-lations were noted.

Services for children and adolescents

A focus on the needs of children emerged.Attention to maternal nutrition, and the pre andpost natal multiple needs of mothers and theirinfants is vital for the normal health and mentalhealth development of children. School aged chil-dren constitute a group that is readily accessiblefor mental health services. School-based mentalhealth activities serve to promote mental health,channel preventive interventions, and educate onthe understanding of mental disorders and thoseaffected by them. Bringing health care workersinto schools also provides an opportunity for earlydetection and treatment of childhood and adoles-cent psychiatric disturbances that often remainundiagnosed. Additionally, children and adolescentsare at high risk for substance misuse and suicidalbehaviour for which sustained prevention and edu-cation are needed. Addressing the special needs ofstreet children and those orphaned by AIDS wasconsidered critical.

Refugees, displaced, indigenous anddisaster-stricken populations

Wars, disasters and displacement have left hugepopulation groups with serious mental healthproblems which countries are unable to addressbecause of limited resources and untrained staff.

Social and economic change is having destructiveimpact on the mental health of indigenous popula-tions which countries acknowledge but are unableto fully address.

Areas for WHO support andcollaboration

Ministers identified ways in which WHOcould provide technical support to countriesat global/regional and country levels.

At the global level, WHO should:

■ Continue global awareness-raising and advocacycampaigns.

■ Provide gender disaggregated estimates of inci-dence and prevalence rates, and on the burden ofmental disorders.

■ Carry out studies on the determinants of mentalhealth problems and the factors that influencemental health outcomes, including spiritual sup-port systems.

■ Promote and support programme evaluation.

■ Produce information (particularly for politiciansand decision makers) on the burden, determi-nants and solutions to mental health problems.

■ Document effectiveness of interventions withspecial reference to prevention, treatment andpatient satisfaction.

■ Update guidelines and materials for prevention,treatment and care of mental disorders.

■ Include more psychotropic drugs in the essentialdrug list and devise strategies to ensure the con-tinuous supply of these essential drugs at afford-able prices.

■ Establish regional and global networks.

■ Mobilize funding support for mental health pro-grammes.

At the national level, WHO should:

■ Support the development of national databaseson mental disorders that can inform policy andservice development.

■ Provide materials and guidelines for communityeducation, awareness raising, and anti-stigmacampaigns.

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■ Collaborate with countries in the implementa-tion of programmes to repair the psychologicaldamage of war and conflict.

■ Provide technical expertise for capacity buildingin research and evaluation.

■ Assist in the formulation of mental health policyand plans, and training of different cadres ofhealth professionals in mental health care.

■ Ensure supply of essential psychotropic drugs.

■ Assist in addressing harmful traditional practices.

■ Assist in mobilizing resources for national pro-grammes.


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A new beginning

Senator the Hon. Phillip C. Goddard

Minister of HealthBarbados

Speech to the plenary

Mr. President, Director-General, colleagueMinisters, ladies and gentlemen, I have thehonour and pleasure to share with you the

salient points of the Ministerial Round Tables onMental Health that were held on Tuesday, May15th.

First let me say that Ministers spoke with greatunanimity on the importance of mental health tohealth and human development and the relativeunder investment in this area of health services. Inthe words of one of our peers, “for too long we hidthis subject”. Another said “our concern for infec-tious diseases should not deter us from dealingwith mental health problems”.Yet another stated,“we must find a share for mental health out of ourlimited budgets”.

Given this response, it is not surprising that allMinisters expressed appreciation to the WorldHealth Organization for placing this subject on theworld health agenda.The overriding theme thatemerged from the discussions was that mentalhealth affected all spheres of human endeavour andthat there is no health without mental health.

Ministers agreed that raising the level of awarenesswas the first priority. Policy makers in governmentand civil society need to be sensitized about thehuge and complex nature of the economic burdenof mental illness and the need for more resourcesto treat mental illness.To quote another Minister,we must “dispel the unjustified pessimism aboutthe treatment of mental disorders”. Indeed, it wasrecognized that new technologies were availablethat are based on scientific evidence. Many of theseare within the affordable range of most countriestoday.

We must also recognize the reinforcing loopbetween poverty and mental disorders.Whilepoverty is often a powerful determinant of mentaldisorders, it is equally true that mental disorderscould deepen poverty. Many families without sup-port could fall into the abyss of poverty fromwhich it would be difficult or impossible to extri-cate themselves.

Ministers agreed that the stigma associated withmental illness was a severe stumbling blockbecause, among many other reasons, it preventedpeople from seeking help. Health professionals arenot immune from the impact of stigma, which they

need to overcome to effectively manage the care oftheir patients. Stigma can also have an insidiouseffect on health policy, such as health insurersdenying parity for the care of mental disorders. Anunderstanding of mental health has to start early inlife, and one Minister commented on the need formental health to be placed in the schools’ curriculato help change attitudes.

Ministers discussed the need to move mentalhealth care from outdated centralized institutionsto community-based alternatives. “For too long,mental health institutions were placed in remotelocations, out of site and out of mind” said oneMinister, “they need to be brought back into popu-lation centres”. Furthermore, he noted “serviceslocated in general hospitals and clinics do not bearthe stigma of the old mental hospitals”.

Of course this transference of care into the com-munity requires new structures and the appropri-ate training of mental health care providers. It wasrecognized that evidence-based interventions in thecommunity require proper knowledge and newskills.This massive effort, that entails the engage-ment of primary health workers to deliver mentalhealth care, poses a challenge for which Ministerswould like to have the support of the World HealthOrganization, particularly in training rural healthcare providers.

There was general agreement that the steady sup-ply of psychotropic drugs was of fundamentalimportance if proper care is to be provided. Manyideas were floated in this regard; one of them wasjoint purchase of drugs by regional entities toreduce the cost to individual countries. It was alsorecognized that in many countries, faith and tradi-tional healers outnumbered mental health workers,and treated large segments of the population. Notmuch was known about their effectiveness, howev-er, and particularly so where traditional and mod-ern methods of treatment coexist.The WorldHealth Organization was asked to devise method-ologies to study these phenomena and to assist inconducting the necessary research. Another areamentioned in this context were studies to providenational epidemiological data and evaluation ofservices including customer satisfaction.

Ministers from war torn countries and regionsraised the need to involve the World HealthOrganization in restoring the mental health of


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traumatized populations. Strategies and techniquesto deal with large numbers of displaced victims ofviolence are needed along with the assistance toimplement the appropriate remedial actions.

Sadly, violence afflicts those countries at peace aswell. It was recognized that there was an alarmingincrease in violence against women in many coun-tries. Ministers often mentioned that domestic vio-lence should be considered an epidemic that oughtto be eradicated. In addition to the physical dam-age and injury caused by domestic violence, therewas also a significant impact on mental health thatwas often more damaging and long-lasting than thephysical injuries.This was evident in the high rateof depression and anxiety disorders amongwomen. Ministers wanted to better understand thegender-based mental health issues.They were allagreed that there was a need for short-term andlong-term strategies to curtail violence againstwomen, their families, the fabric of the communi-ties and ultimately their nations.

The Round Table discussions were at times livelyand informative.They generated much interest. Acomplete report of the issues highlighted duringthe course of the discussions is contained in thereport which I invite you to take back with you.

Finally, I conclude by saying that Ministers sharethe universal concern of listening to people, andcommit to strengthening the pivotal role thepatients and families play in the treatment of men-tal illness. I would further remind you of the pow-erful presentation in the opening Plenary sessionmade by a mother who related her real life experi-ence of living with her son as she struggled to copewith the effects of his schizophrenia.We walkedwith her as she described his trauma and his slowrecovery.We rejoiced with her as together theybegan the process of recovery and the joy of hisfirst job.

Madame, I am sure that I can now say on behalf ofus, your message has been heard.

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Renewing commitment to mental health

Regionalstatements

Regional Office for Africa

Dr Ebrahim M. Samba

Regional Director

Dr Custodia Mandlhate

Regional Adviser for Mental Health

The mental health situation in Africa is a veryserious one indeed. It is recognized thatpoverty, civil strife, armed conflict, alcohol

and drug abuse, among others, stand out as themain causes of mental problems which are a majorconcern of a number of countries in our Region.Needless to say, the HIV/AIDS pandemic is wors-ening the situation, adding considerably to thealready existing psychosocial problems and creat-ing unprecedented need for support, counsellingand care for those affected.

In Africa, political turmoil deserves special men-tion as a causative factor of mental problems. Aswe observe World Health Day today, more than 20of the 46 countries in our Region are experiencingone form of civil disturbance or other.This hascreated at least 10 million refugees and more than30 million internally displaced persons. All thesepeople, especially women, children and the elderlyamong them, are invariably severely stressed physi-cally, psychologically and emotionally.

Also in Africa, as elsewhere, mental problemsremain a hidden burden. Consider some of theeconomic and social costs: lost production frompremature deaths (e.g. suicide); lost productivity ofthe mentally ill who are unemployed, underem-ployed or unemployable; lost productivity of fami-ly members providing care; the cost of accidents bypeople who are psychologically disturbed; directand indirect costs for families caring for the men-tally ill. If we add to these the incalculable emo-tional burden and the diminished quality of life forfamily members of people with mental illness, themagnitude of the problem becomes easier toappreciate.

In most countries of the African Region, mentalhealth programmes are limited to curative healthcare of poor quality, usually provided in decrepithospitals located far away from residential areas.These conditions create a serious problem ofaccess to and acceptability of the treatment.

Hence, dropout rates are very high, and follow-uptreatment as an outpatient is seriously hampered.In those countries where some services are provid-ed, these are mainly for adults with major psychi-atric disorders, the needs of children not beingcatered for.

Also, the pervasive effect of social exclusion result-ing from stigma and discrimination prevents peoplefrom acknowledging their mental health problems,disclosing them to others and seeking treatment.

This situation is not helped by weak or totalabsence of policies, programmes and legislation todeal with the problem in many of our countries.

For example, a recent survey in the 46 countries ofour Region indicates that only half of them havemental health and substance abuse policies.

Although 74% and 71% respectively of the coun-tries have mental health programmes and legisla-tions, these were developed relatively recently –only in the last five years. Some of the most dis-tressing statistics emerging from the survey relateto financing: 84% of the countries spend less that1% of their total health budget (usually 10% orless of the national budget) on mental health.

However, on the positive side, the report indicatesthe existence of drug policies and updated lists ofessential drugs in 93 % of the countries; 64% ofthe countries also have included drugs for thetreatment of conditions like epilepsy, depressionand major disorders like psychosis. Unfortunately,most people who need these drugs cannot affordthem because the costs are prohibitive.The situa-tion is particularly serious in rural Africa whereantidepressants, anticonvulsants and antipsychoticdrugs are rarely available. In relation to the issue ofaccess, it is pertinent for countries to make overalltreatment for mental illness available to the generalpopulation.Therefore, mental health needs to beintegrated into general health, especially primaryhealth care.

All these show very clearly that our countries needto rank mental health higher on their scale ofhealth priorities by providing the necessary fundingas well as appropriate policy and legal frameworksto deal with the problem.

We therefore appeal to individuals, families, com-munities and Governments to use this year to


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rededicate themselves to raising the profile ofmental health, and to creating a solid basis forchanging the present scenario regarding mentalhealth in our Region.

A real beginning was made in Windhoek in 1999when our Health Ministers adopted the RegionalStrategy for Mental Health.

This Strategy serves as a tool to be used byMember States to identify priorities and developand implement programmes at various levels of thehealth system, with particular emphasis on actionat the district and community levels.

The aim of the strategy for mental health and theprevention and control of substance abuse is tohelp prevent and control mental, neurological andpsychosocial disorders, thus contributing to theimprovement of the quality of life of the popula-tions.This can be achieved through the formulationand strengthening of national mental health poli-cies and the development and implementation ofprogrammes in all the Member States in theAfrican Region.

While adopting and implementing the regionalstrategy, all Member States should integrate mentalhealth and the prevention of substance abuse intotheir national health services.This will lead to:

■ a reduction in the incidence and prevalence ofspecific mental and neurological disorders(epilepsy, depression, mental retardation andpsychosocial disorders due to man-made disas-ters) and other prevalent conditions;

■ equitable access to cost-effective mental, neuro-logical and psychosocial care;

■ progress in the adoption of healthy lifestyles; and

■ improvement in the quality of life.

Today, thanks to advances in science and medicine,mental disorders can be correctly diagnosed andtreated with medications or short-term therapy ora combination of approaches.

It is therefore the collective responsibility of all,particularly Governments, to take appropriatemeasures to increase access to care; to improvepublic awareness of effective treatments; to popu-larize the use of effective community-based servic-es; to ensure the existence of conducive socioeco-nomic environments for our people to live in, and

to factor mental health into general health pro-grammes.

We, at WHO, pledge to continue to respond tothese challenges by assisting Member States todevelop evidence-based policies and effectivestrategies that will help our populations achievethe highest possible state of health.

Stop exclusion. Dare to care.

This is the ultimate challenge!

Regional Office for the Americas

Dr George Alleyne

Regional Director

Dr Caldas de Almeida

Coordinator, Program on Mental Health

The Pan American Health Organization,WHO’s Regional Office for the Americas(PAHO/WHO) and the countries of the

Americas have been working together for decadesto promote mental health and improve mentalhealth care in the Region.

These efforts have led to significant advances, par-ticularly following the 1990 Caracas Declaration.These advances include the establishment ofnational mental health policies, plans, and legisla-tion in several countries; the development of inno-vative experiences of community mental healthservices; and the promotion of specific programsfor the treatment of the most prevalent disorders.

Although these advances represent important mile-stones, we recognize that much more must bedone in order for mental health to recover fromthe historical neglect to which it has been subject-ed worldwide, and to meet the mental healthneeds of all populations in the Americas. Manyproblems remain.

For example, in the last few years spectacularprogress has been made toward understandingmental health problems, as well as toward thedevelopment of new and more effective treat-ments.Yet, despite the availability of effectivetreatments for most mental disorders, millions ofpeople suffering from depression, schizophrenia,epilepsy, and other disorders with devastating con-

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sequences still do not have access to these treat-ments.

Similarly, although comprehensive communityservices have proven more cost effective than theolder centralized models, and are preferred bypatients and families, in most places mental healthcare continues to be centered in old institutionsseparated from the general health system and thecommunity.

The recognition of these realities, together withrecent data showing the true magnitude of theimpact of mental disorders, has led to an increasedawareness of the need to mobilize all of civil socie-ty, including policy makers, professionals, users,families, and NGOs, to change the situation.

WHO initiatives and events dedicated to mentalhealth in 2001 have begun this urgently neededprocess of mobilization at the global level and havealready elevated mental health on the global politi-cal agenda.

PAHO/WHO, and the countries of the Americas,have collaborated enthusiastically in these initia-tives and, taking advantage of the unique opportu-nity created in 2001 by the World Health Day, theWorld Health Assembly, and the World HealthReport, are strongly committed to reinforcingtechnical cooperation in mental health.

Based on an evaluation of the current situation, thefollowing objectives have been defined for priorityattention in the Region:

■ implementing national mental health policies andplans ensuring: (a) the restructuring of mentalhealth services, leading to the development ofcomprehensive community-based services andintegrating all necessary facilities and programsto meet the different needs of the populations;(b) the provision of essential treatments for themost prevalent mental disorders, in particulardepression; c) the development of preventive andhealth promotion interventions;

■ creating/revising mental health legislation inte-grating the key elements of mental health policy,and providing basic guidance to protect therights of people with mental health problems;

■ raising awareness and fighting stigma related tomental disorders;

■ reducing inequity and addressing issues of parityto ensure that: (a) disadvantaged populations,refugees, and victims of disasters have access toservices that meet their specific needs; b) parityof mental health services with other types ofservices is achieved;

■ promoting mental health training for health pro-fessionals;

■ improving monitoring and evaluation of theimplementation of mental health plans; and

■ increasing the participation of users and familiesin mental health care.

To attain these objectives, the following actions arespecifically being emphasized in technical coopera-tion with countries:

■ collection and dissemination of information onmental health;

■ development of country capacities to plan, man-age and evaluate mental health services; and,

■ dissemination of guidelines on cost-effectiveinterventions and development of innovativeexperiences.

The establishment of partnerships in the areas oftraining, research and policy development is also akey element of the defined strategy.The confer-ence “Mental Health in the Americas: Partneringfor Progress”, planned for November 2001, willseek to promote these partnerships, taking advan-tage of the momentum created by WHO initia-tives.


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Regional Office for the Eastern Mediterranean

Dr Hussein A. Gezairy

Regional Director

Dr Ahmad Mohit


The selection of mental health as the themeof the year 2001 is a reflection and recogni-tion of the increasing importance of the role

mental health plays in the everyday life of humanbeings.We would like to take this opportunity todispel a common misconception that mental healthis restricted to the treatment of mentally ill per-sons. Mental health is concerned with all aspects ofour daily life, be they emotional, intellectual orbehavioural.The quality of relationships we devel-op and maintain with fellow human beings, ourfamilial bonds, the nurturing milieu we provide forour children to develop their potential, societieswhere individual members are respected and caredfor, civil societies tolerant of dissent, are alldependent on mental health. Mental health thusencompasses, and interacts with, cultural life, tra-ditions, religious aspirations and spiritual life of apopulation.

The countries of the Eastern MediterraneanRegion of WHO are blessed with the existence ofstrong family ties, cohesive social institutions andthe presence of spiritual and religious beliefs hav-ing the potential to positively affect the mentalhealth of the population. However, the Region alsofaces a number of issues which can adversely affectmental health. Our population is very young and isfaced with uncertainties about its future.Youngpeople receive many conflicting cultural messagesrequiring reconciliation of traditions with the newtrends, causing insurmountable stress in manyinstances.Waves of migration and unplannedurbanization, bringing in their wake poverty andloss of social capital, are placing heavy stress notonly on the infrastructure but on the coping abili-ties of individuals as well. A number of countriesof the Region face war, occupation, sanctions andinternal conflicts, and millions of refugees in dif-ferent parts of the Region are straining the socialfabric of the societies they live in as well as facingthe burden of nonassimilation in an alien culture.

There are also existing and emerging issues of theelderly, women and children, who are “doubly vul-nerable” to develop mental health problems.

As far as diseases are concerned, the Region is par-ticularly faced with issues of depression, epilepsy,management of the chronically ill and suicide, theincidence of which is on the rise in many parts ofthe Region. Substance abuse is a major mentalhealth and development problem in the Regionwith grave public health consequences such asincreasing the risk of HIV and other blood-borneinfections.

In the past 15 years, the countries of the EasternMediterranean Region have adopted national pro-grammes of mental health as a method of meetingthe needs of the population.The main strategicapproach of all these programmes is integration ofmental health within the existing health systems,including primary health care. Accordingly, theobjective of the almost all of the national pro-grammes of mental health that are developed incollaboration between WHO and Member States isto develop proper systems for the realization ofsuch integration. Such programmes that havespecifically been put to experience in the countriesof the Eastern Mediterranean Region of WHOduring the last decade have been blessed by a num-ber of opportunities and struggled with a numberof constraints.Thus, the future success and/or fail-ure of such programmes would depend on the cor-rect understanding of these opportunities and con-straints and on finding ways to deal with them.

In some countries, such as Bahrain, Cyprus,Islamic Republic of Iran, Pakistan, Saudi Arabia andTunisia, mental health needs are addressed throughintegration of mental health into existing generalhealth systems in more than one area of the coun-try or on a nationwide basis. Other countries, suchas Egypt, Jordan and the Republic of Yemen, havewell sustained projects of integration of mentalhealth in some areas.There are good examples ofschool mental health programmes in Egypt, IslamicRepublic of Iran, Pakistan and Tunisia. Pakistan andTunisia have also modernized their legislation.Sudan has worked on both modernizing the mentalhealth programme and utilizing the traditionalhealers. Cyprus, Lebanon and Morocco are exam-ples of effective use of NGOs. In Afghanistan athree-month diploma course was coordinated by


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WHO/EMRO in collaboration with the twoneighbouring countries of Islamic Republic of Iranand Pakistan.This model has been recently used totrain a new group, this time using the trainerstrained, in a move towards self sufficiency.Theexperience of Afghanistan can be utilized for coun-tries with similar conditions.

At the regional level, the Region held a majoradvocacy event for mental health connected withthe Region’s ministers of health or their represen-tatives, and signed a declaration in support of men-tal health during the Regional Committee of 1997in Teheran, Islamic Republic of Iran. As a follow-upto this event, a 10-item programme for develop-ment of mental health was proposed and MemberStates asked to choose from among a number ofactivities and start implementation in their respec-tive countries.

As we enter the new millennium, developingcountries face a number of burning issues and chal-lenges that affect all aspects of health, includingmental health. Population explosion, unplannedurbanization, scarcity of human resources, reliabledata and systematic approach to health deliveryand referral and a number of cultural issues areamong these. On the other hand, it is fair to saythat since the middle of this century the generalattitude towards mental health has been changingin both developing and developed countries.Reasons for this change include the coincidence ofmany factors like scientific and technologicaladvancements and socioeconomic changes.Theintroduction of a more accurate and holistic defini-tion of mental health, new scientific discoveriesregarding the etiology and treatment of mental ill-nesses and their treatment, and the possibility ofreturning a considerable number of patients totheir homes and the community are among thesefactors. One of the major by-products of thesedevelopments is the introduction of much bettercoordination between the general and mentalhealth services. Integration of mental health withinprimary health care systems is a major product ofthis coordination.

Let us conclude by pledging to continue to developmental health in the Region and collaborate withMember States to provide the minimum necessarymental health care for all. Let us also note that atthis stage of the development we need to realisti-

cally assess our programmes and determine whatchallenges we face, what assets and opportunitieswe have and what constraints are ahead of us. Onlythrough such a comprehensive approach and trueunderstanding of the real needs and specificationsof each country and community can we developthe capacity to provide an acceptable level of men-tal health for our people.

Regional Office for Europe

Dr Marc Danzon

Regional Director

Dr Wolfgang Rutz


A case for action

Depression and depression-related morbidityand mortality are an important focus of theMental Health Programme of the European

office of the World Health Organization.The dis-tribution of these conditions is not homogeneousthroughout the region. Some countries haverecorded decreasing suicide and depression preva-lence rates while others show increasing depres-sion rates but stable or decreasing suicides. In yetothers, both depression and suicide rates are on theincrease. Among the reasons accounting for thisunevenness are differences in access to mentalhealth services as well as differences in quality ofservices for diagnosis, treatment and monitoring ofdepressive disorders.

In a number of countries affected by rapid socialtransitions, mortality rates are on the increase.These rates can be related to social stress, helpless-ness and loss of identity brought about by sudden,disruptive and severe changes in income, employ-ment, living conditions and belief systems of largenumbers of people who are powerless to resistthem. Such changes can pose overwhelming threatsto mental health through increases in alcoholabuse, depression, suicide, violence, accidents aswell as cardio- and cerebrovascular diseases. Familyviolence is a widespread problem in countriesundergoing rapid transition and armed conflict.

And so is sexual violence which affects women andgirls disproportionately.


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Studies have shown that in Western Europe one infour persons needs psychiatric treatment duringtheir life-time, in some countries, this figure is onein three. Among adolescents, about 15-20% havemental problems. However, mental problems arenot necessarily accurately reflected in the numberof health service contacts since most of thoserequiring mental health care do not use the services.

As in other WHO regions, many European coun-tries spend less than 3% of their health budgets onmental health care, although mental ill health caneasily amount to one third to a half of all healthcare costs.

Mental health services development and obstacles for implementation

More than 50% of all patients in some EasternEuropean countries continue to be treated in largemental hospitals. Stigma and discrimination withregard to mental illness makes early interventionextremely difficult, especially in rural areas.However, there is consensus among most MemberStates on the need to shift from psychiatric hospi-tals to community-based services and on theinvolvement of personnel in mental health care.

Obstacles in Europe are often found in outdatedlegislation concerning the rights of doctors andpatients and in the lack of or limited insurancecoverage for outpatient care. Also, the transfer ofinpatient services to outpatient settings has provedto be complex especially from the stand point offinancing.

Sizable minorities in European countries are affect-ed by poverty and deprivation creating large num-bers of people with increased vulnerabilities tomental and behavioural disorders. Since it is notonly the degree of poverty but the increasing gapbetween the richest and poorest in society whichact as powerful determinants, many people are atrisk of mental problems in the unequal societies inEurope. Overcoming poverty might contribute toimprove mental health but it will not be enough; amore equitable distribution of wealth remains achallenge for all countries.


In some countries positive changes have been madeover the years to reduce stigmatization and humanrights’ violations of people with mental illnessincluding legislative reforms. Such reforms takeinto account the right to freedom and autonomy aswell as the right to health and treatment.Theseefforts have been potentiated by the extensive cele-brations of World Health Day 2001 throughoutEurope. Mass media initiatives aimed at raisingawareness and improving the quality and quantityof information on mental health issues have inten-sified everywhere and it is expected that themomentum generated will be sustained over thenext years.

WHO/EURO response

In order to address the finding that about 40% ofEuropean Member States have no government-sanctioned national mental health plan,WHO/EURO is assisting many of its MemberStates to establish or strengthen their nationalmental health plans.The regional office is activelypursuing technical collaboration activities withmember states to reduce premature mortality incountries undergoing rapid transitions and thosefacing conflicts, address and eradicate stigma andhuman rights violations, control the rise in depres-sion and suicides, and, buffer the effect of genderdisparities in mental health. An area of specialfocus is to assist countries in pursuing psychiatricreforms through the establishment of community-based mental health services and the utilization ofthe primary care system with the active involve-ment of consumers and families.

Mechanisms for collecting reliable country infor-mation, promoting and carrying out research andestablishing programmatic guidelines on variousaspects of mental health have included the settingup specific Task Forces such as the ones onPremature Mortality, National Assessments andMental Health Audits and Destigmatization.Thework of these Task Forces will help to assess thesituation in countries, identify the key determi-nants of mental problems in various populationgroups and asses their impact, analyse the obstaclesto service improvement, design appropriate inter-ventions and strategies and monitor the implemen-


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tation and follow-up of national programmes onmental health. Another objective of the Task Forcesis to evaluate different models of interventions forpromotion, prevention and care and to disseminateevidence-based information on successful strategiesand approaches to Member States.

An example is provided by the heavy toll of mentalhealth problems associated with violence, alcoholaddiction and suicide in men.WHO/EURO isdocumenting this trend and designing appropriateintervention strategies based on different models.Also being investigated are the factors that protectfemales in times of change and transition andwhich lead to better coping by women.The abilityof women to engage in social networking to keep asense of control of their lives and to ask for help intime of need may provide a useful resource modelfor men.

Similarly, research generated in Western Europeancountries is being used to assist East Europeancountries to understand the complex socio-psycho-logical processes currently being experienced bytheir populations. Promoting the practices of main-taining strong family ties, cohesive networks offamilies and friends, and spiritual and religiousbeliefs will hopefully protect some of the sociallydistressed societies from major mental health prob-lems. EURO will continue to promote bilateraland multilateral collaboration including exchangeof experience between Eastern and WesternEuropean countries in a mutually respectful way.

A European Ministerial meeting will be convenedin the near future to provide further direction andguidance to EURO’s mental health programme andto reach consensus on its broad strategic direc-tions.

Regional Office for South-East Asia

Dr Uton Muchtar Rafei

Regional Director

Dr Vijay Chandra


Populations of Member Countries of theWorld Health Organization’s South-East AsiaRegion have suffered for ages from many

communicable diseases. Some have been successful-ly controlled, while others continue to be seriouspublic health problems. However, it is now increas-ingly clear that noncommunicable diseases, includ-ing mental and neurological disorders, also causeuntold suffering and death in the Region.Worldwide, an estimated 450 million people sufferfrom mental and neurological disorders or frompsychosocial problems related to alcohol and drugabuse. Our Region accounts for a substantial pro-portion of such people.Thus, the Region faces thedouble burden of disease – both communicable andnoncommunicable. Moreover, with the populationincreasing in number and age, Member Countrieswill be burdened with an ever-growing number ofpatients with mental and neurological disorders. Asstated by Dr Gro Harlem Brundtland, the Director-General of WHO, “Many of them suffer silently, andbeyond the suffering and beyond the absence ofcare lie the frontiers of stigma, shame, exclusionand, more often than we care to know, death.”

In SEAR Member Countries, mental health pro-grammes have generally concentrated on hospital-based psychiatry. However, there is increasingawareness in these countries of the need to shiftthe emphasis to community-based mental healthprogrammes.The WHO Regional Office forSouth-East Asia is concentrating on supportingMember Countries to develop community-basedmental health programmes and also programmesfor prevention of harm from alcohol and sub-stances of abuse.The programmes will be gender-appropriate and culture-sensitive and reach out toall segments of the population, including marginal-ized groups.

There are many barriers to the implementation ofcommunity mental health projects and pro-


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grammes.While some countries have developedmental health policies, there has not been adequateimplementation. Governments urgently need to besensitized on the importance of mental health andon clearly defining the goals and objectives forcommunity-based mental health programmes.Mental health services should be integrated intothe overall primary health care system. At the sametime, innovative community-based programmesneed to be developed and research into relevantissues and traditional practices promoted.Communities have to be educated and informedabout mental and neurological illnesses to removethe numerous myths and misconceptions aboutthese conditions. But most important, the stigmaand discrimination associated with mental illnessmust be removed.

The Regional Office is developing strategies forcommunity-based programmes based on five “A”s:Availability, Acceptability, Accessibility, Affordablemedications and Assessment.

Availability

Services to address at least the minimum needs ofpopulations in mental and neurological disordersshould be available to everyone regardless of wherethey live.The key questions are: what are the mini-mum services needed and who will deliver them?

Acceptability

Large segments of populations in the countriescontinue to perpetuate superstitions and falsebeliefs about mental and neurological illnesses.Many believe that these illnesses are due to “evilspirits”.Thus, even if appropriate medical servicesare made available, they would rather go to sorcer-ers and faith-healers. Populations need to beinformed and educated about the nature of neu-ropsychiatric illnesses.

Accessibility

Services should be available to the community, andat a time convenient to them. If a worker has togive up his daily wages, and travel a substantial dis-tance to see a medical professional who is onlyavailable for a few hours a day, he/she is unlikelyto seek these services.

Affordable medications

Frequently, medications are beyond the reach ofthe poor. Every effort should be made to ensure anuninterrupted provision of essential medications,at a reasonable cost.Thus, government policies interms of pricing and the role of the pharmaceuticalindustry in distribution and pricing become criti-cal.

Assessment

Being new, these programmes need to be continu-ously assessed to ensure appropriateness and cost-effectiveness. Changes in the ongoing programmesbased on impartial evaluations are essential.

Mental health care, unlike many other areas ofhealth, does not generally demand costly technolo-gy. Rather, it requires the sensitive deployment ofpersonnel who have been properly trained in theidentification of illnesses, use of relatively inexpen-sive drugs and psychological support skills on anoutpatient basis.What is needed, above all, is foreveryone concerned to work closely together toaddress the multifaceted challenges of mentalhealth.


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Regional Office for the Western Pacific

Dr Shigeru Omi

Regional Director

Dr Helen Hermann

Regional Adviser (a.i.) for Mental Health

Mental health is the foundation of all health.Scientific evidence and research today underscorethe inseparable links between mental and physicalhealth. But while physical health has improved inthe Western Pacific Region, mental health hasdeclined over the last 50 years.

Social and economic factors have had a significantnegative effect on the level of mental health. Mentaland neurological disorders include common disor-ders such as depression, anxiety, and substanceabuse and dependence; less common but disablingconditions such as schizophrenia; epilepsy anddementia; and intellectual disability. Suicide is animportant problem closely linked to mental health.

According to some estimates, the burden of mentaldisorders is higher in the Western Pacific Regionthan in some other parts of the world. In the rela-tively affluent countries of the Region, mental disor-ders accounted for 27% of the disease burden in1999, and in the other countries the figure was 15%.

The obstacles to improving mental health rangefrom poverty, family disruption, uncontrolledurbanization, disasters and armed conflict, andproblems resulting from the situation of refugeesand displaced persons, to community attitudes andknowledge, insufficient attention to healthy poli-cies, low priority for services, and outmoded andinadequate service provision aggravated by weaklinks to community resources.

In the Western Pacific Region, two key strategicdirections are proposed to improve mental health.First, the application of the public health approach tomental health promotion and the prevention and treatmentof illness. This includes intersectoral approaches tomental health promotion (including legislation, poli-cy and workforce training), gathering and dissemi-nating the evidence of the effect on mental health ofdecisions in these areas, more specifically, preven-tion of disorders among groups at high risk (such asthose with harmful use of alcohol and new mothers

with a history of depression), and organization ofacceptable, accessible and effective health services.

Second, the integration of mental health services intogeneral health services and the wider community.Integrated services of a good standard will providefor (a) early recognition and treatment of mentalhealth problems and mental disorders, and (b) con-tinuity of care close to home, family and employ-ment for those with persisting disabilities.Providing quality service will require improvingcommunity awareness and reducing the stigma anddiscrimination affecting those with mental disor-ders and their families; easy and quick access totreatment and care; improved provision and organ-ization of mental health services; appropriate legalprotection; workforce training in mental healthskills; service standards and accreditation; inclusionof support for consumers and families, self-helpand advocacy associations in treatment and plan-ning; a culture of service and programme researchand evaluation; and attention to the psychosocialaspects of health care.

It is recognized that to improve mental health andaddress the challenges posed by mental disorders,WHO/WPRO and its partners will need to takeconcerted action. Action is needed at several levels– awareness, policy and intervention – and indeveloped and developing countries alike.WPROwill, therefore, work with countries and otherpartners to:

■ analyse the situation and develop policies andprogrammes that reflect emerging perspectivesin mental health;

■ develop the technology needed for prevention,treatment and rehabilitation programmes;

■ integrate mental health care into general healthcare;

■ reorient services from hospital-based to commu-nity mental health care;

■ develop a culture of research and evaluation; and

■ include mental health in health promotion pro-grammes.

WHO/WPRO is committed to using the frame-work of an agreed mental health strategy to workwith Member States and other partners to translatethese elements into action.


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WHO’s response to theMinisters call for action

Benedetto Saraceno

DirectorDepartment of Mental Health and Substance DependenceWorld Health OrganizationGeneva

Epilogue

It is with a deep sense of satisfaction that weare witnessing the emergence of a phenome-nal movement for improving mental health at

international and national levels.This movement isthe result of a series of events that unfolded pro-gressively throughout 2001 in WHO and countriesaround the world. Never before did Mental Healthreceive such central focus during a single year, norwas there ever before a stronger sense of solidarityand mobilization of people around this criticalhealth concern. Non-governmental organizations,private sector entities, academics, professionalgroups, and the media have expressed eagerness toteam up with governments and civil society toincrease access and means of addressing the mentalhealth needs of all people.

Key amongst the recent events that have led to thisglobal response for mental health is undoubtedlythe consensus reached by more than one hundredMinisters of Health on the need to prioritize themental health needs of their populations since thiswas threatening the wellbeing of large segments oftheir populations and compromising the socioeco-nomic development of their nations.They madeclear their beliefs by stating that the round tableson the theme of mental health were “long over due”and “historic” because “for too long we hid the subject”,and that “our concern for infectious diseases should notdeter us from dealing with mental healthproblems…...we must find a share for mental health outof our limited budgets”.This new political commit-ment provides an important platform for scalingup action in mental health.

The reasons that have propelled WHO to bringmental health into the limelight are multiple andwell described in the different sections of thisbook. On the one hand there is the alarming epi-demiological burden and projected increases inincidence and prevalence of mental, neurologicaland behavioural disorders, the vast treatment gapand, the epidemic stigmatization and human rightsviolations of people with mental problems. On theother hand, there is the solid scientific evidencethat provides us with strong basis for action.Psychotropic drugs with less adverse side effectsare now available to treat different crippling disor-ders, such as schizophrenia and depression.Themechanisms of their action are better known andindications for their proper use have been system-atized and made available for specialized and non

specialized medical personnel. Psychological inter-ventions for depression have been researched andtheir success rates documented.The effect of mod-ifying the family environment to reduce negativeoutcomes in some disorders such as schizophrenia,have been carefully tested.We have also made hugeadvances in identifying the best channels for deliv-ering these treatments to people in the context ofthe primary health care and as close as possible tocommunities where people live.

Indeed, evidence is replacing ideology or traditionand all this new information is persuading manythat the practice of mental health care can nowhave a scientific anchor. But progress in actuallymaking the shift from knowledge to action is slowand uneven in countries. Recent surveys carriedout by WHO Department of Mental Health showthat no more than one third of persons with schiz-ophrenia receive any treatment. It is likely thetreatment gap is much higher since the basis forthe calculations world-wide were studies carriedout in countries where mental health care wasmore readily available.The case of epilepsy alsoillustrates well the treatment gap. Between 60 to90% of treatable patients with epilepsy receive nocare, 5% or less of people who have depressive dis-orders have access to treatment in resource poorcountries. Moreover, even when treatments areaccessible, people do not seek care for long peri-ods of time because of the fear of being stigmatizedby health workers, community and society at large.And, the prevalence rate of mental disorders can-not be reduced without reduction in the treatmentlag.

These facts beg an appropriate response by govern-ments.The reorientation of services, the use ofavailable technologies and the promotion ofhealthy public policies can make a difference. Itwas time therefore for WHO to stimulate andcatalyse a collective response for mental healthaction by taking the evidence to the internationalcommunity, governments and the public.This iswhat we tried to achieve through the messages oftheWorld Health Day (7th April) which reached allsectors of society.

This is also what we tried to achieve through theMinisterial Round Tables in the World HealthAssembly this year by arousing the interest and moti-vation of health ministers to place mental health


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squarely on the health and development agendas oftheir countries.The results of the Assembly RoundTables have been very encouraging. 132 Ministersof Health from all parts of the world came togeth-er and collectively expressed their political com-mitment for addressing people’s needs in this area.They highlighted their strengths as well as theirshortfalls in so doing during their discussions.Theyalso made a strong call for international supportspecifying WHO’s intensified technical support inpriority areas. Based on these requests, we are pro-posing a global mental health strategy to ensurethat WHO at headquarters, regional and countrylevels can assist countries effectively in achievingtheir national mental health goals.

The strategy consists of the four following pillars:

■ generating information and disseminating itwidely;

■ supporting countries in developing their policies;programmes and services;

■ promoting research and building nationalresearch capacity;

■ strengthening advocacy and protection of humanrights.

The first pillar addresses two essential elements:one which aims at increasing significantly the quan-tity and quality of information available to policy-makers and service providers on the science andprogramme experience related to mental healthcare, promotion and prevention.We believe thateven if a small fraction of what is known can bemade available to those who plan and provide serv-ices, it will have a large impact.The second armaddresses the existence of tremendous gaps inknowledge about the state of mental health incountries as well as lack of information on coun-tries’ capacity to address the factors affecting men-tal health. Intensified support to countries willneed to be provided for building national informa-tion systems for the collection of reliable datarelating to mental health systems and their moni-toring, the evaluation of service delivery, and thecollection of basic epidemiological information.Particular attention will be given to ensure theseefforts are compatible with and linked to broaderhealth sector information systems.

The second pillar of the strategy will redress thecurrent situation in which more than 40% of coun-

tries have no mental health policy and over 30%have no mental health programme. Even countriesthat do have mental health policies often disap-pointingly neglect some of the more vulnerablepopulations. For example, over 90% of countrieshave no mental health policy that includes childrenand adolescents. Providing a comprehensive pack-age of support to countries to develop capacity forpolicy and service development in prevention,treatment and surveillance of mental disorders istherefore a much-needed activity.The developmentof the package would be accompanied by technicalassistance to countries, upon their request, forplanning and financing of comprehensive mentalhealth systems. Essential elements will include leg-islation, service planning especially the integrationof mental health into the larger public health sys-tem, human resource development, services forespecially vulnerable populations such as women,children, elders, refugees, adolescents and thosewith chronic physical illnesses and/or disabilities,and quality of care.

The third pillar of the strategy addresses researchand country support for building research capacity.The impetus for considering research one of thefour pillars of our strategy is driven by the under-standing that there is currently very limitedresearch capacity in most countries and a seriouslack of trained researchers, especially in low andmiddle income countries.Yet this is a critical andessential element of health system development.Most current research on mental health is conduct-ed in a few wealthy countries and we know thatthe relevance and transferability of findings fromwealthy countries to poorer countries remainsquestionable.This is a serious contributing factorto the lack of locally relevant and evidence basedmental health policies and practices based on oper-ational research findings. Encouraging and sup-porting countries to build the necessary infrastruc-ture to sustain research capability, in particularapplied research, is essential for improved efficien-cy and effectiveness of services as well as forextending knowledge about the causes, preventivemeasures, and the possibilities of treatments.

The fourth pillar, pertains to the critical role of sus-taining advocacy for mental health at the interna-tional, regional and national levels.Through the useof partnership relationships with governments,NGOs and community groups, countries will be

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supported in developing their important advocacysector in order to position mental health on the pub-lic agenda, to promote a greater understanding andacceptance of those affected by mental illness, topromote legislation for the protection of the humanrights of people with mental illness, to reduce thepervasive effects of social exclusion resulting fromstigma and discrimination and the out-dated natureof many mental institutions. Less exclusion, less dis-crimination will help those afflicted and their fami-lies to lead better and more productive lives andencourage those in need to seek treatment.

The systematic process of awareness raising andadvocacy launched through the World Health Daycampaign “Stop exclusion. Dare to care”, will con-tinue to provide the platform for generating enthu-siasm, inspiring people to represent the needs offamilies and consumers in policy, legislation andservice delivery; and ensuring that the response ofthe mental health system matches the real needs ofpeople with mental illness.

While beneficial results of this strategy are alreadyevident, we expect much more substantial impactwithin the next three to five years. In order to bet-ter assess the impact of these activities, a systemat-ic and in-built mechanism of evaluation is beingput in place.We believe that we can optimally tar-get our limited resources only through a continu-ous evaluation of the results of what we do,whether the area is research,policy/programme/service development or advo-cacy.The same applies for countries.

In conclusion,WHO wishes to pay tribute to theMinisters of Health who iterated a strong call formental health action during the World HealthAssembly of 2001. In aligning our strategic direc-tions with their expressed concerns and priorities,we want to ensure that our vision and goals arecollective and that they follow pathways that arerealistic as well as achievable.We appeal to all whoshare this vision to join us in improving access andquality of mental health care for all those who havewaited far too long.


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List of participants of the round tables

Annex

ROUND TABLE – Room VI I

Chair Mr Phillip Goddard (Barbados)

Facilitators Professor Jill Astbury (Australia)Professor Arthur Kleinman (United States of America)

Belgium Mrs Magda Aelvoet

Burkina Faso Mr Pierre Tapsoba

Cameroon Mr U. Olanguena Awono

Chile Dr Carmen López

Denmark Mr Arne Rolighed

Dominica Dr John Toussaint

Ecuador Dr Patricio Jandriska

Ethiopia Dr Menilik Desta

Fiji Mr Pita K. Nacuva

Germany Mrs U. Schmidt

Hungary Mr Gyula Pulay

Lesotho Mr T. Mabote

Mexico Dr Julio Frenk Mora

Mongolia Professor P. Nymadawa

Morocco Mr Thami El Khyari

Namibia Dr Libertina Amathila

Nepal Mr Ram Krishna Tamrakar

Oman Dr Ali Bin Mohammed Bin Moosa

Pakistan Dr A.M. Kasi

Paraguay Dr Martin Chiola

Poland Professor Grzegorz Opala

Qatar Dr H.A.H. Al-Bin-ali

Republic of Korea Dr Kyeong Ho Lee

Saint Kitts and Nevis Mr Earl Martin

San Marino Mr Romeo Morri

Senegal Mr Abdoul Aziz Diop

Singapore Professor Ee Heok Kua

Slovenia Mr Dorjan Marusic

South Africa Dr M.E.Tshabalala-Msimang

Turkey Professor Orhan Canbolat

Zambia Dr L. Mumba


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ROUND TABLE – Room XI I

Chair Mr Lyonpo Sangay Ngedup (Bhutan)

Facilitators Dr J. López-Ibor (Spain)Dr Sylvia Kaaya (United Republic of Tanzania)

Angola Dr Albertina Hamukwaya

Belarus Dr Igor Zelenkevich

Bosnia and Herzegovina Dr Zeljko Misanovic

Botswana Ms Joy Phumaphi

Brazil Dr João Yunes

Brunei Darussalam Mr Ahmad Matnor

Democratic Republic of the Congo Professor Mashako Mamba

Gabon Mr Faustin Boukoubi

Greece Professor Christina Spyraki

Grenada Dr Clarice Modeste-Curwen

Guatemala Mr Mario Bolaños Duarte

Haiti Dr Henri-Claude Voltaire

Israel Dr A. Leventhal

Jordan Dr S. Kharabseh

Lao People’s Democratic Republic Dr Boungnong Boupha

Liberia Dr Peter S. Coleman

Madagascar Professor Henriette Ratsimbazafimahefa

Maldives Mr Ahmed Abdullah

Nicaragua Dra Mariángeles Argüello

Norway Mr Tore Tønne

Peru Sr Dr Eduardo Pretell Zárate

Rwanda Dr Ezéchias Rwabuhihi

Samoa Mr M. Siafausa Vui

Sierra Leone Dr I.I.Tejan Jalloh

Slovakia Mr Svätopluk Hlavacka

Sri Lanka Mr W.D.J. Seneviratne

Switzerland Ms Ruth Dreifuss

Uganda Dr C. Kiyonga

United Arab Emirates Mr Hamad Abdul Rahman Al-Madfaa

United States of America Mr Tommy Thompson

Yemen Dr Abdul Nasser Ali Al-Munibari

A N N E X

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ROUND TABLE – Room XVI I

Chair Mrs Annette King (New Zealand)

Facilitators Professor Julian Leff (United Kingdom of Great Britain and Northern Ireland) Dr Lourdes Ignacio (Philippines)

Algeria Dr M. Abdelmoumène

Bahamas Dr Ronald Knowles

Bangladesh Mr Sheikh Fazlul Karim Selim

Canada Mr A. Rock

China Dr Peng Yu

Côte d’Ivoire Professor Raymond Abouo N’Dori

Cuba Dr Carlos Dotres Martínez

Cyprus Mr Frixos Savvides

Egypt Professor Ismail Sallam

France Dr Bernard Kouchner

Gambia Mr Y. Kassama

Georgia Dr A. Gamkrelidze

India Dr C.P.Thakur

Iran (Islamic Republic of) Dr Mohammad Farhadi

Japan Mr Jungoro Kondo

Mali Dr Fatoumata Traoré Nafo

Mozambique Dr Francisco Ferreira Songane

Myanmar Mr Ket Sein

Netherlands Dr E. Borst-Eilers

Niger Mr Assoumane Adamou

Nigeria Professor A.B.C. Nwosu

Panama Dr Fernando Gracia García

Papua New Guinea Mr Ludger Mond

Portugal Mr José Manuel Boquinhas

Russian Federation Professor V.N. Krasnov

Saudi Arabia Dr Mohamed Abdullah Al Shawoosh

The former Yugoslav Republic of Macedonia Dr Muarem Nedzipi

Tunisia Dr H. Abdessalem

United Kingdom of Great Britain and Northern Ireland Ms Jane Hutt

Uruguay Dr E.Touyá

Viet Nam Professor Pham Manh Hung

Zimbabwe Dr Timothy J. Stamps


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ROUND TABLE – Room XVI I I

Chair Professor M. Eyad Chatty (Syrian Arab Republic)

Facilitators Dr Vikram Patel (India)Ms Paula Mogne (Mozambique)

Argentina Dr Hector Lombardo

Australia Professor John Mathews

Austria Professor Reinhart Waneck

Bahrain Dr Faisal Radhi Al-Mousawi

Benin Professor G. Ahyi

Bolivia Dr Guillermo Cuentas-Yáñez

Chad Mme Fatimé Kimto

Colombia Sra Sara Ordoñez Noriega

Croatia Dr A. Gilic

Czech Republic Professor Bohumil Fise

Democratic People’s Republic of Korea Mr Ri Si Hong

Dominican Republic Sra Angela Caba

Finland Dr Jarkko Eskola

Ghana Dr Richard W. Anane

Guinea Dr Mamadou Saliou Diallo

Guinea-Bissau Dr Francisco Dias

Honduras Dr Plutarco Castellanos

Iceland Mr David Gunnarsson

Indonesia Dr Achmad Sujudi

Iraq Dr Omid Midhat Mubarak

Italy Dr F. Oleari

Jamaica Mr John Junor

Malaysia Mr Chua Jui Meng

Mauritius Mr Ashok Kumar Jugnauth

Romania Dr Daniela Bartos

Saint Lucia Mrs Sarah Flood Beaubrun

Sudan Dr Ahmed Bilal Osman

Sweden Mr Lars Engqvist

Thailand Dr Winai Wiriyakitjar

Tonga Dr V.T.Tangi

Trinidad and Tobago Dr Rampersad Parasram

United Republic of Tanzania Ms Anna M. Abdallah

Venezuela Dra María Lourdes Urbaneja Durant

Yugoslavia Dr M. Kovac

A N N E X

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Mental health is the capacity

of the individual, the group and the environment

to interact with one another in ways that

promote subjective well-being,

the optimal development and use of mental abilities,

the achievement of individual and collective goals

consistent with justice and

the attainment and preservation

of conditions of fundamental equality.

World Health OrganizationDepartment of Mental Health and Substance Dependence

Avenue Appia 201211 Geneva 27

SwitzerlandTel:+41 22 791 21 11Fax:+41 22 791 41 60E-mail: [email protected]

Website: www.who.int/mental_health WH

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