* This text was contributed by Thomas Bornemann, Mental Health and Substance Dependence, WHO, and Walter Gulbinat, Consultant, Global Forum for Health Research .
12 World Health Report 2001. World Health Organization, Geneva.
13 N e u rological, Psychiatric, and Developmental Disorders: Meeting the challenges in the developing world. Institute of Medicine, USA, 2001.
14 World Health Report 2001. World Health Organization, Geneva.
15 Srinivasa Murthy, WHO. Paper presented at Forum 5, October 2001.
16 Project ATLAS, WHO 2000-2001. Geneva 2001.
people will develop one or more mental or behavioural disorders at some stage in their lives.12 Recent estimates show that, in low-to middle-income countries, neuro l o g i c a l , psychiatric and developmental disord e r s account for nearly 15% of DALYs, 12%
of all deaths, and 34% of DALYs fro m noncommunicable diseases13.
Mental disorders have clear economic costs.
Sufferers and their families or care givers often experience reduced productivity at home and in the workplace. Lost wages, combined with the possibility of catastrophic health care costs, can seriously affect patients and their families’ financial situation, creating or worsening poverty.
Mental health problems can lead to antisocial and self-harming behaviours, substance misuse and risk-taking behaviours which expose individuals to potential harm from outcomes such as accidents and sexually transmitted diseases. Poverty limits the treatment of mentally ill patients and good mental health contributes to well-being and to incre a s e d p roductivity and social cohesiveness. Mental d i s o rders also affect the course and outcome of co-morbid chronic conditions, such as cancer, h e a rt disease, diabetes and HIV/AIDS.
2. Mental health and the intern a t i o n a l agenda
(a) World Health Organization
In 2001, for the first time WHO devoted World Health Day and the World Health Reportto the issue of mental health.14 During the World Health Assembly, all four ministerial roundtables focused on this issue.
As a follow up to these activities, WHO
launched the mental health Global Action Programme which is described below.
At the World Health Assembly, a session on mental health and neurological development reviewed the main messages of the WHR 200115 as well as key future research areas.
The re p o rt identified that the burden of mental and neurological disorders is large, cost-effective interventions are available but still not used adequately and examples of
“best practices” illustrate what can be achieved following sustained action. The R e p o rt recommends that all countries, regardless of resources available, should take action to:
• provide treatment in primary care
• make psychotropic drugs available
• give care in the community
• educate the public
• involve communities, families and consumers
• establish national policies, pro g r a m m e s and legislation
• develop human resources
• establish links with other sectors
• monitor community mental health
• support more research.
The uneven distribution of re s o u rces for mental health within countries was described based on the findings of WHO’s AT L A S project.16 Data collected from 185 countries revealed that over 40% of countries do not have a mental health policy, 25% do not have legislation on mental health, 28% do not have a separate budget for mental health, 37% do not have mental health facilities and 70% of the world’s population has access to less than one psychiatrist per 100 000 people.
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17 Neurological, Psychiatric, and Developmental Disorders: Meeting the challenges in the developing world. Institute of Medicine, 2001.
18 “Final Report, International Consortium for Mental Health and Policy Research.” Global Forum for Health Research, 2001.
In response to these two documents, WHO launched a five-year Mental Health Global Action Programme (mhGAP) to provide a clear and coherent strategy for closing the gap between what is urgently needed and what is currently available in an effort to reduce the burden of mental disorders worldwide. The goal is to support Member States by strengthening their capacity to reduce the stigma and burden of mental disorders, with a particular emphasis on six conditions (depression, schizophrenia, alcohol and drug dependence, dementia, epilepsy and suicide).
The mhGAP will have four core strategies:
• information
• policy and service development
• advocacy
• research.
(b) Institute of Medicine
In June 2001, the Institute of Medicine (IOM) of the US Academy of Sciences, supported by the Global Forum for Health Research, four institutions of the National Institutes of Health (NIH) and the US Centers for Disease C o n t rol and Prevention (CDC), jointly published a report on Neurological, Psychiatric, and Developmental Disorders: Meeting the challenges in the developing world.17
In order to identify opportunities for research leading to successful interventions in the near future, the re p o rt focused on:
(i) developmental disorders; (ii) bipolar disorders; (iii) depression; (iv) epilepsy; (v) s c h i z o p h renia; (vi) stroke. Each of these disorders or group of disorders is common, and preventable or treatable.
In addition to future research areas quoted b e l o w, the main recommendations of the report are:
• Increase public and professional awareness and understanding in low- and middle-income countries.
• Intervene to reduce stigma and ease the burden of discrimination often associated with these disorders.
• Extend and strengthen existing systems of primary care to deliver health services.
• Make cost-effective interventions available to patients.
• Create national centres for training and research on brain disorders.
• C reate a programme to facilitate competitive funding for research and for the development of new or enhanced institutions devoted to brain disorders in low- and middle-income countries.
(c) A research network supported by the Global Forum18
An increasing number of countries are reviewing and reorganizing the structure of their national health care services in an effort to limit costs, while at the same time enhancing equity and effectiveness. As a result, they need ready access to the basic tools for mental health policy formulation: for assessing the mental health status of the population; for understanding the strengths and weaknesses of the actual system in place;
and for studying the alternatives that exist and may already be in operation in other countries.
There is no universally applicable blueprint for formulating and implementing national mental health policy. In response, the Global F o rum launched a collaborative re s e a rc h project with a focus on Mental Health Policy and Services. Funding covered the period from March 2000 to December 2001, which was devoted to the development of methods and instruments. The objectives were: (i) to
identify and document key elements of a national mental health policy; (ii) to provide tools and methods for assessing the current situation regarding a country’s mental health policy, programmes, services and care; and (iii) to establish a global network of expertise (institutions and experts).
A Co-ordinating Centre in each of the six WHO Regions was identified, and regional groups established. Each group adapted a research protocol to the regional sociocultural situation and reviewed research instruments to assess the mental health situation in selected countries. Countries involved included Azerbaijan, Bulgaria, Chile, India, Iran, Lithuania, Malaysia, Nepal, Pakistan, the Philippines, Thailand, Trinidad and Tobago, Uganda, Ukraine and Zambia. The countries started the process of completing National Mental Health Country Profiles.
The work during this two-year project period resulted in the following products (available on request from the Global Forum):
• The Mental Health Country Profile: a description of the structures and human resources available in a country.
• The Mental Health Policy Template: a tool to evaluate policy elements.
• The Focus Group Approach: a method for involving the major stakeholders for research.
• An international network of re s o u rc e centres for mental health policy and system research.
3. Mental health needs
It is important to clarify what is meant by mental health. WHO defines health as “a state of complete physical, mental and social well-being and not only the absence of disease and
infirmities”. And the World Health Report 2001 describes how mental health has been variously defined by scholars from different c u l t u res, concluding that “it is generally agreed that mental health is broader than a lack of mental disorders”19.
The following categories illustrate the various dimensions related to mental health20 (Insert 8.6.1).
4. De-institutionalization of mental health patients and treatment
The last 100 years of mental health management saw a shift in the way communities approach this. While mental health patients were normally treated in mental health institutions, over the past three decades there has been a gradual shift towards the de-institutionalization of mental health s e rvices. The decision of the Italian G o v e rnment in 1978 to close all mental hospitals received global attention. Since then, most other countries have been trying to find an optimal balance between specialist and primary health care services and between hospital and community care. However, this requires strengthening community health care systems to look after these patients, emphasizing the need for training of staff and for adequate financing for mental care referral systems. The following include some of the key requirements for de-institutionalization to be effective:
• The de-institutionalization of patients with severe mental illness needs to be linked to an upgrading of the health care systems within the community that will have to receive them.
• In order to deliver care to a significant segment of the mentally ill population, primary care and social services must have
19 World Health Report 2001, World Health Organization, Geneva.
20 Report on a meeting of the project’s Organizing Committee, Kampala, 13-14 March 2000.
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