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Minister
Aelvoet,
Commissioner
Byrne,
Excellencies,
Ladies and
Gentlemen,
It is a great pleasure for me to be here today.
As a physician, and later as a Prime Minister, I
saw for myself how hard it was to strengthen mental health policies in
my own country, Norway. This brought home to me the difficulties faced
by those working to improve mental health in both developed and
developing countries.
I saw how mental health issues so often were at the
periphery of public health practice.
But it is not logical for mental health to
be so marginalized. For years there has been enough knowledge about
mental illness to reveal similarities with the issues and structure of
physical health.
It is also not right that mental health is
on the margins, because the separation of mental health from other
health concerns has contributed to stigma, discrimination and the slow
progress of mental health services.
The World Health Organization has a clear mandate
to promote equity in human health throughout the world. During the
last three years we have sought ways to move mental health into a more
prominent position within global public health efforts.
There is abundant evidence of the need to do this. Let
us review the available information about the extent to which mental
ill health contributes to the global burden of disease.
Almost 500 million people are suffering from mental
disorders today. One in four families have at least one member with a
mental disorder at any point in time. And they are on the increase.
From 12 per cent of the total burden of disease and projections
for 2020 reach 15 per cent. Mental disorders account for 30 per cent
of all years lived with disability. Depressive disorders are the
fourth leading cause of disease and disability. They are expected to
rank second by 2020.
Those are the global figures. But also in Europe,
mental disorders figure among the leading causes of disease and
disability. In the WHO European Region, and remember that it stretches
as far east as Vladivostok and as far south as Tashkent, 33 million
people per year have been estimated to suffer from severe depression.
Depression is also a condition increasingly
affecting adolescents. In a recent European investigation, 5 per
cent of all girls and 1.3 per cent of all boys aged 16, in the country
studied, fulfilled the criteria for severe depression. Fourteen per
cent of girls and about 5 per cent of boys studied were found to be
moderately depressed.
European suicide rates range from 11 to 36 per 100
000 population. The highest rates in the Region are also the highest
in the world.
There are three factors contributing to the
increasing importance of mental ill health in the global burden of
disease.
First of all: We are living in a world of rapid
change. This is experienced by people living in the calmest and
most prosperous corners of the world. They encounter newness at a
breath-taking pace: from new technology to new jobs to new fashions in
entertainment and culture. They are being swirled along in the
rapidity of global transformation.
In the Eastern European states, the end of central
planning and control has led to an even faster pace of change.
Change in itself is not negative. After all, the
human quest for progress is motivating much of our behaviour. And,
much of the change we see today is for the better.
Yet people exposed to rapid change have to cope
with insecurity and unpredictability. And, some of the consequences of
change clearly are negative This is especially the case if change is
imposed on people who are powerless to influence how it affects them.
The second determinant of mental ill health is
poverty. Over the past decades, the world has seen great progress
on many fronts. Great technological breakthroughs. Millions of people
better off. Richness, abundance, and lifestyles characterized by more
opportunity and more choice.
But, in spite of the spectacular growth since 1970,
more than three billion people - that is half of the world’s
population - still remain poor and live on less than two US dollars
per day. Of these, 1.3 billion live on less than one US dollar a
day.
A recent study sought information from 60,000 poor
people in 60 countries. They were asked to share their realities,
their hopes and expectations for the future. When we listen to what
they say, we hear the importance that they give to the peace of mind
that comes from enjoying good health, from a sense of community, from
personal safety and from the predictability of life events. Higher
income is necessary, but not sufficient.
The third influence on levels of mental ill health
is the ageing of the world's populations. Over the coming decades,
we will see a great shift in the demographic structures of both
developing and industrialized countries.
There are currently about 600 million people in the
world aged 60 and over. This figure is expected to rise to 1020
million within the next 20 years - a 70 per cent increase in the size
of this age group. And, by 2020, approximately 70 per cent of this
elderly population will be living in developing countries.
The social consequences of this demographic
transformation also includes an increased risk of some mental
illnesses - the incidence of depression and dementia increases with
age.
Although mental health is part of the WHO
definition of health since its adoption, for many years there were few
interventions to address mental health problems. Patients were kept in
separate hospitals, and mental health was not part of public health
priorities.
There is today a new understanding of both mental
health and mental disorders based on advances in neuroscience and in
behavioural medicine. Three of last years' Nobel Prizes were awarded
to scientists working on mental health and neurological disorders.
This understanding offers a new hope for those suffering from mental
disorders. They will benefit if improved and more cost-effective
interventions can be made more widely available.
We are more aware of the real burden of mental
disorders and their costs in human, social and economic terms. We know
of the barriers - particularly stigma, discrimination and inadequate
services - preventing millions of people from receiving the treatment
they need.
As we analyse this new evidence on mental
disorders, we can see the clear links between thought, feelings and
physical illnesses. Depression can be a risk factor of heart disease
and on the other hand, supportive group therapy for women with breast
cancer results in longer life. No longer do we see genetics and
environment as two separate and contrasting dimensions to mental ill
health: we now recognize that it is the simultaneous effects of human
genetics and the environment.
We now have better ways of solving mental health
problems. For example, 60 per cent of people with depression can
recover with a proper combination of antidepressant drugs and
psychotherapy. Nordic studies show a 20-30 per cent decrease in
suicide rates after general practitioners were trained to recognize
and treat depression.
We are seeing, in many countries, a new trend from
institutional care to community based care. From separating mental
disorders to integrating them into general health care and prevention
services. Several countries in Western Europe have been spearheading
this trend - charting out bold new pathways to improve care and
prevention.
Families with mental illness are being empowered.
Human rights are being recognized as a major concern of mental health
services. Key elements of mental health care are being openly debated.
The cost-effectiveness of different treatments for depression,
schizophrenia, alcohol and drug dependence, epilepsy, and mental
retardation is more clearly understood. People with mental disorders
are being integrated into the work force through a groundbreaking
system of enterprises in many European countries, including
co-operatives of persons with mental illness and sheltered employment.
However, there is a long way to go before we can
say that solutions and resources for mental health match those
invested in physical health. The size and effectiveness of the
response to mental ill health do not match the burden on individuals
and societies. If we stay in Europe, many countries spend less than 3
per cent of their health budgets on mental health care, although the
consequences of mental ill health can easily amount to one third to
one half of all health care costs. In addition, the burden is
unequally distributed. The poor often have a greater risk of mental
disorder and less access to treatment.
Policies that orient mental health action in a
systematic and comprehensive way have definite health benefits. Yet,
one third of the countries of the WHO European Region still have no
explicit policies.
More than half of all patients in some eastern
European countries are treated in large mental hospitals housing more
than 1000 people. This type of institutional treatment often lead to
loss of social skills, excessive restrictions, human rights
violations, dependence and reduced opportunities for rehabilitation.
Studies show that mental health problems account
for up to 30 per cent of consultations with general practitioners in
Europe. Twelve of the countries of the WHO European Region, however,
have not integrated the services, keeping mental health and primary
care working on parallel tracks. In one out of five European
countries, primary care does not include freely available access to at
least three of the essential psychotropic drugs.
Why is the situation so unsatisfactory? Mental
illness is still a taboo subject. All of us in this hall know the
difficulties of structured discussion about mental illness within the
context of public health policy outside our own profession. It is hard
to break the silence. It is not easy for the neighbour, the community
leader, the local politician - even the prime minister - to dare to
care for those who are mentally ill. The result is a tragic waste
of lives, and of productive livelihoods.
This silence and denial leads to discrimination. In
many countries around the world, insurance companies discriminate
between physical and mental disorders. Labour policies are less open
to welcoming people with a history of mental disorders than those with
physical ones. In some countries, the basic human rights of people
with mental illnesses are not realized, often in the institutions
designed to care for them - the psychiatric hospitals.
As a result, people who are mentally ill tend to be
stigmatized: those who need help, treatment, care and prevention are
often unwilling to seek it out. Societies hide their people who
are affected by mental ill health.
We all know how important it is to address the
issues of stigma and discrimination - together - and to break the
silence about mental ill health. Fortunately, we see some powerful
examples of progress - particularly through the actions of groups of
people who have themselves been affected by mental illness.
Earlier this month, WHO released this year's World
Health Report. Its theme is mental health and its title is "New
Understanding New Hope".
This report draws the map over the vast landscape
of mental and neurological disorders and what we know about them. It
reviews the status of the global response to the burden on mental ill
health.
But it also sets out some very concrete directions
for what countries need to do to respond effectively to the challenges
we are facing.
In drawing together information on the burden of
mental ill health, the potential for effective responses and
experiences of different countries, WHO offers 10 key recommendations
for a strategic response.
Some of them I have already touched upon, such as
the need to provide treatment for mental illness in primary health
care, to make medicines for psychiatric illness more widely available,
and to make mental health care available in the community. But in many
countries, it is just as important to establish national policies,
programmes and legislation for mental health.
There is a need to match global strategic
directions to the reality of individual countries. For these reasons,
WHO proposes that national officials and community groups identify a
number of minimum actions to be undertaken for mental well-being.
Without focusing on individual countries, WHO has
offered guidance that allows every nation to recognize itself in one
of three scenarios and consequently, to adopt and implement actions
that might be appropriate to its own situation.
We also have available tools and instruments to
effect change. A collection of examples of national mental health
policies to serve as benchmarks and examples of good practices, models
for working with families of the mentally ill, training materials for
primary health care personnel and assessment tools for health care
workers to document mental disability. We are also initiating research
into the cost effectiveness of mental health interventions in primary
health care.
We are already beginning to see change. On the
World Health Day which was dedicated to mental health this year, a
national committee to monitor the state of human rights of mentally
ill persons and their families was established in the Ukraine. France
announced a policy to phase out psychiatric institutions in favour of
community-based mental health services, just to give two examples.
Our engagement does not end with the end of this
year which we have dedicated to mental health. We have developed a new
"Global Action Programme" or "GAP" The name is no
coincidence. This five year programme will focus on helping countries
closing the treatment gap. It represents a comprehensive strategy
for closing the gap between effective and available mental health
services.
The GAP has identified four core strategies:
Information, Policy and Service Development, Advocacy, and Research.
These four strategies are fundamentally related to one another. Information
concerning the magnitude, burden, determinants and treatment of mental
disorders leads to enhanced awareness and advocacy against stigma
and discrimination. This in turn creates the necessary conditions
for the formulation and implementation of integrated policy and
services, which in turn serves to generate more advocacy and
information for better decisions. Countries’ research capacity
drives this relationship.
In more ways than one, we make this simple point:
we have the means and the scientific knowledge to help people with
mental and brain disorders. Governments have been remiss, as has been
the public health community. By accident or by design, we are all
responsible for this situation. As the world's leading public health
agency, WHO has one, and only one option to ensure that ours will
be the last generation that allows shame and stigma to rule over
science and reason.
Thank you.
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